also, although rarely, upon other parts. But one or several may be
present, or they may exist in numbers.
#What is the course of milium?#
The lesions develop slowly, and may then remain stationary for years.
Their presence gives rise to no disturbance, and, unless they are large
in size or exist in numbers, causes but slight disfigurement.
[Illustration: Fig. 10. Milium Needle.]
In rare instances they may undergo calcareous metamorphosis,
constituting the so-called _cutaneous calculi_.
#What is the anatomical seat of milium?#
The sebaceous gland (probably one or several of the
superficially-situated acini), the duct of which is in some manner
obliterated, the sebaceous matter collects, becomes inspissated and
calcareous, forming the pin-head lesion. The epidermis is the external
covering.
#What is the treatment?#
The usual plan is to prick or incise each lesion and press out the
contents. In some milia it may be necessary also, in order to prevent a
return, to touch the base of the excavation with tincture of iodine or
with silver nitrate. Electrolysis is also effectual. In those cases
where the lesions are numerous the production of exfoliation of the
epiderm by means of resorcin applications (see acne) is a good plan.
#Steatoma.#
(_Synonyms:_ Sebaceous Cyst; Sebaceous Tumor; Wen.)
#Describe steatoma.#
Steatoma, or sebaceous cyst, appears as a variously-sized, elevated,
rounded or semi-globular, soft or firm tumor, freely movable and
painless, and having its seat in the corium or subcutaneous tissue. The
overlying skin is normal in color, or it may be whitish or pale from
distention; in some a gland-duct orifice may be seen, but, as a rule,
this is absent.
#What are the favorite regions for the development of steatoma?#
The scalp, face and back. One or several may be present.
#What is the course of sebaceous cysts?#
Their growth is slow, and, after attaining a variable size, may remain
stationary. They may exist indefinitely without causing any
inconvenience beyond the disfigurement. Exceptionally, in enormously
distended growths, suppuration and ulceration result.
#What is the pathology?#
A steatoma is a cyst of the sebaceous gland and duct, produced by
retained secretion. The contents may be hard and friable, soft and
cheesy, or even fluid, of a grayish, whitish or yellowish color, and
with or without a fetid odor; the mass consisting of fat-drops,
epidermic cells, cholesterin, and sometimes hairs.
#Are sebaceous cysts likely to be confounded with gummata?#
No. Gummata grow more rapidly, are usually painful to the touch, are not
freely movable, and tend to break down and ulcerate.
#Describe the treatment of steatoma.#
A linear incision is made, and the mass and enveloping sac dissected
out. If the sac is permitted to remain, reproduction almost invariably
takes place.
#CLASS II.--INFLAMMATIONS.#
#Erythema Simplex.#
#What do you understand by erythema simplex?#
Erythema simplex is a hyperaemic disorder characterized by redness,
occurring in the form of variously-sized and shaped, diffused or
circumscribed, non-elevated patches.
#Name the two general classes into which the simple erythemata are
divided.#
Idiopathic and symptomatic.
#What do you include in the idiopathic class?#
Those erythemas due to external causes, such as cold and heat (_erythema
caloricum_), the action of the sun (_erythema solare_), traumatism
(_erythema traumaticum_), and the various poisons or chemical irritants
(_erythema venenatum_).
#What do you include in the symptomatic class?#
Those rashes often preceding or accompanying certain of the systemic
diseases, and those due to disorders of the digestive tract, stomachic
and intestinal toxins, to the ingestion of certain drugs, and to use of
the therapeutic serums.
#Describe the symptoms of erythema simplex.#
The essential symptom is redness--simple hyperaemia--without elevation or
infiltration, disappearing under pressure, and sometimes attended by
slight heat or burning; it may be patchy or diffused. In the idiopathic
class, if the cause is continued, dermatitis may result.
#What is to be said about the distribution of the simple erythemata?#
The idiopathic rashes, as inferred from the nature of the causes, are
usually limited.
The symptomatic erythemas are more or less generalized; desquamation
sometimes follows.
#Describe the treatment of the simple erythemata.#
A removal of the cause in idiopathic rashes is all that is needed, the
erythema sooner or later subsiding. The same may be stated of the
symptomatic erythemata, but in these there is at times difficulty in
recognizing the etiological factor; constitutional treatment, if
necessary, is to be based upon general principles. Intestinal
antiseptics are useful in some instances.
