auto-inoculable. At times it seems to prevail in epidemic form. Pyogenic
microorganisms are now regarded as causative. A relationship to
vaccination has been alleged by some observers. It is more commonly
observed in infants and young children.
#From what diseases is impetigo contagiosa to be differentiated?#
From eczema, pemphigus, and ecthyma.
#How does impetigo contagiosa differ from these several diseases?#
By the character of the lesions, their growth, their superficial nature,
their course, the absence of an inflammatory base and areola, the thin,
yellowish, wafer-like crusts, and usually a history of contagion.
#State the prognosis.#
The effect of treatment is usually prompt. The disease, indeed, tends to
spontaneous disappearance in two to four weeks; in exceptional
instances, more especially in those cases in which itching is present,
the excoriations or scratch-marks become inoculated, and in this way it
may persist several weeks.
#What is the treatment of impetigo contagiosa?#
Treatment consists in the destruction of the auto-inoculable properties
of the contents of the lesions; this is effected by removing the crusts
by means of warm water-and-soap washings, and subsequently rubbing in an
ointment of ammoniated mercury, ten to twenty grains to the ounce. Some
cases respond more rapidly to the use of a drying ointment, such as
Lassar's paste, with ten to twenty grains of white precipitate or
sulphur to the ounce. In itching cases, a saturated solution of boric
acid, or a carbolic-acid lotion, one to two drachms to the pint, is to
be employed for general application.
#Impetigo Herpetiformis.#
#Describe impetigo herpetiformis.#
Impetigo herpetiformis is an extremely rare disease, observed usually in
pregnant women, and is characterized by the appearance of numerous
isolated and closely-crowded pin-head-sized superficial pustules, which
show a decided disposition to the formation of circular groups or
patches. The central portion of these groups dries to crusts, while new
pustules appear at the peripheral portion. They tend to coalesce, and in
this manner a greater part of the whole surface may, in the course of
weeks or months, become involved. Profound constitutional disturbance,
usually of a septic character, precedes and accompanies the disease; in
almost every instance a fatal termination sooner or later results.
It is possibly a grave type of dermatitis herpetiformis.
#Ecthyma.#
#Give a descriptive definition of ecthyma.#
Ecthyma is a disease characterized by the appearance of one, several or
more discrete, finger-nail-sized, flat, usually markedly inflammatory
pustules.
#Describe the symptoms and course of ecthyma.#
The lesions begin as small, usually pea-sized, pustules; increase
somewhat in area, and when fully developed are dime-sized, or larger,
somewhat flat, with a markedly inflammatory base and areola. At first
yellowish they soon become, from the admixture of blood, reddish, and
dry to brownish crusts, beneath which will be found superficial
excoriations. The individual pustules are usually somewhat acute in
their course, but new lesions may continue to appear from day to day or
week to week. As a rule, not more than five to twenty are present at one
time, and in most cases they are seated on the legs. More or less
pigmentation, and sometimes superficial scarring, may remain to mark the
site of the lesions.
Itching is rarely present, but there may be more or less pain and
tenderness.
#What is the cause of ecthyma?#
It is essentially a disease of the poorly cared-for and ill-fed; the
direct exciting cause is the introduction of pyogenic microorganisms
into the follicular openings. It is closely allied to impetigo
contagiosa, and may in fact be regarded as a markedly inflammatory form
of the latter affection. It seems much less contagious, however. It is
commonly observed in male adults.
#From what diseases is ecthyma to be differentiated?#
From impetigo contagiosa, and the flat pustular syphiloderm.
#How is it distinguished from these several diseases?#
The size, shape, inflammatory action, and the depraved general
condition, the distribution and lesser-contagiousness will distinguish
it from impetigo contagiosa; and the absence of concomitant symptoms of
syphilis, and of positive ulceration, as well as its distribution and
more rapid and inflammatory course, will exclude the pustular
syphiloderm.
#State the prognosis.#
The disease is readily curable, disappearing upon the removal of the
predisposing cause and the employment of local antiseptic applications.
#What treatment is to be advised?#
Good food, proper hygiene and tonic remedies; and, locally, removal of
the crusts and stimulation of the underlying surface with an ointment of
ammoniated mercury, ten to thirty grains to the ounce.
