Essentials of Diseases of the Skin
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Title: Essentials of Diseases of the Skin
Author: Henry Weightman Stelwagon
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ESSENTIALS OF DISEASES OF THE SKIN
Including the Syphilodermata
Arranged in the Form of Questions and Answers Prepared Especially
for Students of Medicine
by
HENRY W. STELWAGON, M.D., PH.D.
* * * * *
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ESSENTIALS OF DISEASES OF THE SKIN.
Since the issue of the first volume of the
#Saunders Question-Compends#,
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Saunders' Question-Compends. No. 11.
ESSENTIALS OF DISEASES OF THE SKIN
Including the Syphilodermata
Arranged in the Form of Questions and Answers Prepared Especially
for Students of Medicine
by
HENRY W. STELWAGON, M.D., PH.D.
Professor of Dermatology in the Jefferson Medical College, Philadelphia;
Dermatologist to the Howard and Philadelphia Hospitals, etc.
Seventh Edition, Thoroughly Revised
Illustrated
Philadelphia and London
W. B. Saunders Company
1909
Set up, electrotyped, printed, 1890. Reprinted July, 1891.
Revised, reprinted, June, 1894. Reprinted March, 1897.
Revised, reprinted, August, 1899. Reprinted
September, 1901, May, 1902, September, 1903.
Revised, reprinted January, 1905.
Reprinted March, 1906. Revised,
reprinted March, 1909.
Printed in America
Press of
W. B. Saunders Company
Philadelphia
PREFACE TO SEVENTH EDITION.
In the present--seventh--edition the subject matter, especially as
regards the practical part, has been gone over carefully and the
necessary corrections and additions made. Nineteen new illustrations
have been added, a few of the old ones being eliminated. It is hoped
that the continued demand for this compend means a widening interest in
the study of diseases of the skin, sufficiently keen as to lead to the
desire for a still greater knowledge.
H.W.S.
PREFACE TO FIRST EDITION.
Much of the present volume is, in a measure, the outcome of a thorough
revision, remodelling and simplification of the various articles
contributed by the author to Pepper's System of Medicine, Buck's
Reference Handbook of the Medical Sciences, and Keating's Cyclopaedia of
the Diseases of Children. Moreover, in the endeavor to present the
subject as tersely and briefly as compatible with clear understanding,
the several standard treatises on diseases of the skin by Tilbury Fox,
Duhring, Hyde, Robinson, Anderson, and Crocker, have been freely
consulted, that of the last-named author suggesting the pictorial
presentation of the "Anatomy of the Skin." The space allotted to each
disease has been based upon relative importance. As to treatment, the
best and approved methods only--those which are founded upon the
aggregate experience of dermatologists--are referred to.
For general information a statistical table from the Transactions of the
American Dermatological Association is appended.
H.W.S.
CONTENTS.
PAGE
ANATOMY OF THE SKIN 17
The Epidermis 18
The Blood-vessels 19
The Nervous and Vascular Papillae 20
The Hair and Hair-follicle 21
SYMPTOMATOLOGY 22
Primary Lesions 22
Secondary Lesions 23
Distribution and Configuration 24
Relative Frequency 26
Contagiousness 27
Rapidity of Cure 27
Ointment Bases 27
CLASS I.--DISORDERS OF THE GLANDS 28
Hyperidrosis 28
Sudamen 30
Hydrocystoma 31
Anidrosis 31
Bromidrosis 32
Chromidrosis 32
Uridrosis 33
Phosphoridrosis 33
Seborrh[oe]a (Eczema Seborrhoicum) 33
Comedo 38
Milium 42
Steatoma 43
CLASS II.--INFLAMMATIONS 44
Erythema Simplex 44
Erythema Intertrigo 45
Erythema Multiforme 46
Erythema Nodosum 50
Erythema Induratum 51
Urticaria 52
Urticaria Pigmentosa 56
Dermatitis 58
Dermatitis Medicamentosa 60
X-Ray Dermatitis 63
Dermatitis Factitia 64
Dermatitis Gangraenosa 65
Erysipelas 66
Phlegmona Diffusa 68
Furunculus 68
Carbunculus 70
Pustula Maligna 72
Post-mortem Pustule 73
Framb[oe]sia 73
Verruga Peruana 73
Equinia 74
Miliaria 74
Pompholyx 76
Herpes Simplex 78
Hydroa Vacciniforme 80
Epidermolysis Bullosa 80
Dermatitis Repens 81
Herpes Zoster 81
Dermatitis Herpetiformis 83
Psoriasis 86
Pityriasis Rosea 95
Dermatitis Exfoliativa 96
Lichen Planus 98
Pityriasis Rubra Pilaris 99
Lichen Scrofulosus 100
Eczema 100
Prurigo 118
Acne 119
Acne Rosacea 126
Sycosis 130
Dermatitis Papillaris Capillitii 135
Impetigo Contagiosa 136
Impetigo Herpetiformis 138
Ecthyma 138
Pemphigus 140
CLASS III.--HEMORRHAGES 144
Purpura 144
Scorbutus 146
CLASS IV.--HYPERTROPHIES 148
Lentigo 148
Chloasma 149
Keratosis Pilaris 151
Keratosis Follicularis 153
Molluscum Epitheliale 153
Callositas 155
Clavus 156
Cornu Cutaneum 158
Verruca 160
Naevus Pigmentosus 162
Ichthyosis 165
Onychauxis 167
Hypertrichosis 168
[OE]dema Neonatorum 170
Sclerema Neonatorum 171
Scleroderma 172
Elephantiasis 174
Dermatolysis 176
CLASS V.--ATROPHIES 177
Albinismus 177
Vitiligo 178
Canities 180
Alopecia 181
Alopecia Areata 183
Atrophia Pilorum Propria 187
Atrophia Unguis 188
Atrophia Cutis 189
CLASS VI.--NEW GROWTHS 191
Keloid 191
Fibroma 192
Neuroma 194
Xanthoma 195
Myoma 196
Angioma 196
Telangiectasis 197
Lymphangioma 198
Rhinoscleroma 198
Lupus Erythematosus 199
Lupus Vulgaris 203
Tuberculosis Cutis 209
Ainhum 212
Mycetoma 212
Perforating Ulcer of the Foot 213
Syphilis Cutanea 213
Lepra 231
Pellagra 235
Epithelioma 236
Paget's Disease of the Nipple 240
Sarcoma 241
Granuloma Fungoides 242
CLASS VII.--NEUROSES 244
Hyperaesthesia 244
Dermatalgia 244
Anaesthesia 244
Pruritus 244
CLASS VIII.--PARASITIC AFFECTIONS 247
Tinea Favosa 247
Tinea Trichophytina 251
Tinea Imbricata 261
Tinea Versicolor 262
Erythrasma 265
Actinomycosis 266
Blastomycetic Dermatitis 266
Scabies 267
Pediculosis 271
Pediculosis Capitis 272
Pediculosis Corporis 274
Pediculosis Pubis 275
Cysticercus Cellulosae 276
Filaria Medinensis 277
Ixodes 277
Leptus 277
[OE]strus 278
Pulex Penetrans 278
Cimex Lectularius 278
Culex 279
Pulex Irritans 279
TABLE showing Relative Frequency of the Various
Diseases of the Skin 280
DISEASES OF THE SKIN.
#ANATOMY OF THE SKIN.#
[Illustration: Fig. I.
Vertical section of the skin--Diagrammatic. (_After Heitsmann._)]
#The Epidermis.#
[Illustration: Fig. 2.
_c_, corneous (horny) layer; _g_, granular layer; _m_, mucous layer
(rete Malpighii).
The stratum lucidum is the layer just above the granular layer.
Nerve terminations--_n_, afferent nerve; _b_, terminal nerve bulbs;
_l_, cell of Langerhans. (_After Ranvier._)]
#The Blood-vessels.#
[Illustration: Fig. 3.
_C_, epidermis; _D_, corium; _P_, papillae; _S_, sweat-gland duct.
_v_, arterial and venous capillaries (superficial, or papillary plexus)
of the papillae. Deep plexus is partly shown at lower margin of the
diagram; _vs_--an intermediate plexus, an outgrowth from the deep
plexus, supplying sweat-glands, and giving a loop to hair papilla.
(_After Ranvier._)]
#The Nervous and Vascular Papillae.#
[Illustration: Fig. 4.
_a_, a vascular papilla; _b_, a nervous papilla; _c_, a blood-vessel;
_d_, a nerve fibre; _e_, a tactile corpuscle. (_After Biesiadecki._)]
#The Hair and Hair-Follicle.#
[Illustration: Fig. 5. _A_, shaft of the hair; _B_, root of the hair;
_C_, cuticle of the hair; _D_, medullary substance of the hair. _E_,
external layer of the hair-follicle; _F_, middle layer of the
hair-follicle; _G_, internal layer of the hair-follicle; _H_, papilla of
the hair; _I_, external root-sheath; _J_, outer layer of the internal
root-sheath; _K_, internal layer of the internal root-sheath. (_After
Duhring._)]
#SYMPTOMATOLOGY.#
The symptoms of cutaneous disease may be objective, subjective or both;
and in some diseases, also, there may be systemic disturbance.
#What do you mean by objective symptoms?#
Those symptoms visible to the eye or touch.
#What do you understand by subjective symptoms?#
Those which relate to sensation, such as itching, tingling, burning,
pain, tenderness, heat, anaesthesia, and hyperaesthesia.
#What do you mean by systemic symptoms?#
Those general symptoms, slight or profound, which are sometimes
associated, primarily or secondarily, with the cutaneous disease, as,
for example, the systemic disturbance in leprosy, pemphigus, and purpura
hemorrhagica.
#Into what two classes of lesions are the objective symptoms commonly
divided?#
Primary (or elementary), and
Secondary (or consecutive).
#Primary Lesions.#
#What are primary lesions?#
Those objective lesions with which cutaneous diseases begin. They may
continue as such or may undergo modification, passing into the secondary
or consecutive lesions.
#Enumerate the primary lesions.#
Macules, papules, tubercles, wheals, tumors, vesicles, blebs and
pustules.
#What are macules (maculae)?#
Variously-sized, shaped and tinted spots and discolorations, without
elevation or depression; as, for example, freckles, spots of purpura,
macules of cutaneous syphilis.
#What are papules (papulae)?#
Small, circumscribed, solid elevations, rarely exceeding the size of a
split-pea, and usually superficially seated; as, for example, the
papules of eczema, of acne, and of cutaneous syphilis.
#What are tubercles (tubercula)?#
Circumscribed, solid elevations, commonly pea-sized and usually
deep-seated; as, for example, the tubercles of syphilis, of leprosy, and
of lupus.
#What are wheals (pomphi)?#
Variously-sized and shaped, whitish, pinkish or reddish elevations, of
an evanescent character; as, for example, the lesions of urticaria, the
lesions produced by the bite of a mosquito or by the sting of a nettle.
#What are tumors (tumores)?#
Soft or firm elevations, usually large and prominent, and having their
seat in the corium and subcutaneous tissue; as, for example, sebaceous
tumors, gummata, and the lesions of fibroma.
#What are vesicles (vesiculae)?#
Pin-head to pea-sized, circumscribed epidermal elevations, containing
serous fluid; as, for example, the so-called fever-blisters, the lesions
of herpes zoster, and of vesicular eczema.
#What are blebs (bullae)?#
Rounded or irregularly-shaped, pea to egg-sized epidermic elevations,
with fluid contents; in short, they are essentially the same as vesicles
and pustules except as to size; as, for example, the blebs of pemphigus,
rhus poisoning, and syphilis.
#What are pustules (pustulae)?#
Circumscribed epidermic elevations containing pus; as, for example, the
pustules of acne, of impetigo, and of sycosis.
#Secondary Lesions.#
#What are secondary lesions?#
Those lesions resulting from accidental or natural change, modification
or termination of the primary lesions.
#Enumerate the secondary lesions.#
Scales, crusts, excoriations, fissures, ulcers, scars and stains.
#What are scales (squamae)?#
Dry, laminated, epidermal exfoliations; as, for example, the scales of
psoriasis, ichthyosis, and eczema.
#What are crusts (crustae)?#
Dried effete masses of exudation; as, for example, the crusts of
impetigo, of eczema, and of the pustular and ulcerating syphilodermata.
#What are excoriations (excoriationes)?#
Superficial, usually epidermal, linear or punctate loss of tissue; as,
for example, ordinary scratch-marks.
#What are fissures (rhagades)?#
Linear cracks or wounds, involving the epidermis, or epidermis and
corium; as, for example, the cracks which often occur in eczema when
seated about the joints, the cracks of chapped lips and hands.
#What are ulcers (ulcera)?#
Rounded or irregularly-shaped and sized loss of skin and subcutaneous
tissue resulting from disease; as, for example, the ulcers of syphilis
and of cancer.
#What are scars (cicatrices)?#
Connective-tissue new formations replacing loss of substance.
#What are stains?#
Discolorations left by cutaneous disease, which stains may be transitory
or permanent.
#Distribution and Configuration.#
#What do you mean by a patch of eruption?#
A single group or aggregation of lesions or an area of disease.
#When is an eruption said to be limited or localized?#
When it is confined to one part or region.
#When is an eruption said to be general or generalized?#
When it is scattered, uniformly or irregularly, over the entire surface.
#When is an eruption universal?#
When the whole integument is involved, without any intervening healthy
skin.
#When is an eruption said to be discrete?#
When the lesions constituting the eruption are isolated, having more or
less intervening normal skin.
#When is an eruption confluent?#
When the lesions constituting the eruption are so closely crowded that a
solid sheet results.
#When is an eruption uniform?#
When the lesions constituting the eruption are all of one type or
character.
#When is an eruption multiform?#
When the lesions constituting the eruption are of two or more types or
characters.
#When are lesions said to be aggregated?#
When they tend to form groups or closely-crowded patches.
#When are lesions disseminated?#
When they are irregularly scattered, with no tendency to form groups or
patches.
#When is a patch of eruption said to be circinate?#
When it presents a rounded form, and usually tending to clear in the
centre; as, for example, a patch of ringworm.
#When is a patch of eruption said to be annular?#
When it is ring-shaped, the central portion being clear; as, for
example, in erythema annulare.
#What meaning is conveyed by the term "iris"?#
The patch of eruption is made up of several concentric rings. Difference
of duration of the individual rings, usually slight, tends to give the
patch variegated coloration; as, for example, in erythema iris and
herpes iris.
#What meaning is conveyed by the term "marginate"?#
The sheet of eruption is sharply defined against the healthy skin; as,
for example, in erythema marginatum, eczema marginatum.
#What meaning is conveyed by the qualifying term "circumscribed"?#
The term is applied to small, usually more or less rounded, patches,
when sharply defined; as, for example, the typical patches of psoriasis.
#When is the qualifying term "gyrate" employed?#
When the patches arrange themselves in an irregular winding or
festoon-like manner; as, for instance, in some cases of psoriasis. It
results, usually, from the coalescence of several rings, the eruption
disappearing at the points of contact.
#When is an eruption said to be serpiginous?#
When the eruption spreads at the border, clearing up at the older part;
as, for instance, in the serpiginous syphiloderm.
#RELATIVE FREQUENCY.#
#Name the more common cutaneous diseases and state approximately their
frequency.#
Eczema, 30.4%; syphilis cutanea, 11.2%; acne, 7.3%; pediculosis, 4%;
psoriasis, 3.3%; ringworm, 3.2%; dermatitis, 2.6%; scabies, 2.6%;
urticaria, 2.5%; pruritus, 2.1%; seborrh[oe]a, 2.1%; herpes simplex,
1.7%; favus, 1.7%; impetigo, 1.4%; herpes zoster, 1.2%; verruca, 1.1%;
tinea versicolor, 1%. Total: eighteen diseases, representing 81 per
cent. of all cases met with.
(These percentages are based upon statistics, public and private, of the
American Dermatological Association, covering a period of ten years. In
private practice the proportion of cases of pediculosis, scabies, favus,
and impetigo is much smaller, while acne, acne rosacea, seborrh[oe]a,
epithelioma, and lupus are relatively more frequent.)
#CONTAGIOUSNESS.#
#Name the more actively contagious skin diseases.#
Impetigo contagiosa, ringworm, favus, scabies and pediculosis; excluding
the exanthemata, erysipelas, syphilis and certain rare and doubtful
diseases.
[At the present time when most diseases are presumed to be due to
bacteria or parasites the belief in contagiousness, under certain
conditions, has considerably broadened.]
#RAPIDITY OF CURE.#
#Is the rapid cure of a skin disease fraught with any danger to the
patient?#
No. It was formerly so considered, especially by the public and general
profession, and the impression still holds to some extent, but it is not
in accord with dermatological experience.
#OINTMENT BASES.#
#Name the several fats in common use for ointment bases.#
Lard, petrolatum (or cosmoline or vaseline), cold cream and lanolin.
#State the relative advantages of these several bases.#
_Lard_ is the best all-around base, possessing penetrating properties
scarcely exceeded by any other fat.
_Petrolatum_ is also valuable, having little, if any, tendency to
change; it is useful as a protective, but is lacking in its power of
penetration.
_Cold Cream_ (ungt. aquae rosae) is soothing and cooling, and may often be
used when other fatty applications disagree.
_Lanolin_ is said to surpass in its power of penetration all other
bases, but this is not borne out by experience. It is an unsatisfactory
base when used alone. It should be mixed with another base in about the
proportion of 25% to 50%.
These several bases may, and often with advantage, be variously
combined.
#What is to be added to these several bases if a stiffer ointment is
required?#
Simple cerate, wax, spermaceti, or suet; or in some instances, a
pulverulent substance, such as starch, boric acid, and zinc oxide.
#CLASS I.--DISORDERS OF THE GLANDS.#
#Hyperidrosis.#
[Illustration: Fig. 6.
A normal sweat-gland, highly magnified. (_After Neumann._)
_a_, Sweat-coil: _b_, sweat-duct; _c_, lumen of duct; _d_,
connective-tissue capsule; _e_ and _f_, arterial trunk and
capillaries.]
#What is hyperidrosis?#
Hyperidrosis is a functional disturbance of the sweat-glands,
characterized by an increased production of sweat. This increase may be
slight or excessive, local or general.
#As a local affection, what parts are most commonly involved?#
The hands, feet, especially the palmar and plantar surfaces, the axillae
and the genitalia.
#Describe the symptoms of the local forms of hyperidrosis.#
The essential, and frequently the sole symptom, is more or less profuse
sweating.
If the hands are the parts involved, they are noted to be wet, clammy
and sometimes cold.
If involving the soles, the skin often becomes more or less macerated
and sodden in appearance, and as a result of this maceration and
continued irritation they may become inflamed, especially about the
borders of the affected parts, and present a pinkish or pinkish-red
color, having a violaceous tinge. The sweat undergoes change and becomes
offensive.
#Is hyperidrosis acute or chronic?#
Usually chronic, although it may also occur as an acute affection.
#What is the etiology of hyperidrosis?#
Debility is commonly the cause in general hyperidrosis; the local forms
are probably neurotic in origin.
#What is the prognosis?#
The disease is usually persistent and often rebellious to treatment; in
many instances a permanent cure is possible, in others palliation.
Relapses are not uncommon.
#What systemic remedies are employed in hyperidrosis?#
Ergot, belladonna, gallic acid, mineral acids, and tonics.
Constitutional treatment is rarely of benefit in the local forms of
hyperidrosis, and external applications are seldom of service in general
hyperidrosis. Precipitated sulphur, a teaspoonful twice daily, is also
well spoken of, combined, if necessary, with an astringent.
#What external remedies are employed in the local forms?#
Astringent lotions of zinc sulphate, tannin and alum, applied several
times daily, with or without the supplementary use of dusting-powders.
Weak solutions of formaldehyde, one to one hundred, are sometimes of
value.
Dusting-powders of boric acid and zinc oxide, to which may be added from
ten to thirty grains of salicylic acid to the ounce, to be used freely
and often:--
[Rx] Pulv. ac. salicylici ................. gr. x-xxx.
Pulv. ac. borici ..................... [dram]v.
Pulv. zinci oxidi .................... [dram]iij M.
Diachylon ointment, and an ointment containing a drachm of tannin to the
ounce; more especially applicable in hyperidrosis of the feet. The parts
are first thoroughly washed, rubbed dry with towels and dusting-powder,
and the ointment applied on strips of muslin or lint and bound on; the
dressing is renewed twice daily, the parts each time being rubbed dry
with soft towels and dusting-powder, and the treatment continued for ten
days to two weeks, after which the dusting-powder is to be used alone
for several weeks. No water is to be used after the first washing until
the ointment is discontinued. One such course will occasionally suffice,
but not infrequently a repetition is necessary.
