Chapter II: The Peculiarities of Certain Accidental Acute and Chronic Diseases (10)

That morbid vascularization exists, is shown by the peculiar mottled appearance of the skin, which has often been interpreted as a proof of vaso-motor paralysis (Duchenne). On such an hypothesis, further, the curious and otherwise inexplicable relations between pseudo-hypertrophy and hæmophilia[84] would be explained. The one or the other hereditary disease would be due to imperfection in the blood-vessels--here of structure, there of architecture. This imperfection could be directly traced to the mesoblast in the embryo, in which the vascular tissues exclusively originate. Whether we should admit the bold speculation of His[85] that the tissues of the mesoblast are exclusively derived from the ovum, while {578} the archiblastic tissues--the nervous, muscular, epithelial, and glandular--come from the substance of the spermatozoa fused with it, is beyond the scope of this paper to discuss. But were this speculation well founded, the independent morbid tendencies of the mesoblast would be rendered by so much the more plausible.

[Footnote 84: Part of which do not exist between pseudo-hypertrophy and progressive atrophy, since the latter disease is not exclusively inherited through the mother.]

[Footnote 85: _Unsere Körper Form_.]

The fact that the disease begins in the extensor muscles of the lower extremities is probably to be explained by the rapid development of these muscles during early childhood, and by the functional strain imposed on them during the effort of learning to walk. It is thus really analogous to the début of progressive atrophy in the muscles of the hands of adults--the muscles whose functional activity is the most incessant and the most complex during adult life.

The preponderance of the disease in males remains unexplained, unless it be that the greater extent of muscular development in the male necessitates a greater intensity of developmental force for the muscles, whose deficiency, therefore, would earlier be made manifest.

DIAGNOSIS.--The diagnosis of pseudo-hypertrophic paralysis can never be difficult in typical cases and at an advanced period of the disease. During the early period the diagnosis rests on the gradual diminution of force in the lower extremities, without atrophy or with apparently excellent development of their muscles; the straddling of the legs, lordosis, and lateral oscillation, all at first slight, but constantly becoming more and more emphasized; the peculiar method of rising by placing the hands on the knees and then gradually climbing up the thighs. In the second period the enlargement of the calf or other muscles of the lower limbs, in the third the extension of the paresis to the upper extremities, associated with wasting of the pectorals and usually some of the extensors of the back, confirm beyond question the diagnosis. This may be further established by examination of small fragments of muscular fibre removed by means of the harpoon or trocar, and the repeated examinations, which serve, moreover, to mark the progress of the disease.

Few diseases require to be differentiated. One very rare disease that might be confounded with pseudo-hypertrophy is the infantile form of progressive muscular atrophy. This is distinguished from the ordinary form of atrophy by beginning in the muscles of the face,[86] especially the orbicularis oris, from whose defective contractility the lips become thick and motionless. The morbid process then progresses downward, and is thus in notable contrast with that of pseudo-hypertrophy, which invariably begins in the lower limbs and extends upward, invading the face only by exception.

[Footnote 86: Duchenne has seen seventeen cases of this disease.]

It is probably after the establishment of talipes equinus and of flexions at the knee- or hip-joint that pseudo-hypertrophy would be most liable to be confounded with infantile atrophic paralysis. In the latter, however, the talipes is much more rarely double, and, if existing, is usually complicated with varus. At an advanced stage of pseudo-hypertrophy the enlargement of the calf is apt to be confined to its upper part, and the retraction of the lower half simulates atrophy, even when this has not really set in. At this stage, moreover, the thighs and gluteal regions are usually atrophied, so that the resemblance to an atrophic paralysis may be considerable. This may be still further increased in those rare {579} cases of extensive polio-myelitis, where paralysis of one or more of the upper extremities coincides with lumbar paraplegia. It is extremely rare, however, that both arms are paralyzed and atrophied,[87] while this is the rule, with approximative symmetry, in pseudo-hypertrophy. In the latter disease, moreover, there are paralysis and atrophy of the muscles of the trunk and abdomen, which is scarcely ever seen, and never to the same extent, in atrophic paralysis. The reflex excitability is lost in the latter disease, as also the faradic; the latter, often intact in pseudo-hypertrophy, rarely is quite abolished. Finally, the history of the case is generally decisive: gradual development in the one, sudden onset, with immediate maximum intensity of paralysis, in the other; primitive wasting of the paralyzed muscles in the spinal paralysis, enlargement preceding the atrophy in the pseudo-hypertrophic paralysis.

[Footnote 87: A patient described by Eulenburg was affected by such general paralysis, but recovered after five months' treatment.]

Rachitis, with its frequent polysarcia and paretic gait, might sometimes lead to a suspicion of muscular pseudo-hypertrophy, as, conversely, the earlier symptoms of the latter disease may be erroneously referred to rachitis. The error is all the more facile because children afflicted with pseudo-hypertrophy are not unfrequently rachitic, and the symptoms of specific paralysis and muscular sclerosis may easily seem to deepen out of those of muscular inertia and subcutaneous fat which are due to the nutritive diathesis. The consistency of the enlarged limbs is, however, different--soft and flabby in rachitis, hard, even stony, in pseudo-hypertrophy. When in the latter the subcutaneous fat is atrophied instead of increased, the muscles seem to make hernial protrusions through the emaciated skin.

Congenital cerebral disease, due to intra-uterine lesion, causes imperfect walking, and even contraction of the calf-muscles, which may simulate the analogous symptoms of pseudo-hypertrophic paralysis. But the trunk is bent straight forward, and not bent in lordosis; the lower extremities tend to cross in spastic paraplegia; there is no lateral oscillation of the trunk, and the faradic contractility is always preserved. The progress of the diseases suffices to decide all doubts.