The following mild antiseptic lotion, which materially lessens the
tendency to the formation of new lesions, may be applied to the affected
region two or three times daily:--
[Rx] Acidi borici, ........................ [dram]iv
Resorcini, ........................... [dram]ij
Glycerinae, ........................... f[dram]ij
Alcoholis, ........................... f[Oz]j
Aquae, ........... q.s. ad ............ Oj. M.
A weak lotion of thymol, corrosive sublimate or ichthyol would doubtless
be equally effectual.
#Pemphigus.#
#What do you understand by pemphigus?#
Pemphigus is an acute or chronic disease characterized by the successive
formation of irregularly-scattered, variously-sized blebs.
#Name the varieties met with.#
Two varieties are usually described--pemphigus vulgaris and pemphigus
foliaceus.
#Describe the symptoms and course of pemphigus vulgaris.#
With or without precursory symptoms of systemic disturbance, irregularly
scattered blebs, few or in numbers, make their appearance, arising from
erythematous spots or from apparently normal skin. They vary in size
from a pea to a large egg, are rounded or ovalish, usually distended,
and contain a yellowish fluid which, later, becomes cloudy or puriform.
If ruptured, the rete is exposed, but the skin soon regains its normal
condition; if undisturbed, the fluid usually disappears by absorption.
Each lesion runs its course in several days or a week.
A grave type of pemphigus is exceptionally observed in the
newborn--_pemphigus neonatorum_.
#What course does pemphigus vulgaris pursue?#
Usually chronic. The disease may subside in several months and the
process come to an end, constituting the acute type. As a rule, however,
the disease is chronic, new blebs continuing to appear from time to time
for an indefinite period.
[Illustration: Fig. 30. Pemphigus (mulatto).]
#In what respects does the severe form of pemphigus vulgaris differ from
the ordinary type?#
In the severe or malignant type the eruption is more profuse; there is
marked, and often grave, systemic depression, and the lesions are
attended with ulcerative action.
#Describe the symptoms and course of pemphigus foliaceus.#
In this, the grave type of the disease, the blebs are loose and flaccid,
with milky or puriform contents, rupturing and drying to crusts, which
are cast off, disclosing the reddened corium. New blebs appear on the
sites of disappearing or half-ruptured lesions, and the whole surface
may be thus involved and the disease continue for years, compromising
the general health and eventually ending fatally.
In some cases of pemphigus (pemphigus vegetans) a vegetating or
papillomatous condition develops from the base of the lesion, with an
offensive discharge; it is usually a grave type of the malady.
Exceptionally cases (dermatitis vegetans) are met with which have a
close similarity in their symptoms to pemphigus vegetans, but in which
the eruption is more or less limited to the genitocrural region. The
disorder is not malignant and usually yields to cleanliness and
antiseptics.
#What is the character of the subjective symptoms in pemphigus?#
The subjective symptoms consist variously of heat, tenderness, pain,
burning and itching, and may be slight or troublesome.
#What is known in regard to the etiology of pemphigus?#
The causes are obscure; general debility, overwork, shock, nervous
exhaustion, and septic conditions (microorganisms) are thought to be of
influence. There seems no doubt that those who have to do with cattle
products, especially butchers, are subjects of acute and usually grave
pemphigus. Vaccination has exceptionally been responsible for the
disease, probably through some coincidental infection. The disease is
not contagious, nor is it due to syphilis. It may occur at any age.
It is a rare disease, especially in this country. Most of the cases
diagnosed as pemphigus by the inexperienced are examples of bullous
urticaria, bullous erythema multiforme, and impetigo contagiosa.
#What is the pathology?#
The lesions are superficially seated, usually between the horny layer
and upper part of the rete. Round-cell infiltration and dilated blood
vessels are found about the papillae and in the subcutaneous tissue. The
contents of the blebs, always of alkaline reaction, are at first serous,
later containing blood corpuscles, pus, fatty-acid crystals, epithelial
cells, and occasionally uric acid crystals and free ammonia.
#From what diseases is pemphigus to be differentiated?#
From herpes iris, the bullous syphiloderm, impetigo contagiosa and
dermatitis herpetiformis.
