upon general principles; moderate doses of quinia, with one-sixth grain
of zinc phosphide, four or five times daily, appear in some cases to
have a special value. The accompanying neuralgic pain may be so intense
as to require anodynes. _Local treatment_ should be of a soothing and
protective character. A dusting-powder of oxide of zinc and starch (to
the ounce of which twenty to thirty grains of camphor may be added)
proves useful; and over this, in order that the parts be further
protected, a bandage or a layer of cotton batting. Oxide-of-zinc
ointment, and in those cases in which there is much pain, ointments
containing powdered opium or belladonna, or orthoform, may be used. A
mild galvanic current applied daily to the parts is often of great
advantage, both in its influence upon the course of the eruption and
upon the neuralgic pain. The plan, so often advised, of painting the
parts with flexible collodion is not to be commended.
#Dermatitis Herpetiformis.#
(_Synonyms:_ Hydroa Herpetiforme (Tilbury Fox); Herpes Gestationis
(Bulkley); Pemphigus Prurigiuosus; Duhring's Disease.)
#Give a definition of dermatitis herpetiformis.#
Dermatitis herpetiformis is a somewhat rare inflammatory disease,
characterized by an eruption of an erythematous, papular, vesicular,
pustular, bullous or mixed type, with a decided disposition toward
grouping, accompanied by itching and burning sensations, with, as a
rule, more or less consequent pigmentation, and pursuing usually a
chronic course with remissions.
#Describe the erythematous type of dermatitis herpetiformis.#
The character of the eruption in the erythematous type resembles closely
that of erythema multiforme and of urticaria, especially the former. The
efflorescences usually make their appearance in crops, and are more or
less persistent; fading sooner or later, however, and giving place to
new outbreaks. Vesicles are often intermingled, developing from
erythematous and erythemato-papular lesions or arising from apparently
normal skin.
It may continue in the same type, or change to the vesicular, bullous or
other variety.
#Describe the papular type of dermatitis herpetiformis.#
This is rarely seen as consisting purely of papular lesions, but is
commonly associated with the erythematous and vesicular varieties. In a
measure it resembles the papular manifestations of erythema multiforme,
with a distinct disposition toward group formation. The papules tend,
sooner or later, to develop into vesicles, new papular outbreaks
occurring from time to time; or the whole eruption changes to the
vesicular or other type of the disease. It is not a common type.
#Describe the vesicular type of dermatitis herpetiformis.#
This is the common clinical type of the disease, and is characterized by
pin-head to pea-sized, rounded or irregularly-shaped, distended or
flattened and stellate vesicles, occurring, for the most part, in
irregular and segmental groups of three or more lesions, seated either
upon apparently normal integument or upon hyperaemic or inflammatory
skin. They exhibit no tendency to spontaneous rupture, but after
remaining a shorter or longer time, are broken or disappear by
absorption. The lesions tend to appear in crops. It may, as it not
infrequently does, continue in the same type, or it may become more or
less erythematous or bullous in character. In not a few instances
pustules, few or in numbers, are at times intermingled.
#Describe the pustular type of dermatitis herpetiformis.#
This is rare. It is similar in its clinical characters to the vesicular
type, except that the lesions are pustular. It is met with, as a rule,
in association with the vesicular and bullous varieties of the disease.
#Describe the bullous type of dermatitis herpetiformis.#
The bullous expression of the disease is usually of a markedly
inflammatory nature, often innumerable blebs, small and large, appearing
almost continuously, and in some instances involving the greater part of
the surface. The lesions arise from erythematous skin, from preexisting
vesicles or vesicular groups, or from apparently normal integument.
There is a marked disposition to appear in clusters. A change of type to
the erythematous or vesicular varieties is not unusual.
#Describe the mixed type of dermatitis herpetiformis.#
In this type the eruption is made up of erythematous patches, vesicles,
bullae, and often with pustules intermingled, appearing irregularly or in
crops, and with a tendency to patch or group formation.
#Describe the characters of the vesicles, pustules and blebs.#
As a rule, these several lesions, especially the vesicles and blebs, are
somewhat peculiar: they are usually of a strikingly irregular outline,
oblong, stellate, quadrate, and when drying are apt to have a puckered
appearance. They are herpetic in that they show little disposition to
spontaneous rupture, occur in groups, and are usually seated upon
erythematous or inflammatory skin--in some respects similar to the
groups of simple herpes and herpes zoster.
