{604} with symptoms of general disturbance, is sometimes seen in
patients taking salicylic acid or its salts. An efflorescence of
vesicles and pustules about the hands and feet, with profuse sweating,
has been recorded. A case in which ecchymotic patches about the back
and neighboring regions appeared from the use of this drug has been
reported.
Santonine.--An instance of an urticarial outbreak with oedema of the
eyelids and swelling of the face has been observed following the
ingestion of this drug.
Stramonium,--An erythematous efflorescence has been recorded as
following this drug.
Strychnia.--A case is on record in which a rash of a scarlatinoid type
followed a dose of one-twenty-fourth of a grain of strychnia.
Turpentine.--Both erythematous and papular eruptions, usually itchy,
have appeared as the result of large doses of turpentine, occurring
principally about the face and upper trunk, the papules being minute in
character. A vesicular eruption has also been noticed somewhat similar
to vesicular eczema.
DERMATITIS FACTITIA.--Feigned diseases of the skin are not uncommon.
Erythema, vesicles, bullæ, and gangrene have been brought about,
chiefly in hysterical females, to gain sympathy, or, as also in other
individuals, for the purpose of deception, by the action of friction,
acids, or strong alkalies.
Dermatitis Gangrænosa.
Dermatitis gangrænosa, or gangrene of the skin, is a rare affection. It
may be idiopathic or symptomatic. As an idiopathic disease it begins
usually as circular, erythematous, dark-red spots, tending to appear
symmetrically, either painful and hyperæsthetic or without sensation.
Malaise, fever, and symptoms of debility usually precede and accompany
its development. The lesions go on to gangrene and sloughing, recovery
taking place or a fatal termination gradually resulting. There may be
several or as many as thirty or forty patches. The progress of the
disease, whether terminating fatally or in recovery, is slow, usually
of several months' duration. Gangrene of the skin as a symptomatic
affection is occasionally seen in grave cerebral and spinal diseases,
and also in diabetes.
Furunculus.
Furunculus, or boil, is a deep-seated, inflammatory disease,
characterized by one or more variously-sized, circumscribed, rounded,
more or less acuminated, firm, painful formations, usually terminating
in central suppuration.
In the beginning the lesion appears as a reddish spot, small, rounded,
imperfectly defined, inflammatory, and painful to the touch, having its
seat in the corium; it gradually becomes larger, raised, and with
marked tendency to central suppuration, usually maturing in from one to
two weeks, when it appears as a painful, deep-red, rounded, pointed,
inflammatory formation, varying in size from a pea to a walnut,
exhibiting central suppuration, the so-called core. In some cases there
is no {605} tendency to core-formation, such lesions being popularly
designated blind boils.
A furuncle is usually painful, of a throbbing nature, which persists
until suppuration has taken place and the contents discharged. The
intensity of the inflammation gives rise to considerable areolar
swelling and hyperæmia. There may be but one lesion present, or, as
more frequently happens, several may exist at the same time scattered
over different regions. In the latter case, after a partial or complete
disappearance of the first crop, a second outbreak frequently occurs,
to be followed later by a third, and so on, constituting furunculosis.
The lesions are usually isolated. No region of the body is exempt; the
face, neck, back, and buttocks are favorite localities. Sympathetic
constitutional disturbance, more or less marked in severe cases, is
usually present. Boils sometimes occur in association with eczema. In
general, they are the result of a depressed state of the system.
Friction, a contusion, or similar local irritation is often the
exciting cause. They are met with in association with diabetes, pyæmia,
uræmia, chlorosis, fevers, and like conditions. Although observed at
all periods of life, they are more common during adolescence and in old
age. The view has been advanced that a furuncle is due to the presence
of a microbe (Torula pyogenica). According to Pasteur, this bacterium
is identical with that of abscesses of the soft parts, etc.
