Class II.—Inflammations

Erythema Simplex.

What do you understand by erythema simplex?

Erythema simplex is a hyperæmic 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 hyperæmia—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 hyperæmic 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 hyperæmic, 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:—

℞ Pulv. calaminæ,
Pulv. zinci oxidi, ....................āā......... ʒiss.
Glycerinæ, ....................................... ♏xxx
Alcoholis, ...................................... fʒij
Aquæ, ............................................ 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.

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 œdema, 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).

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 hæmorrhagica, 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 hæmorrhagica.

Urticaria hæmorrhagica 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 œdema?

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 œdematosa, acute circumscribed œdema, angioneurotic œdema). 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 œdematous 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 œdema 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:—

℞ Acidi carbolici, ................................. ʒj-ʒiij
Acidi borici, .................................... ʒiv
Glycerinæ, ...................................... fʒj
Alcoholis, ...................................... f℥ij
Aquæ, ........................................... f℥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 œdema and pigment deposit in the epidermal portion, and cellular infiltration made up principally of mast-cells.

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 œdema 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.

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.

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.

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.

Fig. 15.

x-ray burn

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.

Fig. 16.

Dermatitis Factitia—note the unusually uniform and regular character and arrangement of the lesions.

Dermatitis Gangrænosa.

Dermatitis Gangrænosa.

What do you understand by dermatitis gangrænosa?

Dermatitis gangrænosa (erythema gangrænosum, 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, œdema, 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 hyperæmia 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:—

℞ Ichthyol, ........................................ ʒj
Emp. plumbi, ..................................... ʒij
Emp. resinæ, ..................................... ʒj. 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, septicæmia 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.

Frambœsia.

(Synonyms: Yaws; Pian.)

Describe frambœsia.

Frambœsia 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 areolæ 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:—

℞ Aeidi carbolici, ................................. ʒss-ʒj
Acidi borici, .................................... ʒiv
Glycerinæ, ...................................... fʒj
Alcoholis, ...................................... f℥ij
Aquæ, ............................................ ℥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:—

℞ Pulv. acidi borici,
Pulv. talci veneti,
Pulv. zinci oxidi,
Pulv. amyli, ..........................āā......... ʒij. 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:—

℞ Pulv. ac. salicylici, ............................ gr. x
Pulv. ac. borici,
Pulv. amyli, ..................āā................. ʒij
Petrolati, ....................................... ʒiv. 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 hyperæmic 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 præputialis) 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 gonorrhœa, 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:—

℞ Zinci oxidi,
Calaminæ, ..............āā........................ gr. v
Glycerinæ,
Alcoholis, .............āā........................ ♏vj
Aquæ, ............................................ ℥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 hyperæmic 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 hyperæmic 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 preëxisting 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, bullæ, 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 septicæmic. 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:—

℞ Ac. carbolici, ................................... ʒj-ʒij
Thymol, .......................................... gr. xvj.
Glycerinæ, ....................................... ℥ss-℥j
Alcoholis, ...................................... f℥ij
Aquæ, 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.

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, hyperæmic, 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.

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.

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 seborrhœa. 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 seborrhœa differ from psoriasis?

Seborrhœa of the scalp is usually diffused, with but little redness and no infiltration; moreover, the scales of seborrhœa are greasy, dirty gray or brownish, while those of psoriasis are dry and commonly whitish or mother-of-pearl colored. Psoriasis of the scalp rarely exists independently of other patches elsewhere on the general surface.

That variety of seborrhœa, 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; seborrhœa, 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 potassæ 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 anæmic 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, β-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:—

℞ Chrysarobini, .................................... ʒj
Acidi salicylici, ................................ gr. xx
Etheris, ........................................ fʒj
Ol. ricini, ...................................... ♏x
Collodii, ....................................... fʒvij. M.

Or it may be used in liquor gutta-perchæ (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.

β-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 seborrhœa (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, ʒij; vaselin, ʒiv) 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.

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.

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 seborrhœa.

Describe the symptoms of erythematous eczema.

Erythematous eczema (eczema erythematosum) begins as one or more small or large, irregularly outlined hyperæmic 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.

Its most common site is the face, but it is not infrequent upon other parts.

Fig. 21.

Eczema Rubrum.

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.

It is seen most frequently upon the extremities, especially the flexor surfaces.

Fig. 22.

Eczema Squamosum et tissum.

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 œdema 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 preëxisting 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.

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.

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 hyperæmia 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, seborrhœa, 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 seborrhœa (eczema seborrhoicum) in a suspected case of eczema?

Seborrhœa 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 potassæ, 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:—

℞ Calaminæ,
Zinci oxidi, .................āā.................. ʒ ij-ʒ iij
Glycerinæ,
Alcoholis, ...................āā................. fʒss
Liq. calcis, .................................... f℥ij
Aquæ, .............. q.s. ... ad ................ f℥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 to four ounces of water.

