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diff --git a/25944-8.txt b/25944-8.txt new file mode 100644 index 0000000..9360a02 --- /dev/null +++ b/25944-8.txt @@ -0,0 +1,14599 @@ +The Project Gutenberg eBook, Essentials of Diseases of the Skin, by Henry +Weightman Stelwagon + + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + + + + +Title: Essentials of Diseases of the Skin + Including the Syphilodermata Arranged in the Form of Questions and Answers Prepared Especially for Students of Medicine + + +Author: Henry Weightman Stelwagon + + + +Release Date: July 1, 2008 [eBook #25944] + +Language: English + +Character set encoding: ISO-8859-1 + + +***START OF THE PROJECT GUTENBERG EBOOK ESSENTIALS OF DISEASES OF THE +SKIN*** + + +E-text prepared by Kevin Handy, Ronnie Sahlberg, cbott, John Hagerson, and +the Project Gutenberg Online Distributed Proofreading Team +(https://www.pgdp.net) + + + +Note: Project Gutenberg also has an HTML version of this + file which includes the original illustrations. + See 25944-h.htm or 25944-h.zip: + (https://www.gutenberg.org/dirs/2/5/9/4/25944/25944-h/25944-h.htm) + or + (https://www.gutenberg.org/dirs/2/5/9/4/25944/25944-h.zip) + + +Transcriber's note: + + This book contains many characters not displayed by ASCII or + iso-8859-1 (Latin1) character sets. In the text file these + characters have been denoted by enclosing explanatory text + within square brackets. Two of the more commonly occurring + such characters are the oe-ligature (denoted by [oe] or [OE]) + and a-macron (denoted by [=a]. Some, but not all, of the + other such characters display properly in the html version. + + Text enclosed between pound signs was in bold face in the + original (#bold face#). + + A detailed transcriber's note is at the end of the e-text. + + + + + +ESSENTIALS OF DISEASES OF THE SKIN + +Including the Syphilodermata + +Arranged in the Form of Questions and Answers Prepared Especially +for Students of Medicine + +by + +HENRY W. STELWAGON, M.D., PH.D. + + * * * * * + +Get the Best The New Standard + + + DORLAND'S + + AMERICAN ILLUSTRATED + + MEDICAL DICTIONARY + + + For Students and Practitioners + + +A New and Complete Dictionary of the terms used in Medicine, Surgery, +Dentistry, Pharmacy, Chemistry, and kindred branches; together with new +and elaborate Tables of Arteries, Muscles, Nerves, Veins, etc.; of +Bacilli, Bacteria, Micrococci, etc.; Eponymic Tables of Diseases, +Operations, Signs and Symptoms, Stains, Tests, Methods of Treatment, +etc. By W.A.N. Dorland, M.D., Editor of the American Pocket Medical +Dictionary. Large octavo, nearly 800 pages, bound in full flexible +leather. Price, $4.50 net; with thumb index, $5.00 net. + + +JUST ISSUED--NEW (4) REVISED EDITION--2000 NEW WORDS + + + _It contains a maximum amount of matter in a minimum + space and at the lowest possible cost._ + + +This book contains #double the material in the ordinary students' +dictionary#, and yet, by the use of a clear, condensed type and thin +paper of the finest quality, is only 1-3/4 inches in thickness. It is +bound in full flexible leather, and is just the kind of a book that a +man will want to keep on his desk for constant reference. The book makes +a special feature of #the newer words#, and defines hundreds of +important terms not to be found in any other dictionary. It is +especially #full in the matter of tables#, containing more than a +hundred of great practical value, including new tables of Tests, Stains +and Staining Methods. A new feature is the inclusion of numerous +handsome illustrations, many of them in colors, drawn and engraved +specially for this book. + + "I must acknowledge my astonishment at seeing how much he has + condensed within relatively small space. I find nothing to + criticise, very much to commend, and was interested in finding some + of the new words which are not in other recent + dictionaries."--Roswell Park, _Professor of Principles and Practice + of Surgery and Clinical Surgery, University of Buffalo_. + + "Dr. Dorland's Dictionary is admirable. It is so well gotten up and + of such convenient size. No errors have been found in my use of + it."--Howard A. Kelly, _Professor of Gynecology, Johns Hopkins + University, Baltimore_. + + W. B. SAUNDERS COMPANY, 925 Walnut St., Phila. + London: 9, Henrietta Street, Covent Garden + + +Fifth Edition, Just Ready With Complete Vocabulary + + + THE + + AMERICAN POCKET + + MEDICAL DICTIONARY + + + EDITED BY + + W.A. NEWMAN DORLAND, A.M., M.D., + + Assistant Demonstrator of Obstetrics, University of Pennsylvania. + + + HUNDREDS OF NEW TERMS + + Bound in Full Leather, Limp, with Gold Edges. Price, $1.00 net; with + Patent Thumb Index, $1.25 net. + + +The book is an #absolutely new one#. It is not a revision of any old work, +but it has been written entirely anew and is constructed on lines that +experience has shown to be the most practical for a work of this kind. +It aims to be #complete#, and to that end contains practically all the +terms of modern medicine. This makes an unusually large vocabulary. +Besides the ordinary dictionary terms the book contains a wealth of +#anatomical and other tables#. This matter is of particular value to +students for memorizing in preparation for examination. + + + "I am struck at once with admiration at the compact size and + attractive exterior. I can recommend it to our students without + reserve."--James W. Holland, M.D., _of Jefferson Medical College_. + + "This is a handy pocket dictionary, which is so full and complete + that it puts to shame some of the more pretentious + volumes."--_Journal of the American Medical Association._ + + "We have consulted it for the meaning of many new and rare terms, + and have not met with a disappointment. The definitions are + exquisitely clear and concise. We have never found so much + information in so small a space."--_Dublin Journal of Medical + Science._ + + "This is a handy little volume that, upon examination, seems fairly + to fulfil the promise of its title, and to contain a vast amount of + information in a very small space.... It is somewhat surprising + that it contains so many of the rarer terms used in + medicine."--_Bulletin Johns Hopkins Hospital_, Baltimore. + + + + W. B. SAUNDERS COMPANY, 925 Walnut St., Phila. + London: 9, Henrietta Street, Covent Garden + + * * * * * + + +ESSENTIALS OF DISEASES OF THE SKIN. + + Since the issue of the first volume of the + #Saunders Question-Compends#, + + OVER 290,000 COPIES + + of these unrivalled publications have been sold. + This enormous sale is indisputable evidence of + the value of these self-helps to students and + physicians. + + +Saunders' Question-Compends. No. 11. + +ESSENTIALS OF DISEASES OF THE SKIN + +Including the Syphilodermata + +Arranged in the Form of Questions and Answers Prepared Especially +for Students of Medicine + +by + +HENRY W. STELWAGON, M.D., PH.D. + +Professor of Dermatology in the Jefferson Medical College, Philadelphia; +Dermatologist to the Howard and Philadelphia Hospitals, etc. + +Seventh Edition, Thoroughly Revised + +Illustrated + + + + + + + +Philadelphia and London +W. B. Saunders Company +1909 + +Set up, electrotyped, printed, 1890. Reprinted July, 1891. +Revised, reprinted, June, 1894. Reprinted March, 1897. +Revised, reprinted, August, 1899. Reprinted +September, 1901, May, 1902, September, 1903. +Revised, reprinted January, 1905. +Reprinted March, 1906. Revised, +reprinted March, 1909. + +Printed in America + +Press of +W. B. Saunders Company +Philadelphia + + + + +PREFACE TO SEVENTH EDITION. + + +In the present--seventh--edition the subject matter, especially as +regards the practical part, has been gone over carefully and the +necessary corrections and additions made. Nineteen new illustrations +have been added, a few of the old ones being eliminated. It is hoped +that the continued demand for this compend means a widening interest in +the study of diseases of the skin, sufficiently keen as to lead to the +desire for a still greater knowledge. + + H.W.S. + + +PREFACE TO FIRST EDITION. + + +Much of the present volume is, in a measure, the outcome of a thorough +revision, remodelling and simplification of the various articles +contributed by the author to Pepper's System of Medicine, Buck's +Reference Handbook of the Medical Sciences, and Keating's Cyclopædia of +the Diseases of Children. Moreover, in the endeavor to present the +subject as tersely and briefly as compatible with clear understanding, +the several standard treatises on diseases of the skin by Tilbury Fox, +Duhring, Hyde, Robinson, Anderson, and Crocker, have been freely +consulted, that of the last-named author suggesting the pictorial +presentation of the "Anatomy of the Skin." The space allotted to each +disease has been based upon relative importance. As to treatment, the +best and approved methods only--those which are founded upon the +aggregate experience of dermatologists--are referred to. + +For general information a statistical table from the Transactions of the +American Dermatological Association is appended. + + H.W.S. + + +CONTENTS. + + + PAGE +ANATOMY OF THE SKIN 17 + The Epidermis 18 + The Blood-vessels 19 + The Nervous and Vascular Papillæ 20 + The Hair and Hair-follicle 21 + +SYMPTOMATOLOGY 22 + Primary Lesions 22 + Secondary Lesions 23 + Distribution and Configuration 24 + Relative Frequency 26 + Contagiousness 27 + Rapidity of Cure 27 + Ointment Bases 27 + +CLASS I.--DISORDERS OF THE GLANDS 28 + Hyperidrosis 28 + Sudamen 30 + Hydrocystoma 31 + Anidrosis 31 + Bromidrosis 32 + Chromidrosis 32 + Uridrosis 33 + Phosphoridrosis 33 + Seborrh[oe]a (Eczema Seborrhoicum) 33 + Comedo 38 + Milium 42 + Steatoma 43 + +CLASS II.--INFLAMMATIONS 44 + Erythema Simplex 44 + Erythema Intertrigo 45 + Erythema Multiforme 46 + Erythema Nodosum 50 + Erythema Induratum 51 + Urticaria 52 + Urticaria Pigmentosa 56 + Dermatitis 58 + Dermatitis Medicamentosa 60 + X-Ray Dermatitis 63 + Dermatitis Factitia 64 + Dermatitis Gangrænosa 65 + Erysipelas 66 + Phlegmona Diffusa 68 + Furunculus 68 + Carbunculus 70 + Pustula Maligna 72 + Post-mortem Pustule 73 + Framb[oe]sia 73 + Verruga Peruana 73 + Equinia 74 + Miliaria 74 + Pompholyx 76 + Herpes Simplex 78 + Hydroa Vacciniforme 80 + Epidermolysis Bullosa 80 + Dermatitis Repens 81 + Herpes Zoster 81 + Dermatitis Herpetiformis 83 + Psoriasis 86 + Pityriasis Rosea 95 + Dermatitis Exfoliativa 96 + Lichen Planus 98 + Pityriasis Rubra Pilaris 99 + Lichen Scrofulosus 100 + Eczema 100 + Prurigo 118 + Acne 119 + Acne Rosacea 126 + Sycosis 130 + Dermatitis Papillaris Capillitii 135 + Impetigo Contagiosa 136 + Impetigo Herpetiformis 138 + Ecthyma 138 + Pemphigus 140 + +CLASS III.--HEMORRHAGES 144 + Purpura 144 + Scorbutus 146 + +CLASS IV.--HYPERTROPHIES 148 + Lentigo 148 + Chloasma 149 + Keratosis Pilaris 151 + Keratosis Follicularis 153 + Molluscum Epitheliale 153 + Callositas 155 + Clavus 156 + Cornu Cutaneum 158 + Verruca 160 + Nævus Pigmentosus 162 + Ichthyosis 165 + Onychauxis 167 + Hypertrichosis 168 + [OE]dema Neonatorum 170 + Sclerema Neonatorum 171 + Scleroderma 172 + Elephantiasis 174 + Dermatolysis 176 + +CLASS V.--ATROPHIES 177 + Albinismus 177 + Vitiligo 178 + Canities 180 + Alopecia 181 + Alopecia Areata 183 + Atrophia Pilorum Propria 187 + Atrophia Unguis 188 + Atrophia Cutis 189 + +CLASS VI.--NEW GROWTHS 191 + Keloid 191 + Fibroma 192 + Neuroma 194 + Xanthoma 195 + Myoma 196 + Angioma 196 + Telangiectasis 197 + Lymphangioma 198 + Rhinoscleroma 198 + Lupus Erythematosus 199 + Lupus Vulgaris 203 + Tuberculosis Cutis 209 + Ainhum 212 + Mycetoma 212 + Perforating Ulcer of the Foot 213 + Syphilis Cutanea 213 + Lepra 231 + Pellagra 235 + Epithelioma 236 + Paget's Disease of the Nipple 240 + Sarcoma 241 + Granuloma Fungoides 242 + +CLASS VII.--NEUROSES 244 + Hyperæsthesia 244 + Dermatalgia 244 + Anæsthesia 244 + Pruritus 244 + +CLASS VIII.--PARASITIC AFFECTIONS 247 + Tinea Favosa 247 + Tinea Trichophytina 251 + Tinea Imbricata 261 + Tinea Versicolor 262 + Erythrasma 265 + Actinomycosis 266 + Blastomycetic Dermatitis 266 + Scabies 267 + Pediculosis 271 + Pediculosis Capitis 272 + Pediculosis Corporis 274 + Pediculosis Pubis 275 + Cysticercus Cellulosæ 276 + Filaria Medinensis 277 + Ixodes 277 + Leptus 277 + [OE]strus 278 + Pulex Penetrans 278 + Cimex Lectularius 278 + Culex 279 + Pulex Irritans 279 + +TABLE showing Relative Frequency of the Various + Diseases of the Skin 280 + + + + +DISEASES OF THE SKIN. + +#ANATOMY OF THE SKIN.# + + +[Illustration: Fig. I. + Vertical section of the skin--Diagrammatic. (_After Heitsmann._)] + + + + + #The Epidermis.# + + +[Illustration: Fig. 2. + _c_, corneous (horny) layer; _g_, granular layer; _m_, mucous layer + (rete Malpighii). + The stratum lucidum is the layer just above the granular layer. + Nerve terminations--_n_, afferent nerve; _b_, terminal nerve bulbs; + _l_, cell of Langerhans. (_After Ranvier._)] + + + + + #The Blood-vessels.# + + +[Illustration: Fig. 3. + _C_, epidermis; _D_, corium; _P_, papillæ; _S_, sweat-gland duct. + _v_, arterial and venous capillaries (superficial, or papillary plexus) + of the papillæ. Deep plexus is partly shown at lower margin of the + diagram; _vs_--an intermediate plexus, an outgrowth from the deep + plexus, supplying sweat-glands, and giving a loop to hair papilla. + (_After Ranvier._)] + + + + + #The Nervous and Vascular Papillæ.# + + +[Illustration: Fig. 4. + _a_, a vascular papilla; _b_, a nervous papilla; _c_, a blood-vessel; + _d_, a nerve fibre; _e_, a tactile corpuscle. (_After Biesiadecki._)] + + + + + #The Hair and Hair-Follicle.# + + +[Illustration: Fig. 5. _A_, shaft of the hair; _B_, root of the hair; +_C_, cuticle of the hair; _D_, medullary substance of the hair. _E_, +external layer of the hair-follicle; _F_, middle layer of the +hair-follicle; _G_, internal layer of the hair-follicle; _H_, papilla of +the hair; _I_, external root-sheath; _J_, outer layer of the internal +root-sheath; _K_, internal layer of the internal root-sheath. (_After +Duhring._)] + + + + +#SYMPTOMATOLOGY.# + + +The symptoms of cutaneous disease may be objective, subjective or both; +and in some diseases, also, there may be systemic disturbance. + + +#What do you mean by objective symptoms?# + +Those symptoms visible to the eye or touch. + + +#What do you understand by subjective symptoms?# + +Those which relate to sensation, such as itching, tingling, burning, +pain, tenderness, heat, anæsthesia, and hyperæsthesia. + + +#What do you mean by systemic symptoms?# + +Those general symptoms, slight or profound, which are sometimes +associated, primarily or secondarily, with the cutaneous disease, as, +for example, the systemic disturbance in leprosy, pemphigus, and purpura +hemorrhagica. + + +#Into what two classes of lesions are the objective symptoms commonly +divided?# + + Primary (or elementary), and + Secondary (or consecutive). + + + + #Primary Lesions.# + + +#What are primary lesions?# + +Those objective lesions with which cutaneous diseases begin. They may +continue as such or may undergo modification, passing into the secondary +or consecutive lesions. + + +#Enumerate the primary lesions.# + +Macules, papules, tubercles, wheals, tumors, vesicles, blebs and +pustules. + + +#What are macules (maculæ)?# + +Variously-sized, shaped and tinted spots and discolorations, without +elevation or depression; as, for example, freckles, spots of purpura, +macules of cutaneous syphilis. + + +#What are papules (papulæ)?# + +Small, circumscribed, solid elevations, rarely exceeding the size of a +split-pea, and usually superficially seated; as, for example, the +papules of eczema, of acne, and of cutaneous syphilis. + + +#What are tubercles (tubercula)?# + +Circumscribed, solid elevations, commonly pea-sized and usually +deep-seated; as, for example, the tubercles of syphilis, of leprosy, and +of lupus. + + +#What are wheals (pomphi)?# + +Variously-sized and shaped, whitish, pinkish or reddish elevations, of +an evanescent character; as, for example, the lesions of urticaria, the +lesions produced by the bite of a mosquito or by the sting of a nettle. + + +#What are tumors (tumores)?# + +Soft or firm elevations, usually large and prominent, and having their +seat in the corium and subcutaneous tissue; as, for example, sebaceous +tumors, gummata, and the lesions of fibroma. + + +#What are vesicles (vesiculæ)?# + +Pin-head to pea-sized, circumscribed epidermal elevations, containing +serous fluid; as, for example, the so-called fever-blisters, the lesions +of herpes zoster, and of vesicular eczema. + + +#What are blebs (bullæ)?# + +Rounded or irregularly-shaped, pea to egg-sized epidermic elevations, +with fluid contents; in short, they are essentially the same as vesicles +and pustules except as to size; as, for example, the blebs of pemphigus, +rhus poisoning, and syphilis. + + +#What are pustules (pustulæ)?# + +Circumscribed epidermic elevations containing pus; as, for example, the +pustules of acne, of impetigo, and of sycosis. + + + + #Secondary Lesions.# + + +#What are secondary lesions?# + +Those lesions resulting from accidental or natural change, modification +or termination of the primary lesions. + + +#Enumerate the secondary lesions.# + +Scales, crusts, excoriations, fissures, ulcers, scars and stains. + + +#What are scales (squamæ)?# + +Dry, laminated, epidermal exfoliations; as, for example, the scales of +psoriasis, ichthyosis, and eczema. + + +#What are crusts (crustæ)?# + +Dried effete masses of exudation; as, for example, the crusts of +impetigo, of eczema, and of the pustular and ulcerating syphilodermata. + + +#What are excoriations (excoriationes)?# + +Superficial, usually epidermal, linear or punctate loss of tissue; as, +for example, ordinary scratch-marks. + + +#What are fissures (rhagades)?# + +Linear cracks or wounds, involving the epidermis, or epidermis and +corium; as, for example, the cracks which often occur in eczema when +seated about the joints, the cracks of chapped lips and hands. + + +#What are ulcers (ulcera)?# + +Rounded or irregularly-shaped and sized loss of skin and subcutaneous +tissue resulting from disease; as, for example, the ulcers of syphilis +and of cancer. + + +#What are scars (cicatrices)?# + +Connective-tissue new formations replacing loss of substance. + + +#What are stains?# + +Discolorations left by cutaneous disease, which stains may be transitory +or permanent. + + + + #Distribution and Configuration.# + + +#What do you mean by a patch of eruption?# + +A single group or aggregation of lesions or an area of disease. + + +#When is an eruption said to be limited or localized?# + +When it is confined to one part or region. + + +#When is an eruption said to be general or generalized?# + +When it is scattered, uniformly or irregularly, over the entire surface. + + +#When is an eruption universal?# + +When the whole integument is involved, without any intervening healthy +skin. + + +#When is an eruption said to be discrete?# + +When the lesions constituting the eruption are isolated, having more or +less intervening normal skin. + + +#When is an eruption confluent?# + +When the lesions constituting the eruption are so closely crowded that a +solid sheet results. + + +#When is an eruption uniform?# + +When the lesions constituting the eruption are all of one type or +character. + + +#When is an eruption multiform?# + +When the lesions constituting the eruption are of two or more types or +characters. + + +#When are lesions said to be aggregated?# + +When they tend to form groups or closely-crowded patches. + + +#When are lesions disseminated?# + +When they are irregularly scattered, with no tendency to form groups or +patches. + + +#When is a patch of eruption said to be circinate?# + +When it presents a rounded form, and usually tending to clear in the +centre; as, for example, a patch of ringworm. + + +#When is a patch of eruption said to be annular?# + +When it is ring-shaped, the central portion being clear; as, for +example, in erythema annulare. + + +#What meaning is conveyed by the term "iris"?# + +The patch of eruption is made up of several concentric rings. Difference +of duration of the individual rings, usually slight, tends to give the +patch variegated coloration; as, for example, in erythema iris and +herpes iris. + + +#What meaning is conveyed by the term "marginate"?# + +The sheet of eruption is sharply defined against the healthy skin; as, +for example, in erythema marginatum, eczema marginatum. + + +#What meaning is conveyed by the qualifying term "circumscribed"?# + +The term is applied to small, usually more or less rounded, patches, +when sharply defined; as, for example, the typical patches of psoriasis. + + +#When is the qualifying term "gyrate" employed?# + +When the patches arrange themselves in an irregular winding or +festoon-like manner; as, for instance, in some cases of psoriasis. It +results, usually, from the coalescence of several rings, the eruption +disappearing at the points of contact. + + +#When is an eruption said to be serpiginous?# + +When the eruption spreads at the border, clearing up at the older part; +as, for instance, in the serpiginous syphiloderm. + + + + #RELATIVE FREQUENCY.# + + +#Name the more common cutaneous diseases and state approximately their +frequency.# + +Eczema, 30.4%; syphilis cutanea, 11.2%; acne, 7.3%; pediculosis, 4%; +psoriasis, 3.3%; ringworm, 3.2%; dermatitis, 2.6%; scabies, 2.6%; +urticaria, 2.5%; pruritus, 2.1%; seborrh[oe]a, 2.1%; herpes simplex, +1.7%; favus, 1.7%; impetigo, 1.4%; herpes zoster, 1.2%; verruca, 1.1%; +tinea versicolor, 1%. Total: eighteen diseases, representing 81 per +cent. of all cases met with. + +(These percentages are based upon statistics, public and private, of the +American Dermatological Association, covering a period of ten years. In +private practice the proportion of cases of pediculosis, scabies, favus, +and impetigo is much smaller, while acne, acne rosacea, seborrh[oe]a, +epithelioma, and lupus are relatively more frequent.) + + + + #CONTAGIOUSNESS.# + + +#Name the more actively contagious skin diseases.# + +Impetigo contagiosa, ringworm, favus, scabies and pediculosis; excluding +the exanthemata, erysipelas, syphilis and certain rare and doubtful +diseases. + +[At the present time when most diseases are presumed to be due to +bacteria or parasites the belief in contagiousness, under certain +conditions, has considerably broadened.] + + + + #RAPIDITY OF CURE.# + + +#Is the rapid cure of a skin disease fraught with any danger to the +patient?# + +No. It was formerly so considered, especially by the public and general +profession, and the impression still holds to some extent, but it is not +in accord with dermatological experience. + + + + #OINTMENT BASES.# + + +#Name the several fats in common use for ointment bases.# + +Lard, petrolatum (or cosmoline or vaseline), cold cream and lanolin. + + +#State the relative advantages of these several bases.# + +_Lard_ is the best all-around base, possessing penetrating properties +scarcely exceeded by any other fat. + +_Petrolatum_ is also valuable, having little, if any, tendency to +change; it is useful as a protective, but is lacking in its power of +penetration. + +_Cold Cream_ (ungt. aquæ rosæ) is soothing and cooling, and may often be +used when other fatty applications disagree. + +_Lanolin_ is said to surpass in its power of penetration all other +bases, but this is not borne out by experience. It is an unsatisfactory +base when used alone. It should be mixed with another base in about the +proportion of 25% to 50%. + +These several bases may, and often with advantage, be variously +combined. + + +#What is to be added to these several bases if a stiffer ointment is +required?# + +Simple cerate, wax, spermaceti, or suet; or in some instances, a +pulverulent substance, such as starch, boric acid, and zinc oxide. + + + + +#CLASS I.--DISORDERS OF THE GLANDS.# + + + #Hyperidrosis.# + + +[Illustration: Fig. 6. + A normal sweat-gland, highly magnified. (_After Neumann._) + _a_, Sweat-coil: _b_, sweat-duct; _c_, lumen of duct; _d_, + connective-tissue capsule; _e_ and _f_, arterial trunk and + capillaries.] + + +#What is hyperidrosis?# + +Hyperidrosis is a functional disturbance of the sweat-glands, +characterized by an increased production of sweat. This increase may be +slight or excessive, local or general. + + +#As a local affection, what parts are most commonly involved?# + +The hands, feet, especially the palmar and plantar surfaces, the axillæ +and the genitalia. + + +#Describe the symptoms of the local forms of hyperidrosis.# + +The essential, and frequently the sole symptom, is more or less profuse +sweating. + +If the hands are the parts involved, they are noted to be wet, clammy +and sometimes cold. + +If involving the soles, the skin often becomes more or less macerated +and sodden in appearance, and as a result of this maceration and +continued irritation they may become inflamed, especially about the +borders of the affected parts, and present a pinkish or pinkish-red +color, having a violaceous tinge. The sweat undergoes change and becomes +offensive. + + +#Is hyperidrosis acute or chronic?# + +Usually chronic, although it may also occur as an acute affection. + + +#What is the etiology of hyperidrosis?# + +Debility is commonly the cause in general hyperidrosis; the local forms +are probably neurotic in origin. + + +#What is the prognosis?# + +The disease is usually persistent and often rebellious to treatment; in +many instances a permanent cure is possible, in others palliation. +Relapses are not uncommon. + + +#What systemic remedies are employed in hyperidrosis?# + +Ergot, belladonna, gallic acid, mineral acids, and tonics. +Constitutional treatment is rarely of benefit in the local forms of +hyperidrosis, and external applications are seldom of service in general +hyperidrosis. Precipitated sulphur, a teaspoonful twice daily, is also +well spoken of, combined, if necessary, with an astringent. + + +#What external remedies are employed in the local forms?# + +Astringent lotions of zinc sulphate, tannin and alum, applied several +times daily, with or without the supplementary use of dusting-powders. +Weak solutions of formaldehyde, one to one hundred, are sometimes of +value. + +Dusting-powders of boric acid and zinc oxide, to which may be added from +ten to thirty grains of salicylic acid to the ounce, to be used freely +and often:-- + + [Rx] Pulv. ac. salicylici ................. gr. x-xxx. + Pulv. ac. borici ..................... [dram]v. + Pulv. zinci oxidi .................... [dram]iij M. + +Diachylon ointment, and an ointment containing a drachm of tannin to the +ounce; more especially applicable in hyperidrosis of the feet. The parts +are first thoroughly washed, rubbed dry with towels and dusting-powder, +and the ointment applied on strips of muslin or lint and bound on; the +dressing is renewed twice daily, the parts each time being rubbed dry +with soft towels and dusting-powder, and the treatment continued for ten +days to two weeks, after which the dusting-powder is to be used alone +for several weeks. No water is to be used after the first washing until +the ointment is discontinued. One such course will occasionally suffice, +but not infrequently a repetition is necessary. + +Faradization and galvanization are sometimes serviceable. Repeated mild +exposures to the Röntgen rays have a favorable influence in some +instances. + + + + #Sudamen.# + (_Synonym:_ Miliaria crystallina.) + + +#What is sudamen?# + +Sudamen is a non-inflammatory disorder of the sweat-glands, +characterized by pin-point to pin-head-sized, discrete but thickly-set, +superficial, translucent whitish vesicles. + + +#Describe the clinical characters.# + +The lesions develop rapidly and in great numbers, either irregularly or +in crops, and are usually to be seen as discrete, closely-crowded, +whitish, or pearl-colored minute elevations, occurring most abundantly +upon the trunk. In appearance they resemble minute dew-drops. They are +non-inflammatory, without areola, never become purulent, and evince no +tendency to rupture, the fluid disappearing by absorption, and the +epidermal covering by desquamation. + + +#Give the course and duration of sudamen.# + +New crops may appear as the older lesions are disappearing, and the +affection persist for some time, or, on the other hand, the whole +process may come to an end in several days or a week. In short, the +course and duration depend upon the subsidence or persistence of the +cause. + + +#What is the anatomical seat of sudamen?# + +The lesions are formed between the lamellæ of the corneous layer, +usually the upper part; and are thought to be due to some change in the +character of the epithelial cells of this layer, probably from high +temperature, giving rise to a blocking up of the surface outlet. + + +#What is the cause of sudamen?# + +Debility, especially when associated with high fever. The eruption is +often seen in the course of typhus, typhoid and rheumatic fevers. + + +#How would you treat sudamen?# + +By constitutional remedies directed against the predisposing factor or +factors, and the application of cooling lotions of vinegar or alcohol +and water, or dusting-powders of starch and lycopodium. + + + + #Hydrocystoma.# + + +#Describe hydrocystoma.# + +Hydrocystoma is a cystic affection of the sweat-gland ducts, seated upon +the face. The lesions may be present in scant numbers or in more or less +profusion. They have the appearance of boiled sago grains imbedded in +the skin; the larger lesions may have a bluish color, especially about +the periphery. It is not common, and is usually seen in washerwomen and +laundresses, or those exposed to moist heat. In some cases it tends to +disappear during the winter months. There are no subjective symptoms. + +Treatment consists of puncturing the lesions and application of +dusting-powder. Avoidance of the exciting cause (moist heat) is +important. + + + + #Anidrosis.# + + +#Describe anidrosis.# + +It is the opposite condition of hyperidrosis, and is characterized by +diminution or suppression of the sweat secretion. It occurs to some +extent in certain systemic diseases and also in some affections of the +skin, such as ichthyosis; nerve-injuries may give rise to localized +sweat-suppression. + +Treatment is based upon general principles; friction, warm and hot-vapor +baths, electricity and similar measures are of service. + + + + #Bromidrosis.# + (_Synonym:_ Osmidrosis.) + + +#Describe bromidrosis.# + +Bromidrosis is a functional disturbance of the sweat-glands +characterized by a sweat secretion of an offensive odor. The sweat +production may be normal in quantity or more or less excessive, usually +the latter. The condition may be local or general, commonly the former. +It is closely allied to hyperidrosis, and may often be considered +identical, the odor resulting from rapid decomposition of the sweat +secretion. The decomposition and resulting odor have been thought due to +the presence of bacteria. + + +#What parts are most commonly affected in bromidrosis?# + +The feet and the axillæ. + + +#What is the treatment of bromidrosis?# + +It is essentially the same as that of hyperidrosis (_q. v._), consisting +of applications of astringent lotions, dusting-powders, especially those +containing boric acid and salicylic acid, and the continuous application +of diachylon ointment. In obstinate cases weak formaldehyde solutions, +Röntgen rays, and high-frequency currents can be tried. + + + + #Chromidrosis.# + + +#Describe chromidrosis.# + +This is a functional disorder of the sweat-glands characterized by a +secretion variously colored, and usually increased in quantity. It is, +as a rule, limited to a circumscribed area. The most common color is +red. The condition is probably of neurotic origin and tends to recur. +(True chromidrosis is extremely rare; most of the cases formerly thought +to be such are now known to be examples of pseudochromidrosis.) + +Treatment should be invigorating and tonic, with special reference +toward the nervous system. The various methods of local electrization +should also be resorted to. + +Mild antiseptic and astringent lotions or dusting powders should also be +advised. + +_Red chromidrosis_ or _Pseudochromidrosis_ is a condition in which the +coloring of the sweat occurs after its excretion and is due to the +presence of chromatogenous bacteria which are found attached to the +hairs of the part in agglutinated masses. The axilla is the favorite +site. Treatment consists of frequent soap-and-water washings, and the +application of boric acid, resorcin, and corrosive sublimate lotions. + + + + #Uridrosis.# + + +#Describe uridrosis.# + +Uridrosis is a rare condition in which the sweat secretion contains the +elements of the urine, especially urea. In marked cases the salt may be +noticeable upon the skin as a colorless or whitish crystalline deposit. +In most instances it has been preceded or accompanied by partial or +complete suppression of the renal functions. + + + + #Phosphoridrosis.# + + +#Describe phosphoridrosis.# + +Phosphoridrosis is a rare condition, in which the sweat is +phosphorescent. It has been observed in the later stages of phthisis, in +miliaria, and in those who have eaten of putrid fish. + + + + #Seborrh[oe]a (Eczema Seborrhoicum).# + _Synonyms:_ (Steatorrh[oe]a; Acne sebacea; Ichthyosis sebacea; Dandruff.) + + +#What is seborrh[oe]a?# + +Seborrh[oe]a is a disease of the sebaceous glands, characterized by an +excessive and abnormal secretion of sebaceous matter, appearing on the +skin as an oily coating, crusts, or scales. + +In many cases the sweat-glands are likewise implicated, and the process +may also be distinctly, although usually mildly, inflammatory. + + +#At what age is seborrh[oe]a usually observed?# + +Between fifteen and forty. It may, however, occur at any age. + + +#Name the parts most commonly affected.# + +The scalp, face, and (less frequently) the sternal and interscapular +regions of the trunk. It is sometimes seen on other parts. + + +#What varieties of seborrh[oe]a are encountered?# + +Seborrh[oe]a oleosa and seborrh[oe]a sicca; not infrequently the disease +is of a mixed type. + + +#What are the symptoms of seborrh[oe]a oleosa?# + +The sole symptom is an unnatural oiliness, variable as to degree. Its +most common sites are the regions of the scalp, nose, and forehead. In +many instances mild rosacea coexists with oily seborrh[oe]a of the nose. + + +#Give the symptoms of seborrh[oe]a sicca.# + +A variable degree of greasy scalines, which may be seated upon a pale, +hyperæmic or mildly inflammatory surface. + +The parts affected are covered scantily or more or less abundantly with +somewhat greasy, grayish, or brownish-gray scales. If upon the scalp +(_dandruff_, _pityriasis capitis_), small particles of scales are found +scattered through the hair, and when the latter is brushed or combed, +fall over the shoulders. If upon the face, in addition to the scaliness, +the sebaceous ducts are usually seen to be enlarged and filled with +sebaceous matter. + + +#Describe the symptoms of the ordinary or mixed type.# + +It is common upon the scalp. The skin is covered with irregularly +diffused, greasy, grayish or brownish scales and crusts, in some cases +moderate in quantity, in others so great that large irregular masses are +formed, pasting the hair to the scalp. If removed, the scales and crusts +rapidly re-form. The skin beneath is found slate-colored, hyperæmic or +mildly inflammatory, and exceptionally it has in places an eczematous +aspect (_eczema seborrhoicum_). Extraneous matter, such as dust and +dirt, collects upon the parts, and the whole mass may become more or +less offensive. There is a strong tendency to falling-out of the hair. +Itching may or may not be present. + +[Illustration: Seborrh[oe]a (Eczema Seborrhoicum).] + + +#Describe the symptoms of seborrh[oe]a of the trunk and other parts.# + +[Illustration: Fig. 7. + A normal sebaceous gland in connection with a lanugo hair. + (_After Neumann._) + _a_, Capsule; _b_, fatty secretion; _c_, _h_, secreting cells; _d_, root + of lanugo hair; _e_, hair-sac; _f_, hair-shaft; _g_, acini of sebaceous + gland.] + +Seborrh[oe]a corporis differs in a measure, in its symptoms, from +seborrh[oe]a of the scalp and is usually illustrative of the variety +known as eczema seborrhoicum; it occurs as one or several irregular or +circinate, slightly hyperæmic or moderately inflammatory patches, +covered with dirty or grayish-looking greasy scales or crusts, usually +moderate in quantity, and upon removal are found to have projections +into the sebaceous ducts. It is commonly seen upon the sternal and +interscapular regions. It rarely exists independently in these regions, +being usually associated with and following the disease on the scalp. It +may also invade the axillæ, genitocrural, and other regions. + + +#What is the usual course of seborrh[oe]a?# + +Essentially chronic, the disease varying in intensity from time to time. +In occasional instances it disappears spontaneously. + + +#Give the cause or causes of seborrh[oe]a.# + +General debility, anæmia, chlorosis, dyspepsia, and similar conditions +are to be variously looked upon as predisposing. + +In some instances, however, the disease seems to be purely local in +character, and to be entirely independent of any constitutional or +predisposing condition. The view recently advanced that the disease is +of parasitic nature and contagious has been steadily gaining ground. + + +#What is the pathology of seborrh[oe]a?# + +Seborrh[oe]a is a disease of the sebaceous glands, and probably often +involving the sweat-glands also; its products, as found upon the skin, +consisting of the sebaceous secretion, epithelial cells from the glands +and ducts, and more or less extraneous matter. Not infrequently +evidences of superficial inflammatory action are also to be found, and +it is especially for this type that the name eczema seborrhoicum is most +appropriate. In long-continued and neglected cases slight atrophy of the +gland-structures may occur. + + +#With what diseases are you likely to confound seborrh[oe]a?# + +Upon the scalp, with eczema and psoriasis; upon the face, with lupus +erythematosus and eczema; and upon the trunk, with psoriasis and +ringworm. + +As a rule, the clinical features of seborrh[oe]a are sufficiently +characteristic to prevent error. + + +#What are the differential points?# + +Eczema, psoriasis, and lupus erythematosus are diseases in which there +are distinct _inflammatory symptoms_, such as thickening and +infiltration and redness; moreover, psoriasis, and this holds true as to +ringworm also, occurs in sharply-defined, circumscribed patches, and +lupus erythematosus has a peculiar violaceous tint and an elevated and +marginate border. A microscopic examination of the epidermic scrapings +would be of crucial value in differentiating from ringworm. + +Quite frequently, especially in the interscapular and sternal regions, +the segmental configuration constitutes an important feature of +seborrh[oe]a--of the eczema seborrhoicum variety. + + +#What is the prognosis in seborrh[oe]a?# + +Favorable. All types are curable, and when upon the non-hairy regions, +usually readily so; upon the scalp it is often obstinate. Relapses are +not uncommon. + +In those cases of seborrh[oe]a capitis which have been long-continued or +neglected, and attended with loss of hair, this loss may be more or less +permanent, although ordinarily much can be done to promote a regrowth +(see _Treatment of Alopecia_). + + +#How would you treat seborrh[oe]a of the scalp?# + +By constitutional (if indicated) and local remedies; the former having +in view correction or modification of the predisposing factor or +factors, and the latter removal of the sebaceous accumulations and the +application of mildly stimulating antiseptic ointments or lotions. + + +#What constitutional remedies are commonly employed?# + +The various tonics, such as iron, quinine, strychnia, cod-liver oil, +arsenic, the vegetable bitters, laxatives, malt and similar +preparations. The line of treatment is to be based upon indications. + + +#How do you free the scalp of the sebaceous accumulations?# + +In mild types of the disease shampooing with simple Castile soap (or any +other good toilet soap) and hot water will suffice; in those cases in +which there is considerable scale-and crust-formation the tincture of +green soap (tinct. saponis viridis) is to be employed in place of the +toilet soap, and in some of these latter cases it may be necessary to +soften the crusts with a previous soaking with olive oil. + +The frequency of the shampoo depends upon the conditions. In mild cases +once in five or ten days will be sufficiently frequent to keep the parts +clean, but in those cases in which there is rapid scale-or +crust-production once daily or every second day may at first be +demanded. + + +#Name the most effectual applications in seborrh[oe]a capitis.# + +Sulphur, ammoniated mercury, salicylic acid, resorcin, and carbolic +acid. + +Sulphur is used in the form of an ointment, from twenty grains to one +drachm in the ounce. Ammoniated mercury, in the form of an ointment, ten +to sixty grains to the ounce. Salicylic acid, either alone as an +ointment, ten to thirty grains to the ounce; or it may often be added +with advantage, in the same proportion, to the sulphur or ammoniated +mercury ointment above named. Resorcin, either as an ointment, ten to +thirty grains to the ounce, or as an alcoholic or aqueous lotion, as the +following:-- + + [Rx] Resorcini ............................ [dram]j-[dram]iss. + Ol. ricini ........................... [minim]xxx-f[dram]ij. + Alcoholis ............................ f[Oz]iv. M. + +Carbolic acid, to the amount of ten to thirty grains, can be added to +this. If an aqueous lotion is desirable, then in the above formula the +oleum ricini is replaced with glycerine, and the alcohol with water; +three to five minims of glycerine in each ounce is usually sufficient, +as a greater quantity makes the resulting lotion sticky. Petrolatum +alone, or with 10 to 30 per cent. lanolin, is usually the most +satisfactory base for the ointments. In some cases of the inflammatory +variety the skin is found quite irritable, and the mildest applications +are at first only admissible. + + +#How are the remedies to be applied?# + +A small quantity of the lotion, ointment, or oil is gently applied to +the skin; when to the scalp, a lotion or oil can be conveniently applied +by means of an eye-dropper. In the beginning of the treatment an +application once or twice daily is ordered; later, as the disease +becomes less active, once every second or third day. + + +#How is seborrh[oe]a upon other parts to be treated?# + +In the same general manner as seborrh[oe]a of the scalp, except that the +local applications must be somewhat weaker. The several sulphur lotions +employed in the treatment of acne (_q. v._) may also be used when the +disease is upon these parts. In obstinate patchy cases occasional +paintings with a 20 to 50 per cent alcoholic solution of resorcin is +curative; following the painting a mild salve should be used. + + + + #Comedo.# + (_Synonyms:_ Blackheads; Flesh-worms.) + + +#What is comedo?# + +Comedo is a disorder of the sebaceous glands, characterized by yellowish +or blackish pin-point or pin-head-sized puncta or elevations +corresponding to the gland-orifices. + + +#At what age and upon what parts are comedones found?# + +Usually between fifteen and thirty, and upon the face and upper part of +the trunk, where they may exist sparsely or in great numbers. They are +occasionally associated with oily seborrh[oe]a, the parts presenting a +greasy or soiled appearance. + +Exceptionally they occur as distinct, and usually symmetrical, groups +upon the forehead or the cheeks. On the upper trunk so-called double and +multiple comedo have been noted--the two, three, or even four +closely-contiguous blackheads are, beneath the surface, +intercommunicable, the dividing duct-walls having apparently disappeared +by fusion. + + +#Describe an individual lesion.# + +It is pin-point to pin-head in size, dark yellowish, and usually with a +central blackish point (hence the name _blackheads_). There is scarcely +perceptible elevation, unless the amount of retained secretion is +excessive. Upon pressure this may be ejected, the small, rounded orifice +through which it is expressed giving it a thread-like shape (hence the +name _flesh-worms_). + + +#What is the usual course of comedo?# + +Chronic. The lesions may persist indefinitely or the condition may be +somewhat variable. In many instances, either as a result of pressure or +in consequence of chemical change in the sebaceous plugs or of the +addition of a microbic factor, inflammation is excited and acne results. +The two conditions are, in fact, usually associated. + +[Illustration: Fig. 8. + Demodex Folliculorum, X 300. Ventral surface. (_After Simon._)] + + +#To what may comedo often be ascribed?# + +To disorders of digestion, constipation, chlorosis, menstrual +disturbance, lack of tone in the muscular fibres of the skin, the +infrequent use of soap, and working in a dirty or dusty atmosphere. + +A small parasite (_demodex folliculorum_, _acarus folliculorum_) is +sometimes found in the sebaceous mass, but its presence is without +etiological significance, as it is also found in healthy follicles. A +microbacillus has been found by several observers, and credited with +etiological influence. + + +#What is the pathology of comedo?# + +The sebaceous ducts or glands, or both, become blocked up with retained +secretion and epithelial cells. The dark points which usually mark the +lesions are probably due to accumulation of dirt, but may, as some +writers maintain, be due to the presence of pigment-granules resulting +from chemical change in the sebaceous matter. + + +#Is there any difficulty in the diagnosis of comedo?# + +No. It can scarcely be confounded with milium, as in this latter disease +the lesion has no open outlet, no black point, and the contents cannot +be squeezed out. + + +#Give the prognosis of comedo.# + +The result of treatment is usually favorable, although the disease is +often rebellious. Relapses are not uncommon. + + +#How would you treat a case of comedo?# + +By systemic (if indicated) and local measures. + +The constitutional treatment aims at correction or palliation of the +predisposing conditions, and the external applications have in view a +removal of the sebaceous plugs and stimulation of the glands and skin to +healthy action. + +[Illustration: Fig. 9. Comedo Extractor.] + + +#Name the systemic remedies commonly employed.# + +Cod-liver oil, iron, quinine, arsenic, nux vomica and other tonics; +ergot in those cases in which there is lack of muscular tone, salines +and aperient pills in constipation. The digestion is to be looked after +and the bowels kept regular; indigestible food of all kinds is to be +interdicted. Hygienic measures, such as general and local bathing, local +massage, calisthenics, and open-air exercise, are of service. + + +#Describe the local treatment.# + +Steaming the face or prolonged applications of hot water; washing with +ordinary toilet soap and hot water, or, in sluggish cases, using +tincture of green soap (tinct. saponis viridis) instead of the toilet +soap; removal of the sebaceous plugs by mechanical means, such as +lateral pressure with the finger ends or perpendicular pressure with a +watch-key with rounded edges, or with an instrument specially contrived +for this purpose; and after these preliminary measures, which should be +carried out every night, a stimulating sulphur ointment or lotion, such +as employed in the treatment of acne (_q. v._), is to be thoroughly +applied. The following is valuable:-- + + [Rx] Zinci sulphatis, + Potassi sulphureti, . [=a][=a] ....... [dram]j-[dram]iv. + Alcoholi ............................. f[Oz]ss. + Aquæ, ................. q.s. ad ...... f[Oz]iv. M. + +Should slight scaliness or a mild degree of irritation of the skin be +brought about, active external treatment is to be discontinued for a few +days and soothing applications made. Resorcin, in lotion, 3 to 25 per +cent strength, is through the exfoliation it provokes, frequently of +value; the resorcin paste referred to in acne can also be used for this +purpose. + +Moderately strong applications of the Faradic current, repeated once or +twice weekly, are sometimes of service; also weak to moderately strong +applications of the continuous and high-frequency currents. Röntgen-ray +treatment can also be resorted to in extremely obstinate cases. + +In occasional instances sulphur preparations not only fail to do good, +but materially aggravate the condition. In such cases, if resorcin +preparations also fail, the mercurial lotion and ointment employed in +acne may be prescribed. Mercurial and sulphur applications should not be +used, it need scarcely be said, within a week or ten days of each other, +otherwise an increase in the comedones and a slight darkening of the +skin result from the formation of the black sulphuret of mercury. + + + + #Milium.# + (_Synonyms:_ Grutum; Strophulus Albidus.) + + +#What is milium?# + +Milium consists in the formation of small, whitish or yellowish, +rounded, pearly, non-inflammatory elevations situated in the upper part +of the corium. + + +#Describe the clinical appearances.# + +The lesions are usually pin-head in size, whitish or yellowish, +seemingly more or less translucent, rounded or acuminated, without +aperture or duct, are superficially seated in the skin, and project +slightly above the surface. + +They appear about the face, especially about the eyelids; they may occur +also, although rarely, upon other parts. But one or several may be +present, or they may exist in numbers. + + +#What is the course of milium?# + +The lesions develop slowly, and may then remain stationary for years. +Their presence gives rise to no disturbance, and, unless they are large +in size or exist in numbers, causes but slight disfigurement. + +[Illustration: Fig. 10. Milium Needle.] + +In rare instances they may undergo calcareous metamorphosis, +constituting the so-called _cutaneous calculi_. + + +#What is the anatomical seat of milium?# + +The sebaceous gland (probably one or several of the +superficially-situated acini), the duct of which is in some manner +obliterated, the sebaceous matter collects, becomes inspissated and +calcareous, forming the pin-head lesion. The epidermis is the external +covering. + + +#What is the treatment?# + +The usual plan is to prick or incise each lesion and press out the +contents. In some milia it may be necessary also, in order to prevent a +return, to touch the base of the excavation with tincture of iodine or +with silver nitrate. Electrolysis is also effectual. In those cases +where the lesions are numerous the production of exfoliation of the +epiderm by means of resorcin applications (see acne) is a good plan. + + + + #Steatoma.# + (_Synonyms:_ Sebaceous Cyst; Sebaceous Tumor; Wen.) + + +#Describe steatoma.# + +Steatoma, or sebaceous cyst, appears as a variously-sized, elevated, +rounded or semi-globular, soft or firm tumor, freely movable and +painless, and having its seat in the corium or subcutaneous tissue. The +overlying skin is normal in color, or it may be whitish or pale from +distention; in some a gland-duct orifice may be seen, but, as a rule, +this is absent. + + +#What are the favorite regions for the development of steatoma?# + +The scalp, face and back. One or several may be present. + + +#What is the course of sebaceous cysts?# + +Their growth is slow, and, after attaining a variable size, may remain +stationary. They may exist indefinitely without causing any +inconvenience beyond the disfigurement. Exceptionally, in enormously +distended growths, suppuration and ulceration result. + + +#What is the pathology?# + +A steatoma is a cyst of the sebaceous gland and duct, produced by +retained secretion. The contents may be hard and friable, soft and +cheesy, or even fluid, of a grayish, whitish or yellowish color, and +with or without a fetid odor; the mass consisting of fat-drops, +epidermic cells, cholesterin, and sometimes hairs. + + +#Are sebaceous cysts likely to be confounded with gummata?# + +No. Gummata grow more rapidly, are usually painful to the touch, are not +freely movable, and tend to break down and ulcerate. + + +#Describe the treatment of steatoma.# + +A linear incision is made, and the mass and enveloping sac dissected +out. If the sac is permitted to remain, reproduction almost invariably +takes place. + + + + +#CLASS II.--INFLAMMATIONS.# + + + #Erythema Simplex.# + + +#What do you understand by erythema simplex?# + +Erythema simplex is a hyperæmic disorder characterized by redness, +occurring in the form of variously-sized and shaped, diffused or +circumscribed, non-elevated patches. + + +#Name the two general classes into which the simple erythemata are +divided.# + +Idiopathic and symptomatic. + + +#What do you include in the idiopathic class?# + +Those erythemas due to external causes, such as cold and heat (_erythema +caloricum_), the action of the sun (_erythema solare_), traumatism +(_erythema traumaticum_), and the various poisons or chemical irritants +(_erythema venenatum_). + + +#What do you include in the symptomatic class?# + +Those rashes often preceding or accompanying certain of the systemic +diseases, and those due to disorders of the digestive tract, stomachic +and intestinal toxins, to the ingestion of certain drugs, and to use of +the therapeutic serums. + + +#Describe the symptoms of erythema simplex.# + +The essential symptom is redness--simple hyperæmia--without elevation or +infiltration, disappearing under pressure, and sometimes attended by +slight heat or burning; it may be patchy or diffused. In the idiopathic +class, if the cause is continued, dermatitis may result. + + +#What is to be said about the distribution of the simple erythemata?# + +The idiopathic rashes, as inferred from the nature of the causes, are +usually limited. + +The symptomatic erythemas are more or less generalized; desquamation +sometimes follows. + + +#Describe the treatment of the simple erythemata.# + +A removal of the cause in idiopathic rashes is all that is needed, the +erythema sooner or later subsiding. The same may be stated of the +symptomatic erythemata, but in these there is at times difficulty in +recognizing the etiological factor; constitutional treatment, if +necessary, is to be based upon general principles. Intestinal +antiseptics are useful in some instances. + +Local treatment, which is rarely needed, consists of the use of +dusting-powders or mild cooling and astringent lotions, such as are +employed in the treatment of acute eczema (q. v.). + + + + #Erythema Intertrigo.# + (_Synonym:_ Chafing.) + + +#What do you understand by erythema intertrigo?# + +Erythema intertrigo is a hyperæmic disorder occurring on parts where the +natural folds of the skin come in contact, and is characterized by +redness, to which may be added an abraded surface and maceration of the +epidermis. + + +#Describe the symptoms of erythema intertrigo.# + +The skin of the involved region gradually becomes hyperæmic, but is +without elevation or infiltration; a feeling of heat and soreness is +usually experienced. If the condition continue, the increased +perspiration and moisture of the parts give rise to maceration of the +epidermis and a mucoid discharge; actual inflammation may eventually +result. + + +#What is the course of erythema intertrigo?# + +The affection may pass away in a few days or persist several weeks, the +duration depending, in a great measure, upon the cause. + + +#Mention the causes of erythema intertrigo.# + +The causes are usually local. It is seen chiefly in children, especially +in fat subjects, in whom friction and moisture of contiguous parts of +the body, usually the region of the neck, buttocks and genitalia, are +more common; in such, uncleanliness or the too free use of soap washings +will often act as the exciting factor. Disorders of the stomach or +intestinal canal apparently have a predisposing influence. + + +#What treatment would you advise in erythema intertrigo?# + +The folds or parts are to be kept from contact by means of lint or +absorbent cotton; thin, flat bags of cheese cloth or similar material +partly filled with dusting-powder, and kept clean by frequent changes, +are excellent for this purpose, and usually curative. Cleanliness is +essential, but it is to be kept within the bounds of common sense. +Dusting-powders and cooling and astringent lotions, such as are employed +in the treatment of acute eczema (_q. v._), can also be advised. The +following lotion is valuable:-- + + [Rx] Pulv. calaminæ, + Pulv. zinci oxidi, .. [=a][=a] ...... [dram]iss. + Glycerinæ, .......................... [minum]xxx + Alcoholis, .......................... f[dram]ij + Aquæ, ............................... Oss. M. + +Exceptionally a mild ointment, alone or supplementary to a lotion, acts +more satisfactorily. + +In persistent or obstinate cases attention should also be directed to +the state of the general health, especially as regards the digestive +tract. + + + + #Erythema Multiforme.# + + +#What is erythema multiforme?# + +Erythema multiforme is an acute, inflammatory disease, characterized by +reddish, more or less variegated macules, papules, and tubercles, +occurring as discrete lesions or in patches of various size and shape. + + +#Upon what parts of the body does the eruption appear?# + +Usually upon the extremities, especially the dorsal aspect, from the +knees and elbows down, and about the face and neck; it may, however, be +more or less general. + + +#Describe the symptoms of erythema multiforme.# + +With or without precursory symptoms of malaise, gastric uneasiness or +rheumatic pains, the eruption suddenly makes its appearance, assuming an +erythematous, papular, tubercular or mixed character; as a rule, one +type of lesion predominates. The lesions tend to increase in size and +intensity, remain stationary for several days or a week, and then +gradually fade; during this time there may have been outbreaks of new +lesions. In color they are pink, red, or violaceous. Slight itching may +or may not be present. Exceptionally, in general cases, the eruption +partakes of the nature of both urticaria and erythema multiforme, and +itching may be quite a decided symptom. In some instances there is +preceding and accompanying febrile action, usually slight in character; +in others there may be some rheumatic swelling of one or more joints. + +[Illustration: Fig. 11. + Erythema Multiforme, in which many of the lesions have become + bullous--Erythema Bullosum.] + + +#What type of the eruption is most common?# + +The papular, appearing usually upon the backs of the hands and forearms, +and not infrequently, also, upon the face, legs and feet. The papules +are usually pea-sized, flattened, and of a dark red or violaceous color. + + +#Describe the various shapes which the erythematous lesions may assume.# + +Often the patches are distinctly ring-shaped, with a clear +centre--_erythema annulare_; or they are made up of several concentric +rings, presenting variegated coloring--_erythema iris_; or a more or +less extensive patch may spread with a sharply-defined border, the older +part tending to fade--_erythema marginatum_; or several rings may +coalesce, with a disappearance of the coalescing parts, and serpentine +lines or bands result--_erythema gyratum_. + + +#Does the eruption of erythema multiforme ever assume a vesicular or +bullous character?# + +Yes. In exceptional instances, the inflammatory process may be +sufficiently intense to produce vesiculation, usually at the summits of +the papules--_erythema vesiculosum_; and in some instances, blebs may be +formed--_erythema bullosum_. A vesicular or bullous lesion may become +immediately surrounded by a ring-like vesicle or bleb, and outside of +this another form; a patch may be made up of as many as several such +rings--_herpes iris_. In the vesicular and bullous cases the lips and +the mucous membranes of the mouth and nose also may be the seat of +similar lesions. + + +#What is the course of erythema multiforme?