Beiersdorf, an apothecary of Hamburg, Germany. The muslin plasters
consist of muslin incorporated with a layer of stiff ointment; the
gutta-percha plasters consist of muslin faced with a thin layer of
india-rubber, the medication being spread upon the rubber coating.]
Prurigo.
Prurigo is a chronic inflammatory disease, characterized by discrete
pinhead- to small pea-sized, solid, firmly-seated papules, slightly
raised, {640} of a pale-red color, accompanied by general thickening of
the skin and itching. The disease manifests itself by the development
of small firm elevations, which at first are scarcely perceptible; but
they may be distinctly felt by passing the hand over the surface.
Later, they may be seen as slightly-raised papules, varying in size
from a milletseed to a small pea, of the same color as the surrounding
skin or of a pinkish hue, and to the touch are found to be well-defined
inflammatory deposits. The lesions are discrete, may be present in
great numbers and in close proximity, and show no tendency to group,
being irregularly distributed. There is rarely distinct
scale-formation, but the papules are usually covered with roughened,
dry epidermis, and are frequently perforated with hairs.
Itching, usually intense, is a constant symptom, giving rise to
scratching, and as a consequence many of the lesions are covered with
blood-crusts and the skin is markedly excoriated. In course of time,
either as a symptom of the disease or as a result of the scratching and
consequent hyperæmia, or more probably resulting from both, the skin
becomes thickened and the surface harsh or rough. The extensor surfaces
of the legs, especially the tibial regions, and later the forearms and
arms, and in marked cases the trunk, are the regions usually invaded.
The palms and soles escape, and only in rare cases is the head
involved. As a result of strong local remedies or scratching, or of
both, a simple dermatitis or an eczema may develop as a complication.
In consequence also of the cutaneous irritation the lymphatic glands,
especially the inguinal, may become engorged--prurigo buboes (Hebra).
The causes of the disease are obscure. It is common in Austria, and is
occasionally met with in France and England, but it is almost unknown
in the United States. It is met with, as Hebra states, almost
exclusively in poor subjects and those ill nourished in childhood, and
so most often in foundlings and beggars' children. The disease is not
hereditary. It usually develops, however, in early childhood, and is
worse in winter than in summer. Anatomically, the lesions differ but
slightly from those of papular eczema. The papillæ and rete show a
moderate amount of cell and serous infiltration. Later, as a result of
the chronic inflammation, thickening, increased cell-infiltration,
atrophied sweat and sebaceous glands, and pigmentation are observed.
The process, according to various authorities, begins in the papillary
layer.
Prurigo has been, and is still, erroneously confounded with pruritus
and pediculosis, diseases which have nothing in common with that
affection except the itching and resulting excoriations--symptoms, as
is well known, common to many diseases. In pruritus there is no
structural change in the skin except that produced by scratching, a
point of difference that is diagnostic. The thickening of the skin and
the harsh, rough surface encountered in prurigo are absent in pruritus.
The latter disease is usually one of middle or old age; prurigo, on the
other hand, dates from childhood. In pediculosis the lesions, punctate
or papular in form, are consequent upon the wounds of the pediculus,
and are most numerous about the trunk, especially the shoulders and
hips. Between simple eczema and prurigo the diagnosis is not difficult.
It is to be remembered, however, that eczema may exist as a
complication, in which case, after its disappearance, the
characteristics of prurigo become evident.
{641} Severe cases are said to be incurable, according to Hebra and
others, but in the milder forms of the disease a cure may be effected.
Good food, hygiene, and tonic remedies, and systematic local treatment
similar to that generally employed in chronic eczema, are the measures
indicated. Naphthol, in the form of a 5 per cent. ointment for adults
and a ½ per cent. ointment for children, has been found by Kaposi to be
of value.
Acne.
Acne, or acne vulgaris, is an inflammatory, usually chronic, disease of
the sebaceous glands, characterized by papules, tubercles or pustules,
or a combination of these lesions, occurring for the most part about
the face. There are several so-called varieties of acne, although
examples of all these forms may be seen usually in an individual case,
and instances in which all the lesions are of the same type or
character are practically not encountered. Other disorders of the
sebaceous glands, as comedo and seborrhoea, are often seen associated
with this affection. In fact, hypersecretion or retention of the
sebaceous matter is the exciting cause of the inflammation.