The following wash, especially in the dry form of the disease:—

℞ Ac. borici, ...................................... ʒiv
Ac. carbolici, ................................... ʒj
Glycerinæ, ....................................... ʒij
Alcoholis, ....................................... ʒij
Aquæ, ............... q.s. ad. ................... Oj. M.

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:—

℞ Talci venet,
Zinci oxidi, ...............āā.................... ʒiv
Amyli, ........................................... ℥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:

℞ Ac. salicylici, .................................. gr. v-x
Pulv. amyli,
Pulv. zinci oxidi, ...............āā.............. ʒij
Petrolati, ....................................... ʒiv M.

Or the following ointment:—

℞ Calaminæ, ........................................ ʒj
Ungt. zinci oxidi, ............................... ʒvij. 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:—

℞ Zinci oxidi, ..................................... ʒij
Liq. plumbi subacetat. dilut., .................. fʒvj
Glycerinæ, ...................................... fʒij
Infus. picis liq., .............................. f℥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:—

℞ Hydrargyri ammoniat. seu Hydrargyri
chloridi mit., ................................. gr. x-xxx
Ac. carbolici, ................................... gr. v-x
Ungt. zinci oxidi, ............................... ℥j. M.

Another formula, more especially useful in eczema of the hands and legs, is the following:—

℞ Ac. salicylici, .................................. gr. xxx
Emp. plumbi,
Emp. saponis,
Petrolati, ...................āā.................. ℥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:—

℞ Ungt. picis liq., ................................ ʒj
Ungt. zinci oxidi, ............................... ʒvij. 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 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:—

℞ Saponis viridis,
Picis liq.,
Alcoholis, ....................āā................. ʒiij. M.
SIG. To be well rubbed in.

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:—

℞ Gelatin, ......................................... ℥j
Zinci oxidi, ..................................... ℥ss
Glycerini, ....................................... ℥iss
Aquæ, ............................................ ℥ii-℥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:

℞ Tragacanth, ...................................... gr. lxxv
Glycerini, ....................................... ♏ xxx
Ac. carbolici, ................................... gr. x-xx
Zinci oxidi, ..................................... ʒiss-ʒiiss. 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.

℞ Bassorin, ........................................ ʒx
Dextrin, ......................................... ʒvj
Glycerini, ....................................... ℥ij.
Aquæ, ................................... q.s. ad. ℥iij.

It should be prepared cold.

Another “drying dressing” which may be used in cool weather is:

℞ Zinci oxidi, ..................................... ℥j
Glycerini, ....................................... ℥ss
Mucilag. acaciæ, ................................. ℥ii-℥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 β-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 hyperæmia 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.

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:—

℞ Ext. rhamni pursh. fl., ......................... fʒij-fʒiv
Tinct. nucis vom., .............................. fʒiij
Tinct. cardamomi comp., ................. q.s. ad. ℥iij. M.
SIG.—fʒ t.d.

Or Hunyadi Janos or Friedrichshall water may be employed for a laxative purpose.

In chlorotic and anæmic cases the ferruginous preparations are of advantage. Cod-liver oil is often a remedy of great value, and is especially useful in strumous and debilitated subjects. Calx sulphurata in pill form, one-tenth to one-fourth grain four or five times daily, is said, acts well in the pustular variety. In some instances, more particularly in sluggish papular acne, arsenic, especially the sulphide of arsenic, acts favorably. Upon the whole, the line of

treatment that keeps in view proper and healthy action of the gastro-intestinal canal is the most successful.

In inflammatory cases occurring in robust individuals the following is often of service:—

℞ Potassii acetat., ................................ ʒiv
Liq. potassæ, ................................... fʒij
Liq. ammonii acetat., ............ q.s. ad. ..... f℥iij. M.
SIG.—fʒj-fʒij t.d., largely diluted.

State the character of the local treatment in acne.

This must vary somewhat with the local conditions. Cases which are acute in character, in the sense that the lesions are markedly hyperæmic, tender and painful, require milder applications, and in exceptional instances soothing remedies are to be prescribed. As a rule, however, stimulating applications may be employed from the start.

The remedies are, for obvious reasons, most conveniently applied at bedtime.

What preliminary measures are to be advised in ordinary acne cases?

Washing the parts gently or vigorously, according to the irritability of the skin, with warm water and soap; subsequently rinsing, and sponging for several minutes with hot water, and rubbing dry with a soft towel; after which the remedial application is made. In sluggish and non-irritable cases sapo viridis or its tincture may often be advantageously used in place of the ordinary toilet soap.

