removability of the exciting and predisposing causes, and the attention
the patient can give to the treatment.
In eczema involving the lips, face, scrotum, and leg, and especially
when this last-named exhibits a varicose condition of the veins, a cure
is effected, as a rule, only through persistent and prolonged treatment.
#Does eczema ever leave scars?#
No. Upon the legs, in long-continued cases, more or less pigmentation
usually remains.
#How is eczema treated?#
As a rule, eczema requires for its removal both constitutional and
external treatment.
Certain cases, however, seem to be entirely local in their nature, and
in these cases external treatment alone will have satisfactory results.
#What general measures as to hygiene and diet are commonly advisable?#
Fresh air, exercise, moderate indulgence in calisthenics, regular
habits, a plain, nutritious diet; abstention from such articles of food
as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese,
pickles, condiments, excessive coffee or tea drinking, etc. As a rule,
also, beer, wine, and other stimulants are to be interdicted.
#Upon what grounds is the line or plan of constitutional treatment to be
based?#
Upon indications in the individual case. A careful examination into the
patient's general health will usually give the cue to the line of
treatment to be adopted.
#Mention the important remedies variously employed in the constitutional
treatment.#
_Tonics_--such as cod-liver oil, quinine, nux vomica, the vegetable
bitters, iron, arsenic, malt, etc.
_Alkalies_--sodium salicylate, potassium bicarbonate, liquor potassae,
and lithium carbonate.
_Alteratives_--calomel, colchicum, arsenic, and potassium iodide.
_Diuretics_--potassium acetate, potassium citrate, and oil of copaiba.
_Laxatives_--the various salines, aperient spring waters, castor oil,
cascara sagrada, aloes and other vegetable cathartics.
_Digestives_--pepsin, pancreatin, muriatic acid and the various bitter
tonics.
#Are there any remedies which have a specific influence?#
No; although arsenic, in exceptional instances, seems to exert a special
action. Cod-liver oil is also of great value in some cases.
Upon the whole the most important remedies are those which keep in view
the maintenance of a proper and healthful condition of the
gastro-intestinal tract, and especially with regular and rather free
action of the bowels.
#In what class of cases does arsenic often prove of service?#
In the sluggish, dry, erythematous, scaly and papular types.
#In what cases is arsenic usually contraindicated?#
It should never be employed in acute cases; nor in any instance (unless
its action is watched), in which the degree of inflammatory action is
marked, as an aggravation of the disease usually results.
#What should be the character of the external treatment?#
It depends mainly upon the degree of inflammatory action; but the stage
of the disease, the extent involved, and the ability of the patient to
carry out the details of treatment, also have a bearing upon the
selection of the plan to be advised.
#What is to be said about the use of soap and water in eczema?#
In acute and subacute conditions soap and water are to be employed, as a
rule, as infrequently and as sparingly as possible, as the disease is
often aggravated by their too free use. Washing is necessary, however,
for cleanliness and occasionally, also, for the removal of the crusts.
On the other hand, in chronic, sluggish types the use of soap and water
frequently has a therapeutic value.
#How often should remedial applications be made?#
Usually twice daily, although in some case, and especially those of an
acute type, applications should be made every few hours.
#Mention several remedies or plans of treatment to be used in the acute
or actively inflammatory cases.#
Black wash and oxide-of-zinc ointment conjointly, the wash thoroughly
dabbed on, allowed to dry, the parts gently smeared with ointment; or
the ointment may be applied spread on lint as a plaster.
Boric-acid wash (15 grains to the ounce) and oxide-of-zinc ointment,
applied in the same manner as the above.
A lotion containing calamine and zinc oxide, the sediment drying and
coating over the affected surface:--
[Rx] Calaminae,
Zinci oxidi, ... [=a][=a] ......... [dram]ij-[dram]iij
Glycerinae,
Alcoholis, ..... [=a][=a] ......... f[dram]ss
Liq. calcis, ...................... f[Oz]ij
Aquae, .......... q.s. ad .......... f[Oz]vj. M.
Another excellent lotion somewhat similar to the last, but of oily
character, is made up of three drachms each of calamine and zinc oxide,
one drachm of boric acid, ten to thirty drops of carbolic acid, and
three ounces each of lime-water and oil of sweet almonds.
