Chapter IV: Part 4

The disease first appears upon the tibial regions, and its earliest manifestation may be urticarial, but there soon develop the characteristic small, millet-seed-sized, or larger, firm elevations, which may be of the natural color of the skin or of a pinkish tinge. The lesions, whilst discrete, are in great numbers, and closely crowded. The overlying skin is dry, rough and harsh; itching is intense, and, as a result of the scratching, excoriations and blood crusts are commonly present. In consequence of the irritation, the inguinal glands are enlarged. Sooner or later the integument becomes considerably thickened, hard and rough. Eczematous symptoms may be superadded. In severe cases the entire extensor surfaces of the legs and arms, and in some instances the trunk also, are invaded. It is worse in the winter season.

#What is known in regard to etiology and pathology?#

It is a disease of the ill-fed and neglected, usually developing in early childhood, and persisting throughout life. It is extremely rare, even in its milder types, in this country. Clinically and pathologically it bears some resemblance to papular eczema.

#Give the prognosis and treatment of prurigo.#

The disease, in its severer types is, as a rule, incurable, but much can be done to alleviate the condition. Good, nourishing food, pure air and exercise are of importance. Tonics and cod-liver oil are usually beneficial. The local management is similar to that employed in chronic eczema. An ointment of [beta]-naphthol, one-half to five per cent. strength, is highly extolled.

#Acne.#

#Give a definition of acne.#

Acne is an inflammatory, usually chronic, disease of the sebaceous glands, characterized by papules, tubercles, or pustules, or a mixture of these lesions, and seated usually about the face.

#At what age does acne usually occur?#

Between the ages of fifteen and thirty, at which time the glandular structures are naturally more or less active.

#Describe the symptoms of acne.#

Irregularly scattered over the face, and in some cases also over the neck, shoulders and upper part of the trunk, are to be seen several, fifty or more, pin-head- to pea-sized papules, tubercles or pustules; commonly the eruption is of a mixed type (_acne vulgaris_), the several kinds of lesions in all stages of evolution and subsidence presenting in the single case. Interspersed may generally be seen blackheads, or comedones. The lesions may be sluggish in character, or they may be markedly inflammatory, with hard and indurated bases. In the course of several days or weeks, the papules and tubercles tend gradually to disappear by absorption; or, and as commonly the case, they become pustular, discharge their contents, or dry and slowly or rapidly disappear, with or without leaving a permanent trace, new lesions arising, here and there, to take their place. In exceptional instances the eruption is limited to the back, and in these cases the eruption is usually extensive and persistent, and not infrequently leaves scars.

#What do you understand by acne punctata, acne papulosa, acne pustulosa, acne indurata, acne atrophica, acne hypertrophica, and acne cachecticorum?#

These several terms indicate that the lesions present are, for the most part, of one particular character or variety.

#Describe the lesions giving rise to the names of these various types.#

Blocking up of the outlet of the sebaceous gland (comedo), which is usually the beginning of an acne lesion, may cause a moderate degree of hyperaemia and inflammation, and a slight elevation, with a central yellowish or blackish point results--the lesion of _acne punctata_; if the inflammation is of a higher grade or progresses, the elevation is reddened and more prominent--_acne papulosa_; if the inflammatory action continues, the interior or central portion of the papule suppurates and a pustule results--_acne pustulosa_; the pustule, in some cases, may have a markedly inflammatory and hard base--_acne indurata_; and not infrequently the lesions in disappearing may leave a pit-like atrophy or depression--_acne atrophica_; or, on the contrary, connective-tissue new growth may follow their disappearance--_acne hypertrophica_; and, in strumous or cachectic individuals, the lesions may be more or less furuncular in type, often of the nature of dermic abscesses, usually of a cold or sluggish character, and of more general distribution--_acne cachecticorum_.

#What is acne artificialis?#

Acne artificialis is a term applied to an acne or acne-like eruption produced by the ingestion of certain drugs, as the bromides and iodides, and by the external use of tar; this is also called _tar acne_.

#What course does acne pursue?#

Essentially chronic. The individual lesions usually run their course in several days or one or two weeks, but new lesions continue to appear from time to time, and the disease thus persists, with more or less variation, for months or years. In many cases there is, toward the age of twenty-five or thirty, a tendency to spontaneous disappearance of the disease.

#Is the eruption in acne usually abundant?#

It varies in different cases and at different periods in the same case. In some instances, not more than five or ten papules and pustules are present at one time; in others they may be numerous. Not infrequently several lesions make their appearance, gradually run their course, and the face continues free for days or one or two weeks.