The blackheads, so far as practicable, are to be removed by pressure with the fingers or with a suitable instrument (see Comedo), and the superficial pustules punctured and the contents pressed out. Scraping the affected parts with a blunt curette is a valuable measure, but is temporarily disfiguring. As a rule, however, cases do just as well without puncturing and scraping, and these methods sometimes leave behind scarring.

State the methods of external medication commonly employed.

By ointments and lotions. If an ointment is used, it is to be thoroughly rubbed in, in small quantity; if a lotion is employed, it is to be well shaken, the parts freely dabbed with it for several minutes and then allowed to dry on.

State the object in view in local medication.

To hasten the maturation and disappearance of the existing lesions, and to stimulate the skin and glands to healthy action.

If slight irritation or scaliness results, the application is to be intermitted one or two nights; in the meantime nothing except the hot-water sponging, with or without the application of a mild soothing ointment, is to be employed.

Is it usually necessary to change from one external remedy to another in the course of treatment?

Yes. After a certain time one remedy, as a rule, loses its effect, and a change from lotion to ointment or the reverse, and from one lotion or ointment to another, will often be found necessary in order to bring about continuous improvement.

Name the various important remedies and combinations employed in the external treatment of acne.

Sulphur is the most valuable. It may often be applied with benefit as a simple ointment:—

℞ Sulphur, præcip., ................................ ʒss-ʒj
Adipis benz.
Lanolin, .....................āā.................. ʒij.

Or it may be used as a lotion, as in the annexed formula:—

℞ Sulphur, præcip., ................................ ʒiss
Pulv. tragacanthæ, ............................... gr. x1
Pulv. camphoræ, .................................. gr. xx
Liq. calcis,........ q.s. ad. ................... f℥iv. M.

Another lotion, especially useful in those cases in which an oily condition of the skin is present, is the following:—

℞ Sulphur, præcip., ................................ ʒiss
Etheris, ........................................ fʒiv
Alcoholis, ...................................... f℥iijss. M.

A compound lotion containing sulphur in one of its combinations is also valuable in many cases:—

℞ Zinci sulphatis,
Potassii sulphureti, ................āā........... ʒss-ʒiv
Aquæ, ............................................ ℥iv. M.

(The salts should be dissolved separately and then mixed; reaction takes place and the resulting lotion, when shaken, is milky in appearance, and free from odor; allowed to stand the particles settle, the sediment constituting about one-fourth to three-fourths of the whole bulk).

At times the addition to this formula of several drachms of alcohol and of five to ten minims of glycerin is of advantage.

An external remedy, often valuable, is ichthyol. It is thus prescribed:—

℞ Ichthyol, ........................................ ʒss-ʒj
Cerat. simp., .................................... ʒiv. M.

The various mercurial ointments, especially one of white precipitate, five to fifteen per cent. strength, are sometimes beneficial.

A compound lotion, containing mercury, which frequently proves serviceable, is:—

℞ Hydrarg. chlorid. corros., ....................... gr. ii-viij
Zinci sulphatis, ................................. gr. x-xx
Tinct. benzoini, ................................ fʒij
Aquæ, ................... q.s. ad. .............. f℥iv.

In extremely sluggish cases the following, used cautiously, is of value:—

℞ Ichthyol,
Saponis viridis,
Sulphur, præcip.,
Lanolin, .......................āā................ ʒj.

In such instances the application of a strong alcoholic resorcin lotion, ten to twenty-five per cent. strength, repeated several times daily till marked irritation and exfoliation occur (a matter usually of one to three days), will sometimes be followed by marked improvement. Acne of the back is treated with the same applications, but usually stronger; in this region applications of Vleminckx's solution and formaldehyde solution, weakened considerably, at first at least, prove of value.

Obstinate and indurated lesions may be incised, the contents pressed out, and the interior touched with carbolic acid by means of a pointed stick. The x-ray has proved a most valuable addition to our resources in the treatment of acne, and is especially serviceable in extensive and obstinate cases. An exposure should be made about twice weekly, at a distance of five to ten inches and for from three to ten minutes, and a tube of medium vacuum used. It must be used with great caution and never beyond the production of the mildest erythema. The hair, eyes, and lips should be protected. The x-ray treatment is best reserved for obstinate cases, and then used mildly, and rather as an adjuvant to the ordinary methods than as the sole measure.

What precaution is to be taken in advising a change from a sulphur to a mercurial preparation or the reverse?

Several days should be allowed to intervene, otherwise a disagreeable, although temporary, staining or darkening of the skin results—from the formation of the black sulphuret of mercury.

Acne Rosacea.

Give a descriptive definition of acne rosacea.

Acne rosacea is a chronic, hyperæmic or inflammatory disease, limited to the face, especially to the nose and cheeks, characterized by redness, dilatation and enlargement of the bloodvessels, more or less acne and hypertrophy.