Carbolic-acid lotion, about two drachms to the pint of water, to which
may be added two or three drachms each of glycerin and alcohol; or, if
there is intense itching, carbolic acid may be added to the several
washes already mentioned.
A lotion made of one or two drachms of liquor carbonis detergens[A] to
four ounces of water.
The following wash, especially in the dry form of the disease:--
[Rx] Ac. borici, .......................... [dram]iv
Ac. carbolici, ....................... [dram]j
Glycerinae, ........................... [dram]ij
Alcoholis, ........................... [dram]ij
Aquae, ............. q.s. ad .......... Oj. M.
[Footnote A: Liquor carbonis detergens is made by mixing together nine
ounces of tincture soap bark and four ounces of coal tar, allowing to
digest for eight days, and filtering. The tincture of soap bark used is
made with one pound of soap bark to one gallon of 95 per cent. alcohol,
digesting for a week or so. Instead of the proprietary name above, Prof.
Duhring has suggested that of tinctura picis mineralis comp.]
Dusting-powders, of starch, zinc oxide and Venetian talc, alone or
severally combined, applied freely and often, so as to afford protection
to the inflamed surface:--
[Rx] Talci venet,
Zinci oxidi, ....... [=a][=a] ........ [dram]iv
Amyli, ............................... [Oz]j M.
If washes or dusting-powders should disagree or are not desirable or
practicable, ointments may be employed, such as--
Oxide-of-zinc ointment, cold cream, petrolatum, plain or carbolated,
diachylon ointment (if fresh and well prepared), and a paste-like
ointment, as the following, usually called "salicylic-acid paste"; in
markedly itchy cases, five to fifteen grains of carbolic may be added to
each ounce:
[Rx] Ac. salicylici, ...................... gr. v-x
Pulv. amyli,
Pulv. zinci oxidi, .... [=a][=a] ..... [dram]ij
Petrolati, ........................... [dram]iv M.
Or the following ointment:--
[Rx] Calaminae, ............................ [dram]j
Ungt. zinci oxidi, ................... [dram]vij. M.
#Name several external remedies and combinations useful in eczema of a
subacute or mildly inflammatory type.#
The various remedies and combinations useful when the symptoms are acute
or markedly inflammatory (mentioned above), and more especially the
several following:--
[Rx] Zinci oxidi, ......................... [dram]ij
Liq. plumbi subacetat. dilut., ....... f[dram]vj
Glycerinae, ........................... f[dram]ij
Infus. picis liq., ................... f[Oz]iij M.
A lotion containing resorcin, five to thirty grains to the ounce.
Solution of zinc sulphate, one-half to three grains to the ounce.
An ointment containing calomel or ammoniated mercury, as in the annexed
formula:--
[Rx] Hydrargyri ammoniat. seu Hydrargyri
chloridi mit., ................... gr. x-xxx
Ac. carbolici, ..................... gr. v-x
Ungt. zinci oxidi, ................. [Oz]j M.
Another formula, more especially useful in eczema of the hands and legs,
is the following:--
[Rx] Ac. salicylici, ...................... gr. xxx
Emp. plumbi,
Emp. saponis,
Petrolati, ...... [=a][=a] ........... [Oz]j. M.
(This is to be applied as a plaster, spread on strips of lint, and
changed every twelve or twenty-four hours.)
The paste-like ointment, referred to as useful in acute eczema, may also
be used with a larger proportion (20 to 60 grains to the ounce) of
salicylic acid.
The following, containing tar, may often be employed with advantage:--
[Rx] Ungt. picis liq., .................... [dram]j
Ungt. zinci oxidi, ................... [dram]vij. M.
#What is to be said in regard to the use of tarry applications?#
Ointments or lotions containing tar should always be tried at first upon
a limited surface, as occasionally skins are met with upon which this
remedy acts as a more or less violent irritant. The coal tar lotion
(liquor carbonis detergens) is the least likely to disagree and may be
used as a mild ointment, one or two drachms to the ounce, or it may be
diluted and used as a weak lotion as already referred to.
#What external remedies are to be employed in eczema of a sluggish type?#
The various remedies and combinations (mentioned above) useful in acute
and subacute eczema may often be employed with benefit, but, as a rule,
stronger applications are necessary, especially in the thick and
leathery patches. The following are the most valuable:--
An ointment of calomel or ammoniated mercury; forty to sixty grains to
the ounce.
