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, ...... āā ........... [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, .......... āā ....... [dram]iij. M.

SIG. To be well rubbed in.

[Footnote B: [Rx] Potassae, ............................. [dram]j Picis liq., .......................... [dram]ij Aquae, ................................ [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 Aquae, ................................ [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. Aquae, ....................... 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. acaciae, ..................... [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 hyperaemia and inflammation, and a slight elevation, with a central yellowish or blackish point results—the lesion of acne punctata; if the inflammation is of a higher grade or progresses, the elevation is reddened and more prominent—acne papulosa; if the inflammatory action continues, the interior or central portion of the papule suppurates and a pustule results—acne pustulosa; the pustule, in some cases, may have a markedly inflammatory and hard base—acne indurata; and not infrequently the lesions in disappearing may leave a pit-like atrophy or depression—acne atrophica; or, on the contrary, connective-tissue new growth may follow their disappearance—acne hypertrophica; and, in strumous or cachectic individuals, the lesions may be more or less furuncular in type, often of the nature of dermic abscesses, usually of a cold or sluggish character, and of more general distribution—acne cachecticorum.

What is acne artificialis?

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

What course does acne pursue?

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



Is the eruption in acne usually abundant?

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

Does the eruption in acne disappear without leaving a trace?

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

Are there any subjective symptoms in acne?

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

State the immediate or direct cause of an acne lesion.

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

Name the indirect or predisposing causes of acne.

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

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

The disease is more common in individuals of light complexion.

Is there any difficulty in the diagnosis of acne?

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

In what respect does the pustular syphiloderm differ from acne?

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

What is the pathology of acne?

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

State the prognosis of acne.

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

What measures of treatment are usually demanded in acne?

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

Upon what is the constitutional treatment based?

Upon indications. Diet and hygienic measures are important.

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

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

SIG.—f[dram]t.d.

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

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



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

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

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

State the character of the local treatment in acne.

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

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

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

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

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

State the methods of external medication commonly employed.

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

State the object in view in local medication.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



Acne Rosacea.

Give a descriptive definition of acne rosacea.

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

Describe the symptoms of acne rosacea.

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

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



Are there any subjective symptoms in acne rosacea?

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

What do you know in regard to the etiology?

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

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

Is acne rosacea easily recognized?

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

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

State the prognosis of acne rosacea.

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

What is the method of treatment?

Both constitutional and local measures are demanded in most cases.

Upon what is the constitutional treatment to be based?

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

What is the external treatment?

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

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

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

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

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

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

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

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

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

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



Acne Varioliformis. (Synonyms: Acne Frontalis; Acne Rodens; Acne Necrotica; Lupoid Acne; Necrotic Granuloma.)

Describe acne varioliformis.

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

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

Give the prognosis and treatment.

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



Sycosis. (Synonyms: Sycosis Vulgaris; Sycosis Non-parasitica; Folliculitis Barbae; Sycosis Coccogenica.)

What do you understand by sycosis?

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

Describe the symptoms of sycosis.

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



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

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

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

Does conspicuous hair loss occur in sycosis?

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

State the character of the subjective symptoms.

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

What is the course of the disease?

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

State the causes of sycosis.

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

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

What is the pathology of sycosis?

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

How would you distinguish sycosis from eczema?

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

How would you exclude tinea sycosis in the diagnosis?

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

Give the prognosis of sycosis.

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

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

How is sycosis to be treated?

Mainly, and often exclusively, by external applications.



Is constitutional treatment of no avail in sycosis?

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

Describe the external treatment.

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

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



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

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

What would you advise in regard to shaving?

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

When is depilation advisable as a therapeutic measure?

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

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



Dermatitis Papillaris Capillitii. (Synonym: Acne Keloid.)



Describe dermatitis papillaris capillitii.

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

Give the treatment.

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



Impetigo Contagiosa.

Give a descriptive definition of impetigo contagiosa.

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

Upon what parts does the eruption commonly appear?

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

Describe the symptoms of impetigo contagiosa.

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

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

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

State the cause of the disease.

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

From what diseases is impetigo contagiosa to be differentiated?

From eczema, pemphigus, and ecthyma.

How does impetigo contagiosa differ from these several diseases?

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

State the prognosis.

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

What is the treatment of impetigo contagiosa?

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



Impetigo Herpetiformis.

Describe impetigo herpetiformis.