# + +Acute, the symptoms disappearing spontaneously, usually in one to three +or four weeks. In some instances the recurrences take place so rapidly +that the disease assumes a chronic aspect; it is possible that such +cases are midway cases between this disease and dermatitis +herpetiformis. + + +#Mention the etiological factors in erythema multiforme.# + +The causes are obscure. Digestive disturbance, rheumatic conditions, and +the ingestion of certain drugs are at times influential. Intestinal +toxins are doubtless important etiological factors in some cases. +Certain foods, such as are apt to undergo rapid putrefactive or +fermentative change, especially pork meats, oysters, fish, crabs, +lobsters, etc., are, therefore, not infrequently of apparent causative +influence. It is most frequently observed in spring and autumn months, +and in early adult life. The disease is not uncommon. + + +#What is the pathology of erythema multiforme?# + +It is a mildly inflammatory disorder, somewhat similar to urticaria, and +presumably due to vasomotor disturbance; the amount of exudation, which +is variable, determines the character of the lesions. + + +#Name the diagnostic points of erythema multiforme.# + +The multiformity of the eruption, the size of the papules, often its +limitation to certain parts, its course and the entire or comparative +absence of itching. + +It resembles urticaria at times, but the lesions of this latter disease +are evanescent, disappearing and reappearing usually in the most +capricious manner, are commonly seated about the trunk, and are +exceedingly itchy. + +In the vesicular and bullous types the acute character of the outbreak, +the often segmental and ring-like shape, their frequent origin from +erythematous papules, and the distribution and association with the more +common manifestations, are always suggestive. + + +#What prognosis would you give in erythema multiforme?# + +Always favorable; the eruption usually disappears in ten days to three +weeks, although in rare instances new crops may appear from day to day +or week to week, and the process last one or two months. One or more +recurrences in succeeding years are not uncommon. Those rare cases in +which vesicular or bullous lesions are also seen on the lips and in the +mouth, are more prone to longer duration and to more frequent +recurrences. + + +#What remedies are commonly prescribed in erythema multiforme?# + +Quinin, and, if constipation is present, saline laxatives. Calcined +magnesia is valuable as a laxative. Intestinal antiseptics, such as +salol, thymol, and sodium salicylate, are valuable in cases probably due +to intestinal toxins. In those exceptional instances in which there may +be associated febrile action and rheumatic swelling of the joints, the +patient should be kept in bed till these symptoms subside. Local +applications are rarely required, but in those exceptional cases in +which itching or burning is present, cooling lotions of alcohol and +water or vinegar and water are to be prescribed. The vesicular and +bullous types demand mild protective applications, such as used in +eczema and pemphigus. + + + + #Erythema Nodosum.# + (_Synonym:_ Dermatitis contusiformis.) + + +#What is erythema nodosum?# + +Erythema nodosum is an inflammatory affection, of an acute type, +characterized by the formation of variously-sized, roundish, more or +less elevated erythematous nodes. + + +#Is there any special region of predilection for the eruption of erythema +nodosum?# + +Yes. The tibial surfaces, to which the eruption is often limited; not +infrequently, however, other parts may be involved, more especially the +arms and forearms. + + +#Describe the symptoms of erythema nodosum.# + +The eruption makes its appearance suddenly, and is usually ushered in +with febrile disturbance, gastric uneasiness, malaise, and rheumatic +pains and swelling about the joints. The lesions vary in size from a +cherry to a hen's egg, are rounded or ovalish, tender and painful, have +a glistening and tense look, and are of a bright red, erysipelatous +color which merges gradually into the sound skin. At first they are +somewhat hard, but later they soften and appear as if about to break +down, but this, however, never occurs, absorption invariably taking +place. In occasional instances they are hemorrhagic. Exceptionally the +lesions of erythema multiforme are also present. Lymphangitis is +sometimes observed. In rare instances symptoms pointing to visceral +involvement, to cerebral invasion, and to heart complications have been +observed. + + +#Are the lesions in erythema nodosum usually numerous?# + +No. As a rule not more than five to twenty nodes are present. + + +#What is the course of erythema nodosum?# + +Acute. The disease terminating usually in one to three weeks. As the +lesions are disappearing they present the various changes of color +observed in an ordinary bruise. + + +#What is known in regard to the etiology?# + +The affection is closely allied to erythema multiforme, and is, indeed, +by some considered a form of that disease. It occurs most frequently in +children and young adults, and usually in the spring and autumn months. +Intestinal toxins are thought responsible in some cases. Digestive +disturbance and rheumatic pain and swellings are often associated with +it. By many the malady is thought to be a specific infection. + + +#What is the pathology of erythema nodosum?# + +The disease is to be viewed as an inflammatory [oe]dema, probably +resulting, in some instances at least, from an inflammation of the +lymphatics or an embolism of the cutaneous vessels. + + +#What diseases may erythema nodosum resemble?# + +Bruises, abscesses, and gummata. + + +#How are the lesions of erythema nodosum to be distinguished from these +several conditions?# + +By the bright red or rosy tint, the apparently violent character of the +process, the number, situation and course of the lesions. + + +#State the prognosis of erythema nodosum.# + +Favorable, recovery usually taking place in ten days to several weeks. + + +#State the treatment to be advised in erythema nodosum.# + +Rest, relative or absolute, depending upon the severity of the case, and +an unstimulating diet; internally intestinal antiseptics, quinin and +saline laxatives, and locally applications of lead-water and laudanum. + + + + #Erythema Induratum.# + (_Synonym:_ Erythema induratum scrofulosorum.) + + +#What do you understand by erythema induratum?# + +A rare disease characterized in the beginning by one or more usually +deep-seated nodules, and, as a rule, seated in the legs, especially the +calf region. The nodules gradually enlarge, the skin becomes reddish, +violaceous or livid in color. Absorption may take place slowly, or the +indurations may break down, resulting in an indolent, rather deep-seated +ulcer, closely resembling a gummatous ulcer. The disease is slow and +persistent, and is commonly met with in girls and young women, usually +of strumous type. It suggests a tuberculous origin. + +Treatment consists in administration of cod-liver oil, phosphorus and +other tonics. Rest is of service. Locally antiseptic applications, and +support with roller bandage are to be advised. + + + + #Urticaria.# + (_Synonyms:_ Hives; Nettlerash.) + + +#Give a definition of urticaria.# + +Urticaria is an inflammatory affection characterized by evanescent +whitish, pinkish or reddish elevations, or wheals, variable as to size +and shape, and attended by itching, stinging or pricking sensations. + + +#Describe the symptoms of urticaria.# + +The eruption, erythematous in character and consisting of isolated pea +or bean-sized elevations or of linear streaks or irregular patches, +limited or more or less general, and usually intensely itchy, makes its +appearance suddenly, with or without symptoms of preceding gastric +derangement. The lesions are soft or firm, reddish or pinkish-white, +with the peripheral portion of a bright red color, and are fugacious in +character, disappearing and reappearing in the most capricious manner. +In many cases simply drawing the finger over the skin will bring out +irregular and linear wheals. In exceptional cases this peculiar property +is so pronounced and constant that at any time letters and other symbols +may be produced at will, even when such subjects are free from the +ordinary urticarial lesions (_urticaria factitia_, _dermatographism_, +_autographism_). + +The mucous membrane of the mouth and throat may also be the seat of +wheals and urticarial swellings. + + +#What is the ordinary course of urticaria?# + +Acute. The disease is usually at an end in several hours or days. + + +#Does urticaria always pursue an acute course?# + +No. In exceptional instances the disease is chronic, in the sense that +new lesions continue to appear and disappear irregularly from time to +time for months or several years, the skin rarely being entirely free +(_chronic urticaria_). + + +[Illustration: Fig. 12. + Dermatographism. (_After C.N. Davis._)] + + +#Are subjective symptoms always present in urticaria?# + +Yes. Itching is commonly a conspicuous symptom, although at times +pricking, stinging or a feeling of burning constitutes the chief +sensation. + + +#In what way may the eruption be atypical?# + +Exceptionally the wheals, or lesions, are peculiar as to formation, or +another condition or disease may be associated, hence the varieties +known as urticaria papulosa, urticaria hæmorrhagica, urticaria tuberosa, +and urticaria bullosa. + + +#Describe urticaria papulosa.# + +Urticaria papulosa (formerly called _lichen urticatus_) is a variety in +which the lesions are small and papular, developing usually out of the +ordinary wheals. They appear as a rule suddenly, rarely in great +numbers, are scattered, and after a few hours or, more commonly, days +gradually disappear. The itching is intense, and in consequence their +apices are excoriated. Sometimes the papules are capped with a small +vesicle (vesicular urticaria). It is seen more particularly in ill-cared +for and badly-nourished young children. + + +#Describe urticaria hæmorrhagica.# + +Urticaria hæmorrhagica is characterized by lesions similar to ordinary +wheals, except that they are somewhat hemorrhagic, partaking, in fact, +of the nature of both urticaria and purpura. + + +#Describe urticaria tuberosa.# + +In urticaria tuberosa the lesions, instead of being pea- or bean-sized, +as in typical urticaria, are large and node-like (also called _giant +urticaria_). + + +#What is acute-circumscribed [oe]dema?# + +In rare instances there occurs, along with the ordinary lesions of the +disease or as its sole manifestation, sudden and evanescent swelling of +the eyelids, ears, lips, tongue, hands, fingers, or feet (_urticaria +[oe]dematosa_, _acute_ _circumscribed [oe]dema_, _angioneurotic [oe]dema_). +One or several of these parts only may be affected at the one attack; in +recurrences, so usual in this variety, the same or other parts may +exhibit the manifestation. + +(These [oe]dematous swellings occurring alone might be looked upon, as +they are by most observers, as an independent affection, but its close +relationship to ordinary urticaria is often evident.) + + +#Describe urticaria bullosa.# + +Urticaria bullosa is a variety in which the inflammatory action has been +sufficiently great to give rise to fluid exudation, the wheals resulting +in the formation of blebs. + + +#What is the etiology of urticaria?# + +Any irritation from disease, functional or organic, of any internal +organ, may give rise to the eruption in those predisposed. Gastric +derangement from indigestible or peculiar articles of food, intestinal +toxins, and the ingestion of certain drugs are often provocative. The +so-called "shell-fish" group of foods play an important etiological part +in some cases. Idiosyncrasy to certain articles of food is also +responsible in occasional instances. Various rheumatic and nervous +disorders are not infrequently associated with it, and are doubtless of +etiological significance. External irritants, also, in predisposed +subjects, are at times responsible. + + +#What is the pathology of urticaria?# + +Anatomically a wheal is seen to be a more or less firm elevation +consisting of a circumscribed or somewhat diffused collection of +semi-fluid material in the upper layers of the skin. The vasomotor +nervous system is probably the main factor in its production; dilatation +following spasm of the vessels results in effusion, and in consequence, +the overfilled vessels of the central portion are emptied by pressure of +the exudation and the central paleness results, while the pressed-back +blood gives rise to the bright red periphery. + + +#From what diseases is urticaria to be differentiated?# + +From erythema simplex, erythema multiforme, erythema nodosum, and +erysipelas. + + +#Mention the diagnostic points of urticaria.# + +The acuteness, character of the lesions, their evanescent nature, the +irregular or general distribution, and the intense itching. + + +#What is the prognosis in urticaria?# + +The acute disease is usually of short duration, disappearing +spontaneously or as the result of treatment, in several hours or days; +it may recur upon exposure to the exciting cause. The prognosis of +chronic urticaria is to be guarded, and will depend upon the ability to +discover and remove or modify the predisposing condition. + + +#What systemic measures are to be prescribed in acute urticaria?# + +Removal of the etiological factor is of first importance. This will be +found in most cases to be gastric disturbance from the ingestion of +improper or indigestible food, and in such cases a saline purgative is +to be given, probably the best for this purpose being the laxative +antacid, magnesia; or if the case is severe and food is still in the +stomach, an emetic, such as mustard or ipecac, will act more promptly. +Alkalies, especially sodium salicylate, and intestinal antiseptics are +useful. Calcium chloride in doses of five to twenty grains should be +tried in obstinate cases. The diet should be, for the time, of a simple +character. + + +#What systemic measures are to be prescribed in chronic and recurrent +urticaria?# + +The cause must be sought for and treatment directed toward its removal +or modification. Treatment will, therefore, depend upon indications. In +obscure cases, quinine, sodium salicylate, arsenic, pilocarpine, +_atropia_, potassium bromide, calcium chloride, and ichthyol are to be +variously tried; general galvanization is at times useful, as is also a +change of scene and climate. A proper dietary and the maintenance of +free action of the bowels, preferably, as a rule, with a saline +laxative, is of great importance in these chronic cases. + +In acute circumscribed [oe]dema treatment is essentially that of +urticaria, the diet being given special attention. + + +#What external applications would you advise for the relief of the +subjective symptoms?# + +Cooling lotions of alcohol and water or vinegar and water; lotions of +carbolic acid, one to three drachms to the pint; of thymol, one-fourth +to one drachm to the pint of alcohol and water; of liquor carbonis +detergens, one to three ounces to the pint of water, or the following:-- + + [Rx] Acidi carbolici, ..................... [dram]j-[dram]iij + Acidi borici, ........................ [dram]iv + Glycerinæ, ........................... f[dram]j + Alcoholis, ........................... f[Oz]ij + Aquæ, ................................ f[Oz]xiv. M. + +Alkaline baths are also useful, and may advantageously be followed by +dusting-powders of starch and zinc oxide. + + + + #Urticaria Pigmentosa.# + (_Synonym:_ Xanthelasmoidea.) + + +#Describe urticaria pigmentosa.# + +Urticaria pigmentosa is a rare disease, variously viewed as an unusual +form of urticaria and as an urticaria-like eruption in which there is an +element of new growth in the lesions. It begins usually in infancy or +early childhood and continues for months or years, and is characterized +by slightly, moderately, or intensely itchy, wheal-like elevations, +which are more or less persistent and leave yellowish, orange-colored, +greenish or brownish stains. Exceptionally subjective symptoms are +almost entirely absent. Anatomical studies show that the lesion has in +some respects the structure of an ordinary wheal, with [oe]dema and +pigment deposit in the epidermal portion, and cellular infiltration made +up principally of mast-cells. + +[Illustration: Fig. 13. + Urticaria Pigmentosa.] + +The nature of the disease is obscure and treatment unsatisfactory. +Ordinarily as early youth or adult life is reached it spontaneously +disappears. The treatment advised is usually on the same lines as that +of chronic urticaria. + + + + #Dermatitis.# + + +#What is implied by the term dermatitis?# + +Dermatitis, or inflammation of the skin, is a term employed to designate +those cases of cutaneous disturbance, usually acute in character, which +are due to the action of irritants. + + +#Mention some examples of cutaneous disturbance to which this term is +applied.# + +The dermatic inflammation due to the action of excessive heat or cold, +to caustics and other chemical irritants, and to the ingestion of +certain drugs. + + +#What several varieties are commonly described?# + +Dermatitis traumatica, dermatitis calorica, dermatitis venenata, and +dermatitis medicamentosa. + + +#Describe dermatitis traumatica.# + +Under this head are included all forms of cutaneous inflammation due to +traumatism. To the dermatologist the most common met with is that +produced by the various animal parasites and from continued scratching; +in such, if the cause has been long-continued and persistent, a variable +degree of inflammatory thickening of the skin and pigmentation result, +the latter not infrequently being more or less permanent. The +inflammation due to tight-fitting garments, bandages, to constant +pressure (as bed-sores), etc., also illustrates this class. + + +#What is the treatment of dermatitis traumatica?# + +Removal of the cause, and, if necessary, the application of soothing +ointments or lotions; in bed-sores, soap plaster, plain or with one to +five per cent. of ichthyol. + + +#What is dermatitis calorica?# + +Cutaneous inflammation, varying from a slight erythematous to a +gangrenous character, produced by excessive heat (_dermatitis +ambustionis_, _burns_) or cold (_dermatitis congelationis_, +_frostbite_). + + +#Give the treatment of dermatitis calorica.# + +In burns, if of a mild degree, the application of sodium bicarbonate, as +a powder or saturated solution, is useful; in the more severe grade, a +two- to five-per-cent. solution will probably be found of greater +advantage. Other soothing applications may also be employed. In recent +years a one-per-cent. solution of picric acid has been commended for the +slighter burns of limited extent. Upon the whole, there is nothing yet +so generally useful and soothing in these cases as the so-called Carron +oil; in some cases more valuable with 1/2 to 1 minim of carbolic acid +added to each ounce. + +In frostbite, seen immediately after exposure, the parts are to be +brought gradually back to a normal temperature, at first by rubbing with +snow or applying cold water. Subsequently, in ordinary chilblains, +stimulating applications, such as oil of turpentine, balsam of Peru, +tincture of iodine, ichthyol, and strongly carbolized ointments are of +most benefit. If the frostbite is of a vesicular, pustular, bullous, or +escharotic character, the treatment consists in the application of +soothing remedies, such as are employed in other like inflammatory +conditions. + + +#What do you understand by dermatitis venenata?# + +All inflammatory conditions of the skin due to contact with deleterious +substances such as caustic, chemical irritants, iodoform, etc., are +included under this head, but the most common causes are the rhus +plants--_poison ivy_ (or _poison oak_) and _poison sumach_ (_poison +dogwood_). Mere proximity to these plants will, in some individuals, +provoke cutaneous disturbance (_rhus poisoning_, _ivy poisoning_), +although they may be handled by others with impunity. + +Many other plants are also known to produce cutaneous irritation in +certain subjects; among these may be mentioned the nettle, primrose, +cowhage, smartweed, balm of Gilead, oleander, and rue. + +The local action of iodoform (_iodoform dermatitis_) in some individuals +is that of a decided irritant, bringing about a dermatitis, which often +spreads much beyond the parts of application, and which in those +eczematously inclined may result in a veritable and persistent eczema. + + +#Describe the symptoms of rhus poisoning.# + +The symptoms appear usually soon after exposure, and consist of an +inflammatory condition of the skin of an eczematous nature, varying in +degree from an erythematous to a bullous character, and with or without +[oe]dema and swelling. As a rule, marked itching and burning are +present. The face, hands, forearms and genitalia are favorite parts, +although it may in many instances involve a greater portion of the whole +surface. + + +#What is the course of rhus poisoning?# + +It runs an acute course, terminating in recovery in one to six weeks. In +those eczematously inclined, however, it may result in a veritable and +persistent form of that disease. + + +#How would you treat rhus poisoning?# + +By soothing and astringent applications, such as are employed in acute +eczema (_q. v._), which are to be used freely. Among the most valuable +are: a lotion of fluid extract of grindelia robusta, one to two drachms +to four ounces of water; lotio nigra, either alone or followed by the +oxide-of-zinc ointment; a saturated solution of boric acid, with a half +to two drachms of carbolic acid to the pint; a lotion of zinc sulphate, +a half to four grains to the ounce; weak alkaline lotions; cold cream, +petrolatum, and oxide-of-zinc ointments. + + +#How would you treat the dermatitis due to other deleterious substances +of this class?# + +By applications of a soothing and protective character, similar to those +used in eczema and burns. + + + + #Dermatitis Medicamentosa.# + + +#What do you understand by dermatitis medicamentosa?# + +Under this head are included all eruptions due to the ingestion or +absorption of certain drugs. + +In rare instances one dose will have such effect; commonly, however, it +results only after several days' or weeks' continued administration. +With some drugs such effect is the rule, with others it is exceptional, +nor are all individuals equally susceptible. + + +#How is the eruption produced in dermatitis medicamentosa?# + +In some instances it is probably due to the elimination of the drug +through the cutaneous structures; in others, to the action of the +drug upon the nervous system. The view that the drug acts as a toxin or +generates some toxin or irritant material in the blood, to which the +eruptive phenomena may be due, has also been advanced. + +[Illustration: Dermatitis medicamentosa. + Bullous dermatitis from iodide of potassium.] + + +#What is the character of the eruption in dermatitis medicamentosa?# + +It may be erythematous, papular, urticarial, vesicular, pustular or +bullous, and, if the administration of the drug is continued, even +gangrenous. + + +#Name the more common drugs having such action.# + +Antipyrin, arsenic, atropia (or belladonna), bromides, chloral, copaiba, +cubebs, digitalis, iodides, mercury, opium (or morphia), quinine, +salicylic acid, stramonium, acetanilid, sulphonal, phenacetin, +turpentine, many of the new coal-tar derivatives, etc. + + +#State frequency and types of eruption due to the ingestion of antipyrin.# + +Not uncommon. _Erythematous_, morbilliform and erythemato-papular; +itching is usually present and moderate desquamation may follow. +Acetanilid, sulphonal, phenacetin, and other drugs of this class may +provoke like eruptions. + + +#Mention frequency and types of eruption due to the ingestion of arsenic.# + +Rare. Erythematous, erythemato-papular; exceptionally, herpetic, and +pigmentary. Herpes zoster has been thought to follow its use. Keratosis +of the palms and soles has also been occasionally observed, which, in +rare instances, has developed into epithelioma. + + +#Mention frequency and types of eruption due to the ingestion of atropia +(or belladonna).# + +Not uncommon. _Erythematous_ and _scarlatinoid_; usually no febrile +disturbance, and desquamation seldom follows. + + +#Give frequency and types of cutaneous disturbance following the +administration of the bromides (bromine).# + +Common. _Pustular_, sometimes furuncular and carbuncular and +superficially ulcerative. In exceptional instances papillomatous or +vegetating lesions have been observed. Co-administration of arsenic or +potassium bitartrate is thought to have a preventive influence in some +cases. + + +#State frequency and types of cutaneous disturbance due to the +administration of chloral.# + +Occasional. Scarlatinoid and urticarial, and exceptionally purpuric; in +rare instances, if drug is continued, eruption becomes vesicular, +hemorrhagic, ulcerative and even gangrenous. + + +#State frequency and types of eruption following the administration of +copaiba.# + +Not uncommon. _Urticarial_, erythemato-papular and _scarlatinoid_. + + +#Mention frequency and types of eruption resulting from the ingestion of +cubebs.# + +Uncommon. Erythematous and small papular. + +[Illustration: Fig. 14. + A somewhat rare form of eruption from the ingestion of iodine compounds. + (_After J.C. McGuire._)] + + +#Mention frequency and types of eruption resulting from the +administration of digitalis.# + +Exceptional. Scarlatinoid and papular. + + +#State frequency and types of eruption resulting from the iodides +(iodine).# + +Common. _Pustular_, but may be erythematous, papular, vesicular, +bullous, tuberous, purpuric and hemorrhagic. Co-administration of +arsenic or potassium bitartrate is thought to have a preventive +influence in some cases. + + +#Give the frequency and types of eruption observed to follow the +administration of mercury.# + +Exceptional. Erythematous and erysipelatous. + + +#Give the frequency and types of the cutaneous disturbance following the +ingestion of opium (or morphia).# + +Not uncommon. Erythematous and _scarlatinoid_, and sometimes urticarial. + + +#Mention the frequency and the types of eruption following the +administration of quinine.# + +Not infrequent. Usually _erythematous_, but may be urticarial, +erythemato-papular, and even purpuric. There is, in some instances, +preceding or accompanying systemic disturbance. Furfuraceous or lamellar +desquamation often follows. + + +#State frequency and types of eruption resulting from the ingestion of +salicylic acid.# + +Not common. Erythematous and urticarial; exceptionally, vesicular, +pustular, bullous, and ecchymotic. + + +#Give frequency and type of cutaneous disturbance due to the +administration of stramonium.# + +Not common. Erythematous. + + +#State frequency and types of eruption resulting from the administration +of turpentine.# + +Not uncommon. _Erythematous_, and small-papular; exceptionally +vesicular. + + + + #X-Ray Dermatitis.# + + +#What several grades of x-ray dermatitis (x-ray burns, Rontgen-ray burns) +are observed?# + +Three grades are usually described: erythema, superficial vesication, +and necrosis. The first and second may come on shortly--a few hours to +several days--after exposure; occasionally later. The third grade may +present also in the first several days, but in many cases one to several +weeks may elapse before it appears; it is quite commonly preceded by +erythema and vesication. The necrosis may be superficial or deep, and +quite usually results in a persistent ulcer covered by a leathery +coating; it is usually painful. + +[Illustration: Fig. 15. _x_-ray burn] + + +#Give the prognosis and treatment of x-ray dermatitis.# + +The first grade--the erythematous--usually disappears in one to ten +days; the second grade requires one to several weeks, and may be quite +sore and tender; the severe or necrotic burns are persistent, sometimes +lasting for months and several years, with little tendency to +spontaneous disappearance, and rebellious to treatment. + +Treatment of the milder types is that of erythema (_q. v._); the necrotic +type occasionally demands thorough curetting and skin-grafting before it +will heal. + + + #Dermatitis Factitia.# + (_Synonym:_ Feigned Eruptions.) + + +#What do you understand by feigned eruptions?# + +Feigned, or artificial, eruptions, occasionally met with in hysterical +females and in others, are produced, for the purpose of exciting +sympathy or of deception, by the action of friction, cantharides, acids +or strong alkalies; the cutaneous disturbance may, therefore, be +erythematous, vesicular, bullous, or gangrenous. It is usually limited +in extent, and, as a rule, seen only on parts easily reached by the +hands. + +[Illustration: Fig. 16. + Dermatitis Factitia--note the unusually uniform and regular character + and arrangement of the lesions.] + + + + #Dermatitis Gangrænosa.# + + +#What do you understand by dermatitis gangrænosa?# + +Dermatitis gangrænosa (_erythema gangrænosum_, _Raynaud's disease_, +_spontaneous gangrene_) is an exceedingly rare affection, characterized +by the formation of gangrenous spots and patches. It may be idiopathic +or symptomatic. Some of these cases, especially in hysterical subjects, +belong under the "feigned eruptions," being self-produced. + +As an idiopathic disease, it begins as erythematous, dark-red +spots--usually preceded and accompanied by mild or grave systemic +disturbance--which gradually pass into gangrene and sloughing; the +eventual termination may be fatal, or recovery may take place. As a +symptomatic disease, it is occasionally met with in diabetes and in +grave cerebral and spinal affections. + +In Raynaud's disease (symmetric gangrene) the parts affected are the +extremities, such as fingers and toes, the ears and nose, only +occasionally other parts. The first symptoms observed are coldness and +paleness of the part; followed sooner or later by congestion of a dark +red, livid, or bluish color, with sometimes swelling, and tenderness and +shooting pains. The termination is usually in gangrene of a dry +character, with, in some instances, vesicles and blebs along the edges; +in other cases the parts become atrophied, withered, and indurated. + +Treatment is based upon general principles. + + + + #Erysipelas.# + + +#What is erysipelas?# + +Erysipelas is an acute specific inflammation of the skin and +subcutaneous tissue, commonly of the face, characterized by shining +redness, swelling, [oe]dema, heat, and a tendency in some cases to +vesicle- and bleb-formation, and accompanied by more or less febrile +disturbance. + + +#Describe the symptoms and course of erysipelas.# + +A decided rigor or a feeling of chilliness followed by febrile action +usually ushers in the cutaneous disturbance. The skin at a certain point +or part, commonly where there is a lesion of continuity, becomes bright +red and swollen; this spreads by peripheral extension, and in the course +of several hours involves a portion or the whole region. The parts are +shining red, swollen, of an elevated temperature, and sharply defined +against the sound skin. After several days or a week, during which time +there is usually continued mild or severe febrile action, the process +begins to subside, and is followed by epidermic desquamation. + +In some cases vesicles and blebs may be present; in other cases the +disease seriously involves the deeper parts, and is accompanied by grave +constitutional symptoms. In exceptional instances sloughing takes place. + +A mild, transitory, limited, and often recurrent erysipelatous condition +of the outlet and immediate neighborhood of one or both nostrils is met +with, taking its origin from an inflammation of the hair-follicles just +inside the margin of the nose; constitutional symptoms are usually +wanting. Somewhat similar, doubtless, is the erysipelatous inflammation +(_erysipeloid_) observed on the fingers and hands of butchers, etc., +starting from a wound, apparently as a result of infection from putrid +meat or fish. + + +#What is erysipelas migrans (or erysipelas ambulans)?# + +A variety of erysipelas which, after a few hours or days, disappears at +one region and appears at another, and so continues for one or several +weeks. + + +#What is the cause of erysipelas?# + +The disease is due to a specific streptococcus--the streptococcus of +Fehleisen. Depression of the vital forces and local abrasions are +predisposing factors. + + +#State the diagnostic points.# + +The character of the onset, the shining redness and swelling, the +sharply-defined border, and the accompanying febrile disturbance. + + +#What is the prognosis in erysipelas?# + +In most instances the disease runs a favorable course, terminating in +recovery in one to three weeks. Exceptionally, in severe cases, a fatal +termination ensues. + + +#What is the treatment of erysipelas?# + +_Internally_, a purge, followed by the tincture of the chloride of iron +and quinia, and stimulants if needed. _Locally_, one to three per cent. +carbolic-acid lotion or ointment, a saturated solution of boric acid, or +a ten- to twenty-per-cent. aqueous solution or ointment of ichthyol may +be employed. + +In some cases the spread of the disease is apparently controlled by +painting the bordering healthy skin with a ring of tincture of iodine or +strong solution of nitrate of silver. + + + + #Phlegmona Diffusa.# + + +#What do you understand by phlegmona diffusa?# + +Phlegmona diffusa is a more or less extensive inflammation of the +cutaneous and subcutaneous tissues presenting symptoms partaking of the +nature of both deep erysipelas and flat carbuncles, and usually attended +with varying constitutional disturbance. Suppuration at several points +takes place, and sloughing may ensue. Recovery usually finally results, +but a fatal issue is possible. + +Treatment is based upon general principles. + + + + #Furunculus.# + (_Synonyms:_ Furuncle; Boil.) + + +#Define furunculus.# + +Furunculus, or boil, is an acute, deep-seated, inflammatory, +circumscribed, rounded or more or less acuminated, firm, painful +formation, usually terminating in central suppuration. + + +#Describe the symptoms and course.# + +A boil begins as a small, rounded or imperfectly defined reddish spot, +or as a small, superficial pustule; it increases in size, and when well +advanced appears as a pea or cherry-sized, circumscribed, reddish +elevation, with more or less surrounding hyperæmia and swelling; it is +painful and tender, and ends, in the course of several days or a week, +in the formation of a central slough or "_core_," which finally involves +the central overlying skin (_pointing_). One or several may be present, +gradually maturing and disappearing. Insignificant scarring may remain. + +In some cases sympathetic constitutional disturbance is noticed. + + +#What is a blind boil?# + +A sluggish boil exhibiting little, if any, tendency to point or break. + + +#What is furunculosis?# + +Furunculosis is that condition in which boils, singly or in crops, +continue to appear, irregularly, for weeks or months. + + +#State the etiology of furuncle.# + +A depraved state of the general health is often to be considered as a +predisposing factor. Persistent furunculosis is not infrequent in +diabetes mellitus. The immediate exciting cause is the entrance into the +follicle of a microbe, the staphylococcus pyogenes aureus. It is not +improbable, however, that boils may also be due to other pus-producing +organisms. + +Workmen in paraffin oils or other petroleum products often present +numerous furuncles and cutaneous abscesses. Conditions favoring a +persistent miliaria have also a causative influence, especially observed +in infants and young children. In these latter, especially among the +poorer classes, sluggish boils or subcutaneous abscesses about the scalp +in hot weather, are not at all infrequent. + + +#What is the pathology of furuncle?# + +A boil is an inflammatory formation having its starting point in a +sebaceous-gland, sweat-gland, or hair-follicle. The core, or central +slough, is composed of pus and of the tissue of the gland in which it +had its origin. + + +#How would you distinguish a boil from a carbuncle?# + +A boil is comparatively small, rounded or acuminate, and has but one +point of suppuration; a carbuncle is large, flattened, intensely +painful, often with grave systemic disturbance, and has, moreover, +several centres of suppuration. + + +#State the prognosis.# + +When occurring in crops (furunculosis) the affection is often +rebellious; recovery, however, finally resulting. + + +#What is the method of treatment of furunculus?# + +If there be but one lesion, with no tendency to the appearance of +others, local treatment alone is usually employed. If, however, several +or more are present, or if there is a tendency to successive +development, both constitutional and local measures are demanded. + + +#Name the internal remedies employed.# + +Such nutrients and tonics as cod-liver oil, malt, quinine, strychnia, +iron and arsenic; in some instances calx sulphurata, one-tenth- to +one-fourth-grain doses every three or four hours has been thought to be +of service. Brewers' yeast has been recently again brought forward as a +remedy of value. + + +#What is the external treatment?# + +Local treatment consists in the beginning, with the hope of aborting the +lesion, of the application of carbolic acid to the central portion, or +the use of a twenty-five-per-cent. ointment of ichthyol applied as a +plaster:-- + + [Rx] Ichthyol, ............................ [dram]j + Emp. plumbi, ........................... [dram]ij + Emp. resinæ, ........................... [dram]j. M. + +Or the injection of a five-per-cent. solution of carbolic acid into the +apex of the boil may be tried if the formation is more advanced. If +suppuration is fully established, evacuation of the contents, followed +by antiseptic applications, constitutes the best method. + +A saturated solution of boric acid or a lotion of corrosive sublimate +(one to three grains to the ounce) applied to the immediate neighborhood +of the boil or boils tends to prevent the formation of new lesions. +Frequent washing of the parts with soap and water or tincture of green +soap and water is also a preventive measure of value. In repeatedly +infected areas, mild exposures to _x_-rays, at intervals of a few days, +will often prove of curative value. + + + + #Carbunculus.# + (_Synonyms:_ Anthrax; Carbuncle.) + + +#What is carbuncle?# + +A carbuncle is an acute, usually egg to palm-sized, circumscribed, +phlegmonous inflammation of the skin and subcutaneous structures, +terminating in a slough. + + +#At what age and upon what parts is carbuncle usually observed?# + +In middle and advanced life, and more commonly in men. + +It is seen most frequently at the nape of the neck and upon the upper +part of the back. + + +#What are the symptoms and course of carbuncle?# + +There is rarely more than one lesion present. It begins, usually with +preceding and accompanying malaise, chilliness and febrile disturbance, +as a firm, flat, inflammatory infiltration in the deeper skin and +subcutaneous tissue, spreading laterally and finally involving an area +of one to several inches in diameter. The infiltration and swelling +increase, the skin becomes of dark red color, and sooner or later, +usually at the end of ten days or two weeks, softening and suppuration +begin to take place, the skin finally giving away at several points, +through which sanious pus exudes; the whole mass finally sloughs away +either in portions or in its entirety, resulting in a deep ulcer, which +slowly heals and leaves a permanent cicatrix. + +In some cases, especially in old people, constitutional disturbance of a +grave character is noted, septicæmia is developed, and a fatal result +may ensue. + + +#What is the cause of carbuncle?# + +The same causes are considered to be operative in carbunculus as in +furuncle; general debility and depression, from whatever cause, +predisposing to its formation, and the introduction of a microbe, +probably the same as in furunculus, being at present looked upon as the +exciting factor. + + +#What is the pathology?# + +The inflammation starts simultaneously from numerous points, from the +hair-follicles, sweat-glands or sebaceous glands. The inflammatory +centres break down, and the pus finds its way to the surface; finally +the process ends in gangrene of the whole area. + + +#How would you distinguish carbuncle from a boil?# + +By its flat character, greater size, and multiple points of suppuration. + + +#What is the prognosis of carbuncle?# + +Occurring in those greatly debilitated or in late life, and in those +cases in which two or more lesions exist, or when seated about the head, +the prognosis is always to be guarded, as a fatal result is not +uncommon. In fact, in every instance the disease is to be considered of +possible serious import. + + +#What constitutional treatment is usually employed in carbuncle?# + +A full nutritious diet, the use of such remedies as iron, quinia, nux +vomica, with malt and stimulants, if indicated. Calx sulphurata, +one-tenth to one-fourth grain every two or three hours, appears, in some +instances, to have a beneficial effect. If the pain is severe, morphia +or chloral should be given. + + +#What external measures are employed?# + +In the early part of the formation, injection of a five or ten per cent. +carbolic acid solution, or covering the whole area with a twenty-five +per cent. ichthyol ointment, may be employed. When it has broken down +the pus may be drawn out with a cupping-glass, and carbolized glycerine +or carbolized water introduced into each opening, and the ichthyol +ointment superimposed. If the whole part has sloughed, it should be +removed as rapidly as possible, and antiseptic dressings used. Or, if +its progress is slow, and grave systemic disturbance be present, the +whole part may be incised and curetted, and then treated antiseptically. +Mild exposure to the _x_-rays is also to be commended. + + + + #Pustula Maligna.# + (_Synonyms:_ Anthrax; Malignant Pustule.) + + +#What is malignant pustule?# + +Malignant pustule is a furuncle- or carbuncle-like lesion resulting from +inoculation of the virus generated in animals suffering from splenic +fever, or "charbon," and is accompanied by constitutional symptoms of +more or less gravity. A fatal termination is not unusual. + + +#What is the cause of pustula maligna?# + +The disease is due to the presence of the bacillus anthracis. + + +#What is the treatment of malignant pustule?# + +Early excision or destruction with caustic potash, with subsequent +antiseptic dressings; and internally the free use of stimulants and +tonics. + + + + #Post-mortem Pustule.# + (_Synonym:_ Dissection Wound.) + + +#Describe post-mortem pustule.# + +Post-mortem pustule develops at the point of inoculation, beginning as +an itchy red spot, becoming vesico-pustular, and later pustular, with +usually a broad inflammatory base, and accompanied with more or less +pain and redness and not infrequently lymphangitis, erysipelatous +swelling, and slight or severe sympathetic constitutional disturbance. + + +#What is the treatment of post-mortem pustule?# + +Treatment consists in opening the pustule and thorough cauterization, +and the subsequent use of antiseptic applications or dressings. +_Internally_ quinia and stimulants if indicated. + + + + #Framb[oe]sia.# + (_Synonyms:_ Yaws; Pian.) + + +#Describe framb[oe]sia.# + +Framb[oe]sia is an endemic, contagious disease met with in tropical +countries, characterized by the appearance of variously-sized papules, +tubercles, and tumors, which, when developed, resemble currants and +small raspberries, and finally break down and ulcerate. It is +accompanied by constitutional symptoms of variable severity. + +Hygienic measures, good food, tonics, and antiseptic and stimulating +applications are curative. + + + #Verruga Peruana.# + (_Synonyms:_ Peruvian Warts; Carrion's Disease; Oroya Fever.) + + +#Describe verruga peruana.# + +A specific inoculable affection endemic in some valleys of the Western +Andes, in Peru, and characterized by a prodromal febrile period and +subsequent outbreak of peculiar pin-head- to pea-sized, or larger, +bright reddish, rounded, wart-like elevations. The prodromal symptoms, +of an irregular malarial or typhoid type, with associated rheumatic and +muscular pains, may last for weeks or several months, usually abating +when eruption presents. The lesions may be crowded together in great +bunches. The face and limbs are favorite localities. The disease is +inoculable and thought to be due to a bacillus. + +The fatality varies between 10 and 20 per cent. Tonics and stimulants +are prescribed. + + + + #Equinia.# + (_Synonyms:_ Farcy; Glanders.) + + +#What is equinia, or glanders?# + +A rare contagious specific disease of a malignant type, derived from the +horse, and characterized by grave constitutional symptoms, inflammation +of the nasal and respiratory passages, and a deep-seated +papulo-pustular, or tubercular, nodular (_farcy buds_), ulcerative +eruption. A fatal issue is not uncommon. It is due to a micro-organism. + +Treatment, both local and constitutional, is based upon general +principles. + + + + #Miliaria.# + (_Synonyms:_ Prickly Heat; Heat Rash; Lichen Tropicus; Red Gum; + Strophulus.) + + +#What do you understand by miliaria?# + +An acute mildly inflammatory disorder of the sweat-glands, characterized +by the appearance of minute, discrete but closely crowded papules, +vesico-papules, and vesicles. + + +#Describe the symptoms of miliaria.# + +The eruption, consisting of pin-point to millet-seed-sized papules, +vesico-papules, vesicles, or a mixture of these lesions, discrete but +usually numerous and closely crowded, appears suddenly, occurring upon a +limited portion of the surface, or, as commonly observed, involving a +greater part or the whole integument. The trunk is a favorite locality. +The papular lesions are pinkish or reddish, and the vesicles whitish or +yellowish, surrounded by inflammatory areola, thus giving the whole +eruption a bright red appearance--_miliaria rubra_. Later, the areolæ +fade, the transparent contents of the vesicles become somewhat opaque +and yellowish-white, and the eruption has a whitish or yellowish +cast--_miliaria alba_. In long-continued cases, especially in children, +boils and cutaneous abscesses sometimes develop; and it may also develop +into a true eczema. + +Itching, or a feeling of burning, slight or intense, is usually present. + + +#What is the course of the eruption?# + +The vesicles show no disposition to rupture, but dry up in a few days or +a week, disappearing by absorption and with slight subsequent +desquamation; the papular lesions gradually fade away, and the +affection, if the exciting cause has ceased to act, terminates. + + +#What is the cause of miliaria?# + +Excessive heat. Debilitated individuals, especially children, are more +prone to an attack. Being too warmly clad is often causative. + + +#What is the nature of the disease?# + +The affection is considered to be due to sweat-obstruction, with mild +inflammatory symptoms as a cause or consequence, congestion and +exudation taking place about the ducts, giving rise to papules or +vesicles, according to the intensity of the process. + + +#How would you distinguish miliaria from papular and vesicular eczema, +and from sudamen?# + +The papules of eczema are larger, more elevated, firmer, slower in their +evolution, of longer duration, and are markedly itchy. + +The vesicles of eczema are usually larger, tend to become confluent, and +also to rupture and become crusted; there is marked itchiness, and the +inflammatory action is usually severe and persistent. + +In sudamen there is absence of inflammatory symptoms. + + +#What is the prognosis of miliaria?# + +The affection, under favorable circumstances, disappears in a few days +or weeks. If the cause persists, as for instance, in infants or young +children too warmly clad, it may result in eczema. + + +#What is the treatment of miliaria?# + +Removal of the cause, and in debilitated subjects the administration of +tonics; together with the application of cooling and astringent lotions, +as the following:-- + + [Rx] Aeidi carbolici, ..................... [dram]ss-[dram]j + Acidi borici, ........................ [dram]iv + Glycerinæ, ........................... f[dram]j + Alcoholis, ........................... f[Oz]ij + Aquæ, ................................ [Oz]xiv. M. + + +This is sometimes more efficient if zinc oxide, six to eight drachms, is +added. + +Lotions of alcohol and water or vinegar and water, and also the various +lotions used in acute eczema, are often employed with relief. + +Dusting-powders of starch, boric acid, lycopodium, talc, and zinc oxide +are also valuable; the following combination is satisfactory:-- + + [Rx] Pulv. acidi borici, + Pulv. talci veneti, + Pulv. zinci oxidi, + Pulv. amyli, .............[=a][=a].....[dram]ij. M. + +Probably the best plan is to use a lotion and a dusting-powder +conjointly; dabbing on the wash freely, allowing it to dry, and then +dusting over with the powder. + + + + #Pompholyx.# + (_Synonyms:_ Dysidrosis; Cheiro-pompholyx.) + + +#What is pompholyx?# + +Pompholyx is a rare disease of the skin of a vesicular and bullous +character, and limited to the hands and feet. + + +#Describe the symptoms of pompholyx.# + +In most instances the hands only are affected. It begins usually with a +feeling of burning, tingling or tenderness of the parts, followed +rapidly by the appearance of deeply-seated vesicles, especially between +the fingers and on the palmar aspect. These beginning lesions look not +unlike sago grains imbedded in the skin. In some instances the disease +does not extend beyond this stage, the vesicles disappearing after a few +days or weeks by absorption, and usually without desquamation. +Ordinarily, however, the lesions increase in size, new ones arise, +become confluent, and blebs result, the skin in places appearing as if +undermined with serous exudation. The parts are commonly inflamed to a +slight or marked degree. The skin comes off in flakes, new lesions may +appear for several days or two or three weeks, and the process then +declines, recovery gradually taking place. + +There are no constitutional symptoms, although it is usually noticed +that the general health is below par. + + +#What is the character of the subjective symptoms in pompholyx?# + +The subjective symptoms consist of a feeling of tension, burning and +tenderness, and sometimes itching. Not infrequently, also there is +neuralgic pain. + + +#What is the cause of pompholyx?# + +The eruption is thought to be due to a depressed state of the nervous +system. It is more common in women, and is met with chiefly in adult and +middle life. + + +#What is the pathology?# + +Opinion is divided; some considering it a disease of the sweat-glands +and others an inflammatory disease independent of these structures. + + +#State the diagnostic features of pompholyx.# + +The distribution and the peculiar characters and course of the eruption. + +It is to be differentiated from eczema. + + +#What is the prognosis?# + +For the immediate attack, favorable, recovery taking place in several +weeks or a few months. Recurrences at irregular intervals are not +uncommon. + + +#What is the treatment of pompholyx?# + +The general health is to be looked after, and the patient placed under +good hygienic conditions. Remedies of a tonic nature, directed +especially toward improving the state of the nervous system, are to be +prescribed. _Locally_, soothing and anodyne applications, such as +lead-water and laudanum, boric-acid lotion, oxide-of-zinc, boric-acid +and diachylon ointments, are most suitable; or the parts may be +enveloped with the following:-- + + [Rx] Pulv. ac. salicylici, ................ gr. x + Pulv. ac. borici, + Pulv. amyli, .......... [=a][=a] ..... [dram]ij + Petrolati, ........................... [dram]iv. M. + +In fact, the external treatment is similar to that employed in acute +eczema. + + + + #Herpes Simplex.# + (_Synonym:_ Fever Blisters.) + + +#What is herpes simplex?# + +An acute inflammatory disease, characterized by the formation of +pin-head to pea-sized vesicles, arranged in groups, and occurring for +the most part about the face and genitalia. + + +#Describe the symptoms of herpes simplex.# + +In severe cases, malaise and pyrexia may precede the eruption, but +usually it appears without any precursory or constitutional symptoms. A +feeling of heat and burning in the parts is often complained of. The +vesicles, which are commonly pin-head in size, are usually upon a +hyperæmic or inflammatory base, and tend to occur in groups or clusters. +Their contents are usually clear, subsequently becoming more or less +milky or puriform. There is no tendency to spontaneous rupture, but +should they be broken a superficial excoriation results. In a short time +they dry to crusts which soon fall off, leaving no permanent trace. + + +#Is the eruption in herpes simplex abundant?# + +No. As a rule not more than one or two clusters or groups are observed. + + +#Upon what parts does the eruption occur?# + +Usually about the face (_herpes facialis_), and most frequently about +the lips (_herpes labialis_); on the genitalia (_herpes progenitalis_), +the lesions are commonly found on the prepuce (_herpes præputialis_) in +the male, and on the labia minora and labia majora in the female. + + +#State the causes of herpes simplex.# + +Herpes facialis is often observed in association with colds and febrile +and lung diseases. Malaria, digestive disturbance, and nervous disorders +are not infrequently predisposing factors. Herpes progenitalis is said +to occur more frequently in those who have previously had some venereal +disease, especially gonorrh[oe]a, but this is questionable. It is +probably often purely neurotic. + + +#What are the diagnostic points?# + +The appearance of one or several vesicular groups or clusters about the +face, and especially about the lips, is usually sufficiently +characteristic. The same holds true ordinarily when the eruption is seen +on the prepuce or other parts of the genitalia; it is only when the +vesicles become rubbed or abraded and irritated that it might be +mistaken for a venereal sore, but the history, course and duration will +usually serve to differentiate. + + +#Give the prognosis.# + +The eruption will usually disappear in several days or one or two weeks +without treatment. Remedial applications, however, exert a favorable +influence. Herpes progenitalis exhibits a strong disposition to +recurrence. + + +#What is the treatment of herpes facialis?# + +Anointing the parts with camphorated cold cream, with spirits of camphor +or similar evaporating and stimulating applications will at times afford +relief to the burning, and shorten the course. + + +#What is the treatment of herpes progenitalis?# + +In herpes about the genitalia cleanliness is of first importance. A +saturated solution of boric acid, a dusting-powder of calomel or oxide +of zinc, and the following lotion, containing calamine and oxide of +zinc, are valuable:-- + + [Rx] Zinci oxidi, + Calaminæ, .......... [=a][=a] ........ gr. v + Glycerinæ, + Alcoholis, ......... [=a][=a] ........ [minim]vj + Aquæ, ................................ [Oz]j M. + +In obstinate recurrent cases, frequent applications of a mild galvanic +current will have a favorable influence. + + + + #Hydroa Vacciniforme.# + (_Synonyms:_ Recurrent Summer Eruption; Hydroa Puerorum; Hydroa + Aestivale.) + + +#Describe hydroa vacciniforme.# + +It is a rare vesicular disease usually seen in boys (only two or three +exceptions), occurring upon uncovered parts, especially the nose, +cheeks, and ears. The lesions begin as red spots, discrete or in groups, +rapidly exhibit vesiculation, and later umbilication; the contents +become milky, dry to crusts, which fall off and leave small pit-like +scars. Fresh outbreaks may take place almost continuously, and the +process go on indefinitely, at least up to youth or manhood, when the +tendency subsides. Its activity is usually limited to the warm season. +Arthritic symptoms and general disturbance are sometimes noted in severe +cases. + +It is doubtless a vasomotor neurosis. Exposure to sun and wind is an +important, if not essential, etiological factor. Primarily the lesion +begins in the rete middle layers, and is purely vesicular in character; +later, necrosis of the rete and extending deep in the corium is +observed. + +Treatment so far has only been palliative, consisting of the +applications employed in similar conditions. Constitutional medication +is based upon general principles. The patient should avoid exposure to +the sun, strong wind and excessive artificial heat. + + + + #Epidermolysis Bullosa.# + + +#Describe epidermolysis bullosa.# + +This is a rare, usually hereditary, disease or condition, characterized +by the formation of vesicles and blebs on any part subjected to slight +rubbing or irritation. No scarring is left, and no pigmentation noted. +The predisposition to these lesions persists indefinitely. The general +health is not involved. The nature of the disease is obscure. + +Treatment has no influence in modifying or lessening this tendency. The +vulnerable parts should so far as possible be protected from knocks and +undue friction. + + + + #Dermatitis Repens.# + + +#What do you understand by dermatitis repens?# + +It is a rare spreading dermatitis starting from an injury, extending by +a serous undermining of the epidermis, and usually occurring upon the +upper extremities. + +It usually begins shortly after an injury, and, as a rule, presents +itself by redness and serous exudation. The overlying epidermis breaks, +and the area of disease gradually progresses by an extension of the +serous undermining process, the denuded part looking red and raw, with +usually an oozing surface. As the disease spreads the oldest part +becomes dry and heals, the new epidermal covering being thin and +atrophic in appearance. Its most usual beginning is on some part of the +hand, and from here it may spread up the arm and involve considerable +area. + +The injury from which it starts may be extremely insignificant, +apparently affording an opening for the introduction of the causative +factor, doubtless parasitic. Beyond a feeling of soreness there seem to +be no special subjective symptoms. + + +#Give the prognosis and treatment.# + +The malady shows but little tendency to spontaneous cure. The frequent +or constant application of a mild antiseptic lotion, such as boric acid +and resorcin, or of a mild parasiticide ointment will generally bring +the disease gradually to an end. + + + + #Herpes Zoster.# + (_Synonyms:_ Zoster; Zona; Shingles.) + + +#Give a definition of herpes zoster.# + +Herpes zoster is an acute, self-limited, inflammatory disease, +characterized by groups of vesicles upon inflammatory bases, situated +over or along a nerve tract. + + +#Upon what parts of the body may the eruption appear?# + +It may appear upon any part, following the course of a nerve; it is +therefore always limited in extent, and confined to one side of the +body. It is probably most common about the intercostal, lumbar and +supra-orbital regions. In rare instances the eruption has been observed +to be bilateral. + + +#Are there any subjective or constitutional symptoms?