{"1": {"fulltext": "BHH", "height": "4439", "width": "2577", "jp2-path": "practicaltreatis00hyde_0001.jp2"}, "2": {"fulltext": "f\\nr\\nG v\\n.n\\n\u00e2\u0096\u00a0H.", "height": "4385", "width": "2557", "jp2-path": "practicaltreatis00hyde_0002.jp2"}, "3": {"fulltext": "6\\nA\\nV- V\\ny\\n-o\\nr v,\\no\\no N\\n^1\\n\u00c2\u00ab5\\n-V\\n\u00e2\u0096\u00a00\\nf -p\\nV\\nc\\n0\\nV", "height": "4306", "width": "2310", "jp2-path": "practicaltreatis00hyde_0003.jp2"}, "4": {"fulltext": "", "height": "4377", "width": "2433", "jp2-path": "practicaltreatis00hyde_0004.jp2"}, "5": {"fulltext": "", "height": "4306", "width": "2310", "jp2-path": "practicaltreatis00hyde_0005.jp2"}, "6": {"fulltext": "", "height": "4385", "width": "2419", "jp2-path": "practicaltreatis00hyde_0006.jp2"}, "7": {"fulltext": "o\\n/J2z", "height": "4306", "width": "2310", "jp2-path": "practicaltreatis00hyde_0007.jp2"}, "8": {"fulltext": "PLATE I.\\nI.\\nf\\ni\\niJ*T\\nill\\nf\\nNsevus Lipomatodes.\\n(From a Photograph of one of the author s patients.)", "height": "4387", "width": "2461", "jp2-path": "practicaltreatis00hyde_0008.jp2"}, "9": {"fulltext": "A PRACTICAL TREATISE\\nON\\nDISEASES OF THE SKIN\\nFOR THE USE OF\\nSTUDENTS AND PRACTITIONERS\\nTSYy\\nJAMES NEVINS HYDE, A.M., M.D.\\nPROFESSOR OF SKIN, GENITOURINARY, AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE,\\nCHICAGO; DERMATOLOGIST TO THE PRESBYTERIAN, AUGUSTANA, AND MICHAEL\\nREESE HOSPITALS OF CHICAGO; AND CONSULTING DERMATOLOGIST TO\\nTHE CHICAGO HOSPITAL FOR WOMEN AND CHILDREN;\\nAND\\nFRANK HUGH MONTGOMERY, M.D.\\nASSOCIATE PROFESSOR OF SKIN, GENITO-URINARY, AND VENEREAL DISEASES, RUSH MEDICAL\\nCOLLEGE, CHICAGO PROFESSOR OF SKIN AND VENEREAL DISEASES, CHICAGO\\nCLINICAL SCHOOL ATTENDING PHYSICIAN FOR SKIN AND VENE-\\nREAL DISEASES, ST. ELIZABETH HOSPITAL, CHICAGO\\nSIXTH AND EEVISED EDITION\\nILLUSTRATED WITH 107 ENGRAVINGS AND 27 PLATES IN COLORS\\nAND MONOCHROME\\nLEA BROTHERS CO.\\nPHILADELPHIA AND NEW YORK\\n1901", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0009.jp2"}, "10": {"fulltext": "THE LIBRARY OF\\nCONGRESS,\\nTwo Copies\\nReceived\\nMAY. 10\\n1901\\nCopyright\\nENTRY\\nCLASS O/XXc Urn.\\nC\\n7\\nCOPY\\nB.\\nEntered according to Act of Congress, in the year 1901, by\\nLEA BROTHERS CO.,\\nIn the Office of the Librarian of Congress, at Washington. All rights reserved.\\nr I C t t\\nC i\\nELECTRCTYPED BY\\nWfeSTOOTT THOMSON, PHILADA.", "height": "4385", "width": "2448", "jp2-path": "practicaltreatis00hyde_0010.jp2"}, "11": {"fulltext": "TO\\nJAMES CLARKE WHITE, M. D.\\nPROFESSOR OF DERMATOLOGY\\nHARVARD UNIVERSITY\\nFIRST PRESIDENT OF THE\\nAMERICAN DERMATOL.OG-IGAL ASSOCIATION\\nTHIS TREATISE IS\\nWITH HIS PERMISSION\\nINSCRIBED", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0011.jp2"}, "12": {"fulltext": "", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0012.jp2"}, "13": {"fulltext": "PREFACE TO THE SIXTH EDITION.\\nThe rapid exhaustion of the Fifth Edition of this work has neces-\\nsitated a revision at a date earlier than was anticipated. Among the\\nsubjects that have been wholly or in part rewritten for this Sixth\\nEdition are Anatomy, General Diagnosis, Herpes Simplex, Herpes\\nZoster, Acne, Psoriasis, Scleroderma, Tuberculosis, Blastomycosis, and\\nCarates. Minor changes and additions have been made wherever\\nnecessary to place the work abreast of the most recent developments\\nin dermatology.\\nThree new plates and some new engravings have been added.\\nIn this, as in the preceding edition of the treatise, the names of\\nauthors mentioned in the text refer to their latest editions.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0013.jp2"}, "14": {"fulltext": "", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0014.jp2"}, "15": {"fulltext": "PUBLISHERS NOTE.\\nThe history of this work is one of growing appreciation and success.\\nIts first edition appeared in 1883, the second in 1888, the third in\\n1893, the fourth in 1897, the fifth toward the close of 1899, and the\\nsixth early in 1901. One year has, accordingly, sufficed to exhaust a\\nlarger edition than was ever before published, and has again brought\\nto the authors the opportunity of revising their work thoroughly to\\ndate, as they had done on every previous occasion. This standard\\ntreatise has come to be regarded as a source of information Avhich can\\nbe trusted to give always the best and latest knowledge of practical\\ndermatology.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0015.jp2"}, "16": {"fulltext": "", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0016.jp2"}, "17": {"fulltext": "CONTENTS.\\nPAGE\\nAnatomy and Physiology of the Skin 17\\nGeneral Symptomatology 51\\nGeneral Etiology 63\\nGeneral Pathology 70\\nGeneral Diagnosis 72\\nGeneral Prognosis 82\\nGeneral Therapeutics 84\\nClassification 109\\nDISEASES OF THE SKIN.\\nCLASS I.\\nDISOEDEES OF THE GLANDS.\\n1. Of the Sweat-glands Ill\\nHyperidrosis Ill\\nSudamen 115\\nMiliary Fever 116\\nHydrocystoma 117\\nAnidrosis 118\\nBromidrosis 119\\nChromidrosis 120\\nUridrosis 122\\nHaematidrosis 123\\nHidradenitis Suppurativa 123\\n2. Of the Sebaceous Glands 124\\nSeborrhoea 124\\nAsteatosis 136\\nComedo 137\\nMilium 142\\nSteatoma 144\\nCongenital Fibro-sebaceous Disease 145\\nPainless Dermoid Cysts 146\\nEare Consequences of Sebaceous Cystic Disease 146\\nCLASS II.\\nINFLAMMATIONS.\\nExanthemata 147\\nMorbilli 147\\nEotheln 151\\nScarlatina 152\\nVariola 157\\nVaricella 165\\nVaccinia 167\\nix", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0017.jp2"}, "18": {"fulltext": "x CONTENTS.\\nPAG*\\nErythma 171\\nSymptomatic Erythema 174\\nErythema Scarlatiniforme 175\\nErythema Pernio 176\\nErythema Intertrigo 177\\nErythema Multiforme 18C\\nHerpes Iris 184\\nErythema Nodosum 185\\nPellagra 186\\nAcrodynia 187\\nUrticaria 188\\nUrticaria Pigmentosa 196\\nAngioneurotic (Edema 198\\nDermatitis 200\\nTraumatica 200\\nVenenata 201\\nCalorica 204\\nCongelatio 206\\nMedicamentosa 207\\nEeigned Eruptions 216\\nGangrenosa 217\\nChronic Pustular, etc 217\\nSymmetrical Gangrene, etc. (Raynaud s Disease) 219\\nErysipelas 220\\nErysipeloid 226\\nEurunculus 226\\nCarbunculus 229\\nAnthrax 233\\nEquinia 235\\nDissection-wounds and Animal Poisons 236\\nDelhi Boil 237\\nPhlegmone Diffusa 239\\nSycosis 240\\nImpetigo 247\\nContagiosa 248\\nEcthyma 251\\nConglomerate Pustular Folliculitis 253\\nFolliculitis and Perifolliculitis 254\\nHerpes Simplex 255\\nHerpes Zoster 258\\nDermatitis Herpetiformis 265\\nHerpes Iris 266\\nPompholyx 269\\nPsoriasis 271\\nPityriasis rosea 289\\nDermatitis Exfoliativa 290\\nDermatitis Exfoliativa Infantum 292\\nPityriasis Rubra 293\\nPityriasis Rubra Pilaris 296\\nEpidemic Exfoliative Dermatitis 298\\nParakeratosis Variegata 300\\nLichen Ruber 300\\nLichen Planus 304\\nLichen Annularis 309", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0018.jp2"}, "19": {"fulltext": "CONTENTS. xi\\nPAGE\\nLichenification 310\\nEczema 310\\nTopical and Special Varieties 356\\nOf Children 356\\nOf the Scalp 357\\nOf the Face 359\\nOf the Lips 361\\nCheilitis Glandularis, etc 362\\nOf the Nostrils 363\\nOf the Ears 363\\nOf the Eyelids 365\\nOf the Beard 366\\nOf the Genital Organs 367\\nOf the Anus and Anal Kegion 370\\nOf the Nipple and Breast of Women 372\\nOf the Umhilicus 373\\nOf the Thighs 373\\nOf the Hands and Feet 375\\nOf the Nails 378\\nUniversal 379\\nOf the Tropics 379\\nEczema Seborrhceicum 381\\nDermatitis Repens 387\\nPrurigo 387\\nAcne 391\\nAcne Rosacea 404\\nAcne Varioliformis 409\\nImpetigo Herpetiformis 411\\nPemphigus 412\\nAcute 414\\nChronic 414\\nFoliaceus 416\\nNeonatorum 417\\nOf Young Girls 417\\nVegetans 418\\nHydroa 423\\nVacciniforme 424\\n^Estivale 425\\nEpidermolysis Bullosa Hereditaria 426\\nCLASS III.\\nHEMORRHAGES.\\nPurpura 429\\nSimplex 430\\nRheumatica 430\\nHemorrhagica 432\\nScorbutica 432\\nCLASS IV.\\nHYPERTROPHIES.\\nLentigo 435\\nChloasma 436", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0019.jp2"}, "20": {"fulltext": "xn CONTENTS.\\nPAGE\\nAnomalous Discoloration 439\\nKeratosis 442\\nPilaris 442\\nSenilis 445\\nFollicularis 445\\nKeratodermia Palmaris et Plantaris 448\\nAngiokeratoma 449\\nKeratosis Follicularis Contagiosa 450\\nHyperkeratosis Striata et Follicularis 451\\nParakeratosis Scutularis 451\\nParakeratosis 451\\nMolluscum Epitheliale 452\\nCallositas 456\\nCallositas with Complications 457\\nClavus 457\\nCornu Cutaneum 459\\nVerruca 460\\nMultiple Cutaneous Tumors, Pruritic 465\\nSynovial Lesions of the Skin 466\\nPapilloma 466\\nPapilloma Area Elevatum 467\\nPapilloma Neuroticum 467\\nNsevus Pigmentosus 467\\nLinear Nsevus 468\\nAcanthosis Nigricans 469\\nXerosis 470\\nIchthyosis 471\\nCongenita 474\\nLinguae 474\\nOnychauxis 477\\nParonychia 478\\nOnychomycosis 478\\nSyphilitic Onychia 478\\nHypertrichosis 480\\nNeurotica 481\\nPlica Polonica 481\\nNeuropathic Plica 482\\n(Edema Neonatorum 486\\nAcute Sclerema Neonatorum 487\\nScleroderma 488\\nHemiatrophia Facialis 491\\nElephantiasis 494\\nLymph-scrotum 496\\nAcromegaly 497\\nCLASS V.\\nATROPHIES.\\nLeucoderma 501\\nAlhinismus 502\\nVitiligo 502\\nCanities 505\\nAlopecia 507\\nCongenitalis 507", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0020.jp2"}, "21": {"fulltext": "CONTENTS. xiii\\nPAGE\\nAlopecia Senilis 508\\nPrematura 508\\nFurfuracea 509\\nAreata 511\\nCircumscripta 513\\nFollicularis 518\\nKeloid-Acne 520\\nUlerythema Aphryogenes 521\\nAtrophia Pilorum Propria 522\\nFragilitas Crinium 522\\nUndescrihed Form of Atrophy of Hairs of Beard 522\\nTrichorrhexis Nodosa 522\\nMonilethrix 524\\nNodose Swellings of Shafts of Hair 525\\nExpansions and Fissures of Hairs 525\\nLepothrix 525\\nPiedra 526\\nBeigel s Disease 526\\nTinea Nodosa 526\\nAtrophia Unguis 526\\nAchromia Unguium 527\\nAtrophia Cutis 528\\nSenilis 528\\nMaculosa et Striata 529\\nDiffuse, Idiopathic 530\\nPartial Symptomatic 530\\nGlossy Skin 531\\nBlanching Atrophy of Skin 531\\nMultiple Benign Tumor-like New-growths 532\\nKraurosis Vulvae 532\\nPerforating Ulcer of the Foot 533\\nMorvan s Disease 534\\nAinhum 535\\nCLASS VI.\\nNEW-GKOWTHS.\\nKeloid 539\\nCicatricial Keloid 540\\nCicatrix 542\\nFibroma 544\\nDermatolysis 546\\nNeuroma 548\\nXanthoma 550\\nXanthoma Diabeticorum 554\\nColloid Metamorphosis of the Skin 555\\nAdenoma of the Sebaceous Glands 556\\nCoil-glands 558\\nMultiple Benign Cystic Epithelioma 558\\nLymphangioma Tuberosum Multiplex 559\\nLeukeratosis Buccalis 560\\nMyoma 562\\nAngioma 563", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0021.jp2"}, "22": {"fulltext": "xiv CONTENTS.\\nPAGE\\nAngioma Nsevus Vasculosus 563\\nTelangiectasis 564\\nCavernosum 565\\nSerpiginosum 568\\nLymphangioma 569\\nCircumscriptum 570\\nXeroderma Pigmentosum 572\\nRhinoscleroma 574\\nTuberculosis Cutis 576\\n1. Lupus Vulgaris 576\\n2. Tuberculosis Cutis Verrucosa 581\\nA. Verruca Necrogenica 581\\nB. Tuberculosis Verrucosa Cutis 582\\nC. Other Verrucous Tuberculoses 582\\n3. Tuberculosis Cutis Orificialis 583\\n4. Scrofuloderma 584\\nTuberculous Dactylitis 586\\nSuppurative Tubercular Lymphangiectasis 586\\nTuberculosis Cutis Serpiginosa 586\\nLymphangitis Tuberculosa Cutanea 586\\n5. The Dermatoses of the Scrofulous 599\\nA. Lichen Scrofulosorum 599\\nB. Erythema In dura turn Scrofulosorum 600\\nC. Necrotic Granuloma 601\\nD. Eolliclis 602\\nE. Lupus Pernio 602\\nErysipelas Perstans 603\\nE. Pustular Scrofuloderm 603\\nAcneiform Group of Para-tuberculoses 603\\nLupus Erythematosus 604\\nSyphilis 614\\nChancre 616\\nSyphilodermata 619\\nSyphiloderma Maculosum 623\\nPapulosum 626\\nVesiculosum 631\\nPustulosum 631\\nBullosum 634\\nTuberculosum 635\\nSerpiginosum 635\\nGummatosum 637\\nErythanthema Syphiliticum 638\\nSyphilis of Mucous Surfaces 639\\nSyphiloderma Infantile, Acquisitum et Hsereditarium 641\\nChancroid 665\\nLepra 670\\nTuberosa 671\\nMaculosa 673\\nAngesthetica 674\\nThe Sartian Disease 683\\nFrambesia 684\\nParangi 685\\nDoncla Ndugu 686\\nVerruga Peruana 686", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0022.jp2"}, "23": {"fulltext": "CONTENTS. xv\\nPAGE\\nMycosis Fungoides 687\\nSarcoma Cutis 693\\nA. Melanotic Sarcoma 698\\nB. Primary Non -melanotic Sarcoma 694\\nIdiopathic Multiple Pigment Sarcoma 695\\nKecurrent Fibroid of the Skin 695\\nCarcinoma 697\\nEpithelioma 697\\nSuperficial, or Discoid 697\\nKodent Ulcer 697\\nDeep 698\\nPapillary 699\\nCancer of the Head 700\\nLower Lip 701\\nGenital Organs 701\\nExtremities 702\\nMucous Surfaces 702\\nPaget s Disease 708\\nCancer of Connective Tissue 709\\nen Cuirasse 710\\nTuberose Carcinoma 711\\nMelanotic Carcinoma 711\\nEndothelioma 712\\nCLASS VII.\\nSENSOKY DEKMATO-NEUKOSES.\\nHyperesthesia 713\\nDermatalgia 714\\nAnaesthesia 716\\nParesthesia 716\\nPruritus 717\\nHiemalis 718\\nPrairie Itch 725\\nMyxcedema 726\\nCLASS VIII.\\nPAEASITIC AFFECTIONS.\\nDisorders due to Vegetable Parasites 729\\nTinea Favosa 729\\nFavus of the Nail 731\\nTinea Trichophytina 737\\nTinea Circinata 739\\nEczema Marginatum 741\\nTinea Trichophytina Unguium 741\\nTinea Tonsurans 746\\nTinea Kerion 752\\nTinea Sycosis 753\\nPrecautions in Tinea Favosa and Trichophytina 758\\nTinea Imbricata 759\\nTinea Versicolor 760", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0023.jp2"}, "24": {"fulltext": "xvi CONTENTS.\\nPAGE\\nErythrasma 764\\nLa Perleche 766\\nMyringomycosis 766\\nCarates 767\\nMycetoma 768\\nActinomycosis of the Skin 771\\nBlastomycosis of the Skin 774\\nRefractory Subcutaneous Abscesses caused by Sporothrix 778\\nDiseases due to Animal Parasites 778\\nScabies 778\\nDemodex Folliculorum 788\\nPulex Penetrans 789\\nIrritans 789\\nEilaria Medinensis 790\\nCraw-Craw 792\\nCysticercus Cellulosae Cutis 792\\nEchinococcus 793\\nDistoma Hepaticum 793\\nLeptus 793\\nDipterous Larvae in the Skin 795\\nIxodes 796\\nPediculosis 796\\nCapillitii 797\\nCorporis 799\\nPubis 802\\nVagabond s Disease 804\\nPediculi and Acari from Lower Animals 804\\nCimex Lectularius 805\\nCulex Pipiens 806\\nProtozoa and Sporozoa 807", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0024.jp2"}, "25": {"fulltext": "LIST OF ILLUSTRATIONS.\\nFIG. PAGE\\n1. Section of skin from the palm of the hand 18\\n2. Subcutaneous fat-tissue 20\\n3. Columnae adiposse 22\\n4. Vertical section of skin after injection (from beneath) with Berlin blue 23\\n5. Vascular and nervous papillae 24\\n6. Scalp of a colored man horizontal section 25\\n7. Prickle-cells 26\\n8. Pacinian body, after silver staining 31\\n9. Section of papilla containing a tactile body (from the skin of a finger) 32\\n10. Transverse section of nervous papilla 33\\n11. Section of hair-follicle during the formation of a new hair 37\\n12. Hair-follicle in longitudinal section 37\\n13. Lower portion of hair-pouch from the lip of a kitten 39\\n14. Transverse section of hair and follicle 40\\n15. 16. Sebaceous glands of the second class from the alae of the nose 42\\n17. Coil of a sweat-gland 43\\n18. A sweat-pore traversing the epithelial layers of the skin 44\\n19. Section of skin from the palm of the hand 45\\n20. Thin section of the skin of the finger removed at the site of a\\nsweat-pore 47\\n21. Vertical section of one-half of nail and matrix 48\\n22. Implantation of the nail at its border 50\\n23. Irido-platinum needle 107\\n24. Milium needle 107\\n25. Scarifying-spud 107\\n26. Epilating-forceps 108\\n27. Piffard s grappling-forceps 108\\n28. Piffard s cutisector 108\\n29. 30. Dermal curettes 108\\n31. Hess s glass pleximeter 108\\n32. Comedo-extractor 108\\n33. Cutaneous punch 108\\n34. Massering-ball 108\\n35. Section of a comedo 138\\n36. Cysts of the scalp 144\\n37. Photomicrograph of the bacillus scarlatinas 155\\n38. Vertical section of pustule at the beginning of pustulation in variola 159\\nB xvii", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0025.jp2"}, "26": {"fulltext": "xvm LIST OF ILLUSTRATIONS.\\nFIG. PAGE\\n39. Vertical section of one-half of an undeveloped pustule 161\\n40. Autographism in urticaria 189\\n41. Urticaria pigmentosa 197\\n42. Papilloma, due to ingestion of the iodine compounds 211\\n43. Feigned eruption 217\\n44. Vertical section of carbuncle 230\\n45. Section of carbuncle 230\\n46. Authrax bacilli and pus-corpuscles 234\\n47. Longitudinal section of the third spinal ganglion of the right lumbar\\nregion, from a case of lumbo-inguinal zoster 263\\n48. Vertical section of skin from a patch of psoriasis 276\\n49. Acne necrotica 410\\n50. Hydroa vacciniforme 425\\n51. Molluscum epitheliale 453\\n52. Molluscous corpuscles 454\\n53. 54. Cutaneous horns 459\\n55. Vertical section of the summit of a pointed wart 464\\n56. Ichthyosis hystrix 472\\n57. Ichthyosis hystrix, vertical section 473\\n58. The Russian dog-faced man 480\\n59. Elephantiasis of the foot and leg 496\\n60. Elephantiasis scroti 496\\n61. Vitiligo in a negro boy 504\\n62. Trichorrhexis nodosa 523\\n63. Keloid 540\\n64. Multiple fibromata 545\\n65. Neuroma of the skin external appearance 548\\n66. Microscopic structure of neuroma 549\\n67. Lupus vulgaris of the leg 580\\n68. Verruca necrogenica 581\\n69. Section of lupus of the face 589\\n70. Lupus erythematosus of the face 605\\n71. Chancre of the tongue 617\\n72. Facial cicatrices of tubercular syphilodermata after twenty-five years\\nof infection 622\\n73. Vegetating condylomata of the vulva 629\\n74. Ulcerative tubercular syphiloderm 636\\n75. Syphiloma of the vulva with gummatous changes in labia and clitoris 637\\n76. Lee s safety-lamp for fumigation 658\\n77. Lepra tuberculosa 671\\n78. Tubercular leprosy 672\\n79. Anaesthetic leprosy with mutilating results 675\\n80. Larynx of patient affected with lepra tuberculosa 677\\n81. 82. Larynges of lepers affected with lepra tuberculosa 678\\n83. Bacilli of leprosy 679", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0026.jp2"}, "27": {"fulltext": "LIST OF ILLUSTRATIONS. xix\\nFIG. PAGE\\n84. Mycosis fungoides 689\\n85. Sarcoma 696\\n86. Epithelioma, vertical section 703\\n87. Cancer en cuirasse 710\\n88. Achorion Schonleinii 732\\n89. Epidermis invaded by trichophyton 743\\n90. Hair invaded by trichophyton 749\\n91. Filaments and spores of trichophyton from the beard 755\\n92. Microsporon furfur 762\\n93. Microsporon minutissimum 765\\n94. Osseous lesions in mycetoma 769\\n95. Blastomycosis 775\\n96. Female acarus 779\\n97. Acarian furrow 781\\n98. Demodex folliculorum 789\\n99. Leptus Americanus 794\\n100. Leptus autumnalis 794\\n101. Rouget 794\\n102. (Estrus 795\\n103. Larvae from body of child 795\\n104. Pediculus capillitii 797\\n105. Ova of head-louse 797\\n106. Pediculus corporis 799\\n107. Pediculus pubis 803", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0027.jp2"}, "28": {"fulltext": "LIST OF PLATES.\\nPlate I. Nsevus Lipomatodes frontispiece.\\nPlate II. Erythema Multiforme, Circinate type facing page 180\\nPlate III. Dermatitis Herpetiformis facing page 265\\nPlate IV. Pityriasis Rosea facing page 289\\nPlate V. Pityriasis Rubra Pilaris facing page 296\\nPlate VI. Acne-keloid of the Back facing page 394\\nPlate VII. Purpura due to Copaiba facing page 42i\u00c2\u00bb\\nPlate VIII. Keratosis Punctata facing page 448\\nPlate IX. Palmar Keratosis due to Arsenic facing page 449\\nPlate X. Congenital Warts facing page 461\\nPlate XI. Syphilis of the Nails facing page 478\\nPlate XII. Circumscribed Scleroderma facing page 489\\nPlate XIII. Elephantiasis Telangiectodes of the Upper Lip\\nand Portions of the Face facing page 495\\nPlate XIV. Malum Perforans Pedis, with Symmetrical\\nKeratoma of the Palms and Soles faring page 533\\nPlate XV. Multiple Fibroma of the Back facing page 544\\nPlate XVI. Fibroma Pendulum facing page 546\\nPlate XVII. Xanthoma of the Hands, Elbows, and Knees facing page 550\\nPlate XVIII. Xanthoma Tuberosum of Hands facing page 551\\nPlate XIX. Xanthoma Diabeticorum facing page 554\\nPlate XX. Lupus Hypertrophicus of the Face facing page 577\\nPlate XXL Large Pustulo-crustaceous Syphiloderm of the\\nScalp and Body facing page 632\\nPlate XXII. Tubercular Syphiloderm, Resolutive and Ser-\\npiginous facing page 635\\nPlate XXIII. Pre-fungoid Stage of Mycosis Fungoides -.facing page 687\\nPlate XXIV. Microsporon Audouini and Megalosporon\\nEndothrix, X 500 facing page 737\\nPlate XXV. Mycetoma facing page 768\\nPlate XXVI. Blastomycosis of the Skin facing page 774\\nPlate XXVII. Histological and Bacteriological Features of\\nBlastomycosis facing page 111\\nxx", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0028.jp2"}, "29": {"fulltext": "I. ANATOMY AND PHYSIOLOGY OF\\nTHE SKIN.\\nThe skin is the living envelope of the human body; it is closely\\nassociated with underlying structures;, and by its situation is brought\\ninto intimate relation also with the external world. The skin is a\\ncomplex, elastic, and sensitive organ, varying greatly in different con-\\nditions of climate, age, sex, health, and race; and varying also in the\\ncharacteristics exhibited in different localities upon the same indi-\\nvidual. Thus, in color there is a wide range between the fair skin of\\nthe blonde and the black skin of the negro, between the rosy pink of\\nthe infant s palm and the dark-brown hue of the genital region of the\\naged. J ne skin varies also in pliability and thickness, being delicate\\nand lax over the eyelids, the lips, and the prepuce?; and much thicker\\nand more firmly attached over the palms and the soles.\\nThe appearance of the skin, even in conditions of health, changes\\nwithin appreciable limits. It i- the exposed parts (such as the face)\\nwhich the eve of the physician most frequently searches, and which\\nbetray evidence of mental emotions, physiological fluxes, sedentary or\\nactive habits of life, and fatigue or unusual conditions of vigor.\\nViewed externally, the -kin i- -ecu to be traversed by superficial\\nand deeper furrows, dotted with numerous depressions representing the\\nmouths of its follicle-, at the digital extremities protected by the nails,\\nand provided very generally with coarse or with fine, downy hairs,\\nwhich in some parts are of sufficient growth to conceal the skin from\\nview. This pilary growth serves not merely as an ornament of the\\nbody, but also as a protection to some of its regions most sensitive to\\nthermal changes.\\nBy its extraordinary sensitiveness to different degrees of tempera-\\nture and to the physical properties of the bodies with which it is\\nbrought into contact the skin becomes, even when unaided by the eye,\\na valuable means of preserving the human frame from external in-\\njury. This protective function is, in part, due to the horny character\\nof its outer layer, as a consequence of which the loss of essential fluids\\nand the ingress of noxious substances are equally restricted.\\nOne of the most important functions of the skin is the part it\\nplays in regulating the body-temperature. The temperature-variations\\nat its surface, modified naturally by the character and quantity of the\\nclothing when such is worn, produce corresponding variations in the\\nsmooth muscles and contractile blood-vessels of the skin. By enlarge-\\nment or diminution of the lumen of these vessels, whether resulting\\ndirectly from the action of heat or of cold at the surra ce, or indirectly\\nthrough an effect upon the vasomotor centres, large quantities of blood\\n2 17", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0029.jp2"}, "30": {"fulltext": "18\\nANATOMY AND PHYSIOLOGY OF THE SKIN\\nare brought to or removed from the superficies of the body. In oue\\ncase the blood is cooled by evaporation at the body-surface in the\\nother, the loss of heat by such evaporation is greatly restricted. This\\nFig. 1.\\nJ_.\\nm\\nSection of skin from the palm of the hand, magnified l. )0 diameters: a, stratum corneum\\na its superficial layer b, stratum lucidum c, stratum granulosum d. stratum mucosum(rete):\\ne, pars papillaris of the corium, loops of capillary vessels showing in vascular papillae f, pars\\nreticularis of the corium, showing coarse interlacing connective-tissue bundles g. transverse\\nsection of the latter; h, double-contoured nerve-fibres passing to tactile body; i, coil-glands\\nk, ducts of coil-glands 1, sweat-pores passing to surface of the epidermis; m. arteries of the\\nskin terminating in capillaries n, veins of the skin forming plexuses; o. fat-cells, encompas\\nby capillary loops, in relation with coil-elands (the capillaries of the latter are purposely omitted\\nin the drawing) p, obliquely and transversely divided bundles of connective-tissue fibres of the\\ncorium and subcutaneous tissue.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0030.jp2"}, "31": {"fulltext": "ANATOMY. 19\\nprocess is materially influenced by acceleration or retardation of the\\nheart s action, whether produced by psychical or by physical causes. It\\nis also modified by the occurrence of sweating, as a result of which heat\\nin varying amounts is rendered latent, and either watery vapor escapes\\nfrom the surface; or sweat is exuded in drops, the aggregate of which\\nmay be several pounds in weight in the course of twenty-four hours.\\nTo a limited degree the skin is capable of acting as a respiratory\\nagent, eliminating carbonic acid gas with watery vapor, and possibly\\nalso absorbing oxygen in small amount. Its power of absorbing ali-\\nments, medicaments, and toxic substances has as yet but imperfectly\\nbeen determined. Substances in a liquid state are practically not\\nabsorbed so long as the horny layer of the epidermis is intact. With\\nthis layer intact minute particles of matter have been conveyed to\\nthe deeper structures in the operations of skiagraphy, of cataphoresis,\\nand of dielectrolysis. The actual loss, however, of this external\\nprotective layer permits the ready absorption of many liquids. Gases\\nmay be absorbed by the unbroken skin, and to a less extent are some\\nfats and oils, as well as a few substances in a finely powdered state.\\nSuch absorption, when it occurs, is probably effected through the\\nportal of a hair-follicle and the ducts of the cutaneous glands.\\nThe skin is provided with a natural unguent, by which, in a state\\nof health, it is constantly anointed. The fatty and oily secretions of\\nthe skin are concerned n t merely in the anointing of the general sur-\\nface and of the hairs, but also in the regulation of the body-tempera-\\nture and in the prevention of maceration of the tissues by the sweat.\\nThe complex organ called the skin is essential to the life of the\\nindividual. The sexual, and possibly other, organs of the human\\nbody may have their functions arrested, or they may even be obliter-\\nated by destructive processes, and life still continue; but if all the\\nfunctions of the skin were suspended for a sufficient period of time\\nthe result would be fatal to human life. In its relations alone to\\nthe complicated processes by which the heat of the body is main-\\ntained at a relatively fixed standard the skin exhibits its impor-\\ntance to the general economy. It is thus seen to be, not an isolated\\nmembrane stretched mechanically over an artificial machine, but is one\\nof several living and potential systems of the body, each system being\\nin intimate union with all others.\\nDevelopmknt of the Skix. The corium is developed in intra-\\nuterine life from the superficial layer of the mesoblast (the skin-plate\\nof Remak). Its lower portions become first visible in a myxofibrous\\nstructure, which between the seventh and eighth months is replaced by\\na collagenous substance, from which the bundles of connective tissue\\ndevelop, finer fibrillas becoming later elastic fibres.\\nThe epidermis springs from the ectoderm, and has therefore no\\nprimary histological relation with the corium, though at about the fourth\\nmonth it is projected upon the papillary layer so as to give rise to the\\ngrooves and interdigitations which produce in the skin of the adult\\nan important and intimate connection between the two. At first a\\nsingle layer, later two, three, and more rows of prickle-cells develop\\nup to the fifth month, the horny covering persisting up to the seventh", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0031.jp2"}, "32": {"fulltext": "20\\nANATOMY AND PHYSIOLOGY OF THE SKIN.\\nmonth merely as a thin stratum composed of but two rows of cells.\\nThe appendages of the skin are mostly developed between the sixth\\nand eighth months.\\nThe integument of the body, when studied with the aid of the micro-\\nscope, is found to be composed of several organic parts, which arc the\\nsubcutaneous connective tissue (the hypoderm), resting on the deeper\\nstructures of the body then, more externally, the corium, or true\\nskin lastly, an outermost coat, the epidermis, or cuticle Beside\\nthese parts, the skin contains coil-glands, sebaceous glands, hairs, nails,\\nblood-vessels, lymph-vessels, muscles, pigment, and nerves. It will\\nbe instructive to study the deeper part- of* the -kin before considering\\nthose more superficially disposed, as their mutual relations will thus\\nbe made clearer.\\nSUBCUTANEOUS TISSUE STRATUM SUBCUTANEUM\\nThe subcutaneous tissue, or hypoderm, is differentiated from the\\ncorium between the third and the fourth month of foetal life. It\\nis a structure serving a mechanical purpose as a receptacle lor fat, and\\nfor the support of vessels and nerves passing from the tissue beneath\\nto the corium which lies next above 1 ii. It contains, also, coil-glands,\\nsome of the hair-follicles more\\nFig. 2. deeply seated than their fellows,\\nand Pacinian corpuscles. There\\ni no distinct boundary-line be-\\ntween the upper limits of the sul)-\\nCUtaneous tissue and the overlying\\ncorium, to which it projects co-\\nlumnar masses of fat, extending\\nobliquely to the coil-glands and\\nthe hair-follicles above, often with\\nlateral, horizontally disposed pro-\\nlongations of similar shape. It\\nis built up of loose connective-\\ntissue bundles, prolonged from\\nthe aponeuroses, fasciae, and the\\nmembranes lying beneath.\\nThe subcutaneous ti sue is\\nfirmly attached to the skin over\\nthe extensor surfaces of the artic-\\nulations, the palms and soles, and\\nthe groins by short, coarse bundles,\\nbetween which are single or mul-\\ntilocular spaces lined with endo-\\nthelia secreting a mucoid fluid.\\nThese spaces are the Bursae Mu-\\ncosae. Elsewhere, as in the eye-\\nlids, the penis, the scrotum, and the auricle of the ear, the attachment\\nto the skin is by loose, delicate connective tissue containing no fat-\\nSubcutaneous fat-tissue, the fat having\\nbeen extracted with turpentine B, bundles of\\nfibrous connective tissue, carrying: injected\\nblood-vessels C, capsules of fat-globules,\\nwith oblong nuclei. Magnified 500 diameters.\\n(After Heitzmann.)", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0032.jp2"}, "33": {"fulltext": "t\\nTHE OIll CM. 21\\nobules. All other fibrous tracts are arranged obliquely; they admit,\\ntheir extension, of various degrees of pliability, and inclose rhom-\\nboidal spaces containing more or less numerous fat-globules. These\\nspaces are lobular d, are bounded by a delicate fibrous connective tissue,\\nand are abundantly supplied with blood-vessels. This layer is termed\\nthe Panniculus Adiposus.\\nThe deposit of fat in the body i tly reduced in all disea\\nproductive of emaciation, bul never wholly disappears during life. In\\ncases of obesity, fal is deposited in excess of normal limits, and it may\\nthen be concerned in the production or th aggravation of disease. It\\nis largely due to the greater or lesser volume of the panniculus adiposus\\nthat the natural outlines of the body are made to the eye graceful and\\nattractive, or the reverse.\\nColumnse Adiposae (Fat-columns of Warren). These are\\ncolumnar prolongations from the adipose tissue of the panniculus\\nadiposus below, passing in nearly vertical position to the bases of the\\nhair-pouches, especially conspicuous in the thickened integument of\\nthe hack, the neck, and the shoulders. The columnar axes are more or\\nless parallel with the erectores pilorum muscles, and aid in supporting\\nthe coil-glands and the blood-vessels and lymphatic vessel.-. The\\nrniirs jlhr u.r of the Kn-lich ;nv e \u00c2\u00bbne-~| iapcd DiaSSeS of connective tlSBUe\\nwhich extend from the Lower borders i the corium, and which pene-\\ntrate for a space into the adipose tissue. The part which these com-\\nponents of the skin play in the formation of carbuncle is set forth in\\nthat connection.\\nTHE CORIUM.\\nThe corium Derm tit-. Jutis Veb or True Skin) i- com-\\nposed of bundles of fibres of connective tissue, the decussations f which\\nproduce a dense felt-work, coarsesl toward the subcutaneous tissue\\nupon which it rests inferiorly, and finest in the outermost portion\\nwhich is in contact with the epidermis above. The bundles are com-\\nposed chiefly of fibres of white fibrous tissue, but are accompanied by\\na varying number of elastic fibres. Connective-tissue corpuscles are\\nalso present in small numbers. There is a u cement-substance, or\\nbasis-substance, surrounding all the fibre- and holding the various ele-\\nments of the skin together. The derma is rich in blood-vessels and\\ncapillaries, especially in the papillary layer, and contains many nerve-,\\nnerve-endings, and terminal nerve-organs. It further contains lym-\\nphatics, smaller muscle-fibres, hair-, sweat-glands, and sebaceous glands.\\nIts thickness varies greatly with different individuals and at different\\nages. It is thinnest in the infant, and on the eyelids, the prepuce, and\\nthe inner surfaces of the labia majora. It is thickest iti vigorous adults,\\nand over the back, the buttocks, the palms, and the soles.\\nThe bundles of the connective tissue of the derma accompany all\\nelongations of an epithelial character. They produce the follicles\\naround the root-sheaths of the hair, the capsules around the coil-\\nelands, and the layers which surround their ducts.\\nJorresponding with their anatomical structure the upper and lower\\nportions of the derma are called respectively the papillary layer and", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0033.jp2"}, "34": {"fulltext": "22\\nANATOMY AND PHYSIOLOGY OF THE SKIN.\\nthe reticular layer. There is no sharp dividing-line between these\\nlayers, the pars reticularis passing gradually into the pars papillaris\\nabove and into the subcutaneous tissue below.\\nCleavage of the Skin. The fibres and bundles of connective\\ntissue in the skin are arranged according to a definite plan. Puncture\\nFig. 3.\\nVertical section of the skin showing a, epidermis b, erector pili muscle; tf, columns adi-\\nposse; c, coil-gland suspended in the columnse adiposse h, sebaceous gland; p, horizontal\\nprolongations of the column fibrous bundles of the corium g, panniculus adiposus k, band\\nof fibrous tissue extending into the panniculus adiposus. (After Wakken.)\\nof the integument with a sharp and well-rounded instrument is pro-\\nductive not of a circular opening, but of a longitudinal slit. The\\nextensibility and retractive power of the skin are largely dependent\\nupon the arrangement of these fibres.\\nPars Eeticularis. The reticular layer of the corium is made up,\\nas has been seen, of interlacing connective-tissue bundles, with inter-\\nspaces increasingly larger from without inward. The fineness of the\\nbundles decreases, in the same way, from within outward, being finest\\nwhere the minute papillae of the corium project into the rete, and\\ncoarsest near the subcutaneous tissue.\\nPars Papillaris. The papillary layer of the corium lies in con-\\ntact with the rete above, and is connected below with the deeper retic-\\nular portion of the true skin. Between the rete and the papillae of\\nthe derma a hyaline substance is interposed, which is supposed to be\\nidentical with the cement-substance surrounding and separating the\\nfibrillar of the corium. The basal membrane once thought to be\\nstretched between the rete mucosum of the epidermis and the papillary\\nlayer of the corium cannot be demonstrated to exist.\\nViewed obliquely with an amplification of about three hundred\\ndiameters, it will be seen that long and slender filaments from the\\nprickle-cells of the mucous layer of the epidermis encircle in a spiral", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0034.jp2"}, "35": {"fulltext": "THE CORIUM.\\n23\\ndirection both nervous and vascular papillae. At the apices of the\\nlatter these threads completely surround the connective-tissue fibres.\\nThe name of this portion of the derma is intended to describe its\\nchief characteristics, the existence of numerous digital prolongations or\\nnipple-like prominences of the corium, made up of delicate connective-\\nFio. 4.\\nVertical section of skin after Injection (from beneath) of areolar tissue with Berlin blue:\\nepidermis corium g, panniculus adiposus h, sebaceous gland. (After Warhen.)\\ntissue fibres which do not interlace and which are abundantly provided\\nwith nuclei. The papillae spring each from a single, or several from a\\ncommon, ovoid base their bulbous, conical, or blunt apices reach into\\nthe rete, which also dips down between them in prolongations termed\\nrete-pegs. The papillae vary in size in different parts of the body,\\nand also in their disposition and shape, being in places arranged in\\nlinear series, and in others in concentric whorls, with definite centres,\\nthus producing crossing-furrows, visible to the naked eye as markings\\nupon the outer surface of the epidermis. The largest are found on the\\npalms and soles and over the inner faces of the digits. It has been\\nestimated that one hundred are developed within each square millimetre\\nof the body-surface.\\nIn horizontal sections of the skin the papillae, being transversely\\ndivided, appear as circular or ovoid areas, in which can be recognized\\ncentrally a transversely or obliquely divided capillary loop. Between\\nthese areas is seen the interpapillary reticulum of the mucous layer.\\nThe growth of the rete downward and of the corium upward results\\nin mutual effects of pressure and counter-pressure the equilibrium of\\nwhich is constantly adjusted by the mechanical and vital necessities\\nof such union.\\nWhen the papilla? are completely exposed, after removal of the\\noverlying cement-substance and of the epidermis above, their exterior\\nsurface is seen to be uniformly marked with series after series of", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0035.jp2"}, "36": {"fulltext": "24\\nANATOMY AND PHYSIOLOGY OF THE SKIN.\\nalternating furrows and ridges of exceeding delicacy and more or less\\nconcentrically disposed. Into the grooves are admitted corresponding\\ndentations that can be recognized on the under surface of the layer of\\nepithelial cells next the corium. They may, however, be the furrows\\nleft after separation of the long prickles wrapped about the papillae\\nand traceable to the mucous layer.\\nFig. 5.\\nVascular and nervous papillse a, vessel 6, nervous papilla c, vessel d, nerve-fibre e, cor-\\npusculum tactus transversely divided nervous filaments g, epithelia of rete. (After Biesia-\\ndecki.)\\nTwo varieties of papillae are distinguished the vascular and the\\nnervous the former contain the terminal loops of a minute artery and\\nvein, and the latter the terminations of medullated nerve-fibres.\\nThe greater number of the papillae are of the vascular variety, being\\ntraversed by a vertically disposed loop of vessels, consisting of an\\narterial and a venous capillary. The office of the vascular loop is\\nevidently not merely to supply nutriment for the epidermis above, but\\nalso to provide for the cooling of the blood when brought in large\\nquantities to the surface of the body. Occasionally, two or more of\\nsuch loops can be recognized in a single papilla.\\nThe nervous papillae contain the tactile corpuscles, which subserve\\nan important purpose in providing for the sensibility of the integument.\\nThe tactile corpuscles are described in connection with the nerves of\\nthe skin. Ultimate terminations of nerves can be recognized in the\\nvascular papillae, and at times minute vascular loops can be seen in the\\npapillae largely occupied with the corpuscles of touch.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0036.jp2"}, "37": {"fulltext": "THE EPIDERMIS.\\nTHE EPIDERMIS (CUTICULA).\\n25\\nThe epidermis (Scarf-skin, or Cuticle) is the most external of\\nthe several membranes of the body, being in close contact on one side\\nwith the corium, or true skin, and exposed on the other to the atmos-\\nphere by which it is surrounded. The latter surface is therefore rela-\\ntively drier, while the former is constantly moistened by fluids from the\\nvessels which ramify beneath it.\\nFig. 6.\\nScalp of a negro\u00e2\u0080\u0094 horizontal section: B, rete mucosum Pi, row of columnar epithelia\\n(cut obliquely) supplied with dark-brown pigment-granules Pa, papilla (cut transversely)\\nD, derma. Magnified 500 diameters. (After Heitzmann.)\\nNo genetic relation exists between the epidermis and the corium, not-\\nwithstanding their intimate union and mutual relationship. The epi-\\ndermis is developed from the ectoderm, the corium from a superficial\\nlayer of the mesoblast. Their behavior both in health and in disease\\nis marked by the widest difference.\\nHerxheimer s Spiral Fibres begin with the line of union of the\\ncorium and epidermis, and run in a spiral or zigzag direction between\\nthe cells and parallel with their long axes. They are most abundant\\nin the deeper portions of the rete, and lie for the most part parallel\\nwith the long axes of the palisade rete-cells. They have been supposed\\nto be a part of the canal-system for the distribution of the juices sent\\nto the rete. They are conspicuous in inflammatory states. Other views\\npoint to the protoplasmic character of the cell-spirals, as also to the\\npossibility that they are related to the collagen of the corium.\\nThe epidermis varies greatly in thickness in different portions of\\nthe body for example, the epidermis of the palms and soles exceeds\\nin vertical section that which covers the dorsum of the hands and feet,\\nand that which protects such sensitive parts as the eyelids, lips,\\ntemples, and prepuce. The epidermis is composed of the following\\nprincipal layers, named in order from within outward the stratum\\nmucosum, the stratum granulosum, the stratum lucidum, and the\\nstratum corneum. Each of these strata, or layers, is histogenetically", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0037.jp2"}, "38": {"fulltext": "26\\nANATOMY AND PHYSIOLOGY OF THE SKIN.\\nderived from the one which is deeper in situation. Beside these,\\nRanvier and others recognize a stratum germinativum, a stratum\\nfilamentosum, a stratum intermedium, and a stratum disjunctum.\\nThe Rete Mucosum (Mucous Layee, Peickle-layee, Stratum\\nMucosum, Eete Malpighii or Malpighianum) is the deepest of\\nthe epidermal layers, and rests upon the corium below. It is now\\ngenerally designated as the rete. The corium is intimately united\\nwith it by a series of interdigitations, which are commonly described\\nFig. 7.\\nPrickle-cells from a condyloma (magnified about 625 diameters) a, cavity of cell-nucleus\\nb, nucleus c, nucleolus; d, prickles\u00e2\u0080\u0094 these are greatly developed on the protoplasm cf the\\ncells. The dots on the surface of the protoplasmic mass represent the appearance of the prickles\\nwhen directed toward the eye of the observer. Some of the protoplasmic threads are seen pass-\\ning from one cell to another.\\nas prolongations of the derma into the substance of the rete, but it is\\nequally true that the rete sends down prolongations (the rete-pegs\\ninto the derma. The two, in the need of an intimate union to resist\\nfriction and to insure vascular supply, are thus closely locked together.\\nThe stratum mucosum is built up of nucleated epithelial cells, poly-\\nhedral in outline and diffusely colored. These cells are masses of\\ngranular protoplasm, living matter, which by their relation to one\\nanother form a protoplasmic network enveloping the entire surface of\\nthe body and lining all channels and cavities in direct or indirect con-\\nnection with the surface. These elements are flattened by reason of\\ntheir apposition, and are separated from one another by an intercellular\\ncement-substance. There is a system of channels between the epi-\\nthelia by which the nutritive fluids are conveyed from cell to cell.\\nAll are, however, uninterruptedly united by delicate spokes, known as\\nprickles, spines, or thorns. The living matter, which produces a deli-\\ncate reticulum within each protoplasmic body, its points of intersection\\nbeing termed nuclei, nucleoli, and granules, sends forth the filaments\\nwhich produce continuity through all the living layers of the epithelial\\nelements, as well as through the underlying layers of the connective\\ntissue. The epithelia are unprovided with either blood-vessels or", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0038.jp2"}, "39": {"fulltext": "THE EPIDERMIS. 27\\nlymph- vessels but are supplied with a large number of nerves, which,\\nin the shape of very minute beaded fibres, traverse the intercellular\\nsubstance, and which are in direct communication with the reticulum\\nof living matter within the protoplasmic bodies themselves.\\nThe masses of protoplasm just described play the most important\\npart in all the pathological and physiological processes observed in\\nthe skin. It is probable that in the embryo all the appendages of\\nthe skin are formed directly by their assimilative and reproductive\\nprocesses and it is certain that in health and in disease they ire the\\nultimate source of all secretions.\\nNext the corium is a layer of cells, columnar in form, often largely\\nprovided with pigment, and arranged with their long axes nearly at\\nright angles to the plane of that portion of the corium upon which they\\nare superimposed. It is this row of cells which in certain cutaneous\\naffections displays in largest measure the phenomena of karyokinesis.\\nSegmentation of these cells occurs after a mitotic or thread-like meta-\\nmorphosis of the nucleus in the deeper layers of the rete (stratum ger-\\nminativum). More externally the cells are rounded or cuboidal in\\nshape, with large, distinct nuclei. They are not arranged in definite\\nstrata except in the outermost layers, where the cells are somewhat\\nflattened and elongated (stratum filamentosum). Between the cells in\\nthe deeper layers outwandered leucocytes may at times be recognized.\\nLangerhans Cells are elongated, irregularly stellate, non-nucle-\\nated bodies found chiefly in the deeper parts of the rete. They have\\nbeen looked upon as pigment-cells devoid of pigment, as wandering\\ncells, lymphoid cells, and as colorless tissue-corpuscles.\\nThe Stratum Granulosum (Granular Layer) of the epidermis,\\nlying immediately above the stratum filamentosum, is built up of three\\nor four rows of horizontally disposed granular bodies, united to one\\nanother by short, broad threads. Between these bodies the intercellular\\nspaces are so contracted that nutritive fluids cannot easily filter out-\\nward and the nuclei of the cells are usually shrunken. These have\\nbeen studied carefully by Ranvier, Kolliker, Waldeyer, and others.\\nAccording to these observers, the roundish granules which give this\\nlayer of epithelium its peculiar name and appearance consist of elei din\\nor keratohyalin, a substance essential to the process of cornification in\\nthe elements making up the horny layer of the skin, nails, etc. These\\ngranules first appear in the neighborhood of the nuclei of some of\\nthe large prickle-cells in the rete, but they are best studied in the\\ngranular layer, the cells of which are often completely filled with them.\\nAccording to Unna, the color of the skin in the white races depends\\nupon this layer alone.\\nThe Stratum Intermedium of Ranvier is practically a sub-\\ndivision of the stratum lucidum, from which it is distinguished chiefly\\nby the fact that it takes a reddish stain after treatment with picro-\\ncarmine. It is here that the process of keratinization of the epidermis\\nis first to be detected.\\nThe Stratum Lucidum (Septum Lucidum) of Oehl lies imme-\\ndiately above the stratum intermedium, and appears under the micro-\\nscope as a delicate, brightly colored line consisting of two or three rows", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0039.jp2"}, "40": {"fulltext": "28 ANATOMY AND PHYSIOLOGY OF THE SKIN\\nof transversely disposed, glistening epithelia, differing in translucency\\nfrom those situated on either side. The stratum lucidum thus marks\\nwith tolerable distinctness the boundary-lines of the rows of cells above\\nand below it. Its epithelial bodies seem to have lost suddenly the\\nrefractive, shining granules of keratohyalin conspicuous in the\\nstratum granulosum below. These granules are generally supposed to\\nhave disappeared in consequence of their solution in the protoplasm\\nof the cell-body, which has thus acquired an added brilliancy and\\nclearness.\\nThe Stratum Corneum (Horny Layer) of the epidermis is its\\noutermost and widest layer, extending from the stratum lucidum below\\nto the external environments of the body. In its lower portion the\\npolygonal plates of which it is composed indicate very clearly their\\nrelationship to the cells in the prickle-layer. The nuclei appear in\\nplaces only as shrivelled and inconspicuous relics of the protoplasmic\\nthreads or there may be merely vacant nuclear spaces marking their\\noriginal site. Occasionally, on the edges, rudiments of the prickle-\\nthreads may still be recognized. More externally the dried, lifeless,\\nhorn-like plates of which this layer is composed become mere cornified\\nshells, generally lying in horizontal strata, and becoming more curled\\nand wrinkled as the surface of the skin is reached, often being imbri-\\ncated, but preserving the polygonal outlines of epithelia relieved of the\\nforces of pressure and counter-pressure exerted in the deeper parts of\\nthe epidermis. These elements are rarely pigmented, save in the case\\nof the negro, in whom the intense staining of the deepest parts of the\\nmucous layer extends measurably to the external strata. This staining\\nin the colored races is produced by granules of pigment arranged about\\nan unpigmented nucleus in the prickle-cells. The cells of the horny\\nlayer contain fatty material in very considerable proportion, a provision\\nby which the suppleness of the skin is maintained and undue evapora-\\ntion prevented.\\nAfter digestion with pepsin and trypsin the horny cells may be seen\\nto be connected by more or less persistent threads, visible after pro-\\nlonged digestion as a large-meshed reticulum, with strands formed from\\na double row of cornified filaments united by short horny bridges.\\nThe Stratum Disjunctum of Eanvier is the most superficial of\\nthe layers of the stratum corneum, differing chiefly from the latter in\\nthat it is indifferently colored by osmic acid.\\nEpitrichiae Layer. Welcker, 1 Minot, 2 and Bowen 3 have de-\\nscribed a layer of large cells, with round nuclei much larger than those\\nof the epidermal layers beneath, covering the entire body of the human\\nembryo during the early months of its existence. This layer, histologic-\\nally, is quite distinct from the outer cells of the stratum corneum, and\\ncorresponds with the epitrichium of certain animals. It usually dis-\\nappears before the sixth or seventh month of uterine life.\\n1 Ueber die Entwickelung und den Bau der Haut und der Haare bei Bradypus.\\nHalle, 1854.\\n2 American Naturalist,, June, 1886.\\n3 Anatomischen Anzieger, iv. Jahrgang (1889), Nr. 13 u. 14 and Jour. Cutan. and\\nVen. Dis., 1895, p. 485.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0040.jp2"}, "41": {"fulltext": "BLOOD-VESSELS. 29\\nBLOOD-VESSELS.\\nThe arteries and veins supply the skin from subcutaneous branches\\nwhich penetrate the underlying fasciae, and proceed by subdivision to\\nbe distributed to all portions of the integument below the epidermis,\\nthe distribution being especially abundant about the glands and fol-\\nlicles of the skin and the inferior and superior parts of the corium.\\nThey are always more abundant upon the flexor than upon the extensor\\nfaces of the extremities. Just beneath the papillary laypr of the\\ncorium there is a minutely ramifying plexus of fine capillaries, the\\nloops of which extend into the papillae above. This and the coarser\\nplexus in the deeper portion of the derma are well defined, and have\\nbeen designated as superior and inferior partes vasculares of the corium\\nalso, as the upper and lower vascular net. They are connected by more\\nor less regularly placed and nearly vertical communicating branches.\\nA fourth division of the vascular system of the skin is found in the\\nsubcutaneous connective tissue, in which the vessels are numerous a\\nfifth is represented by the vessels distributed to the papillae; and lastly,\\na sixth includes the vascular channels supplying the accessories of the\\nintegument.\\nThe arterioles which supply the sweat-glands surround the coils\\nof the latter in a delicate basket-like plexus, and terminate in two or\\nthree veinlets, one of which always accompanies the duct of the gland\\nupward as far as the papillary layer, where it anastomoses with the\\nvessels of that part of the skin. The ascending arterioles supply the\\nsebaceous glands and hair-follicles, and, breaking up into smaller and\\nyet smaller branches, finally furnish a single or a double capillary loop\\nto each papilla. These capillaries of the papillary layer anastomose\\nfreely with those transversely arranged in the upper portion of the\\nhair-follicles, from which loops also pass to the sebaceous glands. The\\nhair-papilla has a vascular supply similar to that of each of the other\\npapillae of the corium.\\nUnna divides the vessels distributed to the skin into the papillary\\nsystem and the system of the coil-glands and fat-tissue. The first\\nsystem includes the ascending loops which traverse the vascular pa-\\npillae, and the branches supplying lower portions of the corium. The\\nsecond system embraces the vessels running upward to the coil-glands\\nand downward to the fat-tissue. In the papillary vascular system the\\narteries are narrow and the veins wide. Each of the vessels consists\\nmerely of an endothelial tube augmented, as the subcutaneous tissue is\\nreached, by both media and adventitia. According to Hover, a sin-\\ngular duplex arrangement of vessels in the distal phalanges of both\\nfingers and toes results in a distinct communication between the arte-\\nries and veins. Other observers deny the existence of such anas-\\ntomosis.\\nVasomotor nerves are twined around these vessels in all their rami-\\nfications. The whole vascular system, as thus arranged, plays a most\\nimportant part in all the healthy and morbid processes which occur in\\nthe skin, as well as in the physiological changes distinguishable to the\\neye in the phenomena of blanching and blushing.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0041.jp2"}, "42": {"fulltext": "30 ANATOMY AND PHYSIOLOGY OF THE SKIN.\\nLYMPHATIC VESSELS.\\nThe skin in all its parts is provided with a closed system of lym-\\nphatic channels, designed to subserve the necessities of the important\\nprocesses of absorption, and traversed by lymph the currents of which\\nare continuously directed to the large vessels of the structures beneath\\nthe skin. These channels include: first, juice-spaces, provided or not\\nwith independent walls, usually without, and not freely communicating\\nwith the endothelium-lined vessels second^ lymphatic vessels proper.\\nThese conduits do not connect with blood-vessels.\\nThe juice-spaces, or lymph-spaces, separate the epithelial bodies which\\nmake up the stratum mucosum of the epidermis, and they also extend\\nbetween the protoplasmic threads, or prickles, that unite them. Such\\nconduits may be regarded either as delicate excavations in the cement-\\nsubstance between the epithelia, or as irregular channels in a soft,\\nviscid, albuminoid, and readily coagulable substance between the pro-\\ntoplasmic threads. At times this intercellular substance seems capable\\nof obstructing the conduits by which it is tunnelled. These juice-\\nspaces exist in the papillae of the corium, and encircle the several\\nglands, hair-follicles, and nail-beds of the skin. They also sheathe\\nthe connective-tissue fibrillar of the corium and surround the fat-cells.\\nAccording to Darier, the derma is a true lymphatic sponge.\\nThe lymphatic vessels are relatively few, but they form a continuous\\nmeshwork with transversely and vertically disposed branches supply-\\ning all parts of the skin below the epidermis. The juice-spaces com-\\nmunicate with these vessels in the papillary portion of the corium\\nthrough minute orifices in the vascular walls, the vessels themselves\\nbeing here represented by blind terminal loops. As these vessels pass\\nto the deeper portions of the corium and below it they increase in size.\\nThe current of the lymph flows from the papillary apices to all parts\\nof the rete, like the currents in the delta of a river, a reflux occurring\\nat the lower limit of the interpapillary depressions of the rete down-\\nward, possibly through the sweat-pores which traverse the epidermis\\nat these points. Thence the current flows freely downward to the\\nlymphatic vessels in the corium, but the stream from the juice-spaces\\nabout the coil-glands and fat-tissue is retarded by reason of a more\\nrestricted communication with the lymphatic vessels below. In conse-\\nquence of the retardation due to this anatomical peculiarity the forma-\\ntion of fat by filtration is facilitated.\\nNERVES.\\nThe skin, in view of the number and mode of distribution of its\\nnervous elements, may be regarded as a vast area of sensitive nerve-\\nterminals. INon-medullated and medullated nerve-fibres, each in places\\nbeing substituted for the other, are supplied to the skin from horizon-\\ntally disposed bundles of nerve-twigs in the subcutaneous tissue. These\\nfibres traverse the corium in connection with the blood-vessels, and\\nbecome finer as they ascend, until they form a subepithelial plexus just\\nbelow the epidermis.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0042.jp2"}, "43": {"fulltext": "NER VES.\\n31\\nExceedingly delicate Non-medullated Fibres penetrate in great\\nabundance to the epidermis between the epithelia, and are not to be\\nconfounded with the migratory cells found in this situation. Here,\\ntraversing the intercellular substance by the side of the juice-spaces,\\nthese fibres either terminate between the prickle-cells as ultimate bul-\\nbous terminations of finely beaded fibrillar or penetrate the epithelia them-\\nselves in pairs. Each prickle-cell is supplied with a pair of these beaded\\nfilaments, which may be either applied to the nucleus of the cell or be\\nseen to encircle the nucleus more or less completely. Above the stra-\\ntum granulosum these nervous threads cannot be recognized.\\nSimilar nerve-filaments are supplied to the sheaths of the hairs and\\nthe ducts of the coil-glands. It is by means of these numerous and\\ndelicate fibres that the perception of sensation in the skin is accom-\\nplished.\\nMotor filaments are also distributed to the sheaths of the blood-\\nvessels (vasomotor nerves), in which they are finally lost. Other motor\\nfilaments supply the muscles, and trophic nerves are distributed to all\\nthe secreting organs of the skin and to all its protoplasmic formations.\\nThe Medullated Nerve -fibres of the skin in one or several loops\\npass upward into the papilla?, and then turn backward to the subpapil-\\nlary region. Some of these fibres, after such reversion, again ascend to\\nan adjacent papilla others are supplied to the Pacinian and tactile cor-\\npuscles.\\nFig. 8.\\nPacinian body, after silver staining,\\nshowing superimposed endothelial lay-\\ners. (After Renaut.)\\nSection of Pacinian body from a duck s bill;\\ng.L, lamellar envelope; g.h, hyaline zone of the\\nlamellar envelope b.t, terminal bulb of the nerve\\ng.p, n.g.p, layer investing the cavity of the body.\\n(After Renatjt.)\\nThe Pacinian Corpuscles (named from the anatomist Pacini), also\\ncalled Corpuscles of Vateb, exist subcutaneously only upon nerves\\nintended for cutaneous supply they are ovoid bodies, two or more mil-\\nlimetres in diameter. Each corpuscle consists of a series of concentric,", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0043.jp2"}, "44": {"fulltext": "32\\nANATOMY AND PHYSIOLOGY OF THE SKIN.\\nnucleated, vascular capsules, arranged after the manner of the capsules\\nof the onion, more closely united at the periphery than at the centre,\\nand surrounding a protoplasmic core. The medullated nerve to which\\nthe body is attached gradually loses its myeline envelope, and termi-\\nnates in the centre of this core, after traversing the greater part of its\\naxis, in one or several minutely club-shaped filaments. The myeline\\nFig. 9.\\nSection of a papilla still covered by a portion of the stratum mucosum and containing a\\ntactile body (from the skin of a finger). The corpuscle of Meissner is seen to consist of minute\\nlobules, made up of a homogeneous protoplasm, with numerous oval nuclei and nervous fibrillse\\nwound in a spiral direction about the mass of the corpuscle. The extension of the fibrillae to the\\nmucous layer is shown. The sources of the nerve-filaments are demonstrated to be (1) the axis-\\ncylinders of one or two double-contoured nerve-fibres, splitting into their original fibrillse on\\narriving at the corpuscle, winding about the latter in characteristic spirals, and passing to the\\npalisade-layer of the prickle-cells of the rete, between which, on account of the long prickles\\nof the latter and the general resemblance of the two in thickness and contour, it is difficult to\\ntrace them further; (2) filaments from another double-contoured nerve-fibre (h) pass directly to\\nthe inferior layer of cells in the rete without establishing relations with the tactile body; (3)\\nfibrillae derived from the network of nervous fibrillae in the pars papillaris of the corium (K),\\nalso passing more or less directly to the stratum mucosum. a, cells of the rete; 6, prickles of\\nthe latter; c, body of papilla d, nuclei of connective tissue forming papilla e, protoplasmic part\\nof the tactile body with its nuclei fibrillae of the corpuscle g, double-contoured nerve-librcs\\ndirectly supplying the rete k, nervous fibrillae derived from the network in the pars papillaris\\nI, nervous fibrillae entering the epidermis between the rete-cells, leaving the rorpusculum tactus\\nat m.\\nsheath is lost in the tissue of the concentric capsules. The nerve may,\\nafter supplying one capsule, penetrate a second or even a third. In\\nsuch cases the nerve regains its sheath as it issues from the corpuscle at\\nits opposite pole. Robinson believes that the nerve forms a plexus or\\nloop within the corpuscle, and escapes from it at one of its poles.\\nThe precise function of the Pacinian corpuscle is unknown. Its", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0044.jp2"}, "45": {"fulltext": "NERVES.\\nconnection with the tactile sense is suggested by its location, since\\nthese bodies are most numerous in the subcutaneous tissue of the nipple,\\nthe penis, the digits, and in parts similarly sensitive. These corpuscles\\nbear an analogy to the organ of vision each body having a capsular\\ncharacter; each being provided with a special nerve-filament, which\\nenters the corpuscle at one pole; each also receiving its impressions at\\nthe extremity of the capsule opposite that at which it receives its\\nnervous supply.\\nFig. 10.\\nTransverse Bectlon of nervous papilla surrounded by cells of the stratum mucosum: a,\\n{trotoplasmic lobules of the corpusculum tactus; b, nervous fibrillar spirally wound about the\\natter; c, transverse section of double-contoured nerve-fibres cavity of nucleus (.out of focus).\\nAccording to Krause, the Pacinian corpuscles aid in the appreciation\\nof impressions produced by pressure and traction. Whether specially\\nconcerned in distinguishing sensations of heat, cold, moisture, pressure,\\ntraction, or weight, it is evident that they contribute but little, if at all,\\nto the perception of ordinary impressions upon the skin, and they are\\nnot known to play any part in cutaneous diseases.\\nThe Tactile Corpuscles (Corpuscles of MEissNERoroF Wagner)\\narc ovoid bodies found in about one in four of the papilla? in the pars\\npapillaris of the corium. Each corpuscle is composed of from one to\\nthree capsules. Minute lobules of a homogeneous protoplasm with\\noval nuclei are found in each. These corpuscles receive medullated\\nnerve-fibres, and arc made up of closely compressed, flat connective-\\ntissue fibres with minute nuclei, which are so packed together as to\\nform a spindle-shaped mass occupying the greater part of the papilla\\nin which each corpuscle is found and surrounded by a somewhat denser\\nconnective-tissue capsule. The myeline sheath of the nerve-fibres is\\nlost in the fibrous tissue of the corpuscle. Externally viewed they\\nseem to be transversely striated.\\nThe axis-cylinder of the nerve-filament distributed to each corpuscle\\ndivides into numerous delicate nerve-threads which in part encircle the\\n3", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0045.jp2"}, "46": {"fulltext": "34 ANATOMY AND PHYSIOLOGY OF THE SKIN.\\ncorpuscles and also penetrate within. Each corpuscle is provided with\\nan afferent and an efferent nerve, the former approaching the corpuscle\\nfrom the subpapillary region and entering at or near its base. Occa-\\nsionally the afferent fibre is furnished by an adjacent papilla. As the\\nfilament that enters the corpuscle frequently divides, two or more\\nefferent fibres may then escape from it. Afferent fibres reach the rete\\nabove after encircling the tactile corpuscles others, side by side, arrive\\nat the rete without coming into contact with the former.\\nThe discovery of nerve-filaments in and among the epithelia of the\\nepidermis in such abundance as to provide fully for tactile sensation\\nin the skin leaves the exact function of these corpuscles in partial ob-\\nscurity. There can be little doubt, however, as to their association\\nwith the perception of certain qualities of foreign bodies with which\\nthe skin may be brought into contact.\\nMerkel s Touch-cells are oval, nucleated bodies found in the\\nlower animals, but also in man. They are supposed to be connected\\nwith the ultimate nerve-fibres. They resemble cells in a mitotic state,\\nand are found in the upper part of the corium as well as the epidermis,\\nand in regions in which the tactile corpuscles are few, as over the\\nabdominal surface.\\nThe Corpuscles of Krause (Bulb-corpuscles: Kolbenkor-\\nperchen) are rounded or oval-shaped bodies formed of a connective-\\ntissue envelope and a non-nucleated bulb to which some delicate nerve-\\nfibres penetrate. These bodies are found chiefly along the borders of\\nthe lips, over the glans penis, the clitoris, and the tongue.\\nPIGMENT.\\nThe hue of the living integument is due in part to the degree of\\nvascularity and distention of the vessels in the corium, and in part\\nalso to pigmentation of the epidermis. The coloring-matter of the\\nskin in health is deposited chiefly in from one to four rows of cells\\nin the lower stratum of the rete, the fine granules of pigment staining\\nboth the cell-bodv and the nucleus, the latter more vividly. The\\ndegree of vascularity of the skin is responsible for most of the flesh-\\ntints, but the colors seen in the various races of men are wholly related\\nto the character and quantity of pigment found in the rete. Rarely,\\npigment-cells are found in the corium in a state of health. This\\npigmentation depends upon a distinct and uniform coloration of the\\nepithelia, and also upon minute granules of pigment entangled in the\\nreticulum of living matter in the same part. Extreme variation in\\nthe distribution of pigment is noticeable both in health and in disease,\\nand in individuals and races, being at times related to climatic and\\nsimilar influences. This fact is well illustrated by the wide range\\nbetween the flaxen-haired, pink-eyed albino and the blackest specimens\\nof the negro, each, with small exception, being of African descent.\\nIt has already been noted that in the colored races the pigment may\\nstain the epithelial cells and their nuclei as high as the granular layer\\nand that to this layer only is due the characteristic color of the skin\\nof the white races. Pigment is not normally found either in the horny", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0046.jp2"}, "47": {"fulltext": "MUSCLES. 35\\nlayer of the skin or in the subepithelial tissues. Waldeyer claims to\\nhave recognized it in normal connective tissue.\\nThe source of the pigment in the skin has not been positively de-\\ntermined. It is believed by some to be carried by leucocytes from the\\ncorium beneath to the rete above; others have thought that the pig-\\nmented cells themselves were capable of migration. Yet others teach\\nthat the pigment is produced de novo within the rete-cells. It is most\\nprobable that the pigment is derived from the subepidermal structures,\\nand is originally obtained from the blood itself.\\nThe relation existing between the two sources of skin-coloration,\\nviz., the blood and pigment, is interesting and suggestive. The un-\\naided eye, looking at the outer surface of the body, makes little dis-\\ntinction between these two color-sources. It is certain that solar heat\\nexerts a manifest influence upon both, and that in extravasations of\\nblood into the substance of the skin every shade of color visible in the\\nspectrum may at times be distinguished.\\nMUSCLES.\\nStriated Muscular Fibres extend from the subcutaneous tissue into\\nthe derma; in the case of man they are found chiefly upon the face\\nand neck, where they are the analogues of more powerful skin-moving\\nmuscles possessed by several of the lower animals. Some, as those in\\nthe region of the lace, serve to give expression to mental emotion by\\nthe production of facial movements.\\nNon-striated Muscular Fibres exist either as minute oblique fas-\\nciculi in connection with the glands and follicles of the skin; or as\\nannular bands, such as those which surround the nipple; or as radiat-\\ning and more or less parallel rods, such as antagonize the orbicularis\\nin the eyelids.\\nThe Arrectores (Erectores) Pilorum are muscles found usually\\nin connection with the hair-follicles. They originate by minute multiple\\nfasciculi from the papillary portion of the corium, and are inserted at\\nseveral points into the outer layer of several adjacent hair-follicles, just\\nabove the plane t the apex of the hair-papilla. Their general direc-\\n1 tion is oblique, and their muscle-bundles are embraced and traversed\\nby elastic fibres which form a dense network about them. Elastic\\nthreads also connect them intimately with the connective-tissue bun-\\ndies of the corium, and serve as tendons at either extremity of each\\ni muscular fasciculus.\\nThe muscles, by virtue of their oblique direction and mode of attach-\\nment, include in the angle subtended by their muscular fibres the\\nI sebaceous glands connected with the hair-follicles. It follows, there-\\nfore, that by their contraction they aid in the expulsion of the seba-\\nceous secretion formed in the gland but their intimate union with\\nthe elastic tissue, which is evenly and generally distributed throughout\\nthe framework of the corium, results in their discharge of a still more\\nI important function in connection with the regulation of the body-tem-\\nperature, since by virtue of direct compression exerted upon the skin\\nthe blood may be driven from the surface in a centripetal direction", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0047.jp2"}, "48": {"fulltext": "36 ANATOMY AND PHYSIOLOGY OF THE SKIN.\\nand its cooling in a great degree prevented, as in the well-known\\nphenomena resulting in the production of the cutis anserina, or goose-\\nflesh. The reverse of this naturally follows when the muscles expand\\nunder the influence of external heat. The anatomical connections of\\nthe arrectores pilorum are such that their contraction serves to ap-\\nproximate several of the papillae of the corium, including the hair-\\npapilla. Thus, by their contraction the sebaceous secretion may be\\nextruded, or, as is more particularly exhibited in the lower animals,\\nsuch hairs as the bristles of the boar may be erected.\\nMuscular Membranes exist in the skin of the scrotum, over the\\npenis, about the nipple, and elsewhere. They are simply layers of\\nsmooth muscular fibres, which suffice when contracting to move the\\nportions of skin to which they are distributed.\\nHAIES.\\nHairs are cylindrical, elongated, and pointed epithelial filaments,\\nderived from the epidermis, and obliquely implanted in depressions in\\nthe rete and corium, known as hair-sacs, or hair-follicles. They\\nare found on all the superficies of the body except the palms and\\nsoles, the dorsum of the distal phalanges of the hands and feet, and\\nthe skin of the penis. Hairs occur in three tolerably distinct classes.\\nThese are the fine, downy hairs, or lanugo, covering the face, the\\ntrunk, and the limbs the long, soft hairs, such as those implanted\\nupon the scalp, the pubes, and the axillae and the short hairs, includ-\\ning the soft varieties seen upon the brow and the stiff hairs of the\\neyelids.\\nThe hairs are first developed in the third month of foetal life, when\\na short epithelial, cone is formed, the base of which is gradually sur-\\nrounded by connective-tissue cells, and finally indented from below by a\\nrudimentary hair-papilla. Gradually the tip of the rudimentary hair\\nperforates the primitive hair-cone and becomes a mature filament.\\nAt about the period of birth, sometimes earlier, occasionally later,\\nthe bed-hairs, as they are called by Unna, are replaced by papil-\\nlary hairs. The term bed-hair is applied to primary hairs unprovided\\nwith papillae, and implanted in shallow follicles, from the sides of\\nwhich productive epithelial offshoots have been sent out. Usually at\\nthe end of foetal life these bed-hairs have been for two months growing\\nout of the hair-bed, or that part of the epithelium found in the cen-\\ntral part of the hair-sac.\\nHairs thus differ from nails not only in their anatomical features, but\\nparticularly as to their physiological reproduction. Hairs are period-\\nically cast off and replaced by new filaments. The nails are shed and\\nreformed only in disease in health they enjoy a continuous growth\\nduring the life of the body. When a hair is about to be shed it sepa-\\nrates from its papilla in the hair-follicle and rises in the latter till it\\nreaches above the level of the papillary apex. It is for a time held\\nin place with sufficient firmness by the prickle-layer only, thus forming\\nthe bed-hair already described. Later an epithelial bud is projected\\neither into the vacant follicle below or into the corium on either side,", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0048.jp2"}, "49": {"fulltext": "HAIRS.\\n37\\nfrom which a new hair is formed, somewhat as the hair is formed in\\nthe primitive cone of foetal life. The subsequent growth outward of\\nthe new papillary hair separates the bed-hair from its connection with\\nthe prickle-layer, and this filament is shed.\\nFig. 11.\\nFig. 12.\\nSection of a hair-follicle during the forma-\\ntion of a new hair a, external and middle\\nroot-sheaths b.vitreous membrane c, papilla\\nwith vascular loop d, external root-sheath\\ni, internal root-sheath cuticle of hair-fol-\\nlicle g, cuticle of hair h, i, young hair I,\\nbulb of old hair; k, debris of external root-\\nsheath of hair recently expelled. (After\\nEbner.)\\nHair- follicle in longitudinal section: a,\\nmouth of follicle b. neck c, bulb d, e, der-\\nmic coat outer root-sheath g, inner root-\\nsheath h, hair; k, its medulla; I, hair-knob\\nm, adipose tissue n, hair-mnscle o, papilla\\nof skin p, papilla of hair s, rete mucosum,\\ncontinuous with outer root-sheath ep, horny\\nlayer t, sebaceous gland.\\nIn studying the mature hairs the parts to be considered are the\\nhair-follicle, and the bulb, shaft, and point of the hair.\\nHair-follicle. The hair-follicle is a sac-like pouch in the corium,", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0049.jp2"}, "50": {"fulltext": "38 ANATOMY AND PHYSIOLOGY OF THE SKIN\\nin which depression the hair-filament is implanted by its bulb and there\\nfirmly secured. The direction of this follicle is always at an oblique\\nangle with the plane of the cutaneous surface upon which it opens, and\\nthus is determined the set of the hairs, which is always fixed and at a\\nsimilar angle. Viewed as a whole, the integument of the body over its\\nentire area exhibits determinate whorls of both short and long hairs\\nwith definite centres, such as those which may be recognized at the\\nvertex of the scalp, the centres of the lips, the umbilicus, etc. By this\\ndisposition the symmetrical appearance of the hairy parts is preserved,\\nand, as a consequence of the same provision, physiological loss of the\\nhair of the head is not productive of deformity, but rather adds dignity\\nto the aspect of the elderly man.\\nThe hair-follicle embraces the lower two-thirds of that portion of\\nthe hair which is imbedded in the skin, together w T ith the envelopes of\\nthe latter, termed the hair-sheaths. Above the sebaceous glands the\\nsheaths of the hair-follicle are lost in the papillary layer. The follicle\\nis constituted of the connective tissue of the corium in three layers an\\nexternal longitudinal fibrous layer a middle transverse layer and\\nan internal homogeneous or vitreous layer. At the base of the sac a\\nfibrous pedicle may often be traced as low as the subcutaneous tissue.\\nIf the hair-pouch were made artificially by thrusting into the skin\\nfrom without inward a blunt-pointed pin before which the tissue was\\ngradually pushed, it is evident that the external layer, the stratum\\ncorneum, of the epidermis would be the first depressed, and finally\\nwould form the inner surface of the pouch. This represents the inner\\nroot-sheath of the hair. Next to this the pin would carry before it the\\nmucous layer of the epidermis, which then would form the outer root-\\nsheath of the hair. Outside of both would lie the connective tissue of\\nthe corium.\\nThe Outer Root-sheath, or the prickle-layer of the hair-follicle,\\naccompanies the involutions of the stratum corneum and the stratum\\ngranulosum from without into the funnel-shaped neck of the hair-pouch\\nas far as the openings of the ducts of the sebaceous glands. There,\\nabandoned by the two other layers of the epidermis, the root-sheath is\\nthinned in proportion as the papilla, which rises from below and which\\nit closely surrounds, increases in size. It thus forms a hollow cylinder\\ntraversed by the hair and its envelopes, with a relatively wide, external,\\nfunnel-shaped opening, only partially filled by the shaft of the hair,\\nand a narrower opening within, which embraces the neck of the hair-\\npapilla.\\nThe Inner Root-sheath, or matrix of the root-sheath, is exter-\\nnally in relation with the outer root-sheath, or prickle-layer, of the hair-\\nfollicle. The protoplasm of the cells of which it is constituted contains\\nkeratohyalin in varying quantities, the amount being natural lv greater\\nin the cells lying nearest the hair-filament. That part of the sheath\\nformerly termed Henle s layer is the more externally situated cel-\\nlular envelope of this internal root-sheath, and is most conspicuous in\\nthat part of the hair-sac above the level of the papilla. That part of\\nthe sheath formerly called Huxley s layer is the more internally sit-\\nuated part of the same sheath, somewhat higher in the follicle. These", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0050.jp2"}, "51": {"fulltext": "HAIRS.\\n39\\nare not distinctly different structures, but only a single structure in\\ndifferent situations. Whether termed the internal root-sheath or the\\nmatrix of the root-sheath, it springs from the neck of the papilla, and\\nrises as high as the neck of the follicle. It contains keratohyalin, which\\nis actively concerned in the cornification of the hair-tissue.\\nBetween this internal root-sheath and the cells constituting the cor-\\ntex of the hair there is found, according to Unna, the common matrix\\nFig. 13.\\nLower portion of hair-pouch from the lip of a kitten: F, follicle; T, transverse section of\\nconnective-tissue bundles of derma M, arrector pili muscle IS, inner root-sheath OS, outer\\nroot-sheath; P, papilla C, cuticle; R, root of hair; H, hyaline, or so-called structureless,\\nmembrane. Magnified 500 diameters. (After Heitzmann.)\\nof the cuticulse, forming respectively the cuticle of the root-sheath and\\nthe cuticle of the hair. The former is composed of cells with their\\nlong axes parallel with the circumference of the hair, while those\\nforming the cuticle of the hair are arranged perpendicularly to the sur-\\nface. These cuticulse are securely locked together by projection of\\ntheir cell-edges, while united in the hair-follicle.\\nThe Bulb (or Root) is that portion of the hair imbedded in the", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0051.jp2"}, "52": {"fulltext": "40\\nANATOMY AND PHYSIOLOGY OF THE SKIN.\\nFig. 14.\\nskin, toward which the shaft of the hair gradually increases in thick-\\nness as it descends. The bulb is embraced by the hair-follicle, though\\nits root-sheaths are interposed and implanted below at the base of the\\nsac upon a nipple-shaped prolongation of the corium that may be re-\\ngarded as analogous to the vascular papillae of the papillary layer of\\nthe corium.\\nThe bulb of the hair embraces the papilla, and is constituted of pig-\\nmented cells externally, forming what is called the cortex or cor-\\ntical portion. This is the larger of the two structures of which the\\nhair is composed, and its cells become vertically elongated and narrow\\nas they are pushed outward in the process of growth.\\nThe Shaft of the Hair is that portion which extends from the exit\\nof the hair at the surface of the skin to its extremity the latter, when\\nuncut, always tapers to a perfectly acuminate point, as illustrated by\\nthe uncut hairs of the eyelids and those of\\nthe lower animals. The hair-shaft is either\\nstraight, curled, wavy, or alternately varied\\nin diameter. A transverse section pre-\\nsenting an ovoid or ellipsoidal outline sug-\\ngests an irregularly compressed circle. The\\ndegree of this flattening varies in different\\nraces, and is the cause of variability with\\nrespect to straightness or curliness. As\\nhairs are to a marked degree hygroscopic,\\nand not only absorb but can be deprived\\nof a portion of their water, these states of\\nwaviness are subject to variation according\\nto the aqueous condition of the media by\\nwhich an individual is surrounded.\\nThe color of the hair is dependent upon\\nthe pigment it contains, the color of the\\nhair-cells, and the quantity of air contained\\nin the medulla. Variation in these three factors produces the wide\\nrange between a snowy whiteness and an ebony black.\\nThe coloring-matter of the hair is thus stored in both its horny and\\nits medullary portions, and is distinct both within and between the\\nepithelial elements of which the hair is composed. This pigmentation\\ncorresponds in great part with the amount of pigment distributed to\\nother parts of the integument, and sustains a close relation to the\\ngeneral nutrition of the body. Its subjection to the influence of the\\ntrophic nerves is well demonstrated by the phenomena of rapid blanch-\\ning of the hairs. Excessive sweating, whether physiological or induced\\nby the action of pilocarpine, has also a distinct influence upon the shade\\nof color of hair.\\nThe membrane which invests the shaft of the hair is the cuticle,\\ncomposed of numerous flattened plates, non-nucleated and non-pig-\\nmented, regularly overlaid so as to resemble closely adherent fish-scales\\nwhen viewed under the microscope on the flat side, and the overlapping\\ntiles of the roof of a house when seen on the edge.\\nThe Cortex of the hair, constituting the greater part of its bulk, is\\nTransverse section of hair and\\nfollicle.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0052.jp2"}, "53": {"fulltext": "SEBACEOUS GLANDS. 41\\ncomposed of flat, nucleated, pigmented, fusiform epidermal cells. The\\nstrength, elasticity, and extensibility of the hair are chiefly due to the\\ncortical substance, and in particular to the firmness with which these\\nepidermal cells are attached to one another.\\nThe Medulla of the hair is found best developed in the short, strong\\nhairs of the beard and eyelashes, being wanting in the lanugo-hairs.\\nIt consists of a loosely packed mass of epidermal elements with inter-\\nspersed air-spaces, differing in shape, developed in the centre of the\\naxis of the shaft. This part of the hair contains also the pigment and\\nfatty matters, which are here arranged as in the rete of the epidermis.\\nSeen under the microscope, the medulla appears as a continuous or\\ninterrupted longitudinal band extending from the bulb, or the part\\nimplanted in the follicle, to the extremity, or point, of the hair. The\\npurpose of this difference in the constitution of the cortex and medulla\\nof the hair is doubtless to insure, on well-known mechanical principles,\\na maximum of strength, extensibility, and elasticity, with a minimum\\nof volume.\\nSEBACEOUS GLANDS.\\nThe sebaceous, or sebiparous, glands are pyriform bodies, usually\\nracemose in development, situated in the corium, never in the subcuta-\\nneous tissue they furnish a more or less consistent and fatty secretion\\ndestined to anoint the skin and hairs. Thev can usually be distin-\\nguished as of three classes, though only two of these classes include\\nglands which are associated with hairs in the embryo.\\nThe first class includes the sebaceous glands, which, strictly speak-\\ning, are appendages of the hairs and hair-follicles. They are developed\\nearly in fcetal life from minute, lateral, bud-like prolongations from\\nthe outer root-sheath of the hair. From two to six of these prolonga-\\ntions spring from the prickle-layer of the hair-follicle, and the prickle-\\ncells in the axis of each bud speedily undergo fatty metamorphosis.\\nIn the mature gland each acinus is formed of a membrana propria\\nsupporting layers of nucleated cuboidal epithelia undergoing fatty\\nmetamorphosis. Gradually the fatty cells are pushed outward toward\\nthe duct of the gland, where, sooner or later, their rupture releases\\nnumerous drops of fat (sebum) just where the hair emerges from the\\nclosely applied follicle below to the funnel-shaped mouth of the hair-\\npouch above. Externally each gland is provided with a layer of con-\\nnective tissue. Sebaceous follicles are found in connection with the\\n1 long, soft hairs, as those of the scalp and the axillae, several being\\ngrouped around a single hair-sac.\\nThe second class includes the large and complex glandular structures\\nto which the lanugo-, or rudimentary, hairs seem accessory, the orifices\\nof their respective ducts opening directly upon the cutaneous surface.\\nThese glands are chiefly found upon the glabrous portions of the skin,\\ni as upon the face in both sexes and upon portions of the trunk and\\nextremities.\\nThe third class includes those sebaceous glands, much the smallest\\nf in number, opening directly upon the surface and unconnected with\\nhairs or hair-follicles. Such are the glandular odoriferse of the male", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0053.jp2"}, "54": {"fulltext": "42\\nANATOMY AND PHYSIOLOGY OF THE SKIN\\nand female genitalia, and those existing about the lips and in the areola\\nof the nipple. These glands might be designated as glands of the\\nmucous orifices.\\nThe Meibomian and Tysonian Glands are of the largest order\\nof sebaceous glands. The former exist within the free border of the eye-\\nlids the latter, upon the glans penis and the inner face of the prepuce.\\nThey are unconnected with hairs, and in this respect differ from other\\ntypes of sebaceous glands.\\nFig. 15.\\nSebaceous glands of the second class, from the alae of the nose. (After Sappey.)\\nThe Glandule Ceruminos^: are situated in the sebaceous tissue\\nof the meatus of the ear, and contribute to the waxy secretions there\\nfurnished. The glands of Moll found in the eyelids are to be\\nclassed with the sweat-glands.\\nThe Sebaceous Secretion contains, chemically, water, palmitic and\\noleic acids, palmitin and olein soaps, and the saline constituents of the\\nother organic animal compounds, chlorides and phosphates of the alka-\\nlies and earths. The extrusion of the secreted sebum from the ducts\\nof these glands is greatly favored by the action of the arrectores pilo-\\nrum muscles, by the contractions of which the gland is to a degree com-\\npressed. This is the reverse of what occurs in the coil-glands, the\\nsecretion of which is impeded by the action of these same muscles.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0054.jp2"}, "55": {"fulltext": "COIL-GLANDS.\\n43\\nCOIL-GLANDS.\\nThe coil-glands (Sweat or Sudoriparous Glands, Glandule\\nGlomtformes), found within the skin of all regions of the body, are\\nglobular coils situated in the subcutaneous tissue and in the deeper\\nportions of the corium. They appear first in the fifth month of foetal\\nlife as buds projected down-\\nward from the prickle- Fig. 17.\\nlayer of the epidermis.\\nThese projections always\\nform between the papillse\\nof the corium, and spring\\nfrom the rete-pegs between\\nthese papillae. Long, thin\\ncones of epithelium thus\\ngradually traverse the co-\\nrium, and become slightly\\nbulbous at the lower ex-\\ntremity to form later the\\ncoil. The lumen, when\\nformed, extends rapidly to\\nthe epidermis, and after\\nthis is reached there is\\nformed from within out-\\nward an opening, which\\nbecomes the sweat-pore.\\nAfter birth these glands\\nare found in all parts of\\nthe body, but in certain\\nregions, such as the axillae,\\nthe groins, the palms, the soles, and about the anus, the coil-glands are\\nmultiple, of unusual size, and often peculiarly arranged. They are\\nspecially numerous in the palms and soles, where, according to Krause,\\nthere are between two and three thousand to the square inch.\\nThe Coil is a convoluted tube, of fairly uniform lumen, terminating\\nin a csecal pouch, lined with nucleated cubical epithelia in a single\\n1 layer of granular appearance, which are the secretory cells of the gland.\\nOutside of the tube are smooth muscular fibres running parallel with\\nI or in a spiral direction about the coil. Surrounding both muscle-\\nbundles and epithelium is a connective-tissue membrane. The glomer-\\nulus, or coil, is globular in outline and reddish yellow in color. In\\nJ the larger glands irregular dilatations and constrictions of the tube are\\nconspicuous.\\nThe Excretory Duct of the coil-gland passes from the glomerulus\\nbelow to the epidermis above in a straight or a spiral course. It is\\nI lined with a delicate hyaline cuticle (discovered by Heynold), beneath\\nwhich is a double layer of cuboidal epithelium. Externally is a mem-\\nI brana propria, unprovided with muscular fibres. Its outermost sheath\\nis the usual connective-tissue layer. When the duct reaches the border-\\nline of the epidermis its inner cuticle and external connective-tissue\\nCoil of a sweat-gland S, tubule lined with cuboidal\\nepithelia; T, central calibre of the tubule D, beginning\\nof the duct; C, connective tissue with injected blood-\\nvessels. Magnified 500 diameters. (After Heitzmann.)", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0055.jp2"}, "56": {"fulltext": "44\\nANATOMY AND PHYSIOLOGY OF THE SKIN.\\nsheath both are lost here it becomes a sweat-pore. It opens at times\\nwithin a hair-pouch.\\nThe Sweat-pore is a continuation of the excretory duct of the\\ncoil-gland after the loss of its cuticle and connective-tissue sheath. It\\nis the loss of these sheaths and the consequent intimate relation of the\\ncanal to the epithelia of the epidermis that furnish the special basis\\nfor this distinction. The sweat-pore is merely a wall-less canal or chan-\\nnel, spirally directed or running a straight course from the duct of the\\ncoil-gland below to the outermost stratum of the epidermis above. It\\nSweat-pore traversing the epithelial layers of the skin: BP, papilla with injected blood-\\nvessels; V, valley between two papillae; D, duct in the rete mucosum E, E, epidermal layer;\\nPL, coarsely granular epithelia, deeply stained with carmine P, duct with corkscrew-windings\\nin the epidermal layer. Magnified 200 diameters. (After Heitzmann.)\\nhas no other wall than that formed by the cells of the prickle-layer\\nbelow and of the other layers of the epidermis, which successively sur-\\nround this canal, narrow below and funnel-shaped above. Eleidin-\\ngranules are found in the cells which border the sweat-pore at a some-\\nwhat lower plane than the stratum granulosum. Hence the lumen of\\nthe sweat-pore, if such a term be permissible, is in free communication\\nwith the juice-spaces of the epidermis.\\nThe Secretion of the coil-glands consists largely of globules of fat\\nand granules of pigment. The function of the coil-glands, therefore,\\nis plainly the lubrication of the skin with unguent, a task performed\\nonly in small part by the sebaceous glands, and by them chiefly for the\\npilary covering of the body. The palms of the hands and the soles of\\nthe feet are thus lubricated with fat by the coil-glands.\\nThe total number of coil-glands in the body is estimated to be\\nbetween two and three millions, and the total length of the uncoiled\\nglands about eight miles. These figures serve to give an approximate\\nidea of their great physiological importance, and of the extent to which\\nviolation of the rules of hygiene possesses interest from a pathological\\npoint of view.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0056.jp2"}, "57": {"fulltext": "COIL-GLANDS.\\n45\\nThe function of the sweat-pores which communicate directly with\\nthe excretory ducts of the coil-glands is distinct from that of the coil-\\nFig. 19.\\n;-a\\nr\\n3tf\\nSection of the skin from the palm of the hand (hardened in Moeller s fluid and treated with\\nglacial acetic acid), magnified 300 diameters, showing epidermis and pars papillaris of the corium\\ntraversed by the excretory duct of a coil-gland terminating in a sweat-pore a, stratum corneum\\na its superficial layer, the cells in the upper and lower layers somewhat larger than those\\nsituated between the two b, stratum lucidum c, stratum granulosum d, stratum mucosum\\ne, rete-pegs interpapillary process of rete meeting duct of coil-gland g, g, papillae em-\\nbraced by long prickles extending from lower palisade-layer of the rete h, blood-vessels of\\npapillae; i, bundles of connective-tissue fibres of pars papillaris; k, section of spiral duct of\\ncoil-gland and sweat-pore.\\ni\\nglands, since it provides for the transmission outward of the watery\\nfluids of the skin. The channel described as the sweat-pore is in ample", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0057.jp2"}, "58": {"fulltext": "46 ANATOMY AND PHYSIOLOGY OF THE SKIN\\nand free communication with the intercellular spaces of the epidermis\\nand this anatomical peculiarity provides fully for the needs of evapo-\\nration at the surface of the body.\\nThe Sweat excreted by the body differs under varying conditions of\\ntemperature, humidity of the air, and the amount and character of the\\narticles ingested by the individual, either as food, drink, or medica-\\nment. Nearly 98 per cent, of the secretion is pure water, the remain-\\ning proportions representing the saline constituents of the other fluids\\nfurnished by the animal in life. In all chemical analyses of the sweat\\na source of error lies in the difficulty of securing the. fluid secretion\\nunmingled with that produced by the sebaceous glands and the same,\\nit may be said in passing, is true of the chemical analysis of the sebum.\\nAccording to Duhring, potassium iodide, benzoin, and succinic and\\ntartaric acids may be excreted with the perspiration.\\nUnna, following in the lines indicated by Meissner, asserts that the\\ncoil-glands actually produce the subcutaneous fat-cushion and the\\nanatomical basis of such a statement is clear. The coil-glands and\\nthe fat-cushion appear at the same period of foetal life and develop in\\nthe same proportions. At birth the clusters of fat are most conspicu-\\nous where the coil-glands are most numerous. In the adult the greater\\nnumber of coil-glands are subcutaneous in situation and are closely\\nsurrounded by fat-globules while those glands which do not descend\\nbelow the corium, though not thus surrounded, are regularly met by\\ncolumns of fat advancing toward them from below. The credit of\\ndiscovering and naming these Fat-columns belongs to Warren,\\nwhose studies were principally directed to the anatomy of the thick\\ncutis vera. 1 The back and shoulders of a vigorous adult furnish\\nan integument much thicker than the hide of many pachydermatous\\nanimals. The papillae are imperfectly formed and are represented by\\nan undulating line. The follicles of the lanugo-hairs penetrate only\\nthe superficial layers of the cutis. From the bases of the hair-folli-\\ncles nearly vertical clefts, or slender, columnar-shaped spaces, extend\\nobliquely to the panniculus adiposus. These shafts are named fat-\\ncolumns or fat-canals, as they are entirely occupied by adipose\\ntissue. (See Figs. 3 and 4.)\\nThe fat-columns are four millimetres in length, and are slisrhtlv wider\\nthan the hair-follicles above. Their long axes form a slight angle with\\nthat of the follicle, but they are nearly parallel with that of the erector\\npili muscle. The horizontal prolongations are given off on either side\\nof the middle of this axis, partly fat-filled. Near this point the coil\\nof a sweat-gland is seen to be held in place by a few delicate fibres.\\nThe duct of the gland runs to the top of this space, whence it may\\nbe traced to the side of the hair-follicle. The connective-tissue fibres\\nseem to terminate abruptly at the edges of these columns. The cleft\\nslightly widens below, and on the side toward which its axis leans the\\nfibers of connective tissue form a bundle penetrating below to the\\nsubcutaneous fat. The erector pili muscle is inserted partly into the\\nbase of the follicle and partly into the apex of the fat-canal. These\\ncolumns correspond in number with that of the hairs. The blood-\\n1 Satterthwaite s Manual of Histology, p. 420. New York, 1881.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0058.jp2"}, "59": {"fulltext": "COIL-GLANDS.\\n47\\nvessels they contain, which spring from the subcutaneous plexus, bifur-\\ncate at the lateral clefts. Unna demonstrates that the fat-columns\\ninvariably advance toward the coil-glands either singly or in groups,\\nand that the connection of the fat-columns with the hair-follicles is a\\nmere incident of that advance.\\nThe alternation of muscular fibres with the secretory cells of the\\nducts of the coil-glands is a provision for the extrusion of the gland-\\nsecretion onward. The same anatomical arrangement permits free com-\\nmunication between the epithelia and the lymph-spaces which reach\\ninto the connective-tissue sheath of the gland. As a result, the lymph\\nflows freely among the secreting elements of the gland and its duct.\\nFig. 20.\\nThin section of the skin of a finder, removed at the site of a sweat-pore. Magnified 150\\ndiameters. The cavities or spaces seenin the epidermis are. some, apparently uncolored others\\narc blackened by the action of osmic acid npon fat originally contained in either cells or spaces\\nbetween the latter. The effect is due to excretion of fat by the coil-glands, and the condition\\nshown is not exhibited in all sections of the skin made at the same level. It is probably transi-\\ntory, and is most apparent when the skin is macerated by sweat.\\nThis lymph, loaded with fat, streams away from the coils, and before it\\nreaches the lymphatic trunks its fat-globules are filtered away in the\\nsubcutaneous tissue.\\nOdorous Emanations from the Skin. The skin of the human\\njbody in health is the constant source of odorous emanations, which, in\\npathological conditions, may greatly be increased or otherwise changed.\\nThe nature and exact sources of these emanations are as yet imperfectly\\nunderstood. Were they exclusively volatile, gaseous, or vaporous, even\\nthough capable of condensation upon external bodies, this would scarcely\\nexplain the well-known fact that some of the lower animals are capable\\nof tracing the track of a human being for miles over a wind-swept\\npath until the soil pressed by the foot is covered with water. There\\nis strong reason to believe that these emanations are vehicles by which\\ncertain contagious and infectious diseases are transmitted from one\\nindividual to another. They at times contain living matter derived\\n]from the protoplasm of the body, and are capable of conveying bacteria\\nin compact masses and in enormous quantities through the atmosphere\\nwhen it is agitated by a current of air. Some of the schizomycetes", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0059.jp2"}, "60": {"fulltext": "48\\nANATOMY AND PHYSIOLOGY OF THE SKIN.\\nweigh but one-ten-billionth of a milligramme, and are transported\\nthrough space in the most attenuated of media. These emanations are\\nproperly regarded as having their origin in the secreting system of the\\nskin, but in what proportion the several secreting glands participate in\\ntheir production it is difficult to establish. The sweat at times, even\\nto human nostrils, exhales a distinct odor, though, as before indicated,\\nto what extent this is due to the admixture of sweat with sebaceous\\nmaterial it is difficult to determine. Peculiarly fetid and disgusting\\nodors occasionally originate in chemically altered sebum exuded in\\nregions of the body where the influence of the sweat-secretion must\\nbe, from the locality under examination, partly eliminated.\\nNAILS.\\nNails are dense, elastic, and translucent concavo-convex plates, or\\nshells, of horny tissue, placed upon the dorsum of the terminal extrem-\\nities of the distal phalanges of the fingers and toes. They result from\\nan oblique invagination of embryonal epidermis, with modification of\\nthe keratinization-process at the level of the invagination (Darier).\\nEach nail has a free border at the distal portion of the pulp of the\\ndigit, with sides and proximal borders let into distinct furrows of the\\nskin. The convex surface of the nail is exposed the concave, regard-\\ning the phalanx, is implanted upon the nail-bed beneath.\\nVertical section of one-half of nail and matrix a, nail-substance 6, horny layer c, mucous\\nlayer; d, papillae of corium; e, nail-furrow destitute of papillae; /.horny layer of the ungual\\nfurrow rising above the nail g, papillae of skin of dorsal surface of the finger.\\nIn the embryo the first change looking to the formation of a nail\\nconsists in a peculiar smoothness and brilliancy of the epidermis cov-\\nering the dorsum of the distal phalanges. Later, an epithelial ridge\\nor line, with a groove in front of it, traverses the tip of the finger.\\nThus, three regions are defined the region behind the ridge, the nail-\\nwall that in the groove, the nail-bed and that in front of the groove,\\nthe pulp of the last phalanx of the digit. A collection of large prickle-\\ncells at the orifice of the nail-fold soon furnishes the first trace of the\\nrudimentary nail. Mature nail-cells finally push forward between the\\nprickle- and horny layers of the nail-bed, which, by fan-shaped bundles", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0060.jp2"}, "61": {"fulltext": "NAILS. 49\\nof follicles, is firmly united to the periosteum of the phalanx. Lastly,\\na thin plate of horny material with a free edge is visible externally in\\nthe fingers and toes of the newborn child.\\nIn the adult, Avhat is termed the Matrix of the nail is the tissue\\nfrom which springs the horny plate. The cells of the matrix are cyl-\\nindriform below and flattened superficially, with a fibrillary structure,\\nand, instead of a stratum granulosum, are supplied with a layer of cells\\nof brownish color charged with a keratogenous substance. The matrix\\nis separated into, first, a posterior part, filled with from three to six\\nrows of papillae; and next, in advance of this, a lenticular space with\\ncurved borders, the anterior limit of which corresponds with the an-\\nterior border of the lunula. The area included in these two divisions\\nis provided with papillae grouped in symmetrically converging ridges,\\ndecreasing in size as they pass forward. This forms the matrix of the\\nnail. Further forward, the Nail-bed proper in other words, the\\ntissue that supports, rather than produces, the horny plate is com-\\nposed of higher ridges of papillae, the grooves and summits of which\\nare covered with prickle-cells, and the height of which is uniformly\\nmaintained as they stretch forward toward the pulp of the finger.\\nThe Nail-fold, crescentic in shape, clasps the nail posteriorly and\\nlaterally. It is formed of connective tissue, the bundles of which are inter-\\npenetrated by numerous coil-glands and fat-columns. The epidermis\\nbeneath the nail exhibits prickle-, granular, and horny layers. As the\\nnail is gradually liberated from its bed both at the sides and point the\\ncornification of the horny layer becomes more complete, so that finally,\\nas the nail-plate is pushed forward, it no longer rides over the cells of\\nthe rete, but over a completely cornified tissue.\\nIf the pulp of a nail-bearing phalanx be pressed with moderate\\nforce against any firm object, the naked eye can detect upon the sur-\\nface of the nail, just behind its free border, a yellowish-white band,\\nconvex anteriorly and somewhat increasing in width laterally. This\\nline is also visible when no pressure is exerted upon the digit, its\\nwidth varying under the conditions described. This border represents\\nthe space in which the three layers of the epidermis from the skin of\\nthe point of the finger, viz., the horny, the granular, and the prickle-\\nlayer, successively come in contact with the under surface of the nail.\\nThe Lunula is the relatively light-colored space extending from the\\nmiddle part of the nail-fold posteriorly to its well-defined convex bor-\\nder in front. After artificial removal of the nail-fold the lunula is seen\\nto extend to the posterior and enclosed border of the nail-plate. It,\\ntherefore, represents that part of the matrix of the nail not concealed\\nby the nail-fold. Its color is not due to absence of vascularity, but is\\nowing solely to the relative opacity of the keratogenous cells which are\\nconcerned in the production of the horny threads that form the nail.\\nThe Nail (True Nail, or Nail-plate) originates only from the\\nfloor of the nail-fold as far forward as the anterior edge of the lunula.