imperfect walking, and even contraction of the calf-muscles, which may
simulate the analogous symptoms of pseudo-hypertrophic paralysis. But
the trunk is bent straight forward, and not bent in lordosis; the lower
extremities tend to cross in spastic paraplegia; there is no lateral
oscillation of the trunk, and the faradic contractility is always
preserved. The progress of the diseases suffices to decide all doubts.
TREATMENT.--The excessively bad prognosis of pseudo-hypertrophic
paralysis may be inferred from the foregoing description. Duchenne
claims to have had two cases brought to him at the early stage of the
disease. The first (Obs. 9) was a boy attacked at the age of seven and
a half with paresis of the lower extremities. He soon began to walk
with a straddling gait, lordosis, and lateral oscillation. Thirty-four
months later some enlargement of the calves was noticed, but the
disease remained stationary for six months, when the patient was
brought to Duchenne. He was treated by hydro-therapeutics, massage, and
faradization of the affected muscles. Cure was complete in six months.
The second case, (Obs. 13) was a little girl six and a half years old.
Paresis of the lower limbs began at the age of four and a half, and
rapidly increased. The legs and thighs began to enlarge shortly after
the first appearance of the paresis. Treatment began in about a year,
and was conducted as in the first case, but in addition cod-liver oil
and bitters were administered internally. Cure after a few months'
treatment.
Duchenne refers the beneficial effect of the faradic current to a {580}
stimulating action on the vaso-motor nerves and capillary circulation,
which he assumes to be paralyzed in this disease. The important point
is to exert this stimulus before the hyperplasia of the connective
tissue is far advanced.
Benedikt claims to have improved five cases by galvanization of the
sympathetic. But the treatment was certainly based on an erroneous
theory of the disease, and the alleged results must be received with
caution.
Uhde[88] claims to have arrested the progress of the disease in the
gastrocnemii muscles by a double tenotomy operation performed for the
relief of pes equinus. The patient was a boy of eleven, in whom the
disease had begun at the age of five. At the time of observation all
the muscles of the legs, as also the glutæi and sacro-lumbales, were
hypertrophied. The feet could not be brought to the ground, owing to
retraction of the calf-muscles: standing and walking were entirely
impossible, and even the power to move the limbs in a recumbent
position was very much limited. Faradization during a fortnight
produced no effect. Then the tendons were cut, and faradization
continued. In a month the patient could execute slight movements in
bed; three weeks later he could walk along the ward; and four months
after the operation he could walk alone and with the soles of the feet
flat on the ground. The calves were softer than before, and diminished
in circumference. But as the history stops here, it is possible that
the two latter changes depended on a substitution of fatty infiltration
for sclerosis. By this, moreover, the muscular fibre would be less
compressed, and in its temporary liberation would for a while seem to
regain part of its force. The last case of alleged recovery that we
have seen is by Donkin.[89]
[Footnote 88: _Langenbeck's Archiv für Chir._, Bd. xvi., 1874.]
[Footnote 89: _Brit. Med. Journ._, 1882, vol. i.]
Gowers remarks[90] that treatment must be directed rather against the
effects of the morbid process than against the morbid process itself,
which, as a primary error of development,[91] must be, to a large
extent, beyond our influence. As internal remedies, Gowers recommends
arsenic, phosphorus, and cod-liver oil, noting that iron and strychnine
seem to have no effect.
[Footnote 90: _Loc. cit._, p. 52.]
[Footnote 91: Gowers says, "of the muscular tissue," but we have shown
reasons why this should rather be sought in the blood-vessels of the
part.]
Faradization also, which is nearly always used, must have nearly always
disappointed expectation, or more cures would be recorded. Systematic
muscular exercises are recommended as the appropriate physiological
stimulus to muscular growth. But in view of the fact that precisely
those muscles are earliest and most profoundly affected which are
exposed to the most strenuous influence of this stimulus, it is
theoretically doubtful whether this advice be valuable.
{581}
DISEASES OF THE SKIN.
{582}
{583}
DISEASES OF THE SKIN.[1]
BY LOUIS A. DUHRING, M.D., AND HENRY W. STELWAGON, M.D.
