Chapter II: The Peculiarities of Certain Accidental Acute and Chronic Diseases (13)

DIAGNOSIS.--It must be remembered that the disease is capable of appearing in a multitude of forms, some of which are so dissimilar in their clinical features as sometimes to occasion embarrassment in the diagnosis. No other disease except syphilis manifests itself in such a variety of forms. In all cases where the lesions are varied or where they are ill defined the eruption should be viewed as a whole, when the characters of the process will usually be apparent. Thus a variable amount of infiltration, with swelling or thickening, is almost always present, the skin being more or less red and inflammatory. Moisture or positive discharge, with slight or extensive crusting, is a frequent though by no means a constant symptom, and when present is characteristic. Itching is experienced in almost all cases, and is generally a marked symptom. In some cases heat and burning are complained of.

Cases are occasionally met with in which the eruption bears some resemblance to erysipelas and scarlatina, but the absence of systemic symptoms in eczema would prevent an error in diagnosis. Papular eczema may at times simulate the papular manifestations of urticaria, especially in children, but in ordinary cases there is no likelihood of confounding the diseases. Herpes zoster in its early stage may bear a resemblance to a patch of vesicular or papular eczema, but the grouping of the lesions and the burning or pain in the former disease will generally prove sufficient to distinguish them. Seborrhoea, especially as it occurs upon the scalp, may be mistaken for squamous eczema, but in seborrhoea the scales are greasy, containing more or less sebaceous matter, and the distribution of the disease is usually more uniform than in eczema; and, finally, in the latter affection the skin is reddish, inflamed, often thickened, and usually itchy.

Psoriasis and squamous eczema frequently simulate each other, and in {631} some instances the resemblance is so close that error in diagnosis may readily occur. Both diseases are common, and are liable to invade all regions. In eczema the patches usually fade away into the healthy skin, whereas in psoriasis their margins are generally sharply defined. In eczema the scales are usually scanty, thin and small; in psoriasis they are abundant, whitish or silvery, large and imbricated. These points, taken in connection with the history of the case, will serve to aid in the diagnosis.

The rare disease pityriasis rubra may be confounded with squamous eczema, but the peculiar abundant, thin, papery scaling of this affection is not met with in eczema. Sometimes papular eczema resembles lichen ruber, but with attention to the characteristics of the lesions in the latter disease the diagnosis in most cases offers no difficulty. The resemblance of tinea circinata to eczema in some cases is to be borne in mind, but in the latter disease there is wanting the tendency to circular and marginate forms so characteristic of the parasitic disease. The microscope should always be employed in doubtful cases. Both tinea sycosis and sycosis may be confounded with eczema of the hairy portion of the face, but the follicular involvement in the former affections is the diagnostic point to be remembered. Scabies in its early stages often looks much like papular, vesicular, or pustular eczema, and care should in all cases be taken to make a correct diagnosis. The history of scabies, the regions involved, the distribution and multiformity of the lesions, and the presence of the parasite, as shown by the extraction of the mite or by the burrow, are all points to be duly inquired into. Eczema seldom simulates syphilis. They are most likely to be confounded one with the other when occurring in chronic forms about the scalp and the hands and feet.

PROGNOSIS.--Under favorable circumstances eczema is always a curable disease. In the prognosis of the affection as regards the probable length of time required to remove it an opinion should be guardedly expressed. It depends upon the extent of the disease, the duration, the attention the patient can give to the treatment, and the ease with which the exciting causes can be removed. Where the disease is the result of nervous prostration, as seen in those who have been mentally overworked from whatever cause, the cure will take place slowly, and many relapses will probably occur before positive recovery sets in.

Where the exciting causes cannot be entirely removed recovery is slow, and a complete or permanent cure is sometimes impossible. Thus in eczema about the hands in those who are obliged to wet or wash the parts frequently, to handle chemicals, dyestuffs, or otherwise expose the parts to the action of deleterious substances, a cure of the affection is exceedingly difficult. The same may be said in regard to eczema of the scrotum and neighboring regions, where the natural heat and moisture are constant and exciting, and to a certain extent irremovable, causes. In eczema of the lower limbs depending upon a condition of varicose veins the disease is obstinate. On the other hand, there are many cases of acute eczema met with which run a rapid course and end favorably. Eczema of the face, lips, and other exposed parts is, for evident reasons, apt to prove rebellious. In each case, then, all these points are to be taken into consideration in rendering an opinion upon the probable duration and termination of the disease.

{632} TREATMENT.--There is no other disease of the skin which requires so thorough a knowledge of general medicine for its successful management as does eczema. The exciting cause of the affection is to be ascertained and to be properly treated. It is the specialist who has as the groundwork a comprehensive knowledge of general medicine who is best able to cope successfully with the disease under consideration. In the management of eczema both constitutional and local treatment will be necessary. It is true that some authorities depend upon external applications alone, but, judging from our own experience, a combination of external and internal treatment promises decidedly better results. In those cases in which the exciting cause has disappeared and the eczema persists from habit, as it were, the simplest local treatment may bring about a cure. But these are, unfortunately, exceptional instances. In almost all cases external treatment is indispensable.

Constitutional Treatment.--There are no specific remedies for eczema. Arsenic, it is true, acts in some cases admirably, but these instances are rather exceptional; the proportion of cases in which it may be prescribed with the hope of advantage is not very large. It not infrequently proves positively injurious. It is in the dry, scaly, and papular forms of the disease, and especially those in which the inflammation is of a low grade, that it acts most happily. The drug is to be given in sufficiently large doses to obtain slight evidences of its physiological action; toxic effects are to be avoided. It should never be given in acute cases. In small doses (one or two minims of Fowler's solution) arsenic is frequently of value as a tonic, acting then in the same manner as other tonics. When the physiological effects of the drug are desirable the dose should be gauged accordingly, beginning with two or three minims three times daily, and increasing gradually up to five or six or even more minims; as soon as the action of the drug becomes evident, as shown by a slight conjunctival injection and puffiness about the eyelids, the dose should be diminished and its administration continued for an extended period.

