Chapter 5

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 hyperæmia 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. resinæ, ........................... [dram]j. M.

Or the injection of a five-per-cent. solution of carbolic acid into the apex of the boil may be tried if the formation is more advanced. If suppuration is fully established, evacuation of the contents, followed by antiseptic applications, constitutes the best method.

A saturated solution of boric acid or a lotion of corrosive sublimate (one to three grains to the ounce) applied to the immediate neighborhood of the boil or boils tends to prevent the formation of new lesions. Frequent washing of the parts with soap and water or tincture of green soap and water is also a preventive measure of value. In repeatedly infected areas, mild exposures to _x_-rays, at intervals of a few days, will often prove of curative value.

#Carbunculus.# (_Synonyms:_ Anthrax; Carbuncle.)

#What is carbuncle?#

A carbuncle is an acute, usually egg to palm-sized, circumscribed, phlegmonous inflammation of the skin and subcutaneous structures, terminating in a slough.

#At what age and upon what parts is carbuncle usually observed?#

In middle and advanced life, and more commonly in men.

It is seen most frequently at the nape of the neck and upon the upper part of the back.

#What are the symptoms and course of carbuncle?#

There is rarely more than one lesion present. It begins, usually with preceding and accompanying malaise, chilliness and febrile disturbance, as a firm, flat, inflammatory infiltration in the deeper skin and subcutaneous tissue, spreading laterally and finally involving an area of one to several inches in diameter. The infiltration and swelling increase, the skin becomes of dark red color, and sooner or later, usually at the end of ten days or two weeks, softening and suppuration begin to take place, the skin finally giving away at several points, through which sanious pus exudes; the whole mass finally sloughs away either in portions or in its entirety, resulting in a deep ulcer, which slowly heals and leaves a permanent cicatrix.

In some cases, especially in old people, constitutional disturbance of a grave character is noted, septicæmia is developed, and a fatal result may ensue.

#What is the cause of carbuncle?#

The same causes are considered to be operative in carbunculus as in furuncle; general debility and depression, from whatever cause, predisposing to its formation, and the introduction of a microbe, probably the same as in furunculus, being at present looked upon as the exciting factor.

#What is the pathology?#

The inflammation starts simultaneously from numerous points, from the hair-follicles, sweat-glands or sebaceous glands. The inflammatory centres break down, and the pus finds its way to the surface; finally the process ends in gangrene of the whole area.

#How would you distinguish carbuncle from a boil?#

By its flat character, greater size, and multiple points of suppuration.

#What is the prognosis of carbuncle?#

Occurring in those greatly debilitated or in late life, and in those cases in which two or more lesions exist, or when seated about the head, the prognosis is always to be guarded, as a fatal result is not uncommon. In fact, in every instance the disease is to be considered of possible serious import.

#What constitutional treatment is usually employed in carbuncle?#

A full nutritious diet, the use of such remedies as iron, quinia, nux vomica, with malt and stimulants, if indicated. Calx sulphurata, one-tenth to one-fourth grain every two or three hours, appears, in some instances, to have a beneficial effect. If the pain is severe, morphia or chloral should be given.

#What external measures are employed?#

In the early part of the formation, injection of a five or ten per cent. carbolic acid solution, or covering the whole area with a twenty-five per cent. ichthyol ointment, may be employed. When it has broken down the pus may be drawn out with a cupping-glass, and carbolized glycerine or carbolized water introduced into each opening, and the ichthyol ointment superimposed. If the whole part has sloughed, it should be removed as rapidly as possible, and antiseptic dressings used. Or, if its progress is slow, and grave systemic disturbance be present, the whole part may be incised and curetted, and then treated antiseptically. Mild exposure to the _x_-rays is also to be commended.

#Pustula Maligna.# (_Synonyms:_ Anthrax; Malignant Pustule.)