[Footnote 1: In the general arrangement and order of diseases the
classification adopted by the American Dermatological Association has
been followed.
For obvious reasons, personal references are almost entirely omitted in
the text, but the authors desire to acknowledge valuable suggestions
derived from the writings of J. C. White, R. W. Taylor, L. D. Bulkley,
J. N. Hyde, W. A. Hardaway, A. R. Robinson, H. G. Piffard, A. Van
Harlingen, G. H. Fox, and others.]
CLASS I.--DISORDERS OF SECRETION.
Hyperidrosis.
Hyperidrosis, or excessive sweating, is a functional disturbance of the
sweat-glands characterized by an increased flow of sweat. It may be
local or general, slight or excessive. As a local affection, the form
which mainly interests the dermatologist, it occurs usually about the
hands and feet, especially the palmar and plantar surfaces, and also
about the axillæ and genitalia. If the secretion is excessive,
maceration of the epidermis results, with tenderness, and even
inflammation, of the parts as a consequence: this is not infrequently
the result when the feet are involved, a sodden appearance of the parts
being not unusual. The affection may be acute or chronic, the latter
usually being the case. It is purely a functional disorder, no
anatomical changes taking place in the glands or surrounding tissues.
There is no change in the nature of the secretion. Debility is usually
the fault in general hyperidrosis. The causes of the local varieties
are in many cases obscure. Faulty innervation is doubtless frequently
an important factor. The nervous system possesses a powerful control
over this secretion. The diagnosis presents no difficulties, as there
is no other affection with which it could be confounded. Prickly heat
and oily seborrhoea are considered to bear some resemblance, but
confusion is not likely to occur. Although some cases are readily
relieved, the majority prove obstinate. The duration, locality, and
extent of the affection, as well as the condition of the general
health, are to be considered in pronouncing a prognosis. The disease is
liable to relapse.
Concerning treatment, in addition to quinine and the ordinary tonic
remedies, belladonna and ergot may be referred to as being useful,
particularly the former. Local treatment is always demanded.
Dusting-powders are useful, such as starch or lycopodium powder, to
which from ten to thirty grains of salicylic acid to the ounce may be
added with {584} benefit. They are to be applied freely, so as to
absorb the secretions. Astringent lotions are also of value, and
constitute the most agreeable method of treatment. One drachm of tannic
acid to six ounces of alcohol will be found of service. Solutions of
alum and of zinc sulphate may also be employed. Boric acid, either in
powder or in the form of a saturated solution, and tincture of
belladonna as a lotion, full strength or diluted with alcohol, are both
useful. A successful plan of treatment is that by diachylon ointment
(unguentum diachyli) as recommended by Hebra. The parts are first
cleansed and dried, and then the ointment applied on strips of muslin
as a plaster. It is to be renewed twice daily, the parts on each
occasion being rubbed dry with lint or a soft towel and lycopodium or
starch powder. Water is not to be employed. The treatment must be
continued one or two weeks, and then the ointment omitted, and a
dusting-powder used night and morning for several weeks. In many cases
relief results from one such course; others may require several
repetitions. If a good diachylon ointment is not procurable, the same
plan may be followed out with an ointment made by melting together
equal parts of lead plaster and cosmoline, or with an ointment of
tannic acid, a drachm to the ounce.
Anidrosis.
Anidrosis is a functional disorder of the sweat-glands characterized by
a diminution or suppression of the secretion. It is the opposite
condition of hyperidrosis, and occurs to a slight extent in certain
general diseases, and also in some affections of the skin, as
ichthyosis. It sometimes occurs as an idiopathic disorder, and may
cause much discomfort. Occasionally in nerve-injury localized areas of
diminished or suppressed secretion occur. The treatment should be
conducted upon general principles, including warm or vapor baths and
friction.
Bromidrosis.