TREATMENT.--The excessively bad prognosis of pseudo-hypertrophic paralysis may be inferred from the foregoing description. Duchenne claims to have had two cases brought to him at the early stage of the disease. The first (Obs. 9) was a boy attacked at the age of seven and a half with paresis of the lower extremities. He soon began to walk with a straddling gait, lordosis, and lateral oscillation. Thirty-four months later some enlargement of the calves was noticed, but the disease remained stationary for six months, when the patient was brought to Duchenne. He was treated by hydro-therapeutics, massage, and faradization of the affected muscles. Cure was complete in six months.

The second case, (Obs. 13) was a little girl six and a half years old. Paresis of the lower limbs began at the age of four and a half, and rapidly increased. The legs and thighs began to enlarge shortly after the first appearance of the paresis. Treatment began in about a year, and was conducted as in the first case, but in addition cod-liver oil and bitters were administered internally. Cure after a few months' treatment.

Duchenne refers the beneficial effect of the faradic current to a {580} stimulating action on the vaso-motor nerves and capillary circulation, which he assumes to be paralyzed in this disease. The important point is to exert this stimulus before the hyperplasia of the connective tissue is far advanced.

Benedikt claims to have improved five cases by galvanization of the sympathetic. But the treatment was certainly based on an erroneous theory of the disease, and the alleged results must be received with caution.

Uhde[88] claims to have arrested the progress of the disease in the gastrocnemii muscles by a double tenotomy operation performed for the relief of pes equinus. The patient was a boy of eleven, in whom the disease had begun at the age of five. At the time of observation all the muscles of the legs, as also the glutæi and sacro-lumbales, were hypertrophied. The feet could not be brought to the ground, owing to retraction of the calf-muscles: standing and walking were entirely impossible, and even the power to move the limbs in a recumbent position was very much limited. Faradization during a fortnight produced no effect. Then the tendons were cut, and faradization continued. In a month the patient could execute slight movements in bed; three weeks later he could walk along the ward; and four months after the operation he could walk alone and with the soles of the feet flat on the ground. The calves were softer than before, and diminished in circumference. But as the history stops here, it is possible that the two latter changes depended on a substitution of fatty infiltration for sclerosis. By this, moreover, the muscular fibre would be less compressed, and in its temporary liberation would for a while seem to regain part of its force. The last case of alleged recovery that we have seen is by Donkin.[89]

[Footnote 88: _Langenbeck's Archiv für Chir._, Bd. xvi., 1874.]

[Footnote 89: _Brit. Med. Journ._, 1882, vol. i.]

Gowers remarks[90] that treatment must be directed rather against the effects of the morbid process than against the morbid process itself, which, as a primary error of development,[91] must be, to a large extent, beyond our influence. As internal remedies, Gowers recommends arsenic, phosphorus, and cod-liver oil, noting that iron and strychnine seem to have no effect.

[Footnote 90: _Loc. cit._, p. 52.]

[Footnote 91: Gowers says, "of the muscular tissue," but we have shown reasons why this should rather be sought in the blood-vessels of the part.]

Faradization also, which is nearly always used, must have nearly always disappointed expectation, or more cures would be recorded. Systematic muscular exercises are recommended as the appropriate physiological stimulus to muscular growth. But in view of the fact that precisely those muscles are earliest and most profoundly affected which are exposed to the most strenuous influence of this stimulus, it is theoretically doubtful whether this advice be valuable.

{581}

DISEASES OF THE SKIN.

{582}

{583}

DISEASES OF THE SKIN.[1]

BY LOUIS A. DUHRING, M.D., AND HENRY W. STELWAGON, M.D.

[Footnote 1: In the general arrangement and order of diseases the classification adopted by the American Dermatological Association has been followed.

For obvious reasons, personal references are almost entirely omitted in the text, but the authors desire to acknowledge valuable suggestions derived from the writings of J. C. White, R. W. Taylor, L. D. Bulkley, J. N. Hyde, W. A. Hardaway, A. R. Robinson, H. G. Piffard, A. Van Harlingen, G. H. Fox, and others.]

CLASS I.--DISORDERS OF SECRETION.

Hyperidrosis.

Hyperidrosis, or excessive sweating, is a functional disturbance of the sweat-glands characterized by an increased flow of sweat. It may be local or general, slight or excessive. As a local affection, the form which mainly interests the dermatologist, it occurs usually about the hands and feet, especially the palmar and plantar surfaces, and also about the axillæ and genitalia. If the secretion is excessive, maceration of the epidermis results, with tenderness, and even inflammation, of the parts as a consequence: this is not infrequently the result when the feet are involved, a sodden appearance of the parts being not unusual. The affection may be acute or chronic, the latter usually being the case. It is purely a functional disorder, no anatomical changes taking place in the glands or surrounding tissues. There is no change in the nature of the secretion. Debility is usually the fault in general hyperidrosis. The causes of the local varieties are in many cases obscure. Faulty innervation is doubtless frequently an important factor. The nervous system possesses a powerful control over this secretion. The diagnosis presents no difficulties, as there is no other affection with which it could be confounded. Prickly heat and oily seborrhoea are considered to bear some resemblance, but confusion is not likely to occur. Although some cases are readily relieved, the majority prove obstinate. The duration, locality, and extent of the affection, as well as the condition of the general health, are to be considered in pronouncing a prognosis. The disease is liable to relapse.