#How do these several diseases differ from pemphigus?#
The acute course, small lesions, concentric arrangement, variegated
colors, and distribution, in herpes iris; the thick, bulky, greenish
crusts, the underlying ulceration, the course, history, and the presence
of concomitant symptoms of syphilis, in the bullous syphiloderm; the
history, course, distribution, the character of the crusting, and the
contagious and auto-inoculable properties of the contents of the
lesions, in impetigo contagiosa; the tendency to appear in groups, the
smaller lesions, the intense itchiness, course, multiform characters of
the eruption and the disposition to change of type in dermatitis
herpetiformis,--will serve as differential points.
#State the prognosis of pemphigus.#
Its duration is uncertain, and the issue may in severe cases be fatal.
In the milder types, after months or several years, recovery may take
place.
The extent and severity of the disease and the general condition of the
patient are always to be considered before an opinion is expressed.
Pemphigus neonatorum usually ends fatally.
#Give the treatment of pemphigus.#
Both constitutional and local measures are demanded. Good nutritious
food and hygienic regulations are essential. Arsenic and quinia are the
most valuable remedies. The former, in occasional instances, seems to
have a specific influence, and should always be tried, beginning with
small doses and increasing gradually to the point of tolerance and
continued for several weeks or longer. The remedy should not be set
aside as long as there are signs of improvement, unless the supervention
of stomachic, intestinal or other disturbance demand its discontinuance.
Other tonics, such as iron, strychnia and cod-liver oil, are also at
times of service.
The blebs should be opened and the parts anointed or covered with a mild
ointment. In more general cases bran, starch and gelatin baths, and in
severe cases the continuous bath, if practicable, are to be used.
#CLASS III.--HEMORRHAGES.#
#Purpura.#
#Define purpura.#
Purpura is a hemorrhagic affection characterized by the appearance of
variously-sized, usually non-elevated, smooth, reddish or purplish spots
or patches, not disappearing under pressure.
#Name the several varieties met with.#
Three--purpura simplex, purpura rheumatica and purpura haemorrhagica;
denoting, respectively, the mild, moderate and severe grade of the
disease. The division is, to a great extent, an arbitrary one.
#Describe the clinical appearance and course of an individual lesion of
purpura.#
The spot, which may be pin-head, pea-, bean-sized or larger, appears
suddenly, and is of a bright red or purplish red color. Its brightness
gradually fades, the color changing to a bluish, bluish-green, bluish-
or greenish-yellow, dirty yellowish, yellowish-white, and finally
disappearing; varying in duration from several days to several weeks.
#Describe the symptoms of purpura simplex.#
Purpura simplex, or the mild form, shows itself as pin-point to pea- or
bean-sized, bright or dark-red spots, limited, as a rule, to the limbs,
especially the lower extremities; fading gradually away and coming to an
end in a few weeks, or new crops appearing irregularly for several
months. There is rarely any systemic disturbance, and, as a rule, no
subjective symptoms; in exceptional cases an urticarial element is
added--_purpura urticans_.
#Describe the symptoms of purpura rheumatica.#
Purpura rheumatica (also called _peliosis rheumatica_) is usually
preceded by symptoms of malaise, rheumatic pains and sometimes
swelling about the joints; these phenomena abate and frequently disappear
upon the outbreak of the eruption. The lesions are pea- to dime-sized,
smooth, non-elevated, or slightly raised, and of a reddish or purplish
color; the eruption may be more or less generalized, most abundant upon
the limbs, or it may be limited to these parts. It may end in a few weeks,
or may persist for several months, new spots appearing irregularly or in
the form of crops.
As somewhat allied to this is another form (_Schoenlein's disease_),
quite alarming in its symptoms. It is rare. It is characterized by
symptoms partaking of the nature of rheumatism, purpuric spots, blotches
and ecchymoses, erythema multiforme, and often associated with
considerable edema. The throat is also usually invaded, and indeed the
first symptom is commonly in this region. Considerable constitutional
disturbance, of a threatening character, is commonly observed. Recovery
usually takes place.
_Henoch's purpura_, observed chiefly in children, resembles the above,
with the erythema multiforme character and the [oe]dematous swellings
more pronounced, while the actual purpuric symptoms are less
conspicuous. Gastric and intestinal symptoms and hemorrhages from the
mucous membrane are commonly noted. It is fatal in about 20 per cent. of
the cases.