The lesion usually has its starting-point in a sebaceous gland in the
upper part of the corium, or, deeper, in a sweat-gland or
hair-follicle. Beginning in a sweat-gland in the deeper structures it
constitutes the so-called connective-tissue furuncle, or hydroadenitis
of some authors. The core, or central suppuration, is usually made up
of the tissue of the gland in which the boil had its origin, and pus,
and when cast off appears as a whitish, tough, pultaceous mass. A more
or less permanent cicatrix usually results. There is only one affection
with which a furuncle is likely to be confounded--namely, carbuncle. In
this latter, however, the lesion is considerably larger, flattened
instead of rounded and pointed, the pain of an intense character and in
a measure independent of touch or injury. Moreover, a carbuncle has
several points of suppuration, the boil having but one, and the former,
moreover, is rarely multiple.
When occurring in crops, the affection is often rebellious to
treatment. Both constitutional and local measures, especially the
former, are demanded. Functional disorders are to be regulated, and any
faulty condition of the general health corrected. Tonics, such as
quinine, iron, strychnia, mineral acids, and arsenic, are not
infrequently of service. The last remedy usually proves of most value
in those cases in which the lesions appear in crops. The preparations
of sulphur are of positive service in many cases of the disease;
hyposulphite of sodium, ten or fifteen grains three or four times
daily, is one of the most valuable remedies we possess, and with the
same view calx sulphurata, one-tenth to one-half grain five or six
times daily, may be prescribed. Alkalies, especially liquor potassæ in
ten or fifteen minim doses, are not infrequently beneficial. The
compound syrup of the hypophosphites may also be employed with the hope
of obtaining relief. In regard to the diet, the most nutritious food,
liberally partaken of, is, as a rule, to be advised. At times change of
air and scene will act most happily.
{606} Concerning the local treatment, the lesion in the first stage may
possibly be aborted, or at least modified in its course, by the
application to the forming core of a strong solution or of a crystal of
carbolic acid. This procedure is preferable to the actual cautery. If
the lesion be farther advanced, a drop of carbolic acid and glycerin,
equal parts, will often give instantaneous relief and arrest the
progress of the boil. A few drops of a 5 per cent. carbolic-acid
solution may also be injected into the apex of the boil with good
results. For the same purpose painting the parts with tincture of
camphor or tincture of iodine is advised. An ointment of carbolic
acid--as, for example, resin cerate an ounce, carbolic acid from
fifteen to thirty grains--applied as a plaster will be found useful.
The application of poultices affords ease in some cases. As soon as
suppuration has been fully established evacuation of the contents will
shorten the course of the process. If the boil is open and discharging,
boric acid in powder, freely applied, has been recommended.
* * * * *
ALEPPO BOUTON, BOIL, OR EVIL, DELHI BOIL, AND BISKRA BOUTON.--The first
of these diseases, the Aleppo bouton, boil, or evil, is observed at
Aleppo, Bagdad, and the neighboring regions. Delhi boil is not uncommon
in India, and the Biskra bouton is found in Algeria and elsewhere along
the African coast. In fact, these diseases are more or less epidemic in
these countries. They have been considered as allied to furuncle, but
their true nature is somewhat obscure. The three affections are
probably examples of the same disease, modified, it may be, by climate,
habits, etc. They begin as a papule or tubercle, soon becoming a
pustule, and then ulcerate, leaving a cicatrix.
Carbunculus.
Carbunculus (anthrax, carbuncle) is a firm, more or less circumscribed,
painful, deep-seated inflammation of the skin and subcutaneous
structures, variable as to size, terminating in a slough. General
malaise, slight fever, and chilliness precede and usher in the disease.
Locally, there appears at first a more or less circumscribed, circular
redness, with swelling, tenderness, and pain. Soon a phlegmonous
inflammation develops, the surface at times showing vesiculation, the
lesion involving an area several inches in diameter and of considerable
depth. The progress of the disease is not uniform. At the end of a week
or two suppuration is fully established, the first signs of this
process appearing about the hair-follicles. The tissues are now soft
and boggy; the skin becomes gangrenous, breaking down at numerous
points, disclosing centres of suppuration, giving the lesion a
cribriform appearance. Finally, the whole mass sloughs away either as
an entirety or in portions, and results in an open, deep ulcer with
hard and raised edges, which gradually granulates and heals, leaving a
pigmented cicatrix. The area involved varies, and may be extensive,
sometimes as much as six or eight inches in diameter. The favorite
localities for its development are the nape of the neck, shoulders,
back, and buttocks. As a rule, the process ends in three to six weeks.