Describe the symptoms of acne rosacea.

The disease may be slight or well-marked. Redness, capillary dilatation, and acne lesions seated on the nose and cheeks, and sometimes on chin and forehead also, constitute in most cases the entire symptomatology.

A mild variety consists in simple redness or hyperæmia, involving the nose chiefly and often exclusively, and is to be looked upon as a passive congestion; this is not uncommon in young adults and is often associated with an oily seborrhœa of the same parts. In many cases the condition does not progress beyond this stage. In other cases, however, sooner or later the dilated capillaries become permanently enlarged (telangiectasis) and acne lesions are often present— constituting the middle stage or grade of the disease; this is the type most frequently met with. In exceptional instances, still further hypertrophy of the bloodvessels ensues, the glands are enlarged, and a variable degree of connective-tissue new growth is added; this latter is usually slight, but may be excessive, the nose presenting an enlarged and lobulated appearance (rhinophyma).

Fig. 25.

Acne Rosacea.

Are there any subjective symptoms in acne rosacea?

As a rule, no. Some of the acne lesions may be tender and painful, and at times there is a feeling of heat and burning.

What do you know in regard to the etiology?

In many cases the causes are obscure. Chronic digestive and intestinal disorders, anæmia, chlorosis, continued exposure to heat or cold, menstrual and uterine irregularities, and the too free use of spirituous liquors, tea, etc. are often responsible factors.

It is essentially a disease of adult life, common about middle age, occurring in both sexes, but rarely reaching the same degree of development in women as observed at times in men.

Is acne rosacea easily recognized?

Yes. The redness, acne lesions, dilated capillaries, and, at times, the glandular and connective-tissue hypertrophy; the limitation of the eruption to the face, especially the region of the nose; the evident involvement of the sebaceous glands, the absence of ulceration, taken with the history of the case, are characteristic.

It is to be distinguished from the tubercular syphiloderm and lupus vulgaris, diseases to which it may bear rough resemblance.

State the prognosis of acne rosacea.

All cases may be favorably influenced by treatment; the mild and moderately-developed types are, as a rule, curable, but usually obstinate. It is a persistent disease, showing little, if any, tendency to disappear spontaneously.

What is the method of treatment?

Both constitutional and local measures are demanded in most cases.

Upon what is the constitutional treatment to be based?

The constitutional treatment, beyond a regulation of the diet, is to be based upon a correct appreciation of the etiological factors in the individual case. There are no special remedies. Iron, cod-liver oil, tonics, ergot, alkalies, saline laxatives, and similar drugs are to be variously prescribed.

What is the external treatment?

In many respects, both as to the preliminary measures and remedies, essentially the same as that employed in the treatment of simple acne (q. v.). The x-ray treatment is not so efficient in this disease, however, as in acne. In addition to the treatment there found, several other applications deserve mention:—

In many cases Vleminckx's solution is valuable, applied diluted with one to ten parts of water. Also, a mucilaginous paste containing sulphur:—

℞ Mucilag. acaciæ, ................................ fʒiij
Glycerinæ, ...................................... fʒij
Sulphur, præcip., ................................ ʒiij. M.

Or a similar paste with the glycerine in the foregoing replaced with ichthyol may be used.

In what manner are the dilated bloodvessels and connective-tissue hypertrophy to be treated?

The enlarged capillaries are to be destroyed by incision or by electrolysis. Properly managed the vessels may be thus destroyed, but unless the predisposing causes have disappeared or have been remedied, a new growth may take place.

If the knife is employed, the vessels are either slit in their length or cut transversely at several points. The method by electrolysis is the same as used in the removal of superfluous hair (q. v.).; the needle may, if the vessel is short, be inserted along its calibre, or if long, may be inserted at several points in its length.

Excessive connective-tissue growth, exceptionally met with, is to be treated by ablation with the scissors or knife.

Acne Varioliformis.

(Synonyms: Acne Frontalis; Acne Rodens; Acne Necrotica; Lupoid Acne; Necrotic Granuloma.)

Describe acne varioliformis.

Acne varioliformis is characterized by lesions of a moderately superficial papulo-pustular type, which in disappearing leave slight or well-marked pit-like scars. The forehead and scalp are the favorite sites, but they may also occur elsewhere. The eruption is rather scanty as a rule, consisting usually of ten to thirty lesions. They begin as small maculo-papules, as papules, or as minute nodules in or on the skin, and gradually become small pea-sized, with a tendency to slight vesiculation or pustulation at the central part. The lesion is sluggish in its course, drying to a thin crust, which finally falls off, leaving a depressed variola-like scar. New lesions arise from time to time, and the disease thus continues almost indefinitely. There may or may not be itching. In what appears to be a variety of this disease, known usually as acne urticata, there is considerable itching just at the time the lesion is appearing. The malady is not frequent, but occurs in both sexes, usually in those between the ages of twenty and fifty. It seems probable that the eruption is parasitic in origin.