Faradization and galvanization are sometimes serviceable. Repeated mild
exposures to the Roentgen rays have a favorable influence in some
instances.
#Sudamen.#
(_Synonym:_ Miliaria crystallina.)
#What is sudamen?#
Sudamen is a non-inflammatory disorder of the sweat-glands,
characterized by pin-point to pin-head-sized, discrete but thickly-set,
superficial, translucent whitish vesicles.
#Describe the clinical characters.#
The lesions develop rapidly and in great numbers, either irregularly or
in crops, and are usually to be seen as discrete, closely-crowded,
whitish, or pearl-colored minute elevations, occurring most abundantly
upon the trunk. In appearance they resemble minute dew-drops. They are
non-inflammatory, without areola, never become purulent, and evince no
tendency to rupture, the fluid disappearing by absorption, and the
epidermal covering by desquamation.
#Give the course and duration of sudamen.#
New crops may appear as the older lesions are disappearing, and the
affection persist for some time, or, on the other hand, the whole
process may come to an end in several days or a week. In short, the
course and duration depend upon the subsidence or persistence of the
cause.
#What is the anatomical seat of sudamen?#
The lesions are formed between the lamellae of the corneous layer,
usually the upper part; and are thought to be due to some change in the
character of the epithelial cells of this layer, probably from high
temperature, giving rise to a blocking up of the surface outlet.
#What is the cause of sudamen?#
Debility, especially when associated with high fever. The eruption is
often seen in the course of typhus, typhoid and rheumatic fevers.
#How would you treat sudamen?#
By constitutional remedies directed against the predisposing factor or
factors, and the application of cooling lotions of vinegar or alcohol
and water, or dusting-powders of starch and lycopodium.
#Hydrocystoma.#
#Describe hydrocystoma.#
Hydrocystoma is a cystic affection of the sweat-gland ducts, seated upon
the face. The lesions may be present in scant numbers or in more or less
profusion. They have the appearance of boiled sago grains imbedded in
the skin; the larger lesions may have a bluish color, especially about
the periphery. It is not common, and is usually seen in washerwomen and
laundresses, or those exposed to moist heat. In some cases it tends to
disappear during the winter months. There are no subjective symptoms.
Treatment consists of puncturing the lesions and application of
dusting-powder. Avoidance of the exciting cause (moist heat) is
important.
#Anidrosis.#
#Describe anidrosis.#
It is the opposite condition of hyperidrosis, and is characterized by
diminution or suppression of the sweat secretion. It occurs to some
extent in certain systemic diseases and also in some affections of the
skin, such as ichthyosis; nerve-injuries may give rise to localized
sweat-suppression.
Treatment is based upon general principles; friction, warm and hot-vapor
baths, electricity and similar measures are of service.
#Bromidrosis.#
(_Synonym:_ Osmidrosis.)
#Describe bromidrosis.#
Bromidrosis is a functional disturbance of the sweat-glands
characterized by a sweat secretion of an offensive odor. The sweat
production may be normal in quantity or more or less excessive, usually
the latter. The condition may be local or general, commonly the former.
It is closely allied to hyperidrosis, and may often be considered
identical, the odor resulting from rapid decomposition of the sweat
secretion. The decomposition and resulting odor have been thought due to
the presence of bacteria.
#What parts are most commonly affected in bromidrosis?#
The feet and the axillae.
#What is the treatment of bromidrosis?#
It is essentially the same as that of hyperidrosis (_q. v._), consisting
of applications of astringent lotions, dusting-powders, especially those
containing boric acid and salicylic acid, and the continuous application
of diachylon ointment. In obstinate cases weak formaldehyde solutions,
Roentgen rays, and high-frequency currents can be tried.
#Chromidrosis.#
#Describe chromidrosis.#
This is a functional disorder of the sweat-glands characterized by a
secretion variously colored, and usually increased in quantity. It is,
as a rule, limited to a circumscribed area. The most common color is
red. The condition is probably of neurotic origin and tends to recur.
(True chromidrosis is extremely rare; most of the cases formerly thought
to be such are now known to be examples of pseudochromidrosis.)
Treatment should be invigorating and tonic, with special reference
toward the nervous system. The various methods of local electrization
should also be resorted to.
Mild antiseptic and astringent lotions or dusting powders should also be
advised.
_Red chromidrosis_ or _Pseudochromidrosis_ is a condition in which the
coloring of the sweat occurs after its excretion and is due to the
presence of chromatogenous bacteria which are found attached to the
hairs of the part in agglutinated masses. The axilla is the favorite
site. Treatment consists of frequent soap-and-water washings, and the
application of boric acid, resorcin, and corrosive sublimate lotions.
#Uridrosis.#
#Describe uridrosis.#
Uridrosis is a rare condition in which the sweat secretion contains the
elements of the urine, especially urea. In marked cases the salt may be
noticeable upon the skin as a colorless or whitish crystalline deposit.
In most instances it has been preceded or accompanied by partial or
complete suppression of the renal functions.
#Phosphoridrosis.#
#Describe phosphoridrosis.#
Phosphoridrosis is a rare condition, in which the sweat is
phosphorescent. It has been observed in the later stages of phthisis, in
miliaria, and in those who have eaten of putrid fish.
#Seborrh[oe]a (Eczema Seborrhoicum).#
_Synonyms:_ (Steatorrh[oe]a; Acne sebacea; Ichthyosis sebacea; Dandruff.)
#What is seborrh[oe]a?#
Seborrh[oe]a is a disease of the sebaceous glands, characterized by an
excessive and abnormal secretion of sebaceous matter, appearing on the
skin as an oily coating, crusts, or scales.
In many cases the sweat-glands are likewise implicated, and the process
may also be distinctly, although usually mildly, inflammatory.
#At what age is seborrh[oe]a usually observed?#
Between fifteen and forty. It may, however, occur at any age.
#Name the parts most commonly affected.#
The scalp, face, and (less frequently) the sternal and interscapular
regions of the trunk. It is sometimes seen on other parts.
#What varieties of seborrh[oe]a are encountered?#
Seborrh[oe]a oleosa and seborrh[oe]a sicca; not infrequently the disease
is of a mixed type.
#What are the symptoms of seborrh[oe]a oleosa?#
The sole symptom is an unnatural oiliness, variable as to degree. Its
most common sites are the regions of the scalp, nose, and forehead. In
many instances mild rosacea coexists with oily seborrh[oe]a of the nose.
#Give the symptoms of seborrh[oe]a sicca.#
A variable degree of greasy scalines, which may be seated upon a pale,
hyperaemic or mildly inflammatory surface.
The parts affected are covered scantily or more or less abundantly with
somewhat greasy, grayish, or brownish-gray scales. If upon the scalp
(_dandruff_, _pityriasis capitis_), small particles of scales are found
scattered through the hair, and when the latter is brushed or combed,
fall over the shoulders. If upon the face, in addition to the scaliness,
the sebaceous ducts are usually seen to be enlarged and filled with
sebaceous matter.
#Describe the symptoms of the ordinary or mixed type.#
It is common upon the scalp. The skin is covered with irregularly
diffused, greasy, grayish or brownish scales and crusts, in some cases
moderate in quantity, in others so great that large irregular masses are
formed, pasting the hair to the scalp. If removed, the scales and crusts
rapidly re-form. The skin beneath is found slate-colored, hyperaemic or
mildly inflammatory, and exceptionally it has in places an eczematous
aspect (_eczema seborrhoicum_). Extraneous matter, such as dust and
dirt, collects upon the parts, and the whole mass may become more or
less offensive. There is a strong tendency to falling-out of the hair.
Itching may or may not be present.
[Illustration: Seborrh[oe]a (Eczema Seborrhoicum).]
#Describe the symptoms of seborrh[oe]a of the trunk and other parts.#
[Illustration: Fig. 7.
A normal sebaceous gland in connection with a lanugo hair.
(_After Neumann._)
_a_, Capsule; _b_, fatty secretion; _c_, _h_, secreting cells; _d_, root
of lanugo hair; _e_, hair-sac; _f_, hair-shaft; _g_, acini of sebaceous
gland.]
Seborrh[oe]a corporis differs in a measure, in its symptoms, from
seborrh[oe]a of the scalp and is usually illustrative of the variety
known as eczema seborrhoicum; it occurs as one or several irregular or
circinate, slightly hyperaemic or moderately inflammatory patches,
covered with dirty or grayish-looking greasy scales or crusts, usually
moderate in quantity, and upon removal are found to have projections
into the sebaceous ducts. It is commonly seen upon the sternal and
interscapular regions. It rarely exists independently in these regions,
being usually associated with and following the disease on the scalp. It
may also invade the axillae, genitocrural, and other regions.
#What is the usual course of seborrh[oe]a?#
Essentially chronic, the disease varying in intensity from time to time.
In occasional instances it disappears spontaneously.
#Give the cause or causes of seborrh[oe]a.#
General debility, anaemia, chlorosis, dyspepsia, and similar conditions
are to be variously looked upon as predisposing.
In some instances, however, the disease seems to be purely local in
character, and to be entirely independent of any constitutional or
predisposing condition. The view recently advanced that the disease is
of parasitic nature and contagious has been steadily gaining ground.
#What is the pathology of seborrh[oe]a?#
Seborrh[oe]a is a disease of the sebaceous glands, and probably often
involving the sweat-glands also; its products, as found upon the skin,
consisting of the sebaceous secretion, epithelial cells from the glands
and ducts, and more or less extraneous matter. Not infrequently
evidences of superficial inflammatory action are also to be found, and
it is especially for this type that the name eczema seborrhoicum is most
appropriate. In long-continued and neglected cases slight atrophy of the
gland-structures may occur.
#With what diseases are you likely to confound seborrh[oe]a?#
Upon the scalp, with eczema and psoriasis; upon the face, with lupus
erythematosus and eczema; and upon the trunk, with psoriasis and
ringworm.
As a rule, the clinical features of seborrh[oe]a are sufficiently
characteristic to prevent error.
#What are the differential points?#
Eczema, psoriasis, and lupus erythematosus are diseases in which there
are distinct _inflammatory symptoms_, such as thickening and
infiltration and redness; moreover, psoriasis, and this holds true as to
ringworm also, occurs in sharply-defined, circumscribed patches, and
lupus erythematosus has a peculiar violaceous tint and an elevated and
marginate border. A microscopic examination of the epidermic scrapings
would be of crucial value in differentiating from ringworm.
Quite frequently, especially in the interscapular and sternal regions,
the segmental configuration constitutes an important feature of
seborrh[oe]a--of the eczema seborrhoicum variety.
#What is the prognosis in seborrh[oe]a?#
Favorable. All types are curable, and when upon the non-hairy regions,
usually readily so; upon the scalp it is often obstinate. Relapses are
not uncommon.
In those cases of seborrh[oe]a capitis which have been long-continued or
neglected, and attended with loss of hair, this loss may be more or less
permanent, although ordinarily much can be done to promote a regrowth
(see _Treatment of Alopecia_).
#How would you treat seborrh[oe]a of the scalp?#
By constitutional (if indicated) and local remedies; the former having
in view correction or modification of the predisposing factor or
factors, and the latter removal of the sebaceous accumulations and the
application of mildly stimulating antiseptic ointments or lotions.
#What constitutional remedies are commonly employed?#
The various tonics, such as iron, quinine, strychnia, cod-liver oil,
arsenic, the vegetable bitters, laxatives, malt and similar
preparations. The line of treatment is to be based upon indications.
#How do you free the scalp of the sebaceous accumulations?#
In mild types of the disease shampooing with simple Castile soap (or any
other good toilet soap) and hot water will suffice; in those cases in
which there is considerable scale-and crust-formation the tincture of
green soap (tinct. saponis viridis) is to be employed in place of the
toilet soap, and in some of these latter cases it may be necessary to
soften the crusts with a previous soaking with olive oil.
The frequency of the shampoo depends upon the conditions. In mild cases
once in five or ten days will be sufficiently frequent to keep the parts
clean, but in those cases in which there is rapid scale-or
crust-production once daily or every second day may at first be
demanded.
#Name the most effectual applications in seborrh[oe]a capitis.#
Sulphur, ammoniated mercury, salicylic acid, resorcin, and carbolic
acid.
Sulphur is used in the form of an ointment, from twenty grains to one
drachm in the ounce. Ammoniated mercury, in the form of an ointment, ten
to sixty grains to the ounce. Salicylic acid, either alone as an
ointment, ten to thirty grains to the ounce; or it may often be added
with advantage, in the same proportion, to the sulphur or ammoniated
mercury ointment above named. Resorcin, either as an ointment, ten to
thirty grains to the ounce, or as an alcoholic or aqueous lotion, as the
following:--
[Rx] Resorcini ............................ [dram]j-[dram]iss.
Ol. ricini ........................... [minim]xxx-f[dram]ij.
Alcoholis ............................ f[Oz]iv. M.
Carbolic acid, to the amount of ten to thirty grains, can be added to
this. If an aqueous lotion is desirable, then in the above formula the
oleum ricini is replaced with glycerine, and the alcohol with water;
three to five minims of glycerine in each ounce is usually sufficient,
as a greater quantity makes the resulting lotion sticky. Petrolatum
alone, or with 10 to 30 per cent. lanolin, is usually the most
satisfactory base for the ointments. In some cases of the inflammatory
variety the skin is found quite irritable, and the mildest applications
are at first only admissible.
#How are the remedies to be applied?#
A small quantity of the lotion, ointment, or oil is gently applied to
the skin; when to the scalp, a lotion or oil can be conveniently applied
by means of an eye-dropper. In the beginning of the treatment an
application once or twice daily is ordered; later, as the disease
becomes less active, once every second or third day.
#How is seborrh[oe]a upon other parts to be treated?#
In the same general manner as seborrh[oe]a of the scalp, except that the
local applications must be somewhat weaker. The several sulphur lotions
employed in the treatment of acne (_q. v._) may also be used when the
disease is upon these parts. In obstinate patchy cases occasional
paintings with a 20 to 50 per cent alcoholic solution of resorcin is
curative; following the painting a mild salve should be used.
#Comedo.#
(_Synonyms:_ Blackheads; Flesh-worms.)
#What is comedo?#
Comedo is a disorder of the sebaceous glands, characterized by yellowish
or blackish pin-point or pin-head-sized puncta or elevations
corresponding to the gland-orifices.
#At what age and upon what parts are comedones found?#
Usually between fifteen and thirty, and upon the face and upper part of
the trunk, where they may exist sparsely or in great numbers. They are
occasionally associated with oily seborrh[oe]a, the parts presenting a
greasy or soiled appearance.
Exceptionally they occur as distinct, and usually symmetrical, groups
upon the forehead or the cheeks. On the upper trunk so-called double and
multiple comedo have been noted--the two, three, or even four
closely-contiguous blackheads are, beneath the surface,
intercommunicable, the dividing duct-walls having apparently disappeared
by fusion.
#Describe an individual lesion.#
It is pin-point to pin-head in size, dark yellowish, and usually with a
central blackish point (hence the name _blackheads_). There is scarcely
perceptible elevation, unless the amount of retained secretion is
excessive. Upon pressure this may be ejected, the small, rounded orifice
through which it is expressed giving it a thread-like shape (hence the
name _flesh-worms_).
#What is the usual course of comedo?#
Chronic. The lesions may persist indefinitely or the condition may be
somewhat variable. In many instances, either as a result of pressure or
in consequence of chemical change in the sebaceous plugs or of the
addition of a microbic factor, inflammation is excited and acne results.
The two conditions are, in fact, usually associated.
[Illustration: Fig. 8.
Demodex Folliculorum, X 300. Ventral surface. (_After Simon._)]
#To what may comedo often be ascribed?#
To disorders of digestion, constipation, chlorosis, menstrual
disturbance, lack of tone in the muscular fibres of the skin, the
infrequent use of soap, and working in a dirty or dusty atmosphere.
A small parasite (_demodex folliculorum_, _acarus folliculorum_) is
sometimes found in the sebaceous mass, but its presence is without
etiological significance, as it is also found in healthy follicles. A
microbacillus has been found by several observers, and credited with
etiological influence.
#What is the pathology of comedo?#
The sebaceous ducts or glands, or both, become blocked up with retained
secretion and epithelial cells. The dark points which usually mark the
lesions are probably due to accumulation of dirt, but may, as some
writers maintain, be due to the presence of pigment-granules resulting
from chemical change in the sebaceous matter.
#Is there any difficulty in the diagnosis of comedo?#
No. It can scarcely be confounded with milium, as in this latter disease
the lesion has no open outlet, no black point, and the contents cannot
be squeezed out.
#Give the prognosis of comedo.#
The result of treatment is usually favorable, although the disease is
often rebellious. Relapses are not uncommon.
#How would you treat a case of comedo?#
By systemic (if indicated) and local measures.
The constitutional treatment aims at correction or palliation of the
predisposing conditions, and the external applications have in view a
removal of the sebaceous plugs and stimulation of the glands and skin to
healthy action.
[Illustration: Fig. 9. Comedo Extractor.]
#Name the systemic remedies commonly employed.#
Cod-liver oil, iron, quinine, arsenic, nux vomica and other tonics;
ergot in those cases in which there is lack of muscular tone, salines
and aperient pills in constipation. The digestion is to be looked after
and the bowels kept regular; indigestible food of all kinds is to be
interdicted. Hygienic measures, such as general and local bathing, local
massage, calisthenics, and open-air exercise, are of service.
#Describe the local treatment.#
Steaming the face or prolonged applications of hot water; washing with
ordinary toilet soap and hot water, or, in sluggish cases, using
tincture of green soap (tinct. saponis viridis) instead of the toilet
soap; removal of the sebaceous plugs by mechanical means, such as
lateral pressure with the finger ends or perpendicular pressure with a
watch-key with rounded edges, or with an instrument specially contrived
for this purpose; and after these preliminary measures, which should be
carried out every night, a stimulating sulphur ointment or lotion, such
as employed in the treatment of acne (_q. v._), is to be thoroughly
applied. The following is valuable:--
[Rx] Zinci sulphatis,
Potassi sulphureti, . [=a][=a] ....... [dram]j-[dram]iv.
Alcoholi ............................. f[Oz]ss.
Aquae, ................. q.s. ad ...... f[Oz]iv. M.
Should slight scaliness or a mild degree of irritation of the skin be
brought about, active external treatment is to be discontinued for a few
days and soothing applications made. Resorcin, in lotion, 3 to 25 per
cent strength, is through the exfoliation it provokes, frequently of
value; the resorcin paste referred to in acne can also be used for this
purpose.
Moderately strong applications of the Faradic current, repeated once or
twice weekly, are sometimes of service; also weak to moderately strong
applications of the continuous and high-frequency currents. Roentgen-ray
treatment can also be resorted to in extremely obstinate cases.
In occasional instances sulphur preparations not only fail to do good,
but materially aggravate the condition. In such cases, if resorcin
preparations also fail, the mercurial lotion and ointment employed in
acne may be prescribed. Mercurial and sulphur applications should not be
used, it need scarcely be said, within a week or ten days of each other,
otherwise an increase in the comedones and a slight darkening of the
skin result from the formation of the black sulphuret of mercury.
#Milium.#
(_Synonyms:_ Grutum; Strophulus Albidus.)
#What is milium?#
Milium consists in the formation of small, whitish or yellowish,
rounded, pearly, non-inflammatory elevations situated in the upper part
of the corium.
#Describe the clinical appearances.#
The lesions are usually pin-head in size, whitish or yellowish,
seemingly more or less translucent, rounded or acuminated, without
aperture or duct, are superficially seated in the skin, and project
slightly above the surface.
They appear about the face, especially about the eyelids; they may occur
also, although rarely, upon other parts. But one or several may be
present, or they may exist in numbers.
#What is the course of milium?#
The lesions develop slowly, and may then remain stationary for years.
Their presence gives rise to no disturbance, and, unless they are large
in size or exist in numbers, causes but slight disfigurement.
[Illustration: Fig. 10. Milium Needle.]
In rare instances they may undergo calcareous metamorphosis,
constituting the so-called _cutaneous calculi_.
#What is the anatomical seat of milium?#
The sebaceous gland (probably one or several of the
superficially-situated acini), the duct of which is in some manner
obliterated, the sebaceous matter collects, becomes inspissated and
calcareous, forming the pin-head lesion. The epidermis is the external
covering.