In the management of eczema attention should be given to the subject of diet. The food should be nutritious but plain, avoiding such articles as pork, salted meats, pastry, cabbage, gravies and sauces, pickles, cheese, condiments, beer and wine, etc. In anæmic and debilitated individuals a moderate use of stimulants may prove useful. Fresh air and exercise are often of aid in the treatment. The various remedies to be employed internally will depend upon the cause or causes which have brought about the attack. In robust persons and those of full habit laxatives or purgatives will prove of positive service. A useful formula for such cases, and also for those in whom constipation is present, is the following:

Rx. Magnesii sulphatis, ounce iss;
Potassii bitartratis, drachm iv;
Sulphuris præcip., drachm ij;
Glycerinæ, fluidrachm ij;
Aquæ menthæ pip., q. s. ad fluidounce iv.

M.--S. A tablespoonful in a tumblerful of water a half hour before breakfast. If this dose of the mixture fails to produce one or two free evacuations daily, then as much as double the quantity may be taken or a dose may be taken morning and evening. In many cases an aperient combined with a tonic is indicated. This is the case in those who are {633} dyspeptic and debilitated, and in whom there is more or less constipation present. The following formula is available for such cases:

Rx. Magnesii sulphatis, ounce iss;
Ferri sulphatis, gr. iv;
Acidi sulphurici dilut., fluidrachm ij;
Aquæ menthæ pip., fluidounce iv.

M.--S. A tablespoonful in a tumblerful of water a half hour before the morning meal. In some cases the acid is contraindicated, and then the mixture may be prescribed without this ingredient. Although this formula is found to agree with most individuals, there are some who are either not able to take it or in whom it is found to aggravate the dyspepsia or to cause more or less gastric disturbance. In these cases the following formula has proved of value:

Rx. Ext. cascaræ sagradæ fl., fluidrachm iv;
Acidi muriatici dilut., fluidrachm ij;
Elix. calisayæ, fluidounce iij drachm ij.

M.--S. A teaspoonful in a large wineglassful of water before or after meals. The laxative effect of the mixture is more marked when it is taken twenty or thirty minutes before meals. In some cases it will be found necessary to increase the proportion of the cascara sagrada, while, on the other hand, not infrequently a less quantity may be sufficiently active. In acute eczema laxatives, especially the salines, are of great service. The various mineral-spring waters may also be mentioned as useful. Of these Friedrichshall, Hunyadi Janos, the Hathorn and Geyser Springs of Saratoga, are the most serviceable. A tonic aperient where there is only slight constipation is the following:

Rx. Sodii phosphatis, drachm vj;
Acidi phosphorici dilut., fluidrachm iij;
Syr. zingiberis, fluidounce j;
Infus. gentianæ comp., fluidounce iiss.

M.--S. A tablespoonful in a wineglassful of water three times daily.

The following aperient mixtures may be prescribed for children:

Rx. Syr. rhei aromat.,
Olei ricini, aa. fluidounce ij.

M.--S. A teaspoonful two or three times daily, according to the effect.

Rx. Ext. cascaræ sagradæ fl., fluidrachm ij;
Syr. aurantii cort., fluidrachm vj.

M.--S. A teaspoonful in water at bed-time.

Occasional laxative doses of calomel are often valuable both in children and adults. Dyspepsia, if present, should receive appropriate treatment. The bitter tonics, mineral acids, alkalies, and the various artificial aids to digestion may be employed as seem indicated. Where malaria is suspected, full doses of quinine and small doses of arsenic should be prescribed. In these cases, as also in those in which there may be anæmia or chlorosis, the preparations of iron may be prescribed. If a gouty diathesis appears to be at the foundation of the attack, purgatives, the alkalies, and colchicum are to be advised. In these cases, if of an acute or subacute type, the following formula is serviceable:

Rx. Potassii acetatis, ounce j;
Liquor, potassæ, fluidrachm vj;
Aquæ menthæ pip., fluidounce iij drachm ij.

{634} M.--S. A teaspoonful in a half gobletful of water an hour before meals. In cases of a chronic type the following may sometimes prove of benefit:

Rx. Potassii iodidi, drachm v gr. xx;
Liquor. potassii arsenit., fluidrachm iss;
Liquor. potassæ, fluidrachm vss;
Aquæ, fluidounce iij.

M.--S. A teaspoonful in a half gobletful of water after meals.

In some gouty and rheumatic cases wine of colchicum may be added to the above two prescriptions with advantage. Where a scrofulous tendency exists cod-liver oil is a valuable remedy; also in all cases of impaired nutrition, in moderate doses, long continued, it will often prove useful, especially in children.

External Treatment.--The local treatment of eczema is based upon the pathological conditions present. The acute disease requires entirely different management from that employed in chronic cases. The stage of the disease and the amount of skin involved, whether in the form of a circumscribed patch or as a diffuse eruption, are points to be taken into consideration in the selection of a remedy and the mode of its application. The several varieties, the erythematous, papular, vesicular, pustular and squamous, and also the secondary forms rubrum, fissum and verrucosum, all demand applications appropriate to the condition. In acute erythematous or vesicular eczema caution is to be exercised in the selection of remedies. Only the milder applications, as a rule, are tolerated. That which will agree with one may not agree with another. It is advisable to try the remedy upon a small portion of the diseased surface to see if it is acceptable to the skin. In these varieties also soap and water should, as much as possible, be avoided.