#Does the eruption in acne disappear without leaving a trace?#

In many instances no permanent trace remains, but in others slight or conspicuous scarring is left to mark the site of the lesions.

#Are there any subjective symptoms in acne?#

As a rule, not; but markedly inflammatory lesions are painful.

#State the immediate or direct cause of an acne lesion.#

Hypersecretion or retention of sebaceous matter. Recent investigations point to the possibility of a special bacillus being the exciting cause, in some instances at least. The pyogenic cocci are added factors in the pustular and furuncular cases.

#Name the indirect or predisposing causes of acne.#

Digestive disturbance, constipation, menstrual irregularities, chlorosis, general debility, lack of tone in the muscular fibres of the skin, scrofulosis; and medicinal substances such as the iodides and bromides internally, and tar externally.

Working in a dusty or dirty atmosphere is often influential, resulting in a blocking-up of the gland ducts. Workmen in paraffin oils or other petroleum products often present a furuncle-like acne.

The disease is more common in individuals of light complexion.

#Is there any difficulty in the diagnosis of acne?#

Not if it be remembered that acne eruption is limited to certain parts and is always follicular, and that the several stages, from the comedo to the matured lesion, are usually to be seen in the individual case.

#In what respect does the pustular syphiloderm differ from acne?#

By its general distribution, the longer duration of the individual lesions, the darker color, and the presence of concomitant symptoms of syphilis.

#What is the pathology of acne?#

Primarily, acne is a folliculitis, due to retention or decomposition of the sebaceous secretion or to the introduction of a micro-organism; subsequently, the tissue immediately surrounding becoming involved, with the possible destruction of the sebaceous follicle as a result. The degree of inflammatory action determines the character of the lesions.

#State the prognosis of acne.#

It is usually an obstinate disease, but curable. Some cases yield readily, others are exceedingly rebellious, especially acne of the back. Success depends in a great measure upon a recognition and removal of the predisposing condition. Treatment is ordinarily a matter of months.

#What measures of treatment are usually demanded in acne?#

Constitutional and local measures; the former when indicated, the latter always.

#Upon what is the constitutional treatment based?#

Upon indications. Diet and hygienic measures are important.

In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin, saline and vegetable laxatives, are variously prescribed. Special mention may be made of the following:--

[Rx] Ext. rhamni pursh. fl., .............. f[dram]ij-f[dram]iv
Tinct. nucis vom., ................... f[dram]iij
Tinct. cardamomi comp., .......q.s. ad [Oz]iij. M.

SIG.--f[dram]t.d.

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

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

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

[Rx] Potassii acetat., .................... [dram]iv
Liq. potassae, ........................ f[dram]ij
Liq. ammonii acetat., .... q.s. ad ... f[Oz]iij. M.

SIG.--f[dram]j-f[dram]ij t.d., largely diluted.

#State the character of the local treatment in acne.#

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

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

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

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

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

#State the methods of external medication commonly employed.#

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

#State the object in view in local medication.#

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

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

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

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

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

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

[Rx] Sulphur, praecip., .................... [dram]ss-[dram]j
Adipis benz.
Lanolin, ............ [=a][=a] ....... [dram]ij.

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

[Rx] Sulphur, praecip., .................... [dram]iss
Pulv. tragacanthae, ................... gr. x1
Pulv. camphorae, ...................... gr. xx
Liq. calcis, ........ q.s. ad ........ f[Oz]iv. M.

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

[Rx] Sulphur, praecip., .................... [dram]iss
Etheris, ............................. f[dram]iv
Alcoholis, ........................... f[Oz]iijss. M.

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

[Rx] Zinci sulphatis,
Potassii sulphureti, .... [=a][=a] ... [dram]ss-[dram]iv
Aquae, ................................ [Oz]iv. M.

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

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

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

[Rx] Ichthyol, ............................ [dram]ss-[dram]j
Cerat. simp., ........................ [dram]iv. M.

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

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

[Rx] Hydrarg. chlorid. corros., ........... gr. ii-viij
Zinci sulphatis, ..................... gr. x-xx
Tinct. benzoini, ..................... f[dram]ij
Aquae, ............ q.s. ad ........... f[Oz]iv.

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

[Rx] Ichthyol,
Saponis viridis,
Sulphur, praecip.,
Lanolin, ............. [=a][=a] ...... [dram]j.