\\nAs to its formation, it may, therefore, be imagined as springing from its\\nmatrix vertically in the form of an involuted, shield-shaped plate, its\\nconvexity regarding the proximal phalanx. It may then be viewed\\nas pressed downward over its nail-bed in front, with partially unfolded\\n4", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0061.jp2"}, "62": {"fulltext": "50\\nANATOMY AND PHYSIOLOGY OF THE SKIN.\\nedges enwrapped by the epidermis of the sides, the narrowed point\\nof the shield, elongated when untrinimed, projecting at some distance\\nbeyond the tip of the finger.\\nWith this conception it is easy to understand that the nail is con-\\nstituted of horny filaments, or coherent strata of cornified cells, passing\\nfrom the matrix or floor of the nail-fold. The upper surface of the\\nnail grows, therefore, from the bottom of the nail-fold the under sur-\\nface, from the lunula and the intermediate layers proportionately from\\nthe parts between, that interlock with corresponding grooves on the\\nupper face of the bed.\\nFig. 22.\\nImplantation of a nail at its border P, papillee decreasing in size toward the middle line\\nR, rete mucosum, which broadens toward the border of the nail, and forms irregular prolonga-\\ntions; R E, epidermal layer; N, plate of the nail. Magnified 500 diameters. (After Heitzmann.)\\nUnlike the hairs, the growth of the nails, when not modified by\\ntraumatism or disease, is continuous and without definite limit during\\nthe life of the individual. The growth is from the matrix to the free\\nborder, more actively in the young than in the old, and in summer than\\nin winter. From one hundred to one hundred and sixty days are\\nrequired for reproduction of an entire finger-nail, and about three times\\nthat period for the nail of a toe. The uncut nail is produced in the\\nform of an elongated, pointed, claw-like talon.\\nNails are extremely sensitive to even moderate perversion of sys-\\ntemic nutrition and either in loss of brilliancy and polish or in\\ndeeper structural alterations betray evidences of changes in the health\\nof the individual.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0062.jp2"}, "63": {"fulltext": "II. -GENERAL SYMPTOMATOLOGY.\\nIn cutaneous, as in other, diseases the clinical signs or symptoms\\nof a morbid process are those by which a disease is recognized alike\\nby the patient and the physician. These signs and symptoms are di-\\nvided into subjective and objective the former are those appreciated\\nby the patient alone in consequence of his sensations the latter are\\nj those detected by the eye and the touch of another who undertakes the\\n1 investigation of the disease. It should be remembered, however and\\nthis is a matter of some importance in this connection that there are\\nmanifested to the eye and touch of the patient many objective signs\\ni which are liable to be interpreted or misinterpreted by him, with con-\\nsequences not to be ignored.\\nSUBJECTIVE SYMPTOMS.\\nThe purely subjective symptoms of a disease of the skin are those\\nmanifested to the patient by sensations other than those connected with\\nvision and his own sense of touch. They include sensations of itching,\\nsmarting, tickling, pricking, and burning sensations as of increased or\\ndiminished susceptibility to the contact of foreign bodies of increased\\nor diminished temperature pain in various grades of severity and\\ndisordered sensations, such as those suggesting the crawling of insects\\nover the part, the passing of currents of hot or cold vapors or liquids,\\nI and the compression of portions of the skin as by cords, bands, or\\nj closely fitting plates. The character of the subjective sensations ex-\\nperienced by a patient often proves an aid to the physician in recogniz-\\nj ing the nature, not merely of a present disease, but also of one which\\nhas preceded. Thus, the sensation produced by an attack of erysipelas\\nis rarely an itching, while the latter is highly characteristic of eczema\\nI and scabies the pain of zoster and the tingling of urticaria being dis-\\ntinctly different, not only from each other, but also from the subjective\\nsymptoms named above.\\nOBJECTIVE SYMPTOMS.\\nThe study of the objective symptoms of a cutaneous disease is of\\nparamount importance. In no respect does the skilled physician so\\ndistinguish himself from one who is unskilled as in ability to recognize\\nthe typical or atypical objective features presented in diseases of the\\nj skin. This study is one which no diagnostician can safely neglect, and\\nI its rewards are precious in every department of medical science. These\\nsymptoms are spread before the eye, and their legibility increases with\\nevery hour of careful observation,\\n51", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0063.jp2"}, "64": {"fulltext": "52 GENERAL SYMPTOMATOLOGY.\\nThese signs of skin-disease or, more literally, skin-injury are\\ncalled lesions (efflorescences, elements of an eruption), and it is\\nusual to classify them as primary and secondary. Such division, how-\\never, is open to criticism, since, in point of time merely, some of the\\nso-called primary lesions of the skin become in turn secondary and\\neven tertiary. Thus, a papule which might at one time be called\\nprimary, may be transformed wholly or in part into a vesicle, which\\nthus becomes a secondary lesion, and such vesicle again, in the evolu-\\ntion of a disease, may become a tertiary pustule, and the latter finally\\nmay result in a quaternary crust. In the following pages these\\nsymptoms of skin disease are distinguished as elementary and con-\\nsecutive.\\nElementary Lesions. In describing the average size of cutaneous\\nlesions it is less convenient to state their measurement in fractions of\\na line or of a millimetre than to convey an approximate idea by a\\ncomparison with familiar objects of relatively fixed dimensions. The\\nobjects usually selected for this purpose, beginning with the smallest,\\nare seeds of the poppy, mustard, and rape the coffee-bean the pea\\nthe bean the cherry the finger-nail the chestnut the horse-chest-\\nnut the egg of the hen and of the goose the orange. To these may\\nalso be added the point and head of a pin. The student will find it\\nuseful to familiarize himself with the size of the small seeds men-\\ntioned, that their names may at once suggest to him the relative size\\nof the lesions with which they are compared.\\nMaculae (spots, or stains) are generally circumscribed\\nalterations in the color of the integument, differing in\\nsize, shape, hue, and duration of the dyschromia, and un-\\naccompanied by elevation or depression of the skin-sur-\\nFACE.\\nMaculae may be due to arterial or venous hyperemia, to the escape\\nof the coloring-matters of the blood into the skin, to acquired and\\ncongenital telangiectasis, and to pigment-anomalies. Examples of\\nmaculae are to be found in the exanthematous rashes (measles) in\\nlocalized hyperemia of the capillary plexuses of the corium, disappear-\\ning in various degrees according to the pressure exerted on the part\\n(rosacea) in visible acquired development of blood-vessels in the\\nskin (telangiectasis) in congenital vascularization of the surface (naevi)\\nin variously colored blood-extravasations and stases (purpura) in\\nstains produced by contact with dyes (hand-workers in anil in) and\\nin pigmentary changes such as those produced by solar heat (freckles)\\nor by leprosy.\\nExtensive non-circumscribed changes in the skin-color are seen in\\nthe course of several general disturbances of the economy, as in yel-\\nlow fever, cancer, chlorosis, albinism, Addison s disease, argyria, and\\nicterus.\\nSpots of various color and device are also produced by the inten-\\ntional or accidental introduction of pigmented particles beneath the epi-\\ndermis, as by the process of tattooing, the explosion of gunpowder, etc.\\nMaculae exhibit a wide variation in color from a rosy pink to a\\nchocolate brown or even a black. This difference has suggested the", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0064.jp2"}, "65": {"fulltext": "OBJECTIVE SYMPTOMS. 53\\nemployment of such descriptive terms as roseola, erythema, and\\npurpura, which, unfortunately, serve to distinguish both the features\\nof diseases and the diseases themselves.\\nA macula which encircles another lesion, as, for example, the halo\\naround a vaccine vesicle, is called an areola. Linear hemorrhagic\\nstreaks are called vibices punctate and larger extravasations of\\nblood are termed petechia and ecchymoses.\\nPapula (papules) are solid or compressible, ephemeral\\nor persistent, circumscribed projections from the surface\\nof the skin, varying in size from that of a poppy-seed\\nto that of a coffee-bean.\\nThese exceedingly common skin-symptoms vary greatly in their\\nshape, color, location, career, and significance. Thus, they may be flat-\\ntened at the apex, acuminate or pointed, conical, rounded, or depressed\\nat the summit to form an umbilication they may be pale, rosy, dark\\nor lurid red, purplish, or even blackish they may develop in transi-\\ntory or persistent processes they may be transformed into lesions\\ncontaining fluids may desiccate and furnish scales either at apex or\\nbase may degenerate into ulcers or may enlarge into tubercles or\\ntumors may be scratched, torn, or rubbed so as to lose their typical\\nappearance may come and go may be sensitive to sudden changes in\\nthe blood-current, and yet be persistent.\\nThe mixed forms described above are generally named vesico-pap-\\nular or papulo-vesicular, papulo-squamous, papulo-pustular lesions, etc.\\nLesions which simulate the papule, and which, though described\\nunder that title, really belong to another category, are the small, semi-\\nsolid elevations of the surface that form at the orifices of the ducts of\\nthe cutaneous glands and follicles. Thus, they may consist of little\\nheaps of epidermis about the hair-follicles (lichen pilaris, keratosis\\npilaris), or of inspissated sebum collected in one of or in all the acini\\nof the sebaceous glands (comedo).\\nThe concomitants of an eruption of papular type also vary. Thus,\\nthere may be a febrile process, or extensive infiltration of the skin\\nabout and beneath the papules (prurigo), or itching of the most intol-\\nerable character (eczema papillosum), or production of trifling sensa-\\ntions of annoyance, as a slight burning without other subjective symp-\\ntoms (acne, lichen planus).\\nPapules transformed into moist lesions become covered with a crust.\\nPapules scratched or torn by the finger-nails usually betray the fact in\\nthe minute and flat blood-scales dried upon their surface. Papules which\\nulcerate may be followed by scars, and those which have undergone\\nthe process of involution may be followed by macular sequelae.\\nPOMPHI (URTIG^, WHEALS) ARE MORE OR LESS TRANSITORY,\\nROSY RED AND WHITISH, IRREGULAR SHAPED AND SIZED ELEVA-\\nTIONS OF THE SURFACE OF THE SKIN, PRODUCED BY BLOOD-\\nSTASIS IN SPASM OF THE VESSELS, ACCOMPANIED BY A TINGLING\\nOR A PRICKLING SENSATION, AND CHARACTERIZED BY RAPIDITY\\nOF EVOLUTION AND FREQUENCY OF RECURRENCE.\\nThe typical wheal is seen in the disease known as nettle-rash\\n(urticaria), in which closely packed, shining, roundish and whitish", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0065.jp2"}, "66": {"fulltext": "54 GENERAL SYMPTOMATOLOGY.\\npea- to finger-nail-sized elevations of the skin are visible, surrounded\\nby a slightly rosy border. Wheals are firm to the touch, and ar-\\nranged in patches, circles, bands, gyrations, or striations, often disap-\\npearing in a brief time and recurring with or without a renewal of the\\ncause. They are occasioned by a rapid exudation of serum into the\\nrete or pars papillaris of the corium. This is due to clonic vascular\\nspasm, producing irregularities in the lumen of the skin-capillaries,\\nunder the influence of the vasomotor nerves which supply a small\\narea of the superior pars vascularis of the derma. The sensations pro-\\nduced are stinging, burning, pricking, and itching. Wheals are often\\nsurrounded by an areola.\\nGiant -wheals are such as have the dimensions of a hen s egg, or\\ncover extensive areas of integument, as, for example, the entire surface\\nof a buttock or a shoulder.\\nRelics of disappeared wheals are usually transitory erythematous\\nmaculae, but in rare cases there is left a more or less deep pigmentation\\nwhich slowly disappears (urticaria pigmentosa).\\nAt times the wheal-like condition is assumed by papillae, as also by\\nlesions resulting from such traumatisms as the bites of insects, reptiles,\\nhorses, dogs, etc.\\nTUBERCULA (TUBERCLES) ABE CIRCUMSCRIBED, SOLID, GENERALLY\\nINCOMPRESSIBLE AND PERSISTENT NODOSITIES OF THE SKIN, VARYING\\nIN SIZE FROM THAT OF A COFFEE-BEAN TO THAT OF A CHERRY.\\nIt should be carefully noted that tubercles occurring in diseases of\\nthe skin bear no relation whatever to the nodules having the same name\\nwhich develop in pulmonary tuberculosis. The dermatological title\\nrelates solely to the size of the lesion.\\nTubercles may largely be projected from the free surface of the\\nintegument, or be deep seated in the skin, and but a small portion\\nbecome evident to the view externally. Their varieties as to shape,\\ncolor, size, and other features correspond in great part with those de-\\nscribed in connection with papules. They may be attached by a broad\\nbase to the skin, or be pedunculated, or even pendulous. Their seat is\\nusually in the deeper portions of the corium or in the subcutaneous\\nconnective tissue. Degenerating and ulcerating tubercles arc followed,\\nas might be supposed in view of their volume, by considerable destruc-\\ntion of tissue, and correspondingly in cases of repair by extensive\\ncicatrices. Tubercles are seen in such diseases as fibroma, molluscum\\nepitheliale, syphilis, leprosy, sarcoma, and cancer.\\nTubercles are often described as merely enlarged papules, but the\\ndistinction between these two forms of lesions will better be recognized\\nwhen attention is paid to the particular portion of the skin in which\\neach takes its origin. Papules spring oftenest from the superficial\\nlayers of the derma tubercles, from the deeper layers. At times a\\ntubercle may project from the surface to a less extent than a papule,\\nthough its larger volume is evident as soon as the skin within which\\nit has developed is handled.\\nTubercles due to a cellular infiltration may cease to be circumscribed,\\nand by coalescence furnish a diffuse involvement of both the skin and\\nthe subcutaneous tissue.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0066.jp2"}, "67": {"fulltext": "OBJECTIVE SYMPTOMS. 55\\nPapulo-tuberdes are transitional forms assignable to either of the\\ntwo lesions named.\\nPhymata (tumores, tumors) are masses of solid tissue, or of\\nsolid tissue more or less commingled with fluids of variable\\nconsistency, differing in size, shape, color, and in the benig-\\nnity or malignity of their career, located either within or\\nbeneath the skin, or, being attached to the skin, projecting\\nfrom it to a variable extent.\\nThe mere fact that a lesion of the skin approaches hi dimensions the\\nsize of a tumor is in itself an element of gravity. Tumors may origi-\\nnate in mere hyperplasia of the living matter; may consist of new\\nformations of greater or lesser danger to the vicinage or to the general\\neconomy may be formed of blood-vessels or of hymphatic vessels, or\\nof both in the same lesion may embody large fluid-containing cysts\\nmay be built up of nerve-tissue, fat, bundles of connective-tissue fibres,\\nglandular elements, and indeed of any of the elements which exist\\nphysiologically in the human integument.\\nExamples of tumors are seen in fibroma, sarcoma, carcinoma, and\\nrhinoscleroma.\\nVesicul.e (vesicles, phlyctene, phlyctenule) are acumi-\\nnate, ROUNDED OR FLATTENED ELEVATIONS OF THE HORNY LAYER\\nOF THE EPIDERMIS AVITH LIMPID, LACTESCENT, OR SANGUINOLENT\\nFLUID CONTENTS, VARYING IN SIZE FROM THAT OF A POPPY-SEED TO\\nTHAT OF A COFFEE-BEAN.\\nTypical vesicles are seen in the minute, transitory lesions occurring\\nin the vesicular form of eczema. They are usually filled with a clear\\nserum. Variations from this type, however, are common. Thus, they\\nmay be either flattened, acuminate, roundish, umbilicated, or conical\\nmay be fully distended or partially collapsed upon their contents may\\nhave a short or long duration may be distended with a milky, chylous,\\nor blood-stained fluid may be opalescent, yellowish, reddish, or black-\\nish in color several may coalesce to form a many-chambered bulla.\\nOne or several may undergo transformation into pustules or bullae.\\nVesicles may terminate by accidental or spontaneous rupture, their\\ncontents freely flowing forth upon the surface of the peripheral integu-\\nment or they may desiccate to a crust or may even terminate by\\none of the ulcerative processes. They may or may not be accompanied\\nby pruritus. Minute vesicles, which are merely the external apices of\\nlarge-chambered accumulations of fluid beneath, occasionally form upon\\nthe surface of the skin. Such are seen in the course of lymphangiec-\\ntasis.\\nPUSTULE (PUSTULES) ARE CIRCUMSCRIBED CUTANEOUS ABSCESSES,\\nCOVERED WITH AN EPIDERMAL ROOF-WALL, AND VARYING IN SIZE\\nFROM THAT OF A MILLET-SEED TO THAT OF A FILBERT.\\nThe typical pustule contains pus, and is colored yellowish, yellowish\\ngreen, or brownish green, according to the admixture of its contents\\nwith blood. The pus being an inflammatory product, necessarily indi-\\ncates the occurrence of an inflammatory process at the base of the\\npustule. Pustules, like vesicles, may be roundish, acuminate, globoid,\\nconical, or umbilicated, and surrounded by an inflamed or normal", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0067.jp2"}, "68": {"fulltext": "56 GENERAL SYMPTOMATOLOGY.\\nintegument may be superficial or be deep-seated may terminate by\\nrupture or by desiccation may or may not be followed by an ulcer\\nand ultimate cicatrix. They may be seated either upon the free surface\\nof the skin, or at an orifice of a follicle, in which case they represent\\nan inflammation with purulent product in the duct or the gland\\nbeneath.\\nPustules may originate as such, or as a consequence of transforma-\\ntion of vesicles, or after a change in a papule, which may thus come to\\nhave a purulent apex. According to Auspitz, they invariably originate\\nfrom vesicles. Pustules often result in the formation of crusts, the\\nlatter varying in color according as the pustules from which they orig-\\ninated contained a clear serum or blood.\\nTransitional forms between vesicles and pustules are termed vesico-\\npustules. Pustules of a large size, resting upon an indurated, engorged,\\nand elevated base are often called ecthymatous.\\nPustules are seen in syphilis, variola, eczema, scabies, acne, and many\\nother cutaneous diseases, including several forms of dermatitis medica-\\nmentosa. Many contain pus-cocci some furnish a neutral, or pseudo-,\\npus destitute of micro-organisms.\\nBullae (blebs) are superficial or deep-seated elevations\\nof the skin having fluid contents, differing in color, shape,\\nand career, and varying in size from that of a coffee-bean\\nto that of a goose-egg.\\nBlebs have been described as large vesicles but this fails to define\\nexactly their pathological character. Like vesicles, they may contain\\nserum, lymph, blood, or pus, and may variously be colored according,\\nto the degrees in which their contents become visible through a semi-\\ntransparent roof-wall. They may be globoid, hemispherical, oval,\\ncrescentic, semi-crescentic, or conical, and may even exhibit angles.\\nThey may be seated upon an apparently unaltered or an evidently\\nmorbid integument and may or may not present a peripheral areola.\\nBullae may persist or may rupture may desiccate or may degenerate\\ninto ulcers may collapse after the escape of their contents, and the\\nroof-wall become glued to the base from which it was originally raised.\\nBullae usually occur in extremely debilitated states of the system, and\\nare, as a rule, of graver portent than other fluid-containing lesions of\\nthe skin. They occur in scalds and burns, in pemphigus, leprosy,\\nerysipelas, syphilis, and moist gangrene.\\nConsecutive Lesions. Squamae (scales) are attached or\\nEXFOLIATED EPITHELIAL LAMELLA WHICH HAVE BECOME APPRECI-\\nABLE AT THE SURFACE AS THE RESULT OF SOME MORBID PROCESS\\nIN THE SKIN.\\nThere is constantly in progress over the superficies of the body\\nphysiological desquamation, the evidences of which are not pronounced\\nin skins properly cleansed by ablution. In morbid processes, how-\\never, desquamation may occur as a distinct symptom in various forms.\\nThus, the scales may be minute, fine, branny, dirty white or yellowish\\nthey may be large, pearly white, shining may be dry or fatty may\\nbe aggregated so as to resemble flaky pie-crust may exfoliate in\\nextensive sheets, as from the entire sole of the foot or the palm of the", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0068.jp2"}, "69": {"fulltext": "OBJECTIVE SYMPTOMS. 57\\nhand, or in glove-finger-like sheaths, as from the surface of a digit\\nthey may be scanty, scarcely perceptible, and so firmly attached as to\\nrequire force for their removal they may fall spontaneously in a pul-\\nverulent shower, being so abundant as to encumber the garments or the\\nbed-clothing of the patient.\\nFurfuraceous or pityriasic desquamation is that form in which fine,\\nbran-like scales are shed from the surface.\\nScales are frequently intermingled Avith other lesions, often succeed-\\ning the latter. Thus, a papule may scale at its apex, or surround its\\nbase with a collarette of loosened epidermal plates, beneath or between\\nwhich a macular stain is visible. Again, scales may develop from\\nmacule, tubercle, or tumor. Though generally conceded to be evi-\\ndences of a dry and non-discharging disease of the skin, they are at\\ntimes accompanied or succeeded by moisture of the part affected.\\nThe term scales is sometimes applied to the flattened plates of dried\\nsebum that form on the scalp and on portions of the trunk in sebor-\\nrhea sicca.\\nScales occur in eczema, psoriasis, pityriasis, ichthyosis, syphilis, and\\nin several of the parasitic diseases of the skin.\\nCrustje (crusts) are relics of the desiccation of patho-\\nlogical PRODUCTS OF THE SKIN.\\nCrusts never occur as primary symptoms of disease. When formed\\nby the desiccation of serum only they are of a yellowish, straw-yellow-\\nish, or reddish-yellow hue when composed largely of dried pus they\\nare colored greenish or greenish yellow and when there has been an\\nadmixture of blood they are usually brownish or blackish. At times\\nthey suggest in appearance gum, honey, or Venice turpentine in\\nshape they may have the form of the concavo-convex lid of a watch-\\ncase in color and shape they may resemble the half-shell of an oyster\\nor the carapace of a small turtle. They may be delicate and thin,\\nbulky and thick, friable or mealy may be firmly attached to the sub-\\njacent tissues or readily separable may cover a sound though tender\\nand reddened epidermis may conceal a superficial or a deep, foul-\\nbased ulcer, by secretions from beneath which they are raised above\\nthe plane of the skin and increased in thickness they may be circum-\\nscribed and no larger than a small finger-nail may envelop an entire\\nlimb or organ, as the leg or the penis or, finally, may be so irregu-\\nlarly disposed among other lesions papules, pustules, excoriations, and\\nopen ulcers that it is difficult to define their outline, or even to recog-\\nnize their identity. Crusts formed of dried sebum are greasy to the\\ntouch, dirty yellowish in shade, and usually seated upon a non-infil-\\ntrated base.\\nCrusts are common in eczema, syphilis, leprosy, seborrhea, and in a\\nlarge number of other diseases of the integument.\\nExcoriations are superficial solutions of continuity,\\nusually involving portions of the skin affected with pru-\\nritus, and resulting from mechanical violence.\\nExcoriations, in appearance among the most trivial of skin-lesions,\\npossess a value from the diagnostic point of view which can scarcely be\\noverestimated. They occur as striated, linear, punctate, circular, or", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0069.jp2"}, "70": {"fulltext": "58 GENERAL SYMPTOMATOLOGY.\\nirregularly shaped, furrowed wounds, at times involving areas of flat\\nsurface, oozing with serum or blood, covered with dried blood or crusts,\\nyellowish or reddish in hue, and for the most part both induced and\\naccompanied by severe pruritus. They may coexist with hyperemia\\nand infiltration of the skin beneath, brought on by the irritative char-\\nacter of the continuous, or, more frequently, interrupted, cause by\\nwhich they were begotten.\\nExcoriations become significant according as they indicate scratch-\\ning, tearing, or other species of wounding by the finger-nails, and the\\nrubbing of portions of the integument with foreign bodies. In the\\nformer case they are significantly recognized in those portions of the\\nbody most accessible to the hands, though in the case of eczematous\\nchildren and infants they may originate by the rubbing together of the\\nknees, or the rubbing of one leg by the feet and toes of the other leg.\\nThe loss of tissue may extend deeper than the rete, at times invading\\nthe papillse of the corium, which bleed in consequence.\\nExcoriations may occur without the appearance of other lesions, as\\nin the disease called pruritus but where itching is severe and\\ninduced by a cutaneous exanthem the lesions constituting the latter\\nmay be intermingled with, obscured by, or even obliterated by excoria-\\ntions and the pathological processes to which they give origin. Thus,\\nmacules, vesicles, pustules, and papules may undergo change; and the\\nrecognition of the type of the existing disease may correspondingly be\\ndifficult. Excoriations are common in skins wounded by lice, bed-\\nbugs, and gnats; in the subjects of eczema, scabies, intertrigo, and\\nprurigo and in individuals with special sensitiveness of the integu-\\nment to the action of a medicament employed either internally or ex-\\nternally.\\nEhagades (fissures) are linear solutions of continuity,\\nusually occurring in previously infiltrated portions of the\\nSKIN.\\nFissures may extend to the derma, and invade yet deeper struct-\\nures; may be painful or the reverse; may be dry, secretory, or in-\\ncrusted; are often hemorrhagic, and usually are formed with sharply\\ncut walls. They are of frequent occurrence in the vicinity of the\\narticulations, in which situations they are induced or aggravated by\\nthe joint-movements stretching or tearing tissue the extensibility of which\\nhas been diminished by any morbid process. Fissures may terminate\\nin ulceration they vary as to length, curve, and tenderness they are\\noften exquisitely painful, and greatly complicate the skin-disease in\\nwhich they form; they may follow the curve traced by the boundaries\\nof bodily organs near which they occur as, for example, the line of\\nthe posterior junction of the ear with the head, or that of the breast\\nof a woman with the thoracic wall upon which it rests.\\nFissures occur in eczema, syphilis, dermatitis, and lichen ruber.\\nUlcera (ulcers) are losses of substance resulting from a\\nprevious pathological process involving the corium, and, in\\nsome cases, the subcutaneous tissue.\\nCutaneous ulcers differ greatly in size, shape, color, edges, base,\\ncareer, and, indeed, in all their characteristics. Every ulcer has an", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0070.jp2"}, "71": {"fulltext": "OBJECTIVE SYMPTOMS. 59\\noutline, a base, a floor, edges, and a secretion. The outline may be\\ncircular, crescentic, reniform, ovoid, serpiginous, or with horseshoe-\\nlike contour. The base, or underlying tissue, may be soft, supple,\\nindurated, or in a state of active inflammation, with consequent infil-\\ntration. The floor may be glazed, shallow, deep, excavated, cup- or\\nfunnel-shaped, worm-eaten, crateriform, sloughy, covered with a\\ntenacious or a readily removed secretion, granular, puriform, or hem-\\norrhagic. The edges may be clean-cut, having a punched-out appear-\\nance, undermined, everted, ragged, irregular, or contracting, with a\\nwhitish inner border of advancing cicatrization. The secretion may\\nbe scanty, limpid, puriform, profuse, ichorous, and odorless, or exhale\\nan offensive stench. Ulcers may be so crust-covered as to be invisible,\\nor so exposed and erosive in action as to render the affected surface in\\nthe highest degree unsightly. They may be acute or chronic, insensi-\\ntive or productive of intense pain; may heal by cicatrization, remain\\nopen for a lifetime, or prove fatal either by destruction of parts essen-\\ntial to life or by exhaustion of the vital forces.\\nCicatrices (scars) are new-formed substitutes for lost con-\\nnective tissue.\\nScars never succeed excoriations, fissures, or other solutions of con-\\ntinuity in the skin that have not penetrated as far as the derma and\\nresulted in destruction of a portion of the elements of which the derma\\nis built up. They possess the highest importance for the diagnostician,\\nsince they point invariably to a pathological process the career of which\\nis terminated, the characteristic features of which termination they fre-\\nquently embody. They may be regarded as the special and persistent\\nimprints upon the integument of the serious disorders from which it\\nhas suffered.\\nTo a certain extent, as already shown, scars retain traces of the spe-\\ncial peculiarities of the lesions, and even of the diseases, which they\\nsucceed. The identification, however, of the individual predecessor in\\neach instance is, in the present state of our knowledge, not always pos-\\nsible from a study of cicatrices alone. The extent of knowledge in\\nthis direction, however, is rapidly increasing; and in many cases the\\ncertainty thus acquired is of incalculable value to the diagnostician.\\nScars are remarkable for their tendency to contraction and gradual\\ndecoloration. They may be minute, punctate, extensive in area,\\nattached to underlying tissues, depressed, raised above the plane of the\\nperipheral skin, seamed with furrows, pliable and soft, indurated, trav-\\nersed by ridges, knotted, or as irregular in contour as the ulcers\\nalready described. They may extend in digital, linear, or annular pro-\\nlongations toward contiguous portions of the skin, and by subsequent\\ncontraction induce considerable distortion and deformity. Thus, they\\nmay drag down an eyelid, and ectropion ensue; may glue the lobe of\\nan ear to the cheek may evert lip or nostril. When recent they are\\nusually reddish in tint when older they may be pigmented in centre\\nor at circumference or, as is common, may exhibit a gradual decolora-\\ntion centrifugal in its progress. They may be the seat of pain from\\nan entrapped nerve-filament may reopen to ulceration or may be\\nunaccompanied by subjective sensation. Not rarely they become the", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0071.jp2"}, "72": {"fulltext": "60 GENERAL SYMPTOMATOLOGY.\\nsource of keloid. Scars are unprovided with hairs, papillae, or the ori-\\nfices of sweat-pores and sebaceous gland-ducts. As implied in the\\ndefinition given above, scars may result from any disease or injury\\nof the skin that involves loss of connective-tissue elements in the\\ncorium.\\nUnclassified Lesions. To the several lesions defined above Bazin\\nadds, as elementary forms, the mucous patch of syphilis, the cuniculus,\\nor furrow, produced in the skin by the Acarus scabiei, and the sulphur-\\ncolored crusts of favus. Among the elementary lesions of the skin,\\nBrocq includes the gumma, or firm, deeply situated, often subcutaneous\\nmass commonly degenerating centrally rather than, as may the tubercle,\\nfrom without inwardly while among the consecutive (so-called second-\\nary lesions of the skin the same author considers lichenization or\\nlichenification. These are terms chiefly employed by French writers\\nto designate the changes in the skin produced by long-continued ex-\\nternal irritation, the thickened and infiltrated integument assuming\\na yellowish-brown or reddish-brown tint, the exposed surface being\\nstudded with pinhead, pin-point, or slightly larger, shining and flattened\\nisolated elevations, with delicate furrows separating each from the\\nother. These, however, are not general, but special features of\\nindividual disorders, and are best studied in connection with the\\nlatter.\\nThe elementary lesions of the skin are termed by Auspitz anthe-\\nmata groups of such lesions, synanthemata and, in accordance with\\ncommon usage, generalized eruptions affecting the entire surface of the\\nbody, exanthemata. The word erythanthema is used to describe groups\\ncomposed of several of the elementary lesions of the skin, as, for ex-\\nample, of papules, vesicles, and pustules rising from a common red-\\ndened and hypersemic base.\\nIn addition to the names of the lesions of the skin just enumerated,\\ncertain peculiarities of cutaneous symptoms are described in qualifying\\nterms which here require definition. They relate chiefly to the color,\\nshape, distribution, and method or period of evolution of lesions as\\nthey are observed in individual cases. The more important of these\\nterms, as used by modern writers, are alphabetically arranged below,\\nwith a brief explanation appended to each.\\nAbdominalis. Located on the abdominal surface.\\nAcquisitus. Acquired.\\nActjminatus. Having a pointed apex.\\nAcutus. Of acute course.\\nAdultorttm. Occurring in adult years.\\nJEstivalis. Occurring in the summer season.\\nAggregates. Collected in patches.\\nAgrius. Acute, or angry in appearance.\\nAlbidus. Of whitish color.\\nAngiectaticus. Vascularized.\\nAnnularis. T T t f\\nAnnulatus. In the form of a rm S-\\nApyreticus. Unaccompanied by fever.\\nAreatus. Occurring in areas.\\nArtifictalis. Producible artificially.\\nAsymmetricalis. Of different distribution on the two lateral halves of the bodv.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0072.jp2"}, "73": {"fulltext": "OBJECTIVE SYMPTOMS. 61\\nAutumnalis. Occurring in the autumn.\\nBrachialis. Occurring on the surface of the arm.\\nCachecticorum. Occurring in debilitated subjects.\\nCapitis. Occurring on the head, usually the scalp.\\nCavernosus. Large chambered.\\nChronicus. Chronic in course.\\nCircinatus. Of circular outline.\\nCircumscriptus. Having a definite contour.\\nL-onfertus. Arranged in close proximity, with coalescence of lesions.\\nContagiosus. Capable of transmission by contagion.\\nCorporis. Occurring on the surface of the body employed usually to designate an\\neruption upon the trunk, as distinguished from that on the head or the extremities.\\nCrustosus. Crusted.\\nCrystallinus. Of crystalline appearance.\\nDiffusus. Irregularly disposed.\\nDiscretus. Having isolated lesions.\\nDisseminatus. Disseminate without regularity of distribution.\\nEruption. Is used of the totality of all patches and lesions upon the person of\\none individual.\\nErythematosus. Having a reddish blush.\\nEssentialis. Idiopathic.\\nExfoliativus. Having a tendency to exfoliation or shedding from the surface of\\nthe body.\\nExulcerans. Exhibiting lesions with a tendency to superficial ulceration.\\nFacialis. Located on the face, usually as distinguished from the scalp.\\nFavosa. Displaying crusts of favus.\\nFebrilis. Accompanied by a febrile process.\\nFemoralis. Occurring on the surface of the thigh.\\nFibrosus. Composed of fibrous tissue.\\nFiguratus. Having a figured appearance.\\nFlavescens. Of yellowish hue.\\nFoliaceus. Kesembling a leaf or leaves.\\nFollicularis. Concerning the cutaneous follicles.\\nFungoides. Resembling a fungus.\\nFurfuraceus. Exhibiting numerous fine, bran-like scales.\\nGuttatus. Of the size of a drop of water.\\nGyratus. Having a serpiginous or gyrate outline, which is usually the result of a\\ncoalescence of imperfect circles or semicircles.\\nHerpetiformis. Vesicular or herpetic in type.\\nHiemalis. Occurring in the winter season.\\nHumidus. Accompanied by moisture.\\nHypertrophicus. Characterized by hypertrophy.\\nHystrix. Having lesions projected or erected like quills.\\nImbricatus. With crusts or scales overlain like tiles.\\nImpetiginodes. Pustular.\\nInfantilis. Occurring in infancy.\\nIntertinctus. Distinguished by color.\\nIris. Occurring in more or less distinctly defined concentric rings.\\nLabialis. Occurring upon the surface of the lip.\\nLenticularis. Of the size of a small bean.\\nLividus. Deeply colored.\\nMaculosus. Discolored.\\nMadidans. Characterized by moisture.\\nMarginatus. Having a defined margin.\\nMedic amentosus. Produced by external or (more commonly) internal medication.\\nMelanodes. Of blackish color.\\nMiliaris. Of the size of a millet-seed.\\nMitis. Of mild, benignant type the reverse of agrius.\\nMultiformis. Exhibiting simultaneously several types of elementary lesions.\\nNeonatorum. Occurring in the newborn.\\nNeuriticus. Having nervous association.\\nNigricans. Of a black or blackish color.\\nNodosus. With development of nodes or tuberosities of the surface.\\nNummularis. Of the size of small coins.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0073.jp2"}, "74": {"fulltext": "62 GENERAL SYMPTOMATOLOGY.\\nOleosus. Accompanied by an oily secretion.\\nPalmaris. Occurring on the palms.\\nParasiticus f Produced by an animal or a vegetable parasite.\\nPatch. The aggregation of several isolated or confluent lesions.\\nPhlegmonosus. Accompanied by deep-seated inflammation.\\nPhlyct^enoides. Characterized by groups of small vesicles.\\nPigmentosus. Accompanied by pigmentation.\\nPilaris. Eelated to the hair.\\nPlantaris. Situated on the soles of the feet.\\nPlanus. Flat.\\nPolymorphous. The Greek equivalent of the Latin multiform.\\nPr^putialis. Situated upon the prepuce.\\nProgenitalis. Situated upon the exposed mucous surfaces of the genitalia.\\nPruriginosus. Accompanied by itching.\\nPubts. Located upon the skin or hairs of the pubes.\\nPunctatus. Occurring in dots or points.\\nRhagadiformis. Fissured, or tending to produce fissures.\\nRosaceus. Having a rosy or pinkish hue.\\nRuber. Red usually dark red in color.\\nScutiformis. Having the shape of a shield.\\nSebaceus. Concerning the sebaceous glands or their secretion.\\nSenilis. Occurring in advanced years.\\nSerpiginosus. Literally, creeping advancing in irregular gyrations.\\nSiccus. Dry unaccompanied by moisture.\\nSolitarius. Exhibiting an isolated lesion, or with isolated lesions.\\nSymmetric alls. Similarly distributed on the two lateral halves of the body.\\nToxicus. Poisonous.\\nUniformis. Exhibiting lesions all of one type.\\nUniversalis. Affecting the entire surface of the body.\\nUrticatus. Accompanied by wheals.\\nUterinus. With association of uterine disorder.\\nVariegatus. Exhibiting several distinct colors.\\nVasculosds. Accompanied by vascular development.\\nVernalis. Occurring chiefly in the spring of the year.\\nVersicolor. Exhibiting several shades of the same color.\\nVulgaris. Of the usual or commonly observed type.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0074.jp2"}, "75": {"fulltext": "III. GENERAL ETIOLOGY.\\nThe study of the causes of skin-diseases gives a glimpse of the eti-\\nology of diseases in general. In the lowest representatives of life the\\ngreatest dangers to existence originate in exposure to assault from other\\nand stronger representatives in search of their prey in other terms,\\nan external danger. In man, the highest representative of the animal\\nscale, the perils of existence are complicated by his social necessities\\nand his artificial methods. He can never, however, at any period of\\nhis existence, divest himself from the necessity of exposure to external\\nperil. The plan of his organs and the play of his normal activities are\\nperfect, even to the recovery from all but mortal injury aud repair of\\nmoderate loss. The struggle for existence of the ideal man is intended\\nto be with that which is without his body meanwhile furnishing him\\nwith a comfortable tenement and a fair fortress. In the purview of\\nnature there should be no internal revolt. When such occurs it is\\nusually the result of his ignorance, his folly, or his vice.\\nViewed comprehensively the causes of diseases of the skin are seen\\nto be numerous extremely different from each other some effective\\nsingly, others either alone or in combination Avith similar or different\\nagencies some operating slowly, others rapidly some operating from\\nwithin the body, others from without some directly, yet others only\\nvery indirectly, exerting their forces upon the integument. The results\\nare as diverse as the causes themselves. Some dermatoses produced by\\na single cause are similar in symptoms others, originating from like\\ncauses, present scarcely the slightest resemblance to each other. It is\\nfrom a study of this interesting field that much of the experience of\\nthe diagnostician is derived.\\nFor convenience of classification, it is well to consider the causes of\\ndiseases of the skin first, as internal agencies secondly, as external\\nagencies thirdly, as agencies which modify diseases produced by any\\nof the original factors capable of their production.\\nINTERNAL CAUSES.\\nHeredity. Some cutaneous disorders, such as syphilis, are capable\\nof transmission to a second generation. The prevalent doctrines, how-\\never, respecting the inheritance of a large number of cutaneous affec-\\ntions are without question erroneous. Still the fact remains, that\\nwhether keratosis, psoriasis, and some other diseases not recognizable\\nat birth (as may be the lesions of syphilis), are at times the result of\\ninheritance, it is certain that a predisposition to diseases of many kinds\\nis in perhaps the majority of cases transmitted to a second generation.\\n63", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0075.jp2"}, "76": {"fulltext": "64 GENERAL ETIOLOGY.\\nThe weakness or vulnerability of a given organ of the body renders it\\nespecially liable to external or internal sources of damage, and may be\\nstrictly inherited.\\nVisceral and Constitutional Disorders. The group of affections\\ncommonly included in the language of the schools as within the field\\nof inner medicine furnishes a large list of causes effective in the\\nproduction of cutaneous maladies. Among visceral disorders may be\\nnamed those of the kidneys (Bright/ s disease, albuminuria, diabetes),\\ngiving rise to pruritus, angioneurotic cedema, eczema of the uterus,\\ngiving rise to certain pigmentary changes in the skin of the central\\nor peripheral nervous system, as in urticaria, herpes, hemiatrophia, prur-\\nitus, alopecia of the alimentary canal, producing eczema, acne, urti-\\ncaria, etc.; of the adrenals, as in morbus Addisonii and of the stomach,\\nas in several of the gastric dyspepsias, which are capable of producing\\nurticaria, erythema, acne, and rosacea.\\nAmong the constitutional affections capable of originating disorders\\nof the skin may be named glycosuria (apart from renal diabetes), which\\nmay be productive of glycosuric xanthoma syphilis, which is respon-\\nsible for an extended list of dermatoses gout and rheumatism, which\\ninfluence to a remarkable degree the oncoming of certain eczemas of\\nthe anal and other regions, multiform erythema, acne rosacea, and\\npurpura and disorders of the respiratory tract, some of which (e. g.,\\nasthma) are well known to have a distinct relation to eczematous out-\\nbreaks, with which their attacks may alternate.\\nThe Nervous System is responsible for a number of dermatoses.\\nThe nerve-centres, nerve-trunks, and nerve-terminals may largely influ-\\nence inflammatory, congestive, and atrophic states cerebral, spinal, and\\nsympathetic nervous changes (trauma, new-growths, simple inflammatory\\nthickenings, etc.) may be directly or indirectly concerned in attacks of\\npemphigus, zoster, scleroderma, urticaria, hyperidrosis, alopecia, and\\neven grave ulceration of the skin. Pigment-changes in the skin and\\nits accessories (hair and nails) have been produced by such causes.\\nPsychical perturbations, as in the shock following traumatisms, ter-\\nror, bereavement, great and prolonged anxiety, and even the excite-\\nments of success in war and business have a demonstrable effect both\\non the nutrition and color of the skin and of the hairs and nails, as\\nwell as in the production of exanthemata, such as bullae, vesicles, and\\nseveral types of dermatitis. In the same connection may be named\\nthe results of maternal impressions upon the foetus, which, among the\\nignorant and to an extent also among men of science, are believed to\\nbe responsible for so-called mother s marks, including pigmentary,\\npapular, and vascular nsevi, as well as the larger lipomatous tumors\\nassociated with hairy moles. The disorders designated hysterical\\nneuroses constitute a small group of affections occurring chiefly in\\nyoung and hysterical women, characterized by the occurrence of vesic-\\nular and bullous lesions, some taking on a gangrenous aspect, others\\nexhibiting oddly arranged and defined streaks of dermatitis, to which\\nlatter the suspicion justly attaches that the lesions have been in great\\npart produced by the patients themselves.\\nThe Sexual System of both men and women, especially in young", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0076.jp2"}, "77": {"fulltext": "INTERNAL CAUSES. 65\\nsubjects, may be a source of cutaneous disorders. Among them may\\nbe named the seborrheas, acnes, and comedones, often aggravated by\\nmenstruation and by perversion of function in both sexes, progenital\\nand menstrual herpes, pemphigus virginum, and certain of the erythem-\\nata. The several cutaneous affections recognized in the pregnant con-\\ndition are often unquestionably associated with the condition of the\\ngravid uterus. Of these, the most common are scarlatiniform erythema,\\nimpetigo herpetiformis, dermatitis herpetiformis, and verrucse of the\\nvulvar region.\\nAuto -infection. This is a field of investigation the confines of\\nwhich have been barely touched by the explorations of modern science.\\nAt present it is demonstrable merely that the alimentary tract is trav-\\nersed by innumerable micro-organisms which are wholly innocuous.\\nUnder certain favoring conditions, however, these germs may either be\\ncommingled with others introduced from without, and thus become in\\nvarious degrees dangerous to the economy from slight perversion of\\nhealth to actual destruction of life in a relatively brief period of\\ntime or the innocuous parasites with and without the cooperation of\\nthe toxins they engender may suddenly become inimical to health from\\na change in their condition.\\nIngesta. Food and medicines are responsible for many cutaneous\\nlesions in consequence, first, either of an inherent toxic quality in the\\nsubstance ingested or, secondly, in consequence of a special irritability\\nof the alimentary canal existing at the time of such ingestion, the\\ncause of the disorder being at other times ineffective.\\nAmong the foods capable of producing urticarial distress may be\\nnamed shell-fish, the smaller berries having seeds, cheese, pickles,\\noatmeal, buckwheat, mushrooms, olives, the skins and seeds of grapes\\nand of oranges, and certain kinds of fish, as well as alcoholic bever-\\nages. A large list of medicinal substances is enumerated in the chap-\\nter on Dermatitis Medicamentosa which are capable of producing skin-\\neruptions. Among these may be named, as illustrative of the group,\\nthe salts of bromine and of iodine, arsenic, quinine, copaiba, belladonna,\\nand a number of the new remedies produced by the action of glacial\\nacetic acid upon the petroleum-products, such as antifebrin and phe-\\nnacetine.\\nThe Physiological Crises are not in themselves primary causes\\nof dermatoses, seeing that the larger number of all members of the\\nhuman family survive them without harm to the skin. It is none\\nthe less true that they furnish influences which modify and at times\\ninvite exanthemata. The possibilities of the pregnant state in con-\\nnection with cutaneous disease have already been explained. Denti-\\ntion is a period in which the child is often tormented by an eczema\\ndisplayed in greatest profusion over the cheeks; and the puberal\\nepoch of both sexes is one in which are manifested many of the dis-\\norders related to the repression, perversion, or excessive indulgence\\nof the sexual function. Many of the chloasmata are conspicuous in\\nwomen at the time of the menopause and this also is a period in which\\nmay be recognized irregularities in the performance of the sweat-func-\\ntion as well as in the subjective sensations experienced in the skin.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0077.jp2"}, "78": {"fulltext": "6Q GENERAL ETIOLOGY.\\nEXTERNAL CAUSES.\\nInnumerable agencies operate from without capable of exciting or\\naggravating cutaneous affections in fact, it may be set down that few\\nif any of the forces operating externally upon the skin from the begin-\\nning to the end of life may not exert an unfavorable effect upon it if\\ntheir operation be excessive, untimely, or associated with other exter-\\nnally operating factors. Briefly, some of these agencies operate singly\\nothers in cooperation some operate with grave, others with trifling\\neffect some invariably, others but rarely, induce a deleterious effect\\nupon the skin some, though exerting an influence wholly external to\\nthe skin-surface, cooperate with internal agencies. In the latter class\\nmay be named the hand of the syphilitic subject, which may exhibit\\nsyphilodermata largely due to the influence of the articles handled\\nin the trade or occupation of the subject of the disease.\\nScratching is a fruitful source of cutaneous trouble either when\\noperating to originate or to aggravate an exanthem. Its symptoms are\\ncarefully studied by all diagnosticians, as they betray evidences of\\nitching, which the efforts at scratching are exerted to alleviate.\\nThe regions most affected when scratching is severe (as in prurigo,\\nscabies, pediculosis, and the forms of pruritus dependent upon visceral\\ndisease, such as glycosuria, tuberculosis of the adrenals, etc.) are, as a\\nrule, those most readily reached by the hands either of an infant or\\nan adult. In these parts may then be recognized the excoriations, fre-\\nquently in two, three, or four parallel or approximated lines, blood-\\nspecks, pustules, papules, thickening, and even extreme induration and\\npigmentation of the skin, due solely to the traumatisms of the surface\\nof the integument.\\nSolar Light and Heat, and Thermal Changes (whether due to\\nsolar or artificial influence, as well as cold), are frequent and efficient\\nsources of damage to the skin from the slightest grade of inflam-\\nmation to the severest destruction. To solar light is to be attrib-\\nuted the production of freckles, tan, and other pigmentations of the\\nsurface to heat are to be attributed the erythema, the eczema, and\\nthe various grades of dermatitis which may follow exposure to the di-\\nrect rays of the sun. Other temperature-effects, including those pro-\\nduced by extremes of both heat and cold, are to be classed in the same\\ncategory. Exposure of the skin to a temperature of over 100\u00c2\u00b0 F. pro-\\nduces merely a transient erythema, which under a further elevation of\\nsixty-five degrees will not subside for several days. At a temperature\\nof 212\u00c2\u00b0 F. all grades of acute dermatitis are awakened, with the pro-\\nduction of bullae, up to the point at which complete destruction of the\\nintegument occurs.\\nThe Influence of the Seasons is of the same general character.\\nSome cutaneous diseases are worse in summer others in winter.\\nPrickly heat (lichen tropicus) is peculiar to certain warm seasons\\nfrostbite, with its subsequent hyperemia, exudation, or gangrene, occurs\\nin winter pruritus is common in cold weather erythema multiforme\\nis most frequent in the autumn and in the spring.\\nExposure of the Naked Skin to the X-rays in securing skiagraphs", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0078.jp2"}, "79": {"fulltext": "EXTERNAL CAUSES. 67\\nand similar records, the serious effects of which have been noted, are\\nprobably due less to burning than to the actual transmission of exceed-\\ningly minute metallic particles carried not merely to the skin itself, but\\nto the subcutaneous tissues, and even to the deepest structures examined\\nby the aid of the ray. As a result, not merely severe and persistent\\ninflammation and ulcerations of the entire skin have been produced,\\nbut changes have been wrought in the bones and periosteum.\\nClimate has a determining influence upon many cutaneous disorders,\\nand this of a sort which it is difficult to assign either to internal or\\nexternal influence. The effects of climate are exceedingly complex, and\\nprobably include the agencies which favorably or unfavorably affect\\nthe health in the direction of atmospheric humidity or dryness abun-\\ndance or scarcity of sunlight; the prevalence of favoring or injurious\\nwinds and storms a salubrious or insalubrious food- and water-supply\\nthe average temperature of the earth s surface by day and by night\\nthe presence or absence of sources of malarial plasmodia and proxim-\\nity to the sea, to mountain regions, or to extensive growths of pine\\nforests. Thus leprosy, Lombardy erysipelas (pellagra), biskra bouton,\\nainhum, and other affections, though not seen exclusively in one coun-\\ntry, are for the most part prevalent in countries Avhich may well be\\nI contrasted with others where such affections are regarded as curiosities.\\nMycetoma, for example, has been studied for the most part in India,\\nwhile less than half a dozen cases of that disorder have been recognized\\nin the North American continent.\\nOccupation. An enormous number of dermatoses are due exclu-\\nj sively to the occupations of men and women. In France, where such\\nI occupations are highly specialized on account of the artistic and skilled\\nwork of the people in numerous lines, these disorders are known as\\nthe professional dermatoses, and the diagnostician there is often en-\\nabled to decide the character of the work performed by the laborer on\\ninspection of his hands. The workers in dyes, in chemicals, and in\\ndrugs suffer in one way the men who handle tiles, bricks, mortar,\\nor clay in another the baker, the confectioner, the cook, the laundress,\\nthe green-grocer, the seamstress, the shoemaker, the carpenter, and the\\nmachinist have each their forms of erythema, dermatitis, keratosis,\\nor induration. Similarly those whose faces are much exposed, as the\\nwheelmen of vessels, tram car-drivers, locomotive-engineers, and day-\\nlaborers, exhibit symptoms in that region. Butchers, w r ool-workers,\\ncattle-men, and sheep-shearers are liable to contract glanders, ring-\\nworm, or malignant pustule. They avIio handle the bodies of the dead\\nare prone to tuberculosis of the hands (anatomical tubercle), and those\\ncompelled to stand much of the time are exposed to the consequences\\nof varicose veins of the legs and resulting eczema of that region.\\nClothing The coarse clothing worn by the poorer classes is often\\na source of skin-mischief, particularly when employed for infants and\\npersons of both sexes and all ages exhibit marked results from the\\ni wearing of flannel next the skin. Often the influence of clothing is\\nI commingled with that of dyes, as when brightly tinted flannel colored\\nwith anilin produces a dermatitis of high grade with distinct staining\\nof the skin over which such clothing has been worn. In the same list", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0079.jp2"}, "80": {"fulltext": "68 GENERAL ETIOLOGY.\\nmust be included the effects produced by ill-fitting shoes, corsets,\\ntrusses, napkins, pads, supporters, crutches, orthopaedic apparatus,\\nhat-bands, stockings, garters, and chest-protectors. Here, too, more\\nthan one cause may be efficient in the production of disease, as when\\nclothing becomes a nidus for parasites, or is worn next the skin when\\nsoiled with abnormal or even physiological secretions.\\nChemical, Medicinal, and Mechanical Irritation may be respon-\\nsible for many affections of the integument. Of articles effective in the\\nfirst category, may -be named the stronger acids and alkalies of those\\nin the second class, arnica, cro ton-oil, mustard, Mucund pruriens; of\\nthose in the last class may be suggested all substances capable of ex-\\nerting undue friction upon the surface, such as pumice-stone, combs,\\nbrushes, towels, and the articles employed in the operations of the\\nmanicure.\\nFilth is a potent factor in both the production and the aggravation\\nof skin-diseases, its effects being decidedly most apparent in patients\\napplying to the public dispensaries. In infants the skin unwashed\\neven for a fortnight usually becomes the seat of an irritating urticaria.\\nTraumatism plays a most important part in cutaneous etiology. It\\nincludes the action, in scratching, of the nails, the knees, heels, elbows,\\netc., as well as the influence of several articles used for the same pur-\\npose pieces of cloth of various kinds, etc. In this way excoriations,\\nand even infiltrations, of the skin are induced. Under the head of\\ntraumatisms should be considered also injuries of the skin-surface pro-\\nduced by animals, occasionally with the added effect of a toxicant.\\nHere are included the wounds produced by lice, fleas, bugs, and acari\\nthe bites of serpents, horses, dogs, and cats and the accidents produc-\\ning traumatism of every kind, not omitting the intentional wounds in-\\nflicted by the surgeon and their results.\\nTransmission by Contagion, by Infection, and by Parasites.\\nSome disorders with cutaneous phenomena are transmissible from dis-\\neased to healthy persons through the medium of the atmosphere, and\\nare termed infectious; others are termed contagious when transmis-\\nsible solely by contact. Some maladies, such as variola, scarlatina, and\\nmeasles, are conveyed by both methods, and hence belong to the cate-\\ngory of both contagious and infectious disorders. Yet others are\\ntransmissible only through infection with a specific virus such dis-\\neases are syphilis and lepra. By many writers the terms infectious\\nand contagious are used as synonyms.\\nParasitic Diseases. Under this title were once included solely the\\ndermatoses induced by the presence of the animal and vegetable para-\\nsites. Among the former may be named scabies and pediculosis\\namong the latter, ringworm of the scalp and of the beard. But the\\nterm parasite has acquired a much wider scope since the recognition of\\nthe micro-organisms which have been demonstrated to be efficient in\\nthe production of a long list of cutaneous affections. Among these may\\nbe named the bacilli productive of cutaneous tuberculosis and of\\nlepra the pus-cocci, responsible for the several forms of impetigo and\\npustular eczema and the streptococci, recognized in several forms of\\ndermatitis. In most of the dermatoses which are recorded to-day as", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0080.jp2"}, "81": {"fulltext": "EXTERNAL CAUSES. 69\\nparasitic, germs have been recognized, which either singly or in coop-\\neration with others have been proved to be effective in the production\\nof these disorders, or have been demonstrated to play an active part\\nin either their extension or exacerbation.\\nThe popular ideas respecting the frequency and danger of contagion\\nin diseases of the skin are often erroneous. The non-parasitic affec-\\ntions are, and probably always will be, more numerous than all others.\\nThe danger of communicating scabies, syphilis, and other affections by\\nhandshaking is not as great as is generally believed. On the other\\nhand, the dangers which by the mass of people are little considered\\nare often the graver and more to be avoided. Among these may be\\nnamed the use in public of the roller-towel, the drinking in common\\nfrom public cups and glasses, promiscuous kissing, contact with the\\nlower animals exhibiting diseases of the hide, of fur, or of feathers, the\\nwearing of a stocking on one foot which the day before was worn over\\nthe surface of a fellow-member the seat of disease, and the wearing of\\nvelvet- or fur-trimmed collars on top-coats after the occurrence of a\\ndisease of the skin of that part of the neck with which the garment is\\nnaturally brought into contact.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0081.jp2"}, "82": {"fulltext": "IV. GENERAL PATHOLOGY.\\nThe pathological processes and changes in the skin correspond in\\ngeneral to those occurring in other organs of the body, but they are\\nmodified by the peculiar and complex structure of the integument and\\nby its exposure to many and varied external influences. Frequently\\nthe skin is but one of several organs involved in a common process, as\\nin malnutrition, syphilis, or leprosy. More commonly the pathological\\nchanges in the skin which are largely or entirely dependent upon general\\nconditions are not accompanied by similar alterations of other organs.\\nIn this category belong the toxic erythemas, some eczemas, and many\\nother dermatoses. In a large number of disorders of the skin no dis-\\nturbance of the general economy can be discovered. The relation of\\ncutaneous disease to toxaemias, to vasomotor, nervous, trophic, and\\nother constitutional disturbances, and also to micro-organisms and\\nother local influences is discussed in the chapter on General Etiology.\\nMany of the pathological processes involving the skin are but imper-\\nfectly understood, and are difficult to study because of their constant\\nmodification by external influences but the pathological anatomy ex-\\nplaining these processes has been extensively investigated, and offers a\\nfavorable field for further research, since the freely exposed surface\\nrenders it easy to remove tissue for study at any desired stage of the\\nprocess.\\nThe vascular portion of the skin is the corium, in which inflamma-\\ntory, hypertrophic, atrophic, and other changes, including new-growths,\\ncorrespond more or less closely with similar changes in other organs of\\nthe body. Special features are found in the involvement of the coil-\\nglands and sebaceous glands, and of the hair-follicles. The large\\namount of elastic tissue and the degeneration to which it is subject\\nmay greatly modify the histological appearances of a section under\\nexamination.\\nIt is chiefly the epidermis, however, with its peculiar structure and\\nits independence genetically of the corium that gives to cutaneous path-\\nology its chief characteristics and presents its most difficult problems.\\nThe rete is the most important layer, and participates in all inflamma-\\ntory and in most other diseases of the skin. It is subject to intercel-\\nlular and cellular oedema, to several forms of cell-degeneration, to hy-\\npertrophy and to atrophy, and is specially active in all epithelial new-\\ngrowths. In its deeper layers of cells occur the various modifications\\nof the true pigment of the skin. In a large class of cutaneous dis-\\norders, characterized by an excessive or abnormal cornification (hyper-\\nkeratosis and parakeratosis) of the upper rete-cells in the formation\\n70", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0082.jp2"}, "83": {"fulltext": "GENERAL PATHOLOGY. 71\\nof the horny layer, the most manifest changes are in the granular and\\nthe horny strata.\\nThe inflammatory diseases of the skin have been supposed to begin\\nin the corium, the epidermis being secondarily involved. It is prob-\\nable, however, that in many instances the vascular disturbances are\\npreceded by changes in the terminal nerve-filaments and adjacent cells\\nof the rete.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0083.jp2"}, "84": {"fulltext": "V. GENERAL DIAGNOSIS.\\nThe establishment of an accurate diagnosis in cutaneous diseases is\\nessential to their successful management. This statement is rendered\\nnecessary in this connection by the prevalence of a belief among the\\nuneducated that the disorders of the skin, exhibited for the most part\\nin visible symptoms, can safely be treated on general principles with-\\nout a recognition of the nature of the malady. By many practitioners\\nthe demand for an accurate diagnosis is ignored in consequence of a\\ntoo general impression that the desired end is to be pursued through\\ngreat and perplexing obscurity. Yet with patience, method, a habit\\nof careful observation (without which no physician is successful), and\\na reasonable degree of skill both practitioner and student can, in the\\nlarge proportion of all cases, attain their purpose.\\nIt is a popular error that the sole requisite for establishing a diag-\\nnosis is the exhibition of an affected portion of the integument to the\\neye of him who is consulted with a view to its relief. The physician\\nis supposed to inspect this surface attentively for a few moments, and\\nthen to pronounce definitely upon the nature of the disease present\\nand the therapeutic measures to be adopted. While such a procedure\\nis possible to the expert in a limited number of cutaneous disorders, in\\na large number of cases far more than this is requisite, and, indeed,\\nis fully as essential here as in the investigation of disease involving\\nany other organ of the body.\\nIt is true that erythema, urticaria, dermatitis, eczema, purpura,\\nalopecia, and many other affections of the skin may often be recognized\\nafter simple and brief inspection of the region involved but the cause\\nof such disorders and their relation to the general health of the patient,\\nall of which knowledge is essential to their proper treatment, can only\\nbe obtained after a much more thorough examination. As a rule, it is\\ndesirable, first, to secure a history of the physical and mental condition\\nof the patient in the past then should follow the special history of the\\ndisorders of the skin; lastly, an examination of the patient and of the\\naffected integument. The family history may be of value in making a\\ndiagnosis. For the purpose of methodically arriving at these facts,\\nand of preserving them for future reference, they should systematically\\nbe recorded. The following are some of the points upon which it will\\ngenerally be found useful to secure information\\nThe name, residence, age, sex, occupation, and married or unmarried\\nstate of the patient should be known, as also, whenever practicable,\\nthe health-history of parents and children. In the case of women it\\nis not only necessary to learn the history of the menstrual function in\\nthe past, but it is of the highest importance to be informed also as to\\n72", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0084.jp2"}, "85": {"fulltext": "GENERAL DIAGNOSIS. 73\\nthe previous occurrence of abortions and miscarriages, and, if such\\nhave occurred, the order observed by these with relation to the birth\\nof viable infants. The significance and value of several of these facts\\nhave been described in the chapter on Etiology. With respect to the\\nhistory of the products of conception, it should never be forgotten\\nthat it has a most important bearing upon the question of syphilitic\\ninfection. The absolute exclusion of syphilis in any obscure case is a\\nlong step in the direction of an accurate diagnosis. In the instance\\nof male patients, questions will usually elicit either admission or denial\\nof the fact of a precedent or present venereal disease, and the answers\\nshould be regarded as valueless or trustworthy according as they are\\nor are not substantiated by corroborative clinical facts.\\nThen should follow some record of the habits of the patient, as to\\nactive or sedentary employment, bathing, food, and drink, including\\nunder the latter term the use of beer, wine, and spirits. The history\\nof any previous disorders, whether of the skin or other organs, should\\nbe satisfactorily clear, and the dates of occurrence, recurrence, and con-\\nvalescence be at least approximately discovered. The patient should\\nalso make known whether he has had refreshing sleep whether he has\\nundergone mental anxieties (domestic, financial, etc.) whether he has\\nsuffered in his digestive, respiratory, circulatory, genito-urinary, or\\nnervous system. Defects in elimination, assimilation, and nutrition\\nshould be noted and when the symptoms suggest disease of other\\norgans than the skin the patient should be subjected to the proper\\nphysical examination.\\nThis much ascertained, the patient should be encouraged to narrate\\nas succinctly as possible, and as far as may be in his own terms, the\\nhistory of the present cutaneous disorder. A systematic series of\\nquestions put by the examiner should disclose, if possible the cause\\nof the disorder its appearance when first seen, and any changes in\\ncharacter and type which have since occurred the regions of the\\nbody affected, in order of involvement the method of extension, by\\nperipheral enlargement of the early areas, or by the appearance of new\\nlesions at a distance from the first ones the rapidity and regularity of\\nthe progress of the disease and its duration the subjective sensations\\nand the influence of seasons and temperature upon the disorder. The\\ntreatment to which the disease has been subjected should then be de-\\ntailed, this frequently furnishing a key to the diagnosis and therapy\\nof the malady. In an incredibly large proportion of all cases ignor-\\nantly directed and vicious internal or external medication has either\\nbegotten or aggravated the disease of the skin. This much ascertained,\\nthe physician is ready to examine the affected surface for himself.\\nDuring, however, the verbal interrogations which are required for\\nthis part of the exploration of the case, the watchful and observant\\npractitioner will probably have secured for himself some useful infor-\\nmation of which the patient is totally unconscious. Much of this is\\ndifficult to describe, as it is the rich fruit of wide experience and care-\\nful scrutiny. With a gentle, courteous, and sympathizing manner the\\ndiagnostician must combine the art of a detective and the skill of a\\nswordsman. Glancing occasionally at the face of his patient while", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0085.jp2"}, "86": {"fulltext": "74 GENERAL DIAGNOSIS.\\nmaking record of the answers given, he will, of course, have observed\\nany eruption upon that portion of the body. He will have made a\\nmental note of the temperament of the sufferer, and of any movement\\nmade by the latter indicating a tendency to scratch or rub portions\\nof the skin. He will have noticed the posture, clothing, and head-\\napparel the existence of hair on the scalp or extensive baldness\\nthe condition of the exposed hands as indicating manual labor or the\\nreverse and, in the absence of facial lesions, will have observed the\\nspecial tint of the skin of the face, as suggesting ansemia, chlorosis, or\\na general condition of cachexia. The facial expression, .as indicative\\nof anxiety or placidity, habits of debauch, sexual excesses, etc., will not\\nhave escaped his attention. All this and much more will possibly have\\nenabled the questioner to direct his interrogatories into the channel in\\nwhich they will elicit the most useful responses. The posture, cries,\\nfacial expression, and general condition of nutrition of the infant will\\nhave been no less carefully noted.\\nProceeding to the examination of the affected integument, the phy-\\nsician must assure himself of a good light, as colors are best distin-\\nguished by daylight and artificial illumination should be reserved for\\nexploration of the cavities of the body. The air of the apartment\\nshould be sufficiently warm to permit of exposure of the person with-\\nout discomfort and without causing disturbance of the cutaneous cir-\\nculation. Adult males and children of both sexes should have the\\nclothing completely removed so that all portions of the skin may be\\ninspected. One portion of the body may, however, be examined, and\\nthen covered if desired, while the examiner proceeds to direct his\\nattention to another part. In the case of women the investigations\\nshould be conducted with all the tact and delicacy to which the sex is\\nentitled.\\nThe examination, whenever practicable, should extend over the entire\\nsurface of the integument. The importance of this point can scarcely\\nbe exaggerated. It must be remembered that the physician should be\\nvery much wiser than his patient, and the assurances of the latter are\\nalways to be accepted with reserve. Thus, one who merely exposes his\\nleg, stating that this is the only part of his body affected, may have\\nconcealed beneath his clothing extensive varicosities of the veins of\\nthe thigh, a typical syphilitic exanthem over the belly, a significant\\nscar on the elbow, an extensive patch of tinea versicolor on the surface\\nof the chest, or a blennorrhagic discharge from the urethra, the medi-\\ncation of which has induced the rash for which he seeks relief. These\\nare not the rare, but are the common cases of a daily experience.\\nObservation should be had at this time of the general and special\\nfeatures of the eruption. As to the former, the following considera-\\ntions should be borne in mind\\nThe original manifestations of a cutaneous disease may be masked\\nor entirely hidden by the lesions resulting from scratching, or by a\\ndermatitis due to local applications, or to drugs swallowed for the\\nrelief of the original disorder. It is of the greatest importance that\\nthe accidental nature of these symptoms be recognized, as they other-\\nwise lead to great confusion in diagnosis.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0086.jp2"}, "87": {"fulltext": "GENERAL DIAGNOSIS. 75\\nA very few diseases may involve the entire surface of the body,\\nleaving no part unaffected, and are then called universal more fre-\\nquently an eruption aifects at one time several or most of the regions\\nof the body-surface, and is then called generalized much more com-\\nmonly an eruption aifects a considerable portion of but one or several\\nregions, and is said to be diffuse or it is limited to small areas of one\\nor several definite regions, and is known as a local eruption.\\nA symmetrical eruption, one equally distributed over corresponding\\nregions of the two lateral halves of the body, is rarely the result of an\\netiological factor operating upon the outer skin. It more often points\\nto an efficient cause of so-called internal origin, one influencing the\\ninner skin or the internal organs. An eruption affecting the covered\\nintegument, never creeping out upon the exposed surfaces, suggests the\\noperation of the clothing, as the latter may chance to prove the nidus\\nor protector of a parasite, the fabric which has been colored by a noxi-\\nous dye, the recipient of a chemically altered secretion which has proved\\nirritating to the surface, the instrument of friction, or the source of\\nincreased temperature at the surface by its non-conductivity of heat\\nand unseasonable thickness. An eruption accompanied by excoriations\\nand scratch-lines is usually severest in the parts most accessible to the\\nhands, and least developed where the latter have the least play, as\\nover some parts of the back. An eruption limited to the hands is\\nlikely to be one induced by an agent to which the hands alone have\\nbeen exposed. Such are the eruptions originating in the trades and\\ndomestic occupations in the latter, an eruption more distinct on the\\nright hand, and especially about the right thumb and index finger, tells\\nits own story when the hand-worker is not ambidextrous nor left-\\nhanded. Artificially and intentionally produced eruptions, as in ma-\\nlingering, hysteria, mental depravity, and insanity, usually occur also\\nin parts to which the right hand finds easy access.\\nEruptions occurring on the face, the hands, and the genitalia of\\nmen, or on the face, hands, and mammae of women, point to external\\ncontact or contagion (poison-ivy, scabies, croton-oil, etc.), since, next\\nto the face, the hands are more commonly brought in contact with the\\nparts named in the sexes respectively, as the wearing-apparel of each\\nsuggests.\\nAn eruption limited to the forehead suggests an inspection of the\\nhat-band, the veil, or the overlying false hair to the ears of women,\\na glimpse at possibly cheap ear-rings to the centre of the root of the\\nneck, before or behind, a scrutiny of the collar-button and collar to\\nthe anus of the baby, an inquiry as to the changing of its napkins\\nto the wrists of the adult, a question as to the cuffs worn to the feet,\\ninformation respecting gaiters, varicose veins, recently cut corns, and\\nill-fitting boots. Eruptions springing from each of these causes have\\nlong and vainly been treated as diseases of the blood.\\nEruptions markedly asymmetrical are indicative of asymmetrically\\noperating causes that is, the accidents of environment, or else influ-\\nences exerted within the body unequally on its two lateral halves,\\nThus, an orthopaedic apparatus worn to correct talipes excites a der-\\nmatitis of the leg of the affected side only and zoster of the trunk is", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0087.jp2"}, "88": {"fulltext": "76 GENERAL DIAGNOSIS.\\nevident on that side supplied by the intercostal nerve which has been\\ninflamed. The greater stress may be laid on this peculiarity, as the\\nlaw of symmetry, in eruptions not occasioned by causes operating on\\nthe outer skin, is faithfully observed in nature. The earlier syphilides,\\nthe quinine-exantheni, rubeola, and even lupus erythematosus, are re- i\\nmarkable illustrations of this fact.\\nProceeding with the visible characteristics of the disorder, the phy-\\nsician will not fail to note an acuteness or chronicity of the eruption\\nalso, the presence or absence of an exudate on the surface.\\nAfter obtaining an impression of the general features of an eruption\\nthe individual lesions should be carefully studied. The type of lesion\\n(papule, tubercle, vesicle, etc.) should be noted. When the lesions are\\nmultiform the different types should be examined to determine, if pos-\\nsible, which are primary and which secondary in appearance, which are\\nessential and which accidental in the process. For the purpose of\\nstudying the characteristics of the individual lesions, those of most\\nrecent appearance (usually at the border of a patch), and as yet un-\\nmodified by scratching, treatment, and other influences, should be\\nselected. Often, however, the full evolution of a lesion requires time,\\nand its successive stages should be determined by observing a number\\nof lesions of different ages.\\nThe arrangement of lesions varies greatly in different diseases.\\nWhen grouped such lesions may develop in circular, oval, angular, or\\nirregular-shaped areas or in circinate, gyrate, serpiginous, straight, or\\nirregular bands and lines. In some affections (as ringworm, psoriasis,\\nsyphilis) the areas may clear in the centre as the border progresses.\\nLesions may be grouped, and yet discrete in that each lesion preserves\\nits outline and identity or they may coalesce so completely that all\\ntrace of the form of the individual lesion is lost.\\nThe definition of lesions is another important diagnostic feature in\\nwhich cutaneous affections vary greatly the line dividing the diseased\\nfrom the normal skin may be so sharp and fine that it can be traced\\nwith the point of a pin or the lesion may shade so gradually into the\\nnormal skin that its outline cannot be definitely determined, and it is\\nsaid to have poor definition or none.\\nThe color of lesions of the skin often depends greatly upon circum-\\nstances having no bearing upon the disease in question. It thus varies\\nwith the natural color (light or dark) of the individual s skin, with the\\ntemperature of the surface, and with the amount of irritation to which\\nthe surface has been subjected by friction of rough clothing, scratching,\\ntreatment, etc. There are, however, some diseases (syphilis, lichen\\nplanus, tinea versicolor, favus, and others) in which the color may be\\nof great importance in the diagnosis, and there are many maladies in\\nwhich consideration of this characteristic of the eruption is of value\\nif the accidental modifications be borne in mind. The acuteness or\\nchronicity of a disease is often indicated by the color of the lesions.\\nThe persistence, modification, or disappearance of color under pressure\\nshould be noted. For this purpose a small glass disc or glass tongue-\\ndepressor is better than the finger.\\nIn judging of the size of a lesion it is sometimes important to learn,", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0088.jp2"}, "89": {"fulltext": "GENERAL DIAGNOSIS. 77\\nby palpation, how much of it is above the general surface of the skin\\nand how much is more deeply situated. In noting the shape of papules,\\ntubercles, vesicles, and pustules, both apex and base should be taken\\ninto consideration. Thus, the apex may be pointed (acuminate), rounded\\n(obtuse), flat (plane), or depressed (umbilicated). The base may be\\nround, oval, angular, polygonal, or irregular.\\nThe situation of lesions in or about the hair-follicles or at the\\nopening of the ducts of the sebaceous or coil-glands is a diagnostic\\npoint of great value. It is important to know if certain lesions\\nappeared first on normal skin, or if they originated in other lesions.\\nThus, vesicles and pustules may arise from sound surfaces, or from the\\napices of papules or tubercles. The majority of even the elementary\\nlesions are probably preceded by macules, which, however, are usually\\nso transitory as to be unrecognized and unimportant.\\nThe career of an individual lesion, which often bears no relation to\\nthe duration of the disease as a whole, should be noted. Thus, the\\nvesicle of eczema rarely exists as such for more than a few hours,\\nthough by the formation of new vesicles eczema may persist for months,\\nwhile in zoster individual vesicles last several days, though the disease\\nas a whole is short-lived. In some diseases the type of lesion remains\\nthe same throughout its career unless modified by treatment or external\\ninfluences, while in others the type changes or is complicated by other\\ntypes. Thus, the papule may be modified by developing at its apex a\\nvesicle or pustule. The career of lesions can usually be studied, not\\nonly by watching them from day to day, but also and more easily\\nby observing at one time a number of lesions in various stages of\\ndevelopment.\\nAs the lesions of different affections vary greatly in their evolution\\nand career, so do they in their involution. While in the majority of\\ninstances it is the recent and newly formed lesion that is most desira-\\nble for purposes of study, there is often much to be learned from the\\nmanner in which lesions disappear and in the traces they leave behind.\\nThe papule or tubercle which ulcerates usually suggests (aside from\\nsome rare diseases) syphilis, tuberculosis, or carcinoma, and may be\\nsufficient to exclude from the diagnosis the possibility of psoriasis,\\nseborrhoea, and other superficial affections. In a doubtful case the\\ntermination of some of the lesions in scar-tissue may be the one fact\\nneeded to make a differential diagnosis between seborrhoea and lupus\\nerythematosus, or between a circinate form of psoriasis and a similar\\ntype of syphilitic eruption. Pigmentation sufficiently characteristic\\nfor a diagnosis is left after the otherwise complete involution of some\\nlesions. This is most frequently true in zoster, lichen planus, and\\nsome forms of syphilitic eruptions. In estimating the time of involu-\\ntion of lesions and in making a prognosis regarding the disappearance\\nof pigmentation (a point upon which patients are often very solicitous)\\nit should be remembered that pigment is usually removed very slowly\\nfrom the lower extremities and other dependent portions of the body,\\nand that in such localities it may persist for months or years after it\\nhas disappeared from parts in which the return-circulation is better.\\nCertain lesions have special features that should be studied. These", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0089.jp2"}, "90": {"fulltext": "78 GENERAL DIAGNOSIS.\\nare given in detail in the last division of the outline at the end of this\\nchapter.\\nBefore concluding his examination the physician will rupture a\\nbleb, pustule, or vesicle, should such be found, to discover the nature\\nof its contents. He will remove one or several crusts in sight, to\\nexpose the surface on which they rest. He will scrape away a few\\nscales with the dermal curette for a similar reason. He will pinch up\\nbetween his thumb and finger a portion of each part, in order to deter-\\nmine its infiltrated condition, its atrophy, or its attachment to the tissues\\nbeneath. He will pass his hands over the surface to recognize the firm-\\nness or the softness of the lesions, their inflammatory, hyperplastic,\\nor neoplastic character, their dryness or moisture, and the existence of\\nsebaceous or of perspiratory secretion. He will look at the mouths of\\nthe follicles where such secretion is retained or is abundantly exuded.\\nHe will discover any lice or their ova between or upon the hairs, any\\nascarides at play about the anus, any morbid formation of the nail or\\ndeformity of its matrix. He will examine for inguinal, post-cervical,\\naxillary, and epitrochlear adenopathy, and will thus be often greatly\\naided in his task. This done, he will question in turn for himself, and\\nby the methods recognized in medical science, the organs of the body\\nother than the skin. He will inspect the tongue carefully, and if then\\nhe considers himself through with the mouth he will be guilty of\\ngreat error. The gums rarely deceive the questioning eye; the inside\\nof the lips, the fauces, and the tonsils are all to be searched. A\\nmucous patch here will often echo the story of a palmar or a plantar\\nsphiloderm. The laryngoscope may be called for in syphilis, cancer,\\nlupus, and leprosy. The degree of distention of the belly and the\\nregion of hepatic dulness should not be overlooked. The genitalia of\\nmen, and of children and infants, can usually be explored. For\\nwomen unaffected with syphilis or disease limited to these parts an\\nexception in this particular should usually be made.\\nIn many cases the microscopical and bacteriological examination\\nof hairs, scales, crusts, exudate, or tissue will aid greatly in the diag-\\nnosis, and should not be neglected. In some instances such examina-\\ntions are essential to the formation of a correct diagnosis.\\nWith the necessary reserve of all very obscure cases, it may be said\\nthat the physician who has conscientiously conducted an examination\\nafter the manner described above is in possession of the diagnosis for\\nwhich he seeks. If the facts thus acquired have properly been re-\\ncorded, and yet do not spell out such a diagnosis to his eyes, they will\\nprobably be legible to others with a wider experience or riper judg-\\nment, to whom such a record mav be shown. It is not claimed that\\nthis exhaustive method of examination is requisite in every case, as,\\nfor example, in order to recognize a favus or to differentiate erysipelas\\nfrom erythema. But it is certain that few obscure cases of skin dis-\\nease will remain such under severe scrutiny, and the establishment of\\na thorough and exhaustive method of examination is important in the\\nearliest experience with disease. Let the student or the practitioner\\nconduct such an examination in the first few cases of eruption upon\\nthe surface of the body for which his advice is sought, and he will", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0090.jp2"}, "91": {"fulltext": "GENERAL DIAGNOSIS.\\n79\\nestablish a habit of observation in comparison with which his pecuniary\\nor professional success in the management of the same cases will in-\\ndeed be of trivial worth.\\nUpon one special point should the inexperienced physician be\\nguarded. It relates to the acceptance of a diagnosis which is not\\nbased upon such an examination as that given in outline above. A\\ndiagnosis by a patient is usually faulty, and the verdict of even skilled\\npractitioners may be founded upon an error. The careful diagnostician\\nshould begin his task in a spirit of skepticism, and pronounce definitely\\nonly upon ascertained facts. The man who says he has an eczema\\nmay be louse-bitten the woman who has been overheated may\\nprove syphilitic. The patient recognized as suffering from ringworm\\nof the beard may not have been iufected under the hands of a barber.\\nFinally, the eruptions upon patients unmistakably syphilitic are often\\nof other than syphilitic origin. These infected subjects men, women,\\nand children are exposed daily to the accidents from which the non-\\ninfected suffer. They exhibit acne, physiological alopecia, and der-\\nmatitis medicamentosa equally with the non-syphi]itic.\\nThe following outline for the methodical examination of a patient\\naffected with skin-disease is based on the subjects considered in the\\npreceding pages, and is given in such detail that a careful investigation\\nof the questions suggested should furnish material for all but excep-\\ntional cases. For the average case much may be omitted.\\nThe first attempts to follow such a scheme are necessarily tedious, and\\ntherefore often discouraging; but one patient thus carefully examined\\nis of greater educational value than an aimless and indefinite examina-\\ntion of a dozen cases. There is no greater economy of time than is\\nfound in methodical and systematic habits of work.\\nHISTORY.\\nI. Name and Kesidence.\\nII. Age.\\nIII. Sex.\\nIV. Married or Unmarried.\\n1. Children.\\na. Living.\\nb. Dead.\\n2. Abortions or Miscarriages.\\nV. Family History.\\nVI. Individual History, including that\\nof previous skin-diseases.\\nVII. Occupation.\\nVIII. Habits, of eating, drinking, bathing,\\ntobacco-usage, etc.\\nIX. Present State of Health.\\n(Note the condition of the digestive, re-\\nspiratory, circulatory, genito-urinary,\\nand nervous systems also, defects in\\nassimilation, elimination, and nutri-\\ntion.)\\nX. History of Present Skin-dis-\\neases.\\n1. Cause\u00e2\u0080\u0094 if known.\\n2. Character at first.\\n3. Sites affected in order.\\n4. Manner of progressing.\\na. Slow or rapid.\\nb. Steady or irregular.\\nc. With exacerbations and remis-\\nsions.\\nd. With periods of entire freedom\\nfrom symptoms.\\n5. Changes in character.\\n6. Subjective sensations.\\n7. Duration.\\n8. Effect of temperature and seasons.\\n9. Treatment to date.\\nOBJECTIVE SYMPTOMS.\\nB.\\nAccidental Complications due to\\nscratching, treatment, etc.\\nSite.\\n1. Universal.\\n2. Generalized.\\n3. Diffuse.\\n4. Local. (Note influence of clothing, occu-\\npation, etc.,\\nC. Symmetry, or asymmetry.\\nD. Acuteness, or chronicity.\\nE. Moisture, or absence of.\\nF. Individual Lesions.\\n1. Elementary (macule, paprde, wheal, tuber-\\ncle, tumor, vesicle, pustule, or bleb).\\n2. Consecutive (scale, crust, excoriation, fis-\\nsure, ulcer, or scar).", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0091.jp2"}, "92": {"fulltext": "80\\nGENERAL DIAGNOSIS.\\nI. Uniformity, or multiformity.\\nII. Arrangement.\\n1. Isolated\\n2. Grouped.\\n3. Discrete.\\n4. Coalescing.\\n5. Irregular.\\nIII.\\nDefinition.\\nnone.)\\n(Sharp, fair, poor, or\\nIV. Elevation, or depression.\\nV. Color.\\n1. Under pressure.\\nVI. Shape.\\n1. Apex.\\n2. Base.\\nVII. Size.\\n1. Superficial.\\n2. Deep.\\nVIII. Anatomical site.\\nIX. Consistence.\\n1. Firm.\\n2. Soft.\\nX. Base.\\n1. Color.\\n2. Infiltration.\\nXI. Evolution.\\n1. From sound skin.\\n2. From other lesions.\\nXII. Career.\\n1. Transitory.\\n2. Persistent.\\n3. Type.\\na. Simple.\\nb. Changing,\\nc. Modified.\\nXIII. Involution.\\n1. Resorption.\\n2. Exfoliation.\\n3. Ulceration.\\n4. Atrophy, etc.\\nXIV. Sequelae.\\n1. Stains.\\n2. Scars.\\nSPECIAL FEATURES TO BE OBSERVED IN CERTAIN LESIONS.\\nA. Vesicles, Pustules, or Blebs.\\nI. Koof.\\n1. Tense.\\n2. Flaccid.\\n3. Easily ruptured.\\nII. Contents.\\n1. Translucent, or opaque.\\n2. Serous.\\n3. Purulent.\\n4. Hemorrhagic.\\nIII. Surface beneath.\\nIV. Areola.\\nV. Involution.\\n1. Desiccation.\\n2. Rupture.\\n3. Crusts.\\nB. Scales.\\nI. Size.\\nII. Color.\\nIII. Quantity.\\nIV. Consistence.\\n1. Dry.\\n2. Fatty.\\n3. Friable.\\n4. Tough.\\nV. Attachment.\\n1. Firm.\\n2. Slight.\\nVI. Surface beneath.\\n1. Color.\\n2. Dry.\\n3. Greasy.\\n4. Hemorrhagic.\\nC. Crusts.\\nI. Size.\\nII. Shape.\\nIII. Color.\\nIV. Composition.\\n1. Serum.\\n2. Pus.\\n3. Blood.\\nV. Attachment.\\nVI. Thickness.\\nVII. Consistence.\\nVIII. Surface beneath.\\nD. Excoriations.\\nI. Distribution.\\nU. Shape.\\nIII. Arrangement.\\nIV. Kelation to other lesions.\\nV. Exudation.\\nE. Fissures.\\nI. Distribution.\\nII. Size.\\n1. Length.\\n2. Depth.\\nIII. Pain.\\nIV. Moisture.\\nF. Ulcers.\\nI. Size.\\nII. Shape.\\nIII. Depth.\\nIV. Base.\\n1. Soft.\\n2. Infiltrated.\\n3. Indurated.\\nV. Edges.\\n1. Sloping.\\n2. Perpendicular.\\n3. Punched.\\n4. Ragged.\\n5. Everted.\\n6. Undermined.\\n7. Soft.\\n8. Indurated.\\nVI. Floor.\\n1. Smooth.\\n2. Uneven.\\n3. Clean.\\n4. Pus-covered.\\n5. Granular.\\n6. Sloughing.\\n7. Hemorrhagic.\\n8. Glazed,", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0092.jp2"}, "93": {"fulltext": "GENERAL DIAGNOSIS.\\n81\\nVII. Secretion.\\n1. Scanty.\\n2. Profuse.\\n3. Serous.\\n4. Purulent.\\n5. Hemorrhagic.\\n6. Odor.\\nVIII. Pain.\\nIX. Crust.\\nX. Evolution.\\nXI. Duration.\\nXII. Involution.\\n{Note carefully the number and location\\nof ulcers, the age of the patient, and the\\ncharacter of scars if present.)\\nG. Scars.\\nI. Size.\\nII. Shape.\\nIII. Color.\\nIV. Depression, or elevation.\\nV. Texture.\\n1. Soft, pliable.\\n2. Hard, indurated.\\n3. Thin.\\n4. Thick.\\n5. Smooth.\\n6. Rough, corded.\\nVI. Attachment.\\nVII. Deformity.\\nVIII. Subjective sensation.\\nIX. Absence or presence of hairs, glands,\\nand papillae.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0093.jp2"}, "94": {"fulltext": "VI. GENERAL PROGNOSIS.\\nThe prognosis of most diseases of the human body is formulated\\nwith a view to the decision of the serious question of life or death.\\nOccasionally this question arises in connection with skin-diseases.\\nMany of the latter are trivial, some are grave, a few are inevitably\\nfatal in their termination. Thus, general exfoliative dermatitis, lep-\\nrosy, sarcoma, carcinoma, at times lichen ruber, and variola in the\\nunprotected are of grave portent while the ordinary congestions and\\nexudations, the great majority of all cases of acquired syphilis in\\nadults, and the entirely curable diseases induced by parasites do not\\nexcite alarm in the breast of the average patient with respect to his\\nlongevity.\\nThe questions, however, as to his future, Avhich are urgently pressed\\nby the victim of cutaneous disease, are both numerous and important.\\nHe is anxious as to the time during which he must suffer as to the\\npossibility of conveying the disease to his progeny or other members\\nof his family as to the disfigurement of his person that may result\\nas to the scars which he may carry for the remainder of his life as\\nto the possible recurrences of his malady in the future. The responses\\nto these questions will largely be influenced by the prognosis of the\\nphysician.\\nSome diseases of the skin are acute, pursue a rapid course, and\\nare prompt to disappear. Others are chronic, rebellious to treat-\\nment of the most energetic and skilful character. Others, again,\\nthough not shortening life, are never relieved while life is continued.\\nSome disappear only to reappear at more or less regular intervals.\\nThere are cutaneous diseases which affect one individual but once in\\nhis lifetime others which reappear at the instant the patient is again\\nexposed to their exciting cause. There are cutaneous diseases so dis-\\ntorting and destructive in their effects that their victims have com-\\nmitted suicide under the influence of the morbid emotions which they\\nhave as a consequence experienced.\\nThe mental distress occasioned by even an insignificant cutaneous\\ndisorder is often out of all proportion to its exciting cause, and this\\nshould always be regarded in establishing a prognosis. The sexual\\nhypochondriac has been made insane by an acne and the man or\\nwoman affected with syphilis has been made wretched for years by a\\nrecurrent erythema.\\nAgain, a disease of the skin may coexist with grave lesions of in-\\nternal organs, and the prognosis of the disease of the one be greatly\\ninfluenced by that demanded by the other thus, there is occasional\\ncoexistence of syphilis and phthisis. Pruritus may be associated with\\n82", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0094.jp2"}, "95": {"fulltext": "GENERAL PROGNOSIS. 83\\nalbuminuria and the eczema of an infant starving for want of breast-\\nmilk may hasten its marasmus to a fatal termination.\\nUpon the answers given to his patient inquiring as to the prognosis\\nof the disease of the latter will largely depend the professional success\\nof the physician. Scrupulous honesty should here be welded with all\\nthe skill that science can command. That a disease does not endanger\\nlife is not an argument in favor of its amenability to treatment. The\\npractitioner should never suffer himself to be pushed by his patient to\\nthe position that an obstinate disease is readily manageable. It is the\\nheight of folly to estimate lightly that zoster of the forehead, the scars\\nof which the patient may exhibit to all who afterward look upon his\\nface both in life and in death. He who engages to relieve an alopecia\\nareata in the month may have a year in which to repent his precipi-\\ntancy. There is no way in which the conscientious physician can so\\nreadily secure the confidence of his patient, and with it that will-\\ningness to submit to appropriate treatment which is begotten of such\\nconfidence, as by demonstrating his ability to forecast the future of a\\ndisease in other words, to describe accurately its prognosis.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0095.jp2"}, "96": {"fulltext": "VII. GENERAL THERAPEUTICS.\\nA consideration of the subject of the methods of treating skin-\\ndiseases in general suggests at once the intimate relation which subsists\\nbetween the integument and other organs of the body. The etiology\\nof one largely explains the causes of the disease in all. The patholog-\\nical processes in each are subordinated to the same general laws. The\\nprinciples of treatment are very similar in all the disorders of the\\nbody.\\nThe object to be attained by treating a cutaneous disease is, first,\\nits complete relief; secondly, where relief is impossible, such manage-\\nment of the morbid process as will mitigate its severity and render the\\nvictim of the disease more comfortable. A higher and more scientific\\nachievement than either is the prophylaxis by which man is enabled to\\nescape the disease altogether. He can by his wisdom largely diminish\\nthe danger to which his integument is exposed he can, to a certain\\nextent, shelter himself from extremes of temperature, traumatism, toxic\\nagents, and contagious diseases he can, by observing the simple rules\\nof hygiene, fortify his skin against the lesser evils which may befall\\nit. Here, however, the subject under consideration involves disease\\nwhich is actually present and in progress.\\nThe management of diseases of the skin demands of the practitioner\\na sound knowledge of general medicine and an experience in disorders\\nother than those of the integument. Dermatology is a branch of gen-\\neral medicine, and he who would succeed in the one department must at\\nleast be at home in the other. He who cannot succeed in the one\\nfield will almost surely fail to secure the best results in the other.\\nMuch indeed of the management of diseases of the skin can be cor-\\nrectly described as the pure practice of medicine. Many of the\\nmethods, most of the means of diagnosis, much of the pharmaceutical\\naid utilized by the general practitioner, are indispensable in the field of\\ndermatology.\\nIt is scarcely needful to set it down at this date that the old doctrines\\nrespecting both the danger of driving in certain diseases of the skin,\\nand of the importance of driving out others, are relics of a super-\\nstitious ignorance. There is no disease of the skin the continuance of\\nwhich offers a bar to other disorders or furnishes a guarantee of the\\nfuture health of the patient. There is no disease of the skin which\\ndoes not call for relief as promptly as the requirements and safeguards\\nof science will permit. The retrocession of the exanthematous symp-\\ntoms of a systemic poison are not of the class of involution of lesions\\nto which attention is here directed.\\nIn beginning the treatment of disorders of the skin it is scarcely\\n84", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0096.jp2"}, "97": {"fulltext": "GENERAL THERAPEUTICS. 85\\nnecessary to repeat that the diagnosis should be established by the\\nmethods already detailed and that in attempting to adjust remedies to\\nthe morbid state due attention must be given to the past history of the\\ncomplaint, to its remote or immediate causes, to its duration, to the\\nnature of the disease (whether the latter has changed in type or severity\\nsince the beginning), and in particular to the special features presented\\nat the moment of instituting treatment. The matter of diet is one with\\nrespect to which experts are not as yet upon all points agreed. In\\ngeneral it may be said that in all inflammatory affections the diet\\nshould include food which is simple, digestible, and free from excess of\\nnitrogenous and hydrocarbonaceous principles. The diet appropriate\\nfor the gouty state in the majority of gouty patients suffering from\\ndermatoses must be rigidly enforced, even admitting that too severe a\\nregimen is to be deprecated for the gouty when not actually suffering\\nfrom a crisis of the disease. In all attacks of urticaria the food per-\\nmitted should be made to correspond carefully with the list of articles\\nknown to be incapable of aggravating the disorder, and too much im-\\nportance cannot be attributed to the regulation of the food of infants and\\nchildren affected especially with eczema. In glycosuric xanthoma, in\\nthe pruritus of albuminuria, in the tuberculoses of the skin, in acne\\ncachecticorum, and in other disorders the selection of a dietary appro-\\npriate to the systemic state is of vital importance. On the other hand,\\nit is to be conceded that in some cutaneous maladies, such as vitiligo,\\nthe disorders due to vegetable and animal parasites, in molluscum, and\\nin other affections which might be named, the subject of dietetics is\\nwithout importance.\\nLike all other diseases of the body, those of the skin may be divided\\ninto three classes with relatively fixed limits.\\nThe first class embraces all the diseases which have a natural tendency\\nto pursue their course to a favorable termination. It includes all those\\naffections which, either mild or severe, require absolutely no treatment\\nof an active character. It is the duty of the skilful physician to watch\\nthe evolution of these maladies, and to discharge a most important part\\nby refraining from all therapeutic measures which in such cases might\\nprove hurtful. By his judicious counsel, also, he hinders patients and\\ntheir friends from pursuing a course which might prove prejudicial to\\nthe disease.\\nThe second class embraces all those skin-affections which are either\\ninevitably fatal or hopelessly remediless while life is prolonged. For-\\ntunately, this includes but a small proportion of the large list. Here\\nthe duty of the physician is plain. He should assuage pain, attempt to\\nrelieve deformity, administer to the comfort of the afflicted in other\\nways, and by his patient courage inspire confidence and hope. It\\nmust not be forgotten that the skill of man has not yet reached the\\nacme of human need. In the presence of many diseases of the body\\nhe stands absolutely helpless, and the speediest w T ay to success in such\\ncases is to begin by an honest admission of the plain fact.\\nThe third class of affections naturally embraces all not included in\\nthe first two classes. Here disease may be prolonged or be shortened\\nin its course, rendered acute or chronic, made more or less endurable,", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0097.jp2"}, "98": {"fulltext": "86 GENERAL THERAPEUTICS.\\npermitted to become inveterate, or absolutely be relieved by prompt\\nand energetic measures, according as it is, or is not, judiciously and\\nskilfully managed. Here are gained the most brilliant successes of\\nthe dermatologist here also occur his most humiliating failures.\\nIn the presence of a cutaneous disease which requires treatment the\\nquestion naturally arises as to whether this treatment shall be internal\\nthat is, by medicaments ingested or external that is, by local thera-\\npeusis or by combination of the two methods at the same time.\\nINTERNAL TREATMENT.\\nWith regard to the question of internal treatment, which is one\\nof pressing importance, it can safely be said that there are no remedies\\nto be given by the mouth that can be described as certainly and spe-\\ncifically curative of the diseases of the skin. The number of medicinal\\nagents employed with this end in view is incredibly large, by far the\\ngreater part being obtained from the vegetable kingdom. With few\\nexceptions, some of which are enumerated below, the most esteemed\\nof these agents exert only an indirect therapeutic effect upon the in-\\ntegument. The larger number of medicaments thus used are, it must\\nbe admitted, without value of any kind, but will probably continue to\\nbe vaunted as possessing specific virtue so long as credulity on the one\\nhand, and avarice on the other hand, move the mass of mankind.\\nArsenic has long stood at the head of the list of remedies as valu-\\nable, when ingested, for the relief of cutaneous disorders. It is known\\nto exert its effects almost exclusively upon the epithelia of the skin,\\nand upon these, so far as therapeutic effects are concerned, only when\\nthey are the seat of subacute and chronic exudation. It is known to\\nexert an unfavorable influence upon the epidermis when the latter is\\nin a condition of active inflammation, and if given for long periods of\\ntime may produce pigmentation of the skin of the general surface of\\nthe body and keratosis of the palms and soles. Operating favorably\\nin this limited class of cases, it also operates slowly, requiring months\\nfor the production of its curative effects. Its administration is at all\\ntimes attended with the hazard of producing toxic effects, which, hoAv-\\never, when the result of the exhibition of the drug in medicinal doses\\nare usually limited to a mild exanthem upon the skin, moderate coryza,\\nand some redness from congestion of the vessels in the eyes and eyelids.