is always favorable. The importance of good food and proper hygiene
cannot be overestimated. Tonics may be prescribed as efficient
adjuvants. Iron, quinine, nux vomica, and the mineral acids are
valuable. As a rule, simple measures are sufficient in the external
treatment. If the lesions are numerous and are markedly inflammatory,
alkaline baths, six ounces of sodium bicarbonate or of a similar
alkaline salt to the bath, will be of service. The crusts are to be
removed by poultices or hot-water applications, and the excoriations
dressed with an ointment of ten to twenty grains of ammoniated mercury
in an ounce of oxide-of-zinc ointment. In some cases a more stimulating
ointment is required. Where active stimulation is demanded, touching
the parts with nitrate of silver, diluted carbolic acid or a similar
agent will prove serviceable.
Miliaria.
Miliaria--popularly known as prickly heat or heat-rash--is an acute
inflammatory disorder of the sweat-glands, characterized by pinpoint to
milletseed-sized papules or vesicles, attended usually by sensations of
pricking, tingling, or burning. In some cases the eruption is almost
entirely made up of papular lesions, and constitutes the form of the
affection known as miliaria papulosa. In other cases the lesions are
vesicular in nature, and miliaria vesiculosa is typified. It is chiefly
the papular form to which the name of prickly heat has been applied.
This variety begins with the formation of minute elevated, acuminated,
bright-red papules, occurring usually in great numbers, more or less
crowded together; the individual lesions, however, remain discrete. The
affection may be localized, or, as is usually the case, may involve
considerable surface. In miliaria vesiculosa the lesions are in the
form of vesicles the same in size as the papules, and appear as whitish
or yellowish points surrounded with inflammatory areolæ. They are
usually crowded so closely together as to give the skin a bright-red
look (miliaria rubra). At first the vesicles are transparent and
contain a clear fluid, but as they become older they appear opaque and
yellowish-white (miliaria alba), and instead of the bright-red
appearance the eruption has then a yellowish cast. As in the {655}
papular form of the eruption, small areas may be involved or the
greater part of the entire surface. The trunk is a favorite locality.
The vesicles dry up in a few days, showing no tendency to rupture, and
terminate in slight desquamation. In the majority of cases the eruption
consists of papular, vesico-papular, and vesicular lesions
interspersed. They make their appearance suddenly, usually accompanied
with considerable sweating, and if the cause has ceased to act
terminate in the course of a few days. As a rule, the subjective
symptoms are mild in character, nothing more than slight tingling,
burning, being noted; in others, however, these may be so marked as to
give rise to considerable annoyance. Individuals who are debilitated
seem most prone to an outbreak. Hot weather predisposes to it; in fact,
excessive heat from whatever cause is apt to provoke an attack. It is
especially common in children. The affection as usually met with is
essentially an inflammatory disorder of the sweat-glands, congestion
and exudation taking place about the ducts, giving rise to papules or
vesicles, according to the intensity of the process.
It is to be distinguished from eczema and sudamen. The papules of
eczema are larger, more elevated, firmer, make their appearance more
slowly, and are of much longer duration; moreover, the itching of
papular eczema is usually marked. Vesicular eczema differs from
miliaria vesiculosa by the larger size of the lesions, their
disposition to rupture, their tendency to become confluent, and their
greater itchiness, and by the general features of the eruption both as
regards its appearance and duration. It is to be noted that miliaria
occurring in children from the conjoint effects of warm weather and
superfluous clothing may, if the exciting causes are continued, result
in eczema. Sudamen may be differentiated by the absence of inflammatory
symptoms.
The affection under favorable circumstances runs a rapid course,
disappearing in a few days or weeks. A removal of the exciting cause
will in all cases have a favorable effect. Too active treatment is to
be avoided, not only as being useless but prejudicial. Undue
perspiration should be guarded against. The patient is for the time to
avoid exercise and to be properly clad. Refrigerating diuretics, as
citrate or the acetate of potassium or simple lemon-juice diluted, may
be prescribed. When the eruption is kept up or frequently recurs as a
result of impaired health, tonics, as quinine, iron, and the mineral
acids, will be useful. In the majority of cases local treatment alone
is necessary. Dusting-powders and cooling or astringent lotions are of
most value. Starch and lycopodium powder, equal quantities or with 20
to 30 per cent. of oxide of zinc added, may be used; the surface is to
be kept freely powdered. Astringent lotions may be employed in place of
the dusting-powder, or, what is often advisable, may immediately
precede the latter, the lotion being first applied, allowed to dry on
the surface, and then the powder freely dusted over. A lotion of
alcohol and water and sponging with vinegar and water may be
prescribed.