Usually only one lesion exists. When there are several or where they
follow each other in succession, the general condition is apt to {607}
become markedly depressed, and even a fatal result is not at all
uncommon.
The causes which give rise to the affection are similar to those which
predispose to furuncle. It is generally observed in those whose health
is impaired or broken down. It is more common in men, and is usually
encountered in those past middle age. The inflammation starts
simultaneously at numerous points, usually from the hair-follicles,
sweat and sebaceous glands, extends in all directions, and eventually
terminates in gangrene of the whole area. The inflammatory centres
break down rapidly, from each of which the collected pus finds its way
to the surface, thus producing the cribriform appearance. According to
Warren, the pus ascends by way of the columnæ adiposæ to the
hair-follicles, and thence to the surface. The process may involve
fascia, muscles, and even periosteum and bone. The disease is to be
distinguished from furuncle by its greater size, flatness, and the
multiple points of suppuration. From erysipelas, to which in the
beginning it may have some resemblance, it is to be differentiated by
the hardness, painfulness, and circumscribed character of the lesion.
It is also to be distinguished from malignant pustule. It is always to
be looked upon as a serious affection, especially when occurring in
those past the age of fifty or sixty and in those in a debilitated
condition. Carbuncle when occurring about the face terminates in a
large proportion of the cases fatally.
The treatment is both local and general. The local measures are in the
main the same as advised for furuncle. In the early stages the actual
cautery may arrest the process. Injections of from eight to twelve
drops of a 5 or 10 per cent. solution of carbolic acid will be found
valuable, often affording speedy relief. Frequently-repeated paintings
with tincture of iodine in the early stage may prove of service.
Poultices are of value, and will often diminish the tension and the
pain. A dressing of white lead, laid on thick, is highly spoken of by
Milton and other English observers. When the purulent collections have
broken through the skin the application of a cupping-glass to draw out
the pus has been advised. The wound should be dressed with carbolized
oil. The use of the moist-sponge dressing, with the view of absorbing
the pus, as recommended by McClellan, may be advised. Compression may
also be resorted to with good results. The weight of authority is
against the practice of incision, although in some cases it is to be
recommended, the operation being preceded by hypodermic injections of
cocaine. The general treatment should be of a tonic character.
Iron--preferably the tincture of the chloride--and quinine in large
doses are to be advised. A liberal diet of nourishing food, with a
moderate amount of stimulants, is indicated in almost every case.
Herpes Simplex.
Herpes simplex is an acute, non-contagious, inflammatory disease,
characterized by the formation of pinhead- to pea-sized vesicles
arranged in groups and occurring for the most part about the face and
genitalia. Malaise and pyrexia in severe cases may precede the
eruption. Usually, however, the efflorescence appears without any
systemic disturbance. The lesions {608} are rarely numerous, and appear
in the form of one or more clusters. Sense of heat in the part usually
signalizes the outbreak. The vesicles show no tendency to rupture. The
contents are at first clear, but later become cloudy or puriform, and
dry to yellowish or brownish crusts, which subsequently fall off,
leaving the skin normal. If broken or rubbed, a superficial excoriation
results. The affection is acute, ordinarily running its course, if
unirritated, in a week or ten days. It is liable to recur from time to
time. Occurring about the face, it is designated herpes facialis. It is
usually seen about the lips (herpes labialis), frequently about the alæ
of the nose, and occasionally on other regions of the face. The mucous
membrane of the mouth may also be invaded. The lesions may remain
discrete or may coalesce, forming small blebs.
When the affection shows itself upon the genitalia, it is termed herpes
progenitalis; and when on the prepuce, a common site, herpes
præputialis. In the female, in whom it occurs here much less
frequently, the labia majora and labia minora, as well as the skin
about the vulva, are the parts usually invaded. It is seen most
commonly in the young and middle-aged. Burning, slight itching,
sometimes darting pain, and more or less oedema, may be present. As a
rule, the lesions are not numerous, the average number being five or
six. They incline to group, and ordinarily but one group is seen.