\\nArsenic is used chiefly in psoriasis, acne, squamous eczema, pem-\\nphigus, and lichen ruber its doses in cases of children being rela-\\ntively large. It should invariably be administeted only after eating,\\nand a minimum dose be first employed in order to test the suscepti-\\nbility of the patient to its action. It should be remembered that the\\ntoxic effect of this, as also of several of the other drugs mentioned\\nbelow, is often speedily noticed after the first exhibition of a relatively\\nsmall dose. Toleration once established, the dosage may be cautiously\\nincreased.\\nThe forms in which arsenic is usually administered are the prepa-\\nrations of arsenious acid, such as the popular tablet-triturates made\\nup in different and most commonly administered doses the liquor po-", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0098.jp2"}, "99": {"fulltext": "INTERNAL TREATMENT. 87\\ntassii arsenitis (Fowler s solution) the liquor arsenici et hydrargyri\\niodidi (Donovan s solution) the liquor arsenici chloridi (de Valan-\\ngin s solution) and the Asiatic pill. Duhring s modification of this\\npill is obtained by making 2 grains (0.13) of arsenious acid, and 32\\ngrains (2.2) each of black pepper and licorice powder into thirty-two\\npills by the aid of a sufficient quantity of gum Arabic and water.\\nArsenic is also at times advantageously combined with other indicated\\nmedicinal substances, such as iron and potassium iodide.\\nAn unprejudiced view of the value of arsenic, even in cases prop-\\nerly selected for its internal administration, justifies the conclusion that\\nit is in diseases of the skin a remedy of uncertain effect, and in that\\nproportion disappointing. After collation of the experience of ex-\\nperts it has been shown that the common practice of giving arsenic in\\nmany cutaneous diseases is both harmful and irrational, not merely\\nbecause of its effect in inducing cutaneous congestion and pruritus,\\nbut also because of the reliance placed upon it to the exclusion of\\nother and better methods of treatment and that the beneficial effects\\nsupposed to follow its administration are often due to other causes.\\nNo series of carefully recorded cases has ever been published in which\\nnotable therapeutical results have been shown to result solely from its\\nadministration. Even in pemphigus, psoriasis, chronic eczema, and\\nlichen ruber, in which arsenic has been thought to possess special\\nefficacy, it has in cases conspicuously failed.\\nIt is safest to conclude, first, that arsenic, instead of being one of\\nthe earliest, should be one of the last remedies to be selected in the\\nmanagement of cutaneous diseases by the general practitioner secondly,\\nthat, when thus selected, its value will probably prove greatest if the\\neruptive lesions be seated superficially, be generalized, diffused, or in\\nevident association with neurotic symptoms thirdly, that in any case its\\nfailure to relieve should not be regarded as definite, if only Fowler s\\nsolution has been administered.\\nMercury is a remedy of the greatest value in cutaneous as in other\\naffections. Its specific action upon the liver and intestinal secretions\\ncalls for its employment in many cases in which intestinal elimination is\\ndeficient, in which there is habitual constipation, and in which there is a\\ndecided tendency to congestion of the blood-vessels of the head, of the\\nanogenital region, and even of the low T er extremities. In all of the\\ndistinctly gouty dermatoses, in all eczemas of the florid-faced type of\\npatients, in many cases of intense pruritus resulting from toxic influ-\\nences, and in almost all the eczemas of infancy and childhood, calomel,\\nblue pill, and the gray powder are well nigh indispensable in securing\\nthe speediest and happiest results. Indeed, there are few adult patients\\nseeking relief from a simple inflammatory affection of the skin and\\nhaving at the same time a coated tongue, an offensive breath, and a\\nloaded colon, who will not be benefited at the outset of treatment\\nby free catharsis under the influence of a mercurial. In many cases\\nindeed of aggravated types of engorgement of the skin, localized or\\ngeneralized, a dose of blue mass may be given at night, on successive\\nnights, or for a fortnight or more, and followed by a saline laxative in\\nthe morning, with the best effect upon the exanthem present.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0099.jp2"}, "100": {"fulltext": "88 GENERAL THERAPEUTICS.\\nMercury in the treatment of syphilodermata is of incontestable value,\\nand its injudicious employment in many cases springs from that pre-\\ncise fact. The vulgar prejudice that many disorders of the skin, really\\nnot syphilitic, are obscure manifestations of lues in a preceding genera-\\ntion and amenable to mercurial treatment, is a striking illustration of\\nthe necessity of accurate diagnosis in cutaneous diseases. When\\nsyphilodermata are present corrosive sublimate is often superseded, in\\nconsequence of its irritative effects, by the compounds of the metal\\nwith iodine. The gray powder is useful chiefly in case of infants and\\nchildren, though its not infrequent development of the corrosive chlo-\\nride has limited its employment. Calomel and the mercurial pill should\\nbe employed only for transient eifect, as when administered for long\\nperiods they are much more than the other preparations mentioned\\nlikely to produce ptyalism.\\nIodine and its compounds are also chiefly used in syphilitic disorders\\nof the skin, but they possess a wider range of value than the mercurials\\nin the treatment of other cutaneous affections. Here, too, the abuse of\\nthe drug furnishes a long list of cutaneous disorders either originated\\nor aggravated by its employment. As in the use of arsenic, toleration\\nshould be established before large doses are exhibited. The compounds\\nchiefly used are the iodides of potassium, sodium, lithium, and ammo-\\nnium and iodoform. Iodine has been administered for the relief of the\\nscrofulodermata, lupus, keloid, psoriasis, and syphilitic affections of\\nthe skin. As to the latter, it may be added that in the earlier symp-\\ntoms of lues it is often a source of positive injury.\\nCod-liver Oil is a remedy of special value in diseases of the skin,\\nand was for that reason held in high favor by the distinguished Hebra,\\nthough its action is almost exclusively that of a nutrient of the general\\nsystem. It is employed chiefly for its roborant effects, which are\\nsimilar to those of the digestible aliments. Its special value in the\\ntreatment of infants and children affected with cutaneous diseases can-\\nnot be questioned. It is, moreover, of great use in maturer years, and\\nis advantageously exhibited in eczema, lupus, scrofula, syphilis, scle-\\nroderma, and in all disorders of the integument accompanied by\\nwasting.\\nCathartics, Alkalies, and Diuretics have an important place in\\nthe list of remedies valuable in the management of skin-affections.\\nCathartics are chiefly valuable in eliminating effete or toxic products,\\nbut they are effective also in reducing congestion of the body-surface.\\nThe value of mercurials in this connection has been already suggested.\\nThe saline laxatives and cathartics also are of great service, especially\\nthe magnesic and sodic sulphates, and the Rochelle, Carlsprudel-^ and\\nHunyadi Janos salts. The useful and frequently ordered mistura\\nferri acida is compounded as follows\\nR Magnes. sulphat., ^jss 45\\nAcid, sulph. arora. (vel dilut.), 3j 4\\nFerri sulphat., gr. viij\\nAq. menth. piper., ad giv 120\\n50\\nM. (filtra).\\nSig. A tablespoonful in hot or cold water before breakfast daily.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0100.jp2"}, "101": {"fulltext": "INTERNAL TREATMENT. 89\\nThe alkalies are extremely useful in all cases of gouty disorder, and\\nin erythema, acne, and certain forms of eczema. The carbonates of\\nsodium, potassium, and lithium are chiefly employed, as well as the\\nliquor potassse. The prevalent misconception of the value of lithium\\ncarbonate aud other salts of the same base has produced a reaction\\nwhich suggests a preference of one of the other alkalies when such are\\nindicated. v Diuretics, with the exception of water, are less valuable in\\ncutaneous than in other affections, but they yet are administered often\\nwith special advantage in inflammatory disorders.\\nWater when drunk in sufficient quantities and at proper times is\\nof great value as a diuretic and as an aid to elimination. Soft water\\nis to be preferred, and should be drunk freely at all times except dur-\\ning meals and for an hour after eating. The best results are obtained\\nby drinking a given amount (four to eight, or more, ounces) every hour.\\nAs such a course is usually impracticable outside of hospitals and\\nhealth-resorts, under ordinary circumstances two or three glasses may\\nbe ordered to be taken on rising in the morning and before meals.\\nThe free use of water, especially if iced, with meals is a fruitful source\\nof indigestion as a consequence of the chilling and large dilution of the\\nstomach-contents. The vicious habits of rapid eating and imperfect\\nmastication of food may often be corrected by simply abstaining from\\nthe drinking of liquids during the taking of food.\\nQuinine, administered both as a tonic and an antiperiodic, is largely\\nemployed in cutaneous medicine for its generally recognized systemic\\neffects. It produces, in susceptible individuals, a peculiar smoothness\\nand softness of the skin, which usually disappear when the drug is\\nsuspended. Like arsenic and iodine, it is occasionally the cause of a\\ngeneralized exanthem, and is capable of producing other toxic effects,\\nsuch as failure of the heart s action, dizziness, and tinnitus aurium,\\nsymptoms recognized under the designation of cinchonism. It will, of\\ncourse, exhibit its happiest effects in malarial affections with coincidence\\nof cutaneous symptoms in the form of disease of the skin associated\\nwith a neurosis.\\nSalol is a remedy of special value in many cutaneous disorders asso-\\nciated with intestinal sepsis. It is particularly useful in the forms of\\npustular acne when the subject of the affection has an habitually coated\\ntongue, a foul breath, and defective digestion.\\nErgot and Ergotine, whether by exerting an effect upon the muscle-\\nbundles or the vessels of the derma, or upon the uterus, or yet by its\\ninfluence upon the general economy, is thought to possess some value\\nin the treatment of several cutaneous diseases occurring in both sexes.\\nSuch are acne, purpura, and a few other disorders.\\nCalx Sulphurata was once regarded as the most efficient of the\\nsulphur compounds for internal use in cutaneous diseases. Its sup-\\nposed value in furunculosis has led to its employment also in eczema,\\nacne, and impetigo. It is given in doses of from (0.004) to\\n(0.016) of a grain, three or four times daily. It is, however, a remedy\\nuncertain in operation and of dubious effect.\\nOhrysarobin has been administered internally by Stocquart and\\n1 Ann. de Derm, et de Syph., 1884.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0101.jp2"}, "102": {"fulltext": "90 GENERAL THERAPEUTICS.\\nothers, in doses of (0.01) of a grain, for a number of cutaneous\\ndisorders.\\nIchthyol, mentioned later as of some value when externally em-\\nployed, has also been given by the mouth.\\nJaborandi and Pilocarpine, probably as a result of the free dia-\\nphoresis which they excite, unquestionably exert immediate thera-\\npeutic effects in a number of cutaneous disorders.\\nSulphur, highly esteemed as a popular remedy in cutaneous affec-\\ntions, exerts but little influence upon the latter when it is ingested.\\nIts cathartic effect is the chief reason for its administration. It is\\nrecommended by Crocker in some of the disorders of the sweat-function.\\nAntimony in small doses is of unquestioned value in many diseases\\nof the skin. It is, when not contraindicated, employed with advantage\\nin psoriasis, pruritus, and some of the obstinate forms of eczema.\\nTar, Carbolic Acid, Creosote, Guaiacol, Resorcin, Turpentine,\\nCopaiba, and Phosphorus are remedies which have been employed\\ninternally with appreciable effect in certain cutaneous maladies. They\\nhave been used with advantage in cases of lupus, eczema, psoriasis,\\nand pruritus but the disagreeable effect of their internal administra-\\ntion has been to a great degree a bar to their general employment.\\nThe perles of phosphorus and the elixirs of the same drug obviate\\nthis difficulty in the instance of at least one of these articles. Creosote\\ncarbonate given in capsules is usually well tolerated.\\nAnimal Extracts, Thyroid Extract, and other preparations of the\\nthyroid, adrenal, and other glands of the larger mammals, have in recent\\nyears been employed largely in various diseases of the skin. In myx-\\ncedema decided and brilliant results have been obtained, and the same\\nis true of ichthyosis, psoriasis, and some tuberculous affections of the\\nskin. The depressing action of thyroid-extract on the heart makes it\\nan unsafe remedy to use except with great care.\\nMaltine, and other preparations of malt alone or in the valuable\\ncombinations now on sale, are of marked value in promoting the nutri-\\ntion of the skin. They are especially indicated where there is imper-\\nfect digestion of the carbohydrates, and where fats are not readily\\nassimilated. They are useful in acne, in scleroderma, in syphilis, in\\ntuberculosis of the skin, and in many of the cachexias accompanied\\nby cutaneous symptoms.\\nIron and its several compounds are invaluable in the management\\nof a long list of cutaneous disorders. Iron is indicated in many cases\\nof cachexia and struma in tuberculosis of the skin in syphilis in all\\nthe anaemias and in many cases of purpura and pemphigus. Fortu-\\nnately, iron is often well assimilated when compounded with other drugs,\\nand hence has been suggested the long list of compounds of iron and\\nmercury and of iron and iodine in syphilis of iron and quinine and of\\niron and the vegetable bitters in anorexia and ansemia and of iron with\\ncathartics in atonic constipation.\\nThe Analgesics have occupied a small space in cutaneous medicine,\\nand that space should be more and more restricted. The use of acetan-\\nilid, of opium and its alkaloids, of phenacetine, of potassic bromide,\\nof trional, of sulphonal, and of articles of the same class, has been", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0102.jp2"}, "103": {"fulltext": "INTERNAL TREATMENT. 91\\nindicated for relief of the tormenting pruritus, pain, and insomnia\\naccompanying a long list of dermatoses. Unfortunately, most of the\\npreparations devised to insure relief, after a temporary calmative effect\\nhave a decidedly aggravating influence upon the exanthem present.\\nTo a degree scarcely noticeable in other cases have drug-habits been\\nformed in consequence of the temporary assuagement of the local dis-\\ntress when under the influence of an analgesic. As a rule, the most\\ncompetent physician is he who secures relief for his patient without\\nnarcotizing the nerves which are uttering their protest by abnormal\\nsensation. The expert reserves for the last extremity an ordering of\\nmedicines of the anodyne class in attempting to secure relief.\\nHypodermatic and Intracutaneous Injections of alcohol, arsenic,\\nmercury, cocaine, carbolic acid, the alkaloids of opium, antitoxins,\\nexalgine, of erysipelas-toxins, and other substances have been largely\\nemployed in the management of cutaneous disorders, some with\\nmarked success, others with doubtful results. The most brilliant of\\nthe achievements in this direction are without question the relief of\\nthe syphilodermata by deep intramuscular injections of mercury. The\\ninjection of the antitoxins which have been such a boon in an important\\ngroup of general disorders has, on the whole, proved disappointing in\\ncutaneous medicine. Attention has been directed to the special objec-\\ntions in most of the affections of the skin to the use of anodynes and\\nopiated medicaments by whatever route introduced into the system.\\nThe temporary alleviation, when secured, is gained at too great a cost.\\nTuberculin (Koch s lymph), Thiosinamine, Taurine, and yet\\nother substances have been injected subcutaneously in the management\\nof lupus, acne, eczema, psoriasis, lepra, and other affections. They\\nhave not as yet such an acceptance at the hands of the profession as\\nwould justify their employment in any save specially selected cases.\\nSpraying the skin for antiseptic purposes is of value, and may be\\noften employed with marked advantage. The several solutions of for-\\nmalin are best suited to the purpose. Frigorific sprays for the purpose\\nof freezing a part of the skin selected for operation, as in the case of\\nepithelioma, are indispensable to the operator. Those chiefly employed\\nare discharged from bulbs containing ethyl chloride.\\nNatural Mineral Waters. The chief value of many of the mineral\\nsprings and health-resorts of the United States lies in the change of\\nthe manner of living that they invite and necessitate. Sunshine, pure\\nair, recreation after the care and toil of business, change of climate, of\\nfoods and drinks, and even of cooks, often decide the question of\\nspeedy recovery. Unfortunately, both in America and in Europe,\\nmany of the health-resorts are peopled by unscrupulous charlatans,\\nwith a tendency to attribute all the benefits to be derived from these\\nsources to the medicinal virtues of this or that particular spring, aided\\nalways by treatment according to their own peculiar methods. Many\\npatients affected with disease of the skin are thus made worse by a\\ntemporary residence at noted health-resorts, and, therefore, it is often the\\ncase that a visit to the seashore, to the mountains, or to any healthful\\nplace in the country proves conducive to greater practical results.\\nNone the less the springs of America and Europe having mineral con-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0103.jp2"}, "104": {"fulltext": "92 GENERAL THERAPEUTICS.\\nstituents, in many instances supply a valuable means of treating cuta-\\nneous diseases. The sulphur waters of Richfield Springs, of Sharon\\nSprings, and of Avon Springs, in this country, as of those of Europe,\\noperate chiefly by an influence exerted upon the digestive tract the\\nsprings of West Virginia are examples of calcic waters having for the\\nmost part a diuretic effect. The fine water of the Poland Spring in\\nMaine is chiefly valuable by reason of its remarkable purity. The\\nalkaline waters of Colorado Springs, of Saratoga, and of other sources\\nin America are rapidly securing a reputation equal to that of the\\nfamous Vichy, Carlsbad, and Ems of Europe.\\nThe chemical laboratories, however, are fast placing at the disposal\\nof the consumer the salts, either natural or artificially produced, which\\nrepresent the constituents of most of the waters highly esteemed, both\\nhere and abroad, in the management of disease. In this way the\\nApenta, Hunyadi Janos, Hathorn, Kissengen, Congress, Friedrich-\\nshall, Rakoczy, and other waters may be produced at will by solution\\nof the proper salts in water and the latter in many of our large cities\\nis now furnished after distillation and aeration in such purity that it\\ncompetes with distilled water in the laboratory of the chemist and in\\nthe operations of the photographer.\\nOf the chalybeate and arsenical waters, the former abundant in\\nMichigan and New York, the latter best represented by that of Levico,\\nin the Austrian Tyrol, it may be said that their use is often followed\\nby excellent results, especially when the drinking of the water is as-\\nsociated with the tonic regimen and healthful environment of the\\nsprings from which these waters are obtained.\\nEXTERNAL TREATMENT.\\nIn the external treatment of diseases of the skin the indications are\\nto hasten repair when this is possible to alleviate distress if palliatives\\nonly are admissible to destroy absolutely or excise the diseased tissue\\nwhen this is justifiable. The following are the principal substances\\nemployed as external applications\\nWater, either pure or medicated by holding substances in solution\\nor mechanical suspension, is applied either in baths or as lotions.\\nBaths, local or general, may be employed for days continuously or but\\nfor a few moments at a time. They are given with water varying in\\ntemperature cold, warm, or hot. Rain-water is to be used when\\npracticable.\\nCold baths of short duration are generally followed by a sharp re-\\naction, the skin becoming congested after the normal temperature of\\nthe surface is regained. It is for this reason that cold sponging of the\\ninflamed skin is usually grateful so long as it is continued, and is suc-\\nceeded by an aggravation of the symptoms which it was intended to\\nrelieve. Continued applications of cold water are not open to this\\nobjection.\\nHot baths are followed by a more or less enduring relaxation of the\\nintegument, while tepid water-baths are chiefly macerative of the sur-\\nface. Hot baths are valuable in several of the exudative and hyper-", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0104.jp2"}, "105": {"fulltext": "EXTERNAL TREATMENT. 93\\ntrophic affections of the skin. It should be remembered that the\\napplication of watery lotions to the broken surface of the skin is likely\\nto be followed by endosmosis, unless the specific gravity of the serum\\nof the blood and that of the fluid of the bath or the lotion are nearly\\nthe same. This imbibition of fluids by the broken skin is accom-\\npanied by slight swelling of the tissues and is productive of disagree-\\nable sensations.\\nThe continuous warm water-bath in which the patient is immersed\\neither for the greater part of a day or for a few hours at a time is an\\nexceedingly valuable means of treating pemphigus, the severe grades\\nof burns, and ulcerative affections of the skin.\\nThe most perfect of all applications of water to the surface of the\\nbody is that most resembling the water-bath in which the tender\\nskin of the foetus is immersed for consecutive months. Here the\\nbath is continuous the temperature is that of the viscera of the\\nliving animal and the delicate skin of the unborn child is anointed\\nwith a fatty substance which interferes with the macerative action of\\nthe surrounding fluid so long as the vitality is preserved at the average\\nstandard. The comfort and therapeutic value of a bath prepared and\\nadministered in approximation to this ideal can scarcely be overesti-\\nmated. Were it not for the difficulties with which it is attended, so\\nfar as relates to many portions of the surface of the body, it would\\nbe possible with this single therapeutic measure to rob the exudative\\naffections of the skin of many of their formidable features.\\nVapor, steam, Russian, and Turkish baths are less valuable than is\\nusually supposed in diseases of the skin. The macerative effect they\\nproduce is not always desirable. They possess some value in severe\\ngeneral pruritus, in ichthyosis, and in keratosis pilaris.\\nIn acute inflammations of the skin the application of pure water,\\neven when of proper temperature, is often prejudicial to the integu-\\nment, and soap-and-water washiugs may prove quite harmful. The\\ngreatest caution must be exercised in giving instruction to patients as\\nto the washing of the inflamed skin.\\nWater for external application, as in the bath, is medicated by the\\naddition of a large number of substances, such as marine salt, boric\\nacid, corrosive sublimate, sodic and potassic salts, alum, tannin, the\\nmineral acids, gum Arabic, gelatin, and bran.*\\nThe alkaline bath, made by adding sodium bicarbonate or biborate\\nto water having the proper temperature in the proportion of 12 ounces\\nof either salt to 30 gallons, is usually grateful to the inflamed skin.\\nSulphur-baths are best prepared by adding an ounce of Vleminckx s\\nsolution l to the above-mentioned quantity of water.\\nThe natural Sulphur-baths of Eichfield Springs and Avon Springs,\\nin this country, are efficacious in certain cutaneous affections accom-\\npanied by roughness and thickening of the integument.\\n1 The formula is\\nR Calcis, ^ss; 16\\nSulphur, sublim., Sj 32\\nAq. desk, ^x 3201 M.\\nCoque ad ^vj [200] deinde filtra.\\nSig. Vleminckx s Solution.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0105.jp2"}, "106": {"fulltext": "94 GENERAL THERAPEUTICS.\\nTar-baths are usually given by first anointing the skin of the patient\\nwith the tarry substance to be employed, and by immersing the body\\nin warm water for some hours afterward. The resulting effect can\\nusually be accomplished as well by other measures.\\nSalt- and Marine Baths possess the highest value with respect to\\nthe general health of the individual and are advantageously employed\\nover the body-surface when, for example, the head alone is affected\\nwith a dermatosis (rosacea, acne, erythema), and when the salt is not\\nbrought into contact with the morbid surface. In very many cases\\na sea- or salt-bath produces aggravation of a cutaneous affection, and\\nindeed, in some cases, is capable of begetting the same. A properly\\ndirected salt-bath or lotion, however, is at times positively beneficial,\\nnot merely in chronic, but also in acute affections of the skin.\\nThe strength of the usual marine salt-bath is pound to the gallon,\\nthough 10 pounds of the salt are often added to 25 gallons of w T ater\\nwith advantage. The sea-salt is not preferable to the article obtained\\nfrom the natural brine-wells of the interior of the country. For\\ninvalids the skin of the body may first be well rubbed with the finest\\ntable-salt well warmed in an oven, after which a tepid or warm bath\\nmay be used to cleanse the surface.\\nAntiseptic Baths are most often employed by the surgeon. In the\\nmanagement of skin-affections local baths of boric acid in hot or cold\\nwater may be employed. The acid is soluble in about 25 parts of cold\\nwater. Corrosive-sublimate baths are employed in the strength of 1\\ndrachm (4.) of the mercurial to 30 gallons of water. Local baths thus\\nmedicated are often employed in the cleansing of ulcerated and suppur-\\nating surfaces with a view to subsequent dressing.\\nWhen employed as a lotion, water is made to produce a sedative\\neffect by the addition of opium, belladonna, glycerin, carbolic acid,\\nhydrocyanic acid, zinc, bismuth, mercury, lead, and alkaline bicarbon-\\nates with the sodic biborate. It is rendered stimulating by the ad-\\nmixture of alcohol, most of the acids and alkalies in stronger solution\\nthan in the soothing or sedative lotions, and also by a large number of\\nsubstances which operate upon the surface either mechanically or\\nchemically. Water is also rendered astringent when tannin, lead, and\\nsimilar medicaments are dissolved in it and by its union in various\\nproportions with soaps an d alkalies a solvent effect is produced, either\\nupon the cuticle itself or upon pathological or foreign products upon\\nits surface.\\nSoaps. Soft soap (sapo viridis, sapo mollis) made by the addition\\nof caustic potash in an excess of between 3 and 4 per cent, to an\\nanimal fat, is a substance exceedingly useful in the treatment of skin-\\ndiseases. It is used for the purpose of producing either a detersive or\\nstimulating, and at times a slightly destructive effect either upon the\\nsurface of the skin itself or upon pathological accumulations upon the\\nsurface (crusts, scales, etc.). It may be used as a plaster or with\\nwater and this last either in substance or by the aid of the widely\\nknown Spiritus Saponis Alkalinus which Hebra first devised: 2\\nounces of green soap to 1 ounce of alcohol, flavored with spirit of lav-\\nender. The hard or soda soaps are employed chiefly for toilet purposes.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0106.jp2"}, "107": {"fulltext": "EXTERNAL TREATMENT. 95\\nOver-fatty or superfatted soaps, both soda and potash soaps,\\nare neither alkaline nor neutral in reaction, but contain a slight excess\\nof unsaponified fat. They are exceedingly mild in their detersive\\naction upon the skin, though the lather produced in their use is not so\\nabundant as that with the alkaline soaps. These are usually proprie-\\ntary articles.\\nMedicated Soaps, containing carbolic acid, glycerin, tar, sulphur,\\nand various oils, are sold in the shops but they usually contain so\\nsmall a portion of the individual medicament from which each is\\nnamed that they are practically worthless except for purposes of ablu-\\ntion. Under cold pressure they may be made to contain medicinal\\nsubstances in therapeutic proportions, but other forms of administra-\\ntion of such medicaments are preferable.\\nFatty and Oily Substances are applied to the skin either directly\\nby pouring, or by friction, or by the mediation of compresses, bandages,\\netc., which are saturated or are spread with the material to be applied.\\nThe oils may be used for either nutritive, soothing, or stimulating\\neffects. To the first and second classes belong cod-liver, lard, olive-,\\nalmond-, linseed-, neat s-foot, castor-, and similar oils to the third class\\nbelong the oil of tar, of cade, of white birch, of the cashew-nut, and\\nof juniper.\\nFatty substances are also applied in the form of ointments or\\npomades. They are compounded with various medicinal substances,\\naccording to the requirements of each case, such as the salts of mer-\\ncury, zinc, copper, lead, and sulphur; pyrogallol, chrysarobin, carbolic\\nand hyposulphurous acids tar, camphor, iodoform, balsam of Peru,\\nchloral hydrate, and the extracts of opium, belladonna, etc.\\nThe products of petroleum refinement known as Vaselin and\\nCosmolin, though not true fats, are increasingly employed for similar\\npurposes, and continue to enjoy high favor in America and in Europe.\\nThey are particularly useful as bases for ointments for application to\\nthe hairy portions of the body, such as the scalp, where more consistent\\nsalves paste the hair to the surface in an unsightly mass.\\nIn the class of soothing ointments which are required in many\\ncases in which the skin is the seat of a severe pruritus or is produc-\\ntive of burning sensations, may be named the diachylon, benzoinated\\nzinc-oxide, cold-cream, lanolin, cucumber, petroleum, diachylon,\\nspermaceti, cacao-butter, and olive-oil with vaselin ointments. Those\\nmedicated with the several oleates and with the salts of bismuth, zinc,\\nor lead, are often of great value. As a rule, however, in most cases\\ncalling urgently for soothing applications fat-containing dressings are\\nnot to be preferred to lotions or dusting-powders, or the two last named\\nin combination. Ointments are rubbed gently over the affected sur-\\nface, but they are more efficient when spread on bits of soft muslin and\\nkept in contact with the skin.\\nMcCall Anderson s ointment has long been employed for soothing\\ninflamed surfaces. It is compounded by adding 1 drachm of bismuth\\noxide (4.) to 1 ounce (30.) of oleic acid, 3 drachms (12.) of white wax,\\n9 (36.) of vaselin, and a few minims of the oil of roses. 10 parts of\\nlanolin, with 20 of lard and 30 of rose-water, make another useful", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0107.jp2"}, "108": {"fulltext": "96 GENERAL THERAPEUTICS.\\ncombination. Many of these ointments in the past have been found to\\nbe irritating on account of the fatty acids which they develop, especially\\nin hot weather. They may now all be kept perfectly sweet by the\\naddition of a small quantity of formalin to each jar compounded.\\nThe following formulae are also useful Boric acid, white wax, and\\nparaffin, each 10 parts oil of sweet almonds, 60 parts (H. Hebra).\\nBismuth oxide, 1 drachm (4.) white wax, 6 drachms (24.) vaselin and\\nolive-oil, of each 1 ounce (30.). Boric acid, 1 part glycerin, 24 parts\\nanhydrous lanolin, 5 parts; vaselin, 70 parts (Duhring s boroglycerin\\ncream ointment Other fatty applications are prepared by adding\\nolive-, sweet-almond, or cotton-seed oil, as well as lard and lanolin, to\\nlime-water in nearly equal proportions. These furnish a thick emulsified\\nsubstance which requires to be well shaken before application. Any\\none of these emulsions may be medicated at will by the addition of\\nzinc, bismuth, calamine, or other insoluble substance which is mechani-\\ncally mixed with the fatty emulsion w T hen the whole is well shaken.\\nStimulating ointments are usually made by the addition of such\\nsubstances as tar, mercury, resorcin, salicylic acid, pyrogallic acid,\\nchrysarobin, or sulphur to any one of the several salve-bases in com-\\nmon use.\\nGlycerin, even the best, when applied in its purity to the skin is\\nusually irritating. It is, however, exceedingly useful when diluted or\\nmade a component part of lotions and ointments. When combined\\nwith starch in different proportions it makes a series of combinations\\nknown as glyceroles, or glycerolates. These combinations are pasty,\\nsemisolid substances which are capable of varied medication, as in the\\nglycerole of lead subacetate. They are useful chiefly as protectives\\nof the skin-surface. Glycerin, used in a fluid soap, is an exceedingly\\nvaluable agent when a milder effect is desired than that produced by\\nthe spirit of soap described above. The Vienna preparation known as\\nSarg s fluid soap is an admirable substitute of this sort when a soft\\nshampoo is required for the scalp.\\nPastes employed for local application in diseases of the skin have\\ngreatly been perfected by Lassar and Unna. 1\\nThese pastes are valuable especially in the exudative affections, in\\nwhich salves are often either not well tolerated or actually prove irritating\\nto the skin. The pastes, when applied to such surfaces, form a pro-\\ntective and adhesive dressing, which may be medicated as desired. One\\nof the best and most serviceable pastes is\\nB Zinc, stearat. cum acetanilid.,\\n01. oliv., V aa \u00c2\u00a3ij.\\nUnguent, aq. ros., j\\nOr the following modification of Lassar s paste\\nM.\\nR Zinci oxidi, j\\nTaic, j aa 3y; 8\\nAcid, salicylic, gr. x\\nVaselin., Jss 16\\n1 Monatsch. f. prakt. Derm., February and March, 1884.\\n66\\nM.", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0108.jp2"}, "109": {"fulltext": "EXTERNAL TREATMENT.\\n97\\nEqual parts of lanolin, vaselin, talc, and zinc oxide form a base that\\nis stiffer than the preceding and adheres better. To these bases may be\\nadded various remedies in desired proportions.\\nDuhring s modification of the original Lassar paste is boric acid,\\n9j (1.); starch and zinc oxide, each 3ij (8.); vaselin, ^j (33.). Unna\\nemploys starch, 3 parts glycerin, 2 parts water, 15 parts boiled\\ndown to 15 parts. Half the quantity of any desired medicament may\\nbe added to the amount ordered. Paraffin may be added in the making\\nof very stiff pastes in the proportion of equal parts of this substance\\nand water; twice the quantity of lanolin and about ^V of white wax.\\nOther pastes are prepared with kaolin (terra alba, or Armenian bole\\nof red color when it is desirable to have the application resemble the\\ncolor of the skin), gum, lead, dextrin, glycerin, and other substances.\\nFormulae for each are here appended.\\nKaolin in a pure state, with equal parts of vaselin or glycerin, or\\nwith almond-, olive-, or linseed-oil, in the proportion of two to one, is\\nreadily applied in a thin layer over the skin.\\nFor making lead-pastes, litharge is boiled with twice the quantity of\\nvinegar until the latter has evaporated and there is left a damp but\\ndrying paste, which may be, on occasion, remoistened with a small\\nquantity of vinegar, e. g.:\\nR Lithargyr. subt. pulv., ^jss 45\\nAceti, ly ss; 75.\\nCoque usque ad consistent, pastse: deinde adde ol. lini [v. glycerini, v. ol.\\nolivse], 10.\u00e2\u0080\u0094 M.\\nIn the two forms of paste above described the adhesive and desic-\\ncative qualities are obtained from the main ingredients, but in those\\nresulting from combinations of gum, starch, and dextrin these results\\nare for the most part obtained by the addition of other ingredients, such\\nas sulphur, zinc, etc. A good basis, semisolid, rapidly drying, and\\nfixing its ingredients well upon the surface, is the following:\\nR Zinci oxidi,\\n3J ss\\n45\\nAcid, salicylic,\\nAmyli oryzse, 1\\nGlycerini, j\\nAq. dest.,\\nCoque ad., givss (145).\\n3ss;\\naa 3iij\\n^ijss;\\n2\\n12\\n75\\n)r a sulphur-paste\\nR Sulphur, prsecipit.,\\nCalc. carb.,\\n5ss;\\n45\\n2\\nZinc, oxid.,\\n^ss;\\n15\\nAmyli oryzae,\\nGlycerini,\\nAq. dest.,\\nCoque ad., \u00c2\u00a7iv (120).\\n3iij\\n,^ss;\\nlijss\\n12\\n15\\n75\\nTo make use of dextrin, the official pulverized article is selected,\\nand a simple paste of this forms a good drying base. An added half-\\n7", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0109.jp2"}, "110": {"fulltext": "98\\nGENERAL THERAPEUTICS.\\nweight of glycerin is required if powders are also combined with the\\npaste e. g.:\\nR Zinc, oxid.,\\nDextrin.,\\nAq. dest.,\\nGlycerin.,\\nSulphur, sublim. [vel sod.\\nsulpho-ichthyol.]\\nCoque.\\n3 J ss\\n45\\n33 3SS 5\\n15\\n^jss;\\n45\\n3ss;\\n2\\nA mixture of dextrin and lead is thus prepared\\nB Lithargyr.,\\nAcet.,\\nCoque ad remanent., 50.\\nAdde\\nDextrin., 1\\nAq. dest.,\\nGlycerin., J\\nCoque.\\n3jss;\\naa ^ss;\\n30\\n45\\n151\\nIf too consistent, these pastes are made to spread easily by the\\naddition of a few drops of hot water.\\nFor gum-pastes, gum Arabic is used in the proportion of 1 part\\nof the mucilage and glycerin to 2 parts of the powder selected, mixe^\\nwithout heat e. g.\\nB\\nR\\nB\\nZinc, oxid.,\\nS jss\\n45\\nHydrarg oxid. rub.,\\n3ss;\\n2\\nMucilag. acac,\\nGlycerin., J\\naa\\n^ss;\\n15\\nCret. prasparat.,\\nSulphur, sublim., j\\n5 5\\n3ss;\\n2\\nX CK\\nPicis liquid.,\\n3ij;\\n8\\nAmyli,\\n^ss;\\n15\\nMucilag. acac, 1\\nGlycerin.,\\n_\\n15\\naa\\n3 s s\\nAcid, salicylic,\\n^ss;\\n15\\nGlycerin.,\\n^ss;\\n15\\nMucilag. acac,\\n3j;\\n30\\n01. ricini,\\nSijss\\n10\\nM.\\nM.\\nM.\\nThe following details are to be noted respecting the availability of\\nthese pastes for different ingredients Lead is best used as an acetate,\\neither in a simple paste or with dextrin, the carbonate, oleate, and\\niodide combining well with both. Zinc oxide and sulphur combine well\\nwith kaolin, lead, starch, dextrin, and gum. Sulphur combines well\\nwith the three last named, poorly with kaolin, and not at all with lead.\\nIchthyol suits well with all save the gum-pastes. Naphtol, calomel,\\ncorrosive sublimate, red and white precipitates, carbolic acid, chloral\\nhydrate, camphor, and salicylic acid can be incorporated with all, the\\nlast named in smaller proportion with gum-paste. Tar is better united\\nwith starch, dextrin, and gum than with the others. Iodine and iodo-", "height": "4383", "width": "2392", "jp2-path": "practicaltreatis00hyde_0110.jp2"}, "111": {"fulltext": "EXTERNAL TREATMENT. 99\\nform naturally do not suit well with the starch- and dextrin-pastes.\\nChrysarobin and pyrogallol are united with kaolin and gum-pastes,\\nand should not be added to them. Fatty and soapy substances, if\\ncommingled in large amounts with these pastes, injure their special\\nproperties.\\nGlycogelatins are useful for protecting a surface and excluding the\\nair. They are made with varying proportions of glycerin, gelatin, zinc\\noxide, and water. When cold they are solid, but when melted on a\\nwater-bath can be painted readily over a surface, upon which on cool-\\ning they form an adherent protective coating. Before the gelatin has\\nhardened on the skin it is well to pat it with cotton, or to lay over it a\\npiece of thin gauze or muslin to form an additional protection and to\\nprevent the paste sticking to the clothing. A firm but soft and flexi-\\nble gelatin is made by mixing on a hot-water bath 1 part of zinc\\noxide, 2 of gelatin, 3 of glycerin, and 4 of water. More gelatin in the\\npreparation makes it firmer and causes it to dry quicker. A greater\\nproportion of glycerin, on the other hand, interferes with the complete\\ndrying of the surface, but makes a softer preparation, more acceptable\\nto some skins and very useful where a bandage can be applied. Zinc\\noxide helps give body to the gelatin, but if used in too large proportion\\ninterferes with the coherence of the preparation, so that it cracks when\\ndry. To the glycogelatins may be added white precipitate, sulphur,\\nichthyol, thiol, chrysarobin, iodoform, or other antiseptics. Some drugs,\\nas salicylic acid, resorcin, naphtol, and carbolic acid, tend to destroy\\nthe coherence of the gelatin. Fox says that this obstacle may be\\nremoved by adding to the paste 5 or 10 per cent, of fresh lard.\\nVarnishes, containing glycerin and a single gum, are often very\\nserviceable in protecting the skin. They are especially useful on the\\n\u00c2\u00a3as they are transparent and inconspicuous,\\n^ck s varnish (linimentum exsiccans) is made as follows\\nR Tragacanth, 5 parts.\\nGlycerin, 2\\nDistilled water, 93\\nThe tragacanth is soaked in a portion of water from ten to twelve\\nhours and triturated to a perfectly smooth mass before adding the glyc-\\nerin and other ingredients ordered. The jelly may be prepared without\\ndelay by triturating the tragacanth with boiling water, but the result is\\nnot quite so good.\\nThis jelly is applied without heating and quickly dries on the skin.\\nAn improvement on this varnish is Elliott s bassorin paste, which keeps\\nbetter than the former. The formula is as follows\\nR Bassorin,\\nDextrin,\\nGlycerin,\\nWater to make\\nThis should be kept in a tightly closed jar, as it dries rapidly on\\nexposure to the air. Like the other pastes, it not only serves as\\nLofC.\\n3jss\\n45\\n5vj;\\n24\\nSijss\\n10\\nSiij\\n90", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0111.jp2"}, "112": {"fulltext": "100 GENERAL THERAPEUTICS.\\na protective coating, but also as a base for the application of other\\nremedies.\\nPowders are mechanically dusted over the surface of the skin\\nfor the purpose of protecting it, and occasionally, also, to produce\\nan astringent or antipruritic effect. To be serviceable, they should\\ngenerally be rendered impalpable by sifting them carefully through a\\nfine silk bolting-cloth. They are composed of starch, talc, magnesia,\\nlycopodium, calamine, bismuth, boric acid, the several stearates, cam-\\nphor, tannin, zinc oxide, iodoform, rice, kaolin, magnesium silicate,\\norris root, salicylic acid, aristol, europhen, and similar substances. The\\narticles sold by grocers as gloss starch and corn-starch farina\\nare usually much more finely bolted than the dusting-powders extem-\\nporaneously prepared by chemists. All starchy substances are open\\nto the objection of forming little pasty rolls or cakes when wetted\\nwith serum or with sweat. Lycopodium, which consists of irregularly\\nshaped globular pollen-sporules, never behaves in this way, and is,\\nfor that reason, deservedly popular. Zinc stearate with acetanilid is\\nexcellent for similar reasons, and when dusted on the surface forms\\na dressing impervious to moisture.\\nMedicated powders may be first dissolved in alcohol, ether, or\\nchloroform. The solution is then mixed with starch or with French\\nchalk. Evaporation of the menstruum is conducted without artificial\\nheat, and a fine medicated starch or a chalk-powder results.\\nFor absorbent purposes Grundler 1 has shown that by far the most\\neffective powder is magnesium carbonate.\\nPlasters are employed when it is desired to exert a more or less\\ncontinuous effect upon the skin, and are thus necessarily consistent\\nand desirable. The resin-plasters are less useful in skin-diseases be-\\ncause more irritating than the lead-plasters. In the zinc-oxide adhe-\\nsive plaster the irritating effects of the resin have been entirely over-\\ncome, and the result is a plaster which has excellent adhesive qualities\\nand which rarely causes irritation even to sensitive skins. It thus\\nanswers admirably where simple protection is desired, and may be\\nsafely employed in order to retain other dressings in place. Unna s\\nplaster-mulls are described below. The mercurial plasters are useful,\\nespecially in syphilitic lesions of the skin.\\nA valuable addition to the list of methods for applying medicated\\nointments to the skin has been devised by Unna. His Salve-muslins,\\nor salve-mulls, are strips or bandages of muslin thoroughly impreg-\\nnated and thickly spread with ointments medicated with almost every\\ndesirable substance, from zinc oxide to tar, thymol, salicylic acid, and\\nmercury. They are elegantly made, and when exported are sur-\\nrounded by impermeable tissue, so that they remain fresh and sweet\\nfor several weeks, or even for months if kept in a cool place, but de-\\nteriorate rapidly if exposed to the air of a warm room. They are\\nefficacious, and, as a rule, well liked by patients. They are available\\nin skin-diseases of the exudative class affecting the extremities, but\\nshould be avoided when not recently prepared.\\nUnna s Plaster-mulls seem to be less useful. They are plasters\\n1 Monatshft. f. prakt. Derm., 1888, No. 20.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0112.jp2"}, "113": {"fulltext": "EXTERNAL TREATMENT. 101\\nthinly spread on gutta-percha cloth, and manufactured with a wide\\nrange of medicinal constituents. They serve a good purpose in the\\nprotection of parts of the skin exposed to friction.\\nSalve-pencils (stili unguentes) and Paste-pencils (stili dilubiles),\\nthe latter destitute of fat and soluble when moist, the former insol-\\nuble in water and compounded of fatty substances, are pencil-sized cray-\\nons made with Avax, gum, and starch, for application to limited areas\\nof the skin. The several mercurials, arsenious acid, cocaine, salicylic\\nacid, and other medicaments may be applied in this way to the surface.\\nPoultices are not often ordered in the management of diseases of\\nthe skin, except for the purpose of softening crusts with a view to their\\nremoval. They are made, both warm and cold, with linseed-meal,\\npotato-starch, bread and milk, oatmeal, and cornmeal. These applica-\\ntions are objectionable in all conditions in which a macerative effect of the\\nepidermis is produced and also in whioh micro-organisms may find a\\nculture-field in the mass of the poultice. Poultices, in any needful\\ncase, may be made antiseptic by the addition of formalin, boric acid, or\\nmercuric chloride.\\nLanolin, or wool-fat, was first introduced as a salve-base by Lie-\\nbreich, of Berlin. It is a substance obtained from keratinic tissues,\\nand contains cholesterin-fat instead of glycerin, with but 30 per cent,\\nof water. It has a bright-yellowish color, a distinct odor of the sheep,\\nand is neutral when pure it is never acid in reaction. The refined\\nproduct now placed upon the market is free from cholesterin com-\\npounds and requires no fatty addition. This substance is readily\\nabsorbed from the surface of the skin, and, either pure or medicated,\\nmay be regarded as a useful addition to the bases of ointments. The\\nadeps lana3 answers the same end.\\nOleates of zinc, mercury, copper, lead, and other metals have been\\nemployed with advantage in the topical treatment of disorders of the\\nskin. Of these, the oleates of mercury and of lead are decidedly the\\nmost valuable. The latter is represented by Hebra s white diachylon\\nointment. The mercuric oleate is serviceable in syphilitic, parasitic,\\nand other disorders.\\nThe Vasogen products bid fair to supplant the oleates in their\\nready absorption from the skin-surface. In mercurial inunction vaso-\\ngen-mercury capsules supply the exact amount required for employ-\\nment at each sitting.\\nCollodion and Traumaticin are employed for the purpose of ap-\\nplying a remedy to the skin, and at the same time for protecting or\\ncontracting the surface to which the application is made. Traumaticin\\nis the name given to a solution of gutta-percha in chloroform, in the\\nproportion of 10 per cent. In this way bismuth, cantharides, sulphur,\\nchrysarobin, zinc oxide, white precipitate, iodine, and other substances\\nmay with advantage be applied to the surface, and the action of each\\nbe definitely limited to the margins of a single patch of disease.\\nTar in its several varieties, crude and distilled, together with its\\nderivatives, occupies an important place among efficient topical agents.\\nIn general, it seems to exert upon the epidermis a local influence,\\nwhich extends more deeply as the remedy is continuously applied. At", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0113.jp2"}, "114": {"fulltext": "102 GENERAL THERAPEUTICS.\\ntimes both irritative and inflammatory effects are thus induced, and\\neven systemic intoxication when absorption from the skin occurs. Pix\\nliquida, or the oleum picis, is the favorite article of this group with\\nmost American physicians but the oleum cadini, or oil of juniper,\\nand the oleum rusci, or oil of birch, are rather more generally em-\\nployed by experts. The last-named, found in purity and abundance\\nand to be had at a low price in American markets, is recommended\\nabove the others. In Vienna the distilled oil is preferred, but there is\\ngood reason to believe that the crude oil is decidedly more efficacious.\\nThe skill of a physician intrusted with the management of a disease\\nof the skin might almost be measured by his success in the use of tar.\\nHe who has not had experience in its employment is urgently advised\\nto select one member of the tar-family and learn thoroughly how to\\napply that, singly and in combination, either as a lotion or in salve.\\nProperly employed, it will favor involution of lesions, lessening hyper-\\nemia, infiltration, scaling, and discharge. It serves admirably as an anti-\\npruritic. It may, however, produce severe inflammation of the skin.\\nTo produce the benign or emollient effects of tar, it is best mixed\\nwith some soothing or astringent powder, and with this end in view\\nnothing is better than chalk. Spender s hints 1 for making such an\\nointment are admirable Finely levigated chalk is strewed into melted\\nlard in a stone jar, the whole being stirred until it is cold. Then at\\nfirst the smallest quantity of tar sufficient to make a brownish smear\\nof color is added to the quantity of salve employed for use. This\\ncolor can be successively deepened at will. Auspitz advises the use\\nof the tars in a pure state, applied in very small quantities with a\\nstrong bristle-brush and well rubbed in. In combination with one of\\nthe most valuable of all substances for topical use in cutaneous thera-\\npeutics, viz., sulphur, tar enjoys a special reputation. The Wilkinson\\nsalve modified (q. v.) represents such a combination.\\nA group of substances which occupy a therapeutic position inferior\\nto the tars, but which serve an important end in the management of\\ncutaneous diseases by the production of similar effects, are carbolic\\nacid, creosote, salicylic acid, benzol, naphtol, iodol, thiol, chrysarobin,\\npyrogallol, resorcin, and jequirity.\\nIchthyol, fish-oil, introduced to the profession by Unna, is the\\ndistillate of a bituminous and sulphurous deposit of petrified fishes\\nand marine fossils found in the Tyrol. Its chemical formula is\\nC 26 H 36 S 3 Na 2 6 It has a tarry appearance, odor, and consistency. It\\nis soluble in water, partly so in ether and alcohol, and can be incor-\\nporated in any desired proportion with fat, vaselin, and lanolin. It\\nhas been used both pure and diluted and several proprietary articles\\n(plasters, soaps, salves, and medicated cotton) are in the market. It\\nhas been used both in America and in Europe in cases of leprosy,\\npruritus, acne, sycosis, eczema, psoriasis, and a number of other cuta-\\nneous disorders. 2 It is used in solutions of from 10 to 50 per cent.\\n1 Practitioner, June, 1883, p. 402.\\n2 See Baumann and Schotten Monatshft. f. prakt. Derm., 1883. Unna Ibid.,\\n1882; Dent. med. Zeit., 1883. Samml. klin. Vort., 1885; Lorenz Deut. med. Woch.,\\n1885; Stelwagon: Jour. Cutan. and Ven. Dis., ]886, p. 326; Zeisler: Chicago Med.\\nJour, and Exam., 1886.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0114.jp2"}, "115": {"fulltext": "EXTERNAL TREATMENT. 103\\nand -in salves of from 5 to 20 per cent, strength. As before stated, it\\nis also administered internally, more particularly in the management\\nof rheumatism, in doses of from 1 5 to 20 drops. It does not seem to\\nhave a disturbing effect upon the stomach.\\nUnpleasant results have been reported as following its application\\nin a single instance (Sinclair). A four months old infant sank into a\\nstupor two hours after its head and limbs were smeared with a salve\\ncomposed of one part of ichthyol to five of vaselin.\\nThiol makes an excellent substitute for ichthyol for most purposes,\\nand lacks the unpleasant odor of the latter.\\nResorcin in ointments of the strength of from 5 to 20 per cent,\\nserves as an antipruritic and alterative. Stel wagon reports an anodyne\\neffect following its use. The same experimenter has modified Ihle s\\nformula by adding 1 drachm (4.) of resorcin to 1 to 2 drachms (4.-8.)\\nof castor-oil, 5 minims (0.33) of Peruvian balsam, and 4 ounces (120.)\\nof alcohol, for use in alopecia and seborrhoea of the scalp. It is a\\nvaluable parasiticide in lotions of the strength of from 5 to 10 per\\ncent., and is especially useful in disorders of the scalp due to seborrhoea.\\nNaphtol, or /3-naphtol, as it is termed chemically, first introduced\\nby Kaposi, is chiefly valuable in scabies, but has also been used in the\\nmanagement of eczema, psoriasis, and other exudative affections. Van\\nHarlingen 1 has found it to answer well in seborrhoea of the scalp.\\nNeisser has described renal disorders as resulting from its use in chil-\\ndren, but MM. Josias and Nocard 2 report that in ordinary medicinal\\ndoses it is harmless. The fact that the naphtol preparations are odor-\\nless and do not stain the skin is to be set down in their favor.\\nBoric Acid is of great value in oliseases of the skin and is exten-\\nsively employed as a lotion and in ointments and powolers. As a rule,\\nit exercises a seolative effect upon the surface to which it is applied.\\nOver mucous surfaces it is occasionally a source of moderate irritation.\\nSalicylic Acid operates especially upon the keratinized tissues of the\\nepidermis, softening and separating the external portions of the horny\\nlayer from its deeper connections. For this reason it has a special\\nvalue in all the hyperkeratosic dermatoses. In somewhat weak strength\\nit is employed as an antipruritic agent. It is most often employed in\\nsalves or pastes but is also used in lotions, being soluble in 2.5 parts\\nof alcohol, 2 parts of ether, or 450 parts of water. It is a common\\ningredient of most of the popular corn- and wart-cures.\\nCarbolic Acid, since in value as an antiseptic it has been largely\\nsurpassed by other articles, is chiefly employed to-day upon the skin\\nas an antipruritic. It is applied in the form of lotion, salve, and\\npaste, but much more often in lotions having the strength of from\\n10 to 20 grains to the ounce (0.66-1.33 ad 30.). Other acids nitric,\\nsulphuric, lactic, acetic, muriatic, benzonic, tannic, chromic are em-\\nployed either for caustic, destructive, or stimulating effect, usually in\\nliquid form. Tannic acid, however, is occasionally employed as a\\npowder, in which form its astringent quality is combined with the\\nsoothing or antiseptic effect of other substances in poAvder.\\n1 Araer. Jour. Med. Sci., Oct., 1883.\\n2 Ann. de Derm, et de Syph., May, 1885.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0115.jp2"}, "116": {"fulltext": "104 GENERAL THERAPEUTICS.\\nChrysarobin, Pyrogallol, and Anthrarobin are useful as cutaneous\\nstimulants capable of determining in the skin to which they are applied\\na characteristic dermatitis limited to the site of the application. Chrysa-\\nrobin is especially useful in the local treatment of psoriasis, lepra,\\nand the disorders due to vegetable parasites. It is employed in from\\n1 to 10 per cent, strength, in salve, lotion, or in collodion. A useful\\ncombination in the parasitic disorders of the scalp due to the micro-\\nsporon Audouini or to the trichophytons is a solution of chrysarobin in\\noil of turpentine, about 1 part in 250. A chief objection to its use is\\nthe consequent staining of the skin and articles of apparel. On the\\nscalp the hairs are turned to a yellowish-green shade. Pyrogallol\\noxidizes after exposure and turns the skin a blackish color. It is\\nuseful in many cases of lichen planus, eczema, and the diseases due to\\nthe vegetable parasites. It has been employed in the strength of 50\\nper cent, in the removal of epitheliomata. Anthrarobin, though in-\\nferior to both of the other articles named, is effective in the same gen-\\neral manner.\\nIodine, especially in the form of tincture, is useful as a local appli-\\ncation in certain of the seborrheas, and as a parasiticide. It is often\\nemployed with mercury in the form of an ointment. The ointments\\ncompounded of the salts of iodine, with mercury, though of unques-\\ntioned efficacy, are less employed to-day than formerly.\\nJequirity (Abrus precatmus), employed by ophthalmologists for\\nthe purpose of inducing artificial inflammation of the conjunctiva, has\\nbeen used by Shoemaker in the management of lupoid and other\\nulcers. One part of the cleansed, decorticated, and bruised grains,\\nmacerated for twenty-four hours, and reduced by rubbing in a mortar\\nto a smooth paste, was added to sufficient water to make four parts.\\nThis emulsion was used for local application.\\nSulphur, popularly employed chiefly as a laxative or for the local\\ntreatment of scabies, has also a deserved reputation in cutaneous thera-\\npeutics as an external agent in a wide range of non-parasitic disorders.\\nHebra once regarded it as valueless in eczema, but his opinions on this\\npoint are not now generally accepted. Precipitated sulphur is to\\nbe preferred to the other compounds of the pharmacopoeia. It may\\nmechanically be incorporated with salve-bases, or chemically combined\\nwith vaselin and other petroleum-products, a process by which, as\\nexperiments have shown, its therapeutic value is not increased. It is\\nalso applied after mechanical union with various substances as a lotion.\\nIt is irritating to the acutely inflamed skin, but is much better tolerated\\nthan the tars in conditions of subacute or chronic exudation.\\nFormaldehyd is a valuable antiseptic agent most commonly em-\\nployed as formalin, a proprietary preparation representing 40 per cent,\\nof the compound. Formalin in the strength of 1 per cent, commonly\\nproduces a slight irritation over the thin skin of the face and after\\napplication in the strength of 2 per cent., which should be rarely\\nexceeded on the cutaneous surface, there follows a decided sensation\\nof burning with a resulting transient erythema. It is a remedy of\\nthe highest value in the treatment of syphilodermata, acne, seborrhea,\\n1 Lancet, Aug., 3884, p. 185.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0116.jp2"}, "117": {"fulltext": "EXTERNAL TREATMENT. 105\\nthe disorders produced by the vegetable parasities, several of the\\neczemas, impetigo, and other affections. It is well to color the solution\\nwith a trace of fuchsin.\\nPyoktanin-blue is employed in aqueous saturated solution as a\\nparasiticide in those disorders of the skin especially which affect regions\\nbeneath the clothing or which may be protected by dressings from ex-\\nposure to the eye. It is highly valuable as a local and painless appli-\\ncation in circumscribed patches of weeping or scaly eczema, in many\\nof the ulcerating syphilodermata, in lupus, and in ringworm. It\\nshould be applied daily in several coats, each coat being permitted to\\ndry before the next is superimposed.\\nPotassium Permanganate belongs to the same category as pyok-\\ntanin-blue, with the disadvantage that it is in some strengths produc-\\ntive of pain, while the pyoktanin solution is unproductive of pain.\\nFrom 2 to 10 per cent, solutions of the potassic salt may be painted\\non the affected surface one or more times daily till the desired effect\\nis produced. The indications for its use are those which the pyok-\\ntanin solution is intended to meet.\\nMercury and its compounds are of value in the local treatment of\\nmany disorders of the skin, syphilitic and non-syphilitic. The prepa-\\nrations of mercury employed as topical agents in the treatment of\\ndiseases of the skin are of the highest value. They include corrosive\\nsublimate, calomel, the red and yellow oxides, the biniodide and cinna-\\nbar, the white and red precipitates, and the nitrate. The most com-\\nmonly employed of their combinations are the black wash, oint-\\nment of the nitrate, and mercurial ointment. Fumigation of the\\nsurface by vaporization of either cinnabar or calomel or the two in\\ncombination is chiefly employed in the local treatment of syphilo-\\ndermata. The bichloride is most often applied as a lotion calomel\\nand white precipitate in ointments though calomel is often effec-\\ntively combined with talc or starch as a powder. Startin s nitric oxid\\nof mercury ointment represents a combination of two mercurials red\\nmercuric oxide, 6 grains (0.40) mercury bisulphate, 4 grains (0.25)\\nsimple cerate, 1 ounce (30.). Corrosive sublimate as a parasiticide is\\nof great importance in the treatment of several cutaneous disorders due\\nto the presence of micro-organisms, as, for example, lupus vulgaris.\\nChloral- camphor and Phenol- camphor have value chiefly as anti-\\npruritics. The former is obtained by rubbing together chloral hydrate\\nand gum-camphor (Bulkley) until they form a clear liquid of pungent\\nodor. Phenol-camphor is made by gradually adding camphor to melted\\ncrystals of carbolic acid, a colorless liquid resulting having the fragrant\\nodor of camphor without that of the acid. It is a useful local anaes-\\nthetic agent, being insoluble in water, but freely soluble in chloroform,\\nether, and alcohol.\\nMany Agents are employed upon the surface of the integument to\\nproduce in various degrees a caustic or destructive effect. Among\\nthese may be named the thermo-cautery (Paquelin-knife), galvano-\\ncaustic apparatus, the mineral acids and alkalies, sodium ethylate,\\narsenic, zinc chloride, several mercurial compounds, mercuric nitrate,\\nmercuric chloride, antimonious chloride, cupric sulphate, and argentic", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0117.jp2"}, "118": {"fulltext": "106 GENERA L THERAPEUTICS.\\nnitrate. Several of these substances in weak solution are employed as\\nmilder agents for the production of irritative or even inflammatory\\neffects. To the latter class should be added iodine in tincture, chloro-\\nform, tartar emetic, croton-oil, and cantharides. These destructive\\neffects are of advantage in the treatment of disorders of the integu-\\nment due to parasites, either animal or vegetable. Of those employed\\nfor this purpose, and not mentioned above, may be named petroleum\\nand staphysagria, for the destruction of lice sulphur, styrax, and\\nbalsam of Peru, for the destruction of acari and sulphur and its com-\\npounds and a number of derivatives from tar, for the destruction of\\nvegetable parasites.\\nCounter-irritation over the Vasomotor Centres, as recommended\\nby Crocker, is an efficient means of relieving fixed and obstinate cuta-\\nneous disorders. It may be produced by the action of sinapisms,\\nblisters, or caustics over the region selected for such irritation.\\nA large list of medicinal substances might be added which are oc-\\ncasionally employed in cutaneous affections, some very rarely, the most\\nwith questionable effect. Among them may be named alcohol, which\\nis of high value as a disinfectant, and hydrogen peroxide, having a\\nsimilar effect ether, the opium alkaloids, cocaine, belladonna, cannabis\\nindica, and aconite, for anaesthetic and antipruritic effect; and ergot,\\ncantharides, mustard, croton-oil, tartar emetic, benzoin, capsicum, rose-\\nmary, and the several salts of lead. Many of the articles named, such\\nas cantharides, rosemary, and capsicum, are employed as lotions for the\\nscalp in the several alopecias.\\nThe salts of zinc (sulphate, sulphocarbolate, acetate, oxide), of copper,\\nalum, lead, bismuth, and other metals are of service in diseases of the\\nskin as productive of both astringent and stimulating or even of caustic\\neffects. The careful adjustment of the dosage in each instance is of the\\nhighest importance, and is practically indispensable for the production\\nof beneficial effects.\\nElectrolysis is a method of the greatest value in the treatment of\\na large number of cutaneous affections, such as hypertrichosis, telan-\\ngiectases, molluscous tumors, warts, etc. It is accomplished by the\\naid of the galvanic battery in the manner described in this work in the\\npages devoted to the first of the disorders named.\\nThe Minor and other Surgical Operations required in the manage-\\nment of some affections of the skin are detailed in the treatises devoted\\nto that subject. Among such procedures may be named skin-grafting,\\nboth by the methods of Reverdin and Thiersch, and the several devices\\nof plastic surgery. Strictly dermatological procedures to which resort\\nmust often be made are epilation in hyphogenous sycosis and other\\naffections massage, especially by the massering-ball the operations\\non the face, especially in acne, when opening small abscesses, removing\\ncomedones, and incising papules and multiple scarification, as in telan-\\ngiectases and other lesions.\\nNumerous Surgical and other Appliances are found useful as\\nadjuvants in the treatment of skin-diseases. They may be employed\\nto support, protect, or compress the surface, or merely to aid in the", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0118.jp2"}, "119": {"fulltext": "EXTERNAL TREATMENT.\\n107\\nretention of dressings or external medicaments. Thus, the ordinary\\nroller-bandage is applicable to many portions of the body the suspen-\\nder, or suspensory bag, to the scrotum elastic or inelastic stockings\\nto the feet and legs kid, rubber, and thread gloves to the feet and\\nfingers and various skull-caps, face-masks, and mittens are employed\\nin the case of infants and children to protect affected surfaces from the\\ntraumatisms of scratching.\\nApart from the surgical apparatus required for ablation of tumors\\nor severe operations, a number of instruments are required for the\\ndaily use of the dermatologist. Among these may be named\\nA set of variously sized dermal curettes. These sharp-edged spoons\\nare for erasion of the surface, and should, for general use, have in each\\na fenestrum large enough to permit the escape from the floor of the\\nspoon of all collected substances. The small-sized spoons, however,\\nwith solid bowl and sharp edges, largely used in Vienna, are prefer-\\nable for use, especially about the face, in many skin -affections. Epilat-\\ning-forceps, with easy springs and smooth blades meeting in perfect\\napposition a set of Piffard s comedone-extractors, provided at each\\nextremity with a differently sized, minute, spoon-shaped and perforated\\nbowl, the convex surface of which is pressed over the comedo with the\\norifice immediately over the black head of the plug. This is a great im-\\nprovement over the old-fashioned comedo-extractor shaped like a watch-\\nkey, and the discomfort to the patient by its use is greatly reduced.\\nA set of half-inch and four-inch lenses for examining the surface of the\\nskin needle-holders with light handles for firmly grasping the needles\\nused in opening pustules, etc. The needles, some of them, should\\nbe flat, with a double-cutting edge, others be rounded neatly on an\\nemery-wheel, and all of them carefully disinfected if used more than\\nonce. Too many precautions cannot be taken in the practice of der-\\nmatology with respect to the disinfection of all instruments made to\\npenetrate the skin. Probes, exploring-needles, fine dressing-forceps,\\ndelicate straight and curved scissors, and other instruments from the\\nordinary pocket-case of the surgeon, are indispensable. The instru-\\nments required for use in connection with the galvanic battery are\\nenumerated in the chapter on Hypertrichosis.\\nFig. 23.\\nIrido-platinum needle.\\nFig. 24.\\nMiliiim-needle.\\nFro. 25.\\nSearifying-spnd.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0119.jp2"}, "120": {"fulltext": "108\\nGENERAL THERAPEUTICS.\\nEpilating-forceps.\\nFig. 27.\\nPiffard s grappling-forceps.\\nFig. 28.\\nPiffard s cutisector.\\nFig. 29.\\nFig. 30.\\nDermal curettes.\\nFig. 31.\\nT.IEMMM-GQ-NX\\nHess s glass pleximeter, for observing the skin under pressure.\\nFig. 32.\\nPiffard s modification of Unna s comedo-extractor.\\nFig. 33.\\no ^4 of real size.\\nKeyes s cutaneous punch.\\nFig. 34.\\nHyde s massering-ball.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0120.jp2"}, "121": {"fulltext": "VIII. CLASSIFICATION.\\nThe numerous attempts which have been made to classify diseases\\nof the skin according to their nature and relations have been in response\\nto the generally recognized demand for a systematic arrangement of all\\nscientific facts. As regards dermatology, not only have these attempts\\nbeen numerous and based upon different principles, but the results which\\nthey have accomplished have also been in the highest degree divergent.\\nNo classification yet devised has secured general acceptance. While it\\nis certain that no one system of classification has been perfect, and that\\neach has exhibited defects, it is equally true that of the large number\\neach has possessed some merit of its own. No perfectly satisfactory\\nclassification of cutaneous diseases can be made until the knowledge of\\ndiseases of the skin has been greatly enlarged.\\nOne of the most acceptable of the systems thus far proposed is that\\nof Hebra. In it cutaneous disorders are arranged in the following\\nnine classes\\nClass 1. Disorders of secretion.\\nClass 2. Hyperemias.\\nClass 3. Exudations.\\nClass 4. Hemorrhages.\\nClass 5. Hypertrophies.\\nClass 6. Atrophies.\\nClass 7. New Growths.\\nClass 8. Neuroses.\\nClass 9. Parasites.\\nSince this classification was devised by Hebra none has been pro-\\nposed which compares in ingenuity with the arrangement made by\\nAuspitz. The principle of this classification is to place together those\\ndiseases and groups of diseases which present a clinical unity, the general\\npathological process being the predominant characteristic for selection\\nindividual characteristics, such as symptoms, localization, anatomical\\npeculiarities, etc., being only brought thus predominantly forward when\\ncoinciding with the real nature of the class, the group, or the skin-\\ndisease in question. 1 Auspitz s nine classes are\\n1. Simple Inflammatory Dermatoses 2. Angioneurotic Dermatoses;\\n3. Neurotic Dermatoses 4. Stasic Dermatoses 5. Hemorrhagic Der-\\nmatoses 6. Idioneuroses 7. Epidermidoses 8. Chorioblastoses\\n9. Dermatomy coses.\\nUnder these classes, by the aid of divisions and subdivisions, an\\nelaborate scheme is presented which embraces not only all cutaneous\\n1 System d. Hautkrankheiten. Wien, 1881,\\n109", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0121.jp2"}, "122": {"fulltext": "110 CLASSIFICA TION.\\ndiseases, but also all pathological processes recognized in the skin.\\nThe mere presentation of this system has been followed by an advance\\nin the nosology of cutaneous medicine more satisfactory than any since\\nthe contributions to this subject by Hebra.\\nAuspitz s classification, however, is open to various objections on the\\npart of the student of dermatology. It is elaborated to the extent of\\nplacing the names of some diseases in more than one family, and hence\\nis confusing to the beginner. It is better adapted to the needs of the\\nexpert than of the student, for it introduces to the study rather of\\nmorbid processes in the skin than of the complexus of those processes\\nwhich are recognized in disease.\\nWhether the principle of classification be anatomical, etiological, or\\npathological whether it be based on the processes actually occurring\\nin the skin, or on those deeper factors and forces which operate cen-\\ntrifugally upon the skin, and on which that organ depends for all its\\nfunctions and even its existence whether it proceed etiologically from\\ncauses which are immediate or those which are remote, it is easy to see\\nthat, as knowledge in each of these directions enlarges, the exact position\\nof any one disease in any given classification must be rendered insecure.\\nNever was this observation more suggestive than at this day, when the\\npathogeny of numerous skin-disorders is revealed in the light thrown on\\nthe subject by the discovery of hitherto unknown inferior organisms.\\nIndeed, to this last cause, awakening grave doubts as to the precision\\nof much that was once esteemed fact, may be attributed the declining\\ninterest in the general subject of classification of diseases of the skin.\\nThe solution of its problems has practically been deferred by common\\nconsent to a date when the questions thus suggested can more satisfac-\\ntorily be answered. Several recent writers have contented themselves\\nwith an alphabetical indexing of the names of skin-diseases as an order\\nuseful simply for reference.\\nThe arrangement of titles of diseases of the skin in this treatise is\\na modification of the scheme first proposed by Hebra on the lines recog-\\nnized by the American Dermatological Association in its classification\\nadopted in 1884. In the successive editions of this w T ork which have\\nappeared since this classification was first accepted, changes from time\\nto time have been made ivhich were rendered necessary by the advance-\\nments of science. As the arrangement stands to-day it should be\\nregarded as a mode of grouping diseases for the convenience of the\\nstudent rather than as an attempt at a scientific classification of diseases\\nof the skin.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0122.jp2"}, "123": {"fulltext": "DISEASES OF THE SEXN\\nCLASS I.\\nDISORDERS OF THE GLANDS.\\nIn this class of disorders are grouped the functional affections of the\\nsweat-glands, or coil-glands, the sweat-pores, and the sebaceous glands.\\nThese disorders may be betrayed in quantitative or in qualitative\\nchanges in the secretion, or in retention of the latter in the whole or\\nin a part of the secretory apparatus. When a disease of the skin\\nceases to be purely functional in type, and is accompanied by an exud-\\native process, glandular or periglandular in situation, such disease\\nis properly classed with another group of affections. With a view,\\nhowever, to convenience of arrangement there have been placed in\\nthis class a few dermatoses which cannot be regarded as strictly func-\\ntional affections.\\n1. DISORDERS OF THE SWEAT-GLANDS.\\nHYPERIDROSIS.\\n(Gr. virep, in excess vdup, water.)\\n(Idrosis, Hydrosis, Ephidrosis, Sudatoria, Polyidrosis,\\nHyperhidrosis.)\\nHyperidrosis is an exaggerated quantitative effusion of sweat, the\\n.secretion accumulating in visible drops upon the surface of the skin.\\nSymptoms. This condition may be physiological, as the result of\\nactive exertion in a medium of high temperature or it may be patho-\\nlogical in character, and in the latter case be either general or partial.\\nGeneral sweating to a pathological extent chiefly occurs in the obese,\\njbut also in those who are the subjects of constitutional disease (phthisis,\\n(the various febrile disorders, etc.). It is the fertile source of the vari-\\nous forms of intertrigo, sudamina, and miliaria. Local hyperidrosis\\nis the exaggerated quantitative effusion of sweat limited to certain defi-\\nnite portions of the skin, as the palms, the soles, the dorsa of the\\nrhands and feet, the interdigital spaces, the genitals, the axilla?, and the\\ntemples. In such cases the secretion occurs moderately or greatly in\\nill", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0123.jp2"}, "124": {"fulltext": "112 DISORDERS OF THE GLANDS.\\nexcess, varying in this respect somewhat in different degrees of tem-\\nperature and in rapidity of the circulation it is occasionally, but not\\ncommonly, accompanied by fetor. It may involve one or both sides\\nof the body, being generally symmetrical upon the extremities and\\nasymmetrical upon portions of the face.\\nIts topical expression may be studied in the hands, which are con-\\ntinually moistened, clammy, or dripping with fluid within a brief time\\nafter the most careful drying of the parts. In the case of a woman,\\nthe instincts of whose sex prompt her to take such precautions, the\\ndress is constantly protected from contact with the macerated palms\\nby a handkerchief or similar article which is always in readiness. The\\ndisadvantages thus arising in individuals of both sexes who are en-\\ngaged as tradespeople, artists, hand-workers, etc., are obvious. In\\nwomen of social position no small complaint is made of the disagree-\\nable result produced after wearing kid gloves for even a short time,\\nthe material of which is soon soiled by its complete saturation with the\\nsecretion from the skin.\\nWith and without this local excess occurs the hyperidrosis of the\\nfeet, aggravated by the mechanical force of gravity and the need of\\nconstant covering. The stockings and the leather of the boots, shoes,\\nor gaiters are saturated with the secretion, and rapidly become subject\\nto chemical alteration. There is usually an offensive odor of the re-\\ngion, originating partly in the primary fetor of the secretions them-\\nselves, and partly in the subsequent chemical decomposition of the\\nlatter, rapidly progressing under the influence of the soiled and often\\nstinking investments of the feet.\\nThe integument, constantly macerated, may become both painful\\nand tender occasionally there is vesiculation or exfoliation of patches\\nof sodden epidermis. When the genitals are involved, especially in\\nmen, erythema and intertrigo are the frequent results.\\nEtiology. The disease is frequently recognized in persons suf-\\nfering from an habitually rapid or slow pulse or from organic cardiac\\ndisease in rare cases it is congenital. In other instances it is asso-\\nciated in one person with disorders not apparently related to it. In\\nthe case of a hospital-patient recently examined, a woman, twenty-\\nfour years of age, was affected with severe tylosis of the feet, from\\nwhich were exfoliated extensive lamellated casts of the soles. She had\\nalso typical hyperidrosis of the hands.\\nIn no portion of the nervous system has a localized centre for excito-\\nsudoral or inhibitory effects been recognized. Traumatisms, gliomata,\\ngummata, scleroses, and other lesions affecting the cerebrum, medulla,\\ncord, ganglia, and trunks of the sympathetic nervous system have\\nbeen followed by local hyperidrosis, but they have all repeatedly failed\\nto induce such morbid sudoral symptoms, while a fit of anger or sudden\\nfright has been as conspicuously effective as any. In short, the pre-\\ndominant influence of the nervous system in an etiological sense must\\nbe admitted here as in physiological sweating, and to the sympathetic\\nbranches of that system must be assigned the greater influence for most\\ncases. A paralysis or paresis of the sympathetic is held to explain the\\noccasional coincidence of pulmonary and cardiac disorders with either", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0124.jp2"}, "125": {"fulltext": "HYPERIDR OSIS. 1 1 3\\ngeneral or partial excessive sweating. Compression of the sympathetic\\nby adenomata, aneurisms, carcinomata, etc., has been followed by\\nmarked symptoms of this disorder. The disease is encountered in\\nindividuals of both sexes, and in all ages and degrees of general health,\\nas also in those who are and those who are not cleanly. There is\\nreason to believe that the facial asymmetrical hyperidroses associated\\nwith migraine, neuralgias, hemicrania, etc., are etiologically and path-\\nologically distinct from the similar symmetrical affections of the hands\\nand feet. The last-named disorders certainly occur with conspicuous\\nfrequency in young women who are the subjects of hysteria, chloro-\\nansemia, some form of dysmenorrhea, or cardiac trouble.\\nPathology. Robinson, who examined a number of sections from\\nthe palm of the hand, failed to detect any abnormal feature either in\\nthe glands or in the epithelium. The disorder is to be regarded as\\npurely functional and any anatomical changes in the coil-glands\\nor the sweat-pores are probably accidents of such derangement of\\nfunction.\\nTreatment. When universal, hyperidrosis is to be treated internally\\nby the aid of such remedies as are indicated by the general condition\\nof the patient, and especially by the condition of the heart. The\\nvarious ferruginous tonics, mineral acids, arsenic, strychnine, stroph-\\ntmthus, quinine (the latter particularly when, as is often the case, a\\nmalarial affection is responsible for the disorder), and ergot, with both\\nbelladonna and atropine, are all of unquestioned value. Even though\\nbut temporarily serviceable, belladonna and atropine are well used at\\nthe outset of most cases. Aconite, jaborandi and pilocarpine, white\\nagaric (agaricin is recommended in doses of grain (0.011), repeated\\nas required), carbolic and salicylic acids may be named as in the\\nsecond rank. Meat should always be largely eliminated from the\\ndietary.\\nExternal treatment, which is often promptly efficacious, should not\\nbe neglected in any case. The simplest method is by wiping, not wash-\\ning, the skin-surface until it is dry, and applying a dusting-powder, such\\nas lycopodium, talc, salicylic acid, boric acid, bismuth, magnesia, chloral\\nhydrate (1 part to 5 or 6 of starch), or starch. Alternately with either\\nof these, or in lieu of them, baths or lotions may be employed, aqueous\\nor alcoholic, and medicated with corrosive sublimate, formalin (1 to 5\\nper cent, solution), tannic acid, ferrous sulphate, naphtol (Kaposi), tur-\\npentine, zinc sulphate, alum, potassium permanganate, or common\\nsalt. Daily sponging of the affected surface with weak solutions of\\nformalin (1 to 6 per cent.) will remove the odor, and will in most\\ncases greatly diminish the amount of perspiration, but on suspension\\nof the treatment the condition usually returns. Fox l advises a lotion\\ncontaining 1 part of quinine to 100 of alcohol. Van Harlingen\\nrecommends the use of juniper-tar or carbolic-acid soap with the\\nbath as alone sufficient to relieve some cases. Grosse 2 praises highly\\ntannoform, either in powder (1 part to 2 of talcum) or as a 25 per\\ncent, plaster.\\nJ Jour. Cutan. and Ven. Dis., 1885, p. 24.\\n2 Klin, therap. Woch., 1899, Nos. 16 and 17.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0125.jp2"}, "126": {"fulltext": "114 DISORDERS OF THE GLANDS.\\nFor hyperidrosis of the feet the treatment by the method of Hebra\\nlias deservedly high repute. It consists in neatly and completely\\nenveloping the entire foot, the toes separately, after thorough washing\\nand drying, in strips of cotton-cloth over which is spread to the thick-\\nness of a common knife-blade the unguentum diachyli albi. This\\nunguent is made by boiling 1 part of the best litharge with about\\n4 parts of pure olive-oil, to which a little water is added while the\\nmaterials are stirred together over a slow fire. The parts are well\\nbandaged, and the patient either remains subsequently at rest or pur-\\nsues his vocation, wearing over the feet shoes and stockings which\\nhave not previously been worn. In twenty-four hours the feet are\\nredressed without washing, after dry rubbing with charpie and a dust-\\ning-powder. This treatment is repeated daily for from ten to twenty\\ndays, after wdiich a dusting-powder (boric acid) may be substituted\\nfor the local dressing. There occurs a parchment-like desquamation\\nof the epidermis in thick, yellowish-brown lamella?, beneath which is\\nformed a new and at first tender but apparently normal epidermis.\\nWhen the latter has lost its tenderness the feet are for the first time\\nwashed Avith water. In case of failure the routine of treatment\\nis repeated as often as requisite. It is scarcely necessary to add\\nthat no ill effects are known to have resulted from the therapeutic\\nmeasures adopted in checking a local hyperidrosis. For the dia-\\nchylon salve there may be substituted tar, ichthyol, or naphtol\\nointment.\\nGerdeck l makes three applications to the soles, at intervals of about\\neight hours, of the strongest solutions of formalin the skin of the indi-\\nvidual will bear. In some instances full strength is well tolerated. A\\nfew drops are put in the shoes, the influence on the leather being pre-\\nservative and not destructive. Relief follows for several weeks, when\\nthe treatment may be repeated.\\nFredericq employs finely pulverized tartaric acid, applied at first\\nwith some caution, and always in small quantities. Stewart first bathes\\nthe feet in hot water and then soaks them for a few moments, once\\nonly, in a solution of potassium permanganate, 4 to 6 grains to the\\nounce (0.266-0.4 to 32.), after which the plaster selected for use may\\nbe applied as directed above. Legoux orders pediluvia of tar-water\\ntwice daily for three days, followed by painting of the feet with a\\nsolution of iron perchloride. Morrow 2 recommends foot-baths in the\\nextract of pin us Canadensis, followed by the application of boric acid,\\nor of salicylic acid mixed with lycopodium.\\nPrognosis. The future of any case of hyperidrosis is uncertain.\\nThe disease, whether local or general, may spontaneously disappear,\\nmay recur, may promptly be amenable to treatment, or may prove\\nobstinate to all therapy. Myrtle 3 reports the case of a male patient,\\nseventy-seven years old, who sweated to death after repeated recur-\\nrences of severe hyperidrosis, and after temporary relief from the use\\nof Fowler s solution.\\n\u00e2\u0080\u00a2La Kiforma Medic;), 1898, No. 38.\\n2 See his resume of this subject in Jour. Cutan. and Ven. Dis., vol. v., p. 68.\\n3 Medical Press, Februarv 25, 1886.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0126.jp2"}, "127": {"fulltext": "SUDAMEN. 115\\nSUDAMEN.\\n(Lat. sudor, sweat.)\\n(Miliaria Crystallina.)\\nSymptoms. In this disorder the lesions are thickly agglomerated,\\nbut discrete, transitory, and translucent, pin-point-sized vesicles, re-\\nsembling dew-drops or seed-pearls, upon the surface of the skin, often\\nrequiring the touch to define their real character. The lesions are\\nusually -limited to certain regions of the body, as the trunk, and here\\nmore generally upon the front and sides of the belly and in the iliac\\nregions, though they may occur upon any part. Their course is rapid,\\nboth in evolution and involution, and their sequelae are exceedingly\\ndelicate desquamative flakes, the thin roof-wall, which originally cov-\\nered the sweat-drops, having been lifted from the superficial stratum\\nof the horny layer of the epidermis. They contain each a droplet of\\nsweat, which is removed by evaporation. They are usually preceded\\nby an attack of pruritus, and may follow the hyperidrosis of systemic\\ndebility, enteric and continued fevers, phthisis, inflammatory rheuma-\\ntism, pneumonia, and other asthenic conditions. They may also result\\nfrom violent exercise, the elevated temperature of the summer season,\\nflannel underclothing, vapor-baths, and the application of wet hot\\ncloths to the surface of the skin.\\nThe lesions are the result of the accumulation of sweat in high tem-\\n1 peratures of the external surface of the body or of the medium by\\nwhich the body is surrounded, and usually in states of adynamia. The\\nsweat accumulates between the most superficial layers of the stratum\\ncorneum. Sudamina mav hence occur at all a^es and in both sexes.\\nThree forms of sudamina have been described (a) sudamina alba\\n(b) sudamina rubra and (c) sudamina crystallina. The last named is\\nthe only form to which the term suclamen is properly applied, since it\\ni alone of the three designates a purely functional derangement of the\\nsweat-secreting apparatus.\\nThe first term, sudamina alba (miliaria alba), is applied to the lesions\\noccurring where there is maceration of the vesicular wall and when\\nthe contents become opalescent. This form is rare. The second term,\\nj sudamina rubra (miliaria rubra, miliaria papulosa, lichen tropicus,\\nprickly heat is applied to inflammatory lesions which may accom-\\npany profuse sweating. These lesions are numerous pin-point- to pin-\\nhead-sized vesicles surrounded by a reddish halo, or papules of the\\ni same dimensions, or the two lesions commingled, almost invariably\\naccompanied by hyperidrosis, though the latter may be absent in high\\nj temperatures. The marked tingling, pricking, and burning sensations\\nj by which they are accompanied are often in the highest degree dis-\\nI tressing, and may solicit rubbing of the affected part, though the\\nscratching elicited by severe pruritus is not common. Minute crusts\\ni may form after vesicular rupture. The attack may be mild or severe,\\nand may last for a few days or for a few weeks or months, the result\\nof continuous aggravation or of the production of new crops of lesions", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0127.jp2"}, "128": {"fulltext": "116 DISORDERS OF THE GLANDS.\\nafter each recurrence of the cause. The affection is not rarely com-\\nplicated in obese individuals by all varieties of intertrigo and eczema.\\nSudamina crystallina are, however, the sole lesions which may properly\\nbe referred to this class of affections. These vesicles are always free\\nfrom inflammatory symptoms, presenting a limpid, dewdrop-like aspect\\nthat is characteristic.\\nEtiology. The disease is induced by excessive sweating, often in\\nconsequence of an elevated temperature also, however, as a result of\\na systemic asthenia, as indicated above. The vesicles may occur as\\nsymptoms of the death-agony.\\nPathology. Robinson reports that the contents of the vesicles are\\npure sweat without admixture of lymphoid corpuscles. The fluid col-\\nlects between the laminae of the deeper part of the corneous layer. A\\nrupture of the wall of the sweat-duct may occur, but there may be instead\\nobliteration merely of the sweat-pore by a sudden effusion of watery\\nfluids toward the epidermis, that pass with moderate pressure through\\nthe wall-less sides of the pore into the spaces between the epithelial\\ncells, where a chamber is readily formed. Torok found the walls of\\nthe vesicle composed purely of the corneous layer with a sweat-pore\\nopening at the lower border of the chamber.\\nDiagnosis. No difficulty can arise in making a diagnosis if the\\npeculiar characters of the sudamen be kept in view. All pustular\\nlesions have different contents all bullous lesions are larger, or are\\nseated on an engorged base, or they lack the limpid clearness of the\\nsudamen, because, however transparent the contents, they are mostly\\ncovered by a thicker and less transparent roof. The halo about the\\nlesions of miliaria rubra, or their rosy-pink shade, will determine their\\ncharacter. In varicella the lesions are chambered.\\nTreatment. Only the simplest treatment is required. Alkaline\\nand bran baths may be employed, of the temperature most grateful to\\nthe skin. Afterward the surface may be dusted with one or several of\\nthe dusting-powders, such as starch, lycopodium, or boric acid, named\\nin the chapter on General Therapeutics. The internal treatment is\\nthat indicated by the condition of the patient.\\nMiliary Fever, sweating sickness, suette miliaire of the\\nFrench, is an epidemic disorder, accompanied by sweating and a cuta-\\nneous exanthem. Pineau l gives a description of the disease as it oc-\\ncurred in epidemic form on the island of Oleron, where of one thous-\\nand patients affected, between one hundred and fifty and two hundred\\nperished. The eruption appeared in the form of hyperaemic maculae,\\ndisappearing under pressure, after which there rapidly formed myriads\\nof reddish or whitish, grouped, unequally sized, acuminate papules,\\nrising from a whitish and macerated surface. Among these papules\\nwere interspersed lesions of sudamina. The region of the face was\\nnot spared, and the conjunctivae were occasionally affected. In the\\ncourse of from two to four days pinhead- to bean-sized, varioliform\\nbut non-umbilicated pustules formed in the site of some of the papules,\\nthe contents of which disappeared by resorption, the final lesions pre-\\n1 Arch. gen. de Med., Jan., 1882, p. 25,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0128.jp2"}, "129": {"fulltext": "HYDROCYSTOMA. 117\\nsen ted being large, flat, reddish papules, the skin of the face partic-\\nularly becoming reddened and swollen. In the course of from ten to\\ntwelve days general desquamation ensued, with extensive palmar and\\nplantar losses. Relapses occurred in some cases with diffuse redness\\nof the surface or with crops of reddish plaques, or yet again with the\\noccurrence of furuncles. The sensations were those of myriads of\\nneedles thrust into the skin.\\nThe exanthem was accompanied in some cases by fever. In the\\nfatal cases death resulted from exhaustion.\\nGeber and other writers, however, believe that the lesions described\\nare not peculiar to any special disease, and they deny the possibility of\\nan independent miliary fever.\\nHYDROCYSTOMA.\\n(HlDROCYSTOMA, CYSTS OF THE COIL-DUCT.)\\nRobinson, of New York, in 1893, 1 published a report of his studies\\nin this affection, which he first described eleven years previously, in a\\npaper read before the American Dermatological Association. Reports\\nof cases and studies of the disease have been made also by Hutchin-\\nson, Jackson, Jamieson, Rosenthal, Hallopeau, and others.\\nSymptoms. The lesions are discrete or closely set, few or exceed-\\ningly numerous, tense, well-developed, clear, shining, pinhead- to pea-\\nsized vesicles, never inflammatory and never superficially seated, that\\nis, never as near to the surface as the vesicles of miliaria, because the\\nbase of all hydrocystomata is to be found in the corium. The lesions\\nare Avhitish in color, or when of greater age and size are dark bluish,\\nespecially at the periphery, some resembling boiled sago-grains. No\\nsigns of inflammation are present. Occasionally a mild hypersemia\\nbecomes evident at the periphery of a single cyst. The contents are\\nI pellucid, never changing to a yellowish hue, and when uninjured\\ni resolve in time by desiccation, leaving a short-lived pigmentation. The\\nI contents of the vesicles are always slightly acid. They are always\\naccompanied by very free sweating.\\nEtiology. The disease occurs almost invariably in middle-aged\\ni women, more often in those engaged as laundresses who have been\\nsweating freely over the washtub, the face being simultaneously ex-\\ni posed to warm vapor. There is usually aggravation of the disorder\\nin summer, and either complete or partial relief in winter. Aggrava-\\ntion has been noted at the time of the menstrual period. One of\\nHutchinson s cases exhibited lesions on a single side of the face only.\\nRobinson reports a case occurring in a young man. The few patients\\nseen by us were all of the dispensary class, and were women who\\nworked much over the w r ashtub.\\nPathology. The epidermis, hair-sacs, and sebaceous glands are\\nin all parts normal, the papillary layers being involved only when\\nthe cyst approaches the upper part of the corium, where a thin plate\\nj of flattened papillary body is found above. Below, in places, the\\n1 Jour. Cutan. and Gen.-Urin. Dis., August, 1893.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0129.jp2"}, "130": {"fulltext": "118 DISORDERS OF THE GLANDS.\\nlumen of the sweat-duct is found enlarged and distended with liquid\\nand a granular material. The enlargement in the duct begins above\\nthe coil of the gland, and usually in the lower part of the corium.\\nThere is some perivascular leucocytosis in progress here and there in\\nthe vicinity of the vessels, but this was not a marked feature in any\\none of the several sections examined by Robinson. The cavities of\\neach duct were found lined with epithelial cells.\\nDiagnosis. The lesions of sudamen and pompholyx are readily\\ndistinguished by their superficial character and their situation, as they\\nare rarely discovered upon the face. The vesicles of eczema are short\\nlived and inflammatory. In adenoma of the sweat-glands the lesions\\nare often painful and usually firmer and larger than in hydrocystoma.\\nTreatment. The lesions can be caused to disappear by puncturing\\neach, thus permitting the escape of the imprisoned fluid. This should\\nbe followed by the application of dusting-powders, due care being had\\nto avoid the effective causes of the malady.\\nANIDROSIS.\\n(Gr. privative vdup, water.\\n(Anhidrosis. Ger. and Fr., Anidrose.)\\nThis name is properly applied to those morbid conditions in which\\nno sweat is secreted from the surface of the body. Hypohidrosis is a\\nterm more exactly used to designate a relative, general or partial de-\\ncrease in the quantity of the sudoral fluid. The former term, however,\\nis often used to indicate the latter.\\nComplete anidrosis occurs naturally only when the sudoral appa-\\nratus has been involved in destructive or other changes in the skin\\n(scars, atrophy, etc.).\\nDiminution in the quantity of sweat excreted, or its complete sup-\\npression, whether general or local, is a symptom of several disorders,\\nbut as a separate cutaneous affection it has no existence. This con-\\ndition is common to many dermatoses, as, for example, ichthyosis,\\npsoriasis, and some forms of eczema but in these the symptomatic\\ncharacter of the anomaly is illustrated by the fact that when the skin\\nis relieved of these cutaneous troubles the function of sweat-secretion\\nis restored. Similarly in neuralgias and certain forms of paralysis a\\ncircumscribed and temporary anidrosis may be the local expression of\\nthe nervous disturbance, precisely as in the case of the symmetrical\\nhyperidroses. Lastly, there are individuals exhibiting the idiosyncrasy\\nof either sweating not at all or quite imperceptibly in elevated tempera-\\ntures, phenomena which should be ascribed rather to peculiarities in\\nthe equilibrium of the heat-exchanging factors than to congenital\\ndeficiency of the sweat-glands.\\nStrauss and Bloch regard the occurrence of hypohidrosis and ani-\\ndrosis as differential diagnostic symptoms of diffuse myelitis, polio-\\nmyelitis, and cerebral paralysis.\\nTreatment. The measures capable of stimulating the sweat-secre-\\ntion are ingestion of water in quantity by the mouth, the external ap-", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0130.jp2"}, "131": {"fulltext": "BROMIDROSIS. 119\\nplication of heat in a dry or moist atmosphere, and the use of jaborandi\\nor pilocarpine by the mouth or by hypodermatic injection. In the\\nanidrosis accompanying cutaneous disease the indication is always pri-\\nmarily for the relief of the latter.\\nBROMIDROSIS.\\n(Gr. ftptipoc, a stench vdup, water.)\\n(Bromhidrosis, Osmidrosis, Fetid or Stinking Sweat.\\nGer., Stinkender Schweiss.)\\nSymptoms. In bromidrosis the perspiration is effused in such a\\nstate that it can immediately be perceived to possess an unusual odor,\\nor, as Hebra taught was the case with the majority of patients, to be\\nrapidly changed to that condition. It is often associated with hyperi-\\ndrosis, but may occur independently of the latter, and like the latter\\nalso be either general or localized. The odor may be either agreeable\\nor disagreeable, having been in various cases compared to that of\\ncertain flowers and fruits as well as to that of several stench-emitting-\\nanimals. In this respect the sweat presents a striking analogy to the\\nurine, with which it sustains a close and well-recognized physiological\\nrelation.\\nGeneral bromidrosis may be physiological, as in the case of indi-\\nviduals of the African race, or in those with dark skins who are pro-\\nfusely sweating during labor or in high temperatures. General patho-\\nlogical bromidrosis is rare. The odors emanating from the person in\\nulcerating syphilodermata, small-pox, malignant pemphigus, mycosis\\nfungoVdes, and other disorders may, in certain cases, be associated with\\nthe sweat-secretion, but in other cases they doubtless are connected\\nwith the decomposition of pathological products of the inflammatory\\nprocess.\\nThe local varieties of bromidrosis affect the regions in which the\\nsweat is oftenest secreted in excess and its immediate evaporation pre-\\nvented, as in the axilla?, the groins, the feet, the anogenital and the in-\\ntermammary and inframammary regions. In a qualitative sense every\\ndegree of odorousness is noted, from that which is merely slightly\\nagreeable or offensive to the most intolerable stench. When com-\\nplicated by a seborrhoea in situations where the parts are not only\\nwarm, moist, and covered by clothing, but also subjected to friction\\nand remaining uncleansed, the most intolerable and nauseous fetor is\\nperceived.\\nSweat may be effused in a normal condition upon and within the\\narticles of clothing worn, and subsequently generate a stench by chem-\\nical changes both in the clothing and the fluid by which that clothing\\nis saturated. This fact should never be forgotten in the practical\\nmanagement of any case.\\nEtiology and Pathology. Thin has recognized micro-organisms\\n{Bacterium fwtidum) in sweat obtained from the feet. Parkes con-\\ncludes that the only cause of the disease is the covering of the foot,\\nas soldiers with uncovered feet do not suffer from this affection. It", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0131.jp2"}, "132": {"fulltext": "120 DISOEDERS OF THE GLANDS.\\nis occasionally due to emotional causes, to chronic alcoholism, or to the\\ngouty state.\\nTreatment. The treatment of bromidrosis is in general that of\\nhyperidrosis already described. Formalin solutions in the strength\\nof from 1 to 10 per cent, in alcohol are of the greatest value. They\\nshould be followed by the use of boric acid in powder externally.\\nThin l successfully employed stockings and cork-soles thoroughly dried\\nafter being saturated for hours in a jar containing a solution of boric\\nacid. The efficacy of this measure he ascribes to the fact that the odor\\nis the result of the development in the secretions of the Bacterium\\nfwtidum. An ointment is also employed by him for similar purposes\\nit is a solution of boric acid in glycerin incorporated with a fatty basis\\nof white wax and almond-oil, making thus a glycerated cream of\\nboric acid. Armingaud, of the French Academy, has reported excel-\\nlent results following the subcutaneous injection of 3 grains (0.20)\\nof pilocarpine nitrate eight of which operations were successful in\\nlessening the abnormal sweat-fetor. Clement Hawkins 2 finely tritu-\\nrates 15 grains (1.) of red lead oxide, and to this adds gradually\\n1 ounce (32.) of Goulard s extract. This preparation is used as a\\nlotion following a nightly foot-bath containing 1 ounce (32.) of alum.\\nFox 3 advises a 1 per cent, solution of chloral or of potassium per-\\nmanganate as a topical application.\\nInternally sodium salicylate has been employed with success in\\n5-grain (0.33) doses.\\nCHROMIDROSIS.\\n(Gr. xpupa, color: vdop, water.)\\n(Ephidrosis Tincta. Ger. and Fr., Chromidrose.)\\nBy this term is indicated the condition in which effused sweat\\nexhibits an abnormal color yellowish, reddish, greenish, or blackish.\\nCyanhidrosis is the term that has been employed to indicate blue\\nsweating.\\nIn cases of chromidrosis there has usually been a copious secretion\\nof fluid. Authors have variously attributed the color of the sweat to\\nthe presence of compounds of phosphorus, iron, cyanogen, indican,\\nPrussian blue, hsematin, chromogen, and even to parasitic vegetations\\nupon the skin-surface. Women, much more often than men, exhibit\\nthe free deposit of pigment upon the skin, and in view of the admitted\\nrarity of chromidrosis the suspicion arises that in some of the cases\\nreported there was free pigmentation of the surface, by which the fluid\\nexuded was immediately stained or colored. Duhring reports a single\\ncase of red sweating in a vigorous male patient. Usually, however, the\\nphenomenon occurs in persons who are debilitated and betray some evi-\\ndence of impairment of other organs than the skin, thus furnishing an\\nindication for treatment.\\nBabesiu, 4 of Pesth, reports some interesting cases of this disorder\\n1 Practitioner, December, 1881, p. 2101.\\n2 Brit. Med. Jour., May 7, 1881.\\n3 Loc. cit.\\n4 Lancet, 1862.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0132.jp2"}, "133": {"fulltext": "CHR OMIDR OSIS. 2 1\\nin which the symptoms were due to the presence of bacteria, a fact\\nconfirmed by us in several instances. In eight patients, three of them\\nwomen, there was considerable pruritus with pale-red to blood-red\\nsweat in one of the patients the skin and hairs w r ere reddened. The\\naxillae were the seat of this colored perspiration. In all the cases\\nmicroscopical examination revealed similar changes. The hairs of\\nthe axillae were thin, pale red, brittle, and surrounded with a col-\\nloid-looking, rusty, or bright-red sheath, in places of considerable\\nthickness and having a rough surface. This sheath consisted of red\\nmasses presenting a radiating striation, more or less confluent, appar-\\nently proceeding from fibres of the cortex of the hair or from some\\nbroken part of its surface. The radiating striation was found to be\\ndue to the aggregation of round or ovoid bacteria (scarcely a micro-\\nmillimetre in diameter), which were united in zoogloea masses by a\\nreddish intermediate substance. Nodular swellings on the hair were\\nproduced by the infiltration of the organism between the separated\\nfibrils. The roots of the hair were free from bacteria. The red tint\\nof the sweat was found to depend upon numerous roundish masses of\\nzoogloea.\\nT. C. Fox reports also two cases of Cy anhidrosis in which a deep\\nbluish-black pigment was exuded upon the skin of the circumorbital\\nregion. The amorphous granules were found insoluble in almost all\\nhot or cold reagents, but they displayed a deep-blue color when moist-\\nened with glycerin, and a purplish hue when dissolved in hot sulphuric\\nacid.\\nMitchell 2 describes an unusual case under the title of Seborrhoea\\nNigricans, in which there was a dark greasy-looking discoloration\\nof the eyelids and adjacent skin.