found in most cases to be gastric disturbance from the ingestion of
improper or indigestible food, and in such cases a saline purgative is
to be given, probably the best for this purpose being the laxative
antacid, magnesia; or if the case is severe and food is still in the
stomach, an emetic, such as mustard or ipecac, will act more promptly.
Alkalies, especially sodium salicylate, and intestinal antiseptics are
useful. Calcium chloride in doses of five to twenty grains should be
tried in obstinate cases. The diet should be, for the time, of a simple
character.
#What systemic measures are to be prescribed in chronic and recurrent
urticaria?#
The cause must be sought for and treatment directed toward its removal
or modification. Treatment will, therefore, depend upon indications. In
obscure cases, quinine, sodium salicylate, arsenic, pilocarpine,
_atropia_, potassium bromide, calcium chloride, and ichthyol are to be
variously tried; general galvanization is at times useful, as is also a
change of scene and climate. A proper dietary and the maintenance of
free action of the bowels, preferably, as a rule, with a saline
laxative, is of great importance in these chronic cases.
In acute circumscribed [oe]dema treatment is essentially that of
urticaria, the diet being given special attention.
#What external applications would you advise for the relief of the
subjective symptoms?#
Cooling lotions of alcohol and water or vinegar and water; lotions of
carbolic acid, one to three drachms to the pint; of thymol, one-fourth
to one drachm to the pint of alcohol and water; of liquor carbonis
detergens, one to three ounces to the pint of water, or the following:--
[Rx] Acidi carbolici, ..................... [dram]j-[dram]iij
Acidi borici, ........................ [dram]iv
Glycerinae, ........................... f[dram]j
Alcoholis, ........................... f[Oz]ij
Aquae, ................................ f[Oz]xiv. M.
Alkaline baths are also useful, and may advantageously be followed by
dusting-powders of starch and zinc oxide.
#Urticaria Pigmentosa.#
(_Synonym:_ Xanthelasmoidea.)
#Describe urticaria pigmentosa.#
Urticaria pigmentosa is a rare disease, variously viewed as an unusual
form of urticaria and as an urticaria-like eruption in which there is an
element of new growth in the lesions. It begins usually in infancy or
early childhood and continues for months or years, and is characterized
by slightly, moderately, or intensely itchy, wheal-like elevations,
which are more or less persistent and leave yellowish, orange-colored,
greenish or brownish stains. Exceptionally subjective symptoms are
almost entirely absent. Anatomical studies show that the lesion has in
some respects the structure of an ordinary wheal, with [oe]dema and
pigment deposit in the epidermal portion, and cellular infiltration made
up principally of mast-cells.
[Illustration: Fig. 13.
Urticaria Pigmentosa.]
The nature of the disease is obscure and treatment unsatisfactory.
Ordinarily as early youth or adult life is reached it spontaneously
disappears. The treatment advised is usually on the same lines as that
of chronic urticaria.
#Dermatitis.#
#What is implied by the term dermatitis?#
Dermatitis, or inflammation of the skin, is a term employed to designate
those cases of cutaneous disturbance, usually acute in character, which
are due to the action of irritants.
#Mention some examples of cutaneous disturbance to which this term is
applied.#
The dermatic inflammation due to the action of excessive heat or cold,
to caustics and other chemical irritants, and to the ingestion of
certain drugs.
#What several varieties are commonly described?#
Dermatitis traumatica, dermatitis calorica, dermatitis venenata, and
dermatitis medicamentosa.
#Describe dermatitis traumatica.#
Under this head are included all forms of cutaneous inflammation due to
traumatism. To the dermatologist the most common met with is that
produced by the various animal parasites and from continued scratching;
in such, if the cause has been long-continued and persistent, a variable
degree of inflammatory thickening of the skin and pigmentation result,
the latter not infrequently being more or less permanent. The
inflammation due to tight-fitting garments, bandages, to constant
pressure (as bed-sores), etc., also illustrates this class.
#What is the treatment of dermatitis traumatica?#
Removal of the cause, and, if necessary, the application of soothing
ointments or lotions; in bed-sores, soap plaster, plain or with one to
five per cent. of ichthyol.
#What is dermatitis calorica?#
Cutaneous inflammation, varying from a slight erythematous to a
gangrenous character, produced by excessive heat (_dermatitis
ambustionis_, _burns_) or cold (_dermatitis congelationis_,
_frostbite_).