# + +Yes; there is, as a rule, neuralgic pain preceding, during and following +the eruption; and in some cases, also, there may be in the beginning +mild febrile disturbance. There is also a variable degree of tenderness +and pain. + + +#What are the characters of the eruption?# + +Several or more hyperæmic or inflammatory patches over a nerve course +appear, upon which are seated vesico-papules irregularly grouped; these +vesico-papules become distinct vesicles, of size from a pin-head to a +pea, and soon dry and give rise to thin, yellowish or brownish crusts, +which drop off, leaving in most instances no permanent trace, in others +more or less scarring. In some cases the lesions may become pustular +and, on the other hand, the eruption may be abortive, stopping short of +full vesiculation. + + +#What is known in regard to the nature of the disease?# + +An inflamed and irritable state of the spinal ganglia, nerve tract, or +peripheral branches is directly responsible for the eruption, and this +state may be due to atmospheric changes, cold, nerve-injuries and +similar influences. The view has also been advanced that the disease is +of specific and infectious character. + + +#Give the chief diagnostic features of herpes zoster.# + +The prodromic neuralgic pain, the appearance of grouped vesicles upon +inflammatory bases following the course of a nerve tract, and the +limitation of the eruption to one side of the body. + + +#What is the prognosis?# + +Favorable; the symptoms usually disappearing in two to four weeks. In +some instances, however, the neuralgic pains may be persistent, and in +zoster of the supra-orbital region the eye may suffer permanent damage. + + +#How would you treat herpes zoster?# + +_Constitutional treatment_, usually tonic in character, is to be based +upon general principles; moderate doses of quinia, with one-sixth grain +of zinc phosphide, four or five times daily, appear in some cases to +have a special value. The accompanying neuralgic pain may be so intense +as to require anodynes. _Local treatment_ should be of a soothing and +protective character. A dusting-powder of oxide of zinc and starch (to +the ounce of which twenty to thirty grains of camphor may be added) +proves useful; and over this, in order that the parts be further +protected, a bandage or a layer of cotton batting. Oxide-of-zinc +ointment, and in those cases in which there is much pain, ointments +containing powdered opium or belladonna, or orthoform, may be used. A +mild galvanic current applied daily to the parts is often of great +advantage, both in its influence upon the course of the eruption and +upon the neuralgic pain. The plan, so often advised, of painting the +parts with flexible collodion is not to be commended. + + + + #Dermatitis Herpetiformis.# + (_Synonyms:_ Hydroa Herpetiforme (Tilbury Fox); Herpes Gestationis + (Bulkley); Pemphigus Prurigiuosus; Duhring's Disease.) + + +#Give a definition of dermatitis herpetiformis.# + +Dermatitis herpetiformis is a somewhat rare inflammatory disease, +characterized by an eruption of an erythematous, papular, vesicular, +pustular, bullous or mixed type, with a decided disposition toward +grouping, accompanied by itching and burning sensations, with, as a +rule, more or less consequent pigmentation, and pursuing usually a +chronic course with remissions. + + +#Describe the erythematous type of dermatitis herpetiformis.# + +The character of the eruption in the erythematous type resembles closely +that of erythema multiforme and of urticaria, especially the former. The +efflorescences usually make their appearance in crops, and are more or +less persistent; fading sooner or later, however, and giving place to +new outbreaks. Vesicles are often intermingled, developing from +erythematous and erythemato-papular lesions or arising from apparently +normal skin. + +It may continue in the same type, or change to the vesicular, bullous or +other variety. + + +#Describe the papular type of dermatitis herpetiformis.# + +This is rarely seen as consisting purely of papular lesions, but is +commonly associated with the erythematous and vesicular varieties. In a +measure it resembles the papular manifestations of erythema multiforme, +with a distinct disposition toward group formation. The papules tend, +sooner or later, to develop into vesicles, new papular outbreaks +occurring from time to time; or the whole eruption changes to the +vesicular or other type of the disease. It is not a common type. + + +#Describe the vesicular type of dermatitis herpetiformis.# + +This is the common clinical type of the disease, and is characterized by +pin-head to pea-sized, rounded or irregularly-shaped, distended or +flattened and stellate vesicles, occurring, for the most part, in +irregular and segmental groups of three or more lesions, seated either +upon apparently normal integument or upon hyperæmic or inflammatory +skin. They exhibit no tendency to spontaneous rupture, but after +remaining a shorter or longer time, are broken or disappear by +absorption. The lesions tend to appear in crops. It may, as it not +infrequently does, continue in the same type, or it may become more or +less erythematous or bullous in character. In not a few instances +pustules, few or in numbers, are at times intermingled. + + +#Describe the pustular type of dermatitis herpetiformis.# + +This is rare. It is similar in its clinical characters to the vesicular +type, except that the lesions are pustular. It is met with, as a rule, +in association with the vesicular and bullous varieties of the disease. + + +#Describe the bullous type of dermatitis herpetiformis.# + +The bullous expression of the disease is usually of a markedly +inflammatory nature, often innumerable blebs, small and large, appearing +almost continuously, and in some instances involving the greater part of +the surface. The lesions arise from erythematous skin, from preëxisting +vesicles or vesicular groups, or from apparently normal integument. +There is a marked disposition to appear in clusters. A change of type to +the erythematous or vesicular varieties is not unusual. + + +#Describe the mixed type of dermatitis herpetiformis.# + +In this type the eruption is made up of erythematous patches, vesicles, +bullæ, and often with pustules intermingled, appearing irregularly or in +crops, and with a tendency to patch or group formation. + + +#Describe the characters of the vesicles, pustules and blebs.# + +As a rule, these several lesions, especially the vesicles and blebs, are +somewhat peculiar: they are usually of a strikingly irregular outline, +oblong, stellate, quadrate, and when drying are apt to have a puckered +appearance. They are herpetic in that they show little disposition to +spontaneous rupture, occur in groups, and are usually seated upon +erythematous or inflammatory skin--in some respects similar to the +groups of simple herpes and herpes zoster. + + +#What is to be said in regard to the subjective symptoms?# + +The subjective symptoms are usually the most troublesome feature of the +disease, consisting of intense and persistent itching and a feeling of +heat and burning. + + +#Are there any constitutional symptoms in dermatitis herpetiformis?# + +As a rule, not, excepting the distress and depression necessarily +consequent upon the intense itchiness and loss of sleep. In the pustular +and bullous varieties there may be mild or grave systemic symptoms, but +even in these types the constitutional involvement is, in most +instances, slight in comparison to the intensity of the cutaneous +disturbance. + + +#What is the course of dermatitis herpetiformis?# + +Extremely chronic, in most instances lasting, with remissions, +indefinitely. The skin is rarely entirely free. From time to time the +type of the disease may undergo change. From the continued irritation +and scratching more or less pigmentation results. + + +#What is to be said in regard to the etiology?# + +The disease is in many instances essentially neurotic, and in +exceptional instances septicæmic. Pregnancy and the parturient state are +factors in some instances (so-called herpes gestationis). It is possible +in some instances that the eruption may be an expression of a mild +toxemia of gastro-intestinal origin. In some cases no cause can be +assigned. In the majority of patients the general health, considering +the violence of the eruptive phenomena, remains comparatively +undisturbed. + +Nervous shock and mental worry are factors in some cases. Polyuria, +with sugar in the urine, has occasionally been noted. Eosinophile +cells have been found both in the vesicles and the blood. In some +instances--exceptionally, it is true--the disease has appeared shortly +after vaccination. + + +#Mention the diagnostic features of dermatitis herpetiformis.# + +The multiformity of the eruption, the characters of the lesions, the +disposition to grouping, the absence of tendency to form solid sheets of +eruption (as in eczema), the intense itching, history, chronicity and +course. In doubtful cases, an observation of several weeks will always +suffice to distinguish it from eczema, erythema multiforme, herpes iris +and pemphigus, diseases to which it at times bears strong resemblance. + + +#Give the prognosis of dermatitis herpetiformis.# + +An opinion as to the outcome of the disease should be guarded. It is +exceedingly rebellious to treatment, and relapses are the rule. +Exceptionally the bullous and pustular varieties prove eventually fatal. +The erythematous and vesicular varieties are the most favorable. + + +#State the treatment to be advised.# + +There are no special remedies. Constitutional treatment must be +conducted upon general principles. A free action of the bowels is to be +maintained. In occasional instances arsenic in progressive doses seems +of value. Externally protective and antipruritic applications, such as +are employed in the treatment of eczema and pemphigus, are to be +employed:-- + + [Rx] Ac. carbolici, ....................... [dram]j-[dram]ij + Thymol, .............................. gr. xvj. + Glycerinæ, ........................... [Oz]ss-[Oz]j + Alcoholis, ........................... f[Oz]ij + Aquæ, q.s., ......... ad ............. Oj. M. + +Other valuable applications are: lotions of carbolic acid, of liquor +carbonis detergens, of boric acid; alkaline baths, mild sulphur ointment +and carbolized oxide-of-zinc ointment, and dusting-powders of starch, +zinc oxide, talc and boric acid. A two- to ten-per-cent. ichthyol lotion +or ointment is sometimes of advantage; thiol employed in the same manner +has also been commended. + + + + #Psoriasis.# + + +#Give a definition of psoriasis.# + +Psoriasis is a chronic, inflammatory disease, characterized by dry, +reddish, variously-sized, rounded, sharply-defined, more or less +infiltrated, scaly patches. + +[Illustration: Psoriasis.] + + +#At what age does psoriasis usually first make its appearance?# + +Most commonly between the ages of fifteen and thirty. It is rarely seen +before the tenth year, and a first attack is uncommon after the age of +forty. + + +#Has psoriasis any special parts of predilection?# + +The extensor surfaces of the limbs, especially the elbows and knees, are +favorite localities, and even when the eruption is more or less general, +these regions are usually most conspicuously involved. The face often +escapes, and the palms and soles, likewise the nails, are rarely +involved. In exceptional instances, the eruption is limited almost +exclusively to the scalp. + + +#Are there any constitutional or subjective symptoms in psoriasis?# + +There is no systemic disturbance; but a variable amount of itching may +be present, although, as a rule, it is not a troublesome symptom. + + +#Describe the clinical appearances of a typical, well developed case.# + +Twenty or a hundred or more lesions, varying in size from a pin-head to +a silver dollar, are usually present. They are sharply defined against +the sound skin, are reddish, slightly elevated and infiltrated, and more +or less abundantly covered with whitish, grayish or mother-of-pearl +colored scales. The patches are usually scattered over the general +surface, but are frequently more numerous on the extensor surfaces of +the arms and legs, especially about the elbows and knees. Several +closely-lying lesions may coalesce and a large, irregular patch be +formed; some of the patches, also, may be more or less circinate, the +central portion having, in a measure or completely, disappeared. + + +#Give the development and history of a single lesion.# + +Every single patch of psoriasis begins as a pin-point or pin-head-sized, +hyperæmic, scaly, slightly-elevated lesion; it increases gradually, and +in the course of several days or weeks usually reaches the size of a +dime or larger, and then may remain stationary; or involution begins to +take place, usually by a disappearance, partially or completely, of the +central portion, and finally of the whole patch. + + +#Describe the so-called clinical varieties of psoriasis.# + +As clinically met with, the patches present are, as a rule, in all +stages of development. In some instances, however, the lesions, or the +most of them, progress no further than pin-head in size, and then remain +stationary, constituting _psoriasis punctata_; in other cases, they +may stop short after having reached the size of drops--_psoriasis +guttata_; in others (and this is the usual clinical type) the patches +develop to the size of coins--_psoriasis nummularis_. In some cases +there is a strong tendency for the central part of the lesions to +disappear, and the process then remain stationary, the patches being +ring-shaped--_psoriasis circinata_; and occasionally several such rings +coalesce, the coalescing portions disappearing and the eruption be more +or less serpentine--_psoriasis gyrata_. Or, in other instances, several +large contiguous lesions may coalesce and a diffused, infiltrated patch +covering considerable surface results--_psoriasis diffusa, psoriasis +inveterata_. + +[Illustration: Fig. 17. Psoriasis.] + + +#Is the eruption of psoriasis always dry?# + +Yes. + + +#What course does psoriasis pursue?# + +As a rule, eminently chronic. Patches may remain almost indefinitely, or +may gradually disappear and new lesions appear elsewhere, and so the +disease may continue for months and, sometimes, for years; or, after +continuing for a longer or shorter period, may subside and the skin +remain free for several months or one or two years, and, in rare +instances, may never return. + +[Illustration: Fig. 18. Psoriasis.] + + +#Is the course of psoriasis influenced by the seasons?# + +As a rule, yes; there is a natural tendency for the disease to become +less active or to disappear altogether during the warm months. + + +#What is known in regard to the etiology of psoriasis?# + +The causes of the disease are always more or less obscure. There is +often a hereditary tendency, and the gouty and rheumatic diathesis must +occasionally be considered potential. In some instances it is apparently +influenced by the state of the general health. It is a rather common +disease and is met with in all walks of life. + + +#Is psoriasis contagious?# + +No. In recent years the fact of its exhibiting a family tendency has +been thought as much suggestive of contagiousness as of heredity. + + +#What is the pathology?# + +According to modern investigations, it is an inflammation induced by +hyperplasia of the rete mucosum; and it is beginning to be believed that +this hyperplasia may have a parasitic factor as the starting-cause. + + +#With what diseases are you likely to confound psoriasis?# + +Chiefly with squamous eczema and the papulo-squamous syphiloderm; and on +the scalp, also with seborrh[oe]a. It can scarcely be confounded with +ringworm. + + +#How is psoriasis to be distinguished from squamous eczema?# + +By the sharply-defined, circumscribed, scattered, scaly patches, and by +the history and course of the individual lesions. + + +#In what respects does the papulo-squamous syphiloderm differ from +psoriasis?# + +The scales of the squamous syphilide are usually dirty gray in color and +more or less scanty; the patches are coppery in hue, and usually several +or more characteristic scaleless, infiltrated papules are to be found. +The face, palms, and soles are often the seat of the syphilitic +eruption; and, moreover, _concomitant symptoms of syphilis_, such as +sore throat, mucous patches, glandular enlargement, rheumatic pains, +falling out of the hair, together with the history of the initial +lesion, are one, several, or all usually present. + + +#How does seborrh[oe]a differ from psoriasis?# + +Seborrh[oe]a of the scalp is usually diffused, with but little redness +and no infiltration; moreover, the scales of seborrh[oe]a are greasy, +dirty gray or brownish, while those of psoriasis are dry and comonly +whitish or mother-of-pearl colored. Psoriasis of the scalp rarely exists +independently of other patches elsewhere on the general surface. + +That variety of seborrh[oe]a, commonly known as eczema seborrhoicum, +presents at times, both on scalp and general surface, a strong +resemblance to psoriasis, but the character of the scales and +distribution of psoriasis, as above stated, are distinguishing points; +seborrh[oe]a, moreover, favors hairy surfaces and in extensive examples +the scalp, eyebrows, sternal, and pubic regions rarely escape. + + +#How does psoriasis differ from ringworm?# + +By its greater scaliness, by its higher degree of inflammatory action, +and by its larger number of patches, as also by its history. In ringworm +_all_ the patches tend to clear up in the centre; in psoriasis this is +rarely, if ever, so. If there is still any doubt, microscopic +examination of the scrapings will determine. + + +#Give the prognosis of psoriasis.# + +The prognosis is usually favorable, so far as concerns the immediate +eruption, but as to recurrences, nothing positive can be stated. In rare +instances, however, the cure remains permanent. + + +#How is psoriasis treated?# + +Both constitutional and local remedies are demanded in most cases. + + +#Do dietary measures exert any influence?# + +As a rule, no; but the food should be plain, and an excess of meat +avoided. + + +#Name the important constitutional remedies usually employed in +psoriasis.# + +_Arsenic_ is of first importance. It is not suitable in acute or +markedly inflammatory types; but is most useful in the sluggish, chronic +forms of the disease. The dose should never be pushed beyond slight +physiological action. It may be given as arsenious acid in pill form, +one-fiftieth to one-tenth of a grain three times daily, or as Fowler's +solution, three to ten minims at a dose. + +_Alkalies_, of which liquor potassæ is the most eligible. It is to be +given in ten to twenty minim doses, largely diluted. It is valuable in +robust, plethoric, rheumatic or gouty individuals with psoriasis of an +acute or markedly inflammatory type; it is not to be given to +debilitated or anæmic subjects. + +_Salicin_, sodium salicylate, and salophen in moderately full doses act +well in some cases. Occasionally thyroid preparations have a good +effect. + +_Potassium Iodide_, in doses of thirty to one hundred grains, t.d., acts +favorably in some instances; there are no special indications pointing +toward its selection, unless it be the existence of a gouty or rheumatic +diathesis. + +Oil of copaiba, potassium acetate, oil of turpentine, oil of juniper, +and other diuretics are valuable in some instances, and, while often +failing, sometimes exert a rapid influence, especially in those cases in +which the disease is extensive and inflammatory. Wine of antimony, given +cautiously, is also sometimes of service in the acute inflammatory type +in robust subjects. + + +#Are such remedies as iron, quinine, nux vomica and cod-liver oil ever +useful in psoriasis?# + +Yes. In debilitated subjects the administration of such remedies is at +times attended with improvement in the cutaneous eruption. + + +#What are the indications as regards the external measures?# + +Removal of the scales, and the use of soothing or stimulating +applications, according to the individual case. + + +#How are the scales removed?# + +In ordinary cases, either by warm, plain, or alkaline baths, or +hot-water-and-soap washings; in those cases in which the scaling is +abundant and adherent, washing with sapo viridis and hot water may be +required. Baths of sal ammoniac, two to six ounces to the bath are also +valuable in removing the scaliness. The tincture of green soap (tinctura +saponis viridis) is especially valuable for cleansing purposes in +psoriasis of the scalp. The hot vapor bath once or twice weekly is +serviceable in keeping the scaliness in abeyance, and has, moreover, in +some cases, a therapeutic value. + +The frequency of the baths or washings will depend upon the rapidity +with which the scales are reproduced. + + +#Are soothing applications often demanded in psoriasis?# + +In exceptional cases; in those in which the disease is acute, markedly +inflammatory and rapidly progressing, mild, soothing applications must +be temporarily employed, such as plain or bran baths, with the use of +some bland oil or ointment. As a rule, however, the conditions, when +coming under observation, are such as to permit of stimulating +applications from the start. The most efficient soothing applications +are the mild lotions and ointments employed in eczema of acute type. + + +#How are the stimulating remedies employed in psoriasis applied?# + +As ointments, oils, and paints (pigmenta). + +An ointment, if employed, is to be thoroughly rubbed in the diseased +areas once or twice daily. The same may be said of the oily +applications. The paints (medicated collodion and gutta-percha solution) +are applied with a brush, once daily, or every second or third day, +depending mainly upon the length of time the film remains intact and +adherent. + + +#Name the several important external remedies.# + +Chrysarobin, pyrogallol, tar, ammoniated mercury, [beta]-naphthol, +and resorcin. + + +#Are these several external remedies equally serviceable in all cases?# + +No. Their action differs slightly or greatly according to the case and +individual. A change from one to another is often necessary. + + +#In what forms and strength are these remedies to be applied?# + +_Chrysarobin_ is applied in several ways: as an ointment, twenty to +sixty grains to the ounce, rubbed in once or twice daily; this is the +most rapid but least cleanly and eligible method. As a pigment, or +paint, as in the following:-- + + [Rx] Chrysarobini, ........................ [dram]j + Acidi salicylici, .................... gr. xx + Etheris, ............................. f[dram]j + Ol. ricini, .......................... [minim]x + Collodii, ............................ f[dram]vij. M. + +Or it may be used in liquor gutta-perchæ (traumaticin), a drachm to the +ounce. It may also be employed in chloroform, a drachm to the ounce; this +is painted on, the chloroform evaporating, leaving a thin film of +chrysarobin; over this is painted flexible collodion. If the patches are +few and large, chrysarobin rubber-plaster may be used. + +Chrysarobin is usually rapid in its effect, but it has certain +disadvantages; it may cause an inflammation of the surrounding skin, +and, if used near the eyes, may give rise to conjunctivitis. As a rule, +it should not be employed about the head. Moreover, it stains the linen +permanently and the skin temporarily. + +_Pyrogallol_ is valuable, and is employed in the same manner and +strength as chrysarobin. In collodion it should at first not be used of +greater strength than three to four per cent., as in this form +pyrogallol sometimes acts with unexpected energy. It is less rapid than +chrysarobin, but it rarely inflames the surrounding integument. It +stains the linen a light brown, however, and is not to be used over an +extensive surface for fear of absorption and toxic effect. Oxidized +pyrogallic acid, a somewhat milder drug in its effect, has been highly +commended, and has the alleged advantage of being free from toxic +action. + +_Tar_ is, all things considered, the most important external remedy. It +is comparatively slow in its action, but is useful in almost all cases. +As employed usually it is prescribed in ointment form, either as the +official tar ointment, full strength or weakened with lard or +petrolatum. It may also be used as pix liquida, with equal part of +alcohol. Or the tar oils, oil of cade (ol. cadini), and oil of birch +(ol. rusci) may be employed, either as oily applications or incorporated +with ointment or with alcohol. Liquor carbonis detergens, in ointment, +one to three drachms to the ounce of simple cerate and lanolin is a mild +tarry application which is often useful. In stubborn patches an +occasional thorough rubbing with a mixture of equal parts of liquor +carbonis detergens and Vleminckx's solution, followed by a mild +ointment, sometimes proves of value. In whatsoever form tar is employed +it should be thoroughly rubbed in, once or twice daily, the excess wiped +off, and the parts then dusted with starch or similar powder. + +_Ammoniated mercury_ is applied in ointment form, twenty to sixty grains +to the ounce. Compared to other remedies it is clean and free from +staining, although, as a rule, not so uniformly efficacious. It is +especially useful for application to the scalp and exposed parts. It +should not be used over extensive surface for fear of absorption. + +_[beta]-Naphthol_ and _resorcin_ are applied as ointments, thirty to +sixty grains to the ounce, and as they are (especially the former) +practically free from staining, may be used for exposed surfaces. + +Gallacetophenone and aristol also act well in some cases, applied in +five- to ten-per-cent. strength, as ointments. + +In obstinate patches the _x_-ray may be resorted to, employing it with +caution and in the same manner as in other diseases. + + + + #Pityriasis Rosea.# + (_Synonym:_ Pityriasis Maculata et Circinata.) + + +#What do you understand by pityriasis rosea?# + +Pityriasis rosea is a disease of a mildly inflammatory nature, +characterized by discrete, and later frequently confluent, variously +sized, slightly raised scaly macules of a pinkish to rosy-red, often +salmon-tinged, color. + + +#Upon what part of the body is the eruption usually found?# + +The trunk is the chief seat of the eruption, although not infrequently +it is more or less general. + + +#Describe the symptoms of pityriasis rosea.# + +The lesions, which appear rapidly or slowly, are but slightly elevated, +somewhat scaly, usually rounded, except when several coalesce, when an +irregularly outlined patch results. At first they are pale or bright +pink or reddish, later a salmon tint (which is often characteristic) is +noticed. The scaliness is bran-like or flaky, of a dirty gray color, +and, as a rule, less marked in the central portion; it is never +abundant. The skin is rarely thickened, the process being usually +exceedingly superficial. + + +#What course does pityriasis rosea pursue?# + +The eruption makes its appearance, as a rule, somewhat rapidly, usually +attaining its full development in the course of one or two weeks, and +then begins gradually to decline, the whole process occupying one or two +months. + + +#To what is pityriasis rosea to be attributed?# + +The cause is not known; it is variously considered as allied to +seborrh[oe]a (eczema seborrhoicum), as being of a vegetable-parasitic +origin, and as a mildly inflammatory affection somewhat similar to +psoriasis. It is not a frequent disease. + + +#How is pityriasis rosea distinguished from ringworm, psoriasis and the +squamous syphiloderm?# + +From ringworm, by its rapid appearance, its distribution, the number of +patches, and, if necessary, by microscopic examination of the scrapings. + +Psoriasis is a more inflammatory disease, is seen usually more +abundantly upon the limbs, the scales are profuse and silvery, and the +underlying skin is red and has a glazed look; moreover, psoriasis, as a +rule, appears slowly and runs a chronic course. + +The squamous syphiloderm differs in its history, distribution, and above +all, by the presence of concomitant symptoms of syphilis, such as +glandular enlargement, sore throat, mucous patches, rheumatic pains, and +falling out of the hair. + + +#State the prognosis of pityriasis rosea.# + +It is favorable, the disease tending to spontaneous disappearance, +usually in the course of several weeks or one or two months. + + +#What treatment is to be advised in pityriasis rosea?# + +Laxatives and intestinal antiseptics, and ointments of salicylic acid +(5-15 grains to the ounce), of sulphur (10-40 grains to the ounce); or a +compound ointment containing both these ingredients can be prescribed. +The ointment base can be equal parts of white vaselin and cold cream; in +some instances Lassar's paste (starch powder, zinc oxid powder, each, +[dram]ij; vaselin, [dram]iv) seems more satisfactory. + + + + #Dermatitis Exfoliativa.# + (_Synonyms:_ General Exfoliative Dermatitis; Recurrent Exfoliative + Dermatitis; Desquamative Scarlatiniform Erythema; Acute General + Dermatitis; Recurrent Exfoliative Erythema; Pityriasis Rubra.) + + +#Describe dermatitis exfoliativa.# + +Dermatitis exfoliativa is an inflammatory disease of an acute type, +characterized by a more or less general erythematous inflammation, in +exceptional instances vesicular or bullous, with epidermic desquamation +or exfoliation accompanying or following its development. Constitutional +disturbance, which may be of a serious character, is sometimes present. +It is a rare and obscure affection, running its course usually in +several weeks or months, but exhibiting a decided tendency to relapse +and recurrence. In many cases it is persistently chronic, with +exacerbations and remissions. In some instances it develops from a +long-continued and more or less generalized eczema or psoriasis, and in +exceptional cases it is started by the careless use of mercurial +ointment and of chrysarobin ointment. + +[Illustration: Fig. 19. Dermatitis Exfoliativa.] + +In another type of the disease, formerly described as _pityriasis +rubra_, the skin is pale red or violaceous-red, but is rarely thickened, +continued exfoliation in the form of thin plates taking place. Its +course is variable, lasting for years, with remissions. + +An exfoliating generalized dermatitis is exceptionally observed in the +first weeks of life (_dermatitis exfoliativa neonatorum_), lasting some +weeks, and in most cases followed by recovery. There are no special +constitutional symptoms, the fatal cases usually dying of marasmus. + +As will be seen dermatitis exfoliativa varies considerably in degree; it +may be extremely mild, resembling in appearance the scarlet-fever +eruption (erythema scarlatiniforme) and running a rapid course; or the +skin-condition and the systemic symptoms may be of grave and persistent +character. + + +#Give the treatment of dermatitis exfoliativa.# + +General treatment is based upon indications, and externally soothing +applications, such as are employed in acute and subacute eczema, are to +be used. + + + + #Lichen Planus.# + + +#What is lichen planus?# + +Lichen planus is an inflammatory disease characterized by small, flat +and angular, smooth and shining, or scaly, discrete or confluent, red or +violaceous-red papules, having a distinctly papular or papulo-squamous +course, and attended with more or less itching. + + +#Describe the symptoms of lichen planus.# + +The eruption, as a rule, begins slowly, usually showing itself upon the +extremities; the forearms, wrists and legs being favorite localities. It +may appear as one or more groups or in the form of short or long bands. +Occasionally its evolution is rapid and a considerable part of the +surface may be invaded. The lesions are pin-head to small pea-sized, +irregularly grouped or so closely crowded together as to form solid +patches; they are quadrangular or polygonal in shape, usually flat, with +central depression or umbilication, and are reddish or violaceous in +color. At first they have a glazed or shining appearance; later, +becoming slightly scaly, the scaliness being more marked where solid +patches have resulted. New papules may appear from time to time, the +older lesions disappearing and leaving persistent reddish or brownish +pigmentation. Exceptionally the eruption presents in bands or lines, +like rows of beads (_lichen moniliformis_). Very exceptionally a +vesicular or bleb tendency in some of the lesions has been noted; +doubtless, in most instances at least, this has been due to the arsenic +so generally administered in this disease. In rare instances lichen +planus lesions are also seen on the glans penis and on the buccal mucous +membrane. In some cases, especially in the region of the ankle, the +papules become quite large (_lichen planus hypertrophicus_), and in +occasional cases there is a tendency in some of the lesions or patches +to clear up centrally. There is, as a rule, considerable itching. There +are no constitutional symptoms. + + +#What is the etiology of lichen planus?# + +In some cases the disease is distinctly neurotic in character, in others +no cause can be assigned. It is more especially met with at middle age, +and among the wealthier, professional, and luxurious classes. + +Pathologically the first change noted in the epidermis is thought to be +an acanthosis, followed by epithelial atrophy, and a hyperkeratosis, +intercellular edema, and colloid degeneration of the prickle cells. + + +#Does the disease bear any resemblance to the miliary papular syphilide, +psoriasis, and papular eczema?# + +In some instances it does, but the irregular and angular outline, the +slightly-umbilicated, flattened, smooth or scaly summits, and the +dull-red or violaceous color, the history and course, of lichen planus, +will serve to differentiate. + + +#State the prognosis.# + +Under proper management the eruption, although often obstinate, yields +to treatment. + + +#What treatment would you prescribe in lichen planus?# + +A general tonic plan of medication is indicated in most cases, with such +remedies as iron, quinine, nux vomica, and cod-liver oil and other +nutrients. In many instances arsenic exerts a special influence, and +should always be tried. Mercurials in moderate dosage have also a +favorable action in most cases. Locally, antipruritic and stimulating +applications, such as are used in the treatment of eczema, are to be +employed, alkaline baths and tarry applications deserving special +mention. Liquor carbonis detergens, applied weakened with several parts +water, is a valuable application. In some cases, particularly if the +disease is limited, external applications alone often suffice to bring +about a cure. + + + + #Pityriasis Rubra Pilaris.# + (_Synonyms:_ Lichen Ruber; Lichen Ruber Acuminatus.) + + +#Describe pityriasis rubra pilaris.# + +Pityriasis rubra pilaris is an extremely rare disease, usually of a +mildly inflammatory nature, characterized by grayish, pale-red or +reddish-brown follicular papules with somewhat hard or horny centres; +discrete and confluent, and covering a part or the entire surface. The +skin is harsh, dry and rough, feeling to the touch somewhat like the +surface of a nutmeg-grater or a coarse file. More or less scaliness is +usually present in the confluent patches and on the palms and soles; in +these latter regions the papules are rarely seen. The duration of the +disease is variable, and relapses are common. It bears resemblance at +times to keratosis pilaris, ichthyosis, dermatitis exfoliativa; it is +considered identical with the lichen ruber acuminatus of Kaposi, and by +many also with the lichen ruber of Hebra. The etiology is obscure. + +Treatment, both constitutional and local, is to be based upon general +principles; stimulating applications, with frequent baths, such as are +advised in psoriasis, are the most satisfactory. It is rebellious, and +not much more than palliation can be effected in some cases, in others +the outlook is more hopeful. + + + + #Lichen Scrofulosus.# + + +#Describe lichen scrofulosus.# + +Lichen scrofulosus is a chronic, inflammatory disease, characterized by +millet-seed-sized, rounded or flat, reddish or yellowish, more or less +grouped, desquamating papules. The lesions have their start about the +hair-follicles, occur usually upon the trunk, tend to group and form +patches, and sooner or later become covered with minute scales. As a +rule, there is no itching. It is a rare disease, and but seldom met with +in America; it is seen chiefly in children and young people of a +scrofulous diathesis. Scarring, slight in character, may or may not +follow. + + +#What is the treatment of lichen scrofulosus?# + +The condition responds to tonics and anti-strumous remedies. + + + + #Eczema.# + (_Synonym:_ Tetter; Salt Rheum.) + + +#What is eczema?# + +An acute, subacute or chronic inflammatory disease, characterized in the +beginning by the appearance of erythema, papules, vesicles or pustules, +or a combination of these lesions, with a variable amount of +infiltration and thickening, terminating either in discharge with the +formation of crusts, in absorption, or in desquamation, and accompanied +by more or less intense itching and a feeling of heat or burning. + + +#What are the several primary types of eczema?# + +Erythematous, papular, vesicular and pustular; all cases begin as one or +more of these types, but not infrequently lose these characters and +develop into the common clinical or secondary types--eczema rubrum and +eczema squamosum. + +[Illustration: Fig. 20. Papular Eczema (leg).] + + +#What other types are met with clinically?# + +Eczema rubrum, eczema squamosum, eczema fissum, eczema sclerosum and +eczema verrucosum. Eczema seborrhoicum is probably a closely allied +disease, occupying a middle position between ordinary eczema and +seborrh[oe]a. + + +#Describe the symptoms of erythematous eczema.# + +Erythematous eczema (_eczema erythematosum_) begins as one or more small +or large, irregularly outlined hyperæmic macules or patches, with or +without slight or marked swelling, and with more or less itching or +burning. At first it may be ill-defined, but it tends to spread and its +features to become more pronounced. It may be limited to a certain +region, or it may be more or less general. When fully developed, the +skin is harsh and dry, of a mottled, reddish or violaceous color, +thickened, infiltrated and usually slightly scaly, with, at times, a +tendency toward the formation of oozing areas. Punctate and linear +scratch-marks may usually be seen scattered over the affected region. + +[Illustration: Fig. 21. Eczema Rubrum.] + +Its most common site is the face, but it is not infrequent upon other +parts. + + +#What course does erythematous eczema pursue?# + +It tends to chronicity, continuing as the erythematous form, or the skin +may become considerably thickened and markedly scaly, constituting +eczema squamosum; or a moist oozing surface, with more or less crusting, +may take its place--eczema rubrum. + + +#Describe the symptoms of papular eczema.# + +Papular eczema (_eczema papulosum_) is characterized by the appearance, +usually in numbers, of discrete, aggregated or closely-crowded, reddish, +pin-head-sized acuminated or rounded papules. Vesicles and +vesico-papules are often intermingled. The itching is commonly intense, +as often attested by the presence of scratch-marks and blood crusts. + +[Illustration: Fig. 22. Eczema Squamosum et tissum.] + +It is seen most frequently upon the extremities, especially the flexor +surfaces. + + +#What course does papular eczema pursue?# + +The lesions tend, sooner or later, to disappear, but are usually +replaced by others, the disease thus persisting for weeks or months; in +places where closely crowded, a solid, thickened, scaly sheet of +eruption may result--eczema squamosum. + + +#Describe the symptoms of vesicular eczema.# + +Vesicular eczema (_Eczema vesiculosum_) usually appears, on one or +several regions, as more or less diffused inflammatory reddened patches, +upon which rapidly develop numerous closely-crowded pin-point to +pin-head-sized vesicles, which tend to become confluent and form a solid +sheet of eruption. The vesicles soon mature and rupture, the discharge +drying to yellowish, honeycomb-like crusts. The oozing is usually more +or less continuous, or the disease may decline, the crusts be cast off, +to be quickly followed by a new crop of vesicles. In those cases in +which the process is markedly acute, considerable swelling and [oe]dema +are present. Scattered papules, vesico-papules and pustules may usually +be seen upon the involved area or about the border. + +The face in infants (_crusta lactea_, or _milk crust_, of older +writers), the neck, flexor surfaces and the fingers are its favorite +localities. + + +#What course does vesicular eczema pursue?# + +Usually chronic, with acute exacerbations. Not infrequently it passes +into eczema rubrum. + + +#Describe the symptoms of pustular eczema.# + +Pustular eczema (_eczema pustulosum_, _eczema impetiginosum_) is probably +the least common of all the varieties. It is similar, although usually +less actively inflammatory, in its symptoms to eczema vesiculosum, the +lesions being pustular from the start or developing from preëxisting +vesicles; not infrequently the eruption is mixed, the pustules +predominating. There is a marked tendency to rupturing of the lesions, +the discharge drying to thick, yellowish, brownish or greenish crusts. + +Its most common sites are the scalp and face, especially in young people +and in those who are ill-nourished and strumous. + + +#What course does pustular eczema pursue?# + +Usually chronic, continuing as the same type, or passing into eczema +rubrum. + + +#Describe the symptoms of squamous eczema.# + +Squamous eczema (_eczema squamosum_) may be defined as a clinical +variety, the chief symptoms of which are a variable degree of scaliness, +more or less thickening, infiltration, and redness, with commonly a +tendency to cracking or fissuring of the skin, especially when the +disease is seated about the joints. It is developed, as a rule, from the +erythematous or papular type. Itching is slight or intense. + +The disease is not uncommon upon the scalp. + + +#What is the course of squamous eczema?# + +Essentially chronic. + +[Illustration: Fig. 23. Eczema of the Face and Scalp.] + + +#Describe the symptoms of eczema rubrum.# + +Eczema rubrum is characterized by a red, raw-looking, weeping, oozing or +discharging surface, attended with more or less inflammatory thickening, +infiltration and swelling; the exudation, consisting of serum, sometimes +bloody, dries into thick yellowish or reddish-brown crusts. At one time +the whole diseased area may be hidden under a mass of crusting, at other +times a red, raw-looking, weeping surface (_eczema madidans_) is the +most striking feature. Itching is slight or intense, or the subjective +symptom may be a feeling of burning. It is an important clinical type, +usually developing from the vesicular, pustular or other primary +variety. + +It is common about the face and scalp in children, and the middle and +lower part of the leg in elderly people. + + +#What is the course of eczema rubrum?# + +Chronic, varying in intensity from time to time. + + +#Describe the symptoms of fissured eczema.# + +The conspicuous symptom is a marked tendency to fissuring or cracking of +the skin (_eczema fissum_; _eczema rimosum_). This tendency is usually a +part of an erythematous or squamous eczema, the fissuring constituting +the most conspicuous and troublesome symptom. _Chapping_ is an extremely +mild but familiar example of this type. + +It is especially common about the hands and fingers. + + +#What is the course of fissured eczema?# + +It is more or less persistent, the tendency to fissuring varying +considerably according to the state of the weather, often disappearing +spontaneously in the summer months. + + +#Describe eczema sclerosum and eczema verrucosum.# + +In eczema sclerosum the skin is thickened, infiltrated, hard, and almost +horny. Eczema verrucosum presents similar conditions, but, in addition, +displays a tendency to papillary or wart-like hypertrophy. In both +varieties the disease is usually seated about the ankle or the foot, +developing from the papular or squamous type. They are uncommon, and +obstinately chronic. + + +#State the nature of the subjective symptoms in eczema.# + +Itching, commonly intense, is usually a conspicuous symptom; it may be +more or less paroxysmal. In some cases burning and heat constitute the +main subjective phenomena. + + +#Is eczema accompanied by febrile or systemic symptoms?# + +No. In rare instances, in acute universal eczema, slight febrile action, +or other systemic disturbance, may be noted at the time of the outbreak. + + +#Is the eczematous eruption (patch or patches) sharply defined against +the neighboring sound skin?# + +No. In almost all instances the diseased area merges gradually and +imperceptibly into the surrounding healthy integument. + + +#What is the character of eczema as regards the degree of inflammatory +action?# + +The inflammatory action may be acute, subacute or sluggish in character, +and may be so from the start and so continue throughout its whole +course; or it may, as is usually the case, vary in intensity from time +to time. + + +#State the character of eczema as regards duration.# + +As a rule, it is a persistent disease, showing little, if any, tendency +to spontaneous disappearance. + + +#Is eczema influenced by the seasons?# + +Yes. With comparatively few exceptions the disease is most common and +much worse in cold, windy, winter weather. + + +#To what may eczema be ascribed?# + +Eczema may be due to constitutional or local causes, or to both. It may +be considered, in fact, as a reaction of the skin tissues against some +irritant, and the latter may have its origin from within or without. + + +#Name some of the important constitutional or predisposing causes.# + +Gouty diathesis, rheumatic diathesis, disorders of the digestive tract, +general debility or lack of tone, an exhausted state of the nervous +system, dentition and struma. + + +#Is a constitutional cause sufficient to provoke an attack?# + +Yes; but often the attack is brought about in those so predisposed by +some local or external irritant. + + +#Mention some of the external causes.# + +Heat and cold, sharp, biting winds, excessive use of water, strong +soaps, vaccination, dyes and dyestuffs, chemical irritants, and the +like. There is a growing belief that some cases presenting eczematous +aspects are probably parasitic in origin. In fact, some observers hold +to the microbic view of all cases of eczema. + +Contact with the rhus plants, while producing a peculiar dermatitis, +usually running an acute course terminating in recovery, may, in those +predisposed, provoke a veritable and persistent eczema. In fact, in our +examination as to causes in a given case, especially of the hands and face, +all possible exciting factors should be inquired into, such as the handling +of plants, chemicals, dyes, etc. + +[Illustration: Fig. 24. Eczema of Face.] + + +#Is eczema contagious?# + +No. The acceptance of a parasitic cause for the disease, however, +necessarily carries with it the possibility of contagiousness under +favoring conditions. Such is not supported, however, by practical +experience. + + +#What is the pathology?# + +The process is an inflammatory one, characterized in all cases by +hyperæmia and exudation, varying in degree according to the intensity +and duration of the disease. The rete and papillary layer are especially +involved, although in severe and chronic cases the lower part of the +corium and even the subcutaneous tissue may share in the process. + + +#Do the cutaneous manifestations of the eruptive fevers bear resemblance +to the erythematous type of eczema?# + +Scarlatina and erysipelas may, to a slight extent, but the presence or +absence of febrile and other constitutional symptoms will usually serve +to differentiate. + + +#What common skin diseases resemble some phases of eczema?# + +Psoriasis, seborrh[oe]a, sycosis, scabies and ringworm. + + +#How would you exclude psoriasis in a suspected case of eczema (squamous +eczema)?# + +Psoriasis occurs in variously-sized, rounded, _sharply-defined_ patches, +usually scattered irregularly over the general surface, with special +predilection for the elbows and knees. They are covered more or less +abundantly with whitish, silvery or mother-of-pearl colored imbricated +scales. The patches are always dry, and itching is, as a rule, slight, +or may be entirely absent. Eczema, on the contrary, is often localized, +appearing as one or more large, irregularly diffused patches; it merges +imperceptibly into the sound skin, and there is often a history of +characteristic serous or gummy oozing; the scaling is usually slight and +itching almost invariably a prominent symptom. + + +#How would you exclude seborrh[oe]a (eczema seborrhoicum) in a suspected +case of eczema?# + +Seborrh[oe]a of the scalp is more commonly over the whole of that region +and is relatively free from inflammatory symptoms; the scales are of a +greasy character and the itching is usually slight or nil. On the other +hand, in eczema of this region the parts are rarely invaded in their +entirety; there may be at times the characteristic serous or gummy +oozing; inflammatory symptoms are usually well-marked, the scales are +dry and the itching is, as a rule, a prominent symptom. These same +differences serve to differentiate the diseases in other regions. + + +#How does scabies differ from eczema?# + +Scabies differs from eczema in its peculiar distribution, the presence +of the burrows, the absence of any tendency to patch formation, and +usually by a clear history of contagion. + + +#How would you exclude ringworm in a suspected case of eczema?# + +Ringworm is to be distinguished by its circular form, its fading in the +centre, and in doubtful cases by microscopic examination of the +scrapings. + + +#How does eczema differ from sycosis?# + +Sycosis is limited to the hairy region of the face, is distinctly a +follicular inflammation, and is rarely very itchy; eczema is diffused, +usually involves other parts of the face, and itching is an annoying +symptom. + + +#State the general prognosis of eczema.# + +The disease is, under favorable circumstances, curable, some cases +yielding more or less readily, others proving exceedingly rebellious. +The length of time to bring about a result is always uncertain, and an +opinion on this point should be guarded. + + +#Upon what would you base your prognosis in the individual case?# + +The extent of disease, its duration and previous behavior, the +removability of the exciting and predisposing causes, and the attention +the patient can give to the treatment. + +In eczema involving the lips, face, scrotum, and leg, and especially +when this last-named exhibits a varicose condition of the veins, a cure +is effected, as a rule, only through persistent and prolonged treatment. + + +#Does eczema ever leave scars?# + +No. Upon the legs, in long-continued cases, more or less pigmentation +usually remains. + + +#How is eczema treated?# + +As a rule, eczema requires for its removal both constitutional and +external treatment. + +Certain cases, however, seem to be entirely local in their nature, and +in these cases external treatment alone will have satisfactory results. + + +#What general measures as to hygiene and diet are commonly advisable?# + +Fresh air, exercise, moderate indulgence in calisthenics, regular +habits, a plain, nutritious diet; abstention from such articles of food +as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese, +pickles, condiments, excessive coffee or tea drinking, etc. As a rule, +also, beer, wine, and other stimulants are to be interdicted. + + +#Upon what grounds is the line or plan of constitutional treatment to be +based?# + +Upon indications in the individual case. A careful examination into the +patient's general health will usually give the cue to the line of +treatment to be adopted. + + +#Mention the important remedies variously employed in the constitutional +treatment.# + +_Tonics_--such as cod-liver oil, quinine, nux vomica, the vegetable +bitters, iron, arsenic, malt, etc. + +_Alkalies_--sodium salicylate, potassium bicarbonate, liquor potassæ, +and lithium carbonate. + +_Alteratives_--calomel, colchicum, arsenic, and potassium iodide. + +_Diuretics_--potassium acetate, potassium citrate, and oil of copaiba. + +_Laxatives_--the various salines, aperient spring waters, castor oil, +cascara sagrada, aloes and other vegetable cathartics. + +_Digestives_--pepsin, pancreatin, muriatic acid and the various bitter +tonics. + + +#Are there any remedies which have a specific influence?# + +No; although arsenic, in exceptional instances, seems to exert a special +action. Cod-liver oil is also of great value in some cases. + +Upon the whole the most important remedies are those which keep in view +the maintenance of a proper and healthful condition of the +gastro-intestinal tract, and especially with regular and rather free +action of the bowels. + + +#In what class of cases does arsenic often prove of service?# + +In the sluggish, dry, erythematous, scaly and papular types. + + +#In what cases is arsenic usually contraindicated?# + +It should never be employed in acute cases; nor in any instance (unless +its action is watched), in which the degree of inflammatory action is +marked, as an aggravation of the disease usually results. + + +#What should be the character of the external treatment?# + +It depends mainly upon the degree of inflammatory action; but the stage +of the disease, the extent involved, and the ability of the patient to +carry out the details of treatment, also have a bearing upon the +selection of the plan to be advised. + + +#What is to be said about the use of soap and water in eczema?# + +In acute and subacute conditions soap and water are to be employed, as a +rule, as infrequently and as sparingly as possible, as the disease is +often aggravated by their too free use. Washing is necessary, however, +for cleanliness and occasionally, also, for the removal of the crusts. +On the other hand, in chronic, sluggish types the use of soap and water +frequently has a therapeutic value. + + +#How often should remedial applications be made?# + +Usually twice daily, although in some case, and especially those of an +acute type, applications should be made every few hours. + + +#Mention several remedies or plans of treatment to be used in the acute +or actively inflammatory cases.# + +Black wash and oxide-of-zinc ointment conjointly, the wash thoroughly +dabbed on, allowed to dry, the parts gently smeared with ointment; or +the ointment may be applied spread on lint as a plaster. + +Boric-acid wash (15 grains to the ounce) and oxide-of-zinc ointment, +applied in the same manner as the above. + +A lotion containing calamine and zinc oxide, the sediment drying and +coating over the affected surface:-- + + [Rx] Calaminæ, + Zinci oxidi, ... [=a][=a] ......... [dram]ij-[dram]iij + Glycerinæ, + Alcoholis, ..... [=a][=a] ......... f[dram]ss + Liq. calcis, ...................... f[Oz]ij + Aquæ, .......... q.s. ad .......... f[Oz]vj. M. + +Another excellent lotion somewhat similar to the last, but of oily +character, is made up of three drachms each of calamine and zinc oxide, +one drachm of boric acid, ten to thirty drops of carbolic acid, and +three ounces each of lime-water and oil of sweet almonds. + +Carbolic-acid lotion, about two drachms to the pint of water, to which +may be added two or three drachms each of glycerin and alcohol; or, if +there is intense itching, carbolic acid may be added to the several +washes already mentioned. + +A lotion made of one or two drachms of liquor carbonis detergens[A] to +four ounces of water. + +The following wash, especially in the dry form of the disease:-- + + [Rx] Ac. borici, .......................... [dram]iv + Ac. carbolici, ....................... [dram]j + Glycerinæ, ........................... [dram]ij + Alcoholis, ........................... [dram]ij + Aquæ, ............. q.s. ad .......... Oj. M. + +[Footnote A: Liquor carbonis detergens is made by mixing together nine + ounces of tincture soap bark and four ounces of coal tar, allowing to + digest for eight days, and filtering. The tincture of soap bark used is + made with one pound of soap bark to one gallon of 95 per cent. alcohol, + digesting for a week or so. Instead of the proprietary name above, Prof. + Duhring has suggested that of tinctura picis mineralis comp.] + +Dusting-powders, of starch, zinc oxide and Venetian talc, alone or +severally combined, applied freely and often, so as to afford protection +to the inflamed surface:-- + + [Rx] Talci venet, + Zinci oxidi, ....... [=a][=a] ........ [dram]iv + Amyli, ............................... [Oz]j M. + +If washes or dusting-powders should disagree or are not desirable or +practicable, ointments may be employed, such as-- + +Oxide-of-zinc ointment, cold cream, petrolatum, plain or carbolated, +diachylon ointment (if fresh and well prepared), and a paste-like +ointment, as the following, usually called "salicylic-acid paste"; in +markedly itchy cases, five to fifteen grains of carbolic may be added to +each ounce: + + [Rx] Ac. salicylici, ...................... gr. v-x + Pulv. amyli, + Pulv. zinci oxidi, .... [=a][=a] ..... [dram]ij + Petrolati, ........................... [dram]iv M. + +Or the following ointment:-- + + [Rx] Calaminæ, ............................ [dram]j + Ungt. zinci oxidi, ................... [dram]vij. M. + + +#Name several external remedies and combinations useful in eczema of a +subacute or mildly inflammatory type.# + +The various remedies and combinations useful when the symptoms are acute +or markedly inflammatory (mentioned above), and more especially the +several following:-- + + [Rx] Zinci oxidi, ......................... [dram]ij + Liq. plumbi subacetat. dilut., ....... f[dram]vj + Glycerinæ, ........................... f[dram]ij + Infus. picis liq., ................... f[Oz]iij M. + +A lotion containing resorcin, five to thirty grains to the ounce. + +Solution of zinc sulphate, one-half to three grains to the ounce. + +An ointment containing calomel or ammoniated mercury, as in the annexed +formula:-- + + [Rx] Hydrargyri ammoniat. seu Hydrargyri + chloridi mit., ................... gr. x-xxx + Ac. carbolici, ..................... gr. v-x + Ungt. zinci oxidi, ................. [Oz]j M. + +Another formula, more especially useful in eczema of the hands and legs, +is the following:-- + + [Rx] Ac. salicylici, ...................... gr. xxx + Emp. plumbi, + Emp. saponis, + Petrolati, ...... [=a][=a] ........... [Oz]j. M. + +(This is to be applied as a plaster, spread on strips of lint, and +changed every twelve or twenty-four hours.) + +The paste-like ointment, referred to as useful in acute eczema, may also +be used with a larger proportion (20 to 60 grains to the ounce) of +salicylic acid. + +The following, containing tar, may often be employed with advantage:-- + + [Rx] Ungt. picis liq., .................... [dram]j + Ungt. zinci oxidi, ................... [dram]vij. M. + + +#What is to be said in regard to the use of tarry applications?# + +Ointments or lotions containing tar should always be tried at first upon +a limited surface, as occasionally skins are met with upon which this +remedy acts as a more or less violent irritant. The coal tar lotion +(liquor carbonis detergens) is the least likely to disagree and may be +used as a mild ointment, one or two drachms to the ounce, or it may be +diluted and used as a weak lotion as already referred to. + + +#What external remedies are to be employed in eczema of a sluggish type?