\\nThe hypothesis, that certain cases described as chromidrosis are\\nreally instances of mechanical w T ashing of pigment to the surface in the\\nprofuse sweating of the debilitated, is strengthened by the phenomena\\nof simultaneous hair-coloration. Thus, Prentiss 3 reports the case of a\\nyoung woman, affected with acute cystitis and passing purulent urine,\\nwhose hair, under the influence of profuse sweating induced by the\\naction of pilocarpine, changed speedily from a light blonde to a nearly\\njet-black hue. At the meeting in 1881 of the American Dermatolog-\\nical Association we exhibited hairs of a middle-aged man that had\\nchanged in a night from a grayish-white to a greenish and yellowish-\\nbrown hue. White, of Boston, has observed several similar cases of\\nhair-coloration as the result of profuse sweats. In the year 1884 this\\nobserver reported to the Association the case of a workman in a sugar-\\nrefinery whose sweat from the left side of the body was of a bright-\\nyellow color for several months. Though sought for, no bacteria were\\ndiscovered.\\nIn a case observed by Bergmann a mycelium was recognized which\\nw T as subsequently cultivated. Eberth has recognized bacteria in both\\nnormal and yellow sweat.\\n1 Med. Press and Circ, Jan. 1, 1881.\\n2 Phila. Med. Jour., Jan. 15, 1898.\\n3 Phila. Med. Times, July 2, 1881.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0133.jp2"}, "134": {"fulltext": "122 DISORDERS OF THE GLANDS.\\nLe Hoy de Mericourt, first to name this disorder/ also 2 described a\\ncase of rosy sweating in an infant.\\nFereol believes that in these cases there is actually an absence of\\nsweat, and prefers to call the disorder chromocrinia.\\nIn all cases, before accepting statements of patients as to the exist-\\nence of symptoms of this character, it is needful to eliminate the possi-\\nbilities of deceit and accident. Coloring-matters received upon the\\nhands may be either wilfully or ignorantly transferred to the surface\\nof the body.\\nGreenish sweating, due to the presence of copper in the system,\\nhas been reported in a few instances. We have observed one case of\\nthis disorder in which the effect was produced by the copper plate of an\\nelectrode in contact with an abraded surface of the skin.\\nPhosphorescent Sweating is reported to have occurred after the\\neating of phosphorescent fish and the ingestion of phosphorus for\\nmedicinal purposes.\\nThe Treatment of these several conditions is that of the general\\nstate of the patients exhibiting these symptoms.\\nURIDROSIS.\\n(Gr. ovpov, urine; vSop, water.)\\n(Ger., Harnschweiss Fr., Uridrose.)\\nUridrosis is that condition in which some of the constituents of the\\nurine, chiefly urea, are excreted in excess with the sweat.\\nWhile a small amount of urea is to be recognized in normal sweat,\\nthis ingredient under peculiar conditions may be increased, and, together\\nwith urinary salts, be deposited upon the skin-surface after evaporation\\nof the exuded fluid. Such symptoms have usually occurred either as the\\nresult of grave constitutional affections (such as cholera), or of organic\\nrenal diseases accompanied by anaemia, or of the ingestion of jaborandi.\\nIn a few cases the symptoms have been presented in individuals who\\nwere apparently in good health. The salts of the urine appeared upon\\nthe skins of these patients in the form of minute lamellae, or of a fine\\npowder of whitish color and crystalline aspect. In some cases reported\\nthe symptoms have been noted to precede by a few days a fatal issue.\\nThe constantly adjusted equilibrium between the sweat- secretion and\\nthe urinary excretion would explain, for cases of a mild type, tem-\\nporary augmentation in the urea found in the sweat of unusually free\\ndiaphoresis. Geber supposes that decomposition-products, such as\\nammonium carbonate, possibly in association with volatile fatty acids,\\nmay in part account for these conditions.\\nIn the effort to eliminate certain substances accidentally or pur-\\nposely introduced into the system the sweat may possibly become\\ncharged with iodine, turpentine, tar, arsenic, and other substances.\\nSeveral of the eruptions described in the chapter on Dermatitis Medica-\\nmentosa are due to a similar eliminative effort, especially those accom-\\n1 Arch. gen. He Med.. November, 1857.\\n2 La France He d., 1884.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0134.jp2"}, "135": {"fulltext": "HTDRADENITIS SUPPURATIVA. 123\\npanied by excessive sweating and the production of vesiculation. In\\nthe same manner it may be inferred that the sweat is at times charged\\nwith excrementitious and other products of the body as, for example,\\nthe elements of the bile. In patients affected w T ith yellow fever the\\nskin and even the sweat which exudes from it often exhibit the char-\\nacteristic hue of that disease. The so-called Galactidrosis, from\\nsupposed metastasis of milk, does not occur cases thus described have\\nbeen instances of pathological sweat in the puerperal state.\\nELemattdrosis, or bloody sweat, reported as observed by several\\nauthors (Foot, Ebers, Parrot), is the name applied to conditions in which\\nblood has been seen to exude from an unbroken skin. The phenomena\\ndescribed under this title belong properly to the ensemble of symp-\\ntoms called hsernophilia, and may in some cases be due to direct\\ntransudation of red and white blood-corpuscles and fibrin into the inter-\\nepithelial spaces traversed by the sweat-pores. Geber points to the\\nneuralgic, hyperaesthetic, pruritic, or emotional symptoms that are usual\\nprecursors to the flow of pale or bright-red blood. The fact that\\npatients thus affected are mostly women, hysterical, dysmenorrhoeic,\\nor near the puberal epoch, also throws light upon these cases in many\\nof them petechia?, or signs of hemorrhage into other tissues of the\\nbody, are observed.\\nHYDRADENITIS SUPPURATIVA.\\n(Hydradenitis Destruens Suppurativa Folliculitis Exul-\\ncerans Spiradenitis Unna Acnitis Barthelemy Hy-\\ndros adenitis Disseminata Suppurativa (Dubreutlh).)\\nThis disorder was described in 1864 by Verneuil, and since then\\nhas been observed by Dubreuilh, 1 Pollitzer, 2 and others.\\nThe lesions begin as deep-seated, firm, shot-like, uncolored, insensi-\\ntive nodules over which the skin is movable and unaffected. Each\\nnodule slowly enlarges for a week or longer until it attains the size of a\\npea and becomes soft, slightly painful, and attached to the skin, which\\nis then reddened. On puncture the lesion gives exit to a drop or two\\nof pus but if left to itself it becomes yellowish, bursts spontaneously,\\nand becomes covered with a dirty adherent crust which soon falls,\\nleaving a pigmented spot, and ultimately a slightly depressed scar.\\nThe most common sites of the disorder are the regions of the axillae,\\nanus, nipples, scrotum, and labia majora. In these parts the lesions\\nmay be single or more numerous. They occur also in large numbers\\nover other parts of the body, especially on the face, scalp, neck, but-\\ntocks, and extremities. No cases have been reported with lesions on\\nthe soles.\\nOccasionally several nodules coalesce to form a flat tumor with a\\nnumber of openings or the small, firm lesions of the first stage may\\npersist as such for months, terminating in absorption. The disease is\\n1 Arch, de Med. exper. et d Anat. pathol., 1893, i.\\n2 Jour. Cutan. and Gen.-Urin. Dis., 1892, p. 9. Also, Morrow s System, vol. iii.,\\np. 771.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0135.jp2"}, "136": {"fulltext": "124 DISORDERS OF THE O LANDS.\\nusually chronic in its course, and with successive lesions or crops of\\nlesions may endure for months or years.\\nEtiology and Pathology. As predisposing causes should be\\ncounted all conditions, general or local, which tend to lower the\\nvitality of the tissues. The origin is unknown, though it is probably\\nto be sought in local infection or in the action of some toxic agent\\nexcreted by the coil-glands.\\nThe process has been shown to be a diffuse inflammation of the coil-\\nglands and periglandular tissue, usually terminating in necrotic sup-\\npuration and destruction of the gland. No micro-organisms have been\\nrecognized in the cases examined.\\nTreatment. The general condition of the patient should furnish\\nthe indications for the treatment of each case. Locally the nodules\\nshould be opened and dressed antiseptically. The disease is stub-\\nborn, but eventually terminates in recovery.\\nPrimarily the coil-epithelium undergoes changes which are respon-\\nsible for the cellular infiltration of the peripheral tissue.\\n2. DISORDERS OF THE SEBACEOUS GLANDS.\\nSEBORRHEA.\\n(Lat. sebum, tallow Gr. peu, to flow.)\\n(Steatorrhea, Acne Sebacea, Dandruff, Seborrhagia, Seba-\\nceous Flux, Stearrhcea. Ger., Schmeerfluss Fr., Sebor-\\nRHEE.)\\nThe clinical phenomena described under the title of seborrhoea are\\nnot due solely to a catarrh of the sebaceous glands, but result from\\nseveral different pathological processes in which the coil-glands and\\nepidermal layers are more or less involved. In the absence of suffi-\\ncient knowledge of the pathology of these conditions they are in these\\npages considered chiefly from a clinical standpoint. The inflammatory\\nprocesses in which the fat-producing glands seem to play an important\\npart are described under the head of eczema seborrhoicum.\\nSymptoms. Seborrhoea occurs in two forms. According to the\\ncondition of the excreted product, they are described as seborrhoea\\nsicca and seborrhoea oleosa. These two forms are recognized clinically\\nas of separate occurrence, and also as existing occasionally at the same\\ntime in one person. Either form of the disease may be limited to\\ncertain sites of preference, or be generalized so as to extend over all\\nportions of the body provided with sebaceous glands. The commonest\\nseats of the disease are: the scalp, the face, the genital region, the\\ndorsum of the body between the scapulae, and the anterior surface of\\nthe chest. It appears at all periods of life and in both sexes. As\\nthe sebaceous glands are mainly appendages of the hair- follicles, the\\nlesions of the disease differ somewhat according as they exist in the\\nregions covered with long or. with lanugo-hairs. For the same reason\\na difference marks the career of the disease. At times it is a trivial\\nand short-lived affection at other times it is persistent and intractable,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0136.jp2"}, "137": {"fulltext": "SEBORRHCEA. 125\\nlasting for years and possibly for a lifetime. The individuals thus\\naffected exhibit a difference also with respect to the condition of gen-\\neral health. Some are anaemic, chlorotic, or asthenic; some are of\\nsanguine temperament, fleshy, red-faced, and thick-skinned; others\\nagain are absolutely healthy, so far as can be discovered, except for the\\nlocal sebaceous disorder. The latter fact is of some significance. One\\nmay see extreme types of seborrhcea in vigorous men who have worn\\nmerely for one month a skull-cap to which was fastened an apparatus\\nfor relief of fracture of the lower jaw. The skin affected with a sebor-\\nrhea is usually anaemic, and is either dry or humid. The subjective\\nsensations are either slight and limited to a moderate degree of itching,\\nof which the patient does not complain until he is questioned upon the\\nsubject, or these sensations are altogether wanting. At other times the\\nglands or periglandular tissues are affected with a mild form of inflam-\\nmation, and then the involved surface may be reddened and become\\nthe seat of a considerable pruritus.\\nSeborrhcea Oleosa. This form of seborrhoea, variously known as\\nhyperidrosis oleosa (Brocq), seborrhoea simplex (Unna), stearrhoea sim-\\nplex (Wilson), acn6 sebacee fluente, etc., is in its pronounced features\\nrarer than seborrhoea sicca, but to a less degree it is a condition suffi-\\nciently common in many forms of the disease. The sebaceous secretion\\nis exuded as an oily fluid upon the surface both of the hairy and so-\\ncalled non-hairy parts of the skin. In the former situation, both in\\nadults and infants, the free oily substance is seen to cover as a coating\\nboth skin and hairs, and, especially in bald adults, to produce a glisten-\\ning and shining appearance of the scalp. The secretion often concretes\\ninto masses, forming the crusts of seborrhoea sicca. The same greasy\\nlayer can be seen over the non-hairy portions of the skin, especially\\nabout the nose, forehead, and cheeks. Free drops of oil can occasion-\\nally be wiped from such surfaces with a handkerchief. The ducts of\\nthe sebaceous follicles here are either patulous or plugged with come-\\ndones the skin-surface may be reddened or be pallid, but it is usually\\ncold to the touch. The oily substance serves to entrap particles of dust,\\nsoot, etc., floating in the air; thus a peculiarly dirty or even blackish hue\\nof the face is often produced. This form of seborrhoea, though most com-\\nmon on the face and scalp, may occur on the chest, the back, the pubes,\\nthe genitals, and rarely on the other parts of the body. In the negro,\\nin whom the sebaceous glands are usually well developed and active,\\nthe oily forms of seborrhoea are common, and the flux at times is practi-\\ncally physiological. Even in the absence of their frequent anointing\\nwith palm-oil, one can see in Africa naked blacks whose skins shine\\nfrom exuded grease.\\nSubjective symptoms in seborrhoea oleosa are usually slight, though\\na moderate amount of itching is commonly present. On the scalp the\\ndisease often produces an alopecia which does not, as a rule, respond\\nreadily to treatment.\\nSeborrhcea Sicca. Seborrhoea sicca, as the term is generally accepted,\\nvaries greatly in its manifestations, but in general its features may be\\ndivided into the scaling and the crusting form of the disease. The scal-\\ning form, variously known as seborrhoea furfuracea or pityriasiformis,", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0137.jp2"}, "138": {"fulltext": "126 DISORDERS OF THE GLANDS.\\npityriasis simplex, eczema seborrhoicum, eczema squamosum, etc., is most\\ncommon on the scalp, in which region it is popularly known as dan-\\ndruff. Seborrhcea capitis in its commonest form is recognized in the\\nadult by the formation on the scalp of fine, branny, slightly greasy,\\nwhite or grayish scales, which may be so abundantly shed as to fall\\nfreely and cover the shoulders of the patient whenever the hair is\\nbrushed or otherwise disturbed. At other times these fatty scales are\\nmore or less adherent to the scalp-surface, or are piled up in laminae\\none upon another. These scales may mat the hairs to the scalp\\nor be disseminated through the mass of the hair, some of the hairs\\npenetrating a flattened greasy scale, as a twig might be passed through\\nthe centre of a leaf. In consequence of their deprivation of unguent\\nthe hairs to which the affected glands are accessory become dry and\\nlustreless, and fall from their follicles. If the process be not arrested,\\natrophy of the hair-follicles ensues, the resulting alopecia becoming\\npermanent.\\nFortunately, the seborrhcea is usually symmetrical, and, in like\\nmanner, the baldness which it occasions. The resulting disfigurement\\nis of the character of symmetrical senile alopecia, which is chiefly\\nannoying because of the premature loss of hair. When this loss is\\nasymmetrical, which is decidedly exceptional, the disfigurement is\\ngreater.\\nThe affection may be circumscribed, and in conspicuously exhibited\\npatches covered by thin, mealy, grayish or whitish scales or thick\\nyellowish masses may paste the hairs firmly to the surface of the scalp.\\nThe disease may extend uniformly over the entire surface of the scalp,\\nor, as is frequently noticed, may fringe the brow at the line of the\\nhairs and then extend chiefly over the vertex, being conspicuous at the\\nline where the hairs are parted from vertex to brow.\\nBeneath the scales or crusts of dried sebum the scalp is usually\\nlustreless and of a slate-gray color. As the disease does certainly at\\ntimes exhibit intermediate between functional and inflammatory forms,\\nthe adjacent tissues may present a hypersemic or even an exudative\\nfeature, with true epithelial desquamation and considerable itching\\nalopecia pityroi des, pityriasis simplex. One group of cases, assign-\\nable to this class, deserves mention. In these cases there is a tol-\\nerably well-diffused seborrhcea sicca of the scalp, and irregularly\\ndistributed over the surface are filbert-sized, generally circular, dark-\\nreddish patches, covered with a moist secretion or a friable, gran-\\nular, reddish-yellow crust. These patches are scalp excoriations\\nproduced by the finger-nails. They are most common in nervous\\npatients, who cannot resist forcibly digging the scalp on the slightest\\nprovocation.\\nThe eyebrows, the region covered by the beard, and the pubic hairs\\nmay be affected, although less frequently, in the manner described above.\\nIn the latter region the itching is often more severe than when the\\ndisorder is limited to the scalp. The disease not infrequently extends\\nfrom the scalp to the adjacent portions of the face, neck, and ears. In\\nthese situations the skin is usually slightly reddened, while the scales\\nare thin, adherent, and not verv abundant, These features may appear", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0138.jp2"}, "139": {"fulltext": "SEBORRHCEA. 127\\non the portions of the face more distant from the scalp, and on other\\nparts of the body, in the form of dry, roughened patches which scale\\nmore or less, but which are only slightly, if at all, reddened. On such\\nsurfaces the condition may shade insensibly into those described under\\neczema seborrhoicum.\\nThe crusting forms of seborrhcea may occur on any of the hairy or\\nnon-hairy parts of the body, but are most common on the scalp and\\nface. Occurring in infancy, the disease is known as milk-crust, or\\nas crusta lactea. This may merely be persistence of the dried vernix\\ncaseosa about the vertex in the newborn, or it may occur in scalps which\\nhave been perfectly cleansed after birth. The crust differs somewhat\\nin color with the tint of the child s complexion, and may vary from a\\nlight yellow to a dark brown it may be thick, greasy, and mat the\\nhairs or be thin, dry, and friable. This crust is a frequent compli-\\ncation of the eczematous disorders of the scalp, and, as a consequence,\\nevery variety of hypersemia and inflammation may affect the tissue\\nbeneath the crust. In infants and children, however, the resulting\\nalopecia is never permanent, as the rapidly growing follicles hasten\\nto reproduce the hair. The disease is neither contagious nor followed\\nby cicatrices, points upon which mothers are usually solicitous. The\\nregion of the brow, the surface covered by the beard of the male, and\\nthe pubic hairs may be involved in this type of the disease, though less\\nfrequently than in the furfuraceous form.\\nThe so-called flower-leaf type of seborrhcea (petaloides) is seen\\nchiefly upon the anterior and posterior surface of the upper part of the\\ntrunk, especially over the sternum and between the shoulders. Here\\noccur sharply defined patches slightly elevated at the margin, reddened\\nin various shades, the color diminishing from periphery to centre. The\\nresemblance to a flower-leaf is in many cases striking often a clover-\\nleaf is suggested by three foliate patches united more or less distinctly\\nat a common point. These features are more often encountered in men\\nwith a hairy chest, the faintly reddish patches gleaming between the thick\\nand strong pilary filaments. In all these cases careful examination will\\nreveal the seborrhoeic state of the patient either by discovery of a\\nseborrhcea of the scalp, or of acne of the face, etc.\\nOn the face this form of seborrhcea is characterized chiefly by the\\naccumulation of thick, dirty-yellowish, and even yellowish-black accu-\\nmulations of sebaceous matter, often adherent to the surface and disfig-\\nuring the features by the mask produced. This condition is conspic-\\nuous about the nose, where the disease is at times symmetrically dis-\\nposed. The crusts once removed, the skin beneath is generally found\\nto be pallid or slightly reddened, with the orifices of the sebaceous\\nducts patulous while the under surface of the separated crust is seen\\nto project downward in corresponding delicate prolongations compara-\\nble to stalactites. The crusts rapidly reform when the disease is not\\narrested. They are found in the furrows on either side of the nostrils,\\non the brows, the cheeks, and the pavilion of the pinna of the ear.\\nThey are most common at the puberal epoch in both sexes, when the\\nsebaceous glands of the skin undoubtedly sympathize with the changes\\noccurring: at the beo;inmncr of the sexual life,", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0139.jp2"}, "140": {"fulltext": "128 DISORDERS OF THE GLANDS.\\nSeborrhoea may affect the eyelids, which are then reddened, slightly\\nswollen, and in various degrees covered with minute crusts (less fre-\\nquently with scales). The eyelashes often fall, and in cases of long\\nstanding their loss may be permanent owing to atrophy of the\\nfollicles.\\nSeborrhoea of the umbilicus assumes special features, since the fatty\\nmatters in this region are remarkable for their tendency to speedy\\ndecomposition, with the production of an exceedingly fetid odor, which\\nmay prove to be the source of a mild grade of inflammation. In the\\nlatter event a reddish halo surrounds the umbilical depression, which\\nmay furnish a thin sero-purulent discharge.\\nSeborrhoea of the genitals in men is usually located in the sulcus\\nbehind the corona glandis, though in individuals with a tight or a redun-\\ndant prepuce it may be more extended. In women the accumulation\\noccurs about the clitoris and vestibulum, though the external labia may\\nbe covered with the secretion in various degrees of fluidity. The\\nsmegma preputii supplied by the glands of Tyson may thus be the\\nsource of trouble either by its retention or its secretion in abnormal\\nquantity or quality. In either event the tendency, as in umbilical\\nseborrhoea, is to decomposition, fetid odor, and subsequent irritation,\\nwhich may provoke inflammation of severe grade. The retention of\\nthis smegma beneath a tight or a redundant prepuce in men may be the\\ncause of many reflex symptoms, such as incoordinated movements of\\nthe lower extremities, nocturnal enuresis and pollutions, hernia, and\\nirritability of the testis. In some cases the secretion forms a ring (as\\nhard as the rind of cheese) encircling the glans. It should be remem-\\nbered that the young of both sexes as well as adults are liable to be\\nthus affected, and that in young female children these symptoms may.\\nhave a medico-legal interest in connection with suspicion of criminal\\nassault.\\nSeborrhoea generalis, affecting the entire surface of the body, is an\\nexceedingly rare disorder. In the infant (Sebokrhcea Squamosa\\nNeonatorum, Ichthyosis Sebacea) the skin is universally spread\\nwith a greasy layer, which is rapidly renewed after removal, and\\nbeneath which the skin appears to be varnished in reddish-brown\\nshades. The consequent stiffening of the integument produces painful\\nfissures, inability to take the nipple, and consequent marasmus.\\nIn adults the disease may occur in marasmic subjects and in old\\npeople in the form of a persistent fine scaling on the trunk and extensor\\nsurfaces of the limbs, and is known as Pityriasis Tabescentium. A\\nyet rarer form is described by Kaposi under the name of Cutis Tes-\\ntacea, in which large portions of the skin, especially the extensor sur-\\nfaces of the limbs, are covered with greenish-brown or blackish crusts\\nwhich are more or less broken up into plates.\\nEtiology Seborrhoea is probably parasitic in its direct origin, but\\nmay depend in part upon other conditions which act as predisposing\\ncauses. Many cases of seborrhoea occur in young male and female\\nsubjects affected with chlorosis or conditions analogous to that state.\\nOther cases are essentially of local origin. A seborrhoea can be pro-\\nduced artificially in a healthy individual in the course of a few weeks", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0140.jp2"}, "141": {"fulltext": "SEBORRHCEA. 129\\nby simple local measures without interference with the general economy.\\nWomen with long hair are usually disposed to take special care of the\\nscalp upon which it grows. Men with short hair attend chiefly to its\\ndisposition upon the head, and often neglect the care of the scalp.\\nSuch neglect is sufficient cause in some cases to produce seborrhoea\\nsicca of this region. In certain types of the disease, and especially\\nin those occurring on the non-hairy portions of the skin, chlorosis,\\nstruma, malnutrition, obstinate constipation, disorders of digestion and\\nmenstruation, and sedentary habits of life are present as predisposing\\ncauses. The sebum of individuals who have fatty livers from chronic\\nalcoholism is peculiarly fluid and oily and few of the disorders of the\\nsebaceous glands characterized by inspissation of the secretion occur in\\nsuch persons.\\nSeborrhoea oleosa is found more frequently in persons of dark com-\\nplexion, while seborrhoea sicca is more common in blondes. A family\\ntendency to furfuraceous seborrhoea of the scalp and a resulting alopecia\\nmay often be noted.\\nAmong the direct causes of this affection, as also of several other\\ndiseases of the sebaceous glands, may be named the excessive use of\\ntobacco the wearing of stiff, heavy, and ill-ventilated hats chronic\\nalcoholism, gout, and syphilis.\\nPathology. Seborrhoea oleosa in its simplest form is a hypersecre-\\ntion of the fat-producing glands. That the oil-glands are active agents\\nin this process is now accepted.\\nSeborrhoea sicca has been supposed to be due to an abnormal func-\\ntional activity and an imperfect fatty metamorphosis of the cells of\\nthe sebaceous glands. The fatty crusts, however, contain not only\\nabnormal products of the fat-producing glands, but also exfoliated cells\\nof the epidermis and hair-follicles. Most of the conditions described\\nunder seborrhoea sicca are primarily inflammatory and probably para-\\nsitic in origin, and in some of the simple pityriasic forms the sebaceous\\nglands are not involved. Furfuraceous seborrhoea may exist for years\\nwithout clinical evidences of inflammation.\\nAccording to Unna, alopecia precedes atrophy of the papillae, and\\nin the early stages is due to a choking of the upper part of the hair-\\nfollicles with horny cells. The bed-hairs are thus loosened from the\\nfollicle and shed, while the lower part of the follicles, the papilla?, and\\nthe papillary hairs are intact. As the process continues the follicles\\nare gradually dilated and filled with horny cells to a greater depth\\nuntil the entire follicle, including the papilla, is atrophied and perma-\\nnent alopecia results.\\nMany of the clinical symptoms and pathological facts related to all\\nforms of pure seborrhoea have a close connection with eczema sebor-\\nrhoicum, the chapter devoted to which should be consulted in this\\nconnection. The efforts made by Unna to establish a morococcus as\\nthe effective agent in the production of this group of affections have\\nnot been successful. The microbacillus of Unna and Sabouraud appar-\\nently bears a very constant relation to seborrhoeal disorders, but its\\nexact etiological position has not been determined. (See Alopecia\\nAreata.)\\n9", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0141.jp2"}, "142": {"fulltext": "130 DISORDERS OF THE GLANDS.\\nDiagnosis. Seborrhoea is to be distinguished from\\nEczema. The objective points of difference between eczema and\\nseborrhoea depend upon the inflammatory character of eczema, upon\\nthe reddened, iufiltrated, or discharging skin, and upon the consider-\\nable itching which it occasions. In squamous eczema the scales are\\nrarely so abundant as to be shed freely from the surface, and are not\\ngreasy. It should be remembered, however, that the two diseases often\\ncoexist. Inflammation of those parts of the skin well supplied with\\nsebaceous glands usually assumes one of the types described as eczema\\nseborrhoicum. Eczema of the scalp in infants is frequently accom-\\npanied by a seborrhoea, a fact which clearly shows that the technical\\ndistinctions between many diseases, useful though they be for analytical\\nstudy, are not always capable of clinical demonstration.\\nIchthyosis. This is a congenital disease, usually involving the en-\\ntire surface of the body, while seborrhoea is generally acquired and is\\nrarely universal. The distinction between ichthyosis and the rare gen-\\neralized forms of seborrhoea described above might involve a difficulty\\nbut in the latter the greasy character of the crusts, their color, and the\\nmarasmic condition of the subject would sufficiently distinguish the two\\ndisorders.\\nImpetigo. The only possibility of error in diagnosis would occur\\nduring the crusting stage of impetigo upon the scalp. But impetigo is\\nan acute disease, with comparatively small, circumscribed, and isolated\\nlesions, with crusts differing in character from the sebaceous matters\\nformed in seborrhoea, and beneath such crusts the integument is red-\\ndened and evidently the seat of an exudation.\\nLupus Erythematosus. Lupus erythematosus, though occurring on\\nthe face, is rare on the scalp it is accompanied by characteristic\\nchanges in the structure of the skin, and is often followed by a scar.\\nIts lesions are darker red than the congestive patches beneath certain\\nseborrhoeas of the non-hairy parts. The scales of lupus are tenacious\\nand dry, and require scraping for their removal those of seborrhoea\\nare greasy and more readily detached. The contour of the seborrhoeic\\npatch is ill-defined compared with that of lupus, which is very distinct,\\nexception being made of the mask-like crusts seen in certain of the\\nfacial seborrhoeas, in which the greasy character of the layer is very\\nevident. Hebra, in 1 845, described a seborrhoea congestiva, which\\nit would indeed be difficult to distinguish from lupus erythematosus, as\\nthe former is really an early stage of the latter. Typical cases of the\\ntwo diseases are widely different and readily distinguished the atypical\\nforms might lead to confusion.\\nPsoriasis. Psoriasis of the scalp may resemble seborrhoea sicca, but\\nthe latter is rarely developed in such a universal exanthem as is fre-\\nquent in the former. There will come under observation few doubtful\\ncases in which a psoriatic patch on an elbow, a knee, a leg, or over the\\nsacrum will not point to the nature of the disease. The scales of\\npsoriasis are lustrous, larger, and not greasy unless fatty applications\\nhave been made to soften them and, moreover, they cover a reddened\\nand exuding patch of integument. Psoriasis of the scalp and face\\nprefers the areas of the forehead adjacent to the hairs of the scalp,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0142.jp2"}, "143": {"fulltext": "SEBORRHEA. 131\\nand rarely departs boldly to the nose and the furrows beside the nos-\\ntrils favorite sites of seborrhoea. In seborrhoea of the scalp the hairs\\nare loosened and fall, a condition not present in psoriasis.\\nSyphilis. Some forms of the pustular syphilodermata located upon\\nthe scalp and face, if observed only in the stage of crusting, might be\\nconfounded with seborrhoea. Here the history of the case, the discov-\\nery of other signs of syphilis (adenopathy, mucous patches, etc.), and\\nthe character of the secretion and the surface beneath the crust,\\nt )gether with the smaller size, more definite outline, and characteristic\\ngrouping of the lesions, should point to the identity of the disease.\\nIn syphilitic crusts about the angles of the nostrils there is often a\\npeculiar reddish-brown tint of the skin at the edge of the patch,\\nthe so-called copper color, which is significant. Crusts of the\\nhairy scalp in syphilis are very often accompanied by post-cervical\\nadenopathy, and especially by indurated enlargement of the occipital\\nglands.\\nTinea Circinata and Tinea Tonsurans. In ringworm of the hairy\\nparts, as also of the body, the microscopical discovery of the parasite\\nwill always point to the nature of the disease. Upon the scalp the\\naffected patches are seldom so diffuse as in seborrhoea, are usually circu-\\nlar, are often accompanied by fragility of the hairs, and in the latter\\ncase the discovery of stumps of hairs is significant. There are also a\\nhistory of contagion and an absence of the greasy conditions of the\\nscales characteristic of seborrhoea.\\nTreatment. The general and internal treatment of seborrhoea should\\nbe varied to meet the requirements of the individual case. The prep-\\narations most often indicated are iron in anaemic young women, cathar-\\ntics in sluggishness of the bowels, and cod-liver oil when there is impair-\\nment of nutrition. Duhring recommends calcium sulphide in doses of\\nfrom t T q- (0.0066) to (0.0133) of a grain. Arsenic, employed in the\\nmanner suggested by Sir Erasmus Wilson, is praised by Hebra\\nB Vin. ferri, f^j ss 45\\nSyrup, simpl., f g\\nLiq. potass, arsenit., j J\\nAq. destill., f gij 60 M.\\nSig. A teaspoonful to be taken three times daily with the meal.\\nIn many cases the acid iron mixture of Startin, or some modifica-\\ntion of it, admirably meets the indications present\\nR\\nMagnes. sulph.,\\n\u00c2\u00a7ij;\\n60\\nFerri sulphat.,\\n9ss-9j\\n0.66-1\\nAcid, sulph. dilut.,\\nf 3ij-f3iv;\\n8-16\\nInfus. quassiae,\\nad f^iv;\\n120\\n33\\nM.\\nSig. A teaspoonful in water, to be taken through a tube after eating.\\nThe preparations of matzool, malt, and maltine, now largely em-\\nployed in the treatment of wasting diseases, will be found available in\\ni cases in which cod-liver oil cannot be well taken. Lastly, the bitter\\ntonics may be needed. Throughout the treatment the physician should\\ninsure a careful observance of the laws of hygiene. Sunlight, nutri-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0143.jp2"}, "144": {"fulltext": "132 DISORDERS OF THE GLANDS.\\ntious food, and open-air exercise are not to be disregarded. Many\\nyoung women of indolent habits are greatly benefited by sending them\\ndaily to riding-schools for an hour s equitation.\\nIn cases in which it can be tolerated, daily cool salt-and-water\\nsponging of the entire body-surface, followed by brisk friction, may\\nbe employed with advantage. The salt is added to the water in the\\nstrength of pound to the gallon. There is no advantage to be gained\\nby using the preparations of sea-salt sold in the shops. The bath\\nis omitted during the menstrual period in women, and in the case of\\ndelicate patients. It is, without question, the most valuable of hygienic\\nmeasures in the management of the disease.\\nThe first indication to be met by local treatment in seborrhoea is the\\nremoval of the crusts and the fatty matters accumulated upon the\\nsurface. It is always well to warn patients, especially if the disorder\\nbe upon the scalp in an aggravated form and occur in young women\\nwith apparently luxuriant tresses, that a considerable loss of hair\\nwill result. Many of the hair-filaments are so impoverished by the\\ndisease and so loosened in their follicles that a complete cleansing\\nof the scalp-surface will bring the hairs away in quantities sufficient to\\nthreaten speedy baldness and it is not rarely the case that patients\\nattribute this to the treatment rather than to the disease. The fatty\\naccumulations are first to be soaked with some oily fluid to facilitate\\ntheir removal for this purpose olive-oil, cod-liver oil, vaselin, cold-\\ncream salve, almond-oil, glycerin, or lard is usually employed. The\\nsubstance selected should be used in quantity sufficient to permeate\\nall crusts. It may be poured over or be rubbed into the scalp several\\ntimes in the twenty-four hours, and at night a flannel or other cap\\nshould be worn. In the case of children and infants gentleness is\\nrequired in thus treating the scalp, especially in the subsequent wash-\\nings, lest the surface be irritated. In young women it is rarely neces-\\nsary to cut the hair. As soon as the soaking with oil is complete the\\ncrusts are to be removed by washing with soap and water, though when\\nthe accumulations are bulky, masses may be gently removed with the\\nfingers or a comb. When the scalp is tender ordinary toilet or Sarg s\\nglycerin soap may be applied with warm water but it is usual, in the\\ncase of adults, to employ the spiritus saponis alkalinus of Hebra 2\\nparts of green soap digested in 1 of alcohol, filtered, and flavored\\nwith lavender or bergamot. The surface should be thoroughly sponged\\nwith the spirit, and then warm water added until lather is abundantly\\nproduced over the scalp, when an excess of water is finally used to\\ncleanse the part of crusts, oil, and soap. The scalp and hairs are then\\nthoroughly dried and anointed with some bland, fatty substance if the\\nexposed surface be tender and irritable if not, with some stimulating\\npomade or lotion.\\nIn cases in which milder effects are required the scalp may be washed\\nwith water containing such alkaline substances as borax, ammonia, or\\npotassium carbonate. The popular prejudice against these articles is\\nbased upon the abuse of strong alkaline lotions in the hands of inex-\\nperienced persons. Such lotions may readily be tested by the tongue\\nbefore use upon the scalp. They should in all cases be followed by", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0144.jp2"}, "145": {"fulltext": "SEBORRHEA. 133\\nan oily or greasy application medicated to meet the requirements of the\\ncase.\\nThe last-named precaution is an important one. However extensive\\nthe seborrheic crusts, it is possible to remove them completely in every\\ncase by the measures described above, and with the first treatment\\npatients are often delighted. Their disappointment is correspondingly\\ngreat when they discover that the seborrhcea is not at an end, and\\nthat in the course of a few days the fatty plates are as freely as ever\\ndeposited on the scalp, disseminated through the hairs, and showered\\nupon the shoulders. Some will even declare that the soapy applications\\naggravate the disorder by increasing the seborrhcea. It should, there-\\nfore, never be forgotten that, having disposed of the extraneous matters\\naccumulated upon the surface, there is still to be remedied a functional\\ndisorder of the sebaceous glands of the part.\\nIn every case, then, after the use of soap and water, which may\\nbe repeated as often as need be, daily, at intervals of several days,\\nor once a week, the scalp is to be thoroughly anointed. For this pur-\\npose olive-oil, cod-liver oil properly scented, almond-oil, vaselin, or\\nglycerin and water may be used. Van Harlingen recommends, as a sub-\\nstitute for other oils, the oleum sesami (oil of benne), since it does not\\ndry and clog as do the former. An ounce (30.) of this oil rubbed up\\nwith 5 grains (0.33) of powdered benzoin, and digested for three hours\\nover a water-bath, with the addition of 3 drops of absolute alcohol,\\nand filtered, furnishes an excellent basis for oily mixtures to be used on\\nthe scalp.\\nMorison 1 has devised an ingenious instrument for the application\\nof oily lotions to the scalp. The fluid is contained in a small reser-\\nvoir, to which is connected a comb with perforated teeth through the\\nlatter the substance selected for medication of the scalp readily passes\\ndown to the surface between the hairs. A. medicine-dropper, though\\nless convenient, will answer the same purpose.\\nIn the place of oils after these ablutions pomades are often used\\nwith more advantage. For this purpose vaselin, lanolin, lard, and the\\nzinc-oleate ointment furnish the best bases. To obtain the desired\\nconsistency, any one of these may be used alone or in combination\\nwith the others or with an oil.\\nCrocker advocates prior to the application of oily preparations to\\nthe scalp the use of a lotion containing acetic acid, the object being to\\naid the penetration of the remedy.\\nOf the many remedies employed and recommended, resorcin, sul-\\nphur, and the red oxide, bichloride, or ammonio-chloride of mercury are\\nthe most serviceable. Resorcin alone gives satisfactory results in the\\ngreat majority of cases. This remedy may be used in a spirit lotion\\n(from 25 to 75 per cent, of alcohol) in strength varying from 2 to 10\\nper cent., or in the form of an ointment, 10 to 60 grains to the ounce\\n(0.66-4. to 30.). Lotions are well adapted to cases in which ether\\nis little inflammation and in which decided stimulation is required.\\nAs they are cleanly and easy of application, they are more pleasing to\\nmost patients, and especially to women with long hair. Their efficacy\\n1 Maryland Med. Jour., January, 1885.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0145.jp2"}, "146": {"fulltext": "134\\nDISORDERS OF THE GLANDS.\\nis often enhanced by the addition of a small amount of oil. Mercuric\\nchloride is admirably adapted for use in lotions. A good formula is\\nfollows\\nas\\nR Resorcin.,\\nHydrarg. bichlorid.,\\n01. amygdal. dulc,\\nTinct. cantharid.,\\nSpts. vin. rect.,\\nAq. destill., q.\\nSig. To be rubbed into the scalp.\\nSijss\\n10\\ngr- y\\n3ij;\\n3ij;\\nSy;\\ns. ad f |jvj\\n8\\n8\\n60\\n180\\n13\\nM.\\nFor this may be substituted ounce (15.) of resorcin in 2 ounces\\n(60.) of alcohol and 6 ounces (180.) of rose-water.\\nSulphur enjoys a high reputation in the treatment of all sebaceous\\ngland disorders; in the form of an ointment, 15 grains (1.) to a\\ndrachm (4.) to the ounce (30.) of cold cream, it is often of service.\\nOne-half the quantity, or as much, of resorcin may often with advan-\\ntage be added to the pomade. Sulphur may also be used as a powder,\\neither alone or in combination with talc, salicylic acid, boric acid,\\nstarch, or camphor and as a lotion with alcohol, glycerin, and rose-\\nor cologne-water. The alterative effect of the mercurials is also as\\nevident in seborrhoea as in many other cutaneous disorders. At the\\nhead of the list, for this special purpose, stands the red mercuric oxide\\nin strength of from 2 to 4 grains (0.133-0.266) to the ounce (30.) of\\nointment; but ammoniated mercury, and calomel in the proportion\\nof from 5 to 10 grains (0.333-0.666) to the ounce (30.), may be often\\nsubstituted for the former with advantage. Carbolic, salicylic, and\\nboric acids, from 1 to 5 per cent, in alcoholic solutions, with or with-\\nout the addition of oil or of glycerin, are often of service. The\\ntars are useful in many obstinate cases. Tar-soap may be employed\\nin the washing; or oleum rusci added in the strength of 1 to 10 parts\\nto any of the salves recommended above. Ichthyol in ointments of\\nthe strength of from 5 to 10 per cent, has also proved efficacious.\\nBesides these substances, tincture of cantharides, capsicum, and nux\\nvomica are frequently incorporated with advantage into lotions and\\npomades for use upon the scalp. Most of the pomades can be rendered\\nsufficiently fluent for use in this situation by adding 1 or 2 drachms\\n(4.-8.) of glycerin to the ounce (30.) of lard or of cold cream. An\\nexcellent formula for the scalp is the following\\nR Sulphur, prsecipit.,\\nLanolin.,\\nGlycerin.,\\nAq. rosse, j\\nSaponis,\\nSig. Ointment for scalp.\\nVeiel recommends\\nR\\nffl;\\naa Sijss;\\nBss;\\n4\\n10\\nExtra, cinchon. frig, par., \u00c2\u00a3j\\nBals. Peruv., gtts. xv\\nCantharid. tinct., gtts. xxiv-gss\\nSucc. citri, ^l xv\\nUng. pomat., ^jss\\nSig. To be rubbed into the scalp once or twice daily.\\n1\\n1\\n1.5-2\\n1\\n45\\n80 M.\\n33\\nM.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0146.jp2"}, "147": {"fulltext": "SEBORRHCEA. 135\\nRepeated applications and patient care of the scalp are necessary to\\nsecure complete relief in the case of a disease as essentially chronic as\\nseborrhcea. At times the local treatment may be changed with advan-\\ntage. Not infrequently too vigorous treatment is followed by a more\\nor less acute dermatitis. In this case stimulating preparations should\\nbe replaced by soothing ointments or lotions until the induced inflam-\\nmation has subsided.\\nThe treatment outlined above for the hairy portions may be used\\nwith success also for the relief of seborrhcea of the non-hairy portions\\nof the body, especially the face. Here, it will be observed, the crusts\\nhave a tendency to re-form, and the most persistent treatment is nec-\\nessary to secure permanent relief. Occasionally, after cleansing the\\nsurface with soap and spirit-lotions according to the indications of each\\ncase, it is of advantage to apply the ointment selected for subsequent\\napplication, not only by gently smearing it on the parts with the tips\\nof the fingers (always the most effective method), but also by spreading\\nit on a compress, which, for the night at least, may be fixed in contact\\nwith the part. Unna s lead-plaster mulls, used for this purpose in\\nGermany, may fairly well be imitated by drawing strips of cheesecloth\\nthrough heated diachylon ointment and then smoothly smearing them\\nwith the same material. When the tendency to re-formation of the\\ncrust is abated one or more of the dusting-powders may at times be\\nemployed with advantage for the purpose of protecting the skin or of\\nexercising upon it an astringent effect.\\nSeborrhcea oleosa is best treated with lotions or with powders.\\nShould the skin become irritated under these applications, ointments\\nmay be substituted for a time. Astringent lotions or powders contain-\\ning tannin, gallic acid, zinc sulphate, ferrous sulphate, zinc oxide,\\nbismuth subnitrate, etc., are often serviceable.\\nThe local treatment of seborrhoea of the genitals is somewhat differ-\\nent. Ointments rarely answer well in disorders of the mucous sur-\\nfaces, and green soap is too irritating for similar employment. Here\\nwashing with a good toilet-soap and warm water is sufficient for the\\npurposes of cleanliness, and diluted lotions containing alcohol, in the\\nform of whisky, brandy, or aromatic wine, suffice. These lotions can\\nbe made astringent with tannin, alum, or zinc sulphate, and when\\nthere is pain or tenderness opium may be added. In this form of the\\ndisease, as also in seborrhoea of the umbilicus, carbolic acid or chlori-\\nnated soda may be necessary to correct fetor. After the employment\\nof these lotions boric acid with talc (1 part to 4), or zinc oxide and\\nstarch (1 part to 8), may be dusted over the part. In the generalized\\nvarieties of the disease the surface is to be thoroughly anointed with\\noil. The body, especially that of infants, is to be swathed in flannel\\nor other good non-conductor of heat, and a roborant treatment directed\\nto the general adynamia.\\nIn the grave forms of seborrhcea of infants (described as keratosis\\nsebacea, ichthyosis sebacea, etc.) the body must be kept anointed with\\noils or fats. Artificial feeding is demanded by the condition of the\\nmouth.\\nPrognosis. In forming a prognosis in cases of seborrhoea of the", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0147.jp2"}, "148": {"fulltext": "136 DISORDERS OF THE GLANDS.\\nscalp it must be remembered that the disease is frequently obstinate,\\nand shows a decided tendency to recur unless some treatment be con-\\ntinued for weeks or months after the scalp is apparently well. The\\nresulting loss of hair, if symmetrical, may be remediless, but much\\nmay be done in the way of saving the hair which is left. Facial\\nseborrhoea is much more amenable to treatment seborrhoea of the\\ngenitals and the umbilicus is an entirely manageable disease. When\\nthe affection is generalized the prognosis is in the highest degree un-\\nfavorable.\\nASTEATOSIS.\\n(Gr. a, privative oreap, fat.)\\n(Get: and Ft\\\\, Asteatose.)\\nAsteatosis is that condition of the skin in which there is absolute\\nor relative deficiency of the sebaceous secretion.\\nSymptoms. Insufficient lubrication of the skin by its natural\\nunguent may be either general or partial, and occur as an idiopathic\\nor a symptomatic disorder. It is produced artificially by any agents\\nwhich continually withdraw the fatty substance from the skin-surface,\\nas in those trades necessitating the constant immersion of any part of\\nthe body in strong alkaline solutions or in waters strongly impregnated\\nwith calcium and potassium salts. As an idiopathic affection it is\\nof rare occurrence, but it is not an infrequent accompaniment of\\nother local or constitutional diseases, such as psoriasis, lepra, xeroderma\\npigmentosum, ichthyosis, and lichen ruber. In these cases the skin\\nbecomes dry, often thickened and indurated, and, as a consequence,\\nfriable, and prone to desquamation, fissures, and chaps. To the touch,\\nthe absence of sebaceous secretion is noticeable in the objective sensation\\nproduced. Asteatosis is a well-marked feature of the marasmus of old\\nage. Some authors have described under this title the dry thickening\\nand induration of the palm of the hand accompanied by curving of\\nthe fingers toward the plane of their flexor tendons, a condition that\\nis occasionally to be observed in laundresses.\\nPathology. In cases of asteatosis the lumen of the coil-gland is\\ncommonly dilated, the epithelium is swollen, the loops of the coil\\nmarkedly thickened, and there is produced a compression of the inter-\\ntubular connective tissue, as Unna has shown.\\nTreatment. No internal medicaments are known to have the power\\nespecially of stimulating the sebaceous secretion. None, indeed, could\\nbe capable of having such action when, as is often the case in the dis-\\norders characterized by asteatosis, there has resulted an atrophy of the\\nsebaceous glands. For external application of an artificial unguent,\\ncod-liver oil, almond-oil, lanolin, palm-oil, vaselin, lard, or butter may\\nbe employed. Vaselin is in many cases to be preferred, as the other\\narticles named are liable to become rancid after oxidation, and thus act\\nas irritants. Elliott prefers liquid albolene or benzol. With such\\npartial or general lubrications, however, a warm bath of soap and\\nwater should be ordered every second or third day immediately\\nafter the bath the inunction may be repeated.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0148.jp2"}, "149": {"fulltext": "COMEDO. 137\\nPrognosis. In all cases in which the asteatosis is induced by agents\\noperating externally upon the surface a reasonable hope of recovery\\nmay be entertained after withdrawal of the cause. Persistence of the\\nlatter is liable to be succeeded by the occurrence of eczema or dermatitis\\nmedicamentosa. A complete cure can scarcely be expected when this\\ncondition is a symptom of one of the disorders already named.\\nCOMEDO.\\n(Lat. comedo, spendthrift.)\\n(Black-head. Ger., Mitesser Fr., Acne Poxctttee.)\\nSymptoms. Comedones, which occur exclusively in the ducts of\\nthe sebaceous glands, consist each of a whitish fatty plug formed by\\ninspissation of the secretion of these glands, one extremity of the plug\\nbeing visible at the surface when it is in situ. Occasionally the come-\\ndones project to an appreciable distance above the general level of\\nthe integument, but often the extremity of each plug is slightly de-\\npressed below that level. There may be but two or three comedones\\nupon the face, which is their commonest seat or the nose, forehead,\\ncheeks, and chin, the front and back of the neck, the back of the\\ntrunk, and the penis may be studded with them thickly. The visible\\nextremity of the comedo varies in size from that of a needle-point to\\nthat of a pinhead. Comedones are readily expressed from the follicles\\nin which they are lodged, and when thus examined they are seen to be\\nwhitish moulds of inspissated sebum, one or two lines in length, the\\nexposed extremity of each comedone having become blackened by\\ndiffused pigment deposited w T ithin. The popular idea that the black\\nhead of the comedo is produced by dirt entrapped by the sebaceous\\nmass is without foundation. In consequence of this suggestive appear-\\nance of the lesion the disease has been called vulgarly black-heads\\nand skin-worms. The deformity produced in the face when these\\nlesions exist there in large numbers is strikingly conspicuous, and\\nit is for the relief of this appearance chiefly that the practitioner is\\nconsulted. The subjective symptoms awakened are of trifling moment.\\nThe disorder is essentially chronic in its course. Isolated comedones\\nmay be observed for years in one situation without apparent change or\\nmodification of any sort, and without producing the slightest local or\\nconstitutional derangement. Others appear, only to disappear under\\nthe influence of the usual hygienic regimen of the skin of the face.\\nOthers, again, serve to irritate the skin in which they are implanted,\\nprecisely as though they were foreign bodies and the sebaceous glands\\nand periglandular tissues, with and without the operation of such cause,\\nexhibit grades of hyperaeiiiia and inflammation. Comedones may\\noccur as the sole lesions of the skin, even to the extent of great\\nmultiplicity or they may coexist with other diseases of the glands,\\nchiefly acne. They may occur at any period of life, but, like seborrhoea,\\nare most frequently observed at the puberal epoch in both sexes. The\\ndisease tends to disappear in women earlier than in men, in whose case\\nit may be prolonged to the twentieth or thirtieth year.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0149.jp2"}, "150": {"fulltext": "138\\nDISORDERS OF THE GLANDS.\\nCrocker l has called attention to the occurrence of comedones in chil-\\ndren, with a special tendency to grouping in places subjected to heat\\nand moisture, and also to their occurrence upon the hairy scalp.\\nOccasionally a so-called double comedo is formed, there being-\\nexpressed from the skin a plug of inspissated sebum, each extremity of\\nwhich is discolored. Whether this double comedo is due to a duplicity\\nof efferent ducts in a single gland, or to an artificial or pathological\\nconnection between two adjacent glands, is not clear. 2\\nEtiology. Much has been written with reference to neglect of the\\nskin as a cause of comedo, the non-employment of soap in washing\\nFig. 35.\\nSection of a comedo a, excretory duct of a sebaceous gland filled with a comedo it con-\\ntains also two small hairs with brush-like inferior extremities into it opens a small hair-\\nfollicle (c) the contained hair (d), after touching the opposite wall of the duct, curves down-\\nward at (After Kaposi.)\\nthe face, and the influence of the trades, as in the case of those who\\nwork in metals, dust, and tar; but observation shows that these are\\nexceptional causes. On the one hand, very obstinate and generalized\\nlesions occur in the skin of intelligent young men and women of the\\nupper social classes, who regularly wash their faces Avith toilet-soap,\\nwho are rarely exposed to dust, and whose habits and recreations are\\nof the most healthful character. On the other hand, observing the\\ngrimy faces of coalheavers, machinists, masons, and ink-manufact-\\n1 Lancet, April 19, 1884.\\n2 Ohmann-Dumesnil Jour. Cutan. and Ven. Dis., Feb., 1886.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0150.jp2"}, "151": {"fulltext": "COMEDO. 139\\nurers, one is impressed with the rarity of the disease in such laborers.\\nOther causes of the constipation of the gland are unquestionably to\\nbe sought for in most cases. It is true that chlorotic young women,\\naffected also with dyspepsia and torpor of the bowels, may exhibit the\\ndisease; and it is equally certain that many cases occur in peculiarly\\nthick-skinned brunettes, or in men with a characteristic reddish-brown\\nand greasy-looking complexion. Nevertheless, many such individuals\\nnever suffer from comedones, while often a perfectly healthy, fair-\\nskinned girl will be greatly mortified by the disfigurement of her\\nface.\\nIn yet other patients there is unmistakable connection between this\\ndisorder and chlorosis, scrofulosis, dyspepsia, habitual constipation of\\nthe bowels, menstrual derangements, and cachexia. This connection\\nis demonstrated by the remarkable improvement manifested in the\\nuntreated skin when restoration of the general health is assured.\\nThe microbacillus of Unna and Sabouraud may be found, as a rule,\\nin the comedo-plug, but whether the bacillus causes or follows the for-\\nmation of the comedo is an unsettled question.\\nPathology. The comedo is a dense collection of concentrically\\npacked epithelial plates mingled with masses of cholesterin, with frag-\\nments of epithelia that have undergone fatty transformation, with mi-\\nnute lanugo-hairs, and occasionally, upon the exterior, with the Acarus\\nfolliculorum. This mite, first detected by Henle in the ceruminous\\nglands, was by Simon and others once believed to be the cause of the\\ncomedo, a view now abandoned. This parasite, in persons upon whose\\nskin it exists, can be detected in masses of commingled sebum and epi-\\nthelial plates scraped from the free surface of the integument, as also\\nupon the skin-surfaces of those who do not exhibit any disorder of the\\nsebaceous glands.\\nThe comedo-plug is located either in the excretory duct of the seba-\\nceous gland or in the pouch-shaped canal common to the sebaceous\\ngland and the hair-follicle. It is divided by horny septa, and Avhen\\nrecent has a hollow tail. The older and denser comedones have\\na horny extremity within the deeper part of the skin. It will be\\nremembered that in the class of sebaceous glands chiefly involved\\nin the comedo the hair-follicle is rather an appendage to the gland,\\nthe relation between the two, evident upon the scalp, for example,\\nbeing here reversed. According to Biesiadecki, the hair-follicle in\\nsuch cases often forms an obtuse or even a right angle to the duct\\nof the gland, and the point of the hair being thus projected against the\\nwall of the duct is occasionally curved downward upon itself, thus\\nexciting irritation at the point of impact and subsequent multiplica-\\ntion of the protoplasmic elements lining the canal. Thus he explains\\nthe epithelial character of the outer envelope of the plug; the special\\noccurrence of the disease at the puberal epoch, when, as is well known,\\nthere is an especially active growth of the hairs; and, lastly, the fre-\\nquent discovery of lanugo-filaments in the expressed contents of the\\ncommon excretory duct.\\nThe blackness of the head is readily made to disappear when the\\nextruded plug is treated with muriatic or nitric acid. It is to be", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0151.jp2"}, "152": {"fulltext": "140 DISORDERS OF THE GLANDS.\\nnoted that the pigment thus rendered soluble extends for some distance\\nbelow the exterior face of the plug.\\nDiagnosis. The recognition of the disorder is attended with no\\ndifficulty, patients themselves being usually sufficiently observant to\\nidentify the affection, though frequently misled as to the character of\\nthe skin-worm. It is, as might be expected, a frequent coincident\\nof acne its lesions, when commingled with those of the disease last\\nnamed, being either in preponderance or so infrequent as scarcely to\\nattract the attention of the patient. A condition somewhat resembling\\ncomedo may be produced upon the face when tar or ointments of\\nmercury and sulphur are applied to it at the same time, the resulting\\nblack sulphuret appearing conspicuously at various points upon the\\nskin, often at the orifices of the sebaceous glands.\\nTreatment. The internal treatment of patients affected with\\ncomedo is that described in connection with the subject of sebor-\\nrhea. Cod-liver oil, iron, the bitter tonics, and the medicaments in-\\ndicated by any special condition of the patient s health are not to be\\nomitted. Open-air exercise, daily cool salt-and-water bathing, as in\\nthe management of seborrhea, and the avoidance of all medicinal and\\ndietary articles which might tend to aggravate the disorder, are also\\nimperative. Many of these patients require at the outset alterative\\ncathartics, among which may be named the pill of blue mass (taken for\\nten or more consecutive evenings, and followed by the effervescing\\nsodium phosphate in the morning), calomel, cascara sagrada, and\\ncastor-oil.\\nEven aggravated cases of comedo are completely relieved when\\nuntreated in the course of time. The relief, however, may require\\nyears for completion. The rarity of comedones in middle life and\\nadvanced years sufficiently attests this fact. Presumably this natural\\ncure is due to more vigorous growth of lanugo-hairs with the increment\\nof age, which thus push slowly forward to the surface the excrementi-\\ntious mass, until it is gradually removed by ordinary friction and ablu-\\ntion. Absence of comedones from the scalp, where the hair is vigorous,\\nis certainly a significant fact.\\nComedones are removed artificially with the aid of an extractor.\\nThe instrument formerly employed for this purpose was shaped like a\\nwatch-key, the cylinder having a smooth bore and bevelled extremity.\\nThis clumsy tool is far surpassed by the exceedingly convenient com-\\nedo-extractor designed by Unna and modified by Piffard. Each end has\\na convex bowl-like surface, with apertures cut to gauge and the orifices\\nslightly countersunk. This extractor, presser, is productive of far\\nless pain to the patient than other instruments, and can be wielded, on\\naccount of its long shank, with greater precision and ease by the physi-\\ncian. The surface to be operated upon is best previously moistened by\\nspraying it with a solution of formalin (0.5 per cent.), of borolyptol,\\nof thymol and glycerin, or of eucalyptol and glycerin. Often a sharp-\\nedged or well-rounded needle, firmly held in a needle-holder, may\\nadvantageously be employed alternately with the extractor, in opening\\ncertain follicles or loosening the plug of others. Many patients affected\\nwith comedo are advantageously treated by the aid of the massering-", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0152.jp2"}, "153": {"fulltext": "COMEDO. 141\\nball, described in the chapter on the management of Acne. All these\\ninstruments should be disinfected scrupulously before use. The dan-\\nger of such manipulations should never be overlooked. There are good\\nreasons for selecting the hour before sleep as the time for all vigorous\\ntopical applications to the face. Ointments then applied can be left in\\ncontact with the skin during the night, and the patient be at liberty to\\nresume his usual vocation in the daytime, his face being free from con-\\nspicuous evidence of local treatment.\\nAn ordinary watch-key, a curette, the thumb-nail, or a spatula may\\nalso, on occasion, be used in the extraction of comedones, w T hich, if\\nfew, may be expressed at one sitting, or, if numerous, be removed on\\nseparate occasions. Repetition of the process is usually required\\nowing to re-formation of the plugs.\\nOnce the comedones are removed the skin should be sponged and\\nbathed with hot water, then thoroughly dried, and anointed with an\\nointment which may be medicated to suit the indications of each case.\\nSulphur, as in all functional disorders of the sebaceous glands, en-\\njoys here also the highest reputation. In the strength of 10 grains\\n(0.66) to 1 drachm (4.) to the ounce (30.) of cold cream or vaselin,\\nit may be applied as an ointment or as a lotion, in combination with\\nspirit of wine, glycerin, etc. A useful application is suggested by\\nPiifard equal parts of sublimed sulphur, alcohol, compound tincture\\nof lavender, glycerin, and camphor- water.\\nMercurials are also of some advantage locally, but, as before indi-\\ncated, they should not be employed at the same time w T ith preparations\\nof sulphur. The use at night, especially in obstinate cases, of the\\nwhite-precipitate ointment, or of one compounded of 2 grains (0.133)\\nof the red oxide to the ounce (30.) of cold-cream salve, will often prove\\nof benefit. In the case of coarser skins, corrosive sublimate, 1 to 2\\ngrains (0.066 to 0.133) to the ounce (30.) of glycerin and rose-water,\\nmay be substituted for the red-oxide ointment.\\nWhen extraction of the plug is not attempted nor permitted, some-\\nthing may yet be done to remove the inspissated mass. Repeated\\nsponging every third night with 1 ounce (30.) of green soap, digested\\nin an equal quantity of cologne-water, will at first seem to render the\\ncomedo more conspicuous, but will slowly operate to dissolve the\\nsebaceous secretion.\\nAn ointment containing 4 parts of kaolin, 3 of glycerin, and 2\\nof acetic acid, with or without the addition of a small quantity of\\nethereal oil, may be applied at night for a few nights in succession,\\nthe eyes being carefully protected, when the black points of the lesions\\nare removed, and the comedones are then readily extracted. Citric or\\ndilute hydrochloric acid is employed with the same end in view.\\nThese topical remedies cannot be considered as efficient in every form\\nof comedo.\\nActors, actresses, and women of fashion will, while under treatment,\\noccasionally persist in using various colored toilet-powders, the inju-\\nrious ingredients of which are often the cause of the disease. The\\npractitioner may then either refuse to be responsible for the care of the\\ncase, may substitute a harmless for a noxious powder, or may gently", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0153.jp2"}, "154": {"fulltext": "142 DISORDERS OF THE GLANDS.\\nanoint the face after his treatment of it with a bland ointment or the\\nLassar paste, upon the surface of which the theatrical effects are sub-\\nsequently produced. In such cases the use of soap and water with each\\ndressing is more than usually imperative.\\nComedones of the penis need not be treated. This injunction is\\nsuggested by the occasional demand made upon the physician by the\\nsexual hypochondriac, who regards these lesions with a degree of alarm\\nwhich he can best appreciate who has been confronted with a case of\\nthis kind.\\nPrognosis. As the disease naturally tends to spontaneous though\\noccasionally long-deferred resolution, the prognosis is favorable. Treat-\\nment in most cases will accomplish much in hastening the disappear-\\nance of the comedones. The most obstinate forms are those in which\\nthe face, the back of the ears, the inside of the auricle, the neck, and\\nthe shoulders are studded with relatively small indolent comedo-points,\\nabout which the circular lip of the duct rises in a whitish rim. This\\nrim, when felt with the finger, produces the impression of hyperplasia\\nof the wall of the duct. Such cases, however, are nearly allied to the\\nforms of acne described elsewhere. With exceeding rarity, the comedo\\nis merely the introduction to a more serious local affection. In early life\\na single prominent lesion is formed, and though the plug be frequently\\nremoved and finally be no longer reproduced, the orifice of the duct\\nremains patulous in middle life. Slowly thereafter its walls undergo a\\nmetamorphosis and a warty epithelioma may result.\\nMILIUM.\\n(Lat. milium, a millet-seed.)\\n(Geutum, Strophulus Albidus, Acne Albida.)\\nSymptoms. Milia occur upon and about the eyelids, the cheeks,\\nthe temples the penis, scrotum, and corona glandis of men and the\\ninternal face of the labia minora of women. They are millet-seed-\\nto pinhead-sized, globoid masses, rarely attaining the dimensions of a\\ncoffee-bean, showing within the epidermis as though kernels of rice\\nwere lying there immediately beneath a translucent layer of tissue.\\nThey occasionally project from the surface to such an extent as to\\nresemble small-sized vesicles having milky contents. In color they\\nare yellowish and whitish. They are often congenital, and can be\\nrecognized about the lids and temples of the newborn infant they are\\nalso seen, however, in middle life, when they develop very slowly,\\nand sometimes persist for years. They are often observed in the\\nneighborhood of cicatrices, which in such cases have usually been\\neffective in their production. They occasion no subjective sensation,\\nand are commonly so insignificant as to induce no deformity. They\\nnever degenerate by ulcerative processes, but when not artificially\\nremoved are, in the course of years, exfoliated in the natural processes\\nof physiological desquamation.\\nEtiology. Milia are at times produced mechanically the stroke\\nof a knife-blade, accidentally or in the processes of surgery, separating", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0154.jp2"}, "155": {"fulltext": "MILIUM. 143\\none or more of the acini of a sebaceous gland from the main body.\\nThe contracting bands of a cicatrix, after destruction of tissue from\\nany cause, may operate in a similar way with precisely the same result.\\nThey may occur in connection with acne, for which in many cases no\\ncause can be found.\\nPathology. When a milium is incised externally a spherical body\\nof nearly corresponding size may be expressed, though it may require\\ntearing from a minute pedicle below, which represents the attachment\\nto the hair-follicle. The small mass thus extracted is seen to be a\\nhorny cyst composed of several thin envelopes, suggesting the capsules\\nof the onion and representing cornified epithelia which have not under-\\ngone fatty metamorphosis, and in the centre of which is a fatty nucleus.\\nThere is never any lobular formation. Each of these horny cysts is\\ndeveloped in connection with the lanugo hair-follicles, distending the\\nlatter, as Unna has shown, irregularly and on one side. The process\\nrepresents a hyperkeratosis of the epithelium of the hair-follicles.\\nThe epithelia from which the contents of milia are produced at\\ntimes tend to develop into horny or other formations. Thus, Foster,\\nof Boston, describes a case in which the process of calcification had\\napparently been complete Wagner observed colloid contents in cer-\\ntain opalescent lesions which appeared on the cheeks and temples of a\\nwoman Barensprung and Hebra report numbers of acutely produced\\nmilia following pemphigus and erysipelas and Virchow and Bind-\\nfieisch describe milia of the hair-sacs and similar lesions accompanied\\nby cysts of the adjacent hair-follicles. In some cases the cause of\\n1 milia is to be sought in obscure changes by which the epithelia of the\\nfollicle are primarily affected.\\nRobinson believes that milia originate from miscarried embryonic\\nepithelia from hair-follicles or from the mucous layer of the epidermis.\\nDiagnosis. Milia might be mistaken for minute vesicles containing\\na milky fluid, but puncture of the lesion, with expulsion of its contents,\\nat once discloses their character. Comedones with blackish external\\npoints, surrounded by the patulous orifice of the excretory duct and\\nprolonged more deeply into the substance of the skin, could scarcely be\\nconfounded Avith milia.\\nThe most minute of the lesions of xanthoma have a yellowish color, and\\ncannot as readily be scraped away from the subjacent tissue as can milia.\\nTreatment, Milia rarely require treatment, as they are usually\\nrelatively few in number, and produce neither subjective sensation nor\\ndeformity. If desired, they may be opened with a fine milium-needle\\nand their contents turned out, or they may be scraped off with a\\nj curette. To insure their non-recurrence, the little sac left after the\\n.operation may be entered with a needle which has been dipped in a 50\\nper cent, solution of chromic acid. This operation may have to be re-\\npeated in the rare cases in which the lesions exhibit a tendency to recur.\\nThe simplest and most elegant method of removing these and many\\nsimilar-sized lesions of the skin is by the galvanic battery. With from\\nfour to six cells in the circuit the negative pole is connected with a\\nfine needle, which is introduced within and beneath the lesion, while\\nthe moistened sponge of the positive pole is in contact with the skin of", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0155.jp2"}, "156": {"fulltext": "144\\nDISORDERS OF THE GLANDS.\\nthe patient. This operation is bloodless and effectual, insignificant\\nscars resulting.\\nThe Prognosis is always favorable.\\nSTEATOMA.\\n(Gr. oreap, fat.)\\n(Wen, Pseudo-atheroma, Sebaceous Cyst.)\\nSymptoms. The history of the development and career of wens\\ndoes not greatly differ from that of milia, already described. Wens\\nare usually of slow growth unattended by subjective sensation occur\\nas single or multiple, fixed or movable tumors on the head, the trunk,\\nor the genitals and, being larger than milia, may attain the size of a\\nhen s egg. Centrally or laterally placed is usually seen on the surface\\nof each a patulous orifice closed with a blackened horny plug suggesting\\na giant-comedo. They are situated beneath, within, or upon the skin\\nare usually unattached to the deeper contiguous tissues and develop\\ninto irregularly globular, occasionally large button-shaped masses,\\ncovered by an integument usually unprovided with hairs. This\\nenvelope may be normal in hue, or unnaturally whitish from pressure\\nor, especially upon the bald scalp of certain fleshy men of middle\\nyears, reddened, shining, and greasy in appearance. Their semisolid\\ncheesy and milky contents often emit a nauseous odor. At times the\\ncysts are to be distinguished only by passing the fingers through the\\nlong hairs of the scalp beneath which they are hidden at other times\\nthey are so conspicuous in consequence of physiological alopecia as to\\noccasion considerable disfigurement. They vary greatly in consistency,\\nbut usually produce to the touch a cer-\\ntain feeling of elasticity, especially if\\nthe cyst be tensely distended. They\\nare rarely attacked by inflammation,\\nresulting in suppuration and ulceration.\\nTumors of this kind may be exceed-\\ningly numerous. MacLaren s patient, 1\\na lad nineteen years old, exhibited\\ntumors over the entire surface of the\\nbody they proved on examination to\\nbe sebaceous cysts, but they presented\\nall the appearances of multiple fibro-\\nmata.\\nPathology. Wens represent dis-\\ntention of the sebaceous glands by their\\ncontents, and response to the constant\\npressure in hypertrophy of the gland-\\nular envelope. Their contents, which\\nare semisolid, curdy, cheesy, and gran-\\nular, fluid and milky, or fluid and\\npurulent, are the inspissated or chemi-\\ncally altered products of the gland-secretion, recognizable as such .by\\nFig. 36.\\nCysts of the scalp, one of them being\\nlaid open to show its contents. (Gross.)\\n1 Brit. Med. Jour., Oct., 1886.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0156.jp2"}, "157": {"fulltext": "STEATOMA. 145\\nthe materials of which they are composed masses of fat and debris of\\nepithelia, with an occasional lanugo- or undeveloped hair.\\nIn some cases wens are more than mere retention-cysts, a benign\\nnew-growth of connective tissue forming the mass of the tumor. Cal-\\ncareous and atheromatous changes in the contents of the cyst are\\ncommon. Torok, Chiari, and others claim that the majority of these\\ngrowths are really dermoid cysts. Torok found a true papillary body\\nin the walls of many of these cysts, and states, furthermore, that such\\ncysts contained no fat.\\nDiagnosis. Steatomata are to be distinguished from true athero-\\nmata by observing that the latter exhibit no opening, never have\\nodorous contents, always originate in the hypoderm, and frequently\\noccur in portions of the skin other than the scalp. Steatomata are\\nalso to be distinguished from fatty tumors, which, however, are more\\ncommonly observed about the scapulae, loins, buttocks, and extremities\\nwhile wens are very rarely found except about the scalp and neck\\nthey lack also the peculiar pillowy 7 feel of fatty tumors. Suppurat-\\ning wens in the regions named may readily be mistaken for circum-\\nscribed abscesses if regard be not had for the history of the tumor\\nusually long preceding. Syphilitic nodes of the same parts are usually\\nboth tender and painful osteomata are also firmly attached.\\nTreatment. The removal of a wen is accomplished by excision,\\nafter previous puncture of the sac and removal of its contents.\\nWith antiseptic precautions ablation of these lesions from any\\npart of the body may be regarded as unattended with great risk.\\nSeveral fatal cases, however, are on record as the result of this opera-\\ntion, due not so much to the nature of the excised tumor as to its\\nsituation, surgical wounds of the scalp being particularly liable to\\nerysipelatous and other complications. As the incision required for\\nthe removal of the wen must necessarily extend some distance on\\neither side of the tumor, there results a linear scar, which on the bald\\nscalp is often a very conspicuous relic of the lesion. In consequence\\nof the possibility of danger many surgeons prefer destruction of a\\nprominent section of the mass with acid or alkali, leaving the sac, after\\nexpulsion of its contents, to wither gradually, though it may then be\\noften withdrawn with forceps.\\nComplete obliteration is sometimes effected by puncture, expression\\nof the contents, and subsequent induction of artificial inflammation in the\\nwalls of the cyst by injection of tincture of iodine, pure sulphuric ether,\\nor other irritating fluid, as in the operation for relief of hydrocele.\\nPrognosis. The removal of the wall of the cyst is not followed by\\na return of the lesion. In debilitated and cachectic patients there may\\nbe spontaneous ulceration and sloughing, with or without surgical in-\\nterference. Mr. Thomas Bryant 1 reports a carcinomatous tumor\\nfollowing the removal of a steatoma from the buttock of a woman\\nsixty-three years of age.\\nCongenital Fibrosebaceous Disease. Crocker reports two\\ninstances occurring in infants who at birth exhibited signs of the\\n1 Brit. Med. Jour., May 13, 1884.\\n10", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0157.jp2"}, "158": {"fulltext": "146 DISORDERS OF THE GLANDS.\\ndisease, in which patches with an area of several square inches were\\nvisible on the face, the front of the neck, and in front of and above\\nthe ear. These patches were slightly raised, of a pale reddish-yellow\\ncolor, finely granular over the surface, and consisted of closely aggre-\\ngated, pale-yellowish, pin-point-sized papules, the patches being sharply\\ndefined with many comedones at the borders. These growths, on sec-\\ntion, seemed to be due to a fibrous hypertrophy resulting in atrophy\\nof the hair-follicles and coil-glands, and separation of the lobes of the\\nsebaceous glands.\\nPainless Dermoid Cysts. These occur, either as single, few,\\nor more often as exceedingly numerous, un colored or yellowish-\\nwhite pinhead- to small nut-sized lesions, strongly resembling multi-\\nple fibromata, but all containing a sebaceous or cheese-like matter\\nwhen incised and the contents expressed. They are subcutaneous in\\nsituation, and like atheromata exhibit no opening. They occur chiefly\\nabout the nose and over the temples. Jamieson, Hebra, Rayer, Pol-\\nlitzer, 1 and others have reported cases, the last-named observer finding\\na well-defined cyst- wall with cystic contents consisting of typical epi-\\nthelium transformed into horny cells undergoing fatty degeneration.\\nPathologically they are recognized as embryonal cysts of tardy evolu-\\ntion. In different cases they are found to contain horny masses, bones,\\nteeth, wisps of hair, cartilage, and a turbid fluid.\\nRare Consequences of Sebaceous Cystic Disease are reported\\nby Cook, Hutchinson, and others, in cases in which steatomata in\\ntypical situations resulted in ulcerations of malignant type in still\\nother cases fungous tumors of considerable size formed, requiring surg-\\nical attention.\\n1 Jour. Cutan. and Gen.-Urin. Dis., Aug., 1891.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0158.jp2"}, "159": {"fulltext": "CLASS II.\\nINFLAMMATIONS.\\nEXANTHEMATA.\\n(Gr. e^dvdTj/ia, blossoming, flowering.)\\nFor a detailed consideration of the phenomena of the exanthematous\\nfevers the reader is referred to the standard treatises on the subject\\nin the field of general medicine. Space is allotted here merely to a\\ndescription of the cutaneous lesions by which they are severally char-\\nacterized. These are unlike in each disease, yet all exhibit certain\\ncommon characteristics. In all the eruptions are symmetrical, and in\\ntypical cases are general. In each the efflorescence is succeeded by a\\ndesquamative or exfoliating condition of the skin. In each there is,\\nwithin relatively fixed limits, a distinct stadium of the pathological\\nprocess within which it is completed, and beyond which, however per-\\nsistent may be its remote sequelae, there is no chronic manifestation\\nof the disorder. Each, also, is produced solely by its specific con-\\ntagium, derived exclusively from an animal body affected with the same\\ndisease, being never, so far as known, generated from any other source,\\nnor merging by imperceptible degrees the one into another. Two of\\nthese may rarely concur, but under such circumstances the one is\\nalways more pronounced in its features, which either closely precede or\\nfollow those of another. No specific medication is known to be capable\\nof arresting any one of them, each pursuing its course uninterruptedly\\nto a favorable or a fatal termination, according to the intensity of the\\npoison present in each case and to the more or less favorable or unfavor-\\nable conditions of the sufferer. Finally, it seems probable that at no\\ndistant date specific bacteria or micrococci will be demonstrated to be\\netiological factors in the production of each.\\nMORBILLI.\\n(Measles, Rubeola. Ger., Maseru; Fr., Eougeole.)\\nThis disease is preceded by a period of incubation lasting from eight\\nto twenty-one (usually between twelve and fifteen) days, a period in\\n1 which there may be no evidence of ill health, or merely a moderate\\ndegree of lassitude and inappetence. To this period succeeds a pro-\\ndromic fever, the temperature rising to 103\u00c2\u00b0-104\u00c2\u00b0 F., occasionally\\nalternating with chills or a sensation of chilliness, dryness of the skin,\\npains in the head, thirst, occasionally sweating, rarely convulsions in\\n147", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0159.jp2"}, "160": {"fulltext": "148 INFLAMMATIONS.\\nchildren, and almost invariably a serous catarrh of the mucous sur-\\nfaces, with specially pronounced ocular, nasal, pharyngeal, and laryn-\\ngeal phenomena. By the second or third day the temperature begins\\nto decline, while the catarrhal symptoms increase, these being mani-\\nfested in sneezing, a copious secretion from the eyes and nose, and\\nengorgement of the exposed mucous surfaces, especially of the conjunc-\\ntivae, the nares, and the throat. Occasionally the tongue and the fauces\\nexhibit a few closely set, isolated, minute reddish puncta (enanthem).\\nIn consequence of the implication of the larynx, the trachea, and ulti-\\nmately the larger bronchi, there is a hoarse, frequently an incessant\\nand teasing cough of a convulsive character, accompanied by expectora-\\ntion of mucus and muco-pus in moderate quantity. This prodromic\\nperiod lasts from three to five days, but in exceptional cases is pro-\\nlonged to twice that length of time. Upon its conclusion the exanthem\\nappears, usually on the fourth day, with aggravation of the fever, the\\ntemperature rising to 104\u00c2\u00b0-106\u00c2\u00b0 F., and remaining at that point until\\nthe eruption has reached its apogee, when it commonly declines pari\\npassu with the severity of the skin-symptoms.\\nKoplik s 1 diagnostic early sign of measles is the development on\\nthe mucous membrane of the lips and cheeks of children, often as early\\nas seventy-two hours before the appearance of a characteristic exanthem,\\nof bluish-white spots or of brilliantly red patches with a bluish-white\\npunctum centrally situated in each. The occurrence of this early sign\\nof the disease has been corroborated by many observers.\\nThe eruption of measles usually appears first upon the face (the\\nforehead and temples), and thence extends in about thirty hours over\\nthe neck, the upper portion of the trunk, and the superior extremities.\\nBetween the fourth and the sixth day of the disease it usually attains\\nits deepest shades of color and its maximum of development over the\\nentire surface of the body, including the palms and the soles. This\\nmaximum attained, the eruption gradually fades; the tumid condition\\nof the skin, most noticeable on the face, also subsides; the catarrhal\\nsymptoms and cough become less annoying; and the patient enters\\nupon the period of desquamation.\\nThe eruption is almost invariably symmetrical, and is characterized\\nby the occurrence of a diffuse reddish, yellowish-red, mulberry-red,\\ndeep raspberry-red, or, in extreme cases, violaceous-tinted coloration\\nof the skin, or of pea- to small finger-nail-sized fairly well-defined\\nmacules, either not elevated or very slightly raised above the general\\nlevel of the integument; or by the occurrence of large pinhead-sized,\\ndiscrete papules, much more rarely pin-point-sized vesicles, correspond-\\ning in color with the shades described above, and highly suggestive of\\nthe first efflorescence in variola. These lesions become pale under\\npressure, exhibiting then a yellowish tint, and are often set together\\nclosely, particularly over the upper segment of the body, in patches\\nsuggesting a crescentic outline. The term suggesting is here used\\npurposely, as it is difficult, by selecting a single patch, to determine by\\nthe eye alone the existence of such a configuration while an examina-\\ntion of the eruption as a whole may often very clearly convey this\\n1 Arch, of Psediat. December, 1896 N. Y. Med. Kecord, April 9, 1898,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0160.jp2"}, "161": {"fulltext": "MORBILLI. 149\\nimpression to the sight. Usually, patches of sound skin can be recog-\\nnized even when the eruption appears to be confluent, complete con-\\nfluence never occurring so as to form a sheet or mask over the entire\\nskin-surface. Individual lesions may so merge as to be well-nigh\\nindistinguishable separately; yet, on the wdiole, the eruption deserves\\nfully the plural character of its English name. It is made up in all\\ncases of innumerable elements, whose identity is never wholly lost.\\nThe subjective sensation awakened is occasionally a severe itching or\\nburning; frequently this is an insignificant matter compared with other\\ndisagreeable symptoms the cough, coryza, and fever.\\nThe exanthem spreads from the face to the upper extremities on the\\nsecond day, and over the lower limbs on the third day of the rash. Its\\ncomplex expression usually coincides with decided aggravation of the\\ncatarrhal symptoms.\\nDesquamation is accomplished usually with cessation of fever and\\nthe production of delicate yellowish-brown pigmentations of the surface\\nwhere the elements of the eruption have existed, involution being first\\nmanifested in the site of the lesions which were earliest to develop.\\nGradually and simultaneously the catarrhal symptoms of the respiratory\\npassages diminish in severity. This final stage of the disease is usually\\nterminated in a fortnight from the date of invasion.\\nThe complications and anomalies of measles depend upon the intens-\\nity of the poison, displayed in the most formidable symptoms where\\nhuman beings are crowded together, as in camps and prisons upon\\nthe degree of physical vigor and also upon the various hygienic sur-\\nroundings of the victims of the disease. Thus, the period of efflores-\\ncence may be unusually prolonged the eruption may disappear\\nsuddenly, and as rapidly reappear; the cutaneous symptoms may alone\\nbe wanting the latter may be commingled with petechia due to\\ncutaneous extravasation of blood, which may also be accompanied by\\nsevere epistaxis and the catarrhal condition of the mucous surfaces\\naffected may terminate in croupal or in diphtheritic disease, may be\\nfollowed by capillary bronchitis, catarrhal pneumonia, and even by\\npulmonary tuberculosis. Typhoid conditions may also supervene, and\\nchronic inflammatory affections of the eyes and of the Schneiderian\\nmembrane result.\\nThe Pathology of the cutaneous lesions in measles is that merely\\nof acute hyperaernia occasionally passing into exudation, limited for the\\nmost part to the vascular papillae of the corium and the perifollicular\\nplexuses of blood-vessels. There is oedema of the fatty tissue surround-\\ning the coil-glands, in the sheaths of the larger vessels, the cutaneous\\nmuscles, and the hair-follicles. The coils, follicles, and muscles seem\\nto swim free in widely dilated spaces. There is no cellular exudation\\nand no mitosis (Unna). Post mortem the eruption fades, as the result\\nof gravitation of the blood from the anterior aspect of the body as it\\nreclines upon the dorsum.\\nWhile it is possible that the etiology of measles will be based upon\\ndiscovery of micro-organisms, no observer can claim to have con-\\nclusively established this fact. Bacteria of small size and remark-\\nable motility have been found in the blood by Coze and Feltz micro-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0161.jp2"}, "162": {"fulltext": "150 INFLAMMATIONS.\\ncocci in the trachea by Klebs spherical bodies in the breath of chil-\\ndren, and post mortem in the lungs and liver by Braidwood and\\nVacher and similar organisms in the vesicles and pustules of malig-\\nnant measles by Keating and Formad. 1\\nThe disease is chiefly one of infancy, probably because at that age\\nthere is always the largest number of individuals unprotected by pre-\\nvious attacks. In every case the malady results from contagion, medi-\\nate or immediate, from an infected human subject. It spares neither\\nage nor sex, though it is much rarer in advanced years than at other\\nperiods of life, probably because of the large number who at such\\nperiod enjoy immunity.\\nThe Diagnosis of importance is between scarlatina and variola.\\nTypical cases with a well-developed eruption can scarcely be mistaken\\nfor either if the symptoms displayed are assigned their full weight.\\nIt would be useless, however, to deny the fact that there occur atypical\\nforms which have again and again confused the most expert diagnos-\\nticians in all cases of doubt the prudent practitioner will refuse to\\ndecide as to the nature of the disease until the symptoms have, in the\\nlapse of time, fully been declared. The resemblance between ill-\\ndeveloped measles and certain of the eruptions seen in varioloid is in\\nthe highest degree striking, and the greatest skill, at a given moment of\\ntime, will in cases utterly fail to make a decision between the two. A\\ndistinctly crescentic character of the eruption, the presence of catarrhal\\nsymptoms, the continuance of fever alter the efflorescence is com-\\npleted, the color of the eruption, and the discovery of the nature of\\nthe disease from which the contagion was derived, will all point in the\\ndirection of the truth. From scarlatina measles is much more readily\\ndifferentiated by the macular or papular elements of its eruption by\\ntheir color by their appearance to a marked degree upon the face\\nand by the absence of the characteristic sore throat and usually intense\\nfebrile access of the first-named disease. From the various forms of\\nerythema accompanied by fever, measles can always be distinguished\\nby the irregular temperature-record as well as by the character of\\nthe eruption. The diagnosis between rubeola and rothlen is given\\nlater.\\nThe Treatment of measles should strictly be limited to careful\\nhygienic attention to the invalid, including a restricted fever diet,\\nand the use of only such medicaments as are especially indicated.\\nThe antithermic remedies employed in the general management of the\\nfebrile process may be required in special cases.\\nIn the way of local treatment the skin should be anointed with a\\nbland, oily, or fatty substance, to relieve the pruritic sensations, espe-\\ncially after sponging of the surface once daily with a weak alkaline\\nsolution, which may be used cool without fear of producing reper-\\ncussion of the exanthem. The chamber of the invalid should be\\n1 Canon and Pielicke have recognized bacilli in fourteen instances in the blood, as\\nalso in secretions from the nose and conjunctivas, and in lung-tissue after death from\\nmeasles. These organisms were cultivated with marked success in bouillon. Czajowski\\ncultivated a long, slender bacillus with blunt ends in nineteen cases; while Dohle de-\\nscribes flagellated protoplasmic bodies found by him in the blood, and supposed to be\\netiologically effective. Sternberg s Magnan s Bacteria. New York, 1884.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0162.jp2"}, "163": {"fulltext": "ROTHELK 151\\nsomewhat darkened for the sake of the eyes, but pure air should con-\\nstantly be admitted.\\nThe Prognosis is in general favorable, but is of the gravest in special\\nconditions. All the complications named above increase the gravity\\nof the disease, which is also enhanced among men crowded together in\\ncamps, children in public charities, pregnant women, the cachectic and\\nthose greatly enfeebled from disease, very young infants, old men and\\nwomen, and residents of islands that have been long unvisited by epi-\\ndemics of the malady.\\nThe disease has been demonstrated to produce itself by contagion\\ntwo to four days before the appearance of the rash, while the capability\\nof transmission is usually lost between the twentieth and the thirtieth\\nday after the exanthem is fully developed.\\nROTHELN.\\n(Rubeola, Rubeola Notha, Rubella, German Measles, Hy-\\nbrid Measles, French Measles, Epidemic Roseola. Fr.,\\nRubeole.)\\nSymptoms. This disease has an incubative period lasting from\\nfourteen to twenty-one days, followed either by the eruption or by\\nshort-lived prodromes lasting for a few hours to a single day. These\\nsymptoms are malaise, cephalalgia, articular pains, anorexia, and\\nnausea. The occipital, cervical, and other glands may at this time\\nbecome large and tender. After a pyrexic period, rarely lasting\\nlonger than a few hours and in many cases absent, the eruption ap-\\npears, occurring for the most part in the regions affected by measles,\\nin the form of multiple, pin-point- to small pinhead-sized macules,\\nbut smaller than the lesions displayed in that disease, and decidedly\\nlighter in color. The shade is from a rosy or pinkish to a crimson\\nred, rarely lurid, never of dark mulberry or violaceous hue. This color\\nat times will be perceptible beyond the line of the lesions as a deli-\\ncate halo, a circumstance which strongly distinguishes the exanthem\\nfrom morbilli. The lesions, moreover, are seldom arranged in cres-\\ncentic outline, being more often grouped in roundish or oval patches.\\nOften, indeed, the elements of the eruption are discrete and dissemin-\\nated. The fauces are occasionally reddened in puncta. The eruption\\ncommonly fades in from a few hours to one to two days, and there may\\nbe slight resulting cutaneous desquamation.\\nThe rash of rotheln is to be distinguished from that of measles by\\nthe recognition of the features described above, particularly by the\\ncolor, contour, and date of occurrence of the exanthem the transitory\\ncharacter of the fever when the latter is present the cervical adenop-\\nathy and the rapidity with which involution of the disease progresses.\\nBy the temperature-record alone of the patient it may be differenti-\\nated from scarlatina, though the rashes are dissimilar in the two dis-\\neases. It is also not to be confounded with the erythematous affec-\\ntions of the skin. One of the most striking characteristics of the disease\\ncan be best recognized in a ward filled with children, all of whom are", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0163.jp2"}, "164": {"fulltext": "152 INFLAMMATIONS.\\nsimultaneously affected with the disorder. That characteristic is the\\nremarkable mildness of the phenomena displayed in every case.\\nWhile the symptoms of roth el n are so defined as to justify a reason-\\nable certainty in its diagnosis, it is now generally accepted that the\\nmalady exhibits no characteristics that may not be often assumed by\\nmeasles. Further, by some observers the identity of the affection, as\\ndistinguished from all others, has been called in question.\\nTreatment.\u00e2\u0080\u0094 Kotheln should be treated by rest in bed, an abundant\\nsupply of fresh air, strict asepsis, and the usual diet of fever-patients.\\nMedication by drugs is rarely indicated.\\nSCARLATINA.\\n(Scarlet Fever, Scarlet Eash, Canker Rash.\\nGer., Scharlach; F?\\\\, Scarlatine.)\\nThe period of incubation of scarlet fever varies between twenty-four\\nhours and six days, the average duration being about three days. The\\nreason of this variation is to be sought, not in any changeability in the\\nmode of evolution of the disease, but in the fact that its poison is less\\nvolatile and less rapidly dissipated than is that of measles, the result\\nbeing that it may remain potential for longer periods in connection with\\narticles through the medium of which it is transferred from one indi-\\nvidual to another. This incubative period, like that described in con-\\nnection with measles, may be unproductive of physical symptoms, or\\nmay be associated Avith ill-defined malaise.\\nSymptoms The prodromes of the disease in typical cases are\\nmarked by the occurrence of a rapid and bounding pulse, an exceedingly\\ndry skin, vomiting, headache, and a characteristic sore-throat. When\\nexamination of the mouth is made the tongue is seen to be thickly coated,\\nand its filiform papillae reddened and prominent, features of the\\nso-called strawberry-tongue. The velum, the pillars of the fauces,\\nthe tonsils, and all exposed mucous surfaces are engorged, tumid, red-\\ndened, and often covered with deep reddish puncta, which represent\\nhyperemia of the perifollicular tissues. Thirst is extreme, and degluti-\\ntion is often in the highest degree painful. In severe cases the mucous\\nsurfaces named may speedily exhibit finger-nail- to pigeon-egg-sized\\nashy ulcerations with a lurid halo at the periphery. In children there\\nmay be syncope, delirium, convulsions, vomiting, or, when the poison\\nhas been intense, fatal results from shock of the nervous centres. This\\nprodromal period usually lasts from twelve to twenty-four hours,\\nthough it may be prolonged for two days more. In this respect scar-\\nlatina is markedly distinguished from measles. This stage is termi-\\nnated by the appearance of the exanthem, but the fever persists without\\nabatement after the explosion and the other symptoms of the disease\\nare then in no wise ameliorated. Authors describe three distinct types\\nof the disease the simple, the septic, and the toxic.\\nThe eruption in scarlatina usually spares the face, however much\\nthe latter may display two damask-colored cheeks under the febrile\\nflush, may become tumid with the blood pumped through the throbbing", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0164.jp2"}, "165": {"fulltext": "SCARLATINA. 153\\ncarotids, or even may exhibit a few scanty lesions upon the forehead\\nand temples. About the mouth the integument is always pallid this\\nis far different from the picture presented in measles. The eruption is\\nbetrayed, first, in the form of light- or deep- red pinhead-sized puncta,\\nclosely agglomerated and, second, in the form of a superadded ery-\\nthema, giving to the eye the impression of a diffuse reddish blush.\\nThe rash develops early about the neck and the clavicular regions,\\nand it rapidly spreads to the trunk and extremities, including the\\ndorsal surfaces of the hands and feet, attaining complete development\\nin the course of the second day. It is then of a distinctly scarlet\\ncolor, whence the disease derives its name in Latin, English, and\\nGerman, a coloration frequently compared with the appearance of a\\nboiled lobster. Upon the limbs it is often developed in punctate\\nform, while the occurrence of a diffuse scarlet blush is most dis-\\ntinctly perceived by the eye in the examination of the trunk, where\\nthe rash is seen to fade under pressure. In any event the ery-\\nthematous blush commonly disappears before the individual elements\\nof the rash are removed. The eruption can be made to disappear on\\npressure in the early stages of the affection. Drawing the finger-nail\\nrapidly over the surface of the skin is followed by the formation of a\\nwhitish line, which persists for a time sufficient to enable one to describe\\na letter upon the skin. This period of efflorescence lasts for from one\\nor two days to an entire week, during which the febrile and other\\nsymptoms continue unabated.\\nThe rash usually persists at its maximum of development from one\\nto three days, the concomitant symptoms continuing without noticeable\\nabatement. Among the latter may be named the occurrence of albu-\\nmin in a urinary secretion of diminished specific gravity, with occa-\\nsionally the presence of epithelium, recognizable under the microscope\\nas derived from the lining membrane of the uriniferous tubules of the\\nkidney.\\nHaving attained its apogee, the eruption in favorable cases begins\\nto fade, the part first affected exhibiting earliest a lighter shade, while\\nthe other pathological phenomena diminish in severity, the sore-throat,\\nespecially in ulcerated conditions, alone persisting. In from four to\\nten days longer the eruption disappears, leaving a brownish-yellow pig-\\nmentation of the skin-surface simultaneously the other symptoms of\\nthe disease vanish.\\nThe desquamation which ensues as convalescence progresses is\\ngeneral, and is often proportioned in extent to the severity of the pre-\\nceding eruption, though it may be generalized after a well-nigh imper-\\nceptible exanthem. Desquamation is more pronounced and character-\\nistic in scarlatina than in any other of the eruptive fevers. It may be\\nsuperficial and furfuraceous in character, or the epidermis may fall in\\nlamellated layers for example, the sheath of an entire finger, with the\\nnail, or that of the entire palm. In this way sheets, ribbons, and\\nshreds of the horny layer of the skin may fall from its surface and\\nexpose a new and often tender epidermis beneath. The hairs may\\nsimultaneously be shed. When this desquamation is finished the\\nstadium of the disease may be regarded as concluded, the entire period", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0165.jp2"}, "166": {"fulltext": "1 54 1NFLAMMA TI0N8.\\nlasting in uncomplicated cases from a fortnight to a month or six\\nweeks.\\nThe complications, anomalies, and remote sequels of scarlatina\\nare so numerous as to furnish a vast array of facts for the study of the\\npathologist. The reader need merely be reminded in these pages that\\nthe usual incubative and prodromic stages of the disease may be brief\\nas to time, or be so brusquely followed by eruptive phenomena as to be\\nindistinguishable. The latter may also first occur upon the extremities\\nor trunk, and later on the neck and over the clavicles or at once\\ncover the totality of the surface by a rapid explosion, or be extremely\\nshort-lived, or be altogether absent, or be unusually prolonged and\\nvisible for even a fortnight upon the surface of the body, appearing and\\nwell-nigh disappearing without appreciable cause. To a proportionate\\nextent the stage of desquamation may be reached precociously or tardily,\\nand the exfoliating process tediously be prolonged and of intense type,\\njeoparding in this manner the future of the convalescent prostrated\\nby the fever which has passed or the sympathetic fever which may thus\\nbe awakened.\\nThe anomalies of the scarlatinal rash are numerous, but they depend,\\nin general, less upon a variation in the intensity of the poison than\\nupon the physical condition of the patient. Thus, the affected surface\\nmay be elevated slightly above the general level there may be no\\ncoincident pyrexia the skin may exhibit irregularly disposed mottlings\\nand maculations, the rash may be characterized by the occurrence of\\nmiliary papules, minute vesicles, or purpuric lesions, well defined\\nagainst the general scarlet color of the skin by their violaceous shade\\nand due to cutaneous extravasation of blood. The rare bullous, pus-\\ntular, and urticarial lesions which may appear upon the skin are acci-\\ndental and bear no relation to the specific history of the disease.\\nCatarrhal and parenchymatous nephritis is justly dreaded during\\nthe desquamative period of the malady, when it may prove fatal after\\na relatively benignant manifestation of the disease in its prodromal\\nand eruptive stages. Gastro-intestinal disorders may also prove\\ndangerous. An otitis externa, media, or interna may perforate the\\ntympanum, destroy the ossicles, induce caries of the mastoid process\\nof the temporal bone, and prove fatal by the eventual production of\\nmeningitis or phlebitis. To this grave list of disorders which may\\ncomplicate scarlet fever must be added pneumonia, pericarditis, pleu-\\nritis, peritonitis, chronic purulent nasal catarrh (which may result\\nin caries of the nasal bones), destruction of the cornea as a result of\\nsevere keratitis, persistent adenopathy of the subcutaneous glands, and\\nmalnutrition in many forms, which may so impair the vigor of the\\nconstitution as to leave the sufferer a physical wreck for the remainder\\nof life.\\nSeptic (Anginose) Scarlatina is characterized by the gravity\\nof the throat-symptoms. In such cases a parenchymatous inflamma-\\ntion of the tonsils, velum, and fauces supervenes at an early period,\\nwith enormous tumefaction involvement of the submucous tissue and\\nneighboring glands and ulcerative, suppurative, and even gangrenous\\ncomplications which speedily may prove fatal.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0166.jp2"}, "167": {"fulltext": "SCARLATINA.\\n155\\nToxic Scarlatina (Scarlatiniform Typhus). Another severe\\ntype of this disease is that in which symptoms of typhus are pro-\\nnounced. Here the patient may perish within a few hours, after being\\nattacked and before the eruption appears, exhibiting comatose or con-\\nvulsive symptoms, indicating the profound influence upon the nervous\\ncentres of the intensely intoxicated blood or the eruption may appear\\nill developed, often livid, hemorrhagic or petechial in type, and be fol-\\nlowed by albuminuria, meningitis, diarrhoea, coma, and death.\\nFig. 37.\\nMicrophotograph of the edge of a small colony of Bacillus scarlatinae\\nB, outer edge of growth.