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ESSENTIALS OF DISEASES OF THE SKIN
Including the Syphilodermata
Arranged in the Form of Questions and Answers Prepared Especially
for Students of Medicine
by
HENRY W. STELWAGON, M.D., PH.D.
* * * * *
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Besides the ordinary dictionary terms the book contains a wealth of
#anatomical and other tables#. This matter is of particular value to
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W. B. SAUNDERS COMPANY, 925 Walnut St., Phila.
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ESSENTIALS OF DISEASES OF THE SKIN.
Since the issue of the first volume of the
#Saunders Question-Compends#,
OVER 290,000 COPIES
of these unrivalled publications have been sold.
This enormous sale is indisputable evidence of
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physicians.
Saunders' Question-Compends. No. 11.
ESSENTIALS OF DISEASES OF THE SKIN
Including the Syphilodermata
Arranged in the Form of Questions and Answers Prepared Especially
for Students of Medicine
by
HENRY W. STELWAGON, M.D., PH.D.
Professor of Dermatology in the Jefferson Medical College, Philadelphia;
Dermatologist to the Howard and Philadelphia Hospitals, etc.
Seventh Edition, Thoroughly Revised
Illustrated
Philadelphia and London
W. B. Saunders Company
1909
Set up, electrotyped, printed, 1890. Reprinted July, 1891.
Revised, reprinted, June, 1894. Reprinted March, 1897.
Revised, reprinted, August, 1899. Reprinted
September, 1901, May, 1902, September, 1903.
Revised, reprinted January, 1905.
Reprinted March, 1906. Revised,
reprinted March, 1909.
Printed in America
Press of
W. B. Saunders Company
Philadelphia
PREFACE TO SEVENTH EDITION.
In the present--seventh--edition the subject matter, especially as
regards the practical part, has been gone over carefully and the
necessary corrections and additions made. Nineteen new illustrations
have been added, a few of the old ones being eliminated. It is hoped
that the continued demand for this compend means a widening interest in
the study of diseases of the skin, sufficiently keen as to lead to the
desire for a still greater knowledge.
H.W.S.
PREFACE TO FIRST EDITION.
Much of the present volume is, in a measure, the outcome of a thorough
revision, remodelling and simplification of the various articles
contributed by the author to Pepper's System of Medicine, Buck's
Reference Handbook of the Medical Sciences, and Keating's Cyclopaedia of
the Diseases of Children. Moreover, in the endeavor to present the
subject as tersely and briefly as compatible with clear understanding,
the several standard treatises on diseases of the skin by Tilbury Fox,
Duhring, Hyde, Robinson, Anderson, and Crocker, have been freely
consulted, that of the last-named author suggesting the pictorial
presentation of the "Anatomy of the Skin." The space allotted to each
disease has been based upon relative importance. As to treatment, the
best and approved methods only--those which are founded upon the
aggregate experience of dermatologists--are referred to.
For general information a statistical table from the Transactions of the
American Dermatological Association is appended.
H.W.S.
CONTENTS.
PAGE
ANATOMY OF THE SKIN 17
The Epidermis 18
The Blood-vessels 19
The Nervous and Vascular Papillae 20
The Hair and Hair-follicle 21
SYMPTOMATOLOGY 22
Primary Lesions 22
Secondary Lesions 23
Distribution and Configuration 24
Relative Frequency 26
Contagiousness 27
Rapidity of Cure 27
Ointment Bases 27
CLASS I.--DISORDERS OF THE GLANDS 28
Hyperidrosis 28
Sudamen 30
Hydrocystoma 31
Anidrosis 31
Bromidrosis 32
Chromidrosis 32
Uridrosis 33
Phosphoridrosis 33
Seborrh[oe]a (Eczema Seborrhoicum) 33
Comedo 38
Milium 42
Steatoma 43
CLASS II.--INFLAMMATIONS 44
Erythema Simplex 44
Erythema Intertrigo 45
Erythema Multiforme 46
Erythema Nodosum 50
Erythema Induratum 51
Urticaria 52
Urticaria Pigmentosa 56
Dermatitis 58
Dermatitis Medicamentosa 60
X-Ray Dermatitis 63
Dermatitis Factitia 64
Dermatitis Gangraenosa 65
Erysipelas 66
Phlegmona Diffusa 68
Furunculus 68
Carbunculus 70
Pustula Maligna 72
Post-mortem Pustule 73
Framb[oe]sia 73
Verruga Peruana 73
Equinia 74
Miliaria 74
Pompholyx 76
Herpes Simplex 78
Hydroa Vacciniforme 80
Epidermolysis Bullosa 80
Dermatitis Repens 81
Herpes Zoster 81
Dermatitis Herpetiformis 83
Psoriasis 86
Pityriasis Rosea 95