Pompholyx.
Under this head (and also that of Dysidrosis) a rare disease of the
skin has been described, characterized by peculiar vesicles and blebs
and an excoriated state of the skin, with subsequent exfoliation of the
{656} epidermis. It consists at first of deep-seated vesicular lesions,
which resemble small boiled sago-grains implanted in the skin,
accompanied by a variable degree of inflammation. As the lesions grow
they incline to coalesce, thus forming small or large blebs showing but
little if any disposition to rupture. Sooner or later the fluid is
reabsorbed or exudes, the epidermis peeling off, usually in large
flakes or pieces, sometimes in the form of a cast of the fingers or
hand. In most cases burning sensations, tenderness, and soreness are
complained of. The disease pursues a variable course. Ordinarily, the
process lasts from two to eight weeks. Relapses as well as recurrences
of the disease may take place. It attacks by preference the hands, more
especially the palms and the sides of the fingers, from which
circumstance it was originally designated cheiro-pompholyx; but it may
invade the feet and also other regions.
The same disease has been described with the two names given, some
observers regarding it as being due to a disordered state of the sweat
apparatus, others as being an inflammatory affection. We incline to the
latter view, looking upon true dysidrosis as a form of miliaria. The
disease under consideration is without question neurotic in origin. It
occurs chiefly in those suffering from nervous debility or prostration
arising from varied causes. It is due to impaired, faulty innervation.
It is most liable to be mistaken for vesicular eczema or pemphigus. The
treatment should be general, consisting of such remedies as quinine and
arsenic, together with good food and proper hygiene. Local treatment
may be prescribed as in the case of eczema, but the result in most
cases is not as satisfactory as in that disease.
Pemphigus.
Pemphigus is an acute or chronic bullous disease, characterized by the
successive formation of variously sized and shaped blebs. Two varieties
are met with--pemphigus vulgaris and pemphigus foliaceus--the symptoms
of which differ considerably. Pemphigus vulgaris, the usual form of the
disease, appears with or without precursory symptoms. In marked cases
headache and fever may precede the cutaneous outbreak. All portions of
the body may suffer, but the extremities are more commonly the seat of
the eruption. The mucous membrane of the mouth and vagina may also be
involved. The lesions, as a rule, are rarely seen in large numbers, a
dozen or so usually being present at one time. They vary in size from a
pea to a large egg, and are generally rounded or ovalish, fully
distended, and according to the size are elevated from a few lines to
an inch above the surrounding skin. There is but little inflammation
attending their formation. In some cases the blebs arise from
erythematous spots or wheals, but generally from apparently normal
skin. The fluid is yellowish, later often becoming cloudy or puriform.
At times slight hemorrhage occurs, giving the lesions a reddish or
purplish color. Spontaneous rupture of the lesions seldom occurs, the
contents usually disappearing by absorption. Each bleb runs its course
in from two to eight days. Itching and burning are rarely prominent
symptoms, in some cases being scarcely noticeable or absent, in others
present to a marked degree, constituting pemphigus pruriginosus. In
children pemphigus vulgaris is {657} usually attended with systemic
disturbance; in adults, as a rule, only in severe cases. The disease
may be acute or chronic. Acute pemphigus is rare, and occurs, as a
rule, only in children. It usually runs a favorable course, except in
ill-nourished children, in whom it may take on a malignant type and
have a fatal termination. Chronic pemphigus may be benign or malignant.
In the benign form the eruption may persist several months by
successive outbreaks, and then disappear, or the blebs may form
irregularly and indefinitely. In the former case there may be but the
one attack, or, as commonly occurs, relapses may follow after months or
years. In the malignant form the disease is more violent, with marked
systemic depression and ulcerative action, and may frequently have an
unfavorable termination.