\\nA, central zone\\nEtiology. The disease is produced exclusively by contagion derived\\nfrom the animal body affected with scarlatina, either mediately or\\nimmediately. It attacks individuals of both sexes and all ages, chil-\\ndren and infants more frequently, the aged more rarely, probably in\\nconsequence of their respective conditions as regards immunity con-\\nferred by a previous attack, since, in general, the disease occurs but\\nonce in a lifetime. Individual idiosyncrasy must account for the cases\\nin which unprotected infants exposed to the disease fail to receive it, a\\nfact noted occasionally in epidemics of all the exanthemata. The con-\\ntagious element, which is volatile in its nature, seems to be most active\\nduring the eruptive stage of the disease.\\nPathology. Klein has recognized a streptococcus, isolated and\\noccurring in chains, which has produced in the lower animals symptoms\\nstrongly suggestive of scarlatina, but irrefragable proof of the etiological\\nimportance of the germ has not been adduced. Class 1 describes a\\nDiplococcus scarlatinae, for which he claims to have obtained an anti-\\n^hila. Med. Jour., March 24, 1900.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0167.jp2"}, "168": {"fulltext": "1 56 INFLAMMA TIONS.\\ntoxin proving capable of protecting guinea-pigs against the disease\\ninoculated in animals which died in control-experiments in six or seven\\ndays. It cannot be asserted, however, that the essential micro-organism\\nof scarlet fever has yet been clearly demonstrated. Scarlatina at times\\nfollows injuries and surgical operations, due, as Atkinson supposes, 1 to\\ndiminished powers of resistance to the disease.\\nThe cutaneous lesions of scarlatina, like those of measles, depend\\nupon hyperemia and a moderate degree of exudation. The latter,\\nwhen it occurs, is limited for the most part to the rete and papillary\\nlayer of the corium. The signs of the disorder are not apparent in the\\ndead body unless there have been exudation of blood and the conse-\\nquent formation of petechia?.\\nAccording to Unna, the epidermis, when the disease is fully devel-\\noped, is the seat of a parakeratosis productive of scaling, while the\\nprickle-layer shows neither oedema nor emigration. In the cutis\\nthere is a maximum of congestion without distinct oedema. The gen-\\neral vasomotor disturbance leading to a species of vascular paralysis\\nis supposed to be due to changes in the nervous centres produced by\\nthe disease.\\nThe Diagnosis between measles, rotheln, erysipelas, and the erythe-\\nmata in general is readily established. The sore-throat, intense fever,\\npunctiform scarlet rash reaching to the border of the inferior maxilla,\\nand the distinct, whitish-yellow line traceable by the finger-nail when\\npassed rapidly over the surface, are all characteristic. In measles the\\nmacular character of the rash and its crescentic arrangement, in con-\\nnection with the catarrhal symptoms, will usually be recognized. From\\nerysipelas scarlatina can always be distinguished by the absence of the\\npeculiar, shining, smooth, or glazed and tumid condition of the affected\\narea. From all other rashes scarlet fever can be distinguished by the\\npyrexic symptoms and resulting desquamation. For the distinction\\nbetween scarlatina and erythema scarlatiniforme the paragraphs\\ndevoted to a description of the malady last named may be consulted.\\nGreat care should be taken not to confound the drug-rashes having\\na scarlatiniform appearance with the specific disease under considera-\\ntion. Thus, belladonna, in doses of 1 minim of the tincture every\\nhour to the extent of four doses, has produced an abundant scarlatini-\\nform eruption in children, a diagnostic point of importance in view of\\nthe fact that the drug named has been employed as a prophylactic\\nagainst the disease. For eruptions of this sort due to quinine and\\nother drugs the reader is referred to the pages devoted to Dermatitis\\nMedicamentosa.\\nTreatment. The modern treatment of uncomplicated scarlatina is\\nantiseptic and expectant, after provision is made for an abundant supply\\nof fresh air, disinfection, a proper regulation of food and drink, and\\nthe local use of baths, tepid or cool, for the purpose of reducing the\\nbody-temperature. After each of these baths the skin should be com-\\npletely anointed with a fatty substance, such as cold-cream salve, scented\\nalmond- or olive-oil, or with vaselin. These inunctions are not only\\ngrateful to the patient, but they reduce the body-temperature to a\\n1 Jour. Cutan. and Ven. Dis., October, 1886, vol. iv.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0168.jp2"}, "169": {"fulltext": "VARIOLA. 157\\nslight degree. All treatment other than that suggested above per-\\ntains to the field of general medicine, and should be limited to the\\nspecial conditions presented in each case. Such treatment includes the\\nmanagement of disorders of the eye, ear, throat, kidneys, and other\\nviscera, the involvement of which constitutes a complication of the\\ndisease.\\nThe Prognosis of the malady should always be established with\\nreserve. It is largely based upon the relative intensity of the symp-\\ntoms, the vigor and age of the subject, and the presence or the absence\\nof serious complications. Albuminuria is rarely absent, and is not per se\\nalarming but anasarca and other evidences of profound interference\\nwith the renal function are to be assigned due weight. In general,\\nit may be said that a high range of temperature early and ulcerative\\nthroat-lesions the puerperal state tardy development, rapid and un-\\ntimely disappearance, or undue prolongation of the exanthem and its\\nadmixture with petechia? to such an extent as to indicate extensive\\nhemorrhagic extravasation, are all formidable symptoms. Finally, it\\nmust not be forgotten that the mildest and simplest forms of the disease,\\nafter the fastigium is passed and convalescence is actually established,\\nmay terminate fatally by the supervention of uraemia, cerebral paralysis,\\nor even meningitis, consequent upon secondary changes in the middle\\nor internal ear.\\nVARIOLA.\\n(Lat. varus, a blotch.)\\n(Small-pox, The Pocks. Ger., Blattern, Pocken Fr., Petite\\nVerole Ital., Najuolo.)\\nThe variations of variola as to the severity, character, and duration\\nof its symptoms are so great as to preclude complete description of this\\nmalady within the limits here assigned. The following paragraphs are\\ntherefore devoted to a sketch merely of its more commonly recognized\\ncharacters.\\nSymptoms. ^The period of incubation of the unmitigated disease\\nvaries between five and twenty or more days, occupying usually twelve\\ndays or a fortnight. It is characterized by the peculiarities of that\\nperiod recognized in all the exanthemata, there being few and insignifi-\\ncant or no evidences of physical discomfort. The prodromic stage is\\nushered in generally by a vespertine chill, succeeded by fever, with a\\ntemperature rising to 104\u00c2\u00b0-106\u00c2\u00b0 F., which is commonly associated\\nwith severe and characteristic pain in the loins, headache, epigastric\\npain, nausea or vomiting, and occasionally in young subjects with\\ndelirium and convulsions. The fever continues, with alternations of\\nexacerbations and partial relief, or sensations of chilliness, during the\\nsecond and third days. At the same time there may be faucial hyper-\\nemia and moderate dysphagia. Occasionally, before the cutaneous\\nexanthem appears, minute reddish papules may be recognized upon the\\nbuccal membrane.\\nInitial Rashes (Variolous Erythema Variolous Rose-\\nola). These may be either (a) erythematous in character, and gen-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0169.jp2"}, "170": {"fulltext": "158 INFLAMMATIONS.\\neral or partial or (6) hemorrhagic, in the form of pure petechiae or of\\nadmixtures of petechial and erythematous blotches.\\nOn the second and third days there appears, in some cases, espe-\\ncially in menstruating women and in young subjects, a cutaneous\\nefflorescence, the significance of which has often been misinterpreted,\\nthus leading to many errors in diagnosis. To Hebra we are indebted\\nfor its distinct recognition as a cutaneous prodrome in variola. The\\ninterpretation of this exanthem is a matter of special importance to\\nthe diagnostician, as many have been deceived respecting its nature\\nand significance. It is characterized by the occurrence of irregularly\\ndisposed and distinctly outlined maculations, puncta, striae, streaks, or\\ndiffuse blush of bright or lurid reddish hue the invaded integument\\nbeing at times slightly tumid, and thus elevated above the general\\nlevel. The affected part may also be the seat of moderate pruritus.\\nThe blush may fade under pressure, but rarely does so perfectly. One\\ncannot by the finger produce upon it a visible whitish spot. The rash\\noccurs most often about the groins, the hypogastric region, the pubes,\\nand the inner faces of the thighs; and on examining these parts the\\nphysician will usually discover the evidence, in adult women, of recent\\nor present menstruation, or of the puerperal state. It occurs also\\nabout the axillae, the extensor faces of the larger and smaller joints,\\nand the lumbar and clavicular regions. Often a broad area of the\\nintegument in these parts may exhibit a sheet or mask of dull crimson\\nerythema, upon which may form pinhead- to bean-sized, dull-reddish\\npapules, not losing their color under pressure, or more rarely petechiae,\\nvesicles, and wheals. All these are precursory phenomena, and are\\nnot transformed into characteristic variolous lesions. They fade almost\\ncompletely before the latter appear. Rarely, a few scattered papules\\nmay be distinguished upon the face and the arms before the variolous\\nerythema fades. Often the papules in full development are even less\\nprofusely displayed on the site of the precedent efflorescence. The\\nlatter need not be necessarily regarded as a symptom of portentous\\ngravity. The entire surface of the belly may be covered with a uni-\\nform erythematous blush of dull-crimson hue, followed by confluent\\nvariola, and the patient ultimately recover. The physician, then, con-\\nfronted with a deep-red erythema of the regions named, especially of\\nthe groins, the lower part of the belly, and the thighs of a menstru-\\nating woman affected with high fever, nausea, vomiting, and lumbar\\npain, should invariably suspect the presence of variola.\\nThe vividly red or empurpled rashes of hemorrhagic type occur\\nmost frequently in the localities named above when the disease assumes\\na grave aspect, as in hemorrhagic variola.\\nThe Small-pox Eruption. The period of the eruption in variola\\nis characterized, at its earliest, by punctiform, subcutaneous discolora-\\ntions which photography alone can reveal. Commonly the patient\\nwill be seen on the morning of the third or fourth day with the face\\nand scalp covered with pinhead-sized and larger, firm conical papules,\\nthe touch of which to the finger suggests to most English observers the\\nfeeling of shot. Later, these papules develop upon the trunk and\\nlimbs and in well-marked cases every portion of the body-surface is", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0170.jp2"}, "171": {"fulltext": "VARIOLA.\\n159\\ninvaded, including the palms and soles. The lesions may be sur-\\nrounded by a narrow rosy areola upon the trunk. They may be\\nunproductive of subjective sensations or be slightly tender.\\nAs a rule, there is complete defervescence when the exanthem ap-\\npears, the patient experiencing such relief that if an adult has chanced\\nnot to view his face in a mirror nor to be informed of his appearance\\nby those in attendance upon him, he will often regard himself as com-\\npletely relieved of his three days illness. In other cases the febrile\\nsymptoms persist with a lowered temperature.\\nFro. 38.\\nVertical section of pustule at the beginning of pustulation a, umbilication at the site of an\\nexcretory canal b, reticulum within the epidermis; c, reticulum of smaller meshes containing\\nlymph- and pus-giobules. (After Rindfleisch.)\\nDuring the first two days of the eruptive period the papules increase\\nin number and become correspondingly agglomerated while those of\\nearliest appearance become transformed into vesicles containing a trans-\\nlucent serum, the roof-wall of many of them exhibiting an umbilica-\\ntion. This umbilication of the vesicle is characteristic, and slightly\\ndifferent from that observed in bullous and pustular lesions. The\\ncentral depression is disproportionately large, and about it the yet un-\\ndistended epidermis is often irregularly puckered or fluted. Even in\\nthis period the lapse of a few hours will produce a lactescent appear-\\nance in the formerly translucent contents.\\nFrom the sixth to the twelfth day the transformation of these lesions\\ninto pustules is effected, the process beginning, as in all the metamor-\\nphoses of the disease, in the vesicles of greatest age, those, namely, on\\nthe face and upper portions of the body. The lesions simultaneously\\nenlarge until they are of the size of an average-sized pea, are surrounded\\nwith a distinctly ovoid areola, and, being fully distended, rupture the\\ncentrally placed filament which held down the roof-wall, consequently\\nthe umbilication of the pustules is lost. With this process of suppura-\\ntion is awakened the so-called secondary fever, a pathological process\\nevidently not essential to the disease, as it does not occur in mitigated", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0171.jp2"}, "172": {"fulltext": "1 60 INFLAMMATIONS.\\ncases. This secondary fever is born of the extensive process of suppura-\\ntion occurring in the skin and other organs, and may be symptomatic,\\nsympathetic, or septicemic in character. It thus varies in different\\ncases with the character and severity of the process by which it is\\nexcited, being transitory in mild cases, and in others terminating only\\nwith death. At this time the patient is usually in a most distressing\\ncondition. The skin of the face and of other attacked regions is\\nswollen, thickly covered with pustules, and the features indistinguish-\\nable in the tumid and closed lids, the oedematous lips, disfigured nostrils,\\nand pus-obstructed mucous outlets. Deglutition becomes painful and\\noften impossible, the saliva flows from the lips, and the mucus from the\\nnares dries with the pus upon the exterior of the visage. The pustules\\nrecognized upon the integument are represented also in the gastro-\\nintestinal tract. In an autopsy of a patient dead at this stage of the\\ndisease the entire canal from the mouth to the anus, as also the genito-\\nurinary and respiratory passages, may be completely covered with\\nclosely agglomerated and well-distended pustules. The career of those\\nwithin the mouth can usually be studied by eye-observation. In this\\nsituation they rapidly lose their epithelial roof-wall by reason of the\\nheat, moisture, and friction to which they are subjected, and then\\nexhibit a reddened and excoriated surface, over which there is re-\\nformation of the epidermal layer. Gangrenous complications are rare.\\nBetween the thirteenth and the fourteenth day desiccation begins,\\nand is usually completed within from ten days to a fortnight the pus-\\ntules rupture, and the exuded pus concretes into yellowish or brownish,\\nrarely blackish crusts, or the latter are formed by the desiccation of\\nthe entire envelope and contents. The pulse usually at the same\\ntime diminishes in frequency and secondary defervescence occurs, the\\ntumefaction of the integument decreases, and at times the peculiarly\\ncharacteristic and often intolerably fetid odor from the patieut is less\\nperceptibly exhaled. In from four to six weeks the course of the\\ndisease is completed. The immediate traces of the eruption are purplish\\nand violaceous pigmentations, which slowly disappear. When cicatrices\\nresult they are slightly depressed, at first of a dull purplish hue, later\\ndead-white, lustrous, usually symmetrical in disposition, and most\\ndistinct upon the surfaces exposed to the light and air, such as the face.\\nThough persistent, they are rendered somewhat less deforming in the\\nprogress of years. When closely set together they produce a character-\\nistic ridged and corded appearance, due to the elevation of narrow\\nbands of unaffected integument between the depressed surfaces of scars.\\nThe several departures from the pronounced type of the disease described\\nabove present variations differing widely from the most benignant forms.\\nBrief reference only can be made to these variations.\\nVarioloid, whether occurring after vaccination or not, is a modified\\ntype of variola. With it should be classed all those forms of the dis-\\norder occurring in the human subject, and described by authors under\\nthe titles swine-pox, horn-pox, etc. In these cases there may\\nbe a severe prodromic fever and a scantily developed exanthem rapid\\ninvolution of lesions; abortion of the latter in any of their several", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0172.jp2"}, "173": {"fulltext": "VARIOLA.\\n161\\nstages from papule to crust absence of secondary fever transmission\\nof the disease in a mild or mitigated form from one individual to\\nanother, so that an entire community, vaccinated and unvaccinated\\nalike, may suffer from an epidemic disorder of this moderate grade\\nFig. 39.\\nVertical section of one-half of an undeveloped variola-pustule a, old epidermis o,eplthelia\\nof rete above the alveoli; c, new-formed epidermis d, alveoli filled with pus-globules; g, flat-\\ntened and infiltrated papillae lying beneath the pustule. (After Auspitz and Basch.)\\nwithout the occurrence among them of a single case of typical variola.\\nIt is scarcely necessary to add that a patient with varioloid, especially\\ndaring an epidemic, may transmit to the unprotected a malignant form\\nof the disease.\\nHemorrhagic Variola, fortunately rare and too often confounded\\nin the past with black measles/ is much more formidable, viewed\\nfrom every point. When cutaneous hemorrhages occur during the\\ncourse of small-pox they do not necessarily indicate that the case is\\none of so-called varioliform purpura/ since these losses may be acci-\\ndents of the pathological process. In this malignant form of the disease,\\nagainst the ravages of which vaccination often presents but a feeble\\nbarrier, the prodromic stage is followed by a deep purplish redness of\\nthe surface which is characterized by pinhead- to split-pea-sized, firm,\\nclosely set papular lesions, suggesting the occurrence of measles in a\\npeculiarly severe form. The febrile, nervous, and other symptoms of\\nthe disease are proportionately intense. Ecchymoses appear upon the\\nconjunctival membrane. Gradually the color of the exanthem, that at\\nfirst disappeared under pressure, refuses thus to yield and assumes a\\nbluish-black shade. Ecchymotic patches may be intermingled with\\nthe papules, rapidly widening to palm-sized and larger areas. The\\nmucous surfaces share in these colors, being also infiltrated with effused\\nblood, and the muco-cutaneous orifices are crust-covered and exhale\\nan extreme fetor. Blood may escape from the bowels, bladder, mouth,\\nor vagina. Signs of grave systemic and visceral complications are\\n11", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0173.jp2"}, "174": {"fulltext": "162 INFLAMMATIONS.\\nalways present. Vesiculation, pustulation, and the typical transforma-\\ntions of variolous lesions are all wanting. In the few cases observed\\nby us death speedily supervened, either from shock, coma, hemor-\\nrhagic infarction of the lungs, or rapid exhaustion. Intermediate\\nforms between hemorrhagic and true variola are described, in which\\nforms the pustules occurring in the variolous type of the disease merely\\nfill with blood in consequence of accidents possessing a purely local\\nsignificance.\\nConfluent Variola is another severe form, less malignant, how-\\never, than that just described. It is characterized by intensity of the\\nprodromic fever, which often scarcely abates with the appearance of\\nthe exanthem. The latter is developed in deeply implanted, firm pap-\\nules, closely set together, succeeded by vesicles and pustules, which,\\nas they enlarge, fully occupy the entire surface of the integument, and\\naccomplish a perfect coalescence. In well-marked cases there is scarcely\\na pinhead-sized area of the entire surface of the body that is not\\ninvaded. The tissues become enormously oedematous; the deformity\\nof the face renders the features indistinguishable. Hemorrhagic pus-\\ntules and even patches of a gangrenous pulp may be intermingled with\\nsheets of suppurating surface. Phonation, respiration, and degluti-\\ntion are proportionately impeded or are absolutely subverted by the\\ntumefaction and suppuration of the mucous membranes of the respira-\\ntory and gastro-intestinal tracts. When the patient survives until the\\nstage of desiccation is reached the body presents an aspect as revolt-\\ning as that ever displayed by a living being. A thick brownish or\\nblackish-brown mask envelops the swollen head, trunk, and limbs, and\\nthe odor exhaled from the body is intolerably repulsive. All the sys-\\ntemic phenomena are proportionately grave, and are accompanied by\\none or more of the complications of the malady pneumonia, pleuro-\\npneumonia, albuminuria, diarrhoea, various motor and sensory paral-\\nyses, subcutaneous furuncles, and abscesses. The eyes may suffer from\\npustular and ulcerative changes in the conjunctiva, cornea, and deeper\\ntissues, with resulting inflammation of every grade to panophthalmia\\nand consequent loss of vision. Often the patients, with surprising powers\\nof resistance, will survive until extensive sheets of crusts have fallen\\nfrom the skin-surface, and then perish sloAvly in a typhoid condition\\nwith low remittent or continuous fever. Every such case does not,\\nhowever, terminate fatally. Children may rally from the severest form\\nof confluent variola, and afterward enjoy vigorous health, thus illus-\\ntrating the wonderful recuperative energy of the natural forces under\\nthe most adverse circumstances.\\nEtiology. Variola is always the result of mediate or immediate\\ncontagion. It is a disease both contagious and infectious, being trans-\\nmissible by volatile emanations from the victims of the disease. It is\\nalso artificially inoculable. When transmitted by the latter process\\nits period of incubation is somewhat shortened, and often its successive\\nmanifestations become less formidable. The history of inoculated\\nhuman variola has, however, received but little attention during late", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0174.jp2"}, "175": {"fulltext": "VARIOLA. 163\\nyears, since the practice properly has been forbidden by law. The\\ndisease is, to a certain extent, transmissible from man to the lower\\nanimals, and the reverse. It attacks individuals of both sexes and all\\nages, including the foetus in utero, which may be ushered at an untimely\\nhour into the world, macerated or recently dead and covered with the\\nlesions of variola. The disease in the larger cities is decidedly more\\nfrequent in winter than in summer, possibly because in the colder\\nmonths the opportunities are greater for spread of the contagion in\\nartificially heated dwellings in which numbers of individuals are\\ncrowded together. Islanders, long un visited by an epidemic and un-\\nprotected by vaccination, may suffer equally in the summer season.\\nPathology. The parasitic nature of variola has not been demon-\\nstrated. Coze, Feltz, Baudouin, Luginbuhl, Weigert, Hallier, and\\nCohn have recognized micro-organisms, both bacteria and micrococci, in\\nthe blood of variolous patients. None of these organisms has yet been\\nutilized in the production of the disease but Cohn l regards these para-\\nsites as instances of a twin race of the micrococcus vaccinae discov-\\nered in vaccine-lymph. The secondary fever of the disease is without\\nquestion septicemic, and is due to pus-cocci and their toxin.\\nAccording to Unna, the main distinction between the vesicle of vari-\\ncella and that of variola lies in the slow growth of the one and the prompt\\nsuppuration which is added to the fibrinoid degeneration of the other.\\nThe epithelium of the lower prickle-layer undergoes speedily balloon-\\ning colliquation not only at the apices of the papillae, but also in the\\ndepths of the ridges. A gradual division of the vesicle follows into an\\nupper and a lower story, with a lateral extension of the cavity in the\\nupper prickle-layer, a somewhat characteristic oedema, and mitotic pro-\\nliferation of the semisolid cushion below. The umbilication is pro-\\nduced less by the action of centrally placed epithelia acting as guy-\\nropes than by the enormous force of the exudation at the periphery in\\ncontrast with the slight activity of the central parts, as a result of which\\nthe latter are simply left behind/ 7 Gradually there follows a dense\\ncollection of plasma-cells in the adventitial sheaths of the blood-vessels.\\nThe latter subsequently dilate, and the line of demarcation between\\nthe cutis and rete becomes well-nigh indistinguishable on account of\\nthe stream of leucocytes thither. Healing begins at a later stage by\\nthe formation and gradual contraction of a thin layer of epithelial cells\\nlying close to the connective tissue and extending from all sides beneath\\nthe pustule.\\nDiagnosis. The difficulty attending the diagnosis of variola in its\\nprodromic and earliest eruptive stages, from measles, is considered in\\nthe description of the latter disease. The general demand, indeed,\\nupon the physician for an exact and definite diagnosis of every case\\nbefore its complete evolution, is founded upon an erroneous conception\\nof possibilities, and the sooner this is generally recognized the better\\nfor all concerned. A delay of even a few hours will often verify or\\nremove a suspicion. Fully as much mortification on the part of the\\nphysician and damage to the best interests of the patient may result\\nfrom an error in one direction as in the other. The wisest course in\\n1 See Magnan, loc. cit., p. 411.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0175.jp2"}, "176": {"fulltext": "164 INFLAMMATIONS.\\nevery doubtful case is to admit the doubt and to visit the patient fre-\\nquently for the purpose of observing the development of the disease\\nuntil that doubt is removed. Typical cases of variola are recognized\\nwith ease from the character of the symptoms presented. Syphilis and\\nacne are always distinguished by the absence of fever and their relative\\nchronicity.\\nThe Prognosis of variola is largely dependent upon the degree of\\nprotection conferred by previous vaccination. Independent of vacci-\\nnation, the age and vigor of the patient, the presence or absence of an\\nepidemic of severe or mild type, the extent of the eruption, and the\\ncharacter of the surroundings of the patient are elements of prime\\nimportance. Very young and aged subjects, women pregnant or in\\nthe puerperal state, and, as Hebra has shown, those who have suffered\\nfrom a previous attack of the same disorder, are all unfavorably dis-\\nposed with respect to the final result. Confluent and hemorrhagic forms\\nof the disease are, naturally, the gravest. Unmitigated variola, under\\nthe most favorable circumstances, is one of the greatest scourges of iiu-\\nmanity, and as such will probably always destroy a frightful propor-\\ntion of its victims. At the same time the conscientious physician\\nneeds to be impressed with the fact that, under the most discouraging\\ncircumstances, the patient, disfigured to the greatest extent by an en-\\nvelope of blackened crust, and in a state of extreme physical prostra-\\ntion, with many of his bodily functions almost completely suspended,\\nmay even from the midst of such peril be won back to life and vigor.\\nThe assiduous attentions of a skilful nurse, guided by the inspiring\\npresence and councils of a physician who is himself fearless of the\\nmalady, will often achieve the result. Upon the latter point it is\\ninteresting to note that physicians in active practice who do not hesitate\\nto expose themselves freely to the disease in the discharge of the duties\\nof their profession rarely suffer in their own persons.\\nThe Treatment of variola should, in general, be limited to the\\nindications presented in each case. ~No remedies can be employed\\nwhich have the least power to abort the disease. Kaposi calls atten-\\ntion to the striking fact in this connection, that syphilis, for many of\\nthe manifestations of which mercury is a specific, is a disease the second\\nincubation-period of which is measured by weeks, and yet neither by\\nexcision of its initial sclerosis nor by mercurials can the subsequent\\nmanifestations of the disease be completely prevented. Certainly no\\nspecifics are recognized as of value in variola. The patient should be\\nkept in a relatively dark room with an abundant supply of fresh air\\nof a uniform temperature, and antiseptic solutions should constantly\\nbe at hand into which all the ejecta are received immediately. He\\nshould be given ice when this is acceptable to the palate, cool water\\nad libitum, and his strength should sedulously be supported by a liquid\\nanimal diet. The body may be sponged with or bathed in cool or\\ntepid water as often as is grateful to the patient. In severe or con-\\nfluent cases the immersion of the body in the continuous warm water-\\nbath is followed by brilliant results in hastening the desiccation and\\nfall of the crusts and subsequent repair. A bath of this character given\\nfor merely two or three hours in the day is often of great value. With", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0176.jp2"}, "177": {"fulltext": "VARICELLA. 165\\nand without these external measures gargles of potassium chlorate,\\nmyrrh, honey, or carbolic acid will be found acceptable to the mouth\\nand palate. The constant attention of an efficient nurse bestowing\\nassiduous care upon the mouth, the skin, and the eyes may be regarded\\nas an essential part of all sound treatment.\\nWith a view to the prevention of pitting, no measures of a therapeu-\\ntic character will prevent the occurrence of a distinct cicatrix whenever\\npus has eroded or otherwise destroyed the integrity of the papillary\\nlayer of the coriuuL Every effort, therefore, should be exerted to\\nprevent extension of the suppurative process to the true skin. The\\nfollowing measures have approved themselves as of practical value\\nFirst, the sick-room should be moderately darkened and yet be amply\\nprovided with fresh air. Second, a solution of pure sodium hypo-\\nsulphite should be administered night and day in the dose of from 15\\nto 20 grains (1.-1.3) every three or four hours. The variolous lesions\\npursue a milder course under this internal treatment, and in some\\ncases even the vesicles shrivel before pustulation is fairly begun.\\nThird, the skin of the face, after sponging with a weak formalin lotior,\\nshould be anointed with a bland fatty substance such as vaselin, almond-\\noil, or fresh lard, and over the unguent may be laid silk-enveloped\\ncompresses, dipped in tepid, weak solutions of carbolic or boric acid, or\\nof thymol. The anointing of the surface before the application of the\\nlotion is commonly more grateful to the patient, but the skin may\\nconstantly be moistened with the aqueous lotion alone. Here, again,\\nthe assiduous attention of the nurse is a matter of importance. The\\npowder of europhen topically is often applied with advantage.\\nThe edges of the eyelids should daily be anointed with freshly\\nprepared cold-cream salve. Puncture of the cornea may be required\\nfor the relief of hypopyon. Diarrhoea and other symptoms of visceral\\nderangement should be relieved by appropriate medication. As a rule,\\nthe administration of narcotics for the relief of pain is objectionable.\\nThroughout the course of the disease the strength of the sufferer should\\nbe supported by a generous use of animal broths or of milk; in typhoid\\nconditions a judicious employment of stimulants may be necessary.\\nVARICELLA.\\n(Chicken-pox. Ger., Spitzblattern, Wasserpocken\\nFr., Variolette.)\\nSymptoms. This disease has an incubative period lasting from ten\\ndays to a fortnight, after which there is occurrence of malaise, chilliness,\\nand languor. The patients are usually children, who may suffer thus\\nfrom fever of a moderate grade (99\u00c2\u00b0-100\u00c2\u00b0 F.) lasting from a few hours\\nto two or three days, after which defervescence is commonly complete.\\nWith the onset of the fever or even without, the rash appears, first on\\nthe head and trunk, in the form of rosy macules or slightly elevated\\nlesions lacking the characteristic shot-like feeling of the variolous\\nI papule. These macules rapidly become vesicular, the lesions being\\npinhead- to pea-sized, limpid, superficial in situation, differently shaped\\nfrom variolous lesions, and very rarely umbilicated, puckered, or", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0177.jp2"}, "178": {"fulltext": "166 INFLAMMATIONS.\\nfluted as in small-pox. The macules appear in successive crops,\\nand are often surrounded by a faint pinkish or reddish halo. Their\\ncontents become cloudy or lactescent rather than puriform, and they\\ndesiccate as early as the second day, forming thin, light, superficial\\ncrusts. The lesions may be abundant in one region, as, for example,\\nover the back or the chest, but are never both abundant and generalized\\nand never confluent. Like variolous lesions, they extend at times to\\nthe mucous surfaces of the eyes, the mouth, and the genital regions.\\nOccasionally they are productive of pruritic sensations. Often the course\\nof the disease is so mild and the exanthem so slight as scarcely to\\nattract attention. Cicatrices result only in places, chiefly the face,\\nwhere the lesions have been subjected to local irritation.\\nDiagnosis. The doctrine that varicella is a mitigated form of\\nvariola has been practically abandoned in consequence of the researches\\nof pathologists. It is of vast importance that the essential differences\\nbetween the two diseases be exactly and generally recognized.\\nIn variola the invasion-period of relatively fixed limits, the speedy\\ntransformation of the lesions into minute, firm papules, their early\\nappearance on the exposed parts of the face and wrists, the age of the\\npatient, the thermic variations, the prodromic rashes, and the rapid\\ntransformation of the papules into umbilicated vesicles, are all\\nimportant diagnostic points. In varicella the trunk usually exhibits\\nthe greater number of lesions, which appear also in successive crops.\\nBeside the characteristics of the cutaneous lesions the catarrhal symp-\\ntoms of measles and the sore-throat of scarlatina will point to the\\nnature of these disorders. Impetigo contagiosa is to be carefully dis-\\ntinguished from varicella, since the two affections occur at times side\\nby side in one hospital ward, and occasionally the former succeeds the\\nlatter. The lesions of impetigo contagiosa are often larger, generally\\nmore persistent, and the crusts bulkier than in varicella, and the\\npatients rarely exhibit pyrexic symptoms.\\nPathology. According to Unna, the varicellous process begins\\nwith a reticulating liquefaction of some of the prickle-cells of the\\ncentral and upper portion of the rete in which the first congestive focus\\nis seen. The complete liquefaction of the contents of the loculus is fol-\\nlowed by confluence of adjacent cavities and rapid dilatation to the\\npoint of formation of a vesicle, the non-liquefied and persistent epithe-\\nlium being compressed so as to form the septa, while the cells above\\nproduce similarly the roof- wall. The epithelial cells of the base undergo,\\non the other hand, ballooning colliquation (transformation of cells\\ninto hollow spheres or balloons having the form of peculiar giant-cells),\\na change affecting especially the centre of the pock, its lateral margins,\\nand even at times its septa. Internally, these ballooned cells merge\\ninto simple oedematous epithelium with constricted nuclei. Careful\\nobservation of the lesions of varicella demonstrates that the vesicles are\\nas distinctly divided into septa as are those of variola. These lesions\\nare never monolocular. Their benign course is explained pathologi-\\ncally by their superficial position, by the absence of purulent infection,\\nand by early repair with young epithelium. The absence of umbilica-\\ntion is explained by the acuity of the process. Bareggi, Guttmann,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0178.jp2"}, "179": {"fulltext": "VACCINIA. 167\\nPfeiffer, and others claim to have discovered micrococci and protozoa\\nboth in the blood-corpuscles and in serum obtained from subjects of\\nthe disease but no pathogenic relation of these germs has been estab-\\nlished.\\nTreatment. The management of uncomplicated cases of varicella\\nis limited to the avoidance of exposure to sources of aggravation of\\nthe affection. Often a dusting-powder may be applied over the sur-\\nface after a lotion of thin oatmeal-water. Cases complicated by the\\naccidents of exposure or by the intensity of the disease are to be\\ntreated by the resources of general medicine according to the indica-\\ntions presented.\\nVACCINIA.\\n(Cow-pox. Ger., Kuhpocken; Fr., Vaccine.)\\nThe limits of this volume forbid a discussion of the interesting\\nquestions concerning the relations of cow-pox as it occurs spontane-\\nously in the milch cow, to human variola. A careful collation of the\\nresults obtained by a large number of vacciniculturists of recent days\\nrenders it clear that it is a matter of great difficulty to transmit variola\\nfrom man to the heifer that where this rare result is obtained the\\nlymph derived from the lesions on the udder or the belly of the animal\\nis liable to produce variola when retransmitted to man and that spon-\\ntaneous cow-pox alone seems to furnish a lymph which is safely inoc-\\nulable in generations to the human race.\\nOf greater importance is it to note that, either by arm-to-arm vac-\\ncination as was formerly extensively practised, or by the use of the\\nanimal virus which is now well-nigh exclusively employed, there has\\nbeen conferred upon millions of human beings a degree of protection\\nagainst variola the value of which is beyond estimate. In both methods\\nthe lymph is originally derived from the female of the bovine race,\\npreferably during the puerperal state, and its sources are the vesicular\\nlesions of vaccinia spontaneously arising or artificially cultivated about\\nthe teats, udder, and adjacent parts. The introduction of this lymph\\ninto the skin of the human subject is termed vaccination.\\nThe operation of vaccination should eliminate to the largest extent\\nthe possibility of transmitting any other contagious disease than the\\none intended. With this object in view, no better instrument can be\\ndevised than a clean needle, one which has been properly disinfected\\nand not previously employed for any purpose. The skin of the part\\nselected for vaccination being first cleansed antiseptically and sub-\\njected to slight tension by the left hand, the vaccinator should scratch\\nor scrape off the epidermis with the needle, held in the right hand,\\nby a series of parallel and crossed strokes, so as to make three or\\nfour superficial erosions three inches or more apart. Each of these\\nmultiplex wounds should have the size of the nail of the little finger,\\nand should in no case bleed, but merely ooze with serum slightly\\ntinged with blood. At such points the lymph, preferably extruded by\\nair-pressure from a slender glass-tube in which it has been hermetically\\nsealed, is to be slowly and thoroughly rubbed in.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0179.jp2"}, "180": {"fulltext": "168 INFLAMMATIONS.\\nBetween the third and the fourth day after a successful vaccination\\nof the unprotected a light-reddish, pinhead-sized papule rises at each\\ninoculated point. Between the fifth and the sixth day it becomes\\ntransformed into a translucent, well-distended, occasionally umbilicated\\nvesicle, which, when single, may attain the size of a finger-nail. Spring-\\ning from the multiplex abrasions described above, a minute papule\\nusually forms at each point of intersection of the crossed lines pro-\\nduced by the scratching with the needle, and the subsequent vesicles\\ncoalesce, thus forming a compound lesion of rather peculiar aspect.\\nIt appears often as a small coin-sized plaque, elevated to the extent of\\na line or more beyond the general level of the skin-surface, with a rim\\nformed of numerous discrete or confluent vesicles, which in either case\\nare closely set together. The compound plaque seems to develop after-\\nward as a single lesion, its centre being depressed. After the ninth\\nday the fluid becomes opalescent, and desiccates in a reddish-brown\\ncrust, which, examined in section in a good light after it is completely\\ndried, exhibits a smooth, homogeneous, shining appearance with a color\\nhaving the shade of amber.\\nFully as important as any of the metamorphoses of this lesion is\\nits rosy-red areola, in the absence of which it has been held that there\\nis not proper protection. The areola, which endures from about the\\nfifth to the tenth day, completely encircles the compound vesicle in\\nthe form of a halo having a diameter of several inches, the tissue it\\ninvades being often slightly tumid. When the pathological process in\\nthe focus of this areola is intensified, either as the result of the irritant\\ncharacter of the virus or from extrinsic causes (undue exertion of the\\nvaccinated part), the areola may spread down the arm or over the\\nthigh or leg and eventually cover a dense, brawny, and deeply red-\\ndened integument. Dermatitis, erysipelas, lymphangitis, adenopathy,\\nand severe grades of inflammation of the subcutaneous tissues may for\\nsimilar reasons complicate the process, which may terminate by central\\nsloughing, ulceration, slow repair, and the production of an atypical\\ncicatrix. Ordinarily the subjective phenomena are limited to a mild\\nor annoying itching of the vaccinated surface in other cases severe\\nburning pain, a feeling of tension, and even sympathetic fever may\\nbe aroused.\\nThe acme of a successful vaccination is usually attained between the\\ntenth and the fourteenth day, after which the symptoms of the dis-\\norder gradually subside, the crust falling, if undisturbed, in the course\\nof the ensuing week. When animal virus is employed the duration\\nof each of these stages of the disease is usually somewhat prolonged.\\nThe cicatrix, at first slightly reddened or pigmented, gradually as-\\nsumes the dead-white appearance of scars in general. When typical\\nit is slightly depressed, circular, not irregular nor deformed by ridges,\\ncords, or bands, and foveolated, exhibiting a series of peripheral\\npits or depressions, each of which represents the site of a former\\nminute vesicle of simple type. The degree of protection is based in\\npart upon the multiplicity of typical cicatrices.\\nThe complications of vaccination are due first, to the character of\\nthe virus employed second, to the character of the soil in which it is", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0180.jp2"}, "181": {"fulltext": "VACCINIA. 169\\nimplanted and, third, to the external accidents to which the vaccine-\\nlesion is subjected. Respecting the first of these sources, there are few\\ncontagious diseases beside syphilis which may be transmitted by vac-\\ncination. When this accident occurs it may be due either to syphilis\\nin the vaccinifer or to the use of instruments soiled with infectious\\nsecretions. The lymph from a typical vaccine-vesicle upon the skin\\nof an intensely syphilitic vaccinifer will necessarily transmit syphilis if\\naccidentally it be commingled with either blood or the products of\\ninflammation at the base of the pock. The stage and intensity of the\\ndisease in the vaccinifer are elements which cannot be ignored in fore-\\ncasting the issue. The vaccine-lesion may complete its career during\\nthe incubative period of the initial sclerosis, the existence of which at\\nthe site of vaccination is commonly declared later by induration, ulcer-\\nation, pigmentation, and axillary adenopathy. The occurrence of a\\ngeneralized syphiloderm before the chancre of vaccination is completely\\nhealed may be the first symptom to arouse suspicion. The popular\\nimpression regarding the frequency of this accident is erroneous. The\\nrarest of all modes of transmission of syphilis is that by vaccination.\\nIn all such cases the possibility that the syphilis may be hereditary\\nand its symptoms simply coincident in point of time with those of\\nvaccinia, should not be forgotten.\\nExceedingly dangerous is that vaccine-virus, however good its early\\ncharacter, in which decomposition or putrefactive changes have oc-\\ncurred after exposure, in a liquid form, to the action of heat and the\\natmosphere. Vaccination with lymph thus changed has rapidly been\\nfollowed by fatal results, in consequence of the supervention of pyaemia\\nor septicaemia.\\nComplications of vaccinia, due to the character or predisposition of\\nthe tissues in which the virus is introduced by the vaccinator, are\\nusually ascribed by the ignorant or the prejudiced to the causes just\\nconsidered. Post hoc ergo propter hoc is the sole logic of the unin-\\nformed. In this way each of a series of maladies has been ascribed\\nto impurities and humors introduced by vaccination. The argu-\\nments used in support of these assumptions are without basis in the\\nmost of cases. The cutaneous symptoms which may be awakened by\\nvaccination are numerous. It will be remembered that the contents\\nof the typical vaccine-vesicle are auto-inoculable, and that thus the\\nscratching by young patients may produce an abundant crop of typical\\nor torn vesicles upon the arms, legs, thighs, hands, and fingers. But\\nvaccination may awaken in the patient, as explained above, a latent\\nsyphilis, as also a list of cutaneous disorders not contagious in\\ncharacter. Thus, an erythema (roseola vaccinia, vaccinola, etc.),\\neczema in many of its forms, and other exudative processes may be\\naroused first in the integument by the turbulence of a successful\\nvaccination.\\nThese rashes may become generalized, and may even assume a for-\\nmidable appearance. They may appear at any time from the second\\nto the fourteenth day after vaccination. A scarlatiniform rash, dif-\\nfused or in patches, is described by some authors as occurring in this\\nway, accompanied by mild fever, and resembling German measles.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0181.jp2"}, "182": {"fulltext": "170 INFLAMMATIONS.\\nSimilarly generalized eruptions, resembling erythema multiforme, ery-\\nthema scarlatiniforme, eczema, psoriasis, pemphigus, urticaria, impetigo\\ncontagiosa, varicella, and other cutaneous disorders, may appear for the\\nfirst time within the limits named above. They usually disappear\\nwithin a brief time after the vaccine-vesicle has completed its involu-\\ntion, and may be followed by slight desquamation or pigmentation.\\nVery rarely vaccinia is followed by purpuric symptoms and by the\\ndevelopment of lupus-nodules at the site of inoculation.\\nAnomalies of the vaccine-vesicle are occasionally noted as to shape,\\ncareer, and resulting cicatrix, which are difficult to explain. Thus,\\nthe papulo-vesicle may not exhibit an umbilicated centre, or may com-\\nplete its course within unusually short limits; or a harmless ulceration\\nmay progress beneath its crust, requiring a week, or even more, for\\ncomplete cicatrization. The so-called raspberry-sore results from\\ncoalescence of small papules, so as to form a pigmented tubercle. The\\nscars resulting from many of these irregular and non-protective results\\nof vaccination usually form atypical cicatrices, being, in one case, small\\npalm-sized, deforming, corded, and representative of large tissue-loss\\nand, in another case, irregular and inconspicuous.\\nLastly, the complications of vaccinia due to external accidents of\\nthe lesion are usually inflammatory in character. The excessive use\\nof the vaccinated arm in labor and of the vaccinated leg in walking,\\nstanding, and other exertion, may induce, as indicated above, every\\ngrade of dermatitis and even ulcerative changes in the site of the in-\\noculation, as a result of the intensity of the process. For these acci-\\ndents rest is essential, with the free use of a dusting-powder over the\\ninflamed surface. In exaggerated cases lotions of lead- water and opium\\nmay be employed. These conditions are usually relieved without\\ndifficulty as soon as the part is put to rest. The atypical scar which\\nresults seems to be in such cases as protective as others, if only the\\naccident have occurred to a typically progressing lesion with distinctly\\nperfect areola. Vaccine-cicatrices are to be distinguished in anomalous\\nsituations from maculae atrophica?, the scars of syphilis, and other scar-\\nleaving disorders.\\nGenekalized Vaccinia (vaccinal eruptive fever) usually results\\nfrom a non-cutaneous introduction of vaccine virus; and is characterized\\nby the production of vesicles of vaccinia in crops, which resemble\\nstrongly the lesions of variola. Supernumerary vesicles form, at times\\non the mucous surfaces of the mouth, with febrile symptoms and sub-\\nsidence of the eruption in about three weeks.\\nPathology. In the vaccine vesicle, according to Unna, the epi-\\nthelium undergoes ballooning as in variola and varicella, but in the\\nfirst-named affection the two forms of degeneration, reticulating col-\\nliquation and ballooning, are peculiarly commingled. The greater\\nprominence of the ballooning may be due in part to the juvenile char-\\nacter of even the oldest cells. The existence of an inoculation- wound\\nhas a marked influence on the microscopical picture, the resulting\\nfissure being filled with blood-disks inside the horny layer, w T hich is", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0182.jp2"}, "183": {"fulltext": "ERYTHEMA. 171\\nsomewhat thickened. In vaccinia, as in the two maladies which path-\\nologically it most resembles in its lesions, the formation of the vesicle\\nis by chambers, the septa consisting of collections of cells (granular and\\nothers) which seem to be the remains of the sweat-pores.\\nMicrococci have been recognized by Cohn in vaccine-lymph. These\\nhave been named micrococci vaccinae, but their relation to similar\\norganisms discovered in the blood and tissues of variolous patients has\\nnot been determined. Wolff 1 claims to have cultivated these organisms\\nthrough fifteen generations. Strauss demonstrated their existence in\\nthe vaccinal pustules of the calf. 2\\nLipp, of Gratz, reported to the International Medical Congress, in\\nLondon, that he had recognized great similarity, if not identity, be-\\ntween the micrococci of vaccinia and those of variola that he had\\ncultivated to the second generation, but had then been unsuccessful in\\nproducing inoculation-effects. These organisms were always arranged\\nin groups of four or multiples of four.\\nSteinhaus 3 reports that Unna s ballooning and reticular degenera-\\ntions play no part in the formation of the pock in animals. The process\\nis, instead, Ziegler s dropsical degeneration with typical mitoses, but\\nwithout division of the cell-nucleus.\\nTreatment. The management of the severer types of vaccinia and\\nof the complications of the disease is to be conducted in accordance\\nwith the principles of treatment described in connection with derma-\\ntitis venenata and acute eczema.\\nERYTHEMA.\\n(Gr. epvdrjjua redness.\\n(Rose Rash. Ft., Erytheme Ger., Hautrothe.)\\nErythema is, strictly speaking, a mere redness of the skin due to\\ncongestion of the cutaneous vessels. Much confusion has arisen from\\nthe fact that the term is used to indicate a mere symptom, and is also\\napplied to two fairly well-defined groups of cutaneous diseases. Red-\\nness of the skin, varying greatly in its intensity, duration, and distri-\\nbution, is seen in many different conditions and diseases of the integu-\\nment and of the general economy. In the so-called idiopathic\\nerythemas the redness may be the sole symptom recognizable, but it\\nis usually produced by some definite internal or external form of irri-\\ntation, or is symptomatic of systemic disease. Erythema may simply\\nbe hypersemic and be due to a congestion, active or passive, of the\\ncutaneous blood-vessels, or the process may go on to exudation and\\ninflammation. From a pathological point of view it is evident that no\\nsharp line can be drawn between erythema hypersemicum and erythema\\nexudativum, yet for clinical purposes it is convenient to make this dis-\\ntinction.\\n1 Berlin, klin. Woch., January 22, 1883.\\n2 See Magnan, loc. cit.\\n3 Gaz. Lekarsk., 1898, xviii., p. 274.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0183.jp2"}, "184": {"fulltext": "172 INFLAMMATIONS.\\nERYTHEMA HYPEKJEMICUM (seu SIMPLEX).\\nErythema simplex is a coloration of the skin in various shades of\\nredness, temporarily disappearing under pressure, the lesions differing\\nin size and shape according to the extent and degree of the hyperemia\\nby which they are induced.\\nSimple erythema is seen in the phenomenon known as blushing.\\nOrdinarily this is a purely physiological and transitory hyperemia due\\nto emotional causes. Cases occur in which the hyperemia thus\\ninduced persists for hours, together with palpitation and other evi-\\ndences of circulatory disturbance. Here the erythema is symptomatic\\nof either physical or mental disorder. With the former may be classed\\nthose disorders in which portions of the face remain flushed after eat-\\ning, exercising, exposure to heat, etc.\\nUnder idiopathic erythema, have been classed simple forms of\\nerythema for which no cause is recognized. In the great majority of\\ncases a careful search will disclose the disease or condition of w T hich\\nthe erythema is but a symptom. The cause may be found in external\\nirritation too slight and too transient to produce a dermatitis, in dis-\\nturbances of the alimentary canal, in the nervous irritability of children\\ndue to teething, in a drug-idiosyncrasy, or in one of many other\\nderangements of the general economy. Again, the erythema may be a\\nmore or less important diagnostic symptom of graver constitutional\\ndisease, as in the exanthemata, typhoid fever, etc. The color in ery-\\nthema may vary from a delicate pink or rosy shade to a dark-reddish\\nhue; it may be transitory or persistent, and may be limited to circum-\\nscribed points, or macules, or be displayed in diffuse, ill-defined areas.\\nThe character, duration, and distribution of these rashes when due to\\nsimple causes often depend largely upon the peculiarity of the indi-\\nvidual. The same source of disturbance or irritation may produce\\ndifferent effects on the skins of different persons.\\nErythema traumaticum is the result of friction, rubbing, pressure,\\nscratching, or similar external contacts. It is observed, for example,\\nin the part pressed by the pad of a truss in the colored circle left\\nabout the leg where a tight garter has been worn and the sides of the\\nnose where pressure is exerted by a newly applied pair of eye-glasses.\\nThese traumatic hyperemias are readily converted into exudative\\naffections if the traumatism be long continued. Intermittent pressure\\nupon the skin permits restoration of the vascular equilibrium, and the\\nintegument responds to the demand made upon it by increasing in\\nthickness continuous pressure, on the contrary, admits of no such\\nrestoration, and the tissue finally becomes thinner, and yields before\\nthe agent inflicting the injury. Inflammation resulting in ulceration\\nmay finally supervene.\\nErythema Caloricum (Erythema ab Igne). Extremes of heat and\\ncold, either natural or artificial, are sufficient to induce transitory red-\\nness of the skin-surface. In the erythema induced especially by solar\\nheat there is frequently an increase in the pigmentation of the surface,\\nas in the production of freckles and tan in persons whose skins are", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0184.jp2"}, "185": {"fulltext": "ERYTHEMA HYPERMMICUM. 173\\nreddened by the sun. The darker, brownish, and chocolate-colored\\nstains of the hands and face are thus induced.\\nErythema ab igne occurs in annular and odd-looking gyrate patches\\non the anterior surfaces of the legs in cooks, firemen and stokers, and\\nin persons exposing that portion of the body to the direct action of\\nheat. The annular patches may be several centimetres in diameter,\\nand vary in shade from a light to a deep red or even a purplish tint,\\nintense, often permanent pigmentation resulting as the erythema sub-\\nsides. Perry 1 believes that the phenomena are due chiefly to a blood-\\ndisintegration occurring in and around the walls of the plexus of super-\\nficial veins. He adds that the name ephelis ab igne better describes\\nthe condition.\\nErythema Venenatum. A number of chemical substances, dyes,\\nand vegetable poisons are capable of producing transient hyperemia\\nof the skin. Among these may be mentioned cantharides, capsicum,\\nmustard, anilin, chloroform, .ether, arnica, and several of the essential\\noils.\\nErythema Gangrenosum. Under this title several singular affections\\nof the skin have been described, in which erythematous patches\\nappeared and were followed by greater or less extensive destruction of\\none or more of the several layers of the skin. T. C. Fox, in a descrip-\\ntion of the appearances in two cases of the affection under his observa-\\ntion, concludes that these patches are the symptoms of a feigned disease,\\nor of one produced artificially for the purpose of exciting sympathy,\\netc. The majority of these cases are more properly described with\\ndermatitis gangrenosa.\\nErythema Lseve is an obsolete term once employed to designate the\\nshining redness of the skin in oedema of the lower extremities following\\nany disorder sufficient to induce local tumefaction.\\nErythema Paratrimma is a term once employed for the form of deep\\nand lurid redness preceding the formation of a bedsore, an accident\\nwhich under modern methods of nursing is as obsolete as the name\\nonce given it.\\nErythema Fugax is a term applied to a transitory redness of\\nthe skin, usually occurring in small areas, which appears and dis-\\nappears very much as do the lesions of urticaria in fact, it may well\\nbe considered a mild form of urticaria in which typical wheals are\\nabsent.\\nThe Diagnosis of simple erythema is not difficult, since without\\nexudation there is an absence of all other elementary or secondary\\nlesions of the skin. The difficult point in diagnosis is to establish the\\ncause.\\nThe Treatment of most of the erythemas depends entirely on the\\nunderlying cause. For the condition of the skin little if any treat-\\nment is necessary. A dusting-powder is often of service, and if there\\nbe itching or burning an antipruritic or soothing lotion may be indi-\\ncated. Ointments are rarely required.\\n1 Brit. Jour, of Derm., 1900, p. 94.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0185.jp2"}, "186": {"fulltext": "174 INFLAMMATIONS.\\nSYMPTOMATIC ERYTHEMA.\\nThis may be of either active or passive form. A long list of phys-\\niological and pathological causes operating upon the system at large are\\ncapable of inducing active symptomatic hyperemia of the skin. The\\nlarge majority of these erythemas are toxic in origin. The redness\\nmay be generally diffused, or occur in surface-mottlings and markings\\nof various sizes and shapes. Thus, the skin of the face may be red-\\ndened intensely in a paroxysm of rage and that of the limbs of a teething\\nchild be covered with rosy maculations in consequence of the reflection\\nto the surface, through the medium of the nervous system, of the irri-\\ntation induced by the eruption of a tooth. In consequence of the rosy\\ntint assumed by several of these rashes they have long been termed\\nu roseola, a name which to-day is held to describe a symptom rather\\nthan a disease. The word roseola is still associated in the minds of\\nmany with the earliest syphiloderm, but that eruption is now designated\\nby the best authors as the erythematous, or macular, syphilide.\\nRoseola infantilis is sometimes described as a distinct affection\\nin which there are fever and constitutional disturbance lasting a few\\nhours or even a few days. The exanthem varies greatly in extent and\\ndistribution. It is usually macular or punctate, but may be finely\\npapular it is most common on the trunk, but may appear on other\\nparts of the body it may closely simulate scarlatina or measles. It is\\nprobable that these phenomena are always the manifestations of some\\nsystemic or local disorder, and not, as the name w r ould indicate, due to\\na definite disease.\\nSeveral of the severer constitutional maladies betray their morbid\\ninfluence upon the central nervous system by a prompt efflorescence of\\nthis character. A lurid erythema of the axillary or the inguinal re-\\ngion may precede by several days the eruption of confluent variola.\\nCholera, cerebrospinal meningitis, diphtheria, enteric and other fevers\\nare thus at times accompanied, preceded, or followed by rashes. A\\nstudy of these rashes is of the utmost importance to the diagnostician.\\nChildren who are really susceptible to the disease are often supposed\\nto possess an immunity from scarlatina, as the symptomatic erythema\\npreviously displayed was misconstrued. Vaccination may be followed\\nin from one to eight or nine days by a macular or more diffuse ery-\\nthema of the trunk and extremities, usually accompanied by some\\nfebrile reaction.\\nSymptomatic passive erythema is usually characterized by a cyan-\\notic, purplish or darker hue of the integument, resulting largely from\\naccumulation in excess of carbon dioxide in the blood. The tempera-\\nture of such skins is either normal or below the normal standard, as in\\nthose cases in which gangrene ensues. A long list of conditions may\\nbe named in which these symptoms are noted, including derangement\\nof the blood-vessels from imperfect innervation, direct pressure, or\\ndisease of the heart or vascular walls.\\nThese erythemas may be either circumscribed in area or general-\\nized. The term livedo is applied to circumscribed regions of passive\\nerythema. Sometimes the nose, cheeks, fingers, or toes exhibit this", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0186.jp2"}, "187": {"fulltext": "SYMPTOMATIC ERYTHEMA. 175\\nform of disease. The so-called symmetrical gangrene of the fingers\\nbelongs to the same category. Cardiac cyanosis, or Morbus Coeruleus,\\nis a name given to a generalized dark-blue discoloration of the entire\\nsurface, due to continued patency of the foramen ovale.\\nErythema Scarlatiniforme\\n(Scarlatinoid Erythema, Desquamative Scarlatiniform\\nErythema, Scarlatinoid e, Erythema Punctatum, Eoseola\\nScarlatiniforme, Scarlet Rash, Erytheme Infectueux,\\nDermatitis Scarlatiniformis Recidivans). Erythema scarlatini-\\nforme is a name given to an eruption arising from a large number of\\ncauses and varying considerably in character, but having a tendency\\nto simulate the rash of scarlatina. This condition has been described\\nas an idiopathic disease, but it has so often been demonstrated to be\\na symptom only of other disorders that its existence as an independent\\naffection may well be doubted.\\nBesnier, Brocq, and other French authors describe an erytheme sca/*-\\nlatino ide, which is acute in type, and which is always secondary to\\nother infectious diseases, to auto-toxsemia, or to medicinal or food-tox-\\nsemia and an erytheme scarlatiniforme desquamatif, which is subacute\\nin type, and which may be idiopathic, secondary to other infectious\\ndiseases, or be produced artificially by drugs. While it is often clin-\\nically convenient to make a distinction between acute and subacute\\nforms of scarlatiniform erythema, there are no good pathological or etio-\\nlogical grounds for making such distinctions, since a given drug or\\ngiven form of intoxication may produce the acute type in one individual\\nand the chronic form in another.\\nSymptoms. In the acute type, which is the more common of the\\ntwo forms, the rash may be preceded by a day or two of fever and\\nother evidences of constitutional disturbance, or it may appear sud-\\ndenly without premonitory symptoms. The exanthem spreads rapidly\\nand in a few hours, or at most in two or three days, reaches its full\\ndevelopment. The rash may be punctiform, macular, or diffuse, and\\nthe color may be any of the shades of red, but it is usually a bright\\nscarlet. In some instances it has all the appearances of a typical\\nscarlatinal rash, except that it may begin on any part of the body,\\noften sparing the face, and that desquamation begins much earlier\\n(three or four days after the onset of the malady) than in scarlatina.\\nThere are usually some fever, malaise, and other constitutional disturb-\\nances that may vary greatly in intensity, depending upon the disease of\\nwhich the exanthem is a symptom. The mucous membrane of the\\nmouth, the tongue, and the fauces may be reddened or be denuded of\\nepithelium, but the characteristic strawberry-tongue of scarlatina is want-\\ning. The nails and the hair may be shed, but only in exceptional cases.\\nDesquamation usually begins in from two to six days, sometimes\\nbefore the disappearance of the rash, and it may even occur on sur-\\nfaces which had not perceptibly been reddened. The scales are usually\\nfurfuraceous, but they may be large and abundant in rare instances\\nthe entire epidermis of the hand may be shed in glove-like form.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0187.jp2"}, "188": {"fulltext": "176 INFLAMMATIONS.\\nThe subacute forms of scarlatiniform erythema differ from those\\ndescribed above in that constitutional disturbances are less, the rash\\nhas a greater tendency to be diffuse, and, together with the desquama-\\ntion, may persist for weeks or for months, recurrences being frequent.\\nOccasionally cases are found in which recurrences are so frequent as to\\nmake the condition practically continuous and clinically indistinguish-\\nable from the milder forms of dermatitis exfoliativa.\\nEtiology. Idiosyncrasy is a most important factor in the etiology\\nof those forms of erythema which appear in certain predisposed indi-\\nviduals as a result of causes totally insufficient to produce the same\\nphenomena in most persons. The exciting factor is usually, if not\\nalways, some form of toxaemia. Among many causes reported are\\ninfectious diseases, septicemic conditions, toxaemias of varied origins,\\nperitonitis, rheumatism, ague in children, gonorrhoea, abscess, empyema,\\nuraemia, tuberculin-injections, sewer-gas poisoning (Crocker), certain\\narticles of food, and many drugs. The causes are sometimes external, as\\nwhen following mercurial inunctions, exposure to high temperature, etc.\\nDiagnosis. It is most important to distinguish this rash from that\\nof scarlet fever. Commonly the diagnosis is not difficult, as in ery-\\nthema scarlatiniforme the constitutional symptoms are slight the rash\\nappears rapidly, beginning on any part of the body the lesions are\\nexclusively cutaneous desquamation begins early and is extensive\\nthe fauces though red are not swollen and there is absence of the\\nstrawberry-tongue and of all history of contagion. Occasionally the\\nrash may closely resemble that of measles or rotheln, but the history\\nof the case and the absence of other symptoms peculiar to these affec-\\ntions should make the diagnosis clear. As a rule, an examination of\\nthe rash alone is insufficient, and a diagnosis of erythema scarlatini-\\nforme should not be made until the other exanthemata have been con-\\nsidered and excluded.\\nTreatment. This depends entirely on the underlying cause or con-\\ndition. Toxins present should be eliminated as rapidly as possible.\\nThe rash itself rarely calls for treatment. If there be itching or burn-\\ning sensations, a simple dusting-powder, with or without an anti-\\npruritic or a soothing lotion, may be used to make the patient more\\ncomfortable.\\nERYTHEMA PERNIO (PERNIO, CHILBLAINS\\nIs a form of erythema occurring in persons having a feeble circulation\\nor strumous diathesis, usually in the young and the very old. The\\nredness is most conspicuous, as a rule, on the hands and feet, merely\\nbecause of the distance of these organs from the centres of circulation.\\nThe redness is of either a light or a dusky shade is accompanied by\\ntenderness, itching, and burning sensations, especially when the part is\\nbrought near an artificial source of heat and may be the origin of\\nexudative and other affections of the skin, though the ulceration and\\nsloughing which occur in extreme cases are really the results of freez-\\ning the organs rather than of simple exposure to cold when the circu-\\nlation is impaired.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0188.jp2"}, "189": {"fulltext": "ERYTHEMA INTERTRIGO. Ill\\nThe Diagnosis is readily made when it is observed that the redness\\ndisappears on pressure, and also that the parts are actually cool rather\\nthan hot, the coolness being appreciable by the touch. Not rarely\\nthey are both cool and moistened with sweat. Pernio may closely\\nresemble an early stage of lupus erythematosus, but the latter does not\\nvary regularly with the seasons as does pernio, which usually disap-\\npears in summer and reappears in winter. The two conditions are at\\ntimes related, as individuals are seen with pernio of the hands or the\\nfeet, and lupus erythematosus of the face. Cases are recorded in which\\nthe site of a recurring pernio has become the seat of a typical lupus\\nerythematosus.\\nThe Treatment of pernio should be directed to improvement of the\\ncirculation and the general health. Warm clothing to protect the af-\\nfected parts together with active exercise may do much to prevent re-\\ncurrence of the disease. Fowler s solution is considered a prophylactic\\nif given in small doses at the beginning of cold weather. The local\\ntreatment is by brisk friction and stimulating lotions, such as camphor-\\nated soap-liniment acetous, spirituous, and vinous lotions or the use\\nof the ordinary bay rum of the shops. Afterward the parts should\\nbe well dusted with boric acid, and bandaged or wrapped in cotton.\\nThe severer forms of the disease are considered under Dermatitis\\nCalorica.\\nERYTHEMA INTERTRIGO\\nIs a hypersemic condition of those cutaneous and muco-cutaneous sur-\\nfaces which are in constant apposition, and between which there is a\\nhypersecretion or retention of sweat.\\nSymptoms. The erythema is limited to portions of the integument\\nwhich lie in contact with each other, and is subject to certain modifica-\\ntions. The sites of such contact in the human body are the axillae, the\\ngroins, the cleft between the nates, the intermammary and inframam-\\nmary spaces in women, the superior and inner faces of the thighs, the\\nscroto-femoral and the labio-femoral clefts in the sexes respectively, the\\nflexures of the joints, and in especially obese individuals all those parts\\nwhere the integument is thrown into fleshy folds, as about the necks of\\ninfants, and even over the crest of the ilia in fat women. In these\\nlocalities the disorder, beginning as an erythema traumaticum, proceeds\\nby its irritative effects to stimulate the secretion of sweat, which is\\nfreely poured out between the adjacent folds of the skin, and may there\\ntemporarily be imprisoned. The surface, heated and reddened, is also\\nsomewhat macerated by the effused perspiration, and the latter, when\\nchemically altered, as it is frequently under these circumstances, adds\\nstill further to the original disorder. The ground is thus w 7 ell pre-\\npared for an exudative process, which not infrequently supervenes in\\nthe form of a dermatitis or an eczema marginatum but the disorder may\\nbe limited to mere hyperemia with hyperidrosis, and disappear before\\nthe supervention of actual inflammation.\\nThe sensations produced are those of heat and tenderness. When\\nthe parts in contact are separated the surfaces are seen to be reddened\\nand chafed. Here and there very superficial abrasions of the macerated\\n12", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0189.jp2"}, "190": {"fulltext": "1 78 1NFLA MM A TIONS.\\nepidermis become evident. One such abrasion is always especially\\nsignificant. It is the linear and superficial excoriation which marks\\nthe line of deepest contact of the two apposed surfaces of the skin at\\nthe bottom of the angle formed by the two. An offensive odor usually\\nproceeds from the part in consequence of the secreted fluid. The secre-\\ntions of an intertrigo stain, but do not stiffen, the linen of the patient,\\nand they thus differ from the serous fluid poured out in an exudative\\ndermatitis.\\nEtiology. The disease is chiefly induced by heat, friction, and\\nmoisture these causes occasionally cooperating. The heat may merely\\nbe that of the natural temperature of the body, or it may be increased\\nby that due to season and climate. The friction also may merely be\\nthat originating between the surfaces in apposition, or it may be in-\\ncreased by clothing or other articles worn next the skin. The moisture\\nwhich produces maceration of the epidermis is that originating in the\\nperspiratory follicles, their secretion being doubtless stimulated by the\\nheat and friction. The interchange of operation of these three factors,\\nlastly, is shown by the fact that friction, if severe, is capable of increas-\\ning the temperature of the part to which it is applied.\\nAs aggravating causes may be named other physiological secretions\\nand excretions retained in contact with the surfaces affected with an\\nintertrigo. Thus, the feces of the infant left in contact with its nates\\nupon the napkin the urine of the old man with paralysis of the bladder\\nor with overflow from prostatic disease the milk of nursing women\\ndribbling over the breast to the inframammary region retained lochial,\\nmenstrual, and similar discharges, are all efficient in this regard, and\\nare particularly liable to induce that form of dermatitis to which the\\nintertrigo then plays a subordinate part. Fleshy and gouty persons\\nchiefly suffer from these accidents.\\nDiagnosis. The recognition of a simple erythema intertrigo is a\\nmatter of no difficulty if regard be had to the exciting and aggravating\\ncauses enumerated above, and to the special localities in which such\\nhyperemia generally originates. If an eczema or a dermatitis super-\\nvene, the fact will appear from increased subjective sensation (usually\\nsevere itching), from an infiltration of the affected integument, and\\nfrom the appearance of those lesions and discharges which are signifi-\\ncant of these forms of inflammation of the skin. It must be remem-\\nbered that transition from a simple erythema to a dermatitis of these\\nregions is of frequent occurrence. Erythema intertrigo may occur as\\na mild form of eczema seborrhoeicum.\\nThe special sites of preference of intertrigo are those of the disease\\nnamed by Hebra eczema marginatum, or ringworm as it occurs upon\\nthe parts of the thighs covered by the reinforcing patch in the\\ntrowsers of cavalrymen. The disease is properly named tinea cir-\\ncinata cruris, though it is found also about the axillae, the buttocks,\\nand the groins of both sexes. Here the disorder, however, is of the\\nexudative type, and, moreover, is distinguished by a characteristic\\nfestooning of the elevated border marking the advancing limit of\\nthe disease. The microscope, by revealing the existence of a fungus,\\nwill, of course, put an end to any doubt. In intertrigo the most", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0190.jp2"}, "191": {"fulltext": "ERYTHEMA INTERTRIGO. 179\\nmarked evidence of disease is to be recognized in the deeper parts of\\nthe cleft between the two adjacent skin-surfaces, while in tinea cir-\\ncinata cruris the growth of the parasite is most active at the advancing\\nborder of the patch, which is, moreover, perceptibly elevated above the\\nsound skin.\\nTreatment. Intertrigo is an exceedingly common affection of the\\nskin, and it occasionally proves of great annoyance to those suffering\\nfrom it. The skill of the young practitioner is often tested early in his\\nprofessional career by his management of such cases and not a little\\nmay depend upon the success with which he is rewarded. Gouty\\npatients always require limitation of the diet, and often also medication\\nwith alkalies and mercurial cathartics.\\nThe affected surfaces should gently be cleansed by ablution with\\nsoap and warm water, and the offensive odor of the secretions remedied\\nby the addition to the water of a weak solution of formalin, of carbolic\\nacid, or of the dilute liquor sodse chlorinatse. The parts are then to be\\ncarefully dried with a freshly laundered towel or a soft handkerchief,\\nand afterward one of the dusting-powders very thoroughly applied.\\nTo be of service, these powders must be impalpable, and, if compounded\\nby a druggist, be sifted through fine silk bolting-cloth. The articles\\nchiefly used for this purpose are zinc stearate with acetanilid, bismuth,\\nstarch, zinc oxide, French chalk, lycopodium, or, when an antipruritic\\neffect is desired, camphor. Combinations of several of these are at\\ntimes effective. The formula of McCall Anderson is highly esteemed:\\nM.\\nFor the purpose of absorbing excessive perspiration magnesium\\ncarbonate is the most effective of all the powders.\\nThe following is the formula for a dusting-powder recommended\\nby Klamann\\nR Talc, venet. pulv.,\\nAcid, salicyl.,\\nMagnes. ust. subtil, pulv.,\\nSig. Dusting-powder.\\nFinely bolted starch answers well alone or in combination with some\\nof the other articles above named. 2\\nThe affected surfaces of the skin must also be separated in order to\\nprevent further friction. A thin strip of lint, antiseptic cotton, or\\nmedicated wool may be used for this purpose, and must be inserted as\\nfar as the deeper portions of the cleft in which the secretion chiefly\\nforms. Occasionally it will be found useful to anoint this absorbent\\nlayer with cold-cream salve or with vaselin. Where an astringent effect\\nis desired lycopodium or other dusting-powder may be compounded with\\n1 Hebam. Kalend., Obstet, Gazette, March, 1882.\\n2 Unna s salve-muslins and pastes will be found effectual and neat applications in\\nmany forms of intertrigo.\\nR\\nZinci oxid. pulv.,\\n,^ss;\\n16\\nCamphorae pulv.,\\n3jss\\n6\\nAmyli pulv.,\\nBj;\\n32\\nSig.\\nAnderson s dusting-powder.\\n3v;\\n20\\ngr. J\\n18\\n3jss\\n6\\nM", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0191.jp2"}, "192": {"fulltext": "180 INFLAMMATIONS.\\ntannin, alum, or similar substances. The list of lotions also may at\\ntimes be consulted with advantage. Thus, cologne-water, weak spirit\\nlotions, tannin, or aromatic wine, or magnesium carbonate, may each be\\nserviceable. Lastly, carron oil (equal parts of lime-water and linseed-\\noil), spread thickly upon linen, will possibly give more relief than other\\narticles named, the chief objection to it being the consequent soiling of\\nthe patient s clothing.\\nERYTHEMA MULTIFORME.\\n(Erythema Exsudativum Multiforme. Fr., Erytheme\\nPapulo-tuberculeux.)\\nSymptoms. In this affection the most common lesions are erythem-\\natous maculae, flattened papula?, and even large flat nodosities. Vesi-\\ncles and bullae occur in a few cases. While multiformity is the rule,\\none type of lesion usually predominates in each case. The eruption is\\nnearly always symmetrical, and occurs usually upon portions of the\\nextremities, the forearms, the legs, and the dorsum of the hands and\\nfeet. It occurs exceptionally on other parts of the body, and rarely\\nupon the mucous membrane of the mouth, nose, and conjunctiva. It\\nhas been seen on the sclerotic. From the beginning the lesions are\\nmore or less flat, elevated, and \u00c2\u00a9edematous. The eruption, which is\\ngenerally recognized in well-defined patches, usually begins with\\npinhead- to finger-nail-sized macules of a darkish-, bluish-, or purplish-\\nred shade that lose their color under the pressure of the finger, and in\\nthe course of some hours exhibit tumefaction in various degrees, thus\\nproducing the papules, tubercles, and nodes already described. In\\nmany cases there is a remarkable tendency to a flattening and widening\\nof the lesions to a point, when they closely resemble a floridly tinted\\ncondyloma. The disease may persist for but a few days, but in severer\\ngrades it lasts for several weeks or months. Recurrent attacks through\\na period of years are not uncommon. In the height of the exudative\\nprocess there is usually an efflux of the coloring-matter of the blood\\ninto the skin which is the site of the several lesions, and thus are pro-\\nduced the singular shades of reddish black, purple and red, blue and\\nred, yellow and orange, black and blue, that are characteristic of\\nsimple bruises of the extremities when the injury has been sufficient\\nto cause extravasation of blood. The lesions occur in various shapes,\\nsizes, and shades, a number of names having been used to designate\\ntheir several appearances, that require explanation though they are\\nwithout practical value.\\nThe exanthem is peculiar in that it is especially likely to develop\\nand recur in the spring and autumn, is not capable of being awakened\\nto activity by external irritation solely, and is productive of rather\\ninsignificant subjective sensations (burning and smarting) as compared\\nwith other rashes of even less brilliant hue.\\nErythema Annulare or Circinatum) is characterized by a central\\ndepression and paling of color, and a peripheral extension of the ery-\\nthematous patch in the form of a ring.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0192.jp2"}, "193": {"fulltext": "PLATE II.\\nErythema Multiforme Cireinate-type.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0193.jp2"}, "194": {"fulltext": "", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0194.jp2"}, "195": {"fulltext": "ERYTHEMA MULTIFORME. 181\\nErythema Figuratum occurs in gyrations formed by coalescence of\\ntwo or more annular circles.\\nErythema Induratum is considered with the tuberculous affections of\\nthe skin.\\nErythema Marginatum is that form of the disease in which a dis-\\ntinctly elevated and denned marginal band is left as the sequel of an\\nerythematous patch.\\nErythema Papulatum (or Papulosum) and Erythema Tuberculatum\\n(or Tuberculosum) are those forms in which occur lesions respectively\\nof a papular or a tubercular type.\\nErythema Urticatum is that form in which there is severe itching,\\nand, as a result, scratching of the lesions, with crusts of dark dried\\nblood at the summit of each. The crust is surrounded by the light-red\\nor bluish-red, flattened or elevated patch characteristic of the disease.\\nErythema Vesiculosum and Erythema Bullosum are exceptional forms\\nin which the exudation is sufficient to raise the horny layer of the\\nepidermis into larger or smaller serum-containing chambers, which may\\nbe, as regards the erythematous patch, of central or peripheral situation,\\nand which may crown the summit of papule or tubercle. The fluid is\\nusually removed by absorption, and is rarely set free by rupture of the\\nvesicle or bleb.\\nErythema Iris (Herpes Iris, Hydroa Vesiculeux) is the result of suc-\\ncessive erythematous centric lesions, which at times form several dif-\\nerently shaded concentric rings.\\nAt the onset there appear one or several vesicles or vesico-papules,\\nwhich pursue their rapid career in two or three days. Upon the hyper-\\nsemic ring Avhich surrounds these lesions a second and even a third and\\nfourth circlet of similar lesions form, each pushing the areola further\\nto the periphery of the patch. The older lesions are in full retrogres-\\nsion, while the newer vesicles are in process of evolution and the red\\nblush which surrounds the earlier lesions is undergoing color-changes\\nfrom vivid to purple and paler hues, while the zone of the latest vesicles\\nis assuming its intensest shade. The lesions are pinhead- to pea-sized,\\nrather persistent and firm, and terminate more often by resolution than\\nby rupture and crusting. The concentric and parti-colored rings may\\nmake up a single patch an inch or more in diameter, or several such\\npatches may form upon the surface of the integument. In the latter\\ncase the central disk of some of the patches will be seen to be composed\\nof confluent lesions. The subjective sensations produced are usually\\ntrifling;.\\nAtypical forms occur in which the lesions are developed imperfectly\\nfrom papules, and also in which, in consequence of an unusual exudation\\nof serum, bullae appear. These may coalesce or be filled with blood\\nor hematuria may result, with severe involvement of the mucous mem-\\nbrane of the lips, the tongue, the soft palate, and other parts of the\\nmouth, ulceration rapidly ensuing. Cases with these complications\\nshould really be classified with the grave forms of pemphigus, to which\\nthey properly belong.\\nErythema Nodosum (Dermatitis Contusiformis Fr., Eryth-\\neme Noueux) is a form of erythema multiforme, regarded by several", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0195.jp2"}, "196": {"fulltext": "182 INFLAMMATIONS.\\nauthors as a distinct affection, in which the characteristic lesions are\\nof the dimensions of semi-globular pea- to fist-sized tumors, pale red\\nto livid blue in color, tender upon pressure, and exhibiting in their\\ninvolution the variegations of hue already described. They occur\\nchiefly upon the legs and dorsum of the feet, but also more rarely upon\\nthe trunk and the face. Though occasionally becoming so soft to the\\ntouch that fluctuation may seem to be present, they never terminate by\\nsuppuration.\\nUnna lays stress in the distinction between this disease and erythema\\nmultiforme upon the fact that the lesions of erythema nodosum never\\nwiden concentrically, never produce bullae, and never exhibit annular\\nvesicles.\\nThe nodose lesions occur most often in youth, in girls more often\\nthan in boys, with acute or subacute symptoms frequently with rheu-\\nmatoid pains and febrile temperatures. The oval or roundish, eryth-\\nematous or empurpled nodes, varying in size from that of a small nut\\nto that of a pigeon s egg, are most often seen on the lower limbs,\\nthough they appear also on the thighs, the buttocks, and the fore-\\narms. They are usually tender on pressure, and often painful. They\\nmay disappear in a fortnight, but occasionally observe a stadium of\\nsix weeks duration, forming and disappearing in crops. The petechial\\nappearance of the spots where they have existed is that of the charac-\\nteristic black-and-blue mark. By some authors this disease is\\nrecorded as associated with tuberculosis, an observation probably due\\nto the fact that it appears so often among the poorly nourished and\\nill-housed. It unquestionably occurs most frequently in the spring\\nand autumn, and is not infrequently associated with arthritis or a rheu-\\nmatic diathesis. Other causes cited are malarial chills, temperature-\\nchanges, endocarditis, urethral irritation (blennorrhagic, instrumental),\\nmedicamentous ingesta, alcoholic excesses, and dentition\\nA number of medicaments, when ingested or externally employed,\\nare capable of producing eruptions identical in appearance with the\\nlesions of erythema multiforme. For descriptions of these the reader\\nis referred to the sections devoted to Dermatitis Medicamentosa and\\nDermatitis Venenata. Quinine, arsenic, belladonna, chloral, salicylic\\nacid, iodine and bromine compounds, and other substances are often\\nresponsible for these symptoms.\\nThe name multiforme, given to this disease by Hebra, is justified\\nby the singular diversity of lesions which it displays. These lesions\\nare remarkable, not merely for their variety, but also for their occur-\\nrence in such variety both simultaneously and successively, and for\\ntheir rapid change from one type to another.\\nThe subjective symptoms, save in the urticarial form of the dis-\\nease, are usually of a trifling character. The slight sense of heat and\\nburning awakened by the lesions is altogether out of proportion to\\nthe extent of their development.\\nThe symptoms, however, indicative of a general disturbance of the\\nsystem may be of a marked character. General malaise, fever, inap-\\npetence, pharyngeal inflammation, chills, severe gastro-intestinal dis-", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0196.jp2"}, "197": {"fulltext": "ERYTHEMA MULTIFORME. 183\\norder, rheumatoid involvement of the articulations, and even organic\\nchanges in the heart (valves, endocardium, and pericardium), lungs,\\nand kidneys have all been noted as coincident or as causative phe-\\nnomena. In many of these cases it is clear that the exanthem belongs\\nto the list of symptomatic erythemata, and that it is of insignificance\\nin comparison with the grave general condition. It may thus be the\\nprecursor of typhoid fever, malaria, or severe articular rheumatism, or\\nmay become even an abortive expression of these disorders. With\\nthese exceptions, however, the prognosis is in general favorable, as the\\ndisease may terminate in a few days, and rarely exceeds a month in\\nduration.\\nOccasionally the mucous membranes are affected to a disagreeable or\\neven painful extent. Thus, a sudden tumefaction of the uvula may\\nsupervene upon the cutaneous symptoms, in cases sufficient to impede\\nrespiration or the lining membrane of the larynx may be involved,\\nand the resulting aphonia in various degrees persist for two or three\\ndays.\\nEtiology. The affection is commonest in the spring and autumn\\nit occurs in the young or in the early periods of adult life the papular\\nand tubercular forms are more common in men, and the nodose forms\\nin women many patients are affected with rheumatism. In two valu-\\nable contributions to the study of the visceral complications of the\\nerythema group Osier has shown that the cutaneous symptoms may\\nbe merely surface-expressions of a visceral disorder and indeed that\\nthe skin-symptoms may wholly be absent when the disease is in prog-\\nress. In the eighteen cases studied by him there were three sets of\\nsymptoms: (a) polymorphous skin-lesions, including acute circum-\\nscribed oedema, urticaria, purpura, and ordinary forms of erythema\\nmultiforme (b) visceral lesions, including (1) gastro-intestinal crises\\nin which severe colic, with or Avithout vomiting, diarrhoea, or bloody\\nstools, was frequent, (2) hseniaturia and nephritis, (3) hemorrhages from\\nmucous surfaces, (4) cerebral symptoms, (5) pulmonary complications\\nand (c) infiltration of synovial sheaths and periarticular tissues, and\\narthritis. In some of his cases a given visceral lesion had been accom-\\npanied at different times in the same individual by each of the types\\nof cutaneous lesions.\\nThe etiology of erthema multiforme includes a list of varying and.\\nwidely differing causes. Among the concurrent disorders may be\\nnamed: cardiac affections, diphtheria, toxaemias, and neurotic disturb-\\nances. Severe manifestations of the disease have been observed in a\\nyoung woman with extensive ulceration of the cervix uteri. Tilbury\\nFox noted a frequency of symptoms in young servants brought to town\\nfrom the country. It is not rare in young female immigrants who\\nhave recently made a steerage passage to America. Mackenzie 2 has\\ncalled attention to the relationship of erythema multiforme to rheuma-\\ntism and to purpura rheumatica.\\nThere can be little doubt that erythema multiforme, arthritic pur-\\npura, urticaria, and acute circumscribed oedema are closely related.\\n1 Amer. Jour. Med. Sci., December, 1895 and Brit. Jour, of Derm., July, 1900.\\n2 Brit. Jour, of Derm., April, 1896.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0197.jp2"}, "198": {"fulltext": "184 INFLAMMATIONS.\\nThe reasons for such belief, as stated by Osier, are the similarity\\nof conditions under which these disorders occur, the identity of the\\nvisceral manifestations, and the substitution of these affections for each\\nother in one and the same patient at different times.\\nPathology. Erythema multiforme is essentially a hypersemia of\\nthe integument that, under certain obscure influences, advances more\\nor less rapidly to the stage of a mild grade of inflammation with conse-\\nquent exudation. If, with Landois and Lewis, it be accepted that\\nthe process is the result of vasomotor nerve influence, it cannot be\\ndetermined whether these nerves are irritated at their points of origin\\nor of distribution. In the case of erythema nodosum Hebra advanced\\nthe hypothesis that the morbid process is essentially an inflammation\\nof the lymphatic vessels. In some cases it is evident that there is\\nextravasation of blood from the vessels into the skin of the affected\\npart.\\nLeloir 1 discovered in the papules, tubercles, and bullae of erythema\\nmultiforme only the phenomena of hypersemia and exudation limited\\nto the corium and subcutaneous tissue; and Villemin 2 simply confirms\\nthese facts. Singer 3 has shown that the skin-lesions in erythema multi-\\nforme are for the most part evidences of staphylococci and strepto-\\ncocci in the blood. Crocker, examining a patch of erythema tuber-\\nculatum, recognized merely a cell-effusion in the upper portion of the\\ncorium extending sparsely below, and then chiefly along the ducts and\\nfollicles. There was slight rete-proliferation. Unna recognizes both\\nin erythema multiforme and erythema nodosum vascular dilatation,\\ncell-proliferation especially around the vessel-walls with cell-emigra-\\ntion, and oedema of the cutis. In two cases of the iris-type Pardee 4\\nfound simply an acute exudative inflammation of the upper part of the\\ncorium.\\nThere is evidently a toxin responsible for these changes, the nature\\nof which has not been determined.\\nDiagnosis. Erythema multiforme is always to be carefully distin-\\nguished from the traumatism producing braises, especially upon the\\nlower extremities. This point may have an interesting bearing\\nupon certain medico-legal questions, especially in the case of young\\nchildren.\\nThe tendency of the disease here considered to symmetrical arrange-\\nment upon the two sides of the body, the occurrence of lesions evi-\\ndently dating from several periods in which successive crops appear,\\nand the absence of all history of external injury, will usually suffice to\\nestablish a diagnosis. Among the precocious affections of the subcu-\\ntaneous connective tissue in syphilis Mauriac described a lesion re-\\nsembling somewhat the symptoms of erythema nodosum but in such\\ncases, and especially in women, mucous patches of the vulva, of the anus,\\nor of the mouth, with coincident adenopathy, Avould point to the real\\nnature of the disease. Syphilitic nodes and gummata are distinguished\\n^ull. de la Soc. an at., 1884, p. 294.\\n2 Gaz. hebdom., 1886, Nos. 22 and 23.\\n3 Wien. klin. Woch., 1897, 38.\\nJohns Hopkins Hosp. Bull., July, 1898.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0198.jp2"}, "199": {"fulltext": "ERYTHEMA MULTIFORME. 185\\nfrom the lesions of the nodose forms of erythema by the pain attending\\nthe former, their fewness, their overlying integument untinted save\\nwhen actually softening and approaching disintegration, their obvi-\\nously subcutaneous site, and the usual concomitant symptoms of late\\nlues.\\nThe chief points by which a diagnosis of the erythemata in general\\nis established are the recognition of the vivid coloring of most of the\\nlesions their oedematous character their symmetry as a rule the pig-\\nmentation following those situated on the lower limbs their frequent\\nassociation with rheumatism or rheumatoid pains, febrile phenomena,\\nmalaise, or other constitutional disturbances. The wheals of urticaria\\nare smaller, more whitish centrally, more closely packed together, less\\nsymmetrical, rarely grouped, and, as a rule, decidedly more acute than\\nthose of erythema. Cases difficult to assign to either disease are com-\\nmon, and an error in either direction is not serious. Rubella (German\\nmeasles) is to be distinguished by its adenopathy, its pharyngeal symp-\\ntoms, and its flattish spots. In eczema erythematosum there is less\\ndefinition of each patch, and the redness is commonly diffuse papular\\nforms of eczema are usually commingled with other readily distin-\\nguished symptoms of that disease.\\nPotassium iodide and a few other drugs administered internally are\\ncapable of producing almost every one of the lesions described above.\\nIn the erythemata for which iodine and bromine salts have been admin-\\nistered, with the production of skin-symptoms, the confusion produced\\nbecomes a fruitful source of error.\\nTreatment. As in the majority of instances the disease under con-\\nsideration progresses naturally to a favorable termination within the\\ncourse of a few weeks, the duty of the physician is usually limited to the\\nquestion of diagnosis and to a study of the etiology in each case, with\\nthe purpose of preventing future attacks. He should remember that\\nthe larger lesions seen in erythema nodosum never suppurate, and thus\\nshould not be tempted to open them with a lancet. Local treatment is\\noften unnecessary. For the relief of the slight burning or itching present\\nin some cases a dusting-powder, sedative or antipruritic lotion, or other\\nprotective dressing may be employed. Bullae and vesicles should be\\nevacuated and protected with a simple antiseptic dressing. Internally\\nsuch medication should be employed as is indicated by the general\\ncondition of the patient. Iron, quinine, the salicylates, salol, strych-\\nnine, and dilute hydrochloric acid will be found beneficial in many\\ncases. Constipation and indigestion are to be corrected by appro-\\npriate measures. When the disorder accompanies rheumatic or other\\nsystemic disease internal treatment is to be directed to the general\\ncondition present. When the erythema produces extensive oedema\\nof the uvula incisions may be requisite to prevent dyspnoea and\\ndysphagia.\\nPrognosis. It will be gathered from what has preceded that the\\nprognosis is usually favorable, but necessarily varies with the constitu-\\ntional disease of which the erythema may be a mere symptom. The\\nmalady may relapse in susceptible individuals at those periods of the\\nyear when it is most frequently observed.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0199.jp2"}, "200": {"fulltext": "186 INFLAMMA TIONS.\\nPELLAGRA.\\n(Lat. pellis, the skin ceger, diseased.)\\n(Lombaedy Erysipelas, Lombabdy Lepbosy, Risipola Lom-\\nbabda, La Rosa, Mal Roxo.)\\nThis disease has attracted attention by its extensive ravages in Lom-\\nbardy and the contiguous provinces, including a portion of Southern\\nEgypt, France, and Spain. It is a constitutional epidemic disorder,\\naccompanied by an exanthem which justifies its brief consideration in\\nthis connection.\\nSymptoms. The earliest symptoms of the disease, usually first\\nnoted in the spring, are prodromic, and characterized by marked fatigue,\\nmalaise, and occasionally by febrile symptoms. Soon the face, neck,\\nchest, backs of the hands, and forearms (when exposed to the sun)\\nare affected with a symmetrical erythema of a dull lurid hue, disap-\\npearing on pressure, which may be accompanied by desquamation,\\noccurring in successive years chiefly in the summer season, often fading\\nin the autumn, at times with desquamation. After frequent relapses\\nthe skin becomes of a dark olive-brown, bluish-red, or deeply pigmented\\nand bronzed hue, and general exfoliation of the epidermis follows in\\nlarge flakes. Simultaneously, an extraordinary degree of muscular\\nfeebleness is noticed the skin becomes at first pruritic or hypersesthetic\\nlater, distinct atrophy occurs; and a sensation of chilliness is induced,\\nsimilar to that observed in general exfoliative dermatitis. As in that\\ndisease also, the fingers gradually become semiflexed into the palm, and\\ngastro-intestinal derangements supervene, accompanied by a furred\\ntongue, inappetence, colicky pains, and diarrhoea. Disorders of the\\nnervous system are betrayed by melancholia, disturbed vision, idiocy,\\nconvulsions, and symptoms of meningitis. Post mortem, pachymenin-\\ngitis, with induration, atrophy, and other secondary changes in the\\nbrain and cord, have been observed.\\nThe erythema displayed is one corresponding largely with that of the\\nother symptomatic erythemata. Its colors are in different hues according\\nto the age and sex of the patient and the stage of the disease. It disap-\\npears under pressure at first later it may persist even before the pig-\\nmented condition is produced it may be of congestive type and accom-\\npanied by bullous efflorescence and crusting with erosive features. It\\nmay subside in a fortnight not to return, or return with successive sea-\\nsons till the integument becomes gradually wrinkled, thinned, and in\\nthe xerodermatous state of impoverished senility.\\nAfter the eruptive symptoms the important features are the mus-\\ncular feebleness, the remarkable tendency to chills alternating with\\nfebrile accesses, the flexion, more or less persistent, of the fingers into\\nthe palms, and, in fatal cases, changes in the nervous centres, such as\\npachymeningitis and sclerosis of nerve-tissue, producing during the life\\nof the patient paralytic and paretic symptoms, melancholia, imbecility,\\nand dementia.\\nEtiology and Pathology. Pellagra originates in the use, as an", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0200.jp2"}, "201": {"fulltext": "PELLAGRA. 187\\narticle of diet, of maize which has been improperly dried or has devel-\\noped deleterious substances after its reduction to a coarse powder.\\nLombroso 1 has produced the symptoms of the disease experimentally\\nand has demonstrated as etiological factors toxins developed during the\\nspoiling of maize, though numerous mycotic and parasitic organisms\\nare also present during the process, pure cultures of which produce no\\nsymptoms of the malady. In 113 autopsies, of which 70 were made\\nby himself, Lombroso discovered: exudation into the membranes of\\nthe cord, liver, kidneys, and spleen atrophy of viscera supplied by\\nthe vagus fatty degeneration of kidneys, liver, myocardium, and ves-\\nsels and cells of the cord; pigment-changes in cells of brain, cord,\\nliver, kidneys, and heart; atheroma, calvities, dermato-sclerosis, and\\nsclerosis of cord. Individuals have suffered from the disease, it is true,\\nwho never partook of maize, and also those who were not specially\\nexposed to the action of the sun, which in some cases seems to have\\nserved as an aggravation of the malady. The wretchedness, poverty,\\npoor food, and moral and social condition of the inhabitants of pel-\\nlagrous districts, many of them toiling under a burning sun, half-\\nstarved, emaciated, and despairing, explain in part only the symptoms\\nof the scourge which afflicts them.\\nThe distinction between pellagra and pseudo-pellagra has an etio-\\nlogical basis one class of patients suffering from classical symptoms\\nsolely produced by the specific toxins of the disease the other class\\ndebilitated by alcoholism, malaria, uraemia, and other morbific factors.\\nIn cachectic men and women who have never been exposed to the sun\\nand have not been known to be poisoned by eating decomposed or fer-\\nmented maize, the symptoms of pellagra have been noted while in\\nothers mere exposure to the rays of the sun of the cachectic and of\\nthose suffering from visceral maladies (gastric carcinoma, disease of the\\nsuprarenal capsules, etc.) has not produced characteristic lesions of\\npellagra.\\nThe Treatment is by prophylaxis improvement of the hygienic\\nand climatic conditions of the patient quinine and tonics in cases of\\ndebility; proper management of nervous and gastric troubles; and,\\nwhen practicable, a generous dietary. Lombroso recommends, as a\\nprophylactic measure, care in the storing of grain.\\nThe Prognosis is favorable in some cases, which may be so mild as\\nto be scarcely noticeable in others it is grave and in districts where\\nthe disease prevails extensively the mortality may be formidable.\\nAcrodynia (Epidemic Erythema) is an affection suggesting in\\nits symptoms those of pellagra. It first occurred in Paris, in the year\\n1828, in an infirmary for aged men; and has been since recognized in\\nepidemic form in France, Belgium, Algiers, Mexico, and a few other\\ncountries.\\nThe disease begins with facial oedema, gastric distress, conjunctival\\ninjection, and hyperaesthetic symptoms, with a sense of formication and\\npricking in the parts chiefly affected. The cutaneous lesions are ery-\\nthematous, displayed in points over the extremities, and especially over\\n1 Die Lehre v. d. Pellagra. Coblentz, Berlin, 1898.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0201.jp2"}, "202": {"fulltext": "188 INFLAMMATIONS.\\nthe hands and the feet, particularly their palmar and plantar sur-\\nfaces. It has either a simple or a polymorphic expression, and is\\nconcluded by a furfuraceous or lamellated desquamation. When fluid-\\ncontaining lesions are produced, these are either vesicular or bullous,\\nand filled with limpid or reddish contents. When the consequent\\nexfoliation occurs over the palmar and plantar surfaces there may be a\\ndesquamation similar to that occurring in some of the exfoliating der-\\nmatoses, large horny flakes and casts being either firmly adherent to,\\nor separable from, the tissues beneath.\\nThe grave complications of cases are oedema followed by atrophy,\\nparetic symptoms, febrile and gastric complications, and senile ma-\\nrasmus.\\nOne of the most characteristic features of the disorder is the blackish\\nhue of the skin of affected persons over the breasts, belly, flanks, chest,\\naxillae, and inguinal regions.\\nThe Pathology is obscure the Treatment, that indicated by the\\ngeneral ill-health of the patients and the Prognosis, unfavorable.\\nURTICARIA.\\nLat. urtiea, the nettle.)\\n(Hives, Nettle-rash. Fr., Urticaire Ger., Nesselsttch,\\nNesselfieber.)\\nSymptoms. This disorder may be ushered in by constitutional\\nsymptoms, such as inappetence, malaise, cephalalgia, or mild pyrexic\\nphenomena lasting for a few hours or even a day or more.\\nWith, and often without, such prodromic symptoms the eruption\\nsuddenly appears in the form of wheals upon the skin-surface, that\\nfrequently disappear with equal rapidity, leaving no traces of their\\nexistence save a slight and transitory hypersemia of the affected spot.