#What is to be said in regard to the subjective symptoms?#
The subjective symptoms are usually the most troublesome feature of the
disease, consisting of intense and persistent itching and a feeling of
heat and burning.
#Are there any constitutional symptoms in dermatitis herpetiformis?#
As a rule, not, excepting the distress and depression necessarily
consequent upon the intense itchiness and loss of sleep. In the pustular
and bullous varieties there may be mild or grave systemic symptoms, but
even in these types the constitutional involvement is, in most
instances, slight in comparison to the intensity of the cutaneous
disturbance.
#What is the course of dermatitis herpetiformis?#
Extremely chronic, in most instances lasting, with remissions,
indefinitely. The skin is rarely entirely free. From time to time the
type of the disease may undergo change. From the continued irritation
and scratching more or less pigmentation results.
#What is to be said in regard to the etiology?#
The disease is in many instances essentially neurotic, and in
exceptional instances septicaemic. Pregnancy and the parturient state are
factors in some instances (so-called herpes gestationis). It is possible
in some instances that the eruption may be an expression of a mild
toxemia of gastro-intestinal origin. In some cases no cause can be
assigned. In the majority of patients the general health, considering
the violence of the eruptive phenomena, remains comparatively
undisturbed.
Nervous shock and mental worry are factors in some cases. Polyuria,
with sugar in the urine, has occasionally been noted. Eosinophile
cells have been found both in the vesicles and the blood. In some
instances--exceptionally, it is true--the disease has appeared shortly
after vaccination.
#Mention the diagnostic features of dermatitis herpetiformis.#
The multiformity of the eruption, the characters of the lesions, the
disposition to grouping, the absence of tendency to form solid sheets of
eruption (as in eczema), the intense itching, history, chronicity and
course. In doubtful cases, an observation of several weeks will always
suffice to distinguish it from eczema, erythema multiforme, herpes iris
and pemphigus, diseases to which it at times bears strong resemblance.
#Give the prognosis of dermatitis herpetiformis.#
An opinion as to the outcome of the disease should be guarded. It is
exceedingly rebellious to treatment, and relapses are the rule.
Exceptionally the bullous and pustular varieties prove eventually fatal.
The erythematous and vesicular varieties are the most favorable.
#State the treatment to be advised.#
There are no special remedies. Constitutional treatment must be
conducted upon general principles. A free action of the bowels is to be
maintained. In occasional instances arsenic in progressive doses seems
of value. Externally protective and antipruritic applications, such as
are employed in the treatment of eczema and pemphigus, are to be
employed:--
[Rx] Ac. carbolici, ....................... [dram]j-[dram]ij
Thymol, .............................. gr. xvj.
Glycerinae, ........................... [Oz]ss-[Oz]j
Alcoholis, ........................... f[Oz]ij
Aquae, q.s., ......... ad ............. Oj. M.
Other valuable applications are: lotions of carbolic acid, of liquor
carbonis detergens, of boric acid; alkaline baths, mild sulphur ointment
and carbolized oxide-of-zinc ointment, and dusting-powders of starch,
zinc oxide, talc and boric acid. A two- to ten-per-cent. ichthyol lotion
or ointment is sometimes of advantage; thiol employed in the same manner
has also been commended.
#Psoriasis.#
#Give a definition of psoriasis.#
Psoriasis is a chronic, inflammatory disease, characterized by dry,
reddish, variously-sized, rounded, sharply-defined, more or less
infiltrated, scaly patches.
[Illustration: Psoriasis.]
#At what age does psoriasis usually first make its appearance?#
Most commonly between the ages of fifteen and thirty. It is rarely seen
before the tenth year, and a first attack is uncommon after the age of
forty.
#Has psoriasis any special parts of predilection?#
The extensor surfaces of the limbs, especially the elbows and knees, are
favorite localities, and even when the eruption is more or less general,
these regions are usually most conspicuously involved. The face often
escapes, and the palms and soles, likewise the nails, are rarely
involved. In exceptional instances, the eruption is limited almost
exclusively to the scalp.
#Are there any constitutional or subjective symptoms in psoriasis?#
There is no systemic disturbance; but a variable amount of itching may
be present, although, as a rule, it is not a troublesome symptom.