Local treatment, which is rarely needed, consists of the use of
dusting-powders or mild cooling and astringent lotions, such as are
employed in the treatment of acute eczema (q. v.).
#Erythema Intertrigo.#
(_Synonym:_ Chafing.)
#What do you understand by erythema intertrigo?#
Erythema intertrigo is a hyperaemic disorder occurring on parts where the
natural folds of the skin come in contact, and is characterized by
redness, to which may be added an abraded surface and maceration of the
epidermis.
#Describe the symptoms of erythema intertrigo.#
The skin of the involved region gradually becomes hyperaemic, but is
without elevation or infiltration; a feeling of heat and soreness is
usually experienced. If the condition continue, the increased
perspiration and moisture of the parts give rise to maceration of the
epidermis and a mucoid discharge; actual inflammation may eventually
result.
#What is the course of erythema intertrigo?#
The affection may pass away in a few days or persist several weeks, the
duration depending, in a great measure, upon the cause.
#Mention the causes of erythema intertrigo.#
The causes are usually local. It is seen chiefly in children, especially
in fat subjects, in whom friction and moisture of contiguous parts of
the body, usually the region of the neck, buttocks and genitalia, are
more common; in such, uncleanliness or the too free use of soap washings
will often act as the exciting factor. Disorders of the stomach or
intestinal canal apparently have a predisposing influence.
#What treatment would you advise in erythema intertrigo?#
The folds or parts are to be kept from contact by means of lint or
absorbent cotton; thin, flat bags of cheese cloth or similar material
partly filled with dusting-powder, and kept clean by frequent changes,
are excellent for this purpose, and usually curative. Cleanliness is
essential, but it is to be kept within the bounds of common sense.
Dusting-powders and cooling and astringent lotions, such as are employed
in the treatment of acute eczema (_q. v._), can also be advised. The
following lotion is valuable:--
[Rx] Pulv. calaminae,
Pulv. zinci oxidi, .. [=a][=a] ...... [dram]iss.
Glycerinae, .......................... [minum]xxx
Alcoholis, .......................... f[dram]ij
Aquae, ............................... Oss. M.
Exceptionally a mild ointment, alone or supplementary to a lotion, acts
more satisfactorily.
In persistent or obstinate cases attention should also be directed to
the state of the general health, especially as regards the digestive
tract.
#Erythema Multiforme.#
#What is erythema multiforme?#
Erythema multiforme is an acute, inflammatory disease, characterized by
reddish, more or less variegated macules, papules, and tubercles,
occurring as discrete lesions or in patches of various size and shape.
#Upon what parts of the body does the eruption appear?#
Usually upon the extremities, especially the dorsal aspect, from the
knees and elbows down, and about the face and neck; it may, however, be
more or less general.
#Describe the symptoms of erythema multiforme.#
With or without precursory symptoms of malaise, gastric uneasiness or
rheumatic pains, the eruption suddenly makes its appearance, assuming an
erythematous, papular, tubercular or mixed character; as a rule, one
type of lesion predominates. The lesions tend to increase in size and
intensity, remain stationary for several days or a week, and then
gradually fade; during this time there may have been outbreaks of new
lesions. In color they are pink, red, or violaceous. Slight itching may
or may not be present. Exceptionally, in general cases, the eruption
partakes of the nature of both urticaria and erythema multiforme, and
itching may be quite a decided symptom. In some instances there is
preceding and accompanying febrile action, usually slight in character;
in others there may be some rheumatic swelling of one or more joints.
[Illustration: Fig. 11.
Erythema Multiforme, in which many of the lesions have become
bullous--Erythema Bullosum.]
#What type of the eruption is most common?#
The papular, appearing usually upon the backs of the hands and forearms,
and not infrequently, also, upon the face, legs and feet. The papules
are usually pea-sized, flattened, and of a dark red or violaceous color.