#What is the treatment?#
The usual plan is to prick or incise each lesion and press out the
contents. In some milia it may be necessary also, in order to prevent a
return, to touch the base of the excavation with tincture of iodine or
with silver nitrate. Electrolysis is also effectual. In those cases
where the lesions are numerous the production of exfoliation of the
epiderm by means of resorcin applications (see acne) is a good plan.
#Steatoma.#
(_Synonyms:_ Sebaceous Cyst; Sebaceous Tumor; Wen.)
#Describe steatoma.#
Steatoma, or sebaceous cyst, appears as a variously-sized, elevated,
rounded or semi-globular, soft or firm tumor, freely movable and
painless, and having its seat in the corium or subcutaneous tissue. The
overlying skin is normal in color, or it may be whitish or pale from
distention; in some a gland-duct orifice may be seen, but, as a rule,
this is absent.
#What are the favorite regions for the development of steatoma?#
The scalp, face and back. One or several may be present.
#What is the course of sebaceous cysts?#
Their growth is slow, and, after attaining a variable size, may remain
stationary. They may exist indefinitely without causing any
inconvenience beyond the disfigurement. Exceptionally, in enormously
distended growths, suppuration and ulceration result.
#What is the pathology?#
A steatoma is a cyst of the sebaceous gland and duct, produced by
retained secretion. The contents may be hard and friable, soft and
cheesy, or even fluid, of a grayish, whitish or yellowish color, and
with or without a fetid odor; the mass consisting of fat-drops,
epidermic cells, cholesterin, and sometimes hairs.
#Are sebaceous cysts likely to be confounded with gummata?#
No. Gummata grow more rapidly, are usually painful to the touch, are not
freely movable, and tend to break down and ulcerate.
#Describe the treatment of steatoma.#
A linear incision is made, and the mass and enveloping sac dissected
out. If the sac is permitted to remain, reproduction almost invariably
takes place.
#CLASS II.--INFLAMMATIONS.#
#Erythema Simplex.#
#What do you understand by erythema simplex?#
Erythema simplex is a hyperaemic disorder characterized by redness,
occurring in the form of variously-sized and shaped, diffused or
circumscribed, non-elevated patches.
#Name the two general classes into which the simple erythemata are
divided.#
Idiopathic and symptomatic.
#What do you include in the idiopathic class?#
Those erythemas due to external causes, such as cold and heat (_erythema
caloricum_), the action of the sun (_erythema solare_), traumatism
(_erythema traumaticum_), and the various poisons or chemical irritants
(_erythema venenatum_).
#What do you include in the symptomatic class?#
Those rashes often preceding or accompanying certain of the systemic
diseases, and those due to disorders of the digestive tract, stomachic
and intestinal toxins, to the ingestion of certain drugs, and to use of
the therapeutic serums.
#Describe the symptoms of erythema simplex.#
The essential symptom is redness--simple hyperaemia--without elevation or
infiltration, disappearing under pressure, and sometimes attended by
slight heat or burning; it may be patchy or diffused. In the idiopathic
class, if the cause is continued, dermatitis may result.
#What is to be said about the distribution of the simple erythemata?#
The idiopathic rashes, as inferred from the nature of the causes, are
usually limited.
The symptomatic erythemas are more or less generalized; desquamation
sometimes follows.
#Describe the treatment of the simple erythemata.#
A removal of the cause in idiopathic rashes is all that is needed, the
erythema sooner or later subsiding. The same may be stated of the
symptomatic erythemata, but in these there is at times difficulty in
recognizing the etiological factor; constitutional treatment, if
necessary, is to be based upon general principles. Intestinal
antiseptics are useful in some instances.
Local treatment, which is rarely needed, consists of the use of
dusting-powders or mild cooling and astringent lotions, such as are
employed in the treatment of acute eczema (q. v.).
#Erythema Intertrigo.#
(_Synonym:_ Chafing.)
#What do you understand by erythema intertrigo?#
Erythema intertrigo is a hyperaemic disorder occurring on parts where the
natural folds of the skin come in contact, and is characterized by
redness, to which may be added an abraded surface and maceration of the
epidermis.
#Describe the symptoms of erythema intertrigo.#
The skin of the involved region gradually becomes hyperaemic, but is
without elevation or infiltration; a feeling of heat and soreness is
usually experienced. If the condition continue, the increased
perspiration and moisture of the parts give rise to maceration of the
epidermis and a mucoid discharge; actual inflammation may eventually
result.
#What is the course of erythema intertrigo?#
The affection may pass away in a few days or persist several weeks, the
duration depending, in a great measure, upon the cause.
#Mention the causes of erythema intertrigo.#
The causes are usually local. It is seen chiefly in children, especially
in fat subjects, in whom friction and moisture of contiguous parts of
the body, usually the region of the neck, buttocks and genitalia, are
more common; in such, uncleanliness or the too free use of soap washings
will often act as the exciting factor. Disorders of the stomach or
intestinal canal apparently have a predisposing influence.
#What treatment would you advise in erythema intertrigo?#
The folds or parts are to be kept from contact by means of lint or
absorbent cotton; thin, flat bags of cheese cloth or similar material
partly filled with dusting-powder, and kept clean by frequent changes,
are excellent for this purpose, and usually curative. Cleanliness is
essential, but it is to be kept within the bounds of common sense.
Dusting-powders and cooling and astringent lotions, such as are employed
in the treatment of acute eczema (_q. v._), can also be advised. The
following lotion is valuable:--
[Rx] Pulv. calaminae,
Pulv. zinci oxidi, .. [=a][=a] ...... [dram]iss.
Glycerinae, .......................... [minum]xxx
Alcoholis, .......................... f[dram]ij
Aquae, ............................... Oss. M.
Exceptionally a mild ointment, alone or supplementary to a lotion, acts
more satisfactorily.
In persistent or obstinate cases attention should also be directed to
the state of the general health, especially as regards the digestive
tract.
#Erythema Multiforme.#
#What is erythema multiforme?#
Erythema multiforme is an acute, inflammatory disease, characterized by
reddish, more or less variegated macules, papules, and tubercles,
occurring as discrete lesions or in patches of various size and shape.
#Upon what parts of the body does the eruption appear?#
Usually upon the extremities, especially the dorsal aspect, from the
knees and elbows down, and about the face and neck; it may, however, be
more or less general.
#Describe the symptoms of erythema multiforme.#
With or without precursory symptoms of malaise, gastric uneasiness or
rheumatic pains, the eruption suddenly makes its appearance, assuming an
erythematous, papular, tubercular or mixed character; as a rule, one
type of lesion predominates. The lesions tend to increase in size and
intensity, remain stationary for several days or a week, and then
gradually fade; during this time there may have been outbreaks of new
lesions. In color they are pink, red, or violaceous. Slight itching may
or may not be present. Exceptionally, in general cases, the eruption
partakes of the nature of both urticaria and erythema multiforme, and
itching may be quite a decided symptom. In some instances there is
preceding and accompanying febrile action, usually slight in character;
in others there may be some rheumatic swelling of one or more joints.
[Illustration: Fig. 11.
Erythema Multiforme, in which many of the lesions have become
bullous--Erythema Bullosum.]
#What type of the eruption is most common?#
The papular, appearing usually upon the backs of the hands and forearms,
and not infrequently, also, upon the face, legs and feet. The papules
are usually pea-sized, flattened, and of a dark red or violaceous color.
#Describe the various shapes which the erythematous lesions may assume.#
Often the patches are distinctly ring-shaped, with a clear
centre--_erythema annulare_; or they are made up of several concentric
rings, presenting variegated coloring--_erythema iris_; or a more or
less extensive patch may spread with a sharply-defined border, the older
part tending to fade--_erythema marginatum_; or several rings may
coalesce, with a disappearance of the coalescing parts, and serpentine
lines or bands result--_erythema gyratum_.
#Does the eruption of erythema multiforme ever assume a vesicular or
bullous character?#
Yes. In exceptional instances, the inflammatory process may be
sufficiently intense to produce vesiculation, usually at the summits of
the papules--_erythema vesiculosum_; and in some instances, blebs may be
formed--_erythema bullosum_. A vesicular or bullous lesion may become
immediately surrounded by a ring-like vesicle or bleb, and outside of
this another form; a patch may be made up of as many as several such
rings--_herpes iris_. In the vesicular and bullous cases the lips and
the mucous membranes of the mouth and nose also may be the seat of
similar lesions.
#What is the course of erythema multiforme?#
Acute, the symptoms disappearing spontaneously, usually in one to three
or four weeks. In some instances the recurrences take place so rapidly
that the disease assumes a chronic aspect; it is possible that such
cases are midway cases between this disease and dermatitis
herpetiformis.
#Mention the etiological factors in erythema multiforme.#
The causes are obscure. Digestive disturbance, rheumatic conditions, and
the ingestion of certain drugs are at times influential. Intestinal
toxins are doubtless important etiological factors in some cases.
Certain foods, such as are apt to undergo rapid putrefactive or
fermentative change, especially pork meats, oysters, fish, crabs,
lobsters, etc., are, therefore, not infrequently of apparent causative
influence. It is most frequently observed in spring and autumn months,
and in early adult life. The disease is not uncommon.
#What is the pathology of erythema multiforme?#
It is a mildly inflammatory disorder, somewhat similar to urticaria, and
presumably due to vasomotor disturbance; the amount of exudation, which
is variable, determines the character of the lesions.
#Name the diagnostic points of erythema multiforme.#
The multiformity of the eruption, the size of the papules, often its
limitation to certain parts, its course and the entire or comparative
absence of itching.
It resembles urticaria at times, but the lesions of this latter disease
are evanescent, disappearing and reappearing usually in the most
capricious manner, are commonly seated about the trunk, and are
exceedingly itchy.
In the vesicular and bullous types the acute character of the outbreak,
the often segmental and ring-like shape, their frequent origin from
erythematous papules, and the distribution and association with the more
common manifestations, are always suggestive.
#What prognosis would you give in erythema multiforme?#
Always favorable; the eruption usually disappears in ten days to three
weeks, although in rare instances new crops may appear from day to day
or week to week, and the process last one or two months. One or more
recurrences in succeeding years are not uncommon. Those rare cases in
which vesicular or bullous lesions are also seen on the lips and in the
mouth, are more prone to longer duration and to more frequent
recurrences.
#What remedies are commonly prescribed in erythema multiforme?#
Quinin, and, if constipation is present, saline laxatives. Calcined
magnesia is valuable as a laxative. Intestinal antiseptics, such as
salol, thymol, and sodium salicylate, are valuable in cases probably due
to intestinal toxins. In those exceptional instances in which there may
be associated febrile action and rheumatic swelling of the joints, the
patient should be kept in bed till these symptoms subside. Local
applications are rarely required, but in those exceptional cases in
which itching or burning is present, cooling lotions of alcohol and
water or vinegar and water are to be prescribed. The vesicular and
bullous types demand mild protective applications, such as used in
eczema and pemphigus.
#Erythema Nodosum.#
(_Synonym:_ Dermatitis contusiformis.)
#What is erythema nodosum?#
Erythema nodosum is an inflammatory affection, of an acute type,
characterized by the formation of variously-sized, roundish, more or
less elevated erythematous nodes.
#Is there any special region of predilection for the eruption of erythema
nodosum?#
Yes. The tibial surfaces, to which the eruption is often limited; not
infrequently, however, other parts may be involved, more especially the
arms and forearms.
#Describe the symptoms of erythema nodosum.#
The eruption makes its appearance suddenly, and is usually ushered in
with febrile disturbance, gastric uneasiness, malaise, and rheumatic
pains and swelling about the joints. The lesions vary in size from a
cherry to a hen's egg, are rounded or ovalish, tender and painful, have
a glistening and tense look, and are of a bright red, erysipelatous
color which merges gradually into the sound skin. At first they are
somewhat hard, but later they soften and appear as if about to break
down, but this, however, never occurs, absorption invariably taking
place. In occasional instances they are hemorrhagic. Exceptionally the
lesions of erythema multiforme are also present. Lymphangitis is
sometimes observed. In rare instances symptoms pointing to visceral
involvement, to cerebral invasion, and to heart complications have been
observed.
#Are the lesions in erythema nodosum usually numerous?#
No. As a rule not more than five to twenty nodes are present.
#What is the course of erythema nodosum?#
Acute. The disease terminating usually in one to three weeks. As the
lesions are disappearing they present the various changes of color
observed in an ordinary bruise.
#What is known in regard to the etiology?#
The affection is closely allied to erythema multiforme, and is, indeed,
by some considered a form of that disease. It occurs most frequently in
children and young adults, and usually in the spring and autumn months.
Intestinal toxins are thought responsible in some cases. Digestive
disturbance and rheumatic pain and swellings are often associated with
it. By many the malady is thought to be a specific infection.
#What is the pathology of erythema nodosum?#
The disease is to be viewed as an inflammatory [oe]dema, probably
resulting, in some instances at least, from an inflammation of the
lymphatics or an embolism of the cutaneous vessels.
#What diseases may erythema nodosum resemble?#
Bruises, abscesses, and gummata.
#How are the lesions of erythema nodosum to be distinguished from these
several conditions?#
By the bright red or rosy tint, the apparently violent character of the
process, the number, situation and course of the lesions.
#State the prognosis of erythema nodosum.#
Favorable, recovery usually taking place in ten days to several weeks.
#State the treatment to be advised in erythema nodosum.#
Rest, relative or absolute, depending upon the severity of the case, and
an unstimulating diet; internally intestinal antiseptics, quinin and
saline laxatives, and locally applications of lead-water and laudanum.
#Erythema Induratum.#
(_Synonym:_ Erythema induratum scrofulosorum.)
#What do you understand by erythema induratum?#
A rare disease characterized in the beginning by one or more usually
deep-seated nodules, and, as a rule, seated in the legs, especially the
calf region. The nodules gradually enlarge, the skin becomes reddish,
violaceous or livid in color. Absorption may take place slowly, or the
indurations may break down, resulting in an indolent, rather deep-seated
ulcer, closely resembling a gummatous ulcer. The disease is slow and
persistent, and is commonly met with in girls and young women, usually
of strumous type. It suggests a tuberculous origin.
Treatment consists in administration of cod-liver oil, phosphorus and
other tonics. Rest is of service. Locally antiseptic applications, and
support with roller bandage are to be advised.
#Urticaria.#
(_Synonyms:_ Hives; Nettlerash.)
#Give a definition of urticaria.#
Urticaria is an inflammatory affection characterized by evanescent
whitish, pinkish or reddish elevations, or wheals, variable as to size
and shape, and attended by itching, stinging or pricking sensations.
#Describe the symptoms of urticaria.#
The eruption, erythematous in character and consisting of isolated pea
or bean-sized elevations or of linear streaks or irregular patches,
limited or more or less general, and usually intensely itchy, makes its
appearance suddenly, with or without symptoms of preceding gastric
derangement. The lesions are soft or firm, reddish or pinkish-white,
with the peripheral portion of a bright red color, and are fugacious in
character, disappearing and reappearing in the most capricious manner.
In many cases simply drawing the finger over the skin will bring out
irregular and linear wheals. In exceptional cases this peculiar property
is so pronounced and constant that at any time letters and other symbols
may be produced at will, even when such subjects are free from the
ordinary urticarial lesions (_urticaria factitia_, _dermatographism_,
_autographism_).
The mucous membrane of the mouth and throat may also be the seat of
wheals and urticarial swellings.
#What is the ordinary course of urticaria?#
Acute. The disease is usually at an end in several hours or days.
#Does urticaria always pursue an acute course?#
No. In exceptional instances the disease is chronic, in the sense that
new lesions continue to appear and disappear irregularly from time to
time for months or several years, the skin rarely being entirely free
(_chronic urticaria_).
[Illustration: Fig. 12.
Dermatographism. (_After C.N. Davis._)]
#Are subjective symptoms always present in urticaria?#
Yes. Itching is commonly a conspicuous symptom, although at times
pricking, stinging or a feeling of burning constitutes the chief
sensation.
#In what way may the eruption be atypical?#
Exceptionally the wheals, or lesions, are peculiar as to formation, or
another condition or disease may be associated, hence the varieties
known as urticaria papulosa, urticaria haemorrhagica, urticaria tuberosa,
and urticaria bullosa.
#Describe urticaria papulosa.#
Urticaria papulosa (formerly called _lichen urticatus_) is a variety in
which the lesions are small and papular, developing usually out of the
ordinary wheals. They appear as a rule suddenly, rarely in great
numbers, are scattered, and after a few hours or, more commonly, days
gradually disappear. The itching is intense, and in consequence their
apices are excoriated. Sometimes the papules are capped with a small
vesicle (vesicular urticaria). It is seen more particularly in ill-cared
for and badly-nourished young children.
#Describe urticaria haemorrhagica.#
Urticaria haemorrhagica is characterized by lesions similar to ordinary
wheals, except that they are somewhat hemorrhagic, partaking, in fact,
of the nature of both urticaria and purpura.
#Describe urticaria tuberosa.#
In urticaria tuberosa the lesions, instead of being pea- or bean-sized,
as in typical urticaria, are large and node-like (also called _giant
urticaria_).
#What is acute-circumscribed [oe]dema?#
In rare instances there occurs, along with the ordinary lesions of the
disease or as its sole manifestation, sudden and evanescent swelling of
the eyelids, ears, lips, tongue, hands, fingers, or feet (_urticaria
[oe]dematosa_, _acute_ _circumscribed [oe]dema_, _angioneurotic [oe]dema_).
One or several of these parts only may be affected at the one attack; in
recurrences, so usual in this variety, the same or other parts may
exhibit the manifestation.
(These [oe]dematous swellings occurring alone might be looked upon, as
they are by most observers, as an independent affection, but its close
relationship to ordinary urticaria is often evident.)
#Describe urticaria bullosa.#
Urticaria bullosa is a variety in which the inflammatory action has been
sufficiently great to give rise to fluid exudation, the wheals resulting
in the formation of blebs.
#What is the etiology of urticaria?#
Any irritation from disease, functional or organic, of any internal
organ, may give rise to the eruption in those predisposed. Gastric
derangement from indigestible or peculiar articles of food, intestinal
toxins, and the ingestion of certain drugs are often provocative. The
so-called "shell-fish" group of foods play an important etiological part
in some cases. Idiosyncrasy to certain articles of food is also
responsible in occasional instances. Various rheumatic and nervous
disorders are not infrequently associated with it, and are doubtless of
etiological significance. External irritants, also, in predisposed
subjects, are at times responsible.
#What is the pathology of urticaria?#
Anatomically a wheal is seen to be a more or less firm elevation
consisting of a circumscribed or somewhat diffused collection of
semi-fluid material in the upper layers of the skin. The vasomotor
nervous system is probably the main factor in its production; dilatation
following spasm of the vessels results in effusion, and in consequence,
the overfilled vessels of the central portion are emptied by pressure of
the exudation and the central paleness results, while the pressed-back
blood gives rise to the bright red periphery.
#From what diseases is urticaria to be differentiated?#
From erythema simplex, erythema multiforme, erythema nodosum, and
erysipelas.
#Mention the diagnostic points of urticaria.#
The acuteness, character of the lesions, their evanescent nature, the
irregular or general distribution, and the intense itching.
#What is the prognosis in urticaria?#
The acute disease is usually of short duration, disappearing
spontaneously or as the result of treatment, in several hours or days;
it may recur upon exposure to the exciting cause. The prognosis of
chronic urticaria is to be guarded, and will depend upon the ability to
discover and remove or modify the predisposing condition.
#What systemic measures are to be prescribed in acute urticaria?#
Removal of the etiological factor is of first importance. This will be
found in most cases to be gastric disturbance from the ingestion of
improper or indigestible food, and in such cases a saline purgative is
to be given, probably the best for this purpose being the laxative
antacid, magnesia; or if the case is severe and food is still in the
stomach, an emetic, such as mustard or ipecac, will act more promptly.
Alkalies, especially sodium salicylate, and intestinal antiseptics are
useful. Calcium chloride in doses of five to twenty grains should be
tried in obstinate cases. The diet should be, for the time, of a simple
character.
#What systemic measures are to be prescribed in chronic and recurrent
urticaria?#
The cause must be sought for and treatment directed toward its removal
or modification. Treatment will, therefore, depend upon indications. In
obscure cases, quinine, sodium salicylate, arsenic, pilocarpine,
_atropia_, potassium bromide, calcium chloride, and ichthyol are to be
variously tried; general galvanization is at times useful, as is also a
change of scene and climate. A proper dietary and the maintenance of
free action of the bowels, preferably, as a rule, with a saline
laxative, is of great importance in these chronic cases.