The maladies variously known as hydradenitis suppurativa, acnitis, spiradenitis, folliclis, granuloma necroticum, etc., in which the lesions, primarily at least, are somewhat deeper seated, sluggish in their course, and followed by scarring, could be also included under this head.

Give the prognosis and treatment.

The disease is rebellious and tends to recur. The most efficient applications are those of sulphur and resorcin, the same as prescribed in ordinary acne.

Sycosis.

(Synonyms: Sycosis Vulgaris; Sycosis Non-parasitica; Folliculitis Barbæ; Sycosis Coccogenica.)

What do you understand by sycosis?

Sycosis is a chronic, inflammatory affection involving the hair-follicles, usually of the moustache and bearded regions only, and characterized by papules, tubercles, and pustules perforated by hairs.

Describe the symptoms of sycosis.

Sycosis begins by the formation of papules and pustules about the hair-follicles; the lesions occur in numbers, in close proximity, and together with the accompanying inflammation, make up a small or large area. The pustules are small, rounded, flat or acuminated, discrete, and yellowish in color; they are perforated by hairs, show no tendency to rupture, and are apt to occur in crops, drying to thin yellowish or brownish crusts. Papules and tubercles are often intermingled. More or less swelling and infiltration are noticeable.

Fig. 26.

Sycosis—not infrequently begins in, and sometimes limited to, this region.

The disease is seen, as a rule, only on the bearded part of the face, either about the cheeks, chin or upper lip, involving a small portion or the whole of these parts. It is also sometimes met with involving the hair follicles just within the nasal orifice, and may even be limited to this region.

Occasionally a sycosiform eruption, usually of the side of the bearded region, leaves behind a smooth or keloidal scar, the disease gradually extending—ulerythema sycosiforme (lupoid sycosis).

An inflammation of the hair-follicles of the scalp apparently sycosiform in character, occurring as discrete or aggregated lesions, is sometimes observed, the follicles being destroyed and atrophy or slight scarring resulting—folliculitis decalvans.

Does conspicuous hair loss occur in sycosis?

Ordinarily not; the hairs are, especially at first, usually firmly seated, but in those cases in which suppuration is active, and has involved the follicles, they may, as a rule, be easily extracted. In some cases destruction of the follicles ensues and slight scarring and permanent hair loss result.

State the character of the subjective symptoms.

Pain and itching and a sense of burning, variable as to degree, may be present.

What is the course of the disease?

Essentially chronic, the inflammatory action being of a subacute or sluggish character, with acute exacerbations.

State the causes of sycosis.

Upon the upper lip it may have its origin in a nasal catarrh. Entrance into the follicles of pyogenic micrococci is now regarded as the essential factor. This view being accepted, carries with it the possibility of contagiousness.

It is seen in the male sex only, usually in those between the ages of twenty-five and fifty; and is met with in those in good and bad health, and among rich and poor. It is comparatively infrequent.

What is the pathology of sycosis?

The disease is primarily a perifolliculitis, the follicle and its sheath subsequently becoming involved in the inflammatory process.

How would you distinguish sycosis from eczema?

Eczema is rarely sharply limited to the bearded region, but is apt to involve other parts of the face; moreover, the lesions are usually confluent, and there is either an oozing, red crusted surface, or it is dry and scaly.

How would you exclude tinea sycosis in the diagnosis?

In tinea sycosis, or ringworm sycosis, the history of the case is different. The parts are distinctly lumpy and nodular; the hairs are soon involved and become dry, brittle, loose, and fall out, or they may be readily extracted. The superficial type of ringworm sycosis is readily distinguished by the ring-like character of the patches. In doubtful cases, microscopic examination of the hairs may be resorted to.

Give the prognosis of sycosis.

The disease is curable, but almost invariably obstinate and rebellious to treatment. The duration, extent, and character of the inflammatory process must all be considered. An expression of an opinion as to the length of time required for a cure should always be guarded.

Ulerythema sycosiforme is extremely obstinate. Folliculitis decalvans is also rebellious.

How is sycosis to be treated?

Mainly, and often exclusively, by external applications.

Fig. 27.

Sycosis.

Is constitutional treatment of no avail in sycosis?

In some instances; but, as a rule, it is negative. If indicated, such remedies as tonics, alteratives, cod-liver oil and the like are to be prescribed.

Describe the external treatment.

Crusting, if present, is to be removed by warm embrocations. If the inflammation is of a high grade, and the parts tender and painful, soothing applications, such as bland oils, black wash and oxide-of-zinc ointment, cold cream and petrolatum, are to be used; boric-acid solution, fifteen grains to the ounce, may be advised in place of black wash.