Unless irritated they run the same favorable course as when on other
regions. If, however, as often happens, especially when occurring about
the inner surface of the prepuce or the glans, or on the inner surface
of the labia, the vesicles break down and excoriations resembling
ulcers result. The disease is even more prone to recur than when on
other parts.
Herpes of the face is often observed in association with lung and
febrile diseases. Malaria is sometimes the cause, and digestive and
nervous disorders frequently predispose to it. Herpes of the genitalia,
it is stated, is seen most frequently in those who have previously had
gonorrhoea, chancroid, or chancre, especially the first. It may be
that, occurring in such persons, it excites solicitude, and hence
medical relief is sought, and the relative frequency of such causes
unduly increased. A long prepuce is a predisposing factor.
The characters of the eruption, as it occurs about the face, are so
well marked as to preclude an error in diagnosis. About the genitalia,
however, the lesions may become abraded or irritated, and may simulate
chancroids. The history, course, and character of the two affections
should in doubtful cases be carefully considered before expressing a
positive opinion.
In herpes facialis, flexible collodion, camphorated cold cream, or the
lotion of zinc sulphate and potassium sulphide (see treatment of acne
for formula) may be prescribed. In herpes progenitalis cleanliness is
of great importance. Liquor gutta-perchæ, a paste composed of equal
parts of mucilage of acacia, glycerin, and oxide of zinc, lotions of
sulphate of zinc, a few grains to the ounce, and of ammonia-water, may
be prescribed. A saturated solution of boric acid and a dressing of
borated absorbent cotton are likewise useful, while in some cases
dusting the parts with calomel will prove beneficial. Where the
affection recurs, if the prepuce is long, circumcision may afford
future immunity.
{609} Herpes Iris.
Herpes iris is an acute non-contagious disease, consisting of one or
more groups of inflammatory vesicles or blebs, arranged usually in the
form of more or less complete concentric rings, the whole efflorescence
being somewhat variegated in color.
The eruption most frequently appears on the backs of the hands and
feet, especially the former. It begins as a simple papule or vesicle,
which soon disappears, a ring of discrete or confluent vesicles now
appearing around the periphery. The process may be arrested at this
stage, the lesions soon undergoing involution, or still another ring
may form. The vesicles may be discrete or confluent, but usually they
coalesce, forming small or large blebs. The number of groups or patches
in most cases is not large, three or four usually being present at one
period; but sometimes as many as a dozen or more exist. The eruption is
usually symmetrical. The difference in the age of the several rings
that go to form a single patch gives rise to the variegated colors
which characterize the disease. In size the vesicles vary from a
pinhead to a pea, and the patches from a fraction of an inch to several
inches in diameter. They contain a yellowish, clear, or puriform fluid
which rapidly dries to crusts. New patches, as a rule, continue to
appear in crops for a few weeks, when the process gradually subsides,
leaving slight pigmentation, which soon fades away. Variations in the
type of the efflorescence are not uncommon. In some instances the
lesions barely reach vesiculation, being rather papulo-vesicular, while
in others blebs may appear at the beginning in the place of vesicles.
The subjective symptoms of itching and burning are either lacking or
are not marked. Malaise or slight febrile action may usher in the
disease, or, as is usually the case, constitutional disturbance is not
observed. The affection is comparatively rare. Recurrences may take
place, usually at intervals of a year or more.
It is seen chiefly in spring and autumn, and is met with in both sexes,
but is more common in children and young persons. Its nature is
obscure. It is probably due to the same causes that are responsible for
erythema multiforme, a disease to which it is very closely allied. The
process also is intimately identical with that affection, it being,
apparently, merely an advanced stage or modification of that disease.