#Describe the clinical appearances of a typical, well developed case.#
Twenty or a hundred or more lesions, varying in size from a pin-head to
a silver dollar, are usually present. They are sharply defined against
the sound skin, are reddish, slightly elevated and infiltrated, and more
or less abundantly covered with whitish, grayish or mother-of-pearl
colored scales. The patches are usually scattered over the general
surface, but are frequently more numerous on the extensor surfaces of
the arms and legs, especially about the elbows and knees. Several
closely-lying lesions may coalesce and a large, irregular patch be
formed; some of the patches, also, may be more or less circinate, the
central portion having, in a measure or completely, disappeared.
#Give the development and history of a single lesion.#
Every single patch of psoriasis begins as a pin-point or pin-head-sized,
hyperaemic, scaly, slightly-elevated lesion; it increases gradually, and
in the course of several days or weeks usually reaches the size of a
dime or larger, and then may remain stationary; or involution begins to
take place, usually by a disappearance, partially or completely, of the
central portion, and finally of the whole patch.
#Describe the so-called clinical varieties of psoriasis.#
As clinically met with, the patches present are, as a rule, in all
stages of development. In some instances, however, the lesions, or the
most of them, progress no further than pin-head in size, and then remain
stationary, constituting _psoriasis punctata_; in other cases, they
may stop short after having reached the size of drops--_psoriasis
guttata_; in others (and this is the usual clinical type) the patches
develop to the size of coins--_psoriasis nummularis_. In some cases
there is a strong tendency for the central part of the lesions to
disappear, and the process then remain stationary, the patches being
ring-shaped--_psoriasis circinata_; and occasionally several such rings
coalesce, the coalescing portions disappearing and the eruption be more
or less serpentine--_psoriasis gyrata_. Or, in other instances, several
large contiguous lesions may coalesce and a diffused, infiltrated patch
covering considerable surface results--_psoriasis diffusa, psoriasis
inveterata_.
[Illustration: Fig. 17. Psoriasis.]
#Is the eruption of psoriasis always dry?#
Yes.
#What course does psoriasis pursue?#
As a rule, eminently chronic. Patches may remain almost indefinitely, or
may gradually disappear and new lesions appear elsewhere, and so the
disease may continue for months and, sometimes, for years; or, after
continuing for a longer or shorter period, may subside and the skin
remain free for several months or one or two years, and, in rare
instances, may never return.
[Illustration: Fig. 18. Psoriasis.]
#Is the course of psoriasis influenced by the seasons?#
As a rule, yes; there is a natural tendency for the disease to become
less active or to disappear altogether during the warm months.
#What is known in regard to the etiology of psoriasis?#
The causes of the disease are always more or less obscure. There is
often a hereditary tendency, and the gouty and rheumatic diathesis must
occasionally be considered potential. In some instances it is apparently
influenced by the state of the general health. It is a rather common
disease and is met with in all walks of life.
#Is psoriasis contagious?#
No. In recent years the fact of its exhibiting a family tendency has
been thought as much suggestive of contagiousness as of heredity.
#What is the pathology?#
According to modern investigations, it is an inflammation induced by
hyperplasia of the rete mucosum; and it is beginning to be believed that
this hyperplasia may have a parasitic factor as the starting-cause.
#With what diseases are you likely to confound psoriasis?#
Chiefly with squamous eczema and the papulo-squamous syphiloderm; and on
the scalp, also with seborrh[oe]a. It can scarcely be confounded with
ringworm.
#How is psoriasis to be distinguished from squamous eczema?#
By the sharply-defined, circumscribed, scattered, scaly patches, and by
the history and course of the individual lesions.
#In what respects does the papulo-squamous syphiloderm differ from
psoriasis?#
The scales of the squamous syphilide are usually dirty gray in color and
more or less scanty; the patches are coppery in hue, and usually several
or more characteristic scaleless, infiltrated papules are to be found.
The face, palms, and soles are often the seat of the syphilitic
eruption; and, moreover, _concomitant symptoms of syphilis_, such as
sore throat, mucous patches, glandular enlargement, rheumatic pains,
falling out of the hair, together with the history of the initial
lesion, are one, several, or all usually present.
#How does seborrh[oe]a differ from psoriasis?#
Seborrh[oe]a of the scalp is usually diffused, with but little redness
and no infiltration; moreover, the scales of seborrh[oe]a are greasy,
dirty gray or brownish, while those of psoriasis are dry and comonly
whitish or mother-of-pearl colored. Psoriasis of the scalp rarely exists
independently of other patches elsewhere on the general surface.