#Describe the symptoms of purpura haemorrhagica.#
Purpura haemorrhagica (also called _land scurvy_) is characterized
usually by premonitory, and frequently accompanying, symptoms of general
distress, and by the appearance of coin to palm-sized, red or purplish
hemorrhagic spots or patches, smooth, non-elevated or raised. Hemorrhage
from the mouth, gums and other parts, slight or serious in character,
may occur. New lesions continue to appear for several days or weeks; and
in exceptional instances, repeated relapses take place, and the disease
thus persists for months. It may end fatally.
#State the etiology of purpura.#
In most instances no cause can be assigned. The disease occurs at all
ages from childhood to advanced life, and in individuals, apparently, in
good and bad health alike. The hemorrhagic type is oftener seen in
subjects debilitated or in a depraved state of health. A microorganism
is also looked upon as a factor by some observers, especially in the
grave type of disease.
#State the diagnostic characters of purpura.#
The appearance, irregularly or in crops, of bright-red or purplish
spots, evidently of hemorrhagic nature, and not _disappearing upon
pressure_, and as they are fading, going through the several changes of
color usually observed in any ecchymosis.
#How does scurvy (scorbutus) differ from purpura?#
Scurvy, which may resemble the severe grade of purpura, has a different
history, a recognizable cause, usually a peculiar distribution, and is
accompanied with general weakness and a spongy, soft and bleeding
condition of the gums.
#What is the pathology of purpura?#
The lesion of purpura consists essentially of a hemorrhage into the
cutaneous tissues. The blood is subsequently absorbed, the haematin
undergoing changes of color from a red to greenish and pale yellow, and
finally fading away.
#State the prognosis#
The milder varieties disappear in the course of several weeks or months,
and are rarely of serious import; the outcome of purpura haemorrhagica is
somewhat uncertain; although usually favorable, a fatal result from
internal hemorrhage is possible. The variety known as Schoenlein's
disease is alarming, but seldom fatal. Henoch's disease is, however,
always of grave import.
#What is the treatment of purpura?#
Hygienic and dietary measures, the administration of tonics and
astringents, and, in severe cases, by relative or absolute rest.
The drugs commonly prescribed are: ergot, oil of erigeron, oil of
turpentine, quinia, strychnia, iron, mineral acids, and gallic acid.
_External_ treatment is rarely called for, but if deemed advisable,
astringent lotions may be employed.
#Scorbutus.#
(_Synonyms:_ Scurvy; Sea Scurvy; Purpura Scorbutica.)
#Describe scorbutus.#
Scurvy is a peculiar constitutional state, developed in those living
under bad hygienic conditions, and is characterized by emaciation,
general febrile and asthenic symptoms, a more or less swollen, turgid
and spongy and even gangrenous condition of the gums; and concomitantly,
or sooner or later, by the appearance, usually upon the lower portion of
the legs only, of dark-colored hemorrhagic patches or blotches. The skin
of the affected part may become brawny and slightly scaly, and not
infrequently may break down and ulcerate. Hemorrhages from the various
mucous surfaces, slight or grave, may also take place.
#State the etiology of scurvy.#
It is due to long-continued deprivation of proper food, especially of
fruits and vegetables. Other bad hygienic conditions favor its
development. It is seen most commonly in sailors and others taking long
voyages.
#How is scurvy to be distinguished from purpura?#
By the asthenic and emaciated general condition and the peculiar puffy,
spongy state of the gums. The cutaneous manifestation is more diffused,
forming usually large palm-sized patches, and, as a rule, limited to the
region of the ankles or lower part of the legs.
#Give the prognosis of scurvy.#
The disease is remediable, and usually rapidly so. In those instances in
which the same bad hygienic conditions and the ingestion of improper
food are continued, death finally results.
#What treatment would you advise in scurvy?#
Proper food, with an abundance of fruit and vegetables. Lemon or lime
juice is especially valuable, and is to be taken freely. If indicated,
tonics and stimulants are also to be prescribed. For the relief of the
tumid, spongy condition of the gums, astringent and antiseptic mouth
washes are to be employed.
The cutaneous manifestations, when tending to ulceration, are to be
treated upon general principles.