#Give the treatment of dermatitis calorica.#
In burns, if of a mild degree, the application of sodium bicarbonate, as
a powder or saturated solution, is useful; in the more severe grade, a
two- to five-per-cent. solution will probably be found of greater
advantage. Other soothing applications may also be employed. In recent
years a one-per-cent. solution of picric acid has been commended for the
slighter burns of limited extent. Upon the whole, there is nothing yet
so generally useful and soothing in these cases as the so-called Carron
oil; in some cases more valuable with 1/2 to 1 minim of carbolic acid
added to each ounce.
In frostbite, seen immediately after exposure, the parts are to be
brought gradually back to a normal temperature, at first by rubbing with
snow or applying cold water. Subsequently, in ordinary chilblains,
stimulating applications, such as oil of turpentine, balsam of Peru,
tincture of iodine, ichthyol, and strongly carbolized ointments are of
most benefit. If the frostbite is of a vesicular, pustular, bullous, or
escharotic character, the treatment consists in the application of
soothing remedies, such as are employed in other like inflammatory
conditions.
#What do you understand by dermatitis venenata?#
All inflammatory conditions of the skin due to contact with deleterious
substances such as caustic, chemical irritants, iodoform, etc., are
included under this head, but the most common causes are the rhus
plants--_poison ivy_ (or _poison oak_) and _poison sumach_ (_poison
dogwood_). Mere proximity to these plants will, in some individuals,
provoke cutaneous disturbance (_rhus poisoning_, _ivy poisoning_),
although they may be handled by others with impunity.
Many other plants are also known to produce cutaneous irritation in
certain subjects; among these may be mentioned the nettle, primrose,
cowhage, smartweed, balm of Gilead, oleander, and rue.
The local action of iodoform (_iodoform dermatitis_) in some individuals
is that of a decided irritant, bringing about a dermatitis, which often
spreads much beyond the parts of application, and which in those
eczematously inclined may result in a veritable and persistent eczema.
#Describe the symptoms of rhus poisoning.#
The symptoms appear usually soon after exposure, and consist of an
inflammatory condition of the skin of an eczematous nature, varying in
degree from an erythematous to a bullous character, and with or without
[oe]dema and swelling. As a rule, marked itching and burning are
present. The face, hands, forearms and genitalia are favorite parts,
although it may in many instances involve a greater portion of the whole
surface.
#What is the course of rhus poisoning?#
It runs an acute course, terminating in recovery in one to six weeks. In
those eczematously inclined, however, it may result in a veritable and
persistent form of that disease.
#How would you treat rhus poisoning?#
By soothing and astringent applications, such as are employed in acute
eczema (_q. v._), which are to be used freely. Among the most valuable
are: a lotion of fluid extract of grindelia robusta, one to two drachms
to four ounces of water; lotio nigra, either alone or followed by the
oxide-of-zinc ointment; a saturated solution of boric acid, with a half
to two drachms of carbolic acid to the pint; a lotion of zinc sulphate,
a half to four grains to the ounce; weak alkaline lotions; cold cream,
petrolatum, and oxide-of-zinc ointments.
#How would you treat the dermatitis due to other deleterious substances
of this class?#
By applications of a soothing and protective character, similar to those
used in eczema and burns.
#Dermatitis Medicamentosa.#
#What do you understand by dermatitis medicamentosa?#
Under this head are included all eruptions due to the ingestion or
absorption of certain drugs.
In rare instances one dose will have such effect; commonly, however, it
results only after several days' or weeks' continued administration.
With some drugs such effect is the rule, with others it is exceptional,
nor are all individuals equally susceptible.
#How is the eruption produced in dermatitis medicamentosa?#
In some instances it is probably due to the elimination of the drug
through the cutaneous structures; in others, to the action of the
drug upon the nervous system. The view that the drug acts as a toxin or
generates some toxin or irritant material in the blood, to which the
eruptive phenomena may be due, has also been advanced.
[Illustration: Dermatitis medicamentosa.
Bullous dermatitis from iodide of potassium.]
#What is the character of the eruption in dermatitis medicamentosa?#
It may be erythematous, papular, urticarial, vesicular, pustular or
bullous, and, if the administration of the drug is continued, even
gangrenous.