That variety of seborrh[oe]a, commonly known as eczema seborrhoicum,
presents at times, both on scalp and general surface, a strong
resemblance to psoriasis, but the character of the scales and
distribution of psoriasis, as above stated, are distinguishing points;
seborrh[oe]a, moreover, favors hairy surfaces and in extensive examples
the scalp, eyebrows, sternal, and pubic regions rarely escape.
#How does psoriasis differ from ringworm?#
By its greater scaliness, by its higher degree of inflammatory action,
and by its larger number of patches, as also by its history. In ringworm
_all_ the patches tend to clear up in the centre; in psoriasis this is
rarely, if ever, so. If there is still any doubt, microscopic
examination of the scrapings will determine.
#Give the prognosis of psoriasis.#
The prognosis is usually favorable, so far as concerns the immediate
eruption, but as to recurrences, nothing positive can be stated. In rare
instances, however, the cure remains permanent.
#How is psoriasis treated?#
Both constitutional and local remedies are demanded in most cases.
#Do dietary measures exert any influence?#
As a rule, no; but the food should be plain, and an excess of meat
avoided.
#Name the important constitutional remedies usually employed in
psoriasis.#
_Arsenic_ is of first importance. It is not suitable in acute or
markedly inflammatory types; but is most useful in the sluggish, chronic
forms of the disease. The dose should never be pushed beyond slight
physiological action. It may be given as arsenious acid in pill form,
one-fiftieth to one-tenth of a grain three times daily, or as Fowler's
solution, three to ten minims at a dose.
_Alkalies_, of which liquor potassae is the most eligible. It is to be
given in ten to twenty minim doses, largely diluted. It is valuable in
robust, plethoric, rheumatic or gouty individuals with psoriasis of an
acute or markedly inflammatory type; it is not to be given to
debilitated or anaemic subjects.
_Salicin_, sodium salicylate, and salophen in moderately full doses act
well in some cases. Occasionally thyroid preparations have a good
effect.
_Potassium Iodide_, in doses of thirty to one hundred grains, t.d., acts
favorably in some instances; there are no special indications pointing
toward its selection, unless it be the existence of a gouty or rheumatic
diathesis.
Oil of copaiba, potassium acetate, oil of turpentine, oil of juniper,
and other diuretics are valuable in some instances, and, while often
failing, sometimes exert a rapid influence, especially in those cases in
which the disease is extensive and inflammatory. Wine of antimony, given
cautiously, is also sometimes of service in the acute inflammatory type
in robust subjects.
#Are such remedies as iron, quinine, nux vomica and cod-liver oil ever
useful in psoriasis?#
Yes. In debilitated subjects the administration of such remedies is at
times attended with improvement in the cutaneous eruption.
#What are the indications as regards the external measures?#
Removal of the scales, and the use of soothing or stimulating
applications, according to the individual case.
#How are the scales removed?#
In ordinary cases, either by warm, plain, or alkaline baths, or
hot-water-and-soap washings; in those cases in which the scaling is
abundant and adherent, washing with sapo viridis and hot water may be
required. Baths of sal ammoniac, two to six ounces to the bath are also
valuable in removing the scaliness. The tincture of green soap (tinctura
saponis viridis) is especially valuable for cleansing purposes in
psoriasis of the scalp. The hot vapor bath once or twice weekly is
serviceable in keeping the scaliness in abeyance, and has, moreover, in
some cases, a therapeutic value.
The frequency of the baths or washings will depend upon the rapidity
with which the scales are reproduced.
#Are soothing applications often demanded in psoriasis?#
In exceptional cases; in those in which the disease is acute, markedly
inflammatory and rapidly progressing, mild, soothing applications must
be temporarily employed, such as plain or bran baths, with the use of
some bland oil or ointment. As a rule, however, the conditions, when
coming under observation, are such as to permit of stimulating
applications from the start. The most efficient soothing applications
are the mild lotions and ointments employed in eczema of acute type.
#How are the stimulating remedies employed in psoriasis applied?#
As ointments, oils, and paints (pigmenta).
