Class I.—Disorders of the Glands

Hyperidrosis.

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 axillæ 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:—

℞ Pulv. ac. salicylici, ............................ gr. x-xxx.
Pulv. ac. borici, ................................ ʒv.
Pulv. zinci oxidi, ............................... ʒiij 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 Röntgen 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 lamellæ 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 axillæ.

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, Röntgen 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.

Seborrhœa (Eczema Seborrhoicum).

Synonyms: (Steatorrhœa; Acne sebacea; Ichthyosis sebacea; Dandruff.)

What is seborrhœa?

Seborrhœa 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 seborrhœa 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 seborrhœa are encountered?

Seborrhœa oleosa and seborrhœa sicca; not infrequently the disease is of a mixed type.

What are the symptoms of seborrhœa 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 seborrhœa of the nose.

Give the symptoms of seborrhœa sicca.

A variable degree of greasy scalines, which may be seated upon a pale, hyperæmic 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, hyperæmic 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.

Seborrhœa (Eczema Seborrhoicum).

Describe the symptoms of seborrhœa of the trunk and other parts.

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.

Seborrhœa corporis differs in a measure, in its symptoms, from seborrhœa of the scalp and is usually illustrative of the variety known as eczema seborrhoicum; it occurs as one or several irregular or circinate, slightly hyperæmic 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 axillæ, genitocrural, and other regions.

What is the usual course of seborrhœa?

Essentially chronic, the disease varying in intensity from time to time. In occasional instances it disappears spontaneously.

Give the cause or causes of seborrhœa.

General debility, anæmia, 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 seborrhœa?

Seborrhœa 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 seborrhœa?

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 seborrhœa 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 seborrhœa—of the eczema seborrhoicum variety.

What is the prognosis in seborrhœa?

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 seborrhœa 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 seborrhœa 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 seborrhœa 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:—

℞ Resorcini, ....................................... ʒj-ʒiss.
Ol. ricini, ...................................... ♏xxx-fʒij.
Alcoholis, ...................................... f℥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 seborrhœa upon other parts to be treated?

In the same general manner as seborrhœa 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 seborrhœa, 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.

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.

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:—

℞ Zinci sulphatis,
Potassi sulphureti, ...................āā......... ʒj-ʒiv.
Alcoholi ........................................ f℥ss.
Aquæ, ........................... q.s. ad. ...... f℥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. Röntgen-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.

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.