Chapter II: The Peculiarities of Certain Accidental Acute and Chronic Diseases (14)

Acne rosacea, or rosacea, is a chronic, hyperæmic or inflammatory disease of the face, invading especially the nose and cheeks, characterized by redness, dilatation and enlargement of the blood-vessels, more or less acne, and hypertrophy. The course of the disease divides itself naturally into three stages. There is at first simply a hyperæmia, due to passive congestion. In young subjects the affection is seen in this stage, and rarely passes beyond it. In other cases, however, sooner or later, dilatation and enlargement of the vessels (telangiectasis) take place, and acne papules and pustules are scattered over the parts, constituting the second stage of the disease. This stage is frequently met with, and illustrates the acne rosacea usually seen. Exceptionally, however, the disease progresses, the vessels increase in calibre, the glands are enlarged, and there is more less hypertrophy of the connective tissue and the third stage is developed. The nose may become much enlarged, even lobulated, and in some portions pendulous (rhinophyma). The nose and its immediate neighborhood are the favorite localities for the development of acne rosacea, but it is not infrequently confined to the cheeks, and sometimes is localized upon the forehead, while all these parts are not infrequently affected simultaneously. As a rule, there are no marked subjective symptoms, although in some instances burning or a sense of fulness is complained of.

It is seen in both sexes, but is more frequent in males; in women it rarely, if ever, reaches the same degree of development as in men. It is most common about middle life. The causes are varied. Chronic stomachic and intestinal derangements, anæmia, and chlorosis are common causes. The habitual use of spirituous liquors is not infrequently a source of the disease. Long-continued exposure to excessive cold or heat is in some cases a causative agent. In women, menstrual and uterine difficulties are often the responsible factors; hence in this sex it is much more common at the climacteric period. When occurring in the young about the period of adolescence, it is frequently associated with seborrhoea, and rarely advances beyond a condition of hyperæmia. Pathologically, in the first stage of the disease there is simply a hyperæmia--a stasis; in the second, hypertrophy and dilatation of the vessels are superadded, together with acne and slight hypertrophy of the sebaceous glands; in the third stage there is, in addition, hypertrophy of the connective tissue of the corium.

Acne rosacea is to be distinguished from the tubercular syphiloderm, lupus vulgaris, and acne vulgaris, to which affections it at times bears resemblance. The tubercular syphiloderm is comparatively more rapid in its course; does not necessarily involve the sebaceous glands; has frequently as a consequence ulceration and crusting; is usually confined to a part of the nose; and is unaccompanied with dilatation and enlargement of the blood-vessels. Its history, the firmer consistence, and the more {648} dusky color of the tubercles, and frequently the presence of other evidences of syphilis, are also points of difference. In lupus vulgaris the characteristic soft, yellowish-red papules, the absence of the hypertrophied blood-vessels, the degeneration, ulceration, and cicatricial-tissue formation, the more or less limited character of the eruption, and the history of the case, will serve to distinguish it. A simple case of acne vulgaris can scarcely be confounded with acne rosacea: in many cases, however, the dividing-line is far from being marked; in fact, the disease under consideration is often acne with hyperæmia and dilated blood-vessels superadded.

TREATMENT.--The affection may in all cases be more or less favorably influenced by treatment. The milder cases, although at times obstinate, are curable; but when the disease has advanced to marked dilatation and hypertrophy of the blood-vessels and connective tissue, the prognosis is not so favorable. In all stages of the affection, however, as stated, a great deal can be accomplished by appropriate remedies. External and internal treatment are required in the majority of cases. The former usually proves the more valuable.

Concerning internal remedies, there is no drug that exerts a specific influence. The guide to constitutional treatment should be a study of the etiological causes of the disease. Constipation is frequently present, and hence laxatives, especially the salines, are indicated. Chlorosis in the female is often the predisposing cause, and such remedies as iron, quinine, and strychnia will be found useful. Dyspepsia is one of the most frequent causes, and treatment directed toward a removal of that condition will often be of considerable aid in curing the disease. Menstrual irregularities should be inquired into and the appropriate remedies employed.

There are mainly two classes of external remedies which are used in the treatment--namely, the mercurials and the sulphur preparations. The latter are by far the more valuable, precipitated and sublimed sulphur, the hypochloride of sulphur, and the sulphuret of potassium being the most serviceable. They are prescribed either in the form of lotions or ointments. The officinal sulphur ointment, an ointment of the precipitated sulphur and of the hypochloride of sulphur, of the strength of one or two drachms to the ounce, may be referred to as valuable applications. Sulphur may also be used as a dusting-powder or in the form of a paste, as in the following formula:

Rx. Mucilag. acaciæ, fluidrachm ij;
Glycerinæ, fluidrachm ij;
Sulphur, præcip., drachm iij.

M.--Sig. Use with a brush as a paint.

A lotion containing one to four drachms of precipitated sulphur, twenty or thirty grains of camphor, thirty to sixty grains of tragacanth, in two ounces each of lime-water and orange-flower water, or one of the same quantity of sulphur, two or three drachms of ether, and three and a half ounces of alcohol, will in many cases prove serviceable. A lotion of one or two drachms each of sulphide of potassium and sulphate of zinc, in four ounces of water, is one of great value.

Concerning the mercurials, corrosive sublimate, calomel, and white precipitate are in some cases of service. Corrosive sublimate is prescribed {649} as a lotion of the strength of one-half to four grains to the ounce of water or water and alcohol. Calomel and white precipitate are prescribed in ointment, twenty grains to two drachms of either to the ounce, or they may be used in the form of a powder, full strength or weakened with starch powder, dusted over the surface.