Bromidrosis is a functional disorder of the sweat-glands in which the
secretion, which may be either normal or excessive in quantity, is of
an offensive odor. The quantity is usually excessive, as in
hyperidrosis, but occasionally it is normal in amount, while the odor
is heavy, strong-smelling, offensive, and disgusting. It may be
universal or local in character, more frequently the latter; in either
case the odor is rendered more marked by heat and increased
perspiration. In smallpox, measles, typhus and relapsing fevers, and in
some nervous affections peculiar odors are noticed. Certain drugs, as
sulphur, asafoetida, and like substances, taken internally, may be
detected in the odor of the sweat. It is as a localized disorder,
however, that the affection usually comes under observation, the
axillæ, genitalia, and feet being favored localities, the last named
being the most common region affected. It occurs about the soles and
between the toes, and is generally symmetrical. The sweating, if
excessive, causes after a time more or less maceration, and sometimes
hyperæmia or inflammation; the skin becomes {585} whitish and sodden,
the affected area having a pinkish margin. Both Hebra and Thin consider
the socks and soles of the shoes--which become thoroughly permeated by
the secretion--and not the feet, the source of the odor. The latter
observer states that he has found innumerable bacteria (Bacterium
foetidum) in the fluid in which the sock is soaked. The etiology of the
disease is not well understood, but it is without doubt due to some
nervous derangement.
The treatment is about the same as that advised for hyperidrosis. In
addition, however, to the remedies named for that disorder, there are
several other local remedies that have been found useful in this
disease, among which may be mentioned a wash of potassium permanganate,
two or three grains to the ounce, and chloral, twenty or thirty grains
to the ounce of water or dilute alcohol. Thin recommends the use of
cork soles, which (and also the socks) are first to be soaked in a
boric-acid solution and dried.
Chromidrosis.
Chromidrosis is a functional disorder of the sweat-glands, the
secretion being variously colored and generally increased in quantity.
The color may be blackish, bluish, reddish, greenish or yellowish,
bluish and reddish being the most common. The affection is usually
local, occurring in the form of patches, the face, neck, arms, backs of
the hands and feet, chest, and abdomen being the favorite localities.
The disease is rare. Ferrocyanide of iron, copper, and other substances
have been detected in the secretion, to the presence of which doubtless
the colors are due. It is generally observed in nervous and excitable
persons, chiefly in unmarried women; but it has also been noted in
strong men. It tends to recur, and may appear on different parts of the
body with each manifestation. The treatment should be directed against
the suspected cause, with especial reference to the nervous system.
Uridrosis.
Uridrosis, or urinous sweat, is a functional disorder of the
sweat-glands, the secretion containing the elements of the urine,
especially urea. This latter is occasionally detected in the sweat of
persons apparently in good health. In some cases, however, it exists in
such quantity as to be noticeable on the skin, appearing usually on the
face and hands as a colorless or whitish saline crystalline deposit or
coating. In most of the marked cases reported partial or complete
suppression of the renal function has preceded or accompanied the
condition.
Phosphoridrosis.
Phosphoridrosis is the rare condition in which sweat is phosphorescent.
It is sometimes seen in the later stages of phthisis, also in miliaria,
and occasionally in persons who have eaten of putrid fish.
{586} Sudamen.
Sudamen (syn. miliaria crystallina) is a non-inflammatory disorder of
the sweat-glands characterized by pinpoint- to pinhead-sized, isolated,
superficial, translucent, whitish vesicles. The lesions make their
appearance on any portion of the body, but have a predilection for
certain regions of the trunk, especially where the epidermis is thin.
They show themselves as numerous, closely-crowded, discrete, whitish or
pearl-colored minute elevations, in appearance not unlike dew-drops.
They form rapidly, remaining discrete, never becoming puriform, and
evince no tendency to rupture. They are non-inflammatory, never reddish
in color, and are without areolæ. The fluid disappears by absorption
and the epidermal covering by subsequent desquamation. The lesions may
appear in successive crops or new vesicles may show themselves
irregularly from time to time. On the other hand, the first outbreak
may disappear rapidly, and no further manifestation show itself.
Sudamina occupying the face are usually seen in middle-aged females.
The vesicles here are larger, deeper-seated, and more persistent.
Constitutional debility is a predisposing cause of the disease.