#What is malignant pustule?#

Malignant pustule is a furuncle- or carbuncle-like lesion resulting from inoculation of the virus generated in animals suffering from splenic fever, or "charbon," and is accompanied by constitutional symptoms of more or less gravity. A fatal termination is not unusual.

#What is the cause of pustula maligna?#

The disease is due to the presence of the bacillus anthracis.

#What is the treatment of malignant pustule?#

Early excision or destruction with caustic potash, with subsequent antiseptic dressings; and internally the free use of stimulants and tonics.

#Post-mortem Pustule.# (_Synonym:_ Dissection Wound.)

#Describe post-mortem pustule.#

Post-mortem pustule develops at the point of inoculation, beginning as an itchy red spot, becoming vesico-pustular, and later pustular, with usually a broad inflammatory base, and accompanied with more or less pain and redness and not infrequently lymphangitis, erysipelatous swelling, and slight or severe sympathetic constitutional disturbance.

#What is the treatment of post-mortem pustule?#

Treatment consists in opening the pustule and thorough cauterization, and the subsequent use of antiseptic applications or dressings. _Internally_ quinia and stimulants if indicated.

#Framb[oe]sia.# (_Synonyms:_ Yaws; Pian.)

#Describe framb[oe]sia.#

Framb[oe]sia is an endemic, contagious disease met with in tropical countries, characterized by the appearance of variously-sized papules, tubercles, and tumors, which, when developed, resemble currants and small raspberries, and finally break down and ulcerate. It is accompanied by constitutional symptoms of variable severity.

Hygienic measures, good food, tonics, and antiseptic and stimulating applications are curative.

#Verruga Peruana.# (_Synonyms:_ Peruvian Warts; Carrion's Disease; Oroya Fever.)

#Describe verruga peruana.#

A specific inoculable affection endemic in some valleys of the Western Andes, in Peru, and characterized by a prodromal febrile period and subsequent outbreak of peculiar pin-head- to pea-sized, or larger, bright reddish, rounded, wart-like elevations. The prodromal symptoms, of an irregular malarial or typhoid type, with associated rheumatic and muscular pains, may last for weeks or several months, usually abating when eruption presents. The lesions may be crowded together in great bunches. The face and limbs are favorite localities. The disease is inoculable and thought to be due to a bacillus.

The fatality varies between 10 and 20 per cent. Tonics and stimulants are prescribed.

#Equinia.# (_Synonyms:_ Farcy; Glanders.)

#What is equinia, or glanders?#

A rare contagious specific disease of a malignant type, derived from the horse, and characterized by grave constitutional symptoms, inflammation of the nasal and respiratory passages, and a deep-seated papulo-pustular, or tubercular, nodular (_farcy buds_), ulcerative eruption. A fatal issue is not uncommon. It is due to a micro-organism.

Treatment, both local and constitutional, is based upon general principles.

#Miliaria.# (_Synonyms:_ Prickly Heat; Heat Rash; Lichen Tropicus; Red Gum; Strophulus.)

#What do you understand by miliaria?#

An acute mildly inflammatory disorder of the sweat-glands, characterized by the appearance of minute, discrete but closely crowded papules, vesico-papules, and vesicles.

#Describe the symptoms of miliaria.#

The eruption, consisting of pin-point to millet-seed-sized papules, vesico-papules, vesicles, or a mixture of these lesions, discrete but usually numerous and closely crowded, appears suddenly, occurring upon a limited portion of the surface, or, as commonly observed, involving a greater part or the whole integument. The trunk is a favorite locality. The papular lesions are pinkish or reddish, and the vesicles whitish or yellowish, surrounded by inflammatory areola, thus giving the whole eruption a bright red appearance--_miliaria rubra_. Later, the areolæ fade, the transparent contents of the vesicles become somewhat opaque and yellowish-white, and the eruption has a whitish or yellowish cast--_miliaria alba_. In long-continued cases, especially in children, boils and cutaneous abscesses sometimes develop; and it may also develop into a true eczema.

Itching, or a feeling of burning, slight or intense, is usually present.