Concerning treatment, in addition to quinine and the ordinary tonic remedies, belladonna and ergot may be referred to as being useful, particularly the former. Local treatment is always demanded. Dusting-powders are useful, such as starch or lycopodium powder, to which from ten to thirty grains of salicylic acid to the ounce may be added with {584} benefit. They are to be applied freely, so as to absorb the secretions. Astringent lotions are also of value, and constitute the most agreeable method of treatment. One drachm of tannic acid to six ounces of alcohol will be found of service. Solutions of alum and of zinc sulphate may also be employed. Boric acid, either in powder or in the form of a saturated solution, and tincture of belladonna as a lotion, full strength or diluted with alcohol, are both useful. A successful plan of treatment is that by diachylon ointment (unguentum diachyli) as recommended by Hebra. The parts are first cleansed and dried, and then the ointment applied on strips of muslin as a plaster. It is to be renewed twice daily, the parts on each occasion being rubbed dry with lint or a soft towel and lycopodium or starch powder. Water is not to be employed. The treatment must be continued one or two weeks, and then the ointment omitted, and a dusting-powder used night and morning for several weeks. In many cases relief results from one such course; others may require several repetitions. If a good diachylon ointment is not procurable, the same plan may be followed out with an ointment made by melting together equal parts of lead plaster and cosmoline, or with an ointment of tannic acid, a drachm to the ounce.

Anidrosis.

Anidrosis is a functional disorder of the sweat-glands characterized by a diminution or suppression of the secretion. It is the opposite condition of hyperidrosis, and occurs to a slight extent in certain general diseases, and also in some affections of the skin, as ichthyosis. It sometimes occurs as an idiopathic disorder, and may cause much discomfort. Occasionally in nerve-injury localized areas of diminished or suppressed secretion occur. The treatment should be conducted upon general principles, including warm or vapor baths and friction.

Bromidrosis.

Bromidrosis is a functional disorder of the sweat-glands in which the secretion, which may be either normal or excessive in quantity, is of an offensive odor. The quantity is usually excessive, as in hyperidrosis, but occasionally it is normal in amount, while the odor is heavy, strong-smelling, offensive, and disgusting. It may be universal or local in character, more frequently the latter; in either case the odor is rendered more marked by heat and increased perspiration. In smallpox, measles, typhus and relapsing fevers, and in some nervous affections peculiar odors are noticed. Certain drugs, as sulphur, asafoetida, and like substances, taken internally, may be detected in the odor of the sweat. It is as a localized disorder, however, that the affection usually comes under observation, the axillæ, genitalia, and feet being favored localities, the last named being the most common region affected. It occurs about the soles and between the toes, and is generally symmetrical. The sweating, if excessive, causes after a time more or less maceration, and sometimes hyperæmia or inflammation; the skin becomes {585} whitish and sodden, the affected area having a pinkish margin. Both Hebra and Thin consider the socks and soles of the shoes--which become thoroughly permeated by the secretion--and not the feet, the source of the odor. The latter observer states that he has found innumerable bacteria (Bacterium foetidum) in the fluid in which the sock is soaked. The etiology of the disease is not well understood, but it is without doubt due to some nervous derangement.

The treatment is about the same as that advised for hyperidrosis. In addition, however, to the remedies named for that disorder, there are several other local remedies that have been found useful in this disease, among which may be mentioned a wash of potassium permanganate, two or three grains to the ounce, and chloral, twenty or thirty grains to the ounce of water or dilute alcohol. Thin recommends the use of cork soles, which (and also the socks) are first to be soaked in a boric-acid solution and dried.

Chromidrosis.

Chromidrosis is a functional disorder of the sweat-glands, the secretion being variously colored and generally increased in quantity. The color may be blackish, bluish, reddish, greenish or yellowish, bluish and reddish being the most common. The affection is usually local, occurring in the form of patches, the face, neck, arms, backs of the hands and feet, chest, and abdomen being the favorite localities. The disease is rare. Ferrocyanide of iron, copper, and other substances have been detected in the secretion, to the presence of which doubtless the colors are due. It is generally observed in nervous and excitable persons, chiefly in unmarried women; but it has also been noted in strong men. It tends to recur, and may appear on different parts of the body with each manifestation. The treatment should be directed against the suspected cause, with especial reference to the nervous system.

Uridrosis.

Uridrosis, or urinous sweat, is a functional disorder of the sweat-glands, the secretion containing the elements of the urine, especially urea. This latter is occasionally detected in the sweat of persons apparently in good health. In some cases, however, it exists in such quantity as to be noticeable on the skin, appearing usually on the face and hands as a colorless or whitish saline crystalline deposit or coating. In most of the marked cases reported partial or complete suppression of the renal function has preceded or accompanied the condition.

Phosphoridrosis.

Phosphoridrosis is the rare condition in which sweat is phosphorescent. It is sometimes seen in the later stages of phthisis, also in miliaria, and occasionally in persons who have eaten of putrid fish.

{586} Sudamen.

Sudamen (syn. miliaria crystallina) is a non-inflammatory disorder of the sweat-glands characterized by pinpoint- to pinhead-sized, isolated, superficial, translucent, whitish vesicles. The lesions make their appearance on any portion of the body, but have a predilection for certain regions of the trunk, especially where the epidermis is thin. They show themselves as numerous, closely-crowded, discrete, whitish or pearl-colored minute elevations, in appearance not unlike dew-drops. They form rapidly, remaining discrete, never becoming puriform, and evince no tendency to rupture. They are non-inflammatory, never reddish in color, and are without areolæ. The fluid disappears by absorption and the epidermal covering by subsequent desquamation. The lesions may appear in successive crops or new vesicles may show themselves irregularly from time to time. On the other hand, the first outbreak may disappear rapidly, and no further manifestation show itself. Sudamina occupying the face are usually seen in middle-aged females. The vesicles here are larger, deeper-seated, and more persistent.