For the average case, especially of the vesicular variety, the most successful plan of treatment is with lotio nigra and oxide-of-zinc ointment. The lotion is to be dabbed on by means of a sponge or cloth every three or four hours, ten or fifteen minutes at a time; as soon as dry a small quantity of oxide-of-zinc ointment is to be gently smeared over. In many instances this method furnishes immediate relief to the itching, and under its use the inflammation is soon relieved. Powdering the surface with dusting-powder will sometimes afford ease, starch or lycopodium powder, either alone or together, equal parts, being useful. Subnitrate of bismuth is also of value, proving a more stimulating powder. In some cases a half drachm of finely-powdered camphor to the ounce may be advantageously added to one or another of the simple powders. Powdered Venetian talc is also sometimes useful alone or in combination with starch, a drachm or two of the former to the ounce of the latter. Dusting-powders should in all cases be used freely and often, their chief object being to afford protection to the inflamed surfaces.

Another lotion frequently employed in acute cases of vesicular eczema with free discharge, especially in cases where there is oedema or where the skin is irritable, is one containing calamine and zinc oxide; for example,

Rx. Pulv. zinci oxidi,
Pulv. calaminæ, aa. drachm iiss;
Glycerinæ, fluidrachm j;
Liq. calcis,
Aquæ rosæ, aa. fluidounce iij.

{635} The following may also be mentioned as being useful in similar cases:

Rx. Pulv. calaminæ,
Cretæ præparatæ, aa. drachm j;
Acidi hydrocyanici dilut., fluidrachm ss;
Glycerinæ, fluidrachm ij;
Aquæ,
Liq. calcis, aa. fluidounce iij.

These lotions, as will be seen, contain more or less insoluble powder, and they are to be applied in the same manner as advised when speaking of the use of black wash.

There are other lotions which are often of service. Carbolic acid, one or two drachms to the pint of water, to which may be added a like quantity of glycerin, is in many cases of value, especially in those in which itching is marked. A saturated solution of boric acid, with or without the addition of glycerin, may also be employed in these cases, especially in erythematous eczema. It is one of the most useful of the milder remedies. In this variety, particularly when confined to the flexures, constituting eczema intertrigo, the following formula containing acetate of lead may be prescribed in some cases with benefit:

Rx. Plumbi acetatis, drachm ss;
Acidi acetici dil., fluidrachm ij;
Glycerinæ, fluidrachm iv;
Aquæ, q. s. ad fluidounce vi. M.

In those cases where lotions do not seem to act happily a mild ointment of salicylated suet (2 or 3 per cent. strength) will often relieve the condition. The fluid extract of grindelia robusta, one or two drachms to six ounces of water, seems to suit some cases, but it should be applied cautiously, as in some instances it tends to aggravate. Weak alkaline lotions, a drachm of the bicarbonate of sodium or borate of sodium to the pint of water, and a drachm of the solution of subacetate of lead to the pint, may be also mentioned. Tarry lotions of weak strength are sometimes useful. A drachm of the liquor carbonis detergens to two or four ounces of water, or the liquor picis alkalinus, a drachm to the half pint of water, may afford relief. The former tarry preparation is made by mixing together nine ounces of tincture of soap-bark[2] and four ounces of coal-tar, allowing to digest for eight days and filtering. The formula for the liquor picis alkalinus, the other tarry preparation referred to, is as follows:

Rx. Potassæ, drachm j;
Picis liquidæ, drachm ij;
Aquæ, fluidrachm v. M.

A lotion made up of two drachms of zinc oxide, two drachms of glycerin, six drachms of lead-water, and three ounces of infusion of tar is sometimes valuable in the erythematous form.

[Footnote 2: Tincture of soap-bark is made by digesting for eight days one pound of soap-bark in one gallon of alcohol.]

As a rule, ointments are not so well borne in acute eczema as lotions, but as soon as the more acute symptoms have subsided, and in some instances even during the acute stage, they may be used with benefit. The oxide-of-zinc ointment is well known, and is one of the most soothing; sometimes it is well to reduce the proportion of zinc oxide. {636} Oleate of zinc, in the proportion of one or two drachms to the ounce of vaseline or lard, is somewhat similar to oxide-of-zinc ointment, but is more astringent and stimulating. The oleate of bismuth, pure or with an equal part of vaseline or other fatty base, is also at times of service. The same may be said of the oleate of lead melted with an equal part of lard or vaseline, in this form constituting a soothing and astringent application similar to the well-known diachylon ointment. The latter ointment, if properly prepared, is in the subacute stage often exceedingly valuable. The same objection to this holds as with the different oleates named--that is, the difficulty of securing properly-made preparations. Many are vaunted as such, but our experience is that good preparations are exceptional, and those furnished, instead of acting as expected, often give rise to irritation or marked aggravation. For the acute and subacute stages of the disease the ordinary cold-cream ointment may be in some cases advantageously prescribed. An ointment of equal parts of diachylon plaster and one of the petroleum ointments, as vaseline, constitutes an elegant preparation, useful when a mild, soothing application is called for.

A paste made up as follows may also be recommended for the subacute condition, and at times suits even during the active inflammatory stage:

Rx. Pulv. zinci oxidi, ounce ss;
Mucilag. acaciæ,
Glycerinæ, aa. fluidounce j.