Pemphigus foliaceus, the other variety of the disease, is rare. The
blebs are loose and flaccid, with milky or puriform contents, rupture,
and the oozing liquid dries to crusts, which are cast off, disclosing
the reddened corium beneath. The blebs may coalesce and involve
considerable surface, and may appear in rapid succession on other
regions and on the sites of disappearing or half-ruptured lesions; even
the whole surface may become involved, the process continuing for
years, undermining the general health and eventually destroying the
patient.
Pemphigus is a rare disease, and seems to be of even less frequent
occurrence in this country than abroad. It is not contagious, nor is it
due to syphilis, the so-called syphilitic pemphigus being a bullous
syphiloderm and not a true pemphigus. General debility, overwork,
shock, and nervous prostration are influential in producing the
disease. Occasionally an hereditary tendency is traceable.
The contents of blebs are at first colorless or yellowish, consisting
of serum,--later containing blood-corpuscles, pus, fatty-acid crystals,
and epithelial cells, and occasionally uric-acid crystals and free
ammonia. The reaction is alkaline, becoming more markedly so as the
contents grow older. The lesions are superficially seated, between the
horny layer and upper part of the rete and the lengthened cells of the
rete and the corium. The papillæ and subcutaneous tissues show
round-cell infiltration and dilated blood-vessels.
Herpes iris and the bullous syphiloderm are to be excluded in the
diagnosis. In herpes iris the acute course, small lesions, variegated
colors, the usually marked areola, the decided tendency to concentric
arrangement of the lesions, the seat of the disease,--all tend to
distinguish it from pemphigus. The thick, bulky, greenish crusts of the
bullous syphilide, with the underlying ulceration, its course, and the
presence of concomitant symptoms of that disease, taken with the
history of the case, are points of difference. Impetigo contagiosa may
at times strikingly resemble pemphigus, but the history of the case,
its distribution, the contagious and auto-inoculable properties of the
contents of the lesions, and the characteristic crusting of the former
disease,--are all available in the differential diagnosis. The blebs of
pemphigus are to be distinguished also from the accidental blebs of
urticaria and of erythema multiforme. It is to be remembered also that
cases sometimes come under observation in which blebs are, for the sake
of feigning disease, produced artificially, the subjects being usually
hysterical women.
Pemphigus is in most cases a grave disease. The unfavorable {658}
symptoms are the presence of numerous bullæ, the rapid and successive
development of new lesions, flabby walls, frequent febrile attacks,
loss of strength, and marasmus. It is injudicious, even in mild cases,
to express an opinion as to the probable duration of the disease. Both
constitutional and local treatment, especially the former, are
demanded. The general health should receive careful study and faulty
conditions corrected. Good food, milk, wine, or ale, eggs and meat are
in most cases to be advised. Suitable hygienic regulations should also
receive attention. Arsenic in appropriate doses, long continued, has in
some cases almost a specific action: on the whole, it must be regarded
as our most valuable remedy. Quinine in full doses, cod-liver oil,
iron, and the mineral acids are also of service. External treatment is
of importance, and is in many cases demanded for the comfort of the
patient. The blebs are to be opened as soon as developed, and the parts
anointed with oxide-of-zinc ointment. Lotio nigra, used as in eczema,
will sometimes be found soothing, as also lotions containing liquor
carbonis detergens or liquor picis alkalinus. Dusting-powders of zinc
oxide with talc and starch are likewise useful. Baths containing bran,
starch, or gelatin sometimes afford ease. Corrosive-sublimate baths,
one or two drachms to the bath, and alkaline baths in some cases prove
of service. After the bath an application of an ointment or mild
dusting-powder may be made to advantage. Where baths prove unsuitable
or are impracticable, mild ointments may be used, such as diachylon
ointment, vaseline, cold cream, or zinc ointment, spread upon cloth and
bound down with bandages.
CLASS IV.--HYPERTROPHIES.[5]
[Footnote 5: Purpura, constituting Class III., appears in Vol. II. p.
186, as a separate article by I. E. Atkinson.]
Lentigo.