An ointment, if employed, is to be thoroughly rubbed in the diseased
areas once or twice daily. The same may be said of the oily
applications. The paints (medicated collodion and gutta-percha solution)
are applied with a brush, once daily, or every second or third day,
depending mainly upon the length of time the film remains intact and
adherent.
#Name the several important external remedies.#
Chrysarobin, pyrogallol, tar, ammoniated mercury, [beta]-naphthol,
and resorcin.
#Are these several external remedies equally serviceable in all cases?#
No. Their action differs slightly or greatly according to the case and
individual. A change from one to another is often necessary.
#In what forms and strength are these remedies to be applied?#
_Chrysarobin_ is applied in several ways: as an ointment, twenty to
sixty grains to the ounce, rubbed in once or twice daily; this is the
most rapid but least cleanly and eligible method. As a pigment, or
paint, as in the following:--
[Rx] Chrysarobini, ........................ [dram]j
Acidi salicylici, .................... gr. xx
Etheris, ............................. f[dram]j
Ol. ricini, .......................... [minim]x
Collodii, ............................ f[dram]vij. M.
Or it may be used in liquor gutta-perchae (traumaticin), a drachm to the
ounce. It may also be employed in chloroform, a drachm to the ounce; this
is painted on, the chloroform evaporating, leaving a thin film of
chrysarobin; over this is painted flexible collodion. If the patches are
few and large, chrysarobin rubber-plaster may be used.
Chrysarobin is usually rapid in its effect, but it has certain
disadvantages; it may cause an inflammation of the surrounding skin,
and, if used near the eyes, may give rise to conjunctivitis. As a rule,
it should not be employed about the head. Moreover, it stains the linen
permanently and the skin temporarily.
_Pyrogallol_ is valuable, and is employed in the same manner and
strength as chrysarobin. In collodion it should at first not be used of
greater strength than three to four per cent., as in this form
pyrogallol sometimes acts with unexpected energy. It is less rapid than
chrysarobin, but it rarely inflames the surrounding integument. It
stains the linen a light brown, however, and is not to be used over an
extensive surface for fear of absorption and toxic effect. Oxidized
pyrogallic acid, a somewhat milder drug in its effect, has been highly
commended, and has the alleged advantage of being free from toxic
action.
_Tar_ is, all things considered, the most important external remedy. It
is comparatively slow in its action, but is useful in almost all cases.
As employed usually it is prescribed in ointment form, either as the
official tar ointment, full strength or weakened with lard or
petrolatum. It may also be used as pix liquida, with equal part of
alcohol. Or the tar oils, oil of cade (ol. cadini), and oil of birch
(ol. rusci) may be employed, either as oily applications or incorporated
with ointment or with alcohol. Liquor carbonis detergens, in ointment,
one to three drachms to the ounce of simple cerate and lanolin is a mild
tarry application which is often useful. In stubborn patches an
occasional thorough rubbing with a mixture of equal parts of liquor
carbonis detergens and Vleminckx's solution, followed by a mild
ointment, sometimes proves of value. In whatsoever form tar is employed
it should be thoroughly rubbed in, once or twice daily, the excess wiped
off, and the parts then dusted with starch or similar powder.
_Ammoniated mercury_ is applied in ointment form, twenty to sixty grains
to the ounce. Compared to other remedies it is clean and free from
staining, although, as a rule, not so uniformly efficacious. It is
especially useful for application to the scalp and exposed parts. It
should not be used over extensive surface for fear of absorption.
_[beta]-Naphthol_ and _resorcin_ are applied as ointments, thirty to
sixty grains to the ounce, and as they are (especially the former)
practically free from staining, may be used for exposed surfaces.
Gallacetophenone and aristol also act well in some cases, applied in
five- to ten-per-cent. strength, as ointments.
In obstinate patches the _x_-ray may be resorted to, employing it with
caution and in the same manner as in other diseases.
#Pityriasis Rosea.#
(_Synonym:_ Pityriasis Maculata et Circinata.)
#What do you understand by pityriasis rosea?#
Pityriasis rosea is a disease of a mildly inflammatory nature,
characterized by discrete, and later frequently confluent, variously
sized, slightly raised scaly macules of a pinkish to rosy-red, often
salmon-tinged, color.
#Upon what part of the body is the eruption usually found?#
The trunk is the chief seat of the eruption, although not infrequently
it is more or less general.
#Describe the symptoms of pityriasis rosea.#