M.--S. Apply with a brush two or three times daily. To this formula, if there is considerable itching present, carbolic acid or salicylic acid in the proportion of 2 per cent. may be added. Glycerite of tannic acid sometimes proves of value, especially in the erythematous varieties of the disease, more particularly when occurring about the face. In like cases glycerite of subacetate of lead may be prescribed. The following is Squire's formula: Acetate of lead, 5 parts; litharge, 3½ parts; glycerin, 20 parts, by weight. Mix and expose to a temperature of 350° F., and filter through a hot-water funnel. The fluid resultant contains 129 grains of the subacetate of lead to the ounce, which is to be diluted with from two to six parts of glycerin or with water. This preparation may sometimes be used with benefit in chronic eczema of the legs applied on strips bound on with a bandage. In these cases the following paste, suggested by Unna, proves useful:

Rx. Kaolini,
Ol. lini, aa. drachm vj;
Zinci oxidi, ounce ss;
Liq. plumbi subacetat., fluidounce ss. M.

This is painted on and allowed to dry, and then bandaged for twenty-four hours. In some skins, however, glycerin invariably irritates.

In the papular form the tarry lotions named and carbolic-acid lotion are of most benefit. These cases are from the beginning inclined to take on the chronic type, and the more stimulating applications are well borne. Thymol, one or two grains to the ounce of alcohol and water, is also useful.

In chronic eczema, and, in fact, in all cases of eczema, after the active inflammatory symptoms have more or less subsided--which usually takes place soon after the beginning of the outbreak--stimulating applications are to be resorted to. In fact, the {637} dividing-line between acute and chronic eczema is difficult to define. The products of the disease, be they crusts or scales, must be removed in order that the remedial application may be brought in contact with the diseased surface. Thoroughly saturating the part with oil, and subsequently washing with warm water and soap, will usually suffice to remove the accumulations. On the non-hairy surface a bland oil, lard, or a non-irritating ointment thickly spread on the parts, will soon be followed by softening and removal of the crusts or scales. If these more simple measures are not sufficient, washings with sapo viridis and warm water are to be advised for this purpose, immediately afterward applying a mild unguent. On the scalp, instead of the pure green soap, the spiritus saponatus kalinus is more satisfactory. In patches which are covered with thickened epidermic masses, as in eczema of the palms, strong applications are necessary to remove the accumulations. For this purpose green soap or salicylic acid may be used. Of these, salicylic acid is in most cases to be preferred. It may be applied as an alcoholic solution, 5 or 8 per cent. strength, or in ointment form, fifteen to forty grains to the ounce.

After a removal of the products of the disease the remedies proper are to be applied. The various ointments already named for the treatment of the acute and subacute types may also be employed in the chronic cases. In some instances they may prove sufficient, but in the majority it will be found necessary to have immediate recourse to the stronger ointments and lotions. In small patches washing the parts with green soap and hot water and following with unguentum diachlyi or a similar ointment will be sufficient.

The mercurials are of great value in the treatment of eczema, used either alone or in combination with various other remedies. An ointment of the mild chloride of mercury, twenty to eighty grains to the ounce, is valuable in many cases. Citrine ointment, weakened, and ammoniated mercury, in the same proportion as calomel, are also well-known and very useful preparations, likewise acceptable in many cases. To these ointments tar may often be advantageously added, in the strength of one or two drachms to the ounce. Carbolic acid in ointment, ten to twenty grains to the ounce, may also be mentioned as often proving serviceable. A compound ointment, prized in the Blackfriars Hospital for Skin Diseases, London, is composed of acetate of lead, ten grains; oxide of zinc, twenty grains; calomel, ten grains; citrine ointment, twenty grains; palm oil, half an ounce; benzoated lard, enough to make one ounce. Another mildly stimulating preparation is composed of bisulphide of mercury and red precipitate, each six grains; lard, one ounce.

Tarry preparations constitute the most generally efficacious applications in the treatment of all forms of chronic eczema, where this remedy is at all tolerated by the skin, especially in the squamous variety of the disease. A good formula, and one that is often of service even in the subacute variety, is the following:

Rx. Picis liquidæ,
Zinci oxidi, aa. drachm j;
Ugt. aquæ rosæ, drachm vj.

M. Ft. ugt.--This is to be gently but thoroughly rubbed into the {638} diseased skin. There are three preparations of tar that may be interchangeably employed: these are the ordinary pix liquida, oleum cadinum, and oleum rusci. The oleum rusci is the least unpleasant. They may be employed in the strength of 10 to 50 per cent., either in ointment form or with alcohol. If used upon the scalp, the lotion form, with alcohol, is to be preferred. In the use of a tarry preparation, to be efficient it is to be gently but thoroughly worked into the patches, so that it permeates the skin; the excess may be wiped off. The liquor picis alkalinus, already mentioned in speaking of the treatment of acute eczema, may be used either in the form of an ointment, in the strength of one or two drachms to the ounce, or in the form of a lotion, in the strength of two to eight drachms to the half pint. This tarry preparation may even be employed in full strength to small and thickened patches, applying carefully and using no other treatment, or following the application immediately with a simple or tarry ointment. In cases of verrucous eczema or in patches of thickened papular or squamous eczema, used in the manner described, it is often curative. It is a strong remedy, and is to be employed with caution. The liquor carbonis detergens, in the strength of one or two drachms to the ounce of water, is also valuable in these chronic cases. It is a safe plan in the use of these tarry preparations to begin with a mild strength and then increase if advisable. An equally efficacious formula for the thick, leathery patches of chronic eczema is the following:

Rx. Saponis viridis,
Picis liquidæ,
Alcoholis, aa. drachm iv.

M.--S. Rub in twice daily. There is another mildly alkaline tarry preparation, the goudron de Guyot, somewhat similar in composition to the liquor picis alkalinus, which at times seems to suit when the other tarry applications fail to benefit.