Dermatitis Exfoliativa 96
Lichen Planus 98
Pityriasis Rubra Pilaris 99
Lichen Scrofulosus 100
Eczema 100
Prurigo 118
Acne 119
Acne Rosacea 126
Sycosis 130
Dermatitis Papillaris Capillitii 135
Impetigo Contagiosa 136
Impetigo Herpetiformis 138
Ecthyma 138
Pemphigus 140
CLASS III.--HEMORRHAGES 144
Purpura 144
Scorbutus 146
CLASS IV.--HYPERTROPHIES 148
Lentigo 148
Chloasma 149
Keratosis Pilaris 151
Keratosis Follicularis 153
Molluscum Epitheliale 153
Callositas 155
Clavus 156
Cornu Cutaneum 158
Verruca 160
Naevus Pigmentosus 162
Ichthyosis 165
Onychauxis 167
Hypertrichosis 168
[OE]dema Neonatorum 170
Sclerema Neonatorum 171
Scleroderma 172
Elephantiasis 174
Dermatolysis 176
CLASS V.--ATROPHIES 177
Albinismus 177
Vitiligo 178
Canities 180
Alopecia 181
Alopecia Areata 183
Atrophia Pilorum Propria 187
Atrophia Unguis 188
Atrophia Cutis 189
CLASS VI.--NEW GROWTHS 191
Keloid 191
Fibroma 192
Neuroma 194
Xanthoma 195
Myoma 196
Angioma 196
Telangiectasis 197
Lymphangioma 198
Rhinoscleroma 198
Lupus Erythematosus 199
Lupus Vulgaris 203
Tuberculosis Cutis 209
Ainhum 212
Mycetoma 212
Perforating Ulcer of the Foot 213
Syphilis Cutanea 213
Lepra 231
Pellagra 235
Epithelioma 236
Paget's Disease of the Nipple 240
Sarcoma 241
Granuloma Fungoides 242
CLASS VII.--NEUROSES 244
Hyperaesthesia 244
Dermatalgia 244
Anaesthesia 244
Pruritus 244
CLASS VIII.--PARASITIC AFFECTIONS 247
Tinea Favosa 247
Tinea Trichophytina 251
Tinea Imbricata 261
Tinea Versicolor 262
Erythrasma 265
Actinomycosis 266
Blastomycetic Dermatitis 266
Scabies 267
Pediculosis 271
Pediculosis Capitis 272
Pediculosis Corporis 274
Pediculosis Pubis 275
Cysticercus Cellulosae 276
Filaria Medinensis 277
Ixodes 277
Leptus 277
[OE]strus 278
Pulex Penetrans 278
Cimex Lectularius 278
Culex 279
Pulex Irritans 279
TABLE showing Relative Frequency of the Various
Diseases of the Skin 280
DISEASES OF THE SKIN.
#ANATOMY OF THE SKIN.#
[Illustration: Fig. I.
Vertical section of the skin--Diagrammatic. (_After Heitsmann._)]
#The Epidermis.#
[Illustration: Fig. 2.
_c_, corneous (horny) layer; _g_, granular layer; _m_, mucous layer
(rete Malpighii).
The stratum lucidum is the layer just above the granular layer.
Nerve terminations--_n_, afferent nerve; _b_, terminal nerve bulbs;
_l_, cell of Langerhans. (_After Ranvier._)]
#The Blood-vessels.#
[Illustration: Fig. 3.
_C_, epidermis; _D_, corium; _P_, papillae; _S_, sweat-gland duct.
_v_, arterial and venous capillaries (superficial, or papillary plexus)
of the papillae. Deep plexus is partly shown at lower margin of the
diagram; _vs_--an intermediate plexus, an outgrowth from the deep
plexus, supplying sweat-glands, and giving a loop to hair papilla.
(_After Ranvier._)]
#The Nervous and Vascular Papillae.#
[Illustration: Fig. 4.
_a_, a vascular papilla; _b_, a nervous papilla; _c_, a blood-vessel;
_d_, a nerve fibre; _e_, a tactile corpuscle. (_After Biesiadecki._)]
#The Hair and Hair-Follicle.#
[Illustration: Fig. 5. _A_, shaft of the hair; _B_, root of the hair;
_C_, cuticle of the hair; _D_, medullary substance of the hair. _E_,
external layer of the hair-follicle; _F_, middle layer of the
hair-follicle; _G_, internal layer of the hair-follicle; _H_, papilla of
the hair; _I_, external root-sheath; _J_, outer layer of the internal
root-sheath; _K_, internal layer of the internal root-sheath. (_After
Duhring._)]
#SYMPTOMATOLOGY.#
The symptoms of cutaneous disease may be objective, subjective or both;
and in some diseases, also, there may be systemic disturbance.
#What do you mean by objective symptoms?#
Those symptoms visible to the eye or touch.
#What do you understand by subjective symptoms?#
Those which relate to sensation, such as itching, tingling, burning,
pain, tenderness, heat, anaesthesia, and hyperaesthesia.
#What do you mean by systemic symptoms?#
Those general symptoms, slight or profound, which are sometimes
associated, primarily or secondarily, with the cutaneous disease, as,
for example, the systemic disturbance in leprosy, pemphigus, and purpura
hemorrhagica.
#Into what two classes of lesions are the objective symptoms commonly
divided?#
Primary (or elementary), and
Secondary (or consecutive).
#Primary Lesions.#
#What are primary lesions?#
Those objective lesions with which cutaneous diseases begin. They may
continue as such or may undergo modification, passing into the secondary
or consecutive lesions.