In most cases, however, astringent and stimulating remedies are demanded from the start, such as: diachylon ointment, alone or with ten to thirty grains of calomel to the ounce; oleate of mercury, as a five- to twenty-per-cent. ointment; precipitated sulphur, one to three drachms to the ounce of benzoated lard, or lard and lanolin; a ten- to twenty-five-per-cent. ichthyol ointment; and resorcin lotion or ointment, ten to twenty per cent. strength.

Fig. 28.

Sycosis.

A change from one application to another will be found necessary in almost all cases.

In obstinate cases the x-ray treatment can be used, as it has proved itself valuable in some instances; as in other diseases, it should be employed cautiously.

What would you advise in regard to shaving?

When bearable (and after a few days' application of soothing remedies it almost always is), it is to be advised in all cases, as it materially aids in the treatment. After a cure is effected it should be continued for some months, until the healthy condition of the parts is thoroughly established.

When is depilation advisable as a therapeutic measure?

When the suppurative process is active, in order to save the follicles from destruction; incising or puncturing the pustules will often accomplish the same end.

Depilation is in all cases a valuable therapeutic measure, but it is painful; as a routine practice, shaving is less objectionable and, upon the whole, is probably as satisfactory. Those who make free use of the x-ray commonly push it to the point of producing depilation.

Dermatitis Papillaris Capillitii.

(Synonym: Acne Keloid.)

Fig. 29.

Dermatitis Papillaris Capillitii

Describe dermatitis papillaris capillitii.

This is a peculiar, mildly inflammatory, sycosiform, keloidal, acne-like disease of the hairy border of the back of the neck, often extending upward to the occipital region; partaking, especially later in its course, somewhat of the nature of keloid. Several or more acne-like lesions, papular and pustular, closely grouped or bunched, appear, developing slowly, usually to the size of peas; are red, pale red, or whitish, often enveloping small tufts of hair, and attended with more or less hair loss. Its course is gradual and persistent. It is an exceedingly rare condition, the exact nature of which is still obscure.

Give the treatment.

Treatment, which is usually unsatisfactory, consists of stimulating applications—the same, in fact, as employed in sycosis, sulphur and ichthyol deserving special mention. Depilation is essential.

Impetigo Contagiosa.

Give a descriptive definition of impetigo contagiosa.

Impetigo contagiosa is an acute, contagious, inflammatory disease, characterized by the formation of discrete, superficial, flat, rounded, or ovalish vesicles or blebs, soon becoming vesico-pustular, and drying to thin yellowish crusts.

Upon what parts does the eruption commonly appear?

Upon the face, scalp, and hands, and exceptionally upon other regions.

Describe the symptoms of impetigo contagiosa.

One, several or more small pin-head-sized papulo-vesicles or vesicles make their appearance, usually upon the face and fingers. In the male adult the region of the neck and beard is a favorite situation. They increase in size by extending peripherally, but are more or less flattened and umbilicated, and are without conspicuous areola. The lesions may attain the size of a dime or larger, and when close together may coalesce and form a large patch. In some cases distinct blebs result, and a picture of pemphigus eruption presented; it is probable that many of the cases of “contagious pemphigus” belong to this class. New lesions may appear for several days, but finally, in the course of a week or ten days, they have all dried to thin, wafer-like crusts, of a straw or light-yellow color, but slightly adherent, and appearing as if stuck on; these soon drop off, leaving faint reddish spots, which gradually fade. In some cases there is so decided a tendency to clear and dry up centrally while spreading peripherally that the eruption has a ring-like aspect; this seems especially so in the bearded region of the male adult.

Instead of presenting as described, it may occur as one or more pea- or finger-nail-sized, rounded and elevated, usually firm, discrete pustules, scattered over one part, or more commonly over various regions, such as the face, hands, feet and lower extremities. The pustules are such from the beginning, and when developed are usually of the size of a pea or finger-nail, elevated, semi-globular or rounded, with somewhat thick and tough walls, and of a whitish or yellowish color; at first there may be a slight inflammatory areola, but as the lesion matures this almost, if not entirely, disappears. The pustules show no disposition to umbilication, rupture or coalescence; drying in the course of several days or a week to yellowish or brownish crusts, which soon drop off, leaving no permanent trace. This variety was formerly thought to be a distinct disease, and was described under the name of impetigo simplex.

As a rule there are no constitutional symptoms, but in the more severe cases the eruption may be preceded by febrile disturbance and malaise. Itching may or may not be present.

State the cause of the disease.