If the retained sebaceous mass causes a moderate degree of hyperæmia or
inflammation, a slight elevation with a central whitish or blackish
point results, constituting the lesion of acne punctata. If the
inflammation is of a higher grade, the elevation is more marked,
reddened, and papular, the lesion being known as acne papulosa. If the
process is still more active, the central portion of the papule
suppurates and acne pustulosa results. The surrounding inflammation of
this form is often of a violent type, and the lesion may be situated
upon a hard and inflamed base, and then is designated acne indurata. In
some cases of acne the disappearing lesions leave more or less atrophy
about the gland-ducts in the form of pit-like depressions--acne
atrophica. On the other hand, at times there results connective-tissue
hypertrophy about the glands--acne hypertrophica. In strumous,
cachectic individuals the lesions, which are usually pustular in type,
or at times furuncular, almost of the nature of dermic abscesses, may
be more general in distribution, and are, moreover, usually of a more
sluggish character, constituting the so-called acne cachecticorum. The
efflorescence which follows the prolonged ingestion of the iodides and
bromides is usually of a more inflammatory type, the glands and
follicles being sometimes seriously and irreparably involved. This form
of acne, as well as that resulting from the external action of tar,
characterized by the formation of all kinds of lesions with a minute
central blackish deposit of tar and more or less inflammation of the
surrounding skin, constitutes acne artificialis.
The most common form of acne is that in which the pustule predominates.
The lesions, in all the varieties, are usually confined to the face,
the forehead, cheeks, and chin being favorite localities; not
infrequently, however, the eruption also involves the shoulders and
upper part of the back. They are irregularly distributed and tend to
appear in crops. Sometimes the face and shoulders are spared, and the
lesions, being confined to the back, extend as far down as the lumbar
region or even to the thighs. In these cases the lesions are usually
{642} of a papulo-pustular character and are sluggish in their
evolution. As a rule, an acne papule or pustule runs an acute course,
disappearing in the course of one or two weeks, and a new lesion
appearing at another point to supply its place. The disease is
essentially chronic, in the sense that the parts are never or seldom
free, new lesions forming and old ones disappearing from time to time,
in some cases indefinitely. As a rule, there are no subjective
symptoms, but in some markedly inflammatory cases the lesions are
painful; in other exceptional instances there is slight itching.
The disease is common about the age of puberty, and occurs in both
sexes. Chronic derangement of the digestive apparatus is a frequent
factor. Those of a light complexion are more liable to its development,
while menstrual difficulties, chlorosis, scrofulosis, and general
debility may all predispose to the disease. Medicinal substances, such
as the iodides and bromides, and tar externally, are also prone to
produce acne-form lesions. The retention of the secretion within the
sebaceous gland is the first step in the formation of an acne lesion,
and its presence--or it may be its decomposition--gives rise to
inflammation, which usually involves the gland-structure and the
surrounding tissue. Primarily, it is a folliculitis, the tissue
immediately about the follicle subsequently becoming involved,
constituting a perifolliculitis. As a result of this latter process, or
from inflammation and changes within the gland without much surrounding
inflammation, the destruction of the sebaceous follicles may ensue. The
hair-follicles at times are also involved in the process. The degree of
inflammation determines the character of the lesion; if mild in
character, the simple papule or pustule results; if of a severe grade,
the lesion of the indurated and hypertrophied forms follows.
Acne resembles at times the papular and pustular syphiloderms. In
syphilis the distribution of the eruption, the history of the case, the
color, the duration of the individual lesions, the tendency of the
papules or pustules to group, and usually the presence of other
evidence of the disease, will serve to distinguish it from acne. Tar
acne may be recognized by the history, the black points at the
follicular openings, and usually evidence of the presence of tar about
the patient. Acne resulting from the ingestion of the bromides and
iodides is almost always of an acute and markedly inflammatory type,
the lesions being scattered over the general surface, and are usually
larger and more virulent in character than those of acne vulgaris. From
acne rosacea it may be known by the characters referred to in speaking
of that disease.