In acute circumscribed [oe]dema treatment is essentially that of
urticaria, the diet being given special attention.
#What external applications would you advise for the relief of the
subjective symptoms?#
Cooling lotions of alcohol and water or vinegar and water; lotions of
carbolic acid, one to three drachms to the pint; of thymol, one-fourth
to one drachm to the pint of alcohol and water; of liquor carbonis
detergens, one to three ounces to the pint of water, or the following:--
[Rx] Acidi carbolici, ..................... [dram]j-[dram]iij
Acidi borici, ........................ [dram]iv
Glycerinae, ........................... f[dram]j
Alcoholis, ........................... f[Oz]ij
Aquae, ................................ f[Oz]xiv. M.
Alkaline baths are also useful, and may advantageously be followed by
dusting-powders of starch and zinc oxide.
#Urticaria Pigmentosa.#
(_Synonym:_ Xanthelasmoidea.)
#Describe urticaria pigmentosa.#
Urticaria pigmentosa is a rare disease, variously viewed as an unusual
form of urticaria and as an urticaria-like eruption in which there is an
element of new growth in the lesions. It begins usually in infancy or
early childhood and continues for months or years, and is characterized
by slightly, moderately, or intensely itchy, wheal-like elevations,
which are more or less persistent and leave yellowish, orange-colored,
greenish or brownish stains. Exceptionally subjective symptoms are
almost entirely absent. Anatomical studies show that the lesion has in
some respects the structure of an ordinary wheal, with [oe]dema and
pigment deposit in the epidermal portion, and cellular infiltration made
up principally of mast-cells.
[Illustration: Fig. 13.
Urticaria Pigmentosa.]
The nature of the disease is obscure and treatment unsatisfactory.
Ordinarily as early youth or adult life is reached it spontaneously
disappears. The treatment advised is usually on the same lines as that
of chronic urticaria.
#Dermatitis.#
#What is implied by the term dermatitis?#
Dermatitis, or inflammation of the skin, is a term employed to designate
those cases of cutaneous disturbance, usually acute in character, which
are due to the action of irritants.
#Mention some examples of cutaneous disturbance to which this term is
applied.#
The dermatic inflammation due to the action of excessive heat or cold,
to caustics and other chemical irritants, and to the ingestion of
certain drugs.
#What several varieties are commonly described?#
Dermatitis traumatica, dermatitis calorica, dermatitis venenata, and
dermatitis medicamentosa.
#Describe dermatitis traumatica.#
Under this head are included all forms of cutaneous inflammation due to
traumatism. To the dermatologist the most common met with is that
produced by the various animal parasites and from continued scratching;
in such, if the cause has been long-continued and persistent, a variable
degree of inflammatory thickening of the skin and pigmentation result,
the latter not infrequently being more or less permanent. The
inflammation due to tight-fitting garments, bandages, to constant
pressure (as bed-sores), etc., also illustrates this class.
#What is the treatment of dermatitis traumatica?#
Removal of the cause, and, if necessary, the application of soothing
ointments or lotions; in bed-sores, soap plaster, plain or with one to
five per cent. of ichthyol.
#What is dermatitis calorica?#
Cutaneous inflammation, varying from a slight erythematous to a
gangrenous character, produced by excessive heat (_dermatitis
ambustionis_, _burns_) or cold (_dermatitis congelationis_,
_frostbite_).
#Give the treatment of dermatitis calorica.#
In burns, if of a mild degree, the application of sodium bicarbonate, as
a powder or saturated solution, is useful; in the more severe grade, a
two- to five-per-cent. solution will probably be found of greater
advantage. Other soothing applications may also be employed. In recent
years a one-per-cent. solution of picric acid has been commended for the
slighter burns of limited extent. Upon the whole, there is nothing yet
so generally useful and soothing in these cases as the so-called Carron
oil; in some cases more valuable with 1/2 to 1 minim of carbolic acid
added to each ounce.
In frostbite, seen immediately after exposure, the parts are to be
brought gradually back to a normal temperature, at first by rubbing with
snow or applying cold water. Subsequently, in ordinary chilblains,
stimulating applications, such as oil of turpentine, balsam of Peru,
tincture of iodine, ichthyol, and strongly carbolized ointments are of
most benefit. If the frostbite is of a vesicular, pustular, bullous, or
escharotic character, the treatment consists in the application of
soothing remedies, such as are employed in other like inflammatory
conditions.
#What do you understand by dermatitis venenata?#
All inflammatory conditions of the skin due to contact with deleterious
substances such as caustic, chemical irritants, iodoform, etc., are
included under this head, but the most common causes are the rhus
plants--_poison ivy_ (or _poison oak_) and _poison sumach_ (_poison
dogwood_). Mere proximity to these plants will, in some individuals,
provoke cutaneous disturbance (_rhus poisoning_, _ivy poisoning_),
although they may be handled by others with impunity.
Many other plants are also known to produce cutaneous irritation in
certain subjects; among these may be mentioned the nettle, primrose,
cowhage, smartweed, balm of Gilead, oleander, and rue.
The local action of iodoform (_iodoform dermatitis_) in some individuals
is that of a decided irritant, bringing about a dermatitis, which often
spreads much beyond the parts of application, and which in those
eczematously inclined may result in a veritable and persistent eczema.
#Describe the symptoms of rhus poisoning.#
The symptoms appear usually soon after exposure, and consist of an
inflammatory condition of the skin of an eczematous nature, varying in
degree from an erythematous to a bullous character, and with or without
[oe]dema and swelling. As a rule, marked itching and burning are
present. The face, hands, forearms and genitalia are favorite parts,
although it may in many instances involve a greater portion of the whole
surface.
#What is the course of rhus poisoning?#
It runs an acute course, terminating in recovery in one to six weeks. In
those eczematously inclined, however, it may result in a veritable and
persistent form of that disease.
#How would you treat rhus poisoning?#
By soothing and astringent applications, such as are employed in acute
eczema (_q. v._), which are to be used freely. Among the most valuable
are: a lotion of fluid extract of grindelia robusta, one to two drachms
to four ounces of water; lotio nigra, either alone or followed by the
oxide-of-zinc ointment; a saturated solution of boric acid, with a half
to two drachms of carbolic acid to the pint; a lotion of zinc sulphate,
a half to four grains to the ounce; weak alkaline lotions; cold cream,
petrolatum, and oxide-of-zinc ointments.
#How would you treat the dermatitis due to other deleterious substances
of this class?#
By applications of a soothing and protective character, similar to those
used in eczema and burns.
#Dermatitis Medicamentosa.#
#What do you understand by dermatitis medicamentosa?#
Under this head are included all eruptions due to the ingestion or
absorption of certain drugs.
In rare instances one dose will have such effect; commonly, however, it
results only after several days' or weeks' continued administration.
With some drugs such effect is the rule, with others it is exceptional,
nor are all individuals equally susceptible.
#How is the eruption produced in dermatitis medicamentosa?#
In some instances it is probably due to the elimination of the drug
through the cutaneous structures; in others, to the action of the
drug upon the nervous system. The view that the drug acts as a toxin or
generates some toxin or irritant material in the blood, to which the
eruptive phenomena may be due, has also been advanced.
[Illustration: Dermatitis medicamentosa.
Bullous dermatitis from iodide of potassium.]
#What is the character of the eruption in dermatitis medicamentosa?#
It may be erythematous, papular, urticarial, vesicular, pustular or
bullous, and, if the administration of the drug is continued, even
gangrenous.
#Name the more common drugs having such action.#
Antipyrin, arsenic, atropia (or belladonna), bromides, chloral, copaiba,
cubebs, digitalis, iodides, mercury, opium (or morphia), quinine,
salicylic acid, stramonium, acetanilid, sulphonal, phenacetin,
turpentine, many of the new coal-tar derivatives, etc.
#State frequency and types of eruption due to the ingestion of antipyrin.#
Not uncommon. _Erythematous_, morbilliform and erythemato-papular;
itching is usually present and moderate desquamation may follow.
Acetanilid, sulphonal, phenacetin, and other drugs of this class may
provoke like eruptions.
#Mention frequency and types of eruption due to the ingestion of arsenic.#
Rare. Erythematous, erythemato-papular; exceptionally, herpetic, and
pigmentary. Herpes zoster has been thought to follow its use. Keratosis
of the palms and soles has also been occasionally observed, which, in
rare instances, has developed into epithelioma.
#Mention frequency and types of eruption due to the ingestion of atropia
(or belladonna).#
Not uncommon. _Erythematous_ and _scarlatinoid_; usually no febrile
disturbance, and desquamation seldom follows.
#Give frequency and types of cutaneous disturbance following the
administration of the bromides (bromine).#
Common. _Pustular_, sometimes furuncular and carbuncular and
superficially ulcerative. In exceptional instances papillomatous or
vegetating lesions have been observed. Co-administration of arsenic or
potassium bitartrate is thought to have a preventive influence in some
cases.
#State frequency and types of cutaneous disturbance due to the
administration of chloral.#
Occasional. Scarlatinoid and urticarial, and exceptionally purpuric; in
rare instances, if drug is continued, eruption becomes vesicular,
hemorrhagic, ulcerative and even gangrenous.
#State frequency and types of eruption following the administration of
copaiba.#
Not uncommon. _Urticarial_, erythemato-papular and _scarlatinoid_.
#Mention frequency and types of eruption resulting from the ingestion of
cubebs.#
Uncommon. Erythematous and small papular.
[Illustration: Fig. 14.
A somewhat rare form of eruption from the ingestion of iodine compounds.
(_After J.C. McGuire._)]
#Mention frequency and types of eruption resulting from the
administration of digitalis.#
Exceptional. Scarlatinoid and papular.
#State frequency and types of eruption resulting from the iodides
(iodine).#
Common. _Pustular_, but may be erythematous, papular, vesicular,
bullous, tuberous, purpuric and hemorrhagic. Co-administration of
arsenic or potassium bitartrate is thought to have a preventive
influence in some cases.
#Give the frequency and types of eruption observed to follow the
administration of mercury.#
Exceptional. Erythematous and erysipelatous.
#Give the frequency and types of the cutaneous disturbance following the
ingestion of opium (or morphia).#
Not uncommon. Erythematous and _scarlatinoid_, and sometimes urticarial.
#Mention the frequency and the types of eruption following the
administration of quinine.#
Not infrequent. Usually _erythematous_, but may be urticarial,
erythemato-papular, and even purpuric. There is, in some instances,
preceding or accompanying systemic disturbance. Furfuraceous or lamellar
desquamation often follows.
#State frequency and types of eruption resulting from the ingestion of
salicylic acid.#
Not common. Erythematous and urticarial; exceptionally, vesicular,
pustular, bullous, and ecchymotic.
#Give frequency and type of cutaneous disturbance due to the
administration of stramonium.#
Not common. Erythematous.
#State frequency and types of eruption resulting from the administration
of turpentine.#
Not uncommon. _Erythematous_, and small-papular; exceptionally
vesicular.
#X-Ray Dermatitis.#
#What several grades of x-ray dermatitis (x-ray burns, Rontgen-ray burns)
are observed?#
Three grades are usually described: erythema, superficial vesication,
and necrosis. The first and second may come on shortly--a few hours to
several days--after exposure; occasionally later. The third grade may
present also in the first several days, but in many cases one to several
weeks may elapse before it appears; it is quite commonly preceded by
erythema and vesication. The necrosis may be superficial or deep, and
quite usually results in a persistent ulcer covered by a leathery
coating; it is usually painful.
[Illustration: Fig. 15. _x_-ray burn]
#Give the prognosis and treatment of x-ray dermatitis.#
The first grade--the erythematous--usually disappears in one to ten
days; the second grade requires one to several weeks, and may be quite
sore and tender; the severe or necrotic burns are persistent, sometimes
lasting for months and several years, with little tendency to
spontaneous disappearance, and rebellious to treatment.
Treatment of the milder types is that of erythema (_q. v._); the necrotic
type occasionally demands thorough curetting and skin-grafting before it
will heal.
#Dermatitis Factitia.#
(_Synonym:_ Feigned Eruptions.)
#What do you understand by feigned eruptions?#
Feigned, or artificial, eruptions, occasionally met with in hysterical
females and in others, are produced, for the purpose of exciting
sympathy or of deception, by the action of friction, cantharides, acids
or strong alkalies; the cutaneous disturbance may, therefore, be
erythematous, vesicular, bullous, or gangrenous. It is usually limited
in extent, and, as a rule, seen only on parts easily reached by the
hands.
[Illustration: Fig. 16.
Dermatitis Factitia--note the unusually uniform and regular character
and arrangement of the lesions.]
#Dermatitis Gangraenosa.#
#What do you understand by dermatitis gangraenosa?#
Dermatitis gangraenosa (_erythema gangraenosum_, _Raynaud's disease_,
_spontaneous gangrene_) is an exceedingly rare affection, characterized
by the formation of gangrenous spots and patches. It may be idiopathic
or symptomatic. Some of these cases, especially in hysterical subjects,
belong under the "feigned eruptions," being self-produced.
As an idiopathic disease, it begins as erythematous, dark-red
spots--usually preceded and accompanied by mild or grave systemic
disturbance--which gradually pass into gangrene and sloughing; the
eventual termination may be fatal, or recovery may take place. As a
symptomatic disease, it is occasionally met with in diabetes and in
grave cerebral and spinal affections.
In Raynaud's disease (symmetric gangrene) the parts affected are the
extremities, such as fingers and toes, the ears and nose, only
occasionally other parts. The first symptoms observed are coldness and
paleness of the part; followed sooner or later by congestion of a dark
red, livid, or bluish color, with sometimes swelling, and tenderness and
shooting pains. The termination is usually in gangrene of a dry
character, with, in some instances, vesicles and blebs along the edges;
in other cases the parts become atrophied, withered, and indurated.
Treatment is based upon general principles.
#Erysipelas.#
#What is erysipelas?#
Erysipelas is an acute specific inflammation of the skin and
subcutaneous tissue, commonly of the face, characterized by shining
redness, swelling, [oe]dema, heat, and a tendency in some cases to
vesicle- and bleb-formation, and accompanied by more or less febrile
disturbance.
#Describe the symptoms and course of erysipelas.#
A decided rigor or a feeling of chilliness followed by febrile action
usually ushers in the cutaneous disturbance. The skin at a certain point
or part, commonly where there is a lesion of continuity, becomes bright
red and swollen; this spreads by peripheral extension, and in the course
of several hours involves a portion or the whole region. The parts are
shining red, swollen, of an elevated temperature, and sharply defined
against the sound skin. After several days or a week, during which time
there is usually continued mild or severe febrile action, the process
begins to subside, and is followed by epidermic desquamation.
In some cases vesicles and blebs may be present; in other cases the
disease seriously involves the deeper parts, and is accompanied by grave
constitutional symptoms. In exceptional instances sloughing takes place.
A mild, transitory, limited, and often recurrent erysipelatous condition
of the outlet and immediate neighborhood of one or both nostrils is met
with, taking its origin from an inflammation of the hair-follicles just
inside the margin of the nose; constitutional symptoms are usually
wanting. Somewhat similar, doubtless, is the erysipelatous inflammation
(_erysipeloid_) observed on the fingers and hands of butchers, etc.,
starting from a wound, apparently as a result of infection from putrid
meat or fish.
#What is erysipelas migrans (or erysipelas ambulans)?#
A variety of erysipelas which, after a few hours or days, disappears at
one region and appears at another, and so continues for one or several
weeks.
#What is the cause of erysipelas?#
The disease is due to a specific streptococcus--the streptococcus of
Fehleisen. Depression of the vital forces and local abrasions are
predisposing factors.
#State the diagnostic points.#
The character of the onset, the shining redness and swelling, the
sharply-defined border, and the accompanying febrile disturbance.
#What is the prognosis in erysipelas?#
In most instances the disease runs a favorable course, terminating in
recovery in one to three weeks. Exceptionally, in severe cases, a fatal
termination ensues.
#What is the treatment of erysipelas?#
_Internally_, a purge, followed by the tincture of the chloride of iron
and quinia, and stimulants if needed. _Locally_, one to three per cent.
carbolic-acid lotion or ointment, a saturated solution of boric acid, or
a ten- to twenty-per-cent. aqueous solution or ointment of ichthyol may
be employed.
In some cases the spread of the disease is apparently controlled by
painting the bordering healthy skin with a ring of tincture of iodine or
strong solution of nitrate of silver.
#Phlegmona Diffusa.#
#What do you understand by phlegmona diffusa?#
Phlegmona diffusa is a more or less extensive inflammation of the
cutaneous and subcutaneous tissues presenting symptoms partaking of the
nature of both deep erysipelas and flat carbuncles, and usually attended
with varying constitutional disturbance. Suppuration at several points
takes place, and sloughing may ensue. Recovery usually finally results,
but a fatal issue is possible.
Treatment is based upon general principles.
#Furunculus.#
(_Synonyms:_ Furuncle; Boil.)
#Define furunculus.#
Furunculus, or boil, is an acute, deep-seated, inflammatory,
circumscribed, rounded or more or less acuminated, firm, painful
formation, usually terminating in central suppuration.
#Describe the symptoms and course.#
A boil begins as a small, rounded or imperfectly defined reddish spot,
or as a small, superficial pustule; it increases in size, and when well
advanced appears as a pea or cherry-sized, circumscribed, reddish
elevation, with more or less surrounding hyperaemia and swelling; it is
painful and tender, and ends, in the course of several days or a week,
in the formation of a central slough or "_core_," which finally involves
the central overlying skin (_pointing_). One or several may be present,
gradually maturing and disappearing. Insignificant scarring may remain.
In some cases sympathetic constitutional disturbance is noticed.
#What is a blind boil?#
A sluggish boil exhibiting little, if any, tendency to point or break.
#What is furunculosis?#
Furunculosis is that condition in which boils, singly or in crops,
continue to appear, irregularly, for weeks or months.
#State the etiology of furuncle.#
A depraved state of the general health is often to be considered as a
predisposing factor. Persistent furunculosis is not infrequent in
diabetes mellitus. The immediate exciting cause is the entrance into the
follicle of a microbe, the staphylococcus pyogenes aureus. It is not
improbable, however, that boils may also be due to other pus-producing
organisms.
Workmen in paraffin oils or other petroleum products often present
numerous furuncles and cutaneous abscesses. Conditions favoring a
persistent miliaria have also a causative influence, especially observed
in infants and young children. In these latter, especially among the
poorer classes, sluggish boils or subcutaneous abscesses about the scalp
in hot weather, are not at all infrequent.
#What is the pathology of furuncle?#
A boil is an inflammatory formation having its starting point in a
sebaceous-gland, sweat-gland, or hair-follicle. The core, or central
slough, is composed of pus and of the tissue of the gland in which it
had its origin.
#How would you distinguish a boil from a carbuncle?#
A boil is comparatively small, rounded or acuminate, and has but one
point of suppuration; a carbuncle is large, flattened, intensely
painful, often with grave systemic disturbance, and has, moreover,
several centres of suppuration.
#State the prognosis.#
When occurring in crops (furunculosis) the affection is often
rebellious; recovery, however, finally resulting.
#What is the method of treatment of furunculus?#
If there be but one lesion, with no tendency to the appearance of
others, local treatment alone is usually employed. If, however, several
or more are present, or if there is a tendency to successive
development, both constitutional and local measures are demanded.
#Name the internal remedies employed.#
Such nutrients and tonics as cod-liver oil, malt, quinine, strychnia,
iron and arsenic; in some instances calx sulphurata, one-tenth- to
one-fourth-grain doses every three or four hours has been thought to be
of service. Brewers' yeast has been recently again brought forward as a
remedy of value.
#What is the external treatment?#
Local treatment consists in the beginning, with the hope of aborting the
lesion, of the application of carbolic acid to the central portion, or
the use of a twenty-five-per-cent. ointment of ichthyol applied as a
plaster:--
[Rx] Ichthyol, ............................ [dram]j
Emp. plumbi, ........................... [dram]ij
Emp. resinae, ........................... [dram]j. M.
Or the injection of a five-per-cent. solution of carbolic acid into the
apex of the boil may be tried if the formation is more advanced. If
suppuration is fully established, evacuation of the contents, followed
by antiseptic applications, constitutes the best method.
A saturated solution of boric acid or a lotion of corrosive sublimate
(one to three grains to the ounce) applied to the immediate neighborhood
of the boil or boils tends to prevent the formation of new lesions.