#Describe the various shapes which the erythematous lesions may assume.#
Often the patches are distinctly ring-shaped, with a clear
centre--_erythema annulare_; or they are made up of several concentric
rings, presenting variegated coloring--_erythema iris_; or a more or
less extensive patch may spread with a sharply-defined border, the older
part tending to fade--_erythema marginatum_; or several rings may
coalesce, with a disappearance of the coalescing parts, and serpentine
lines or bands result--_erythema gyratum_.
#Does the eruption of erythema multiforme ever assume a vesicular or
bullous character?#
Yes. In exceptional instances, the inflammatory process may be
sufficiently intense to produce vesiculation, usually at the summits of
the papules--_erythema vesiculosum_; and in some instances, blebs may be
formed--_erythema bullosum_. A vesicular or bullous lesion may become
immediately surrounded by a ring-like vesicle or bleb, and outside of
this another form; a patch may be made up of as many as several such
rings--_herpes iris_. In the vesicular and bullous cases the lips and
the mucous membranes of the mouth and nose also may be the seat of
similar lesions.
#What is the course of erythema multiforme?#
Acute, the symptoms disappearing spontaneously, usually in one to three
or four weeks. In some instances the recurrences take place so rapidly
that the disease assumes a chronic aspect; it is possible that such
cases are midway cases between this disease and dermatitis
herpetiformis.
#Mention the etiological factors in erythema multiforme.#
The causes are obscure. Digestive disturbance, rheumatic conditions, and
the ingestion of certain drugs are at times influential. Intestinal
toxins are doubtless important etiological factors in some cases.
Certain foods, such as are apt to undergo rapid putrefactive or
fermentative change, especially pork meats, oysters, fish, crabs,
lobsters, etc., are, therefore, not infrequently of apparent causative
influence. It is most frequently observed in spring and autumn months,
and in early adult life. The disease is not uncommon.
#What is the pathology of erythema multiforme?#
It is a mildly inflammatory disorder, somewhat similar to urticaria, and
presumably due to vasomotor disturbance; the amount of exudation, which
is variable, determines the character of the lesions.
#Name the diagnostic points of erythema multiforme.#
The multiformity of the eruption, the size of the papules, often its
limitation to certain parts, its course and the entire or comparative
absence of itching.
It resembles urticaria at times, but the lesions of this latter disease
are evanescent, disappearing and reappearing usually in the most
capricious manner, are commonly seated about the trunk, and are
exceedingly itchy.
In the vesicular and bullous types the acute character of the outbreak,
the often segmental and ring-like shape, their frequent origin from
erythematous papules, and the distribution and association with the more
common manifestations, are always suggestive.
#What prognosis would you give in erythema multiforme?#
Always favorable; the eruption usually disappears in ten days to three
weeks, although in rare instances new crops may appear from day to day
or week to week, and the process last one or two months. One or more
recurrences in succeeding years are not uncommon. Those rare cases in
which vesicular or bullous lesions are also seen on the lips and in the
mouth, are more prone to longer duration and to more frequent
recurrences.
#What remedies are commonly prescribed in erythema multiforme?#
Quinin, and, if constipation is present, saline laxatives. Calcined
magnesia is valuable as a laxative. Intestinal antiseptics, such as
salol, thymol, and sodium salicylate, are valuable in cases probably due
to intestinal toxins. In those exceptional instances in which there may
be associated febrile action and rheumatic swelling of the joints, the
patient should be kept in bed till these symptoms subside. Local
applications are rarely required, but in those exceptional cases in
which itching or burning is present, cooling lotions of alcohol and
water or vinegar and water are to be prescribed. The vesicular and
bullous types demand mild protective applications, such as used in
eczema and pemphigus.
#Erythema Nodosum.#
(_Synonym:_ Dermatitis contusiformis.)
#What is erythema nodosum?#
Erythema nodosum is an inflammatory affection, of an acute type,
characterized by the formation of variously-sized, roundish, more or
less elevated erythematous nodes.
#Is there any special region of predilection for the eruption of erythema
nodosum?#
Yes. The tibial surfaces, to which the eruption is often limited; not
infrequently, however, other parts may be involved, more especially the
arms and forearms.