Strong salicylic-acid ointment; a half to one drachm of salicylic acid
to the ounce of lard.
Tar ointment, official strength; or the various tar oils, alone or with
alcohol, as a lotion, or in ointment form.
Liquor picis alkalinus[B] is a valuable remedy in chronic _thickened_,
_hard_ and _verrucous_ patches, but is a strong preparation and must be
used with caution. It is applied diluted, one part with from eight to
thirty-two parts of water; or in ointment, one or two drachms to the
ounce. In such cases, also, the following is useful:--
[Rx] Saponis viridis,
Picis liq.,
Alcoholis, .......... [=a][=a] ....... [dram]iij. M.
SIG. To be well rubbed in.
[Footnote B:
[Rx] Potassae, ............................. [dram]j
Picis liq., .......................... [dram]ij
Aquae, ................................ [dram]v.
Dissolve the potash in the water, and gradually add to the tar in a
mortar, with thorough stirring.]
In similar cases, also, the parts may be thoroughly washed or scrubbed
with sapo viridis and hot water until somewhat tender, rinsed off,
dried, and a mild ointment applied as a plaster.
Lactic acid, applied with one to ten or more parts of water is also of
value in the sclerous and verrucous types. Caustic potash solutions,
used cautiously, may also be occasionally employed to advantage in these
cases.
Another remedy of value in these cases, as well as in others of more or
less limited nature, is the _x_-ray. Exposures every few days, of short
duration and 4 to 10 inches distance, with medium vacuum tube. This
method has served me well in occasional cases; caution is necessary, and
it should not be pushed further than the production of the mildest
reaction. The repeated application of a high-frequency current, by means
of the vacuum electrodes, is a safer and sometimes an equally beneficial
method.
#Is there any method of treating eczema with fixed dressings?#
Several plans have been advised from time to time; some are costly, and
some require too great attention to details, and are therefore
impracticable for general employment. The following are those in more
common use:--
The _gelatin dressing_, as originally ordered, is made by melting over a
water-bath one part of gelatin in two parts of water--quickly painting
it over the diseased area; it dries rapidly, and to prevent cracking
glycerine is brushed over the surface. Or the glycerine may be
incorporated with the gelatin and water in the following proportion:
glycerine, one part; gelatin, four parts, and water eight parts.
Medicinal substances may be incorporated with the gelatin mixture.
A good formula is the following:--
[Rx] Gelatin, ............................. [Oz]j
Zinci oxidi, ......................... [Oz]ss
Glycerini, ........................... [Oz]iss
Aquae, ................................ [Oz]ii-[Oz]iij.
This should be prepared over a water-bath, and two per cent. ichthyol
added. A thin gauze bandage can be applied to the parts over which this
dressing is painted, before it is completely dry; it makes a comfortable
fixed dressing and may remain on several days.
_Plaster-mull_ and _gutta-percha plaster_. The plaster-mull, consisting
of muslin incorporated with a layer of stiff ointment, and the
gutta-percha plaster, consisting of muslin faced with a thin layer of
India-rubber, the medication being spread upon the rubber coating.
_Rubber plasters._ These are medicated with the various drugs used in
the external treatment of skin diseases, and are often of service in
chronic patches.
Two new excipients for fixed dressings have recently been
introduced--bassorin and plasment; the former is made from gum
tragacanth, and the latter from Irish moss.
The following is a satisfactory formula for a tragacanth dressing:
[Rx] Tragacanth, .......................... gr. lxxv
Glycerini, ........................... [minim] xxx
Ac. carbolici, ....................... gr. x-xx
Zinci oxidi, ......................... [dram]iss-[dram]iiss. M.
This is painted over the parts and allowed to dry, and a mild dusting
powder sprinkled over. It cannot be used in warm weather or in folds, as
it is apt to get sticky. The following is a bassorin paste which may be
variously medicated.
[Rx] Bassorin, ............................ [dram]x
Dextrin, ............................. [dram]vj
Glycerini, ........................... [Oz]ij.
Aquae, ....................... q.s. ad. [Oz]iij.
It should be prepared cold.
Another "drying dressing" which may be used in cool weather is:
[Rx] Zinci oxidi, ......................... [Oz]j
Glycerini, ........................... [Oz]ss
Mucilag. acaciae, ..................... [Oz]ii-[Oz]iv.
It may be variously medicated.