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

It is possibly a grave type of dermatitis herpetiformis.



Ecthyma.

Give a descriptive definition of ecthyma.

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

Describe the symptoms and course of ecthyma.

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

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

What is the cause of ecthyma?

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

From what diseases is ecthyma to be differentiated?

From impetigo contagiosa, and the flat pustular syphiloderm.

How is it distinguished from these several diseases?

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

State the prognosis.

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

What treatment is to be advised?

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

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

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

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



Pemphigus.

What do you understand by pemphigus?

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

Name the varieties met with.

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

Describe the symptoms and course of pemphigus vulgaris.

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

A grave type of pemphigus is exceptionally observed in the newborn—pemphigus neonatorum.

What course does pemphigus vulgaris pursue?

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



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

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

Describe the symptoms and course of pemphigus foliaceus.

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

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

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

What is the character of the subjective symptoms in pemphigus?

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

What is known in regard to the etiology of pemphigus?

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

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

What is the pathology?

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

From what diseases is pemphigus to be differentiated?

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

How do these several diseases differ from pemphigus?

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

State the prognosis of pemphigus.

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

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

Pemphigus neonatorum usually ends fatally.

Give the treatment of pemphigus.

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

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



CLASS III.—HEMORRHAGES.

Purpura.

Define purpura.

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

Name the several varieties met with.

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

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

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

Describe the symptoms of purpura simplex.

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

Describe the symptoms of purpura rheumatica.

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

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

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

Describe the symptoms of purpura haemorrhagica.

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

State the etiology of purpura.

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

State the diagnostic characters of purpura.

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

How does scurvy (scorbutus) differ from purpura?

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

What is the pathology of purpura?

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

State the prognosis

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

What is the treatment of purpura?

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

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



Scorbutus. (Synonyms: Scurvy; Sea Scurvy; Purpura Scorbutica.)

Describe scorbutus.

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

State the etiology of scurvy.

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

How is scurvy to be distinguished from purpura?

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

Give the prognosis of scurvy.

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

What treatment would you advise in scurvy?

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

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



CLASS IV.—HYPERTROPHIES.

Lentigo. (Synonym: Freckle.)

Describe lentigo.

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

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

What is the pathology of lentigo?

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

State the prognosis.

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

Name the several applications commonly employed for their removal.

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

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

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



Chloasma.

What do you understand by chloasma?

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

Describe the clinical appearances of chloasma.

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

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

Idiopathic and symptomatic.

What cases of chloasma are included in the idiopathic group?

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

What cases of chloasma are included in the symptomatic group?

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

What is chloasma uterinum?

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

What is argyria?

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

State the pathology of chloasma.

The sole change consists in an increased deposit of pigment.

Give the prognosis of chloasma.

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

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

Upon general principles; there are no special remedies.

How do external remedies act?

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

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

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

Name the several applications commonly employed.

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

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

And also the following:—

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

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

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

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

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

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



Keratosis Pilaris. (Synonyms: Pityriasis Pilaris; Lichen Pilaris.)

What is meant by keratosis pilaris?

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

Describe the clinical appearances of keratosis pilaris.

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.



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 papillae. 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.



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 papillae 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 papillae and some bloodvessels. They have their starting-point in the rete mucosum, either from that lying above the papillae 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 papillae, 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.



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.



Naevus Pigmentosus. (Synonym: Mole.)

Describe naevus pigmentosus.

Naevus 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 naevus pigmentosus met with.

Naevus spilus, naevus pilosus, naevus verrucosus, and naevus lipomatodes. So-called linear naevus might also be considered as belonging in this group.

What is naevus spilus?

A smooth and flat naevus, consisting essentially of augmented pigmentation alone.



What is naevus pilosus?

A naevus upon which there is an abnormal growth of hair, slight or excessive.

What is naevus verrucosus?

A naevus to which is added hypertrophy of the papillae, giving rise to a furrowed and uneven surface.

What is linear naevus?

Linear naevus 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 naevus lipomatodes?

A naevus with excessive fat and connective-tissue hypertrophy.

State the etiology of naevus pigmentosus.

The causes are obscure. The growths are usually congenital; but the smooth, non-hairy moles may be acquired.

Give the pathology of naevus 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 papillae are greatly hypertrophied, in addition to the increased pigmentation. There is, as a rule, more or less connective-tissue hypertrophy.