# + +The various remedies and combinations (mentioned above) useful in acute +and subacute eczema may often be employed with benefit, but, as a rule, +stronger applications are necessary, especially in the thick and +leathery patches. The following are the most valuable:-- + +An ointment of calomel or ammoniated mercury; forty to sixty grains to +the ounce. + +Strong salicylic-acid ointment; a half to one drachm of salicylic acid +to the ounce of lard. + +Tar ointment, official strength; or the various tar oils, alone or with +alcohol, as a lotion, or in ointment form. + +Liquor picis alkalinus[B] is a valuable remedy in chronic _thickened_, +_hard_ and _verrucous_ patches, but is a strong preparation and must be +used with caution. It is applied diluted, one part with from eight to +thirty-two parts of water; or in ointment, one or two drachms to the +ounce. In such cases, also, the following is useful:-- + + [Rx] Saponis viridis, + Picis liq., + Alcoholis, .......... [=a][=a] ....... [dram]iij. M. + + SIG. To be well rubbed in. + +[Footnote B: + [Rx] Potassæ, ............................. [dram]j + Picis liq., .......................... [dram]ij + Aquæ, ................................ [dram]v. + + Dissolve the potash in the water, and gradually add to the tar in a + mortar, with thorough stirring.] + +In similar cases, also, the parts may be thoroughly washed or scrubbed +with sapo viridis and hot water until somewhat tender, rinsed off, +dried, and a mild ointment applied as a plaster. + +Lactic acid, applied with one to ten or more parts of water is also of +value in the sclerous and verrucous types. Caustic potash solutions, +used cautiously, may also be occasionally employed to advantage in these +cases. + +Another remedy of value in these cases, as well as in others of more or +less limited nature, is the _x_-ray. Exposures every few days, of short +duration and 4 to 10 inches distance, with medium vacuum tube. This +method has served me well in occasional cases; caution is necessary, and +it should not be pushed further than the production of the mildest +reaction. The repeated application of a high-frequency current, by means +of the vacuum electrodes, is a safer and sometimes an equally beneficial +method. + + +#Is there any method of treating eczema with fixed dressings?# + +Several plans have been advised from time to time; some are costly, and +some require too great attention to details, and are therefore +impracticable for general employment. The following are those in more +common use:-- + +The _gelatin dressing_, as originally ordered, is made by melting over a +water-bath one part of gelatin in two parts of water--quickly painting +it over the diseased area; it dries rapidly, and to prevent cracking +glycerine is brushed over the surface. Or the glycerine may be +incorporated with the gelatin and water in the following proportion: +glycerine, one part; gelatin, four parts, and water eight parts. +Medicinal substances may be incorporated with the gelatin mixture. + +A good formula is the following:-- + + [Rx] Gelatin, ............................. [Oz]j + Zinci oxidi, ......................... [Oz]ss + Glycerini, ........................... [Oz]iss + Aquæ, ................................ [Oz]ii-[Oz]iij. + +This should be prepared over a water-bath, and two per cent. ichthyol +added. A thin gauze bandage can be applied to the parts over which this +dressing is painted, before it is completely dry; it makes a comfortable +fixed dressing and may remain on several days. + +_Plaster-mull_ and _gutta-percha plaster_. The plaster-mull, consisting +of muslin incorporated with a layer of stiff ointment, and the +gutta-percha plaster, consisting of muslin faced with a thin layer of +India-rubber, the medication being spread upon the rubber coating. + +_Rubber plasters._ These are medicated with the various drugs used in +the external treatment of skin diseases, and are often of service in +chronic patches. + +Two new excipients for fixed dressings have recently been +introduced--bassorin and plasment; the former is made from gum +tragacanth, and the latter from Irish moss. + +The following is a satisfactory formula for a tragacanth dressing: + + [Rx] Tragacanth, .......................... gr. lxxv + Glycerini, ........................... [minim] xxx + Ac. carbolici, ....................... gr. x-xx + Zinci oxidi, ......................... [dram]iss-[dram]iiss. M. + +This is painted over the parts and allowed to dry, and a mild dusting +powder sprinkled over. It cannot be used in warm weather or in folds, as +it is apt to get sticky. The following is a bassorin paste which may be +variously medicated. + + [Rx] Bassorin, ............................ [dram]x + Dextrin, ............................. [dram]vj + Glycerini, ........................... [Oz]ij. + Aquæ, ....................... q.s. ad. [Oz]iij. + +It should be prepared cold. + +Another "drying dressing" which may be used in cool weather is: + + [Rx] Zinci oxidi, ......................... [Oz]j + Glycerini, ........................... [Oz]ss + Mucilag. acaciæ, ..................... [Oz]ii-[Oz]iv. + +It may be variously medicated. + +The plaster-mull is used in all types, especially the acute; the gelatin +dressing, and the gutta-percha plaster, in the subacute and chronic; and +the rubber plaster in chronic, sluggish patches only. Acacia, +tragacanth, bassorin and plasment applications are used in cases of a +subacute and chronic character. + + + + #Prurigo.# + + +#Define prurigo.# + +Prurigo is a chronic, inflammatory disease, characterized by discrete, +pin-head- to small pea-sized, solid, firmly-seated, slightly raised, +pale-red papules, accompanied by itching and more or less general +thickening of the affected skin. + + +#Describe the symptoms and course of prurigo.# + +The disease first appears upon the tibial regions, and its earliest +manifestation may be urticarial, but there soon develop the +characteristic small, millet-seed-sized, or larger, firm elevations, +which may be of the natural color of the skin or of a pinkish tinge. The +lesions, whilst discrete, are in great numbers, and closely crowded. The +overlying skin is dry, rough and harsh; itching is intense, and, as a +result of the scratching, excoriations and blood crusts are commonly +present. In consequence of the irritation, the inguinal glands are +enlarged. Sooner or later the integument becomes considerably thickened, +hard and rough. Eczematous symptoms may be superadded. In severe cases +the entire extensor surfaces of the legs and arms, and in some instances +the trunk also, are invaded. It is worse in the winter season. + + +#What is known in regard to etiology and pathology?# + +It is a disease of the ill-fed and neglected, usually developing in +early childhood, and persisting throughout life. It is extremely rare, +even in its milder types, in this country. Clinically and pathologically +it bears some resemblance to papular eczema. + + +#Give the prognosis and treatment of prurigo.# + +The disease, in its severer types is, as a rule, incurable, but much can +be done to alleviate the condition. Good, nourishing food, pure air and +exercise are of importance. Tonics and cod-liver oil are usually +beneficial. The local management is similar to that employed in chronic +eczema. An ointment of [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 +hyperæmia and inflammation, and a slight elevation, with a central +yellowish or blackish point results--the lesion of _acne punctata_; if +the inflammation is of a higher grade or progresses, the elevation is +reddened and more prominent--_acne papulosa_; if the inflammatory action +continues, the interior or central portion of the papule suppurates and +a pustule results--_acne pustulosa_; the pustule, in some cases, may +have a markedly inflammatory and hard base--_acne indurata_; and not +infrequently the lesions in disappearing may leave a pit-like atrophy or +depression--_acne atrophica_; or, on the contrary, connective-tissue new +growth may follow their disappearance--_acne hypertrophica_; and, in +strumous or cachectic individuals, the lesions may be more or less +furuncular in type, often of the nature of dermic abscesses, usually of +a cold or sluggish character, and of more general distribution--_acne +cachecticorum_. + + +#What is acne artificialis?# + +Acne artificialis is a term applied to an acne or acne-like eruption +produced by the ingestion of certain drugs, as the bromides and iodides, +and by the external use of tar; this is also called _tar acne_. + + +#What course does acne pursue?# + +Essentially chronic. The individual lesions usually run their course in +several days or one or two weeks, but new lesions continue to appear +from time to time, and the disease thus persists, with more or less +variation, for months or years. In many cases there is, toward the age +of twenty-five or thirty, a tendency to spontaneous disappearance of the +disease. + +[Illustration: Acne.] + + +#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 anæmic cases the ferruginous preparations are of +advantage. Cod-liver oil is often a remedy of great value, and is +especially useful in strumous and debilitated subjects. Calx sulphurata +in pill form, one-tenth to one-fourth grain four or five times daily, is +said, acts well in the pustular variety. In some instances, more +particularly in sluggish papular acne, arsenic, especially the sulphide +of arsenic, acts favorably. Upon the whole, the line of treatment +that keeps in view proper and healthy action of the gastro-intestinal +canal is the most successful. + +[Illustration: Acne of back.] + +In inflammatory cases occurring in robust individuals the following is +often of service:-- + + [Rx] Potassii acetat., .................... [dram]iv + Liq. potassæ, ........................ 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 hyperæmic, +tender and painful, require milder applications, and in exceptional +instances soothing remedies are to be prescribed. As a rule, however, +stimulating applications may be employed from the start. + +The remedies are, for obvious reasons, most conveniently applied at +bedtime. + + +#What preliminary measures are to be advised in ordinary acne cases?# + +Washing the parts gently or vigorously, according to the irritability of +the skin, with warm water and soap; subsequently rinsing, and sponging +for several minutes with hot water, and rubbing dry with a soft towel; +after which the remedial application is made. In sluggish and +non-irritable cases sapo viridis or its tincture may often be +advantageously used in place of the ordinary toilet soap. + +The blackheads, so far as practicable, are to be removed by pressure +with the fingers or with a suitable instrument (see Comedo), and the +superficial pustules punctured and the contents pressed out. Scraping +the affected parts with a blunt curette is a valuable measure, but is +temporarily disfiguring. As a rule, however, cases do just as well +without puncturing and scraping, and these methods sometimes leave +behind scarring. + + +#State the methods of external medication commonly employed.# + +By ointments and lotions. If an ointment is used, it is to be thoroughly +rubbed in, in small quantity; if a lotion is employed, it is to be well +shaken, the parts freely dabbed with it for several minutes and then +allowed to dry on. + + +#State the object in view in local medication.# + +To hasten the maturation and disappearance of the existing lesions, and +to stimulate the skin and glands to healthy action. + +If slight irritation or scaliness results, the application is to be +intermitted one or two nights; in the meantime nothing except the +hot-water sponging, with or without the application of a mild soothing +ointment, is to be employed. + + +#Is it usually necessary to change from one external remedy to another in +the course of treatment?# + +Yes. After a certain time one remedy, as a rule, loses its effect, and a +change from lotion to ointment or the reverse, and from one lotion or +ointment to another, will often be found necessary in order to bring +about continuous improvement. + + +#Name the various important remedies and combinations employed in the +external treatment of acne.# + +Sulphur is the most valuable. It may often be applied with benefit as a +simple ointment:-- + + [Rx] Sulphur, præcip., .................... [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, præcip., .................... [dram]iss + Pulv. tragacanthæ, ................... gr. x1 + Pulv. camphoræ, ...................... 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, præcip., .................... [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 + Aquæ, ................................ [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 + Aquæ, ............ q.s. ad ........... f[Oz]iv. + +In extremely sluggish cases the following, used cautiously, is of +value:-- + + [Rx] Ichthyol, + Saponis viridis, + Sulphur, præcip., + 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, hyperæmic or inflammatory disease, limited to +the face, especially to the nose and cheeks, characterized by redness, +dilatation and enlargement of the bloodvessels, more or less acne and +hypertrophy. + + +#Describe the symptoms of acne rosacea.# + +The disease may be slight or well-marked. Redness, capillary dilatation, +and acne lesions seated on the nose and cheeks, and sometimes on chin +and forehead also, constitute in most cases the entire symptomatology. + +A mild variety consists in simple redness or hyperæmia, involving the +nose chiefly and often exclusively, and is to be looked upon as a +passive congestion; this is not uncommon in young adults and is +often associated with an oily 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_). + +[Illustration: Fig. 25. Acne Rosacea.] + + +#Are there any subjective symptoms in acne rosacea?# + +As a rule, no. Some of the acne lesions may be tender and painful, and +at times there is a feeling of heat and burning. + + +#What do you know in regard to the etiology?# + +In many cases the causes are obscure. Chronic digestive and intestinal +disorders, anæmia, chlorosis, continued exposure to heat or cold, +menstrual and uterine irregularities, and the too free use of spirituous +liquors, tea, etc. are often responsible factors. + +It is essentially a disease of adult life, common about middle age, +occurring in both sexes, but rarely reaching the same degree of +development in women as observed at times in men. + + +#Is acne rosacea easily recognized?# + +Yes. The redness, acne lesions, dilated capillaries, and, at times, the +glandular and connective-tissue hypertrophy; the limitation of the +eruption to the face, especially the region of the nose; the evident +involvement of the sebaceous glands, the absence of ulceration, taken +with the history of the case, are characteristic. + +It is to be distinguished from the tubercular syphiloderm and lupus +vulgaris, diseases to which it may bear rough resemblance. + + +#State the prognosis of acne rosacea.# + +All cases may be favorably influenced by treatment; the mild and +moderately-developed types are, as a rule, curable, but usually +obstinate. It is a persistent disease, showing little, if any, tendency +to disappear spontaneously. + + +#What is the method of treatment?# + +Both constitutional and local measures are demanded in most cases. + + +#Upon what is the constitutional treatment to be based?# + +The constitutional treatment, beyond a regulation of the diet, is to be +based upon a correct appreciation of the etiological factors in the +individual case. There are no special remedies. Iron, cod-liver oil, +tonics, ergot, alkalies, saline laxatives, and similar drugs are to be +variously prescribed. + + +#What is the external treatment?# + +In many respects, both as to the preliminary measures and remedies, +essentially the same as that employed in the treatment of simple acne +(_q. v._). The _x_-ray treatment is not so efficient in this disease, +however, as in acne. In addition to the treatment there found, several +other applications deserve mention:-- + +In many cases _Vleminckx's solution_[C] is valuable, applied diluted +with one to ten parts of water. Also, a mucilaginous paste containing +sulphur:-- + + [Rx] Mucilag. acaciæ, ..................... f[dram]iij + Glycerinæ, ........................... f[dram]ij + Sulphur, præcip., .................... [dram]iij. M. + +[Footnote C: + [Rx] Calcis, .............................. [Oz]ss + Sulph. sublimat., .................... [Oz]j + Aquæ, ................................ [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 + Barbæ; Sycosis Coccogenica.) + + +#What do you understand by sycosis?# + +Sycosis is a chronic, inflammatory affection involving the +hair-follicles, usually of the moustache and bearded regions only, and +characterized by papules, tubercles, and pustules perforated by hairs. + + +#Describe the symptoms of sycosis.# + +Sycosis begins by the formation of papules and pustules about the +hair-follicles; the lesions occur in numbers, in close proximity, +and together with the accompanying inflammation, make up a small or large +area. The pustules are small, rounded, flat or acuminated, discrete, and +yellowish in color; they are perforated by hairs, show no tendency to +rupture, and are apt to occur in crops, drying to thin yellowish or +brownish crusts. Papules and tubercles are often intermingled. More or +less swelling and infiltration are noticeable. + +[Illustration: Fig. 26. + Sycosis--not infrequently begins in, and sometimes limited to, this + region.] + +The disease is seen, as a rule, only on the bearded part of the face, +either about the cheeks, chin or upper lip, involving a small portion or +the whole of these parts. It is also sometimes met with involving the +hair follicles just within the nasal orifice, and may even be limited to +this region. + +Occasionally a sycosiform eruption, usually of the side of the bearded +region, leaves behind a smooth or keloidal scar, the disease gradually +extending--_ulerythema sycosiforme_ (lupoid sycosis). + +An inflammation of the hair-follicles of the scalp apparently sycosiform +in character, occurring as discrete or aggregated lesions, is sometimes +observed, the follicles being destroyed and atrophy or slight scarring +resulting--_folliculitis decalvans_. + + +#Does conspicuous hair loss occur in sycosis?# + +Ordinarily not; the hairs are, especially at first, usually firmly +seated, but in those cases in which suppuration is active, and has +involved the follicles, they may, as a rule, be easily extracted. In +some cases destruction of the follicles ensues and slight scarring and +permanent hair loss result. + + +#State the character of the subjective symptoms.# + +Pain and itching and a sense of burning, variable as to degree, may be +present. + + +#What is the course of the disease?# + +Essentially chronic, the inflammatory action being of a subacute or +sluggish character, with acute exacerbations. + + +#State the causes of sycosis.# + +Upon the upper lip it may have its origin in a nasal catarrh. Entrance +into the follicles of pyogenic micrococci is now regarded as the +essential factor. This view being accepted, carries with it the +possibility of contagiousness. + +It is seen in the male sex only, usually in those between the ages of +twenty-five and fifty; and is met with in those in good and bad health, +and among rich and poor. It is comparatively infrequent. + + +#What is the pathology of sycosis?# + +The disease is primarily a perifolliculitis, the follicle and its sheath +subsequently becoming involved in the inflammatory process. + + +#How would you distinguish sycosis from eczema?# + +Eczema is rarely sharply limited to the bearded region, but is apt to +involve other parts of the face; moreover, the lesions are usually +confluent, and there is either an oozing, red crusted surface, or it is +dry and scaly. + + +#How would you exclude tinea sycosis in the diagnosis?# + +In tinea sycosis, or ringworm sycosis, the history of the case is +different. The parts are distinctly lumpy and nodular; the hairs are +soon involved and become dry, brittle, loose, and fall out, or they may +be readily extracted. The superficial type of ringworm sycosis is +readily distinguished by the ring-like character of the patches. In +doubtful cases, microscopic examination of the hairs may be resorted to. + + +#Give the prognosis of sycosis.# + +The disease is curable, but almost invariably obstinate and rebellious +to treatment. The duration, extent, and character of the inflammatory +process must all be considered. An expression of an opinion as to the +length of time required for a cure should always be guarded. + +Ulerythema sycosiforme is extremely obstinate. Folliculitis decalvans is +also rebellious. + + +#How is sycosis to be treated?# + +Mainly, and often exclusively, by external applications. + +[Illustration: Fig. 27. Sycosis.] + + +#Is constitutional treatment of no avail in sycosis?# + +In some instances; but, as a rule, it is negative. If indicated, such +remedies as tonics, alteratives, cod-liver oil and the like are to be +prescribed. + + +#Describe the external treatment.# + +Crusting, if present, is to be removed by warm embrocations. If the +inflammation is of a high grade, and the parts tender and painful, +soothing applications, such as bland oils, black wash and oxide-of-zinc +ointment, cold cream and petrolatum, are to be used; boric-acid +solution, fifteen grains to the ounce, may be advised in place of black +wash. + +In most cases, however, astringent and stimulating remedies are demanded +from the start, such as: diachylon ointment, alone or with ten to thirty +grains of calomel to the ounce; oleate of mercury, as a five- to +twenty-per-cent. ointment; precipitated sulphur, one to three drachms to +the ounce of benzoated lard, or lard and lanolin; a ten- to +twenty-five-per-cent. ichthyol ointment; and resorcin lotion or +ointment, ten to twenty per cent. strength. + +[Illustration: Fig. 28. Sycosis.] + +A change from one application to another will be found necessary in +almost all cases. + +In obstinate cases the x-ray treatment can be used, as it has proved +itself valuable in some instances; as in other diseases, it should be +employed cautiously. + + +#What would you advise in regard to shaving?# + +When bearable (and after a few days' application of soothing remedies it +almost always is), it is to be advised in all cases, as it materially +aids in the treatment. After a cure is effected it should be continued +for some months, until the healthy condition of the parts is thoroughly +established. + + +#When is depilation advisable as a therapeutic measure?# + +When the suppurative process is active, in order to save the follicles +from destruction; incising or puncturing the pustules will often +accomplish the same end. + +Depilation is in all cases a valuable therapeutic measure, but it is +painful; as a routine practice, shaving is less objectionable and, upon +the whole, is probably as satisfactory. Those who make free use of the +x-ray commonly push it to the point of producing depilation. + + + + #Dermatitis Papillaris Capillitii.# + (_Synonym:_ Acne Keloid.) + +[Illustration: Fig. 29. Dermatitis Papillaris Capillitii.] + + +#Describe dermatitis papillaris capillitii.# + +This is a peculiar, mildly inflammatory, sycosiform, keloidal, acne-like +disease of the hairy border of the back of the neck, often extending +upward to the occipital region; partaking, especially later in its +course, somewhat of the nature of keloid. Several or more acne-like +lesions, papular and pustular, closely grouped or bunched, appear, +developing slowly, usually to the size of peas; are red, pale red, or +whitish, often enveloping small tufts of hair, and attended with more or +less hair loss. Its course is gradual and persistent. It is an +exceedingly rare condition, the exact nature of which is still obscure. + + +#Give the treatment.# + +Treatment, which is usually unsatisfactory, consists of stimulating +applications--the same, in fact, as employed in sycosis, sulphur and +ichthyol deserving special mention. Depilation is essential. + + + + #Impetigo Contagiosa.# + + +#Give a descriptive definition of impetigo contagiosa.# + +Impetigo contagiosa is an acute, contagious, inflammatory disease, +characterized by the formation of discrete, superficial, flat, rounded, +or ovalish vesicles or blebs, soon becoming vesico-pustular, and drying +to thin yellowish crusts. + + +#Upon what parts does the eruption commonly appear?# + +Upon the face, scalp, and hands, and exceptionally upon other regions. + + +#Describe the symptoms of impetigo contagiosa.# + +One, several or more small pin-head-sized papulo-vesicles or vesicles +make their appearance, usually upon the face and fingers. In the male +adult the region of the neck and beard is a favorite situation. They +increase in size by extending peripherally, but are more or less +flattened and umbilicated, and are without conspicuous areola. The +lesions may attain the size of a dime or larger, and when close together +may coalesce and form a large patch. In some cases distinct blebs +result, and a picture of pemphigus eruption presented; it is probable +that many of the cases of "contagious pemphigus" belong to this class. +New lesions may appear for several days, but finally, in the course of a +week or ten days, they have all dried to thin, wafer-like crusts, of a +straw or light-yellow color, but slightly adherent, and appearing as if +stuck on; these soon drop off, leaving faint reddish spots, which +gradually fade. In some cases there is so decided a tendency to clear +and dry up centrally while spreading peripherally that the eruption has +a ring-like aspect; this seems especially so in the bearded region of +the male adult. + +Instead of presenting as described, it may occur as one or more pea- or +finger-nail-sized, rounded and elevated, usually firm, discrete +pustules, scattered over one part, or more commonly over various +regions, such as the face, hands, feet and lower extremities. The +pustules are such from the beginning, and when developed are usually of +the size of a pea or finger-nail, elevated, semi-globular or rounded, +with somewhat thick and tough walls, and of a whitish or yellowish +color; at first there may be a slight inflammatory areola, but as the +lesion matures this almost, if not entirely, disappears. The pustules +show no disposition to umbilication, rupture or coalescence; drying in +the course of several days or a week to yellowish or brownish crusts, +which soon drop off, leaving no permanent trace. This variety was +formerly thought to be a distinct disease, and was described under the +name of _impetigo simplex_. + +As a rule there are no constitutional symptoms, but in the more severe +cases the eruption may be preceded by febrile disturbance and malaise. +Itching may or may not be present. + + +#State the cause of the disease.# + +It is contagious, the contents of the lesions being inoculable and +auto-inoculable. At times it seems to prevail in epidemic form. Pyogenic +microörganisms are now regarded as causative. A relationship to +vaccination has been alleged by some observers. It is more commonly +observed in infants and young children. + + +#From what diseases is impetigo contagiosa to be differentiated?# + +From eczema, pemphigus, and ecthyma. + + +#How does impetigo contagiosa differ from these several diseases?# + +By the character of the lesions, their growth, their superficial nature, +their course, the absence of an inflammatory base and areola, the thin, +yellowish, wafer-like crusts, and usually a history of contagion. + + +#State the prognosis.# + +The effect of treatment is usually prompt. The disease, indeed, tends to +spontaneous disappearance in two to four weeks; in exceptional +instances, more especially in those cases in which itching is present, +the excoriations or scratch-marks become inoculated, and in this way it +may persist several weeks. + + +#What is the treatment of impetigo contagiosa?# + +Treatment consists in the destruction of the auto-inoculable properties +of the contents of the lesions; this is effected by removing the crusts +by means of warm water-and-soap washings, and subsequently rubbing in an +ointment of ammoniated mercury, ten to twenty grains to the ounce. Some +cases respond more rapidly to the use of a drying ointment, such as +Lassar's paste, with ten to twenty grains of white precipitate or +sulphur to the ounce. In itching cases, a saturated solution of boric +acid, or a carbolic-acid lotion, one to two drachms to the pint, is to +be employed for general application. + + + + #Impetigo Herpetiformis.# + + +#Describe impetigo herpetiformis.# + +Impetigo herpetiformis is an extremely rare disease, observed usually in +pregnant women, and is characterized by the appearance of numerous +isolated and closely-crowded pin-head-sized superficial pustules, which +show a decided disposition to the formation of circular groups or +patches. The central portion of these groups dries to crusts, while new +pustules appear at the peripheral portion. They tend to coalesce, and in +this manner a greater part of the whole surface may, in the course of +weeks or months, become involved. Profound constitutional disturbance, +usually of a septic character, precedes and accompanies the disease; in +almost every instance a fatal termination sooner or later results. + +It is possibly a grave type of dermatitis herpetiformis. + + + + #Ecthyma.# + + +#Give a descriptive definition of ecthyma.# + +Ecthyma is a disease characterized by the appearance of one, several or +more discrete, finger-nail-sized, flat, usually markedly inflammatory +pustules. + + +#Describe the symptoms and course of ecthyma.# + +The lesions begin as small, usually pea-sized, pustules; increase +somewhat in area, and when fully developed are dime-sized, or larger, +somewhat flat, with a markedly inflammatory base and areola. At first +yellowish they soon become, from the admixture of blood, reddish, and +dry to brownish crusts, beneath which will be found superficial +excoriations. The individual pustules are usually somewhat acute in +their course, but new lesions may continue to appear from day to day or +week to week. As a rule, not more than five to twenty are present at one +time, and in most cases they are seated on the legs. More or less +pigmentation, and sometimes superficial scarring, may remain to mark the +site of the lesions. + +Itching is rarely present, but there may be more or less pain and +tenderness. + + +#What is the cause of ecthyma?# + +It is essentially a disease of the poorly cared-for and ill-fed; the +direct exciting cause is the introduction of pyogenic microörganisms +into the follicular openings. It is closely allied to impetigo +contagiosa, and may in fact be regarded as a markedly inflammatory form +of the latter affection. It seems much less contagious, however. It is +commonly observed in male adults. + + +#From what diseases is ecthyma to be differentiated?# + +From impetigo contagiosa, and the flat pustular syphiloderm. + + +#How is it distinguished from these several diseases?# + +The size, shape, inflammatory action, and the depraved general +condition, the distribution and lesser-contagiousness will distinguish +it from impetigo contagiosa; and the absence of concomitant symptoms of +syphilis, and of positive ulceration, as well as its distribution and +more rapid and inflammatory course, will exclude the pustular +syphiloderm. + + +#State the prognosis.# + +The disease is readily curable, disappearing upon the removal of the +predisposing cause and the employment of local antiseptic applications. + + +#What treatment is to be advised?# + +Good food, proper hygiene and tonic remedies; and, locally, removal of +the crusts and stimulation of the underlying surface with an ointment of +ammoniated mercury, ten to thirty grains to the ounce. + +The following mild antiseptic lotion, which materially lessens the +tendency to the formation of new lesions, may be applied to the affected +region two or three times daily:-- + + [Rx] Acidi borici, ........................ [dram]iv + Resorcini, ........................... [dram]ij + Glycerinæ, ........................... f[dram]ij + Alcoholis, ........................... f[Oz]j + Aquæ, ........... q.s. ad ............ Oj. M. + +A weak lotion of thymol, corrosive sublimate or ichthyol would doubtless +be equally effectual. + + + + #Pemphigus.# + + +#What do you understand by pemphigus?# + +Pemphigus is an acute or chronic disease characterized by the successive +formation of irregularly-scattered, variously-sized blebs. + + +#Name the varieties met with.# + +Two varieties are usually described--pemphigus vulgaris and pemphigus +foliaceus. + + +#Describe the symptoms and course of pemphigus vulgaris.# + +With or without precursory symptoms of systemic disturbance, irregularly +scattered blebs, few or in numbers, make their appearance, arising from +erythematous spots or from apparently normal skin. They vary in size +from a pea to a large egg, are rounded or ovalish, usually distended, +and contain a yellowish fluid which, later, becomes cloudy or puriform. +If ruptured, the rete is exposed, but the skin soon regains its normal +condition; if undisturbed, the fluid usually disappears by absorption. +Each lesion runs its course in several days or a week. + +A grave type of pemphigus is exceptionally observed in the +newborn--_pemphigus neonatorum_. + + +#What course does pemphigus vulgaris pursue?# + +Usually chronic. The disease may subside in several months and the +process come to an end, constituting the acute type. As a rule, however, +the disease is chronic, new blebs continuing to appear from time to time +for an indefinite period. + +[Illustration: Fig. 30. Pemphigus (mulatto).] + + +#In what respects does the severe form of pemphigus vulgaris differ from +the ordinary type?# + +In the severe or malignant type the eruption is more profuse; there is +marked, and often grave, systemic depression, and the lesions are +attended with ulcerative action. + + +#Describe the symptoms and course of pemphigus foliaceus.# + +In this, the grave type of the disease, the blebs are loose and flaccid, +with milky or puriform contents, rupturing and drying to crusts, which +are cast off, disclosing the reddened corium. New blebs appear on the +sites of disappearing or half-ruptured lesions, and the whole surface +may be thus involved and the disease continue for years, compromising +the general health and eventually ending fatally. + +In some cases of pemphigus (pemphigus vegetans) a vegetating or +papillomatous condition develops from the base of the lesion, with an +offensive discharge; it is usually a grave type of the malady. + +Exceptionally cases (dermatitis vegetans) are met with which have a +close similarity in their symptoms to pemphigus vegetans, but in which +the eruption is more or less limited to the genitocrural region. The +disorder is not malignant and usually yields to cleanliness and +antiseptics. + + +#What is the character of the subjective symptoms in pemphigus?# + +The subjective symptoms consist variously of heat, tenderness, pain, +burning and itching, and may be slight or troublesome. + + +#What is known in regard to the etiology of pemphigus?# + +The causes are obscure; general debility, overwork, shock, nervous +exhaustion, and septic conditions (microörganisms) are thought to be of +influence. There seems no doubt that those who have to do with cattle +products, especially butchers, are subjects of acute and usually grave +pemphigus. Vaccination has exceptionally been responsible for the +disease, probably through some coincidental infection. The disease is +not contagious, nor is it due to syphilis. It may occur at any age. + +It is a rare disease, especially in this country. Most of the cases +diagnosed as pemphigus by the inexperienced are examples of bullous +urticaria, bullous erythema multiforme, and impetigo contagiosa. + + +#What is the pathology?# + +The lesions are superficially seated, usually between the horny layer +and upper part of the rete. Round-cell infiltration and dilated blood +vessels are found about the papillæ and in the subcutaneous tissue. The +contents of the blebs, always of alkaline reaction, are at first serous, +later containing blood corpuscles, pus, fatty-acid crystals, epithelial +cells, and occasionally uric acid crystals and free ammonia. + + +#From what diseases is pemphigus to be differentiated?# + +From herpes iris, the bullous syphiloderm, impetigo contagiosa and +dermatitis herpetiformis. + + +#How do these several diseases differ from pemphigus?# + +The acute course, small lesions, concentric arrangement, variegated +colors, and distribution, in herpes iris; the thick, bulky, greenish +crusts, the underlying ulceration, the course, history, and the presence +of concomitant symptoms of syphilis, in the bullous syphiloderm; the +history, course, distribution, the character of the crusting, and the +contagious and auto-inoculable properties of the contents of the +lesions, in impetigo contagiosa; the tendency to appear in groups, the +smaller lesions, the intense itchiness, course, multiform characters of +the eruption and the disposition to change of type in dermatitis +herpetiformis,--will serve as differential points. + + +#State the prognosis of pemphigus.# + +Its duration is uncertain, and the issue may in severe cases be fatal. +In the milder types, after months or several years, recovery may take +place. + +The extent and severity of the disease and the general condition of the +patient are always to be considered before an opinion is expressed. + +Pemphigus neonatorum usually ends fatally. + + +#Give the treatment of pemphigus.# + +Both constitutional and local measures are demanded. Good nutritious +food and hygienic regulations are essential. Arsenic and quinia are the +most valuable remedies. The former, in occasional instances, seems to +have a specific influence, and should always be tried, beginning with +small doses and increasing gradually to the point of tolerance and +continued for several weeks or longer. The remedy should not be set +aside as long as there are signs of improvement, unless the supervention +of stomachic, intestinal or other disturbance demand its discontinuance. +Other tonics, such as iron, strychnia and cod-liver oil, are also at +times of service. + +The blebs should be opened and the parts anointed or covered with a mild +ointment. In more general cases bran, starch and gelatin baths, and in +severe cases the continuous bath, if practicable, are to be used. + + + + +#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 hæmorrhagica; +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 (_Schönlein'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 hæmorrhagica.# + +Purpura hæmorrhagica (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 microörganism +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 hæmatin +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 hæmorrhagica is +somewhat uncertain; although usually favorable, a fatal result from +internal hemorrhage is possible. The variety known as Schönlein'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 hyperæmia 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 + Aquæ rosæ, ........................... f[Oz]iv. M. + +And also the following:-- + + [Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij + Zinci sulphat., + Plumbi acetat., ...... [=a][=a] ...... [dram]ss + Aquæ, ................................ 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 +milliampères--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.# + +The lesions are usually limited to the extensor surfaces of the thighs +and arms, especially the former. They appear as pin-head-sized, whitish +or grayish elevations, consisting of accumulations of epithelial matter +about the apertures of the hair follicles. Each elevation is pierced by +a hair, or the hair may be twisted and imprisoned within the epithelial +mass; or it may be broken off just at the point of emergence at the apex +of the papule, in which event it may be seen as a dark, central speck. +The skin is usually dry, rough and harsh, and in marked cases, to the +hand passing over it, feels not unlike a nutmeg-grater. The disease +varies in its development, in most cases being so slight as to escape +attention. As a rule, it is free from itching. + + +#What course does keratosis pilaris pursue?# + +It is sluggish and chronic. + + +#Mention some of the etiological factors.# + +It is not an uncommon disease, and is seen usually in those who are +unaccustomed to frequent bathing, being most frequently met with during +the winter months. It is chiefly observed during early adult life. + + +#Is there any difficulty in the diagnosis?# + +No. It is thought at times to bear some resemblance to goose-flesh +(cutis anserina), the miliary papular syphiloderm in its desquamating +stage, and lichen scrofulosus. In goose-flesh the elevations are +evanescent and of an entirely different character; the papules of the +syphiloderm are usually generalized, of a reddish color, tend to group, +are more solid and deeply-seated, less scaly and are accompanied with +other symptoms of syphilis; in lichen scrofulosus the papules are +larger, incline to occur in groups, and appear usually upon the abdomen. + + +#State the prognosis.# + +The disease yields readily to treatment. + + +#Give the treatment of keratosis pilaris.# + +Frequent warm baths, with the use of a toilet soap or sapo viridis, will +usually be found curative. Alkaline baths are also useful. In obstinate +cases the ordinary mild ointments, glycerine, etc., are to be advised in +conjunction with the baths. + + + + #Keratosis Follicularis.# + + +#Describe keratosis follicularis.# + +Keratosis follicularis (_Darier's disease_, _ichthyosis follicularis_, +_ichthyosis sebacea cornea_, _psorospermosis_) is a rare disease +characterized by pin-head to pea-sized pointed, rounded, or +irregularly-shaped grayish, brownish, red or even black, horny papules +or elevations, arising from the sebaceous or hair-follicles. They are, +for the most part, discrete, with a tendency here and there to form +solid aggregations or areas. Many of them contain projecting cornified +plugs which may be squeezed out, leaving pit-like depressions. The face, +scalp, lower trunk, groins and flanks are the parts chiefly affected. +The view advanced by Darier, that the malady was due to psorosperms, is +now denied, the bodies thought to be such having been demonstrated to be +due to cell transformation. + +As to treatment, in one instance the induction of a substitutive +dermatic inflammation had a favorable influence. + + + #Molluscum Epitheliale.# + (_Synonyms:_ Molluscum Contagiosum; Molluscum Sebaceum; Epithelioma + Molluscum.) + + +#Give a definition of molluscum epitheliale.# + +Molluscum epitheliale is characterized by pin-head to pea-sized, +rounded, semi-globular, or flattened, pearl-like elevations, of a +whitish or pinkish color. + + +#Describe the symptoms and course of molluscum epitheliale.# + +The usual seat is the face; not infrequently, however, the growths occur +on other parts. The lesions begin as pin-head, waxy-looking, rounded or +acuminated elevations, gradually attaining the size of small peas. They +have a broad base or occasionally may tend to become pedunculated. They +rarely exist in profusion, in most cases three to ten or twelve lesions +being present. When fully developed they are somewhat flattened and +umbilicated, with a central, darkish point representing the mouth of the +follicle. They are whitish or pinkish, and look not unlike drops of wax +or pearl buttons. At first they are firm, but eventually, in most cases, +tend to become soft and break down. Not infrequently, however, the +lesions disappear slowly by absorption, without apparent previous +softening. Their course is usually chronic. The contents, a +cheesy-looking mass, may commonly be pressed out without difficulty. + + +#What is the cause of molluscum epitheliale?# + +It is now generally accepted that the disease is mildly contagious. It +occurs chiefly in children, and especially among the poorer classes. The +belief in the parasitic nature of the disease is gaining ground; +recently the opinion has been advanced that it is due to psorosperms +(psorospermosis); but further investigations have indicated that these +bodies were degenerated epithelia. + + +#State the pathology.# + +[Illustration: Fig. 31. Molluscum Epitheliale.] + +According to recent investigations, molluscum epitheliale is to be +regarded as a hyperplasia of the rete, the growth probably beginning in +the hair-follicles; the so-called molluscum bodies--peculiar, rounded or +ovoidal, sharply-defined, fatty-looking bodies found in microscopical +examination of the growth--are to be viewed as a form of epithelial +degeneration. + + +#What are the diagnostic points in molluscum epitheliale?# + +The size of the lesions, their waxy or glistening appearance, and the +presence of the central orifice. + +It is to be differentiated from molluscum fibrosum, warts and acne. + + +#State the prognosis.# + +The growths are amenable to treatment. In some instances the disease, +after existing some weeks, tends to disappear spontaneously. + + +#What is the treatment of molluscum epitheliale?# + +Incision and expression of the contents, and touching the base of the +cavity with silver nitrate. Pedunculated growths may be ligated. In some +cases an ointment of ammoniated mercury, twenty to forty grains to the +ounce, applied, by gently rubbing, once or twice daily, will bring about +a cure. + + + + #Callositas.# + (_Synonyms:_ Tylosis; Tyloma; Callus; Callous; Callosity; Keratoma.) + + +#What do you understand by callositas?# + +A hard, thickened, horny patch made up of the corneous layers of the +epidermis. + + +#Describe the clinical appearances.# + +Callosities are most common about the hands and feet, and consist of +small or large patches of dry, grayish-yellow looking, hard, slight or +excessive epidermic accumulations. They are somewhat elevated, +especially at the central portion, and gradually merge into the healthy +skin. The natural surface lines are in a great measure obliterated, the +patches usually being smooth and horn-like. + +_Keratosis palmaris et plantaris_ (symmetric keratodermia), as regards +the local condition, is a somewhat similar affection. It consists of +hypertrophy of the corneous layer of the palm and soles, usually of a +more or less horny and plate-like character, but is congenital or +hereditary, and not necessarily dependent upon local friction or +pressure. + + +#Are there any inflammatory symptoms in callositas?# + +No; but exceptionally, from accidental injury, the subjacent corium +becomes inflamed, suppurates, and the thickened mass is cast off. + + +#State the causes of callositas.# + +Pressure and friction; for example, on the hands, from the use of +various tools and implements, and on the feet from ill-fitting shoes. It +is, indeed, often to be looked upon as an effort of nature to protect +the more delicate corium. + +In exceptional instances it arises without apparent cause. + + +#What is the pathology?# + +The epidermis alone is involved; it consists, in fact, of a hyperplasia +of the horny layer. + + +#State the prognosis of callositas.# + +If the causes are removed, the accumulation, as a rule, gradually +disappears. The effect of treatment is always rapid and positive, but +unless the etiological factors have ceased to act, the result is usually +but temporary. + + +#How is callositas treated?# + +When treatment is deemed advisable, it consists in softening the parts +with hot-water soakings or poultices, and subsequently shaving or +scraping off the callous mass. The same result may also be often +effected by the continuous application, for several days or a week, of a +10 to 15 per cent. salicylated plaster, or the application of a +salicylated collodion, same strength; it is followed up by hot-water +soaking, the accumulation, as a rule, coming readily away. + + + + #Clavus.# + (_Synonym:_ Corn.) + + +#What is clavus?# + +Clavus, or corn, is a small, circumscribed, flattened, deep-seated, +horny formation usually seated about the toes. + + +#Describe the clinical appearances.# + +Ordinarily a corn has the appearance of a small callosity; the skin is +thickened, polished and horny. Exceptionally, however, occurring on +parts that are naturally more or less moist, as between the toes, +maceration takes place, and the result is the so-called _soft corn_. The +dorsal aspect of the toes is the common site for the ordinary variety. +The usual size is that of a small pea. They are painful on pressure, +and, at times, spontaneously so. + + +#State the causes.# + +Corns are caused by pressure and friction, and may usually be referred +to improperly fitting shoes. + + +#What is the pathology of clavus?# + +It is a hypertrophy of the epiderm. Its shape is conical, with the base +external and the apex pressing upon the papillæ. It is, in fact, a +peculiarly-shaped callosity, the central portion and apex being dense +and horny, forming the so-called core. + + +#Give the treatment of clavus.# + +A simple method of treatment consists in shaving off, after a +preliminary hot-water soaking, the outer portion, and then applying a +ring of felt or like material, with the hollow part immediately over the +site of the core; this should be worn for several weeks. It is also +possible in some cases to extract the whole corn by gently dissecting it +out; the after-treatment being the same as the above. + +Another method is by means of a ten- to fifteen-per-cent. solution of +salicylic acid, in alcohol or collodion, or the following:-- + + [Rx] Ac. salicylici, ...................... gr. xxx + Ext. cannabis Ind., .................. gr. x + Collodii, ............................ f[dram]iv. M. + +This is painted on the corn night and morning for several days, at the +end of which time the parts are soaked in hot water, and the mass or a +greater part of it, will be found, as a rule, to come readily away; one +or two repetitions may be necessary. Lactic acid, with one to several +parts of water, applied once or twice daily, acts in a similar manner. + +Soft corns, after the removal of pressure, may be treated with the solid +stick of nitrate of silver, or by any of the methods already mentioned. + +In order that treatment be permanently successful, the feet are to be +properly fitted. If pressure is removed, corns will commonly disappear +spontaneously. + + + + #Cornu Cutaneum.# + (_Synonyms:_ Cornu Humanum; Cutaneous Horn.) + + +#What is cornu cutaneum?# + +A cutaneous horn is a circumscribed hypertrophy of the epidermis, +forming an outgrowth of horny consistence and of variable size and +shape. + + +#At what age and upon what parts are cutaneous horns observed?# + +They are usually met with late in life, and are mostly seated upon the +face and scalp. + +[Illustration: Fig. 32. + Cutaneous Horns. Showing beginning epitheliomatous degeneration of the + base. (_After Pancoast._)] + + +#Describe the clinical appearances.# + +In appearance cutaneous horns resemble those seen in the lower animals, +differing, if at all, but slightly. They are hard, solid, dry and +somewhat brittle; usually tapering, and may be either straight, curved +or crooked. Their surface is rough, irregular, laminated or fissured, +the ends pointed, blunt or clubbed. The color varies; it is usually +grayish-yellow, but may be even blackish. As commonly seen they are +small in size, a fraction of an inch or an inch or thereabouts in +length, but exceptionally attain considerable proportions. The base, +which rests directly upon the skin, may be broad, flattened, or concave, +with the underlying and adjacent tissues normal or the papillæ +hypertrophied; and in some cases there is more or less inflammation, +which may be followed by suppuration. They are usually solitary +formations. They are not, as a rule, painful, unless knocked or +irritated. + + +#What course do cutaneous horns pursue?# + +Their growth is usually slow, and, after having attained a certain size, +they not infrequently become loose and fall off; they are almost always +reproduced. + + +#What is the cause of these horny growths?# + +The cause is not known; appearing about the genitalia, they usually +develop from acuminated warts. They are rare formations. + + +#State the pathology of cornu cutaneum.# + +Horns consist of closely agglutinated epidermic cells, forming small +columns or rods; in the columns themselves the cells are arranged +concentrically. In the base are found hypertrophic papillæ and some +bloodvessels. They have their starting-point in the rete mucosum, either +from that lying above the papillæ or that lining the follicles and +glands. + + +#Does epitheliomatous degeneration of the base ever occur?# + +Yes. + + +#State the prognosis.# + +Cutaneous horns may be readily and permanently removed. + + +#What is the treatment?# + +Treatment consists in detachment, and subsequent destruction of the +base; the former is accomplished by dissecting the horn away from the +base or forcibly breaking it off, the latter by means of any of the +well-known caustics, such as caustic potash, chloride of zinc and the +galvano-cautery. + +Another method is to excise the base, the horn coming away with it; this +necessitates, however, considerable loss of tissue. + + + + #Verruca.# + (_Synonym:_ Wart.) + + +#What is verruca?# + +Verruca, or wart, is a hard or soft, rounded, flat, acuminated or +filiform, circumscribed epidermal and papillary growth. + + +#Name the several varieties of warts met with.# + +Verruca vulgaris, verruca plana, verruca plana juvenilis, verruca +digitata, verruca filifortnis and verruca acuminata. + + +#Describe verruca vulgaris.# + +This is the common wart, occurring mostly upon the hands. It is rounded, +elevated, circumscribed, hard and horny, with a broad base, and usually +the size of a pea. At first it is smooth and covered with slightly +thickened epidermis, but later this disappears to some extent, the +hypertrophied papillæ, appearing as minute elevations, making up the +growth. One, several or more may be present. + + +#Describe verruca plana.# + +This is the so-called flat wart, and occurs commonly upon the back, +especially in elderly people (_verruca senilis_, _keratosis pigmentosa_). +It is, as a rule, but slightly elevated, is usually dark in color, and +of the size of a pea or finger-nail. + + +#Describe verruca plana juvenilis.# + +The warts are mostly pin-head in size, flat, but slightly elevated, +rounded, irregular or square-shaped, and of a light yellowish-brown +color. They bear resemblance to lichen planus papules. They are apt to +be numerous, often becoming aggregated or fused, and occur usually in +young children, and, as a rule, on the face and hands. + + +#Describe verruca filiformis.# + +This is a thread-like growth about an eighth or fourth of an inch long, +and occurring commonly about the face, eyelids and neck. It is usually +soft to the touch and flexible. + + +#Describe verruca digitata.# + +This is a variety of wart, which, especially about the edges, is marked +by digitations, extending nearly or quite down to the base. It is +commonly seen upon the scalp. + + +#Describe verruca acuminata.# + +This variety (_venereal wart_, _pointed wart_, _pointed condyloma_), +usually occurs about the genitalia, especially upon the mucous and +muco-cutaneous surfaces. It consists of one or more groups of +acuminated, pinkish or reddish, raspberry-like elevations, and, +according to the region, may be dry or moist; if the latter, the +secretion, which is usually yellowish and puriform, from rapid +decomposition, develops an offensive and penetrating odor. The formation +may be the size of a small pea, or may attain the dimensions of a fist. + + +#What is the cause of warts?# + +The etiology is not known. They are more common in adolescent and early +adult life. Irritating secretions are thought to be causative in the +acuminated variety. It is highly probable that a parasitic factor will +finally be demonstrated. They are doubtless mildly contagious. + +[Illustration: Fig. 33. + Verruca Acuminata--about the anus. (_After Ashton._)] + + +#State the pathology of warts.# + +A wart consists of both epidermic and papillary hypertrophy, the +interior of the growth containing a vascular loop. In the acuminated +variety there are marked papillary enlargement, excessive development of +the mucous layer, and an abundant vascular supply. + + +#Give the treatment of warts.# + +For ordinary warts, excision or destruction by caustics. The repeated +application of a saturated alcoholic solution of salicylic acid is often +curative, the upper portion being pared off from time to time. The +filiform and digitate varieties may be snipped off with the scissors, +and the base touched with nitrate of silver; or a ligature may be used. +Curetting is a valuable operative method. The growths may also be +removed by electrolysis. When warts are numerous and close together +parasiticide applications can be daily made to the whole affected +region. For this purpose a boric acid solution, containing five to +thirty grains of resorcin to the ounce, and Vleminckx's solution, at +first diluted, prove the most valuable. + +Verruca acuminata is to be treated by maintaining absolute cleanliness, +and the application of such astringents as liquor plumbi subacetatis, +tincture of iron, powdered alum and boric acid. The salicylic acid +solution may also be used. In obstinate cases, glacial acetic acid or +chromic acid may be cautiously employed. + + + + #Nævus Pigmentosus.# + (_Synonym:_ Mole.) + + +#Describe nævus pigmentosus.# + +Nævus pigmentosus, commonly known as mole, may be defined as a +circumscribed increase in the pigment of the skin, usually associated +with hypertrophy of one or all of the cutaneous structures, especially +of the connective tissue and hair. It occurs singly or in numbers; is +usually pea-, bean-sized or larger, rounded or irregular, smooth or +rough, flat or elevated, and of a color varying from a light brown to +black; the hair found thereon may be either colorless or deeply +pigmented, coarse and of considerable length. It is, as a rule, a +permanent formation. + + +#Name the several varieties of nævus pigmentosus met with.# + +Nævus spilus, nævus pilosus, nævus verrucosus, and nævus lipomatodes. +So-called linear nævus might also be considered as belonging in this +group. + + +#What is nævus spilus?# + +A smooth and flat nævus, consisting essentially of augmented +pigmentation alone. + +[Illustration: Fig. 34. Linear Nævus.] + + +#What is nævus pilosus?# + +A nævus upon which there is an abnormal growth of hair, slight or +excessive. + + +#What is nævus verrucosus?# + +A nævus to which is added hypertrophy of the papillæ, giving rise to a +furrowed and uneven surface. + + +#What is linear nævus?# + +Linear nævus is a formation usually of a verrucous character, more or +less pigmented, sometimes slightly scaly, occurring in band-like or +zoster-like areas, and, as a rule, unilaterally. + + +#What is nævus lipomatodes?# + +A nævus with excessive fat and connective-tissue hypertrophy. + + +#State the etiology of nævus pigmentosus.# + +The causes are obscure. The growths are usually congenital; but the +smooth, non-hairy moles may be acquired. + + +#Give the pathology of nævus pigmentosus.# + +Microscopical examination shows a marked increase in the pigment in the +lowest layers of the rete mucosum, as well as more or less pigmentation +in the corium usually following the course of the bloodvessels; in the +verrucous variety the papillæ are greatly hypertrophied, in addition to +the increased pigmentation. There is, as a rule, more or less +connective-tissue hypertrophy. + + +#What is the treatment of nævus pigmentosus?