#What is the course of the eruption?#

The vesicles show no disposition to rupture, but dry up in a few days or a week, disappearing by absorption and with slight subsequent desquamation; the papular lesions gradually fade away, and the affection, if the exciting cause has ceased to act, terminates.

#What is the cause of miliaria?#

Excessive heat. Debilitated individuals, especially children, are more prone to an attack. Being too warmly clad is often causative.

#What is the nature of the disease?#

The affection is considered to be due to sweat-obstruction, with mild inflammatory symptoms as a cause or consequence, congestion and exudation taking place about the ducts, giving rise to papules or vesicles, according to the intensity of the process.

#How would you distinguish miliaria from papular and vesicular eczema, and from sudamen?#

The papules of eczema are larger, more elevated, firmer, slower in their evolution, of longer duration, and are markedly itchy.

The vesicles of eczema are usually larger, tend to become confluent, and also to rupture and become crusted; there is marked itchiness, and the inflammatory action is usually severe and persistent.

In sudamen there is absence of inflammatory symptoms.

#What is the prognosis of miliaria?#

The affection, under favorable circumstances, disappears in a few days or weeks. If the cause persists, as for instance, in infants or young children too warmly clad, it may result in eczema.

#What is the treatment of miliaria?#

Removal of the cause, and in debilitated subjects the administration of tonics; together with the application of cooling and astringent lotions, as the following:--

[Rx] Aeidi carbolici, ..................... [dram]ss-[dram]j Acidi borici, ........................ [dram]iv Glycerinæ, ........................... f[dram]j Alcoholis, ........................... f[Oz]ij Aquæ, ................................ [Oz]xiv. M.

This is sometimes more efficient if zinc oxide, six to eight drachms, is added.

Lotions of alcohol and water or vinegar and water, and also the various lotions used in acute eczema, are often employed with relief.

Dusting-powders of starch, boric acid, lycopodium, talc, and zinc oxide are also valuable; the following combination is satisfactory:--

[Rx] Pulv. acidi borici, Pulv. talci veneti, Pulv. zinci oxidi, Pulv. amyli, .............[=a][=a].....[dram]ij. M.

Probably the best plan is to use a lotion and a dusting-powder conjointly; dabbing on the wash freely, allowing it to dry, and then dusting over with the powder.

#Pompholyx.# (_Synonyms:_ Dysidrosis; Cheiro-pompholyx.)

#What is pompholyx?#

Pompholyx is a rare disease of the skin of a vesicular and bullous character, and limited to the hands and feet.

#Describe the symptoms of pompholyx.#

In most instances the hands only are affected. It begins usually with a feeling of burning, tingling or tenderness of the parts, followed rapidly by the appearance of deeply-seated vesicles, especially between the fingers and on the palmar aspect. These beginning lesions look not unlike sago grains imbedded in the skin. In some instances the disease does not extend beyond this stage, the vesicles disappearing after a few days or weeks by absorption, and usually without desquamation. Ordinarily, however, the lesions increase in size, new ones arise, become confluent, and blebs result, the skin in places appearing as if undermined with serous exudation. The parts are commonly inflamed to a slight or marked degree. The skin comes off in flakes, new lesions may appear for several days or two or three weeks, and the process then declines, recovery gradually taking place.

There are no constitutional symptoms, although it is usually noticed that the general health is below par.

#What is the character of the subjective symptoms in pompholyx?#

The subjective symptoms consist of a feeling of tension, burning and tenderness, and sometimes itching. Not infrequently, also there is neuralgic pain.

#What is the cause of pompholyx?#

The eruption is thought to be due to a depressed state of the nervous system. It is more common in women, and is met with chiefly in adult and middle life.

#What is the pathology?#

Opinion is divided; some considering it a disease of the sweat-glands and others an inflammatory disease independent of these structures.

#State the diagnostic features of pompholyx.#

The distribution and the peculiar characters and course of the eruption.

It is to be differentiated from eczema.