Constitutional debility is a predisposing cause of the disease. Diseases accompanied with a high temperature--such, for example, as typhus and typhoid fevers, tuberculosis, and acute articular rheumatism--are frequently responsible for the eruption. The vesicles are produced by the collection of sweat in some part of the sweat-duct or epidermis, usually the latter. As ordinarily seen, the vesicles are situated between the lamellæ of the horny layer, the sweat having made its way from a rupture in an obstructed duct. In those exceptional cases of deep-seated and more persistent sudamina occurring about the face, the vesicles are situated in the corium, and are caused by a dilatation of the duct. The affection is to be distinguished from miliaria by the absence of inflammatory symptoms.

The course and duration of the disease depend upon the cause. In the treatment, removal of the etiological factor is of first importance. For external use some simple dusting-powder, such as equal parts of starch and lycopodium, or frequent bathing of the parts with an evaporating lotion, such as alcohol and water or vinegar and water, may be employed.

Seborrhoea.

Seborrhoea is a disease of the sebaceous glands characterized by an excessive and abnormal secretion of sebaceous matter, appearing on the skin as an oily coating, crusts, or scales. Although most commonly seated on the scalp and face, other parts of the general surface may also be attacked. Upon the trunk the sternal and intrascapular regions are the parts most frequently affected. It may occur at any period of life, although more common in adolescent and early adult age. In newly-born infants it constitutes the vernix caseosa, in which case, however, it is physiological rather than pathological. The course of the disease varies, at times disappearing spontaneously or with simple remedies, and in other cases being rebellious even to judicious treatment. It is in most cases influenced by the tone of the general health. In the majority of {587} instances the disease is non-inflammatory; some cases, on the other hand, show intense hyperæmia and even inflammatory signs, while not infrequently the disease varies from time to time in the activity of the process. Itching and burning in a varying degree are sometimes present; the subjective symptoms are, however, rarely marked. The disease is usually better in warm than in cold weather.

There are two clinical varieties of the disease, depending upon the character of the secretion--seborrhoea oleosa and seborrhoea sicca. Seborrhoea oleosa appears as an oily, greasy coating upon the skin, and is seen most frequently about the nose and forehead. The oiliness may be slight or excessive. Seborrhoea sicca is the more common form of the disease, and is seen usually on the scalp and face, and occasionally on other parts of the body. It consists in the formation of dry sebaceous crusts, usually of a grayish-yellow color, which are slightly adherent. Frequently both varieties are seen together, and present products of a mixed character.

Occurring upon the scalp, constituting seborrhea capitis, popularly known as dandruff, the disease is commonly of the dry or mixed variety, and usually involves the whole of that region. Sometimes it occurs in disseminate patches. It appears as small, dry, and pulverulent scales, detached and loose, or as thin or thick, greasy, crust-like, adherent masses. In the latter condition the hairs may be matted or pasted to the scalp. The hair sooner or later becomes affected, and in consequence is dry and lustreless, and gradually falls out. The disease, if neglected, finally causes more or less structural change in the follicles, with permanent alopecia as a result. The skin beneath the crusts in chronic cases is often of a dull, grayish or bluish-gray color; sometimes, however, it is hyperæmic. Occurring on other hairy parts, as the bearded region and eyebrows, the same characters are presented, but ordinarily they are less marked. At times a condition is seen on the scalp in which there is a mild degree of inflammation, with the formation of fine, dry epithelial scales, with slight or marked itching and burning.

Seborrhoea when occurring about the nose and face--seborrhoea faciei--is characterized by more or less redness, oiliness, and sometimes with a moderate amount of scaling and crusting. The follicular openings are enlarged and patulous, and are either free or contain sebaceous plugs. On the trunk--seborrhoea corporis--the disease tends to form circular and confluent scaly patches on a pale or hyperæmic base, with the sebaceous covering extending into the follicles in the form of projections. Or the skin may be slightly reddened, the follicles open and enlarged, the scales having been detached by the rubbing of the clothing. Seborrhoea when involving the genital region--seborrhoea genitalium--presents characters somewhat different. The inner surface of the prepuce, the glans penis, and the sulcus in the male, and the labia and clitoris of the female, are the parts commonly affected. A soft, cheesy mass collects about the parts, which, unless frequently removed, rapidly undergoes decomposition. If neglected or if the disease is marked, inflammatory symptoms may arise.

The disease is functional in character, the increased and usually changed oily secretion, with the epithelial scales from the glands and ducts, forming its products. There is no alteration in the gland structure except in {588} long-continued cases, in which there may be slight atrophy. The affection depends usually upon an impairment of the general health. Chlorosis and anæmia are frequently the predisposing causes. Stomachic, intestinal, and uterine derangements are also, not infrequently, factors. Persons of light complexion are more prone to the dry form, while those of a dark complexion usually show the oily variety. It is also to be noted that the affection is not infrequently seen in persons apparently in perfect health, yielding, however, in such cases to simple external treatment.

Seborrhoea occurring on the scalp must be distinguished from eczema and from psoriasis. In eczema the skin is somewhat infiltrated, thickened, and reddened, and rarely involves the whole scalp; there is less scaliness, and at times more or less of the characteristic gummy exudation and marked itching of that disease. Psoriasis occurs usually in well-defined, circumscribed inflammatory patches, and in most cases shows signs of the disease upon other regions. These same points are of value in differentiating when the disease is upon non-hairy parts. From lupus erythematosus, which it may at times, on the face, closely resemble, it is to be distinguished by the absence of infiltration and thickening, of the sharply-defined border and violaceous or reddish color of that disease, as well as by the absence of atrophic scarring. Seborrhoea differs from ringworm, which it occasionally resembles, especially on the trunk, by its history, slow course, and by the greasiness of the scales. In obscure cases the microscope will determine the question.

TREATMENT.--It is a curable disease, but in the majority of cases proves obstinate. The rapidity of the cure depends in a great measure upon the removal of the predisposing causes. In seborrhoea of the scalp, if the process be allowed to continue through a long period, more or less marked permanent alopecia, especially of the vertex, may result. Even in unfavorable cases, however, much may be done toward promoting a regrowth of hair.