TREATMENT.--Cases of acne vary considerably as to their course and
curability. There is in almost every case a natural inclination toward
disappearance of the eruption at the age of twenty or thirty. Although
the lesions are at any age of the patient generally easily removable by
treatment, relapses are the rule; but the older the patient the less
probability is there of a recurrence. Even in young subjects, however,
the cure may be permanent, depending upon the ability to discover and
remove the cause. The disease requires both constitutional and local
treatment. For the removal of the existing eruption local applications
alone are usually sufficient, but the disposition to the development of
new lesions in most cases yields only to appropriate internal
treatment.
Each case of acne for its successful management demands careful {643}
investigation with a view of discovering the etiological factors. If
these can be ascertained and removed, a successful result is assured.
As already intimated, disorders of digestion play a most important part
in the etiology of this disease, and in a large proportion of cases
remedies appropriate to such conditions are required. The diet is to be
strictly regulated: all indigestible articles of food, such as pork,
salt meats, pastry, cheese, pickles, etc., should be interdicted. If
constipation exists, laxatives are to be prescribed. As a rule, salines
are more serviceable than vegetable preparations for plethoric
individuals, while for others the latter, especially for long-continued
administration, are to be preferred. A change from one to the other is
often advisable. The dose should be sufficient to produce a free
evacuation daily. An excellent tonic aperient mixture is the following:
Rx. Magnesii sulphatis, ounce iss;
Ferri sulphatis, gr. viij;
Acidi sulphurici diluti, fluidrachm ij;
Aquæ menthæ piperitæ, fluidounce iij drachm vi.
M.--S. A tablespoonful in a tumblerful of water a half hour before
breakfast. The tonic effect of such a mixture is best obtained by
prescribing one or two teaspoonfuls in a large wineglassful of water
before each meal: as a rule, however, when thus given its laxative
property is not so well marked. The mint-water may be replaced by a
bitter infusion, such as quassia, but the mixture, unpalatable at the
best, is not improved by such a substitution. In some cases the acid in
the above mixture is contraindicated, and the following, also a
valuable formula, may be prescribed:
Rx. Magnesii sulphatis, ounce iss;
Potassii bitart., drachm iv;
Sulphuris præcip., drachm ij;
Glycerinæ, fluidrachm ij;
Aquæ menthæ pip., fluidounce iv.
M.--S. Tablespoonful in a tumblerful of water a half hour before
breakfast. Hunyadi Janos water, in the dose of a large wineglassful
thirty or forty minutes before the morning meal, is a useful saline,
and is not especially disagreeable. Friedrichshall water is an
efficient laxative and cathartic, but has a nauseous taste and odor.
The ordinary mixture of rhubarb and soda is of value, not only for its
laxative effect, but also for its antacid property where such is
indicated. The following formula, containing cascara sagrada, is of
service:
Rx. Ext. cascaræ sagradæ fl., fluidrachm iv;
Acidi muriatici diluti, fluidrachm ij;
Tincturæ gentianæ comp., fluidounce iij drachm ij.
M.--S. Teaspoonful in a large wineglassful of water before meals. At
times this proportion of cascara sagrada is too large, and, on the
other hand, in some cases it must be increased. A laxative pill, as the
following, containing aloin, belladonna, and strychnia, may be given:
Rx. Aloin, gr. iij;
Ext. belladonnæ, gr. ij;
Strychniæ sulphatis, gr. ¼.
M. Ft. pilul. No. xv.--S. One or two at night. If there is torpor of
the liver, an occasional dose of blue mass or calomel may be
prescribed. {644} When there is flatulence or other symptoms of
fermentative indigestion, a mixture such as the following will be found
useful:
Rx. Sodii hyposulphitis, drachm ijss-ounce j;
Ext. nucis vomicæ fl. fluidrachm ij;
Aquæ menthæ piperitæ, fluidounce iv.
M.--S. Teaspoonful in a large wineglassful of water a half hour before
meals. The hyposulphite of sodium contained in the mixture may have a
laxative effect in addition to its antifermentative action.