Frequent washing of the parts with soap and water or tincture of green
soap and water is also a preventive measure of value. In repeatedly
infected areas, mild exposures to _x_-rays, at intervals of a few days,
will often prove of curative value.
#Carbunculus.#
(_Synonyms:_ Anthrax; Carbuncle.)
#What is carbuncle?#
A carbuncle is an acute, usually egg to palm-sized, circumscribed,
phlegmonous inflammation of the skin and subcutaneous structures,
terminating in a slough.
#At what age and upon what parts is carbuncle usually observed?#
In middle and advanced life, and more commonly in men.
It is seen most frequently at the nape of the neck and upon the upper
part of the back.
#What are the symptoms and course of carbuncle?#
There is rarely more than one lesion present. It begins, usually with
preceding and accompanying malaise, chilliness and febrile disturbance,
as a firm, flat, inflammatory infiltration in the deeper skin and
subcutaneous tissue, spreading laterally and finally involving an area
of one to several inches in diameter. The infiltration and swelling
increase, the skin becomes of dark red color, and sooner or later,
usually at the end of ten days or two weeks, softening and suppuration
begin to take place, the skin finally giving away at several points,
through which sanious pus exudes; the whole mass finally sloughs away
either in portions or in its entirety, resulting in a deep ulcer, which
slowly heals and leaves a permanent cicatrix.
In some cases, especially in old people, constitutional disturbance of a
grave character is noted, septicaemia is developed, and a fatal result
may ensue.
#What is the cause of carbuncle?#
The same causes are considered to be operative in carbunculus as in
furuncle; general debility and depression, from whatever cause,
predisposing to its formation, and the introduction of a microbe,
probably the same as in furunculus, being at present looked upon as the
exciting factor.
#What is the pathology?#
The inflammation starts simultaneously from numerous points, from the
hair-follicles, sweat-glands or sebaceous glands. The inflammatory
centres break down, and the pus finds its way to the surface; finally
the process ends in gangrene of the whole area.
#How would you distinguish carbuncle from a boil?#
By its flat character, greater size, and multiple points of suppuration.
#What is the prognosis of carbuncle?#
Occurring in those greatly debilitated or in late life, and in those
cases in which two or more lesions exist, or when seated about the head,
the prognosis is always to be guarded, as a fatal result is not
uncommon. In fact, in every instance the disease is to be considered of
possible serious import.
#What constitutional treatment is usually employed in carbuncle?#
A full nutritious diet, the use of such remedies as iron, quinia, nux
vomica, with malt and stimulants, if indicated. Calx sulphurata,
one-tenth to one-fourth grain every two or three hours, appears, in some
instances, to have a beneficial effect. If the pain is severe, morphia
or chloral should be given.
#What external measures are employed?#
In the early part of the formation, injection of a five or ten per cent.
carbolic acid solution, or covering the whole area with a twenty-five
per cent. ichthyol ointment, may be employed. When it has broken down
the pus may be drawn out with a cupping-glass, and carbolized glycerine
or carbolized water introduced into each opening, and the ichthyol
ointment superimposed. If the whole part has sloughed, it should be
removed as rapidly as possible, and antiseptic dressings used. Or, if
its progress is slow, and grave systemic disturbance be present, the
whole part may be incised and curetted, and then treated antiseptically.
Mild exposure to the _x_-rays is also to be commended.
#Pustula Maligna.#
(_Synonyms:_ Anthrax; Malignant Pustule.)
#What is malignant pustule?#
Malignant pustule is a furuncle- or carbuncle-like lesion resulting from
inoculation of the virus generated in animals suffering from splenic
fever, or "charbon," and is accompanied by constitutional symptoms of
more or less gravity. A fatal termination is not unusual.
#What is the cause of pustula maligna?#
The disease is due to the presence of the bacillus anthracis.
#What is the treatment of malignant pustule?#
Early excision or destruction with caustic potash, with subsequent
antiseptic dressings; and internally the free use of stimulants and
tonics.
#Post-mortem Pustule.#
(_Synonym:_ Dissection Wound.)
#Describe post-mortem pustule.#
Post-mortem pustule develops at the point of inoculation, beginning as
an itchy red spot, becoming vesico-pustular, and later pustular, with
usually a broad inflammatory base, and accompanied with more or less
pain and redness and not infrequently lymphangitis, erysipelatous
swelling, and slight or severe sympathetic constitutional disturbance.
#What is the treatment of post-mortem pustule?#
Treatment consists in opening the pustule and thorough cauterization,
and the subsequent use of antiseptic applications or dressings.
_Internally_ quinia and stimulants if indicated.
#Framb[oe]sia.#
(_Synonyms:_ Yaws; Pian.)
#Describe framb[oe]sia.#
Framb[oe]sia is an endemic, contagious disease met with in tropical
countries, characterized by the appearance of variously-sized papules,
tubercles, and tumors, which, when developed, resemble currants and
small raspberries, and finally break down and ulcerate. It is
accompanied by constitutional symptoms of variable severity.
Hygienic measures, good food, tonics, and antiseptic and stimulating
applications are curative.
#Verruga Peruana.#
(_Synonyms:_ Peruvian Warts; Carrion's Disease; Oroya Fever.)
#Describe verruga peruana.#
A specific inoculable affection endemic in some valleys of the Western
Andes, in Peru, and characterized by a prodromal febrile period and
subsequent outbreak of peculiar pin-head- to pea-sized, or larger,
bright reddish, rounded, wart-like elevations. The prodromal symptoms,
of an irregular malarial or typhoid type, with associated rheumatic and
muscular pains, may last for weeks or several months, usually abating
when eruption presents. The lesions may be crowded together in great
bunches. The face and limbs are favorite localities. The disease is
inoculable and thought to be due to a bacillus.
The fatality varies between 10 and 20 per cent. Tonics and stimulants
are prescribed.
#Equinia.#
(_Synonyms:_ Farcy; Glanders.)
#What is equinia, or glanders?#
A rare contagious specific disease of a malignant type, derived from the
horse, and characterized by grave constitutional symptoms, inflammation
of the nasal and respiratory passages, and a deep-seated
papulo-pustular, or tubercular, nodular (_farcy buds_), ulcerative
eruption. A fatal issue is not uncommon. It is due to a micro-organism.
Treatment, both local and constitutional, is based upon general
principles.
#Miliaria.#
(_Synonyms:_ Prickly Heat; Heat Rash; Lichen Tropicus; Red Gum;
Strophulus.)
#What do you understand by miliaria?#
An acute mildly inflammatory disorder of the sweat-glands, characterized
by the appearance of minute, discrete but closely crowded papules,
vesico-papules, and vesicles.
#Describe the symptoms of miliaria.#
The eruption, consisting of pin-point to millet-seed-sized papules,
vesico-papules, vesicles, or a mixture of these lesions, discrete but
usually numerous and closely crowded, appears suddenly, occurring upon a
limited portion of the surface, or, as commonly observed, involving a
greater part or the whole integument. The trunk is a favorite locality.
The papular lesions are pinkish or reddish, and the vesicles whitish or
yellowish, surrounded by inflammatory areola, thus giving the whole
eruption a bright red appearance--_miliaria rubra_. Later, the areolae
fade, the transparent contents of the vesicles become somewhat opaque
and yellowish-white, and the eruption has a whitish or yellowish
cast--_miliaria alba_. In long-continued cases, especially in children,
boils and cutaneous abscesses sometimes develop; and it may also develop
into a true eczema.
Itching, or a feeling of burning, slight or intense, is usually present.
#What is the course of the eruption?#
The vesicles show no disposition to rupture, but dry up in a few days or
a week, disappearing by absorption and with slight subsequent
desquamation; the papular lesions gradually fade away, and the
affection, if the exciting cause has ceased to act, terminates.
#What is the cause of miliaria?#
Excessive heat. Debilitated individuals, especially children, are more
prone to an attack. Being too warmly clad is often causative.
#What is the nature of the disease?#
The affection is considered to be due to sweat-obstruction, with mild
inflammatory symptoms as a cause or consequence, congestion and
exudation taking place about the ducts, giving rise to papules or
vesicles, according to the intensity of the process.
#How would you distinguish miliaria from papular and vesicular eczema,
and from sudamen?#
The papules of eczema are larger, more elevated, firmer, slower in their
evolution, of longer duration, and are markedly itchy.
The vesicles of eczema are usually larger, tend to become confluent, and
also to rupture and become crusted; there is marked itchiness, and the
inflammatory action is usually severe and persistent.
In sudamen there is absence of inflammatory symptoms.
#What is the prognosis of miliaria?#
The affection, under favorable circumstances, disappears in a few days
or weeks. If the cause persists, as for instance, in infants or young
children too warmly clad, it may result in eczema.
#What is the treatment of miliaria?#
Removal of the cause, and in debilitated subjects the administration of
tonics; together with the application of cooling and astringent lotions,
as the following:--
[Rx] Aeidi carbolici, ..................... [dram]ss-[dram]j
Acidi borici, ........................ [dram]iv
Glycerinae, ........................... f[dram]j
Alcoholis, ........................... f[Oz]ij
Aquae, ................................ [Oz]xiv. M.
This is sometimes more efficient if zinc oxide, six to eight drachms, is
added.
Lotions of alcohol and water or vinegar and water, and also the various
lotions used in acute eczema, are often employed with relief.
Dusting-powders of starch, boric acid, lycopodium, talc, and zinc oxide
are also valuable; the following combination is satisfactory:--
[Rx] Pulv. acidi borici,
Pulv. talci veneti,
Pulv. zinci oxidi,
Pulv. amyli, .............[=a][=a].....[dram]ij. M.
Probably the best plan is to use a lotion and a dusting-powder
conjointly; dabbing on the wash freely, allowing it to dry, and then
dusting over with the powder.
#Pompholyx.#
(_Synonyms:_ Dysidrosis; Cheiro-pompholyx.)
#What is pompholyx?#
Pompholyx is a rare disease of the skin of a vesicular and bullous
character, and limited to the hands and feet.
#Describe the symptoms of pompholyx.#
In most instances the hands only are affected. It begins usually with a
feeling of burning, tingling or tenderness of the parts, followed
rapidly by the appearance of deeply-seated vesicles, especially between
the fingers and on the palmar aspect. These beginning lesions look not
unlike sago grains imbedded in the skin. In some instances the disease
does not extend beyond this stage, the vesicles disappearing after a few
days or weeks by absorption, and usually without desquamation.
Ordinarily, however, the lesions increase in size, new ones arise,
become confluent, and blebs result, the skin in places appearing as if
undermined with serous exudation. The parts are commonly inflamed to a
slight or marked degree. The skin comes off in flakes, new lesions may
appear for several days or two or three weeks, and the process then
declines, recovery gradually taking place.
There are no constitutional symptoms, although it is usually noticed
that the general health is below par.
#What is the character of the subjective symptoms in pompholyx?#
The subjective symptoms consist of a feeling of tension, burning and
tenderness, and sometimes itching. Not infrequently, also there is
neuralgic pain.
#What is the cause of pompholyx?#
The eruption is thought to be due to a depressed state of the nervous
system. It is more common in women, and is met with chiefly in adult and
middle life.
#What is the pathology?#
Opinion is divided; some considering it a disease of the sweat-glands
and others an inflammatory disease independent of these structures.
#State the diagnostic features of pompholyx.#
The distribution and the peculiar characters and course of the eruption.
It is to be differentiated from eczema.
#What is the prognosis?#
For the immediate attack, favorable, recovery taking place in several
weeks or a few months. Recurrences at irregular intervals are not
uncommon.
#What is the treatment of pompholyx?#
The general health is to be looked after, and the patient placed under
good hygienic conditions. Remedies of a tonic nature, directed
especially toward improving the state of the nervous system, are to be
prescribed. _Locally_, soothing and anodyne applications, such as
lead-water and laudanum, boric-acid lotion, oxide-of-zinc, boric-acid
and diachylon ointments, are most suitable; or the parts may be
enveloped with the following:--
[Rx] Pulv. ac. salicylici, ................ gr. x
Pulv. ac. borici,
Pulv. amyli, .......... [=a][=a] ..... [dram]ij
Petrolati, ........................... [dram]iv. M.
In fact, the external treatment is similar to that employed in acute
eczema.
#Herpes Simplex.#
(_Synonym:_ Fever Blisters.)
#What is herpes simplex?#
An acute inflammatory disease, characterized by the formation of
pin-head to pea-sized vesicles, arranged in groups, and occurring for
the most part about the face and genitalia.
#Describe the symptoms of herpes simplex.#
In severe cases, malaise and pyrexia may precede the eruption, but
usually it appears without any precursory or constitutional symptoms. A
feeling of heat and burning in the parts is often complained of. The
vesicles, which are commonly pin-head in size, are usually upon a
hyperaemic or inflammatory base, and tend to occur in groups or clusters.
Their contents are usually clear, subsequently becoming more or less
milky or puriform. There is no tendency to spontaneous rupture, but
should they be broken a superficial excoriation results. In a short time
they dry to crusts which soon fall off, leaving no permanent trace.
#Is the eruption in herpes simplex abundant?#
No. As a rule not more than one or two clusters or groups are observed.
#Upon what parts does the eruption occur?#
Usually about the face (_herpes facialis_), and most frequently about
the lips (_herpes labialis_); on the genitalia (_herpes progenitalis_),
the lesions are commonly found on the prepuce (_herpes praeputialis_) in
the male, and on the labia minora and labia majora in the female.
#State the causes of herpes simplex.#
Herpes facialis is often observed in association with colds and febrile
and lung diseases. Malaria, digestive disturbance, and nervous disorders
are not infrequently predisposing factors. Herpes progenitalis is said
to occur more frequently in those who have previously had some venereal
disease, especially gonorrh[oe]a, but this is questionable. It is
probably often purely neurotic.
#What are the diagnostic points?#
The appearance of one or several vesicular groups or clusters about the
face, and especially about the lips, is usually sufficiently
characteristic. The same holds true ordinarily when the eruption is seen
on the prepuce or other parts of the genitalia; it is only when the
vesicles become rubbed or abraded and irritated that it might be
mistaken for a venereal sore, but the history, course and duration will
usually serve to differentiate.
#Give the prognosis.#
The eruption will usually disappear in several days or one or two weeks
without treatment. Remedial applications, however, exert a favorable
influence. Herpes progenitalis exhibits a strong disposition to
recurrence.
#What is the treatment of herpes facialis?#
Anointing the parts with camphorated cold cream, with spirits of camphor
or similar evaporating and stimulating applications will at times afford
relief to the burning, and shorten the course.
#What is the treatment of herpes progenitalis?#
In herpes about the genitalia cleanliness is of first importance. A
saturated solution of boric acid, a dusting-powder of calomel or oxide
of zinc, and the following lotion, containing calamine and oxide of
zinc, are valuable:--
[Rx] Zinci oxidi,
Calaminae, .......... [=a][=a] ........ gr. v
Glycerinae,
Alcoholis, ......... [=a][=a] ........ [minim]vj
Aquae, ................................ [Oz]j M.
In obstinate recurrent cases, frequent applications of a mild galvanic
current will have a favorable influence.
#Hydroa Vacciniforme.#
(_Synonyms:_ Recurrent Summer Eruption; Hydroa Puerorum; Hydroa
Aestivale.)
#Describe hydroa vacciniforme.#
It is a rare vesicular disease usually seen in boys (only two or three
exceptions), occurring upon uncovered parts, especially the nose,
cheeks, and ears. The lesions begin as red spots, discrete or in groups,
rapidly exhibit vesiculation, and later umbilication; the contents
become milky, dry to crusts, which fall off and leave small pit-like
scars. Fresh outbreaks may take place almost continuously, and the
process go on indefinitely, at least up to youth or manhood, when the
tendency subsides. Its activity is usually limited to the warm season.
Arthritic symptoms and general disturbance are sometimes noted in severe
cases.
It is doubtless a vasomotor neurosis. Exposure to sun and wind is an
important, if not essential, etiological factor. Primarily the lesion
begins in the rete middle layers, and is purely vesicular in character;
later, necrosis of the rete and extending deep in the corium is
observed.
Treatment so far has only been palliative, consisting of the
applications employed in similar conditions. Constitutional medication
is based upon general principles. The patient should avoid exposure to
the sun, strong wind and excessive artificial heat.
#Epidermolysis Bullosa.#
#Describe epidermolysis bullosa.#
This is a rare, usually hereditary, disease or condition, characterized
by the formation of vesicles and blebs on any part subjected to slight
rubbing or irritation. No scarring is left, and no pigmentation noted.
The predisposition to these lesions persists indefinitely. The general
health is not involved. The nature of the disease is obscure.
Treatment has no influence in modifying or lessening this tendency. The
vulnerable parts should so far as possible be protected from knocks and
undue friction.
#Dermatitis Repens.#
#What do you understand by dermatitis repens?#
It is a rare spreading dermatitis starting from an injury, extending by
a serous undermining of the epidermis, and usually occurring upon the
upper extremities.
It usually begins shortly after an injury, and, as a rule, presents
itself by redness and serous exudation. The overlying epidermis breaks,
and the area of disease gradually progresses by an extension of the
serous undermining process, the denuded part looking red and raw, with
usually an oozing surface. As the disease spreads the oldest part
becomes dry and heals, the new epidermal covering being thin and
atrophic in appearance. Its most usual beginning is on some part of the
hand, and from here it may spread up the arm and involve considerable
area.
The injury from which it starts may be extremely insignificant,
apparently affording an opening for the introduction of the causative
factor, doubtless parasitic. Beyond a feeling of soreness there seem to
be no special subjective symptoms.
#Give the prognosis and treatment.#
The malady shows but little tendency to spontaneous cure. The frequent
or constant application of a mild antiseptic lotion, such as boric acid
and resorcin, or of a mild parasiticide ointment will generally bring
the disease gradually to an end.
#Herpes Zoster.#
(_Synonyms:_ Zoster; Zona; Shingles.)
#Give a definition of herpes zoster.#
Herpes zoster is an acute, self-limited, inflammatory disease,
characterized by groups of vesicles upon inflammatory bases, situated
over or along a nerve tract.
#Upon what parts of the body may the eruption appear?#
It may appear upon any part, following the course of a nerve; it is
therefore always limited in extent, and confined to one side of the
body. It is probably most common about the intercostal, lumbar and
supra-orbital regions. In rare instances the eruption has been observed
to be bilateral.
#Are there any subjective or constitutional symptoms?#
Yes; there is, as a rule, neuralgic pain preceding, during and following
the eruption; and in some cases, also, there may be in the beginning
mild febrile disturbance. There is also a variable degree of tenderness
and pain.
#What are the characters of the eruption?#
Several or more hyperaemic or inflammatory patches over a nerve course
appear, upon which are seated vesico-papules irregularly grouped; these
vesico-papules become distinct vesicles, of size from a pin-head to a
pea, and soon dry and give rise to thin, yellowish or brownish crusts,
which drop off, leaving in most instances no permanent trace, in others
more or less scarring. In some cases the lesions may become pustular
and, on the other hand, the eruption may be abortive, stopping short of
full vesiculation.
#What is known in regard to the nature of the disease?#
An inflamed and irritable state of the spinal ganglia, nerve tract, or
peripheral branches is directly responsible for the eruption, and this
state may be due to atmospheric changes, cold, nerve-injuries and
similar influences. The view has also been advanced that the disease is
of specific and infectious character.
#Give the chief diagnostic features of herpes zoster.#
The prodromic neuralgic pain, the appearance of grouped vesicles upon
inflammatory bases following the course of a nerve tract, and the
limitation of the eruption to one side of the body.
#What is the prognosis?#
Favorable; the symptoms usually disappearing in two to four weeks. In
some instances, however, the neuralgic pains may be persistent, and in
zoster of the supra-orbital region the eye may suffer permanent damage.
#How would you treat herpes zoster?#
_Constitutional treatment_, usually tonic in character, is to be based
upon general principles; moderate doses of quinia, with one-sixth grain
of zinc phosphide, four or five times daily, appear in some cases to
have a special value. The accompanying neuralgic pain may be so intense
as to require anodynes. _Local treatment_ should be of a soothing and
protective character. A dusting-powder of oxide of zinc and starch (to
the ounce of which twenty to thirty grains of camphor may be added)
proves useful; and over this, in order that the parts be further
protected, a bandage or a layer of cotton batting. Oxide-of-zinc
ointment, and in those cases in which there is much pain, ointments
containing powdered opium or belladonna, or orthoform, may be used. A
mild galvanic current applied daily to the parts is often of great
advantage, both in its influence upon the course of the eruption and
upon the neuralgic pain. The plan, so often advised, of painting the
parts with flexible collodion is not to be commended.