Treatment consists in both constitutional and local measures. The former is frequently of importance, with a view of securing, if possible, permanent relief. Iron, quinine, cod-liver oil, and arsenic are useful. In some cases one-tenth to one-quarter grain doses of calx sulphurata, three or four times daily, will prove of benefit. Dyspepsia, if present, is to be relieved. Fresh air and healthful exercise will sometimes aid considerably in effecting a cure.

External treatment is demanded in every case. The crusts and scales are to be removed. If in abundance, oily applications, such as olive or almond oil, are to be made to the parts, and after remaining on for six or twelve hours to be washed off with soap and hot water. In severe cases several repetitions may be found necessary. On the other hand, in mild cases simply washing with castile or ordinary toilet soap and warm water, or with a decoction of soap-bark, will suffice. If scaling and crusting are marked, instead of the plain soap sapo viridis should be used, either alone or in the form of the spiritus saponatus kalinus, consisting of two parts of sapo viridis in one of alcohol, perfumed with an essential oil. A tablespoonful of this poured on the scalp, and then a small quantity of hot water added and the parts rubbed briskly, wall produce considerable lather; the scalp is then to be rinsed with warm water, the hair {589} dried, and an oily or fatty substance applied. If after a removal of the crusts the skin is found to be irritated, a bland ointment, such as petroleum ointment, will be the best application. Glycerin and alcohol, one to four, will be of service if the skin is dry and hyperæmic. Subsequently more stimulating applications may be made; in the greater number of cases these are indicated from the start. Chloral, as in the following prescription, may sometimes be used with benefit:

Rx. Chloralis, scruple ij;
Glycerinæ, minim xx;
Aquæ rosæ, fluidounce iv. M.

Gentle friction should be employed in making the application. If the lotion is too drying, more glycerin may be added. An excellent application in many cases is the following:

Rx. Acidi carbolici, minim xxx;
Olei ricini, fluidrachm ij;
Alcoholis, fluidounce j drachm vj. M.

This may be perfumed with a few drops of any essential oil. If greater stimulation is required, then to this last combination one to three drachms each of tincture of cantharides and tincture of capsicum may be added. Liquid applications may be made as follows: An eye-dropper is filled and introduced between the hairs at different points of the scalp, and a few drops pressed out, and subsequently rubbed in by means of a piece of flannel rag; in this manner the application is brought into intimate association with the skin without to any extent soiling the hair.

Ointments are also useful. Sulphur, one or two drachms to the ounce, is one of the best. Ammoniated mercury, twenty to sixty grains to the ounce, red precipitate, five to twenty grains to the ounce, are both valuable. In some cases tannic acid, one or two drachms to the ounce, acts well; also a naphthol ointment, twenty or thirty grains to the ounce. Tar is also of decided value, and may be added to any of the above ointments or be prescribed alone in ointment, one or two drachms to the ounce. The tarry oils, as oil of white birch and oil of cade, used pure or in the form of tincture, one or two drachms to the ounce of alcohol, are also valuable. They may also be used with ointments. The treatment of seborrhoea of other parts of the body than the scalp is essentially the same, but the applications should be somewhat weaker. The sulphur preparations are the most useful.

The frequency of applications in seborrhoea will depend upon the activity of the process. Once or twice daily in the beginning may gradually be changed to once every other day, or later even less frequently. The soap-and-water washing is to be regulated in the same manner. It is advisable to intermit external treatment occasionally to see if the disease is entirely removed or merely in abeyance.

Comedo.

Comedo is a disorder of the sebaceous glands, consisting of retention of sebaceous matter, characterized by yellowish or blackish pinpoint- to pinhead-sized elevations corresponding to the orifices of the glands. The affection is seated, for the most part, about the face, neck, and upper part {590} of the trunk; it may occur, however, wherever there are sebaceous glands. Each lesion is pinpoint to pinhead in size, whitish or yellowish, and usually with a central blackish point. There is very little elevation unless the amount of retained sebaceous matter is excessive. They may exist sparsely or in great numbers. Not infrequently the regions of the forehead, nose, and chin are studded with the lesions, other parts of the face and the shoulders showing them in smaller numbers. They may be disseminated or grouped. If they exist in profusion they give the face a soiled, greasy look, as if dirty and unwashed. Lateral pressure forces out the sebaceous matter in a thread-like form closely resembling a worm, hence the popular terms flesh-worms and grub-worms. From collection of dust and from other causes the outer ends of the sebaceous plugs become blackened, and this appearance has given rise to the term black-heads. This coloring may possibly, to some extent at least, as has been suggested, be dependent upon a chemical change caused by the action of the air on the exposed portion of the sebaceous collection. According to Unna, it is due to pigment matter, either free or contained within epidermal cells. Krause states that the bluish granules described by Unna are from extraneous sources. Seborrhoea oleosa is often seen to coexist. At times the retained secretion, either as a result of pressure or in consequence of chemical changes in the mass, excites inflammation, and acne results. It is not uncommon to find comedones and acne lesions associated together.

The affection is seen most frequently between the ages of fifteen and thirty. The lesions are sluggish, and are apt to disappear and reappear from time to time, depending upon the activity of the predisposing cause. As the patient advances in age the affection tends to spontaneous disappearance. The causes of the disorder are essentially the same as give rise to acne, a disease to which it is, as may be inferred, closely allied. Thus, disorders of digestion, constipation, chlorosis, scrofulous conditions and menstrual disturbances are often predisposing causes. In addition, the unstriped muscular fibres of the skin lack tone and contract sluggishly. The infrequent use of soap, especially in those with oily skins (seborrhoea oleosa), favors their formation. Working in a dirty or dusty atmosphere may cause mechanical obstruction of the ducts, and in consequence the formation of comedones.