#Enumerate the primary lesions.#
Macules, papules, tubercles, wheals, tumors, vesicles, blebs and
pustules.
#What are macules (maculae)?#
Variously-sized, shaped and tinted spots and discolorations, without
elevation or depression; as, for example, freckles, spots of purpura,
macules of cutaneous syphilis.
#What are papules (papulae)?#
Small, circumscribed, solid elevations, rarely exceeding the size of a
split-pea, and usually superficially seated; as, for example, the
papules of eczema, of acne, and of cutaneous syphilis.
#What are tubercles (tubercula)?#
Circumscribed, solid elevations, commonly pea-sized and usually
deep-seated; as, for example, the tubercles of syphilis, of leprosy, and
of lupus.
#What are wheals (pomphi)?#
Variously-sized and shaped, whitish, pinkish or reddish elevations, of
an evanescent character; as, for example, the lesions of urticaria, the
lesions produced by the bite of a mosquito or by the sting of a nettle.
#What are tumors (tumores)?#
Soft or firm elevations, usually large and prominent, and having their
seat in the corium and subcutaneous tissue; as, for example, sebaceous
tumors, gummata, and the lesions of fibroma.
#What are vesicles (vesiculae)?#
Pin-head to pea-sized, circumscribed epidermal elevations, containing
serous fluid; as, for example, the so-called fever-blisters, the lesions
of herpes zoster, and of vesicular eczema.
#What are blebs (bullae)?#
Rounded or irregularly-shaped, pea to egg-sized epidermic elevations,
with fluid contents; in short, they are essentially the same as vesicles
and pustules except as to size; as, for example, the blebs of pemphigus,
rhus poisoning, and syphilis.
#What are pustules (pustulae)?#
Circumscribed epidermic elevations containing pus; as, for example, the
pustules of acne, of impetigo, and of sycosis.
#Secondary Lesions.#
#What are secondary lesions?#
Those lesions resulting from accidental or natural change, modification
or termination of the primary lesions.
#Enumerate the secondary lesions.#
Scales, crusts, excoriations, fissures, ulcers, scars and stains.
#What are scales (squamae)?#
Dry, laminated, epidermal exfoliations; as, for example, the scales of
psoriasis, ichthyosis, and eczema.
#What are crusts (crustae)?#
Dried effete masses of exudation; as, for example, the crusts of
impetigo, of eczema, and of the pustular and ulcerating syphilodermata.
#What are excoriations (excoriationes)?#
Superficial, usually epidermal, linear or punctate loss of tissue; as,
for example, ordinary scratch-marks.
#What are fissures (rhagades)?#
Linear cracks or wounds, involving the epidermis, or epidermis and
corium; as, for example, the cracks which often occur in eczema when
seated about the joints, the cracks of chapped lips and hands.
#What are ulcers (ulcera)?#
Rounded or irregularly-shaped and sized loss of skin and subcutaneous
tissue resulting from disease; as, for example, the ulcers of syphilis
and of cancer.
#What are scars (cicatrices)?#
Connective-tissue new formations replacing loss of substance.
#What are stains?#
Discolorations left by cutaneous disease, which stains may be transitory
or permanent.
#Distribution and Configuration.#
#What do you mean by a patch of eruption?#
A single group or aggregation of lesions or an area of disease.
#When is an eruption said to be limited or localized?#
When it is confined to one part or region.
#When is an eruption said to be general or generalized?#
When it is scattered, uniformly or irregularly, over the entire surface.
#When is an eruption universal?#
When the whole integument is involved, without any intervening healthy
skin.
#When is an eruption said to be discrete?#
When the lesions constituting the eruption are isolated, having more or
less intervening normal skin.
#When is an eruption confluent?#
When the lesions constituting the eruption are so closely crowded that a
solid sheet results.
#When is an eruption uniform?#
When the lesions constituting the eruption are all of one type or
character.
#When is an eruption multiform?#
When the lesions constituting the eruption are of two or more types or
characters.
#When are lesions said to be aggregated?#
When they tend to form groups or closely-crowded patches.
#When are lesions disseminated?#
When they are irregularly scattered, with no tendency to form groups or
patches.
#When is a patch of eruption said to be circinate?#
When it presents a rounded form, and usually tending to clear in the
centre; as, for example, a patch of ringworm.
#When is a patch of eruption said to be annular?#
When it is ring-shaped, the central portion being clear; as, for
example, in erythema annulare.
#What meaning is conveyed by the term "iris"?#
The patch of eruption is made up of several concentric rings. Difference
of duration of the individual rings, usually slight, tends to give the
patch variegated coloration; as, for example, in erythema iris and
herpes iris.
#What meaning is conveyed by the term "marginate"?#
The sheet of eruption is sharply defined against the healthy skin; as,
for example, in erythema marginatum, eczema marginatum.
#What meaning is conveyed by the qualifying term "circumscribed"?#
The term is applied to small, usually more or less rounded, patches,
when sharply defined; as, for example, the typical patches of psoriasis.
#When is the qualifying term "gyrate" employed?#
When the patches arrange themselves in an irregular winding or
festoon-like manner; as, for instance, in some cases of psoriasis. It
results, usually, from the coalescence of several rings, the eruption
disappearing at the points of contact.