In the treatment of eczema rubrum of the legs Hebra was in the habit of employing the following method: A small quantity of the green soap is to be rubbed into the parts with a flannel rag, employing considerable friction, until all the soap has apparently disappeared; then warm or hot water is to be added and rubbed in in the same manner, an abundant lather being the result. The parts after being rubbed for from five to fifteen minutes, according to the effect, are to be thoroughly rinsed off with simple warm water, and a mild ointment, spread upon cloths, applied. The best ointment for this purpose is the unguentum diachyli, but any mild ointment may be employed. This treatment is to be repeated once or twice daily. In most cases improvement sets in after a few applications. It is an excellent method of treatment, and can be recommended. It requires considerable time and trouble, however, and is therefore not suitable in all cases, for unless the details are properly carried out it may fail.

Salicylic acid is another remedy that is often useful. In thick, leathery patches, an ointment of the strength of thirty to sixty grains to the ounce, applied on cloths or rubbed in, will often produce marked benefit. In the form of a paste it may be used in many cases of subacute and chronic eczema with good effects: {639}

Rx. Acidi salicylici, gr. xx;
Ugt. petrolei, drachm iv;
Amyli,
Zinci oxidi, aa. drachm ij.

M.--S. Apply once or twice daily. If it is used upon the scalp, it should be used with petroleum ointment or lard, the starch and zinc oxide being omitted. Boric acid in the form of a saturated solution, as advised in acute eczema, or in ointment of the strength of a drachm to the ounce, will prove useful in some instances. Sulphur in the form of ointment may also be mentioned as being frequently of value in cases of chronic eczema, especially of the leg. In some cases of subacute and chronic eczema the lotion containing zinc sulphate and potassium sulphide, diluted, mentioned in acne, will be found serviceable. In circumscribed and chronic patches blistering with cantharides is sometimes advisable. In these cases tincture of iodine is also employed. In thickened patches, rebellious to the usual remedies, chrysarobin or pyrogallic acid, as used in psoriasis, may sometimes be applied with benefit.

Mention may here be made of vulcanized india-rubber, used in the form of bandages, the method proving of most value in eczema of the lower extremities, especially in those cases which are due to a condition of varicose veins. It is not suitable in all cases, as in some the disease is aggravated. Reference may also be made to the use of the so-called gelatin dressing. The medicinal substance is incorporated with the gelatin basis, which is made by melting together over a water-bath two parts of water and one of gelatin; and when the application is made the gelatin compound is melted over a water-bath and applied while in the fluid condition; it rapidly hardens and forms an impermeable coating to the diseased part. The dressing is liable to crack, to avoid which, in a measure, a small quantity of glycerin is mixed with the gelatin and water. Another plan is, after the dressing has dried, to brush over the surface a few minims of glycerin. It has, however, cleanliness in its favor, and it is undoubtedly of service in many instances. A good basis formula for the gelatin dressing consists of eight parts of water, four of gelatin, and one of glycerin.

Another form of fixed dressing for scaly patches is with collodion. This may often be made use of when tar is employed, the addition of one or two drachms of pix liquida or one of the tar oils to enough collodion to make an ounce. Such a preparation may be applied to dry and scaly patches, and constitutes an excellent method of application; but tar so applied is not as efficient as when used in solution or in ointment. The gutta-percha and muslin plasters[3] constitute excellent methods of applying remedies; they are cleanly, easily applied, comfortable to the patient, and efficacious.

[Footnote 3: These plasters were devised by Unna, and are made by Beiersdorf, an apothecary of Hamburg, Germany. The muslin plasters consist of muslin incorporated with a layer of stiff ointment; the gutta-percha plasters consist of muslin faced with a thin layer of india-rubber, the medication being spread upon the rubber coating.]

Prurigo.

Prurigo is a chronic inflammatory disease, characterized by discrete pinhead- to small pea-sized, solid, firmly-seated papules, slightly raised, {640} of a pale-red color, accompanied by general thickening of the skin and itching. The disease manifests itself by the development of small firm elevations, which at first are scarcely perceptible; but they may be distinctly felt by passing the hand over the surface. Later, they may be seen as slightly-raised papules, varying in size from a milletseed to a small pea, of the same color as the surrounding skin or of a pinkish hue, and to the touch are found to be well-defined inflammatory deposits. The lesions are discrete, may be present in great numbers and in close proximity, and show no tendency to group, being irregularly distributed. There is rarely distinct scale-formation, but the papules are usually covered with roughened, dry epidermis, and are frequently perforated with hairs.

Itching, usually intense, is a constant symptom, giving rise to scratching, and as a consequence many of the lesions are covered with blood-crusts and the skin is markedly excoriated. In course of time, either as a symptom of the disease or as a result of the scratching and consequent hyperæmia, or more probably resulting from both, the skin becomes thickened and the surface harsh or rough. The extensor surfaces of the legs, especially the tibial regions, and later the forearms and arms, and in marked cases the trunk, are the regions usually invaded. The palms and soles escape, and only in rare cases is the head involved. As a result of strong local remedies or scratching, or of both, a simple dermatitis or an eczema may develop as a complication. In consequence also of the cutaneous irritation the lymphatic glands, especially the inguinal, may become engorged--prurigo buboes (Hebra).

The causes of the disease are obscure. It is common in Austria, and is occasionally met with in France and England, but it is almost unknown in the United States. It is met with, as Hebra states, almost exclusively in poor subjects and those ill nourished in childhood, and so most often in foundlings and beggars' children. The disease is not hereditary. It usually develops, however, in early childhood, and is worse in winter than in summer. Anatomically, the lesions differ but slightly from those of papular eczema. The papillæ and rete show a moderate amount of cell and serous infiltration. Later, as a result of the chronic inflammation, thickening, increased cell-infiltration, atrophied sweat and sebaceous glands, and pigmentation are observed. The process, according to various authorities, begins in the papillary layer.