To a great extent, the treatment of acne rosacea is the same as simple acne, and for other formulæ and for the method of applying the various remedies the reader is referred to that disease. When dilated blood-vessels are present, however, other measures, in addition to those advised above, are to be adopted. There are two methods of destroying the blood-vessels. One plan is by the knife, cutting across the vessels at several points or slitting their whole length, permitting them to bleed; subsequently cold water may be applied. The other method is by means of electrolysis, according to the procedure fully described in the treatment of hypertrichosis. If the vessel is long, inserting the needle at several points along its length will be necessary; if short, insertion at one or two points will suffice. While either of these methods will, if properly managed, destroy the vessels, neither will prevent the growth of new vessels. In those cases, however, in which the cause has long ceased to operate destruction of the existing vessels may not be followed by new growth. Excessive connective-tissue hypertrophy may require ablation by the knife.

Sycosis.

Sycosis (syn., sycosis non-parasitica, folliculitis barbæ) is a chronic inflammatory, non-contagious affection, involving the hair-follicles, appearing generally upon the bearded region, and characterized by papules, tubercles and pustules perforated by hairs. The disease is seen, as a rule, only on the bearded part of the face, either about the cheeks, chin, or upper lip, involving a small portion or the whole of these parts. The hairy portion of the neck may also be invaded. The disease may begin by the formation of papules and pustules about the hair-follicles on previously healthy skin, or chronic hyperæmia, or even eczema, may have preceded. The lesions generally occur in numbers, in close proximity, and, together with the accompanying inflammation, make up a patch of disease involving a greater or less area. The pustules are discrete, flat or acuminated, small in size, yellowish in color, perforated by hairs, show no disposition to rupture, and are, as a rule, apt to appear in crops. They dry to thin yellowish-brown crusts. There is more or less swelling and infiltration. Papules and tubercles may usually be seen intermingled with the pustules, or the former may constitute the greater part of the eruption. At first the hairs are firmly seated, but later, when suppuration has involved the follicles, they may be easily extracted. Not infrequently the hair-follicles are completely destroyed, in which case scarring and alopecia result. The process is chronic, it being of a subacute or chronic character, with, usually, acute exacerbations. Burning sensations, and at times pain or itching, accompany the disease.

According to Robinson, the affection is primarily a perifolliculitis, {650} the first changes, which are those usually observed in vascular connective-tissue inflammations, taking place around the follicle. Later, the follicle and its sheath become involved, the pus and transuded serum finding their way into these structures. At times pus does not enter within the follicle, the changes observed therein being due to the transuded serum. The pus reaches the surface by forcing its way through the epidermis close to the hair. The causes of the disease are not understood. It is usually seen in those between the ages of twenty-five and fifty, in all classes of society, and in those in good or bad health. Persons with eczematous skin and those having thick and stiff hair are especially predisposed to the disease. Local irritation may serve as the exciting cause. The affection is not common. It is not contagious.

The disease is to be distinguished from tinea sycosis and eczema. Tinea sycosis usually begins as a circular scaly patch--in fact, as simple ringworm--later invading the hairs and follicles and giving rise to papules and tubercles. These lesions are larger than in simple sycosis, and appear and feel like lumps and nodules. Moreover, the changes in the hairs in the parasitic disease are characteristic: they become opaque, brittle, loose, and can be readily extracted. If necessary, a microscopical examination of the hairs may be resorted to. In eczema there is either an oozing, red, crusted surface, or it is dry and scaly; the lesions, as a rule, do not remain discrete, are not perforated by hairs, and the eruption is apt to involve other parts of the face. It is scarcely possible to confound the disease with syphilis.

The disease is essentially a chronic one, and under the best management is often rebellious. Relapses are not uncommon. The treatment consists mainly of external measures. Suitable internal remedies are, however, in some cases, as in plethoric or in broken-down subjects, of value. The digestive apparatus is to be looked after. The extremes of heat and cold are to be, as far as possible, avoided. Clipping the hair, or shaving if not too painful, will permit a more thorough application of remedies. If the disease be of an acute type, soothing applications are at first to be advised. If there is crusting, it should be removed by poultices or oily applications. The use of lotio nigra, and subsequently a cloth spread with oxide-of-zinc ointment, as in acute vesicular eczema, may be advised to allay inflammation. Cold cream, vaseline, or applications of lead-water and like remedies, will also be found useful in the acute stage. As a rule, however, astringent and stimulating ointments may be prescribed when the case first comes under observation. As an astringent ointment there is in the average case nothing superior to a good unguentum diachyli. It should be spread thickly on muslin and bound down to the parts, renewing every six or twelve hours. If stimulation is permissible, twenty grains to a drachm of ammoniated mercury or calomel to the ounce of ointment may be prescribed.

If the process be chronic in character, the parts may be washed with sapo viridis and water, and then diachylon ointment applied, repeating the washing every day and the application of the ointment twice or thrice daily. Sulphur, one to three drachms to the ounce of ointment, is a valuable stimulating remedy, and should be applied thoroughly twice daily; citrine ointment, two or three drachms to the ounce of lard or cold cream, will sometimes have a good effect. Shaving will be found useful in many cases. In {651} some instances epilation proves a valuable adjunct to the treatment. In acute stages the hairs should be extracted from the pustules only--in the chronic stage both from papules and pustules. The operation will be rendered less painful by previously steaming or applying hot water to the parts. After the operation the surface should be dressed with a mild ointment. Epilation at the proper time will often save follicles from irreparable destruction; if for any reason it is not advisable, the pustules should be incised, so that free egress may be given to the pus.

Impetigo.