#When is an eruption said to be serpiginous?#
When the eruption spreads at the border, clearing up at the older part;
as, for instance, in the serpiginous syphiloderm.
#RELATIVE FREQUENCY.#
#Name the more common cutaneous diseases and state approximately their
frequency.#
Eczema, 30.4%; syphilis cutanea, 11.2%; acne, 7.3%; pediculosis, 4%;
psoriasis, 3.3%; ringworm, 3.2%; dermatitis, 2.6%; scabies, 2.6%;
urticaria, 2.5%; pruritus, 2.1%; seborrh[oe]a, 2.1%; herpes simplex,
1.7%; favus, 1.7%; impetigo, 1.4%; herpes zoster, 1.2%; verruca, 1.1%;
tinea versicolor, 1%. Total: eighteen diseases, representing 81 per
cent. of all cases met with.
(These percentages are based upon statistics, public and private, of the
American Dermatological Association, covering a period of ten years. In
private practice the proportion of cases of pediculosis, scabies, favus,
and impetigo is much smaller, while acne, acne rosacea, seborrh[oe]a,
epithelioma, and lupus are relatively more frequent.)
#CONTAGIOUSNESS.#
#Name the more actively contagious skin diseases.#
Impetigo contagiosa, ringworm, favus, scabies and pediculosis; excluding
the exanthemata, erysipelas, syphilis and certain rare and doubtful
diseases.
[At the present time when most diseases are presumed to be due to
bacteria or parasites the belief in contagiousness, under certain
conditions, has considerably broadened.]
#RAPIDITY OF CURE.#
#Is the rapid cure of a skin disease fraught with any danger to the
patient?#
No. It was formerly so considered, especially by the public and general
profession, and the impression still holds to some extent, but it is not
in accord with dermatological experience.
#OINTMENT BASES.#
#Name the several fats in common use for ointment bases.#
Lard, petrolatum (or cosmoline or vaseline), cold cream and lanolin.
#State the relative advantages of these several bases.#
_Lard_ is the best all-around base, possessing penetrating properties
scarcely exceeded by any other fat.
_Petrolatum_ is also valuable, having little, if any, tendency to
change; it is useful as a protective, but is lacking in its power of
penetration.
_Cold Cream_ (ungt. aquae rosae) is soothing and cooling, and may often be
used when other fatty applications disagree.
_Lanolin_ is said to surpass in its power of penetration all other
bases, but this is not borne out by experience. It is an unsatisfactory
base when used alone. It should be mixed with another base in about the
proportion of 25% to 50%.
These several bases may, and often with advantage, be variously
combined.
#What is to be added to these several bases if a stiffer ointment is
required?#
Simple cerate, wax, spermaceti, or suet; or in some instances, a
pulverulent substance, such as starch, boric acid, and zinc oxide.
#CLASS I.--DISORDERS OF THE GLANDS.#
#Hyperidrosis.#
[Illustration: Fig. 6.
A normal sweat-gland, highly magnified. (_After Neumann._)
_a_, Sweat-coil: _b_, sweat-duct; _c_, lumen of duct; _d_,
connective-tissue capsule; _e_ and _f_, arterial trunk and
capillaries.]
#What is hyperidrosis?#
Hyperidrosis is a functional disturbance of the sweat-glands,
characterized by an increased production of sweat. This increase may be
slight or excessive, local or general.
#As a local affection, what parts are most commonly involved?#
The hands, feet, especially the palmar and plantar surfaces, the axillae
and the genitalia.
#Describe the symptoms of the local forms of hyperidrosis.#
The essential, and frequently the sole symptom, is more or less profuse
sweating.
If the hands are the parts involved, they are noted to be wet, clammy
and sometimes cold.
If involving the soles, the skin often becomes more or less macerated
and sodden in appearance, and as a result of this maceration and
continued irritation they may become inflamed, especially about the
borders of the affected parts, and present a pinkish or pinkish-red
color, having a violaceous tinge. The sweat undergoes change and becomes
offensive.
#Is hyperidrosis acute or chronic?#
Usually chronic, although it may also occur as an acute affection.
#What is the etiology of hyperidrosis?#
Debility is commonly the cause in general hyperidrosis; the local forms
are probably neurotic in origin.
#What is the prognosis?#
The disease is usually persistent and often rebellious to treatment; in
many instances a permanent cure is possible, in others palliation.
Relapses are not uncommon.
#What systemic remedies are employed in hyperidrosis?#
Ergot, belladonna, gallic acid, mineral acids, and tonics.
Constitutional treatment is rarely of benefit in the local forms of
hyperidrosis, and external applications are seldom of service in general
hyperidrosis. Precipitated sulphur, a teaspoonful twice daily, is also
well spoken of, combined, if necessary, with an astringent.
#What external remedies are employed in the local forms?#
Astringent lotions of zinc sulphate, tannin and alum, applied several
times daily, with or without the supplementary use of dusting-powders.
Weak solutions of formaldehyde, one to one hundred, are sometimes of
value.
Dusting-powders of boric acid and zinc oxide, to which may be added from
ten to thirty grains of salicylic acid to the ounce, to be used freely
and often:--
[Rx] Pulv. ac. salicylici ................. gr. x-xxx.