If there is anæmia or chlorosis, a preparation of iron, combined with
aloes if there is tendency to constipation, is to be prescribed, the
wine of iron being one of the most eligible ferruginous preparations.
Ergot in the dose of a half drachm of the fluid extract has been
recommended in the acne of females, especially where it seems probable
that uterine disturbance is the exciting cause. Possibly its effect is,
as has been suggested, due to its action on the unstriped muscular
fibres of the skin. After one or two weeks' administration it is apt to
cause gastric disturbance and, directly or indirectly, vertiginous
symptoms. Calx sulphurata in the dose of one-tenth to one-half grain
every three or four hours is of value in some cases, usually proving of
most service in the pustular type. In strumous individuals, and in
those whose nutrition is below the average, cod-liver oil is a valuable
remedy. In like cases glycerin in similar doses may be prescribed,
although its action is not so certain.
Arsenic is of decided value in some cases, but proves powerless in
others. The sluggish papular forms are often influenced favorably by
its continued administration. The alterative effect of mercury is
sometimes beneficial, corrosive sublimate in small doses being the most
available preparation. Where the inflammation is of a high grade,
potassium acetate and other alkalies may be prescribed, as in the
following formula:
Rx. Potassii acetatis, drachm v gr. xx;
Liq. potassæ, fluidrachm ijss;
Liq. ammonii acetatis, fluidounce iij drachm v.
M.--Sig. Teaspoonful in a large wineglassful of water one hour before
meals.
Local Treatment.--This is of great importance and is demanded in every
case. In acute acne, rarely encountered, mildly astringent applications
are to be advised. The disease, as generally met with, however, is of a
subacute or chronic character, requiring stimulating measures. External
treatment in these cases has for its object the production of hyperæmia
and the removal of the superficial layers of the epidermis, thus
stimulating the glands and circulation and assisting in the excretion
of the sebaceous matter. For this purpose washing the parts
energetically with sapo viridis and hot water every night, using a
sponge or preferably a piece of flannel, may be advised. After the
soap-washing the parts are to be sponged with hot water for several
minutes, or the face held over a basin containing steaming hot water.
Subsequently, the comedones are to be pressed out by means of pressure
with the fingers, or, better, by a watch-key with rounded edges so as
not to injure the skin. An application of a simple emollient, such as
cold cream or vaseline, may then be made and allowed to remain on over
night. This plan of treatment is to be repeated nightly or every other
night.
In many simple cases of acne the above method of external treatment,
{645} combined with appropriate constitutional medication, will bring
about marked improvement and sometimes permanent relief. In the
majority of cases, however, a more stimulating plan of treatment is
called for. In almost all cases the soap-washing, either with the sapo
viridis or a milder soap, and the sponging with hot water, are to
precede the nightly remedial applications. Among the external remedies
for acne sulphur preparations stand first. Properly managed, they
rarely fail to benefit, and often prove curative. Precipitated sulphur
is the preparation generally employed, and in many cases the most
suitable. It may be prescribed as a powder, in ointment, or in lotion.
As a powder it may be applied pure or mixed with starch, and as an
ointment the following formula can be recommended:
Rx. Sulphuris præcipitati, drachm iss;
Adipis benzoati, drachm iv;
Ugt. petrolei, drachm ijss;
Olei rosæ, gtt. iij.
M. Ft. ugt.--Sig. To be rubbed thoroughly into the skin at night. Or,
instead of the precipitated sulphur in the above ointment, the sulphur
hypochloride may be substituted. As a mild stimulant sulphur soap may
often be ordered with advantage in connection with other remedies.
In sluggish, non-inflammatory cases the following may be used:
Rx. Sulphuris præcipitati,
Potassii carbonatis,
Glycerinæ,
Ugt. petrolei, aa. drachm ij.
M. Ft. ugt.--Sig. Apply at night, rubbing it into the skin. In the
above formula the petroleum ointment may be replaced with the same
quantity of alcohol. In the form of a lotion precipitated sulphur at
times acts more decidedly than as an ointment. There are several useful
formulæ which, as a rule, answer equally well, although in some cases
differing in their beneficial effects. In the average case the
following seems most certain in its results:
Rx. Sulphuris præcipitati, drachm ij;
Pulv. camphoræ, gr. xx;
Pulv. tragacanthæ, gr. xxx;
Aquæ aurantii flor.,
Liq. calcis, aa. fluidounce ij.