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

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

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

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

#Acne Rosacea.#

#Give a descriptive definition of acne rosacea.#

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

#Describe the symptoms of acne rosacea.#

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

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

#Are there any subjective symptoms in acne rosacea?#

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

#What do you know in regard to the etiology?#

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

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

#Is acne rosacea easily recognized?#

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

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

#State the prognosis of acne rosacea.#

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

#What is the method of treatment?#

Both constitutional and local measures are demanded in most cases.

#Upon what is the constitutional treatment to be based?#

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

#What is the external treatment?#

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

In many cases _Vleminckx's solution_[C] is valuable, applied diluted with one to ten parts of water. Also, a mucilaginous paste containing sulphur:--

[Rx] Mucilag. acaciae, ..................... f[dram]iij
Glycerinae, ........................... f[dram]ij
Sulphur, praecip., .................... [dram]iij. M.

[Footnote C:
[Rx] Calcis, .............................. [Oz]ss
Sulph. sublimat., .................... [Oz]j
Aquae, ................................ [Oz]x.

To be boiled down to [Oz]vj and filtered.]

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

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

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

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

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

#Acne Varioliformis.#
(_Synonyms:_ Acne Frontalis; Acne Rodens; Acne Necrotica; Lupoid Acne;
Necrotic Granuloma.)

#Describe acne varioliformis.#

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

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

#Give the prognosis and treatment.#

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

#Sycosis.#
(_Synonyms:_ Sycosis Vulgaris; Sycosis Non-parasitica; Folliculitis
Barbae; Sycosis Coccogenica.)

#What do you understand by sycosis?#

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

#Describe the symptoms of sycosis.#

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

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

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

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

#Does conspicuous hair loss occur in sycosis?#

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

#State the character of the subjective symptoms.#

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

#What is the course of the disease?#

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

#State the causes of sycosis.#

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

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

#What is the pathology of sycosis?#

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

#How would you distinguish sycosis from eczema?#

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

#How would you exclude tinea sycosis in the diagnosis?#

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

#Give the prognosis of sycosis.#

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

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

#How is sycosis to be treated?#

Mainly, and often exclusively, by external applications.

#Is constitutional treatment of no avail in sycosis?#

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

#Describe the external treatment.#

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

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

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

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

#What would you advise in regard to shaving?#

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

#When is depilation advisable as a therapeutic measure?#

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

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

#Dermatitis Papillaris Capillitii.#
(_Synonym:_ Acne Keloid.)

#Describe dermatitis papillaris capillitii.#

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

#Give the treatment.#

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

#Impetigo Contagiosa.#

#Give a descriptive definition of impetigo contagiosa.#

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

#Upon what parts does the eruption commonly appear?#

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

#Describe the symptoms of impetigo contagiosa.#

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

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

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

#State the cause of the disease.#

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

#From what diseases is impetigo contagiosa to be differentiated?#

From eczema, pemphigus, and ecthyma.

#How does impetigo contagiosa differ from these several diseases?#

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

#State the prognosis.#

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

#What is the treatment of impetigo contagiosa?#

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

#Impetigo Herpetiformis.#

#Describe impetigo herpetiformis.#

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

It is possibly a grave type of dermatitis herpetiformis.

#Ecthyma.#

#Give a descriptive definition of ecthyma.#

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

#Describe the symptoms and course of ecthyma.#

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

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

#What is the cause of ecthyma?#

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

#From what diseases is ecthyma to be differentiated?#

From impetigo contagiosa, and the flat pustular syphiloderm.

#How is it distinguished from these several diseases?#

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

#State the prognosis.#

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

#What treatment is to be advised?#

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

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

[Rx] Acidi borici, ........................ [dram]iv
Resorcini, ........................... [dram]ij
Glycerinae, ........................... f[dram]ij
Alcoholis, ........................... f[Oz]j
Aquae, ........... q.s. ad ............ Oj. M.

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

#Pemphigus.#

#What do you understand by pemphigus?#

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

#Name the varieties met with.#

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

#Describe the symptoms and course of pemphigus vulgaris.#

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

A grave type of pemphigus is exceptionally observed in the newborn--_pemphigus neonatorum_.

#What course does pemphigus vulgaris pursue?#

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

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

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

#Describe the symptoms and course of pemphigus foliaceus.#

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

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

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

#What is the character of the subjective symptoms in pemphigus?#

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

#What is known in regard to the etiology of pemphigus?#

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

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

#What is the pathology?#

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

#From what diseases is pemphigus to be differentiated?#

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

#How do these several diseases differ from pemphigus?#

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

#State the prognosis of pemphigus.#

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

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

Pemphigus neonatorum usually ends fatally.