Prurigo has been, and is still, erroneously confounded with pruritus and pediculosis, diseases which have nothing in common with that affection except the itching and resulting excoriations--symptoms, as is well known, common to many diseases. In pruritus there is no structural change in the skin except that produced by scratching, a point of difference that is diagnostic. The thickening of the skin and the harsh, rough surface encountered in prurigo are absent in pruritus. The latter disease is usually one of middle or old age; prurigo, on the other hand, dates from childhood. In pediculosis the lesions, punctate or papular in form, are consequent upon the wounds of the pediculus, and are most numerous about the trunk, especially the shoulders and hips. Between simple eczema and prurigo the diagnosis is not difficult. It is to be remembered, however, that eczema may exist as a complication, in which case, after its disappearance, the characteristics of prurigo become evident.

{641} Severe cases are said to be incurable, according to Hebra and others, but in the milder forms of the disease a cure may be effected. Good food, hygiene, and tonic remedies, and systematic local treatment similar to that generally employed in chronic eczema, are the measures indicated. Naphthol, in the form of a 5 per cent. ointment for adults and a ½ per cent. ointment for children, has been found by Kaposi to be of value.

Acne.

Acne, or acne vulgaris, is an inflammatory, usually chronic, disease of the sebaceous glands, characterized by papules, tubercles or pustules, or a combination of these lesions, occurring for the most part about the face. There are several so-called varieties of acne, although examples of all these forms may be seen usually in an individual case, and instances in which all the lesions are of the same type or character are practically not encountered. Other disorders of the sebaceous glands, as comedo and seborrhoea, are often seen associated with this affection. In fact, hypersecretion or retention of the sebaceous matter is the exciting cause of the inflammation.

If the retained sebaceous mass causes a moderate degree of hyperæmia or inflammation, a slight elevation with a central whitish or blackish point results, constituting the lesion of acne punctata. If the inflammation is of a higher grade, the elevation is more marked, reddened, and papular, the lesion being known as acne papulosa. If the process is still more active, the central portion of the papule suppurates and acne pustulosa results. The surrounding inflammation of this form is often of a violent type, and the lesion may be situated upon a hard and inflamed base, and then is designated acne indurata. In some cases of acne the disappearing lesions leave more or less atrophy about the gland-ducts in the form of pit-like depressions--acne atrophica. On the other hand, at times there results connective-tissue hypertrophy about the glands--acne hypertrophica. In strumous, cachectic individuals the lesions, which are usually pustular in type, or at times furuncular, almost of the nature of dermic abscesses, may be more general in distribution, and are, moreover, usually of a more sluggish character, constituting the so-called acne cachecticorum. The efflorescence which follows the prolonged ingestion of the iodides and bromides is usually of a more inflammatory type, the glands and follicles being sometimes seriously and irreparably involved. This form of acne, as well as that resulting from the external action of tar, characterized by the formation of all kinds of lesions with a minute central blackish deposit of tar and more or less inflammation of the surrounding skin, constitutes acne artificialis.

The most common form of acne is that in which the pustule predominates. The lesions, in all the varieties, are usually confined to the face, the forehead, cheeks, and chin being favorite localities; not infrequently, however, the eruption also involves the shoulders and upper part of the back. They are irregularly distributed and tend to appear in crops. Sometimes the face and shoulders are spared, and the lesions, being confined to the back, extend as far down as the lumbar region or even to the thighs. In these cases the lesions are usually {642} of a papulo-pustular character and are sluggish in their evolution. As a rule, an acne papule or pustule runs an acute course, disappearing in the course of one or two weeks, and a new lesion appearing at another point to supply its place. The disease is essentially chronic, in the sense that the parts are never or seldom free, new lesions forming and old ones disappearing from time to time, in some cases indefinitely. As a rule, there are no subjective symptoms, but in some markedly inflammatory cases the lesions are painful; in other exceptional instances there is slight itching.

The disease is common about the age of puberty, and occurs in both sexes. Chronic derangement of the digestive apparatus is a frequent factor. Those of a light complexion are more liable to its development, while menstrual difficulties, chlorosis, scrofulosis, and general debility may all predispose to the disease. Medicinal substances, such as the iodides and bromides, and tar externally, are also prone to produce acne-form lesions. The retention of the secretion within the sebaceous gland is the first step in the formation of an acne lesion, and its presence--or it may be its decomposition--gives rise to inflammation, which usually involves the gland-structure and the surrounding tissue. Primarily, it is a folliculitis, the tissue immediately about the follicle subsequently becoming involved, constituting a perifolliculitis. As a result of this latter process, or from inflammation and changes within the gland without much surrounding inflammation, the destruction of the sebaceous follicles may ensue. The hair-follicles at times are also involved in the process. The degree of inflammation determines the character of the lesion; if mild in character, the simple papule or pustule results; if of a severe grade, the lesion of the indurated and hypertrophied forms follows.

Acne resembles at times the papular and pustular syphiloderms. In syphilis the distribution of the eruption, the history of the case, the color, the duration of the individual lesions, the tendency of the papules or pustules to group, and usually the presence of other evidence of the disease, will serve to distinguish it from acne. Tar acne may be recognized by the history, the black points at the follicular openings, and usually evidence of the presence of tar about the patient. Acne resulting from the ingestion of the bromides and iodides is almost always of an acute and markedly inflammatory type, the lesions being scattered over the general surface, and are usually larger and more virulent in character than those of acne vulgaris. From acne rosacea it may be known by the characters referred to in speaking of that disease.

TREATMENT.--Cases of acne vary considerably as to their course and curability. There is in almost every case a natural inclination toward disappearance of the eruption at the age of twenty or thirty. Although the lesions are at any age of the patient generally easily removable by treatment, relapses are the rule; but the older the patient the less probability is there of a recurrence. Even in young subjects, however, the cure may be permanent, depending upon the ability to discover and remove the cause. The disease requires both constitutional and local treatment. For the removal of the existing eruption local applications alone are usually sufficient, but the disposition to the development of new lesions in most cases yields only to appropriate internal treatment.