M.--S. Dab on with a mop or rag; shake before using.
A similar mixture in the form of a paste may be made with equal parts
of mucilage of acacia, glycerin, and sulphur, and is to be applied with
a brush, being allowed to remain on the skin over night.
Another sulphur lotion is the following:
Rx. Sulphuris præcipitati, drachm ij;
Glycerinæ, fluidrachm j;
Alcoholis, fluidounce j;
Liq. calcis, fluidounce ij;
Aquæ aurantii flor., fluidounce j.
M.--Sig. Apply with a sponge or rag, shaking well before using.
The annexed is also a good stimulating lotion: {646}
Rx. Sulphuris præcipitati, drachm ij;
Ætheris, fluidrachm iv;
Aquæ cologniensis, fluidrachm iv;
Alcoholis, fluidounce iij.
M.--Sig. Shake well and dab on with a rag.
Potassium sulphide is a preparation of sulphur which often acts
admirably in this disease. It may be employed as an ointment, or,
preferably, as a lotion. An excellent formula, containing the sulphide,
which can be prescribed with advantage in many cases, is the following:
Rx. Potassii sulphidi,
Zinci sulphatis, aa. drachm j;
Aquæ rosæ, fluidounce iv.
M.--S. Apply with a sponge or rag. The resulting lotion from this
mixture is a complex one, a double reaction taking place. The salts
should be separately dissolved, and then mixed. If properly made, the
lotion when shaken is of a milky color and free from odor; upon
standing the particles sink and form a white sediment, the liquid above
being clear. If improperly prepared, as is often the case, it is of a
yellowish tinge with a decided odor of the potassium sulphide, and has
an entirely different effect. Vleminckx's solution,[4] perfumed with an
essential oil, is often of service; it is to be diluted with three to
six parts of water and dabbed on every night, the strength gradually
increased if necessary.
[Footnote 4: See treatment of Psoriasis for formula.]
Another class of external remedies found of service in the treatment of
this disease are the mercurials. They are not so valuable as the
sulphur preparations. Corrosive sublimate, white precipitate, and
calomel are the mercurials commonly used. If sulphur has been
previously employed, several days should intervene and the parts be
repeatedly cleansed before using a mercurial, otherwise the skin is
darkened temporarily by the formation of the black sulphuret of
mercury. Corrosive sublimate is prescribed in the form of a lotion,
from one-half to two grains to the ounce of alcohol and water, or as in
the following formula:
Rx. Hydrargyri chloridi corros., gr. ij;
Zinci sulphatis, gr. xv;
Alcoholis, fluidounce ij;
Aquæ rosæ, fluidounce ij.
M.--S. Apply with a rag. The zinc sulphate renders the lotion
astringent, and is often a valuable addition. Ammoniated mercury,
thirty to sixty grains to the ounce of benzoated lard or cold cream,
will frequently prove serviceable. If the lesions are numerous and are
seated close together, the application is to be made to the entire
surface of the part; on the other hand, if they are sparse, it may be
made to the spots only. The same may be said also in regard to the
sulphur preparations. A 5 or 10 per cent. ointment of oleate of
mercury, rubbed thoroughly into sluggish and indurated lesions, will
often shorten their course by promoting suppuration. In many cases
puncturing the lesions with a sharp knife or scraping with a curette
before applying the hot water will be of assistance in the treatment.
In obstinate indurated lesions, in addition to puncturing the lesions,
the apices may be treated with carbolic acid. The protiodide of
mercury, in the strength of five to fifteen grains to the ounce of
ointment, is well spoken of by some authorities; it is to be used {647}
with care, as it is actively stimulant. In some cases rubbing
energetically over the parts a mixture of sapo viridis and sulphur,
adding enough hot water to make a lather, and allowing it to remain on
over night, will, if repeated nightly until the skin becomes slightly
inflamed and then followed subsequently by a mild ointment, produce a
decided effect.
Acne Rosacea.