Pulv. ac. borici ..................... [dram]v.
Pulv. zinci oxidi .................... [dram]iij M.
Diachylon ointment, and an ointment containing a drachm of tannin to the
ounce; more especially applicable in hyperidrosis of the feet. The parts
are first thoroughly washed, rubbed dry with towels and dusting-powder,
and the ointment applied on strips of muslin or lint and bound on; the
dressing is renewed twice daily, the parts each time being rubbed dry
with soft towels and dusting-powder, and the treatment continued for ten
days to two weeks, after which the dusting-powder is to be used alone
for several weeks. No water is to be used after the first washing until
the ointment is discontinued. One such course will occasionally suffice,
but not infrequently a repetition is necessary.
Faradization and galvanization are sometimes serviceable. Repeated mild
exposures to the Roentgen rays have a favorable influence in some
instances.
#Sudamen.#
(_Synonym:_ Miliaria crystallina.)
#What is sudamen?#
Sudamen is a non-inflammatory disorder of the sweat-glands,
characterized by pin-point to pin-head-sized, discrete but thickly-set,
superficial, translucent whitish vesicles.
#Describe the clinical characters.#
The lesions develop rapidly and in great numbers, either irregularly or
in crops, and are usually to be seen as discrete, closely-crowded,
whitish, or pearl-colored minute elevations, occurring most abundantly
upon the trunk. In appearance they resemble minute dew-drops. They are
non-inflammatory, without areola, never become purulent, and evince no
tendency to rupture, the fluid disappearing by absorption, and the
epidermal covering by desquamation.
#Give the course and duration of sudamen.#
New crops may appear as the older lesions are disappearing, and the
affection persist for some time, or, on the other hand, the whole
process may come to an end in several days or a week. In short, the
course and duration depend upon the subsidence or persistence of the
cause.
#What is the anatomical seat of sudamen?#
The lesions are formed between the lamellae of the corneous layer,
usually the upper part; and are thought to be due to some change in the
character of the epithelial cells of this layer, probably from high
temperature, giving rise to a blocking up of the surface outlet.
#What is the cause of sudamen?#
Debility, especially when associated with high fever. The eruption is
often seen in the course of typhus, typhoid and rheumatic fevers.
#How would you treat sudamen?#
By constitutional remedies directed against the predisposing factor or
factors, and the application of cooling lotions of vinegar or alcohol
and water, or dusting-powders of starch and lycopodium.
#Hydrocystoma.#
#Describe hydrocystoma.#
Hydrocystoma is a cystic affection of the sweat-gland ducts, seated upon
the face. The lesions may be present in scant numbers or in more or less
profusion. They have the appearance of boiled sago grains imbedded in
the skin; the larger lesions may have a bluish color, especially about
the periphery. It is not common, and is usually seen in washerwomen and
laundresses, or those exposed to moist heat. In some cases it tends to
disappear during the winter months. There are no subjective symptoms.
Treatment consists of puncturing the lesions and application of
dusting-powder. Avoidance of the exciting cause (moist heat) is
important.
#Anidrosis.#
#Describe anidrosis.#
It is the opposite condition of hyperidrosis, and is characterized by
diminution or suppression of the sweat secretion. It occurs to some
extent in certain systemic diseases and also in some affections of the
skin, such as ichthyosis; nerve-injuries may give rise to localized
sweat-suppression.
Treatment is based upon general principles; friction, warm and hot-vapor
baths, electricity and similar measures are of service.
#Bromidrosis.#
(_Synonym:_ Osmidrosis.)
#Describe bromidrosis.#
Bromidrosis is a functional disturbance of the sweat-glands
characterized by a sweat secretion of an offensive odor. The sweat
production may be normal in quantity or more or less excessive, usually
the latter. The condition may be local or general, commonly the former.
It is closely allied to hyperidrosis, and may often be considered
identical, the odor resulting from rapid decomposition of the sweat
secretion. The decomposition and resulting odor have been thought due to
the presence of bacteria.
#What parts are most commonly affected in bromidrosis?#
The feet and the axillae.
#What is the treatment of bromidrosis?#
It is essentially the same as that of hyperidrosis (_q. v._), consisting
of applications of astringent lotions, dusting-powders, especially those
containing boric acid and salicylic acid, and the continuous application
of diachylon ointment. In obstinate cases weak formaldehyde solutions,
Roentgen rays, and high-frequency currents can be tried.
#Chromidrosis.#
#Describe chromidrosis.#
This is a functional disorder of the sweat-glands characterized by a
secretion variously colored, and usually increased in quantity. It is,
as a rule, limited to a circumscribed area. The most common color is
red. The condition is probably of neurotic origin and tends to recur.
(True chromidrosis is extremely rare; most of the cases formerly thought
to be such are now known to be examples of pseudochromidrosis.)
Treatment should be invigorating and tonic, with special reference
toward the nervous system. The various methods of local electrization
should also be resorted to.
Mild antiseptic and astringent lotions or dusting powders should also be
advised.