Each case of acne for its successful management demands careful {643} investigation with a view of discovering the etiological factors. If these can be ascertained and removed, a successful result is assured. As already intimated, disorders of digestion play a most important part in the etiology of this disease, and in a large proportion of cases remedies appropriate to such conditions are required. The diet is to be strictly regulated: all indigestible articles of food, such as pork, salt meats, pastry, cheese, pickles, etc., should be interdicted. If constipation exists, laxatives are to be prescribed. As a rule, salines are more serviceable than vegetable preparations for plethoric individuals, while for others the latter, especially for long-continued administration, are to be preferred. A change from one to the other is often advisable. The dose should be sufficient to produce a free evacuation daily. An excellent tonic aperient mixture is the following:

Rx. Magnesii sulphatis, ounce iss;
Ferri sulphatis, gr. viij;
Acidi sulphurici diluti, fluidrachm ij;
Aquæ menthæ piperitæ, fluidounce iij drachm vi.

M.--S. A tablespoonful in a tumblerful of water a half hour before breakfast. The tonic effect of such a mixture is best obtained by prescribing one or two teaspoonfuls in a large wineglassful of water before each meal: as a rule, however, when thus given its laxative property is not so well marked. The mint-water may be replaced by a bitter infusion, such as quassia, but the mixture, unpalatable at the best, is not improved by such a substitution. In some cases the acid in the above mixture is contraindicated, and the following, also a valuable formula, may be prescribed:

Rx. Magnesii sulphatis, ounce iss;
Potassii bitart., drachm iv;
Sulphuris præcip., drachm ij;
Glycerinæ, fluidrachm ij;
Aquæ menthæ pip., fluidounce iv.

M.--S. Tablespoonful in a tumblerful of water a half hour before breakfast. Hunyadi Janos water, in the dose of a large wineglassful thirty or forty minutes before the morning meal, is a useful saline, and is not especially disagreeable. Friedrichshall water is an efficient laxative and cathartic, but has a nauseous taste and odor. The ordinary mixture of rhubarb and soda is of value, not only for its laxative effect, but also for its antacid property where such is indicated. The following formula, containing cascara sagrada, is of service:

Rx. Ext. cascaræ sagradæ fl., fluidrachm iv;
Acidi muriatici diluti, fluidrachm ij;
Tincturæ gentianæ comp., fluidounce iij drachm ij.

M.--S. Teaspoonful in a large wineglassful of water before meals. At times this proportion of cascara sagrada is too large, and, on the other hand, in some cases it must be increased. A laxative pill, as the following, containing aloin, belladonna, and strychnia, may be given:

Rx. Aloin, gr. iij;
Ext. belladonnæ, gr. ij;
Strychniæ sulphatis, gr. ¼.

M. Ft. pilul. No. xv.--S. One or two at night. If there is torpor of the liver, an occasional dose of blue mass or calomel may be prescribed. {644} When there is flatulence or other symptoms of fermentative indigestion, a mixture such as the following will be found useful:

Rx. Sodii hyposulphitis, drachm ijss-ounce j;
Ext. nucis vomicæ fl. fluidrachm ij;
Aquæ menthæ piperitæ, fluidounce iv.

M.--S. Teaspoonful in a large wineglassful of water a half hour before meals. The hyposulphite of sodium contained in the mixture may have a laxative effect in addition to its antifermentative action.

If there is anæmia or chlorosis, a preparation of iron, combined with aloes if there is tendency to constipation, is to be prescribed, the wine of iron being one of the most eligible ferruginous preparations. Ergot in the dose of a half drachm of the fluid extract has been recommended in the acne of females, especially where it seems probable that uterine disturbance is the exciting cause. Possibly its effect is, as has been suggested, due to its action on the unstriped muscular fibres of the skin. After one or two weeks' administration it is apt to cause gastric disturbance and, directly or indirectly, vertiginous symptoms. Calx sulphurata in the dose of one-tenth to one-half grain every three or four hours is of value in some cases, usually proving of most service in the pustular type. In strumous individuals, and in those whose nutrition is below the average, cod-liver oil is a valuable remedy. In like cases glycerin in similar doses may be prescribed, although its action is not so certain.

Arsenic is of decided value in some cases, but proves powerless in others. The sluggish papular forms are often influenced favorably by its continued administration. The alterative effect of mercury is sometimes beneficial, corrosive sublimate in small doses being the most available preparation. Where the inflammation is of a high grade, potassium acetate and other alkalies may be prescribed, as in the following formula:

Rx. Potassii acetatis, drachm v gr. xx;
Liq. potassæ, fluidrachm ijss;
Liq. ammonii acetatis, fluidounce iij drachm v.

M.--Sig. Teaspoonful in a large wineglassful of water one hour before meals.

Local Treatment.--This is of great importance and is demanded in every case. In acute acne, rarely encountered, mildly astringent applications are to be advised. The disease, as generally met with, however, is of a subacute or chronic character, requiring stimulating measures. External treatment in these cases has for its object the production of hyperæmia and the removal of the superficial layers of the epidermis, thus stimulating the glands and circulation and assisting in the excretion of the sebaceous matter. For this purpose washing the parts energetically with sapo viridis and hot water every night, using a sponge or preferably a piece of flannel, may be advised. After the soap-washing the parts are to be sponged with hot water for several minutes, or the face held over a basin containing steaming hot water. Subsequently, the comedones are to be pressed out by means of pressure with the fingers, or, better, by a watch-key with rounded edges so as not to injure the skin. An application of a simple emollient, such as cold cream or vaseline, may then be made and allowed to remain on over night. This plan of treatment is to be repeated nightly or every other night.