The plaster-mull is used in all types, especially the acute; the gelatin
dressing, and the gutta-percha plaster, in the subacute and chronic; and
the rubber plaster in chronic, sluggish patches only. Acacia,
tragacanth, bassorin and plasment applications are used in cases of a
subacute and chronic character.
#Prurigo.#
#Define prurigo.#
Prurigo is a chronic, inflammatory disease, characterized by discrete,
pin-head- to small pea-sized, solid, firmly-seated, slightly raised,
pale-red papules, accompanied by itching and more or less general
thickening of the affected skin.
#Describe the symptoms and course of prurigo.#
The disease first appears upon the tibial regions, and its earliest
manifestation may be urticarial, but there soon develop the
characteristic small, millet-seed-sized, or larger, firm elevations,
which may be of the natural color of the skin or of a pinkish tinge. The
lesions, whilst discrete, are in great numbers, and closely crowded. The
overlying skin is dry, rough and harsh; itching is intense, and, as a
result of the scratching, excoriations and blood crusts are commonly
present. In consequence of the irritation, the inguinal glands are
enlarged. Sooner or later the integument becomes considerably thickened,
hard and rough. Eczematous symptoms may be superadded. In severe cases
the entire extensor surfaces of the legs and arms, and in some instances
the trunk also, are invaded. It is worse in the winter season.
#What is known in regard to etiology and pathology?#
It is a disease of the ill-fed and neglected, usually developing in
early childhood, and persisting throughout life. It is extremely rare,
even in its milder types, in this country. Clinically and pathologically
it bears some resemblance to papular eczema.
#Give the prognosis and treatment of prurigo.#
The disease, in its severer types is, as a rule, incurable, but much can
be done to alleviate the condition. Good, nourishing food, pure air and
exercise are of importance. Tonics and cod-liver oil are usually
beneficial. The local management is similar to that employed in chronic
eczema. An ointment of [beta]-naphthol, one-half to five per cent.
strength, is highly extolled.
#Acne.#
#Give a definition of acne.#
Acne is an inflammatory, usually chronic, disease of the sebaceous
glands, characterized by papules, tubercles, or pustules, or a mixture
of these lesions, and seated usually about the face.
#At what age does acne usually occur?#
Between the ages of fifteen and thirty, at which time the glandular
structures are naturally more or less active.
#Describe the symptoms of acne.#
Irregularly scattered over the face, and in some cases also over the
neck, shoulders and upper part of the trunk, are to be seen several,
fifty or more, pin-head- to pea-sized papules, tubercles or pustules;
commonly the eruption is of a mixed type (_acne vulgaris_), the several
kinds of lesions in all stages of evolution and subsidence presenting in
the single case. Interspersed may generally be seen blackheads, or
comedones. The lesions may be sluggish in character, or they may be
markedly inflammatory, with hard and indurated bases. In the course of
several days or weeks, the papules and tubercles tend gradually to
disappear by absorption; or, and as commonly the case, they become
pustular, discharge their contents, or dry and slowly or rapidly
disappear, with or without leaving a permanent trace, new lesions
arising, here and there, to take their place. In exceptional instances
the eruption is limited to the back, and in these cases the eruption is
usually extensive and persistent, and not infrequently leaves scars.
#What do you understand by acne punctata, acne papulosa, acne pustulosa,
acne indurata, acne atrophica, acne hypertrophica, and acne
cachecticorum?#
These several terms indicate that the lesions present are, for the most
part, of one particular character or variety.
#Describe the lesions giving rise to the names of these various types.#
Blocking up of the outlet of the sebaceous gland (comedo), which is
usually the beginning of an acne lesion, may cause a moderate degree of
hyperaemia and inflammation, and a slight elevation, with a central
yellowish or blackish point results--the lesion of _acne punctata_; if
the inflammation is of a higher grade or progresses, the elevation is
reddened and more prominent--_acne papulosa_; if the inflammatory action
continues, the interior or central portion of the papule suppurates and
a pustule results--_acne pustulosa_; the pustule, in some cases, may
have a markedly inflammatory and hard base--_acne indurata_; and not
infrequently the lesions in disappearing may leave a pit-like atrophy or
depression--_acne atrophica_; or, on the contrary, connective-tissue new
growth may follow their disappearance--_acne hypertrophica_; and, in
strumous or cachectic individuals, the lesions may be more or less
furuncular in type, often of the nature of dermic abscesses, usually of
a cold or sluggish character, and of more general distribution--_acne
cachecticorum_.