_Red chromidrosis_ or _Pseudochromidrosis_ is a condition in which the
coloring of the sweat occurs after its excretion and is due to the
presence of chromatogenous bacteria which are found attached to the
hairs of the part in agglutinated masses. The axilla is the favorite
site. Treatment consists of frequent soap-and-water washings, and the
application of boric acid, resorcin, and corrosive sublimate lotions.
#Uridrosis.#
#Describe uridrosis.#
Uridrosis is a rare condition in which the sweat secretion contains the
elements of the urine, especially urea. In marked cases the salt may be
noticeable upon the skin as a colorless or whitish crystalline deposit.
In most instances it has been preceded or accompanied by partial or
complete suppression of the renal functions.
#Phosphoridrosis.#
#Describe phosphoridrosis.#
Phosphoridrosis is a rare condition, in which the sweat is
phosphorescent. It has been observed in the later stages of phthisis, in
miliaria, and in those who have eaten of putrid fish.
#Seborrh[oe]a (Eczema Seborrhoicum).#
_Synonyms:_ (Steatorrh[oe]a; Acne sebacea; Ichthyosis sebacea; Dandruff.)
#What is seborrh[oe]a?#
Seborrh[oe]a 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.
In many cases the sweat-glands are likewise implicated, and the process
may also be distinctly, although usually mildly, inflammatory.
#At what age is seborrh[oe]a usually observed?#
Between fifteen and forty. It may, however, occur at any age.
#Name the parts most commonly affected.#
The scalp, face, and (less frequently) the sternal and interscapular
regions of the trunk. It is sometimes seen on other parts.
#What varieties of seborrh[oe]a are encountered?#
Seborrh[oe]a oleosa and seborrh[oe]a sicca; not infrequently the disease
is of a mixed type.
#What are the symptoms of seborrh[oe]a oleosa?#
The sole symptom is an unnatural oiliness, variable as to degree. Its
most common sites are the regions of the scalp, nose, and forehead. In
many instances mild rosacea coexists with oily seborrh[oe]a of the nose.
#Give the symptoms of seborrh[oe]a sicca.#
A variable degree of greasy scalines, which may be seated upon a pale,
hyperaemic or mildly inflammatory surface.
The parts affected are covered scantily or more or less abundantly with
somewhat greasy, grayish, or brownish-gray scales. If upon the scalp
(_dandruff_, _pityriasis capitis_), small particles of scales are found
scattered through the hair, and when the latter is brushed or combed,
fall over the shoulders. If upon the face, in addition to the scaliness,
the sebaceous ducts are usually seen to be enlarged and filled with
sebaceous matter.
#Describe the symptoms of the ordinary or mixed type.#
It is common upon the scalp. The skin is covered with irregularly
diffused, greasy, grayish or brownish scales and crusts, in some cases
moderate in quantity, in others so great that large irregular masses are
formed, pasting the hair to the scalp. If removed, the scales and crusts
rapidly re-form. The skin beneath is found slate-colored, hyperaemic or
mildly inflammatory, and exceptionally it has in places an eczematous
aspect (_eczema seborrhoicum_). Extraneous matter, such as dust and
dirt, collects upon the parts, and the whole mass may become more or
less offensive. There is a strong tendency to falling-out of the hair.
Itching may or may not be present.
[Illustration: Seborrh[oe]a (Eczema Seborrhoicum).]
#Describe the symptoms of seborrh[oe]a of the trunk and other parts.#
[Illustration: Fig. 7.
A normal sebaceous gland in connection with a lanugo hair.
(_After Neumann._)
_a_, Capsule; _b_, fatty secretion; _c_, _h_, secreting cells; _d_, root
of lanugo hair; _e_, hair-sac; _f_, hair-shaft; _g_, acini of sebaceous
gland.]
Seborrh[oe]a corporis differs in a measure, in its symptoms, from
seborrh[oe]a of the scalp and is usually illustrative of the variety
known as eczema seborrhoicum; it occurs as one or several irregular or
circinate, slightly hyperaemic or moderately inflammatory patches,
covered with dirty or grayish-looking greasy scales or crusts, usually
moderate in quantity, and upon removal are found to have projections
into the sebaceous ducts. It is commonly seen upon the sternal and
interscapular regions. It rarely exists independently in these regions,
being usually associated with and following the disease on the scalp. It
may also invade the axillae, genitocrural, and other regions.
#What is the usual course of seborrh[oe]a?#
Essentially chronic, the disease varying in intensity from time to time.
In occasional instances it disappears spontaneously.
#Give the cause or causes of seborrh[oe]a.#
General debility, anaemia, chlorosis, dyspepsia, and similar conditions
are to be variously looked upon as predisposing.
In some instances, however, the disease seems to be purely local in
character, and to be entirely independent of any constitutional or
predisposing condition. The view recently advanced that the disease is
of parasitic nature and contagious has been steadily gaining ground.
#What is the pathology of seborrh[oe]a?#
Seborrh[oe]a is a disease of the sebaceous glands, and probably often
involving the sweat-glands also; its products, as found upon the skin,
consisting of the sebaceous secretion, epithelial cells from the glands
and ducts, and more or less extraneous matter. Not infrequently
evidences of superficial inflammatory action are also to be found, and
it is especially for this type that the name eczema seborrhoicum is most
appropriate. In long-continued and neglected cases slight atrophy of the
gland-structures may occur.