Pathologically, the affection has its seat in the sebaceous glands and ducts, consisting essentially of retained secretion and epithelial cells within either the gland or duct or both. The accumulation gives rise to more or less dilatation, which usually increases the longer the comedo exists. The mass consists of epidermic cells, sebaceous matter, and sometimes cholesterin crystals, and one or more lanugo hairs. At times, also, the parasite Demodex folliculorum is found within the mass, but is not responsible in any way for the production of the lesion; it is also often found in healthy follicles. The dark points which usually mark the lesions are due to the accumulation of dirt. The process is an inactive one, occasioning usually no disturbance. The accumulation may increase until a papule is formed, or, on the other hand, may gradually relieve itself. The affection is to be distinguished from acne punctata and milium. Acne is a closely-allied disease, but is inflammatory in its nature; comedo is functional in character: the presence or absence of {591} inflammation, therefore, is a decisive differential point between the two diseases. Milium differs from comedo in the facts that it has no open duct, no black point, and the contents cannot be squeezed out.

The result of treatment is usually favorable, several months sufficing for its removal. On the other hand, occasionally cases are met with which prove rebellious. The aim of constitutional treatment should be to remove the predisposing condition. For this purpose cod-liver oil, iron, quinine, arsenic, and various other tonics, and ergot in full doses, are variously prescribed. At times, small doses (about a tenth to a fourth of a grain) of calx sulphurata have a good effect. Saline aperients are often valuable. An aperient tonic pill of iron, aloes, and strychnia is sometimes serviceable. Open-air exercise and other hygienic measures are to be advised.

External treatment is of great importance,--is in fact indispensable. The condition may in many cases be relieved by local applications alone. Removal of the plugs by mechanical means is to be advised. Lateral pressure with the finger-ends, or perpendicular pressure with a watch-key or similar instrument, will be found effectual. Washing the parts with sapo viridis and hot water, with considerable friction and a kneading motion, will aid in dislodging the sebaceous collections. Instead of the sapo viridis its solution in alcohol, two parts of the soap to one of alcohol (spiritus saponatus kalinus), may be employed. Steaming the face or the application of hot water from ten to twenty minutes will aid in softening the secretion, and with friction and kneading will often have a good effect. Friction with sand soap is also valuable. A soap made of equal parts of green soap (sapo viridis) and finely-pulverized marble may also be used. The use of the dermal curette is at times of service, scraping off the tops of the comedones, rendering their expulsion more easy. After the soap-washing and hot-water application ointments or lotions containing sulphur, such as prescribed in acne, may be applied. The following lotion is often valuable:

Rx. Sulphuris præcipitati, drachm ij;
Ætheris, fluidounce ss;
Alcoholis, fluidounce iijss. M.

S. Shake before using: dab on with a mop for several minutes, allowing it to dry on.

Alkaline lotions containing borax or sodium bicarbonate, ten to twenty grains to the ounce, are often useful. The following paste has been highly spoken of for loosening and dislodging the sebaceous plugs:

Rx. Aceti, drachm ij;
Glycerinæ, drachm iij;
Kaolini, drachm iv. M.

S. Apply over the surface at night. If applied near the eyes, the lids should be kept closed for a few moments, on account of the pungent fumes of the vinegar. The lotion containing zinc sulphate and potassium sulphide, the formula of which is given in the treatment of acne, is of value. Corrosive-sublimate lotions, one-half to two grains to the ounce, are useful in some cases. In changing from a sulphur to a mercurial application, treatment should be suspended for several days, so that the formation of the black sulphuret of mercury, which may darken the skin and comedo plugs to an annoying degree, may be {592} avoided. If treatment brings about considerable irritation of the parts, a result often desirable, it should be omitted temporarily and soothing applications made.

Milium.

Milium, described also as grutum and strophulus albidus, consists in the formation of small, whitish, roundish, pearly, non-inflammatory elevations situated in the upper part of the corium. The lesions are usually pinhead in size, whitish or yellowish, seemingly more or less translucent, rounded or acuminated, without aperture or duct, and appear for the most part about the face, especially about the eyelids, and occasionally elsewhere. One, several, or great numbers may be present; ordinarily, however, but several are to be seen, usually near the eyes. In our experience the affection is observed most frequently in middle-aged women. The lesions develop slowly, and after a certain size is reached may remain stationary for years. Their presence causes no disturbance, and unless large and numerous the affection is but slightly noticeable. Acne and comedo are often found associated with it. The cutaneous calculi occasionally met with are milia which have undergone calcareous metamorphosis. The etiology of the disease, in a great majority of cases, is not known. In some cases, however, the same causes as are operative in the production of comedo and acne seem to have an influence.

Anatomically, the affection is found to have its seat in the sebaceous glands. The duct from some cause is obliterated and the secretion cannot escape. The retained mass consists of sebaceous matter which tends to become inspissated and calcareous, and, as the lesion is without aperture, it cannot be squeezed out. The epidermis constitutes the external covering. It has also been shown by several authorities that the covering proper is either the gland itself or the wall of the hair-follicle, and that in the larger lesions connective-tissue septa are found. According to the investigations of Robinson, two different conditions have been described as milia--one which evidently has its origin in the sebaceous glands or ducts, and the other in which there is no connection whatever with these structures. The lesions are characteristic and the diagnosis easy. The absence of the duct-opening and black point of comedo serves to distinguish it from that disease. The small lesions of xanthoma--a disease which usually has its seat about the eyelids--may resemble it, but can scarcely be confounded with it, as its nature is entirely different.

As regards treatment, it is usually necessary in all cases to incise the lesions and squeeze out or scrape out their contents; in some, touching the base of the excavation with a minute drop of iodine tincture or nitrate of silver may be required to prevent a reappearance. Electrolysis has also been recommended.