Impetigo is an acute inflammatory disease, characterized by the formation of one or more pea- or finger-nail-sized, rounded and elevated, usually firm, discrete pustules, seated upon an inflammatory base. The affection is at times preceded by slight malaise. The lesion is pustular from the beginning, and when well advanced may be of the size of a pea or finger-nail, is rounded, or semiglobular, markedly elevated, yellowish or whitish in color, with at first a more or less pronounced areola, which as the lesion matures becomes less and less marked, and finally almost entirely subsides. The pustule is usually distended, shows no disposition to rupture nor to umbilication, and is characterized by but little surrounding infiltration, and even where several exist close together they show no tendency to coalesce. Ten, twenty, or more lesions are usually present, and are most common about the face, hands, feet, and lower extremities. They dry to crusts of a yellowish or brownish color, which are usually thin and drop off, no pigmentation or scar remaining. The process is of brief duration, is benign in character, and is rarely attended with subjective symptoms. It is commonly seen in children under the age of ten.

The disease, apparently, is not related to eczema; occurs, as a rule, in well-nourished subjects, and is not contagious. The lesion is a typical pustule, the process being distinctly circumscribed. The walls are somewhat thick, and are probably made up of both the horny and mucous layers. There is no inflammatory base. Microscopically, the contents are found to be composed of pus-corpuscles, a few red blood-corpuscles, epithelial cells, and cellular débris. The disease is to be distinguished from pustular eczema, impetigo contagiosa, and erythema. The pustules of eczema are numerous, closely crowded together, small in size, tend to coalesce, with a decided disposition to rupture, and are accompanied by itching. The lesions of impetigo contagiosa are vesicular or vesico-pustular, flattened, superficial, thin-walled, often umbilicated; if close together they tend to coalesce, and dry to lamellar crusts of a yellowish color, and the affection is distinctly contagious. The pustules of ecthyma are flat, with an inflammatory base and areola; the crusts are brownish or blackish, and seated upon a deep excoriation; and the affection is, moreover, usually seen in adults and in those whose general health is markedly below the standard.

The affection rarely calls for treatment, as it tends to spontaneous recovery. Incision and evacuation of the matured lesions and a simple protective dressing of a mild ointment, such as oxide-of-zinc ointment, {652} may be advised. If slight stimulation is desirable, ten or twenty grains of ammoniated mercury may be added to the ounce of the ointment.

Impetigo Contagiosa.

Impetigo contagiosa is an acute, inflammatory, contagious disease, characterized by the formation of discrete, superficial, flat, rounded or ovalish vesicles or blebs, which soon become vesico-pustular and pass into crusts. Precursory febrile symptoms, especially in young children, frequently usher in the eruption. The lesions begin as discrete vesicles, small in size, becoming vesico-pustular and increasing by extension peripherally, reaching the size of a pea or developing into blebs as large as a dime or silver quarter dollar. They are flat, slightly or markedly umbilicated, the umbilication being more marked in the older lesions. Several or a few dozen such vesicles or blebs may be present, and if situated close together may coalesce and form patches. There is very little areola, and the covering of the lesion is thin and withered-looking. The superficial character of the process is a striking feature. In a few days the lesions dry to crusts, thin, granular, wafer-like in character, light-yellowish or straw-colored, and but slightly adherent. If the vesicular or bleb wall or the crust is removed, a slightly excoriated surface is disclosed, resembling a superficial burn, secreting a thin fluid. The lesions are seen most commonly about the face and hands, although they frequently occur on other parts. In some cases one or two dozen lesions are scattered over the general surface. In these instances the resemblance of the whole process to an acute contagious systemic disease with cutaneous manifestations is striking. The lesions of the affection as ordinarily encountered appear simultaneously or in crops. As a rule, there is very little itching, and when it exists is usually present only in the beginning of the disease or at night. The affection is contagious and auto-inoculable, and at times apparently epidemic; is seen most frequently in the warm months, and is confined almost exclusively to children. When occurring in adults it is usually of an abortive type. In addition to the cutaneous covering, the mucous membranes of the mouth and conjunctiva are sometimes affected. As a rule, it runs an acute course, lasting ten days or two weeks. In exceptional instances the disease is anomalous, as regards not only its course, but the character and type of the individual lesions.

The causes of the disease are not understood. Some authorities consider it due to the presence of a parasite,--a view in which we are not prepared to coincide. A fungus--in fact, several varieties--may be found in microscopic examinations of the crusts, but the same may be found in crusts of other diseases, and their presence may be considered as accidental. There seem to be two varieties of the disease, in one of which the lesions are for the most part confined to the face and hands, and in the other the lesions are scattered over the general surface. The affection is encountered most frequently among the poor and ill-cared-for. A relationship to vaccination has at times been noted.

In the diagnosis eczema and simple impetigo are to be excluded. The history, course, and characters of the lesions of contagious impetigo are {653} entirely different from those of these two diseases. The size, growth, isolated character, the non-inclination to rupture, and the comparative absence of itching will serve to distinguish it from eczema. The pustule of simple impetigo is prominently raised; that of contagious impetigo is flat and usually umbilicated; the contents of the former are distinctly pustular, and the crusts thicker, smaller, and usually yellowish-brown; of the latter the contents are rarely more than vesico-pustular, the crust thin, light-yellowish or straw-colored, and has the appearance of being stuck on. Those cases which resemble an exanthem may in the early stages be confounded with varicella, but later the lesions are much larger than seen in that disease. In exceptional instances the resemblance to the blebs of pemphigus is more or less pronounced.

As a rule, but little treatment is necessary, as the affection tends to spontaneous disappearance. In some cases, however, in which there is more or less itching, auto-inoculation at the excoriated points takes place, and in this manner the affection may persist. An ointment of ammoniated mercury, ten or fifteen grains to the ounce, rubbed in the lesions, will have a curative effect; likewise an ointment or lotion of carbolic acid, ten grains to the ounce.