#With what diseases are you likely to confound seborrh[oe]a?#
Upon the scalp, with eczema and psoriasis; upon the face, with lupus
erythematosus and eczema; and upon the trunk, with psoriasis and
ringworm.
As a rule, the clinical features of seborrh[oe]a are sufficiently
characteristic to prevent error.
#What are the differential points?#
Eczema, psoriasis, and lupus erythematosus are diseases in which there
are distinct _inflammatory symptoms_, such as thickening and
infiltration and redness; moreover, psoriasis, and this holds true as to
ringworm also, occurs in sharply-defined, circumscribed patches, and
lupus erythematosus has a peculiar violaceous tint and an elevated and
marginate border. A microscopic examination of the epidermic scrapings
would be of crucial value in differentiating from ringworm.
Quite frequently, especially in the interscapular and sternal regions,
the segmental configuration constitutes an important feature of
seborrh[oe]a--of the eczema seborrhoicum variety.
#What is the prognosis in seborrh[oe]a?#
Favorable. All types are curable, and when upon the non-hairy regions,
usually readily so; upon the scalp it is often obstinate. Relapses are
not uncommon.
In those cases of seborrh[oe]a capitis which have been long-continued or
neglected, and attended with loss of hair, this loss may be more or less
permanent, although ordinarily much can be done to promote a regrowth
(see _Treatment of Alopecia_).
#How would you treat seborrh[oe]a of the scalp?#
By constitutional (if indicated) and local remedies; the former having
in view correction or modification of the predisposing factor or
factors, and the latter removal of the sebaceous accumulations and the
application of mildly stimulating antiseptic ointments or lotions.
#What constitutional remedies are commonly employed?#
The various tonics, such as iron, quinine, strychnia, cod-liver oil,
arsenic, the vegetable bitters, laxatives, malt and similar
preparations. The line of treatment is to be based upon indications.
#How do you free the scalp of the sebaceous accumulations?#
In mild types of the disease shampooing with simple Castile soap (or any
other good toilet soap) and hot water will suffice; in those cases in
which there is considerable scale-and crust-formation the tincture of
green soap (tinct. saponis viridis) is to be employed in place of the
toilet soap, and in some of these latter cases it may be necessary to
soften the crusts with a previous soaking with olive oil.
The frequency of the shampoo depends upon the conditions. In mild cases
once in five or ten days will be sufficiently frequent to keep the parts
clean, but in those cases in which there is rapid scale-or
crust-production once daily or every second day may at first be
demanded.
#Name the most effectual applications in seborrh[oe]a capitis.#
Sulphur, ammoniated mercury, salicylic acid, resorcin, and carbolic
acid.
Sulphur is used in the form of an ointment, from twenty grains to one
drachm in the ounce. Ammoniated mercury, in the form of an ointment, ten
to sixty grains to the ounce. Salicylic acid, either alone as an
ointment, ten to thirty grains to the ounce; or it may often be added
with advantage, in the same proportion, to the sulphur or ammoniated
mercury ointment above named. Resorcin, either as an ointment, ten to
thirty grains to the ounce, or as an alcoholic or aqueous lotion, as the
following:--
[Rx] Resorcini ............................ [dram]j-[dram]iss.
Ol. ricini ........................... [minim]xxx-f[dram]ij.
Alcoholis ............................ f[Oz]iv. M.
Carbolic acid, to the amount of ten to thirty grains, can be added to
this. If an aqueous lotion is desirable, then in the above formula the
oleum ricini is replaced with glycerine, and the alcohol with water;
three to five minims of glycerine in each ounce is usually sufficient,
as a greater quantity makes the resulting lotion sticky. Petrolatum
alone, or with 10 to 30 per cent. lanolin, is usually the most
satisfactory base for the ointments. In some cases of the inflammatory
variety the skin is found quite irritable, and the mildest applications
are at first only admissible.
#How are the remedies to be applied?#
A small quantity of the lotion, ointment, or oil is gently applied to
the skin; when to the scalp, a lotion or oil can be conveniently applied
by means of an eye-dropper. In the beginning of the treatment an
application once or twice daily is ordered; later, as the disease
becomes less active, once every second or third day.
#How is seborrh[oe]a upon other parts to be treated?#
In the same general manner as seborrh[oe]a of the scalp, except that the
local applications must be somewhat weaker. The several sulphur lotions
employed in the treatment of acne (_q. v._) may also be used when the
disease is upon these parts. In obstinate patchy cases occasional
paintings with a 20 to 50 per cent alcoholic solution of resorcin is
curative; following the painting a mild salve should be used.
#Comedo.#
(_Synonyms:_ Blackheads; Flesh-worms.)
#What is comedo?#
Comedo is a disorder of the sebaceous glands, characterized by yellowish
or blackish pin-point or pin-head-sized puncta or elevations
corresponding to the gland-orifices.
#At what age and upon what parts are comedones found?#
Usually between fifteen and thirty, and upon the face and upper part of
the trunk, where they may exist sparsely or in great numbers. They are
occasionally associated with oily seborrh[oe]a, the parts presenting a
greasy or soiled appearance.