It is to be distinguished from ringworm, erythema multiforme, herpes
zoster, pemphigus, and dermatitis herpetiformis. In ringworm the
process is more superficial, and usually is less inflammatory, the
papules or vesico-papules being scarcely distinguishable; in doubtful
cases the microscope will decide. Vesiculation will serve to
differentiate from erythema multiforme. The absence of neuralgic pain,
the distribution, location, and arrangement of the vesicles, are
sufficient to exclude herpes zoster. In pemphigus the size,
distribution, arrangement, mode of formation, and course of the lesions
are different from herpes iris.
The affection tends to spontaneous disappearance in the course of a
week or two; nor does treatment seem to influence materially its
course. The bowels should be opened with saline laxatives, and other
symptoms treated on general principles. Tonics, especially quinine, are
in some cases of value. Locally, dusting-powders, such as oxide of
zinc, starch, and lycopodium, may be frequently applied. Cooling,
antipruritic, or {610} astringent lotions--such, for example, as those
used in acute vesicular eczema--will generally prove grateful.
Herpes Zoster.
Herpes zoster, or zoster, popularly known as shingles, is an acute,
self-limited, inflammatory disease, characterized by groups of vesicles
with inflammatory bases situated along or over a nerve-tract, and
accompanied by more or less neuralgic pain.
As a rule, the cutaneous lesions are preceded, usually for several
days, by neuralgic or burning pains in the part, and in some cases mild
febrile disturbance. An inflamed state of the skin, in the form of one
or several patches, is seen, which is soon followed by the formation of
vesico-papules, which rapidly become distinct vesicles. They vary in
size from a pinhead to a pea, are situated on inflamed bases, and are
irregularly grouped. They may occur in small numbers, or, as is usual,
be numerous, in which case they are crowded together. In the latter
event they may coalesce here and there, forming larger lesions or
irregular patches. They continue to appear for five or six days, remain
stationary a short time, and then begin to subside. One or more groups
may be present; usually a half dozen or more are seen in the one case.
The vesicles contain a clear yellowish liquid, which gradually becomes
puriform; those that appear last rarely reach full development. They
show no tendency to rupture, are distended, subsequently becoming
slightly umbilicated, and by the end of two weeks have gradually dried
to thin yellowish or brownish crusts, which soon drop off. Except in
severe cases, especially the hemorrhagic form, scarring rarely results.
A tendency to group is characteristic of the eruption. The disease is
acute, and runs its course usually in from ten to twenty days.
In some instances the lesions run an abortive course, barely arriving
at the point of vesiculation. On the other hand, small blebs and
pustules may be formed. In severe cases the vesicles may become
hemorrhagic. The neuralgic pain may accompany the disease, and in
severe cases, especially in persons advanced in years, may persist long
after the eruption has subsided. In some cases burning is the only
subjective symptom complained of. The disease is not confined to any
age or sex. It is more common in the winter season. As a rule, it is
limited to one side of the body. Moreover, it is rarely seen in the
same individual twice. The intercostal and lumbar regions show the
eruption most frequently. In zoster of the orbital region the eye
becomes involved, and the disease may in some instances terminate in
loss of sight, and even in destruction of the eyeball. Any nerve-tract
or part of the body may be the seat of the eruption, hence the names
zoster capitis, facialis, brachialis, pectoralis, etc. The disease is
not uncommon.
The eruption is dependent upon an irritable and inflamed state of the
ganglia or nerves--a neuritis. Hence any agent that may bring about
this condition is capable of producing the eruption. Among such may be
included atmospheric changes, sudden checking of the perspiration,
compression, nerve-injuries, operations, and similar influences. In
some instances the eruption is noted to follow the administration of
arsenic. {611} The primary seat of the affection is usually in the
spinal ganglia; they are found softened and altered in structure and
the nerves inflamed and thickened. It may, however, have its beginning
along the tract of a nerve or in the peripheral branches. In fact, it
may be spinal, ganglionic, or peripheral in origin. The vesicles are
found to have their seat in the lower strata of the rete. The
surrounding corium and papillæ show more or less round-cell
infiltration, with dilatation of the papillary blood-vessels. A
perineuritis, with cell-infiltration in and about the neurilemma, is
also usually observed. The vesicles contain rete-cells, pus-corpuscles,
and serum.