Ecthyma.

Ecthyma is characterized by the formation of one or more discrete finger-nail-sized, flat, inflammatory pustules. The pustules are usually few in number, vary in size from that of a pea to a large finger-nail, roundish or ovalish in shape, and are situated on an inflammatory base, with a marked areola of a bright-red color. In the beginning they are yellowish, but later, from an admixture of more or less blood, they become reddish, subsequently drying to brownish but slightly adherent crusts. If the crust is removed, a superficial excoriation, secreting a yellowish fluid, is disclosed. The lesions pursue an acute course, but new pustules are apt to form from time to time. The lower extremities, shoulders and back are favorite localities. The subjective symptoms are usually slight, but burning and pain may be complained of. More or less pigmentation is left to mark the site of the lesions, which sooner or later disappears. The affection is seen in both sexes and at all ages, but is more frequently met with in men.

It is a disease of the poorly-nourished and debilitated; hence it is chiefly seen in the lower walks of life. All causes that tend to reduce the tone of the general health are indirectly responsible for the disease. In such persons external irritants, such as pediculi, bed-bugs, and similar parasites, may provoke the formation of ecthymatous lesions. The affection is not contagious. The process is of a markedly inflammatory type, and tends rapidly to pus-formation. The lesion is a typical pustule, and the excoriation does not extend deeper than the papillary layer. Permanent scarring never results. In the negro, instead of increased pigmentation, loss of pigment results.

The disease is to be distinguished from simple impetigo, contagious impetigo, and the flat pustular syphiloderm. It differs from impetigo in the flat form of the lesion and the character of its crust, and in the more {654} inflammatory nature of the process. The non-contagiousness of the affection, the character and color of the crust, the regions involved, and the course will serve to differentiate it from impetigo contagiosa. In exceptional cases of this latter disease some of the lesions bear considerable resemblance to ecthyma. A striking similarity to the large flat pustule of syphilis is often noticed in ecthyma, and it is here that difficulty in the diagnosis is most likely to be experienced. The local disturbance, such as pain and heat, is generally more marked in ecthyma. The syphiloderm is usually of slower development and runs a more chronic course; moreover, positive ulceration beneath the crusts does not occur in ecthyma. The crusts of syphilis are darker in color, and usually have a greenish hue. Concomitant symptoms of syphilis are almost always present, and are valuable in the diagnosis. Ecthyma can scarcely be confounded with pustular eczema, as the size and discrete character of the pustules and the absence of marked itching are sufficiently distinctive.

Where it is possible for the patient to follow out treatment the result is always favorable. The importance of good food and proper hygiene cannot be overestimated. Tonics may be prescribed as efficient adjuvants. Iron, quinine, nux vomica, and the mineral acids are valuable. As a rule, simple measures are sufficient in the external treatment. If the lesions are numerous and are markedly inflammatory, alkaline baths, six ounces of sodium bicarbonate or of a similar alkaline salt to the bath, will be of service. The crusts are to be removed by poultices or hot-water applications, and the excoriations dressed with an ointment of ten to twenty grains of ammoniated mercury in an ounce of oxide-of-zinc ointment. In some cases a more stimulating ointment is required. Where active stimulation is demanded, touching the parts with nitrate of silver, diluted carbolic acid or a similar agent will prove serviceable.

Miliaria.

Miliaria--popularly known as prickly heat or heat-rash--is an acute inflammatory disorder of the sweat-glands, characterized by pinpoint to milletseed-sized papules or vesicles, attended usually by sensations of pricking, tingling, or burning. In some cases the eruption is almost entirely made up of papular lesions, and constitutes the form of the affection known as miliaria papulosa. In other cases the lesions are vesicular in nature, and miliaria vesiculosa is typified. It is chiefly the papular form to which the name of prickly heat has been applied. This variety begins with the formation of minute elevated, acuminated, bright-red papules, occurring usually in great numbers, more or less crowded together; the individual lesions, however, remain discrete. The affection may be localized, or, as is usually the case, may involve considerable surface. In miliaria vesiculosa the lesions are in the form of vesicles the same in size as the papules, and appear as whitish or yellowish points surrounded with inflammatory areolæ. They are usually crowded so closely together as to give the skin a bright-red look (miliaria rubra). At first the vesicles are transparent and contain a clear fluid, but as they become older they appear opaque and yellowish-white (miliaria alba), and instead of the bright-red appearance the eruption has then a yellowish cast. As in the {655} papular form of the eruption, small areas may be involved or the greater part of the entire surface. The trunk is a favorite locality. The vesicles dry up in a few days, showing no tendency to rupture, and terminate in slight desquamation. In the majority of cases the eruption consists of papular, vesico-papular, and vesicular lesions interspersed. They make their appearance suddenly, usually accompanied with considerable sweating, and if the cause has ceased to act terminate in the course of a few days. As a rule, the subjective symptoms are mild in character, nothing more than slight tingling, burning, being noted; in others, however, these may be so marked as to give rise to considerable annoyance. Individuals who are debilitated seem most prone to an outbreak. Hot weather predisposes to it; in fact, excessive heat from whatever cause is apt to provoke an attack. It is especially common in children. The affection as usually met with is essentially an inflammatory disorder of the sweat-glands, congestion and exudation taking place about the ducts, giving rise to papules or vesicles, according to the intensity of the process.