#What is acne artificialis?#
Acne artificialis is a term applied to an acne or acne-like eruption
produced by the ingestion of certain drugs, as the bromides and iodides,
and by the external use of tar; this is also called _tar acne_.
#What course does acne pursue?#
Essentially chronic. The individual lesions usually run their course in
several days or one or two weeks, but new lesions continue to appear
from time to time, and the disease thus persists, with more or less
variation, for months or years. In many cases there is, toward the age
of twenty-five or thirty, a tendency to spontaneous disappearance of the
disease.
[Illustration: Acne.]
#Is the eruption in acne usually abundant?#
It varies in different cases and at different periods in the same case.
In some instances, not more than five or ten papules and pustules are
present at one time; in others they may be numerous. Not infrequently
several lesions make their appearance, gradually run their course, and
the face continues free for days or one or two weeks.
#Does the eruption in acne disappear without leaving a trace?#
In many instances no permanent trace remains, but in others slight or
conspicuous scarring is left to mark the site of the lesions.
#Are there any subjective symptoms in acne?#
As a rule, not; but markedly inflammatory lesions are painful.
#State the immediate or direct cause of an acne lesion.#
Hypersecretion or retention of sebaceous matter. Recent investigations
point to the possibility of a special bacillus being the exciting cause,
in some instances at least. The pyogenic cocci are added factors in the
pustular and furuncular cases.
#Name the indirect or predisposing causes of acne.#
Digestive disturbance, constipation, menstrual irregularities,
chlorosis, general debility, lack of tone in the muscular fibres of the
skin, scrofulosis; and medicinal substances such as the iodides and
bromides internally, and tar externally.
Working in a dusty or dirty atmosphere is often influential, resulting
in a blocking-up of the gland ducts. Workmen in paraffin oils or other
petroleum products often present a furuncle-like acne.
The disease is more common in individuals of light complexion.
#Is there any difficulty in the diagnosis of acne?#
Not if it be remembered that acne eruption is limited to certain parts
and is always follicular, and that the several stages, from the comedo
to the matured lesion, are usually to be seen in the individual case.
#In what respect does the pustular syphiloderm differ from acne?#
By its general distribution, the longer duration of the individual
lesions, the darker color, and the presence of concomitant symptoms of
syphilis.
#What is the pathology of acne?#
Primarily, acne is a folliculitis, due to retention or decomposition of
the sebaceous secretion or to the introduction of a micro-organism;
subsequently, the tissue immediately surrounding becoming involved, with
the possible destruction of the sebaceous follicle as a result. The
degree of inflammatory action determines the character of the lesions.
#State the prognosis of acne.#
It is usually an obstinate disease, but curable. Some cases yield
readily, others are exceedingly rebellious, especially acne of the back.
Success depends in a great measure upon a recognition and removal of the
predisposing condition. Treatment is ordinarily a matter of months.
#What measures of treatment are usually demanded in acne?#
Constitutional and local measures; the former when indicated, the latter
always.
#Upon what is the constitutional treatment based?#
Upon indications. Diet and hygienic measures are important.
In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin,
saline and vegetable laxatives, are variously prescribed. Special
mention may be made of the following:--
[Rx] Ext. rhamni pursh. fl., .............. f[dram]ij-f[dram]iv
Tinct. nucis vom., ................... f[dram]iij
Tinct. cardamomi comp., .......q.s. ad [Oz]iij. M.
SIG.--f[dram]t.d.
Or Hunyadi Janos or Friedrichshall water may be employed for a laxative
purpose.
In chlorotic and anaemic cases the ferruginous preparations are of
advantage. Cod-liver oil is often a remedy of great value, and is
especially useful in strumous and debilitated subjects. Calx sulphurata
in pill form, one-tenth to one-fourth grain four or five times daily, is
said, acts well in the pustular variety. In some instances, more
particularly in sluggish papular acne, arsenic, especially the sulphide
of arsenic, acts favorably. Upon the whole, the line of treatment
that keeps in view proper and healthy action of the gastro-intestinal
canal is the most successful.
[Illustration: Acne of back.]
In inflammatory cases occurring in robust individuals the following is
often of service:--