Lentigo, or freckle, is characterized by irregularly-shaped, rounded or
angular, pinhead- or pea-sized, yellowish or brownish spots of pigment
deposit, occurring for the most part upon the face and the backs of the
hands. They may appear as blemishes scarcely perceptible to the casual
observer, or to such an extent and with such intensity of color as to
be disfiguring. They may show themselves as discrete or as confluent
lesions, and in the latter event the skin presents a spotted, rusty, or
dirty appearance. As stated, the face and the backs of the hands are
usually attacked, but other regions may also be invaded. They are
encountered at all ages, but usually in young persons, especially in
those of light complexion, and more particularly in red-haired
subjects. They pursue a chronic course, lasting, as a rule, a lifetime,
being, however, in most cases much paler in winter than in summer.
Sometimes the lesions are blackish rather than brownish, and cases are
on record where such were numerous and occupying the general surface.
Blackish freckles are also met with in connection with certain rare
forms of atrophy of the skin proper complicated with telangiectases, as
in the cases reported by Hebra and {659} Kaposi, Taylor, and one of us
(Duhring), an account of which may be found under atrophy of the skin.
The affection consists of a circumscribed deposit of pigment, which in
the majority of cases is due to the influence of the sun's rays, but
there are cases in which the lesions cannot be assigned to this cause,
as, for example, where they occur upon the trunk or other regions not
exposed to light. The treatment will be referred to in connection with
chloasma.
Chloasma.
Chloasma may be described as a pigmentary affection, consisting of
variously sized and shaped, more or less defined, smooth patches of a
yellowish, brownish, or blackish color. The affection is one merely of
coloration, the structure of the skin proper being normal. The spots or
patches vary much as to size and shape. As a rule, they are irregular
in outline, and not infrequently they are angular. They vary in size
from a small coin to a hand or larger. At times the affection may
develop as a diffuse or even as a universal discoloration. The
distribution of the pigment may be uniform, but more frequently it is
mottled, giving the skin a thick, muddy, or dirty appearance. Under
idiopathic chloasma are included the forms of pigmentation due to
various external agencies, as, for example, chemicals, sinapisms, heat,
and long-continued scratching. The symptomatic group comprises uterine
chloasma and the discolorations occurring in connection with certain
general maladies, among which cancer, tuberculosis, Addison's disease,
and malaria may be mentioned. Chloasma is also met with as a symptom in
certain diseases of the skin proper, as scleroderma, morphoea, leprosy,
and syphilis.
Chloasma uterinum, the commonest form, appears in all degrees from a
duskiness or swarthiness of the complexion to pronounced patches of
mottled yellowish or brownish discoloration, occurring on the face
usually of pregnant women. But the same condition is met with also in
single women, and at times in men. In women it usually appears as a
more or less broken patch invading the forehead, extending from temple
to temple, but the nose, cheeks, and chin are likewise very frequently
attacked. It is due both to physiological and to pathological changes
in the uterus, and also to various disorders of the menstrual function.
The nervous system in many cases is without doubt at fault, and to this
cause must be assigned those cases occurring in men. It is encountered,
as a rule, between the ages of twenty-five and fifty. Its course is
variable, depending upon the cause, but, as a rule, it is persistent,
and it may continue for a long period. It is liable to be confounded
with tinea versicolor, from which, however, it may be readily
distinguished by the observation that in the latter disease the surface
of the skin is the seat of more or less furfuraceous desquamation,
which becomes more evident by scraping. In chloasma the skin is normal
in structure. The patches of tinea versicolor are usually more numerous
than those of chloasma, and occupy the trunk, a region seldom invaded
by the latter affection. The face is the common seat of chloasma, a
region practically exempt from tinea versicolor.
The treatment consists in removing the cause where this is possible, or
{660} in modifying it by such general remedies as appear indicated.
Among the various local remedies corrosive sublimate is one of the most
valuable, used in the form of a lotion with water, alcohol, or almond
emulsion. Its strength should vary from half a grain to five grains to
the ounce, according to the region, size of the spot, sensitiveness of
the skin, and the effect produced. Two or three grains to the ounce
will generally be found of sufficient strength; and this may be
applied, dabbed on lightly for five or ten minutes, twice daily, until
irritation or desquamation appears. A lotion recommended by Hardy is
the following:
Rx. Hydrargyri chlor. corros., gr. viiss;
Zinci sulphatis, drachm ss;
Plumbi acetatis, drachm ss;
Aquæ, fluidounce iv. M.