It is to be distinguished from eczema and sudamen. The papules of eczema are larger, more elevated, firmer, make their appearance more slowly, and are of much longer duration; moreover, the itching of papular eczema is usually marked. Vesicular eczema differs from miliaria vesiculosa by the larger size of the lesions, their disposition to rupture, their tendency to become confluent, and their greater itchiness, and by the general features of the eruption both as regards its appearance and duration. It is to be noted that miliaria occurring in children from the conjoint effects of warm weather and superfluous clothing may, if the exciting causes are continued, result in eczema. Sudamen may be differentiated by the absence of inflammatory symptoms.

The affection under favorable circumstances runs a rapid course, disappearing in a few days or weeks. A removal of the exciting cause will in all cases have a favorable effect. Too active treatment is to be avoided, not only as being useless but prejudicial. Undue perspiration should be guarded against. The patient is for the time to avoid exercise and to be properly clad. Refrigerating diuretics, as citrate or the acetate of potassium or simple lemon-juice diluted, may be prescribed. When the eruption is kept up or frequently recurs as a result of impaired health, tonics, as quinine, iron, and the mineral acids, will be useful. In the majority of cases local treatment alone is necessary. Dusting-powders and cooling or astringent lotions are of most value. Starch and lycopodium powder, equal quantities or with 20 to 30 per cent. of oxide of zinc added, may be used; the surface is to be kept freely powdered. Astringent lotions may be employed in place of the dusting-powder, or, what is often advisable, may immediately precede the latter, the lotion being first applied, allowed to dry on the surface, and then the powder freely dusted over. A lotion of alcohol and water and sponging with vinegar and water may be prescribed.

Pompholyx.

Under this head (and also that of Dysidrosis) a rare disease of the skin has been described, characterized by peculiar vesicles and blebs and an excoriated state of the skin, with subsequent exfoliation of the {656} epidermis. It consists at first of deep-seated vesicular lesions, which resemble small boiled sago-grains implanted in the skin, accompanied by a variable degree of inflammation. As the lesions grow they incline to coalesce, thus forming small or large blebs showing but little if any disposition to rupture. Sooner or later the fluid is reabsorbed or exudes, the epidermis peeling off, usually in large flakes or pieces, sometimes in the form of a cast of the fingers or hand. In most cases burning sensations, tenderness, and soreness are complained of. The disease pursues a variable course. Ordinarily, the process lasts from two to eight weeks. Relapses as well as recurrences of the disease may take place. It attacks by preference the hands, more especially the palms and the sides of the fingers, from which circumstance it was originally designated cheiro-pompholyx; but it may invade the feet and also other regions.

The same disease has been described with the two names given, some observers regarding it as being due to a disordered state of the sweat apparatus, others as being an inflammatory affection. We incline to the latter view, looking upon true dysidrosis as a form of miliaria. The disease under consideration is without question neurotic in origin. It occurs chiefly in those suffering from nervous debility or prostration arising from varied causes. It is due to impaired, faulty innervation. It is most liable to be mistaken for vesicular eczema or pemphigus. The treatment should be general, consisting of such remedies as quinine and arsenic, together with good food and proper hygiene. Local treatment may be prescribed as in the case of eczema, but the result in most cases is not as satisfactory as in that disease.

Pemphigus.

Pemphigus is an acute or chronic bullous disease, characterized by the successive formation of variously sized and shaped blebs. Two varieties are met with--pemphigus vulgaris and pemphigus foliaceus--the symptoms of which differ considerably. Pemphigus vulgaris, the usual form of the disease, appears with or without precursory symptoms. In marked cases headache and fever may precede the cutaneous outbreak. All portions of the body may suffer, but the extremities are more commonly the seat of the eruption. The mucous membrane of the mouth and vagina may also be involved. The lesions, as a rule, are rarely seen in large numbers, a dozen or so usually being present at one time. They vary in size from a pea to a large egg, and are generally rounded or ovalish, fully distended, and according to the size are elevated from a few lines to an inch above the surrounding skin. There is but little inflammation attending their formation. In some cases the blebs arise from erythematous spots or wheals, but generally from apparently normal skin. The fluid is yellowish, later often becoming cloudy or puriform. At times slight hemorrhage occurs, giving the lesions a reddish or purplish color. Spontaneous rupture of the lesions seldom occurs, the contents usually disappearing by absorption. Each bleb runs its course in from two to eight days. Itching and burning are rarely prominent symptoms, in some cases being scarcely noticeable or absent, in others present to a marked degree, constituting pemphigus pruriginosus. In children pemphigus vulgaris is {657} usually attended with systemic disturbance; in adults, as a rule, only in severe cases. The disease may be acute or chronic. Acute pemphigus is rare, and occurs, as a rule, only in children. It usually runs a favorable course, except in ill-nourished children, in whom it may take on a malignant type and have a fatal termination. Chronic pemphigus may be benign or malignant. In the benign form the eruption may persist several months by successive outbreaks, and then disappear, or the blebs may form irregularly and indefinitely. In the former case there may be but the one attack, or, as commonly occurs, relapses may follow after months or years. In the malignant form the disease is more violent, with marked systemic depression and ulcerative action, and may frequently have an unfavorable termination.

Pemphigus foliaceus, the other variety of the disease, is rare. The blebs are loose and flaccid, with milky or puriform contents, rupture, and the oozing liquid dries to crusts, which are cast off, disclosing the reddened corium beneath. The blebs may coalesce and involve considerable surface, and may appear in rapid succession on other regions and on the sites of disappearing or half-ruptured lesions; even the whole surface may become involved, the process continuing for years, undermining the general health and eventually destroying the patient.

Pemphigus is a rare disease, and seems to be of even less frequent occurrence in this country than abroad. It is not contagious, nor is it due to syphilis, the so-called syphilitic pemphigus being a bullous syphiloderm and not a true pemphigus. General debility, overwork, shock, and nervous prostration are influential in producing the disease. Occasionally an hereditary tendency is traceable.