# + +In many instances interference is scarcely called for, but when demanded +consists in the removal of the formation either by the knife, by +caustics, or by electrolysis. This last is, in the milder varieties at +least, perhaps the best method, as it is less likely to be followed by +disfiguring cicatrices. In nævus pilosus the removal of the hairs alone +by electrolysis is not infrequently followed by a decided diminution of +the pigmentation. In recent years both liquid air and carbon dioxide +have also been used successfully in the removal of these growths. +Pigmented nævi, which show the least tendency to growth or degenerative +change, should be radically removed, as they not infrequently lead to +carcinomatous and sarcomatous growths. + + + + #Ichthyosis.# + (_Synonym:_ Fish-skin Disease.) + + +#Give a descriptive definition of ichthyosis.# + +Ichthyosis is a chronic, hypertrophic disease, characterized by dryness +and scaliness of the skin, with a variable amount of papillary growth. + + +#At what age is ichthyosis first observed?# + +It is first noticed in infancy or early childhood. In rare instances it +is congenital (ichthyosis congenita), and in such cases it is usually +severe, and of a grave type; the children are, as a rule, prematurely +born, and frequently do not survive many days or weeks. + + +#What extent of surface is involved?# + +Usually the whole surface, but it is most marked upon the extensor +surfaces of the arms and legs, especially at the elbows and knees; the +face and scalp, in mild cases, often remain free. + + +#Name the two varieties of ichthyosis usually described.# + +Ichthyosis simplex and ichthyosis hystrix, terms commonly employed to +designate the mild and severe forms respectively. + + +#Describe the clinical appearances of ichthyosis.# + +The milder forms of the disease may be so slight as to give rise to +simple dryness or harshness of the skin (_xeroderma_); but as commonly +met with it is more developed, more or less marked scaliness in the form +of thin or somewhat thick epidermal plates being present. The papillæ of +the skin are often slightly hypertrophied. In slight cases the color of +the scales is usually light and pearly; in the more marked examples it +is dark gray, olive green or black. + +In the severe variety--ichthyosis hystrix--in addition to scaliness +there is marked papillary hypertrophy, forming warty or spinous patches. +This type is rare, and, as a rule, the surface involved is more or less +limited. + + +#Are there any inflammatory symptoms in ichthyosis?# + +No. In fact, beyond the disfigurement, the disease causes no +inconvenience; in those well-marked cases, however, in which the scales +are thick and more or less immovable, the natural mobility of the parts +is compromised and fissuring often occurs. In the winter months, in the +severer cases, exposed parts may become slightly eczematous. + + +#Does ichthyosis vary somewhat with the season?# + +Yes. In all cases the disease is better in the warm months, and in the +mild forms may entirely disappear during this time. This favorable +change is purely mechanical--due to the maceration to which the +increased activity of the sweat glands gives rise. + + +#Is the general health affected in ichthyosis?# + +No. + + +#What course does ichthyosis pursue?# + +Chronic. Beginning in early infancy or childhood, it usually becomes +gradually more marked until adult age, after which time it, as a rule, +remains stationary. + + +#What is the etiology?# + +Beyond a hereditary influence, which is often a positive factor, the +causes are obscure. It is not a common disease. + + +#State the pathology.# + +Anatomically the essential feature is epidermic hypertrophy, with +usually a varying degree of papillary hypertrophy also. + + +#Mention the diagnostic features of ichthyosis.# + +The harsh, dry skin, epidermic and papillary hypertrophy, the +furfuraceous or plate-like scaliness, the greater development upon the +extensor surfaces, a history of the affection dating from early +childhood, and the absence of inflammatory symptoms. + + +#How is ichthyosis to be distinguished from eczema, psoriasis, and other +scaly inflammatory diseases?# + +By the absence of the inflammatory element. + + +#What is the outlook for a case of ichthyosis?# + +The prognosis is unfavorable as regards a cure, but the process may +usually be kept in abeyance or rendered endurable by proper measures. + + +#What treatment would you prescribe for ichthyosis?# + +Treatment that has in view removal of the scaliness and the maintenance +of a soft and flexible condition of the skin. + +In mild cases frequent warm baths, simple or alkaline, will suffice; in +others an application of an oily or fatty substance, such as the +ordinary oils or ointments, made several hours or immediately before the +bath may be necessary. In moderately developed cases the skin is to be +washed energetically with sapo viridis and hot water, followed by a warm +bath, after which an oily or fatty application is made. In some of the +more severe cases the following plan is often useful: The parts are +first rubbed with a soapy ointment consisting of one part of +precipitated sulphur and seven parts of sapo viridis; a bath is then +taken, the skin wiped dry, and a one to five per cent. ointment of +salicylic acid gently rubbed in. + +Glycerine lotions, one or two drachms to the ounce of water, are also +beneficial; as also the following:-- + + [Rx] Ac. salicylici, ...................... gr. x-xl + Glycerini, ........................... [dram]ss-[dram]j + Lanolin, + Petrolati, .................. [=a][=a] [Oz]ss + +In severe cases of ichthyosis hystrix it may be necessary, also, to +employ caustics or the knife. + + +#What systemic treatment would you prescribe?# + +Constitutional remedies are practically powerless; occasionally some +good is accomplished by the internal administration of linseed oil and +jaborandi. + + + + #Onychauxis.# + (_Synonym:_ Hypertrophy of the Nail.) + + +#Describe onychauxis.# + +Onychauxis, or hypertrophy of the nail, may take place in one or all +directions, and this increase may be, and often is, accompanied by +changes in shape, color, and direction of growth. One or all the nails +may share in the process. As the result of lateral deviation of growth, +the nail presses upon the surrounding tissues, producing a varying +degree of inflammation--_paronychia_. + + +#What is the etiology of hypertrophy of the nail?# + +The condition may be either congenital or acquired. In the latter +instances it is usually the result of the extension to the matrix of +such cutaneous diseases as psoriasis and eczema; or it is produced by +constitutional maladies, such as syphilis. + + +#Give the treatment of hypertrophy of the nail.# + +Treatment consists in the removal of the redundant nail-tissue by means +of the knife or scissors; and, when dependent upon eczema or psoriasis, +the employment of remedies suitable for these diseases. When it is the +result of syphilis, the medication appropriate to this disease is to be +employed. + +In paronychia the nail should be frequently trimmed and a pledget of +lint or cotton be interposed between the edge of the nail and the +adjacent soft parts; astringent powders and lotions may often be +employed with advantage; and in severe and persistent cases excision of +the nail, partial or complete, may be found necessary. + + + + #Hypertrichosis.# + (_Synonyms:_ Hirsuties; Hypertrophy of the Hair; Superfluous Hair.) + + +#What is meant by hypertrichosis?# + +Hypertrichosis is a term applied to excessive growth of hair, either as +regards region, extent, age or sex. + + +#Describe the several conditions met with.# + +The unnatural hair growth may be slight, as, for instance, upon a nævus +(_nævus pilosus_); or it may be excessive, as in the so-called hairy +people (_homines pilosi_); or it may also appear on the face, arms and +other parts in females, resulting from a hypertrophy of the natural +lanugo hairs. + + +#State the causes of hypertrichosis.# + +Hereditary influence is often a factor; the condition may also be +congenital. + +If acquired, the tendency manifests itself usually toward middle life. +In women, it is not infrequently associated with diseases of the +utero-ovarian system; in many instances, however, there is no apparent +cause. Local irritation or stimulation has at times a causative +influence. + + +#How is hypertrichosis to be treated?# + +For general hypertrichosis there is no remedy. Small hairy nævi may be +excised, or, as also in the larger hairy moles, the hairs may be removed +by electrolysis. + +On the faces of women, if the hairs are coarse or large, electrolysis +constitutes the only satisfactory method; if the hairs are small and +lanugo-like, the operation is not to be advised. It is somewhat painful, +but never unbearable. In the past several years the _x_-ray has been +advocated by several writers, but it requires usually numerous exposures +pushed to the point of producing erythema; it is not without risk, and +the hairs are said to return in some months. + + +#What temporary methods are usually resorted to for the removal of +superfluous hair?# + +Shaving, extraction of the hairs and the use of depilatories. As a +depilatory, a powder made up of two drachms of barium sulphide and three +drachms each of zinc oxide and starch, is commonly (and cautiously) +employed; at the time of application enough water is added to the powder +to make a paste, and it is then spread thinly upon the parts, allowed to +remain five to fifteen minutes, or until heat of skin or a burning +sensation is felt, washed off thoroughly, and a soothing ointment +applied. This preparation must be well prepared to be efficient. + + +#Describe the method of removal of superfluous hair by electrolysis.# + +A fine needle in a suitable handle is attached to the _negative_ pole of +a _galvanic_ battery, introduced into the hair-follicle to the depth of +the papilla, and the circuit completed by the patient touching the +positive electrode; in several seconds slight blanching and frothing +usually appear at the point of insertion; a few seconds later the +current is broken by release of the positive electrode, and the needle +is then withdrawn. Sometimes a wheal-like elevation arises, remains +several minutes or hours, and then disappears; or occasionally, probably +from secondary infection, it develops into a pustule. + +A strength of current of a half to two milliamperes is usually +sufficient; the time necessary for the destruction of the papilla +varying from several to thirty seconds. + + +#How are you to know if the papilla has been destroyed?# + +The hair will readily come out with but little, if any, traction. + + +#What is the result if the current has been too strong or too long +continued?# + +The follicle suppurates and a scar results. + + +#Why should contiguous hairs not be operated upon at the same sitting?# + +In order that the chances of marked inflammatory action and scarring +(always possibilities) may be reduced to a minimum. + + +#In case of failure to destroy an individual papilla, should a second +attempt be made at the same sitting?# + +As a rule not, in order to avoid the possibility of too much destructive +action, and consequent scarring. + + +#Can scarring always be prevented?# + +In the average case, with skill and care, the use of an exceedingly fine +needle and the avoidance of too strong a current, _perceptible_ scarring +(scarring perceptible to the ordinary observer or at ordinary distance) +need rarely occur. + + +#What measures are to be advised for the irritation produced by the +operation?# + +Hot-water applications and the use of an ointment made of two drachms +cold cream and ten grains of boric acid are of advantage not only in +reducing the resulting hyperæmia, but also in preventing suppuration and +consequent scarring. To lessen the chances of the latter, cleansing the +parts with alcohol just before and after the operation is also of +service. + + + + #[OE]dema Neonatorum.# + + +#Describe [oe]dema neonatorum.# + +The essential symptoms are [oe]dema and a variable degree of hardness +and induration. It develops in the first few days of life, and usually +upon the extremities, especially the lower. It may remain more or less +limited to these parts, but, as a rule, slowly extends. The skin is of a +yellowish, dusky, or livid color, and sometimes glossy or shining. There +are general symptoms of drowsiness, subnormal temperature, weakened +circulation, and impaired respiration, which gradually increase, and in +eighty to ninety per cent. of the cases lead to death. It is believed to +be similar to anasarca in the adult and to be due to like causes. + +Treatment consists in maintaining the body-heat, sufficient and proper +nourishment and stimulation. + + + + #Sclerema Neonatorum.# + (_Synonyms:_ Scleroderma Neonatorum; Sclerema of the Newborn.) + + +#What is sclerema neonatorum?# + +Sclerema neonatorum is a disease of infancy, showing itself usually at +or shortly after birth, and is characterized by a diffuse stiffness and +rigidity of the integument, accompanied by coldness, [oe]dema, +discoloration, lividity and general circulatory disturbance. + + +#Describe the symptoms, course, nature and treatment of sclerema +neonatorum.# + +As a rule the disease first manifests itself upon the lower extremities, +and then gradually, but usually rapidly, invades the trunk, arms and +face. The surface is cold. The skin, which is noted to be reddish, +purplish or mottled, is [oe]dematous, stiff and tense; in consequence +the infant is unable to move, respires feebly and usually perishes in a +few days or weeks. In extremely exceptional instances the disease, after +involving a small part, may retrogress and recovery take place. + +The disease is rare, and in most cases is found associated with +pneumonia and with affections of the circulatory apparatus. + +Treatment should be directed toward maintaining warmth and proper +alimentation. + + + + #Scleroderma.# + (_Synonyms:_ Sclerema; Scleriasis; Dermatosclerosis; Morph[oe]a; Keloid + of Addison.) + + +#What is scleroderma?# + +Scleroderma is an acute or chronic disease of the skin characterized by +a localized or general, more or less diffuse, usually pigmented, rigid, +stiffened, indurated or hide-bound condition. + +Morph[oe]a, by some formerly thought to be a distinct affection, is now +believed to be a form of scleroderma; as typically met with it is +characterized by one or more rounded, oval, or elongate, coin- to +palm-sized, pinkish, or whitish ivory-looking patches. In some instances +such patches are seen in association with the more classic type of +scleroderma just defined. + + +#Describe the symptoms of ordinary scleroderma.# + +The disease may be acute or chronic, usually the latter. A portion or +almost the entire surface may be involved, or it may occupy variously +sized and shaped areas. The integument becomes more or less rigid and +indurated, hard to the touch, hide-bound, and in marked cases immobile. +[OE]dema may, especially in the more acute cases, precede the +induration. Pigmentation, of a yellowish or brownish color, is often a +precursory and accompanying symptom. The skin feels tight and +contracted, and in some instances numbness and cramp-like pains are +complained of. + + +#Describe the variety known as morph[oe]a.# + +The patches (one, several, or more), occurring most frequently about the +trunk, are in the beginning usually slightly hyperæmic, later becoming +pale-yellowish or white, and having a pinkish or lilac border made up of +minute capillaries. They are, as a rule, sharply defined, with a smooth, +often shining and atrophic-looking surface; are soft, fine or leathery +to the touch, on a level or somewhat depressed, and appearing not unlike +a piece of bacon or ivory laid in the skin. Occasionally the patches are +noted to occur over nerve-tracts. The adjacent skin may be normal or +there may be more or less yellowish or brownish mottling. The subjective +symptoms of tingling, itching, numbness, and even pain, may or may not +be present. + + +#What is the course of the disease?# + +Sooner or later, usually after months or years, the disease ends in +resolution and recovery, or in marked atrophic changes, causing +contraction and deformity. As a rule, the general health remains good. + + +#State the causes of scleroderma.# + +The condition is to be considered as probably of neurotic origin. +Exposure and shock to the nervous system are to be looked upon as +influential. It is a rare disease, observed usually in early adult or +middle life, and is more frequent in women than in men. + + +#What is the pathology?# + +In typical and advanced cases both the true skin and the subcutaneous +connective tissue show a marked increase of connective tissue-element, +with thickening and condensation of the fibers. + + +#Is there any difficulty in reaching a diagnosis in scleroderma?# + +As a rule, no. The characters--rigidity, stiffness, hardness, and +hide-bound condition of the skin--are always distinctive. + +The peculiar appearance, the course and character of the patches, of +morph[oe]a are quite distinctive. + + +#Give the prognosis of scleroderma.# + +It should always be guarded. In many instances recovery takes place, +whilst in others the disease is rebellious, lasting indefinitely. The +prognosis of the variety known as morph[oe]a is less unfavorable than +general scleroderma, and recovery more frequent. + + +#What is the treatment of scleroderma?# + +Tonics, such as arsenic, quinia, nux vomica, and cod-liver oil; +conjointly with the local employment of stimulating, oily or fatty +applications, friction, and electricity. Röntgen-ray treatment is often +of value, more especially in the morph[oe]a type. + + + + #Elephantiasis.# + (_Synonyms:_ Elephantiasis Arabum; Pachydermia; Barbadoes Leg; Elephant + Leg.) + + +#Give a descriptive definition of elephantiasis.# + +Elephantiasis is a chronic hypertrophic disease of the skin and +subcutaneous tissue characterized by enlargement and deformity, +lymphangitis, swelling, [oe]dema, thickening, induration, pigmentation, +and more or less papillary growth. + +[Illustration: Fig. 35. Elephantiasis of moderate development.] + + +#What parts are commonly involved in elephantiasis?# + +Usually one or both legs; occasionally the genitalia; other parts are +seldom affected. + + +#Describe the symptoms of elephantiasis.# + +The disease usually begins with recurrent (at intervals of months or +years) erysipelatous inflammation, with swelling, pain, heat, redness +and lymphangitis; after each attack the parts remain somewhat increased +in size, although at first not noticeably so. After months or one or two +years the enlargement or hypertrophy becomes conspicuous, the part is +chronically swollen, [oe]dematous and hard; the skin is thickened, the +normal lines and folds exaggerated, the papillæ enlarged and prominent, +and with more or less fissuring and pigmentation. + + +#What is the further course of the disease?# + +There is gradual increase in size, the parts in some instances reaching +enormous proportions; the skin becomes rough and warty, eczematous +inflammation is often superadded, and, sooner or later, ulcers, +superficial or deep, form--which, together with the crusting and +moderate scaliness, present a striking picture. There may be periods of +comparative inactivity, or, after reaching a certain development, the +disease may, for a time at least, remain stationary. + + +#Are there any subjective symptoms?# + +A variable degree of pain is often noted, especially marked during the +inflammatory attacks. The general health is not involved. + + +#State the cause of elephantiasis.# + +The etiology is obscure. The disease rarely occurs before puberty. It is +most common in tropical countries, more especially among the poor and +neglected. It is not hereditary, nor can it be said to be contagious. +Inflammation and obstruction of the lymphatics, probably due, according +to late investigations, to the presence of large numbers of filaria +(microscopic thread-worms) in the lymph channels and bloodvessels, is to +be looked upon as the immediate cause. + + +#What is the pathology?# + +All parts of the skin and subcutaneous connective-tissue are +hypertrophied, the lymphatic glands are swollen, the lymph channels and +bloodvessels enlarged, and there is more or less inflammation, with +[oe]dema. Secondarily, from pressure, atrophy and destruction of the +skin-glands, and atrophic degeneration of the fat and muscles result. + + +#What are the diagnostic characters of beginning elephantiasis?# + +Recurrent erysipelatous inflammation, attended with gradual enlargement +of the parts. + +The appearances, later in the course of the disease, are so +characteristic that a mistake is scarcely possible. + + +#Give the prognosis of elephantiasis.# + +If the case comes under treatment in the first months of its +development, the process may probably be checked or held in abeyance; +when well established, rarely more than palliation is possible. + + +#What is the treatment of elephantiasis?# + +The inflammatory attacks are to be treated on general principles. +Quinia, potassium iodide, iron and other tonics are occasionally useful; +and, especially in the earlier stages, climatic change is often of +value. Between the inflammatory attacks the parts are to be rubbed with +an ointment of iodine or mercury, together with galvanization of the +involved part. + +In elephantiasis of the leg, a roller or rubber bandage, or the gum +stocking, is to be worn; compression and ligation of the main artery, +and even excision of the sciatic nerve, have all been employed, with +more or less diminution in size as a result. In elephantiasis of the +genitalia, if the disease is well advanced, excision or amputation of +the parts is to be practised. + +Eczematous inflammation, if present, is to be treated with the ordinary +remedies. + + + + #Dermatolysis.# + (_Synonym:_ Cutis Pendula.) + + +#Give a descriptive definition of dermatolysis.# + +Dermatolysis is a rare disease, consisting of hypertrophy and looseness +of the skin and subcutaneous connective tissue, with a tendency to hang +in folds. + + +#Describe the symptoms and course of dermatolysis.# + +It may be congenital or acquired, and maybe limited to a small or large +area, or develop simultaneously at several regions. All parts of the +skin, including the follicles, glands and subcutaneous connective and +areolar tissue, share in the hypertrophy; and this in exceptional +instances may be so extensive that the integument hangs in folds. The +enlargement of the follicles, natural folds and rugæ gives rise to an +uneven surface, but the skin remains soft and pliable. There is also +increased pigmentation, the integument becoming more or less brownish. + + +#What course does dermatolysis pursue?# + +Its development is slow and usually progressive. It gives rise to no +further inconvenience than its weight and consequent discomfort. + + +#Give the etiology.# + +The etiology is obscure. It is considered by some authors as allied to +molluscum fibrosum, and, in fact, as a manifestation of that disease, +ordinary molluscum tumors sometimes being associated with it. It is not +malignant. + + +#What is the pathology?# + +The disease consists of a simple hypertrophy of all the skin structures +and the subcutaneous connective tissue. + + +#What is the treatment of dermatolysis?# + +Excision when advisable and practicable. + + + + +#CLASS V.--ATROPHIES.# + + + #Albinismus.# + + +#What do you understand by albinismus?# + +Congenital absence, either partial or complete, of the pigment normally +present in the skin, hair and eyes. + + +#Describe complete albinismus.# + +In complete albinismus the skin of the entire body is white, the hair +very fine, soft and white or whitish-yellow in color, the irides are +colorless or light blue, and the pupils, owing to the absence of pigment +in the choroid, are red; this absence of pigment in the eyes gives rise +to photophobia and nystagmus. _Albinos_--a term applied to such +individuals--are commonly of feeble constitution, and may exhibit +imperfect mental development. + + +#Describe partial albinismus.# + +Partial albinismus is met with most frequently in the colored race. In +this form of the affection the pigment is absent in one, several or more +variously-sized patches; usually the hairs growing thereon are likewise +colorless. + + +#Is there any structural change in the skin?# + +No. The functions of the skin are performed in a perfectly natural +manner, and microscopical examination shows no departure from normal +structure save the complete absence of pigment. + + +#What is known in regard to the etiology?# + +Nothing is known of the causes producing albinismus beyond the single +fact that it is frequently hereditary. + + +#Does albinismus admit of treatment?# + +No; the condition is without remedy. + + + + #Vitiligo.# + (_Synonyms:_ Leucoderma; Leucopathia.) + + +#Give a definition of vitiligo.# + +Vitiligo may be defined as a disease involving the pigment of the skin +alone, characterized by several or more progressive, milky-white patches +surrounded by increased pigmentation. + + +#Describe the symptoms of vitiligo.# + +The disease may begin at one or more regions, the backs of the hands, +trunk and face being favorite parts; its appearance is usually +insidious, and the spots may not be especially noticeable until they are +the size of a pea or larger. The patches grow slowly, are milky or dead +white, smooth, non-elevated, and of rounded outline; the bordering skin +is darker than normal, showing increased pigmentation. Several +contiguous spots may coalesce and form a large, irregularly-shaped +patch. Hair growing on the involved skin may or may not be blanched. + +There are no subjective symptoms. + + +#What course does vitiligo pursue?# + +The course of the disease is slow, months and sometimes years elapsing +before it reaches conspicuous development. It may after a time remain +stationary, or, in rare instances, retrogress; as a rule, however, it is +progressive. Exceptionally, the greater part, or even the whole surface +may eventually be involved. + + +#Give the etiology of vitiligo.# + +Disturbed innervation is thought to be influential. The disease develops +often without apparent cause. Alopecia areata and morph[oe]a have been +observed associated with it. + +[Illustration: Fig. 36. Vitiligo.] + + +#State the pathology of vitiligo.# + +The disease consists, anatomically, of both a diminution and increase of +the pigment--the white patch resulting from the former, and the +pigmented borders from the latter. There is no textural change, the skin +in other respects being normal. + + +#From what diseases is vitiligo to be differentiated?# + +From morph[oe]a and from the anæsthetic patches of leprosy. + + +#In what respects do these diseases differ from vitiligo?# + +In morph[oe]a there is textural change, and in leprosy both textural +change and constitutional or other symptoms. + + +#What prognosis is to be given?# + +It should always be guarded, the disease in almost all cases being +irresponsive to treatment. + + +#What is the treatment of vitiligo?# + +The general health is to be looked after, and remedies directed +especially toward the nervous system to be employed. Arsenic, in small +and continued doses, seems at times to have an influence; when there is +lack of general tone it may be prescribed as follows:-- + + [Rx] Liq. potassii arsenitis, ............. f[dram]j + Tinct. nucis vom., ................... f[dram]iij + Elix. calisayæ, ....... q. s. ad ..... f[Oz]iv. M. + + SIG.--f[dram]j t. d. + +Suprarenal-gland preparations in moderate dosage long continued has +appeared in a few instances to be of some benefit. + +When upon exposed parts, stimulation of the patches, with the view of +producing hyperæmia and consequent pigment deposit; conjoined with +suitable applications to the surrounding pigmented skin, with a view to +lessen the coloration (see _treatment of chloasma_), will be of aid in +rendering the disease less conspicuous. Or the condition may be, in a +measure, masked by staining the patches with walnut juice or similar +pigment. + + + + #Canities.# + (_Synonym:_ Grayness of the Hair.) + + +#Describe canities.# + +Canities, or graying of the hair, may occur in localized areas or it may +be more or less general; the blanching may be slight, scarcely amounting +to slight grayness, or it may be complete. It is common to advancing +years (_canities senilis_); it is seen also exceptionally in early life +(_canities præmatura_). The condition is usually permanent. The loss of +pigment takes place, as a rule, slowly, but several apparently authentic +cases have been reported in which the change occurred in the course of a +night or in a few days. + + +#What is the etiology of canities?# + +The causes are obscure. Heredity is usually an influential factor, and +conditions which impair the general nutrition have at times an +etiological bearing. Intense anxiety, fright, and other profound nervous +shock are looked upon as causative in sudden graying of the hair. + + +#Give the treatment.# + +Canities is without remedy. Dyeing, although not to be advised, is often +practised, and the condition thus masked. + + + + #Alopecia.# + (_Synonym:_ Baldness.) + + +#What do you understand by alopecia?# + +By alopecia is meant loss of hair, either partial or complete. + + +#Name the several varieties of alopecia.# + +The so-called varieties are based mainly upon the etiology, and are +named congenital alopecia, premature alopecia and senile alopecia. + + +#Describe congenital alopecia.# + +Congenital alopecia is a rare condition, in which the hair-loss is +usually noted to be patchy, or the general hair-growth may simply be +scanty. In rare instances the hair has been entirely wanting; in such +cases there is usually defective development of other structures, such +as the teeth. + + +#Describe premature alopecia.# + +Loss of hair occurring in early and middle adult life is not uncommon, +and may consist of a simple thinning or of more or less complete +baldness of the whole or greater part of the scalp. It usually develops +slowly, some months or several years passing before the condition is +well established. It is often idiopathic, and without apparent cause +further than probably a hereditary predisposition. It may also be +symptomatic, as, for example, the loss of hair, usually rapid +(_defluvium capillorum_), following systemic diseases, such as the +various fevers, and syphilis; or as a result of a long-continued +seborrh[oe]a or seborrh[oe]ic eczema (_alopecia furfuracea_). + + +#Describe senile alopecia.# + +This is the baldness so frequently seen developing with advancing years, +and may consist merely of a general thinning, or, more commonly a +general thinning with a more or less complete baldness of the temporal +and anterior portion or of the vertex of the scalp. + + +#What is the prognosis in the various varieties of alopecia?# + +In those cases in which there is a positive cause, as, for instance, in +symptomatic alopecia, the prognosis is, as a rule, favorable, especially +if no family predisposition exists. In the congenital and senile +varieties the condition is usually irremediable. In idiopathic premature +alopecia, the prognosis should be extremely guarded. + + +#How would you treat alopecia?# + +By removing or modifying the predisposing factors by appropriate +constitutional remedies, and by the external use of stimulating +applications. + + +#Name several remedies or combinations usually employed in the local +treatment.# + +Sulphur ointment, full strength or weakened with lard or vaseline; a +lotion of resorcin consisting of one or two drachms to four ounces of +alcohol, to which is added ten to thirty minims of castor oil; and a +lotion made up as follows:-- + + [Rx] Tinct. cantharidis, .................. f[dram]iv + Tinct. capsici, ...................... f[Oz]j + Ol. ricini, .......................... f[dram]ss-f[dram]j + Alcoholis, .... q. s. ad ............. f[Oz]iv. M. + +The following is sometimes beneficial:-- + + [Rx] Resorcin, ............................ gr. lxxx + Quininæ (alkaloid), .................. gr. xv + Ol. ricini, .......................... [minim]v-[minim]xx + Alcoholis, ........................... f[Oz]iv.--M. + +Another excellent formula is: + + [Rx] Resorcin, ............................ gr. lxxx-cxx + Ac. carbolici cryst., ................ gr. xx + Spts. myrciæ, ........................ f[Oz]iv.--M. + +And also the various other stimulating applications employed in alopecia +areata (_q. v._). + +Other measures of value are: Faradic electricity applied daily for five +minutes with a metallic brush or comb; daily massage, with the object of +loosening the skin and giving more freedom to cutaneous and subcutaneous +circulation; and the application, two or three times weekly, of static +electricity by means of the static crown electrode. + +(The application selected should be gently--not rubbing--applied daily +or every second or third day, according to the case; if a lotion, +moistening the parts with it; if an ointment, merely greasing the parts. +Shampooing every one to three weeks, according to circumstances.) + + + + #Alopecia Areata.# + (_Synonyms:_ Area Celsi; Alopecia Circumscripta.) + + +#What do you understand by alopecia areata?# + +[Illustration: Fig. 37. Alopecia Areata.] + +Alopecia areata is an affection of the hairy system, in which occur one +or more circumscribed, round or oval patches of complete baldness +unattended by any marked alteration in the skin. + + +#Upon what parts and at what age does the disease occur?# + +In the large majority of cases the disease is limited to the scalp; but +it may invade other portions of the body, as the bearded region, +eyebrows, eyelashes, and, in rare instances, the entire integument. + +It is most common between the ages of ten and forty. + + +#Describe the symptoms of alopecia areata.# + +The disease begins either suddenly, without premonitory symptoms, one or +several patches being formed in a few hours; or, and as is more usually +the case, several days or weeks elapse before the bald area or areas are +sufficiently large to become noticeable. The patches continue to extend +peripherally for a variable period, and then remain stationary, or +several gradually coalesce and form a large, irregular area involving +the entire or a greater portion of the scalp. The skin of the affected +regions is smooth, faintly pink or milky white, and at first presents no +departure from the normal; sooner or later, however, the follicles +become less prominent, and slight atrophy or thinning may occur, the +bald plaques being slightly depressed. + +[Illustration: Fig. 38. Alopecia Areata--complete hair loss.] + +Occasionally, usually about the periphery and in the early stages, a few +hair-stumps may be seen. + + +#What course does alopecia areata pursue?# + +Almost invariably chronic. After the lapse of a variable period the +patches cease to extend, the hairs at the margins of the bald areas +being firmly fixed in the follicles; sooner or later a fine, colorless +lanugo or down shows itself, which may continue to grow until it is +about a half-inch or so in length and then drop out; or it may remain, +become coarser and pigmented, and the parts resume their normal +condition. Not infrequently, however, after growing for a time, the new +hair falls out, and this may happen several times before the termination +of the disease. + + +#Are there any subjective symptoms in alopecia areata?# + +As a rule, not; but occasionally the appearance of the patches is +preceded by severe headache, itching or burning, or other manifestations +of disturbed innervation. + + +#State the cause of alopecia areata.# + +The etiology is obscure. Two theories as to the cause of the disease +exist: one of these regards it as parasitic, and the other considers it +to be trophoneurotic. Doubtless both are right, as a study of the +literature would indicate that there are, as regards etiology, really +two varieties--the contagious and the non-contagious. In America +examples of the contagious variety are uncommon. + + +#Does the skin undergo any alterative or destructive changes?# + +Microscopical examination of the skin of the diseased area shows little +or no alteration in its structure beyond slight thinning. + + +#How do you distinguish alopecia areata from ringworm?# + +The plaques of alopecia areata are smooth, often completely devoid of +hair, and free from scales; while those of ringworm show numerous broken +hairs and stumps, desquamation, and usually symptoms of mild +inflammatory action. In doubtful cases recourse should be had to the +microscope. + + +#What is the prognosis in alopecia areata?# + +The disease is often rebellious, but in children and young adults the +prognosis is almost invariably favorable, permanent loss of hair being +uncommon. The same holds true, but to a much less extent, with the +disease as occurring in those of more advanced age. In extensive +cases--those in which the hair of the entire scalp finally entirely +disappears, and sometimes involves all hairy parts--the prognosis is +unfavorable. Only exceptionally does recovery ensue in such instances. + +The uncertain duration, however, must be borne in mind; months, and in +some instances several years, may elapse before complete restoration of +hair takes place. Relapses are not uncommon. + + +#How is alopecia areata treated?# + +By both constitutional and local measures, the former having in view the +invigoration of the nervous system, and the latter a stimulating and +parasiticidal action of the affected areas. + + +#Give the constitutional treatment.# + +Arsenic is perhaps the most valuable remedy, while quinine, nux vomica, +pilocarpine, cod-liver oil and ferruginous tonics may, in suitable +cases, often be administered with benefit. + + +#Name several remedies or combinations employed in the external treatment +of alopecia areata.# + +Ointments of tar and sulphur of varying strength; the various mercurial +ointments; the tar oils, either pure or with alcohol; stimulating +lotions, containing varying proportions, singly or in combination, of +tincture of capsicum, tincture of cantharides, aqua ammoniæ, and oil of +turpentine. The following is a safe formula, especially in dispensary +and ignorant class practice: + + [Rx] [beta]-naphthol, ..................... [dram]ss-[dram]j + Ol. cadini, .......................... [dram]j + Ungt. sulphuris, .......... q. s. ad ... [Oz]j M. + +The cautious use of a five to twenty per cent. chrysarobin ointment is +of value. Painting the patches with pure carbolic acid or trikresol +every ten days or two weeks sometimes acts well; it should not be +applied over large areas nor used in young children. Galvanization or +faradization of the affected parts may also be employed, and with, +occasionally, beneficial effect. Stimulation with the high-frequency +current by means of the vacuum electrode is also of value. When +practicable, the Finsen light can be applied with hope of benefit and +cure. + + + + #Atrophia Pilorum Propria.# + (_Synonym:_ Atrophy of the Hair.) + + +#What do you understand by atrophy of the hair?# + +An atrophic, brittle, dry condition of the hair, and which may be either +symptomatic or idiopathic. + + +#Describe the several conditions met with.# + +As a symptomatic affection, the dry, brittle condition of the hair met +with in seborrh[oe]a, in severe constitutional diseases, and in the +various vegetable parasitic affections, may be referred to. + +As an idiopathic disease it is rare, consisting simply of a brittleness +and an uneven and irregular formation of the hair-shaft, with a tendency +to split up into filaments (_fragilitas crinium_); or there may be +localized swelling and bursting of the hair-shaft, the nodes thus +produced having a shining, semi-transparent appearance (_trichorrhexis +nodosa_). This latter usually occurs upon the beard and moustache. + + +#State the causes of atrophy of the hair.# + +The causes of the symptomatic variety are usually evident; the etiology +of idiopathic atrophy is obscure, but by many is thought due to +parasitism. + +[Illustration: Fig. 39. Trichorrhexis Nodosa. (_After Michelson._)] + + +#What would be your prognosis and treatment in atrophy of the hair?# + +Symptomatic atrophy usually responds to proper measures, but always +slowly; treatment is based upon the etiological factors. + +For the idiopathic disease little, as a rule, can be done; repeated +shaving or cutting the hair has, in exceptional instances, been followed +by favorable results. + + + + #Atrophia Unguis.# + (_Synonyms:_ Atrophy of the Nails; Onychatrophia.) + + +#Describe atrophy of the nails.# + +The nails are soft, thin and brittle, splitting easily, and are often +opaque and lustreless, and may have a worm-eaten appearance. Several or +more are usually affected. + + +#State the causes of atrophy of the nails.# + +The condition may be congenital or acquired, usually the latter. It may +result from trauma, or be produced by certain cutaneous diseases, +notably eczema and psoriasis; or it may follow injuries or diseases of +the nerves. Syphilis and chronic wasting constitutional diseases may +also interfere with the normal growth of the nail-substance, producing +varying degrees of atrophy. The fungi of tinea trichophytina and tinea +favosa at times invade these structures and lead to more or less +complete disintegration--_onychomycosis_. + +[Illustration: Fig. 40. Atrophy of the Nails.] + + +#What is the treatment of atrophy of the nails?# + +Treatment will depend upon the cause. When it is due to eczema or +psoriasis, appropriate constitutional and local remedies should be +prescribed. If it is the result of syphilis, mercury and potassium +iodide are to be advised. In onychomycosis--an exceedingly obstinate +affection--the nails should be kept closely cut and pared, and a one- to +five-grain solution of corrosive sublimate applied several times a day; +a lotion of sodium hyposulphite, a drachm to the ounce, is also a +valuable and safe application. + + + + #Atrophia Cutis.# + (_Synonyms:_ Atrophoderma; Atrophy of the Skin.) + + +#What do you understand by atrophy of the skin?# + +By atrophy of the skin is meant an idiopathic or symptomatic wasting or +degeneration of its component elements. + + +#State the several conditions met with.# + +Glossy skin, general idiopathic atrophy of the skin, parchment skin, +atrophic lines and spots, senile atrophy, and the atrophy following +certain cutaneous diseases. + + +#Describe glossy skin (atrophoderma neuriticum), and state the treatment.# + +Glossy skin is a rare condition following an injury or disease of the +nerve. It is usually seen about the fingers. The skin is hairless, +faintly reddish, smooth and shining, with a varnished and thin +appearance, and with a tendency to fissuring. More or less severe and +persistent burning pain precedes and accompanies the atrophy. + +Protective applications are called for, the disease tending slowly to +spontaneous disappearance. + + +#Describe general idiopathic atrophy of the skin, and give the treatment.# + +General idiopathic atrophy of the skin is extremely rare, and is +characterized by a gradual, more or less general, degenerative and +quantitative atrophy of the skin structures, accompanied usually with +more or less discoloration and pigmentation. + +Treatment is palliative and based upon indications. + + +#Describe parchment skin, and state the treatment.# + +Parchment skin (_xeroderma pigmentosum_, _angioma pigmentosum et +atrophicum_) is a rare disease, the exact nature of which is not +understood. It is characterized by the appearance of numerous +disseminated, freckle-like pigment-spots, telangiectases, atrophied +muscles, more or less shrinking and contraction of the integument, and +followed, in most instances, by epitheliomatous tumors and ulceration, +and finally death. It is usually slow in its course, beginning in +childhood and lasting for years. It is not infrequently seen in several +children of the same family. + +Treatment is palliative, consisting, if necessary, of the use of +protective applications and of the administration of tonics and +nutrients. + + +#Describe atrophic lines and spots.# + +Atrophic lines and spots (_striæ et maculæ atrophicæ_) may be idiopathic +or symptomatic, the lesions consisting of scar-like or atrophic-looking, +whitish lines and macules, most commonly seen on the trunk. They are +smooth and glistening. Slight hyperæmia usually precedes their +formation. As an idiopathic disease its course is insidious and slow, +and its progress eventually stayed. The so-called _lineæ albicantes_, +resulting from the stretching of the skin produced by pregnancy or +tumors, and from rapid development of fat, may be mentioned as +illustrating the symptomatic variety. + +In course of time the atrophy becomes less conspicuous. + + +#Describe senile atrophy.# + +Senile atrophy is not uncommon, the atrophy resulting, as the name +inferentially implies, from advancing age. It is characterized by +thinning and wasting, dryness, and a wrinkled condition, with more or +less pigmentation and loss of hair. Circumscribed pigmentary deposits +and seborrh[oe]a, with degeneration, are also noted. + + +#What several diseases of the skin are commonly followed by atrophic +changes?# + +Favus, lupus, syphilis, leprosy, scleroderma and morph[oe]a. + + + + +#CLASS VI.--NEW GROWTHS.# + + + #Keloid.# + (_Synonyms:_ Keloid of Alibert; Cheloid.) + + +#Give a descriptive definition of keloid.# + +Keloid is a fibro-cellular new growth of the corium appearing as one or +several variously-sized, irregularly-shaped, elevated, smooth, firm, +pinkish or pale-reddish cicatriform lesions. + + +#Describe the clinical appearance of keloid.# + +The growth begins as a small, hard, elevated, pinkish or reddish +tubercle, increasing gradually, several months or years usually elapsing +before the tumor reaches conspicuous size. When developed, it is one or +more inches in diameter, is sharply defined, elevated, hard, rounded or +oval, fungoid or crab-shaped, and firmly implanted in the skin. It is +usually pinkish, pearl-white, or reddish, commonly devoid of hair, with +no tendency to scaliness, and with, usually, several vessels coursing +over it. In some instances it is tender, and it may be spontaneously +painful. + +The breast, especially over the sternal region, is a favorite site for +its appearance. One, several or more may be present in the single case. + + +#What course does keloid pursue?# + +Chronic; usually lasting throughout life. In rare instances spontaneous +involution takes place. + + +#State the etiology of keloid.# + +The causes are obscure. The growth usually takes its start from some +injury or lesion of continuity; for instance, at the site of burns, +cuts, acne and smallpox scars, etc.--_cicatricial keloid, false keloid_; +or it may also, so it is thought, originate in normal skin--_spontaneous +keloid, true keloid_. + + +#What is the pathology of keloid?# + +The lesion is a connective-tissue new growth having its seat in the +corium. + + +#Is there any difficulty in the diagnosis of keloid?# + +No. It resembles hypertrophic scar; but this latter, which is +essentially keloidal, never extends beyond the line of injury. + + +#Give the prognosis.# + +The growth is persistent and usually irresponsive to treatment. In some +cases, however, there is eventually a tendency to spontaneous +retrogression, up to a certain point at least. + + +#What is the treatment of keloid?# + +Usually palliative, consisting of the continuous application of an +ointment such as the following:-- + + [Rx] Acidi salicylici, .................... gr. x-xx + Emplast. plumbi, + Emplast. saponis, ... [=a][=a] ....... [dram]iij + Petrolati, ........................... [dram]ij. M. + +An ointment of ichthyol, twenty-five per cent. strength, rubbed in once +or twice daily, is sometimes beneficial. + +Operative measures, such as punctate and linear scarification, +electrolysis and excision, are occasionally practised, but the results +are rarely satisfactory and permanent; not infrequently, indeed, renewed +activity in the progress of the growth is noted to follow. The _x_-ray +can be tried with some hope of improvement. The administration of +thyroid has been thought to have a possible influence in some instances. + + + + #Fibroma.# + (_Synonyms:_ Molluscum Fibrosum; Fibroma Molluscum.) + + +#What do you understand by fibroma?# + +Fibroma is a connective-tissue new growth characterized by one or more +sessile or pedunculated, pea- to egg-sized or larger, soft or firm, +rounded, painless tumors, seated beneath and in the skin. + + +#Describe the clinical appearances of fibroma.# + +The growth may be single, in which case it is apt to be pedunculated or +pendulous, and attain considerable dimensions; as a result of weight or +pressure surface-ulceration may occur. Or, as commonly met with, the +lesions are numerous, scattered over large surface, and vary in size +from a pea to a cherry; the overlying skin being normal, pinkish or +reddish, loose, stretched, hypertrophied or atrophied. + +The tumors are painless. The general health is not involved. + +[Illustration: Fig. 41. Fibroma. (_After Octerlony._)] + + +#What is the course of fibroma?# + +Chronic and persistent. + + +#What is the etiology of fibroma?# + +The cause is not known. Heredity is often noted. The affection is not +common. + + +#State the pathology of fibroma.# + +The growths are variously thought to have their origin in the connective +tissue of the corium, or in that of the walls of the hair-sac, or in the +connective-tissue framework of the fatty tissue. Recent tumors are +composed of gelatinous, newly-formed connective tissue, and the older +growths of a dense, firmly-packed, fibrous tissue. + + +#From what growths is fibroma to be differentiated?# + +From molluscum contagiosum, neuroma and lipoma; the first is +differentiated by its central aperture or depression, neuroma by its +painfulness, and lipoma by its lobulated character and soft feel. + + +#Give the prognosis of fibroma.# + +The disease is persistent, and irresponsive to all treatment save +operative measures. + + +#What is the treatment of fibroma?# + +Treatment consists, when desired and practicable, in the removal of the +growths by the knife, or in large and pedunculated tumors by the +ligature or by the galvano-cautery. + + + + #Neuroma.# + + +#Describe neuroma.# + +Neuroma of the skin is an exceedingly rare disease, characterized by the +formation of variously-sized, usually numerous, firm, immovable and +elastic fibrous tubercles containing new nerve-elements, and accompanied +by violent, paroxysmal pain. Their growth is slow and usually +progressive. Later they are painful upon pressure. They are limited to +one region. + +The tumors are seated in the corium, extending into the deeper +structure, and consist of nerve-fibres, yellow elastic tissue, blood +vessels and lymphoid cells. + +In the two cases reported, excision of the nerve-trunk gave, in one +instance, permanent relief; in the other the effect was only temporary. + + + + #Xanthoma.# + (_Synonyms:_ Vitiligoidea; Xanthelasma.) + + +#What is xanthoma?# + +Xanthoma is a connective-tissue new growth characterized by the +formation of yellowish, circumscribed, irregularly-shaped, +variously-sized, non-indurated, flat or raised patches or tubercles. + + +#Name the two varieties met with.# + +The macular or flat (_xanthoma planum_) and the tubercular (_xanthoma +tuberculatum_ or _tuberosum_). In some instances both varieties +(_xanthoma multiplex_) are seen in the same individual. + + +#Describe the clinical appearances of xanthoma planum.# + +The macular or flat variety is usually seen about the eyelids. It +consists of one, several or more small or large, smooth, opaque, +sharply-defined, often slightly raised, yellowish patches, looking not +unlike pieces of chamois-skin implanted in the skin. + + +#Describe the clinical appearances of xanthoma tuberosum.# + +The tubercular variety is commonly met with upon the neck, trunk and +extremities. It occurs as small, raised, isolated, yellowish nodules, or +as patches made up of aggregations of millet-seed-sized or larger +tubercles. The lesions may be few or they may exist in great numbers. + + +#What is the course of xanthoma?# + +Extremely slow; after reaching a certain development the growths may +remain stationary. + + +#State the etiology of xanthoma.# + +The causes are obscure. Jaundice not infrequently precedes and +accompanies its development, especially in the tubercular variety. The +disease is uncommon, and is usually seen in middle and advanced life, +and more frequently in women. In some cases (_xanthoma diabeticorum_) of +general xanthoma diabetes is the causative factor. + + +#What is the pathology of xanthoma?# + +It is a benign, connective-tissue new growth, with concomitant or +subsequent, but usually partial, fatty degeneration. + + +#Give the prognosis of xanthoma.# + +The condition is persistent, and usually irresponsive to all treatment +save destructive or operative measures. + +#What is the treatment of xanthoma?# + +Treatment consists, in suitable cases, of excision; in some instances, +electrolysis is serviceable. Applications of trichloracetic acid +cautiously made are sometimes of value. In that form of general xanthoma +due to diabetes the treatment of this latter condition will materially +and sometimes completely remove the eruption. + + + + #Myoma.# + (_Synonyms:_ Myoma Cutis; Dermatomyoma; Liomyoma Cutis.) + + +#Describe myoma.# + +The disease is rare, and consists usually of one or several +(exceptionally numerous), variously-sized tumors of the skin, made up of +smooth muscular fibres. They are flat, rounded, oval or pedunculated, +and have a smooth surface and a pale-red color; as a rule, they are +painless. + +The growth is benign, and consists essentially of a new formation of +unstriped muscular fibres; but it may also be composed largely of +connective tissue (_fibromyoma_); or it may contain an abundance of +bloodvessels (_myoma telangiectodes_, _angiomyoma_); or there may be +lymphatic involvement (_lymphangiomyoma_). + + + + #Angioma.# + (_Synonyms:_ Nævus Vasculosus; Nævus Sanguineus.) + + +#Give a definition of angioma.# + +Angioma is a congenital hypertrophy of the vascular tissues of the +corium and subcutaneous tissue. Exceptionally it makes its appearance a +few weeks or a month after birth. + + +#Into what two classes may angiomata be roughly grouped?# + +The flat (or non-elevated) and the prominent (or elevated). + + +#Describe the flat, or non-elevated, variety of angioma.# + +The flat, or non-elevated, angioma (_nævus flammeus_, _nævus simplex_, +_angioma simplex_, _capillary nævus_) may be pin-head- to bean-sized; or +it may involve an area of several inches in diameter, and, exceptionally, +a whole region. It is of a bright- or dark-red color, and is met with +most frequently about the face. In some instances it extends after birth, +reaches a certain size and then remains stationary; occasionally, when +involving a small area, it undergoes involution and disappears. + +The so-called _port-wine mark_ is included in this group. + + +#Describe the prominent, or elevated, variety of angioma.# + +The prominent variety (_venous n[oe]vus_, _angioma cavernosum_, _n[oe]vus +tuberosus_) is variously-sized, often considerably elevated, +clearly-defined, compressible, smooth or lobulated, and of a dark, +purple color; it may, also, be erectile and pulsating. The growth is +usually a single formation, and is met with upon all parts of the body. + + +#What is the pathology of angioma?# + +It is a new growth, consisting of a variable hypertrophy of the +cutaneous and subcutaneous arterial and venous bloodvessels, with or +without an increase of the connective tissue. + + +#Give the treatment of angioma.# + +In some instances, especially in infants, painting the parts repeatedly +with collodion or liquor plumbi subacetatis will act favorably. For +well-established, small, capillary nævi electrolysis or puncturing with +a red-hot needle or with a needle charged with nitric acid may be +employed; for "port-wine mark" frequent and closely contiguous +electrolytic punctures are occasionally followed by a slight diminution +in color. For the _prominent growths_, vaccination, the ligature, +puncturing with the galvano-cautery, and excision are variously resorted +to. + +In recent years applications of liquid air and carbon dioxide have proved +of service in some cases. + + + + #Telangiectasis.# + + +#Describe telangiectasis.# + +Telangiectasis consists of a new growth or enlargement of the cutaneous +capillaries, usually appearing during middle adult life, and seated, for +the most part, about the face. + + +#To what extent may telangiectasis develop?# + +It may be limited to a red dot or point, with several small radiating +capillaries (_nævus araneus_, _spider nævus_), or a whole region, usually +the face, may show numerous scattered or closely-set capillary +enlargements or new formations (_rosacea_). The latter is frequently +associated with acne (_acne rosacea_). + +The etiology is obscure. + + +#What is the treatment of telangiectasis?# + +Destruction of the vessels by electrolysis or by the knife. (See +treatment of acne rosacea.) + + + + #Lymphangioma.# + (_Synonym:_ Lymphangiectodes.) + + +#Describe lymphangioma.# + +Lymphangioma is a rare disease, consisting of localized dilatations of +the lymphatic vessels, appearing as discrete or aggregated pin-head or +pea-sized, compressible, hollow, tubercle-like elevations, of a pinkish +or faint lilac color, and occurring for the most part about the trunk. +It is of slow but usually progressive development, and is unaccompanied +by subjective symptoms. + +A rare condition, Kaposi described as lymphangioma tuberosum multiplex, +characterized by more or less solid, somewhat cystic, pearly to pinkish +red, sometimes crowded lesions, is now known to be "benign cystic +epithelioma"; its most common site is the face. While called "benign," +ulcerative action may eventually ensue. + +Treatment, when demanded, consists of operative measures. + + + + #Rhinoscleroma.# + + +#Describe rhinoscleroma.# + +Rhinoscleroma is a rare and obscure disease, slow but progressive in its +course, characterized by the development of an irregular, dense and +hard, flattened, tubercular, non-ulcerating, cellular new growth, having +its seat about the nose and contiguous parts. The overlying skin is +normal in color, or it may be light- or dark-brown or reddish. Marked +disfigurement and closure, partial or complete, of the nasal orifices +gradually results. It is met with chiefly in Austria and Germany. + +Treatment, consisting of partial or complete extirpation, is rarely +permanent in its results, the disease tending to recur. + + + + #Lupus Erythematosus.# + (_Synonyms:_ Lupus Erythematodes; Lupus Sebaceus; Seborrh[oe]a + Congestiva.) + + +#What is lupus erythematosus?# + +Lupus erythematosus may be roughly defined as a mildly to moderately +inflammatory superficial new-growth formation, characterized by one, +several, or more circumscribed, variously sized and shaped, pinkish or +dark red patches, covered slightly, and more or less irregularly, with +adherent grayish or yellowish scales. + + +#Upon what parts is lupus erythematosus observed?# + +Its common site is the face, usually the nose and cheeks, with a +tendency toward symmetry; it is often limited to these parts, but may +occasionally be seen upon other regions, more especially the lips, ears, +and scalp. In rare instances a great part of the general surface may +become involved. + + +#Describe the symptoms of lupus erythematosus.