Ammoniated mercury, from forty to eighty grains to the ounce of
ointment, may also be referred to as of positive value.
The following formula may also be given:
Rx. Hydrargyri ammoniati, drachm j;
Bismuthi magist., drachm ss;
Ugt. aquæ rosæ, ounce j.
M.--Sig. Apply at night.
Sulphur ointments, as of precipitated sulphur one or two drachms to the
ounce, are also at times useful. The applications may be suspended from
time to time should irritation occur. The treatment in some cases is
followed by good results, while in others it is unsatisfactory. The
discoloration, having been removed, may remain away, or, as often
happens, may recur. The treatment recommended for chloasma is that
which will be found of most service in lentigo.
* * * * *
There are other discolorations, of a different nature, which may be
referred to here, as the staining due to the coloring matter of the
bile, and that sometimes following the internal use of nitrate of
silver, known as argyria, where the skin assumes a bluish-gray, bronze,
or blackish shade. Neumann states that reduced silver is found in all
parts of the skin except the lining epithelia of the glands and the
cells of the mucous layer of the epidermis. The deposit also occurs in
the internal organs.
Keratosis Pilaris.
Keratosis pilaris (also called lichen pilaris and pityriasis pilaris)
is an hypertrophy of the epidermis about the apertures of the
hair-follicles, forming pinhead-sized, conical epidermic elevations.
The lesions are met with usually about the extensor surfaces of the
thighs and arms, especially the former, but they may also occur on
other parts. They are whitish, grayish, or blackish in color, are
rarely larger than a pinhead, each being pierced by a hair, around
which are accumulated, in the form of strata, the horny cells of the
epidermis. In some lesions the hair is broken off at the apex,
appearing as a black central point; in others the hair is not visible,
but is found coiled or twisted up within the papules. The skin is dry,
harsh, or rough, and together with the papules may feel like a
nutmeg-grater. The skin at the base of each papule is of a normal {661}
color or slightly reddened. The elevations consist of an accumulation
of epidermic cells and sebaceous matter about the orifices of the
hair-follicles. The affection in its milder forms is not uncommon, and
is encountered usually in cold weather, and especially in those who
bathe infrequently. It may occur at any age, but is most common in
early adult life. Slight itching is occasionally present. As ordinarily
observed, it is a slight disorder, but shows a tendency to persist. It
resembles somewhat cutis anserina, the miliary papular syphiloderm in
the desquamating stage, and also lichen scrofulosus. In goose-flesh
(cutis anserina) the elevations are of a different nature, being due to
cold, heat, or nervous excitement. The papules of the syphiloderm tend
to group, are firmer, more deeply seated, less scaly, and of a reddish
color. In lichen scrofulosus the papules are more solid in character,
incline to group, are less scaly, and usually appear about the abdomen.
The disease is readily removable by treatment. Hot baths with the free
use of strong soap, as sapo viridis, will usually suffice in ordinary
cases; alkaline baths are also serviceable. In rebellious cases oily
applications, such as the petroleum preparations, lard, and glycerin,
or sulphur ointment, may be used in conjunction with the baths.
Molluscum Epitheliale.
Molluscum epitheliale, also called molluscum contagiosum and molluscum
sebaceum, is characterized by rounded, semiglobular, flattened, or
verrucous papules or tubercles of a whitish or pinkish color, varying
in size from a pinhead to a pea. As generally met with, they are the
size and shape of a small split pea; in other cases they are more
acuminated or are in the form of a very small pearl button. They have a
broad base and are seated close to the general surface. As a rule, they
are multiple, three or six or more being present in different stages of
evolution. They are unaccompanied by subjective symptoms. The skin
covering them is stretched, and they have a glistening or waxy look,
and at times resemble a drop of wax. In consistence they are usually
firm, becoming soft with age. Their summits are sometimes flattened and
umbilicated, with a central darkish point representing the mouth of the
follicle. Their usual seat is the face, especially the eyelids, cheeks,
and chin, but the neck, breast, and genitalia may also be invaded. They
grow slowly in most cases, and are unaccompanied by inflammatory
symptoms. Later, they become soft and tend to break down, with at times
ulceration.