The contents of blebs are at first colorless or yellowish, consisting of serum,--later containing blood-corpuscles, pus, fatty-acid crystals, and epithelial cells, and occasionally uric-acid crystals and free ammonia. The reaction is alkaline, becoming more markedly so as the contents grow older. The lesions are superficially seated, between the horny layer and upper part of the rete and the lengthened cells of the rete and the corium. The papillæ and subcutaneous tissues show round-cell infiltration and dilated blood-vessels.

Herpes iris and the bullous syphiloderm are to be excluded in the diagnosis. In herpes iris the acute course, small lesions, variegated colors, the usually marked areola, the decided tendency to concentric arrangement of the lesions, the seat of the disease,--all tend to distinguish it from pemphigus. The thick, bulky, greenish crusts of the bullous syphilide, with the underlying ulceration, its course, and the presence of concomitant symptoms of that disease, taken with the history of the case, are points of difference. Impetigo contagiosa may at times strikingly resemble pemphigus, but the history of the case, its distribution, the contagious and auto-inoculable properties of the contents of the lesions, and the characteristic crusting of the former disease,--are all available in the differential diagnosis. The blebs of pemphigus are to be distinguished also from the accidental blebs of urticaria and of erythema multiforme. It is to be remembered also that cases sometimes come under observation in which blebs are, for the sake of feigning disease, produced artificially, the subjects being usually hysterical women.

Pemphigus is in most cases a grave disease. The unfavorable {658} symptoms are the presence of numerous bullæ, the rapid and successive development of new lesions, flabby walls, frequent febrile attacks, loss of strength, and marasmus. It is injudicious, even in mild cases, to express an opinion as to the probable duration of the disease. Both constitutional and local treatment, especially the former, are demanded. The general health should receive careful study and faulty conditions corrected. Good food, milk, wine, or ale, eggs and meat are in most cases to be advised. Suitable hygienic regulations should also receive attention. Arsenic in appropriate doses, long continued, has in some cases almost a specific action: on the whole, it must be regarded as our most valuable remedy. Quinine in full doses, cod-liver oil, iron, and the mineral acids are also of service. External treatment is of importance, and is in many cases demanded for the comfort of the patient. The blebs are to be opened as soon as developed, and the parts anointed with oxide-of-zinc ointment. Lotio nigra, used as in eczema, will sometimes be found soothing, as also lotions containing liquor carbonis detergens or liquor picis alkalinus. Dusting-powders of zinc oxide with talc and starch are likewise useful. Baths containing bran, starch, or gelatin sometimes afford ease. Corrosive-sublimate baths, one or two drachms to the bath, and alkaline baths in some cases prove of service. After the bath an application of an ointment or mild dusting-powder may be made to advantage. Where baths prove unsuitable or are impracticable, mild ointments may be used, such as diachylon ointment, vaseline, cold cream, or zinc ointment, spread upon cloth and bound down with bandages.

CLASS IV.--HYPERTROPHIES.[5]

[Footnote 5: Purpura, constituting Class III., appears in Vol. II. p. 186, as a separate article by I. E. Atkinson.]

Lentigo.

Lentigo, or freckle, is characterized by irregularly-shaped, rounded or angular, pinhead- or pea-sized, yellowish or brownish spots of pigment deposit, occurring for the most part upon the face and the backs of the hands. They may appear as blemishes scarcely perceptible to the casual observer, or to such an extent and with such intensity of color as to be disfiguring. They may show themselves as discrete or as confluent lesions, and in the latter event the skin presents a spotted, rusty, or dirty appearance. As stated, the face and the backs of the hands are usually attacked, but other regions may also be invaded. They are encountered at all ages, but usually in young persons, especially in those of light complexion, and more particularly in red-haired subjects. They pursue a chronic course, lasting, as a rule, a lifetime, being, however, in most cases much paler in winter than in summer. Sometimes the lesions are blackish rather than brownish, and cases are on record where such were numerous and occupying the general surface. Blackish freckles are also met with in connection with certain rare forms of atrophy of the skin proper complicated with telangiectases, as in the cases reported by Hebra and {659} Kaposi, Taylor, and one of us (Duhring), an account of which may be found under atrophy of the skin.

The affection consists of a circumscribed deposit of pigment, which in the majority of cases is due to the influence of the sun's rays, but there are cases in which the lesions cannot be assigned to this cause, as, for example, where they occur upon the trunk or other regions not exposed to light. The treatment will be referred to in connection with chloasma.

Chloasma.

Chloasma may be described as a pigmentary affection, consisting of variously sized and shaped, more or less defined, smooth patches of a yellowish, brownish, or blackish color. The affection is one merely of coloration, the structure of the skin proper being normal. The spots or patches vary much as to size and shape. As a rule, they are irregular in outline, and not infrequently they are angular. They vary in size from a small coin to a hand or larger. At times the affection may develop as a diffuse or even as a universal discoloration. The distribution of the pigment may be uniform, but more frequently it is mottled, giving the skin a thick, muddy, or dirty appearance. Under idiopathic chloasma are included the forms of pigmentation due to various external agencies, as, for example, chemicals, sinapisms, heat, and long-continued scratching. The symptomatic group comprises uterine chloasma and the discolorations occurring in connection with certain general maladies, among which cancer, tuberculosis, Addison's disease, and malaria may be mentioned. Chloasma is also met with as a symptom in certain diseases of the skin proper, as scleroderma, morphoea, leprosy, and syphilis.