\\nThe lesions may be as small as a finger-nail or a coffee-bean, and usually\\nare of this size; but in rare instances giant -wheals are seen large\\ntomato-sized projections or flat elevations of broad areas of the integu-\\nment, that cover the greater part of the belly or buttock. In color\\nthe lesions are rosy red or whitish, and are usually surrounded by\\na hypersemic areola. They may be isolated and few, or be numerous\\nand closely packed together they may even coalesce, so that individual\\nwheals are scarcely recognizable. They are usually firm and semisolid\\nto the touch. Rarely, the horny layer of the skin is raised in fluid-\\ncontaining lesions by the sudden effusion of serum beneath. In contour\\nthey are roundish or oval-shaped, but a variety of curious outlines may\\nresult from the irregularity of their development. Concentric circles,\\nlines, bands, and even figures are in this way produced. The finger-\\nnail drawn across the unaffected portions of the skin of a patient with\\nurticaria will often produce a linear wheal urticarial autogram of\\nextent corresponding with the line of irritation (dermographism). In\\nthis way the so-called medium with a sensitive skin exhibits written\\ncharacters upon the surface of his body.\\nThe subjective sensations induced by these lesions are distressing", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0202.jp2"}, "203": {"fulltext": "URTICARIA. 189\\nin varying degrees, according to the susceptibility of the individual.\\nEvery grade of pruritic burning, tickling, crawling, pricking, and\\nespecially stinging sensations, is thus engendered. The efforts of the\\npatient to secure relief by scratching not only serve still further to\\ndevelop the eruption, but also to irritate, tear, and otherwise wound\\nthe lesions already in full evolution. In this way serous effusions are\\nproduced at the summits of the wheals and in this way, also, lesions\\nreally transitory in their course may be changed to more persistent,\\ndeeply colored, flat, lenticular papules. Where the skin is delicate\\nand thin, as is that of the lids and prepuce, considerable oedema may\\nresult.\\nAll parts of the body may become affected, irrespective of age and\\nsex, though children are particularly liable to the disease. There are\\nfew very young children with skins unwashed for an entire month\\nFig. 40.\\n\u00e2\u0096\u00a0\u00e2\u0096\u00a0\u00e2\u0096\u00a0\u00e2\u0096\u00a0HHHHttHm\\nAutographism in urticaria.\\nwho will not exhibit urticarial symptoms if there be an added irrita-\\ntion of the surface. The disease occasionally involves the mucous\\nmembrane of the mouth, pharynx, and larynx.\\nThe lesions numerically may be few or be so numerous as to cover\\nthe entire surface of the body. Though more frequently acute in\\ncourse, they often recur from apparently insignificant causes, or even\\nbecome chronic. In many cases trivial the disease may become so\\naggravated as to make the largest demands upon the skill of the\\nphysician.\\nThe rapidity of appearance and disappearance of the lesions visible\\nupon the skin is a characteristic feature of the disease. In some\\ninstances but a few moments are required after the operation of an\\nefficient cause to develop a large number of closely packed wheals.\\nEven while they are under inspection it can be noted that there is a\\nchange in individual lesions, some fading or completely disappearing,\\nwhile others are newly developing.\\nA number of names have been employed to designate the several\\nexternal peculiarities of the lesions as they are presented to the eye.\\nThus, Urticaria annularis occurs in rings U. figurata, in gyrations\\nfrom union of several lesions or patches of lesions U. vesiculosa and\\nU. bullosa, where there is a vesicular or bullous development at the\\nsummit of the lesion U. papulosa (or Lichen urticatus), where there", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0203.jp2"}, "204": {"fulltext": "190 INFLAMMA TIONS.\\nis a combination of the features of the wheal and the papule, the\\nlesions being naturally grape-seed- to coffee-bean-sized, and covered\\nwith blood-crusts where their apices have been torn in scratching\\nU. tuberosa, where giant -wheals occur, some attaining the size of\\na hen s egg U. hemorrhagica (Purpura urticata), where the urticarial\\nelement is developed in a lesion produced by cutaneous hemorrhage\\nand U. evanida, or perstans, where there is, respectively, a rapid or a\\nslow process of involution in the characteristic symptoms.\\nBaker l reported a case of Urticaria Tuberosa characterized by\\nthe presence in various parts of the body of persistent yellowish-red\\ntubercles, which proceeded to ulceration. The parts most affected were\\nthe knuckles, the elbows, and the ear. These tubercles are said to\\nhave begun in a manner similar to that which characterizes the onset\\nof evanescent urticarial wheals and tubercles. A somewhat similar\\ncase was observed by McCall Anderson. 2\\nUrticaria, like erythema, may be either idiopathic or symptomatic\\nand in each form the urticarial conditions may underlie or be superim-\\nposed upon almost every elementary lesion noted in the integument.\\nThe wheal may complicate (or be complicated by) the macule, papule,\\ntubercle, vesicle, bulla, and pustule. It may spring from an excoria-\\ntion or may result in a fissure. It is common in traumatisms, and is a\\nprominent symptom in the skin bitten by insects, reptiles, or domestic\\nanimals.\\nEtiology. Idiopathic urticaria always results from the action of\\nexternal irritants, prominent among which are the bites or stings of\\nmosquitoes, lice, fleas, bedbugs, gnats, wasps, caterpillars, and bees.\\nThe irritant action of the nettle Urtica urens and U. dioica) has given\\nthe malady its name. Contact with certain species of the jelly-fish is\\nalso effective. The wounds thus inflicted usually give rise to a stinging\\nor a burning sensation, by which the patient is excited to rub or scratch\\nthe part. A wheal is rapidly formed at the site of the injury, and the\\nirritation set up is conveyed to other parts of the skin in the vicinity,\\nso that, especially in children, a single traumatism by an insect may\\nexcite an urticaria covering a much larger area. Many medicaments\\noperate similarly, and it should be added that all the external agencies\\nwhich are capable of irritating the skin, though applied without toxic\\neffect to the mass of men, may produce urticaria in individuals predis-\\nposed to the disease, or having a peculiar intolerance for a particular\\nsubstance. Thus, a common flaxseed poultice when made to cover but\\na small portion of the body has produced violent symptoms of urticaria.\\nClimatic influences, more particularly those in which the surface of the\\nbody is exposed to cold air, are efficient in the production of urti-\\ncaria, as also of bronchial asthma, with the symptoms of which the\\ndisease under consideration, in the case of adults, may often coexist or\\nalternate. Mechanical violence, the application of leeches to the skin-\\nsurface, and surgical traumatisms may also act as exciting causes.\\nSymptomatic urticaria is chiefly of the variety named by authors\\nab ingestis, since it most frequently results from medicinal or from\\n1 Lancet, August, 1881, p. 153.\\n2 Brit. Med. Jour., December 8, 1883,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0204.jp2"}, "205": {"fulltext": "URTICARIA. 191\\ndietary articles taken into the stomach. Of the latter class may be\\nnamed eggs, cheese, pork, sausage, coffee, tea, cocoa, confectionery,\\ncrabs, lobsters, clams, caviar (and several species of fish-roe), oysters,\\nand fish generally, strawberries, cucumbers, skins of grapes, nuts,\\ndates, raisins, almonds, figs, prunes, gooseberries, raspberries, canned\\ntinned fruits, meats, vegetables, oatmeal, pease, beans, onions,\\ngarlic, corn, pickles, sauces, honey, mushrooms, pastry, salads, and\\nspinach. Vinegar, champagne, beer, and alcoholic beverages in gen-\\neral are capable of inducing a similar effect.\\nAmong the medicinal articles capable of inducing urticaria may be\\nnamed the balsams, the turpentines, quinine, glycerin, chloral, valerian,\\narsenic, hyoscyamus, cinchonidine, salicylic acid and the salicylates,\\nsenna, santonin, and opium and its alkaloids.\\nIn the case of children and infants a severe urticarial efflorescence\\nmay be provoked by worms, or by any undigested morsel of food,\\nor indigestible material of any sort that may have been passed into\\nthe stomach. Thus, a bit of orange-peel or a fragment of potato-\\nparing or the skins of grapes may be discovered to lie at the root\\nof the trouble. In the case of adults, also, who have experienced\\nrepeated attacks of urticaria, and suffer from sensitiveness of the gastro-\\nintestinal tract, any food not easily digested by a given individual may\\ninduce in him a return of the disagreeable symptoms.\\nThis undue sensitiveness to the effect of ingesta or of external irri-\\ntants is often an idiosyncrasy peculiar to the individual either on special\\noccasions or at all times, and, given this susceptibility, the effect is\\noften great with a relatively insignificant etiological factor. Thus, a\\nteaspoonful of beer, one grain of quinine, the smallest fragment of\\ncheese, or but a single strawberry, may not only induce an urticarial\\nrash of such extent as to cover the greater part of the surface of the\\nbody, but will also do the same on every occasion when the articles\\nI named are swallowed in the quantities given. The fact that a small\\nquantity of the article ingested can produce urticaria is important,\\nbecause it emphasizes the general characteristics of the medicamentous\\neruptions. The a priori reasoning, that the greater the quantity of\\nthe toxic agent applied or swallowed, the graver the effect, may lead\\n1 to gross errors. It should be remembered, in seeking the explanation\\nfor an urticarial rash, that the smallest amount of apparently innocent\\nsubstances may be responsible for the largest annoyance. In excep-\\ntional cases the mere odors of iodoform, linseed, liquorice, certain\\nplants, etc., have been sufficient to cause an attack of urticaria.\\nOther causes of urticaria may be cited, such as moral emotions (fear,\\nshame, anger) pulmonary diseases, especially asthma gastro-intestinal\\ndisorders, in which ingesta play no part intestinal parasites malaria\\nI the exanthematous fevers, particularly in their prodromal stages dis-\\norders of the uterus, the kidneys, and the nervous centres; pregnancy,\\ndentition, and the irregularities attending the menopause and, lastly,\\nthe following special diseases: pemphigus, prurigo (of Hebra), rheu-\\nmatism, and purpura.\\nThe close affinity of urticaria with acute circumscribed oedema, pur-\\npura, and erythema multiforme is discussed with the last-named disease.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0205.jp2"}, "206": {"fulltext": "192 INFLAMMATIONS.\\nPathology. Urticaria is undoubtedly a vasomotor neurosis. The\\nwheal is a sharply circumscribed oedema, and is produced apparently by\\nan interchange of play between blood-vessels, muscles, nerves, and tis-\\nsue, under the operation of a principle which the French term choc en\\nretour. There is, first, most probably under the influence of the vaso-\\nmotor nerves, a clonic spasm of the capillaries in a limited area of the\\nderma, by which is produced an acute oedema with some serous exuda-\\ntion. The rapidity with which this clonus occurs is greater than that\\nwith which the tissues of the vicinage can accommodate themselves to\\nit, either by imbibition or more diffuse tumefaction, and there results a\\ncounterpressure upon the affected capillaries, by which their lumen is\\nstill further restricted. As the wheal is not a purely fluid-containing\\nnor yet an entirely solid lesion, but is semifluid in consistency, the\\nmechanical pressure is greatest at its centre and least at its periphery.\\nThus are explained the white and relatively bloodless appearance of the\\ncentre of certain wheals, and their rosy or reddened outer border.\\nThe explanation is strengthened by the fact that generally the most\\nacute lesions, those springing into view most rapidly, are chiefly char-\\nacterized by this whitened centre, while those more indolent or even\\nchronic in their career, having been less subject to the interplay of the\\nforces described above, permit of more general vascular injection, and\\nhave a light-crimson or even at times a dull-red centre. Wheals have\\nbeen excised and microscopically examined by Neumann, Vidal, Pon-\\ncet, Unna, and others, with the result of discovering merely evidences\\nof dilatation and engorgement of blood- and lymph-vessels. The deep\\nvascular net shows the greatest dilatation of the lymph-channels. The\\ncompression of the blood- capillaries produces the w T hiteness of the\\nacutely developed wheal. According to Poncet, the lymph-vessels\\nare also choked with lymph-clots. Rohe l explains the occurrence\\nof the wheal by supposing that certain sensitive nerve-fibres of the skin\\npossess also a vasomotor function.\\nUnna believes the wheal is produced by a spastic contraction of the\\nveins. Gilchrist 2 found in the lesions of urticaria factitia of but a\\nfew T minutes duration an increase in the number of round cells and\\nof polymorphonuclear leucocytes, and other evidences of true inflam-\\nmation.\\nDiagnosis. The diagnosis of classical urticaria is so readily made\\nthat the disease is often recognized before the attention of a physician\\nis called to it. As usual, the atypical cases are those in which con-\\nfusion may arise. The chief points to be remembered are the rapid-\\nity of evolution of symptoms, their ephemeral duration, and the char-\\nacteristic sensations they awaken. The action cf the animal parasites\\nand of insects not parasitic should not be overlooked, and the rash be\\nclosely examined for the minute wounds inflicted in this way, often\\ncovered with a minute pin-point- to pinhead-sized dried blood-scale,\\nand usually found in groups of two, three, or more lesions. The\\nvarious forms of erythema papulatum, tuberculatum, and nodosum\\nare liable to be mistaken for urticaria but this is in many cases inev-\\n1 Maryland Med. Jour., May 15, 1881.\\n2 Johns Hopkins Hosp. Bull., July, 1896.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0206.jp2"}, "207": {"fulltext": "URTICARIA. 193\\nitable, as intermediate forms between the two disorders are with diffi-\\nculty assigned to either category. Absence of marked subjective sen-\\nsations and persistence of lesions would generally point to an erythema,\\nwhile marked prevalence of these symptoms would probably decide in\\nfavor of urticarial disease.\\nIn many cases the physician is consulted by a patient who gives a\\nhistory of well-nigh intolerable distress at night or at other capri-\\nciously selected hours, and who repeatedly and vainly endeavors to\\nexhibit the lesions as they appear upon the skin. Being examined on\\nvarious occasions, scarcely a trace of cutaneous disorder is manifest.\\nHere the practitioner has actually to decide upon the character of an\\neruption he never sees the task is rarely difficult, no other than the\\nurticarial eruption behaving in this fashion. Occasionally the physi-\\ncian Avill discover delicate, rosy or deeper stained mottlings of the\\nskin-surface where the wheals have been. At times also he will suc-\\nceed, on the flexor aspect of the forearm, or in some situation in which\\nthe skin is equally delicate, in producing the appearance of one or\\nmore typical lesions by the aid of his finger-nail in scratching, or by\\nrubbing. These cases are more frequently of the chronic or at least\\nof the relapsing class, and the victims of the disease may have a char-\\nacteristic facies, a worn look from loss of sleep or from mental emo-\\ntion. In this class are often those who are mourning the death of\\nrelatives, the loss of property, or separation from home and friends,\\nand those harassed by anxieties.\\nThe several lesions of erythema are larger than those of urticaria, and\\nthey do not develop from characteristic wheals in erythema multiforme\\nthe lesions are far more persistent in type and do not provoke the char-\\nacteristic subjective sensations of urticaria in erysipelas the redness is\\ncharacteristic and the swelling more diffuse.\\nTreatment. Many cases of acute urticaria demand no treatment.\\nThe physician is summoned for a diagnosis. The patient and his\\nfriends are alarmed by the dread of variola or other severe affection,\\nand learning that perhaps a pickled cucumber is alone responsible for\\nthe disorder, they wait with equanimity for the favorable conclusion\\nwhich is always reached. Fortunately, the unusual, severe, and\\nrelapsing forms rarely begin with acute symptoms.\\nNaturally, the first indication to be observed is the removal of the\\ncause, and with this, if possible, accomplished, the next is the exclusion\\nof all aggravating agencies. The discovery of the cause, at times\\nreadily effected, is often the most serious problem presented. An\\nexhaustive and minute examination of the person and the history of the\\npatient, a study of his food, drink, medicine, regime, clothing, sleep-\\ning-apartment, habits, occupations of life, and mental state, are here\\nessential. When the disorder is recent, and is an urticaria ab ingestis,\\na brisk emetic or a cathartic may rid the stomach or the bowels of\\noffending matters. This done, it should be borne in mind that an\\nidiosyncrasy of the patient may at this moment render the skin pecu-\\nliarly sensitive to the action of other ingesta, and the diet, for a few\\ndays certainly, should be prescribed carefully. In many cases the\\nalkalies are indicated by an acid condition of the stomach, and then the\\n13", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0207.jp2"}, "208": {"fulltext": "194 INFLAMMATIONS.\\npreparations of sodium, potassium, or magnesium are useful. Laxa-\\ntives, such as rhubarb, magnesia, the cathartic mineral waters, and, in\\nthe case of children, small doses of castor-oil are frequently indicated\\nwhen there is no suspicion of irritating ingesta. At other times there\\nis marked atony of the digestive organs, when the mineral acids, the\\nbitters, and the ferruginous tonics may be needed. Again, lactopeptin,\\npepsin, or bismuth subcarbonate or subnitrate may be exhibited with\\nadvantage for the relief of the indigestion which may be the promi-\\nnent feature of the attack.\\nOther remedies found useful in the internal treatment of urticaria\\nare sulphurous acid in 1 drachm (4.) doses three times daily in sweet-\\nened water (Da Costa) copaiba sodium nitrite (J. P. Sawyer) strych-\\nnine (Guibout) sodium arseniate, employed by Blondeau in doses of\\nfrom 3V (0.002) to (0.0013) of a grain the fluid extract of ergot\\nin -J drachm (2.) doses (Morrow) atropine sulphate in doses of -g 1\\n(0.001) of a grain (Schwimmer) and sodium salicylate in scruple\\n(1.33) doses. The latter drug has been praised highly by a number of\\nwriters. It is often given in 1 grain (0.06) doses every hour. Pilo-\\ncarpine, or the fluid extract of jaborandi, is known to produce at times\\na powerful effect in relieving surface-congestions of the skin by means\\nof the hyperidrosis it occasions, and in proportion to which it is pro-\\nduced the drug may become dangerous.\\nSchwimmer endorses the following formula for this affection\\nR. Atropinae sulph., gr.\\nGlycerin., I _\\nAq. dest., J aa 3 ss l\\nGum. tragacanth., q. s.\\nFt. pil. No. xx.\\n01\\nM.\\nThe treatment of symptomatic urticaria should have regard also to\\nthat disorder of the viscera or of the general system to which the\\ncutaneous symptoms may be attributed. Gout, as a not infrequent\\ncause of the disease, should not be forgotten in advising treatment.\\nThe uterine complaint of a woman may require appropriate manage-\\nment, as also the diabetes of a patient with an affection of the kidneys.\\nQuinine is indicated, of course, in periodical attacks, but its action in\\nexceptional cases as a direct cause of urticaria should not be over-\\nlooked; the same, to a greater extent, is true of arsenic, potassium\\nbromide and iodide, chloral hydrate, and gelsemium. The larger number\\nof patients are best treated without the employment of these drugs.\\nIn the local treatment of urticaria protection of the sensitive skin\\nfrom all sources of external irritation is the chief object. The complete\\ncovering of an affected region with wadding will often cause a rapid\\ndisappearance of the symptoms. Individual lesions which are sealed\\nwith collodion or plaster usually disappear promptly. The zinc-oxide\\nadhesive plaster is very serviceable, as it does not irritate the skin.\\nThe patient s underclothing should be of soft linen, cotton, or silk, and\\nto prevent friction Avith the skin a dusting-powder may be used freely,\\nboth on the skin and in the meshes of the underwear. Sleep should be\\nsecured without an excess of bed-covering, and places where the temper-", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0208.jp2"}, "209": {"fulltext": "URTICARIA. 195\\nature is for any reason elevated should be carefully avoided by the\\npatient, such as proximity to a fireplace or a droplight, heated places of\\namusement, the kitchen, etc.\\nGreat diversity exists in the methods employed to assuage the\\ndisagreeable sensations experienced in the skin. This diversity is\\nexplained by the varying results obtained in different patients after the\\napplication of the same medicinal agent. Thus, cold and hot water-\\nbaths, baths medicated by marine salt, aromatic vinegar, alcohol, cologne,\\ncamphor, the alkalies, and sulphuric ether (compresses dipped in such\\nsolutions and laid over the part affected), douches, and vapor-baths will,\\nany of them, in the case of some individuals, produce a marked allevi-\\nation of symptoms, and in others will be either inoperative or actually\\nserve to aggravate the symptoms in the highest degree. Hebra asserts\\nthat several of the baths named above are useless, while Kaposi recom-\\nmends cold lotions medicated with aromatic volatile substances. Fox\\nprefers that alcohol, or cologne-water to which benzoic acid has been\\nadded, be dabbed over the part and permitted to evaporate. Solutions\\nof menthol in alcohol and water, 1 part to 500 or 600, operate simi-\\nlarly. Hillairet and Gaucher employ in a similar way a solution con-\\nsisting of one-third of ether and two-thirds of warm water.\\nThe alkaline bath should contain sodium carbonate, sodium biborate,\\nalum, or potassium bicarbonate, either singly or in combination in the\\nstrength of about 6 ounces (180.) of the salt to 30 gallons of water;\\n1 or 2 ounces (30.-60.) of potassium sulphuret may be substituted.\\nThe water is made demulcent by the addition of starch or of gelatin,\\nor by immersing in it a muslin bag containing bran. When it is\\ndesired to employ the acid bath, ounce (15.) of either muriatic or nitric\\nacid is added to the quantity of water given above. The bath of this\\nsize may also be medicated with 1 drachm (4.) of corrosive sublimate;\\nor this drug may be used as a lotion in the strength of from (0.016)\\nto (0.033) grain to the pint. Carbolic, benzoic, salicylic, boric, dilute\\nhydrocyanic, and dilute nitric acids in weak solution are also employed\\nwith advantage in some cases.\\nOther external applications are thymol, ammonium carbonate, potas-\\nsium bromide, ether, chloroform, or chloral-camphor in the strength of\\nto 1 drachm (2.-4.) to the ounce (30.) of ointment. This ointment\\nis prepared by rubbing together equal parts of camphor and chloral\\nuntil a semiliquid results. The preparation is an antipruritic remedy\\nof value, but if not largely diluted will increase the uneasy sensations\\nproduced. In other cases an oily or fatty substance will give more\\nprompt relief, especially if the eruption has been irritated by scratching\\nand tends to persist. Among useful applications may be named the\\nlinimentum calcis of the pharmacopeia, and cold-cream salve, to which\\nmay be added fluid extract of grindelia robusta, 1 part to 20 or 30 of\\nvehicle; also the dusting-powders, which are described in the chapters\\nrelating to General Therapeutics and the Erythemata. These powders\\nare the most cleanly of all external preparations in urticaria, and are\\noften the only local measures required. Among the Germans sulphur,\\nnaphtol, and tar-salves are employed in the management of the disease.\\nOne of the most effective and trustworthy of local applications in", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0209.jp2"}, "210": {"fulltext": "196 INFLAMMATIONS.\\nsevere urticaria is a starch solution. The starch is first mixed with\\ncold water, and is then boiled until the solution is of the consistency\\nof thin mucilage. To each pint of this 1 drachm (4.) of zinc oxide\\nand 2 drachms (8.) of glycerin are added before ebullition is completed.\\nWhen cool and applied to the surface this solution often gives prompt\\nrelief. The same is true of a thin solution of boiled oatmeal.\\nSuch is the empirical treatment of urticaria. It is founded upon no\\nrational method of procedure, because the very capriciousness of the\\ndisease demands and secures relief in one instance by a treatment\\nwhich should be reversed in another. It must be admitted that cases\\noccur in which all treatment seems absolutely valueless, often really\\ninjurious, to the patient. These cases will usually be found to be of\\nthe relapsing or chronic type. The subjects of this form of disease are\\noften plunged into morbid mental states, dreading by day the exacerba-\\ntions of the night, brooding over misfortunes experienced or antici-\\npated, worn by loss of sleep, fearful of a generous regime at the table.\\nHere the treatment is largely moral, and demands the tact and courage\\nof the physician. Travel, change of climate, variation in the routine\\nof life, new social surroundings are here valuable. The widow must\\nbe made to lay aside the heavy crape-veil beneath which her urticaria\\nplays the solitary patient must secure an acceptable companion for a\\nfew hours each day.\\nIt seems probable that to these efficient agencies must be in part\\nascribed the relief so often obtained at various mineral springs, both\\nin America and abroad. Thus, the Karlsbad, Vichy, Saratoga, and\\nWhite Sulphur Springs have all been credited with the production of\\nbeneficial effects in urticaria.\\nPrognosis. The prognosis of an attack of urticaria is, as may be\\nseen in what has preceded, exceedingly variable in different cases.\\nSimple attacks of the acute sort are trivial, and in a few days the\\npatient may retain but the slightest traces of the trouble. In the case\\nof children the attack is often at an end in the course of twenty-four\\nhours.\\nIt should, however, never be forgotten that urticaria may torment\\nthe life of a patient to the utmost bounds of tolerance and seriously\\nimpair the general health. Persistent and rebellious chronic urticaria\\nmay prove to be a more formidable affection than a mild attack of\\nsyphilis.\\nURTICARIA PIGMENTOSA (XANTHELASMOIDEA, Fox).\\nSymptoms. This disorder, once regarded as an affection of great\\nrarity, has now been recognized in almost all the large centres of\\npopulation. The disease is characterized by the occurrence in early\\ninfancy, sometimes but a few hours or a few weeks after birth, of\\nelevated, rosy or reddish, round or oval wheals and nodules, which are\\nsucceeded later by flattish or slightly elevated, light or dark-brownish\\nor buff-colored macules. Exceptional cases are reported in which the\\ndisease made its first appearance a number of years after birth. There\\nare three tolerably distinct types of the affection those exhibiting", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0210.jp2"}, "211": {"fulltext": "URTICARIA PIGMENTOSA.\\n197\\nplane lesions with equally flattened maculations those with tubercular,\\nnodular, or variously sized and shaped wheals and mixed varieties,\\nthe latter being commonest. The mingling of a factitious urticaria\\nwith lesions long existing and long maculated is not rare. A char-\\nacteristic feature of this form of urticaria is the tendency of the wheals\\nto recur at the same site, and wmere pigmentation remains new wheals\\nmay be produced by irritation. Cases may be classified into those\\naccompanied by itching and those not thus characterized but these\\ndifferences are due to accidental rather than to essential causes. The\\neruption, which at the outset may appear as late as the third year,\\ncommonly displays itself first on the neck and shoulders, and then\\nrapidly spreads to the head and the extremities, eventually invading the\\nentire body-surface- in well-marked cases even including the mucous\\nmembranes. The lesions are at first\\nof the usual urticarial type, each Fig. 41.\\nwith delicate zone, but soon lose\\ntheir distinct contour and elevation,\\nand become flatter and pigmented,\\nthe color in pronounced cases being\\na distinct yellow, deepening to a\\ndecided coffee-and-milk hue. After\\nisolated tubercles once acquire the\\ndeeper tint they may persist for\\nyears may return in crops may\\neven at times be commingled with\\nbulla? which desiccate in crusts\\nmay form plaques of infiltration\\nmay be covered with an ery-\\nthematous blush due to hyperemia\\nof parts long affected and, when\\nitching is intense, may exhibit the\\ngeneral signs of the scratched skin.\\nIn a few of the reported cases the\\nnodules were modified by vesicles\\nand vesico-pustules, and were fol-\\nlowed by whitish, instead of pig-\\nmented, spots in a smooth or\\nwrinkled and scar-like skin.\\nEtiology. The cause is un-\\nknown. The sexes are nearly\\nequally represented among patients.\\nPathology. Sections of tuber-\\ncles have been made by numerous\\nobservers, including Unna, Ray-\\nmond, Pick, and Thin. It is clear\\nthat some effusion occurs in the\\ncorium with cell-infiltration and small hemorrhages. The disorder\\nis unquestionably an angioneurosis due to special changes of the vaso-\\nmotor centres. Unna has demonstrated that the papillary body in\\nthese cases is distended by very large flattened mast-cells, the accumu-\\nUrticaria pigmentosa.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0211.jp2"}, "212": {"fulltext": "198 INFLAMMATIONS.\\nlation of which flattens the epidermis above. They lie closely packed\\ntogether arranged in columns by reason of persistence of the collagen-\\nous tissue, between which when spastic oedema is present wide lymph-\\nspaces open.\\nDiagnosis. Urticaria pigmentosa is to be distinguished from the\\nslight pigmentation left after well-marked urticaria of later years by\\nthe beginning of the disease in infancy and by the persistent buff-\\ncolored tubercles. Xanthoma in all its forms is readily distinguished by\\nits persistence in special regions, the eyelids, for example.; by its first\\nappearance in many patients at a later period of life than infancy and\\nby its characteristic chamois-leather-yellow shade.\\nTreatment. No treatment has hitherto been so successful as to\\njustify its recommendation. The internal remedies and local applica-\\ntions advised for urticaria have been employed with varying degrees of\\nsuccess. The best results are obtained after stimulating rather than\\nsoothing baths, at a later period of life than during the first six months.\\nAfter such stimulation with salt and water or alcohol and water a boric-\\nacid dusting-powder may be employed.\\nANGIONEUROTIC (EDEMA.\\n(Acute Circumscribed CEdema, Acute Idiopathic CEdema,\\nPeriodic Swelling, Acute Non-inflammatory CEdema,\\nGiant Swelling.)\\nThis disorder described first by Quincke, and since by many other\\nobservers, 1 is characterized by the occurrence in successive and recur-\\nrent attacks, often acute, rarely persistent in character, of circum-\\nscribed, cedematous plaques, developing with acute symptoms and as\\nrapidly disappearing. The surface of the affected area is commonly\\nreddened in various shades, from a light rosy hue to a livid red. The\\nplaques vary in size from that of a small coin to that of the section of\\na large orange, and may involve an entire organ or limb. As a rule,\\nno itching is awakened. The swellings are commonly the seat of dis-\\nagreeable sensations of fulness, burning, throbbing, or scalding and\\nif the swelling chance to obstruct a mucous tract (nasal, pharyngeal,\\nlaryngeal, etc.) there are symptoms of a distressing character, due to\\nthe transitory occlusion. The disease is occasionally noted in connection\\nwith urticaria, erythema multiforme, and purpura rheumatica.\\nThough each individual outbreak may be rapid of occurrence, the\\ndisorder responsible for the cutaneous symptoms is unquestionably\\nchronic in duration and it is the successive and repeated expression\\nof its influence upon the skin that in rare cases produces a more or less\\npersistent and obstinate cutaneous oedema limited to one portion only\\nof the integument.\\nThe lesions occur upon the conjunctiva, the pharynx, the larynx,\\n(where even fatal obstructive consequences may result), and also as\\nfacial symptoms, especially upon the eyelids and the lips. The lesions\\nare to be recognized also upon the extremities, the trunk, the penis,\\nthe scrotum, and the vulva. In some cases the disorder is well nigh\\n1 Cf. Courtois-Suffit (Annal. de Derm, et de Syph., 1889, p. 859).", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0212.jp2"}, "213": {"fulltext": "ANGIONEUROTIC (EDEMA. 199\\nuniversal. When the soles of the feet are involved the erect position\\nis impossible without incurring severe pain. The persistent oedema,\\ndescribed later and attributed to recurrent attacks of erysipelas and\\nlymphangitis, is not of this class. Wende l described a case of acute\\noedema of the dorsum of the hand followed in forty-eight hours by a\\nsimilar lesion on the forearm, and in seventy-two hours by one on\\nthe face, the attack being accompanied by marked albuminuria and\\nhaemoglobin uria.\\nThe cellular tissue of the skin and mucous membranes is chiefly\\ninvolved but the papillary portion of the corium is also largely con-\\ncerned in the morbid process, as is also the superior vascular plexus of\\nthe pars papillaris.\\nDiagnosis. The disorder should not be confused with erythema\\nmultiforme, erythema nodosum, giant urticaria, syphilitic and rheu-\\ni matic nodes, nor with pseudo-lipomas. Between these affections, par-\\nticularly between the three first named, no precise lines of demarcation\\ncan be drawn, and the diagnosis must be made largely from the con-\\ncomitant symptoms and from the absence, in circumscribed oedema, of\\nitching or pricking sensations, febrile complications, and rheumatoid\\npains.\\nTreatment. Circumscribed oedema is produced under the influence\\nof the trophic and vasomotor nerves it is, hence, amenable chiefly to\\nthose remedial agents which tend to influence favorably the nervous\\ncentres. Internally ergot, iron, mix vomica, quinine, and the sodic\\nsalicylate are indicated. As some cases are probably toxic in origin,\\nefficient elimination should be secured. Diuretics, sudorifics, and\\ncathartics are recommended by Besnier and Doyon. The local treat-\\nment is largely that of urticaria. In chronic cases salt and water may\\nbe applied over the region of the spine by the hands of a competent\\nnurse. The salt is moistened with cold or slightly warmed water,\\naccording to the constitution and temperament of the patient, and is\\nthen briskly rubbed with a firm hand over the entire spinal region.\\nThe back is then sponged for several minutes with pure water, at\\nfirst hot and gradually cooled, until the surface is well reddened, when,\\nlastly, the surface is dried and the patient made to take moderate exer-\\ncise. The result in cases is brilliantly satisfactory. As in chronic urti-\\ncaria, mental anxiety and distress, especially in women, may be respon-\\nsible for a great part of the trouble.\\nCircumscribed and Persistent (Edema of a single member or\\nregion of the body, not of the class of successive and repeated swellings\\nnoted above, is properly considered with the early stages of elephan-\\ntiasis. It results most often from a localized lymphangitis or so-called\\nrecurrent erysipelas (chronic eczema of the face, tumefaction of\\nnose and cheeks due to obstruction by tumors of the antrum of High-\\nmore), and appears upon the face usually as a smooth, shining, whitish\\nor reddish tumefaction, ill defined as a rule, in a few cases with fairly\\ngood definition. The tuberculous toxins may be responsible for some\\ncases. The swelling is usually of firm consistence, but can with some\\n1 Jour. Cutan. and Gen.-Urin. Dis., 1899, vol. xvii., p. 178.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0213.jp2"}, "214": {"fulltext": "200 INFLAMMATIONS.\\npressure be indented with the finger. It is always the seat of passive\\nhyperseinia, never of active inflammation but in the case of smokers of\\ntobacco and hard drinkers an active inflammation is sometimes awak-\\nened. These patches are rarely painful or tender advice is usually\\nsought with a view to the relief of the consequent moderate deformity.\\nThe swellings occur as well upon the lower limbs and breasts of women.\\n(Cf. Erysipelas Perstans.)\\nThe treatment of these cases is by frequent shampooings and em-\\nbrocations, to stimulate the absorbents, aided by elastic. compression.\\nFacial deformities of this class are always benefited by abstention from\\nthe use of tobacco and alcoholic stimulants, the diet at the same time\\nbeing carefully regulated. The nasal cavity, the region of the orbit,\\nand the mouth (caries of the teeth, etc.) should always be examined\\nwith a view to the removal of the cause.\\nDERMATITIS.\\n(Ger., Hautentzundtjng Fr., Dermatite.)\\nInflammation of the skin occurs in a large number of cutaneous\\naffections. Under dermatitis, however, are grouped those inflamma-\\ntions only in which the result is plainly due to a direct influence\\nexerted upon the skin by thermal, chemical, or mechanical agencies.\\nThe inflammatory process may involve the superficial or the deep por-\\ntion of the integument, or it may extend to the subcutaneous tissues, or\\neven deeper. The symptoms vary with the nature of the cause, the\\nextent and degree of its influence, and the circumstances attending its\\noperation. There may be simple hyperemia and oedema of a few hours\\nduration, or there may follow papules, vesicles, bullae, pustules, and\\ncrusts. These lesions may be situated on an intensely reddened and\\nmuch swollen base. In severe cases ulceration, gangrene, and exten-\\nsive scarring may occur. With these phenomena there may be general\\nsymptoms of mild or of severe grade, due to the influence exerted by\\nthe local process upon the general economy. When the exciting cause\\nis of moderate intensity but is long continued there results a chronic\\ndermatitis in which the skin may be more or less thickened and infil-\\ntrated, dull red in color, and covered with fine adherent scales.\\nDERMATITIS TRAUMATICA.\\nExternal violence, varying in character and severity, is capable of\\ninducing dermatitis, the symptoms of which differ in degree, though\\ntheir career is, in general, the same. In this list are included the in-\\nflammations produced by surgical interference with the continuity of\\nthe integument; excoriations caused by scratching, by friction with\\ngarments and other articles injuriously acting upon the skin by the\\nvarious implements handled in the trades and by the bites or the\\nstings of beasts, insects, reptiles, and fishes, when the result is trau-\\nmatic and not toxic in character. These injuries may be in the form\\nof contusion, blow, concussion, pressure, puncture, incision, or lac-\\naration, and the consequences are declared in heat, swelling, redness,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0214.jp2"}, "215": {"fulltext": "DERMATITIS VENENATA. 201\\nand pain in itching, burning, stinging, or pricking sensations with\\nsubsequent inflammatory symptoms varying in grade from mild and\\ntransitory hyperemia and exudation to the severer grades of inflam-\\nmation mentioned in the preceding paragraph.\\nDERMATITIS VENENATA.\\nCertain medicinal and other substances applied to the external sur-\\nface of the skin are capable of exciting inflammation by operating either\\nas caustic, irritant, toxic, or even traumatic agents.\\nSymptoms. Careful observation of a typical case of dermatitis\\nvenenata soon after the onset of symptoms will disclose the exact sur-\\nface of contact, such surface being delicately outlined by a reddened,\\ntolerably well-defined line, within the limitation of which will be seen a\\nslightly tumefied, erythematous area, at times displaying closely packed,\\npin-point-sized papules, vesicles, or pustules. As the dermatitis pro-\\ngresses it is not necessarily limited to the surface with which the irritant\\nhas come in contact. The inflammation may extend to adjacent por-\\ntions of the skin, or, as a result of absorption and consequent toxic effects\\nor of reflex nervous irritation, it may appear on distant surfaces of the\\nbody. Numerous types of cutaneous lesions macules, pustules, papules,\\nvesicles, bullae, wheals, scales, crusts, free serous and purulent discharges,\\nsubcutaneous abscesses, and even gangrene with sloughing may occur,\\nthe result being largely proportioned to the character of the agent pro-\\nducing the injury and to the susceptibility of the individual.\\nEtiology. Among the sources of dermatitis venenata may be named\\nmost of the strong acids and alkalies, croton-oil, cantharides, mustard,\\ntartar emetic, mezereon, the compounds of mercury, arnica, turpentine,\\nether, chloroform, tarry compounds, resorcin many of the dyes, several\\nmembers of the rhus family (Rhus toxicodendron, poison-ivy, and Rhus\\nvenenata, poison-sumach), the nettle, the smartweed (Polygonum pune-\\ntatum), cowhage (Mucuna pruriens), and glass in fine powder or in deli-\\ncate filaments, such as are thrust into the skin when handling certain\\narticles of Venetian glassware. This list might indefinitely be extended,\\nas there are few articles which are not capable of producing some irri-\\ntation of the surface of the skin if applied to it with sufficient vigor\\nand for a certain period of time and in some cases it is difficult to\\ndecide whether the effect is more traumatic than toxic. An almost\\nequally long list of substances of animal origin might be named having\\npoisonous effects upon the integument, such as decomposed or am-\\nmoniacal urine, feces, ichorous pus, and pathologically altered secre-\\ntions from the uterus, the eye, ear, nose, etc.\\nA few of the more common causes of dermatitis are the use of\\nsoap containing an excess of alkali or even minute particles of bone\\nfor laundry, toilet, or other domestic purposes, as also several of\\nthe proprietary articles sold in the shops for similar employment.\\nStockings and other undergarments dyed with anilin, picric acid,\\nchromium, or arsenic the leather lining of the inside of the hat or the\\ncap, and the painted toys to which the lips of children are applied, will\\nbeget mischief in the various regions of contact for each. Duhring", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0215.jp2"}, "216": {"fulltext": "202 INFLAMMATIONS.\\nreports cases in which the dyestuff in the lining of shoes penetrated the\\nmaterial of stockings in women, and produced dermatitis of the feet\\nor the legs.\\nThe tincture of arnica, an article much used as a domestic applica-\\ntion for contused and incised wounds of a simple character, has pro-\\nduced very serious annoyance in some cases, two such having been\\nrecently presented at the authors clinic. The number of these acci-\\ndents is annually increasing. Cartier l reports excessive erysipelatous\\nswelling, a phlyctenular eruption, and submaxillary adenopathy result-\\ning from the external use of arnica. Beauvais reported to the Paris\\nMedical Society gangrenous results in one case. Buchner believes this\\npoisonous action to be due to insects (particularly the Atherix maculatus)\\nfound in the calyx of the arnica-flower. Other native plants, a large\\nnumber of which are enumerated in a valuable monograph by White, 2\\npresented in 1886 before the American Dermatological Association, are\\nsimilarly effective. Wesener 3 reports that the Malacca bean-tree (An-\\nacardium orientale) furnishes a caustic oil, called cardol, or car-\\ndoleum pruriens, that produces, after application to the skin, vesicles\\nand vesico-pustules which contain cardol and terminate by crusting.\\nHe reports a generalized eruption, beginning on the face, due to this\\ncause.\\nThe antiseptic dressings of modern surgery are at times responsible\\nfor eruptive troubles. Among these antiseptics may be named iodo-\\nform, which has produced erythema, vesicles, pustules, and wheals. 4\\nCarbolic-acid and corrosive-sublimate dressings have had similar effects.\\nMany of the articles employed therapeutically by the dermatologist\\nshould be placed in the same category. Green, 5 of London, reports\\noedema of the skin followed by desquamation, resulting from the appli-\\ncation to it of the ointment of ammoniated mercury in the strength of\\n2 drachms (8.) to the ounce (32.).\\nLeszinsky reports a case of dermatitis of the face following the use\\nof a triple extract of heliotrope as a toilet-preparation.\\nAn exceedingly common source of dermatitis is urine retained upon\\nunderclothing of adults. A persistent dermatitis of the scrotum, the\\nperineum, or the inner faces of the thighs in either sex, always calls\\nfor examination as to whether a few drops of urine are not left in con-\\ntact with such underclothing after each act of micturition. Fistula?,\\nurinary incontinence, prostatic disease, stammering of the bladder,\\nimperfect finish of the coup de piston in men, especially after a gonor-\\nrhoea and similar troubles, are all to be remembered.\\nThe eruption produced by the Poison-ivy and other varieties of\\nrhus is almost exclusively an American disease and from its frequency\\nin the United States has attracted a great deal of attention. A certain\\ndegree of susceptibility to the poisonous action of the plant is requisite\\nfor the production of its effects, as some individuals can handle the\\nleaves of the plant with impunity, while others, it is claimed, are\\nx Lyon Med., April 13, 1884.\\n2 Dermatitis Venenata. Boston, 1887.\\n3 Deutsche Arch. f. klin. Med., vol. xxxvi., p. 578.\\n4 See paper of K. W. Taylor, read before the New York Academy of Medicine, 1887.\\n5 Brit. Med. Jour., May 3, 1884.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0216.jp2"}, "217": {"fulltext": "DERMATITIS VENENATA. 203\\naffected by its exhalations within a circle having a radius of several\\nfeet. It is, however, difficult to demonstrate the truth of the last state-\\nment, suspecting, as one may, that such instances may be cases of con-\\ntact with other than the suspected plant. The parts commonly affected\\nare the hands and the regions to which the latter are carried, such as\\nthe face, the genitals, the arms, the thighs, and the neck barefoot\\nchildren suffer in the feet and the legs. Usually the symptoms are\\ndeveloped in the course of a few hours, and they consist of eryth-\\nematous patches; scanty or profuse vesiculation with abundant serous\\nweeping after rupture of the lesions swelling, oedema, and disfigure-\\nment and intense burning and itching sensations. Serious effects are\\noccasionally produced. Deeply attached scars may result from subcu-\\ntaneous abscesses of parts greatly swollen. Occasionally in particu-\\nlarly sensitive skins the eruption spreads from the skin-surface affected\\nby the poison to that where presumably none has been applied. It\\nshould be remembered, however, that articles of clothing may for brief\\nperiods of time furnish sources of further trouble, being worn at the\\nmoment of contact witli the plant, then laid aside, and, the occasion\\nquite forgotten, being subsequently employed. Thus, a pair of un-\\ndressed-kid gloves after lying for two weeks untouched have sufficed\\nto awaken the disease.\\nA number of cases of dermatitis have originated in some parts of\\nthe Orient from contact with the varnish employed in the finishing of\\nlacquered ware. This lacquer is manufactured from a rhus varnish.\\nA few instances of such dermatitis have occurred in America from\\nhandling newly imported articles of this class.\\nDiagnosis. An acute dermatitis appearing suddenly on regions of\\nthe body readily exposed to toxic agents should always arouse sus-\\npicion of dermatitis venenata. A history of contact with some irritat-\\ning substance can usually be obtained. The intlammation in the begin-\\nning is limited to the areas with which the toxic agent came in contact,\\nis often asymmetrical, and has no relation to the general health of the\\npatient. The process often reaches the point of greatest intensity\\nwithin a day or two after its first manifestations, and subsides soon\\n1 after removal of the cause.\\nThe peculiar features of ivy-poisoning have been described in a\\nmonograph on the subject by White, of Boston. 1 According to this\\nauthor, the lateral surfaces of the digits first exhibit the symptoms of\\nthe eruption, later the dorsal surfaces, and latest the thickened palms.\\nThe efflorescence also is more irregularly distributed, more uniformly\\nvesicular, and the vesicles are less transparent than in eczema. The\\nlesions, moreover, are more vesicular and less papular at the outset,\\nand, though suggesting papules by their situation in the palm, are in\\nthat situation readily made to exude serum by puncture with a needle.\\nTreatment. Internal medication is not required. The local treat-\\nment is that of acute eczema. Black wash (preferably dilute), solution\\nof sugar of lead, or oleated lime-water may be employed at first, and be\\nfollowed later by dusting-powders.\\n1 New York: D. Appleton Co., 1878, from the March number of N. Y. Med.\\nJour, of the same vear.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0217.jp2"}, "218": {"fulltext": "204 INFLAMMATIONS.\\nIn ivy-poisoning the application of an alkali, for the purpose of\\nneutralizing the poisonous volatile alkaloid in the leaves of the plant\\n(toxicodendric acid, Maisch), should evidently be considered solely with\\na view to prophylaxis, as it is difficult to understand how such neu-\\ntralization can control the inflammatory process after its onset. The\\nlate Prof. Babcock, of Chicago, a frequent sufferer from this disease\\nfollowing his extended botanical excursions, first made known the value\\nof an ointment made by incorporating a decoction of the inner bark of\\nthe American spice-bush (Benzoin odoriferum) with colcl-cream salve.\\nIt affords prompt relief in cases in which it is employed, the difficulty\\nlying in securing the bark of the shrub in its young and tender\\nstate.\\nMany topical remedies have been vaunted as specifics for the relief\\nof this disorder, from the brine of a pork-barrel to a decoction of the\\nleaves of the plant itself. As the eruption usually subsides when the\\nskin is protected and not irritated by the local treatment, it is not dif-\\nficult to explain the result in most eases, though it is possible there is a\\nparasitic element in the poison. Corrosive-sublimate lotions; saturated\\nsolution of boric acid Carron oil 50 per cent, solution of ichthyol\\ntincture of iron; bromine, 15 drops (1.) to the ounce (30.) of olive-oil\\n(Brown) dilute nitric acid sodium hyposulphite sodium bicarbonate\\nsaturated solution of potassium chlorate; and grindelia robusta, 1\\ndrachm (4.) of the fluid extract to 8 ounces (250.) of water, have each\\nbeen found useful. Complete covering of the affected area with flexible\\ncollodion is frequently effective.\\nDERMATITIS CALORICA.\\nUnder this title are included those affections of the skin induced by\\nextremes of thermal variation.\\nUnduly high temperatures produce in the skin redness in varying\\nshades and a slight degree of swelling, the color not completely disap-\\npearing under pressure. If the exciting agent be withdrawn before\\nfurther effects are induced, the color first deepens, then becomes paler,\\nand in twenty-four hours the process is usually concluded with a very\\ndelicate and transitory resulting pigmentation.\\nRays of heat and heated objects at a temperature from 125\u00c2\u00b0 to\\n175\u00c2\u00b0 F. produce immediately, or after a brief interval, first, an erythema,\\nwhich disappears when the source of the heat is removed; second,\\nafter more prolonged exposure, the symptoms of active inflammation\\nand exudation. Vesicles or bullae, isolated or confluent according\\nto the severity of the cause, may rise from a reddened skin which\\nis usually intensely painful. These lesions are persistent or are\\ntransitory, and are generally filled with a clear serum, which exudes\\nand dries into crusts after rupture of the chamber in which it was\\nimprisoned. At other times the exudation is so abundant that the\\nepidermis rises in broad plates, from beneath which the serum is ex-\\nuded. This process may terminate by a free production of pus upon\\nthe surface and gradual resolution. Adenopathy is a frequent concom-\\nitant symptom. In such dermatitis of extensive areas of the skin the", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0218.jp2"}, "219": {"fulltext": "DERMATITIS CALORIC A. 205\\nintensity of the process may awaken a violent fever, or death may\\nresult from shock or exhaustion.\\nIn yet severer grades there is the production of an eschar, which is\\ndry, brown, blackish, and destitute of all signs of vitality or, as\\nKaposi describes it, is dense, coriaceous, and white as alabaster,\\nthough upon the eschar some vesicles appear, and by their presence\\nsuggest a false conclusion as to the vitality of the tissues upon which\\nthey rest. In from eight to ten days the slough is removed by sup-\\npurative processes, and the scene is closed by the usual phenomena of\\ngranulation and cicatrization. The characteristics of the scar thus\\nproduced are its great irregularity, its tendency to stellate radiation,\\nand the production of ridges, folds, pockets, and bridles.\\nBurns involving one-third the body-surface are of grave portent,\\nand those affecting one-half the body are generally fatal, even though\\nfor from twenty-four to forty-eight hours there may be little complaint\\nof pain. The causes of death in these fatal cases are generally obscure,\\nas the post-mortem results are usually negative. Gastric and duodenal\\nulceration, however, is often recognized. Overheating of the blood,\\nheart-paralysis, oligocythemia, and actual destruction of leucocytes\\nhave all been supposed to be effective in bringing about dissolution.\\nj In cases in which life is prolonged to the third day the complications of\\ni pyaemia, erysipelas, and tetanus may arise. Lastly, exhaustion fol-\\nlowing fever, suppuration, hemorrhage, and visceral affections may\\nlead to fatal results.\\nTreatment. In the treatment of the simplest burns, rest, lotions of\\nlead-water, and cool water, with the application of compresses, are\\nusually sufficient to secure relief; occasionally, dusting-powders may\\nadvantageously be substituted. In the cases in which serum is brought\\n1 rapidly to the surface, with the production of vesicles and bullae, the\\nlatter should be punctured skilfully to give relief to the tension by the\\nevacuation of their contents, but the roof-wall should be preserved, as\\nit may subsequently form an attachment to the exposed derma be-\\nneath. The indications then are to exclude the air as perfectly as\\npossible and to prevent suppuration, indications which are admirably\\nmet by the application of carbolated oil and lime-water with the Lister\\ndressing. Continuous immersion in water having the temperature most\\nagreeable to the patient, as practised by Hebra in cases of severe and\\nextensive burning, produces a speedy and certain amelioration of the\\npain and a favorable condition of the wounds, though it does not avert\\na fatal issue in any dangerous case.\\nThe strictest antiseptic precautions are demanded when the suppura-\\ntive process in the skin is both active and extensive. Disinfection\\nwith a 5 per cent, solution of carbolic acid, or a 2 per cent, resorcin\\nsolution, should be followed by the application of protective silk wet\\nwith a 5 per cent, solution of sodic biborate or bicarbonate, and the\\nwhole enveloped either in borax-lint, antiseptic (mercuric iodide) wool,\\ncarbolized gauze, or salicylated cotton over all, impermeable rubber\\ntissue should be wrapped.\\nMtzsche l first disinfects the burnt surface thoroughly with carbolic\\n1 Deutsche med. Zeit, 1881.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0219.jp2"}, "220": {"fulltext": "206 INFLAMMATIONS.\\nacid, having previously protected the blebs, after which it is covered\\nwith a thick varnish of linseed-oil and litharge mixed by the aid of\\nheat with 5 per cent, of salicylic acid. When this coat is dry a sec-\\nond coat is applied, and the whole is finally covered with a thick\\nlayer of wadding retained in place by an elastic bandage exercising\\nmoderate compression. Cicatrization progresses beneath the dress-\\ning without changing the latter. When suppuration occurs the\\nupper layer of wadding is removed, and dried salicylic acid in\\npowder is sprinkled over the surface, the wadding being afterward\\nreapplied.\\nSkin-grafting may be required to cover the extensive ulcers left by\\nthe larger burns.\\nCongelatio, or dermatitis from congelation, presents usually in\\nthe milder forms circumscribed erythematous patches or plaques, gen-\\nerally recognized under the name of Pernio, or chilblain, seated upon\\nthe digits or, more rarely, upon the face, and occasioning a disagree-\\nable sensation of heat, smarting, or itching, especially after the chilled\\npart has been warmed. 1 Chilblains are bluish or purplish red in\\ncolor, and are often seated on a slightly oedematous integument. They\\nare generally cool to the touch when subjectively hot. Authors have\\nclaimed that anaemia is a chief predisposing cause of the complaint, but\\nit frequently occurs in perfectly healthy young people. Sir Erasmus\\nWilson has suggested that some cases of so-called lupus erythema-\\ntosus of the hands belong to this category.\\nIn the second grade of inflammatory reaction, following the state of\\ncontracted blood-vessels and pallid integument produced immediately\\nby the action of cold, bullae and vesicles form, with underlying ulcers\\nin severe cases.\\nIn the third grade gangrene may occur, with and without the forma-\\ntion of bullae. The frozen part may become insensitive, white, and\\ncold, without the circulation in it of blood- and lymph-currents. From\\nthis condition reaction occurs, with the formation of an eschar, differing\\nafter the death of the patient according to the severity of exposure to\\ncold. If, however, beside the interference with the circulation, the tissue\\nitself has been destroyed, when reaction occurs the part falls at once\\ninto gangrene or there form bullae larger than those described above,\\nfilled with sanguinolent serum or the skin is smooth, marbled with\\nbluish lines, whitish, cold, and insensitive. Mortification ensues,\\nfollowed by the well-known phenomena of the line of demarcation,\\nand, in favorable issues, suppurative separation of the dead part, gran-\\nulation, repair, and cicatrization. As the injuries induced by conge-\\nlation are more frequent upon the extremities, the bones, especially\\nthose of the digits, largely participate in the losses of tissue. Septi-\\ncaemia and a fatal result may follow.\\nChilblains are treated internally by the ferruginous tonics, particu-\\nlarly the tincture of iron, externally by stimulant applications, such\\nas those containing iodine, camphor, carbolic acid, tincture of benzoin,\\nand balsam of Peru. Kaposi recommends\\n1 Consult the chapter devoted to the Erythemata.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0220.jp2"}, "221": {"fulltext": "DERMATITIS MEDICAMENTOSA. 207\\nR Pulv. camphorae, gr. x; 66\\nCretse prseparat., Jj 30\\n01. lini, f gij; 60\\nBalsam. Peruvian., wixx; 1J33 M.\\nFrictions, with or without medication, are generally useful. The\\nparts are to be carefully protected from pressure and undue friction-\\neffects.\\nDilute nitric acid and peppermint- water in equal proportions,\\npainted over the part for three or four successive days, have been\\nrecommended by Lapatin for the treatment of frost-bitten fingers and\\ntoes. Hydrochloric and pyroligneous acids, lemon-juice, 50 per cent,\\nand stronger solutions of ichthyol, collodion, and lead acetate, both in\\nlotions and poultices, are also recommended. Meurisse advises in the\\ni management of both severe ambustio and congelatio that goldbeaters skin\\nbe employed over any salves or lotions applied to the affected surface.\\nIn cases of severe congelation the circulation is to be cautiously\\nrestored by friction performed in an apartment the air of which is\\ncool, to prevent too energetic reaction. Friction with snow is em-\\nployed with safety in America and on the steppes of Russia, where\\nthese accidents are frequent and are grave in results. Perseverance\\ni for hours in this course is often rewarded with success in apparently\\ni desperate cases. Antiseptic dressings are usually demanded when\\ni sloughing and ulceration ensue.\\nDERMATITIS MEDICAMENTOSA.\\nThe importance of recognizing the fact that a given eruption is\\nproduced by an ingested drug can scarcely be overestimated from the\\npoint of view of the diagnostician. The errors committed in this con-\\nnection are so frequent and so annoying to the patient that it is neces-\\ni sary for the physician to inquire very carefully, before treating any\\ni cutaneous disease, as to the medicaments previously swallowed by the\\npatient, and also to be prompt to connect any aggravation of a cutane-\\nous disease with remedies ordered by himself for internal use. The\\nJ following is but an imperfect list of the drugs the internal adminis-\\nJ tration of which may be followed by an exanthem imperfect, because\\nwithout question many have yet to be recognized as possessing such an\\n1 action. As to the modus operandi of such medicinal agents, for the\\nI most part our knowledge on this subject is purely conjectural. Some,\\nfor example potassium iodide, are eliminated in part by the glands of\\nthe skin, and presumably have thus a local effect upon such emunc-\\ntories others, and in this class, probably, should be included quinine,\\ninduce an urticaria scarcely to be distinguished from an urticaria ab\\ningestis. Some operate, possibly, in either or both ways at different\\ntimes or in different individuals. The absurdity of supposing that\\nany disease can be driven out by the ingestion of such drugs should\\nbe relegated to the specious ignorance which first framed such an\\nhypothesis. 1\\n1 For full details of this subject, consult the treatise on Drug-eruptions, by Prince\\nA. Morrow. New York, 1887.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0221.jp2"}, "222": {"fulltext": "208 IN FLA MM A TIONS.\\nAcids. The acids capable of producing macules, papules, erythema,\\ndesquamation, etc., are carbolic, nitric, tannic, benzoic (and sodium ben-\\nzoate), and boric (and sodium borate).\\nModadewkow reports a case in which the pleura was washed out with\\na 5 per cent, solution of boric acid, a part of which was not removed.\\nThere occurred as a result an erythematous rash over the face, the\\ntrunk, and the extremities.\\nAconite. This drug is said to be productive at certain times of\\nmarked diaphoresis with the occurrence of vesiculation and consider-\\nable itching. The diaphoresis in an irritable skin may be responsible\\nfor the trouble.\\nAntipyrin and Other Kemedies of its Class (manufactured by the\\naction of glacial acetic acid upon the petroleum-products). Ernst 1 has\\nbeen followed by many observers in recording rashes resulting from\\nthe administration of antipyrin. The symptoms are discrete and con-\\nfluent patches of bright-red, scarlatiniform, erythematous, and pru-\\nritic macules or papules. Veiel 2 reports oedema with bullae upon the\\nlips and toes, and over the palate, with urticarial lesions of the palms\\nand soles, after ingestion of antipyrin. Brocq, Darier, and others have\\nreported cases in which antipyrin has produced a more or less persist-\\nent erythema in the form of isolated, scattered, sharply defined plaques.\\nThese plaques are usually few in number, and they tend to return in\\nthe same sites whenever the susceptible individual ingests the drug.\\nThe redness and pigmentation may persist for several weeks. Wick-\\nham reports an antipyrin-rash which simulated perfectly a macular\\nsyphiloderm.\\nArsenic. Erythematous, vesicular, papular, and much more rarely\\npustular, bullous, and ulcerative lesions occur upon the face, the\\nback, and the hands after the ingestion of arsenic. The well-known\\neffects of the administration of the drug in toxic doses upon the\\nmucous membranes of the eyes, nose, and mouth need not be\\ndescribed in this connection, nor yet the grave gangrenous symptoms,\\nwith osseous necrosis, that have been observed in workers in the\\nmetal.\\nA bright-red, scarlatiniform blush with a few isolated vesicles has\\ncovered both shoulders of a young Avoman with a delicate skin after\\ntaking three medicinal doses of Fowler s solution, the eruption being\\npresent but less distinct upon her face and hands. In two cases the\\nrash in polymorphic type was limited to the hands alone.\\nYouug patients who have taken arsenic in the largest medicinal\\ndoses for relief of chorea often present as a result a dark discoloration\\nchiefly of the skin of the chest and the neck, but also of other parts of\\nthe body. This discoloration is suggestive of the bronzing seen in\\nAddison s disease. In some instances there are no other cutaneous\\nsymptoms. Guaita and Liege noted these phenomena usually in the\\nfifth month after ingestion of the drug.\\nLong-continued use of arsenic may produce keratosis of the palms\\nand soles of a severe grade, obstinate character, and occasionally grave\\n1 Centralb. f. klin. Med., 1885.\\n2 Arch. f. Derm. u. Syph., 1891, Hft. 1.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0222.jp2"}, "223": {"fulltext": "DERMATITIS MEDICAMENTOSA. 209\\nresults. Administered for relief of psoriasis, the resulting keratoses\\nhave later developed into epitheliomata of malignant type.\\nBy far the largest number of rashes are, however, produced in per-\\nsons previously suifering from the cutaneous disease for the relief of\\nwhich the drug is administered. Here the toxic effect is declared by\\neither first, increased hyperemia of the skin, visible in an erythema-\\ntous patch, or beneath the scales of a squamous patch, or as an areola\\nof bright-red hue about any aggregation of lesions second, by simple\\naggravation of the type of a disease already in existence (recurrence\\nof acuity in a subacute eczema) third, by rapid peripheral extension\\nof a disease which had previously been well limited in contour fourth,\\nby converting a disease exhibiting uniformity of lesions into one char-\\nacterized by multiformity. Each of these results might be illustrated\\nby cases.\\nIn a series of eight cases of poisonous effects produced by arsenical\\npaper-hangings, and reported by Brown, 1 there were, curiously, no\\ncutaneous symptoms.\\nBelladonna. The well-known erythematous, scarlatiniform, or red-\\ndish efflorescence produced by belladonna and its alkaloids is usually\\nlimited to the upper segment of the body, but it may become general-\\nized. It is said to occur more frequently in children, probably because\\nit has been administered largely to individuals of that age under the\\ndelusion that it is useful as a prophylactic in scarlatina. Very dis-\\nagreeable and even dangerous results have followed the instillation into\\nthe eye of atropine as a mydriatic, the rash being accompanied by con-\\nstitutional symptoms.\\nBromine and its Compounds. A full account of the cutaneous\\neffects of bromine and its compounds, when administered internally,\\nis contained in a paper on medicinal eruptions, read in 1880, by\\nVan Harlingen, of Philadelphia, before the American Dermatological\\nAssociation. Acneiform lesions, pustules, macules, maculo-papules,\\npapules, eczemaform moist patches, furuncles, urticarial wheals, scales,\\nand ulcers have been induced by swallowing the bromides of potassium,\\nsodium, ammonium, and lithium. By far the commonest are the\\nacneiform and pustular lesions, occasionally accompanied by pruritus,\\nwhich appear upon the face and the upper portion of the trunk,\\nthough the rash may be very distinct upon the genital region. Duhring\\nreports an interesting observation of a patient in whom the eruption\\nsimulated closely the maculo-papular syphiloderm, the patient having\\ntaken a bromine salt for three years. The eruption first appeared\\nwithin five or six days after decreasing the dose. Kaposi observed\\na case of bromide-rash in a nine-months-old suckling, the mother\\nhaving taken 120 grammes of potassium bromide in two months,\\nherself exhibiting no traces of eruption.\\nA remarkably characteristic exanthem is produced by the admin-\\nistration of potassium bromide, especially to infants and young chil-\\ndren. The lesions are condylomaform, quite numerous, conspicuous\\nabout the face and neck, where they are packed closely together, but\\nthey are also seen on other parts of the body. The small coin- to nut-\\n1 Paper read before the Boston Society for Medical Observation, March 6, 1876.\\n14", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0223.jp2"}, "224": {"fulltext": "210 I NFL A MM A TIONS.\\nsized elevated nodules are usually flattened and they often resemble\\ncarbuncles, as they have a cribriform summit on which multiple points\\nof imprisoned pus are visible. This rash, though rare, has been care-\\nfully studied and well illustrated by chromo-lithographic reproductions.\\nT. C. Fox and Gibbes report these condylomaform nodules in the\\ncase of an infant in which the histology of the lesions was carefully\\nstudied and Fay in a child eleven months old also recognized an\\nexanthem which had been mistaken for molluscum epitheliale. These\\nlesions are somewhat similar to the condylomaform rash seen in chil-\\ndren after the administration of potassium iodide.\\nBrowse, of Cambridge, England, recommends for relief of these\\nsymptoms the application of a solution of salicylic acid, 1 grain to the\\nounce (0.066-30.) of water, frequently applied on lint, he having suc-\\ncessfully treated in this way sores as large as the palm of the hand.\\nCannabis Indica. The only instance reported of an eruption pro-\\nduced by the ingestion of this drug was observed by one of us in the\\ncase of an adult male, who was extensively covered with papulo-vesicular\\nlesions after swallowing 1 grain (0.066) of the extract. 1\\nChloral. An erythematous rash is the commonest of the eruptions\\nproduced by chloral, though wheals, red and yellowish papules, vesi-\\ncles, pustules, and petechial blotches have been observed. The rash\\noccurs upon the face, the neck, the trunk, and the limbs, of the latter\\nespecially on the extensor surfaces. In a man of advanced years\\nand totally deaf, who had slept only under the influence of chloral for\\nfour years, discrete scaly patches as large as saucers covered the hands\\nand the lower extremities.\\nMartinet 2 reports an erythematous and scarlatiniform rash, occa-\\nsionally commingled with urticarial and purpuric lesions, occurring\\nupon the face and neck, the front of the chest, the extensor surfaces of\\nthe larger joints, and the dorsum of the hands and feet. There was\\nno pyrexia nor indisposition, but in some cases there were dyspnoea\\nand cardiac palpitation.\\nCod-liver Oil. According to Farquharson, 3 cod-liver oil after\\nbeing swallowed is capable of producing an acne. This result is trace-\\nable to the use of inferior qualities of the oil.\\nCopaiba and Cubebs. The ingestion of copaiba is occasionally fol-\\nlowed by a vividly red rash, in the form of discrete macules, more\\nrarely maculo-papules, invading chiefly the lower segments of the\\nextremities and the skin of the belly, but often completely covering the\\nbody-surface. The rash may occur in dark mulberry-red petechia, and\\nis always accompanied by pruritus. Inasmuch as the drug is often\\nadministered for the relief of a venereal disorder not syphilitic, care\\nshould be taken not to confound the eruption it may excite with the\\nearly macular syphiloderm. Cubebs is much more rarely followed by\\na similar result.\\nCondurango. Guntz 4 reports the occurrence of furuncular and acnei-\\n1 N. Y. Med. Record, May 11, 1878.\\n2 These de Paris, 1879.\\n3 Brit. Med. Jour., Feb. 22, 1879.\\n4 Vierteljahrschft. f. Derm. u. Syph., 1882.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0224.jp2"}, "225": {"fulltext": "DERMATITIS MEDICAMENTOSA. 211\\nform lesions in twenty patients out of one thousand who were taking\\ncondurango for the relief of syphilis.\\nDigitalis. In Behrend s treatise on diseases of the skin l reference is\\nmade to cases in which macular and maculo-papular rashes succeeded\\nthe ingestion of digitalis.\\nIodine and its Compounds. Potassium iodide is responsible for the\\nlarger number of all eruptions among medicinal rashes. The frequent\\nemployment of this drug and the very marked influence it possesses\\nover the skin render the study of these morbid results important.\\nFig. 42.\\nPapilloma, due to the ingestion of the iodine compounds.\\nUnlike many of the other substances in the list of drugs, the iodine\\ncompounds are followed by some species of rash in probably the larger\\nnumber of all persons who swallow them. As is true also with the\\nbromine compounds, the eruption may persist, or even first appear,\\nafter the drug has been discontinued.\\nThe resulting lesions may be macular, papular, vesicular, bullous,\\npustular, petechial, multiform, or may be circumscribed subcutaneous\\n1 Braunschweig, 1879.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0225.jp2"}, "226": {"fulltext": "212 INFLAMMATIONS.\\nabscesses. In appearance the rashes produced by iodine and its com-\\npounds may simulate those of every other dermatitis.\\nThe macular rash is best seen fully developed over the upper\\nextremities in discrete erythematous patches or as a diffuse blush.\\nGenerally the rash is displayed symmetrically. The hands are often\\naffected, and suggest in appearance the hands of the anilin-worker.\\nThe rash assumes at times the papular type with special production of\\npapules upon the face.\\nBerenguier describes a scarlatiniform rash of sudden occurrence,\\nwith numerous minute discrete vesicles upon the surface of the skin.\\nEczemaform eruptions with abundant serous exudation are also reported.\\nA number of cases are on record in which the administration\\nof the drug was followed by the production of bullae. Bumstead,\\nTaylor, Duhring, Tilbury Fox, Finny, and one of us have described\\nsuch bullae in adults as well as in children. 1 Hallopeau 2 also reports\\na fatal case in which a bullous eruption followed the ingestion of\\npotassium iodide. The eruption occurred chiefly about the head and\\nneck and the upper extremities. The significant rarity of vesicu-\\nlar and bullous lesions in acquired syphilis suggests that at least some\\nof the cases on record were those of rashes induced by the remedy\\ngiven for the relief of the disease.\\nA careful analysis of these bullous rashes leads to their division into\\nthree categories first, those occurring, often with fatal results, in\\ncachectic adult patients second, those occurring as part of the eruptive\\nlesions in a polymorphic group third, those occurring in well-nour-\\nished children, and taking on the appearance of molluscum epitheliale\\nand condyloma-lesions, usually compounded of papulo-vesicles and\\npustules. Erythanthemata of a similar type have also been recognized\\nafter the ingestion of potassium bromide by infants.\\nThe pustules induced by the administration of iodine compounds are\\nseen chiefly upon the face, the neck, the trunk, and the arms. They\\nare usually seated upon a firm base, and may be followed by cicatrices.\\nDuhring has seen an annular patch upon the forehead, made up of\\nminute vesico-pustules, which eventually developed into a globular\\nviolaceous mass nearly two inches in diameter. Large, cherry-sized,\\ntubercular or papillomatous elevations abruptly rising from the surface\\nof the integument may present a cribriform structure, which shows the\\nopen ducts of several suppurating follicles (chin, cheek, nose). A few\\ncases are reported in which fungating tumors were found, producing\\nan appearance almost identical with that of mycosis fungoi des. Neu-\\nmann 3 calls attention to the fact that these severe forms of iodide-\\neruption occur in patients suffering from albuminuria.\\nThe purpuric rash occurs in petechial macules, discrete and miliary,\\nsituated chiefly on the lower extremities. In a case reported by Mac-\\nkenzie (quoted by Van Harlingen) a dose of 1\\\\ grains (0.166) taken\\nby an infant was followed by a fatal result after petechia? appeared.\\nJaborandi and Pilocarpine are capable, when ingested, of inducing\\n1 Arch, of Derm., October, 1870. Jour. Cutan. and Ven. Dis., 1886, p. 383.\\n2 Union Med., March 25, 1882.\\n3 Arch, f, Derm. u. Syph., 1899, vol. xlviii., No. 3.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0226.jp2"}, "227": {"fulltext": "DERMATITIS MEDICAMENTOSA. 213\\nfree diaphoresis erythematous macules, wheals, and pinhead-sized\\npapules have been seen upon the surface as a result.\\nMercury. Mercury when ingested is reported to have produced an\\nerythematous rash upon the surface of the skin. In view of the fact\\nthat the metal has been, in its various compounds, administered for so\\nlong a period of time and for so many various diseases, without the\\nproduction of cutaneous symptoms, it is a fair hypothesis that in the\\nfew reported cases there was coincidence rather than causation. Mer-\\ncurials when applied to the external surface of the body are, as is well\\nknown, capable of exciting, in various degrees, cutaneous irritation and\\ninflammation.\\nOpium and its Alkaloids. -Erythema, wheals, and occasionally in-\\ntense pruritus, with oedema, and subsequent desquamation, have fol-\\nlowed the ingestion of opium and several of its alkaloids, notably\\nmorphine. In its mildest expression this cutaneous effect is limited to\\na characteristic itching about the nostrils that can be perceived in a\\nlarge proportion of all patients as soon as the general effect of the\\nopiate becomes apparent. In some patients there may follow an in-\\ntense* and distressing general pruritus without efflorescence, and it is\\ncertain that the subsequent urticarial efflorescence is caused by the free\\ndiaphoresis which the medicament induces. This fact is a matter\\nof practical moment, as the use of an anodyne for the purpose of\\nprocuring sleep for a patient tormented with a nocturnal pruritus\\nwould seem to be occasionally indicated. Inasmuch as chloral, potas-\\nsium bromide, and the opiates are all capable of aggravating such dis-\\ntress, great caution is needful in such emergencies. In general, it may\\nbe said that the employment of these and similar remedies for the relief\\nof pruritus should be interpreted as a confession of weakness on the\\npart of the physician, who ought to be able to alleviate the distress of\\nhis patient by a judicious employment of topical remedies.\\nPetroleum and its products are responsible for a large list of medic-\\nmentous rashes (see Antipyrin, etc.).\\nPhosphorus.\u00e2\u0080\u0094 Hasse (quoted by Van Harlingen) cites the case of a\\nyoung girl who exhibited a pemphigoid rash after the ingestion of\\nphosphoric acid. According to Farquharson, 1 phosphorus itself is oc-\\ncasionally responsible for purpura with gastro-intestinal derangement\\nand jaundice preceding a fatal issue.\\nPodophyllin. Winterburn 2 reports that those who work in resinoid\\npodophyllin are liable to suffer, as a consequence of this exposure, from\\na cutaneous disease of the scrotum.\\nPotassium Chlorate. Stelwagon and others report that papules and\\nmacules have followed the use of this remedy, administered in the form\\nof tablets.\\nQuinine, Cinchona, and Cinchona Alkaloids. Morrow 3 collected the\\nrecords of over sixty cases of quinine-exanthem, and he shows that\\nits prevailing type is exanthematous, the rash being of a vivid\\nhue, disappearing on pressure, and resembling scarlatina. Other\\n1 Loc. cit.\\n2 Louisville Med. News, April 21, 1882.\\n3 N. Y. Med. Jour., March, 1880, p. 244.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0227.jp2"}, "228": {"fulltext": "214 INFLAMMATIONS.\\nlesions produced are wheals, papules, vesicles, petechia, hemorrhagic\\npurpura, bullae, and in one instance an intense localized dermatitis\\nwith beginning gangrene of the scrotum. In some of the cases the\\nrash appears on repetition of the dose, and even after recourse to\\nother alkaloids. The subjects are mostly women. As with most of\\nthe other exanthem-producing drugs, small doses suffice for the effect\\nwhere the idiosyncrasy exists. The rash has been studied in an adult\\nmale, who, after taking 2 grains (0.133) of quinine sulphate for the\\nfirst time in six years, exhibited an efflorescence (over the entire sur-\\nface of the body) of discrete, finger-nail-sized, salmon- and pinkish-\\ntinted, scarcely elevated patches, accompanied by moderate pruritus.\\nA repetition of the dose was followed by a recurrence of the\\nexanthem.\\nIn several cases desquamation is reported as resulting from the rash.\\nAs to the occurrence of the general symptoms recognized under the\\ntitle cinchonism (tinnitus aurium, etc.), these may and may not\\naccompany the lesions. Morrow makes the pertinent suggestion, in\\nview of the frequent similarity of the rash to that exhibited in scarla-\\ntina, that many cases hitherto recorded as recurrent attacks of that\\ndisease and measles, with other anomalous cutaneous eruptions, may\\nhave been instances of quinine-exanthem.\\nSalicylic Acid and the Salicylates. Reports of cases in which these\\nsubstances after ingestion produced cutaneous symptoms have been\\nmade by Heinlein, Wheeler, and Freudenberg, all cited by Van Har-\\nlingen. The symptoms were diffused redness, urticarial lesions, vesi-\\ncles, pustules, petechia?, and vibices, accompanied by intense pruritus\\nand followed by desquamation. Engman 1 reports an interesting case,\\nincluding the histology of the lesions.\\nSalipyrin. (Edema of the skin and actual loss of tissue have resulted\\nfrom the administration of gramme doses of salipyrin to a man aged\\nfifty-four years (Schmey).\\nSantonin. A generalized eruption of urticarial lesions seated upon\\na reddened surface and accompanied by oedema is reported by Sieve-\\nking as occurring in a child to whom santonin had been administered\\nas a vermifuge. 2\\nSodium Benzoate. Roh6 3 reports two cases in which an erythema-\\ntous rash, with well-defined border, accompanied by itching and slight\\ndesquamation, occurred during the use of sodium benzoate. The patients\\nwere a woman, aged thirty-five years, and a boy suffering from diph-\\ntheria. The eruption disappeared on discontinuance of the remedy,\\nand was made successively to appear and disappear by its alternate use\\nand disuse.\\nSodium Biborate. Gowers 4 reports the occurrence, especially on the\\narms, but also over the trunk and legs, of an eruption resembling\\npsoriasis, after the ingestion of sodium biborate. Some of the\\nresulting patches were one and a half inches in diameter. Three cases\\n1 Jour. Cutan. and Gen.-Urin. Dis., 1899, p. 555.\\n2 Brit. Med. Jour., February 18, 1871.\\n3 Maryland Med. Jour., June 15 1881, p. 91.\\n4 Lancet, September 24, 1881.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0228.jp2"}, "229": {"fulltext": "DERMATITIS MEDICAMENTOSA. 215\\nin all are collated. In two the eruption faded when a solution of\\narsenic was added to the sodium salt.\\nStramonium. Deschamps (cited by Duhring) reports an erythema-\\ntous rash after the administration of the thorn-apple.\\nStrychnine. Skinner (cited by Van Harlingen) reports a case in\\nwhich an eruption of six weeks duration ensued upon the administra-\\ntion of quinine and strychnine together the former in the dose of 1^\\ngrains (0.10), the latter in the dose of grain (0.0025).\\nTanacetum. A case of varioliform eruption produced by the inges-\\ntion of 1^ drachms (6.) of the oil of tansy, administered for abortifa-\\ncient purposes, is reported by Potter. 1 There were antecedent clonic\\nconvulsions. The result was not fatal.\\nTar and Turpentine. Erythematous, vesicular, and papular rashes\\nare reported as resulting from the ingestion of these substances.\\nThe following medicaments may be added to the list of drugs\\ncapable of producing rashes when administered by the mouth\\nAnacardium, alcohol, bitter almonds, antimony, argenti nitras, benzol,\\nchinolin, bitter-sweet, capsicum, cantharides, chloroform (after administra-\\ntion for anaesthetic purposes), duboisin, ergot, ferrous iodide, guarana, kava-\\nkava, creosote, resin, castor-oil, ipecacuanha, hyoscyamus, lactophenin,\\nmatico, lead and its compounds, sulphur and calcium sulphide, veratrum\\nviride, cocaine, conium, pimpinella, rhubarb, sulphonal, tuberculin, and va-\\nlerian.\\nMany of these drugs have been effective in but few instances. There\\nis no reason why the list should not be in the future greatly enlarged,\\nas it is probable that every medicament is capable of producing a\\ntemporary efflorescence when the system exhibits a special sensitiveness\\nto its action.\\nThe Diagnosis of the various medicinal rashes described above does\\nnot, fortunately, demand a recoguition of the essential peculiarities\\nimpressed upon each by the exciting cause, since in many cases such\\npeculiarities do not exist. The same drug may, on the one hand,\\nproduce a rash with symptoms widely differing in a group of\\npatients, while, on the other hand, the urticarise resulting from the\\ningestion of head-cheese/ quinine, and chloral may be indistin-\\nguishable. But to establish the fact that a medicamentous eruption\\nis present in any given case is a long step in the direction of reaching\\nthe precise cause that has been in that case effective. This informa-\\ntion must often be obtained from the lips of the patient. The me-\\ndicinal rashes are in general remarkable for their sudden appearance,\\ntheir symmetry, their diffusion over large areas of integument, the\\npresence of pruritus, the absence of fever, and their existence alike\\nupon exposed and protected surfaces of the skin, thus hinting at the\\naction of some cause not operating externally. Excluding syphilis\\nand the exanthematous fevers, a generalized rash of sudden occurrence\\nshould always raise the suspicion of a dermatitis medicamentosa.\\n1 New England Med. Jour., October 15, 1881.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0229.jp2"}, "230": {"fulltext": "216 INFLAMMATIONS.\\nSimilarly in cases of preexisting cutaneous disease, syphilis, eczema,\\nor psoriasis, the sudden occurrence of lesions of a new type widely\\ndiffused, or of rapid aggravation in situ, or of speedy extension in\\nthe area of those already in existence, should awaken the suspicion,\\nif there be fever, of the exanthemata, and, without a febrile process,\\nof the medicinal rashes. Thus, we have seen two patients with eczema\\nexhibit rapid rise in body-temperature, and subsequently develop a\\ngeneralized variolous rash and it is a matter of common experience\\nto examine patients on the eve of a macular syphiloderm, or even long\\npast the eruptive stage of that disease, showing their faces, necks, and\\nshoulders covered with an acneiform rash produced by potassium\\niodide. The practitioner cannot too strongly be urged to view with\\nexceeding watchfulness the skin of a patient affected with any of the\\ncommon disorders (eczema, acne, and psoriasis) when the eruption\\nbecomes anomalous as to type, distribution, or symptoms.\\nThe medicamentous rashes, as a rule, disappear rapidly after the\\nwithdrawal of the exciting cause, and they require no further manage-\\nment. In some cases the soothing lotions, baths, and dusting-powders\\nemployed in the treatment of acute eczema may be required.\\nIt should not be forgotten that the patient who exhibits these lesions\\nis usually one who has been suffering from the real or fancied disease\\nfor relief of which the drug was taken, and that condition may require\\nrecognition and management.\\nIn Morrow s treatise it is shown that the same drug may produce\\na variety of eruptive phenomena, and that the same eruptive features\\nmay result from the ingestion of different drugs. He points to what\\nhe concludes to be the neurotic origin of many of these rashes, and\\nbelieves that the proof is inconclusive that they are to any considerable\\ndegree brought about by elimination, through the cutaneous glands, of\\nthe noxious element introduced with the drug. Tilden, however, calls\\nattention to the fact that many of these eruptive phenomena are of the\\nnature of angioneuroses, similar to Trousseau s tache c\u00c2\u00a3r\u00c2\u00a3brale, requiring\\noften increase in the irritability of the cutaneous vessels, with exuda-\\ntion of serum, outwandering of blood-cells, and, in case of hemorrhagic\\nlesions, some change in the vascular walls themselves.\\nFEIGNED ERUPTIONS\\nAre usually varieties of dermatitis (erythematous, bullous, traumatic),\\ndiscolorations, or ulcers produced by acids, caustics, and other chem-\\nical agents, or friction, for the purpose of exciting sympathy, extorting\\ncharity, securing hospital comforts, transportation to city life, etc.\\nThe persons employing these devices are, as a rule, criminals, hysterical\\nyoung women, mendicants, soldiers, sailors, or servants seeking release\\nfrom service. The extent to which hysterical women will go is well\\nillustrated in one of the authors cases, a young woman, who had\\nsuffered amputation of one finger and six months later asked to have\\nthe entire hand removed for a gangrene, which disappeared under a\\nfixed dressing, and which she afterward confessed was due to her\\napplications of carbolic acid. The peculiarities, briefly, of these artifi-", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0230.jp2"}, "231": {"fulltext": "DERMATITIS GANGRENOSA.\\n217\\nFig. 43.\\ncial eruptions are their odd appearance, not resembling the well-known\\ntypes of ordinary disease their sharp definition, due to limitation\\nof the disease to the area of contact of\\nthe article employed in its production\\ntheir occurrence on parts most accessible\\nto the hands and the eyes of the sup-\\nposed victim of the disease, being in\\nright-handed persons most percepti-\\nble on the anterior portions of the body,\\nparticularly over the surface of the right\\nthigh or leg, and over the left arm or\\nshoulder evidence of drops where a\\ncaustic liquid has been spilled over the\\nsurface, or of angularity in outline, due,\\nas a rule, to downward flow of a fluid\\nfrom above and staining of the fingers\\nor nails, or of the tissue beneath the\\nlatter, by the operator. In a suspected\\ncase the diagnosis may be made clear by\\ncovering the affected areas with a plaster\\nor other fixed dressing, since the artifi-\\ncial eruption quickly disappears when\\nthe patient is prevented from making\\nthe effective applications.\\nMany cases of dermatitis gangre-\\nnosa and erythema gangrenosum have\\nproved to be produced artificially by the\\npatients themselves. Other diseases have thus been imitated. Among\\nthem may be named sycosis, favus, alopecia, ringworm, scabies,\\nbromidrosis, hsematidrosis, chromidrosis, erysipelas, abscess, and\\nsyphilis.\\nChronic Pustulak Dermatitis with Extension in Periph-\\neral Patches has been described and figured by Hallopeau. 1 The\\ntrunk and the thighs were extensively covered with large deep-brown\\nplaques, having definite borders, and exhibiting here and there over\\nthe integument indurated projections of the size of a thumb-nail. The\\nelementary lesion was a vesico-pustule with a red areola, which spread\\ncentrifugally by multiplication and which eventually became covered\\nwith a crust.\\nFeigned eruption.\\nDERMATITIS GANGRENOSA (SPHACELODERMA).\\nGangrene of the skin may result from a dermatitis originally due to\\nthe action of either excessive cold or heat to the action of externally\\napplied chemical agents (caustics, strong acids, alkalies, etc.) or to\\nshock to ergot and other substances ingested to infectious diseases\\n(lepra, tuberculosis, syphilis, erysipelas) to central nervous disease\\n(decubitus, Raynaud s disease) to disorders of the blood-vessels (embol-\\n1 Int. Jour, of Rare Skin Diseases, 1890, iii. 1.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0231.jp2"}, "232": {"fulltext": "218 INFLAMMATIONS.\\nism, thrombosis, acute and chronic endarteritis obliterans, calcareous\\nchanges in the arterial vascular tunics) to compression of vessels by\\nligature, by tumors, or by inflammatory products.\\nMultiple Gangrene of the Skin is reported as complicating\\ntyphoid fever (Hahl 1 and malaria (Osier 2 Hartzell 3 and others\\nreport cases in which the lesions were apparently auto-inoculable, and\\nin which bacilli and cocci were demonstrated. It is possible that many\\ncases are due to a local infection.\\nCrocker describes two cases, one that of a male, the other that of a\\nfemale patient, in whom, as a consequence of scarlatina or some poorly\\ndefined antecedent disorder, crops of pustules, followed by gangrenous\\nsloughing, occurred in almost all parts of the body, one attack rapidly\\nfollowing another with rise of body-temperature. A pustulo-crusta-\\nceous lesion of the upper eyelids, with gangrene resulting in a small\\ncircular ulcer, is reported as occurring in two healthy children.\\nFournier describes spontaneous gangrene of the penis following\\npruriginous and other papules of the part which were scratched and irri-\\ntated. The gangrenous change in this condition succeeds a dull-reddish\\ncongestion of the part, including the mucous surface of the glans, fol-\\nlowed by vesiculation, enormous tumefaction, and often by lymphan-\\ngitis and erysipelas.\\nSpontaneous Gangrene of the Skin occurs chiefly in hysterical\\nfemale subjects, the affected plaques being irregular in outline and super-\\nficial or deep. After the slough has separated the plaques usually\\ncicatrize without serious mischief resulting. Occasionally they spread\\nas serpiginous lesions over the surface. Though doubt has been cast\\non these cases, in consequence of the discovery among them of feigned\\ndisease, it is certain that the malady occurs as described, without the\\noperation of external agencies. These cases are included in those de-\\nscribed elsewhere as Erythema gangrenosum. In making a diagnosis\\nthe feigned eruptions and their distinctive features should be kept in\\nmind.\\nDiabetic Gangrene has been described by Kaposi as occurring on\\nthe limbs of patients affected with glycosuria. Bullae appear, dry in the\\ncentre, and form black crusts, while new bullae arise at the periphery,\\nthus producing a serpiginously spreading area with vesicular border,\\nresulting in both dry and moist gangrene of the central parts. Similar\\ncases are described by other writers in a few instances large portions\\nof an extremity have been destroyed. Gangrene of fingers and toes\\nwithout bullae is reported.\\nDermatitis Gangrenosa Infantum (Multiple Disseminated\\nGangrene of the Skin in Infants Varicella Gangraenosa Pemphigus\\nGangraenosus Rupia Escharotica Gangrenous Infantile Ecthyma).\\n1 Amer. Jour. Med. Sci., 1900, 251.\\n2 Johns Hopkins Hosp. Bull., 1900, p. 41.\\n3 Amer. Jour. Med. Sci., July, 1898.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0232.jp2"}, "233": {"fulltext": "SYMMETRICAL GANGRENE OF THE EXTREMITIES. 219\\nAs a consequence of the exanthemata (variola, varicella, rubeola, pur-\\npura, erythema nodosum) the head, shoulders, and trunk of some\\nchildren exhibit crust-covered lesions which ulcerate and finally throw\\noff a gangrenous, split-pea- to small coin-sized, deep or shallow slough,\\nafter which repair commonly occurs. Severe losses are produced by a\\nspecies of coalescence of smaller ulcers.\\nThese gangrenous points may occur beneath some previously exist-\\ning lesion or crust, or they may at the outset be spontaneous. In most\\ncases there forms a vesicular lesion with rosy areola, that speedily\\nbursts, leaving a blackish slough about which a circle of eliminating\\ninflammation spreads. Thromboses result in the blood-vessels of the\\nneighboring parts, oedema follows, and there is excited a train of re-\\nactive symptoms fever, vomiting, diarrhoea, albuminuria, cardiac or\\npulmonary troubles. The patient becomes greatly emaciated. Crocker\\nreports hemorrhagic vesicles and bullae in grave cases.\\nBrocq is careful to distinguish between these grave forms of disease\\nand those to which should be denied the appellation dermatitis gan-\\ngrenosa. In these milder forms vesicular lesions may develop, simu-\\nlating those of varicella, occurring perhaps in crops and accompanied\\nby a mild fever. Some among them may be covered with a blackish\\ncrust, may indurate at the base, surround themselves with an angry\\nzone of inflammation, and, especially about the trunk, the thighs, and\\nthe anogenital region, ulcerate beneath the crust. Even though these\\nulcers coalesce and acquire a grave aspect, the result, as a rule, is not\\nunfavorable.\\nThe subjects of this affection are infants and young children, from\\nthree months to several years of age. Beside the exanthemata which\\nmay precede, cases are on record as following tuberculosis, rickets, and\\nsyphilis. The process is one which, originally dependent upon the\\ntoxic effects of specific cocci, evidently requires a special soil for its\\neffective operation.\\nThe treatment should include support of the general system, with\\nlocal antisepsis by the aid of boric-acid solutions, aristol, iodol, and\\nthe dressing of the parts which slough by the usual deodorizing agents.\\nThe prognosis is at times grave.\\nSYMMETRICAL GANGRENE OF THE EXTREMITIES (LOCAL\\nASPHYXIA, RAYNAUD S DISEASE).\\nThis affection is usually first announced by the common signs of\\narrest of circulation in the capillaries, numbness, loss of sensibility,\\nand color of passive congestion (local asphyxia, digiti mortui) in fin-\\ngers and toes exposed to extremes of cold or of heat. The face, nose,\\nears, brows, and other regions and organs may also be involved.\\nEventually subjective sensations are awakened, stinging and lancinat-\\ning pains, pricking and crawling sensations. The parts involved,\\noften the second and third phalanges of the digits, first become livid,\\nthen cold, firm, and black and gangrene of more or less of the af-\\nfected tissue results, usually presenting the dry aspect. Bullae may\\nform along the line of demarcation. Separation of the gangrenous", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0233.jp2"}, "234": {"fulltext": "220 INFLAMMATIONS.\\nportions usually takes place slowly. The entire process may require\\nbut a few days or several weeks for its completion.\\nVariations occur in a singular thinning of the digits, which may\\nbecome indurated and slender or they may be covered with small\\nwhitish cicatrices where a superficial slough has separated or the\\nparts may become cool, white like alabaster, and recover their tone\\nwithout loss of tissue the nails alone may fall or indeed the entire\\nprocess may meet with arrest in the early stage of blueness and asphyx-\\niation of the extremities. The mild forms which terminate in recovery\\nmay recur, and the type may become with each recurrence more severe\\nuntil finally gangrene results.\\nEtiology and Pathology. This disease occurs equally in the two\\nsexes and at all ages, and often in the cold weather of the winter\\nseason. There is a growing suspicion that many cases are of syphilitic\\norigin, as the disease has followed specific infection. It has also suc-\\nceeded tuberculosis, diphtheria, the exanthemata, diabetes, and hsemo-\\nglobinuria. It is apparently due to trophic disturbances, the exact\\nnature of which has not been determined.\\nTreatment is by employment of the galvanic current, stimulation\\n(as in dermatitis with congelation), and friction with stimulating alco-\\nholic, camphorated, or oleaginous lotions. It is desirable to apply both\\nelectricity and (in some cases) dry cupping over the spinal region.\\nThe Prognosis is in some cases grave when the morbid condition\\nis limited to a small part of the body recovery is often satisfactory.\\nERYSIPELAS.\\n(Gr. epvdpog, red ireXka, the skin.)\\n(St. Anthony s Fire. Ger., Eothlauf, Erysipel\\nFr., ICrysipele, La Kose.)\\nSymptoms. This disease is usually preceded by a prodromic\\nperiod of malaise (lasting for twenty-four hours or less), which may be\\nushered in by one or several chills followed by febrile symptoms. The\\nlatter are accompanied by anorexia and often by vomiting with general\\ndepression and headache.\\nThe eruptive symptoms are generally first displayed at a given\\npoint, from which the disease progresses. It is commonly first noticed\\nin a nut- or egg-sized patch, the integument of which is tumid,\\nslightly elevated, irregular in contour, distinctly circumscribed, and\\npresents a rosy or crimson-reddish color with a peculiarly smooth and\\ncharacteristic shining or glazed appearance. The sensations awakened\\nmay be those of moderate pruritus, of pain, heat, or burning. To the\\ntouch the affected part is tender, moderately firm, and perceptibly\\nhotter than normal. The color fades under pressure to a yellowish\\nwhite.\\nIn typical cases the erysipelatous blush and swelling spread over\\nan area which may be of the size of the palm, or may even cover\\nthe surface of an entire limb or a region of the body. In cases of\\nmoderate grade the inflammation attains a maximum of extent and", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0234.jp2"}, "235": {"fulltext": "ERYSIPELAS. 221\\nseverity within a week, remains apparently unaltered for a day or more,\\nand then begins to abate, with amelioration of all the concomitant\\nsymptoms. The fever, which often precedes the eruption, continues\\nunabated during its progress, the temperature rising to 105\u00c2\u00b0 or 106\u00c2\u00b0 F.,\\nwith nocturnal exacerbation, cephalic and lumbar pain, dryness of the\\ntongue, gastric distress, and occasional delirium. As involution of the\\ndisorder is accomplished the redness is replaced by the brownish,\\nbluish-red, and dirty-white shades often seen after the disappearance\\nof erythema multiforme, the epidermis finally desquamating in various\\ndegrees according to the extent of the preceding inflammation.\\nIn other cases, in which the exudation of serum beneath the epi-\\ndermis has been rapid, the epidermis is raised in the form of vesicles,\\npustules, or bullae, more often the latter, and precisely as in the severe\\nforms of dermatitis calorica, with which erysipelas presents a certain\\nanalogy, gangrene of the skin may result in the part affected. This\\ncomplication is particularly liable to follow the disorder when it attacks\\nthe seat of surgical wounds and injuries.\\nThe febrile symptoms are, throughout, persistent and characteristic\\nof a specific toxaemia. The body-temperature, as has been seen, may\\nreach 105\u00c2\u00b0 to 107\u00c2\u00b0 F., with vespertine exacerbations and remissions;\\nit may also become subnormal. If not relieved in the course of seven\\nor eight days, complications may be expected, namely, oedema, abscess,\\nphlegmonous inflammation, gangrene, or inflammatory accidents involv-\\ning the. membranes of the brain, lungs, heart, bowels, kidneys, perito-\\nneum, or joints.\\nErysipelas Ambulans is a term used to describe that form of the\\naffection in which the erysipelatous blush, after involving a given area,\\nspreads with greater or less rapidity to the parts in the vicinage, either\\nby direct extension and uniform advancement in one direction of the\\ntumid and distinctly circumscribed border, or by linear, digital, or irreg-\\nular prolongations radiating from the inflammatory focus. As the\\nblush and swelling advance in one direction there is usually a corre-\\nspondingly rapid disappearance on the other. At other times the disease,\\nwhile extending to a new area and abandoning the old, is relighted in\\nthe latter, and thus an irregularly involved and irregularly extending\\nerysipelatous surface presents for weeks the varying phenomena of the\\ndisease. In yet other cases, chiefly those in which there has been a\\nhistory of traumatism, a long erysipelatous linear streak or band may\\nspread from the site of the traumatism in one direction or another, sug-\\ngesting the indurated lines observed in lymphangitis. In severe cases\\nthe febrile, nervous, and other symptoms are grave, including coma,\\ndelirium, meningitis, and the signs of serious involvement of the lungs,\\npericardium, pleura, and bowels. Metastatic abscesses may also occur\\nin the cutaneous and subcutaneous tissues, the joints, the peritoneal\\ncavity, and even in the viscera. Death may result from these complica-\\ntions, or from shock, exhaustion, or pyaemia.\\nSurgical accidents aside, the face is the commonest seat of the dis-\\nease, on which the disease may be first seen upon one side of the nose,\\na cheek, a lip, or an eyelid. It often attacks the lobe of the ear after\\nthe operation of piercing the lobule for the insertion of ear-rings in", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0235.jp2"}, "236": {"fulltext": "222 INFLAMMATIONS.\\nwomen thence it may extend over the whole face, inclusive of the\\nmucous linings of the mouth and the nose, that present a dry, tumid\\nand glazed appearance, suggestive of the symptoms displayed upon the\\nskin. The inflammation may extend to the hairy parts, but in many\\ncases it exhibits a species of reluctance to transgress the limits there\\npresented. It maybe noticed in cases of mild grade, in which no appli-\\ncations have been made to arrest a local progress, that the elevated\\nborder spreads symmetrically to within a few lines of the male beard\\nor the hairs at the edge of the forehead, and there is- arrested. In\\nseverer grades these limits are surpassed, and then, as a rule, the\\nextension is rapid and formidable. In this way the entire head may\\nbecome enormously swollen, suggesting to a casual observer that it\\nis twice its normal size. The patient then is greatly disfigured\\nhis scarlet lips are swollen and parted, permitting the escape of\\nsaliva the ears, as usual when greatly enlarged, project in a marked\\ndegree from the side of the head the eyelids are \u00c2\u00a9edematous and\\nincapable of separation the face is disfigured by bullae or crusts and\\nthe mind disordered in the violence of the fever or the accesses of\\ndelirium. When recovery ensues the hairs generally fall.