# + +Usually the disease begins as one or several rounded, circumscribed, +pin-head- to pea-sized lesions; slightly scaly, somewhat elevated, and +of a pinkish, reddish or violaceous color. They slowly, or somewhat +rapidly, increase in area, and after attaining variable size remain +stationary; or they may progress and coalesce, and in this manner sooner +or later involve considerable surface. The patches are sharply defined +against the sound skin by an elevated border, while the central portion +is somewhat depressed and usually atrophic. More or less thickening and +infiltration are observed. _There is no tendency to ulceration_. The +scaliness is, as a rule, scanty. The gland-ducts are enlarged, patulous +or plugged with sebaceous and epithelial matter. + +The subjective symptoms of burning and itching are usually slight and +often wanting. + + +#What course does lupus erythematosus pursue?# + +As a rule, the disease is persistent, although somewhat variable. At +times the patches retrogress, involution taking place with or without +slight sieve-like atrophy or scarring. + + +#State the causes of lupus erythematosus.# + +The etiology is obscure. Some observers believe it to be a variety of +cutaneous tuberculosis. It is essentially a disease of adult and middle +age; is more common in women, and more frequent in those having a +tendency to disorders of the sebaceous glands. It may, in fact, begin as +a seborrh[oe]a. + + +#What is the pathology?# + +It was formerly considered a new growth, but recent opinion tends toward +regarding it as a chronic inflammation of the cutis, superinducing +degenerative and atrophic changes. Variable [oe]dema of the prickle +layer and of the cutis is found. There is no tendency to pus formation. + +[Illustration: Fig. 42. Lupus Erythematosus.] + + +#Is there any difficulty in the diagnosis of lupus erythematosus?# + +As a rule, not, as the features of the disease--the sharply +circumscribed outline, the reddish or violaceous color, the elevated +border, the tendency to central depression and atrophy, the plugged up +or patulous sebaceous ducts, the adherent grayish or yellowish scales, +together with the region attacked (usually the nose and cheeks)--are +characteristic. + + +#State the prognosis of lupus erythematosus.# + +The disease is often capricious and extremely rebellious to treatment; +some cases, up to a certain point at least, yield readily, and +occasionally a tendency to spontaneous disappearance is observed; a +complete cure is, however, it must be confessed, rather rare. The +disease in nowise compromises the general health. In those rare +instances of generalized disease the patient has usually died from an +intercurrent tuberculosis. + + +#How is lupus erythematosus to be treated?# + +The general health is to be looked after and systemic treatment +prescribed, if indicated. As a rule, constitutional remedies exert +little, if any, influence, but exceptionally, cod-liver oil, arsenic, +phosphorus, salicin, quinine, or potassium iodide proves of service. + +Locally, according to the case, soothing remedies, stimulating +applications and destruction of the growth by caustics or operative +measures are to be employed. (_Try the milder applications first._) + + +#Mention the stimulating applications commonly employed.# + +Washing the parts energetically with tincture of sapo viridis, rinsing +and applying a soothing ointment, such as cold cream or vaseline. + +A lotion containing zinc sulphate and potassium sulphuret thoroughly +dabbed on the parts morning and evening:-- + + [Rx] Zinci sulphatis, + Potassii sulphurati, .... [=a][=a] ... [dram]i-[dram]iv + Glycerinæ, ........................... [minim]iv + Aquæ, ................................ f[Oz]iv. M. + +The calamine-and-zinc oxide lotion used in acute eczema is also often +extremely valuable. + +Lotions of ichthyol and of resorcin, five to sixty grains to the ounce; +ichthyol in ointment, five- to twenty-per-cent. strength, is also +useful. + +Painting the patches with pure carbolic acid; repeating a day or two +after the crusts have fallen off. + +The continuous application of mercurial plaster. + +Sulphur and tar ointments, officinal strength or weakened with lard, and +also the following:-- + + [Rx] Ol. cadini, + Alcoholis, + Saponis viridis, ..... [=a][=a] ...... [dram]iiss. M. + +(This is to be rubbed in, in small quantity, once or twice daily, and +later a soothing remedy applied.) + +In recent years both the _x_-ray and Finsen light have been used with +variable success. Repeated applications of the high-frequency current, +with the vacuum electrode, have also proved serviceable. Cautious +applications of liquid air or carbon dioxide have also been used with +some success in the past few years. + + +#When are destructive and operative measures justifiable?# + +In obstinate, sluggish, and long-persistent patches, and then only after +other methods of treatment have failed. (Remember that a patch or +patches of the disease _may_ disappear in course of time spontaneously, +and occasionally _without leaving a scar_.) + + +#State the methods of treatment commonly used in obstinate, sluggish and +persistent patches of lupus erythematosus.# + +Cauterization--with nitrate of silver, with applications of pyrogallic +acid in ointment or in liquor gutta-perchæ, fifteen to thirty per cent. +strength, and with solutions (cautiously employed) of caustic potash, +and exceptionally with the galvano-cautery. + +[Illustration: Fig. 43. Single Scarifier.] + +[Illustration: Fig. 44. Multiple Scarifier. + (_As modified by Van Harlingen._)] + +Operative--scarification, either punctate or linear, and erosion with the +curette. (See treatment of lupus vulgaris.) + + + + #Lupus Vulgaris.# + (_Synonyms:_ Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the + Skin.) + + +#What do you understand by lupus vulgaris?# + +Lupus vulgaris is a cellular new growth, characterized by +variously-sized, soft, reddish-brown, papular, tubercular and +infiltrated patches, usually terminating in ulceration and scarring. + + +#Upon what region is lupus vulgaris usually observed?# + +The face, especially the nose, but any part may be invaded. The area +involved may be small or quite extensive, usually the former. + + +#At what age is the disease noted?# + +In many cases it begins in childhood or early adult life, but as it is +persistent and tends to relapse, it may be met with at any age. + + +#Describe the earlier symptoms of lupus vulgaris.# + +The disease begins by the development of several or more pin-head to +small pea-sized, deep-seated, brownish-red or yellowish tubercles, +having their seat in the deeper part of the corium, and which are +somewhat softer and looser in texture than normal tissue. As the disease +progresses, variously-sized and shaped aggregations or patches result, +covered with thin and imperfectly-formed epidermis. + + +#What changes do the lupus tubercles or infiltrations undergo?# + +The lesions, having attained a certain size or development, may remain +so for a time, but sooner or later retrogressive changes occur: the +matured papules or tubercles, or infiltrated patches, slowly disappear +by absorption, fatty degeneration, and exfoliation, leaving a yellowish +or brownish pigmentation, usually with more or less atrophy or +cicatricial-tissue formation--_lupus exfoliativus_; or disintegration +and destruction result, terminating in ulceration--_lupus exedens, lupus +exulcerans_. This latter is the more usual course. + + +#Describe the clinical appearances and behavior of the lupus ulcerations.# + +They are rounded, shallow excavations, with soft and reddish borders. In +exceptional instances exuberant granulations appear--_lupus +hypertrophicus_; or papillary outgrowths are noted--_lupus verrucosus_. +The ulcerations secrete a variable amount of pus, usually slight in +quantity, which leads to more or less crust formation; later, however, +cicatricial tissue, generally of a _firm and fibrous_ character, +results. + +[Illustration: Fig. 45. Lupus of Arm.] + + +#In what manner does the disease spread?# + +The patches spread by the appearance of new tubercles, or infiltrations +at the peripheral portion. New islets and areas of disease may continue +to make their appearance from time to time, usually upon contiguous +parts. + + +#Are the mucous membranes of the mouth, throat and larynx ever involved?# + +In some instances, and either primarily or secondarily. + +[Illustration: Lupus Vulgaris.] + +[Illustration: Lupus Vulgaris.] + + +#Is the bone tissue ever involved in lupus vulgaris?# + +No. + + +#What course does lupus vulgaris pursue?# + +It is slowly but, as a rule, steadily progressive. Several years or more +may elapse before the area of disease is conspicuous. + + +#What is the cause of lupus vulgaris?# + +It is now known to be due to the invasion of the cutaneous structures by +the tubercle bacillus; in short, a tuberculosis of the skin. It is not +infrequently observed in the strumous and debilitated. It is entirely +independent of syphilis. + + +#What is the pathology of lupus vulgaris?# + +According to recent investigations, the infiltrations of lupus are due +chiefly to cell-proliferation and outgrowth from the protoplasmic walls +and adventitia of the bloodvessels and lymphatics. The fibrous-tissue +network, vessels and a portion of the cell infiltration are thus +produced, the fixed and wandering connective-tissue cells of the +inflamed stroma of the cutis being responsible for the other portion of +the new growth (Robinson). + + +#State the diagnostic features of lupus vulgaris.# + +In a typical, developed patch of lupus are to be seen:--cicatricial +formation, usually of a fibrous and tough character; ulcerations; the +yellowish-brown tubercles and infiltration; and the characteristic soft, +small, yellowish or reddish-brown, cutaneous and subcutaneous points and +tubercles. + + +#How does the tubercular syphiloderm differ from lupus vulgaris?# + +The tubercular syphiloderm is much more rapid in its course, the +ulceration is deeper and the discharge copious and often offensive; the +scarring is soft, and, compared to the amount of ulceration, but +slightly disfiguring; and it is, for obvious reasons, a disease of adult +or late life. The history, together with other evidences of previous or +concomitant symptoms of syphilis, will often aid in the differentiation. + + +#How does epithelioma differ from lupus vulgaris?# + +The edges of the epitheliomatous ulcer are hard, elevated and waxy; the +base is uneven, the secretion thin, scanty and apt to be streaked with +blood; the ulceration usually starts from one point, and is often +painful; the tissue destruction may be considerable; there is little, if +any, tendency to the formation of cicatricial tissue; and, finally, it +is usually a disease of advanced age. + + +#In what respects does lupus erythematosus differ from lupus vulgaris?# + +Lupus erythematosus has no papules, tubercles or ulceration. + + +#How does acne rosacea differ from lupus vulgaris?# + +Acne rosacea is characterized by hyperæmia, dilated vessels, papules, +pustules, the absence of ulceration, and a different history. + + +#State the prognosis of lupus vulgaris.# + +Lupus vulgaris is always a chronic disease, often exceedingly rebellious +to treatment, and one that calls for a guarded opinion. Relapses are not +uncommon. + +[Illustration: Fig. 46. + Galvano-cautery Needle, Knife and Spiral Points. (_As devised by + Bésnier._)] + +The general health usually remains good, but in some instances death by +tuberculosis of the lungs has been noted. + + +#Is external or internal treatment called for in lupus vulgaris?# + +Always external, and not infrequently constitutional also. + + +#What is the constitutional treatment?# + +The general health must be cared for; good, nutritious food, fresh air +and out-door exercise, together with, in many cases, the administration +of such remedies as cod-liver oil, potassium iodide, iron and quinine, +are of therapeutic importance. Tuberculin may be tried in severe and +obstinate cases, but its use is not without danger. + + +#State the object of local treatment.# + +The destruction or removal of the diseased tissue. + + +#May milder methods of treatment sometimes prove beneficial and even +curative?# + +Exceptionally, mercurial plaster, corrosive-sublimate lotion and +ointment (gr. j to [Oz]j), a plaster containing five to fifteen per +cent. of salicylic acid and creasote, repeated paintings with carbolic +acid, and the constant application of lead plaster containing twenty per +cent. of ichthyol, are valuable. + +[Illustration: Fig. 47. Double Curette.] + +Of the milder methods, those most in vogue to-day are the _Finsen light_ +and _x-ray_. Either proves extremely valuable in some cases, but the +Finsen method is the favorite method. + + +#What methods are commonly employed for the rapid removal or destruction +of lupus tissue?# + +Cauterization, scarification, erasion and excision are variously +practised; the particular method depending, in great measure, upon the +extent of the disease, the part involved, and other circumstances. + + +#Name the several caustics, and state how they are employed.# + +_Pyrogallic acid_, used as an ointment:-- + + [Rx] Ac. pyrogallici, ..................... [dram]ij + Emplast. plumbi, ..................... [dram]j + Cerat. resinsæ, ...................... [dram]v. M. + +It is applied for one or two weeks. Every several days the parts are +poulticed, the slough thus removed, and the ointment reapplied, and so +on until the diseased tissue has been destroyed. It is useful in those +cases in which a mild and comparatively painless caustic is advisable. +In most cases several repetitions of this plan are necessary. + +_Arsenious acid_, employed as an ointment-- + + [Rx] Ac. arseniosi, ...................... gr. xx + Hydrarg. sulphid. rub., ............. gr. lx + Ungt. aquæ rosæ, .................... [Oz]i.--M. + +It is painful but thorough; it is spread on lint and renewed daily. The +action is usually sufficient in three days, and the parts are then +poulticed until the slough comes away, after which a simple dressing is +employed. Its application is advisable for a small area only--not more +than four square inches--as absorption is possible. + +_Galvano-cautery._--The diseased tissue is destroyed by numerous +punctures with a red-heated point or by linear incision with a +red-heated knife. It is often a practicable and satisfactory method. The +Paquelin cautery and liquid air and carbon dioxide also have their +advocates. + + +#Describe the operative measures employed in the removal of lupus tissue.# + +_Linear Scarification._--The parts are thoroughly cross-tracked, cutting +through the diseased tissue, and subsequently a simple salicylated +ointment applied. The operation is repeated from time to time, and as a +result the new growth undergoes retrogressive changes, and cicatrization +takes place. + +_Punctate Scarification._--By means of a simple or multiple-pointed +instrument numerous closely-set punctures are made, and repeated from +time to time, usually with the same action and result as from linear +scarification. + +_Erasion._--The parts are thoroughly scraped with a curette, and a +supplementary caustic application made, either with caustic potash or +several days' use of the pyrogallic-acid ointment. The result is usually +satisfactory. + +The dental-burr is also useful in breaking up discrete tubercles. + +_Excision._--This is an effective method if the disease consists of a +small pea- or bean-sized circumscribed patch. + +Of these various operative methods those now most favored are erasion +and excision, punctate and linear scarification methods are now rarely +employed. + + + + #Tuberculosis Cutis.#[D] + (_Synonym:_ Scrofuloderma.) + +[Footnote D: The most important clinical variety of this class is lupus + vulgaris, which is considered above, separately, at some length.] + + +#What do you understand by tuberculosis cutis?# + +The term is applied to those peculiar suppurative and ulcerative +conditions of the skin due to the tubercle bacilli. + + +#How does the common type of tuberculosis cutis begin?# + +The most common type of tuberculous ulceration or involvement of the +skin usually results by extension from an underlying caseating and +suppurating lymphatic gland; or it may have its origin as subcutaneous +tubercles independently of these structures. It tends to spread, and may +involve an area of one or several inches. + +[Illustration: Fig. 48. Tuberculosis Verrucosa Cutis (Negro).] + + +#What are the clinical appearances and behavior of this type of +tuberculous ulceration?# + +It is usually superficial, has thin, red, undermined edges of a +violaceous color, and an irregular base with granulations covered +scantily with pus. As a rule, it spreads gradually as a simple +ulceration, with but slight, if any, outlying infiltration. Subjective +symptoms of a painful or troublesome character are rarely present. Its +course is usually progressive but slow and chronic. + +Other symptoms of tuberculosis are commonly to be found. + + +#Are other forms of tuberculosis cutis met with?# + +A papulo-pustular eruption is sometimes observed, especially on the +upper extremities and face; sluggish and chronic in character and +leaving small pit-like scars; has been known as the _small pustular +scrofuloderma_. + +[Illustration: Fig. 49. + Tuberculosis Verrucosa Cutis (patient had a coexistent pulmonary + tuberculosis).] + +An ulcerative papillomatous or verrucous tuberculosis of the skin +(tuberculosis verrucosa cutis) is also occasionally noted, most commonly +seated upon the lower leg or the back of the hand. It may be slight or +extensive. Its mildest phase is the so-called verruca necrogenica. + + +#Describe verruca necrogenica.# + +Verruca necrogenica is a rare, localized, papillary or wart-like +formation, occurring usually about the knuckles or other parts of the +hand. + +It begins, as a rule, as a small, papule-like growth, increasing +gradually in area, and when well advanced appears as a pea, dime-sized +or larger, somewhat inflammatory, elevated, flat, warty mass, with +usually a tendency to slight pus-formation between the hypertrophied +papillæ; the surface may be horny or it may be crusted. It tends to +enlarge slowly and is usually persistent, but it at times undergoes +involution. + +[Illustration: Fig. 50. + Tuberculosis Cutis (Verruca Necrogenica). (_After Model in Guy's + Museum._)] + + +#State the etiology.# + +Heredity, insufficient and unwholesome food, impure air, and the like +are predisposing. The tubercle bacillus is the immediate exciting cause. + +The disease usually appears in childhood or early adult life, and not +infrequently follows in the wake of some severe systemic disease. +Etiologically it is identical in nature with lupus. + + +#How is the tuberculous ulcer to be differentiated from syphilis?# + +By the peculiar character of the tuberculous ulceration, the absence of +outlying tubercles and infiltration, together with its history, course, +and often the presence of other tuberculous symptoms. + + +#State the prognosis.# + +These various types of tuberculosis cutis are, as a rule, more amenable +to treatment than that form known as lupus vulgaris (_q. v._). + + +#What is the treatment of these forms of tuberculosis cutis?# + +Constitutional remedies, such as cod-liver oil, iodide of iron or other +ferruginous tonics, together with good food and pure air; phosphorus +one-hundredth to one-fiftieth of a grain three times daily is also of +benefit in some cases. + +The local treatment consists in thorough curetting and the subsequent +application of a mildly stimulating ointment. The several other plans of +external treatment employed in lupus (_q. v._) are also variously +practised. In recent years the _x_-ray and Finsen light plans have, in a +measure, supplanted the previous methods of treatment. They are slow, +however, and might be, especially the _x_-ray, more satisfactorily +employed as a supplementary measure. + + + + #Ainhum.# + + +#Describe ainhum.# + +Ainhum is a disease of the African race, met with chiefly in Brazil, the +West Indies, and Africa, and consists of a slow but gradual linear +strangulation of one or more of the toes, especially the smallest, +resulting, eventually, in spontaneous amputation. The affected toes +themselves undergo fatty degeneration, often with increase in size, and +are, when strangulation is well advanced, considerably misshapen. The +nature of the disease is obscure. + +_Treatment_ consists, in the early stages, of incision through the +constricting band; when the disease is well advanced, amputation is the +sole recourse. + + + + #Mycetoma.# + (_Synonyms:_ Fungous Foot of India; Madura Foot; Podelcoma.) + + +#Decribe mycetoma.# + +It is a disease involving usually the foot, and is met with chiefly in +India. It is characterized by swelling and the formation of tubercular +or nodular lesions which break down and form the external openings of +sinuses which lead to the interior of the affected part. These +discharge, and are studded with, whitish granules or black, roe-like +masses, mixed with a sanious or sero-purulent fluid. The whole part is +gradually disintegrated, the process lasting indefinitely. Its nature is +obscure; it is thought to be due to a fungus. + +_Treatment_ consists in the early stages, when the disease is limited, +of thorough curetting and cauterization; later, after the part is more +or less involved, amputation, at a point well up beyond the disease, +becomes necessary. Potassium iodide internally may exert a favorable +influence. + + + + #Perforating Ulcer of the Foot.# + + +#Describe perforating ulcer of the foot.# + +Perforating ulcer of the foot is a rare disease, consisting of an +indolent and usually painless sinus leading down to diseased bone. The +external opening, which is through the centre of a corn-like formation, +is small, and may or may not show the presence of granulations. The +affected part is commonly more or less anæsthetic and of subnormal +temperature. One or several may be present, either on one or both feet. +The most common site is over the articulation of the metatarsal bone +with the phalanx of the first or last toe. The disease is dependent upon +impairment or degeneration of the central, truncal or peripheral nerves. + + +#What is to be said in regard to the prognosis and treatment?# + +Treatment, which is, as a rule, unsatisfactory, consists in the +maintenance of absolute rest, and the use of antiseptic and stimulating +applications. Amputation is also resorted to, but even this is at times +futile, as a new sinus may appear upon the stump. + + + + #Syphilis Cutanea.# + (_Synonyms:_ Syphiloderma; Dermatosyphilis; Syphilis of the Skin.) + + +#In what various types may syphilis manifest itself upon the integument?# + +Syphilis may show itself as a macular, papular (rarely vesicular), +pustular, bullous, tubercular and gummatous eruption; or the eruption +may be, in a measure, of a mixed type. + + +#In what respects do the early (or secondary) eruptions of syphilis +differ from those following several years or more after the contraction +of the disease?# + +The early or secondary eruptions are more or less generalized, with +rarely any attempt at special configuration. Their appearance is often +preceded by symptoms of systemic disturbance, such as fever, loss of +appetite, muscular pains and headache; and accompanied by concomitant +signs of the disease, such as enlargement of the lymphatic glands, sore +throat, mucous patches, falling of the hair and rheumatic pains. + + +#State the distinguishing characters of the late eruptions.# + +The late eruptions (those following one or more years after the +contraction of the disease) are usually of tubercular, gummatous or +ulcerative type; are limited in extent, and have a marked tendency to +appear in circular, semicircular or crescentic forms or groups. Pain in +the bones, bone lesions and other symptoms may or may not be present. + + +#What is the color of syphilitic lesions?# + +Usually, a dull brownish-red or ham-red, with at times a yellowish cast. + + +#Are there any subjective symptoms in syphilitic eruptions?# + +As a rule, no; but in exceptional instances of the generalized +eruptions, more especially in negroes, there may be slight itching. + + +#Describe the macular, or erythematous, eruption of syphilis.# + +The _macular syphiloderm_ is a general eruption, showing itself usually +six or eight weeks after the appearance of the chancre. It consists of +small or large, commonly pea- or bean-sized, rounded or +irregularly-shaped, not infrequently slightly raised, macules. When well +established they do not entirely disappear under pressure. At first a +pale-pink or dull, violaceous red, they later become yellowish or +coppery. The eruption is generally profuse; the face, backs of the hands +and feet may escape. It persists several weeks or one or two months; as +a rule, it is rapidly responsive to treatment. + + +#How would you distinguish the macular syphiloderm from measles, rötheln +and tinea versicolor?# + +Measles is to be differentiated by its catarrhal symptoms, fever, form +and situation of the eruption; rötheln, by its small, roundish, +confluent pinkish or reddish patches, its precursory pyrexic symptoms, +its epidemic nature, and short duration; tinea versicolor by its +scaliness, peripheral growth, distribution and history. + +And, finally, by the absence or presence of other symptoms of syphilis. + +[Illustration: Fig. 51. Macular Syphiloderm.] + + +#What several varieties of the papular eruption of syphilis are met with?# + +There are two forms of the papular eruption--the small and large; those +of the latter type may undergo various modifications. + + +#Describe the small-papular eruption of syphilis.# + +The _small-papular syphiloderm_ (_miliary papular syphiloderm_) usually +shows itself in the third or fourth month of the disease, and consists +of a more or less generalized eruption of disseminated or grouped, firm, +rounded or acuminated pin-head to millet-seed-sized papules, with smooth +or slightly scaly summits, and in some lesions showing pointed +pustulation. Scattered minute pustules and some large papules are +usually present. The eruption is profuse, most abundant upon the trunk +and limbs; and in the early part of the outbreak is of a bright- or +dull-red color, later assuming a violaceous or brownish tint. It runs a +chronic course, is somewhat rebellious to treatment, and displays a +tendency to relapse. + +[Illustration: Fig. 52. Moist Papules. (_After Miller._)] + + +#How would you distinguish the small-papular syphiloderm from keratosis +pilaris, psoriasis punctata, papular eczema, and lichen ruber?# + +The distribution and extent of the eruption, the color, the grouping, +with usually the presence of pustules and large papules and other +concomitant symptoms of syphilis, are points of difference. Pustules +never occur in the several diseases named, except in eczema. + + +#Describe the large-papular eruption of syphilis.# + +The _large-papular syphiloderm_ (or _lenticular syphiloderm_) is a +common form of cutaneous syphilis, appearing usually in the first six or +eight months, and consists of a more or less generalized eruption of +pea- to dime-sized or larger, flat, rounded or oval, firmly seated, +more or less raised, dull-red papules; with at first a smooth surface, +which later usually becomes covered with a film of exfoliating +epidermis. The papules, as a rule, develop slowly, remain stationary +several weeks or a few months, and then pass away by absorption, leaving +slight pigmentation, which gradually fades; or they may undergo certain +modifications. In most cases it responds rapidly to treatment. + +[Illustration: Small-papular Syphiloderm.] + +[Illustration: Fig. 53. Palmar Syphiloderm.] + + +#What modifications do the papules of the large-papular syphiloderm +sometimes undergo?# + +They may change into the moist papule and squamous papule. + + +#Describe the moist papule of syphilis.# + +The change into the moist papule (also called _mucous patch, flat +condyloma_) is not uncommon where opposing surfaces and natural folds of +skin are subjected to more or less contact, as about the anus, the +scroto-femoral regions, umbilicus, axillæ and beneath the mammæ. The +dry, flat papules gradually become moist and covered with a grayish, +sticky, mucoid secretion; several may coalesce and form large, flat +patches. They may so remain, or they may become hypertrophic, warty or +papillomatous, with more or less crust formation (_vegetating +syphiloderm_). + +[Illustration: Fig. 54. Annular Syphiloderm. (_After I.E. Atkinson._)] + + +#Describe the squamous papule of syphilis.# + +This tendency of the large-papular eruption to become scaly, when +exhibited, is more or less common to all papules, and constitutes the +_squamous_ or _papulo-squamous syphiloderm_ (improperly called +_psoriasis syphilitica_). The papules become somewhat flattened and are +covered with dry, grayish or dirty-gray, somewhat adherent scales. The +scaling, as compared to that of psoriasis, is, as a rule, relatively +slight. The eruption may be general, as usually the case in the earlier +months of the disease, or it may appear as a relapse or a later +manifestation, and be limited in extent. + +As a limited eruption it is most frequently seen on the palms and +soles--the _palmar and plantar syphiloderm_. Occurring on these parts it +is often rebellious to treatment. + +[Illustration: Maculo-papular syphiloderm.] + + +#How are you to distinguish the papulo-squamous syphiloderm from +psoriasis?# + +In psoriasis the eruption is more inflammatory, and usually bright red; +the scales whitish or pearl-colored and, as a rule, abundant. It is +generally seen in greater profusion upon certain parts, as, for +instance, the extensor surfaces, especially of the elbows and knees. It +is not infrequently itchy, and, moreover, presents a different history. + +In the syphilitic eruption some of the papules almost invariably remain +perfectly free from any tendency to scale formation; there is distinct +deposit or infiltration, and the lesions are of a dark, sluggish red or +ham tint; and, moreover, concomitant symptoms of syphilis are usually +present. + + +#Describe the annular eruption of syphilis.# + +The _annular syphiloderm_ (_circinate syphiloderm_) is observed usually +in association with the large-papular eruption, and consists of several +or more variously sized, ring-like lesions, with a distinctly elevated +solid ridge or wall peripherally and a more or less flattened centre. It +is commonly seen about the mouth, forehead and neck. The lesion appears +to have its origin from an ordinary, usually scaleless or slightly +scaly, large papule, the central portion of which has been incompletely +formed or has become sunken and flattened. The manifestation is rare, +and is seen most frequently in the negro. + + +#What several varieties of the pustular syphiloderm are met with?# + +The small acuminated-pustular syphiloderm, the large acuminated-pustular +syphiloderm, the small flat-pustular syphiloderm, and the large +flat-pustular syphiloderm. + + +#Describe the small acuminated-pustular eruption of syphilis.# + +The _small acuminated-pustular syphiloderm_ (_miliary pustular +syphiloderm_) is an early or late secondary eruption, commonly +encountered in the first six or eight months of the disease. It +consists of a more or less generalized, disseminated or grouped, +millet-seed-sized, acuminated pustules, usually seated upon dull-red, +papular elevations. The eruption is, as a rule, profuse, and usually +involves the hair-follicles. The pustules dry to crusts, which fall off +and are often followed by a slight, fringe-like exfoliation around the +base, constituting a grayish ring or collar. Minute pin-point atrophic +depressions or stains are left, which gradually become less distinct. +Scattered large pustules, and sometimes papules, are not infrequently +present. + + +#Describe the large acuminated-pustular eruption of syphilis.# + +The _large acuminated-pustular syphiloderm_ (_acne-form syphiloderm_, +_variola-form syphiloderm_) is a more or less generalized eruption, +occurring usually in the first six or eight months of the disease. It +consists of small or large pea-sized, disseminated or grouped, +acuminated or rounded pustules, resembling the lesions of acne and +variola. They develop slowly or rapidly, and at first may appear more or +less papular. They dry to somewhat thick crusts, and are seated upon +superficially ulcerated bases. + +It pursues, as a rule, a comparatively rapid and benign course. In +relapses the eruption is usually more or less localized. + + +#How would you distinguish the large acuminated-pustular syphiloderm from +acne and variola?# + +In acne the usual limitation of the lesions to the face or face and +shoulders, the origin, more rapid formation and evolution of the +individual lesions, and the chronic character of the disease, are +usually distinctive points. + +In variola, the intensity of the general symptoms, the shot-like +beginning of the lesions, their course, the umbilication, and the +definite duration, are to be considered. + +The presence or absence of other symptoms of syphilis has, in obscure +cases, an important diagnostic bearing. + + +#Describe the small flat-pustular eruption of syphilis.# + +The _small flat-pustular syphiloderm_ (_impetigo-form syphiloderm_) +consists of a more or less generalized, pea-sized, flat or raised, +discrete, irregularly-grouped, or in places confluent, pustules, +appearing usually in the first year of the disease. The pustules dry +rapidly to yellow, greenish-yellow, or brownish, more or less adherent, +thick, uneven, somewhat granular crusts, beneath which there may be +superficial or deep ulceration; where the lesions are confluent a +continuous sheet of crusting forms. The eruption is often scanty. It is +most frequently observed about the nose, mouth, hairy parts of the face +and scalp, and about the genitalia, frequently in association with +papules on other parts. + + +#Are you likely to mistake the small flat-pustular syphiloderm for any +other eruption?# + +Scarcely; but when upon the scalp, it may bear rough resemblance to +pustular eczema, but the erosion or ulceration will serve to +differentiate. Moreover, concomitant symptoms of syphilis are to be +looked for. + + +#Describe the large flat-pustular eruption of syphilis.# + +The _large flat-pustular syphiloderm_ (_ecthyma-form syphiloderm_) +consists of a more or less generalized, scattered eruption, of large +pea- or dime-sized, flat pustules. They dry rapidly to crusts. The bases +of the lesions are a deep-red or copper color. Two types of the eruption +are met with. + +In one type--the superficial variety--the crust is flat, rounded or +ovalish, of a yellowish-brown or dark-brown color, and seated upon a +superficial erosion or ulcer. The lesions are usually numerous, and most +abundant on the back, shoulders and extremities. It appears, as a rule, +within the first year, and generally runs a benign course. + +[Illustration: Fig. 55. Rupia. (_After Tilbury Fox._)] + +In the other type--the deep variety--the crust is greenish or blackish, +is raised and more bulky, often conical and stratified, like an oyster +shell--_rupia_; beneath the crusts may be seen rounded or +irregular-shaped ulcers, having a greenish-yellow, puriform secretion. +It is usually a late and malignant manifestation. + + +#How would you differentiate the large flat-pustular syphiloderm from +ecthyma?# + +The syphilitic lesions are more numerous, are scattered, are attended +with superficial or deep ulceration, and followed by more or less +scar-formation. Moreover, the history, and presence or absence of other +symptoms of syphilis have an important diagnostic value. + +[Illustration: Fig. 56. Ulcerating Tubercular Syphiloderm.] + + +#Describe the bullous eruption of syphilis.# + +The _bullous syphiloderm_, (of acquired syphilis) is a rare and usually +late eruption, appearing in the form of discrete, disseminated, rounded +or ovalish, pea- to walnut-sized, partially or fully distended, blebs. +The serous contents soon become cloudy and puriform. In some cases the +lesions are distinctly pustular from the beginning. The crust, which +soon forms, is of a yellowish-brown or dark green color, and may be +thick and stratified (_rupia_), as in the deep variety of the large +flat-pustular syphiloderm. The erosions or ulcers beneath the crusts +secrete a greenish-yellow fluid. It is a malignant type of eruption, and +is usually seen in broken-down subjects. + +It is not an uncommon manifestation of hereditary syphilis (_q. v._) in +the newborn. + +[Illustration: Fig. 57. Tubercular Syphiloderm.] + + +#How is the bullous syphiloderm to be differentiated from other +pemphigoid eruptions?# + +By the gravity of the disease, the accompanying ulceration, the course +and history; and by other evidences, past or present, of syphilis. + + +#Describe the tubercular eruption of syphilis.# + +The _tubercular syphiloderm_ (_syphiloderma tuberculosum_) may +exceptionally occur within the first year as a more or less generalized +eruption. As a rule, however, it is a late manifestation, at times +appearing many years after the initial lesion; is limited in extent, and +shows a decided tendency to occur in groups, often forming segments of +circles and circular areas, clearing in the centre and spreading +peripherally. + +It consists (as a late, limited manifestation) of several or more firm, +circumscribed, deeply-seated, smooth, glistening or slightly scaly +elevations; rounded or acuminated in shape, of a yellowish-red, +brownish-red or coppery color and usually of the size of small or large +peas. Several groups may coalesce, and a serpiginous tract result +(_serpiginous tubercular syphiloderm_). The lesions develop slowly, and +are sluggish in their course, remaining, at times, for weeks or months, +with but little change. As a rule, however, they terminate sooner or +later, either by absorption, leaving a more or less permanent pigment +stain with or without slight atrophy (_non-ulcerating tubercular +syphiloderm_), or by ulceration (_ulcerating tubercular syphiloderm_). + +[Illustration: Fig. 58. Ulcerating Tubercular Syphiloderm.] + + +#Describe the ulcerating tubercular syphiloderm.# + +The ulceration may be superficial or deep in character, and involve +several or all of the lesions forming the group. The patch may consist, +therefore, of small, discrete, punched-out ulcers, or of one or more +continuous ulcers, segmented, crescentic or serpiginous in shape. They +are covered with a gummy, grayish-yellow deposit or they may be crusted. +As the ulcerative changes take place, new lesions, especially about the +periphery of the group or patch, may appear from time to time. + +[Illustration: Tubercular Syphiloderm.] + +[Illustration: Large-pustular Syphiloderm.] + +In some instances, more especially about the scalp, the surface of the +ulcerations becomes papillary or wart-like, with an offensive, +yellowish, puriform secretion (_syphilis cutanea papillomatosa_). + + +#From what diseases is the tubercular syphiloderm to be differentiated?# + +From tubercular leprosy, epithelioma and lupus vulgaris, especially the +last-named. + + +#What are the chief diagnostic characters of the tubercular syphiloderm?# + +The tendency to form segments, crescents and circles, the color, the +pigmentation and ulceration, the history, and not infrequently marks or +scars of former eruptions. + +[Illustration: Fig. 59. Tubercular Syphiloderm.] + + +#Describe the gummatous eruption of syphilis.# + +The _gummatous syphiloderm_ (_syphiloderma gummatosum_, _gumma_, +_syphiloma_) is usually a late manifestation, showing itself as one, +several or more painless or slightly painful, rounded or flat, more or +less circumscribed tumors; they are slightly raised, moderately firm, +and have their seat in the subcutaneous tissue. They tend to break down +and ulcerate. + +The lesion begins usually as a pea-sized deposit or infiltration, and grows +slowly or rapidly; when fully developed it may be the size of a walnut, +or even larger. The overlying skin becomes gradually reddish. At first +firm, it is later soft and doughy. It may, even when well advanced, +disappear by absorption, but usually tends to break down, terminating in +a small or large, deep, punched-out ulcer. + +[Illustration: Fig. 60. Tubercular Syphiloderm.] + + +#Does the gummatous syphiloderm invariably appear as a rounded +well-defined tumor?# + +No. Exceptionally, instead of a well-defined tumor, it may appear as a +more or less diffused patch of infiltration, leading eventually to +extensive superficial or deep ulceration. + + +#From what formations is the gummatous syphiloderm to be differentiated?# + +From furuncle, abscess, and sebaceous, fatty and fibroid tumors. + +Attention to the origin, course, and behavior of the lesion, together +with a history, must all be considered in doubtful cases. + +[Illustration: Fig. 61. Large Pustular Syphiloderm.] + + +#What is to be said in regard to the character and time of appearance of +the cutaneous manifestations of hereditary syphilis?# + +In a great measure the cutaneous manifestations of hereditary syphilis +are essentially the same as observed in acquired syphilis. They are +usually noted to occur within the first three months of extra-uterine +life. The macular, papular, and bullous eruptions are most common. + + +#Describe these several cutaneous manifestations of hereditary syphilis.# + +The _macular_ (erythematous) eruption begins as large or small, bright- +or dark-red macules, later presenting a ham or café-au-lait appearance. +At first they disappear upon pressure. The lesions are more or less +numerous, usually become confluent, especially about the folds of the +neck, about the genitalia and buttocks; in these regions resembling +somewhat erythema intertrigo. + +The _papular_ eruption is observed in conjunction with the erythematous +manifestation, or it occurs alone. The lesions are but slightly +elevated, and seem to partake of the nature of both macules and papules. +They are usually discrete, and rarely abundant; they may become decked +with a film-like scale, and at the various points of junction of skin +and mucous membrane, and in the folds, they become abraded and +macerated, developing into _moist papules_. + +The _bullous_ eruption consists of variously-sized, more or less +purulent blebs, and is usually met with at or immediately following +birth. It is most abundant about the hands and feet. Macules and papules +are often interspersed. There may be superficial or deep ulceration +underlying the bullæ. + + +#What other symptoms in addition to the cutaneous manifestations are +noted in hereditary syphilis in the newborn?# + +Mucous patches, and sometimes ulcers, in the mouth and throat; +hoarseness, as shown by the peculiar cry, and indicating involvement of +the larynx; snuffles, a sallow and dirty appearance of the skin, loss of +flesh and often a shriveled or senile look. + + +#What is the pathology of cutaneous syphilis?# + +The syphilitic deposit consists of round-cell infiltration. The mucous +layer, the corium, and in the deep lesions the subcutaneous connective +tissues also, are involved in the process. The infiltration disappears +by absorption or ulceration. The factor now believed to be responsible +for the disease and the pathological changes is the Spirochæta pallida, +discovered by Schaudinn and Hoffmann, and usually found in numbers in +the tissues. + + +#Give the prognosis of cutaneous syphilis.# + +In _acquired syphilis_, favorable; sooner or later, unless the whole +system is so profoundly affected by the syphilitic poison that a fatal +ending ensues, the cutaneous manifestations disappear, either +spontaneously or as the result of treatment. The earlier eruptions will +often pass away without medication, but treatment is of material aid in +moderating their severity and hastening their disappearance, and is to +be looked upon as essential; in the late syphilodermata treatment is +indispensable. In the large pustular, the tubercular and gummatous +lesions, considerable destruction of tissue may take place, and in +consequence scarring result. Ill-health from any cause predisposes to a +relapse, and also adds to the gravity of the case. + +In _hereditary infantile syphilis_, the prognosis is always uncertain: +the more distant from the time of birth the manifestations appear the +more favorable usually is the outcome. + + +#How is cutaneous syphilis to be treated?# + +Always with constitutional remedies; and in the graver eruptions, and +especially in those more or less limited, with local applications also. + + +#What constitutional and local remedies are commonly employed in +cutaneous syphilis?# + +_Constitutional Remedies._--Mercury and potassium iodide; tonics and +nutrients are necessary in some cases. + +_Local Remedies._--Mercurial ointments, lotions and baths, and iodol in +ointment or in (and also calomel) powder form. + + +#Give the constitutional treatment of the earlier, or secondary, +eruptions of syphilis.# + +In secondary or early eruptions mercury alone in almost every case; with +tonics, if called for. If mercury is contraindicated (extremely rare), +potassium iodide may be substituted. + + +#How is mercury usually administered in the eruptions of secondary +syphilis?# + +By the mouth, chiefly as the protiodide, calomel and blue mass, in +dosage just short of mild physiological action; by _inunction_, in the +form of blue ointment; by _hypodermic injection_, usually as corrosive +sublimate solution. The method by _fumigation_, with calomel or +bisulphuret, is now rarely employed. + +The method by the mouth is the common one, and it is only in rare +instances that any other method is necessary or advisable. + + +#What local applications are usually advised in the eruptions of +secondary syphilis?# + +If the eruption is extensive, and more especially in the pustular types, +baths of corrosive sublimate ([dram ii-dram-iv] to Cong. xxx) may be +used; and ointment of ammoniated mercury, twenty to sixty grains to the +ounce, blue ointment, and the ten per cent. oleate of mercury alone or +with an equal quantity of any ointment base. + +The same applications or a dusting powder of calomel may also be used on +moist papules. + + +#How long is mercury to be actively continued in cases of early +(secondary) syphilis?# + +Until one or two months after all manifestations (cutaneous or other) +have disappeared, and then, as a general rule, continued, as a small +daily dose (about one-quarter to one-third of that prescribed during the +active treatment) for a period of two or three months; then another +cycle of the active dosage for a period of four to six weeks; then a +resumption of the smaller daily dose for another two or three months; +and so on, for a period of at least two years. + +(Almost all authorities are agreed as to the importance of prolonged +treatment, but differ somewhat on the question of intermittent or +uninterrupted administration.) + + +#Give the constitutional treatment of the late, or localized, +syphilodermata.# + +Mercury always, usually in small or moderate dosage, as the biniodide or +corrosive chloride, and potassium iodide; the latter in dose varying +from two grains to two drachms or more, t.d., depending upon its action +and the urgency of the case. + + +#How long is constitutional treatment to be continued in cases of the +late syphilodermata?# + +Actively for several weeks after the disappearance of all symptoms, and +then (especially the mercury) continued in smaller dosage (about +one-third) for several months longer. + + +#What applications are usually advised in the late, or localized, +syphilodermata?# + +Ointment of ammoniated mercury, twenty to sixty grains to the ounce; +oleate of mercury, five to ten per cent. strength; mercurial plaster, +full strength or weakened with lard or petrolatum; a two to twenty per +cent. ointment of iodol; resorcin, twenty to sixty grains to the ounce +of ointment base; and lotions of corrosive sublimate, one-half to three +grains to the ounce. + +The following is valuable in offensive and obstinate ulcerations:-- + + [Rx] Hydrarg. chlorid. corros., ........... gr. iv-gr. viij + Ac. carbolici, ....................... gr. x-xx + Alcoholis, ........................... f[dram]iv + Glycerinæ, ........................... f[dram]j + Aquæ, ............ q.s. ad ........... [Oz]iv. M. + +Ointments are to be rubbed in or applied as a plaster; lotions, employed +chiefly in ulcers and ulcerations, are to be thoroughly dabbed on, and +usually supplemented by the application of an ointment. Iodol may also be +applied to ulcers as a dusting-powder, usually mixed with one to several +parts of zinc oxide or boric acid. + + +#Give the treatment of hereditary infantile syphilis.# + +It is essentially the same (but much smaller dosage) as employed in +acquired syphilis. Attention to proper feeding and hygiene is of first +importance. + +Mercury may be given by the mouth, as mercury with chalk (gr. ss-gr. ij, +t.d.); as calomel (gr. 1/20-gr. 1/6, t.d.); and as a solution of +corrosive sublimate (gr. ss-[Oz]vj, [dram]j, t.d.). If mercury is not +well borne by the stomach, it may be administered by inunction; for this +purpose, blue ointment is mixed with one or two parts of lard and spread +(about a drachm) upon an abdominal bandage and applied, being renewed +daily. Treatment by means of baths (gr. x-xxx to the bath) of corrosive +sublimate is, at times, a serviceable method. + +Potassium iodide, if exceptionally deemed preferable, may be given in +the dose of a fractional part of a grain to two or three grains three +times daily. + + +#What local measures are to be advised in cutaneous syphilis of the +newborn?# + +If demanded, applications similar to those employed in eruptions of +acquired syphilis, but not more than one-third to one-half the strength. + + + + #Lepra.# + (_Synonyms:_ Leprosy; Elephantiasis Græcorum.) + + +#What do you understand by leprosy?# + +Lepra, or leprosy, is an endemic, chronic, malignant constitutional +disease, characterized by alterations in the cutaneous, nerve, and bone +structures; varying in its morbid manifestations according to whether +the skin, nerves or other tissues are predominantly involved. + + +#What is the nature of the premonitory symptoms of leprosy?# + +In some instances the active manifestations appear without premonition, +but in the majority of cases symptoms, slight or severe in character, +pointing toward profound constitutional disturbance, such as mental +depression, malaise, chills, febrile attacks, digestive derangements and +bone pains, are noticed for weeks, months, or several years preceding +the outbreak. + + +#What several varieties of leprosy are observed?# + +Two definite forms are usually described--the tubercular and the +anæsthetic. A sharp division-line cannot, however, always be drawn; not +infrequently the manifestations are of a mixed type, or one form may +pass into or gradually present symptoms of the other. + +[Illustration: Fig. 62. Tubercular Leprosy. (_After Stoddard._)] + + +#Describe the symptoms of tubercular leprosy.# + +The formation of tubercles and tubercular masses of infiltration, +usually of a yellowish-brown color, with subsequent ulceration, +constitute the important cutaneous symptoms. Along with, or preceding +these characteristic lesions, blebs and more or less infiltrated, +hyperæsthetic or anæsthetic, pinkish, reddish or pale-yellowish macules +make their appearance from time to time; subsequently fading away or +remaining permanently (_lepra maculosa_). + +When well advanced, the tubercular or nodular masses give rise to great +deformity; the face, a favorite locality, becomes more or less leonine +in appearance (_leontiasis_). The tubercles persist almost indefinitely +without material change, or undergo absorption or ulceration; this last +takes place most commonly about the fingers and toes. The mucous +membrane of the mouth, pharynx and other parts may also become involved. + +[Illustration: Fig. 63. Anæsthetic Leprosy.] + + +#Describe the symptoms of anæsthetic leprosy.# + +Following or along with precursory symptoms denoting general systemic +disturbance, or independently of any prodromal indications, a +hyperæsthetic condition, in localized areas or more or less general, is +observed. Lancinating pains along the nerves and an irregular pemphigoid +eruption are also commonly noted. There soon follows the special +eruption, coming out from time to time, and consisting of several or +more, usually non-elevated, well-defined, pale-yellowish patches, one or +two inches in diameter. As a rule, they are at first neither +hyperæsthetic nor anæsthetic, but may be the seat of slight burning or +itching. They spread peripherally, and tend to clear in the centre. The +patches eventually become markedly anæsthetic, and the overlying skin, +and the skin on other parts as well, becomes atrophic and of a brownish +or yellowish color. The subcutaneous tissues, muscle, hair and nails +undergo atrophic or degenerative changes, and these changes are +especially noted about the hands and feet. These parts become crooked, +the bone tissues are involved, the phalanges dropping off or +disappearing by disintegration or absorption (_lepra mutilans_). Sooner +or later various paralytic symptoms, showing more active involvement of +the nerve trunks, present themselves. + + +#State the cause of leprosy.# + +Present knowledge points to a peculiar bacillus as the active factor, +while climate, soil, heredity, food and habits exert a predisposing +influence. + + +#Is leprosy contagious?# + +The consensus of opinion points to the acceptance of the possible +contagiousness of leprosy; probably by inoculation, but only under +certain unknown favoring conditions. + + +#What are the pathological changes?# + +The lesions consist essentially of a new growth, made up of numerous +small, more or less aggregated round cells, beginning in the walls of +the bloodvessels. In this way the tubercular masses and various other +lesions are formed. As yet, positive involvement ot the central nervous +system has not been shown, but some of the nerve trunks are found to be +inflamed and swollen, with a tendency toward hardening. + + +#What several diseases are to be eliminated in the diagnosis of leprosy?# + +Syphilis, morph[oe]a, vitiligo, lupus, and syringomyelia. + +When well advanced, the aggregate symptoms of leprosy form a picture +which can scarcely be confused with that of any other disease. In +doubtful cases microscopical examinations of the involved tissues, for +the bacilli, should be made. + + +#State the prognosis of leprosy.# + +Unfavorable; a fatal termination is the rule, but may not be reached for +a number of years. The tubercular form is the most grave, the mixed +variety next, and the anæsthetic the least. Patients are not +infrequently carried off by intercurrent disease. Proper management will +often delay the fatal ending, and exceptionally, in the anæsthetic +variety, stay the progress of the disease. + + +#What is the treatment of leprosy?# + +Hygienic measures are important. Chaulmoogra oil and gurjun oil +internally and externally are in some instances of service. Strychnia +alone, or with either of these oils, is ofttimes beneficial. Ichthyol +internally, and external applications of the same drug, and of resorcin, +chrysarobin, and pyrogallic acid, have been extolled. Change of climate, +especially to a region where the disease does not prevail, is often of +great advantage. + + + + #Pellagra.# + (_Synonym:_ Lombardian Leprosy.) + + +#Describe pellagra.# + +Pellagra is a slow but usually progressive disease occurring chiefly in +Italy, due, it is thought, to the continued ingestion of decomposed or +fermented maize. It is characterized by cutaneous symptoms, at first +upon exposed parts, of an erythematous, desquamative, vesicular and +bullous character, and by general constitutional disturbance of a +markedly neurotic type. A fatal ending, if the disease is at all severe +or advanced, is to be expected. + +Treatment is based upon general principles. + + + + #Epithelioma.# + (_Synonyms:_ Skin Cancer; Epithelial Cancer; Carcinoma Epitheliale.) + + +#What several varieties of epithelioma are met with?# + +Three--the superficial, the deep-seated, and the papillomatous. + + +#Describe the clinical appearances and course of the superficial variety +of epithelioma.# + +The superficial, or flat variety (_rodent ulcer_), begins, usually on +the face, as a minute, firm, reddish or yellowish tubercle, as an +aggregation of such, as a warty excrescence, or as a localized +degenerative seborrh[oe]ic patch. The latter lesion (known also as +keratosis senilis, old-age atrophic patches), consisting of a yellowish +or yellowish-brown greasy or hardened scurfy spot or patch is quite +frequently the starting-point of epithelial growths. Sooner or later, +commonly after months or several years, the surface becomes slightly +excoriated, and an insignificant, yellowish or brownish crust is formed. +The excoriation gradually develops into superficial ulceration, and the +diseased area becomes slowly larger and larger. New lesions may +continue, from time to time, to appear about the edges and go through +the same changes. + +[Illustration: Fig. 64. Epithelioma. (_After D. Lewis._)] + +The ulcer has usually an uneven surface, secretes a thin, scanty, viscid +fluid, which dries to a firm, adherent crust. It is usually defined +against the healthy skin by a slightly elevated, hard, roll-like, +waxy-looking border. In rare instances there is a disposition, at +points, to spontaneous involution and scar formation; as a rule, +however, the ulcerative action slowly progresses. + +The general health is unimpaired, the neighboring lymphatic glands are +not involved, and the local condition, beyond the disfigurement, gives +rise to little trouble, unless, as occasionally happens, it passes into +the more malignant, deep-seated variety. + + +#Describe the clinical appearances and course of the deep-seated variety +of epithelioma.# + +The deep-seated variety starts from the superficial form, or it begins +as a tubercle or nodule in the skin. When typically developed, a +reddish, shining tubercle or nodule, or area of infiltration, forms in +the skin or subcutaneous tissue. In the course of weeks or months +superficial or deep-seated ulceration takes place; the ulcer having +hardened, and, as a rule, everted edges. The surface is reddish and +granular, and secretes an ichorous discharge. The infiltration spreads, +the ulcer enlarges both peripherally and in depth--muscle, cartilage and +bone often becoming invaded. The neighboring lymphatic gland may become +implicated, pains of a burning or neuralgic type are experienced, and +from septicæmia, marasmus, or involvement of vital parts, death +eventually ensues. + + +#Describe the clinical appearances and course of the papillomatous +variety of epithelioma.# + +The papillomatous type usually arises from the superficial or +deep-seated variety, or it may begin as a papillary or warty growth. +When fully developed, it presents an ulcerated, fissured and +papillomatous surface, with an ichorous discharge which dries to crusts. +It is slowly progressive, and sooner or later may develop a malignant +tendency. + + +#Upon what parts is epithelioma commonly observed?# + +About the face, especially the nose, eyelids and lips; and also about +the genitalia. It may involve any part. + + +#At what age is epithelioma usually noted?# + +It is essentially a disease of middle and late life, although it is +exceptionally met with in the young. + + +#What is the cause of epithelioma?