#Dermatitis Herpetiformis.#
(_Synonyms:_ Hydroa Herpetiforme (Tilbury Fox); Herpes Gestationis
(Bulkley); Pemphigus Prurigiuosus; Duhring's Disease.)
#Give a definition of dermatitis herpetiformis.#
Dermatitis herpetiformis is a somewhat rare inflammatory disease,
characterized by an eruption of an erythematous, papular, vesicular,
pustular, bullous or mixed type, with a decided disposition toward
grouping, accompanied by itching and burning sensations, with, as a
rule, more or less consequent pigmentation, and pursuing usually a
chronic course with remissions.
#Describe the erythematous type of dermatitis herpetiformis.#
The character of the eruption in the erythematous type resembles closely
that of erythema multiforme and of urticaria, especially the former. The
efflorescences usually make their appearance in crops, and are more or
less persistent; fading sooner or later, however, and giving place to
new outbreaks. Vesicles are often intermingled, developing from
erythematous and erythemato-papular lesions or arising from apparently
normal skin.
It may continue in the same type, or change to the vesicular, bullous or
other variety.
#Describe the papular type of dermatitis herpetiformis.#
This is rarely seen as consisting purely of papular lesions, but is
commonly associated with the erythematous and vesicular varieties. In a
measure it resembles the papular manifestations of erythema multiforme,
with a distinct disposition toward group formation. The papules tend,
sooner or later, to develop into vesicles, new papular outbreaks
occurring from time to time; or the whole eruption changes to the
vesicular or other type of the disease. It is not a common type.
#Describe the vesicular type of dermatitis herpetiformis.#
This is the common clinical type of the disease, and is characterized by
pin-head to pea-sized, rounded or irregularly-shaped, distended or
flattened and stellate vesicles, occurring, for the most part, in
irregular and segmental groups of three or more lesions, seated either
upon apparently normal integument or upon hyperaemic or inflammatory
skin. They exhibit no tendency to spontaneous rupture, but after
remaining a shorter or longer time, are broken or disappear by
absorption. The lesions tend to appear in crops. It may, as it not
infrequently does, continue in the same type, or it may become more or
less erythematous or bullous in character. In not a few instances
pustules, few or in numbers, are at times intermingled.
#Describe the pustular type of dermatitis herpetiformis.#
This is rare. It is similar in its clinical characters to the vesicular
type, except that the lesions are pustular. It is met with, as a rule,
in association with the vesicular and bullous varieties of the disease.
#Describe the bullous type of dermatitis herpetiformis.#
The bullous expression of the disease is usually of a markedly
inflammatory nature, often innumerable blebs, small and large, appearing
almost continuously, and in some instances involving the greater part of
the surface. The lesions arise from erythematous skin, from preexisting
vesicles or vesicular groups, or from apparently normal integument.
There is a marked disposition to appear in clusters. A change of type to
the erythematous or vesicular varieties is not unusual.
#Describe the mixed type of dermatitis herpetiformis.#
In this type the eruption is made up of erythematous patches, vesicles,
bullae, and often with pustules intermingled, appearing irregularly or in
crops, and with a tendency to patch or group formation.
#Describe the characters of the vesicles, pustules and blebs.#
As a rule, these several lesions, especially the vesicles and blebs, are
somewhat peculiar: they are usually of a strikingly irregular outline,
oblong, stellate, quadrate, and when drying are apt to have a puckered
appearance. They are herpetic in that they show little disposition to
spontaneous rupture, occur in groups, and are usually seated upon
erythematous or inflammatory skin--in some respects similar to the
groups of simple herpes and herpes zoster.
#What is to be said in regard to the subjective symptoms?#
The subjective symptoms are usually the most troublesome feature of the
disease, consisting of intense and persistent itching and a feeling of
heat and burning.
#Are there any constitutional symptoms in dermatitis herpetiformis?#
As a rule, not, excepting the distress and depression necessarily
consequent upon the intense itchiness and loss of sleep. In the pustular
and bullous varieties there may be mild or grave systemic symptoms, but
even in these types the constitutional involvement is, in most
instances, slight in comparison to the intensity of the cutaneous
disturbance.
#What is the course of dermatitis herpetiformis?#
Extremely chronic, in most instances lasting, with remissions,
indefinitely. The skin is rarely entirely free. From time to time the
type of the disease may undergo change. From the continued irritation
and scratching more or less pigmentation results.
#What is to be said in regard to the etiology?#
The disease is in many instances essentially neurotic, and in
exceptional instances septicaemic. Pregnancy and the parturient state are
factors in some instances (so-called herpes gestationis). It is possible
in some instances that the eruption may be an expression of a mild
toxemia of gastro-intestinal origin. In some cases no cause can be
assigned. In the majority of patients the general health, considering
the violence of the eruptive phenomena, remains comparatively
undisturbed.
Nervous shock and mental worry are factors in some cases. Polyuria,
with sugar in the urine, has occasionally been noted. Eosinophile
cells have been found both in the vesicles and the blood. In some
instances--exceptionally, it is true--the disease has appeared shortly
after vaccination.
#Mention the diagnostic features of dermatitis herpetiformis.#
The multiformity of the eruption, the characters of the lesions, the
disposition to grouping, the absence of tendency to form solid sheets of
eruption (as in eczema), the intense itching, history, chronicity and
course. In doubtful cases, an observation of several weeks will always
suffice to distinguish it from eczema, erythema multiforme, herpes iris
and pemphigus, diseases to which it at times bears strong resemblance.
#Give the prognosis of dermatitis herpetiformis.#
An opinion as to the outcome of the disease should be guarded. It is
exceedingly rebellious to treatment, and relapses are the rule.
Exceptionally the bullous and pustular varieties prove eventually fatal.
The erythematous and vesicular varieties are the most favorable.
#State the treatment to be advised.#
There are no special remedies. Constitutional treatment must be
conducted upon general principles. A free action of the bowels is to be
maintained. In occasional instances arsenic in progressive doses seems
of value. Externally protective and antipruritic applications, such as
are employed in the treatment of eczema and pemphigus, are to be
employed:--
[Rx] Ac. carbolici, ....................... [dram]j-[dram]ij
Thymol, .............................. gr. xvj.
Glycerinae, ........................... [Oz]ss-[Oz]j
Alcoholis, ........................... f[Oz]ij
Aquae, q.s., ......... ad ............. Oj. M.
Other valuable applications are: lotions of carbolic acid, of liquor
carbonis detergens, of boric acid; alkaline baths, mild sulphur ointment
and carbolized oxide-of-zinc ointment, and dusting-powders of starch,
zinc oxide, talc and boric acid. A two- to ten-per-cent. ichthyol lotion
or ointment is sometimes of advantage; thiol employed in the same manner
has also been commended.
#Psoriasis.#
#Give a definition of psoriasis.#
Psoriasis is a chronic, inflammatory disease, characterized by dry,
reddish, variously-sized, rounded, sharply-defined, more or less
infiltrated, scaly patches.
[Illustration: Psoriasis.]
#At what age does psoriasis usually first make its appearance?#
Most commonly between the ages of fifteen and thirty. It is rarely seen
before the tenth year, and a first attack is uncommon after the age of
forty.
#Has psoriasis any special parts of predilection?#
The extensor surfaces of the limbs, especially the elbows and knees, are
favorite localities, and even when the eruption is more or less general,
these regions are usually most conspicuously involved. The face often
escapes, and the palms and soles, likewise the nails, are rarely
involved. In exceptional instances, the eruption is limited almost
exclusively to the scalp.
#Are there any constitutional or subjective symptoms in psoriasis?#
There is no systemic disturbance; but a variable amount of itching may
be present, although, as a rule, it is not a troublesome symptom.
#Describe the clinical appearances of a typical, well developed case.#
Twenty or a hundred or more lesions, varying in size from a pin-head to
a silver dollar, are usually present. They are sharply defined against
the sound skin, are reddish, slightly elevated and infiltrated, and more
or less abundantly covered with whitish, grayish or mother-of-pearl
colored scales. The patches are usually scattered over the general
surface, but are frequently more numerous on the extensor surfaces of
the arms and legs, especially about the elbows and knees. Several
closely-lying lesions may coalesce and a large, irregular patch be
formed; some of the patches, also, may be more or less circinate, the
central portion having, in a measure or completely, disappeared.
#Give the development and history of a single lesion.#
Every single patch of psoriasis begins as a pin-point or pin-head-sized,
hyperaemic, scaly, slightly-elevated lesion; it increases gradually, and
in the course of several days or weeks usually reaches the size of a
dime or larger, and then may remain stationary; or involution begins to
take place, usually by a disappearance, partially or completely, of the
central portion, and finally of the whole patch.
#Describe the so-called clinical varieties of psoriasis.#
As clinically met with, the patches present are, as a rule, in all
stages of development. In some instances, however, the lesions, or the
most of them, progress no further than pin-head in size, and then remain
stationary, constituting _psoriasis punctata_; in other cases, they
may stop short after having reached the size of drops--_psoriasis
guttata_; in others (and this is the usual clinical type) the patches
develop to the size of coins--_psoriasis nummularis_. In some cases
there is a strong tendency for the central part of the lesions to
disappear, and the process then remain stationary, the patches being
ring-shaped--_psoriasis circinata_; and occasionally several such rings
coalesce, the coalescing portions disappearing and the eruption be more
or less serpentine--_psoriasis gyrata_. Or, in other instances, several
large contiguous lesions may coalesce and a diffused, infiltrated patch
covering considerable surface results--_psoriasis diffusa, psoriasis
inveterata_.
[Illustration: Fig. 17. Psoriasis.]
#Is the eruption of psoriasis always dry?#
Yes.
#What course does psoriasis pursue?#
As a rule, eminently chronic. Patches may remain almost indefinitely, or
may gradually disappear and new lesions appear elsewhere, and so the
disease may continue for months and, sometimes, for years; or, after
continuing for a longer or shorter period, may subside and the skin
remain free for several months or one or two years, and, in rare
instances, may never return.
[Illustration: Fig. 18. Psoriasis.]
#Is the course of psoriasis influenced by the seasons?#
As a rule, yes; there is a natural tendency for the disease to become
less active or to disappear altogether during the warm months.
#What is known in regard to the etiology of psoriasis?#
The causes of the disease are always more or less obscure. There is
often a hereditary tendency, and the gouty and rheumatic diathesis must
occasionally be considered potential. In some instances it is apparently
influenced by the state of the general health. It is a rather common
disease and is met with in all walks of life.
#Is psoriasis contagious?#
No. In recent years the fact of its exhibiting a family tendency has
been thought as much suggestive of contagiousness as of heredity.
#What is the pathology?#
According to modern investigations, it is an inflammation induced by
hyperplasia of the rete mucosum; and it is beginning to be believed that
this hyperplasia may have a parasitic factor as the starting-cause.
#With what diseases are you likely to confound psoriasis?#
Chiefly with squamous eczema and the papulo-squamous syphiloderm; and on
the scalp, also with seborrh[oe]a. It can scarcely be confounded with
ringworm.
#How is psoriasis to be distinguished from squamous eczema?#
By the sharply-defined, circumscribed, scattered, scaly patches, and by
the history and course of the individual lesions.
#In what respects does the papulo-squamous syphiloderm differ from
psoriasis?#
The scales of the squamous syphilide are usually dirty gray in color and
more or less scanty; the patches are coppery in hue, and usually several
or more characteristic scaleless, infiltrated papules are to be found.
The face, palms, and soles are often the seat of the syphilitic
eruption; and, moreover, _concomitant symptoms of syphilis_, such as
sore throat, mucous patches, glandular enlargement, rheumatic pains,
falling out of the hair, together with the history of the initial
lesion, are one, several, or all usually present.
#How does seborrh[oe]a differ from psoriasis?#
Seborrh[oe]a of the scalp is usually diffused, with but little redness
and no infiltration; moreover, the scales of seborrh[oe]a are greasy,
dirty gray or brownish, while those of psoriasis are dry and comonly
whitish or mother-of-pearl colored. Psoriasis of the scalp rarely exists
independently of other patches elsewhere on the general surface.
That variety of seborrh[oe]a, commonly known as eczema seborrhoicum,
presents at times, both on scalp and general surface, a strong
resemblance to psoriasis, but the character of the scales and
distribution of psoriasis, as above stated, are distinguishing points;
seborrh[oe]a, moreover, favors hairy surfaces and in extensive examples
the scalp, eyebrows, sternal, and pubic regions rarely escape.
#How does psoriasis differ from ringworm?#
By its greater scaliness, by its higher degree of inflammatory action,
and by its larger number of patches, as also by its history. In ringworm
_all_ the patches tend to clear up in the centre; in psoriasis this is
rarely, if ever, so. If there is still any doubt, microscopic
examination of the scrapings will determine.
#Give the prognosis of psoriasis.#
The prognosis is usually favorable, so far as concerns the immediate
eruption, but as to recurrences, nothing positive can be stated. In rare
instances, however, the cure remains permanent.
#How is psoriasis treated?#
Both constitutional and local remedies are demanded in most cases.
#Do dietary measures exert any influence?#
As a rule, no; but the food should be plain, and an excess of meat
avoided.
#Name the important constitutional remedies usually employed in
psoriasis.#
_Arsenic_ is of first importance. It is not suitable in acute or
markedly inflammatory types; but is most useful in the sluggish, chronic
forms of the disease. The dose should never be pushed beyond slight
physiological action. It may be given as arsenious acid in pill form,
one-fiftieth to one-tenth of a grain three times daily, or as Fowler's
solution, three to ten minims at a dose.
_Alkalies_, of which liquor potassae is the most eligible. It is to be
given in ten to twenty minim doses, largely diluted. It is valuable in
robust, plethoric, rheumatic or gouty individuals with psoriasis of an
acute or markedly inflammatory type; it is not to be given to
debilitated or anaemic subjects.
_Salicin_, sodium salicylate, and salophen in moderately full doses act
well in some cases. Occasionally thyroid preparations have a good
effect.
_Potassium Iodide_, in doses of thirty to one hundred grains, t.d., acts
favorably in some instances; there are no special indications pointing
toward its selection, unless it be the existence of a gouty or rheumatic
diathesis.
Oil of copaiba, potassium acetate, oil of turpentine, oil of juniper,
and other diuretics are valuable in some instances, and, while often
failing, sometimes exert a rapid influence, especially in those cases in
which the disease is extensive and inflammatory. Wine of antimony, given
cautiously, is also sometimes of service in the acute inflammatory type
in robust subjects.
#Are such remedies as iron, quinine, nux vomica and cod-liver oil ever
useful in psoriasis?#
Yes. In debilitated subjects the administration of such remedies is at
times attended with improvement in the cutaneous eruption.
#What are the indications as regards the external measures?#
Removal of the scales, and the use of soothing or stimulating
applications, according to the individual case.
#How are the scales removed?#
In ordinary cases, either by warm, plain, or alkaline baths, or
hot-water-and-soap washings; in those cases in which the scaling is
abundant and adherent, washing with sapo viridis and hot water may be
required. Baths of sal ammoniac, two to six ounces to the bath are also
valuable in removing the scaliness. The tincture of green soap (tinctura
saponis viridis) is especially valuable for cleansing purposes in
psoriasis of the scalp. The hot vapor bath once or twice weekly is
serviceable in keeping the scaliness in abeyance, and has, moreover, in
some cases, a therapeutic value.
The frequency of the baths or washings will depend upon the rapidity
with which the scales are reproduced.
#Are soothing applications often demanded in psoriasis?#
In exceptional cases; in those in which the disease is acute, markedly
inflammatory and rapidly progressing, mild, soothing applications must
be temporarily employed, such as plain or bran baths, with the use of
some bland oil or ointment. As a rule, however, the conditions, when
coming under observation, are such as to permit of stimulating
applications from the start. The most efficient soothing applications
are the mild lotions and ointments employed in eczema of acute type.
#How are the stimulating remedies employed in psoriasis applied?#
As ointments, oils, and paints (pigmenta).
An ointment, if employed, is to be thoroughly rubbed in the diseased
areas once or twice daily. The same may be said of the oily
applications. The paints (medicated collodion and gutta-percha solution)
are applied with a brush, once daily, or every second or third day,
depending mainly upon the length of time the film remains intact and
adherent.
#Name the several important external remedies.#
Chrysarobin, pyrogallol, tar, ammoniated mercury, [beta]-naphthol,
and resorcin.
#Are these several external remedies equally serviceable in all cases?#
No. Their action differs slightly or greatly according to the case and
individual. A change from one to another is often necessary.
#In what forms and strength are these remedies to be applied?#
_Chrysarobin_ is applied in several ways: as an ointment, twenty to
sixty grains to the ounce, rubbed in once or twice daily; this is the
most rapid but least cleanly and eligible method. As a pigment, or
paint, as in the following:--
[Rx] Chrysarobini, ........................ [dram]j
Acidi salicylici, .................... gr. xx
Etheris, ............................. f[dram]j
Ol. ricini, .......................... [minim]x
Collodii, ............................ f[dram]vij. M.
Or it may be used in liquor gutta-perchae (traumaticin), a drachm to the
ounce. It may also be employed in chloroform, a drachm to the ounce; this
is painted on, the chloroform evaporating, leaving a thin film of
chrysarobin; over this is painted flexible collodion. If the patches are
few and large, chrysarobin rubber-plaster may be used.
Chrysarobin is usually rapid in its effect, but it has certain
disadvantages; it may cause an inflammation of the surrounding skin,
and, if used near the eyes, may give rise to conjunctivitis. As a rule,
it should not be employed about the head. Moreover, it stains the linen
permanently and the skin temporarily.
_Pyrogallol_ is valuable, and is employed in the same manner and
strength as chrysarobin. In collodion it should at first not be used of
greater strength than three to four per cent., as in this form
pyrogallol sometimes acts with unexpected energy. It is less rapid than
chrysarobin, but it rarely inflames the surrounding integument. It
stains the linen a light brown, however, and is not to be used over an
extensive surface for fear of absorption and toxic effect. Oxidized
pyrogallic acid, a somewhat milder drug in its effect, has been highly
commended, and has the alleged advantage of being free from toxic
action.
_Tar_ is, all things considered, the most important external remedy. It
is comparatively slow in its action, but is useful in almost all cases.
As employed usually it is prescribed in ointment form, either as the
official tar ointment, full strength or weakened with lard or
petrolatum. It may also be used as pix liquida, with equal part of
alcohol. Or the tar oils, oil of cade (ol. cadini), and oil of birch
(ol. rusci) may be employed, either as oily applications or incorporated
with ointment or with alcohol. Liquor carbonis detergens, in ointment,
one to three drachms to the ounce of simple cerate and lanolin is a mild
tarry application which is often useful. In stubborn patches an
occasional thorough rubbing with a mixture of equal parts of liquor
carbonis detergens and Vleminckx's solution, followed by a mild
ointment, sometimes proves of value. In whatsoever form tar is employed
it should be thoroughly rubbed in, once or twice daily, the excess wiped
off, and the parts then dusted with starch or similar powder.
_Ammoniated mercury_ is applied in ointment form, twenty to sixty grains
to the ounce. Compared to other remedies it is clean and free from
staining, although, as a rule, not so uniformly efficacious. It is
especially useful for application to the scalp and exposed parts. It
should not be used over extensive surface for fear of absorption.
_[beta]-Naphthol_ and _resorcin_ are applied as ointments, thirty to
sixty grains to the ounce, and as they are (especially the former)
practically free from staining, may be used for exposed surfaces.
Gallacetophenone and aristol also act well in some cases, applied in
five- to ten-per-cent. strength, as ointments.
In obstinate patches the _x_-ray may be resorted to, employing it with
caution and in the same manner as in other diseases.
#Pityriasis Rosea.#
(_Synonym:_ Pityriasis Maculata et Circinata.)
#What do you understand by pityriasis rosea?#
Pityriasis rosea is a disease of a mildly inflammatory nature,
characterized by discrete, and later frequently confluent, variously
sized, slightly raised scaly macules of a pinkish to rosy-red, often
salmon-tinged, color.
#Upon what part of the body is the eruption usually found?#
The trunk is the chief seat of the eruption, although not infrequently
it is more or less general.
#Describe the symptoms of pityriasis rosea.#
The lesions, which appear rapidly or slowly, are but slightly elevated,
somewhat scaly, usually rounded, except when several coalesce, when an
irregularly outlined patch results. At first they are pale or bright
pink or reddish, later a salmon tint (which is often characteristic) is
noticed. The scaliness is bran-like or flaky, of a dirty gray color,
and, as a rule, less marked in the central portion; it is never
abundant. The skin is rarely thickened, the process being usually
exceedingly superficial.