Chloasma uterinum, the commonest form, appears in all degrees from a duskiness or swarthiness of the complexion to pronounced patches of mottled yellowish or brownish discoloration, occurring on the face usually of pregnant women. But the same condition is met with also in single women, and at times in men. In women it usually appears as a more or less broken patch invading the forehead, extending from temple to temple, but the nose, cheeks, and chin are likewise very frequently attacked. It is due both to physiological and to pathological changes in the uterus, and also to various disorders of the menstrual function. The nervous system in many cases is without doubt at fault, and to this cause must be assigned those cases occurring in men. It is encountered, as a rule, between the ages of twenty-five and fifty. Its course is variable, depending upon the cause, but, as a rule, it is persistent, and it may continue for a long period. It is liable to be confounded with tinea versicolor, from which, however, it may be readily distinguished by the observation that in the latter disease the surface of the skin is the seat of more or less furfuraceous desquamation, which becomes more evident by scraping. In chloasma the skin is normal in structure. The patches of tinea versicolor are usually more numerous than those of chloasma, and occupy the trunk, a region seldom invaded by the latter affection. The face is the common seat of chloasma, a region practically exempt from tinea versicolor.

The treatment consists in removing the cause where this is possible, or {660} in modifying it by such general remedies as appear indicated. Among the various local remedies corrosive sublimate is one of the most valuable, used in the form of a lotion with water, alcohol, or almond emulsion. Its strength should vary from half a grain to five grains to the ounce, according to the region, size of the spot, sensitiveness of the skin, and the effect produced. Two or three grains to the ounce will generally be found of sufficient strength; and this may be applied, dabbed on lightly for five or ten minutes, twice daily, until irritation or desquamation appears. A lotion recommended by Hardy is the following:

Rx. Hydrargyri chlor. corros., gr. viiss;
Zinci sulphatis, drachm ss;
Plumbi acetatis, drachm ss;
Aquæ, fluidounce iv. M.

Ammoniated mercury, from forty to eighty grains to the ounce of ointment, may also be referred to as of positive value.

The following formula may also be given:

Rx. Hydrargyri ammoniati, drachm j;
Bismuthi magist., drachm ss;
Ugt. aquæ rosæ, ounce j.

M.--Sig. Apply at night.

Sulphur ointments, as of precipitated sulphur one or two drachms to the ounce, are also at times useful. The applications may be suspended from time to time should irritation occur. The treatment in some cases is followed by good results, while in others it is unsatisfactory. The discoloration, having been removed, may remain away, or, as often happens, may recur. The treatment recommended for chloasma is that which will be found of most service in lentigo.

* * * * *

There are other discolorations, of a different nature, which may be referred to here, as the staining due to the coloring matter of the bile, and that sometimes following the internal use of nitrate of silver, known as argyria, where the skin assumes a bluish-gray, bronze, or blackish shade. Neumann states that reduced silver is found in all parts of the skin except the lining epithelia of the glands and the cells of the mucous layer of the epidermis. The deposit also occurs in the internal organs.

Keratosis Pilaris.

Keratosis pilaris (also called lichen pilaris and pityriasis pilaris) is an hypertrophy of the epidermis about the apertures of the hair-follicles, forming pinhead-sized, conical epidermic elevations. The lesions are met with usually about the extensor surfaces of the thighs and arms, especially the former, but they may also occur on other parts. They are whitish, grayish, or blackish in color, are rarely larger than a pinhead, each being pierced by a hair, around which are accumulated, in the form of strata, the horny cells of the epidermis. In some lesions the hair is broken off at the apex, appearing as a black central point; in others the hair is not visible, but is found coiled or twisted up within the papules. The skin is dry, harsh, or rough, and together with the papules may feel like a nutmeg-grater. The skin at the base of each papule is of a normal {661} color or slightly reddened. The elevations consist of an accumulation of epidermic cells and sebaceous matter about the orifices of the hair-follicles. The affection in its milder forms is not uncommon, and is encountered usually in cold weather, and especially in those who bathe infrequently. It may occur at any age, but is most common in early adult life. Slight itching is occasionally present. As ordinarily observed, it is a slight disorder, but shows a tendency to persist. It resembles somewhat cutis anserina, the miliary papular syphiloderm in the desquamating stage, and also lichen scrofulosus. In goose-flesh (cutis anserina) the elevations are of a different nature, being due to cold, heat, or nervous excitement. The papules of the syphiloderm tend to group, are firmer, more deeply seated, less scaly, and of a reddish color. In lichen scrofulosus the papules are more solid in character, incline to group, are less scaly, and usually appear about the abdomen.

The disease is readily removable by treatment. Hot baths with the free use of strong soap, as sapo viridis, will usually suffice in ordinary cases; alkaline baths are also serviceable. In rebellious cases oily applications, such as the petroleum preparations, lard, and glycerin, or sulphur ointment, may be used in conjunction with the baths.

Molluscum Epitheliale.

Molluscum epitheliale, also called molluscum contagiosum and molluscum sebaceum, is characterized by rounded, semiglobular, flattened, or verrucous papules or tubercles of a whitish or pinkish color, varying in size from a pinhead to a pea. As generally met with, they are the size and shape of a small split pea; in other cases they are more acuminated or are in the form of a very small pearl button. They have a broad base and are seated close to the general surface. As a rule, they are multiple, three or six or more being present in different stages of evolution. They are unaccompanied by subjective symptoms. The skin covering them is stretched, and they have a glistening or waxy look, and at times resemble a drop of wax. In consistence they are usually firm, becoming soft with age. Their summits are sometimes flattened and umbilicated, with a central darkish point representing the mouth of the follicle. Their usual seat is the face, especially the eyelids, cheeks, and chin, but the neck, breast, and genitalia may also be invaded. They grow slowly in most cases, and are unaccompanied by inflammatory symptoms. Later, they become soft and tend to break down, with at times ulceration.