# + +The etiology is obscure. It is not, as a rule, inherited. Any locally +irritated tissue may be the starting point of the disease. + + +#State the pathology.# + +The process consists in the proliferation of epithelial cells from the +mucous layer; the cell-growth takes place downward, in the form of +finger-like prolongations or columns, or it may spread out laterally, so +as to form rounded masses, the centres of which usually undergo horny +transformation, resulting in the formation of onion-like bodies, the +so-called cell-nests or globes. The rapid cell-growth requires increased +nutriment, and hence the bloodvessels become enlarged; moreover, the +pressure of the cell-masses gives rise to irritation and inflammation, +with corresponding serous and round-cell infiltration. + + +#How would you distinguish epithelioma from syphilitic ulceration, wart, +and lupus vulgaris?# + +From syphilis it is to be differentiated by the history, duration, +character of the base and edges, its comparative slow progress, its +usually slight, viscid discharge, often streaked with blood, and, if +necessary, by the therapeutic test. + +Wart or warty growths are to be differentiated by attention to their +history and course. Long-continued observation may be necessary before a +positive opinion is warrantable. The appearance of any tendency to +crusting, to break down or ulcerate is significant of epitheliomatous +degeneration. + +In lupus vulgaris the deposits are peculiar and multiple, the +ulcerations are of different character, the tendency to scar-formation +constant; and, with few exceptions, it has, moreover, its beginning in +childhood or early adult life. + + +#What factors are to be considered in giving a prognosis in epithelioma?# + +The variety, extent, and rapidity of the process. The superficial form +may exist for years, and give rise to no alarm; whereas the +deeper-seated varieties are always to be viewed as serious, and are, +indeed, often fatal. Involving the genitalia, its course is often +strikingly rapid. Relapses, after removal, are not uncommon. + + +#What is the special object in view in the treatment of epithelioma?# + +Thorough destruction or removal of the epitheliomatous tissue. + + +#How is the destruction or removal of the epitheliomatous tissue +effected?# + +By the use of such caustics as caustic potash, chloride-of-zinc paste, +pyrogallic acid, arsenic, and the galvano-cautery; and by operative +measures, such as excision and erasion with the dermal curette, and by +the _x_-ray. (See treatment of lupus vulgaris.) + +In small lesions the use of an arsenical paste is a most admirable +method of treatment, although somewhat painful. The paste is made of one +part powdered acacia and one to two parts arsenious acid; at the time of +application sufficient water is added to make a paste. This is applied +thickly, and a piece of lint superimposed. A good deal of pain and +inflammatory swelling ensue; at the end of twenty-four hours the part is +poulticed till the slough comes away; the ulcer is then treated as a +simple ulcer, under which healing takes place. Occasionally a second +application is found necessary. + +Upon the whole, the best method in the average case is to curette +thoroughly, and supplement with momentary cauterization, with caustic +potash, or with several days' use of the pyrogallic acid ointment. +During the healing process, short exposures to the Röntgen ray--about +every three to five days--is good practice. + +The degenerative changes in the beginning of scurfy, seborrh[oe]ic spots +or patches seen in old people can frequently be lessened or wholly +stopped by the daily application of an ointment containing 5 to 10 per +cent. of sulphur and 2 to 5 per cent. of salicylic acid. + + +#What can be said of the value of the x-ray in epithelioma?# + +The _x_-ray method is now much in vogue, and proves curative in many +superficial cases, and of benefit in some of the deeper-seated +varieties. In most cases it must be pushed to the point of producing a +mild _x_-ray erythema; and in some instances benefit or cure only occurs +after more active exposure, sufficient to cause an _x_-ray burn of the +second degree. The method is not attended with much risk if properly +used. The healthy parts should be protected by lead-foil. Exposure +should be two to five times weekly, at a distance of three to eight +inches, and from five to twenty minutes, employing a tube of medium +vacuum. Unfortunately the method is usually slow. The radium treatment +is essentially similar to that by the _x_-ray. + +The much better plan, as already intimated, is to employ one of the +several operative or caustic methods, and supplementing, while healing, +with the _x_-ray. + + + + #Paget's Disease of the Nipple.# + (_Synonyms:_ Malignant Papillary Dermatitis; Paget's Disease.) + + +#What do you understand by Paget's disease of the nipple?# + +Paget's disease is a rare, inflammatory-looking, malignant disease of +the nipple and areola in women, usually of advancing years, eventually +terminating in cancerous involvement of the entire gland. + + +#Describe the symptoms of Paget's disease.# + +The first symptoms, which usually last for months or years, are +apparently eczematous, accompanied with more or less burning, itching +and tingling. Gradually, the diseased area, which is sharply-defined, +and feels like a thin layer of indurated tissue, presents a florid, +intensely red, very finely-granular, raw surface, attended with a more +or less copious viscid exudation. Sooner or later retraction and +destruction of the nipple, followed by gradual scirrhous involvement of +the whole breast, takes place. + + +#What is the pathology of Paget's disease?# + +Although it was thought at one time to be a cancerous disease resulting +from a continued eczematous inflammation of the parts, there is now but +little doubt that it is of malignant nature from the earliest stages. +The psorosperm-like bodies found, to the presence of which the disease +has by some authorities been attributed (psorospermosis), are now known +to be merely changed and degenerated epithelia. The morbid changes +consist of an inflammation of the papillary region of the derma, leading +to [oe]dema and vacuolation of the constituent cells of the epidermis, +followed by their complete destruction in places and their abnormal +proliferation in others (Fordyce). + + +#State the diagnostic features of Paget's disease.# + +The age of the patient; the sharp limitation; the well-defined, +indurated film of infiltration; the peculiar, red, raw, granulating +appearance; and, later, the retraction of the nipple; and, finally, the +involvement of the deeper parts. + + +#What is the prognosis?# + +If the disease is recognized early, and properly treated, a cure may be +anticipated; later the outlook is that of scirrhus of the breast. + + +#What is the treatment of Paget's disease?# + +Thorough cauterization by means of caustic potash or the +galvano-cautery; or, its extirpation by means of the curette or +excision. After extirpation or cauterization, supplementary treatment by +the _x_-ray is advisable as an additional measure of precaution against +relapse. + +Until the diagnosis is thoroughly established, soothing applications, +such as are employed in acute eczema, are to be advised. + + + + #Sarcoma.# + (_Synonyms:_ Sarcoma Cutis; Sarcoma of the Skin.) + + +#Describe the several varieties of sarcoma.# + +Sarcoma of the skin is a more or less malignant new growth, of rapid or +slow progress, characterized by the appearance of single or multiple, +variously-shaped, discrete, non-pigmented or pigmented tubercles or +tumors, of size varying from that of a shot to a hazelnut or larger. As +a rule the growths are smooth, firm and elastic, somewhat painful upon +pressure, and exhibit a tendency to ulcerate. The overlying skin is at +first normal and somewhat movable, but as the growths approach the +surface it becomes reddened and adherent; or, if the disease is of the +pigmented variety, it acquires a bluish-black color. It is now generally +believed that the most of the pigmented cases formerly thought to be of +sarcomatous nature are really carcinomatous in character. + +The multiple pigmented sarcoma (_melano-sarcoma_) appears first, usually +on the soles and dorsal surfaces of the feet, and later on the hands. +There is more or less diffuse thickening of the integument. The lesions +themselves manifest a disposition to bleed. + + +#State the prognosis and treatment of sarcoma.# + +The disease is always more or less malignant and, as a rule, sooner or +later a fatal termination takes place. It is usually slow in its course. + +Excision or extirpation, _x_-ray exposures, and the administration of +arsenic in increasing dosage (preferably by hypodermic injection) now +are generally considered the most promising in this usually hopeless +malady. + + + + #Granuloma Fungoides.# + + +#Describe granuloma fungoides.# + +A rare form of disease, heretofore looked upon as sarcomatous, but now +generally recognized as granuloma, and formerly described under the +names _mycosis fungoides_, _inflammatory fungoid neoplasm_, and several +others. It is characterized usually by symptoms of an eczematous, +urticarial, and erysipelatous nature, and by the sudden or gradual +appearance of pinkish or reddish, tubercular, nodular, lobulated, or +furrowed tumors or flat infiltrations, which may disappear by involution +or may be followed by ulceration; several or a larger number of the +growths present a mushroom, papillomatous, or fungoid appearance, +sometimes roughly resembling the cut part of a tomato. In most cases the +tumor stage of the malady is not reached for two or more years; in +exceptional instances, however, they appear in the first few months. The +lesions, especially in their early stages, are, as a rule, accompanied +with more or less burning and itching. + + +#State the prognosis and treatment of granuloma fungoides.# + +The malady may last for several years or much longer, a fatal +termination, with rare exceptions, sooner or later taking place. After +the tumor stage is well established, the patient usually succumbs in +from several months to one or two years. + +[Illustration: Fig. 65. Granuloma Fungoides.] + +Treatment consists of tonics, if indicated, and the administration of +arsenic, preferably hypodermically, and Röntgen-ray exposures, along +with the application of mild antiseptics, and operative interference +when necessary or advisable. + + + + +#CLASS VII.--NEUROSES.# + + + #Hyperæsthesia.# + + +#What is hyperæsthesia?# + +By hyperæsthesia is meant increased cutaneous sensibility. It is usually +more or less localized, and is met with as a symptom in functional and +organic nervous diseases. + + + #Dermatalgia.# + (_Synonyms:_ Neuralgia of the Skin; Rheumatism of the Skin; Dermalgia.) + + +#What do you understand by dermatalgia?# + +By dermatalgia is meant a tender or painful condition of the skin +unattended by structural change. It is commonly limited to a small area, +and is usually symptomatic of functional or organic nervous disease. As +an idiopathic affection it is looked upon as of a rheumatic origin. + +Treatment depends upon the cause. + + + #Anæsthesia.# + + +#What is anæsthesia?# + +Anæsthesia is a diminution, comparative or complete, of cutaneous +sensibility. It is usually localized, and is met with in the course of +certain nervous affections. It is also encountered in leprosy, +morph[oe]a and like diseases. + + + + #Pruritus.# + + +#What do you understand by pruritus?# + +Pruritus is a functional disease of the skin, the sole symptom of which +is itching, there being no structural change. + + +#Describe the symptoms of pruritus.# + +The sole and essential symptom is itchiness, usually more or less +paroxysmal, and worse at night. There are no primary structural lesions, +but in severe and persistent cases the parts become so irritated by +continued scratching that secondary lesions, such as papules and slight +thickening and infiltration, may result. It is much more common in +advanced life--_pruritus senilis_. In such cases, as well as in those +cases in younger and middle-aged individuals in which the itchiness +develops at the approach of cold weather and disappears upon the coming +of the warm season (_pruritus hiemalis_), the pruritus is usually more +or less generalized, although not infrequently in the latter the legs +are specially involved. + +In some individuals an attack of pruritus, of variable intensity, +lasting from five to thirty minutes, comes on immediately after a bath +(_bath-pruritus_). It is usually confined to the legs from the hips +down. + + +#Is pruritus always more or less generalized?# + +No; not infrequently the itching is limited to the genital region +(_pruritus scroti_, _pruritus vulvæ_) or to the anus (_pruritus ani_). + + +#To what may pruritus often be ascribed?# + +To digestive and intestinal derangements, hepatic disorders, the uric +acid diathesis, gestation, diabetes mellitus, and a depraved state of +the nervous system. + +Pruritus vulvæ is at times due to irritating discharges, and pruritus +ani occasionally to hemorrhoids and seat-worms. + + +#Is there any difficulty in the diagnosis of pruritus?# + +No. The subjective symptom of itching without the presence of structural +lesions is diagnostic. In those severe and persistent cases in which +excoriations and papules have resulted from the scratching, the history +of the case, together with its course, must be considered. Care should +be taken not to confound it with pediculosis. In this latter the +excoriations usually have a somewhat peculiar distribution, being most +abundant on those parts of the body with which the clothing lies closely +in contact. (See Pediculosis corporis.) + +In pruritus of the genitocrural region the possibility of pediculi being +the cause must be kept in mind; an examination of the parts for the +parasite or for ova (attached to the hairs) would prevent error. (See +Pediculosis pubis.) + + +#What prognosis would you give in pruritus?# + +In the majority of cases the condition responds to proper treatment, but +in others it proves rebellious. The prognosis depends, in fact, upon the +removability of the cause. Temporary relief may always be given by +external applications. + + +#How would you treat pruritus?# + +With systemic remedies directed toward a removal or modification of the +etiological factors, and, for the temporary relief of the itching, +suitable antipruritic applications. In obscure cases, quinia, salophen, +lithia salts, calcium chloride, belladonna, nux vomica, arsenic, +pilocarpine, and general galvanization may be variously tried. Alkalies +prove useful in many cases. + +Exceptionally, the relief furnished by external treatment is more or +less permanent. + + +#Name the important antipruritic applications.# + +Alkaline baths; lotions of carbolic acid ([dram]j-[dram]iij to Oj), of +resorcin ([dram]j-[dram]iv to Oj), of liquor carbonis detergens +([Oz]j-[Oz]iv to Oj), and liquor picis alkalinus ([dram]j-[dram]iv to +Oj), used cautiously. One or several ounces of alcohol and one or two +drachms of glycerin in each pint of these lotions will often be of +advantage, as the following:-- + + [Rx] Ac. carbolici, ....................... [dram]j-[dram]iij + Gylcerinæ, ........................... f[dram]ij + Alcoholis, ........................... f[oz]ij + Aquæ, ......... q.s. ad .............. Oj. M. + +Various dusting-powders, alone or in conjunction with the lotions. + +And in some cases, especially those in which the skin is unnaturally +dry, ointments may be used, such as equal parts of lard, lanolin, and +petrolatum, to the ounce of which may be added from five to thirty +grains of carbolic acid, three to twenty grains of thymol, ten to thirty +minims of chloroform, or two to ten grains of menthol. + + +#What external applications are to be used in the local varieties of +pruritus?# + +In _pruritus ani_ and _pruritus vulvæ_, in addition to the various +applications above, a cocaine ointment, one to ten grains to the ounce, +a strong solution of the same (gr. v-xx to [Oz]j), and an ointment +containing ten to thirty minims of the oil of peppermint to the ounce; +sponging with hot water, often affords temporary relief. + +In pruritus vulvæ, moreover, astringent applications and injections of +zinc sulphate, alum, tannic or acetic acid, in the strength commonly +employed for vaginal injections, are at times curative. + +In bath-pruritus weak glycerine lotions, and an ointment containing a +few grains of thymol and menthol to the ounce sometimes give moderate +relief. Turkish baths are sometimes free from subsequent pruritus. + + + + +#CLASS VIII.--PARASITIC AFFECTIONS.# + + + #Tinea Favosa.# + (_Synonym:_ Favus.) + +#What is tinea favosa?# + +Tinea favosa, or favus, is a contagious vegetable-parasitic disease of +the skin, characterized by pin-head to pea-sized, friable, umbilicated, +cup-shaped yellow crusts, each usually perforated by a hair. + + +#Upon what parts and at what age is favus observed?# + +It is usually met with upon the scalp, but it may occur upon any part of +the integument. Occasionally the nails are invaded. It is seen at all +ages, but is much more common in children. + + +#Describe the symptoms of favus of the scalp.# + +The disease begins as a superficial inflammation or hyperæmic spot, more +or less circumscribed, slightly scaly, and which is soon followed by the +formation of yellowish points about the hair follicles, surrounding the +hair shaft. These yellowish points or crusts increase in size, become +usually as large as small peas, are cup-shaped, with the convex side +pressing down upon the papillary layer, and the concave side raised +several lines above the level of the skin; they are umbilicated, +friable, sulphur-colored, and usually each cup or disc is perforated by +a hair. Upon removal or detachment, the underlying surface is found to +be somewhat excavated, reddened, atrophied and sometimes suppurating. As +the disease progresses the crusting becomes more or less confluent, +forming irregular masses of thick, yellowish, mortar-like crusts or +accumulations, having a peculiar, characteristic odor--that of mice, or +stale, damp straw. The hairs are involved early in the disease, become +brittle, lustreless, break off and fall out. In some instances, +especially near the border of the crusts, are seen pustules or +suppurating points. _Atrophy_ and more or less actual _scarring_ are +sooner or later noted. + +Itching, variable as to degree, is usually present. + + +#What is the course of favus of the scalp?# + +Persistent and slowly progressive. + +[Illustration: Fig. 66. + Achorion Schönleinii X 450. (_After Duhring._) Showing simple mycelium, + in various stages of development, and free spores.] + + +#What are the symptoms of favus when seated upon the general surface?# + +The symptoms are essentially similar to those upon the scalp, modified +somewhat by the anatomical differences of the parts. + +The _nails_, when affected, become yellowish, more or less thickened, +brittle and opaque (_tinea favosa unguium_, _onychomycosis favosa_). + + +#To what is favus due?# + +Solely to the invasion of the cutaneous structures, especially the +epidermal portion, by the vegetable parasite, the _achorion +Schönleinii_. It is contagious. It is a somewhat rare disease in the +native-born, being chiefly observed among the foreign poor. The nails +are rarely affected primarily. + +It is also met with in the lower animals, from which it is doubtless not +infrequently communicated to man. + + +#What are the diagnostic features of favus?# + +The yellow, and often cup-shaped, crusts, brittleness and loss of hair, +atrophy, and the history. + +[Illustration: Fig. 67. Epilating Forceps.] + + +#How would you distinguish favus from eczema and ringworm?# + +From eczema by the condition of the affected hair, the atrophic and +scar-like areas, the odor, and the history. From ringworm by the +crusting and the atrophy. In this latter disease there is usually but +slight scaliness, and rarely any scarring. + +Finally, if necessary, a microscopic examination of the crusts may be +made. + + +#State the method of examination for fungus.# + +A portion of the crust is moistened with liquor potassæ and examined +with a power of three to five hundred diameters. The fungus, (achorion +Schönleinii), consisting of mycelium and spores, is luxuriant and is +readily detected. + + +#State the prognosis of favus.# + +Upon the scalp, favus is extremely chronic and rebellious to treatment, +and a cure in six to twelve months may be considered satisfactory; in +neglected cases permanent baldness, atrophy, and scarring sooner or +later result. Although favus of the scalp persists into adult life, it +becomes less active and, finally, as a rule, gradually disappears, +leaving behind scarred or atrophic bald areas. + +Upon the general surface it usually responds readily to treatment, +excepting favus of the nails, which is always obstinate. + + +#How is favus of the scalp treated?# + +Treatment is entirely local and consists in keeping the parts free from +crusts, in epilation and applications of a parasiticide. + +The crusts are removed by oily applications and soap-and-water washings. +The hair on and around the diseased parts is to be kept closely cut, +and, when practicable, depilation, or extraction of the affected hairs, +is advised; this latter is, in most cases, essential to a cure. Remedial +applications--the so-called parasiticides--are, as a rule, to be made +twice daily. If an ointment is used, it is to be thoroughly rubbed in; +if a lotion, it is to be dabbed on for several minutes and allowed to +soak in. + + +#Name the most important parasiticides.# + +Corrosive sublimate, one to four grains to an ounce of alcohol and +water; carbolic acid, one part to three or more parts of glycerine; a +ten per cent. oleate of mercury; ointments of ammoniated mercury, +sulphur and tar; and sulphurous acid, pure or diluted. The following is +valuable:-- + + [Rx] Sulphur, præcip., .................... [dram]ij + Saponis viridis, + Ol. cadini, ....... [=a][=a] ......... [dram]j + Adipis, .............................. [Oz]ss. M. + +Chrysarobin is a valuable remedy, but must be used with caution; it may +be employed as an ointment, five to ten per cent. strength, as a rubber +plaster, or as a paint, a drachm to an ounce of gutta-percha solution. +Formalin, weakened or full strength, has been extolled. Some observers +have experimentally tried the effect of _x_-ray exposure with alleged +good results, pushing the treatment to the point of producing +depilation; if used great caution should be exercised. + + +#How is favus upon the general surface to be treated?# + +In the same general manner as favus of the scalp, but the remedies +employed should be somewhat weaker. In favus of the nail frequent and +close paring of the affected part and the application, twice daily, of +one of the milder parasiticides, will eventually lead to a good result. + + +#Is constitutional treatment of any value in favus?# + +It is questionable, but in debilitated subjects tonics, especially +cod-liver oil, may be prescribed with the hope of aiding the external +applications. + + + + #Tinea Trichophytina.# + (_Synonym:_ Ringworm.) + + +#What is tinea trichophytina?# + +Tinea trichophytina, or ringworm, is a contagious, vegetable-parasitic +disease due to the invasion of the cutaneous structures by the vegetable +parasite, the trichophyton, or the microsporon Audouinii. + + +#Do the clinical characters of ringworm vary according to the part +affected?# + +Yes, often considerably; thus upon the scalp, upon the general surface, +and upon the bearded region, the disease usually presents totally +different appearances. + + +#Describe the symptoms of ringworm as it occurs upon non-hairy portions +of the body.# + +Ringworm of the general surface (_tinea trichophytina corporis_, _tinea +circinata_) appears as one or more small, slightly-elevated, +sharply-limited, somewhat scaly, hyperæmic spots, with, rarely, minute +papules, vesico-papules, or vesicles, especially at the circumference. +The patch spreads in a uniform manner peripherally, is slightly scaly, +and tends to clear in the centre, assuming a ring-like appearance. When +coming under observation, the patches are usually from one-half to one +inch in diameter, the central portion pale or pale red, and the outer +portion more or less elevated, hyperæmic and somewhat scaly. As commonly +noted one, several or more patches are present. After reaching a certain +size they may remain stationary, or in exceptional cases may tend to +spontaneous disappearance. At times when close together, several may merge +and form a large, irregular, gyrate patch. + +Itching, usually slight, may or may not be present. + +Exceptionally ringworm appears as a markedly inflammatory pustular +circumscribed patch, formerly thought to be a distinct affection and +described under the name of _conglomerate pustular folliculitis_. It +consists of a flat carbuncular or kerion-like inflammation, somewhat +elevated, and usually a dime to silver dollar in area. The most common +seats are the back of the hands and the buttocks. The surface is +cribriform, and a purulent secretion may be pressed out from follicular +openings. + +[Illustration: Fig. 68. + Tinea trichophytina cruris--so-called eczema marginatum--of unusually + extensive development. (_After Piffard._)] + + +#Describe the symptoms of ringworm when occurring about the thighs and +scrotum.# + +In adults, more especially males, the inner portion of the upper part of +the thighs and scrotum (_tinea trichophytina cruris_, so-called _eczema +marginatum_) may be attacked, and here the affection, favored by heat +and moisture, develops rapidly and may soon lose its ordinary clinical +appearances, the inflammatory symptoms becoming especially prominent. +The whole of this region may become involved, presenting all the +symptoms of a true eczema; the border, however, is sharply defined, and +usually one or more outlying patches of the ordinary clinical type of +the disease may be seen. + + +#Describe the symptoms of ringworm when involving the nails.# + +In ringworm of the nails (_tinea trichophytina unguium_) these +structures become soft or brittle, yellowish, opaque and thickened the +changes taking place mainly about the free borders. Ringworm on other +parts usually coexists. + + +#Describe the symptoms of ringworm as it occurs upon the scalp.# + +Ringworm of the scalp (_tinea trichophytina capitis_, _tinea tonsurans_) +begins usually in the same manner as that upon the general surface, but, +as a rule, much more insidiously. Sooner or later, however, the hair and +follicles are invaded by the fungus, and in consequence the hair falls +out or becomes brittle and breaks off. The follicles, except in +long-standing cases, are slightly elevated and prominent, and the patch +may have a puffed or goose-flesh appearance. In addition, there is +slight scaliness. + + +#Describe the appearances of a typical patch of ringworm of the scalp.# + +The patch is rounded, grayish, somewhat scaly, and slightly elevated; +the follicles are somewhat prominent; there is more or less alopecia, +with here and there broken, gnawed-off-looking hairs, some of which may +be broken off just at the outlet of the follicles and more or less +surrounded by a whitish or grayish-white dust. This type is produced by +the small-spore fungus--microsporon. + + +#Does ringworm of the scalp always present typical appearances?# + +Not invariably. In some cases the patch or patches may become almost +completely bald, and in others a tendency to the formation of pustules, +with more or less crust-formation, may be seen. The affection may also +appear as small scattered spots or points. + +[Illustration: Fig. 69. + Ringworm (rather inflammatory type, and produced by the trichophyton).] + +The markedly inflammatory and pustular types are produced by the +large-spore fungus--trichophyton. + + +#What is tinea kerion?# + +Tinea kerion (_kerion_) is a markedly inflammatory type of ringworm of +the scalp involving the deeper tissues, appearing as a more or less +bald, rounded, inflammatory, [oe]dematous, boggy, honeycombed tumor, +discharging from the follicular openings a mucoid secretion. + + +#Does ringworm of the scalp ever occur in adults?# + +No. (Extremely rare exceptions.) + +[Illustration: Fig. 70. + Ringworm Fungus (Trichophyton) x 450. (_After Duhring._) As found in + epidermic scrapings of ringworm, showing mycelium and spores.] + + +#Describe the symptoms of ringworm of the bearded region.# + +Ringworm of the bearded region (_tinea trichophytina barbæ_, _tinea +sycosis_, _parasitic sycosis_, _barber's itch_) begins usually in the +same manner as ringworm on other parts, as one or more rounded, slightly +scaly, hyperæmic patches. In rare instances the disease may persist as +such, with very little tendency to involve the hairs and follicles; but, +as a rule, the hairy structures are soon invaded, many of the hairs +breaking off, and many falling out. From involvement of the follicles, +more or less subcutaneous swelling ensues, the parts assuming a +distinctly _lumpy and nodular_ condition. The skin is usually +considerably reddened, often having a glossy appearance, and studded +with few or numerous pustules. The nodules tend, ordinarily, to break +down and discharge, at one or more of the follicular openings, a glairy, +glutinous, purulent material, which may dry to thick, adherent crusts. + +[Illustration: Fig. 71. + Ringworm Fungus (Microsporon) x 500. (_After Duhring._) Short, + broken-off hair of scalp invaded with masses of free spores.] + +The disease may be limited to one patch, or a large area, even to the +extent of the whole bearded region, becomes involved. The upper lip is +rarely invaded. Ringworm of the bearded region is due to the trichophyton. + +[Illustration: Fig. 72. + Ringworm Fungus (Trichophyton) x 300. (_After Duhring._) Short, stout + hair of beard, with the root-sheath attached, showing free spores and + chains of spores.] + + +#To what is ringworm due?# + +To the presence and growth in the cutaneous structures of a vegetable +parasite. Although the disease is contagious, individuals differ +considerably as to susceptibility. It is much more common in children +than in those past the age of puberty, ringworm of the scalp being +limited to the former (rare exceptions), and tinea sycosis being a +disease of the male adult. + +Until recently the ringworm was thought to be due to but one fungus--the +trichophyton; it is now known that there are several forms of fungi, the +main forms being the small-spored (microsporon Audouini) and the +large-spored (trichophyton). Of this latter there are two main +subvarieties--endothrix and ectothrix. The small-spored fungus is found +as the cause in the majority of scalp cases; the endothrix also commonly +invades the scalp integument. The ectothrix variety is usually derived +directly or indirectly from domestic animals, and is chiefly responsible +for body-ringworm, and for suppurative ringworm, whether upon the +bearded region or elsewhere. + + +#What is the pathology of ringworm?# + +On the general surface the fungus has its seat in the epidermis, +especially in the corneous layer; upon the scalp and bearded region the +epidermis, hair-shaft, root and follicle are invaded. The inflammatory +action may vary considerably in different cases, and at different times +in the same case. + +The fungus consists of mycelium and spores. In the epidermic scrapings +it is never to be found in abundance, and the mycelium predominates, +while in affected hairs the spores and chains of spores are almost +exclusively seen, and are usually present in great profusion. + + +#How do you examine for the fungus?# + +The scrapings or hair should be moistened with liquor potassæ, and +examined with a power from three hundred diameters upward. + + +#How is ringworm of the general surface to be distinguished from eczema, +psoriasis and seborrh[oe]a?# + +By the growth and characters of the patch, the slight scaliness, the +tendency to disappear in the centre, by the history, and, if necessary, +by a microscopic examination of the scales. + + +#How is ringworm of the scalp to be distinguished from alopecia areata, +favus, eczema, seborrh[oe]a, and psoriasis?# + +By the peculiar clinical features of ringworm on this region--the slight +scaliness, broken hair and hair stumps, with a certain amount of +baldness--and in doubtful cases by a microscopical examination of the +hairs. + +In favus, although the same condition of the hair is noted, the yellow, +cup-shaped crusts, and the presence of the atrophic areas in that +disease are pathognomonic. + + +#How is ringworm of the bearded region to be distinguished from eczema +and sycosis?# + +By the peculiar lumpiness of the parts, the brittleness of the hair, +more or less hair loss, and the history. + +The superficial type of ringworm sycosis--those cases in which the +disease remains a surface disease--is readily distinguished, as the +symptoms are essentially the same as ringworm of non-hairy parts, except +that some of the hairs in the areas may become invaded and break off or +fall out. + +In doubtful cases recourse may be had to microscopical examination. + + +#What is the prognosis of ringworm of these several parts?# + +When upon the general surface, the disease usually responds rapidly to +therapeutical applications; upon the scalp it is always a stubborn +affection, and, as a rule, requires several months to a year of +energetic treatment to effect a cure. In this latter region the disease +will disappear spontaneously as the age of fifteen or sixteen is +reached. Tinea sycosis yields in most instances in the course of several +weeks or a few months. + + +#Is ringworm of these several parts treated with the same remedies?# + +As a rule, yes; but the strength must be modified. The scalp will stand +strong applications, as will likewise the bearded region; upon non-hairy +portions the remedies should be used somewhat weaker. They should be +applied twice daily; ointments, if used, being well rubbed in, and +lotions thoroughly dabbed on. + + +#How would you treat ringworm of the general surface?# + +By applications of the milder parasiticides, such as a ten to fifteen +per cent. solution of sodium hyposulphite; carbolic acid, five to thirty +grains to the ounce of water, or lard; a saturated solution of boric +acid; ointments of tar, sulphur and mercury, official strength or +weakened with lard; and tincture of iodine, pure or diluted. + +When occurring upon the upper and inner part of the thighs (so-called +eczema marginatum), the same remedies are to be employed, but usually +stronger. Deserving of special mention is a lotion of corrosive +sublimate, one to four grains to the ounce; or the same remedy, in the +same proportion, may be used in tincture of myrrh or benzoin, and +painted on the parts. + + +#How would you treat ringworm of the scalp?# + +By occasional soap-and-hot-water washing; by extraction of the involved +hairs, when practicable; by carbolic acid or boric acid lotions to the +whole scalp, so as to limit, as much as possible, the spread of the +disease; and by daily (or twice daily) applications to the patches and +involved areas of a parasiticide. The following are the most valuable: +the oleate of mercury, with lard or lanolin, in varying strength, from +ten to twenty per cent.; carbolic acid, with one to three or more parts +of glycerine or oil; corrosive sublimate, in solution in alcohol and +water, one to four grains to the ounce; sulphur ointment; and citrine +ointment, with one or two parts of lard. Chrysarobin is a valuable +remedy, but is to be employed with care; it may be prescribed as a +rubber plaster, or in a solution of gutta-percha, or as an ointment, ten +to fifteen per cent. strength. [beta]-naphthol in ointment form, five +to fifteen per cent. strength, is also useful. An excellent application +for beginning areas on the scalp is a solution of the red iodide of +mercury in iodine tincture, one to three grains to an ounce. + +A compound ointment, containing several of the active remedies named, is +convenient for dispensary practice, such as:-- + + [Rx] [beta]-naphthol, ................. [dram]ss-[dram]j + Ol. cadini, ......................... [dram]j + Ungt. sulphuris, ............ q.s. ad [Oz]j. M. + +In that form known as tinea kerion mild applications are demanded at +first; later the same treatment as in the ordinary type. + + +#How is ringworm of the bearded region to be treated?# + +On the same general plan and with the same remedies (excepting +chrysarobin) as in ringworm of the scalp. Depilation is to be practised +as an essential part of the treatment. Special mention may be made of an +ointment of oleate of mercury, sulphur ointment, a lotion of sodium +hyposulphite ([dram]j-[Oz]j), and a lotion of corrosive sublimate (gr. +j-iv to [Oz]j). The _x_-ray has been used in ringworm of this region +with alleged success, pushing it to the production of a mild erythema +and depilation. The above methods are, however, usually successful, and +are without risk of damage. + + +#How is the certainty of an apparent cure in ringworm of the scalp or +bearded region to be determined?# + +By the continued absence of roughness and of broken hairs and stumps, +and by microscopical examination of the new-growing hairs from time to +time for several weeks after discontinuance of treatment. + +Cure of ringworm of the general surface is usually self-evident. + + +#Is systemic treatment of aid in the cure of ringworm?# + +It is doubtful, although in children in a depraved state of health the +disease is often noted to be especially stubborn, and in such cod-liver +oil and similar remedies may at times prove of benefit. + + + + #Tinea Imbricata.# + (_Synonym:_ Tokelau Ringworm.) + + +#What is tinea imbricata?# + +A vegetable parasitic disease of moist tropical countries, characterized +by the formation of patches composed of concentrically arranged, +imbricated, scaly rings. It may begin at one or several points as a +brownish, slightly raised spot, spreading peripherally; the renewed +epidermis of the central part of the patch goes again through the same +process; the result is a small or large area of concentrically arranged, +imbricated, slightly scaly eruption. Several such areas fusing together +may cover a large part of the surface, the ring-like arrangement being +sometimes more or less completely lost. The malady is chronic. There may +be a variable degree of itching. The cause of the disease, which is of a +contagious nature, is a vegetable parasite closely similar to the +trichophyton. The treatment is by the parasiticides, being essentially +the same, in fact, as ringworm. + + + + #Tinea Versicolor.# + (_Synonyms:_ Pityriasis Versicolor; Chromophytosis.) + + +#What is tinea versicolor?# + +Tinea versicolor is a vegetable-parasitic disease of the skin, +characterized by variously-sized and shaped, slightly scaly, macular +patches of a yellowish-fawn color, and occurring for the most part upon +the upper portion of the trunk. + + +#Describe the symptoms of tinea versicolor.# + +The disease begins as one or more yellowish macular points; these, in +the course of weeks or months, gradually extend, and, together with +other patches that arise, may form a more or less continuous sheet of +eruption. There is slight scaliness, always insignificant and +furfuraceous in character, and at times, except upon close inspection, +scarcely perceptible. The color of the patches is pale or +brownish-yellow; in rare instances, in those of delicate skin, there may +be more or less hyperæmia, and in consequence the eruption is of a +reddish tinge. The number of patches varies; there may be but a few, or, +on the other hand, a profusion. Slight itching, especially when the +parts are warm, is usually present. + + +#Does the eruption of tinea versicolor show predilection for any special +region?# + +Yes; the upper part of the trunk, especially anteriorly, is the usual +seat of the eruption, but in exceptional instances the neck, axillæ, the +arms, the whole trunk, the genitocrural region and poplitea, and in rare +cases even the lower part of the face, may become invaded. + + +#What course does tinea versicolor pursue?# + +Persistent, but somewhat variable; as a rule, however, slowly +progressive and lasting for years. + + +#To what is tinea versicolor due?# + +To a vegetable fungus--the _microsporon furfur_. + +The affection is tolerably common, and occurs in all parts of the world. +With rare exceptions, it is a disease of adults, and while looked upon +as contagious, must be so to an extremely slight degree. + +[Illustration: Fig. 73. + Microsporon Furfur x 400. (_After Duhring._) Showing mycelium in various + stages of development, groups of spores and free spores.] + + +#What is the pathology?# + +The fungus, consisting of mycelium and spores, the latter showing a +marked tendency to aggregate, invades the superficial portion of the +epidermis. + + +#Is tinea versicolor readily diagnosticated?# + +Yes; if the color, peculiar characters and distribution of the eruption +are kept in mind. + +It is not to be confounded with vitiligo, chloasma, or the macular +syphiloderm. If in doubt, have recourse to the microscope. + + +#State the method of examination for fungus.# + +The scrapings are taken from a patch, moistened with liquor potassæ, and +examined with a power of three to five hundred diameters. + + +#State the prognosis of tinea versicolor.# + +With proper management the disease is readily curable. Relapses are not +uncommon. + +[Illustration: Fig. 74. Tinea versicolor.] + + +#What is the treatment of tinea versicolor?# + +It consists in daily washing with soap and hot water (and in obstinate +cases with sapo viridis instead of the ordinary soap) and application +of a lotion of--sulphite or hyposulphite of sodium, a drachm to the +ounce; sulphurous acid, pure or diluted; carbolic acid, or resorcin, +ten to twenty grains to the ounce of water and alcohol; or corrosive +sublimate, one to three grains to the ounce of water. Sulphur and +ammoniated-mercury ointments are also serviceable. The following used +alone, simply as a soap, or in conjunction with a lotion, is often of +special value:-- + + [Rx] Sulphur, præcip., .................... [dram]iv + Saponis viridis, ..................... [dram]xii. M. + +After the disease is apparently cured, an occasional remedial application +should be made for several months, in order to guard against the +possibility of a relapse. + + + + #Erythrasma.# + + +#Describe erythrasma.# + +Erythrasma is an extremely rare disease, due to the presence and growth +in the epidermic structures of the vegetable parasite--the _microsporon +minutissimum_. It is characterized by small and large, slightly +furfuraceous, reddish-yellow or reddish-brown patches, occurring usually +on warm and moist parts, such as the axillary, inguinal, anal and +genitocrural regions. It is slowly progressive and persistent, but is +without disturbing symptoms other than occasional slight itching. + +[Illustration: Fig. 75. + Microsporon Minutissimum x 1000. (_After Riehl._)] + +Treatment, which is rapidly effective, is the same as that employed in +tinea versicolor. + + + + #Dhobie Itch.# + +Dhobie itch is a name used in certain tropical countries to designate a +somewhat peculiar itching eruption of the genitocrural and axillary +regions, and by some also a similar eruption about the feet. It consists +of a dermatitis of variable degree, usually with a festooned, irregular +border, with considerable itching. It is believed that such cases are +variously due to the trichophyton of ringworm, to the microsporon furfur +of tinea versicolor, to the microsporon minutissimus of erythrasma, and +to other parasites. + + + + #Actinomycosis.# + + +#Describe actinomycosis.# + +Actinomycosis of the skin is an affection due to the ray fungus, and +characterized by a sluggish, red, nodular, or lumpy infiltration, +usually with a tendency to break down and form sinuses. The affection +may involve almost any part, but its most common site is about the jaw, +neck, and face. As a rule, the first evidence is a hard subcutaneous +swelling or infiltration, which may increase slightly or considerably. +The overlying skin gradually becomes of a sluggish or dark-red color. +Softening ensues, and the diseased area breaks down at one or more +points, from which there oozes a discharge of a sero-purulent, purulent, +or sanguinolent character. In this discharge can be usually noted +minute, friable, yellowish or yellowish-gray bodies representing +conglomerate collections of the causative fungus. + +The course of the malady is commonly slow and insidious. Unless systemic +pyemic infection occurs or the fungus elements find their way to the +deeper organs or structures the general health remains apparently +undisturbed. + + +#What is the treatment?# + +The administration of moderate to large doses of potassium iodide, +conjointly with curetting or excision of the diseased mass. Local +applications of iodine solution can also be tried. + + + + #Blastomycetic Dermatitis.# + + +#What do you understand by blastomycetic dermatitis?# + +Blastomycetic dermatitis is a rare disease beginning usually as a small +papule or nodule, enlarging slowly, breaking down and developing into a +verrucous or papillomatous-looking area, similar in appearance to +tuberculosis cutis verrucosa. A muco-purulent or purulent secretion can +visually be pressed out from between the papillomatous elevations. It +may also present the appearance of a serpiginous lupus vulgaris or +syphiloderm. As a rule it is slow in its course. Furuncular or +abscess-like formations may develop, usually from secondary infection. +The disease is due to the invasion of the cutaneous tissues by the +blastomyces. + +[Illustration: Blastomycetic dermatitis.] + +Treatment consists in administration of moderate to large doses of +potassium iodide, and in the employment of antiseptic and parasiticide +applications; usually, however, radical treatment, such as employed in +lupus vulgaris, may be necessary. + + + + #Scabies.# + (_Synonym:_ The Itch.) + + +#What is scabies?# + +Scabies, or itch, is a contagious animal-parasitic disease characterized +by a multiform eruption of a somewhat peculiar distribution, attended by +intense itching. + + +#Describe the symptoms of scabies.# + +The penetration and presence of the parasites within the cutaneous +structures besides often giving rise to several or more complete or +imperfectly formed _burrows_, excite varying degrees of irritation, and +in consequence the formation of vesicles, papules and pustules, +accompanied with more or less intense itching. Secondarily, crusting, +and at times a mild or severe grade of dermatitis, may be brought about. +The parasite seeks preferably tender and protected situations, as +between the fingers, on the wrists, especially the flexor surface, in +the folds of the axilla, on the abdomen, about the anal fissure, about +the genitalia, and in females also about the nipples, and hence the +eruption is most abundant about these regions. The inside of the thighs +and the feet are also attacked, as, indeed, may be almost every portion +of the body. The scalp and face are not involved; exceptionally, +however, these parts are invaded in infants and young children. + + +#Is the grade of cutaneous irritation the same in all cases of scabies?# + +No; in those of great cutaneous irritability, especially in children, +the skin being more tender, the type of the eruption is usually much +more inflammatory. In those predisposed a true eczema may arise, and +then, in addition to the characteristic lesions of scabies, eczematous +symptoms are superadded; in long-persistent cases, indeed, the burrows +and other consequent lesions may be more or less completely masked by +the eczematous inflammation, and the true nature of the disease be +greatly obscured. + + +#What do you mean by burrows?# + +Burrows, or _cuniculi_, are tortuous, straight or zigzag, dotted, +slightly elevated, dark-gray or blackish thread-like linear formations, +varying in length from an eighth to a half an inch. + +[Illustration: Fig. 76. + Burrow, or cuniculus, greatly magnified. (_After Kaposi._) Showing the + mite, ova, empty shells and excrement.] + + +#How is a burrow formed?# + +By the impregnated female parasite, which penetrates the epidermis +obliquely to the rete, depositing as it goes along ten or fifteen ova, +forming a minute passage or burrow. + + +#Upon what parts are burrows most commonly to be found?# + +In the interdigital spaces, on the flexor surface of the wrists, about +the mammæ in the female, and on the shaft of the penis in the male. + + +#Are burrows usually present in numbers?# + +No. Several may be found in a single case, but they are rarely numerous, +as the irritation caused by the penetration of the parasites leads +either to violent scratching and their destruction, or gives rise to the +formation of vesicles and pustules, and consequently their formation is +prevented. + + +#What course does scabies pursue?# + +Chronic and progressive, showing no tendency to spontaneous +disappearance. + + +#To what is scabies due?# + +To the invasion of the cutaneous structures by an animal parasite, the +sarcoptes scabiei (_acarus scabiei_). The male mite is never found in +the skin and apparently takes no direct part in the production of the +symptoms. + +[Illustration: Fig. 77. Fig. 78. + Sarcoptes scabiei x 100. + (_After Duhring._) Female. Ventral surface. Male.] + +The disease is contagious to a marked degree, and is most commonly +contracted by sleeping with those affected, or by occupying a bed in +which an affected person has slept. It occurs, for obvious reasons, +usually among the poor, although it is now quite frequently met with +among the better classes. + + +#State the diagnostic features of scabies.# + +The burrows, the peculiar distribution and the multiformity of the +eruption, the progressive development, and usually a history of +contagion. + + +#How do vesicular and pustular eczema differ from scabies?# + +Eczema is usually limited in extent, or irregularly distributed, is +distinctly patchy, with often the formation of large diffused areas; it +is variable in its clinical behavior, better and worse from time to +time, and differs, moreover, in the absence of burrows and of a history +of contagion. + + +#How does pediculosis corporis differ from scabies?# + +In the distribution of the eruption. The pediculi live in the clothing +and go to the skin solely for nourishment, and hence the eruption in +that condition is upon covered parts, especially those parts with which +the clothing lies closely in contact, as around the neck, across the +upper part of the back, about the waist and down the outside of the +thighs; _the hands are free_. + + +#State the prognosis of scabies.# + +It is favorable. The disease is readily cured, and, as soon as the +parasites and their ova are destroyed, the itching and the secondary +symptoms, as a rule, rapidly disappear. + + +#How is scabies treated?# + +Treatment is entirely external, and consists of a preliminary +soap-and-hot-water bath, an application, twice daily for three days, of +a remedy destructive to the parasites and ova, and finally another bath. + +Inquiry as to others of the family should be made, and, if affected, +treated at the same time. The wearing apparel should be looked +after--boiled, baked, or sulphur-fumigated. + + +#What remedial applications are employed in scabies?# + +Sulphur, balsam of Peru, styrax, and [beta]-naphthol, singly or +severally combined. In children, or in those of sensitive skin, the +following:-- + + [Rx] Sulphur. præcip., .................... [dram]iv + Balsam. Peruv., ...................... [dram]ij + Adipis, + Petrolati, ......... [=a][=a] ........ [Oz]iss. M. + +And in adults, or those of non-irritable skin:-- + + [Rx] Sulphur, præcip., .................... [Oz]j + Balsam. Peruv., ...................... [Oz]ss + [beta]-Naphthol, ..................... [dram]ij + Adipis, + Petrolati, ... [=a][=a] ... q.s. ad .. [Oz]iv. M. + +Styrax is a remedy of value and is commonly employed as an ointment in +the strength of one part to two or three parts of lard. + + +#Is one such course of treatment sufficient to bring about a cure?# + +Yes, in ordinary cases, if the applications have been carefully and +thoroughly made; exceptionally, however, some parasites and ova escape +destruction, and consequently itching will again begin to show itself at +the end of a week or ten days, and a repetition of the treatment become +necessary. + + +#Does the secondary dermatitis which is always present in severe cases +require treatment?# + +Only when it is unusually persistent or severe; in such cases the +various soothing applications, lotions or ointments employed in acute +eczema are to be prescribed. + + +#Is a dermatitis due to too active and prolonged treatment ever mistaken +for persistence of the scabies?# + +Yes. + + + + #Pediculosis.# + (_Synonyms:_ Phtheiriasis; Lousiness.) + + +#Define pediculosis.# + +Pediculosis is a term applied to that condition of local or general +cutaneous irritation due to the presence of the animal parasite, the +pediculus, or louse. + + +#Name the several varieties met with.# + +Three varieties are presented, named according to the parts involved, +pediculosis capitis, pediculosis corporis, and pediculosis pubis; the +parasite in each being a distinct species of pediculus. + + + + #Pediculosis Capitis.# + + +#Describe the symptoms of pediculosis capitis.# + +Pediculosis capitis (_pediculosis capillitii_), due to the presence of +the pediculus capitis, occurs much more frequently in children than in +adults. It is characterized by marked itching, and the formation of +various inflammatory lesions, such as papules, pustules and +excoriations--resulting from the irritation produced by the parasites +and from the scratching to which the intense pruritus gives rise. In +fact, an eczematous eruption of the pustular type soon results, attended +with more or less crust formation. In consequence of the cutaneous +irritation the neighboring lymphatic glands may become inflamed and +swollen, and in rare cases suppurate. The occipital region is the part +which is usually most profusely infested, more especially in young girls +and women. In those of delicate skin, especially in children, scattered +papules, vesico-papules, pustules, and excoriations may often be seen +upon the forehead and neck. In some instances, however, especially in +boys, there may be many pediculi present, with but little cutaneous +disturbance, the itching being the sole symptom. + +[Illustration: Fig. 79. + Pediculus Capitis x 25. (_After Duhring._) Female. Dorsal surface.] + +In addition to the pediculi, which, as a rule, may be readily found, their +_ova_, or _nits_, are always to be seen upon the shaft of the hairs, +quite firmly attached. + + +#Describe the appearance of the ova.# + +They are dirty-white or grayish looking, minute, pear-shaped bodies, +visible to the naked eye, and fastened upon the shaft of the hairs with +the small end toward the root. + +[Illustration: Fig. 80. + Ova of the head-louse attached to a hair. Magnified. (_After Kaposi._)] + + +#Is there any difficulty in the diagnosis of pediculosis capitis?# + +No. The diagnosis is readily made, as the pediculi are usually to be +found without difficulty, and even when they exist in small numbers and +are not readily discovered, _the presence of the ova_ will indicate the +nature of the affection. + +Pustular eruptions upon the scalp, especially posteriorly, should always +arouse a suspicion of pediculosis. The possibility of the pediculosis +being secondary to eczema must not be forgotten. + + +#What is the treatment of pediculosis capitis?# + +Treatment consists in the application of some remedy destructive to the +pediculi and their ova. Crude petroleum is effective, one or two +thorough applications over night being usually sufficient; in order to +lessen its inflammability, and also to mask its somewhat disagreeable +odor, it may be mixed with an equal part of olive oil and a small +quantity of balsam of Peru added. + +Tincture of cocculus indicus, pure or diluted, may also be applied with +good results. + +When the parts are markedly eczematous, an ointment of ammoniated +mercury or [beta]-naphthol, thirty to sixty grains to the ounce may +be used. + +Daily shampooing with soap and water, and the twice daily application of +a five per cent. carbolic acid lotion, together with the use of a +fine-toothed comb, is a safe and efficient method for dispensary +practice; as it is, indeed, for any class of patients. + + +#How are the ova or their shells to be removed from the hair?# + +By the frequent use of acid or alkaline lotions, such as dilute acetic +acid and vinegar, or solutions of sodium carbonate and borax. + + + + #Pediculosis Corporis.# + + +#Describe the symptoms of pediculosis corporis.# + +Pediculosis corporis is dependent upon the presence of the pediculus +corporis (_pediculus vestimenti_), a larger variety than that infesting +the scalp. It is characterized by more or less general itching, together +with various inflammatory lesions and excoriations. As the parasites are +to be found chiefly in the folds and seams of the clothing, visiting the +skin for the purpose of feeding, the various symptoms--the minute +hemorrhagic puncta showing the points at which they have been sucking, +and the consequent papules, pustules and excoriations--are, therefore, +to be found most abundantly on those parts with which the clothing comes +closely in contact, as, for instance, around the neck, across the +shoulders, around the waist, and down the outside of the thighs. It is +uncommon in children. + +[Illustration: Fig. 81. + Pediculus Corporis x 25. (_After Duhring._) Female. Dorsal surface.] + + +#State the diagnostic characters of pediculosis corporis.# + +The presence of the minute hemorrhagic puncta, the multiform character +and peculiar distribution of the eruption. Careful search will almost +invariably disclose one or more pediculi. + + +#What is the treatment of pediculosis corporis?# + +The clothing and bed-coverings are to be thoroughly baked or boiled, the +pediculi and their ova being in this manner destroyed; a thymol or +carbolized boric-acid lotion may be used to relieve the cutaneous +irritation. + +When attention to the wearing apparel is not immediately practicable, +ointments of sulphur and staphisagria, and lotions of carbolic acid, may +be advised as temporary measures. The wearing of a bag of loosely woven +texture containing some lump sulphur next to the skin is useful in such +cases; at the temperature of the body the sulphur undergoes slow +oxidation. In hairy individuals the malady is often persistent, due to +the fact that ova have become attached to the hair and a new progeny +soon hatched out. Continued treatment over a few weeks will usually +suffice to rid the patient of their presence. + + + + #Pediculosis Pubis.# + + +#Describe the symptoms of pediculosis pubis.# + +Pediculosis pubis is a condition due to the presence of the pediculus +pubis, or crab-louse. It is characterized by more or less itching about +the genitalia, together with papules, excoriations, and other +inflammatory lesions. The amount of irritation varies; it may be slight, +or, on the other hand, severe. The parasite, which is the smallest of +the three varieties, may be discovered upon close examination seated +near the roots of the hairs, clutching the hair, with its head downward +and buried in the follicle. The ova may be seen attached to the +hair-shafts. + +It infests adults chiefly, being in many instances probably contracted +through sexual intercourse. + + +#Is the pediculus pubis found upon any other part of the body?