#Give the treatment of pemphigus.#

Both constitutional and local measures are demanded. Good nutritious food and hygienic regulations are essential. Arsenic and quinia are the most valuable remedies. The former, in occasional instances, seems to have a specific influence, and should always be tried, beginning with small doses and increasing gradually to the point of tolerance and continued for several weeks or longer. The remedy should not be set aside as long as there are signs of improvement, unless the supervention of stomachic, intestinal or other disturbance demand its discontinuance. Other tonics, such as iron, strychnia and cod-liver oil, are also at times of service.

The blebs should be opened and the parts anointed or covered with a mild ointment. In more general cases bran, starch and gelatin baths, and in severe cases the continuous bath, if practicable, are to be used.

#CLASS III.--HEMORRHAGES.#

#Purpura.#

#Define purpura.#

Purpura is a hemorrhagic affection characterized by the appearance of variously-sized, usually non-elevated, smooth, reddish or purplish spots or patches, not disappearing under pressure.

#Name the several varieties met with.#

Three--purpura simplex, purpura rheumatica and purpura haemorrhagica; denoting, respectively, the mild, moderate and severe grade of the disease. The division is, to a great extent, an arbitrary one.

#Describe the clinical appearance and course of an individual lesion of purpura.#

The spot, which may be pin-head, pea-, bean-sized or larger, appears suddenly, and is of a bright red or purplish red color. Its brightness gradually fades, the color changing to a bluish, bluish-green, bluish- or greenish-yellow, dirty yellowish, yellowish-white, and finally disappearing; varying in duration from several days to several weeks.

#Describe the symptoms of purpura simplex.#

Purpura simplex, or the mild form, shows itself as pin-point to pea- or bean-sized, bright or dark-red spots, limited, as a rule, to the limbs, especially the lower extremities; fading gradually away and coming to an end in a few weeks, or new crops appearing irregularly for several months. There is rarely any systemic disturbance, and, as a rule, no subjective symptoms; in exceptional cases an urticarial element is added--_purpura urticans_.

#Describe the symptoms of purpura rheumatica.#

Purpura rheumatica (also called _peliosis rheumatica_) is usually preceded by symptoms of malaise, rheumatic pains and sometimes swelling about the joints; these phenomena abate and frequently disappear upon the outbreak of the eruption. The lesions are pea- to dime-sized, smooth, non-elevated, or slightly raised, and of a reddish or purplish color; the eruption may be more or less generalized, most abundant upon the limbs, or it may be limited to these parts. It may end in a few weeks, or may persist for several months, new spots appearing irregularly or in the form of crops.

As somewhat allied to this is another form (_Schoenlein's disease_), quite alarming in its symptoms. It is rare. It is characterized by symptoms partaking of the nature of rheumatism, purpuric spots, blotches and ecchymoses, erythema multiforme, and often associated with considerable edema. The throat is also usually invaded, and indeed the first symptom is commonly in this region. Considerable constitutional disturbance, of a threatening character, is commonly observed. Recovery usually takes place.

_Henoch's purpura_, observed chiefly in children, resembles the above, with the erythema multiforme character and the [oe]dematous swellings more pronounced, while the actual purpuric symptoms are less conspicuous. Gastric and intestinal symptoms and hemorrhages from the mucous membrane are commonly noted. It is fatal in about 20 per cent. of the cases.

#Describe the symptoms of purpura haemorrhagica.#

Purpura haemorrhagica (also called _land scurvy_) is characterized usually by premonitory, and frequently accompanying, symptoms of general distress, and by the appearance of coin to palm-sized, red or purplish hemorrhagic spots or patches, smooth, non-elevated or raised. Hemorrhage from the mouth, gums and other parts, slight or serious in character, may occur. New lesions continue to appear for several days or weeks; and in exceptional instances, repeated relapses take place, and the disease thus persists for months. It may end fatally.

#State the etiology of purpura.#

In most instances no cause can be assigned. The disease occurs at all ages from childhood to advanced life, and in individuals, apparently, in good and bad health alike. The hemorrhagic type is oftener seen in subjects debilitated or in a depraved state of health. A microorganism is also looked upon as a factor by some observers, especially in the grave type of disease.

#State the diagnostic characters of purpura.#

The appearance, irregularly or in crops, of bright-red or purplish spots, evidently of hemorrhagic nature, and not _disappearing upon pressure_, and as they are fading, going through the several changes of color usually observed in any ecchymosis.