The disease is rare in this country, and is seldom encountered in our experience either in dispensary or in private practice. It occurs chiefly in children, and more especially among the poorer classes. Its cause is obscure. By some authorities it is considered to be contagious, this view being more generally entertained in England (where the disease seems to be more frequently encountered than elsewhere) than in other countries. The evidence for believing it to be contagious, however, does not seem sufficient to warrant such a conclusion. Inoculation has failed to develop the disease. Some observers consider that the process has its origin in the sebaceous glands, while others--ourselves among the number--hold that it is a disease of the rete mucosum. It is to be regarded as a {662} hyperplasia of the rete. If the tumor be cut into, the contents may usually be expressed in the form of a whitish or yellowish rounded mass of a thick or thin cheesy consistence. Under the microscope it is seen to be composed of epithelial cells with nuclei and of peculiar rounded or ovoidal, sharply-defined, fatty-looking bodies--the so-called molluscum bodies, which are to be viewed as a form of epithelial degeneration. The growth probably begins in the hair-follicles, as originally stated by Virchow and more recently confirmed by Thin.

The disease is to be distinguished from molluscum fibrosum, from papillary warts, and from acne. Local treatment, consisting of incision and expression of the contents, with subsequent cauterization with nitrate of silver, is the best procedure. They may also be ligated. As the disease tends to spontaneous cure, the remedies employed should be simple in character.

Callositas.

Callositas (syn., tylosis, tyloma, callus) is characterized by the formation of a hard or horny thickened patch of epidermis, variously sized and shaped, and of a grayish, yellowish, or brownish color. The patches are usually coin-sized, more or less rounded in shape, grayish, yellowish, or brownish in color, somewhat elevated, and of a dense and firm texture. They are most common about the hands and feet, and in a measure are protective to the more sensitive corium beneath. The ordinary surface lines are less distinct than on the surrounding healthy skin, into which the patch gradually merges. The thickening and elevation may be slight or excessive, and are most marked at the centre. The process rarely gives rise to any annoyance or pain, but when excessive the more delicate movements of the parts are restricted. Occasionally, from accidental injury, the underlying corium becomes inflamed, suppurates, and as a result the thickened mass is cast off. When occurring about the joints from motion of the parts, it may, moreover, become fissured and painful. Pressure and friction are the main factors in the production of a callosity--on the hands from the use of tools and implements, and on the feet from ill-fitting shoes. But cases are seen exceptionally in which there has been no apparent external cause; moreover, the same amount of pressure or friction in different individuals may give rise to different degrees of callosity; hence there must in some cases be other causes which at times enter into its production, as, for example, altered nerve-supply. The epidermis is the only part involved; fissuring and suppuration, it is true, involve the deeper structures, but these conditions are accidental and secondary. A section of a callosity shows a thickening of the horny layer, the corium remaining normal.

Unless the callosity is excessive or gives rise to inconvenience, treatment is rarely demanded. When advisable, the parts are to be softened by means of hot-water applications or poultices, solutions of caustic potash, or sapo viridis used as an ointment; after which the callus may be removed by scraping with a dermal curette or shaving with a sharp knife. An excellent method of treatment consists in the continuous application for some days of a plaster of salicylic acid of 10 or 12 per cent. strength, the same to be renewed every few days; at the end of a week or two the {663} parts should be soaked in hot water, and the mass will readily come away. A solution of salicylic acid in collodion of the same strength or stronger, applied frequently for five or six days, will often act in like manner.

Clavus.

Clavus, or corn, is a small, circumscribed hypertrophy of the horny layer of the epidermis, painful upon pressure, situated usually about the feet. As commonly met with, it is about the size of a pea, with a smooth and shining surface, having a hard and horny feel. Corns are seen most frequently upon the outer surface of the little toe, but are often met with also upon the other toes and on the soles of the feet. Occurring between the toes, the moisture and friction of the part have a softening effect, and as a result the corns are soft and spongy, constituting soft corns. One, several, or more may be present. When slightly developed they cause very little disturbance or discomfort, but if large or irritated they may become sensitive and render walking painful. Continued pressure and friction, as from badly-fitting shoes, are the active factors in their production. Anatomically, a corn is a localized epidermal hypertrophy, consisting of a horny mass, cone-shaped, with the base externally and the apex pressing upon the rete and corium; the cone being made up of concentrically-arranged, closely-packed layers of epidermic cells. The corium upon which this cone-shaped mass presses may be atrophied or hypertrophied.

The first essential in the treatment is a removal of the cause. The feet should be properly fitted. The corn is to be softened by means of continuous or repeated soaking in hot water or by poulticing, after which it may be pared down or extracted. Salicylic acid, either in solution or in the form of a plaster, 15 or 20 per cent. strength, applied for several nights, will often give relief. A well-known and efficient formula is the following:

Rx. Acidi salicylici, gr. xxx;
Ext. cannabis Indicæ, gr. x;
Collodii, fluidounce ss. M.

Sig. Paint on every night and morning. At the end of several days or a week the part is soaked in warm water and the epidermic mass, or greater portion of it, is readily detached. Nitrate of silver is useful after softening of the growth has been brought about, and is also of advantage in the treatment of soft corns. Caustic potash, thirty to sixty grains to the ounce of water or alcohol, is also of service, but is to be employed cautiously. Considerable relief to the soft formation is obtained by separating the toes with a thin layer of raw cotton. A ring of rubber, wadding or felt should be employed to prevent pressure and friction upon a corn, and, as this removes the exciting cause, permanent relief may follow.

Cornu Cutaneum.