It is contagious, the contents of the lesions being inoculable and auto-inoculable. At times it seems to prevail in epidemic form. Pyogenic microörganisms are now regarded as causative. A relationship to vaccination has been alleged by some observers. It is more commonly observed in infants and young children.

From what diseases is impetigo contagiosa to be differentiated?

From eczema, pemphigus, and ecthyma.

How does impetigo contagiosa differ from these several diseases?

By the character of the lesions, their growth, their superficial nature, their course, the absence of an inflammatory base and areola, the thin, yellowish, wafer-like crusts, and usually a history of contagion.

State the prognosis.

The effect of treatment is usually prompt. The disease, indeed, tends to spontaneous disappearance in two to four weeks; in exceptional instances, more especially in those cases in which itching is present, the excoriations or scratch-marks become inoculated, and in this way it may persist several weeks.

What is the treatment of impetigo contagiosa?

Treatment consists in the destruction of the auto-inoculable properties of the contents of the lesions; this is effected by removing the crusts by means of warm water-and-soap washings, and subsequently rubbing in an ointment of ammoniated mercury, ten to twenty grains to the ounce. Some cases respond more rapidly to the use of a drying ointment, such as Lassar's paste, with ten to twenty grains of white precipitate or sulphur to the ounce. In itching cases, a saturated solution of boric acid, or a carbolic-acid lotion, one to two drachms to the pint, is to be employed for general application.

Impetigo Herpetiformis.

Describe impetigo herpetiformis.

Impetigo herpetiformis is an extremely rare disease, observed usually in pregnant women, and is characterized by the appearance of numerous isolated and closely-crowded pin-head-sized superficial pustules, which show a decided disposition to the formation of circular groups or patches. The central portion of these groups dries to crusts, while new pustules appear at the peripheral portion. They tend to coalesce, and in this manner a greater part of the whole surface may, in the course of weeks or months, become involved. Profound constitutional disturbance, usually of a septic character, precedes and accompanies the disease; in almost every instance a fatal termination sooner or later results.

It is possibly a grave type of dermatitis herpetiformis.

Ecthyma.

Give a descriptive definition of ecthyma.

Ecthyma is a disease characterized by the appearance of one, several or more discrete, finger-nail-sized, flat, usually markedly inflammatory pustules.

Describe the symptoms and course of ecthyma.

The lesions begin as small, usually pea-sized, pustules; increase somewhat in area, and when fully developed are dime-sized, or larger, somewhat flat, with a markedly inflammatory base and areola. At first yellowish they soon become, from the admixture of blood, reddish, and dry to brownish crusts, beneath which will be found superficial excoriations. The individual pustules are usually somewhat acute in their course, but new lesions may continue to appear from day to day or week to week. As a rule, not more than five to twenty are present at one time, and in most cases they are seated on the legs. More or less pigmentation, and sometimes superficial scarring, may remain to mark the site of the lesions.

Itching is rarely present, but there may be more or less pain and tenderness.

What is the cause of ecthyma?

It is essentially a disease of the poorly cared-for and ill-fed; the direct exciting cause is the introduction of pyogenic microörganisms into the follicular openings. It is closely allied to impetigo contagiosa, and may in fact be regarded as a markedly inflammatory form of the latter affection. It seems much less contagious, however. It is commonly observed in male adults.

From what diseases is ecthyma to be differentiated?

From impetigo contagiosa, and the flat pustular syphiloderm.

How is it distinguished from these several diseases?

The size, shape, inflammatory action, and the depraved general condition, the distribution and lesser-contagiousness will distinguish it from impetigo contagiosa; and the absence of concomitant symptoms of syphilis, and of positive ulceration, as well as its distribution and more rapid and inflammatory course, will exclude the pustular syphiloderm.

State the prognosis.

The disease is readily curable, disappearing upon the removal of the predisposing cause and the employment of local antiseptic applications.

What treatment is to be advised?

Good food, proper hygiene and tonic remedies; and, locally, removal of the crusts and stimulation of the underlying surface with an ointment of ammoniated mercury, ten to thirty grains to the ounce.

The following mild antiseptic lotion, which materially lessens the tendency to the formation of new lesions, may be applied to the affected region two or three times daily:—

℞ Acidi borici, .................................... ʒiv
Resorcini, ....................................... ʒij
Glycerinæ, ...................................... fʒij
Alcoholis, ...................................... f℥j
Aquæ, ....................q.s. ad. ............... Oj. M.

A weak lotion of thymol, corrosive sublimate or ichthyol would doubtless be equally effectual.

Pemphigus.

What do you understand by pemphigus?

Pemphigus is an acute or chronic disease characterized by the successive formation of irregularly-scattered, variously-sized blebs.

Name the varieties met with.

Two varieties are usually described—pemphigus vulgaris and pemphigus foliaceus.

Describe the symptoms and course of pemphigus vulgaris.