#How does scurvy (scorbutus) differ from purpura?#

Scurvy, which may resemble the severe grade of purpura, has a different history, a recognizable cause, usually a peculiar distribution, and is accompanied with general weakness and a spongy, soft and bleeding condition of the gums.

#What is the pathology of purpura?#

The lesion of purpura consists essentially of a hemorrhage into the cutaneous tissues. The blood is subsequently absorbed, the haematin undergoing changes of color from a red to greenish and pale yellow, and finally fading away.

#State the prognosis#

The milder varieties disappear in the course of several weeks or months, and are rarely of serious import; the outcome of purpura haemorrhagica is somewhat uncertain; although usually favorable, a fatal result from internal hemorrhage is possible. The variety known as Schoenlein's disease is alarming, but seldom fatal. Henoch's disease is, however, always of grave import.

#What is the treatment of purpura?#

Hygienic and dietary measures, the administration of tonics and astringents, and, in severe cases, by relative or absolute rest.

The drugs commonly prescribed are: ergot, oil of erigeron, oil of turpentine, quinia, strychnia, iron, mineral acids, and gallic acid. _External_ treatment is rarely called for, but if deemed advisable, astringent lotions may be employed.

#Scorbutus.#
(_Synonyms:_ Scurvy; Sea Scurvy; Purpura Scorbutica.)

#Describe scorbutus.#

Scurvy is a peculiar constitutional state, developed in those living under bad hygienic conditions, and is characterized by emaciation, general febrile and asthenic symptoms, a more or less swollen, turgid and spongy and even gangrenous condition of the gums; and concomitantly, or sooner or later, by the appearance, usually upon the lower portion of the legs only, of dark-colored hemorrhagic patches or blotches. The skin of the affected part may become brawny and slightly scaly, and not infrequently may break down and ulcerate. Hemorrhages from the various mucous surfaces, slight or grave, may also take place.

#State the etiology of scurvy.#

It is due to long-continued deprivation of proper food, especially of fruits and vegetables. Other bad hygienic conditions favor its development. It is seen most commonly in sailors and others taking long voyages.

#How is scurvy to be distinguished from purpura?#

By the asthenic and emaciated general condition and the peculiar puffy, spongy state of the gums. The cutaneous manifestation is more diffused, forming usually large palm-sized patches, and, as a rule, limited to the region of the ankles or lower part of the legs.

#Give the prognosis of scurvy.#

The disease is remediable, and usually rapidly so. In those instances in which the same bad hygienic conditions and the ingestion of improper food are continued, death finally results.

#What treatment would you advise in scurvy?#

Proper food, with an abundance of fruit and vegetables. Lemon or lime juice is especially valuable, and is to be taken freely. If indicated, tonics and stimulants are also to be prescribed. For the relief of the tumid, spongy condition of the gums, astringent and antiseptic mouth washes are to be employed.

The cutaneous manifestations, when tending to ulceration, are to be treated upon general principles.

#CLASS IV.--HYPERTROPHIES.#

#Lentigo.#
(_Synonym:_ Freckle.)

#Describe lentigo.#

Lentigo, or freckle, is characterized by round or irregular, pin-head to pea-sized, yellowish, brownish or blackish spots, occurring usually about the face and the backs of the hands. It is a common affection, varying somewhat in the degree of development; the freckles present may be few and insignificant, or they may exist in profusion and be quite disfiguring. Heat and exposure favor their development. Those of light complexion, especially those with red hair, are its most common subjects. The color of the lesion is usually a yellowish-brown.

It is common to all ages, but is generally seen in its greatest development during adolescence, the disposition to its appearance becoming less marked as age advances.

#What is the pathology of lentigo?#

Lentigo consists simply of a circumscribed deposit of pigment granules--merely a localized increase of the normal pigment, differing from chloasma (_q. v._) only in the size and shape of the pigmentation.

#State the prognosis.#

The blemishes can be removed by treatment, but their return is almost certain.

#Name the several applications commonly employed for their removal.#

An aqueous or alcoholic solution of corrosive sublimate, one-half to three grains to the ounce; lactic acid, one part to from six to twenty parts of water; and an ointment containing a drachm each of bismuth subnitrate and ammoniated mercury to the ounce.

The applications, which act by removing the epidermal and rete cells and with them the pigment, are made two or three times daily, and their use intermitted for a few days as soon as the skin becomes irritated or scaly.

Touching each freckle for a few seconds with the electric needle, just pricking the epidermis, will occasionally remove the blemish.