Exceptionally they occur as distinct, and usually symmetrical, groups
upon the forehead or the cheeks. On the upper trunk so-called double and
multiple comedo have been noted--the two, three, or even four
closely-contiguous blackheads are, beneath the surface,
intercommunicable, the dividing duct-walls having apparently disappeared
by fusion.
#Describe an individual lesion.#
It is pin-point to pin-head in size, dark yellowish, and usually with a
central blackish point (hence the name _blackheads_). There is scarcely
perceptible elevation, unless the amount of retained secretion is
excessive. Upon pressure this may be ejected, the small, rounded orifice
through which it is expressed giving it a thread-like shape (hence the
name _flesh-worms_).
#What is the usual course of comedo?#
Chronic. The lesions may persist indefinitely or the condition may be
somewhat variable. In many instances, either as a result of pressure or
in consequence of chemical change in the sebaceous plugs or of the
addition of a microbic factor, inflammation is excited and acne results.
The two conditions are, in fact, usually associated.
[Illustration: Fig. 8.
Demodex Folliculorum, X 300. Ventral surface. (_After Simon._)]
#To what may comedo often be ascribed?#
To disorders of digestion, constipation, chlorosis, menstrual
disturbance, lack of tone in the muscular fibres of the skin, the
infrequent use of soap, and working in a dirty or dusty atmosphere.
A small parasite (_demodex folliculorum_, _acarus folliculorum_) is
sometimes found in the sebaceous mass, but its presence is without
etiological significance, as it is also found in healthy follicles. A
microbacillus has been found by several observers, and credited with
etiological influence.
#What is the pathology of comedo?#
The sebaceous ducts or glands, or both, become blocked up with retained
secretion and epithelial cells. The dark points which usually mark the
lesions are probably due to accumulation of dirt, but may, as some
writers maintain, be due to the presence of pigment-granules resulting
from chemical change in the sebaceous matter.
#Is there any difficulty in the diagnosis of comedo?#
No. It can scarcely be confounded with milium, as in this latter disease
the lesion has no open outlet, no black point, and the contents cannot
be squeezed out.
#Give the prognosis of comedo.#
The result of treatment is usually favorable, although the disease is
often rebellious. Relapses are not uncommon.
#How would you treat a case of comedo?#
By systemic (if indicated) and local measures.
The constitutional treatment aims at correction or palliation of the
predisposing conditions, and the external applications have in view a
removal of the sebaceous plugs and stimulation of the glands and skin to
healthy action.
[Illustration: Fig. 9. Comedo Extractor.]
#Name the systemic remedies commonly employed.#
Cod-liver oil, iron, quinine, arsenic, nux vomica and other tonics;
ergot in those cases in which there is lack of muscular tone, salines
and aperient pills in constipation. The digestion is to be looked after
and the bowels kept regular; indigestible food of all kinds is to be
interdicted. Hygienic measures, such as general and local bathing, local
massage, calisthenics, and open-air exercise, are of service.
#Describe the local treatment.#
Steaming the face or prolonged applications of hot water; washing with
ordinary toilet soap and hot water, or, in sluggish cases, using
tincture of green soap (tinct. saponis viridis) instead of the toilet
soap; removal of the sebaceous plugs by mechanical means, such as
lateral pressure with the finger ends or perpendicular pressure with a
watch-key with rounded edges, or with an instrument specially contrived
for this purpose; and after these preliminary measures, which should be
carried out every night, a stimulating sulphur ointment or lotion, such
as employed in the treatment of acne (_q. v._), is to be thoroughly
applied. The following is valuable:--
[Rx] Zinci sulphatis,
Potassi sulphureti, . [=a][=a] ....... [dram]j-[dram]iv.
Alcoholi ............................. f[Oz]ss.
Aquae, ................. q.s. ad ...... f[Oz]iv. M.
Should slight scaliness or a mild degree of irritation of the skin be
brought about, active external treatment is to be discontinued for a few
days and soothing applications made. Resorcin, in lotion, 3 to 25 per
cent strength, is through the exfoliation it provokes, frequently of
value; the resorcin paste referred to in acne can also be used for this
purpose.
Moderately strong applications of the Faradic current, repeated once or
twice weekly, are sometimes of service; also weak to moderately strong
applications of the continuous and high-frequency currents. Roentgen-ray
treatment can also be resorted to in extremely obstinate cases.
In occasional instances sulphur preparations not only fail to do good,
but materially aggravate the condition. In such cases, if resorcin
preparations also fail, the mercurial lotion and ointment employed in
acne may be prescribed. Mercurial and sulphur applications should not be
used, it need scarcely be said, within a week or ten days of each other,
otherwise an increase in the comedones and a slight darkening of the
skin result from the formation of the black sulphuret of mercury.
#Milium.#
(_Synonyms:_ Grutum; Strophulus Albidus.)
#What is milium?#
Milium consists in the formation of small, whitish or yellowish,
rounded, pearly, non-inflammatory elevations situated in the upper part
of the corium.
#Describe the clinical appearances.#
The lesions are usually pin-head in size, whitish or yellowish,
seemingly more or less translucent, rounded or acuminated, without
aperture or duct, are superficially seated in the skin, and project
slightly above the surface.