#What is the prognosis?#

For the immediate attack, favorable, recovery taking place in several weeks or a few months. Recurrences at irregular intervals are not uncommon.

#What is the treatment of pompholyx?#

The general health is to be looked after, and the patient placed under good hygienic conditions. Remedies of a tonic nature, directed especially toward improving the state of the nervous system, are to be prescribed. _Locally_, soothing and anodyne applications, such as lead-water and laudanum, boric-acid lotion, oxide-of-zinc, boric-acid and diachylon ointments, are most suitable; or the parts may be enveloped with the following:--

[Rx] Pulv. ac. salicylici, ................ gr. x Pulv. ac. borici, Pulv. amyli, .......... [=a][=a] ..... [dram]ij Petrolati, ........................... [dram]iv. M.

In fact, the external treatment is similar to that employed in acute eczema.

#Herpes Simplex.# (_Synonym:_ Fever Blisters.)

#What is herpes simplex?#

An acute inflammatory disease, characterized by the formation of pin-head to pea-sized vesicles, arranged in groups, and occurring for the most part about the face and genitalia.

#Describe the symptoms of herpes simplex.#

In severe cases, malaise and pyrexia may precede the eruption, but usually it appears without any precursory or constitutional symptoms. A feeling of heat and burning in the parts is often complained of. The vesicles, which are commonly pin-head in size, are usually upon a hyperæmic or inflammatory base, and tend to occur in groups or clusters. Their contents are usually clear, subsequently becoming more or less milky or puriform. There is no tendency to spontaneous rupture, but should they be broken a superficial excoriation results. In a short time they dry to crusts which soon fall off, leaving no permanent trace.

#Is the eruption in herpes simplex abundant?#

No. As a rule not more than one or two clusters or groups are observed.

#Upon what parts does the eruption occur?#

Usually about the face (_herpes facialis_), and most frequently about the lips (_herpes labialis_); on the genitalia (_herpes progenitalis_), the lesions are commonly found on the prepuce (_herpes præputialis_) in the male, and on the labia minora and labia majora in the female.

#State the causes of herpes simplex.#

Herpes facialis is often observed in association with colds and febrile and lung diseases. Malaria, digestive disturbance, and nervous disorders are not infrequently predisposing factors. Herpes progenitalis is said to occur more frequently in those who have previously had some venereal disease, especially gonorrh[oe]a, but this is questionable. It is probably often purely neurotic.

#What are the diagnostic points?#

The appearance of one or several vesicular groups or clusters about the face, and especially about the lips, is usually sufficiently characteristic. The same holds true ordinarily when the eruption is seen on the prepuce or other parts of the genitalia; it is only when the vesicles become rubbed or abraded and irritated that it might be mistaken for a venereal sore, but the history, course and duration will usually serve to differentiate.

#Give the prognosis.#

The eruption will usually disappear in several days or one or two weeks without treatment. Remedial applications, however, exert a favorable influence. Herpes progenitalis exhibits a strong disposition to recurrence.

#What is the treatment of herpes facialis?#

Anointing the parts with camphorated cold cream, with spirits of camphor or similar evaporating and stimulating applications will at times afford relief to the burning, and shorten the course.

#What is the treatment of herpes progenitalis?#

In herpes about the genitalia cleanliness is of first importance. A saturated solution of boric acid, a dusting-powder of calomel or oxide of zinc, and the following lotion, containing calamine and oxide of zinc, are valuable:--

[Rx] Zinci oxidi, Calaminæ, .......... [=a][=a] ........ gr. v Glycerinæ, Alcoholis, ......... [=a][=a] ........ [minim]vj Aquæ, ................................ [Oz]j M.

In obstinate recurrent cases, frequent applications of a mild galvanic current will have a favorable influence.

#Hydroa Vacciniforme.# (_Synonyms:_ Recurrent Summer Eruption; Hydroa Puerorum; Hydroa Aestivale.)

#Describe hydroa vacciniforme.#