#Name the more common drugs having such action.#
Antipyrin, arsenic, atropia (or belladonna), bromides, chloral, copaiba,
cubebs, digitalis, iodides, mercury, opium (or morphia), quinine,
salicylic acid, stramonium, acetanilid, sulphonal, phenacetin,
turpentine, many of the new coal-tar derivatives, etc.
#State frequency and types of eruption due to the ingestion of antipyrin.#
Not uncommon. _Erythematous_, morbilliform and erythemato-papular;
itching is usually present and moderate desquamation may follow.
Acetanilid, sulphonal, phenacetin, and other drugs of this class may
provoke like eruptions.
#Mention frequency and types of eruption due to the ingestion of arsenic.#
Rare. Erythematous, erythemato-papular; exceptionally, herpetic, and
pigmentary. Herpes zoster has been thought to follow its use. Keratosis
of the palms and soles has also been occasionally observed, which, in
rare instances, has developed into epithelioma.
#Mention frequency and types of eruption due to the ingestion of atropia
(or belladonna).#
Not uncommon. _Erythematous_ and _scarlatinoid_; usually no febrile
disturbance, and desquamation seldom follows.
#Give frequency and types of cutaneous disturbance following the
administration of the bromides (bromine).#
Common. _Pustular_, sometimes furuncular and carbuncular and
superficially ulcerative. In exceptional instances papillomatous or
vegetating lesions have been observed. Co-administration of arsenic or
potassium bitartrate is thought to have a preventive influence in some
cases.
#State frequency and types of cutaneous disturbance due to the
administration of chloral.#
Occasional. Scarlatinoid and urticarial, and exceptionally purpuric; in
rare instances, if drug is continued, eruption becomes vesicular,
hemorrhagic, ulcerative and even gangrenous.
#State frequency and types of eruption following the administration of
copaiba.#
Not uncommon. _Urticarial_, erythemato-papular and _scarlatinoid_.
#Mention frequency and types of eruption resulting from the ingestion of
cubebs.#
Uncommon. Erythematous and small papular.
[Illustration: Fig. 14.
A somewhat rare form of eruption from the ingestion of iodine compounds.
(_After J.C. McGuire._)]
#Mention frequency and types of eruption resulting from the
administration of digitalis.#
Exceptional. Scarlatinoid and papular.
#State frequency and types of eruption resulting from the iodides
(iodine).#
Common. _Pustular_, but may be erythematous, papular, vesicular,
bullous, tuberous, purpuric and hemorrhagic. Co-administration of
arsenic or potassium bitartrate is thought to have a preventive
influence in some cases.
#Give the frequency and types of eruption observed to follow the
administration of mercury.#
Exceptional. Erythematous and erysipelatous.
#Give the frequency and types of the cutaneous disturbance following the
ingestion of opium (or morphia).#
Not uncommon. Erythematous and _scarlatinoid_, and sometimes urticarial.
#Mention the frequency and the types of eruption following the
administration of quinine.#
Not infrequent. Usually _erythematous_, but may be urticarial,
erythemato-papular, and even purpuric. There is, in some instances,
preceding or accompanying systemic disturbance. Furfuraceous or lamellar
desquamation often follows.
#State frequency and types of eruption resulting from the ingestion of
salicylic acid.#
Not common. Erythematous and urticarial; exceptionally, vesicular,
pustular, bullous, and ecchymotic.
#Give frequency and type of cutaneous disturbance due to the
administration of stramonium.#
Not common. Erythematous.
#State frequency and types of eruption resulting from the administration
of turpentine.#
Not uncommon. _Erythematous_, and small-papular; exceptionally
vesicular.
#X-Ray Dermatitis.#
#What several grades of x-ray dermatitis (x-ray burns, Rontgen-ray burns)
are observed?#
Three grades are usually described: erythema, superficial vesication,
and necrosis. The first and second may come on shortly--a few hours to
several days--after exposure; occasionally later. The third grade may
present also in the first several days, but in many cases one to several
weeks may elapse before it appears; it is quite commonly preceded by
erythema and vesication. The necrosis may be superficial or deep, and
quite usually results in a persistent ulcer covered by a leathery
coating; it is usually painful.
[Illustration: Fig. 15. _x_-ray burn]
#Give the prognosis and treatment of x-ray dermatitis.#
The first grade--the erythematous--usually disappears in one to ten
days; the second grade requires one to several weeks, and may be quite
sore and tender; the severe or necrotic burns are persistent, sometimes
lasting for months and several years, with little tendency to
spontaneous disappearance, and rebellious to treatment.