In many simple cases of acne the above method of external treatment, {645} combined with appropriate constitutional medication, will bring about marked improvement and sometimes permanent relief. In the majority of cases, however, a more stimulating plan of treatment is called for. In almost all cases the soap-washing, either with the sapo viridis or a milder soap, and the sponging with hot water, are to precede the nightly remedial applications. Among the external remedies for acne sulphur preparations stand first. Properly managed, they rarely fail to benefit, and often prove curative. Precipitated sulphur is the preparation generally employed, and in many cases the most suitable. It may be prescribed as a powder, in ointment, or in lotion. As a powder it may be applied pure or mixed with starch, and as an ointment the following formula can be recommended:

Rx. Sulphuris præcipitati, drachm iss;
Adipis benzoati, drachm iv;
Ugt. petrolei, drachm ijss;
Olei rosæ, gtt. iij.

M. Ft. ugt.--Sig. To be rubbed thoroughly into the skin at night. Or, instead of the precipitated sulphur in the above ointment, the sulphur hypochloride may be substituted. As a mild stimulant sulphur soap may often be ordered with advantage in connection with other remedies.

In sluggish, non-inflammatory cases the following may be used:

Rx. Sulphuris præcipitati,
Potassii carbonatis,
Glycerinæ,
Ugt. petrolei, aa. drachm ij.

M. Ft. ugt.--Sig. Apply at night, rubbing it into the skin. In the above formula the petroleum ointment may be replaced with the same quantity of alcohol. In the form of a lotion precipitated sulphur at times acts more decidedly than as an ointment. There are several useful formulæ which, as a rule, answer equally well, although in some cases differing in their beneficial effects. In the average case the following seems most certain in its results:

Rx. Sulphuris præcipitati, drachm ij;
Pulv. camphoræ, gr. xx;
Pulv. tragacanthæ, gr. xxx;
Aquæ aurantii flor.,
Liq. calcis, aa. fluidounce ij.

M.--S. Dab on with a mop or rag; shake before using.

A similar mixture in the form of a paste may be made with equal parts of mucilage of acacia, glycerin, and sulphur, and is to be applied with a brush, being allowed to remain on the skin over night.

Another sulphur lotion is the following:

Rx. Sulphuris præcipitati, drachm ij;
Glycerinæ, fluidrachm j;
Alcoholis, fluidounce j;
Liq. calcis, fluidounce ij;
Aquæ aurantii flor., fluidounce j.

M.--Sig. Apply with a sponge or rag, shaking well before using.

The annexed is also a good stimulating lotion: {646}

Rx. Sulphuris præcipitati, drachm ij;
Ætheris, fluidrachm iv;
Aquæ cologniensis, fluidrachm iv;
Alcoholis, fluidounce iij.

M.--Sig. Shake well and dab on with a rag.

Potassium sulphide is a preparation of sulphur which often acts admirably in this disease. It may be employed as an ointment, or, preferably, as a lotion. An excellent formula, containing the sulphide, which can be prescribed with advantage in many cases, is the following:

Rx. Potassii sulphidi,
Zinci sulphatis, aa. drachm j;
Aquæ rosæ, fluidounce iv.

M.--S. Apply with a sponge or rag. The resulting lotion from this mixture is a complex one, a double reaction taking place. The salts should be separately dissolved, and then mixed. If properly made, the lotion when shaken is of a milky color and free from odor; upon standing the particles sink and form a white sediment, the liquid above being clear. If improperly prepared, as is often the case, it is of a yellowish tinge with a decided odor of the potassium sulphide, and has an entirely different effect. Vleminckx's solution,[4] perfumed with an essential oil, is often of service; it is to be diluted with three to six parts of water and dabbed on every night, the strength gradually increased if necessary.

[Footnote 4: See treatment of Psoriasis for formula.]

Another class of external remedies found of service in the treatment of this disease are the mercurials. They are not so valuable as the sulphur preparations. Corrosive sublimate, white precipitate, and calomel are the mercurials commonly used. If sulphur has been previously employed, several days should intervene and the parts be repeatedly cleansed before using a mercurial, otherwise the skin is darkened temporarily by the formation of the black sulphuret of mercury. Corrosive sublimate is prescribed in the form of a lotion, from one-half to two grains to the ounce of alcohol and water, or as in the following formula:

Rx. Hydrargyri chloridi corros., gr. ij;
Zinci sulphatis, gr. xv;
Alcoholis, fluidounce ij;
Aquæ rosæ, fluidounce ij.

M.--S. Apply with a rag. The zinc sulphate renders the lotion astringent, and is often a valuable addition. Ammoniated mercury, thirty to sixty grains to the ounce of benzoated lard or cold cream, will frequently prove serviceable. If the lesions are numerous and are seated close together, the application is to be made to the entire surface of the part; on the other hand, if they are sparse, it may be made to the spots only. The same may be said also in regard to the sulphur preparations. A 5 or 10 per cent. ointment of oleate of mercury, rubbed thoroughly into sluggish and indurated lesions, will often shorten their course by promoting suppuration. In many cases puncturing the lesions with a sharp knife or scraping with a curette before applying the hot water will be of assistance in the treatment. In obstinate indurated lesions, in addition to puncturing the lesions, the apices may be treated with carbolic acid. The protiodide of mercury, in the strength of five to fifteen grains to the ounce of ointment, is well spoken of by some authorities; it is to be used {647} with care, as it is actively stimulant. In some cases rubbing energetically over the parts a mixture of sapo viridis and sulphur, adding enough hot water to make a lather, and allowing it to remain on over night, will, if repeated nightly until the skin becomes slightly inflamed and then followed subsequently by a mild ointment, produce a decided effect.

Acne Rosacea.