#Chloasma.#

#What do you understand by chloasma?#

Chloasma consists of an abnormal deposit of pigment, occurring as variously-sized and shaped, yellowish, brownish or blackish patches.

#Describe the clinical appearances of chloasma.#

Chloasma appears either in ill-defined patches, as is commonly the case, or as a diffuse discoloration. Its appearance is rapid or gradual, generally the latter. The patches are rounded or irregular, and usually shade off into the sound skin. One, several or more may be present, and coalescence may take place, resulting in a large irregular pigmented area. The color is yellowish, or brownish, and may even be blackish (_melasma_, _melanoderma_). The skin is otherwise normal. The face is the most common site.

#Into what two general classes may the various examples of chloasma be grouped?#

Idiopathic and symptomatic.

#What cases of chloasma are included in the idiopathic group?#

All those cases of pigmentation caused by external agents, such as the sun's rays, sinapisms, blisters, continued cutaneous hyperaemia from scratching or any other cause, etc.

#What cases of chloasma are included in the symptomatic group?#

All forms of pigment deposit which occur as a consequence of various organic and systemic diseases, as the pigmentation, for instance, seen in association with tuberculosis, cancer, malaria, Addison's disease, uterine affections, and the like. In such cases, with few exceptions, the pigmentation is usually more or less diffuse.

#What is chloasma uterinum?#

Chloasma uterinum is a term applied to the ill-defined patches of yellowish-brown pigmentation appearing upon the faces of women, usually between the ages of twenty-five and fifty. It is most commonly seen during pregnancy, but may occur in connection with any functional or organic disease of the utero-ovarian apparatus.

#What is argyria?#

Argyria is the term applied to the slate-like discoloration which follows the prolonged administration of silver nitrate.

#State the pathology of chloasma.#

The sole change consists in an increased deposit of pigment.

#Give the prognosis of chloasma.#

Unless a removal of the exciting or predisposing cause is possible, the prognosis is, as a rule, unfavorable, and the relief furnished by local applications usually but temporary.

#If constitutional treatment is advisable, upon what is it to be based?#

Upon general principles; there are no special remedies.

#How do external remedies act?#

Mainly by removing the rete cells and with them the pigmentation; and partly, also, by stimulating the absorbents.

#Are all external remedies which tend to remove the upper layers of the skin equally useful for this purpose?#

No; on the contrary some such applications are followed by an increase in the pigment deposit.

#Name the several applications commonly employed.#

Corrosive sublimate in solution, in the strength of one to four grains to the ounce of alcohol and water; a lotion made up as follows:--

[Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij
Ac. acet. dilut., .................... f[dram]ij
Sodii borat., ........................ [scruple]ij
Aquae rosae, ........................... f[Oz]iv. M.

And also the following:--

[Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij
Zinci sulphat.,
Plumbi acetat., ...... [=a][=a] ...... [dram]ss
Aquae, ................................ f[Oz]iv. M.

And lactic acid, with from five to twenty parts of water; and an ointment containing a drachm each of bismuth subnitrate and white precipitate to the ounce. Hydrogen peroxide occasionally acts well. Trichloracetic acid, usually weakened with one or two parts water, may be cautiously tried. The application of a strong alcoholic solution of resorcin, twenty to fifty per cent. strength, is also valuable, as is also a two to ten per cent. alcoholic solution of salicylic acid.

(Applications are made two or three times daily, and as soon as slight scaliness or irritation is produced are to be discontinued for one or two days.)

_Tattoo-marks_ are difficult to remove. Excision is the surest method. Electrolysis, applying the needle at various points, somewhat close together, and using a fairly strong current--three to eight milliamperes--will exceptionally, especially when repeated several times, produce a reactive inflammation and casting-off of the tissue containing the pigment; a scar is left.

Several writers claim good results with glycerole of papain, pricking it in in the same manner as in tattooing.

_Gun-powder marks._ If recent, but a day or so after their occurrence, the larger specks may be picked or scraped out. Later, electrolysis, using a fairly strong current, may result in their removal. Their removal may also be satisfactorily effected with a minute cutaneous trephine.

#Keratosis Pilaris.#
(_Synonyms:_ Pityriasis Pilaris; Lichen Pilaris.)

#What is meant by keratosis pilaris?#

Keratosis pilaris may be defined as a hypertrophic affection characterized by the formation of pin-head-sized, conical, epidermic elevations seated about the apertures of the hair follicles.

#Describe the clinical appearances of keratosis pilaris.#