\\nAll regions of the body may be invaded, such as the vaccinated\\narm, the leg the skin of which is involved in venous varicosities,\\nthe scrotum or the umbilicus of the infant, the genitalia of the newly\\ndelivered woman, the breast of the nursing-mother, and every surface\\nwhich has been the seat of punctured, incised, contused, or poisoned\\nwounds, or other accidents of the integument to which the germs of the\\ndisease may have had access.\\nChronic Erysipelas. Habitually recurrent and indolent erysip-\\nelatous attacks the identity of which with the disease here described\\nit is difficult to establish, have been noted by several authors. The\\ndiagnostician is often consulted in cases in which an erythematous\\neczema of the face, an acne rosacea, a symptomatic erythema, or\\nan acute inflammatory oedema is described as chronic or recurrent\\nerysipelas. The lesions to which such terms are restricted by care-\\nful writers, however,. are often forms of chronic dermatitis, such, for\\nexample, as occasionally follow dermatitis calorica. Instances occur\\nin which the face, wholly or in part, is the seat of a low grade of in-\\nflammation with local heat, swelling, redness, considerable infiltration,\\nand some tenderness, the skin being irritable and worse after exposure\\nto a high wind or after excesses at the table. But most of such cases\\nfail to exhibit the distinct imprint of erysipelas they are not only\\nchronic in course but are exceedingly indolent, often lasting for years\\nthey are unaccompanied by fever they are distinctly limited in all\\naccesses of aggravation to the same part of the face they are rarely\\ncharacterized by a bullous efflorescence many occur in the subjects\\nof chronic alcoholism and the specific germs of erysipelas are not\\npresent.\\nEtiology. Erysipelas is caused by the streptococci of Fehleisen,\\nwhich gain admission to the tissues through some lesion of the sur-\\nface. The site of infection may be a surgical or other wound, or it may", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0236.jp2"}, "237": {"fulltext": "ERYSIPELAS. 223\\nbe a slight scratch or an unrecognized abrasion of the skin or mucous\\nmembrane.\\nIn the face, catarrhal and ulcerative processes involving the mucous\\nmembrane of the mouth, ears, and nose are often the cause of erysip-\\nelas, these processes occurring in a wide range of disorders from syph-\\nilis of the nasal bones to caries of the teeth. Tuberculous and other\\nulcers, as well as eczema and several skin-diseases, frequently furnish\\na means of ingress to the streptococci. Injuries of, and surgical opera-\\ntions upon, the scalp not conducted with antiseptic precautions, and\\nthe common piercing of the lobe of the ear in women and female\\nchildren for the insertion of ear-rings, may be followed by the appear-\\nance of the disease upon the scalp, as a result of which the hair often\\nfalls Fistules, vaccination, lesions of the tender umbilicus of the\\nnewborn infant, and railway accidents may be named as common causes\\nof the disease in other regions.\\nPredisposing causes of this disease are to be sought for in cachexia,\\ngeneral debility, alcoholism, kidney-disease, epidemic influences, trau-\\nmatism, violation of hygienic rules, and occasionally the recurrence of\\nprevious attacks. Besides these causes, it is alleged that constitutional\\npredisposition and particular articles of diet (mussels) may be responsi-\\nble for the disease.\\nSince the malady is invariably the result of infection due to the\\npresence of a streptococcus, the essential cause lies in the specific germ,\\nin the absence of which none of the predisposing causes named can be\\neffective. It is clear, however, that the predisposing causes suggested\\nare those in which the multiplication of such germs and their entrance\\nto the general economy are most facilitated.\\nPathological Anatomy. Under the microscope the skin and sub-\\ncutaneous tissues are seen to be infiltrated, the exudate being more\\nserous and less rich in protoplasm than that observed in ordinary\\nphlegmonous inflammation of the skin. The bullae represent rapid\\nexudation of this same serosity to the congested epidermis, and the\\nelevation of the latter in consequence. The elements of the rete and\\nconnective tissue are for the same reason swollen, the lymphatic and\\ni blood-vessels are enlarged, and the cutaneous follicles are engorged,\\n1 the root-sheaths of the hairs being occasionally separated, thus neces-\\nsitating temporary loss of the pilary growth. In proportion to the\\nseverity of the exudative process pus-corpuscles may appear, and\\nrepresent, for the most part, degenerative changes in the subcutaneous\\ntissues resulting in abscess. The phenomena are, in short, those of\\nsuperficial or of deep-spreading dermatitis. After death the skin which\\nhas been the seat of the disease cannot be distinguished microscopically\\nfrom that of another part of the body.\\nUnna, whose examinations were made largely in the skin of\\nchildren and infants, found invariably a simultaneous invasion of\\nboth the cutis and the hypoderm in erysipelas, the former recovering\\nfar more rapidly than the latter, and rarely reaching such a grade\\nof activity. The venous capillaries were all enormously distended,\\nas if paralyzed by the poison present, and the collateral lymphatics\\nwith the lymph-spaces were equally dilated. All the cutaneous ves-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0237.jp2"}, "238": {"fulltext": "224 INFLAMMATIONS.\\nsels swarmed with streptococci, both in the central and the marginal\\nzones.\\nDiagnosis. Erysipelas is to be distinguished from the erythemata,\\nfrom dermatitis of various grades, from eczema, and from scarlatina.\\nAs a rule, its recognition is readily effected when the presence of\\nthe fever in erysipelas is kept in view, as also the peculiar shining,\\nswollen, and rosy-reddish to damask hue of the affected parts. The\\nredness is never produced, as in scarlatina, by multiplicity of reddish\\npuncta, nor is it so widely diffused as in that disease. Erysipelas may\\nat times be accompanied by a pruritic sensation, but the patch which it\\naffects is never by any possibility scratched. By this simple test alone\\none may often distinguish an erysipelas of the face from an eczema of\\nthe same region in a child. From a chronic dermatitis with thicken-\\ning of the affected tissues and redness of the surface, erysipelas is to be\\ndistinguished by its tendency to spread, by its acute course, by its fre-\\nquent association with bullous or vesicular lesions, and by the color,\\noutline, and raised border of the affected patch. However, it must be\\nunderstood that to these localized patches of chronic dermatitis several\\nauthors have given the name chronic erysipelas/ the difference\\nbetween the views held on this point being chiefly one of titles.\\nTreatment. The method of treating erysipelas by the administra-\\ntion of the tincture of iron internally has long been popular among\\nAmerican practitioners, but its efficiency is questionable. This prep-\\naration is given in full doses, from 10 to 50 drops, day and night every\\ntwo to three hours, irrespective of the febrile state.\\nThe constitutional treatment is important, but is solely symptomatic,\\nand should be directed to lowering the temperature, to obtaining proper\\nfunctional activity of all the organs of the body, and in prolonged\\ncases to sustaining the strength of the patient. Locally, when the\\nerysipelatous blush has a distinctly circumscribed outline, an annular\\nzone extending for an inch or more in width upon the sound and\\naffected skin may be either covered with tincture of iodine, or be\\npencilled with a crayon of argentic nitrate, or be painted with a saturated\\nsolution of the same salt. The purpose of such treatment is to limit\\nextension of the disease. It is true that these measures will not\\nalways succeed, but it is erroneous to assert with some authors that\\nthey always fail. Certain it is that, whether effective or not in the pro-\\nduction of the result, the advancing border of the disease will often fail\\nto surpass the limits thus artificially described. Collodion has been\\nemployed for a similar purpose, and Darlin x advocated the revival of\\nthis method of treating the disorder, basing its claim on the fact that\\nthe dressing diminishes the temperature of the part thus protected, and\\nthat, by the compression excited, it interferes with septic absorption.\\nHeppel 2 recommends the painting over the surface of a 10 per cent,\\nsolution of carbolic acid in alcohol, as an abortive treatment, for which\\nBraithwaite 3 substitutes a solution of tannin of the same strength.\\nGood results have been reached in the local treatment of erysipelas,\\n1 Bull. gen. de Ther., 1881, vol. ii., p. 239.\\n2 Arch, of Derm., April, 1881.\\n3 Brit. Med. Jour., April, 1881.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0238.jp2"}, "239": {"fulltext": "ERYSIPELAS. 225\\nfirst, by attempting to limit the extension of the disease by the applica-\\ntion of the tincture of iodine over the peripheral zone, and, secondly,\\nby retaining over the entire surface affected neatly applied compresses\\nsaturated with a solution of sodium hyposulphite in the strength of\\nabout 1 drachm (4.) to the ounce (32.).\\nAttempts, however, to limit extension of the disease by local\\napplications of an irritating sort (corrosive sublimate, silver nitrate,\\ncarbolic acid, tar, turpentine, etc.) are by most experts condemned as\\npositively injurious. Dry heat applied by the aid of cotton or wool,\\ncold compresses, or iced lead-lotions with intermissions of application,\\nsalicylic acid, boric acid, iodol, resorcin in solution, or iodoform in\\npowder may be used. A 95 per cent, alcohol or a saturated solution\\nof boric acid often gives good results if painted frequently over and for\\nan inch or more beyond the affected area, or if applied on compresses.\\nKoch applies 1 part of creolin, 4 of iodoform, and 10 of lanolin, cov-\\nered with gutta-percha. Nussbaum uses ichthyol and collodion, or equal\\nparts of ichthyol and vaselin covered with a 10 per cent, salicylic lint.\\nHallopeau praises 1 part to 20 of sodic salicylate in aqueous lotions\\nupon folds of linen. Elliott and others strongly recommend ichthyol\\nin lotions, in oils, or in ointments. It may be used in strength vary-\\ning from 10 to 50 per cent., and is kept constantly applied to the\\naffected area and for some distance beyond it. Tabit claims to abort\\nthe disease with a 10 per cent, solution of iodol in collodion. Injections\\nof antistreptococcic serum have been used with varying success.\\nErysipelas rarely attacks a patient in vigorous health. The large\\nmajority of all the subjects of the disease are either those who have\\npreviously suffered from manifest general ill-health, or who have been\\ncomplaining of local ailments, trifling wounds, nasal catarrh, or surgical\\naccidents. It is these precedent conditions which often demand special\\nattention.\\nIt is needless to add that all surgical indications are to be fully met\\nwhen they are present pus is to be evacuated, crusts removed, and\\ndrainage secured. The physician and surgeon alike should never for-\\nget that the disease is infectious that the patient is to be isolated and\\nto be supplied with an abundance of pure air and that fomites, surg-\\nical instruments, and even the non-disinfected hands of attendants are\\ncapable of transmitting the disease.\\nFinally, there are forms of erysipelas which are remediless they\\nare usually septic in character. The scarlet blush spreading from an\\nirreparable injury of long duration is often the last protest of Nature\\nagainst the damage which even her final resort of gangrene will not\\navail to repair.\\nPrognosis. Under favorable circumstances erysipelas, even of\\nsevere grade and extensive invasion, terminates in complete resolution.\\nReserve should be made, however, in every case, as a serious compli-\\ncation has often transformed the simplest into the gravest form of the\\ndisease. The very young, the cachectic, the victims of drink, the\\naged, the inmates of hospital-wards depressed by other illness, and\\nthose mentally distressed by destitution and neglect, are particularly\\nliable to suffer from grave and fatal forms of the malady.\\n15", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0239.jp2"}, "240": {"fulltext": "226 INFLAMMATIONS.\\nThe patients who fill the beds in most lying-in hospitals are young\\nwomen, either unmarried or deserted by their husbands, and unpro-\\nvided with the necessities of life by those upon whom such a respon-\\nsibility rests. The mental depression thus originating in connection\\nwith septicemic influences is responsible for much of the relation\\nwhich erysipelas often seems to sustain to the puerperal state, as also\\nfor the appalling mortality which it may exhibit under these circum-\\nstances.\\nERYSIPELOID.\\n(Erysipelas Chronicum, Progressive Phlegmon, Erythema\\nMigrans.)\\nThis term is employed by Rosenbach l to designate a special inflam-\\nmation of the integument occurring as a complication chiefly of trau-\\nmatisms. When a wound is infected with the special poison of the\\ndisease a peripherally spreading tumid and empurpled halo encircles\\nthe site of infection, which slowly disappears in the part originally at-\\ntacked while it extends progressively to another area. The advancing\\nborder of the disease is distinctly circumscribed, and may be festooned\\nor scalloped. New points may appear from which the violaceous red-\\nness spreads, while others are in a state of apparent inactivity.\\nThis affection may be complicated with furunculosis, but scaling is said\\nnever to occur. Itching and burning sensations are usually present.\\nRosenbach believes that the source of this disease is a micro-organ-\\nism of the order Cladothrix, existing in putrid flesh and cheese, from\\npure cultures of which organism he is reported to have induced the\\ndisease. His position, however, is unfortified by experiments of other\\nobservers.\\nThe disease affects chiefly the fingers and hand (according to Elliott,\\nalso the scratched toes) of scullions, meat-dressers, fish-dealers, poul-\\ntry-cleaners, and persons of similar occupations. The distinction be-\\ntween this disorder and erysipelas is based chiefly on the indolence of\\nthe former, its more superficial involvement of the skin, and the absence\\nof constitutional symptoms. It is to be carefully distinguished from\\nCrocker s dermatitis repens (some instances of which may be here\\nincluded), from erythema multiforme, from erythema iris, and from\\nringworm of the hands.\\nTreatment is efficient with local application of formalin, ichthyol,\\nresorcin, pyoktan in-blue, pyrogallol, potassic permanganate, or the mer-\\ncurials in salves or in lotions.\\nFURUNCULUS.\\n(Lat. furunculus, a petty knave.)\\n(Boils. Fr., Clou Ger., Blutschware.)\\nFurunculosis is characterized by the occurrence of one or more cir-\\ncumscribed cutaneous or subcutaneous abscesses, called furuncles,\\nwhich usually terminate by necrosis of tissue in the centre of the\\n1 Verk. d. Deutsch. Cong. f. Chirurg., 1887.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0240.jp2"}, "241": {"fulltext": "FUBUNCULUS. 227\\nphlegmon, the expulsion of the necrotic mass in the form of pus or a\\ncore, and a resulting cicatrix.\\nSymptoms. Furuncles commonly begin as tender and painful\\nindurations in the skin or its subjacent tissues, the summit of each\\nnodule soon becoming visible in the epidermis as a reddish punctum.\\nA furuncle is the result of an active inflammatory process, limited to\\na definite area, and of greatest intensity at the centre of the involved\\nmass. This centre is often represented by a hair-follicle, the pustule\\nthat forms subsequently being perforated by a hair.\\nMore or less rapidly thereafter these symptoms are succeeded by\\nincreased redness, heat, and tumefaction, the latter producing a nut-\\nor egg-sized tuberosity, well projected from the surface or fairly im-\\nbedded within or beneath the derma. A yellowish point in the centre\\nof the erythematous swelling soon announces the occurrence of suppu-\\nration. When accidentally or artificially opened at this summit exit\\nis given to thick yellowish pus with which blood may be commingled\\nfrom the traumatism of neighboring capillaries. The small abscess\\nmay then, after discharging for a few days its purulent contents, grad-\\nually close by granulation, or may also expel from its cavity a tenacious,\\npus-covered, yellowish-green slough, known as the core. This evac-\\nuation is usually followed by relief of the tense and throbbing pain\\nwhich is the well-known subjective characteristic of the furuncle.\\nThe length of time requisite for the completion of this process varies\\nwith the extent of tissue involved, from a few days to several weeks.\\nBoils may occur in any part of the body, but are most common about\\nthe face, the auricular region, the neck, the armpits, the anogenital\\nsurfaces, the hips, the buttocks, the breast, and the extremities. They\\nmay occur as single or as multiple lesions, or they may succeed each\\nother in crops, especially about the buttocks, trunk, and thighs, for a\\nperiod of several months. It is this succession of boils to which the\\nterm furunculosis is specially applied. The disease of the skin, in\\npatients suffering from furunculosis, may produce a constitutional effect\\nmanifested in pyrexia, which is usually encountered only in individuals\\nof irritable constitution when the furuncles are few and short-lived.\\nThere is also a decided chloro-anaemia due to the pain, fever, purulent\\ndrain, irritability of nervous centres, inappetence, and consequent per-\\nversion of nutrition.\\nThe sequels of boils are maculations of a violaceous tint, often per-\\nceptible in the skin for weeks and even months after their disappear-\\nance and pinhead- to penny-sized cicatrices which are permanent.\\nEtiology. The microbe which is the immediate cause of boils is\\nthe staphylococcus pyogenes aureus. The remote cause, however, is\\noften exceedingly obscure. It is true that boils are encountered in\\ntypical subjects of diabetes, of the exanthemata, and of hospitalism,\\nin whom anaemia, asthenia, marasmus, malnutrition, and exhaustion\\nresulting from excesses, from grave general disease, from low fevers,\\nand from nervous strain, play a prominent part. But the reverse is\\nalso true.\\nScratching, eczema, scabies, other cutaneous diseases, lice, and ex-\\nternal irritants of various sorts are responsible for many boils, especially", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0241.jp2"}, "242": {"fulltext": "228 INFLAMMATIONS.\\nthose that are few and not followed by similar lesions. When, how-\\never, such sequence occurs it should not be forgotten that the pus is\\nauto-inoculable, and that furuncles, if sufficiently numerous and large,\\nare capable of disturbing the general economy. A collar-button at the\\nback of the neck the edges of an unyielding corset in one unaccus-\\ntomed to it a hard bench a saddle-tree a velvet coat-collar sheltering\\nthe germs responsible for a previous attack and many similar articles\\nmay be the exciting cause of furuncles.\\nAccount should always be had, in cases of persistent furunculosis,\\nof externally operating poisons. In this category must be included\\nsewer-gas emanations, arsenical wall-papers, and the poisons handled\\nin the trades, e. g., by dyers, lead-manufacturers, etc.\\nLastly, it is exceedingly common for patients thus affected to apply\\nto practitioners for remedies intended to purify the blood and, in-\\nasmuch as potassium iodide is often prescribed in response to this\\ndemand, the original trouble is thus enhanced to a manifold extent.\\nMany cases of furunculosis are instances of boils resulting originally\\nfrom external irritation, that have greatly multiplied and finally pro-\\nfoundly affected the system under the impulse of the so-called blood-\\npurifying process.\\nPathology. According to Unna, most furuncles begin with an im-\\npetiginous lesion. Rarely is the hair-follicle the site of implantation\\nof the cocci. After securing access to the rete these germs push before\\nthem the prickle-layer, flatten the papillary body, dig into the cutis,\\nand later produce a perifollicular abscess of a lanugo hair-follicle.\\nThe abscess spreads by colonies of cocci which are swept laterally\\nalong the lymph-channels. Once in the subcutaneous tissue these\\nmicro-organisms find few barriers to their development and extension.\\nThey are found surrounded by dying pus-cells in the centre of every\\nfat-lobule.\\nDiagnosis. Boils are to be distinguished from carbuncles by the\\naggravated symptoms of the latter. Circumscribed furuncular ab-\\nscesses of the groins and the axillae are not to be confounded with\\nsuppurating, sympathetic, or virulent buboes of these regions, associ-\\nated with genital or extragenital contagious venereal sores. Errors\\nof this sort have been made. Furuncles of the anal and genital regions\\nin point of diagnosis may be significant of surgical affections of the\\nneighboring parts (perineal, periprostatic, peri-urethral, and scrotal\\nabscesses in men suppuration of the vulvo-vaginal gland in women,\\netc.).\\nTreatment. The debilitated constitution of many patients affected\\nwith boils indicates clearly the need of a tonic regimen, including the\\nadministration of iron, quinine, and strychnine, the mineral acids, and,\\ncontrary to the generally accepted opinion of the laity, a generous diet\\nof milk, cream, eggs, and fresh meats. To these articles of diet wines\\nand malt liquors may at times be added with advantage. Change of\\nclimate, of diet, of cooks, and of the habits of life is most serviceable in\\ncases of prolonged furunculosis. The mineral waters at some health\\nresorts prove especially valuable for the debility which often results\\nfrom these disorders. The urine should always be examined for sugar,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0242.jp2"}, "243": {"fulltext": "CARBUNCTJLUS. 229\\nalbumin, and an excess of urates. The internal remedies which possess\\nreputation in this complaint are arsenic, sulphur and the sodic sulphites,\\nthe alkalies, tar, fresh yeast in tablespoonful doses, phosphorus, and the\\nsyrup of the hypophosphites of calcium, iron, sodium, and potassium.\\nCalcium sulphide, which was once more highly esteemed than any\\nother of the internal remedies named, is given in doses of to i\\ngrain (0.0066-0.0133) every three or four hours. It is doubt-\\nful whether the drug exerts any influence whatever upon furuncles.\\nIn lithaBmia potassium acetate or citrate is given in large dilution,\\nor the liquor potassse in gouty states colchicum, salol, and the\\nalkalies, including the sodic salicylate. No one of these articles, how-\\never, may be described as an efficient and certain remedy for the com-\\nplaint many cases will progress without hindrance from any or all\\nof them.\\nAttempts in the direction of aborting a furuncle by the topical\\napplication of the stronger alkalies (aqua ammonise) or acids, caustics,\\ncautery, ice, or premature complete excision with the scalpel, occasion-\\nally succeed, but often they fail.\\nThe best methods of local treatment are the simplest. The part\\nmay be frequently bathed with a hot, saturated solution of boric acid, and\\nimmediately after be covered with lint thickly spread with a paste\\nformed of 2 drachms (8.) each of zinc oxide and powdered starch to\\nounce (16.) of vaselin; or with freshly made benzoinated zinc oint-\\nment. When the pain is unusually intense the parts may be dressed\\nwith charpie wet with hot borated lotions and covered with a protective\\ndressing. When the pus is evacuated and the slough wholly or in part\\ndetached, the dressings for most cases, after washing with the hot borated\\nlotion, are: boric acid in powder, iodol, iodoform (objectionable on\\naccount of its odor), aristol, or hydronaphtol (1 part to 100 of fullers\\nearth).\\nViolent squeezing of a furuncle to separate its slough or to evacuate\\nits contents should never be practised.\\nPrognosis. Eventually the worst cases are relieved when unac-\\ncompanied by systemic or visceral disorders, and when the circum-\\nstances of the sufferer permit him to pursue the most advantageous\\ncourse (travel, diet, abstraction from business, etc.). The resulting\\ncicatrices depend upon the severity of the process. Often they are\\nsmall and in the course of years become scarcely distinguishable in\\nexceptional cases they are large, persistent, and disfiguring.\\nCARBUNCULUS.\\n(Lat. carbo, a live coal.)\\n(Anthrax Simplex, Carbuncle. Ger., Carbunkel;\\nFf., Carboncle.)\\nI A carbuncle is a circumscribed cutaneous and subcutaneous abscess,\\nusually larger than a furuncle, that is due to the presence of staphylo-\\ncocci, and is characterized by dense induration and sloughing, termi-\\nnating in favorable cases by the production of a persistent cicatrix.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0243.jp2"}, "244": {"fulltext": "230\\nINFLAMMATIONS.\\nSymptoms. Carbuncles are often preceded by malaise, chill, and\\npyrexia of severe grades. There is commonly a burning pain at the\\nsite of the lesion. In cases in which the carbuncle is formidable and\\nseated upon or near the head alarming symptoms of prostration, stupor,\\nsomnolence, and even coma, may be noted. With and without these\\nconcomitants a dense, dull-red, indurated, and painful phlegmon soon\\nappears, varying in size from that of a small hen s-egg to that of an\\norange and even much larger, involving not only the skin but also\\nthe tissues beneath. Suppuration finally occurs, but the pus is not\\nconfined to a single space it undermines the integument and often\\nFig. 44.\\nVertical section of a carbuncle. Dense network of fibrous bundles, with interspaces communi-\\ncating and extending to the subcutaneous tissue. (After Warren.)\\nFig. 45.\\nf p mp\\nSection of a carbuncle. Infiltrated papillae are seen at I, distended in balloon-shaped figures,\\nbetween which the rete is compressed at p and mp columnse adiposse are seen division of\\nelements, the fibrous bundles resolving into protoplasm. (After Warren.)\\nthrough several apertures leaks out indolently to the free surface. The\\nfenestrated or cribriform appearance of the skin covering the carbuncle\\nconstitutes in this stage one of its most striking features. Through\\nthese apertures may be distinguished the whitish or yellowish pus-\\nsoaked sloughs or portions of a single slough, which can at times be\\nextracted through the orifice. Often the entire mass separates in a\\nsingle slough involving the skin and subcutaneous tissues, leaving a\\ncrateriform ulcer of formidable size, which in favorable cases proceeds\\nto heal by granulation. The resulting cicatrix is at first of a deep\\nviolaceous tint and later becomes blanched. It is indelible.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0244.jp2"}, "245": {"fulltext": "CARMVmVLVS. 231\\nThe fever which usually accompanies this process may be mild or be\\nsevere, or, more commonly in dangerous cases, be of a typhoid char-\\nacter. It results unquestionably from sepsis due to unliberated pus\\nand necrotic tissue, and is naturally most grave in its consequences\\nin patients weakened by previous asthenic disorders. Under these\\nunfavorable circumstances the carbuncle may spread at the periphery,\\nenclosing islands of necrotic tissue and ill-conditioned pus separated\\nby bridges of empurpled, infiltrated, and yielding skin.\\nThe characteristic lesions of this disease most often appear on the\\nback of the neck, the back of the trunk, and the lateral aspect of the\\nhips and thighs, usually in a single development, though occasionally\\ntwo or even three carbuncles of small or of medium size may coexist.\\nThe reason for their appearance in the localities named is clear. It is\\nhere that the skin is most thick and resistant, and, as a consequence,\\npurulent foci when formed are covered in by the most voluminous\\nlayers of the connective tissue of the corium.\\nEtiology. Anthrax simplex is produced by the obscure causes\\nto which reference has already been made as probably effective in the\\nproduction of boils. Carbuncles and boils may coexist; or the one\\nlesion may follow the other and there may occur intermediate forms\\nassignable to either class. The disease is encountered more often in\\nmen than in women, and in later than in earlier life, simply because the\\ntissues constituting its sites of preference offer in these individuals and at\\nthese ages a greater resistance to the exit of pus. The pus-cocci may\\nsustain an etiological or purely an accidental relation to the lesion.\\nCarbuncle is at times an epiphenomenon in cachexia, diabetes, albu-\\nminuria, syphilis, pemphigus, and exfoliative dermatitis.\\nPathology. The pathological anatomy of carbuncle has been well\\ndescribed by Warren, 1 whose observations conclusively show that the\\ninflammatory process here is that seen in the simplest pustule. The\\nspecial symptoms of carbuncle are due solely to the formation of the\\nphlegmon beneath the dense and extremely thick masses of fibrous\\ntissue found in the back for the protection of that comparatively\\ndefenceless portion of the body. The cell-elements, multiplying with\\nthe intensity of the inflammatory process in the subcutaneous adipose\\ntissue, pass upward along the fat-columns, crowd between these and\\npush along the horizontal clefts branching from either side, infiltrate\\nthe derma, pass along the edges of the hair-follicles, fill the papillae\\nuntil the latter balloon with pus, ooze to the surface through the\\ncribriform aperture in the undermined epidermis, and macerate the\\nbundles of fibrous tissue relatively intact that constitute the undetached\\nmass of sloughing tissue.\\nThe constitutional symptoms in carbuncle (pysemic, septicemic, or\\nsympathetic) are due solely to pus-imprisonment. The pus-formation\\nis due to the presence of the staphylococcus pyogenes aureus and its\\ntoxin. Back of all lies the favorable soil (in the diabetic, the cachectic,\\netc.) for multiplication of the micro-organism.\\nDiagnosis. It follows from Avhat has preceded that carbuncle and\\nfuruncle differ solely in the depth of the starting-point of the phlegmon,\\n1 The Pathology of Carbuncle, or Anthrax. Cambridge, 1881, p. 15.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0245.jp2"}, "246": {"fulltext": "232 INFLAMMATIONS.\\nand the density and resisting power of the overlying tissue. The car-\\nbuncle is, therefore, flatter, denser, less rapidly developed, larger, less\\ntender, and more painful opens by many rather than by one or two\\napertures and is followed by larger sloughs, ulcers, and cicatrices, and\\noccasionally by fatal results.\\nTreatment. Crucial and other deep incisions in the local treatment\\nof carbuncle are certainly inferior in results to the course advocated by\\nWood 1 and Talor, 2 whose method is employed in cases with complete\\nsuccess, namely a saturated solution of pure carbolic acid is injected\\nwith a hypodermatic syringe through the several apertures in every direc-\\ntion into the sloughing tissues. When the orifices are not sufficiently\\nnumerous the point of the needle is thrust through the thinned integu-\\nment at the summit of the swelling at several points. The pain is\\nsevere but short-lived the tissues are blanched, indurated, and de-\\nstroyed the slough in a few days is readily separated after division of\\nits slender fibrous attachments and the ulcer rapidly contracts with\\nthe sequel of a smaller scar. It is necessary to use pure acid in satu-\\nrated solution to prevent absorption of the injected fluid and the result-\\ning toxic effects.\\nRelief is afforded in many cases by hot borated lotions and fomen-\\ntations with the requisite skill in the surgical dressing of the parts, by\\ncarbolated lotions, extraction of the slough wholly or in portions with\\nthe forceps, and the subsequent employment of boric acid, iodol, iodo-\\nform, or aristol, or the paste recommended in the treatment of furun-\\ncles. An excellent method of withdrawing the purulent and sloughing\\ncontents of the carbuncle is to apply over it at the proper period an\\nexhausted receiver, such as a common cupping-glass.\\nErasion of the entire abscess with a curette and subsequent anti-\\nseptic dressing is an accepted radical measure of relief for employment\\nin proper cases.\\nThe antiseptic treatment of a carbuncle, however, furnishes the best\\nresults as regards the comfort of the patient and limitation of the\\ndisease. By this treatment there is absolutely no surgical interference\\nwith the lesion beyond the incisions made for the evacuation of pus.\\nViolent squeezing and manipulation of the carbuncle are interdicted\\nit is freely powdered with boric acid, iodol, or iodoform and on it is\\nlaid soft felt cloth thickly spread with any emollient and antiseptic\\nsalve, such as the ordinary zinc-salve. Boric acid in powder or iodol,\\nthickly dusted over the carbuncle and covered with antiseptic wool,\\nwill also be found a useful dressing.\\nInternally calx sulphurata may be administered in full doses it\\nhas, however, a questionable effect in diminishing the pus-formation.\\nOther constitutional treatment may be demanded in furunculosis,\\nincluding the liberal employment of tonics, a generous diet, a strict\\nobservance of the rules of hygiene, and stimulants when indicated.\\nPyrexic, septicemic, pyemic, and adynamic states require the special\\nmanagement of such complications, including cold sponging of the\\nbody-surface in fever, and the use of quinine, the mineral acids, and\\n1 Toledo Med. and Surg. Jour., December, 1880.\\n2 Australicn Med. Gaz., December 1, 1881.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0246.jp2"}, "247": {"fulltext": "ANTHRAX. 233\\nstimulants, with artificially applied heat in the algid condition. The\\nurine should always be examined for sugar and albumin.\\nPrognosis.\u00e2\u0080\u0094 A serious issue need only be anticipated when the com-\\nplications described above are grave in character or they occur in\\nasthenic constitutions.\\nANTHRAX.\\n(Gr. avOpag, a live coal.\\n(Malignant Pustule, Splenic Fever Carbuncle.\\nFr., Pustule Maligne, Charbon.)\\nAnthrax maligna is a carbuncular lesion resulting from infection of\\nthe skin or other organs of the body with a virus containing the\\nanthrax-bacillus, furnished by an animal infected with splenic fever.\\nThis disease in man, fortunately rare of occurrence, results from\\nexternal inoculation, and is always (See) derived from some animal\\naffected with the specific malady variously termed anthrax, charbon,\\nsplenic fever, splenic apoplexy, or Texas fever. After inocu-\\nlation with the disease from an infected animal the human subject may\\n(a) perish from systemic poisoning wholly septicemic in character with\\nfew external symptoms or, (b) when life is sufficiently prolonged, may\\nsuffer from visceral symptoms, and develop subcutaneous tumors or\\n(c) may exhibit the symptoms of the disease now under consideration.\\nIn from twelve hours to three days after inoculation a painless macule,\\nresembling a flea-bite, is first manifested, usually upon the dorsum or\\nother part of the hands or the face to which the virus has had access.\\nThe macule is followed in from twelve to fifteen hours by an inflamma-\\ntory and pruritic papule, which is rapidly transformed into a flaccid\\nvesicle filled with a bloody serum and surmounting a firm indurated\\nnucleus or a larger blood-filled bleb develops reposing upon a some-\\nwhat painful, engorged, and often densely indurated base involving\\nextensively the subcutaneous tissue. One or more similar lesions may\\nfollow in the surrounding integument, coalescence of which lesions pro-\\nduces a large, angry, oedematous, and often gangrenous ulcer with a\\nreddish areola. The area of skin involved may be of the size of that\\nof a small coin or be as large as the palm of the hand. The lymphatic\\nvessels and ganglia enlarge, become inflamed, and often suppurate\\nmetastatic abscesses form and the constitutional symptoms superven-\\ning are those described in connection with Equinia. If recovery is to\\nensue, the gangrenous mass will slough as in favorable cases of car-\\nbuncle if the result is to be fatal, the process is rapidly aggravated by\\ncedematous infiltration extending to a wider area and by greater tissue-\\nnecrosis.\\nIn some cases the accompanying fever is high, with marked delirium\\nin other cases it is of a typhoid character. Death results from shock,\\nsepticaemia, or exhaustion, though in cases in which the lesion is circum-\\nscribed and unattended by constitutional symptoms recovery may\\nensue.\\nEtiology. This disease is induced by infection from one of the", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0247.jp2"}, "248": {"fulltext": "234 INFLAMMATIONS.\\nlower animals, usually horned cattle, that suffer from charbon or\\nsplenic fever, and are handled by herders, ranchmen, etc. The sus-\\nceptibility of the carnivora to the disease is very much less than that\\nof the herbivora. It is claimed that not only direct inoculation may\\nproduce the disease, but that it may be transmitted through the medium\\nof flies and other insects. More recently it is\\nFig. 46. asserted that food, drink, and even inspired air\\nI may be the medium by which the disease is con-\\nveyed.\\nCS5 Pathology. Since the first investigations re-\\nported in 1864 by Davaine to the French Acad-\\nia 9 *f em y Pasteur, Klebs, Koch, Carnevin, and others\\n/H# ^fJS* have demonstrated that splenic fever is solely\\n22? due t\u00c2\u00b0 the multiplication in the blood and tissues\\nof a rod-shaped bacillus, the bacillus anthracis,\\nMalignant pustule bacilli which is non-motile and transparent, measuring\\nand o pus-cor P uscie S (About frQm j to 1 5 fJ to 5 to 20 /jt Under culture the\\nbacilli may develop long filaments many times\\nlarger than the original rods, with a distinct sheath about a protoplasmic\\ncylinder, which filaments after segmentation furnish oval shining spores.\\nThese spores have been cultivated in generations, with resulting germs\\nthat produced the disease artificially in the lower animals.\\nThe pathological anatomy of malignant pustule is that of carbuncle,\\nwith the added fact that specific bacilli and spores are everywhere\\npresent in the blood and debris of tissue. There is an almost char-\\nacteristic oedema of the papillary body, according to Unna the mar-\\ngin of the epithelium is well preserved there is an acute vesicular\\nelevation of the horny stratum without a previous breaking up of the\\nconnective-tissue layer, and this induces a stretching of all the cavities\\nin a vertical direction.\\nDiagnosis. The characteristic features of typical malignant pus-\\ntule are its central eschar, its crown of vesicles, and its indurated\\nbase. In establishing a diagnosis care must be taken to avoid one\\nsource of error. Malignant pustule in man is not of frequent occur-\\nrence in America, but occasionally various cutaneous eruptions are pro-\\nduced upon the hands after contact with animals or their hides upon\\nwhich chemical solutions have been applied for the destruction of lice.\\nThese solutions usually contain arsenic, corrosive sublimate, or other\\nsubstance capable of exciting a localized dermatitis. Chancre of the\\nface, carbuncle, and poisoned wounds are all differentiated by their\\nrelatively indolent course and the absence of gangrene.\\nThe Treatment is to be conducted on the principles of general\\ntherapeutics. Deep incisions of the lesion, extended to the subcutaneous\\nconnective tissue, are often successful when practised before the occur-\\nrence of general symptoms.\\nSuccessful results have also been obtained from excision and iodo-\\nform dressings. Hebra was not in favor of early cauterization of the\\nmalignant pustule, and it may be considered a questionable method of\\nprocedure. A grave case of malignant anthrax is recorded in which\\nrecovery ensued after hypodermatic injection of tincture of iodine.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0248.jp2"}, "249": {"fulltext": "EQTJIN1A. 235\\nThree syringefuls of pure tincture were deposited beneath the skin at\\nthe periphery of the diseased surface, and lint saturated with the same\\nfluid was applied over the slough. Internally, 1 5 drops of iodine tincture\\n(1.), with 3 grains (0.20) of potassium iodide, were also administered.\\nNormal cicatrization followed in this and six other cases recorded.\\nCrucial incisions with the free application afterward of pure car-\\nbolic acid have been followed by good results. Internally, sodium\\nhyposulphite and quinine are successfully employed. The febrile,\\ntyphoid, and adynamic features of the disease are to be treated in\\naccordance with the recognized principles of general medicine.\\nPrognosis. The disease proves fatal in about one-third of all cases.\\nEarly excision gives promise of satisfactory results.\\nEQUINIA.\\nLat. equus, a horse.\\n(Glanders, Farcy. Fr. y Morve, Farcin; Ger., Kotzkrank-\\nHEIT, MALIASMUS.)\\nEquinia is a contagious, virulent, and inoculable disease, transmitted\\nto man from the horse, mule, ass, or other animal and produced by a\\nbacillus resembling that of tuberculosis. It is conveyed either directly\\nor mediately by the application of cloths and other articles which have\\nbeen in contact with the bodies of infected animals.\\nSymptoms. The acute form of this disease commonly follows a\\nperiod of malaise lasting a few hours or a few weeks, during which period\\nthe patient complains of vague pains of a rheumatoid type, followed\\nby thermal variations. The body-temperature rises rapidly to the point\\nof danger, with chills, fever, diarrhoea (often following constipation),\\nand rapid exhaustion, the picture being suggestive of acute septicaemia.\\nThe cutaneous symptoms begin often with an erysipelatoid blush,\\nthe infected and swollen surface, also producing papules, vesicles,\\npustules, and bullae, with dense but ill-defined induration of the sub-\\ncutaneous tissue or reddish and yellowish papules appear, which, as\\nin the case of the fluid-containing lesions, coalesce and furnish a bloody\\ndischarge. These symptoms, in the case of inoculated disease, may\\ndevelop on the site of the healed or healing wound of entry of the\\nvirus, and later become generalized. Sloughing ensues more or less\\nrapidly, sometimes with extensive gangrene, though the patient often\\nsuccumbs before the culmination of the morbid process. The lymph-\\natic vessels are swollen and well defined, often indurated. These symp-\\ntoms chiefly affect the face, hands, feet, and other exposed parts of the\\nbody. There is often a sanious or purulent and offensive discharge\\nfrom the nostrils, the mouth, and the eyes, the inflammatory process\\nspreading rapidly to the deeper mucous surfaces. This catarrh, chiefly\\nnasal in site and declared conspicuously by the nasal voice due to the\\nblocking up of the nostrils by the viscid, foul-smelling, hemorrhagic dis-\\ncharge, is one of the most characteristic features of the malady, and is\\nof importance in the diagnosis.\\nIn the chronic form of the disease the nasal catarrh is less conspic-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0249.jp2"}, "250": {"fulltext": "236 INFLAMMATIONS.\\nuous at the outset, though later it may be a prominent feature of the\\nmalady. A few days or weeks after infection, pustules, as in the acute\\nform, resembling those of variola, but flattened and never umbilicated,\\nbegin as vesicles or even as papules, coalesce to bullae, occur in succes-\\nsive crops, and proceed to the production of multiple abscesses, poorly\\ndefined on the extremities and about the face, much more rarely de-\\nveloped on the trunk. These abscesses may be of phlegmonous type\\nor be deep, brawny infiltrations with purulent foci, extending over\\nmonths of invasion and decline of the disease. From these abscesses,\\npea- to nut-sized over the face, larger on the limbs, flows an abundant,\\nsanious, semiliquid or viscid, yellowish, offensive pus. Ulcers form at\\nmany points, with purplish borders, oval or roundish countour, and thin\\nedges, suggesting the scrofulous ulcer of classical type. The edges may\\nbe soft or indurated. By this multiplication or coalescence the lips,\\nnose, eyelids, and other parts of the face may in part or wholly be\\ndestroyed. The disease may steadily advance or may seem to be\\narrested for a time and reawaken to activity. Meantime the lymphatic\\nglands are either unchanged or are enlarged by sympathy. In the\\ncourse of months or years there is a fatal issue. The disease is, for-\\ntunately, rare.\\nEtiology and Pathology. Equinia is almost invariably produced\\nby infection from horses, a history of contact with such animals being\\none of the important points in establishing a diagnosis. The infection\\nis produced by the glanders-bacillus (Weichselbaum, Schtitz,* Loeffler,\\nBouchard). This organism is nearly of the size of the tubercle-bacillus,\\nhaving been cultivated and found capable of producing the disease in\\nthe lower animals after injection of cultures. The bacilli are abundant\\nin papules, abscesses, blood, and brain-tissue.\\nThe Treatment is that of the septic condition, and is of little avail.\\nThe Prognosis is in the highest degree grave.\\nDISSECTION-WOUNDS AND ANIMAL POISONS.\\nAside from verruca necrogenica, or anatomical tubercle, described\\nin the chapter on Tuberculosis Cutis, lesions generally known as\\ndissection-wounds occur with symptoms of acute poisoning upon\\nthe hands of those exposed in post-mortem examinations and dis-\\nsections. At the inoculation-point, which may be either the site of\\na former abrasion, a rent, or the mouth of an open follicle, a painful\\nvesico-pustule, papule, tubercle, wart, furuncle, or hemorrhagic bulla\\nrapidly rises from an angry and indurated base with hypersemic areola\\nof dull-red shade. Suppuration, crusting, or ulceration, limited to\\nthe seat of the lesion, may follow or there may occur lymphangitis\\nin various grades with consequent pysemic or septicemic involvement\\nof the system. Suppurative and non-suppurative axillary buboes are\\ncommon. Gangrene and necrosis of the soft parts and the bones, espe-\\ncially the phalanges, may ensue, as may also a fatal result from the sys-\\ntemic disorders named. Rarely an acute and fatal septicaemia may\\nresult when the lesion at the point of inoculation is so slight as to pass\\nunnoticed. In a few cases chronic marasmus is induced.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0250.jp2"}, "251": {"fulltext": "DELHI BOIL. 237\\nThe nature of the infection varies in different cases. It is most\\ncommonly due to pyogenic bacteria, but may be caused by the specific\\nmicro-organisms of tetanus, erysipelas, anthrax, or other infectious\\ndisease. The absorption of toxins resulting from the decomposition\\nof animal tissues is undoubtedly an important factor in the infection.\\nThe treatment is to be conducted in accordance with the principles\\nalready described. Prophylaxis, by proper protection of the hands,\\nand the immediate cleansing and disinfection of any accidentally\\nwounded point, are of the highest importance.\\nPustules and other Lesions resulting from Wounds\\ninflicted by Reptiles and Insects are often of an insignificant\\ncharacter. Such are the trivial results of the bites or the stings of flies,\\nfleas, mosquitoes, ants, bees, hornets, etc. At other times, however,\\nserious and even fatal consequences have been recorded. The wounds\\nproduced by the tarantula and the scorpion (which frequently lurk in\\nthe clusters of tropical fruit now imported to almost every part of the\\nUnited States), as also of venomous reptiles, may prove to be grave.\\nUrticarial, vesicular, pustular, papular, bullous, and petechial lesions\\nmay thus originate and be the cause of a more or less severe dermatitis\\nwith toxic symptoms. In the latter event it is common to administer\\nas remedial agents alcoholic stimulants as freely as they can be ingested.\\nDELHI BOIL.\\n(Aleppo Evil, Biskra Bouton, Oriental Button, Oriental\\nUlcer, Gafsa Button, Natal Sore. Fr., Bouton d Orient,\\nClou de Biskra.)\\nThis is a chronic contagious endemic disorder characterized by the\\noccurrence of painful or painless nodosities upon the face, the hands,\\nand other chiefly exposed portions of the body. The lesions are single\\nor multiple, pea- to bean-sized pinkish papulo-tubercles, which in the\\ncourse of three or four months become purulent and ulcerate indolently,\\nor they become covered with crusts and scales. They are often\\ngrouped in patches and followed by characteristic cicatrices. The\\nexact nature of the malady thus variously named is unknown. It is\\nquite fully described by Fox, Farquhar, Pollack, Villemin, and other\\nauthors, as occurring in India, the region about the Euphrates and\\nTigris Rivers, and along the northern coast of Africa, especially Algeria\\nand Morocco.\\nLaveran has described the Biskra bouton as occurring not only\\nin Biskra, but also in the adjoining oasis. It shows itself as an\\nendemic only in the months of September and October and continues\\nuntil December, no new cases appearing in January and February.\\nAll ages, both sexes, the strong and weak, are liable to the disorder.\\nThe eruption affects the face and the extremities by preference, some-\\ntimes also the trunk. It ordinarily attacks the same person but once,\\nyet may recur. So long as the disease prevails the least excoriation\\nhas a tendency to become Biskra bouton. At first there is a reddish,\\n1 Annal. de Derm, et de Syph., 1881, i., p. 173.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0251.jp2"}, "252": {"fulltext": "238 INFLAMMATIONS.\\npainless elevation of the skin, the size of a pin s head, that grows slowly,\\nso that at the end of four or five months it attains the size of a small\\nfuruncle that is livid, sensitive, smooth, and boggy to the touch the\\ncentre of this elevation dries and a brownish rupioid crust forms, which\\nis easily removable. Beneath this crust there usually forms a small\\nround spongy ulcer, with ragged margin, ovoid contour, and ichorous\\ndischarge. The papules may occur in patches bearing thick crusts\\nwhich long persist. The crusts are remarkably dry, and if undisturbed\\nmay eventually fall and leave no scar, though frequently ulceration\\nprogresses beneath the crusts. Healing is followed by the production\\nof a permanent and deforming scar, the entire course of the disease\\nlasting a year.\\nThe ulcers are usually single, but they may be multiple and may\\ncoalesce to form large ulcerating, granulating patches. They are usually\\nirregular in form, with hard borders and soft red floors covered more\\nor less with fungoid granulations and a thin ichorous discharge.\\nLymphangitis, erysipelas, and phlebitis occur as complications.\\nPathology. Elliott, of New York, reports that the disease is\\nlimited to the epidermis and corium, and that its area is occupied by\\nsmall round inflammatory or formative cells and epithelial elements.\\nThere is a distinct line of separation between the healthy and the dis-\\neased tissue. No cryptogamous or other micro-organisms have been recog-\\nnized. The hair-follicles and other glandular structures are intact. The\\ndisease is contagious and inoculable and perhaps auto-inoculable.\\nThe horny layer is loosened the prickle-cells are multiplied periph-\\nerally and centrally thinned or lost. Hyaline spheres and rounded\\nmasses are found between the cells of the infiltrated cutis. Leloir dis-\\ncovered an endarteritis obliterans. The cellular infiltration involves\\nthe entire cutaneous and subcutaneous tissue. The lymph-spaces are\\nwidely distended (Kiehl, Leloir, Duclaux). Unna regards the process\\nas a chronic serofibrinous inflammation of the entire cutis with central\\nnecrosis, softening, and ulceration. Cocci have been found in zoogloea\\nmasses by Duclaux and Heydenreich, but no successful inoculations\\nhave been made with pure cultures.\\nTreatment is not very successful, and often an expectant method is\\nthe best. In the majority of cases the ulcers should be treated on\\nsurgical principles with antiseptic and bactericidal dressings. Iodoform,\\ntincture of iodine, silver nitrate in stick or in solution, and various\\npreparations of the mercurials have been used with success. In some\\ncases caustics, the cautery, or even surgical extirpation may properly\\nbe employed.\\nAltounyan found the best treatment to be painting of the button\\nwith tincture of iodine, and that, as a rule, one attack conferred im-\\nmunity against a second. He believes the disease to result from the\\nbite or the sting of an insect.\\nPhagedena Tropica (Aden Ulcer, Malabar Ulcer). Hirsch,\\nParke, and others describe a disease occurring chiefly among natives\\nof the tropics, but also attacking travellers in tropical countries. It is\\nrare in temperate zones its victims are those chiefly who have been", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0252.jp2"}, "253": {"fulltext": "PHLEGMONE DIFFUSA. 239\\nexhausted by fatigue, malaria, and malnutrition. In these cases a slight\\ntraumatism becomes later the seat of a vesicle or a bleb from which as\\na centre spreads a rapidly phagedenic sore extending by sloughs through\\nskin, muscle, tendon, and bone. The disorder is usually first noticed\\non the exposed parts of the lower limbs, but other regions may earliest\\nbe involved. In mild cases there is arrest of the process before severe\\ndestruction is accomplished, and then cicatrization follows.\\nThe malady is aggravated by all unfavorable climatic and individual\\nconditions. Microbes, supposed to be pathogenic, have been discovered\\nby Boinet, who also cultivated these organisms and produced successful\\ninoculations of animals.\\nThe treatment is precisely that employed for all similar surgical\\nemergencies, viz., support by proper food and medicines; locally, anti-\\nsepsis and parasiticides. The caustics employed by the French are\\ninferior to effective parasiticides, such as borated, salicylated, and sub-\\nlimate dressings, and formaldehyd.\\nPHLEGMONE DIFFUSA.\\n(Gr. (pTieyfiovf], an inflamed tumor.)\\nThe word phlegmon is employed by most English and American\\nwriters to indicate a circumscribed cutaneous inflammation which ter-\\ni minates naturally in suppuration, and which, as to the tissues involved,\\nj is larger than an ecthymatous pustule, yet is not large enough to be\\nI termed an abscess. Circumscribed phlegmons are represented by\\nI most furuncles, and, at one stage of their career, also by carbuncles.\\nIn the disorder under consideration, however, the symptoms, both local\\nand general, are far more serious than either furuncle or carbuncle.\\nThe disease is particularly prone to develop in children, especially\\nI infants, and in women. The first evidence of trouble may be a severe\\nj chill followed by high fever and a deep-seated hammering pain, felt in\\nthe part which is the seat of the disease. This site is soon recognized\\nas an oedematous area, of dull-red or livid hue, tensely infiltrated, of the\\ni familiar brawny type and indeterminate outline. All these symptoms,\\nwhich rapidly increase, as resolution is rarely attained, are followed by\\nj suppuration at one or more points. In diffuse phlegmon, however,\\nthe brawny tenseness of the inflamed skin has been so great that, as a\\nconsequence, vascular thrombosis occurs and the circulation is greatly\\nimpeded between the points at which pus forms or about a single point.\\nThe tissues then become more or less necrotic, both during and after\\nthe formation and evacuation of pus.\\nThe fever meantime may abate or may entirely remit, or, in grave\\ncases, may steadily persist. In the latter event the subcutaneous tis-\\nsue, fasciae, periosteum, bones, joints, and ligaments may be involved.\\nBut in favorable cases the systemic condition is greatly improved\\nwhen pus is no longer deeply or extensively formed, and when the\\ngangrenous shreds and sloughs are well loosened or are entirely\\nremoved.\\nThe acute purulent oedema of English authors and the gangrene", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0253.jp2"}, "254": {"fulltext": "240 INFLAMMATIONS.\\nfoudroyante of the French may be regarded as severe types of diffuse\\nphlegmon. In most of these grave cases patients die septicemic be-\\nfore complete evolution of the cutaneous inflammation is reached. In\\nother cases the affected part, suddenly losing its tense, brawny hard-\\nness, becomes emphysematous or crepitates with bubbles of gas pro-\\nduced by decomposition. The patient may then become somnolent\\nor delirious, or be the victim of an intercurrent and fatal involvement\\nof the kidneys, lungs, liver, spleen, or bowels.\\nThe Treatment of diffuse phlegmon is largely surgical. Incision,\\ndrainage, and disinfection are the three essential requirements. These\\nmeasures thoroughly assured, the systemic treatment is by quinine,\\nstimulants when indicated, and the accepted remedies for the typhoid\\ncondition generally, including rest in the recumbent posture and a\\nproper supply of wholesome air and food. Amputation of limbs may\\nbe necessary to save life.\\nThe Prognosis rests almost entirely upon the extent, diffusion, and\\nseverity of the local inflammation, and upon the systemic condition of\\nthe patient. In a previously healthy subject, with good hygienic en-\\nvironment and the absence of thrombosis, pyaemia, septicaemia, and ery-\\nsipelas, the result will generally be favorable. With the reverse of\\nthese conditions the outcome may be serious as regards the loss of a\\nlimb, deformity, or a fatal issue.\\nSYCOSIS.\\n(Gr. cvkov, a fig.)\\nThe title sycosis no longer indicates an idiopathic affection. It\\nis employed in these pages to designate a group of different disorders,\\nwhich, affecting for the most part the region of the male beard, may\\nbe for practical purposes classified as follows\\nCoccogenous Sycosis includes the most numerous of the cases to\\nwhich the term sycosis non-parasitica was once given, and which are\\nall due to invasion of the pilo-sebaceous crypts by pus-cocci. These\\npyogenic organisms may be either primarily or secondarily effective in\\nproducing the symptoms of the disease. In many cases a suppu-\\nrative folliculitis follows the disorders included in the group last\\nnamed.\\nBacillogenous Sycosis is described by Tommasoli. 1\\nHyphogenous Sycosis (Barbers Itch, Ringwokm of the\\nBeaed) is due to the presence of either the microsporon Audouini or\\nthe trichophytons (Teichophytosis Babb^:). It is described in this\\nwork among the Tinese.\\nA group of Scab-leaving Sycosifoem Deematoses (Lupoid Sy-\\ncosis, Ueeeythema Sycosifoeme, etc.) may also be recognized which\\ndiffer somewhat from those named above. They include the pseudo-\\nsycoses, the eczemas limited to the region of the beard with acneiform\\nfeatures, the eczemas of the same region with seborrhoeic complications,\\ncertain forms of lupus erythematosus of the beard, and the still rarer\\n1 Monatsch. f. prakt. Derm., 1883, p. 403.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0254.jp2"}, "255": {"fulltext": "COCCOGENOUS SYCOSIS. 241\\nsycoses possibly due to tuberculous infection of pustular lesions of the\\nbearded face.\\nCOCCOGENOUS SYCOSIS.\\nNon-parasitic Sycosis, Sycosis Vulgaris, Sycosis Staphy-\\nlogenes, Mentagra, Ficosis, Folliculitis Babb^:. Ger.,\\nBartfinne.)\\nSymptoms. The lesions appear upon the face, involving one or\\nboth cheeks successively or simultaneously, the chin, the upper lip, the\\neyebrows, the scalp, the axillae, and the pubes. The disease, however,\\nis almost always limited to the region of the beard in men. In this\\nrespect sycosis differs from acne and other disorders of the sebaceous\\nglands of the face with which authors have sought to identify it, since\\nnot only is it, as a rule, strictly limited to the region of the beard, but\\nalso the non-hairy portions of the face of the patient are free from\\ncomedones, acne-lesions, and other symptoms of a cutaneous disorder.\\nWhen seated upon the upper lip the first symptoms may be those of\\na nasal catarrh seated elsewhere an eczematous attack may precede\\nthe onset of the disease. It may be ushered in with the acute symptoms\\nexhibited in the early stage of some forms of eczema, and with tume-\\nfaction accompanied by a sensation of heat and burning but often a\\nfew isolated and indolent lesions, the presence of which scarcely\\nawakens attention, are the first traces of the disorder. Soon there may\\nbe recognized a larger or smaller number of discrete, pin-point to split-\\npea-sized, flattened or conical, reddish and painful papules, tubercles,\\nor pustules, the anatomical seat of which is distinguished as the pilary\\nfollicle because of the penetration of each lesion by a filament of hair.\\nThese lesions may persist, and when typically discrete and visible at\\nthe part at which the hair makes its exit from the duct of the follicle\\nthey suggest the appearance of the surface of the fig, whence the disease\\nderives its name. They are apt to occasion a burning and at times a\\ndecidedly pruritic sensation when, being picked or torn open by the\\nfingers, the pus concretes into a crust at the base of the hair. In\\nseverer cases these lesions, while not coalescing, are so closely set\\ntogether as to form a patch of continuous infiltration. These patches\\nmay be weeping or be crusted in the latter case the crusts are apt to\\nbe small and numerous, each crust being limited to the shaft of a single\\nhair, and leaving when removed a minute crateriform excavation at the\\nmouth of the follicle.\\nInvolution of several lesions may be followed by fresh crops, and,\\nsooner or later, distinct patches of disease are thus formed. When\\nfully developed the surface of the skin is reddened, swollen, infiltrated,\\nand thickened covered irregularly with papules, pustules, crusts, and\\nscales, and frequently with excoriations. The disease often lapses into\\nchronic conditions, usually the result of improper treatment, and in\\nancient cases the deformity is characteristic and totally unlike that\\nproduced by the vegetable parasites. The hairs are usually fixed\\nfirmly in their follicles, but from those in which active suppuration is\\nin progress the hairs may be plucked without occasioning much pain.\\n16", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0255.jp2"}, "256": {"fulltext": "242 INFLAMMA T10NS.\\nIn cases which have been treated for years the hairs are thinned and\\ndecidedly lack vigor.\\nIn typical and neglected cases of long standing, in which the region\\nof the beard is involved, an important clinical feature is the symmet-\\nrical, general, and uniform involvement of the entire surface. The\\npicture of one cheek is very nearly that of the other. The sparse\\nhairs scarcely serve to disguise the reddened, tumid, painful surface\\nbeneath, which displays the severe lesions of the malady. Furuncles,\\nabscesses, cicatrices, vegetations, and eczema of the ears may compli-\\ncate the process. Sycosis is occasionally acute in its course, but is\\nmore often chronic and rebellious. A typically chronic and untreated\\ncase of the malady rarely terminates by spontaneous involution.\\nThe thinning of the hairs, described above as a consequence of\\nlong persistence of the disease, is far more characteristic than any\\ndistinctly resulting alopecia the latter, however, very rarely occurs,\\nbut is then remediless. The same may be said of resulting cicatriza-\\ntion, which is one of the rarest consequences, and which is generally\\ndue to bacillogenous infection.\\nThe absence of certain symptoms in this disorder is as significant as\\nis the presence of others. Adenopathy of the cervical glands is very\\nrare, but when present it should awaken suspicion of another malady.\\nThe disease when of longest persistence as to time produces great\\nun sightliness, but not the deep-seated, subcutaneous, small- or large-\\nnut-sized nodules or tubercles, forming the lumps so characteristic\\nof trichophytosis of the beard. Sycosis vulgaris is a disease of chronic\\ncourse, which may endure for years and be characterized by relapses and\\naggravations, but is entirely curable it is only in neglected and im-\\nproperly treated cases that such persistence may be expected.\\nScar-leaving Sycosiform Dermatosis (Lupoid Sycosis, Ulery-\\nthema Sycosiforme, Seborrhee depilante). Under these titles\\nhas been described a somewhat rare affection of the skin of the bearded\\nface in men, the symptoms of which at the outset are practically those\\nof sycosis vulgaris. In the course of the disease, however, whether in\\nconsequence of an added infection or as the result of the evolution of\\nthe malady, a change occurs in which the hair-follicles atrophy and\\nconsiderable scarring results. The scars are often irregularly depressed\\nbetween ridges and linear elevations of the surface. By Unna this\\ndermatosis is grouped with a class of disorders to which he has given\\nthe title of ulerythemata. It is possible that the disease may be\\neventually recognized as a tuberculous complication of ordinary syco-\\nsis or one dependent upon the toxins of tubercle-bacilli. The course\\nof the affection is exceedingly chronic, lasting, with alternations of\\nimprovement and aggravation, for several years. According to\\nRobinson, the inflammation in these cases spreads peripherally upward\\nor downward with a narrow infiltrated margin. The lesions outside of\\nthe follicles may be papular, vesicular, or pustular in type. The\\ntendency to extension from a given centre and to irregular scarring are\\nthe chief characteristic features of the malady.\\nMany of these cases strongly suggest in their features the symptoms\\nof lupus erythematosus. In some instances the two affections are", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0256.jp2"}, "257": {"fulltext": "COCCOGENOUS SYCOSIS. 243\\nindistinguishable. The malady is exceedingly obstinate and often\\nrequires severe local treatment.\\nEtiology. Sycosis vulgaris is unquestionably due to either primary\\nor secondary invasion of the pilo-sebaceous follicle by micro-organisms.\\nObviously in many cases there is a special reason for the accessibility\\nof the germs to the crypts where they are lodged. Shaving, and the\\nuse in common of towels, brushes, combs, etc., in public establishments\\n(club-houses, barber-shops, hotels), and the employment of pillows,\\nlounges, and reclining-chairs in public resorts are often the origin of\\nthe mischief.\\nThe disorder is encountered chiefly among men after puberty, and in\\nthose of all social conditions and grades of health. It is not transmis-\\nsible by heredity. The mere performance of shaving is not known to\\nproduce it. At times the immediate cause of the disease is recognized\\nwhen the upper lip is constantly irritated by a discharge due to profuse\\nnasal catarrh. In other cases, again, all the causes of eczema may be\\ninvoked in explanation of the result.\\nA careful study of many cases suggests that the hairs themselves are\\namong the aggravating causes of the disease and the sources of its\\npeculiar obstinacy. In health the motions of the free shaft of the hair\\ndo not irritate the follicle in which it is set in conditions of disease\\nit is quite different. Each free hair operates like a lever upon the inflamed\\nring-tissue which encircles it on its escape from the follicle beneath,\\nand thus by the touch of the hand, by the action of brushing, by cur-\\nrents of air, or by any agency whatever, movement may be imparted\\nto it. Every such movement teases to a variable degree the previously\\nirritated surface beneath and when estimate is made of the hundreds\\nof such movements to which each hair is subjected during a period of\\ntwenty-four hours, the relative importance of this apparently insig-\\nnificant factor may be appreciated.\\nPathology. The disease is due to pyogenic cocci exciting an inflam-\\nmatory process, which, whether originally follicular or perifollicular\\nin seat, may extend either toward or from the follicle. Sometimes\\nextraction of the hair is followed by a drop of pure pus which exudes\\nfrom the follicle, and the root-sheaths of the hairs are seen to be\\naltered in consequence of the circumscribed follicular abscess. At\\nother times the follicle itself is free from disease, and the exudative\\nprocess has evidently expended itself upon the perifollicular or even the\\ninterfollicular tissues, in which case the papillary layer of the derma\\nexhibits the usual phenomena of hypersernia, infiltration, and multipli-\\ncation of protoplasm, with abundant vascular dilatation.\\nAccording to Robinson, the disease always begins as a perifollicular\\ninflammation, under the influence of which transuded serum penetrates\\nthe follicle. Maceration and eventual destruction of the root-sheath of\\nthe hair result with the ultimate production of pus within and without\\nthe follicle. The pus when the hair remains in the follicle, finds its\\nway to the surface by breaking through the epidermis near the hair;\\noccasionally exit is obtained between the shaft and the follicle-sheath.\\nThe hair-papilla usually escapes destruction, so that permanent", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0257.jp2"}, "258": {"fulltext": "244 INFLAMMATIONS.\\nalopecia seldom follows. The sebaceous glands are occasionally involved\\nand even destroy ed, but the coil-glands are affected in exceptional cases\\nonly. The hair, according to Unna, is closely encapsuled by horny\\ncells which surround the neck of the hair-follicle, like a horse-collar.\\nWhen pus is formed in the cutis, colonies of cocci spread from about\\nthe neck of the follicle into the cutaneous abscess and sometimes as\\ndeeply as the hypoderm. The cocci may also accumulate within the\\nfollicle. In total suppuration of the follicle the tightly packed cocci\\nfill the hair-fissure, occupy the centre of the follicular abscess, and extend\\nparallel to the skin on the under margin of the abscess.\\nThe micro-organisms recognized (by culture and reinfection) as the\\neffective agents in the production of Tommasolr s bacillogenous sycosis\\nwere bacilli with rounded extremities presenting an elliptical or ovoid\\nappearance. They measured 1.0 to 1.5 x 0.25 to 0.3 [i. The symptoms\\nclinically resembled those of coccogenous sycosis.\\nDiagnosis. The most important consideration here is the distinction\\nbetween the coccogenous and the hyphogenous diseases of the region of\\nthe beard, upon which point, naturally, the microscope finally decides.\\nStill the clinical features of the two affections are quite distinct. The\\ncoccogenous form is recognized (a) by the greater redness of the in-\\nvolved surface (6) by the extension of the disease in advanced cases to\\nlarger areas of symmetrical involvement (c) by the more superficial\\ncharacter of the lesions and (d) by the firm implantation of the hairs\\nin their follicles in the earlier periods of the disease, their relative\\nfreedom in all cases from fracture, and the absence of stumps. The\\nhyphogenous disease of the hairs is peculiar, in consequence of (a)\\ndecidedly less redness of the surface attacked (6) the frequent limita-\\ntion of the malady to a circumscribed area, or to several such, irregularly\\ndispersed over a large region (c) the peculiar lumpy, tubercular,\\nnodular, and uneven characters of the patch, upon which Duhring has\\nlaid significant emphasis and (rl) the earlier loosening of the hairs in\\ntheir follicles, as also of the occurrence of fractured hairs and of stumps,\\nexhibiting usually at the bulb unmistakable evidences of the nature of\\nthe disease. The malady is often mistaken for syphilis, chiefly on\\naccount of the unsightliness it produces but the pustular syphiloderm\\nis very much less chronic in its course, is rarely limited for years to the\\nface exclusively, and, when long persistent in one locality, is character-\\nized by ulceration and the production of very characteristic crusts.\\nEczema may complicate the coccogenous disease by preceding or by\\nfollowing it, but typical instances of the two disorders may be recog-\\nnized by the occurrence, in the case of eczema, of a discharging disease,\\nnot usually limited to the region of the beard, characterized by a more\\nintense itching, and with marked absence of the papulo-tubercular lesions\\ndescribed above. The lesions in eczema, moreover, are not invariably\\nperforated by hairs. The shaven face affected with erythematous eczema\\nis reddish in color, and desquamates, after full evolution of the disorder,\\nwithout pustulation.\\nTreatment. In all cases of sycosis the essential and important step\\nis the continued removal of the hairs which, as indicated above, are the\\nchief sources of aggravation of the disease. This removal is best", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0258.jp2"}, "259": {"fulltext": "COCCOGENOUS SYCOSIS. 245\\naccomplished by epilation or by shaving, which, though often painful\\nat the onset, is soon well tolerated by the sufferer. The majority of\\npatients, however, object to removal of the beard, far more on ac-\\ncount of the consequent greater exposure to view of the unsightliness\\ninduced by the disease (then no longer partly masked by the hairs) than\\non account of the distress occasioned by the operation. To these objec-\\ntions there is but one response the shaving is essential the deformity\\nis rapidly relieved after its successful initiation the discomfort dimin-\\nishes with each repetition of the process. For the disease in patients\\npositively refusing to have the beard removed, whose cases are so severe\\nas to require it, the practitioner will do well to decline to be responsible.\\nThere is no limit to the tedious and obstinate course of the malady in\\nthe one case, and in the other the results are speedily satisfactory, often\\nin the course of a few weeks.\\nWhen there is much tenderness, pain, swelling, pustulation, or crust-\\ning, the hairs may first be clipped short, and a bland poultice of oil,\\nelm-bark, or of bread and milk applied. The practice in Vienna is to\\nsubstitute for the poultice strips of soft muslin or linen spread with\\ndiachylon ointment, firmly bandaged over the cheeks, chin, or lips for\\nfrom twelve to twenty-four hours, after which a razor is passed over the\\nentire surface. The integument which thus becomes visible is usually\\na reddened infiltrated area, with pustules, papules, pustulo-papules, and\\nsome crusts dispersed here and there over it. After exit is given to all\\nI purulent collections this area is best treated by hot- water lotions, borated\\nj or alkalinized, and then a bland ointment is to be applied at night and\\na borated dusting-powder in the morning. Formalin lotions of the\\nI strength of 1 to 2 per cent, are valuable in all stages of the disorder.\\nThe subsequent treatment is largely that of eczema of equal grade of\\nseverity. In the more acute periods oleated lime-water, medicated with\\ncalomel or with zinc oxide, to 1 drachm (2.-4.) of either to the pint\\nj (512.), may often be employed with benefit or for this application may\\n,j be substituted 2 ounces (64.) each of linseed-oil, Castile soap, and\\nparaffin, to the pint (512.) of aqua calcis. Later, the Lassar paste or\\nointments may be used, particularly cold-cream salve, to which may be\\nadded either sulphur, zinc oxide, or, less preferably, one of the mercu-\\nrials. Lotions of mercuric chloride, sulphur, alcohol, cologne-water,\\nor iodated glycerin may be useful in stimulating indolent patches of\\ninfiltration. The treatment of these patches is indeed that of chronic\\neczema.\\nEpilation is often essential for relief of the disease and in chronic\\ncases severe methods have been employed, including the use of green\\nj soap, tar, and cauterization with acetic and even with nitric acid. Era-\\nsion with the curette is to be named in the same category. These\\nmeasures have been employed in aggravated cases but as the disease\\nI is certainly curable in a majority of patients without having recourse to\\nthese heroic methods, they are to be regarded in the light of a dernier\\nressort It is not necessary in the majority of coccogenous forms of\\nI sycosis either to epilate or to employ caustics. By repeated and fre-\\nquent use of hot borated water, formalin lotions, and the milder\\ni stimulants, with constant shaving, the desired result is usually", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0259.jp2"}, "260": {"fulltext": "246 INFLAMMATIONS.\\nwithin reach. Shaving should be continued for nearly a year after\\nall traces of the disease have disappeared and it is a point of some\\nimportance to substitute for a fatty application a continuously applied\\nborated powder as soon as the skin will tolerate the persistent use of\\nthe latter.\\nVan Harlingen advises for acute cases a wash composed of pint\\n(256.) of rose-water, to which 1 drachm (4.) each of precipitated zinc\\ncarbonate and zinc oxide in powder have been added, with 2 drachms\\n(8.) of glycerin and dilute liquor plumbi subacetatis. .Veiel recom-\\nmends a solution of pyrogallol (1 part to 50) for painting over the\\nregion affected, followed in the day by emollient cataplasms and in the\\nnight by diachylon or weak tannin ointments. Sycosis of other por-\\ntions of the body is to be treated as described for the region of the\\nbeard.\\nInternally, treatment, when indicated, should be of the kind de-\\nmanded by the condition of the patient. It is a matter worthy of\\nspecial attention, however to purge every previously treated case of\\nsuspicion of artificial element, by withdrawing for a time all internal\\nmedication. The disease is so disfiguring that many patients swallow\\npotassium iodide, arsenic, and other deleterious drugs for months before\\nconsulting one who is wiser than they in these matters. Exposure of\\nthe face to dust, smoke, wind, and other sources of irritation should for\\na time be avoided.\\nIn the hygienic management of these cases all use of tobacco and\\nalcoholic beverages is to be abandoned. Even the drinking of hot\\ntea, coffee, and stimulating beverages of other kinds is to be inter-\\ndicted. The diet should be of the simple character recommended in\\neczema. Inasmuch as many patients suffer from a coincident nasal\\ncatarrh, hot baths should be exchanged for daily cold sponging of the\\nbody-surface, for patients able to endure the shock, followed by brisk\\nfriction with flesh-brush or with coarse towels.\\nIn acute cases it may be desirable to begin treatment with a brisk\\nmercurial cathartic the alkaline diuretics advised by authors will, at\\nleast, do no harm if judiciously employed. The same may be said of\\ncalx sulphurata and minute doses of calomel in the pustular stages of\\nthe affection. But in other cases cod-liver oil and iron are demanded\\nby the general condition of the patient, usually one of the class ex-\\nhibiting the evidences of hospitalism. No firm believer in the\\ncoccogenous etiology of the disorder will, however, expect by these\\nmeasures alone to relieve the disease.\\nPrognosis. The disease is entirely curable, and will, in the large\\nmajority of all cases, either disappear entirely or greatly be improved\\nby judicious treatment. The latter requires the personal supervision\\nof the physician and close attention to details.\\nIn exceptional cases the disorder is exceedingly chronic and obsti-\\nnate, and requires perseverance on the part of both physician and\\npatient to attain the desired end. Relapses are of frequent occurrence,\\ndue usually to neglect of asepsis after apparent recovery. In a few\\nvery rare cases (lupoid sycosis, tuberculosis) there is cicatricial tissue\\nleft after repair.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0260.jp2"}, "261": {"fulltext": "IMPETIGO. 247\\nIMPETIGO.\\n(Lat. impetere, to rush upon.\\n(Ger., Krustenflechte Fr., Dartre Humide.)\\nThe researches of Bockhart and others have demonstrated that\\nthe symptoms once designated by the term impetigo/ 7 as also those\\nof furunculosis and sycosis, are simply the local results of infection\\nwith staphylococci and streptococci. The symptoms to which in dif-\\nferent cases these several names are given differ in consequence of the\\naccidents of location, the sex of the patient, and the opportunities for\\nextension of the disease.\\nHebra stated that, even in his day, the pustular cutaneous affection\\ndescribed by authors under the name impetigo had no existence as\\nan independent disease. Unquestionably a long list of disorders hith-\\nerto described under this term included, in fact, forms of pustular\\neczema. The reasons for retaining the name given above and for\\nassigning to it certain peculiar eruptive features are based upon the\\nsimple tact that the lesions displayed, probably in consequence of the\\noperation in a similar way of like causes, reproduce themselves again\\nand, again, so as to exhibit the same clinical picture in different patients.\\nThe convenience of the name impetigo, as descriptive of a group of\\ncutaneous symptoms, is therefore the sole reason for its retention.\\nThere is, however, among some dermatologists of the French school\\na tendency to consider impetigo a distinct disease and to distinguish\\nseveral forms, each having a definite cause and capable of reproducing\\nitself through inoculation.\\nSymptoms. The disease is not infrequently encountered, being\\nobserved chiefly in children and young adults of both sexes, though\\ntypical symptoms may be exhibited at any period of life. In such\\npatients, from one to twenty or more isolated and often widely separated\\nminute vesicles or vesico-pustules, superficial, without areolae, without\\ninduration, and usually acuminate, appear upon the skin-surface either\\nsimultaneously or in rapid succession occasionally after a slight access\\nof fever. They are speedily transformed into split-pea-sized or larger,\\ncircumscribed, oval or circular pustules, so rapidly transformed, in fact,\\nthat often the early vesicular phase is not manifest, the lesions showing\\nas minute pustules from the first. When fully developed they are\\nglobular, yellowish white in color, discrete, well distended with their\\npuriform, rarely bloody contents, and projected clearly from the surface\\non which they rest. They may be surrounded by an erythematous\\nareola, or simply be superimposed upon an integument of unaltered color.\\nThey may persist as pustules, or may burst, their contents drying into\\na yellowish crust resembling honey, or into brownish-tinted concretions\\nwhich adhere with firmness to the superficial and circumscribed base,\\nwhere a slight weeping can be determined. They run an acute course,\\nusually terminating within a fortnight. They are much more commonly\\nobserved upon the face, but are recognized elsewhere, always sparsely\\nupon the trunk and extremities. The eruption is never in any sense\\ngeneralized, its characteristic feature being the fewness of the lesions,", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0261.jp2"}, "262": {"fulltext": "248 INFLAMMATIONS.\\nwhich are scarcely ever grouped, and which occur in capriciously\\nselected locations. The subjective sensations are slight, and the erup-\\ntion is more often picked than scratched. The disease bears no relation\\nto pustular eczema. It is common in dispensary and hospital patients,\\nand since these are often the victims of neglect and the subjects of vices\\nof nutrition it has been considered the appanage of scrofula. But the\\ndisease is also encountered in well-nourished and rosy-cheeked chil-\\ndren in the latter, when well cared for, the eruption proceeds regularly\\nto resolution, while in the former it is prolonged and often aggravated,\\nthus attracting to a greater degree the attention of the physician. The\\npustules are never umbilicated, never seated upon ulcers, and are never\\nfollowed by cicatrices.\\nImpetigo Contagiosa (Poeeigo Laevalis, Poeeigo Contagiosa,\\nPemphigus Acutus Contagiosus Adultoeum (Pontoppidan), Im-\\npetigo Contagiosa Bullosa). In 1862 Tilbury Fox gave the name\\nimpetigo contagiosa to a group of symptoms which were by him sup-\\nposed to be characteristic of a definite disease. These lesions are now\\nrecognized as those of impetigo.\\nThe eruption, occurring in infancy, childhood, and early adult life,\\nmay be preceded by a febrile process, and appears in the form of rarely\\nnumerous, isolated vesicles, vesico-pustules, pustules, or bulla?, usually\\nabout the face, but also upon the neck, the buttocks, the hands, or the\\nfeet. In severe cases these lesions are surrounded by an areola. The\\nlesions are roundish, flat, have the average size of that of a split pea,\\nand become covered in the course of a few days with dry, granular,\\nstraw-colored crusts which closely adhere to the slightly reddened base\\non which they rest. Beneath the crusts are to be discovered very\\nsuperficial erosions which rapidly become covered with epidermis.\\nThey occasionally coalesce, and their complete involution requires from\\na week to a fortnight. When they are of the dimensions of bullae a\\npseudo-umbilication may be observed at the apex, produced solely by\\nflaccidity of the roof-wall, which is never guyed down, as in variola.\\nThe contents of the lesions are inoculable and auto-inoculable, the dis-\\nease thus spreading from one member of a family to another, and also\\nfrom one part of the body of an individual to another part. The\\nmucous surfaces are occasionally invaded (impetiginous stomatitis). The\\nsubjective sensations are mild, the itching rarely being severe. The\\ndisease runs a tolerably definite course, being usually at an end in a\\nfortnight it may recur. It may be, Kaposi states that it is at all\\ntimes, accompanied by submaxillary adenopathy.\\nImpetigo may be indicative of the symptoms of several widely dif-\\nfering causes, all resulting in a coccogenous or hyphogeneous disorder.\\nIn some cases the irritation is set up by the encroachments of the tricho-\\nphyton. In other cases there are pediculi of the occipital region, and\\nthe scratching set up in children in consequence of attacks of lice fur-\\nnishes the opportunity for infection with staphylococci. In yet other\\ncases the micro-organisms responsible for varicella have operated to\\nproduce the symptoms.\\nThe several clinical pictures differ on account of the greater or lesser", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0262.jp2"}, "263": {"fulltext": "IMPETIGO. 249\\ndiffusion of the contagious elements in each case for example, there\\nmay be a few isolated pea-sized and larger vesico-pustules on a single\\nhand or many may be clustered about the moutli and lips or dense\\ngreenish crusts may succeed such lesions over occiput or scalp or\\nthere may be much larger pustulo-bullous elements over the legs, torn,\\nscratched, and thickly crusted or covered with hemorrhagic incrusta-\\ntions. In rare instances circinate, annular, gyrate, serpiginous, herpetic,\\nvariolaform, and even pustulo-crustaceous lesions have been observed.\\nThe disorder is not often seen in private practice, but in public patients\\nit is seen among the cachectic, the filthy, and the neglected.\\nEtiology. The cause of impetigo is mixed infection with strepto-\\ncocci and staphylococci often the one is grafted upon the other. The\\npeculiarities of the cocci are the shortness of their chains, the slightness\\nof their incurvations, their failure to interlace, and the irregular form\\nof the elements of which the chains are composed. For these reasons\\nan attempt has been made to disassociate, without result thus far, the\\ngerms of this disease from those found in the pus of other affections.\\nThe disease occurs rather at the age of childhood than in infancy and\\nadult life, a period when the hands are first brought into habitual con-\\ntact with the face, these quite suggestively being the sites of election.\\nThe lesions are rarely scratched, being more often torn with the nails in\\npicking, so that the crusts may be somewhat blood-colored. The prac-\\ntice of picking the nose and other parts of the face and the body with\\nunwashed hands is the chief source of mischief. In later life the habit\\nof refraining from carrying the hands to the face when the former are\\nsoiled becomes instinctive. Before this instinct is well established that\\nis, in childhood the hands will convey to the head any particle of filth\\nor of dust with which they may have been brought in contact.\\nThe somewhat obscure relations of the disease to varicella, variola,\\nand other affections occurring in epidemic visitations have attracted\\nthe attention of many observers. The disease is one peculiarly prone\\nto attack children and those in the humbler grades of life.\\nThe eruption often occurs during convalescence from a more or less\\nactively contagious disease. The antecedence of some fever in many\\ncases is admitted by all observers. Duhring and Fox have seen it\\nfollow vaccinia, and the former admits that some connection between\\nthe two seems probable. It may occur typically in a series of children,\\neach of whom is convalescent from varicella.\\nPathology. The lesions have been examined microscopically by\\nBockhart and others, who have thus been able to establish clearly the\\ncoccogen oils origin of the disorder. Plainly, each lesion is but a dis-\\ntinctly circumscribed and superficial pea- to bean-sized abscess, situated\\nbetween the intact corneous and the prickle-layers of the skin. Balzer\\nand Griffon 1 agree with Thibierge and Bezancon in asserting that almost\\nwithout exception the lesions of impetigo and ecthyma contain strepto-\\ncocci and no staphylococci. In some cases, however, the staphylococcus\\npyogenes aureus and albus are present. Larier and other French der-\\nmatologists describe an impetigo strepto-coccogenata circinata, in which\\nthe lesions closely resemble those of herpes iris, and in which the strep-\\n1 La Presse med., 1897, 89, p. 130.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0263.jp2"}, "264": {"fulltext": "250 INFLAMMATIONS.\\ntococcus only is found. Leroux and others, recognizing the fact that\\nmany micro-organisms similar in external appearance have decidedly\\ndiffering potentialities, have suggested that the streptococci responsible\\nfor the several clinical pictures of impetigo may differ in effect.\\nIn Unna s differential diagnosis of the impetigo- and eczema-pustule\\nstress is laid upon the sero-purulent character of the contents of the\\nlatter, the dissemination of cocci throughout the lesion, the softening\\nof the corneous layer in places, and the occurrence of morococci free\\nand within the leucocytes. In impetigo the staphylococci. are clustered,\\nare extracellular, are relatively small, and are clustered beneath the\\nintact roof- wall of the lesion.\\nDewevre 1 reports a number of successful inoculations and auto-inoc-\\nulations practised with the contents of the vesico-pustule, with finely\\npowdered impetiginous crusts, and with the products of scraping the\\nsubjacent erosion. In 1884 one of us succeeded in producing an\\nalmost typical vesico-pustule upon the left forearm by inoculation (all\\ndue precautions being observed) with the moistened debris of crusts.\\nThis inoculation was done in the clinic, the crusts being taken from\\ntypical lesions upon the face of a young girl inoculated while under\\nobservation from the lesions of exactly similar character on the face of\\nher twin sister. The lesions on the forearm produced a characteristic\\ncrust which in seven days was also used for inoculation of two students\\nthen present at the clinic, in one of whom there was no result, and in\\nthe other an abortive lesion.\\nThe disease is contagious, and its lesions inoculable and auto-inocu-\\nlable, whether as a coccogenous or hyphogenous process.\\nDiagnosis. To establish the identity of this affection it is neces-\\nsary to define its exact differences from eczema pustulosum. These\\ndifferences are first, the absence of infiltration of the tissues affected\\nsecond, the absence of itching third, the failure of the lesions to form\\npatches fourth, the isolation and wide separation from one another of\\nlesions distinctly pustular fifth, the large development and rather per-\\nsistent character of the pustules sixth, the evident termination of the\\ndisease, which does not, as does eczema in many cases, progress to form\\na freely discharging and crusting surface, the pustular being but the\\ninitial stage of a distinct morbid process. Manifestly, however, an\\nimpetigo of the sort described is not incompatible with an eczema which\\nis often originated by less irritating causes.\\nIn ecthyma the pustules are in appearance much more formidable\\nthan those of impetigo in consequence of their size, depth, inflamma-\\ntory base, areola, flat hard bulky crust, and erosive action upon the\\nskin.\\nIn varicella the lesions are small, much more widely distributed\\nover the body, and are vesicular only, rarely bullous. In pemphigus\\nand herpes iris the seat, character, and period of evolution of the lesions\\nsuffice to establish the diagnosis.\\nTreatment. Individual pustules are to be opened with an aseptic\\ncomedo-needle the purulent contents gently removed by washing with\\nborated water and the floor smeared with any mild ointment, such as\\n1 Arch, de Med. et de Pharm. mil., Sept. 16, 1885.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0264.jp2"}, "265": {"fulltext": "ECTHYMA. 251\\n5 grains to scruple (0.33-0.66) of ammoniated mercury to the ounce\\n(32.) of cold-cream salve, or bismuth subnitrate J drachm (2.) to the\\nounce (32.), or benzoated zinc salve. Van Harlingen recommends the\\napplication of a salve on bits of muslin, covering the whole with waxed\\npaper. A dusting-powder containing calomel may be substituted for\\nthe salve or be employed afterward. The disease tends to spontaneous\\nrecovery if the lesions be not irritated. When they are situated within\\nreach of a child s tongue which is constantly thrust out to moisten them,\\nthey may linger obstinately and require protection by flexile collodion.\\nECTHYMA.\\n(Gr. endvfia, a pustule sadva), I burn out.\\n(Ger.j ElTERPUSTELN.)\\nThe term ecthyma, like several of the titles of chapters imme-\\ndiately preceding, no longer points to a distinct disease. It represents\\nrather a tolerably definite group of symptoms readily separable clin-\\nically from other affections produced by different causes. The most\\ncommon cause is infection of the skin of the lower extremities with\\npus-cocci after scratching then follow traumatisms, primary and\\nsecondary, associated with pediculi of the body (pediculus vestimenti),\\nand combinations of these with bedbug-bites general filthiness of\\nthe person and clothing of body and bed and the cachexia of most\\npatients in these conditions. The term ecthyma is, however, not\\nto be discarded, as it suggests to the mind not merely these com-\\nposite etiological factors, but the picture in the skin produced as\\na result.\\nThe disease is characterized by the occurrence of one or of several\\nminute vesicles filled with clear serum, which soon become changed\\nto circumscribed, yellowish-gray, reddish or dark-livid, roundish, bean-\\nto filbert-sized pustules, which are the result of a distinctly circum-\\nscribed inflammatory process, limited to the base of each lesion\\nor extending from it at the periphery in a diminishing hyperemia.\\nThis process is distinguished by the formation at the base of the pus-\\ntule of an indurated phlegmon, which is converted into a loss of tissue\\ninvolving in mild cases the superficial, in severe grades the deeper, por-\\ntions of the corium. The purulent or sanguinolent contents of the\\nlesions dry in dark-colored, thick, rough, adherent crusts, the color\\nbeing somewhat dependent upon the quantity of blood with which\\nthey are commingled. On removal of this concretion a minute,\\nshallow, circular pit is discovered, invading the true skin to various\\ndepths, and lined with a tenacious, puriform, and often blood-stained\\nproduct. When carefully wiped clean this solution of continuity,\\nwhich really constitutes a minute ulcer, is seen to have a floor reddish\\nor grayish in color and indolently granulating. Both superficial and\\ndeep-seated types of the disease are recognized with a single ulcer or\\nexceedingly numerous areas of ulceration resulting.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0265.jp2"}, "266": {"fulltext": "252 INFLAMMATIONS.\\nThe pustules may be acutely or indolently developed, and, when\\nmultiple, be coincident or successive. They occasion rather a sensa-\\ntion of heat, burning, and pain than of itching, the latter being usually\\nmore distinct when the lesions are healing under their crusts. Their\\nformation may be preceded by mild general pyrexia. They occur at\\nall ages and in both sexes, usually upon the extremities, and also upon\\nevery portion of the body.\\nThe deeper lesions are followed by persistent punctate or larger\\ncicatrices. The entire course of the disease occupies about two\\nweeks. The subjective phenomena are a sense of heat, burning,\\npain, and soreness. There may be accompanying lymphangitis or\\nadenopathy.\\nEtiology. The pyogenic cocci (in particular streptococci) are the\\nefficient causes of most of the lesions practically the agents capable\\nof producing eczema and dermatitis (traumatism, heat, scratching, para-\\nsites, etc.) either effectively operate or influence to a morbid degree the\\nsubjects of other diseases, such as ansemia, asthenia, struma, variola-\\nconvalescence, and menstrual disorders. Filth and neglect are most\\ncommon aggravations in other words, that circumscribed cutaneous\\nulcer will be the angrier and the deeper which occurs in the victim\\nof any depressing disease whose skin is scratched with nails begrimed\\nwith dirt, and is covered with the products of the excretory processes.\\nThe pus thus produced is in various degrees inoculable and auto-\\ninoculable, as is the product of many inflammatory processes of similar\\ngrade.\\nPathology. In many cases of ecthyma there has been demonstrated\\na streptococcic infection of the skin, usually with but few chains of\\nmicro-organisms visible on bacteriological examination. The pustule\\nof the disease differs from the pustule of eczema or the pustule of im-\\npetigo in the severity of the exudative process by which it is produced,\\nand in its limitation to the exact seat of external irritation. By the\\nextension of that process to the corium there is an actual loss of some\\nof the elements constituting the papillary layer, the result often being\\na cicatrix which contracts as it grows older, and which is, in milder\\ncases, finally barely visible as a minute cicatriform punctum. One who\\nfrequently examines the skin of the entire body with care can usually\\ndetect the ancient sites of these lesions by their indelible though insig-\\nnificant relics.\\nAccording to Unna, the ecthyma-pustule, as distinguished from that\\nof impetigo, is less an epidermal abscess than a result of epidermal\\ninflammation, fibrinous at the centre and exceedingly oedematous at the\\nperiphery. The crust contains fibrin and epidermal layers.\\nSabouraud points out that the original streptococcic infection is\\noften succeeded by a secondary microbian involvement whereby the\\nstaphylococci present are enabled to produce the peripheral lesions of\\nimpetigo, furunculosis, etc.\\nDiagnosis. Ecthyma is liable to be confounded with the other\\npustule-producmg exudative affections, but as the distinction between\\nthem is largely artificial and based upon the severity of the inflamma-\\ntory process, there is small danger in consequence. Kaposi expresses", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0266.jp2"}, "267": {"fulltext": "CONGLOMERATIVE PUSTULAR PERIFOLLICULITIS. 253\\nthe truth in his suggestion that there can be but little objection to the\\nemployment of the term ecthyma when it is desired to characterize pre-\\ncisely the pustular grade of any cutaneous inflammation at a given time.\\nThe pustules of variola are ecthymaform, and many of those seen\\nin syphilis exhibit similar characters but the history of the general\\naffection should throw light upon the identity of the cutaneous disease.\\nIn syphilis, moreover, the ulceration at the base of the lesion exhibits\\nthe pronounced features of the syphilitic ulcer in its secretion, floor,\\nedges, base, crust, and career. The crust, in particular, of the flat\\npustular syphiloderm has the rupioid conical appearance which sug-\\ngests the shell of the oyster, and the underlying ulcer is larger and\\ndeeper than in ecthyma. In the furuncle there is usually a central\\ncore in impetigo the pustules are not deep-seated, and there is no\\nulceration at the base; the crust is superficial, yellowish, firmly ad-\\nherent, and the lesions are more numerous.\\nTreatment. The general treatment of patients affected with\\necthyma is a matter of importance. A proper regulation of the food\\nand hygienic surroundings is not to be neglected. Tonics are fre-\\nquently indispensable, including iron, quinine, and strychnine. The\\ndestruction of any pediculi and the cleansing of the skin with soap and\\nwater will often be sufficient to effect a great change. This fact is\\nwell illustrated in hospital practice, where young patients rapidly im-\\nprove after a bath, followed by inunction with vaselin, and a few sub-\\nstantial meals of a nutritious character. When the lesions are abun-\\ndant the treatment is in general that of pustular eczema. Crusts are to\\nbe removed after soakings with oil or fat and the floors of the former\\npustules, after washing with carbolated water, should be dressed with\\nan ointment containing from 10 to 15 grains (0.666-1.) of mercuric\\nammonio-chloride to the ounce (32.) of lard. If the minute basal ulcers\\nare sluggish, they may, after careful cleansing, be touched with a small\\nswab that has been dipped in a 0.5 per cent, formalin solution or in a\\nsolution of mercuric chloride in tincture of benzoin, 1 grain (0.066) to\\nthe ounce (32.). Carbolic or boric acid or iodoform may be employed\\nfor the same purpose. For the salve mentioned above may be substi-\\ntuted one containing 10 grains (0.66) of calomel, or J drachm (2.) of\\nbismuth subnitrate to the ounce of salve-basis.\\nIn every case of the disease it is desirable to inquire whether any\\nmedicines have been ingested prior to the appearance of the eruption,\\nsince these may be responsible for the lesions.\\nThe Prognosis is always favorable.\\nCONGLOMERATIVE PUSTULAR PERIFOLLICULITIS.\\nLeloir l gave this name to an eruption which he described as appear-\\ning on the backs of the hands and buttocks and occasionally on other\\nparts of the body.\\nThe disease begins by the appearance of a round or oval, somewhat\\nelevated, reddened or purplish plaque, with definite outlines. The\\n1 Annal. de Derm, et de Sypli., 1884, vol. v., p. 437, with plates.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0267.jp2"}, "268": {"fulltext": "254 INFLAMMATIONS.\\nplaque may be no larger than a dime, or it may be of the size of a large\\ncoin or larger, and may be elevated a quarter of an inch above the\\ngeneral level of the skin. Its surface is smooth or mammillated and\\nis perforated by numerous follicular openings from which pus or dried\\nplugs resembling comedones may be expressed. The openings of some\\nof the follicles may be covered by unruptured pustules. Later, the\\npatch becomes more phlegmonous, fluctuation can be detected, the fol-\\nlicles are more patulous, and pus in large quantity can be expressed.\\nThe whole then has much the appearance of a kerion of the scalp or\\nof a flat carbuncle.\\nThere is usually but one such plaque, though there may be two or\\nthree, rarely more. Subjective sensations are slight, though there is\\nusually some itching and burning. There is no systemic disturbance.\\nThe disease runs a rapid course, requiring about a week in which to\\ndevelop, after which it remains stationary for a week or two, and then\\ndisappears under appropriate treatment in from ten to fifteen days.\\nMore or less deep pigmentation remains some time after the lesions\\nheal, but there is no ulceration and in the few cases in which scars are\\nleft they are usually very superficial.\\nFolliculitis and Perifolliculitis. Quinquaud and Pallier 1\\ndescribe a follicular disease which is chronic, becomes papillomatous,\\nand is very stubborn under treatment. Besnier and Doyon 2 enumerate,\\nin all, five varieties of the disease, including two pseudo-ulcerative,\\nserpiginous, and virulent forms which resemble anatomical tubercle.\\nEtiology. These disorders are probably due to contagion, and\\nare seen most frequently in those who work among horses and other\\nanimals.\\nPathology. The process is an inflammation of the follicles, peri-\\nfollicular tissues, and sebaceous glands. Leloir found several forms\\nof micrococci and zoogloea in the pus, but he failed to reproduce the\\ndisease by inoculation-experiments. Quinquaud and Pallier believe\\nthe active agent to be the staphylococcus pyogenes albus, which acci-\\ndentally obtains entrance to the follicles and glands. Sabouraud found\\nin several cases a large-spored trichophyton.\\nTreatment. The treatment is purely local. In the usual milder\\nforms daily evacuation of pus, hot boric-acid fomentations, or frequent\\nhot bathing, with antiseptic dressings, constitute the only treatment\\nnecessary. In stubborn forms stimulating treatment by means of\\nstrong solutions of silver nitrate or of carbolic acid, or by means of the\\nactual cautery, may be indicated. Occasionally it will be necessary to\\nremove the growth with a curette.\\n1 Des perifolliculites suppurees agminees en placards. These de Paris, 1889.\\n2 Kaposi Besnier-Doyon, ed. 1892, vol. i., p. 795.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0268.jp2"}, "269": {"fulltext": "HERPES SIMPLEX. 255\\nHERPES SIMPLEX.\\n(Gr. epnetv, to creep.)\\n(Fr., Dartre; Ger., Blaschenflechte.)\\nThe term herpes is responsible for much of the confusion which\\nhas existed with respect to cutaneous diseases. By the ancients it was\\nemployed, as its etymology suggests, to designate a disease creeping or\\nextending gradually over the surface or within the substance of the\\nskin. By several more modern authors the term is employed in a\\ngeneric sense in a futile attempt to distinguish a series of so-called\\nr herpetic diseases, and even herpetic diatheses from those of a different\\ncomplexion. The significance which attaches to the word in the minds\\nof dermatological authors of to-day is exceedingly simple, and is limited\\nto the conditions described in the following paragraphs. Herpes zoster,\\nthough closely related to other types of herpes, is recognized as a dis-\\ntinct disease, and in this work is considered separately.