#What course does pityriasis rosea pursue?#
The eruption makes its appearance, as a rule, somewhat rapidly, usually
attaining its full development in the course of one or two weeks, and
then begins gradually to decline, the whole process occupying one or two
months.
#To what is pityriasis rosea to be attributed?#
The cause is not known; it is variously considered as allied to
seborrh[oe]a (eczema seborrhoicum), as being of a vegetable-parasitic
origin, and as a mildly inflammatory affection somewhat similar to
psoriasis. It is not a frequent disease.
#How is pityriasis rosea distinguished from ringworm, psoriasis and the
squamous syphiloderm?#
From ringworm, by its rapid appearance, its distribution, the number of
patches, and, if necessary, by microscopic examination of the scrapings.
Psoriasis is a more inflammatory disease, is seen usually more
abundantly upon the limbs, the scales are profuse and silvery, and the
underlying skin is red and has a glazed look; moreover, psoriasis, as a
rule, appears slowly and runs a chronic course.
The squamous syphiloderm differs in its history, distribution, and above
all, by the presence of concomitant symptoms of syphilis, such as
glandular enlargement, sore throat, mucous patches, rheumatic pains, and
falling out of the hair.
#State the prognosis of pityriasis rosea.#
It is favorable, the disease tending to spontaneous disappearance,
usually in the course of several weeks or one or two months.
#What treatment is to be advised in pityriasis rosea?#
Laxatives and intestinal antiseptics, and ointments of salicylic acid
(5-15 grains to the ounce), of sulphur (10-40 grains to the ounce); or a
compound ointment containing both these ingredients can be prescribed.
The ointment base can be equal parts of white vaselin and cold cream; in
some instances Lassar's paste (starch powder, zinc oxid powder, each,
[dram]ij; vaselin, [dram]iv) seems more satisfactory.
#Dermatitis Exfoliativa.#
(_Synonyms:_ General Exfoliative Dermatitis; Recurrent Exfoliative
Dermatitis; Desquamative Scarlatiniform Erythema; Acute General
Dermatitis; Recurrent Exfoliative Erythema; Pityriasis Rubra.)
#Describe dermatitis exfoliativa.#
Dermatitis exfoliativa is an inflammatory disease of an acute type,
characterized by a more or less general erythematous inflammation, in
exceptional instances vesicular or bullous, with epidermic desquamation
or exfoliation accompanying or following its development. Constitutional
disturbance, which may be of a serious character, is sometimes present.
It is a rare and obscure affection, running its course usually in
several weeks or months, but exhibiting a decided tendency to relapse
and recurrence. In many cases it is persistently chronic, with
exacerbations and remissions. In some instances it develops from a
long-continued and more or less generalized eczema or psoriasis, and in
exceptional cases it is started by the careless use of mercurial
ointment and of chrysarobin ointment.
[Illustration: Fig. 19. Dermatitis Exfoliativa.]
In another type of the disease, formerly described as _pityriasis
rubra_, the skin is pale red or violaceous-red, but is rarely thickened,
continued exfoliation in the form of thin plates taking place. Its
course is variable, lasting for years, with remissions.
An exfoliating generalized dermatitis is exceptionally observed in the
first weeks of life (_dermatitis exfoliativa neonatorum_), lasting some
weeks, and in most cases followed by recovery. There are no special
constitutional symptoms, the fatal cases usually dying of marasmus.
As will be seen dermatitis exfoliativa varies considerably in degree; it
may be extremely mild, resembling in appearance the scarlet-fever
eruption (erythema scarlatiniforme) and running a rapid course; or the
skin-condition and the systemic symptoms may be of grave and persistent
character.
#Give the treatment of dermatitis exfoliativa.#
General treatment is based upon indications, and externally soothing
applications, such as are employed in acute and subacute eczema, are to
be used.
#Lichen Planus.#
#What is lichen planus?#
Lichen planus is an inflammatory disease characterized by small, flat
and angular, smooth and shining, or scaly, discrete or confluent, red or
violaceous-red papules, having a distinctly papular or papulo-squamous
course, and attended with more or less itching.
#Describe the symptoms of lichen planus.#
The eruption, as a rule, begins slowly, usually showing itself upon the
extremities; the forearms, wrists and legs being favorite localities. It
may appear as one or more groups or in the form of short or long bands.
Occasionally its evolution is rapid and a considerable part of the
surface may be invaded. The lesions are pin-head to small pea-sized,
irregularly grouped or so closely crowded together as to form solid
patches; they are quadrangular or polygonal in shape, usually flat, with
central depression or umbilication, and are reddish or violaceous in
color. At first they have a glazed or shining appearance; later,
becoming slightly scaly, the scaliness being more marked where solid
patches have resulted. New papules may appear from time to time, the
older lesions disappearing and leaving persistent reddish or brownish
pigmentation. Exceptionally the eruption presents in bands or lines,
like rows of beads (_lichen moniliformis_). Very exceptionally a
vesicular or bleb tendency in some of the lesions has been noted;
doubtless, in most instances at least, this has been due to the arsenic
so generally administered in this disease. In rare instances lichen
planus lesions are also seen on the glans penis and on the buccal mucous
membrane. In some cases, especially in the region of the ankle, the
papules become quite large (_lichen planus hypertrophicus_), and in
occasional cases there is a tendency in some of the lesions or patches
to clear up centrally. There is, as a rule, considerable itching. There
are no constitutional symptoms.
#What is the etiology of lichen planus?#
In some cases the disease is distinctly neurotic in character, in others
no cause can be assigned. It is more especially met with at middle age,
and among the wealthier, professional, and luxurious classes.
Pathologically the first change noted in the epidermis is thought to be
an acanthosis, followed by epithelial atrophy, and a hyperkeratosis,
intercellular edema, and colloid degeneration of the prickle cells.
#Does the disease bear any resemblance to the miliary papular syphilide,
psoriasis, and papular eczema?#
In some instances it does, but the irregular and angular outline, the
slightly-umbilicated, flattened, smooth or scaly summits, and the
dull-red or violaceous color, the history and course, of lichen planus,
will serve to differentiate.
#State the prognosis.#
Under proper management the eruption, although often obstinate, yields
to treatment.
#What treatment would you prescribe in lichen planus?#
A general tonic plan of medication is indicated in most cases, with such
remedies as iron, quinine, nux vomica, and cod-liver oil and other
nutrients. In many instances arsenic exerts a special influence, and
should always be tried. Mercurials in moderate dosage have also a
favorable action in most cases. Locally, antipruritic and stimulating
applications, such as are used in the treatment of eczema, are to be
employed, alkaline baths and tarry applications deserving special
mention. Liquor carbonis detergens, applied weakened with several parts
water, is a valuable application. In some cases, particularly if the
disease is limited, external applications alone often suffice to bring
about a cure.
#Pityriasis Rubra Pilaris.#
(_Synonyms:_ Lichen Ruber; Lichen Ruber Acuminatus.)
#Describe pityriasis rubra pilaris.#
Pityriasis rubra pilaris is an extremely rare disease, usually of a
mildly inflammatory nature, characterized by grayish, pale-red or
reddish-brown follicular papules with somewhat hard or horny centres;
discrete and confluent, and covering a part or the entire surface. The
skin is harsh, dry and rough, feeling to the touch somewhat like the
surface of a nutmeg-grater or a coarse file. More or less scaliness is
usually present in the confluent patches and on the palms and soles; in
these latter regions the papules are rarely seen. The duration of the
disease is variable, and relapses are common. It bears resemblance at
times to keratosis pilaris, ichthyosis, dermatitis exfoliativa; it is
considered identical with the lichen ruber acuminatus of Kaposi, and by
many also with the lichen ruber of Hebra. The etiology is obscure.
Treatment, both constitutional and local, is to be based upon general
principles; stimulating applications, with frequent baths, such as are
advised in psoriasis, are the most satisfactory. It is rebellious, and
not much more than palliation can be effected in some cases, in others
the outlook is more hopeful.
#Lichen Scrofulosus.#
#Describe lichen scrofulosus.#
Lichen scrofulosus is a chronic, inflammatory disease, characterized by
millet-seed-sized, rounded or flat, reddish or yellowish, more or less
grouped, desquamating papules. The lesions have their start about the
hair-follicles, occur usually upon the trunk, tend to group and form
patches, and sooner or later become covered with minute scales. As a
rule, there is no itching. It is a rare disease, and but seldom met with
in America; it is seen chiefly in children and young people of a
scrofulous diathesis. Scarring, slight in character, may or may not
follow.
#What is the treatment of lichen scrofulosus?#
The condition responds to tonics and anti-strumous remedies.
#Eczema.#
(_Synonym:_ Tetter; Salt Rheum.)
#What is eczema?#
An acute, subacute or chronic inflammatory disease, characterized in the
beginning by the appearance of erythema, papules, vesicles or pustules,
or a combination of these lesions, with a variable amount of
infiltration and thickening, terminating either in discharge with the
formation of crusts, in absorption, or in desquamation, and accompanied
by more or less intense itching and a feeling of heat or burning.
#What are the several primary types of eczema?#
Erythematous, papular, vesicular and pustular; all cases begin as one or
more of these types, but not infrequently lose these characters and
develop into the common clinical or secondary types--eczema rubrum and
eczema squamosum.
[Illustration: Fig. 20. Papular Eczema (leg).]
#What other types are met with clinically?#
Eczema rubrum, eczema squamosum, eczema fissum, eczema sclerosum and
eczema verrucosum. Eczema seborrhoicum is probably a closely allied
disease, occupying a middle position between ordinary eczema and
seborrh[oe]a.
#Describe the symptoms of erythematous eczema.#
Erythematous eczema (_eczema erythematosum_) begins as one or more small
or large, irregularly outlined hyperaemic macules or patches, with or
without slight or marked swelling, and with more or less itching or
burning. At first it may be ill-defined, but it tends to spread and its
features to become more pronounced. It may be limited to a certain
region, or it may be more or less general. When fully developed, the
skin is harsh and dry, of a mottled, reddish or violaceous color,
thickened, infiltrated and usually slightly scaly, with, at times, a
tendency toward the formation of oozing areas. Punctate and linear
scratch-marks may usually be seen scattered over the affected region.
[Illustration: Fig. 21. Eczema Rubrum.]
Its most common site is the face, but it is not infrequent upon other
parts.
#What course does erythematous eczema pursue?#
It tends to chronicity, continuing as the erythematous form, or the skin
may become considerably thickened and markedly scaly, constituting
eczema squamosum; or a moist oozing surface, with more or less crusting,
may take its place--eczema rubrum.
#Describe the symptoms of papular eczema.#
Papular eczema (_eczema papulosum_) is characterized by the appearance,
usually in numbers, of discrete, aggregated or closely-crowded, reddish,
pin-head-sized acuminated or rounded papules. Vesicles and
vesico-papules are often intermingled. The itching is commonly intense,
as often attested by the presence of scratch-marks and blood crusts.
[Illustration: Fig. 22. Eczema Squamosum et tissum.]
It is seen most frequently upon the extremities, especially the flexor
surfaces.
#What course does papular eczema pursue?#
The lesions tend, sooner or later, to disappear, but are usually
replaced by others, the disease thus persisting for weeks or months; in
places where closely crowded, a solid, thickened, scaly sheet of
eruption may result--eczema squamosum.
#Describe the symptoms of vesicular eczema.#
Vesicular eczema (_Eczema vesiculosum_) usually appears, on one or
several regions, as more or less diffused inflammatory reddened patches,
upon which rapidly develop numerous closely-crowded pin-point to
pin-head-sized vesicles, which tend to become confluent and form a solid
sheet of eruption. The vesicles soon mature and rupture, the discharge
drying to yellowish, honeycomb-like crusts. The oozing is usually more
or less continuous, or the disease may decline, the crusts be cast off,
to be quickly followed by a new crop of vesicles. In those cases in
which the process is markedly acute, considerable swelling and [oe]dema
are present. Scattered papules, vesico-papules and pustules may usually
be seen upon the involved area or about the border.
The face in infants (_crusta lactea_, or _milk crust_, of older
writers), the neck, flexor surfaces and the fingers are its favorite
localities.
#What course does vesicular eczema pursue?#
Usually chronic, with acute exacerbations. Not infrequently it passes
into eczema rubrum.
#Describe the symptoms of pustular eczema.#
Pustular eczema (_eczema pustulosum_, _eczema impetiginosum_) is probably
the least common of all the varieties. It is similar, although usually
less actively inflammatory, in its symptoms to eczema vesiculosum, the
lesions being pustular from the start or developing from preexisting
vesicles; not infrequently the eruption is mixed, the pustules
predominating. There is a marked tendency to rupturing of the lesions,
the discharge drying to thick, yellowish, brownish or greenish crusts.
Its most common sites are the scalp and face, especially in young people
and in those who are ill-nourished and strumous.
#What course does pustular eczema pursue?#
Usually chronic, continuing as the same type, or passing into eczema
rubrum.
#Describe the symptoms of squamous eczema.#
Squamous eczema (_eczema squamosum_) may be defined as a clinical
variety, the chief symptoms of which are a variable degree of scaliness,
more or less thickening, infiltration, and redness, with commonly a
tendency to cracking or fissuring of the skin, especially when the
disease is seated about the joints. It is developed, as a rule, from the
erythematous or papular type. Itching is slight or intense.
The disease is not uncommon upon the scalp.
#What is the course of squamous eczema?#
Essentially chronic.
[Illustration: Fig. 23. Eczema of the Face and Scalp.]
#Describe the symptoms of eczema rubrum.#
Eczema rubrum is characterized by a red, raw-looking, weeping, oozing or
discharging surface, attended with more or less inflammatory thickening,
infiltration and swelling; the exudation, consisting of serum, sometimes
bloody, dries into thick yellowish or reddish-brown crusts. At one time
the whole diseased area may be hidden under a mass of crusting, at other
times a red, raw-looking, weeping surface (_eczema madidans_) is the
most striking feature. Itching is slight or intense, or the subjective
symptom may be a feeling of burning. It is an important clinical type,
usually developing from the vesicular, pustular or other primary
variety.
It is common about the face and scalp in children, and the middle and
lower part of the leg in elderly people.
#What is the course of eczema rubrum?#
Chronic, varying in intensity from time to time.
#Describe the symptoms of fissured eczema.#
The conspicuous symptom is a marked tendency to fissuring or cracking of
the skin (_eczema fissum_; _eczema rimosum_). This tendency is usually a
part of an erythematous or squamous eczema, the fissuring constituting
the most conspicuous and troublesome symptom. _Chapping_ is an extremely
mild but familiar example of this type.
It is especially common about the hands and fingers.
#What is the course of fissured eczema?#
It is more or less persistent, the tendency to fissuring varying
considerably according to the state of the weather, often disappearing
spontaneously in the summer months.
#Describe eczema sclerosum and eczema verrucosum.#
In eczema sclerosum the skin is thickened, infiltrated, hard, and almost
horny. Eczema verrucosum presents similar conditions, but, in addition,
displays a tendency to papillary or wart-like hypertrophy. In both
varieties the disease is usually seated about the ankle or the foot,
developing from the papular or squamous type. They are uncommon, and
obstinately chronic.
#State the nature of the subjective symptoms in eczema.#
Itching, commonly intense, is usually a conspicuous symptom; it may be
more or less paroxysmal. In some cases burning and heat constitute the
main subjective phenomena.
#Is eczema accompanied by febrile or systemic symptoms?#
No. In rare instances, in acute universal eczema, slight febrile action,
or other systemic disturbance, may be noted at the time of the outbreak.
#Is the eczematous eruption (patch or patches) sharply defined against
the neighboring sound skin?#
No. In almost all instances the diseased area merges gradually and
imperceptibly into the surrounding healthy integument.
#What is the character of eczema as regards the degree of inflammatory
action?#
The inflammatory action may be acute, subacute or sluggish in character,
and may be so from the start and so continue throughout its whole
course; or it may, as is usually the case, vary in intensity from time
to time.
#State the character of eczema as regards duration.#
As a rule, it is a persistent disease, showing little, if any, tendency
to spontaneous disappearance.
#Is eczema influenced by the seasons?#
Yes. With comparatively few exceptions the disease is most common and
much worse in cold, windy, winter weather.
#To what may eczema be ascribed?#
Eczema may be due to constitutional or local causes, or to both. It may
be considered, in fact, as a reaction of the skin tissues against some
irritant, and the latter may have its origin from within or without.
#Name some of the important constitutional or predisposing causes.#
Gouty diathesis, rheumatic diathesis, disorders of the digestive tract,
general debility or lack of tone, an exhausted state of the nervous
system, dentition and struma.
#Is a constitutional cause sufficient to provoke an attack?#
Yes; but often the attack is brought about in those so predisposed by
some local or external irritant.
#Mention some of the external causes.#
Heat and cold, sharp, biting winds, excessive use of water, strong
soaps, vaccination, dyes and dyestuffs, chemical irritants, and the
like. There is a growing belief that some cases presenting eczematous
aspects are probably parasitic in origin. In fact, some observers hold
to the microbic view of all cases of eczema.
Contact with the rhus plants, while producing a peculiar dermatitis,
usually running an acute course terminating in recovery, may, in those
predisposed, provoke a veritable and persistent eczema. In fact, in our
examination as to causes in a given case, especially of the hands and face,
all possible exciting factors should be inquired into, such as the handling
of plants, chemicals, dyes, etc.
[Illustration: Fig. 24. Eczema of Face.]
#Is eczema contagious?#
No. The acceptance of a parasitic cause for the disease, however,
necessarily carries with it the possibility of contagiousness under
favoring conditions. Such is not supported, however, by practical
experience.
#What is the pathology?#
The process is an inflammatory one, characterized in all cases by
hyperaemia and exudation, varying in degree according to the intensity
and duration of the disease. The rete and papillary layer are especially
involved, although in severe and chronic cases the lower part of the
corium and even the subcutaneous tissue may share in the process.
#Do the cutaneous manifestations of the eruptive fevers bear resemblance
to the erythematous type of eczema?#
Scarlatina and erysipelas may, to a slight extent, but the presence or
absence of febrile and other constitutional symptoms will usually serve
to differentiate.
#What common skin diseases resemble some phases of eczema?#
Psoriasis, seborrh[oe]a, sycosis, scabies and ringworm.
#How would you exclude psoriasis in a suspected case of eczema (squamous
eczema)?#
Psoriasis occurs in variously-sized, rounded, _sharply-defined_ patches,
usually scattered irregularly over the general surface, with special
predilection for the elbows and knees. They are covered more or less
abundantly with whitish, silvery or mother-of-pearl colored imbricated
scales. The patches are always dry, and itching is, as a rule, slight,
or may be entirely absent. Eczema, on the contrary, is often localized,
appearing as one or more large, irregularly diffused patches; it merges
imperceptibly into the sound skin, and there is often a history of
characteristic serous or gummy oozing; the scaling is usually slight and
itching almost invariably a prominent symptom.
#How would you exclude seborrh[oe]a (eczema seborrhoicum) in a suspected
case of eczema?#
Seborrh[oe]a of the scalp is more commonly over the whole of that region
and is relatively free from inflammatory symptoms; the scales are of a
greasy character and the itching is usually slight or nil. On the other
hand, in eczema of this region the parts are rarely invaded in their
entirety; there may be at times the characteristic serous or gummy
oozing; inflammatory symptoms are usually well-marked, the scales are
dry and the itching is, as a rule, a prominent symptom. These same
differences serve to differentiate the diseases in other regions.
#How does scabies differ from eczema?#
Scabies differs from eczema in its peculiar distribution, the presence
of the burrows, the absence of any tendency to patch formation, and
usually by a clear history of contagion.
#How would you exclude ringworm in a suspected case of eczema?#
Ringworm is to be distinguished by its circular form, its fading in the
centre, and in doubtful cases by microscopic examination of the
scrapings.
#How does eczema differ from sycosis?#
Sycosis is limited to the hairy region of the face, is distinctly a
follicular inflammation, and is rarely very itchy; eczema is diffused,
usually involves other parts of the face, and itching is an annoying
symptom.
#State the general prognosis of eczema.#
The disease is, under favorable circumstances, curable, some cases
yielding more or less readily, others proving exceedingly rebellious.
The length of time to bring about a result is always uncertain, and an
opinion on this point should be guarded.