Diseases accompanied with a high temperature--such, for example, as
typhus and typhoid fevers, tuberculosis, and acute articular
rheumatism--are frequently responsible for the eruption. The vesicles
are produced by the collection of sweat in some part of the sweat-duct
or epidermis, usually the latter. As ordinarily seen, the vesicles are
situated between the lamellæ of the horny layer, the sweat having made
its way from a rupture in an obstructed duct. In those exceptional
cases of deep-seated and more persistent sudamina occurring about the
face, the vesicles are situated in the corium, and are caused by a
dilatation of the duct. The affection is to be distinguished from
miliaria by the absence of inflammatory symptoms.
The course and duration of the disease depend upon the cause. In the
treatment, removal of the etiological factor is of first importance.
For external use some simple dusting-powder, such as equal parts of
starch and lycopodium, or frequent bathing of the parts with an
evaporating lotion, such as alcohol and water or vinegar and water, may
be employed.
Seborrhoea.
Seborrhoea 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. Although most commonly
seated on the scalp and face, other parts of the general surface may
also be attacked. Upon the trunk the sternal and intrascapular regions
are the parts most frequently affected. It may occur at any period of
life, although more common in adolescent and early adult age. In
newly-born infants it constitutes the vernix caseosa, in which case,
however, it is physiological rather than pathological. The course of
the disease varies, at times disappearing spontaneously or with simple
remedies, and in other cases being rebellious even to judicious
treatment. It is in most cases influenced by the tone of the general
health. In the majority of {587} instances the disease is
non-inflammatory; some cases, on the other hand, show intense hyperæmia
and even inflammatory signs, while not infrequently the disease varies
from time to time in the activity of the process. Itching and burning
in a varying degree are sometimes present; the subjective symptoms are,
however, rarely marked. The disease is usually better in warm than in
cold weather.
There are two clinical varieties of the disease, depending upon the
character of the secretion--seborrhoea oleosa and seborrhoea sicca.
Seborrhoea oleosa appears as an oily, greasy coating upon the skin, and
is seen most frequently about the nose and forehead. The oiliness may
be slight or excessive. Seborrhoea sicca is the more common form of the
disease, and is seen usually on the scalp and face, and occasionally on
other parts of the body. It consists in the formation of dry sebaceous
crusts, usually of a grayish-yellow color, which are slightly adherent.
Frequently both varieties are seen together, and present products of a
mixed character.
Occurring upon the scalp, constituting seborrhea capitis, popularly
known as dandruff, the disease is commonly of the dry or mixed variety,
and usually involves the whole of that region. Sometimes it occurs in
disseminate patches. It appears as small, dry, and pulverulent scales,
detached and loose, or as thin or thick, greasy, crust-like, adherent
masses. In the latter condition the hairs may be matted or pasted to
the scalp. The hair sooner or later becomes affected, and in
consequence is dry and lustreless, and gradually falls out. The
disease, if neglected, finally causes more or less structural change in
the follicles, with permanent alopecia as a result. The skin beneath
the crusts in chronic cases is often of a dull, grayish or bluish-gray
color; sometimes, however, it is hyperæmic. Occurring on other hairy
parts, as the bearded region and eyebrows, the same characters are
presented, but ordinarily they are less marked. At times a condition is
seen on the scalp in which there is a mild degree of inflammation, with
the formation of fine, dry epithelial scales, with slight or marked
itching and burning.
Seborrhoea when occurring about the nose and face--seborrhoea
faciei--is characterized by more or less redness, oiliness, and
sometimes with a moderate amount of scaling and crusting. The
follicular openings are enlarged and patulous, and are either free or
contain sebaceous plugs. On the trunk--seborrhoea corporis--the disease
tends to form circular and confluent scaly patches on a pale or
hyperæmic base, with the sebaceous covering extending into the
follicles in the form of projections. Or the skin may be slightly
reddened, the follicles open and enlarged, the scales having been
detached by the rubbing of the clothing. Seborrhoea when involving the
genital region--seborrhoea genitalium--presents characters somewhat
different. The inner surface of the prepuce, the glans penis, and the
sulcus in the male, and the labia and clitoris of the female, are the
parts commonly affected. A soft, cheesy mass collects about the parts,
which, unless frequently removed, rapidly undergoes decomposition. If
neglected or if the disease is marked, inflammatory symptoms may arise.