With or without precursory symptoms of systemic disturbance, irregularly scattered blebs, few or in numbers, make their appearance, arising from erythematous spots or from apparently normal skin. They vary in size from a pea to a large egg, are rounded or ovalish, usually distended, and contain a yellowish fluid which, later, becomes cloudy or puriform. If ruptured, the rete is exposed, but the skin soon regains its normal condition; if undisturbed, the fluid usually disappears by absorption. Each lesion runs its course in several days or a week.

A grave type of pemphigus is exceptionally observed in the newborn—pemphigus neonatorum.

What course does pemphigus vulgaris pursue?

Usually chronic. The disease may subside in several months and the process come to an end, constituting the acute type. As a rule, however, the disease is chronic, new blebs continuing to appear from time to time for an indefinite period.

Fig. 30.

Pemphigus (mulatto).

In what respects does the severe form of pemphigus vulgaris differ from the ordinary type?

In the severe or malignant type the eruption is more profuse; there is marked, and often grave, systemic depression, and the lesions are attended with ulcerative action.

Describe the symptoms and course of pemphigus foliaceus.

In this, the grave type of the disease, the blebs are loose and flaccid, with milky or puriform contents, rupturing and drying to crusts, which are cast off, disclosing the reddened corium. New blebs appear on the sites of disappearing or half-ruptured lesions, and the whole surface may be thus involved and the disease continue for years, compromising the general health and eventually ending fatally.

In some cases of pemphigus (pemphigus vegetans) a vegetating or papillomatous condition develops from the base of the lesion, with an offensive discharge; it is usually a grave type of the malady.

Exceptionally cases (dermatitis vegetans) are met with which have a close similarity in their symptoms to pemphigus vegetans, but in which the eruption is more or less limited to the genitocrural region. The disorder is not malignant and usually yields to cleanliness and antiseptics.

What is the character of the subjective symptoms in pemphigus?

The subjective symptoms consist variously of heat, tenderness, pain, burning and itching, and may be slight or troublesome.

What is known in regard to the etiology of pemphigus?

The causes are obscure; general debility, overwork, shock, nervous exhaustion, and septic conditions (microörganisms) are thought to be of influence. There seems no doubt that those who have to do with cattle products, especially butchers, are subjects of acute and usually grave pemphigus. Vaccination has exceptionally been responsible for the disease, probably through some coincidental infection. The disease is not contagious, nor is it due to syphilis. It may occur at any age.

It is a rare disease, especially in this country. Most of the cases diagnosed as pemphigus by the inexperienced are examples of bullous urticaria, bullous erythema multiforme, and impetigo contagiosa.

What is the pathology?

The lesions are superficially seated, usually between the horny layer and upper part of the rete. Round-cell infiltration and dilated blood vessels are found about the papillæ and in the subcutaneous tissue. The contents of the blebs, always of alkaline reaction, are at first serous, later containing blood corpuscles, pus, fatty-acid crystals, epithelial cells, and occasionally uric acid crystals and free ammonia.

From what diseases is pemphigus to be differentiated?

From herpes iris, the bullous syphiloderm, impetigo contagiosa and dermatitis herpetiformis.

How do these several diseases differ from pemphigus?

The acute course, small lesions, concentric arrangement, variegated colors, and distribution, in herpes iris; the thick, bulky, greenish crusts, the underlying ulceration, the course, history, and the presence of concomitant symptoms of syphilis, in the bullous syphiloderm; the history, course, distribution, the character of the crusting, and the contagious and auto-inoculable properties of the contents of the lesions, in impetigo contagiosa; the tendency to appear in groups, the smaller lesions, the intense itchiness, course, multiform characters of the eruption and the disposition to change of type in dermatitis herpetiformis,—will serve as differential points.

State the prognosis of pemphigus.

Its duration is uncertain, and the issue may in severe cases be fatal. In the milder types, after months or several years, recovery may take place.

The extent and severity of the disease and the general condition of the patient are always to be considered before an opinion is expressed.

Pemphigus neonatorum usually ends fatally.

Give the treatment of pemphigus.

Both constitutional and local measures are demanded. Good nutritious food and hygienic regulations are essential. Arsenic and quinia are the most valuable remedies. The former, in occasional instances, seems to have a specific influence, and should always be tried, beginning with small doses and increasing gradually to the point of tolerance and continued for several weeks or longer. The remedy should not be set aside as long as there are signs of improvement, unless the supervention of stomachic, intestinal or other disturbance demand its discontinuance. Other tonics, such as iron, strychnia and cod-liver oil, are also at times of service. The blebs should be opened and the parts anointed or covered with a mild ointment. In more general cases bran, starch and gelatin baths, and in severe cases the continuous bath, if practicable, are to be used.