#CLASS IV.--HYPERTROPHIES.#
#Lentigo.#
(_Synonym:_ Freckle.)
#Describe lentigo.#
Lentigo, or freckle, is characterized by round or irregular, pin-head to
pea-sized, yellowish, brownish or blackish spots, occurring usually
about the face and the backs of the hands. It is a common affection,
varying somewhat in the degree of development; the freckles present may
be few and insignificant, or they may exist in profusion and be quite
disfiguring. Heat and exposure favor their development. Those of light
complexion, especially those with red hair, are its most common
subjects. The color of the lesion is usually a yellowish-brown.
It is common to all ages, but is generally seen in its greatest
development during adolescence, the disposition to its appearance
becoming less marked as age advances.
#What is the pathology of lentigo?#
Lentigo consists simply of a circumscribed deposit of pigment
granules--merely a localized increase of the normal pigment, differing
from chloasma (_q. v._) only in the size and shape of the pigmentation.
#State the prognosis.#
The blemishes can be removed by treatment, but their return is almost
certain.
#Name the several applications commonly employed for their removal.#
An aqueous or alcoholic solution of corrosive sublimate, one-half to
three grains to the ounce; lactic acid, one part to from six to twenty
parts of water; and an ointment containing a drachm each of bismuth
subnitrate and ammoniated mercury to the ounce.
The applications, which act by removing the epidermal and rete cells and
with them the pigment, are made two or three times daily, and their use
intermitted for a few days as soon as the skin becomes irritated or
scaly.
Touching each freckle for a few seconds with the electric needle, just
pricking the epidermis, will occasionally remove the blemish.
#Chloasma.#
#What do you understand by chloasma?#
Chloasma consists of an abnormal deposit of pigment, occurring as
variously-sized and shaped, yellowish, brownish or blackish patches.
#Describe the clinical appearances of chloasma.#
Chloasma appears either in ill-defined patches, as is commonly the case,
or as a diffuse discoloration. Its appearance is rapid or gradual,
generally the latter. The patches are rounded or irregular, and usually
shade off into the sound skin. One, several or more may be present, and
coalescence may take place, resulting in a large irregular pigmented
area. The color is yellowish, or brownish, and may even be blackish
(_melasma_, _melanoderma_). The skin is otherwise normal. The face is the
most common site.
#Into what two general classes may the various examples of chloasma be
grouped?#
Idiopathic and symptomatic.
#What cases of chloasma are included in the idiopathic group?#
All those cases of pigmentation caused by external agents, such as the
sun's rays, sinapisms, blisters, continued cutaneous hyperaemia from
scratching or any other cause, etc.
#What cases of chloasma are included in the symptomatic group?#
All forms of pigment deposit which occur as a consequence of various
organic and systemic diseases, as the pigmentation, for instance, seen
in association with tuberculosis, cancer, malaria, Addison's disease,
uterine affections, and the like. In such cases, with few exceptions,
the pigmentation is usually more or less diffuse.
#What is chloasma uterinum?#
Chloasma uterinum is a term applied to the ill-defined patches of
yellowish-brown pigmentation appearing upon the faces of women, usually
between the ages of twenty-five and fifty. It is most commonly seen
during pregnancy, but may occur in connection with any functional or
organic disease of the utero-ovarian apparatus.
#What is argyria?#
Argyria is the term applied to the slate-like discoloration which
follows the prolonged administration of silver nitrate.
#State the pathology of chloasma.#
The sole change consists in an increased deposit of pigment.
#Give the prognosis of chloasma.#
Unless a removal of the exciting or predisposing cause is possible, the
prognosis is, as a rule, unfavorable, and the relief furnished by local
applications usually but temporary.
#If constitutional treatment is advisable, upon what is it to be based?#
Upon general principles; there are no special remedies.
#How do external remedies act?#
Mainly by removing the rete cells and with them the pigmentation; and
partly, also, by stimulating the absorbents.
#Are all external remedies which tend to remove the upper layers of the
skin equally useful for this purpose?#
No; on the contrary some such applications are followed by an increase
in the pigment deposit.
#Name the several applications commonly employed.#
Corrosive sublimate in solution, in the strength of one to four grains
to the ounce of alcohol and water; a lotion made up as follows:--