Treatment of the milder types is that of erythema (_q. v._); the necrotic
type occasionally demands thorough curetting and skin-grafting before it
will heal.
#Dermatitis Factitia.#
(_Synonym:_ Feigned Eruptions.)
#What do you understand by feigned eruptions?#
Feigned, or artificial, eruptions, occasionally met with in hysterical
females and in others, are produced, for the purpose of exciting
sympathy or of deception, by the action of friction, cantharides, acids
or strong alkalies; the cutaneous disturbance may, therefore, be
erythematous, vesicular, bullous, or gangrenous. It is usually limited
in extent, and, as a rule, seen only on parts easily reached by the
hands.
[Illustration: Fig. 16.
Dermatitis Factitia--note the unusually uniform and regular character
and arrangement of the lesions.]
#Dermatitis Gangraenosa.#
#What do you understand by dermatitis gangraenosa?#
Dermatitis gangraenosa (_erythema gangraenosum_, _Raynaud's disease_,
_spontaneous gangrene_) is an exceedingly rare affection, characterized
by the formation of gangrenous spots and patches. It may be idiopathic
or symptomatic. Some of these cases, especially in hysterical subjects,
belong under the "feigned eruptions," being self-produced.
As an idiopathic disease, it begins as erythematous, dark-red
spots--usually preceded and accompanied by mild or grave systemic
disturbance--which gradually pass into gangrene and sloughing; the
eventual termination may be fatal, or recovery may take place. As a
symptomatic disease, it is occasionally met with in diabetes and in
grave cerebral and spinal affections.
In Raynaud's disease (symmetric gangrene) the parts affected are the
extremities, such as fingers and toes, the ears and nose, only
occasionally other parts. The first symptoms observed are coldness and
paleness of the part; followed sooner or later by congestion of a dark
red, livid, or bluish color, with sometimes swelling, and tenderness and
shooting pains. The termination is usually in gangrene of a dry
character, with, in some instances, vesicles and blebs along the edges;
in other cases the parts become atrophied, withered, and indurated.
Treatment is based upon general principles.
#Erysipelas.#
#What is erysipelas?#
Erysipelas is an acute specific inflammation of the skin and
subcutaneous tissue, commonly of the face, characterized by shining
redness, swelling, [oe]dema, heat, and a tendency in some cases to
vesicle- and bleb-formation, and accompanied by more or less febrile
disturbance.
#Describe the symptoms and course of erysipelas.#
A decided rigor or a feeling of chilliness followed by febrile action
usually ushers in the cutaneous disturbance. The skin at a certain point
or part, commonly where there is a lesion of continuity, becomes bright
red and swollen; this spreads by peripheral extension, and in the course
of several hours involves a portion or the whole region. The parts are
shining red, swollen, of an elevated temperature, and sharply defined
against the sound skin. After several days or a week, during which time
there is usually continued mild or severe febrile action, the process
begins to subside, and is followed by epidermic desquamation.
In some cases vesicles and blebs may be present; in other cases the
disease seriously involves the deeper parts, and is accompanied by grave
constitutional symptoms. In exceptional instances sloughing takes place.
A mild, transitory, limited, and often recurrent erysipelatous condition
of the outlet and immediate neighborhood of one or both nostrils is met
with, taking its origin from an inflammation of the hair-follicles just
inside the margin of the nose; constitutional symptoms are usually
wanting. Somewhat similar, doubtless, is the erysipelatous inflammation
(_erysipeloid_) observed on the fingers and hands of butchers, etc.,
starting from a wound, apparently as a result of infection from putrid
meat or fish.
#What is erysipelas migrans (or erysipelas ambulans)?#
A variety of erysipelas which, after a few hours or days, disappears at
one region and appears at another, and so continues for one or several
weeks.
#What is the cause of erysipelas?#
The disease is due to a specific streptococcus--the streptococcus of
Fehleisen. Depression of the vital forces and local abrasions are
predisposing factors.
#State the diagnostic points.#
The character of the onset, the shining redness and swelling, the
sharply-defined border, and the accompanying febrile disturbance.
#What is the prognosis in erysipelas?#
In most instances the disease runs a favorable course, terminating in
recovery in one to three weeks. Exceptionally, in severe cases, a fatal
termination ensues.