#Describe the symptoms of erythema nodosum.#
The eruption makes its appearance suddenly, and is usually ushered in
with febrile disturbance, gastric uneasiness, malaise, and rheumatic
pains and swelling about the joints. The lesions vary in size from a
cherry to a hen's egg, are rounded or ovalish, tender and painful, have
a glistening and tense look, and are of a bright red, erysipelatous
color which merges gradually into the sound skin. At first they are
somewhat hard, but later they soften and appear as if about to break
down, but this, however, never occurs, absorption invariably taking
place. In occasional instances they are hemorrhagic. Exceptionally the
lesions of erythema multiforme are also present. Lymphangitis is
sometimes observed. In rare instances symptoms pointing to visceral
involvement, to cerebral invasion, and to heart complications have been
observed.
#Are the lesions in erythema nodosum usually numerous?#
No. As a rule not more than five to twenty nodes are present.
#What is the course of erythema nodosum?#
Acute. The disease terminating usually in one to three weeks. As the
lesions are disappearing they present the various changes of color
observed in an ordinary bruise.
#What is known in regard to the etiology?#
The affection is closely allied to erythema multiforme, and is, indeed,
by some considered a form of that disease. It occurs most frequently in
children and young adults, and usually in the spring and autumn months.
Intestinal toxins are thought responsible in some cases. Digestive
disturbance and rheumatic pain and swellings are often associated with
it. By many the malady is thought to be a specific infection.
#What is the pathology of erythema nodosum?#
The disease is to be viewed as an inflammatory [oe]dema, probably
resulting, in some instances at least, from an inflammation of the
lymphatics or an embolism of the cutaneous vessels.
#What diseases may erythema nodosum resemble?#
Bruises, abscesses, and gummata.
#How are the lesions of erythema nodosum to be distinguished from these
several conditions?#
By the bright red or rosy tint, the apparently violent character of the
process, the number, situation and course of the lesions.
#State the prognosis of erythema nodosum.#
Favorable, recovery usually taking place in ten days to several weeks.
#State the treatment to be advised in erythema nodosum.#
Rest, relative or absolute, depending upon the severity of the case, and
an unstimulating diet; internally intestinal antiseptics, quinin and
saline laxatives, and locally applications of lead-water and laudanum.
#Erythema Induratum.#
(_Synonym:_ Erythema induratum scrofulosorum.)
#What do you understand by erythema induratum?#
A rare disease characterized in the beginning by one or more usually
deep-seated nodules, and, as a rule, seated in the legs, especially the
calf region. The nodules gradually enlarge, the skin becomes reddish,
violaceous or livid in color. Absorption may take place slowly, or the
indurations may break down, resulting in an indolent, rather deep-seated
ulcer, closely resembling a gummatous ulcer. The disease is slow and
persistent, and is commonly met with in girls and young women, usually
of strumous type. It suggests a tuberculous origin.
Treatment consists in administration of cod-liver oil, phosphorus and
other tonics. Rest is of service. Locally antiseptic applications, and
support with roller bandage are to be advised.
#Urticaria.#
(_Synonyms:_ Hives; Nettlerash.)
#Give a definition of urticaria.#
Urticaria is an inflammatory affection characterized by evanescent
whitish, pinkish or reddish elevations, or wheals, variable as to size
and shape, and attended by itching, stinging or pricking sensations.
#Describe the symptoms of urticaria.#
The eruption, erythematous in character and consisting of isolated pea
or bean-sized elevations or of linear streaks or irregular patches,
limited or more or less general, and usually intensely itchy, makes its
appearance suddenly, with or without symptoms of preceding gastric
derangement. The lesions are soft or firm, reddish or pinkish-white,
with the peripheral portion of a bright red color, and are fugacious in
character, disappearing and reappearing in the most capricious manner.
In many cases simply drawing the finger over the skin will bring out
irregular and linear wheals. In exceptional cases this peculiar property
is so pronounced and constant that at any time letters and other symbols
may be produced at will, even when such subjects are free from the
ordinary urticarial lesions (_urticaria factitia_, _dermatographism_,
_autographism_).
The mucous membrane of the mouth and throat may also be the seat of
wheals and urticarial swellings.
#What is the ordinary course of urticaria?#
Acute. The disease is usually at an end in several hours or days.