Steatoma.

Steatoma--or, as commonly called, sebaceous cyst, sebaceous tumor, or wen--appears as a variously-sized, elevated, roundish, or semi-globular firm or soft tumor having its seat in the corium or subcutaneous tissue. {593} One or several may be present. They are cysts of the sebaceous glands, and may exist wherever these structures occur, but are seen most frequently about the scalp, face, back, and scrotum. They develop slowly, are variable as to size, and may exist indefinitely without causing any inconvenience except disfigurement. The overlying skin is either normal in color or whitish from stretching; on the scalp it is usually devoid of hair. Cysts are usually firm, but may be doughy or soft. As a rule, they are freely movable and painless. In some a gland-duct orifice can be seen; in the majority it is absent. Spontaneous suppuration and ulceration may occasionally take place in enormously distended tumors. Anatomically, steatoma is a cyst of the sebaceous gland and duct, produced by retention of secretion. It is in fact an enormously distended duct and gland whose walls have become thickened into a tough sac. The contents vary, in some being hard and friable, in others soft and cheesy or even fluid, with or without a fetid odor, and of a grayish, whitish or yellowish color. The mass consists of fat-drops, epidermic cells, cholesterin, and sometimes hairs. As a rule, the diagnosis is made without difficulty. Gummata, which may have some resemblance, grow more rapidly, are usually painful to the touch, are not freely movable, and tend to break down and ulcerate. Sebaceous cysts can scarcely be mistaken for fatty tumors and osteomata.

In the treatment excision is radical and most satisfactory. A linear incision is made, and the mass and enveloping sac dissected out. A removal of the sac is necessary, or a reproduction usually takes place. As the scalp wound especially should be treated on antiseptic principles, injecting the tumor with a small quantity of tincture of iodine or other irritant has been successfully employed.

CLASS II.--INFLAMMATIONS.

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. The affection is due to various causes, which may be external or internal. Hence it is usual to divide the affection into two classes--idiopathic and symptomatic. Under the head of idiopathic erythema are described the erythemas due to cold, heat, traumatism, poison, etc. Erythema caloricum arises from the action of heat or cold. If the degree of heat or cold is sufficient, a dermatitis, or even gangrene, may result. In a mild degree, however, simple congestion of the skin--erythema--is produced. It is usually bright red in color, later becoming somewhat darker, and at times is followed by slight desquamation. If produced by the action of the sun--erythema solare--the uncovered parts only are affected. Erythema traumaticum is usually seen {594} as a result of the pressure of tightly-fitting clothes, corsets, bandages, etc. It disappears rapidly upon removal of the cause, without scaling. If the cause is long continued, a dermatitis may be produced. Erythema venenatum is a term applied to the form of hyperæmia resulting from the action of substances poisonous to the skin: such are all irritating chemicals, the ordinary rubefacients, various dyestuffs, acids, alkalies, and the like. The symptomatic erythemas are the more important. The rashes often preceding or accompanying certain of the systemic diseases, such as smallpox, diphtheria, and vaccinia, belong to this class. Disorders of the digestive tract, especially in children, are responsible for many cases. Roseola is a term sometimes applied to the symptomatic rashes. The division-line between simple erythema and dermatitis is often ill-defined.

The indications for treatment in the various erythemata are usually self-evident. A removal of the cause in idiopathic rashes is all that is needed. The same may be stated of the symptomatic erythemata; but here there is at times difficulty in recognizing the etiological factor. Local treatment is rarely necessary. Dusting-powders, mild lotions, or ointments such as used in acute eczema may be prescribed.

* * * * *

ERYTHEMA INTERTRIGO.--Erythema intertrigo--known popularly as chafing--is a hyperæmic disorder occurring on parts where the natural folds of the skin come in contact, characterized by redness and at times an abraded surface and maceration of the epidermis. The causes are usually local. Thus it appears chiefly about the folds of the neck in fat subjects, the nates, groin, perineum, and axillæ. It is seen usually in hot weather in infants and others whose skin is tender. The skin becomes red from chafing, and if long continued or untreated the perspiration of the parts causes more or less maceration of the epiderm and a mucoid discharge. If the condition continues, actual inflammation may be developed. The affection may pass away in a few days or last several weeks. There is a feeling of heat and soreness about the affected parts. Occurring between the nates in infants, a favorite locality, from the friction of the parts, and the action of the feces and urine, it is often persistent. As a rule, it yields readily to treatment. The predisposition to its development, and its continuance are often due in children to derangement of the stomach or intestinal canal.

In the treatment undue moisture and friction of the parts are to be prevented or counteracted. Washing with castile soap and cool water, and cleanliness, should be advised. The folds or parts are to be separated or kept apart with lint, cloth, or absorbent cotton. Dusting-powders are to be used freely, as they constitute the best method of treatment. The following is a good formula:

Rx. Pulv. zinci oxidi, drachm ij;
Pulv. talci Veneti, drachm ij;
Pulv. amyli, drachm iv. M.

Simple starch and lycopodium powder, alone or together, will both prove efficacious. If the affection prove rebellious to this plan of treatment, astringent and alcoholic lotions may be used. Black wash, diluted, dabbed on the parts several times daily, followed by oxide-of-zinc ointment or a dusting-powder, will be found useful in obstinate cases. A weak {595} solution of corrosive sublimate, a fraction of a grain to the ounce, may also prove valuable in some instances. Lotions of zinc sulphate or of acetate of lead, two or three grains to the ounce, and a weak solution of alum, may also be mentioned. A lotion we have often found of service is the following:

Rx. Pulv. calaminæ,
Pulv. zinci oxidi, aa. drachm iss;
Alcoholis, fluidrachm ij;
Aquæ rosæ, fluidounce iv. M.