# + +Yes. Although its favorite habitat is the region of the pubes, it may, +in exceptional instances, also infest the axillæ, the sternal region of +the male, the beard, eyebrows, and even the eyelashes. + + +#State the diagnostic characters of pediculosis pubis.# + +The region involved, itching, variable amount of irritation, and, above +all, the presence of the pediculi and their ova. + +[Illustration: Fig. 82. + Pediculus Pubis x 25. (_After Duhring._) Female. Dorsal surface.] + + +#Name several applications prescribed for pediculosis pubis.# + +A lotion of corrosive sublimate, one to four grains to the ounce; +infusion of tobacco; a ten to twenty per cent. ointment of oleate of +mercury; ammoniated mercury ointment, and a five to ten per cent. +[beta]-naphthol ointment. Repeated washings with vinegar or dilute +acetic acid, or with alkaline lotions, will free the hairs of the ova. + + + + #Cysticercus Cellulosæ.# + + +#Describe the cutaneous disturbance produced by the cysticercus +cellulosæ.# + +The presence of cysticerci in the skin and subcutaneous tissue gives +rise to pea to hazelnut-sized, rounded, firm, movable tumors which, when +developed, may remain unchanged for months. The parasites are disclosed +by microscopic examination. + +Most of the cases have been observed in Germany. + + + + #Filaria Medinensis.# + (_Synonym:_ Guinea-worm.) + + +#State the character of the lesions produced by the filaria medinensis.# + +The young microscopic worm penetrates the skin or deeper tissue, where +it grows gradually, finally reaching several inches or more in length +and about a half-line in thickness; inflammation is excited and a +tumor-like swelling makes its appearance, which, sooner or later, +breaks, disclosing the worm. It may also present a cord-like appearance. +It is rarely met with outside of tropical countries. + +Treatment consists in gradual extraction, or in the injection of a +corrosive sublimate solution (1:1000) into the forming tumor. Asafetida +internally has been found to be curative, the parasite being destroyed +and subsequently absorbed or discharged. + + + + #Ixodes.# + (_Synonym:_ Wood-tick.) + + +#State the character of the cutaneous disturbance produced by the ixodes.# + +The tick sticks its proboscis into the skin and sucks blood until it is +several times its natural size, and then falls off; an urticarial lesion +results. If caught in the act the animal should not be forcibly +extracted, as its proboscis may be thus broken off and remain in the +skin, and give rise to pain and inflammation. It may be made to +relinquish its hold by placing on it a drop of an essential oil. + +A thymol or carbolized boric-acid lotion will relieve the irritation. + + + + #Leptus.# + (_Synonym:_ Harvest-mite.) + + +#State the characters of the lesion produced by the leptus.# + +This minute brick-red mite buries itself in the skin, especially about +the ankles and feet, giving rise to papules, vesicles and pustules. + +Treatment consists of the use of a mild sulphur ointment or of a +carbolic-acid lotion. + + + + #[OE]strus.# + (_Synonym:_ Gad, or Bot-fly.) + + +#Describe the cutaneous disturbance produced by the [oe]strus.# + +The ova are deposited in the skin, develop and give rise to the +formation of furuncle-like tumors with central aperture, through which a +sanious discharge exudes; or as the result of the burrowing of the +larvæ, irregular serpiginous lines or wheals are produced. + +It is chiefly met with in Central and South America. + +_Larva migrant_, or _creeping disease_, is doubtless in this same class. +It is characterized by a thread-like linear formation of an +erythematous, erythemato-papular, or vesicular nature that gradually +extends, the older part disappearing; considerable surface may be +covered before the parasite disappears or dies. The treatment consists +in endeavoring to destroy the organism by means of excision or caustic +applications at the point of its suspected site which is just ahead of +the extending line. + + + + #Pulex Penetrans.# + (_Synonyms:_ Sand Flea; Jigger.) + + +#Describe the cutaneous disturbance produced by the pulex penetrans.# + +This microscopic animal penetrates the skin, especially about the toes, +producing an inflammatory swelling, vesicle or pustule, or even +ulceration. It is met with in warm and tropical countries. + +Treatment consists in extraction. Essential oils are used as a +preventive. A carbolic-acid or alkaline lotion relieves irritation. + + + + #Cimex Lectularius.# + (_Synonym:_ Bed-bug.) + + +#Describe the characters of a bed-bug bite.# + +An inflammatory papule or wheal-like lesion results, somewhat +hemorrhagic; the purpuric or hemorrhagic point or spot remains after the +swelling subsides, but finally, in the course of several days or a few +weeks, disappears. + +Treatment consists in the application of alkaline or acid lotions. + + + + #Culex.# + (_Synonym:_ Gnat; Mosquito.) + + +#Describe the cutaneous disturbance produced by the culex.# + +It consists of an erythematous spot or a wheal-like lesion. + +Alkaline or acid lotions usually give relief. + + + + #Pulex Irritans.# + (_Synonym:_ Common Flea.) + + +#Describe the cutaneous disturbance produced by the pulex irritans.# + +It consists of an erythematous spot with a minute central hemorrhagic +point. In irritable skin, a wheal-like lesion may result. + +Treatment consists of applications of camphor or ammonia-water; carbolic +acid and thymol lotions are also useful. + + + + +RELATIVE FREQUENCY OF THE VARIOUS DISEASES OF SKIN AS SHOWN BY THE +STATISTICS (123,746 CASES) OF THE AMERICAN DERMATOLOGICAL ASSOCIATION +FOR TEN YEARS, 1878-87. + + +-------------------------+-------+-------+ + CLASSIFICATION OF | No. | % | + DISEASES. | Cases | Cases | +-------------------------+-------+-------+ +Class I. Disorders of the| | | + Glands. | | | + 1. OF THE SWEAT GLANDS.| | | + Hyperidrosis | 328 | .265 | + Sudamen | 268 | .216 | + Anidrosis | 11 | .009 | + Bromidrosis | 112 | .090 | + Chromidrosis | 7 | .005 | + Uridrosis | ... | .... | + 2. OF THE SEBACEOUS | | | + GLANDS | 238 | .193 | + Seborrh[oe]a: | 1812 | 1.47 | + a. oleosa | 367 | .296 | + b. sicca | 395 | .319 | + Comedo | 1225 | .989 | + Cyst: | 6 | .004 | + a. Milium | 225 | .183 | + b. Steatoma | 151 | .122 | + Asteatosis | 8 | .006 | + | | | +Class II. Inflammations. | | | + Exanthemata | 1770 | 1.43 | + Erythema simplex | 1064 | .859 | + Erythema multiforme: | 915 | .730 | + a. papulosum | 325 | .262 | + b. bullosum | 37 | .029 | + c. nodosum | 82 | .066 | + Urticaria | 2994 | 2.47 | + pigmentosa | 1 | .0008| + [E]Dermatitis: | 1720 | 1.39 | + a. traumatica | 468 | .378 | + b. venenata | 616 | .498 | + c. calorica | 224 | .187 | + d. medicamentosa | 108 | .087 | + e. gangrænosa | 8 | .006 | + Erysipelas | 1026 | .829 | + Furunculus | 2129 | 1.72 | + Anthrax | 252 | .203 | + Phlegmona diffusa | 265 | .215 | + Pustula maligna | 197 | .159 | + Herpes simplex | 2057 | 1.66 | + Herpes zoster | 1428 | 1.15 | + Dermatitis | | | + herpetiformis | 41 | .033 | + Psoriasis | 4131 | 3.34 | + Pityriasis maculuta | | | + et circinata | 71 | .057 | + Dermatitis | | | + exfoliativa | 16 | .012 | + Pityriasis rubra | 44 | .032 | + Lichen: | 144 | .116 | + a. planus | 154 | .124 | + b. ruber | 27 | .021 | + Eczema: | 37661 |30.43 | + a. erythematosum | .... | .... | + b. papulosum | .... | .... | + c. vesiculosum | .... | .... | + d. madidans | .... | .... | + e. pustulosum | .... | .... | + f. rubrum | .... | .... | + g. squamosum | .... | .... | + Prurigo | 34 | .027 | + Acne | 9077 | 7.34 | + Acne rosacea | 398 | .321 | + Sycosis | 227 | .185 | + Impetigo | 1769 | 1.43 | + Impetigo contagiosa | 600 | .485 | + Impetigo | | | + herpetiformis | 10 | .009 | + Ecthyma | 726 | .587 | + Pemphigus | 183 | .148 | + Ulcers | 3021 | 2.44 | + | | | +Class III. Hemorrhages. | | | + Purpura: | 341 | .275 | + a. simplex | 181 | .145 | + b. hæmorrhagica | 49 | .039 | + | | | +Class IV. Hypertrophies. | | | + 1. OF PIGMENT. | | | + Lentigo | 127 | .103 | + Chloasma | 560 | .452 | + 2. OF EPIDERMAL AND | | | + PAPILLARY LAYERS. | | | + Keratosis: | 94 | .076 | + a. pilaris | 103 | .083 | + b. senilis | 68 | .055 | + Molluscum epitheliale| 172 | .139 | + Callositas | 110 | .090 | + Clavus | 84 | .068 | + Cornu cutaneum | 42 | .034 | + Verruca | 1252 | 1.09 | + Verruca necrogenica | 2 | .001 | + Nævus pigmentosus | 88 | .064 | + Xerosis | 100 | .080 | + Ichthyosis | 309 | .249 | + Onychauxis | 70 | .056 | + Hypertrichosis | 515 | .416 | + 3. OF CONNECTIVE | | | + TISSUE. | | | + Sclerema neonatorum | .... | .... | + Scleroderma | 38 | 0.030 | + Morph[oe]a | 39 | 0.031 | + Elephantiasis | 57 | 0.046 | + Rosacea: | 785 | 0.634 | + a. erythematosa | 381 | 0.308 | + b. hypertrophica | 58 | 0.047 | + Framb[oe]sia | 22 | 0.018 | + | | | +Class V. Atrophies. | | | + 1. OF PIGMENT. | | | + Leucoderma | 77 | 0.062 | + Albinismus | 9 | 0.008 | + Vitiligo | 191 | 0.155 | + Canities | 43 | 0.035 | + 2. OF HAIR. | | | + Alopecia | 926 | 0.749 | + Alopecia furfuracea | 830 | 0.670 | + Alopecia areata | 794 | 0.641 | + Atrophia pilorum | | | + propria | 23 | 0.019 | + Trichorexis nodosa | 3 | 0.002 | + 3. OF NAIL | 26 | 0.021 | + Atrophia unguis | 19 | 0.015 | + 4. OF CUTIS | 6 | 0.005 | + Atrophia senilis | 15 | 0.013 | + Atrophia maculosa et | | | + striata | 23 | 0.019 | + | | | +Class VI. New Growths. | | | + 1. OF CONNECTIVE | | | + TISSUE. | 1 | 0.0008| + Keloid | 152 | 0.124 | + Cicatrix | 89 | 0.065 | + Fibroma | 93 | 0.075 | + Neuroma | 11 | 0.009 | + Xanthoma | 69 | 0.056 | + 2. OF MUSCULAR TISSUE. | | | + Myoma | 1 | 0.0008| + 3. OF VESSELS. | | | + Angioma | 462 | 0.373 | + Angioma pigmentosum | | | + et atrophicum | 13 | 0.010 | + Angioma cavernosum | 22 | 0.018 | + Lymphangioma | 16 | .012 | + 4. Mycosis fongoide | 1 | .0008| + Rhinoscleroma | 3 | .002 | + Lupus erythematosus | 477 | .385 | + Lupus vulgaris | 536 | .433 | + Scrofuloderma | 663 | .536 | + Syphiloderma: | 13888 |11.22 | + a. erythematosum | .... | .... | + b. papulosum | .... | .... | + c. pustulosum | .... | .... | + d. tuberculosum | .... | .... | + e. gummatosum | .... | .... | + Lepra: | 24 | .020 | + a. tuberosa | 7 | .005 | + b. maculosa | 4 | .003 | + c. anæsthetica | 6 | .004 | + Carcinoma | 1068 | .863 | + Sarcoma | 55 | .044 | + | | | +Class VII. Neuroses. | | | + Hyperæsthesia: | 4 | .003 | + a. Pruritus | 2716 | 2.12 | + b. Dermatalgia | 11 | .009 | + Anæsthesia | 22 | .018 | + | | | +Class VIII. Parasitic | | | + Affections. | | | + 1. VEGETABLE. | | | + Tinea favosa | 354 | .286 | + Tinea trichophytina: | 2289 | 1.85 | + a. circinata | 705 | .569 | + b. tonsurans | 675 | .545 | + c. sycosis | 365 | .295 | + Tinea versicolor | 1263 | 1.02 | + 2. ANIMAL. | | | + Scabies | 3192 | 2.58 | + Pediculosis | | | + capillitii | 2579 | 2.09 | + Pediculosis corporis | 1704 | 1.38 | + Pediculosis pubis | 436 | .352 | +-------------------------+-------+-------+ + Total 123746 + +[Footnote E: Indicating affections of this class not properly included + under other titles.] + + + + #INDEX.# + +Acarus folliculorum, 40 + scabiei, 269 + +Achorion Schönleinii, 249 + +Acne, 115-126 + artificialis, 120 + atrophica, 120 + cachecticorum, 120 + frontalis, 129 + hypertrophica, 120 + indurata, 120 + keloid, 135 + lupoid, 129 + necrotica, 129 + papulosa, 120 + punctata, 120 + pustulosa, 120 + rodens, 129 + rosacea, 126-129, 198 + sebacea, 33 + tar, 120 + urticata, 130 + varioliformis, 129 + vulgaris, 119 + +Acnitis, 130 + +Actinomycosis, 266 + +Addison's disease, pigmentation of the skin in, 149 + keloid, 172 + +Ainhum, 212 + +Albinismus, 177 + +Albinos, 177 + +Alopecia, 181-183 + areata, 183-186 + circumscripta, 183 + congenital, 181 + furfuracea, 181 + premature, 181 + senile, 181 + +Anæsthesia, 244 + +Anatomy of the skin, 17-21, 28 + +Angioma, 196, 197 + cavernosum, 197 + pigmentosum et atrophicum, 190 + simplex, 196 + +Angiomyoma, 196 + +Angioneurotic [oe]dema, 54 + +Anidrosis, 31 + +Anthrax, 70, 72 + +Antipruritic applications, 246 + +Antipyrin, eruptions from, 61 + +Area Celsi, 183 + +Argyria, 150 + +Arsenic, eruptions from, 61 + +Artificial eruptions (feigned eruptions), 64 + +Atrophia cutis, 189, 190 + pilorum propria, 187 + unguis, 188, 189 + +Atrophic lines and spots, 190 + +Atrophies, 177-190 + +Atrophoderma, 189 + neuriticum, 189 + +Atrophy of the hair, 187 + of the nails, 188 + of the skin, 189 + general idiopathic, 189 + senile, 190 + +Atropia, eruptions from, 61 + +Autographism, 52 + + +Baldness, 181 + +Barbadoes leg, 174 + +Barbers' itch, 255 + +Bath-pruritis, 245 + +Bed-bug, 278 + +Bed-sores, 58 + +Belladonna, eruptions from, 61 + +Blackheads, 38-41 + +Blanching of the hair, 180 + +Blastomycetic dermatitis, 266 + +Blebs, 23 + +Blood-vessels, 19 + +Boil, 68 + +Bot-fly, 278 + +Bromides, eruptions from, 61 + +Bromidrosis, 32 + +Bullæ, 23 + +Burns, 58 + +Burrows, 268 + + +Calculi, cutaneous, 42 + +Callositas, 155, 156 + +Callosity, 155 + +Callous, 155 + +Callus, 155 + +Cancer, epithelial, 236 + skin, 236 + +Canities, 180 + prematura, 180 + senilis, 180 + +Carbuncle, 70 + +Carbunculus, 70-72 + +Carcinoma epitheliale, 236 + +Carrion's disease, 73 + +Chafing, 45 + +Chapping, 106 + +Charbon, 72 + +Cheiro-pompholyx, 76 + +Cheloid, 191 + +Chloasma, 149-151 + uterinum, 149 + +Chloral, eruptions from, 62 + +Chromidrosis, 32 + red, 33 + +Chromophytosis, 262 + +Chrysarobin, 93 + +Chrysophanic acid (chrysarobin), 93 + +Cicatrices, 24 + +Cimex lectularius, 278 + +Clavus, 156, 157 + +Comedo, 38-41 + extractor, 40 + +Condyloma, flat (or broad), 217 + pointed, 161 + +Configuration, 24 + +Conglomerate pustular folliculitis, 252 + +Contagious impetigo, 136 + +Contagiousness, 27 + +Copaiba, eruptions from, 62 + +Corn, 156 + +Cornu cutaneum, 158, 159 + humanum, 159 + +Crab-louse, 275 + +Creeping disease, 278 + +Crusta lactea, 104 + +Crustæ, 24 + +Crusts, 24 + +Cubebs, eruptions from, 62 + +Culex, 279 + +Cuniculus, 268 + +Curette, 208 + +Cutaneous calculi, 42 + horn, 158 + +Cutis anserina, 152 + pendula, 176 + +Cyst, sebaceous, 43 + +Cysticercus cellulosæ, 276 + + +Dandruff, 33, 34 + +Darier's disease, 153 + +Defluvium capillorum, 181 + +Demodex folliculorum, 40 + +Depilatories, 169 + +Dermalgia, 244 + +Dermatalgia, 244 + +Dermatitis, 58-64 + acute general, 96 + ambustionis, 58 + blastomycetic, 266 + calorica, 58 + congelationis, 58 + contusiformis, 50 + exfoliativa, 96, 97 + general, 96 + neonatorum, 97 + recurrent, 96 + factitia, 64 + gangrænosa, 65 + herpetiformis, 83-86 + iodoform, 59 + malignant papillary, 240 + medicamentosa, 60 + papillaris capillitii, 135 + repens, 81 + traumatica, 58 + vegetans, 142 + venenata, 59 + _x_-ray, 63 + +Dermatographism, 52 + +Dermatolysis, 176 + +Dermatomyoma, 196 + +Dermatosclerosis, 172 + +Dermatosyphilis, 213 + +Dhobi itch, 265 + +Digitalis, eruptions from, 62 + +Disorders of the glands, 28-44 + +Dissection wound, 73 + +Distribution and configuration, 24-26 + +Drug eruptions (dermatitis medicamentosa), 60 + +Duhring's disease, 83 + +Dysidrosis, 76 + + +Ecthyma, 138, 139 + +Eczema, 100-119 + erythematosum, 102 + fissum, 106 + impetiginosum, 104 + madidans, 105 + marginatum, 253 + papulosum, 103 + pustulosum, 104 + rimosum, 106 + rubrum, 105 + sclerosum, 106 + seborrhoicum, 33, 34, 91, 95, 109 + squamosum, 104 + verrucosum, 106 + vesiculosum, 104 + +Electrolysis in removal of hair, 169 + +Elephant leg, 174 + +Elephantiasis, 174-176 + Arabum, 174 + Græcorum, 231 + +Epidermis, 18 + +Epidermolysis bullosa, 80 + +Epilating forceps, 249 + +Epithelial cancer, 236 + +Epithelioma, 236-240 + benign cystic, 198 + molluscum, 153 + +Equinia, 74 + +Erasion, 208 + +Eruptions, feigned (artificial), 64 + medicinal (dermatitis medicamentosa), 60 + +Erysipelas, 66, 67 + ambulans, 67 + migrans, 67 + +Erysipeloid, 67 + +Erythema, 44 + annulare, 48 + bullosum, 48 + caloricum, 44 + desquamative scarlatiniform, 96 + gangrenosum, 65 + gyratum, 48 + induratum, 51 + scrofulosorum, 51 + intertrigo, 45, 46 + iris, 48 + marginatum, 48 + multiforme, 46 + nodosum, 50, 51 + recurrent exfoliative, 96 + simplex, 44 + solare, 44 + traumaticum, 44 + venenatum, 44 + vesiculosum, 48 + +Erythrasma, 265 + +Excessive sweating (hyperidrosis), 28 + +Excoriationes, 24 + +Excoriations, 24 + + +Farcy, 74 + +Favus, 247 + of general surface, 248 + of nails, 249 + of scalp, 247 + +Feigned eruptions, 64 + +Fever blisters, 78 + +Fibroma, 192-194 + molluscum, 192 + +Fibromyoma, 196 + +Filaria, 175 + medinensis, 277 + +Fish-skin disease, 165 + +Fissures, 24 + +Flea, common, 279 + sand, 278 + +Flesh worms, 38-41 + +Folliclis, 130 + +Folliculitis barbæ, 130 + decalvans, 131 + pustular, conglomerate, 252 + +Forceps, epilating, 249 + +Fragilitas crinium, 187 + +Framb[oe]sia, 73 + +Freckle, 148 + +Frost-bite, 58 + +Fungous foot of India, 212 + +Furuncle, 68 + +Furunculosis, 69 + +Furunculus, 68-70 + + +Gad-fly, 278 + +Galvano-cautery, 208 + instruments, 206 + +Gangrene of the skin (dermatitis gangrænosa), 65 + spontaneous, 65 + symmetric, 66 + +Gelatin dressing, 116 + +Giant urticaria, 54 + +Glanders, 74 + +Glands, sebaceous, 33 + sweat, 28 + +Glossy skin, 189 + +Gnat, 279 + +Goose-flesh, 152 + +Granuloma fungoides, 242 + necroticum, 129 + +Grayness of the hair, 180 + +Grutum, 42 + +Guinea-worm, 277 + +Gumma, 225 + +Gun-powder marks, 151 + +Gutta-percha plaster, 117 + + +Hair, 21 + atrophy of, 187 + graying of, 180 + hypertrophy of, 168 + superfluous, 168 + +Hair-follicle, 21 + +Hairy people, 168 + +Harvest mite, 277 + +Heat rash, 74 + +Hemorrhages, 144-146 + +Henoch's purpura, 145, 146 + +Hereditary infantile syphilis, 228 + cutaneous manifestations of, 221 + +Herpes, 78 + facialis, 78 + gestationis, 83 + iris, 48 + labialis, 78 + præputialis, 79 + progenitalis, 78 + simplex, 78-80 + zoster, 81-83 + +Hirsuties, 168 + +Hives, 52 + +Homines pilosi, 168 + +Horn, cutaneous, 158 + +Hydradenitis suppurativa, 130 + +Hydroa æstivale, 80 + herpetiforme, 83 + puerorum, 80 + vacciniforme, 80 + +Hydrocystoma, 31 + +Hyperesthesia, 244 + +Hyperidrosis, 28-30 + +Hypertrichosis, 168-170 + +Hypertrophic scar, 192 + +Hypertrophies, 148-177 + +Hypertrophy of the hair, 168 + of the nail, 167 + + +Ichthyosis, 165-167 + congenita, 165 + follicularis, 153 + hystrix, 165 + sebacea, 33 + cornea, 153 + simplex, 165 + +Impetigo contagiosa, 136, 138 + herpetiformis, 138 + simplex, 137 + +Infantile syphilis, hereditary, 228 + +Inflammations, 44-143 + +Inflammatory fungoid neoplasm, 242 + +Iodides, eruptions from, 62 + +Iodoform dermatitis, 59 + +Itch, 267 + barbers', 255 + dhobie, 265 + mite, 269 + +Ivy poisoning, 59 + +Ixodes, 277 + + +Jigger, 278 + + +Keloid, 172, 192 + cicatricial, 191 + false, 191 + of Addison, 172 + of Alibert, 191 + spontaneous, 191 + true, 191 + +Keratodermia, symmetric, 155 + +Keratoma, 155 + +Keratosis follicularis, 153 + palmaris et plantaris, 155 + pigmentosa, 160 + pilaris, 151, 152 + senilis, 236 + +Kerion, 255 + + +Land scurvy, 145 + +Larva nigrans, 278 + +Lentigo, 148 + +Leontiasis, 233 + +Lepra, 231-235 + +Leprosy, 231 + anæsthetic, 233 + Lombardian, 235 + tubercular, 232 + +Leptus, 277 + +Lesions, 22 + configuration of, 24 + consecutive, 23 + distribution of, 24 + elementary, 22 + primary, 22 + secondary, 23 + +Leucoderma, 178 + +Leucopathia, 178 + +Lichen moniliformis, 98 + pilaris, 151 + planus, 98 + hypertrophicus, 98 + ruber, 99 + acuminatus, 99 + scrofulosus, 100 + tropicus, 74 + urticatus, 53 + +Linæ albicantes, 190 + +Linear nævus, 163 + scarification, 208 + +Liomyoma cutis, 196 + +Liquor carbonic detergens, 113 + picis alkalinus, 116 + +Lombardian leprosy, 235 + +Louse, body (pediculus corporis), 274 + clothes (pediculus corporis), 274 + crab, 275 + head (pediculus capitis), 272 + +Lousiness, 271 + +Lupoid acne, 129 + sycosis, 131 + +Lupus, 203 + erythematodes, 199 + erythematosus, 199-203 + exedens, 203 + exfoliativus, 203 + exulcerans, 203 + hypertrophicus, 204 + sebaceous, 199 + ulcerations, 203 + verrucosus, 204 + vorax, 203 + vulgaris, 203-208 + +Lymphangiectodes, 198 + +Lymphangioma, 198 + tuberosum multiplex, 198 + +Lymphangiomyoma, 196 + + +Maculæ, 22 + et striæ atrophicæ, 190 + +Macules, 22 + +Madura foot, 212 + +Malignant papillary dermatitis, 240 + pustule, 72 + +Medicinal eruptions (dermatitis medicamentosa), 60 + +Melanoderma, 149 + +Melanosarcoma, 242 + +Melasma, 149 + +Mercury, eruptions from, 62 + +Microsporon audouini, 258 + +Microsporon furfur, 262 + minutissimum, 265 + +Miliaria, 74-76 + alba, 75 + crystallina, 30 + rubra, 74 + +Milium, 42, 43 + needle, 42 + +Milk crust, 104 + +Mite, harvest, 277 + itch, 269 + +Moist papule, 216, 217 + +Mole, 162 + +Molluscum contagiosum, 153 + epitheliale, 153-155 + fibrosum, 192 + sebaceum, 153 + +Morphia, eruptions from, 63 + +Morph[oe]a, 172 + +Mosquito, 279 + +Mucous patch, 217 + +Mycetoma, 212 + +Mycosis fungoides, 242 + +Myoma, 196 + cutis, 196 + telangiectodes, 196 + + +Nævus araneus, 198 + capillary, 196 + flammeus, 196 + linear, 163 + lipomatodes, 164 + pigmentosus, 162 + pilosus, 163, 168 + sanguineus, 196 + simplex, 196 + spider, 198 + spilus, 163 + tuberosus, 197 + vasculosus, 196 + venous, 197 + verrucosus, 163 + +Nail, atrophy of, 188 + hypertrophy of, 167 + +Necrotic granuloma, 129 + +Neoplasm, inflammatory fungoid, 242 + +Neoplasmata (new growths), 191, 241 + +Nettlerash, 52 + +Neuralgia of the skin, 244 + +Neuroma, 194 + +Neuroses, 244-247 + +New growths, 191-243 + +Nits, 273 + + +Objective symptoms, 22 + +[OE]dema, acute circumscribed, 54 + neonatorum, 170 + +[OE]strus, 278 + +Ointment bases, 27 + +Onychatrophia, 188 + +Onychauxis, 167, 168 + +Onychomycosis, 188 + favosa, 249 + +Opium, eruptions from, 63 + +Oroya fever, 73 + +Osmidrosis, 32 + +Ova of pediculi, 273 + + +Pachydermia, 174 + +Paget's disease of the nipple, 240 + +Papillæ, nervous and vascular, 20 + +Papulæ, 23 + +Papule, moist, 216, 217 + +Papules, 23 + +Parasitic affections, 247-279 + sycosis, 255 + +Parasiticides, 250, 259 + +Parchment skin, 190 + +Paronychia, 167 + +Patch, mucous, 217 + +Pediculosis, 271 + capillitii, 272 + capitis, 272, 273 + corporis, 274, 275 + pubis, 275, 276 + +Pediculus capitis, 272 + corporis, 274 + pubis, 275 + vestimenti, 274 + +Peliosis rheumatica, 144 + +Pellagra, 235 + +Pemphigus, 140-144 + foliaceus, 141 + neonatorum, 140 + pruriginosus, 83 + vegetans, 142 + vulgaris, 140 + +Perforating ulcer of the foot, 213 + +Peruvian warts, 73 + +Phlegmona diffusa, 68 + +Phosphorescent sweat, 33 + +Phosphoridrosis, 33 + +Phtheiriasis, 271 + +Plan, 73 + +Pityriasis capitis, 34 + maculata et circinata, 95 + pilaris, 151 + rosea, 95, 96 + rubra, 97 + +Pityriasis rubra pilaris, 99 + versicolor, 261 + +Plasment, 117 + +Plaster-mull, 117 + +Podelcoma, 212 + +Poison dogwood, dermatitis from, 59 + ivy, dermatitis from, 59 + sumach, dermatitis from, 59 + vine, dermatitis from, 59 + +Pomphi, 23 + +Pompholyx, 76-78 + +Port-wine mark, 197 + +Post-mortem pustule, 73 + +Prickly heat, 74 + +Primary lesions, 22, 23 + +Prurigo, 118, 119 + +Pruritus, 244-247 + ani, 245 + hiemalis, 245 + scroti, 245 + senilis, 245 + vulvæ, 245 + +Pseudochromidrosis, 33 + +Psoriasis, 86-95 + circinata, 88 + diffusa, 88 + guttata, 88 + gyrata, 88 + inveterata, 88 + nummularis, 88 + punctata, 88 + syphilitica, 218 + +Psorospermosis, 153, 154, 240 + +Pulex irritans, 279 + penetrans, 278 + +Punctate scarification, 208 + +Purpura, 144-146 + hæmorrhagica, 145 + Henoch's, 145, 146 + rheumatica, 144 + scorbutica, 146 + simplex, 144 + urticans, 144 + +Pustula maligna, 72 + +Pustulæ, 23 + +Pustules, 23 + + +Quinine, eruptions from, 63 + + +Rapidity of cure, 27 + +Raynaud's disease, 66 + +Recurrent summer eruption, 80 + +Red chromidrosis, 33 + gum, 74 + +Relative frequency, 26 + +Rhagades, 24 + +Rheumatism of the skin, 244 + +Rhinophyma, 127 + +Rhinoscleroma, 198, 199 + +Rhus poisoning, 59 + +Ringworm, 251 + of bearded region, 255 + of general surface, 251 + of the nail, 253 + of the scalp, 253 + of the thighs and scrotum, 252 + Tokelau, 261 + +Rodent ulcer, 236 + +Rosacea, 198 + acne, 126 + +Rubber plaster, 117 + +Rupia, 221, 222 + + +Salicylic acid, eruptions from, 63 + paste, 113 + +Salt rheum, 100 + +Sand flea, 278 + +Sarcoma, 241, 242 + cutis, 241 + +Sarcoptes scabiei, 269 + +Scabies, 267-271 + +Scales, 24 + +Scarification, linear, 208 + punctate, 208 + +Scarifier, multiple, 202 + single, 202 + +Scars, 24 + hypertrophic, 192 + +Schönlein's disease, 145, 146 + +Sclerema, 172 + neonatorum, 171 + of the newborn, 171 + +Scleriasis, 172 + +Scleroderma, 172, 173 + neonatorum, 171 + +Scorbutus, 146 + +Scrofuloderma, 209 + pustular, small, 210 + +Scurvy, 146 + land, 145 + sea, 146 + +Sebaceous cyst, 43 + gland, 33 + tumor, 43 + +Seborrh[oe]a, 33-38 + congestiva, 199 + oleosa, 34 + sicca, 34 + +Secondary lesions, 23, 24 + +Shingles, 81 + +Skin, anatomy of, 17 + cancer, 236 + general idiopathic atrophy of, 189 + glossy, 189 + looseness of, 176 + +Skin, parchment, 190 + +Spider nævus, 198 + +Spiradenitis, 130 + +Spontaneous gangrene, 65 + +Spots, 22 + +Squamæ, 24 + +Stains, 24 + +Statistics, 280, 281 + +Steatoma, 43 + +Steatorrh[oe]a, 33 + +Stramonium, eruptions from, 63 + +Striæ et maculæ atrophicæ, 190 + +Strophulus, 74 + albidus, 42 + +Subjective symptoms, 22 + +Sudamen, 30, 31 + +Superfluous hair, 168 + +Sweat, colored (chromidrosis), 32 + glands, 28 + phosphorescent, 33 + +Sweating, excessive, 28 + +Sycosis, 130-135 + coccogenica, 130 + non-parasitica, 130 + parasitic, 255 + vulgaris, 130 + +Symmetric gangrene, 66 + keratodermia, 155 + +Symptomatology, 22-26 + +Symptoms, objective, 22 + subjective, 22 + systemic, 22 + +Syphilis cutanea, 213-231 + early eruptions of, 213 + late eruptions of, 214 + papillomatosa, 225 + hereditary, 227 + eruptions of, 227 + of the skin, 213-231 + +Syphiloderm, 213 + acne-form, 220 + annular, 219 + bullous, 222, 228 + circinate, 219 + ecthyma-form, 221 + erythematous, 214, 227 + gummatous, 225 + impetigo-form, 220 + large acuminated-pustular, 220 + flat-pustular, 221 + papular, 216 + lenticular, 216 + macular, 214, 227 + miliary papular, 215 + pustular, 219 + non-ulcerating tubercular, 224 + palmar, 217, 218 + papular, 215, 227 + papulo-squamous, 218 + plantar, 218 + pustular, 219 + serpiginous tubercular, 224 + small acuminated-pustular, 219 + flat-pustular, 220 + papular, 215 + squamous, 218 + tubercular, 223, 224 + ulcerating tubercular, 224 + variola-form, 220 + vegetating, 218 + +Syphiloderma, 213 + +Syphiloma, 225 + + +Tar acne, 120 + +Tattoo-marks, removal of, 151 + +Telangiectasis, 127, 197, 198 + +Tetter, 100 + +Tinea circinata, 251 + favosa, 247-251 + fungus of, 249 + unguium, 249 + imbricata, 261 + kerion, 255 + sycosis, 255 + tonsurans, 253 + trichophytina, 251-261 + barbæ, 255 + capitis, 253 + corporis, 251 + cruris, 252 + fungus of, 258 + unguium, 253 + versicolor, 262-265 + fungus of, 262 + +Tokelau ringworm, 261 + +Traumaticin, 94 + +Trichophyton, 258 + +Trichorrhexis nodosa, 187 + +Tubercles, 23 + +Tubercula, 23 + +Tuberculosis cutis, 209-211 + of the skin, 203 + +Tuberculosis verrucosa cutis, 209, 210 + +Tumor, sebaceous, 43 + +Tumors, 23 + +Turpentine, eruptions from, 63 + +Tyloma, 155 + +Tylosis, 155 + + +Ulcer, perforating, of foot, 213 + rodent, 236 + +Ulcera, 24 + +Ulerythema sycosiforme, 131 + +Uridrosis, 33 + +Urticaria, 52-56 + bullosa, 54 + chronic, 53 + factitia, 52 + hæmorrhagica, 54 + [oe]dematosa, 54 + papulosa, 54 + tuberosa, 54 + giant, 54 + pigmentosa, 59 + vesicular, 54 + + +Venereal wart, 161 + +Verruca, 160-162 + acuminata, 161 + digitata, 160 + filiformis, 160 + necrogenica, 211 + plana, 160 + juvenilis, 160 + senilis, 160 + vulgaris, 160 + +Verruga peruana, 73 + +Vesicles, 23 + +Vesiculæ, 23 + +Vitiligo, 178-180 + +Vitiligoidea, 195 + +Vleminckx's solution, 129 + + +Wart, 160 + Peruvian, 73 + pointed, 161 + venereal, 161 + +Wen, 43 + +Wheals, 23 + +Wood-tick, 277 + +Wound dissection, 73 + + +Xanthelasma, 195 + +Xanthelasmoidea, 56 + +Xanthoma, 195, 196 + diabeticorum, 195 + multiplex, 195 + planum, 195 + tuberculatum, 195 + tuberosum, 195 + +Xeroderma, 165 + +Xeroderma pigmentosum, 190 + +_X_-ray dermatitis, 63 + + +Yaws, 73 + + +Zona, 81 + +Zoster, 81 + + + + + SAUNDERS' BOOKS + + --------- on --------- + + GYNECOLOGY + + and + + OBSTETRICS + + * * * * * + + W. B. SAUNDERS COMPANY + +925 Walnut Street Philadelphia + +9, Henrietta Street Covent Garden, London + +========================================================================= + + SAUNDERS' TEXT-BOOKS CONTINUE TO GAIN + +The list of text-books recommended in the various colleges again shows a +#decided gain for the Saunders publications#. During the present college +year, in the list of recommended books published by 164 colleges (the +other 23 have not published lists), the Saunders books are mentioned +3278 times, as against 3054 the previous year--#an increase of 224#. In +other words, in each of the medical colleges in this country an average +of 20 (18-2/5 the previous year) of the teaching books employed are +publications issued by W. B. Saunders Company. That this increase is not +due alone to the publication of new text-books, but rather to a most +gratifying increase in the recommendation of text-books recognized as +standards, is at once evident from the following: Ashton's Gynecology +shows an increase of 19; DaCosta's Surgery, an increase of 12; Hirst's +Obstetrics, 14; Howell's Physiology, 25; Jackson on the Eye, 16; Sahli's +Diagnostic Methods, 11; Scudder's Fractures, 11; Stengel's Pathology, +13; Stelwagon on the Skin, 11. These are but examples of similar +remarkable gains throughout the entire list, and is undoubted evidence +that the #Saunders text-books are recognized as the best#. + + #A Complete Catalogue of our Publications will be Sent upon Request# + + + + + Bandler's + + Medical Gynecology + + * * * * * + +#Medical Gynecology#. By S. Wyllis Bandler, M.D., Adjunct. Professor of +Diseases of Women, New York Post-Graduate Medical School and Hospital. +Octavo of 680 pages, with 135 original illustrations. Cloth, $5.00 net; +Half Morocco, $6.50 net. + + + #JUST READY--EXCLUSIVELY MEDICAL GYNECOLOGY# + + +This new work by Dr. Bandler is just the book that the physician engaged +in general practice has long needed. It is truly _the practitioner's +gynecology_--planned for him, written for him, and illustrated for him. +There are many gynecologic conditions that do not call for operative +treatment; yet, because of lack of that special knowledge required for +their diagnosis and treatment, the general practitioner has been unable +to treat them intelligently. This work gives just the information the +practitioner needs. It not only deals with those conditions amenable to +non-operative treatment, but it also tells how to recognize those +diseases demanding operative treatment, so that the practitioner will be +enabled to advise his patient at a time when operation will be attended +with the most favorable results. The chapter on Pessaries is especially +full and excellent, the proper manner of introducing the pessary being +clearly described and illustrated with original pictures that show +plainly the correct technic of this procedure. The chapters on Vaginal +and Abdominal Massage, and particularly that on Artificial Hyperemia and +Anemia, are extremely valuable to the practitioner. They express the +very latest advances in these methods of treatment. Hydrotherapy, +especially the Ferguson and Nauheim baths, are treated _in extenso_, and +Electrotherapy receives the full consideration its importance merits. +Pain as a symptom and its alleviation is dealt with in an unusually +practical way, its value as an aid in diagnosis being emphasized. +Gonorrhea and Syphilis and their many complications are treated in +detail, every care being taken to have these sections--of special +interest to the practitioner--complete in every particular. Other +chapters of great importance are those on Constipation, Sterility, +Associated Nervous Conditions in Gynecology, and Pregnancy and Abortion. + + + + + Kelly and Noble's Gynecology + + and Abdominal Surgery + +#Gynecology and Abdominal Surgery#. Edited by Howard A. Kelly, M.D., +Professor of Gynecology in Johns Hopkins University; and Charles P. +Noble, M.D., Clinical Professor of Gynecology in the Woman's Medical +College, Philadelphia. Two imperial octavo volumes of 900 pages each, +containing 650 illustrations, mostly original. Per volume: Cloth, $8.00 +net; Half Morocco, $9.50 net. + + + BOTH VOLUMES NOW READY + + WITH 650 ORIGINAL ILLUSTRATIONS BY HERMANN BECKER + + AND MAX BRÖDEL + + +In view of the intimate association of gynecology with abdominal surgery +the editors have combined these two important subjects in one work. For +this reason the work will be doubly valuable, for not only the +gynecologist and general practitioner will find it an exhaustive +treatise, but the surgeon also will find here the latest technic of the +various abdominal operations. It possesses a number of valuable features +not to be found in any other publication covering the same fields. It +contains a chapter upon the bacteriology and one upon the pathology of +gynecology, dealing fully with the scientific basis of gynecology. In no +other work can this information, prepared by specialists, be found as +separate chapters. There is a large chapter devoted entirely to _medical +gynecology_, written especially for the physician engaged in general +practice. Heretofore the general practitioner was compelled to search +through an entire work in order to obtain the information desired. +_Abdominal surgery_ proper, as distinct from gynecology, is fully +treated, embracing operations upon the stomach, upon the intestines, +upon the liver and bile-ducts, upon the pancreas and spleen, upon the +kidney, ureter, bladder, and the peritoneum. Special attention has been +given to _modern technic_ and illustrations of the very highest order +have been used to make clear the various steps of the operations. +Indeed, the illustrations are truly magnificent, being the work of _Mr. +Hermann Becker_ and _Mr. Max Brödel_, of the Johns Hopkins Hospital. + + + + + Ashton's + + Practice of Gynecology + + * * * * * + +#The Practice of Gynecology#. By W. Easterly Ashton, M.D., LL.D., +Professor of Gynecology in the Medico-Chirurgical College, Philadelphia. +Handsome octavo volume of 1096 pages, containing 1057 original line +drawings. Cloth, $6.50 net; Half Morocco, $8.00 net. + + + RECENTLY ISSUED--NEW (3d) EDITION + + THREE EDITIONS IN EIGHTEEN MONTHS + +Three editions of this work have been demanded in eighteen months. Among +the new additions are: Colonic lavage and flushing, Hirst's treatment +for vaginismus, Dudley's treatment of cystocele, Montgomery's round +ligament operation, Chorio-epithelioma of the Uterus, Passive +Incontinence of the Urine, and Moynihan's methods in Intestinal +Anastomosis. Nothing is left to be taken for granted, the author not +only telling his readers in every instance what should be done, but also +precisely _how to do it_. A distinctly original feature of the book is +the illustrations, numbering about one thousand line drawings made +especially under the author's personal supervision from actual +apparatus, living models, and dissections on the cadaver. These line +drawings show in detail the procedures and operations without obscuring +their purpose by unnecessary and unimportant anatomic surroundings. + + +#Howard A. Kelly, M.D.# + +_Professor of Gynecology, Johns Hopkins University._ + +"It is different from anything that has as yet appeared. The +illustrations are particularly clear and satisfactory. One specially +good feature is the pains with which you describe so many _details_ so +often left to the imagination." + + +#Charles B. Penrose, M.D.,# + +_Formerly Professor of Gynecology, University of Pennsylvania._ + +"I know of no book that goes so thoroughly and satisfactorily into all +the _details_ of everything connected with the subject. In this respect +your book differs from the others." + + +#George M. Edebohls, M.D.# + +_Professor of Diseases of Women, New York Post-Graduate Medical School._ +"I have looked it through and must congratulate you upon having produced +a text-book most admirably adapted to _teach_ gynecology to those who +must get their knowledge, even to the minutest and most elementary +details, from books." + + + + + Webster's + + Diseases _of_ Women + + * * * * * + +#Diseases of Women.# By J. Clarence Webster, M.D. (Edin.), F.R.C.P.E., +Professor of Gynecology and Obstetrics in Rush Medical College. Octavo +of 712 pages, with 372 illustrations. Cloth, $7.00 net; Half Morocco, +$8.50 net. + + + RECENTLY ISSUED--FOR THE PRACTITIONER + + +Dr. Webster has written this work _especially for the general +practitioner_, discussing the clinical features of the subject in their +widest relations to general practice rather than from the standpoint of +specialism. The magnificent illustrations, three hundred and seventy-two +in number, are nearly all original. Drawn by expert anatomic artists +under Dr. Webster's direct supervision, they portray the anatomy of the +parts and the steps in the operations with rare clearness and exactness. + + +#Howard A. Kelly, M.D.#, _Professor of Gynecology, Johns Hopkins +University._ + +"It is undoubtedly one of the best works which has been put on the +market within recent years, showing from start to finish Dr. Webster's +well-known thoroughness. The illustrations are also of the highest +order." + + * * * * * + +#Webster's Obstetrics# + +#A Text-Book of Obstetrics#. By J. Clarence Webster, M.D. (Edin.), +Professor of Obstetrics and Gynecology in Rush Medical College. Octavo +of 767 pages, illustrated. Cloth, $5.00 net; Half Morocco, $6.50 net. + + + RECENTLY ISSUED + + +#Medical Record, New York# + +"The author's remarks on asepsis and antisepsis are admirable, the +chapter on eclampsia is full of good material, and ... the book can be +cordially recommended as a safe guide." + + + + + Cullen's + + Uterine Adenomyoma + + * * * * * + +#Uterine Adenomyoma#. By Thomas S. Cullen, M.D., Associate Professor of +Gynecology, Johns Hopkins University. Octavo of 275 pages, with original +illustrations by Hermann Becker and August Horn. Cloth, $5.00 net. + + + JUST READY + +Dr. Cullen's large clinical experience and his extensive original work +along the lines of gynecologic pathology have enabled him to present his +subject with originality and precision. The work gives the early +literature on adenomyoma, traces the disease through its various stages, +and then gives the detailed findings in a large number of cases +personally examined by the author. Formerly the physician and surgeon +were unable to determine the cause of uterine bleeding, but after +following closely the clinical course of the disease, Dr. Cullen has +found that the majority of these cases can be diagnosed clinically. The +results of these observations he presents in this work. The entire +subject of adenomyoma is dealt with from the standpoint of the +pathologist, the clinician, and the surgeon. The superb illustrations +are the work of Mr. Hermann Becker and Mr. August Horn, of the Johns +Hopkins Hospital. + + * * * * * + + The American + + Text-Book _of_ Obstetrics + + + Recently Issued--New (2d) Edition + + +#The American Text-Book of Obstetrics#. In two volumes. Edited by Richard +C. Norris, M.D.; Art Editor, Robert L. Dickinson, M.D. Two octavos of +about 600 pages each; nearly 900 illustrations, including 49 colored and +half-tone plates. Per volume: Cloth, $3.50 net; Half Morocco, $4.50 net. + + +#American Journal of the Medical Sciences# + +"As an authority, as a book of reference, as a 'working book' for the +student or practitioner, we commend it because we believe there is no +better." + + + + + Hirst's + + Diseases of Women + + * * * * * + +#A Text-Book of Diseases of Women#. By Barton Cooke Hirst, M.D., Professor +of Obstetrics, University of Pennsylvania; Gynecologist to the Howard, +the Orthopedic, and the Philadelphia Hospitals. Octavo of 745 pages, 701 +illustrations, many in colors. Cloth, $5.00 net; Half Morocco, $6.50 +net. + + + RECENTLY ISSUED--NEW (2d) EDITION + + WITH 701 ORIGINAL ILLUSTRATIONS + + +The new edition of this work has just been issued after a careful +revision. As diagnosis and treatment are of the greatest importance in +considering diseases of women, particular attention has been devoted to +these divisions. To this end, also, the work has been magnificently +illuminated with 701 illustrations, for the most part original +photographs and water-colors of actual clinical cases accumulated during +the past fifteen years. The palliative treatment, as well as the radical +operative, is fully described, enabling the general practitioner to +treat many of his own patients without referring them to a specialist. +The author's extensive experience renders this work of unusual value. + + + * * * * * + + OPINIONS OF THE MEDICAL PRESS + + * * * * * + + +#Medical Record, New York# + +"Its merits can be appreciated only by a careful perusal.... Nearly one +hundred pages are devoted to technic, this chapter being in some +respects superior to the descriptions in many text-books." + + +#Boston Medical and Surgical Journal# + +"The author has given special attention to diagnosis and treatment +throughout the book, and has produced a practical treatise which should +be of the greatest value to the student, the general practitioner, and +the specialist." + + +#Medical News, New York# + +"Office treatment is given a due amount of consideration, so that the +work will be as useful to the non-operator as to the specialist." + + + + + Hirst's + + Text-Book of Obstetrics + + New (5th) Edition, Revised + + * * * * * + +#A Text-Book of Obstetrics#. By Barton Cooke Hirst, M.D., Professor of +Obstetrics in the University of Pennsylvania. Handsome octavo, 899 +pages, with 746 illustrations, 39 in colors. Cloth, $5.00 net; Sheep or +Half Morocco, $6.50 net. + + + RECENTLY ISSUED + + +Immediately on its publication this work took its place as the leading +text-book on the subject. Both in this country and abroad it is +recognized as the most satisfactorily written and clearly illustrated +work on obstetrics in the language. The illustrations form one of the +features of the book. They are numerous and the most of them are +original. In this edition the book has been thoroughly revised. More +attention has been given to the diseases of the genital organs +associated with or following childbirth. Many of the old illustrations +have been replaced by better ones, and there have been added a number +entirely new. The work treats the subject from a clinical standpoint. + + + * * * * * + + OPINIONS OF THE MEDICAL PRESS + + * * * * * + + +#British Medical Journal# + +"The popularity of American text-books in this country is one of the +features of recent years. The popularity is probably chiefly due to the +great superiority of their illustration over those of the English +text-books. The illustrations in Dr. Hirst's volume are far more +numerous and far better executed, and therefore more instructive, than +those commonly found in the works of writers on obstetrics in our own +country." + + +#Bulletin of Johns Hopkins Hospital# + +"The work is an admirable one in every sense of the word, concisely but +comprehensively written." + + +#The Medical Record, New York# + +"The illustrations are numerous and are works of art, many of them +appearing for the first time. The author's style, though condensed, is +singularly clear, so that it is never necessary to re-read a sentence in +order to grasp the meaning. As a true model of what a modern text-book +on obstetrics should be, we feel justified in affirming that Dr. Hirst's +book is without a rival." + + + + + Penrose's + + Diseases of Women + + Sixth Revised Edition + + * * * * * + +#A Text-Book of Diseases of Women#. By Charles B. Penrose, M.D., Ph.D., +formerly Professor of Gynecology in the University of Pennsylvania; +Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 550 +pages, with 225 fine original illustrations. Cloth $3.75 net. + + + JUST ISSUED + + +Regularly every year a new edition of this excellent text-book is called +for, and it appears to be in as great favor with physicians as with +students. Indeed, this book has taken its place as the ideal work for +the general practitioner. The author presents the best teaching of +modern gynecology, untrammeled by antiquated ideas and methods. In every +case the most modern and progressive technique is adopted, and the main +points are made clear by excellent illustrations. The new edition has +been carefully revised, much new matter has been added, and a number of +new original illustrations have been introduced. In its revised form +this volume continues to be an admirable exposition of the present +status of gynecologic practice. + + + * * * * * + + PERSONAL AND PRESS OPINIONS + + * * * * * + +#Howard A. Kelly, M.D.,# + +_Professor of Gynecology and Obstetrics, Johns Hopkins University, +Baltimore._ + +"I shall value very highly the copy of Penrose's 'Diseases of Women' +received. I have already recommended it to my class as The Best book." + + +#L.E. Montgomery, M.D.,# + +_Professor of Gynecology, Jefferson Medical College, Philadelphia._ + +"The copy of 'A Text-Book of Diseases of Women' by Penrose received +to-day. I have looked over it and admire it very much. I have no doubt +it will have a large sale, as it justly merits." + + +#Bristol Medico-Chirurgical Journal# + +"This is an excellent work which goes straight to the mark.... The book +may be taken as a trustworthy exposition of modern gynecology." + + + + + GET THE NEW +THE BEST American STANDARD + + Illustrated Dictionary + + Recently Issued--New (4th) Edition + + * * * * * + +#The American Illustrated Medical Dictionary#. A new and complete +dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy, +Chemistry, and kindred branches; with over 100 new and elaborate tables +and many handsome illustrations. By W.A. Newman Dorland, M.D., Editor of +"The American Pocket Medical Dictionary." Large octavo, 850 pages, bound +in full flexible leather. Price, $4.50 net; with thumb index, $5.00 net. + + + Gives a Maximum Amount of Matter in a Minimum Space, and at the + Lowest Possible Cost + + + WITH 2000 NEW TERMS + + +The immediate success of this work is due to the special features that +distinguish it from other books of its kind. It gives a maximum of +matter in a minimum space and at the lowest possible cost. Though it is +practically unabridged, yet by the use of thin bible paper and flexible +morocco binding it is only 1-1/4 inches thick. In this new edition the +book has been thoroughly revised, and upward of two thousand new terms +have been added, thus bringing the book absolutely up to date. The book +contains hundreds of terms not to be found in any other dictionary, over +100 original tables, and many handsome illustrations. + + + * * * * * + + PERSONAL OPINIONS + + * * * * * + +#Howard A. Kelly, M.D.,# + +_Professor of Gynecology, Johns Hopkins University, Baltimore._ + +"Dr. Borland's dictionary is admirable. It is so well gotten up and of +such convenient size. No errors have been found in my use of it." + + +#J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.)# + +_Professor of Surgery, Harvard Medical School._ + +"I regard it as a valuable aid to my medical literary work. It is very +complete and of convenient size to handle comfortably. I use it in +preference to any other." + + + + + Garrigues' + + Diseases of Women + + + Third Edition, Thoroughly Revised + + * * * * * + +#A Text-Book of Diseases of Women#. By Henry J. Garrigues, A.M., M.D., +Gynecologist to St. Mark's Hospital and to the German Dispensary, New +York City. Handsome octavo, 756 pages, with 367 engravings and colored +plates. Cloth, $4.50 net; Sheep or Half Morocco, $6.00 net. + +The first two editions of this work met with a most appreciative +reception by the medical profession both in this country and abroad. In +this edition the entire work has been carefully and thoroughly revised, +and considerable new matter added, bringing the work precisely down to +date. Many new illustrations have been introduced, thus greatly +increasing the value of the book both as a text-book and book of +reference. + + +#Thad. A. Reamy, M.D.,# _Professor of Gynecology, Medical College of +Ohio._ + +"One of the best text-books for students and practitioners which has +been published in the English language; it is condensed, clear, and +comprehensive. The profound learning and great clinical experience of +the distinguished author find expression in this book." + + * * * * * + + American + + Text-Book of Gynecology + +#American Text-Book of Gynecology#. Medical and Surgical. Edited by J.M. +Baldy, M.D., Professor of Gynecology, Philadelphia Polyclinic. Imperial +octavo of 718 pages, with 341 text-illustrations and 38 plates. Cloth, +$6.00 net; Half Morocco, $7.50 net. + + + SECOND REVISED EDITION + + +This volume is thoroughly practical in its teachings, and is intended to +be a working text-book for physicians and students. Many of the most +important subject are considered from an entirely new standpoint, and +are grouped together in a manner somewhat foreign to the accepted +custom. + + +#Boston Medical and Surgical Journal# + +"The most complete exponent of gynecology that we have. No subject seems +to have been neglected." + + + + + Dorland's + + Modern Obstetrics + + * * * * * + +#Modern Obstetrics: General and Operative#. By W.A. Newman Dorland, A.M., +M.D., Assistant Instructor in Obstetrics, University of Pennsylvania; +Associate in Gynecology in the Philadelphia Polyclinic. Handsome octavo +volume of 797 pages, with 201 illustrations. Cloth, $4.00 net. + + Second Edition, Revised and Greatly Enlarged + +In this edition the book has been entirely rewritten and very greatly +enlarged. Among the new subjects introduced are the surgical treatment +of puerperal sepsis, infant mortality, placental transmission of +diseases, serum-therapy of puerperal sepsis, etc. + + +#Journal of the American Medical Association# + +"This work deserves commendation, and that it has received what it +deserves at the hands of the profession is attested by the fact that a +second edition is called for within such a short time. Especially +deserving of praise is the chapter on puerperal sepsis." + + * * * * * + + Davis' Obstetric and + + Gynecologic Nursing + + +#Obstetric and Gynecologic Nursing#. By Edward P. Davis, A.M., M.D., +Professor of Obstetrics in the Jefferson Medical College and +Philadelphia Polyclinic; Obstetrician and Gynecologist, Philadelphia +Hospital. 12mo of 436 pages, illustrated. Buckram, $1.75 net. + + + JUST ISSUED--THIRD REVISED EDITION + + +This volume gives a very clear and accurate idea of the manner to meet +the conditions arising during obstetric and gynecologic nursing. The +third edition has been thoroughly revised. + + +#The Lancet, London# + +"Not only nurses, but even newly qualified medical men, would learn a +great deal by a perusal of this book. It is written in a clear and +pleasant style, and is a work we can recommend." + + + + + Schäffer _and_ Edgar's + + Labor and Operative Obstetrics + + * * * * * + +#Atlas and Epitome of Labor and Operative Obstetrics#. By Dr. O. Schäffer, +of Heidelberg. _From the Fifth Revised and Enlarged German Edition._ +Edited, with additions, by J. Clifton Edgar, M.D., Professor of +Obstetrics and Clinical Midwifery, Cornell University Medical School, +New York. With 14 lithographic plates in colors, 139 other +illustrations, and 111 pages of text. Cloth, $2.00 net. _In Saunders' +Hand-Atlas Series._ + +This book presents the act of parturition and the various obstetric +operations in a series of easily understood illustrations, accompanied +by a text treating the subject from a practical standpoint. + + +#American Medicine# + +"The method of presenting obstetric operations is admirable. The +drawings, representing original work, have the commendable merit of +illustrating instead of confusing." + + * * * * * + + Schäffer _and_ Edgar's Obstetric Diagnosis and Treatment + + +#Atlas and Epitome of Obstetric Diagnosis and Treatment#. By Dr. O. +Schäffer, of Heidelberg. _From the Second Revised German +Edition._Edited, with additions, by J. Clifton Edgar, M.D., Professor of +Obstetrics and Clinical Midwifery, Cornell University Medical School, +N.Y. With 122 colored figures on 56 plates, 38 text-cuts, and 315 pages +of text. Cloth, $3.00 net. _In Saunders' Hand-Atlas Series._ + +This book treats particularly of obstetric operations, and, besides the +wealth of beautiful lithographic illustrations, contains an extensive +text of great value. This text deals with the practical, clinical side +of the subject. + + +#New York Medical Journal# + +"The illustrations are admirably executed, as they are in all of these +atlases, and the text can safely be commended, not only as elucidatory +of the plates, but as expounding the scientific midwifery of to-day." + + + + + Schäffer and Norris' + + Gynecology + + * * * * * + +#Atlas and Epitome of Gynecology#. By Dr. O. Schäffer, of Heidelberg. +_From the Second Revised and Enlarged German Edition._ Edited, with +additions, by Richard C. Norris, A.M., M.D., Assistant Professor of +Obstetrics in the University of Pennsylvania. 207 colored figures on 90 +plates, 65 text-cuts, and 308 pages of text. Cloth, $3.50 net. _In +Saunders' Hand-Atlas Series._ + + +American Journal of the Medical Sciences + +"Of the illustrations it is difficult to speak in too high terms of +approval. They are so clear and true to nature that the accompanying +explanations are almost superfluous. We commend it most earnestly." + + * * * * * + + Galbraith's + + Four Epochs of Woman's Life + + + Second Revised Edition--Recently Issued + + +#The Four Epochs of Woman's Life:# A Study in Hygiene. By Anna M. +Galbraith, M.D., Fellow of the New York Academy of Medicine, etc. With +an Introductory Note by John M. Musser, M.D. Professor of Clinical +Medicine, University of Pennsylvania. 12 mo of 247 pages. Cloth $1.50 +net. + + + MAIDENHOOD, MARRIAGE, MATERNITY, MENOPAUSE + + +In this instructive work are stated, in a modest, pleasing, and +conclusive manner, those truths of which every woman should have a +thorough knowledge. Written, as it is, for the laity, the subject is +discussed in language readily grasped even by those most unfamiliar with +medical subjects. + + +#Birmingham Medical Review, England# + +"We do not as a rule care for medical books written for the instruction +of the public. But we must admit that the advice in Dr. Galbraith's work +is in the main wise and wholesome." + + + + + Schäffer and Webster's + + Operative Gynecology + + +#Atlas and Epitome of Operative Gynecology#. By Dr. O. Schäffer, of +Heidelberg. Edited, with additions, by J. Clarence Webster, M.D. +(Edin.), F.R.C.P.E., Professor of Obstetrics and Gynecology in Rush +Medical College, in affiliation with the University of Chicago. 42 +colored lithographic plates, many text-cuts, a number in colors, and 138 +pages of text. _In Saunders' Hand-Atlas Series._ Cloth, $3.00 net. + + + RECENTLY ISSUED + + +Much patient endeavor has been expended by the author, the artist, and +the lithographer in the preparation of the plates for this Atlas. They +are based on hundreds of photographs taken from nature, and illustrate +most faithfully the various surgical situations. Dr. Schäffer has made a +specialty of demonstrating by illustrations. + + +#Medical Record, New York# + +"The volume should prove most helpful to students and others in grasping +details usually to be acquired only in the amphitheater itself." + + * * * * * + + DeLee's Obstetrics for Nurses + +#Obstetrics for Nurses#. By Joseph B. DeLee, M.D., Professor of +Obstetrics in the Northwestern University Medical School, Chicago; +Lecturer in the Nurses' Training Schools of Mercy, Wesley, Provident, +Cook County, and Chicago Lying-in Hospitals. 12mo of 512 pages, fully +illustrated. + Cloth, $2.50 net. + + + JUST ISSUED--NEW (3d) EDITION + + +While Dr. DeLee has written his work especially for nurses, the +practitioner will also find it useful and instructive, since the duties +of a nurse often devolve upon him in the early years of his practice. +The illustrations are nearly all original and represent photographs +taken from actual scenes. The text is the result of the author's many +years' experience in lecturing to the nurses of five different training +schools. + + +#J. Clifton Edgar, M.D.,# + +_Professor of Obstetrics and Clinical Midwifery, Cornell University, New +York._ + +"It is far and away the best that has come to my notice, and I shall +take great pleasure in recommending it to my nurses, and students as +well." + + + + +#American Pocket Dictionary# Recently issued--5th Ed. + +The American Pocket Medical Dictionary. Edited by W.A. Newman Dorland, +A.M., M.D., Assistant Obstetrician to the Hospital of the University of +Pennsylvania; Fellow of the American Academy of Medicine. With 578 +pages. Full leather, limp, with gold edges, $1.00 net; with patent thumb +index, $1.25 net. + + +#James W. Holland. M.D.,# + +_Professor of Chemistry and Toxicology, at the Jefferson Medical +College, Philadelphia._ + +"I am struck at once with admiration at the compact size and attractive +exterior. I can recommend it to our students without reserve." + + +#Cragin's Gynecology# Recently Issued--New (6th) Ed. + +Essentials of Gynecology. By Edwin B. Cragin, M.D., Professor of +Obstetrics, College of Physicians and Surgeons, New York. Crown octavo, +240 pages, 62 illustrations. Cloth, $1.00 net. _In Saunders' +Question-Compend Series._ + + +#The Medical Record, New York# + +"A handy volume and a distinct improvement on students' compends in +general. No author who was not himself a practical gynecologist could +have consulted the student's needs so thoroughly as Dr. Cragin has +done." + + +#Boisliniere's Obstetric Accidents, Emergencies, and Operations# + +Obstetric Accidents, Emergencies, and Operations. By the late L. Ch. +Boisliniere, M.D., Emeritus Professor of Obstetrics, St. Louis Medical +College; Consulting Physician, St. Louis Female Hospital. 381 pages, +illustrated. Cloth, $2.00 net. + + +#British Medical Journal# + +"It is clearly and concisely written, and is evidently the work of a +teacher and practitioner of large experience. Its merit lies in the +judgment which comes from experience." + + +#Ashton's Obstetrics# Recently Issued--New (6th) Ed. + +Essentials of Obstetrics. By W. Easterly Ashton, M.D., Professor of +Gynecology in the Medico-Chirurgical College, Philadelphia. Crown +octavo, 252 pages, 75 illustrations. Cloth, $1.00 net. _In Saunders' +Question-Compend Series._ + + +#Southern Practitioner# + +"An excellent little volume, containing correct and practical knowledge. +An admirable compend, and the best condensation we have seen." + + +#Barton and Wells' Medical Thesaurus# + +A Thesaurus of Medical Words and Phrases. By Wilfred M. Barton, M.D., +Assistant to Professor of Materia Medica and Therapeutics, Georgetown +University, Washington, D.C.; and WALTER A. WELLS, M.D., Demonstrator +of Laryngology, Georgetown University, Washington, D.C. 12mo of 534 +pages. Flexible leather, $2.50 net; with thumb index, $3.00 net. + + + + + * * * * * + + + +Transcriber's note: + + Changed "dioxid" to "dioxide" in several places + + Made hyphenation of various words consistent + + Page 74: Corrected misspelling of Phlegmona + + Page 135: Corrected misspelling of quantity + + Page 138: changed ',' to '.' at end of sentence + + Page 208: aquæ rosae changed to aquæ rosæ + + Page 210: Fixed typographical error "symptyms" into "symptoms" + + Page 212: Fixed typographical error "Decribe mycetoma" into + "Describe mycetoma" + + Page 213: Fixed typographical error "iodid" into "iodide" + + + +***END OF THE PROJECT GUTENBERG EBOOK ESSENTIALS OF DISEASES OF THE SKIN*** + + +******* This file should be named 25944-8.txt or 25944-8.zip ******* + + +This and all associated files of various formats will be found in: +https://www.gutenberg.org/dirs/2/5/9/4/25944 + + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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