#Does urticaria always pursue an acute course?#
No. In exceptional instances the disease is chronic, in the sense that
new lesions continue to appear and disappear irregularly from time to
time for months or several years, the skin rarely being entirely free
(_chronic urticaria_).
[Illustration: Fig. 12.
Dermatographism. (_After C.N. Davis._)]
#Are subjective symptoms always present in urticaria?#
Yes. Itching is commonly a conspicuous symptom, although at times
pricking, stinging or a feeling of burning constitutes the chief
sensation.
#In what way may the eruption be atypical?#
Exceptionally the wheals, or lesions, are peculiar as to formation, or
another condition or disease may be associated, hence the varieties
known as urticaria papulosa, urticaria haemorrhagica, urticaria tuberosa,
and urticaria bullosa.
#Describe urticaria papulosa.#
Urticaria papulosa (formerly called _lichen urticatus_) is a variety in
which the lesions are small and papular, developing usually out of the
ordinary wheals. They appear as a rule suddenly, rarely in great
numbers, are scattered, and after a few hours or, more commonly, days
gradually disappear. The itching is intense, and in consequence their
apices are excoriated. Sometimes the papules are capped with a small
vesicle (vesicular urticaria). It is seen more particularly in ill-cared
for and badly-nourished young children.
#Describe urticaria haemorrhagica.#
Urticaria haemorrhagica is characterized by lesions similar to ordinary
wheals, except that they are somewhat hemorrhagic, partaking, in fact,
of the nature of both urticaria and purpura.
#Describe urticaria tuberosa.#
In urticaria tuberosa the lesions, instead of being pea- or bean-sized,
as in typical urticaria, are large and node-like (also called _giant
urticaria_).
#What is acute-circumscribed [oe]dema?#
In rare instances there occurs, along with the ordinary lesions of the
disease or as its sole manifestation, sudden and evanescent swelling of
the eyelids, ears, lips, tongue, hands, fingers, or feet (_urticaria
[oe]dematosa_, _acute_ _circumscribed [oe]dema_, _angioneurotic [oe]dema_).
One or several of these parts only may be affected at the one attack; in
recurrences, so usual in this variety, the same or other parts may
exhibit the manifestation.
(These [oe]dematous swellings occurring alone might be looked upon, as
they are by most observers, as an independent affection, but its close
relationship to ordinary urticaria is often evident.)
#Describe urticaria bullosa.#
Urticaria bullosa is a variety in which the inflammatory action has been
sufficiently great to give rise to fluid exudation, the wheals resulting
in the formation of blebs.
#What is the etiology of urticaria?#
Any irritation from disease, functional or organic, of any internal
organ, may give rise to the eruption in those predisposed. Gastric
derangement from indigestible or peculiar articles of food, intestinal
toxins, and the ingestion of certain drugs are often provocative. The
so-called "shell-fish" group of foods play an important etiological part
in some cases. Idiosyncrasy to certain articles of food is also
responsible in occasional instances. Various rheumatic and nervous
disorders are not infrequently associated with it, and are doubtless of
etiological significance. External irritants, also, in predisposed
subjects, are at times responsible.
#What is the pathology of urticaria?#
Anatomically a wheal is seen to be a more or less firm elevation
consisting of a circumscribed or somewhat diffused collection of
semi-fluid material in the upper layers of the skin. The vasomotor
nervous system is probably the main factor in its production; dilatation
following spasm of the vessels results in effusion, and in consequence,
the overfilled vessels of the central portion are emptied by pressure of
the exudation and the central paleness results, while the pressed-back
blood gives rise to the bright red periphery.
#From what diseases is urticaria to be differentiated?#
From erythema simplex, erythema multiforme, erythema nodosum, and
erysipelas.
#Mention the diagnostic points of urticaria.#
The acuteness, character of the lesions, their evanescent nature, the
irregular or general distribution, and the intense itching.
#What is the prognosis in urticaria?#
The acute disease is usually of short duration, disappearing
spontaneously or as the result of treatment, in several hours or days;
it may recur upon exposure to the exciting cause. The prognosis of
chronic urticaria is to be guarded, and will depend upon the ability to
discover and remove or modify the predisposing condition.
#What systemic measures are to be prescribed in acute urticaria?#