#What is the treatment of erysipelas?#
_Internally_, a purge, followed by the tincture of the chloride of iron
and quinia, and stimulants if needed. _Locally_, one to three per cent.
carbolic-acid lotion or ointment, a saturated solution of boric acid, or
a ten- to twenty-per-cent. aqueous solution or ointment of ichthyol may
be employed.
In some cases the spread of the disease is apparently controlled by
painting the bordering healthy skin with a ring of tincture of iodine or
strong solution of nitrate of silver.
#Phlegmona Diffusa.#
#What do you understand by phlegmona diffusa?#
Phlegmona diffusa is a more or less extensive inflammation of the
cutaneous and subcutaneous tissues presenting symptoms partaking of the
nature of both deep erysipelas and flat carbuncles, and usually attended
with varying constitutional disturbance. Suppuration at several points
takes place, and sloughing may ensue. Recovery usually finally results,
but a fatal issue is possible.
Treatment is based upon general principles.
#Furunculus.#
(_Synonyms:_ Furuncle; Boil.)
#Define furunculus.#
Furunculus, or boil, is an acute, deep-seated, inflammatory,
circumscribed, rounded or more or less acuminated, firm, painful
formation, usually terminating in central suppuration.
#Describe the symptoms and course.#
A boil begins as a small, rounded or imperfectly defined reddish spot,
or as a small, superficial pustule; it increases in size, and when well
advanced appears as a pea or cherry-sized, circumscribed, reddish
elevation, with more or less surrounding hyperaemia and swelling; it is
painful and tender, and ends, in the course of several days or a week,
in the formation of a central slough or "_core_," which finally involves
the central overlying skin (_pointing_). One or several may be present,
gradually maturing and disappearing. Insignificant scarring may remain.
In some cases sympathetic constitutional disturbance is noticed.
#What is a blind boil?#
A sluggish boil exhibiting little, if any, tendency to point or break.
#What is furunculosis?#
Furunculosis is that condition in which boils, singly or in crops,
continue to appear, irregularly, for weeks or months.
#State the etiology of furuncle.#
A depraved state of the general health is often to be considered as a
predisposing factor. Persistent furunculosis is not infrequent in
diabetes mellitus. The immediate exciting cause is the entrance into the
follicle of a microbe, the staphylococcus pyogenes aureus. It is not
improbable, however, that boils may also be due to other pus-producing
organisms.
Workmen in paraffin oils or other petroleum products often present
numerous furuncles and cutaneous abscesses. Conditions favoring a
persistent miliaria have also a causative influence, especially observed
in infants and young children. In these latter, especially among the
poorer classes, sluggish boils or subcutaneous abscesses about the scalp
in hot weather, are not at all infrequent.
#What is the pathology of furuncle?#
A boil is an inflammatory formation having its starting point in a
sebaceous-gland, sweat-gland, or hair-follicle. The core, or central
slough, is composed of pus and of the tissue of the gland in which it
had its origin.
#How would you distinguish a boil from a carbuncle?#
A boil is comparatively small, rounded or acuminate, and has but one
point of suppuration; a carbuncle is large, flattened, intensely
painful, often with grave systemic disturbance, and has, moreover,
several centres of suppuration.
#State the prognosis.#
When occurring in crops (furunculosis) the affection is often
rebellious; recovery, however, finally resulting.
#What is the method of treatment of furunculus?#
If there be but one lesion, with no tendency to the appearance of
others, local treatment alone is usually employed. If, however, several
or more are present, or if there is a tendency to successive
development, both constitutional and local measures are demanded.
#Name the internal remedies employed.#
Such nutrients and tonics as cod-liver oil, malt, quinine, strychnia,
iron and arsenic; in some instances calx sulphurata, one-tenth- to
one-fourth-grain doses every three or four hours has been thought to be
of service. Brewers' yeast has been recently again brought forward as a
remedy of value.
#What is the external treatment?#
Local treatment consists in the beginning, with the hope of aborting the
lesion, of the application of carbolic acid to the central portion, or
the use of a twenty-five-per-cent. ointment of ichthyol applied as a
plaster:--
[Rx] Ichthyol, ............................ [dram]j
Emp. plumbi, ........................... [dram]ij
Emp. resinae, ........................... [dram]j. M.