The disease is functional in character, the increased and usually
changed oily secretion, with the epithelial scales from the glands and
ducts, forming its products. There is no alteration in the gland
structure except in {588} long-continued cases, in which there may be
slight atrophy. The affection depends usually upon an impairment of the
general health. Chlorosis and anæmia are frequently the predisposing
causes. Stomachic, intestinal, and uterine derangements are also, not
infrequently, factors. Persons of light complexion are more prone to
the dry form, while those of a dark complexion usually show the oily
variety. It is also to be noted that the affection is not infrequently
seen in persons apparently in perfect health, yielding, however, in
such cases to simple external treatment.
Seborrhoea occurring on the scalp must be distinguished from eczema and
from psoriasis. In eczema the skin is somewhat infiltrated, thickened,
and reddened, and rarely involves the whole scalp; there is less
scaliness, and at times more or less of the characteristic gummy
exudation and marked itching of that disease. Psoriasis occurs usually
in well-defined, circumscribed inflammatory patches, and in most cases
shows signs of the disease upon other regions. These same points are of
value in differentiating when the disease is upon non-hairy parts. From
lupus erythematosus, which it may at times, on the face, closely
resemble, it is to be distinguished by the absence of infiltration and
thickening, of the sharply-defined border and violaceous or reddish
color of that disease, as well as by the absence of atrophic scarring.
Seborrhoea differs from ringworm, which it occasionally resembles,
especially on the trunk, by its history, slow course, and by the
greasiness of the scales. In obscure cases the microscope will
determine the question.
TREATMENT.--It is a curable disease, but in the majority of cases
proves obstinate. The rapidity of the cure depends in a great measure
upon the removal of the predisposing causes. In seborrhoea of the
scalp, if the process be allowed to continue through a long period,
more or less marked permanent alopecia, especially of the vertex, may
result. Even in unfavorable cases, however, much may be done toward
promoting a regrowth of hair.
Treatment consists in both constitutional and local measures. The
former is frequently of importance, with a view of securing, if
possible, permanent relief. Iron, quinine, cod-liver oil, and arsenic
are useful. In some cases one-tenth to one-quarter grain doses of calx
sulphurata, three or four times daily, will prove of benefit.
Dyspepsia, if present, is to be relieved. Fresh air and healthful
exercise will sometimes aid considerably in effecting a cure.
External treatment is demanded in every case. The crusts and scales are
to be removed. If in abundance, oily applications, such as olive or
almond oil, are to be made to the parts, and after remaining on for six
or twelve hours to be washed off with soap and hot water. In severe
cases several repetitions may be found necessary. On the other hand, in
mild cases simply washing with castile or ordinary toilet soap and warm
water, or with a decoction of soap-bark, will suffice. If scaling and
crusting are marked, instead of the plain soap sapo viridis should be
used, either alone or in the form of the spiritus saponatus kalinus,
consisting of two parts of sapo viridis in one of alcohol, perfumed
with an essential oil. A tablespoonful of this poured on the scalp, and
then a small quantity of hot water added and the parts rubbed briskly,
wall produce considerable lather; the scalp is then to be rinsed with
warm water, the hair {589} dried, and an oily or fatty substance
applied. If after a removal of the crusts the skin is found to be
irritated, a bland ointment, such as petroleum ointment, will be the
best application. Glycerin and alcohol, one to four, will be of service
if the skin is dry and hyperæmic. Subsequently more stimulating
applications may be made; in the greater number of cases these are
indicated from the start. Chloral, as in the following prescription,
may sometimes be used with benefit:
Rx. Chloralis, scruple ij;
Glycerinæ, minim xx;
Aquæ rosæ, fluidounce iv. M.
Gentle friction should be employed in making the application. If the
lotion is too drying, more glycerin may be added. An excellent
application in many cases is the following:
Rx. Acidi carbolici, minim xxx;
Olei ricini, fluidrachm ij;
Alcoholis, fluidounce j drachm vj. M.