Sig. Shake before using. Apply several times daily. The local treatment of rebellious cases is, in fact, that which is found efficacious in acute erythematous eczema.

Erythema Multiforme.

Erythema multiforme is an acute inflammatory disease characterized by reddish, more or less variegated macules, papules, and tubercles, occurring discretely or in patches of various size and shape. Certain regions of the body, such as the backs of the hands and feet and the arms and legs, are the parts mainly invaded. The eruption, as the name signifies, is usually marked by the multiformity of its lesions, although, as a rule, one of the forms is generally predominant. Peculiarities which the lesions assume have given rise to the qualifying terms annulare, iris, and marginatum, etc. Thus, when the erythematous patch is circular, fading in the centre, it is called erythema annulare. At times concentric rings, presenting variegated colors, are formed, giving rise to the term erythema iris. When the eruption consists of sharply-defined marginate patches, it is designated erythema marginatum. Most commonly, the eruption appears in the form of papules and tubercles. Erythema papulosum is the form of the disease usually met with. It consists of discrete or aggregated patches of flat papules, variable as to size and shape. In color they are bright red, violaceous, or purplish, disappearing partly under pressure. They fade rapidly, rarely lasting longer than a few weeks. Erythema tuberculosum is a form of the disease occasionally encountered in which the lesions are larger, but of the same general character as in the papular variety.

Erythema multiforme varies as regards duration, averaging about two weeks. During its course new lesions are apt to develop as the older eruption fades away. As the lesions disappear slight pigmentation and desquamation are noticeable. In addition to the parts already named as commonly invaded, the face is sometimes the seat of the eruption. It may, moreover, attack the mucous membranes. The subjective symptoms are rarely marked: usually slight burning and itching are complained of. There may be evidences of constitutional disturbance, such as malaise, headache, rheumatic pains, and gastric derangement, especially at the beginning; as a rule, however, general symptoms are not observed. Relapses, especially from year to year, are not uncommon. The causes of the disease are in most cases obscure. It is most frequent in early adult age. Spring and autumn seem to be predisposing factors, although it is also seen at other periods of the year. Gastric disturbance may give {596} rise to the eruption in some instances. Rheumatism is occasionally associated with it. The affection is more common in the female.

Anatomically, the affection is an exudative disease, resembling urticaria. It is generally regarded as a vaso-motor disturbance. It is closely related to herpes iris and erythema nodosum, and by some these are looked upon as varieties. In regard to the diagnosis, it is to be differentiated from urticaria. In the latter affection itching and burning are prominent and constant symptoms, the lesions are fugacious, and the duration of the disease shorter. It can scarcely be confounded with eczema, in which disease the lesions are smaller and intensely itchy, and the eruption does not assume the different shapes seen in erythema multiforme. Erythema nodosum and herpes iris are also to be differentiated. The prognosis is always favorable, as the affection runs a definite course, usually disappearing at the end of a few weeks. It is rarely influenced by treatment.

Saline laxatives, alkalies, and the bromides may be given and the diet regulated. In the beginning of the attack large doses of quinine may be useful. Locally, applications of alcohol or vinegar and water, or a lotion of carbolic acid, five or ten grains to the ounce of water, will be found of advantage if itching or burning is present. As a rule, active external treatment is not required.

Erythema Nodosum.

Erythema nodosum (syn., dermatitis contusiformis) is an acute inflammatory affection characterized by the formation of variously-sized, roundish or ovalish, more or less elevated erythematous nodes. Febrile disturbance usually ushers in the eruption, often accompanied with gastric derangement, malaise, and rheumatic pains. The efflorescence appears rapidly, having special predilection for the arms and legs, particularly the tibial surfaces. The lesions vary in size, being rarely smaller than a cherry and often as large as an egg, and are ovalish or roundish in shape. They are reddish in color, with a bluish or purplish tinge, which becomes more decided as they grow older. Later, as they are disappearing, yellowish, greenish, and bluish coloration manifests itself, as in the case of a bruise. Not infrequently the lesions are hemorrhagic. When at its height a node has a shining, tense appearance, indicative apparently of beginning suppuration; this latter process, however, does not occur, absorption invariably taking place. Firm and hard at first, as they begin to decline they become softer. They are apt to appear in crops. The lesions are rarely present in large numbers, from five to twenty being the average; occasionally, however, they are much more numerous. The mucous membranes may, as in erythema multiforme, be invaded. They are tender and more or less painful, and are usually accompanied with a sense of burning. Lymphangitis is at times observed. At the end of two or three weeks the affection has usually run its course.

The causes of the disease are not known. It is closely allied to erythema multiforme, and by many observers is regarded as merely a manifestation of that disease. It is generally encountered in the spring and autumn months, and occurs most frequently in children and young {597} persons. It is usually associated with rheumatic pains, and not infrequently with digestive derangement. It is not a common disease. It is regarded by Lewin as an angio-neurosis. According to Hebra, in most cases it is essentially an inflammation of the lymphatics. Bohn regards it as due to embolism of the cutaneous vessels giving rise to inflammatory infarctions. The process is an inflammatory oedema. There is considerable serous transudation, with some blood-corpuscles, and not infrequently with more or less hemorrhage. The lesions usually bear resemblance to bruises, abscesses, and gummata. The rosy hue, the apparently violent character of the process, the number, course, and situation of the lesions, will serve to distinguish it. The prognosis is favorable, as the affection tends to disappear in a few weeks, rarely lasting more than a month.

As spontaneous recovery results, treatment should be conservative. Rest, the more complete the better, sedative applications, as of lead-water and laudanum or of carbolic acid, with the use of saline laxatives and full doses of quinia, are the measures indicated. The diet should be regulated according to the case.

Urticaria.