#Upon what would you base your prognosis in the individual case?#
The extent of disease, its duration and previous behavior, the
removability of the exciting and predisposing causes, and the attention
the patient can give to the treatment.
In eczema involving the lips, face, scrotum, and leg, and especially
when this last-named exhibits a varicose condition of the veins, a cure
is effected, as a rule, only through persistent and prolonged treatment.
#Does eczema ever leave scars?#
No. Upon the legs, in long-continued cases, more or less pigmentation
usually remains.
#How is eczema treated?#
As a rule, eczema requires for its removal both constitutional and
external treatment.
Certain cases, however, seem to be entirely local in their nature, and
in these cases external treatment alone will have satisfactory results.
#What general measures as to hygiene and diet are commonly advisable?#
Fresh air, exercise, moderate indulgence in calisthenics, regular
habits, a plain, nutritious diet; abstention from such articles of food
as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese,
pickles, condiments, excessive coffee or tea drinking, etc. As a rule,
also, beer, wine, and other stimulants are to be interdicted.
#Upon what grounds is the line or plan of constitutional treatment to be
based?#
Upon indications in the individual case. A careful examination into the
patient's general health will usually give the cue to the line of
treatment to be adopted.
#Mention the important remedies variously employed in the constitutional
treatment.#
_Tonics_--such as cod-liver oil, quinine, nux vomica, the vegetable
bitters, iron, arsenic, malt, etc.
_Alkalies_--sodium salicylate, potassium bicarbonate, liquor potassae,
and lithium carbonate.
_Alteratives_--calomel, colchicum, arsenic, and potassium iodide.
_Diuretics_--potassium acetate, potassium citrate, and oil of copaiba.
_Laxatives_--the various salines, aperient spring waters, castor oil,
cascara sagrada, aloes and other vegetable cathartics.
_Digestives_--pepsin, pancreatin, muriatic acid and the various bitter
tonics.
#Are there any remedies which have a specific influence?#
No; although arsenic, in exceptional instances, seems to exert a special
action. Cod-liver oil is also of great value in some cases.
Upon the whole the most important remedies are those which keep in view
the maintenance of a proper and healthful condition of the
gastro-intestinal tract, and especially with regular and rather free
action of the bowels.
#In what class of cases does arsenic often prove of service?#
In the sluggish, dry, erythematous, scaly and papular types.
#In what cases is arsenic usually contraindicated?#
It should never be employed in acute cases; nor in any instance (unless
its action is watched), in which the degree of inflammatory action is
marked, as an aggravation of the disease usually results.
#What should be the character of the external treatment?#
It depends mainly upon the degree of inflammatory action; but the stage
of the disease, the extent involved, and the ability of the patient to
carry out the details of treatment, also have a bearing upon the
selection of the plan to be advised.
#What is to be said about the use of soap and water in eczema?#
In acute and subacute conditions soap and water are to be employed, as a
rule, as infrequently and as sparingly as possible, as the disease is
often aggravated by their too free use. Washing is necessary, however,
for cleanliness and occasionally, also, for the removal of the crusts.
On the other hand, in chronic, sluggish types the use of soap and water
frequently has a therapeutic value.
#How often should remedial applications be made?#
Usually twice daily, although in some case, and especially those of an
acute type, applications should be made every few hours.
#Mention several remedies or plans of treatment to be used in the acute
or actively inflammatory cases.#
Black wash and oxide-of-zinc ointment conjointly, the wash thoroughly
dabbed on, allowed to dry, the parts gently smeared with ointment; or
the ointment may be applied spread on lint as a plaster.
Boric-acid wash (15 grains to the ounce) and oxide-of-zinc ointment,
applied in the same manner as the above.
A lotion containing calamine and zinc oxide, the sediment drying and
coating over the affected surface:--
[Rx] Calaminae,
Zinci oxidi, ... [=a][=a] ......... [dram]ij-[dram]iij
Glycerinae,
Alcoholis, ..... [=a][=a] ......... f[dram]ss
Liq. calcis, ...................... f[Oz]ij
Aquae, .......... q.s. ad .......... f[Oz]vj. M.
Another excellent lotion somewhat similar to the last, but of oily
character, is made up of three drachms each of calamine and zinc oxide,
one drachm of boric acid, ten to thirty drops of carbolic acid, and
three ounces each of lime-water and oil of sweet almonds.
Carbolic-acid lotion, about two drachms to the pint of water, to which
may be added two or three drachms each of glycerin and alcohol; or, if
there is intense itching, carbolic acid may be added to the several
washes already mentioned.
A lotion made of one or two drachms of liquor carbonis detergens[A] to
four ounces of water.
The following wash, especially in the dry form of the disease:--
[Rx] Ac. borici, .......................... [dram]iv
Ac. carbolici, ....................... [dram]j
Glycerinae, ........................... [dram]ij
Alcoholis, ........................... [dram]ij
Aquae, ............. q.s. ad .......... Oj. M.
[Footnote A: Liquor carbonis detergens is made by mixing together nine
ounces of tincture soap bark and four ounces of coal tar, allowing to
digest for eight days, and filtering. The tincture of soap bark used is
made with one pound of soap bark to one gallon of 95 per cent. alcohol,
digesting for a week or so. Instead of the proprietary name above, Prof.
Duhring has suggested that of tinctura picis mineralis comp.]
Dusting-powders, of starch, zinc oxide and Venetian talc, alone or
severally combined, applied freely and often, so as to afford protection
to the inflamed surface:--
[Rx] Talci venet,
Zinci oxidi, ....... [=a][=a] ........ [dram]iv
Amyli, ............................... [Oz]j M.
If washes or dusting-powders should disagree or are not desirable or
practicable, ointments may be employed, such as--
Oxide-of-zinc ointment, cold cream, petrolatum, plain or carbolated,
diachylon ointment (if fresh and well prepared), and a paste-like
ointment, as the following, usually called "salicylic-acid paste"; in
markedly itchy cases, five to fifteen grains of carbolic may be added to
each ounce:
[Rx] Ac. salicylici, ...................... gr. v-x
Pulv. amyli,
Pulv. zinci oxidi, .... [=a][=a] ..... [dram]ij
Petrolati, ........................... [dram]iv M.
Or the following ointment:--
[Rx] Calaminae, ............................ [dram]j
Ungt. zinci oxidi, ................... [dram]vij. M.
#Name several external remedies and combinations useful in eczema of a
subacute or mildly inflammatory type.#
The various remedies and combinations useful when the symptoms are acute
or markedly inflammatory (mentioned above), and more especially the
several following:--
[Rx] Zinci oxidi, ......................... [dram]ij
Liq. plumbi subacetat. dilut., ....... f[dram]vj
Glycerinae, ........................... f[dram]ij
Infus. picis liq., ................... f[Oz]iij M.
A lotion containing resorcin, five to thirty grains to the ounce.
Solution of zinc sulphate, one-half to three grains to the ounce.
An ointment containing calomel or ammoniated mercury, as in the annexed
formula:--
[Rx] Hydrargyri ammoniat. seu Hydrargyri
chloridi mit., ................... gr. x-xxx
Ac. carbolici, ..................... gr. v-x
Ungt. zinci oxidi, ................. [Oz]j M.
Another formula, more especially useful in eczema of the hands and legs,
is the following:--
[Rx] Ac. salicylici, ...................... gr. xxx
Emp. plumbi,
Emp. saponis,
Petrolati, ...... [=a][=a] ........... [Oz]j. M.
(This is to be applied as a plaster, spread on strips of lint, and
changed every twelve or twenty-four hours.)
The paste-like ointment, referred to as useful in acute eczema, may also
be used with a larger proportion (20 to 60 grains to the ounce) of
salicylic acid.
The following, containing tar, may often be employed with advantage:--
[Rx] Ungt. picis liq., .................... [dram]j
Ungt. zinci oxidi, ................... [dram]vij. M.
#What is to be said in regard to the use of tarry applications?#
Ointments or lotions containing tar should always be tried at first upon
a limited surface, as occasionally skins are met with upon which this
remedy acts as a more or less violent irritant. The coal tar lotion
(liquor carbonis detergens) is the least likely to disagree and may be
used as a mild ointment, one or two drachms to the ounce, or it may be
diluted and used as a weak lotion as already referred to.
#What external remedies are to be employed in eczema of a sluggish type?#
The various remedies and combinations (mentioned above) useful in acute
and subacute eczema may often be employed with benefit, but, as a rule,
stronger applications are necessary, especially in the thick and
leathery patches. The following are the most valuable:--
An ointment of calomel or ammoniated mercury; forty to sixty grains to
the ounce.
Strong salicylic-acid ointment; a half to one drachm of salicylic acid
to the ounce of lard.
Tar ointment, official strength; or the various tar oils, alone or with
alcohol, as a lotion, or in ointment form.
Liquor picis alkalinus[B] is a valuable remedy in chronic _thickened_,
_hard_ and _verrucous_ patches, but is a strong preparation and must be
used with caution. It is applied diluted, one part with from eight to
thirty-two parts of water; or in ointment, one or two drachms to the
ounce. In such cases, also, the following is useful:--
[Rx] Saponis viridis,
Picis liq.,
Alcoholis, .......... [=a][=a] ....... [dram]iij. M.
SIG. To be well rubbed in.
[Footnote B:
[Rx] Potassae, ............................. [dram]j
Picis liq., .......................... [dram]ij
Aquae, ................................ [dram]v.
Dissolve the potash in the water, and gradually add to the tar in a
mortar, with thorough stirring.]
In similar cases, also, the parts may be thoroughly washed or scrubbed
with sapo viridis and hot water until somewhat tender, rinsed off,
dried, and a mild ointment applied as a plaster.
Lactic acid, applied with one to ten or more parts of water is also of
value in the sclerous and verrucous types. Caustic potash solutions,
used cautiously, may also be occasionally employed to advantage in these
cases.
Another remedy of value in these cases, as well as in others of more or
less limited nature, is the _x_-ray. Exposures every few days, of short
duration and 4 to 10 inches distance, with medium vacuum tube. This
method has served me well in occasional cases; caution is necessary, and
it should not be pushed further than the production of the mildest
reaction. The repeated application of a high-frequency current, by means
of the vacuum electrodes, is a safer and sometimes an equally beneficial
method.
#Is there any method of treating eczema with fixed dressings?#
Several plans have been advised from time to time; some are costly, and
some require too great attention to details, and are therefore
impracticable for general employment. The following are those in more
common use:--
The _gelatin dressing_, as originally ordered, is made by melting over a
water-bath one part of gelatin in two parts of water--quickly painting
it over the diseased area; it dries rapidly, and to prevent cracking
glycerine is brushed over the surface. Or the glycerine may be
incorporated with the gelatin and water in the following proportion:
glycerine, one part; gelatin, four parts, and water eight parts.
Medicinal substances may be incorporated with the gelatin mixture.
A good formula is the following:--
[Rx] Gelatin, ............................. [Oz]j
Zinci oxidi, ......................... [Oz]ss
Glycerini, ........................... [Oz]iss
Aquae, ................................ [Oz]ii-[Oz]iij.
This should be prepared over a water-bath, and two per cent. ichthyol
added. A thin gauze bandage can be applied to the parts over which this
dressing is painted, before it is completely dry; it makes a comfortable
fixed dressing and may remain on several days.
_Plaster-mull_ and _gutta-percha plaster_. The plaster-mull, consisting
of muslin incorporated with a layer of stiff ointment, and the
gutta-percha plaster, consisting of muslin faced with a thin layer of
India-rubber, the medication being spread upon the rubber coating.
_Rubber plasters._ These are medicated with the various drugs used in
the external treatment of skin diseases, and are often of service in
chronic patches.
Two new excipients for fixed dressings have recently been
introduced--bassorin and plasment; the former is made from gum
tragacanth, and the latter from Irish moss.
The following is a satisfactory formula for a tragacanth dressing:
[Rx] Tragacanth, .......................... gr. lxxv
Glycerini, ........................... [minim] xxx
Ac. carbolici, ....................... gr. x-xx
Zinci oxidi, ......................... [dram]iss-[dram]iiss. M.
This is painted over the parts and allowed to dry, and a mild dusting
powder sprinkled over. It cannot be used in warm weather or in folds, as
it is apt to get sticky. The following is a bassorin paste which may be
variously medicated.
[Rx] Bassorin, ............................ [dram]x
Dextrin, ............................. [dram]vj
Glycerini, ........................... [Oz]ij.
Aquae, ....................... q.s. ad. [Oz]iij.
It should be prepared cold.
Another "drying dressing" which may be used in cool weather is:
[Rx] Zinci oxidi, ......................... [Oz]j
Glycerini, ........................... [Oz]ss
Mucilag. acaciae, ..................... [Oz]ii-[Oz]iv.
It may be variously medicated.
The plaster-mull is used in all types, especially the acute; the gelatin
dressing, and the gutta-percha plaster, in the subacute and chronic; and
the rubber plaster in chronic, sluggish patches only. Acacia,
tragacanth, bassorin and plasment applications are used in cases of a
subacute and chronic character.
#Prurigo.#
#Define prurigo.#
Prurigo is a chronic, inflammatory disease, characterized by discrete,
pin-head- to small pea-sized, solid, firmly-seated, slightly raised,
pale-red papules, accompanied by itching and more or less general
thickening of the affected skin.
#Describe the symptoms and course of prurigo.#
The disease first appears upon the tibial regions, and its earliest
manifestation may be urticarial, but there soon develop the
characteristic small, millet-seed-sized, or larger, firm elevations,
which may be of the natural color of the skin or of a pinkish tinge. The
lesions, whilst discrete, are in great numbers, and closely crowded. The
overlying skin is dry, rough and harsh; itching is intense, and, as a
result of the scratching, excoriations and blood crusts are commonly
present. In consequence of the irritation, the inguinal glands are
enlarged. Sooner or later the integument becomes considerably thickened,
hard and rough. Eczematous symptoms may be superadded. In severe cases
the entire extensor surfaces of the legs and arms, and in some instances
the trunk also, are invaded. It is worse in the winter season.
#What is known in regard to etiology and pathology?#
It is a disease of the ill-fed and neglected, usually developing in
early childhood, and persisting throughout life. It is extremely rare,
even in its milder types, in this country. Clinically and pathologically
it bears some resemblance to papular eczema.
#Give the prognosis and treatment of prurigo.#
The disease, in its severer types is, as a rule, incurable, but much can
be done to alleviate the condition. Good, nourishing food, pure air and
exercise are of importance. Tonics and cod-liver oil are usually
beneficial. The local management is similar to that employed in chronic
eczema. An ointment of [beta]-naphthol, one-half to five per cent.
strength, is highly extolled.
#Acne.#
#Give a definition of acne.#
Acne is an inflammatory, usually chronic, disease of the sebaceous
glands, characterized by papules, tubercles, or pustules, or a mixture
of these lesions, and seated usually about the face.
#At what age does acne usually occur?#
Between the ages of fifteen and thirty, at which time the glandular
structures are naturally more or less active.
#Describe the symptoms of acne.#
Irregularly scattered over the face, and in some cases also over the
neck, shoulders and upper part of the trunk, are to be seen several,
fifty or more, pin-head- to pea-sized papules, tubercles or pustules;
commonly the eruption is of a mixed type (_acne vulgaris_), the several
kinds of lesions in all stages of evolution and subsidence presenting in
the single case. Interspersed may generally be seen blackheads, or
comedones. The lesions may be sluggish in character, or they may be
markedly inflammatory, with hard and indurated bases. In the course of
several days or weeks, the papules and tubercles tend gradually to
disappear by absorption; or, and as commonly the case, they become
pustular, discharge their contents, or dry and slowly or rapidly
disappear, with or without leaving a permanent trace, new lesions
arising, here and there, to take their place. In exceptional instances
the eruption is limited to the back, and in these cases the eruption is
usually extensive and persistent, and not infrequently leaves scars.
#What do you understand by acne punctata, acne papulosa, acne pustulosa,
acne indurata, acne atrophica, acne hypertrophica, and acne
cachecticorum?#
These several terms indicate that the lesions present are, for the most
part, of one particular character or variety.
#Describe the lesions giving rise to the names of these various types.#
Blocking up of the outlet of the sebaceous gland (comedo), which is
usually the beginning of an acne lesion, may cause a moderate degree of
hyperaemia and inflammation, and a slight elevation, with a central
yellowish or blackish point results--the lesion of _acne punctata_; if
the inflammation is of a higher grade or progresses, the elevation is
reddened and more prominent--_acne papulosa_; if the inflammatory action
continues, the interior or central portion of the papule suppurates and
a pustule results--_acne pustulosa_; the pustule, in some cases, may
have a markedly inflammatory and hard base--_acne indurata_; and not
infrequently the lesions in disappearing may leave a pit-like atrophy or
depression--_acne atrophica_; or, on the contrary, connective-tissue new
growth may follow their disappearance--_acne hypertrophica_; and, in
strumous or cachectic individuals, the lesions may be more or less
furuncular in type, often of the nature of dermic abscesses, usually of
a cold or sluggish character, and of more general distribution--_acne
cachecticorum_.
#What is acne artificialis?#
Acne artificialis is a term applied to an acne or acne-like eruption
produced by the ingestion of certain drugs, as the bromides and iodides,
and by the external use of tar; this is also called _tar acne_.
#What course does acne pursue?#
Essentially chronic. The individual lesions usually run their course in
several days or one or two weeks, but new lesions continue to appear
from time to time, and the disease thus persists, with more or less
variation, for months or years. In many cases there is, toward the age
of twenty-five or thirty, a tendency to spontaneous disappearance of the
disease.
[Illustration: Acne.]
#Is the eruption in acne usually abundant?#
It varies in different cases and at different periods in the same case.
In some instances, not more than five or ten papules and pustules are
present at one time; in others they may be numerous. Not infrequently
several lesions make their appearance, gradually run their course, and
the face continues free for days or one or two weeks.
#Does the eruption in acne disappear without leaving a trace?#
In many instances no permanent trace remains, but in others slight or
conspicuous scarring is left to mark the site of the lesions.
#Are there any subjective symptoms in acne?#
As a rule, not; but markedly inflammatory lesions are painful.
#State the immediate or direct cause of an acne lesion.#
Hypersecretion or retention of sebaceous matter. Recent investigations
point to the possibility of a special bacillus being the exciting cause,
in some instances at least. The pyogenic cocci are added factors in the
pustular and furuncular cases.
#Name the indirect or predisposing causes of acne.#
Digestive disturbance, constipation, menstrual irregularities,
chlorosis, general debility, lack of tone in the muscular fibres of the
skin, scrofulosis; and medicinal substances such as the iodides and
bromides internally, and tar externally.
Working in a dusty or dirty atmosphere is often influential, resulting
in a blocking-up of the gland ducts. Workmen in paraffin oils or other
petroleum products often present a furuncle-like acne.
The disease is more common in individuals of light complexion.
#Is there any difficulty in the diagnosis of acne?#
Not if it be remembered that acne eruption is limited to certain parts
and is always follicular, and that the several stages, from the comedo
to the matured lesion, are usually to be seen in the individual case.
#In what respect does the pustular syphiloderm differ from acne?#
By its general distribution, the longer duration of the individual
lesions, the darker color, and the presence of concomitant symptoms of
syphilis.
#What is the pathology of acne?#
Primarily, acne is a folliculitis, due to retention or decomposition of
the sebaceous secretion or to the introduction of a micro-organism;
subsequently, the tissue immediately surrounding becoming involved, with
the possible destruction of the sebaceous follicle as a result. The
degree of inflammatory action determines the character of the lesions.
#State the prognosis of acne.#
It is usually an obstinate disease, but curable. Some cases yield
readily, others are exceedingly rebellious, especially acne of the back.
Success depends in a great measure upon a recognition and removal of the
predisposing condition. Treatment is ordinarily a matter of months.
#What measures of treatment are usually demanded in acne?#
Constitutional and local measures; the former when indicated, the latter
always.
#Upon what is the constitutional treatment based?#
Upon indications. Diet and hygienic measures are important.
In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin,
saline and vegetable laxatives, are variously prescribed. Special
mention may be made of the following:--
[Rx] Ext. rhamni pursh. fl., .............. f[dram]ij-f[dram]iv
Tinct. nucis vom., ................... f[dram]iij
Tinct. cardamomi comp., .......q.s. ad [Oz]iij. M.
SIG.--f[dram]t.d.
Or Hunyadi Janos or Friedrichshall water may be employed for a laxative
purpose.
In chlorotic and anaemic cases the ferruginous preparations are of
advantage. Cod-liver oil is often a remedy of great value, and is
especially us
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