\\nSymptoms. The disease is declared by the occurrence of millet-\\nseed- to coffee-bean-sized vesicles (single or relatively few in number,\\nand in the latter case grouped), which may be preceded or accom-\\npanied by a general febrile process, though in many cases there is no\\nconstitutional disturbance. The vesicles are usually displayed sym-\\nmetrically, are short-lived, surviving but for a few hours, and are filled\\nwith a clear serous fluid Avhich may become lactescent. After acci-\\ndental or spontaneous rupture there is left a slightly tumid superficial\\nexcoriation, which is covered frequently by a light crust and at times\\nis characterized by circumscribed hyperaemia, slight infiltration, or\\noedema of the base and periphery. The lesions rarely persist for more\\nthan a few days, and leave no permanent pigmentation or scar, unless\\ncomplicated by pus-infection. The subjective sensations are not usually\\nsevere they include moderate pain, itching, and heat.\\nHerpes Facialis, Herpes Febrilis, Herpes Labialis, Cold-sores.\\nAbout the lips, the mouth, the cheeks, and the alse of the nose, more\\nj rarely upon other portions of the face, lesions occur singly or in groups,\\npossessing the characters described above. Their occurrence is usually\\nsudden. Their frequency about the lips has suggested one of the titles\\nj under which they are most often described by authors. The tongue,\\nj the buccal membrane, the palate, and the larynx may participate in the\\nI morbid process the lesions in such moist situations being represented\\nby isolated or by grouped dark-grayish patches of epithelium that are\\nsensitive and exfoliate. The functions of the mouth in articulation and\\nmastication are thus rendered painful. Often the lesions coalesce, form-\\ning in an irregular line of elevated epidermis a pea-sized bleb, spread\\nalong the vermilion border of the lip and distended with clear serum.\\nThe burning and itching sensations which accompany the lesions are\\noften marked and distressing. In the course of two or three days thin\\n|f crusts form, the exfoliation of which terminates the disorder. The dis-\\nease is common in acute pneumonia and in malarial and enteric fevers.\\nIn these cases, as Kaposi has shown, the occurrence of the eruption by", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0269.jp2"}, "270": {"fulltext": "256 INFLAMMATIONS.\\nno means augurs favorably in every instance, as, nevertheless, a fatal\\nresult may follow. The connection between labial herpes and rigors\\nhas long been recognized, though particular attention has been directed\\nto this relation by Hutchinson and Symonds. Trophic disturbances,\\ntraumatism, exposure to solar heat, unusual fatigue, a simple coryza,\\nexposure to a draught of cold air, and temporary gastric disorders may\\nsuffice to induce the disease. There are patients who can produce the\\nlesions at will by tickling the lips with a feather, and in some indi-\\nviduals there is an exquisite susceptibility to the disease. The dis-\\norder is always short-lived though often recurrent, and the superficial\\ncrusts which terminate the process are never followed by scars. Sym-\\nmers, of Aberdeen, successfully cultivated a rod- or thread-shaped\\nmicro-organism (solid, filamentous, and without septa) obtained from\\nthe lymph in vesicles of herpes labialis.\\nLabial herpes should not be confounded with the symptoms of La\\nPerleche, described on another page. The disease to which the last\\nname has been given in France is due to a parasite.\\nEpidemic Herpetic Fever, which has been observed by Savage 1 and\\nothers, has prevailed in institutions in which young subjects are con-\\ngregated. There are usually rigor, high fever, a coated tongue, adenop-\\nathy, and a vesicular rash over the face.\\nThe Generalized Herpes of French authors has been rarely seen in\\nthis country.\\nHerpes Progenitalis (Herpes Genitalis, Herpes Prjeputialis) is\\ncharacterized by the appearance of one or a group of transitory vesicles,\\nin men on the inner face of the prepuce, especially upon its upper limb,\\non the glans, on the balano-preputial sulcus, or in the adjacent integu-\\nment; in women, on the hood of the clitoris, the labia minora, the\\ninner face of the labia majora, or adjacent surfaces even as far removed\\nas the buttocks.\\nThe disorder is seen most frequently in young adults and in early\\nmiddle life, its occurrence after the age of fifty being unusual. There\\nis commonly a precedent pruritus or a sensation of heat, sometimes\\nvery considerable pain, followed by the appearance of one or of several\\npinhead-sized vesicles seated upon a tumid and hypersemic base. Within\\nthe preputial sac the lesions may either rupture at an early moment or\\nassume the features above described as presented upon the mucous\\nmembrane of the mouth. The resulting oedema of the prepuce is often\\ndisplayed in an annular tumefaction encircling the glans, while the labia\\nminora perceptibly project from the general vulvar plane. In these\\nlocalities the floors of ruptured vesicles are particularly liable to be\\nirritated (coitus, caustic, etc.), and then pus and even blood may be\\nexuded with much angrier excoriation and the resulting crusts be of\\ndarker shade. In the course of a few days even these crusts fall, and\\nthe disease is at an end. Successive crops of vesicles, however, may\\nprolong the disorder for several weeks. Recurrence is common.\\n1 Jour. Cutan. and Ven. Dis., 1883, p. 253.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0270.jp2"}, "271": {"fulltext": "HERPES SIMPLEX. 257\\nRarely, a first attack of herpes in man results in an extraordinary\\nsensitiveness of the balano-preputial membrane that persists for more\\nthan a year. The patients are often middle-aged men, married, and\\nvirgin as to venereal antecedents. The membrane becomes tumid, tense,\\nslightly glazed, and dark red to dark purple in hue. Upon any undue\\nsliding of the prepuce over the glans there occurs a very superficial\\nfissure, whence a drop of serum oozes. The membrane becomes so\\nsensitive that the passage of the finger over it is resented as though the\\nconjunctiva had been touched. Unusual friction by the clothing or the\\nuse of a stimulating lotion is followed by intense pain and aggravation\\nof symptoms, and the price of coitus is several days rest in bed.\\nNaturally, the diagnosis of herpes progenitalis is between chancroid\\nand chancre. The latter will be manifested by its induration, its period\\nof incubation, and its characteristic inguinal adenopathy. The chan-\\ncroid, whether in pustular form or as an inoculated abrasion, is ab\\norigine ulcerative in tendency, capable of auto-inoculation, and often\\naccompanied by sympathetic, inflammatory, or virulent bubo of one side.\\nBalanitis, with its puriform secretion and superficial patches of reddened\\nepithelium, is readily distinguished from herpes progenitalis by its\\nsymptoms, though the two disorders frequently coexist.\\nThe practitioner should never forget that the patient who exhibits a\\nherpes of the genital region to-day may have been inoculated at the site\\nof the lesion, which to-morrow or later may take on the chancrous\\nmodification. The rule to be followed, then, is very simple. No\\nindividual with progenital herpes can be assured of immunity against\\nsyphilis until the longest period of incubation of the syphilitic chancre\\nhas elapsed since the date of the last suspected exposure.\\nHerpes progenitalis is almost universally the result of naturally or\\nunnaturally induced sexual erethism or of congestion of the genitals\\nfrom other causes. Its occurrence in an individual virgin as to such\\nantecedents may be due to the causes efficient in the production of her-\\npes facialis. In unusually sensitive persons it may be associated with\\ndyspepsia, constipation, and the phenomena of the gouty state. It may\\nfollow any of the venereal diseases or may be induced simply by filth.\\nThough relatively rare in chaste women, it is of common occurrence in\\nprostitutes. In some women it frequently accompanies menstruation\\n(Herpes Mexstrualis).\\nDiday and Doyon 1 believe that true herpes of the genital region is\\nalways of recurrent type, and well marked by its special course, career,\\nand consequences. All others of a false type are divided by them into\\n(1) an irritative form, seen in women as the result of vaginal discharges,\\nsexual irritation, etc. (2) a pseudo-membranous or diphtheroid form,\\nalso occurring for the most part in women, presenting vesicular and\\neven bullous lesions the rupture of which is the signal for pseudo-\\nmembranous transformation and (3) a neuralgic form, which is merely\\nzoster of the genital region.\\nPathology. The eruptive phenomena are due to irritation of the\\nnerves either directly or through reflex excitation. There is in many\\n1 Les Herpes genitalis. Paris, 1886.\\n17", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0271.jp2"}, "272": {"fulltext": "258 INFLAMMATIONS.\\n(probably in all) cases a localized peripheral neuritis of brief duration,\\ninvolving the superficial nerves. According to Unna, there is a coagu-\\nlation-necrosis of the upper prickle-layer. The epithelial elements lose\\ntheir capacity for receiving stains, and undergo a fibrinous transforma-\\ntion by imbibition of a fibrinogenous material from the surrounding\\nmedia. This coagulated mass is readily loosened from the papillse and\\npushed out by the exudate to form a bleb, the roof of which is thus\\nconstituted of the necrotic epidermal layer and the walls of deeper layers\\nwhich have undergone the same change.\\nTreatment. The milder forms of herpes occurring about the lips\\nand the genitalia require the simplest treatment. Sponging with pure\\nwater as hot as can comfortably be tolerated is best followed by local\\nuse of a weak lead-lotion, a simple dusting-powder, or a zinc salve.\\nAlcohol applied locally will sometimes abort the disease. Duhring\\nrecommends highly the following\\nR Zinc, sulphat, __ ~._. -i qqa\\nPotass, sulphid. J aa ^j-3j 1. dd-4\\nAlcohol., 3j 4\\nAquae dest., 3vij 28\\nSig. Shake and apply freely and frequently.\\nM.\\nBlenler states that a 1 per cent, ointment of cocaine gives prompt relief\\nand shortens the course of the disease. About the lips it is well to\\nprotect the lesions with flexile collodion or isinglass plaster. Occurring\\nupon the genital region, the lesions are to be protected by the interposi-\\ntion of a pledget of lint, or a bora ted or salicylated dusting-powder.\\nAs a rule, ointments are unsuited for the moist mucous surface of the\\ngenitals, the malodorous emanations from most diseases of such parts\\nbeing retained by all grease-containing compounds. Lotions answer\\nfar better, and they may be made stimulant with alcohol astringent\\nwith tannin, zinc sulphate, or cupric sulphate anodyne with opium\\nor cocaine and antiseptic with formalin, carbolic acid, or corrosive\\nsublimate. Prophylaxis by the local use of aromatic wine, or tannin\\nand brandy, with a sexual hygiene that will prevent congestion of the\\ngenitals is a matter of importance. Arsenic is often of value in pre-\\nventing recurrences of herpes simplex.\\nHERPES ZOSTER.\\n(Gr. CooTJip, a girdle Lat. cingulum, a girdle.\\n(Shingles, Zona, Zoster, Ignis Sacer, Hemizona.\\nGer., Feuerguertel.)\\nSymptoms. The eruption in this affection is usually preceded, for\\na period lasting from a few hours to days and even weeks, by hyper-\\nesthesia and neuralgic sensations of moderate or of severe intensity.\\nThese sensations are usually limited to the area of the integument sub-\\nsequently or coincidently displaying cutaneous lesions but there are\\nexceptions to this rule, as the pains are at times experienced elsewhere.\\nOften, though limited to the region about to be attacked, the pain", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0272.jp2"}, "273": {"fulltext": "HERPES ZOSTER. 259\\noccurs where it is experienced in other neuralgias, at the points indicated\\nby Romberg as corresponding with regions in which cutaneous branches\\nare given off by the nerve-trunks. There may be mild constitutional\\ndisturbance in the form of malaise or febrile symptoms. Adenopathy\\noccurs frequently in the neighborhood of the eruption, and may be\\ngeneralized.\\nThe lesions of zoster are arranged in from two to a dozen or more\\nirregularly shaped groups, commonly along the cutaneous distribution\\nof a single nerve. These groups are separated by areas of normal\\nintegument, show little tendency to coalesce, and may be widely scat-\\ntered. Aside from the few exceptions which prove the rule, zoster\\noccurs but once in the lifetime of an individual, and is limited to one\\nside of the body.\\nAccording to Fabre, the essential lesion, always present even when\\nvesicles are not seen, is the first macular efflorescence of the disease\\nthat appears in the form of brilliant or dull-red, poorly defined, erythem-\\natous macules, groups of which appear in the tract supplied by the\\naffected nerve. As the patient rarely presents himself for treatment\\nuntil after the appearance of vesicles, the macules usually escape\\nobservation, either having disappeared or being overlooked. The\\nvesicles, which are generally regarded as more characteristic of the\\ndisease, appear afterward in from a few hours to a day or more, spring\\nfrom the macules or from the normal skin, and are accompanied by a\\nsensation of heat. These typically perfect, isolated vesicles vary in\\nsize from that of a rape-seed to that of a coffee-bean. They appear in\\nsuccessive groups of from eight to a dozen or more, which gradually\\nincrease in size and attain maturity simultaneously in from three to\\nseven days.\\nThe lesions, when fully developed, project well from the widely\\nhyperaBmic base from which they spring, are tense from complete dis-\\ntention, and have no tendency to spontaneous rupture so firm is their\\nroof-wall. Later their early limpid contents become lactescent or puri-\\nform in character. When abundant the vesicles may coalesce and form\\nirregular patches. Involution is accomplished by desiccation and the\\nformation of a yellowish-brown crust, which falls in from seven to ten\\ndays after the first appearance of the vesicle. New groups appear during\\na period usually of from six to twelve days, at the end of which time\\nvesicles may be seen in all stages of development and involution. The\\naverage duration of the disease is from ten davs to three weeks. Ex-\\nceptionally, a succession of new lesions may prolong the disease for a\\nmonth or more.\\nDisappearance of the vesicles and crusts is followed often by pigmen-\\ntation, which may persist for weeks or months. Scarring occurs in some\\ncases, especially if the vesicles have been ruptured and exposed to pus-\\ninfection. The scars left by zoster are characteristic. Not only are\\nthey limited to the original seat of the disease, but they have also a\\npeculiar indented look, as if made by a nail-set and hammer. They\\nare angular in outline, and do not exhibit the dead- white color of many\\ncicatrices.\\nThe pain or hyperesthesia of zoster varies greatly in intensity and", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0273.jp2"}, "274": {"fulltext": "260 INFLAMMATIONS.\\nin duration. It is usually mild, but may be very severe, especially in\\nold people. It disappears commonly with, or soon after, the appear-\\nance of the eruption, but may persist for months or even for years.\\nZoster occurs chiefly in the upper part of the body, and, though\\nlimited to one side, this limitation is rarely observed exactly at the\\nmedian vertical line, as a few lesions can usually be seen extending\\nbeyond this boundary.\\nAtypical forms of zoster are seen occasionally. The vesicles may\\nbe typical and few in number, possibly limited to a single group, or\\nthey may be abortive and transitory. Papules or vesico-papules may\\nbe the sole lesions. The vesicles may become transformed into pus-\\ntules or bullae, or be filled with blood from capillary hemorrhage,\\nproducing bluish or blackish lesions, known as Zoster Hjemor-\\nrhagicus, or black herpes. In severe cases there may be ulceration\\nand gangrenous or deep-seated phlegmonous inflammation. Keloid-\\nlike scars occur rarely.\\nRecurrent zoster 1 is rare, but a number of cases are reported in\\nwhich an individual had two or more attacks either in the same or\\nin different regions of the body. In many of the cases reported, how-\\never, the recurrent lesions were not typical of true zoster.\\nZoster of simultaneous occurrence on two sides of the body may be\\nsymmetrical or asymmetrical of development. The disease in either\\nform is exceedingly rare. In our experience the anomaly is generally\\nthe result of herpes either in a syphilitic subject or in one under the\\ninfluence of arsenic. T. C. Fox 2 reports a symmetrical case in an\\ninfant of five months.\\nThe eruption may occur over the terminal filaments of nerves which\\nhave no communicating branches, unless, as suggested by Blaschko, 3\\nthere be an interlacing of fibres in the spinal cord.\\nAnomalous nervous symptoms are: persistence of neuralgia after\\ninvolution of the cutaneous lesions; neuralgia of an intense and intol-\\nerable severity at any period of the disease; painful anaesthesia of the\\nskin; paretic and paralytic phenomena with resulting muscular atrophy;\\nand, in zoster of the head, keratitis and iritis, complete destruction of\\nthe ocular globe, and falling of teeth and hair.\\nAccording to the regions involved the following types of zoster are\\ngenerally recognized\\nZoster Capillitii depends upon involvement of the second branch\\nof the fifth pair of nerves, and its lesions occupy the anterior and pos-\\nterior portions of the scalp.\\nZoster Frontalis occurs in the area supplied by the supra-orbital\\nnerve, which springs from the first branch of the trigeminus. Its\\nlesions extend from the upper eyelid to the vertex, and spread in a\\nfan-shaped figure over one-half of the brow, forehead, and scalp.\\nZoster Ophthalmicus may be a severe and dangerous manifesta-\\n1 For ^resume of the literature cf. Kecurrent Zoster, by Joseph Grindon. Jour.\\nCutan. and Gen.-Urin. Dis., May, 1895.\\n2 Brit. Jour, of Derm., 1898, p. 252.\\n3 Monatsh. fur prakt. Derm., August 15, 1898.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0274.jp2"}, "275": {"fulltext": "HERPES ZOSTER. 261\\ntion of the disease, being often complicated by agonizing neuralgia,\\nformidable involvement of all parts of the eye, even resulting in pan-\\nophthalmia, ulcerative keratitis, pyaemia, meningitis, and death. Typ-\\nical cases of zoster of this region may not, however, exhibit a single\\nuntoward symptom of the disease.\\nZoster Facialis depends upon involvement of the sensory nerve-\\nfibres of the trigeminus distributed to the face, its lesions being dis-\\nplayed over one cheek, the side of the nose, the half of the lip or of\\nthe chin. The facial and seventh nerves may chiefly be affected. Care\\nmust be taken in cases of this variety not to confound the disease upon\\nthe nose with acne or with painful tertiary syphilitic lesions, errors in\\ndiagnosis that have occurred. When the lower jaw is involved there\\nmay be severe toothache, dysphagia, and fall of the teeth, Avith great\\nresulting deformity.\\nZoster Nuch^e, seu Collaris, occupies the region extending for-\\nward from the cervical vertebrae to the clavicle, or upward toward the\\noccipital region and the auricle.\\nZoster Brachialis occupies the region from the last cervical and\\nfirst dorsal vertebrae over the supra-spinous scapular region and the\\ncontiguous portions of the upper arm. Rarely, even the skin of the\\nfingers and that over the first and second ribs are involved. It is a\\ncommon and usually a mild form of the disease, and is characterized\\nby a peculiar isolation of the vesicular groups. It occurs also with\\nlesions of exclusively brachial distribution. Thomson, of London, re-\\nports brachial zoster with involvement of the right internal cutaneous\\nnerve in which two groups of vesicles appeared in the palm of the\\nhand.\\nZoster Pectoralis is the most frequent form of the disease, from\\nwhich the common name shingles originated. The eruption occurs\\nbelow the first dorsal vertebra, covers the skin of the thorax as far as the\\nlumbar vertebrae, and extends from the spinal column behind to the\\nsternal region in front. Two, three, or more of the intercostal nerves\\nin this region are commonly involved, and the neuralgia resulting has\\nfrequently been mistaken for the pain of pleurisy. Children more\\noften display this form than any other variety of zoster.\\nZoster Abdominalis. The area here involved extends from the\\nlumbar vertebrae to the median line of the abdomen. Zoster abdomi-\\nnalis is usually much less pronounced in its features, and the exanthem\\nis less abundant, than in the variety of the disease just described.\\nWhen constipation exists defecation may be attended with consider-\\nable pain.\\nZoster Femoralis covers the buttocks and sacrum, and extends\\nalong the thighs, sweeping from behind forward and from above down-\\nward as far as the popliteal space in some cases involving the leg and\\nfoot. The penis, the scrotum, the labia, the vestibulum vaginae, and\\nthe anus may then exhibit unilaterally arranged vesicles. As this is\\na relatively rare manifestation of the disease, the diagnostician will\\ndo well to recall the possibilities in every case of an exanthem lim-\\nited to one side of the perineum, supposed to be the seat of genital\\neczema.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0275.jp2"}, "276": {"fulltext": "262 INFLAMMA TIONS.\\nEtiology. Herpes zoster occurs in both sexes, and in the young as\\nwell as in the old, though it is rarely seen in infants. It shows a ten-\\ndency to increase in severity with the age of the patient, especially\\nafter middle-life. It is influenced by the seasons, as cold and damp\\nweather serves to increase its frequency in those susceptible to it.\\nFrequently there is a history of recent exposure of the involved region\\nto a draught of cold air. A large list of other depressing agencies are\\nnamed as effective in the production of zoster. Among them are\\ncertain poisons (carbon dioxide, belladonna, and atropine), pyaemia, car-\\ncinoma, fever, measles, pulmonary inflammations (including phthisis),\\nsepticaemia, hemorrhages, traumatism, and malaria. It has also fol-\\nlowed vaccination, the passage of electrical currents, the extraction of\\nteeth, an accidental prick by a thorn, the tapping of hydatids, and\\ngunshot wounds of the body. Inasmuch as no one of these causes\\ncan be cited as certainly effective in all cases, it can merely be said\\nthat any influence sufficient to induce inflammation of a sensory nerve\\nor its ganglion may be followed by the objective signs of the disease.\\nCases are on record in which zoster followed a prolonged course of\\narsenic. Occasionally zoster occurs in epidemics, or coexists with\\nother epidemic disorders, such as influenza. The evidences of direct\\ncontagion in a few instances are very strong. These facts, and the\\nrarity with which zoster recurs in the same individual, together with\\nthe adenopathy which is often present from the beginning of an attack,\\nfavor the growing belief that zoster is, in some instances at least, an\\ninfectious disease. 1\\nPathology. In some cases there is unmistakable evidence of a de-\\nscending interstitial neuritis, but the affection may be associated with\\nirritative action in any portion of the nervous tract from central\\nto peripheral limit. The researches of Barensprung, Rayer, Wagner,\\nCharcot, Kaposi, and others have demonstrated with sufficient clearness\\nthat in zoster there are always, at some point in the corresponding\\nnervous tract (cerebral or spinal centres, ganglia, or the nerves them-\\nselves), pathological changes. In the majority of cases in which a\\npathological lesion is demonstrated there is found an interstitial neuritis\\nof the posterior ganglion or of the posterior spinal root, but neuritis\\nand perineuritis of the peripheral nerves, without change in the more\\ncentrally situated parts of the nervous system, are reported by com-\\npetent observers. In a number of cases multiple neuromata have been\\ndiscovered along the affected nerve, the spinal cord and ganglia remain-\\ning normal. In other instances the irritation of the nerve-tract has\\nbeen due to hemorrhage, degeneration, or pressure from tumors, etc.\\nReflex irritation seems to have been an effective cause in a few cases.\\nAccording to Biesiadecki and Haight, the cutaneous lesions originate\\nin the deeper portions of the rete, precisely as in other vesicular dis-\\neases. The exudate from the hyperaemic corium, especially its papil-\\nlary layer, presses upward into the rete, the epithelia of which are\\nthus separated and vertically elongated, the lacunae between them,\\n1 Hay presents an excellent argument in favor of the infectiousness of zoster, and\\ngives references to literature on the subject in Jour. Cutan. and Gen.-Urin. Dis., 1898,\\np.l.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0276.jp2"}, "277": {"fulltext": "HERPES ZOSTER.\\n263\\nbeing distended with serum and a few round cells. Often the vesicles\\nform about the hair-sacs. As the exudation increases the rete-cells\\nare progressively separated, and finally are discovered free in the ex-\\nuded fluid, though some, in changed form but still united to each other,\\nmay be found in the upper part of the vesicle. Except at the margin,\\nthe mucous and horny layers are separated by the exudation. At first\\nmany-chambered with delicate easily ruptured partitions, the vesicle\\nrepresents finally a single chamber filled with serum containing rete-\\ncells and a few pus-cells, the latter increasing in number as the vesicle\\nFig. 47.\\nLongitudinal section of the third spinal ganglion of the right lumbar region from a case of\\nlumbo-inguinal zoster a,a, ganglion (the black spots correspond with pigmented ganglion-cells\\nthe dark lines with engorged vessels) b,c,d,e, fatty tissues surrounding the ganglion b,b, nerve-\\nfilament divided longitudinally at the points of entrance and exit c.c, nerve-filament divided\\nperpendicularly. (After Kaposi.)\\nchanges its type. Its base at first rests upon the lower portion of the\\nmucous layer later, upon the corium itself, in which all signs of pa-\\npillae are absent. In the vicinity of the vesicle the papillae and corium\\nare infiltrated and the vessels are dilated, but these inflammatory\\nchanges do not extend far into the corium. The deep location of the\\nvesicle, resting as it does upon the papillary layer, accounts for occa-\\nsional destruction of the papillae and consequent scarring.\\nThe vesicle of zoster (and to a less degree that of variola and of\\nvaricella) is peculiar in that it contains in the deeper portion and along\\nthe walls epithelial cells which have undergone transformation into\\nround or ovoid globular bodies, usually larger than the normal cells,\\nwhich have apparently a limiting membrane or double-contoured wall,\\nand contain from two to a dozen or more rounded bodies. These trans-\\nformed epithelial cells have been described as protozoa, but their true\\nnature has been demonstrated by Unna, Gilchrist, 1 and others. Other\\nvaried and extraordinary figures are seen. Among them are rings with\\nfragmentary edges and swollen centres (the edge representing a homo-\\ngenized and fibrinously degenerated protoplasm the centre a homo-\\n1 Johns Hopkins Hosp. Rep., 1896, vol. i.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0277.jp2"}, "278": {"fulltext": "264 INFLAMMATIONS.\\ngenized nucleus). Elsewhere are thin and expanded shells filled with\\nepithelial nuclei. Irregularly ballooning balls, baskets, tubes, hang-\\ning cords, and other odd forms take the place of the trabecular found in\\nother vesicles. Unna names this peculiar change in the epithelial cells\\na ballooning degeneration, to distinguish it from the reticulating\\nforms.\\nDiagnosis. The vesicles of herpes zoster are not rarely confounded\\nwith those of eczema but the distinction between the two is always\\nreadily established. In eczema there is itching but no neuralgia the\\nvesicles tend to rupture spontaneously and never persist as they do in\\nzoster eczematous lesions are also smaller, more acuminate, and rarely\\ndistinctly limited to the lateral half of the body. Herpes simplex is\\nfrequently recurrent, herpes zoster almost never herpes simplex is\\nexceedingly liable to spread around the mucous outlets of the body,\\nand on either side of the latter, while zoster reaches such regions only\\nafter extension from other parts, and is then almost invariably mono-\\nlateral. Its lesions are, moreover, never grouped in the concentric\\ncircles of herpes iris.\\nTreatment. The purpose of local treatment of herpes zoster is to\\nprotect the vesicles from rupture and infection, and to relieve pain.\\nThese ends are best accomplished by thickly dusting the lesions with\\nan anodyne powder, such as Anderson s powder, containing morphine\\nsulphate, 2 grains (0.133) to the ounce (30.) lycopodium with powdered\\nopium, orthoform and boric acid, or zinc stearate with acetanilid, etc.\\nThe vesicles may be punctured with an aseptic needle and the contents\\nevacuated, but rupture of the lesions should not be permitted. Over\\nthe entire affected surface should be gently laid a sheet of soft lint or\\nof antiseptic cotton, its meshes being also filled with the powder, and a\\nbandage, when practicable, smoothly bound over the whole. In the\\nmilder cases nothing more than this treatment is needed from first to last.\\nThe glycogelatins furnish a convenient and effective dressing if the con-\\ntents of the vesicles be first evacuated and the surface rendered as nearly\\naseptic as possible. In cases in which the lesions have ruptured and\\ntheir bases have undergone erosive or ulcerative changes oleated lime-\\nwater with zinc oxide, belladonna, and opium or morphine should be\\napplied, and be covered with Lister protective. Carbolated and anodyne\\nointments may also be used, especially toward the conclusion of the case.\\nBleuler 1 states that applications of 1 part of cocaine in 50 parts each\\nof lanolin and vaselin not only relieve the pain but also shorten the\\nduration of the disease.\\nLotions of carbolic acid and glycerin (1 part to 6), or lead-water\\nand laudanum, or the lead-and-opium wash may be employed.\\nVan Harlingen recommends ounce (15.) each of precipitated zinc\\ncarbonate, powdered zinc oxide, powdered starch, and glycerin, shaken\\nup in i pint (240.) of water.\\nDuhring speaks well of collodion with morphine, in the strength of\\n10 grains (0.66) to the ounce (30.). Kaposi warns against the use\\nof diachylon ointment. Generally, it may be said that ointments\\nshould be the last resort, but those containing from 10 to 20 grains\\n1 Neurologisches Centralblatt, November 15, 1899.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0278.jp2"}, "279": {"fulltext": "", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0279.jp2"}, "280": {"fulltext": "PLATE III.\\nDermatitis Herpetiformis.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0280.jp2"}, "281": {"fulltext": "DERMATITIS HERPETIFORMIS. 265\\n(0.66-1.33) of the aqueous extract of opium or of belladonna to the\\nounce (30.), or a 5 per cent, cocaine salve, will at times give relief from\\npain. The oleate of cocaine and menthol have been used locally with\\ngreat advantage in meeting the same indication. Alcohol or resorcin\\n2 parts, alcohol 100 parts or 1 per cent, alcoholic solutions of menthol\\nor of thymol, may be useful when other measures fail, and it is claimed\\nby some that these remedies will abort the disease if used early. A\\ncontinuous galvanic current of between two and three milliamperes\\nmay be applied over the root of the nerve two or three times daily\\nfor ten minutes at a sitting. Blistering or dry-cupping, or in sthenic\\ncases wet-cupping, may be employed instead of electricity.\\nNo remedy for internal use is known to have the power of abort-\\ning or of shortening an attack. Quinine is certainly indicated and does\\nno harm, but quinine and strychnine in full doses have alike proved\\ninefficacious. Other remedies employed are zinc phosphide in grain\\n(0.022) doses, repeated every three hours, and, if indicated, in com-\\nbination with jr (0.011) grain of the extract of nux vomica; arsenic\\n(Kaposi) and the tonics in general. Anodynes, by mouth or by hypo-\\ndermatic injection, are often indispensable. Inasmuch as many patients\\nconsider the attack a trivial matter, it is of some consequence that they\\nbe warned of the possibilities of the future, and that they be confined\\nto an apartment of equable temperature in which they are not exposed\\nto atmospheric changes. This measure is of special importance in the\\nzosters of the face. A skilled oculist should be consulted in cases in-\\nvolving the eye.\\nPrognosis. Zoster usually runs a benign and self-limited course.\\nThe prognosis in exceptional cases may be in the highest degree grave.\\nMany severe cases have occurred in which patients, after years of\\nintense suffering, have resumed the occupations of life, physical wrecks\\nof their former selves, their faces indented with scars, and the vision\\nof one eye impaired or ruined. Rarely the termination is fatal.\\nDERMATITIS HERPETIFORMIS.\\nDermatitis herpetiformis is a malady which, in one form or another\\nand under different titles, has long been recognized and described.\\nThe credit, however, of clearly establishing its identity, and of recog-\\nnizing one process as differently expressed in the several observations\\nof others, is largely due to Duhring, of Philadelphia. 1\\nThe identity of the disease as a special pathological process has only\\nlately been established. Much investigation is yet required before\\nsettling definitely many of the interesting questions it presents for con-\\nsideration. Duhring regards its vesicular and bullous forms as iden-\\n1 Dermatitis Herpetiformis its Relations to So-called Impetigo Herpetiformis.\\nAmer. Jour. Med. Sci., October, 1884. Dermatitis Herpetiformis Case of, Caused\\nby Nervous Shock, etc. Ibid., January, 1885. Case of Dermatitis Herpetiformis,\\nIllustrating the Pustular Variety of the Disease. Jour. Cutan. and Ven. Dis., vol. i.,\\nNo. 8. Case of Dermatitis Herpetiformis with Peculiar Gelatinous Lesions. Med.\\nNews, March 7, 1885. Notes of a Case of Dermatitis Herpetiformis, etc. N. Y.\\nMed. Jour., November, 1884. A Case of Dermatitis Herpetiformis (Bullosa). Ibid.,\\nJuly, 1884. Cf. Duhring, p. 436.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0281.jp2"}, "282": {"fulltext": "266 INFLAMMATIONS.\\ntical with herpes circinatus bullosus (E. Wilson); pemphigus\\nprurigineux (Hardy) herpes gestationis (Milton, Bulkley, and\\nothers) pemphigus (Klein) pemphigus circinatus (Rayer)\\nherpes phlyctaenoi des (Gibert) pemphigus aigu prurigineux yi\\n(Chausit) herpes iris (Jarish) fatal pemphigus-like dermatitis\\n(Mayer) peculiar skin-eruption recurring during pregnancy (Os-\\nwald) bullous eruption of a peculiar character (Leigh) pem-\\nphigus compost (Devergie) and hydroa (Jones, Bulkley, and\\nothers).\\nSymptoms. Constitutional symptoms are usually slight or wanting,\\nbut the first appearance of the disease and the succeeding attacks or\\nexacerbations are frequently announced by malaise, sensations of chilli-\\nness, decided rigors, or alternations of cold and hot sensations, with\\nsystemic disturbances. The skin usually is the seat of pruritic or\\nof burning sensations, followed in the course of from twelve hours\\nto two days by the appearance of the exanthem, which may be macular,\\npapular, tubercular, vesicular, pustular, or bullous in type, or be com-\\nbinations of these lesions recurring in every variation. The lesions\\nmay be cutaneous, muco-cutaneous, or mucous in situation.\\nThe macular form of eruption appears in small-coin to palm-sized\\npatches, irregularly rounded, coalescing, well or ill defined as to out-\\nline, and slightly raised, suggesting the lesions of erythema multiforme\\nor urticaria. Imperfectly defined maculo-papules, papules, and pap-\\nulo-tuberculous lesions, varying in shape, size, and firmness, may also\\nspring from or be intermingled with the reddish maculations described\\nabove.\\nIn typical development, however, the disease presents cutaneous\\nsymptoms of herpetic type. Flat, slightly elevated, hard, angular,\\nirregularly outlined vesicles may appear, pinhead- to bean-sized, and\\ntensely distended. They may be pale yellow or darker in color and\\nwith or without areolae. When bullae form they may be sparse or be\\nplentiful, and be bean- to egg-sized, with cloudy, lactescent, hemor-\\nrhagic, or purulent contents. Pustules when present are single or are\\nclustered, pinhead- to bean-sized lesions, flat, each surrounded by a\\nlivid areola. When evolution is complete, segments of rings, or dis-\\ntinct rings, of new minute or large pustules surround those first formed,\\nand in less than a week these rupture and become covered with a\\ncrust, which is flat, adherent, and yellowish, greenish, brownish, or\\nblackish in color. When there is coalescence a large coin-sized pustule\\nand crust may result, and even extensive patches of these coalesced\\nlesions may form. The lesions may number from a score or fewer to\\nhundreds.\\nThe imprint of the cutaneous symptoms is multiformity and recur-\\nrence. Vesicles, pustules, and bullae without order or regularity of\\nevolution or of recurrence appear at one and the same time, in rapid or\\nin slow succession, and, without fixed intervals of appearance, for\\nmonths at a time. Generally, however, a prevalence of one special\\ntype of lesions may be noted during a single period of outbreak or of\\nrecurrence. This prevalence is in the direction generally of lesions of\\nan herpetic type, viz., the vesicular and the bullous in groups, though", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0282.jp2"}, "283": {"fulltext": "DERMA TTTIS HERPETIFORMIS. 267\\nless frequently one of the other types may predominate, and rarely\\nvesicles may be absent.\\nAs a result of the conditions described above a peripheral new for-\\nmation of lesions tends to produce marginate patches in which grouping\\noccurs, the groups, however, being interspersed with diffusely dissem-\\ninated lesions of various types. The irregular, angular, or stellate\\nforms of the lesions containing fluid are highly suggestive. Pigmenta-\\ntion and infiltration of the skin are commonly noticed. The subjective\\nsensations of burning increase and diminish as cutaneous lesions are\\nmultiplying or are disappearing. The pruritus is in some cases more\\nsevere than in eczema, and the traumatisms of scratching add greatly\\nto the multiform features of the disease.\\nThe disease lasts for months and even for years. Duhring reports\\ncases lasting from five to fifteen years, with periods of relative or of\\nentire immunity. In one of Duhring s cases there were thumb-nail-\\nsized, raised but flat, golden-yellow-colored lesions, of firm consistency,\\ncontaining a similarly colored, thick, consistent, gelatinous pulp these\\nfeatures have been noted in several other instances.\\nWhen the oral cavity is invaded there appear upon the sodden and\\nmacerated mucous surface pustules and bullae, which rupture, leaving\\nraw and unhealthy-looking erosions, even sloughing patches of mucous\\nmembrane. Crusts form about the nares and the lips, and the stench\\nfrom the patient is intolerable. In the same way the vulva, the anus,\\nand the prepuce may be surrounded by vesicular and bullous lesions\\nwhich form also on the mucous surfaces adjacent, and pursue a course\\nsimilar to that recognized in the mouth.\\nIn grave cases, as the skin-symptoms exhibit a marked aggravation\\nthe systemic condition changes for the worse. After a low fever alter-\\nnating with chills and accompanied by progressive cachexia and emaci-\\nation, an intermittent diarrhoea or a pneumonia may close the scene.\\nThe repulsive appearance of the patient at the last, in severe cases, is\\nas formidable as in fatal cases of confluent variola or of severe pityriasis\\nrubra.\\nEtiology. The disease occurs at all ages, but much more commonly\\nafter adult years have been attained often in individuals of neuras-\\nthenic type or in those in whom the nervous system has been subjected\\nto unusual strain. Mental crises, nervous shock, fright, anger, physical\\nfatigue, and defective renal excretion have all been noted as causes of\\nthe malady. Among other effective conditions have been named men-\\nstrual irregularities, pregnancy, the puerperal state, and septicaemia. It\\nis possible the irritation of the nervous system may be due in every case\\nto a toxaemia, but by many the disease is considered purely a neurosis.\\nPathology. Our personal knowledge of the pathology of this affec-\\ntion is based upon the study of a number of sections of the skin removed\\nfrom the person who was the subject of the sketch from which the\\naccompanying plate was prepared. The following is Duhring s account\\nof the pathology of the affection, which fully substantiates our own\\nconclusions. In the mucous layer are vacuolated cells with shrunken\\nnuclei and a few polynuclear leucocvtes. The granular layer is discern-\\nible. The blood-vessels of the papillae are dilated and contain erythro-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0283.jp2"}, "284": {"fulltext": "268 INFLAMMATIONS.\\ncytes, poly nuclear leucocytes, and eosinophilous cells with fibrin. A\\nsucceeding stage exhibits infiltration of the papillae with polynuclear\\nleucocytes, small mononuclear cells, and eosinophilous cells. In a yet\\nmore advanced stage the infiltration pushes the epidermis upward,\\nleaving a clear space beneath filled with fine fibrinous strands and\\ncoagulated albumin. Larger and larger vesicles are formed by conflu-\\nence of the swollen cells in adjacent papillae, the vesicles becoming filled\\nwith a close, fine or coarse, network of fibrin containing in its meshes\\npolynuclear leucocytes, epithelial cells, eosinophilous cells, and coagulated\\nalbumin. Eosinophiles are seen in many cases between the epithelial\\ncells. The deeper portion of the corium is for the most part unchanged.\\nEosinophilia is present as a rule, but its exact significance is not estab-\\nlished, as it is found in other conditions. Lerrede 1 believes that eosin-\\nophilia when combined with excretion of eosinophiles through the skin\\nis peculiar to dermatitis herpetiformis and allied conditions. 2\\nThe Diagnosis in classical cases is readily made in others the dis-\\ntinction between dermatitis herpetiformis, impetigo herpetiformis, and\\ncertain forms of pemphigus is exceedingly difficult. It is possible that\\nbetween the three there may be transitional forms scarcely to be assigned\\nto the one category or the other. The same is true of certain excep-\\ntional varieties of erythema multiforme. The diagnostic value of the\\npresence of eosinophilous cells (the fluid drawn from the blebs having\\nbeen reported by Lerrede and others as equal to from 30 to 95 per cent,\\nof the total number of leucocytes) has been weakened by the discovery\\nof these same bodies in large numbers in the serum removed from\\nsimple blisters of the skin.\\nThe diagnostic features of the disease are chronicity, with or with-\\nout remissions or intermissions multiformity of the lesions, among\\nwhich those of herpetic type usually predominate the tendency of the\\nlesions to appear in groups or patches the very marked capriciousness\\nand variableness of the recurrences and exacerbations in their times of\\nappearing, and in the nature, extent, and severity of the lesions itching,\\noften intense and more or less pigmentation.\\nTreatment. Internal treatment has been directed to meet the indi-\\ncations, presented. Of great importance are hygienic measures with a\\nview to maintaining the patient s general health. All excesses, excite-\\nment, and everything tending to interfere with the equilibrium of the\\nnervous system should be avoided. A nutritious but simple diet, regu-\\nlar habits of living, with sufficient outdoor life and exercise, are all of\\ngreat value. Medication is directed chiefly toward improving the tone\\nof the nervous system, for which purposes strychnine, quinine, iron,\\nsmall doses of arsenic, and phosphorus may be used. Preparations of\\nmalt and cod-liver oil are often indicated. Mild laxatives, and the free\\ndrinking of water between meals and before meals, are of value in\\naiding elimination. For the same purpose small doses of mercurous\\niodide may be continued for weeks at a time. Stelwagon has found\\n1 Annal. de Derm, et de Syph., April, 1899.\\n2 For a full discussion of the relation of this disease to allied vesicular and bullous\\ndermatoses, cf. articles by Jamieson, Brit. Jour, of Derm., 1898, pp. 73 and 118 Brocq,\\nAnnal. de Derm, et de Syph., 1898, pp. 849 and 945 and Lerrede, Monatshft. f. prakt.\\nDerm., 1898, p. 381.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0284.jp2"}, "285": {"fulltext": "POMPHOLYX. 269\\ngeneral galvanization of value in one or two patients. In exceptional\\ncases arsenic in full doses acts almost as a specific it is of most value\\nin vesicular and bullous eruptions. It should be remembered that when\\narsenic is not suited to a given case large doses of the drug may do\\nmuch harm.\\nOther existing disturbances of the general economy due to rheu-\\nmatic tendencies, kidney-disease, indigestion, constipation, or other cause\\nshould be recognized and properly be treated.\\nLocally treatment is directed to keeping the surface clean and aseptic,\\nand to making the patient comfortable. Duhring recommends stimu-\\nlating applications when they are well tolerated, but in many cases\\nsoothing and sedative preparations are necessary. Among the stimu-\\nlating applications which have proved of value may be mentioned\\nlotions and oils containing tar, carbolic acid (1 to 20 per cent.), ichthyol\\n1 (2 to 10 per cent.), and thymol (1 to 5 grains (0.06-0.33 to 30.) to the\\nounce). Stelwagon highly recommends liquor carbonis detergens in\\nstrength varying from 1 part to 10 parts of water up to the pure solu-\\ntion. Duhring found sulphur ointment (2 drachms of sulphur to the\\nounce (8. to 30.) of great value in cases in which there were vesicular,\\npustular, and bullous lesions. This ointment should be rubbed in vig-\\ni orously, but should be tried on a small surface at a time for fear of\\ninducing irritation.\\nIn most cases a soothing treatment is demanded by means of alka-\\nline, bran-, or other demulcent baths, followed by some of the dusting-\\nI powders or the lotions advised for use in the acute stages of eczema.\\nOintments are not indicated, as a rule, but in a few cases diachylon oint-\\nment (Hebra), Lassar paste, zinc, mercurial, and other pastes and oint-\\nments have been used to advantage. For relief from itching camphor\\nand chloral (1 to 5 per cent.) in oils or ointments may be employed.\\nMany patients are treated with very great comfort to the end in the\\ncontinuous warm water-bath.\\nThe Prognosis is always doubtful, and is often grave. It is not\\ncertain that the disease is ever completely relieved, though temporary\\nrecovery from repeated outbreaks is common.\\nHerpes Gestationis (Pemphigus Hystericus) is a name that\\nhas been employed to designate erythematous, papular, vesicular, and\\nbullous lesions, accompanied by marked pruritic and burning sensa-\\ntions, occurring usually upon the extremities, but also upon other parts\\nof the body. The subjects are usually pregnant or hysterical women,\\nwho are said to exhibit recurrent attacks in successive conditions of\\npregnancy or neurotic disorders. The view of Duhring, that this dis-\\norder should be included under Dermatitis Herpetiformis, should be\\naccepted.\\nPOMPHOLYX.\\n(Gr. tto/x^oIv^ a bubble.)\\n(Cheiro-pompholyx, Dysidrosis.)\\nThe disorder indicated by the above title has been the occasion\\nof no little medical controversy. Observers are not agreed as to its", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0285.jp2"}, "286": {"fulltext": "270 INFLAMMATIONS.\\nnature and identity. Kaposi asserts that the symptoms are those\\nsimply of acute eczema. Tilbury Fox, Hutchinson, Robinson, and\\nothers have made careful studies of the malady. The paragraphs in\\nthis treatise devoted to dysidrosis are intended to call attention to the\\ndisease as it occurs in connection with the affections of the sweat- or\\ncoil-glands.\\nSymptoms. The disease affects simultaneously and, as a rule, sym-\\nmetrically the hands and the feet if either organs are spared, it is com-\\nmonly the feet. One side may be more extensively involved than the\\nother. The eruption is preceded or is accompanied by a burning or a\\ntingling pain, and is characterized by the appearance on the dorsum, or\\nthe sides of the fingers, or over the palms and soles, or over the whole\\nhand or foot, of deeply set, single or numerous, grouped or confluent\\nvesicles, or of vesico-bullae. According to Fox, in the earliest stages\\nof the vesicles annular collections of fluid may be seen about the sweat-\\npores. The appearance of well-developed lesions is compared with that\\nof boiled sago-grains imbedded within the skin. When the bullae attain\\nextreme development the distended lesions, as large as pigeon s eggs,\\nproject from the skin, these lesions being irregularly outlined and con-\\ntaining a neutral or an alkaline fluid, translucent or turbid, and seated\\non an oedematous, often exquisitely painful and sensitive skin. The\\nbullae are said not to rupture spontaneously, but to undergo absorption\\nin a fortnight or more, with exfoliation of the loosened epidermis but\\nthere are well-marked exceptions to the rule. Beneath the purposely\\nruptured bullae is a new-formed and reddened or exfoliated and sodden\\n(which under favorable circumstances becomes later a sound) epidermis.\\nThere may be coincident malaise, thermal changes, marked mental de-\\nspondency, or hebetude. The hyperidrosis mentioned by some authors\\nmay or may not be a prominent feature in the case of affected patients\\nbefore and during the occurrence of the disease. There may be recur-\\nrent attacks in consecutive seasons, and also recrudescence of the dis-\\nease in the affected. It occurs in both sexes, but apparently more often\\nin women in England in America it is believed that more male pa-\\ntients have suffered. The ages of the latter are from those of childhood\\nto those of middle life one well-marked case occurred in a man of\\nsixty. The sufferers, with but few exceptions, are in poor health, are\\nbroken down from nervous overstrain, and are neurasthenic rather than\\ncachectic. Mild types of the disease occur which it is difficult to dis-\\ntinguish from pemphigus benignus.\\nPathology. The differences among observers respecting the char-\\nacter of the disease depend upon whether the view is taken with Fox,\\nCrocker, and others, that the vesicles lie directly connected with or in\\nthe line of the sweat-duct or whether, with Hutchinson, Robinson,\\nand others, no connection with the coil-glands is recognized, the vesi-\\ncles lying in the superior portions of the rete over the papillae and not\\nover the rete-pegs which pass below to meet the ducts of the coil-glands.\\nCrocker, however, found lesions in both situations. The disease ocelli s\\nmost frequently in persons who are worried or nervously depressed, and\\nis probably a neurosis.\\nDiagnosis. Pompholyx is to be differentiated from eczema. The", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0286.jp2"}, "287": {"fulltext": "PSORIASIS. 271\\ntendency of the vesicles to persist, and after intentional rupture to fail\\nto furnish a serous exudate, is strikingly different from the course of\\neczema. Again, there is seldom, if ever, in well-marked pompholyx a\\ntendency to change in type from a serous to a pustular exudation.\\nLastly, eczema of the palms and the soles is almost invariably of ery-\\nthematous type. It differs from pemphigus in the absence of cyclical\\nphenomena, in its special localization, and in its frequent vesicular\\norigin.\\nTreatment. The internal treatment of these cases is of importance.\\nPatients require the best climatic and hygienic environment and mental\\ndistraction. In the way of medicaments, quinine, nux vomica, iron,\\nthe mineral acids, ergot, cod-liver oil, matzool, and kumyss may be\\nneeded. The local treatment is by employment of diluted black wash\\noleated lime-water with zinc oxide or bismuth subnitrate, or Lassar\\npaste covered with boric or salicylated powder or by the application\\nof strips of muslin spread with lead or with zinc salves.\\nThe disorder is in certain subjects due to strictly inherited tendencies.\\nWe have had under observation three typical cases in the person of a\\nmother and two children, one of the latter a girl, all of whom had\\nsuffered since birth from successive crops of vesico-bullous lesions with\\nhyperidrosis of the hands and feet. The heart of each was in an irrita-\\nble state, the pulse-rate of the mother having been repeatedly registered\\nat 122 to the minute. All three patients complained of gastric crises.\\nIn France a number of disorders accompanied by coldness and\\nsweating of the hands and feet, and characterized by lesions limited to\\nthese organs, are cited as instances of dysidrosis. Thus, a passive ery-\\nthema and areas of congestion of the skin of the organs named, dis-\\nplaying non-bullous lesions, are commonly set down in Paris as illus-\\ntrations of dysidrosis. It is usual in America to limit the titles\\ndysidrosis and pompholyx to the affection here described with marked\\nJ preponderance of vesico-bullous lesions as hand and foot symptoms.\\nIn all cases the heart should be examined and the condition of the\\ncirculation carefully determined. Organic and functional cardiac dis-\\nease is responsible for many cases.\\nPSORIASIS.\\n(Gr. ipopa, the itch.)\\n(Lepea, Alphos, Psora. Ger., Schuppenflechte.)\\nSymptoms. In psoriasis the primary lesion is a punctiform macule\\nof reddish-brown tint, which always at the earliest moment of observa-\\ntion is covered with a delicate whitish epidermic scale. When this\\nscale is removed, even by gentle scraping, one or more minute droplets\\nof blood exude from the points beneath which lie the vascular papillae\\nof the corium.\\nThe lesions of psoriasis vary so widely in size, shape, and distribu-\\ntion that the several phases of the disease have been given descriptive\\nnames. These names have no pathological significance, and are used\\nsolely for the purpose of indicating the size, configuration, and distri-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0287.jp2"}, "288": {"fulltext": "272 INFLAMMATIONS.\\nbution of the lesions. When the disease appears in the form of small\\nscale-covered points it is called psoriasis punctata. Should the disease\\nprogress to fuller development, there form patches of larger size, always\\nwith a definite contour, very slightly elevated above the general level\\nof the integument, and covered with whitish, mother-of-pearl-colored\\nscales in abundance. When these scales are about the size of drops\\nof water the disease is termed psoriasis guttata. In more advanced\\nconditions of the disease other names are employed. Thus, psoriasis\\nnummularis is characterized by small coin-sized patches psoriasis cir-\\ncinata or orbicularis, by patches in which the disease is actively exhib-\\nited at the periphery of a circle, in the centre of which the scales have\\ndisappeared psoriasis gyrata and figurata, by coalescence and extension\\nof several patches, forming thus fantastic figures covered with grayish-\\nwhite imbricated scales and psoriasis diffusa, by much more extended\\nand uniform involvement of the skin in large areas. In psoriasis\\nfollicularis the coil-glands and hair- follicles are chiefly invaded.\\nThe greatest variation is exhibited in the progress of the disease,\\nand to this point special attention should be directed. Thus, in a\\nsingle individual the eruption may appear upon one or more regions of\\nthe body in the form of the punctate lesions described above, and\\nthereafter may regularly progress through the degrees suggested by\\nthe list of names given, until the surface of the body is completely\\ncovered from the crown of the head to the soles of the feet. This\\ncondition is, fortunately, very rare, and, indeed, denied by some ob-\\nservers. One rarely sees a case in which a few square inches of sound\\nskin cannot be discovered at some point of the body-surface. More\\noften the eruption tends to remain stationary where one or another\\nof the less extensively developed phases of the disease has been dis-\\nplayed. Thus, the patches may at no time be larger than half an inch\\nin diameter, and, though very numerous, may fail for years to extend\\nbeyond such a limit. They may persist even for a longer period in\\nstill smaller dimensions, or, what is perhaps more common, may occur\\nin guttate forms upon the chest, and in patches as large as the palm\\nover the knee or the sacrum.\\nThe sites of preference of the disease are over the extensor surfaces\\nof the extremities, especially about the elbow and the knee, in which\\nsituation it is decidedly most common. After these locations should\\nbe named, in order, the scalp, the region of the sacrum (on which often\\nthe largest patch upon the body can be discovered), the upper surface\\nof the chest, the face, the belly, and the genitals, more rarely the\\nhands and the feet.\\nThe disease is essentially chronic in its course, is never contagious,\\nand the efflorescence does not usually awaken any subjective sensation.\\nIts features are so pronounced in typical cases that its recognition is\\nfacile, after appreciating the number and distribution of the patches,\\ntheir clean-cut outline, the unaltered integument between the lustrous\\nand shining scales, and the red border of the skin which may crop out\\nfrom beneath the squamous thatch above, or be completely hidden by\\nthe latter. Rarely a single patch betrays the existence of the disorder.\\nWhen the disease is acutely spreading over the skin-surface it has", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0288.jp2"}, "289": {"fulltext": "PSOBIASIS. 273\\noccasionally a different expression, which is often seen in young adults.\\nThe patches are perhaps as large as a pullet s egg; are dark or lurid\\nred over the whole are covered with a more uniformly constituted,\\nthin, squamous film or sheet of semitransparent delicate membrane\\nthrough which the red glare of the patch beneath is visible. This con-\\ndition may also be seen in young persons to whom arsenic has been\\nadministered for the relief of the disease, with the production of irri-\\ntative effects.\\nIn its indolent moods the color of the patch varies somewhat with\\nthe hue of the patient s complexion. Blonde women with flaxen hair\\nand clear tint of the integument often exhibit singularly waxy-whitish\\npatches, decidedly differing in color from those occurring upon the\\nmuddy and greasy integument of dark-skinned men. The scales, which\\nare usually abundant, may adhere with considerable firmness to the\\npatch, or, more frequently, may be shed freely from the surface, in\\npronounced cases powdering the clothing of the patient or the sheets\\nof the bed upon which he reposes at night.\\nThere is never at any time in the course of the uncomplicated\\ndisease the appearance of other lesions or their sequels, such as vesicles,\\npustules, crusts, papules, tubercles, ulcers, or any discharge-feature.\\nThe eruption is dry from first to last. Exception may only be made\\nin the case of patches occurring in situations where motion of the skin\\nproduces fissure, an accidental and by no means characteristic compli-\\ncation. Exception also may be made of certain acute symptoms, espe-\\ncially developed in young and tender skins in which considerable red-\\nness, occasionally with an erythematous halo, appears in and about\\nindividual patches, with the production of itching, heat, burning, pain,\\nor other disagreeable sensations and symptoms of scratching.\\nThe involution of the disease is evident in a gradual cessation of the\\nscale-formation and the exhibition of a normal epidermis which pro-\\ngressively spreads from the centre or is at once perceptible over the\\nI entire surface of the patches. No cicatrization results.\\nUpon the scalp plaques of well-defined contour, covered with thick\\ni whitish scales, may mat the hairs, but alopecia rarely results. The\\ndry condition of these scales contrasts with the greasiness of the\\ncrusts formed in seborrhoea of the scalp. Often a fillet or band of\\ndiseased tissue, one or more inches in width, projects beyond the\\nborder-line of the scalp and forehead. When the vertex is bald\\nfrom physiological loss of hair the patch of psoriasis usually lingers\\n4 near the fringe of the hairs left at the sides of the head, projecting\\nthence to the regions of baldness. On the face, as well as over the\\ngenitals, the lesions are usually both indistinct and small-sized, being\\n1 displayed, as regards the former locality, over the cheeks, chin, and\\nnose, avoiding the parts near the mucous orifices. When there is\\nmuch vascular congestion, especially of the passive kind, the patches\\njf assume a violaceous or purplish tint. All forms of lesions are seen\\nupon the trunk, especially over the dorsum and near the sacrum the\\npatches in well-marked cases encircling the body in ill-defined parallels\\ni reaching from the spine forward. The hands, feet, fingers, and toes\\n\\\\i are not often involved, and the palms and soles only so rarely invaded\\n18", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0289.jp2"}, "290": {"fulltext": "274 INFLAMMATIONS.\\nas to throw doubt upon a diagnosis based upon the existence of the\\ndisease solely in these regions. In severe cases the nails are second-\\narily attacked, being thickened, eroded in points, irregularly lami-\\nnated, rigid, and becoming brittle and yellowish white or dirty whitish\\nin color.\\nThe amount of scaling varies greatly in different persons and in the\\nsame individual sometimes the scales are abundant and thickly heaped\\nup over even small areas; sometimes they are sparse over large areas.\\nIn acute febrile and other intercurrent diseases the disorder may fade\\nor disappear. Where the epidermis is thin the scaling is less there-\\nfore, over flexor surfaces, near the mucous orifices, and on the back of\\nthe hands, the scaling is less than over extensor surfaces, in regions\\nremote from the mucous orifices, and on the palms and soles. The\\nscaling is also less in youth than in advanced years. The disease may\\nfor years be limited to two or three continuously existing patches, or,\\nwhat is far more common, may recur at irregular intervals and under\\nvarying circumstances. As a rule, psoriasis is worse in winter and in\\ncold climates, though patients may demonstrate the reverse of this.\\nThe scales may display, instead of a lustrous white, a deep yellowish\\nshade, and, instead of being imbricated, may form a thin continuous\\nsheet of exfoliated epidermis. When the eruption is disappearing the\\nscales fall, leaving a pigmented or slightly discolored patch of integu-\\nment.\\nAs a rule, psoriasis pursues its course with singularly few complica-\\ntions. The gravest cases are those in which arsenic has been adminis-\\ntered in large doses for relief of the symptoms, when, probably as a\\nresult of the medication, verrucous growths develop in the psoriatic\\npatches, which later become epitheliomatous. 1 At times the eruption\\nis the source of excessive annoyance, being the seat of intense pruritic\\nand burning sensations of a persistent type.\\nThere can be no question that intermediate forms between eczema\\nand psoriasis occur, in which forms it is difficult to determine whether\\nthe two disorders coexist or the one has assumed the features of the\\nother. In these cases there are itching and infiltration of the skin,\\nwith vesicular and other lesions foreign to psoriasis, and a catarrhal\\ndischarge.\\nPsoriasis is not known to affect the mucous surfaces. The lesions\\nof so-called psoriasis linguae are those of leukoplakia buccalis,\\nof smokers patches, of syphilitic disease of the mouth, or flat\\nepitheliomata.\\nEtiology. The causes of psoriasis are not known. As no external\\nor internal factors can be demonstrated to be effective in its production,\\nit is safest to conclude that these unrecognized sources of the affection\\nare limited to the skin itself. So far as known, the disease is neither\\ncontagious nor hereditary. It is not limited to either sex, occupation,\\nor social condition; it bears no definite relation to syphilis, eczema,\\ngout, rheumatism, struma, or dyspepsia it appears in feeble and deli-\\ncate individuals as in the most superb specimens of manly vigor and\\nwomanly beauty, and though not occurring in infancy, yet it often first\\n1 Cf. J. C, White s paper, Amer. Jour, Med. Sci. 1885.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0290.jp2"}, "291": {"fulltext": "PSORIASIS. 275\\nappears in early life. Kaposi reports a single case in which the erup-\\ntion appeared in the eighth month, and Elliot a case of first appearance\\nat the eighteenth month of life. Under these circumstances the ques-\\ntion arises Is this affection of the integument, when uncomplicated by\\nthe symptoms named above, a disease or a deformity? Certainly in\\na very large number of individuals, displaying through life unchanging\\npatches in which the characteristic symptoms are the same year after\\nyear, the ailment would seem more properly to be classed with the\\ndeformities than with the diseases of the skin. In point of frequency\\nthe eruption ranks next after eczema.\\nNo child was ever born psoriatic, yet believers in the possibility of\\nj the transmission of the disease by inheritance are numerous, and some\\nof them are careful observers. Robinson goes so far as to say that in\\nthe majority of all cases there is an inherited predisposition to the\\ndisease. Others conclude it to be an inherited or transmitted form of\\nsyphilis, struma, tuberculosis, rheumatism, or gout. A\u00c2\u00a5eyl thinks that\\ninheritance may possibly be the sole cause. Bazin admits the existence\\nof both an herpetic and an arthritic psoriasis.\\nBearing in mind, on the one hand, the relative frequency of psori-\\nasis, and, on the other hand, the strict tests which should be applied\\ni in order to prove that a disease is actually transmitted by heredity, we\\nfind that the doctrine of heredity in psoriasis fails of establishment.\\ni It is putting a low estimate on the actual figures to state positively\\nI that there must be more than one thousand psoriatic patients in almost\\n1 every country, no one of whose ancestors, so far as known, had psoriasis,\\nsyphilis, or rheumatism. They furnish too large a body of evidence\\nto be either ignored or set aside with a word. Thousands of their\\nchildren are living to-day free for years from any evidence of disease\\nthey, too, call for further proof on this point.\\nIt has long been known that in psoriatic subjects lesions may be\\ndeveloped artificially in the lines of mechanical irritation. In this way,\\ni figures in the shape of anchors, crosses, hearts, etc., have been pro-\\nj duced on the skin of psoriatic patients, one of whom has been inge-\\nniously photographed by Fox, of New York. 1 The disease has also\\nbeen attributed to vasomotor neurosis, to fright, to shock, and to\\nneuralgias.\\nThe disorder is rather more common in male than in female patients\\nand it appears to be rare in the negro races. According to Greenough s\\nstatistics, it represents about 21 per cent, of all cases of cutaneous dis-\\nease. It has followed vaccination, scarlet fever, and other diseases.\\nGowers alone reports the artificial production of psoriasis by the\\n1 internal administration of sodium biborate. Allusion is made to this\\nfact in the chapter on Dermatitis Medicamentosa (q. v.). Further evi-\\ndence would be required to prove that these results differed to any\\nappreciable extent from those recognized in any squamous dermatitis\\nf produced by an ingested drug.\\nIn some cases the disorder is due to exclusion of sunlight from those\\nportions of the body covered with the clothing and the hair. Certain it\\nis that only in extreme cases is the face attacked at a distance from the\\n1 Photographic Illustrations of Cutaneous Diseases. New York.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0291.jp2"}, "292": {"fulltext": "276\\nINFLAMMA TIONS.\\nFig. 48.\\non-\\nline of the hairs upon the brow and bearded region (sides of the nose,\\ncheeks, temples). It is likewise true that after exposure of these parts\\nto abundant sunlight, not only when patients are intentionally treated\\nby such exposures of the nude body to light in hospitals and in private\\npractice, but in occupations which necessitate the same, beneficial results\\nare often well marked.\\nLassar 1 succeeded in producing a disease of the skin in rabbits by\\nrubbing into various portions of their bodies scales, blood, and lymph\\nremoved from psoriatic patches\\nof a male patient. The disease\\nthus induced is said to be capable\\nof transmission to other animals.\\nCampana, Tommasoli, and other\\nItalian observers have repeated\\nthese experiments, with the result\\nof reaching the conclusion that\\npsoriasis is produced by a parasite\\nas yet unrecognized.\\nPathology. The observa-\\ntions of Wertheim, Neumann,\\nAuspitz, Kaposi, and Robinson,\\nof New York, are substantially\\nin accord respecting the general\\ncharacter of the changes occur-\\nring in the course of the disease,\\nthough they differ upon the ques-\\ntion whether it depends upon an\\ninflammatory or a purely hyper-\\nplastic process. Both views are\\nprobably correct, the disease being\\nat times unquestionably the result\\nof a circumscribed inflammation,\\nat other times being associated\\nwith a simple overgrowth of the\\nelements of the epidermis, and\\nagain at times with an inflamma-\\ntion which the hyperplasia has\\nawakened. There is always abun-\\ndant development of epithelia in\\nthe rete, and, in recently formed\\npatches, distention of blood- and lymph-vessels in the papillary layer\\nof the corium beneath. In older plaques the rete either dips down-\\nward to an unusual extent between the papillae, or the latter push\\nupward in the manner of wart-like prolongations. Both hypertrophies\\nconcur. The corium is thickened later by an increase of its elements\\nwhich may involve its entire width as far as the connective tissue. In\\nthe older plaques, also, the connective-tissue elements are often sepa-\\nrated by a slight serous infiltration. Hyper-pigmentation is also noted.\\nThe external root-sheath of the hairs in direct connection with the rete\\n1 Deutsch. med, Zeitg., 1885, No. 93-\\nf-\\nVertical section from an old patch of psoriasis.\\na, hypertrophied horny layer; b, remnants of\\nnuclei c, stratum lucidum d, granular layer\\ne, hypertrophied rete dilated vessels and in-\\nfiltration in corium. (After Leloib and Vidal.)", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0292.jp2"}, "293": {"fulltext": "PSOBIASIS. 277\\nparticipates in the same process, thus explaining the defluvium capillitii\\nof certain cases, and the resulting transient or permanent baldness. The\\nsebaceous glands are secondarily involved in the scalp only.\\nMunro 1 studied 1500 sections cut from six lesions in the earliest\\nperiod of development. He states that the primary lesion in every\\ninstance is a collection of from ten to twenty or more leucocytes in the\\nhorny layer near the surface. Hyperplasia of the horny layer beneath\\nthe miliary abscess follows and pushes the latter toward the surface.\\nOther minute abscesses form in the vicinity and are in turn pushed out\\nto the surface. The scales of psoriasis are thus formed of a series\\nof horny plates, between which are layers of dried fragments of leuco-\\ncytes. In this early period no changes can be found in the corium\\nor deeper layers of the epidermis. Though the abscesses aud\\ntheir location suggest the presence of micro-organisms, none has been\\ndemonstrated.\\nUnna s conclusions respecting the pathology of psoriasis strongly\\nsuggest that in his view the disease is parasitic in origin, and that the\\nmorococcus which he has striven to demonstrate as the efficient cause\\nof eczema is also here effective. There is no evidence, however, that\\npsoriasis has ever been induced artificially by the transference of these\\ncocci to sound from morbid skins. He points out that the readily\\ninduced bleeding from the scraped psoriasis-patch results from the near-\\nness of the head of the papilla to the surface and the thinness of the\\noverlying rete and shows that the vessels about the patch ascending\\nobliquely are usually increased in length and thickness. The enlarge-\\nment of the papillae he believes to be rather a deformity than an increase\\nin volume the result in part of a cellular multiplication and in part of a\\nnot inconsiderable oedema. But little light is thrown on the essential\\ncharacter of the psoriatic process by these observers.\\nLang, 2 of Innsbruck, attracted notice by his alleged discovery of\\ncertain fungous elements in psoriasis that he claims to be the cause of\\nthe disease. These fungi he finds in the whitish pellicle beneath the\\nsuperficial squamous layer, to which Bulkley had already called atten-\\ntion. After stripping the pellicle or a part of it from the surface, and\\nsubjecting it to the action of a 5 per cent, solution of caustic potash,\\nthe epithelium appears translucent, and upon and beneath the epithe-\\nlium double-contoured and highly refractive spores become visible.\\nLang considers this fungus to be of the lowest species, different from\\nany previously recognized upon the skin, and he terms it epidermo-\\nphyton.\\nWeyl, who believes that psoriasis is due to an inherited weakness\\nof the nervous centres, has seen Lang s brood-cells, and he regards\\nthem as myelin-like exudations but this position is disputed by\\nboth Wolff 3 and Eklund, 4 who confirm Lang s observations and who\\nbelieve the disease to be of parasitic origin. They explain the artificial\\nproduction of psoriatic patches in the psoriatic skin by supposing\\n1 Annal. de Derm, et de Syph., 1898, p. 961, and Brit. Jour, of Derm., 1900, p. 63.\\n2 Vierteljahr. f. Derm. u. Syph., 1878.\\n3 Ibid., 1884.\\n4 Annal. de Derm, et de Syph., 1885.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0293.jp2"}, "294": {"fulltext": "278 INFLAMMATIONS.\\nspores to have been deposited beneath the skin, and not previously\\nawakened to activity in the sites of such experiments.\\nDiagnosis o The recognition of a pronounced case of psoriasis is\\nmade with ease, and often by those unskilled in cutaneous disease.\\nAs usual, it is the atypical form of the eruption that awakens doubt.\\nPsoriasis is to be distinguished from\\nEczema. Eczema and psoriasis differ in a striking- manner with\\nrespect to their sites of predilection and their extension from such\\nsites in progressive cases. Eczema, from the head to the toes, elects\\nthe anterior surface of the body, the neighborhood of the mucous out-\\nlets, the flexor faces of the joints and limbs, the crevices, folds, pockets,\\ndepressions, and protected angles of the skin. Psoriasis elects the\\nposterior surfaces of the body, avoids the vicinity of the mucous out-\\nlets, spreads abundantly over the extensor aspect of the joints and\\nextremities, and enjoys the regions of pressure and friction, as the\\nskin over the patella and the olecranon process of the ulna. Psoriasis,\\ncovering the vertex and scalp, lingers at the brow, where its scaly\\nthatch stretches from side to side close to the line of the hairs, and\\ncreeps more indistinctly down the face on either side in front of the\\near, reluctant to spread over the cheeks, nose, and lips. Eczema\\neasily escapes from the scalp to the nose, lips, or chin, or lurks in the\\nfolds of the pinna of the ear. Psoriasis will cover the back and reach\\nforward in front by almost symmetrically disposed parallels in the\\ndirection of the ribs, while eczema sweeps between and beneath the\\nbreasts or around the nipple. As before stated, the largest patch of\\npsoriasis on the body will often be discovered over the sacrum, while\\neczema creeps upward with a diminishing vigor from the anus between\\nthe clefts of the nates. Psoriasis often spares the hands and the feet,\\nwhich eczema punishes.\\nIn individual patches eczema will be recognized by its severe itch-\\ning by the scratching it excites by the history of moisture, dis-\\ncharge, and crusting by its ill-defined outline by its asymmetrical\\ndisposition, except upon the similarly irritated hands and feet and by\\nthe fewer, more yellowish, smaller, and less lustrous scales which char-\\nacterize its squamous varieties.\\nFavus of the scalp might be mistaken for psoriasis of the same re-\\ngion, but the occurrence of sulphur-colored, cup-shaped crusts, the\\nexistence of the parasite, the lustreless and brittle condition of the\\nhairs, and a possible history of contagion will insure identification of\\nfavus. In psoriasis, too, the hairs are usually firmly attached in their\\nfollicles, while they are loosened in favus.\\nLichen Ruber Acuminatus, though a much rarer disease than\\npsoriasis, must in cases be carefully recognized as distinct from the\\nlatter. In lichen ruber the lesions are papular, discrete, and are covered\\nby a few scales, these being yellowish in color and never lustrous.\\nThere is generally a constitutional impairment of health, and, when the\\nwhole epidermis begins to break up in scales, a condition of well-\\nmarked marasmus. When scratched, the patches of the disease do not\\nbleed. Finally, lichen ruber tends to a fatal termination.\\nLichen Planus. In this disorder the scales are at the outset attached", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0294.jp2"}, "295": {"fulltext": "PSORIASIS. 279\\nto the apices of minute polygonal papules, which are situated on the\\nflexor rather than on the extensor aspects of the extremities, on which\\npsoriasis is more abundant. The patches in well-marked cases of\\nlichen planus have a characteristic crimson-red or a purplish hue\\nrarely lacking, and never perfectly seen in psoriasis. The scales,\\nfurther, of lichen planus are of a characteristic silvery whiteness,\\nwhich is never perfectly seen in psoriasis, though imitated by the yel-\\nlowish-white or pearl-white hues of the latter. Lichen planus rarely\\nappears in oval or roundish patches, but is peculiar among all derma-\\ntoses in its angular, linear, and even stellate arrangements.\\nLupus Erythematosus. In any doubtful case in which cicatricial\\ntissue is discovered in the site of a patch on which the disease has\\nexisted the diagnosis is clear, since psoriasis never leaves a scar.\\nLupus prefers the nose, the cheeks, and other parts of the face com-\\nmonly spared by psoriasis unless the eruption be very abundant else-\\nwhere. The scales of lupus are scanty, firmly adherent, yellowish, and\\nattached to the orifices of the ducts of the sebaceous follicles those of\\npsoriasis are abundant, lustrous, and shed freely from the surface.\\nLupus is never, like psoriasis, a generalized eruption and is always\\nmuch more chronic in course. There is a bluish and violaceous tint\\nto the reddish patch of lupus erythematosus, especially when it occurs\\nupon the face, while the highly colored patches of psoriasis are rarely\\nfacial, being more commonly seen on the trunk and extremities, and\\nthe outcropping disks on the face are the least colored of any on the\\nbody.\\nPityriasis Rosea. In this disease the patches are more oval than\\ncircular and the scales are much finer than those in psoriasis pityriasis\\nrosea is, moreover, much more rapid in its career and does not recur.\\nWhen the branny scales are removed the surface beneath does not bleed.\\nThe centre of the patch is usually tawny or salmon-colored. The\\nthoracic surface also may be exclusively involved.\\nPityriasis Rubra. If psoriasis be in any case universal, its dis-\\ntinction from pityriasis rubra would be difficult, if not impossible, on\\nthe basis of our present knowledge. Indeed, any such distinction\\nwould have but little practical value. A few typical isolated patches\\nof a psoriatic character would point to the origin of the disease in any\\ndoubtful case.\\nIn Pityriasis Rubra Pilaris the patches, when such are formed, are\\nrarely circular. More commonly they are widely diffused, irregularly\\noutlined areas covered, not with large scales, but with fine, dry, bran-\\nlike concretions not freely shed because more or less firmly attached to\\nthe underlying surface. Over the scalp the exuvium may exhibit a\\nmoderate degree of greasiness, never the lime-like scales heaped high\\nin typical psoriatic patches of this region. The occurrence of pityri-\\nasis rubra pilaris with intense brownish tint over the tip of the nose\\nand, with pathognomonic symptoms, on the dorsum of the manual\\ndigital phalanges, and the waxy lustre of some of the patches, are\\nimportant features. In the affection last named there is often a long\\nline of demarcation to be recognized, as, for example, along a thigh or\\nover a shoulder, defining the limits on the one side of the widely dif-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0295.jp2"}, "296": {"fulltext": "280 INFLAMMATIONS.\\nfused area of scaliness and on the other of a sound integument. This\\nis rare in psoriasis.\\nSeborrhoea. This disease could only be confounded with psoriasis\\nof the scalp; but the last-named- affection is, in the vast majority of\\ncases, exhibited also in patches upon other portions of the body on\\nwhich seborrhoea is never seen. Seborrhoea of the scalp also occurs in\\nusually diffuse forms, the surface beneath the crusts being rather\\nanaemic and pallid in appearance, not bleeding readily, as in psoriasis.\\nThe crusts, too, in seborrhoea, are distinctly fatty and greasy when\\nrolled between the fingers, and have a dirty-yellowish hue, rarely\\nrecognized in the whitish scales of psoriasis. In psoriasis the hairs are\\nnot progressively loosened and gradually thinned as in seborrhoea.\\nLastly, seborrhceic crusts may fringe slightly the line of the hairs at\\nthe brow, but they rarely form a band an inch or more in width, like\\na frontlet covering the upper half of the forehead, a not uncommon\\ndevelopment in psoriasis.\\nSyphilis. Psoriasis in many cases greatly resembles the squamous\\nand papulo-squamous syphilides. The necessity for a clear recognition\\nof either disease occurring in suggestive patches is often of the highest\\nimportance.\\nIn syphilis the greatest aid will be obtained by a history in both\\nsexes, of infection, adenopathy, and mucous patches; and in women\\nof abortions, miscarriages, or stillbirths. Psoriasis is a singularly uni-\\nform disease; syphilis is decidedly multiform in its manifestations.\\nSyphilitic patches are less symmetrical, more elevated at the edge, and\\nthe scales with which they are covered are fewer, smaller, and dirty\\nwhitish rather than lustrous in color. Their circular outline is often\\nabruptly broken by gaps, with the result of producing semilunar and\\nsmall arc-shaped segments. In syphilis the eruption is less generalized,\\nand shares with other syphilodermata the brownish and purplish hues\\nof the skin beneath, lacking the vivid redness and pinkish red of many\\nnon-syphilitic lesions. The scales of many of the syphilides which\\nresemble psoriasis partake of the character of crusts, being agglutinated\\nby pathological exudations from the patch; they are rarely so exclu-\\nsively squamous as in psoriasis. In syphilis the tendency of the patch\\nis to exhibit an affected surface somewhat beyond the line of the scales\\nin psoriasis the scales more frequently reach beyond the border of\\nthe affected epidermis beneath. The squamous syphiloderm of the\\npalms and soles often occurs only in these localities. Psoriasis is\\nextremely rare in such situations, and is not limited to these regions\\nexclusively. A psoriasiform circlet limited to the region of the mouth,\\nnose, or chin will generally prove to be syphilitic. The disease which\\nhas for a long time persisted in the production of squamous patches can\\ngenerally be demonstrated to be psoriasis, as syphilis changes its type\\nin the course of months.\\nTinea Circinata. In tinea circinata the discovery of the parasite, a\\nhistory of contagion, and the frequent limitation of the disease to a\\nsingle patch (a feature exceedingly rare in psoriasis) will usually suffice\\nto establish a diagnosis. In ringworm of the body the scales are bran-\\nlike, and are more abundantly formed at the margin of the patch", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0296.jp2"}, "297": {"fulltext": "PSORIASIS. 281\\nwhere the fungus is luxuriant; while in psoriasis the scaliness is\\nusually equally pronounced over the entire area of an invaded patch,\\nunless the disease is in process of involution. The occasional occur-\\nrence of vesicles and vesico-papules at the peripheral border of the\\npatch in ringworm is never observed in psoriasis. Ringworm is never\\ngeneralized symmetrically and upon the scalp or beard the discovery\\nof brittle and broken-off hairs should always suggest examination for\\nthe parasite.\\nTreatment.\u00e2\u0080\u0094 Treatment for relief of psoriasis must necessarily be\\nlimited to removal of its objective features. This treatment may be\\ninternal, with a view to the indirect action of the drug selected upon\\nthe skin or topical, with a view merely to the reproduction of a sound\\nepidermis in the patches of disease.\\nInternal Treatment. Arsenic enjoys the highest rank in the internal\\ntreatment of psoriasis. What it is capable of accomplishing in other\\ncases it can with best effect accomplish here. Whatever failures must\\nbe charged to its account in the attempt to relieve other cutaneous\\neruptions cannot safely be ignored in psoriasis. Arsenic administered\\ninternally is assuredly capable of relieving a certain number of cases\\nof psoriasis. Given improperly in any case, it may be either powerless\\nor manifestly be injurious. In a definite proportion of patients, most\\ncarefully selected as fit subjects for its therapeutic action, arsenic will\\nprove utterly valueless in the most skilled hands. It cannot be demon-\\nstrated to possess the power to prevent recurrences of psoriasis, yet\\nthe latter must be recognized as a disease exceedingly liable to recur.\\nUnfortunately, the proportion of cases in which arsenic will and in\\nwhich it will not exhibit its happiest effects is not known.\\nThe following rules for the administration of arsenic are in general\\nto be observed It should be given with or immediately after the in-\\ngestion of food, so that it may be commingled with edible substances\\nin the stomach. It should be given at first in small doses which are\\nto be cautiously increased. The possibility of the production of toxic\\neffects should be remembered, and on their appearance the remedy is to\\nbe given in a smaller dose, and not completely discontinued unless\\nsuch a course be imperative. If its administration be once determined\\nupon, the arsenic should not hastily be withdrawn and another remedy\\nsubstituted, but persistence for months should be enforced if no serious\\nobjection exist, lest the time be wasted which has been already ex-\\npended in the effort to relieve the disease.\\nArsenic is unsuited for all cases of psoriasis occurring with rather\\nacute symptoms, such as subjective sensations and unusually vivid\\nredness of the patches. It should not be given when the disease is\\nin process of evolution, and, therefore, not in psoriasis punctata and\\nguttata, unless the lesions have long been limited to patches of the\\nsizes to which these names are given. For the same reasons it is often\\nobjectionable in the psoriasis of the young, for, though the drug is\\nusually rather well tolerated in early periods of life, it is, unfortu-\\nnately, in the young in whom the disease is also most often encountered\\nin its progressive stages.\\nThe remedial effect of arsenic, when that is obtained, seems to de-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0297.jp2"}, "298": {"fulltext": "282 INFLAMMATIONS.\\npend upon the impression it exerts upon the rete, especially that part\\nof it which lies in connection with the derma. When the metal is\\ninjected subcutaneously its first effects, according to Jamieson and\\nJNunn, 1 are indicated by the appearance of a faint, narrow band along\\nthe base of the columnar epithelia immediately next the corium. This\\nband is due to a softening of the protoplasm which separates the epi-\\ndermal from the dermal elements. Subsequently the remoter epithelia\\nare involved, the protoplasmic threads becoming obscure, the charac-\\nteristic arrangement of the epithelia becoming less evident, and the\\nnatural features of the rete distorted, so that it remains attached to the\\nderma by tags and by the prolongations which it sends down to the\\ncutaneous glands. Jamieson suggests that arsenic stimulates the\\nepithelia to exhaustion, the layer which lies next the blood-vessels con-\\ntaining the metal first appreciating its effects.\\nThe preparation usually employed is Fowler s solution, the exhibi-\\ntion of which should always be begun in doses of from minim (0.033)\\nto 3 minims (0.20), this amount to be contained in a solution of fixed\\nand relatively large dose, such as a teaspoonful of infusion of pepper-\\nmint, wine of iron, dilute syrup of gentian or of orange-blossoms, or\\ncompound tincture of cardamom with water. When only remedial ef-\\nfects are obtained, such as diminution of the scaliness, the dose may\\nsteadily be continued without change for long periods of time, and\\nusually with advantage for some time after the symptoms of the disease\\nhave entirely disappeared. When, without the production of toxic\\neffects the eruption seems unaffected by treatment, the arsenic may\\ncautiously, and always under the direction of the physician only, be\\npushed until 20 and even 30 drops of Fowler s solution (the latter\\nequivalent to grain (0.022) of arsenic) are administered at a dose.\\nThe constitution of the Asiatic pill is given in the chapter on\\nGeneral Therapeutics. This pill is less likely to be as well tolerated\\nby the stomach as Fowler s solution, but cases are on record in which\\nthe psoriasis which proved rebellious under the administration of\\nliquor arsenicalis, Donovan s solution, and other internal remedies,\\nyielded to the solution of arsenious acid in pilular form. Hebra gave\\ntwo thousand Asiatic pills to a single patient before the disease disap-\\npeared and in no instance were ill-effects produced.\\nWith regard to the vulgar opinion respecting the arsenic-habit,\\nwhich a long experience with this dosage has been supposed to beget,\\none never encounters such an instance in a psoriatic subject consuming\\narsenic. Patients who for several consecutive years have, without inter-\\nruption, pursued an arsenical course, thus barely succeeding in keeping\\ntheir cutaneous ailment out of sight, will in many cases affirm that,\\napart from any trifling and accidental toxic symptoms and those evi-\\ndent in the course of the eruption, they would not be sensible of the\\nfact that they had taken the drug.\\nWith an enlarging experience, one views with greater distrust each\\nyear the benefits to be derived from arsenic in any untried case of\\npsoriasis. The great possibilities of its failure, of the repeated recur-\\nrence of the eruption, of the necessity of continuing the medication\\n1 The Histology of Psoriasis, Edinburgh Med. Jour., January, 1879, p. 627.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0298.jp2"}, "299": {"fulltext": "PSORIASIS. 283\\nfor one or two years, and, after that period of time, of witnessing a\\ngeneralized development of the disease to an extent quite equal to that\\nexhibited at the outset all these considerations have weight in the\\nmind of an ordinarily prudent man. Yet, in a minority of cases in\\nwhich, under a judiciously directed arsenical course, the eruption slowly\\ndisappears and fails to recur, the value of the treatment is incontestable.\\nInstead of resorting first to the arsenical dose and afterward to\\nother measures, the order should be reversed. That case of psoriasis\\nwhich fails to respond to other treatment may finally be subjected to\\nthe influence of arsenic. He who, having vainly tried other approved\\nmeasures, essays at last the virtues of this medicament, ought to be\\npatient while testing his case with it. He should be willing to try it\\nfully and fairly, and of all men be least ready to exchange it for a less\\nvaluable substitute. No reference is here made to the effect of con-\\njoined internal medication with arsenic and external treatment by\\ntopical applications. However desirable it may be in the management\\nof any individual case to arrive at the desired end by the speediest\\nmethod, it is evidently needful, in order to assign to arsenic its exact\\ntherapeutic value, to understand w T hat arsenic can accomplish unaided\\nby topical measures.\\nSatisfactory results often follow the internal administration of mer-\\ncurous iodide in grain (0.013) doses after meals. The remedy is\\ngiven, not in cases in which a syphilitic taint is suspected (for psoriasis\\nis not a manifestation of syphilis), but as an alterative. It is believed\\nto be effective in consequence of its special effect on the liver. In\\nsome patients it seems to have little value.\\nCrocker has lately advised the use of sodium salicylate and salicin\\nin all forms of psoriasis, but especially during periods of active devel-\\nopment of the disease, when arsenic usually does harm. Haslund\\nrecommends potassium iodide, increased from the smaller to the largest\\ntolerated doses. As many as six hundred grains of the iodide have\\nbeen administered by this method per diem; it is of occasional service.\\nThe wine of antimony in 5 to 10 minim doses; chrysarobin, grain\\n(0.01) rubbed up with sugar of milk, three times daily; potassium bro-\\nmide and sodium iodide have also been administered with reported\\nsuccess.\\nSodium arseniate in pill-form and ferrous arseniate have been recom-\\nmended by Biell. Lipp injected arsenious acid subcutaneously. Rob-\\ninson advises liquor potassse, potassium citrate or acetate, or sodium\\nbicarbonate in plethoric and rheumatic patients. In the gouty state\\nwith excess of urates in the urine he advises\\nR Potass, acetat., j 30\\nSpts. aether, nit., f^ss; 15\\nVin. colchici, f^ij; 8\\nSyr. aurantii, f 5jss 45 M.\\nSig. A dessertspoonful three times daily in water after meals.\\nAs to the other remedies employed internally for the relief of the\\nmalady, a very fair estimate of their value can be made by remember-\\ning that arsenic is superior to them all. Phosphorus, tar, copaiba, can-\\ntharides, colchicum, and pilocarpine have at times a feeble transitory", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0299.jp2"}, "300": {"fulltext": "284 INFLAMMATIONS.\\ninfluence over the patches of the eruption, but their employment will\\ndisappoint far more often than satisfy. Iron, quinine, cod-liver oil, and\\nthe salts of the alkalies will meet important indications in the treatment\\nof certain classes of patients, but the eruption is often seen in perfectly\\nvigorous and otherwise healthy subjects. The treatment of psoriasis\\nby the administration of extract of the thyroid gland is practically\\nabandoned as fruitless of desirable results.\\nAfter the use of any one of these remedies it is rare to recognize\\nany decided effect upon the cutaneous symptoms, even when patients\\nin whose case they were indicated improve under their use, though the\\nreverse may be true.\\nThe diet suitable for a patient may in brief be described as that\\nwhich is indicated by his or her general condition. Most authors\\nagree upon the value of a greatly restricted diet. Acids, alcohol, and\\nfatty substances should be excluded. Meat should sparingly be sup-\\nplied; cooked vegetables and fruits may freely be eaten. Coffee, tea,\\nand tobacco should in general be interdicted. Passavant, of Frank-\\nfort, on the contrary, claims to have cured himself and others by an\\nexclusive diet of meat.\\nExternal Treatment. The influence of climate in inveterate psoriasis\\nshould never be ignored. Many patients who suffer from repeated re-\\nlapses of the disease are worse in winter, and are either better or entirely\\nfree from the eruption in summer. In mild climates in which the tem-\\nperature is uniformly registered at or near a point of maximum comfort\\nfor the skin this disease is both infrequent and less severe. Given an\\nequable climate many patients obtain prompt relief at the seashore,\\nwhile others improve rapidly under the influence of the dry atmosphere\\nof higher altitudes.\\nThe local treatment of psoriasis requires patience, care, and a cer-\\ntain degree of skill. Properly conducted, its results are reasonably\\nsatisfactory in a large majority of cases. The first indication to be\\nmet is the complete removal of the epidermic scales from the patches,\\nwhich removal is accomplished in various ways. It is preferable\\nto secure first their maceration in some fatty substance, such as one\\nof the oils, or glycerin, or vaselin, after which the scales may be\\nwashed off with the aid of soap and water, the patient being given\\na general bath if the eruption be extensive. If it be localized, these\\noily or fatty substances may be spread upon pieces of lint or cotton,\\nand thus be retained in contact with the skin by a bandage. The\\nscales may also be removed rapidly with a dermal curette, if they\\noccur in few patches, or if the patches are to be found in totality\\nor in part upon some portion of the body in which the disfigurement\\ndemands special attention, as upon the forehead and the cheeks. The\\nsquamous masses are also removable with water alone, as after maceration\\nof the skin in a bath, or after a profuse diaphoresis, or even after mod-\\nerate exudation of sweat, if evaporation of the latter be prevented by\\ncovering the affected part with oiled silk or with rubber cloth. Usually\\nthere is no difficulty in removing these scales, patients often declaring\\nthat they can themselves cleanse the surface. They ask to be shown\\nhow to prevent the recurrence of the desquamation.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0300.jp2"}, "301": {"fulltext": "PSOBIASIS. 285\\nBaths play an important part in the subsequent treatment of the\\ndisease. They may be employed, as by Hebra, so that the patient\\nremains in the water for from four to eight hours in the day or be\\nmedicated by the addition of sulphur, tar, or other substances, so as to\\ncombine a medicative with a macerative effect. In private practice\\nthese baths are much less available than in hospitals. When the erup-\\ntion is generalized and an excessive macerative effect is desired an\\nundershirt and drawers, made of soft rubber cloth, may be worn by the\\npatient for several hours of the day. The sweating is often profuse,\\nand is debilitating to such an extent that the psoriatic skin will rarely\\ntolerate the treatment for an entire day, or even for that part of the\\nday in which active labor is performed. By this sweating alone it\\nwill at times be found possible to secure complete disappearance of the\\npatches.\\nIn other more obstinate cases, or in those in which for any reason\\nvigorous treatment is indicated, as upon the scalp and face, sapo viridis\\nmay be employed with advantage in the soap-and-water treatment.\\nThe spiritus saponis kalinus, 2 ounces (60.) of the soap to 1 ounce (30.)\\nof alcohol, may be briskly rubbed over the patches with the aid of a\\npiece of flannel or a sponge, and then immediately be washed off with\\nthe oil and scales in a surplus of hot water, or be left for a time in\\ncontact with the part. Hebra and Kaposi employ a species of soap-\\npaste, made by rubbing into each patch a small quantity of green soap\\nto which a little water is added until the proper consistency is obtained.\\nThese inunctions are repeated twice daily for six days. The epidermis\\nbecomes brownish-colored, and in three or four days afterward it exfo-\\nliates in lamella3 then a general bath cleanses the surface. In the\\nFrench hospitals a somewhat speedier method is pursued. On the\\nevening of the first day the patient is anointed with green soap, which\\nis retained upon the skin during the night. In the morning he takes\\nan alkaline bath, and immediately after is thoroughly anointed with\\nlard. This course is repeated on the second and third days, after which\\nthe patient is usually ready for topical medication of the diseased parts.\\nFor the more obstinate cases in which exfoliation of the epider-\\nmis is not readily induced more energetic measures have been adopted,\\nsuch as the local use of salicylic acid in alcohol, 1 drachm (4.) to 4 ounces\\n(120.), caustic acid and alkalies, scrubbing the patches with nail-brushes,\\nfloor-brushes, etc., and the use of clean white sand.\\nOnce ready for topical medication, the patches may be subjected to\\nthe local action of the remedy selected for the relief of the disease.\\nSalicylic acid, in paste, ointment, or plaster, in strengths varying from\\n2 to 15 per cent., is often effective. For the face, scalp, and hands\\nthere is no better remedy in the majority of cases than ammoniated\\nmercury in 2 to 20 per cent, ointment or paste. This remedy is cleanly\\nand usually causes the lesions to disappear but it cannot be used over\\nlarge areas without danger of absorption and constitutional symptoms.\\nA remedy of great value in the treatment of psoriasis is chrysarobin\\n(or chrysophanic acid). This is a crystalline powder of the color of old\\ngold, insoluble in water, but is readily dissolved in hot alcohol, acetic\\nacid, benzol, vaselin, and hot fat. It is derived from the Goa powder", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0301.jp2"}, "302": {"fulltext": "286 INFLAMMATIONS.\\nof the East Indies, or the araroba powder of Brazil, the employment\\nof which in psoriasis was first recommended in 1878 by Squire, of Lon-\\ndon. The drug may be applied in strengths varying from 10 to 40\\ngrains (0.66 to 2.66) to the ounce (30.) of ointment, paste, plaster, col-\\nlodion, or liquid gutta-percha. It is occasionally used in lesser and\\ngreater strength, but with pure specimens it is liable in larger propor-\\ntions to produce disagreeable effects. These effects are -declared in a\\nhot, itching, swollen, irritable, and erythematous or darkly stained skin,\\nstretching with tolerable uniformity in every direction from the surface\\nof application. Even in the strength named above it is necessary to\\nbegin its use with caution, testing it by application first to a limited area\\nof integument. These excessive effects usually subside in a few days.\\nWhen the drug produces its most brilliant effects the psoriatic patch,\\npreviously denuded of its scales, assumes a whitish and normal aspect,\\ncontrasting thus somewhat remarkably with the chocolate or brownish-\\nblack discoloration of the stained skin at the periphery. This discolora-\\ntion, when produced either by the ointment directly or by a frequent\\ntransfer of its ingredients to other parts by the medium of the clothing\\nand the hands, involves also the nails, the hairs, and the underlinen of\\nthe psoriatic patient. Its employment upon the face and the scalp is\\nthus largely interdicted. The staining of the skin and its appendages\\ndisappears entirely in time, but always slowly.\\nFox, 1 of New York, employs a soft paste, made by rubbing chry-\\nsarobin with a sufficient quantity of water, which is smeared upon the\\npsoriatic patches, the scales of which have previously been removed\\nby one or more hot baths, with soap friction. As soon as the paste\\nhas dried, which it does in one or two minutes, a layer of collodion\\nis allowed to flow over each patch, and to harden into a protective\\ncoating. This coating will remain in place for several days or longer,\\naccording to the location of the patches when it falls or is washed off,\\nthe application of the powder and the collodion should be repeated.\\nBy this procedure the chrysarobin in full strength is kept in contact\\nwith the affected skin, and is prevented from exciting undue inflamma-\\ntion of surrounding parts or from staining the clothing. A mixture\\nof the powder and the collodion may be used, but it is less efficacious.\\nA film of collodion doubtless interferes with the action of the acid\\nupon the skin. A somewhat similar plan consists in the use of gutta-\\npercha tissue to retain a strong chrysarobin ointment in contact with\\npsoriatic patches. The edges of this tissue will adhere tightly to the\\nskin if a small camePs-hair brush, dipped in chloroform, be passed\\nrapidly beneath them. Following Auspitz s plan, Fox has added 10\\nparts of chrysarobin and 10 of salicylic acid to 15 of sulphuric ether\\nand 100 of flexile collodion. This mixture rapidly dries over the\\npsoriatic patch, on which its specific effects are produced.\\nTar is among the most valuable remedies in the local treatment of\\npsoriasis. It will, however, accomplish the result desired only when so\\napplied that it is well tolerated by the skin. In very young patients, as\\nalso in those whose skins are tender and irritable, or those suffering\\nfrom any of the acute phases of the disease, it may prove decidedly\\n1 Med. News, March 18, 1882, p. 289.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0302.jp2"}, "303": {"fulltext": "PSORIASIS. 287\\ninjurious. The rule should be always to employ it at first tentatively\\nover a relatively small portion of the affected surface, upon which the\\nmedicament should remain for several hours, as tar will not in all cases\\npromptly produce its injurious effects. These effects are, subjectively,\\na sense of heat and pain; and, objectively, heat to the touch, redness,\\nand tumefaction. Often black puncta are visible when the tar is lodged\\nin the orifices of the cutaneous follicles, simulating thus the black\\nhead of the comedo, a condition termed by Hebra tar-acne.\\nPix liquida, oil of cade, or preferably oleum rusci may be employed\\nin the form of a salve, 1 drachm (4.) of either to the ounce (30.) of\\nlard or other fatty basis (lanolin, vaselin, etc.). A thin stratum of this\\nointment several times in the day or merely at night may be painted\\nover or well rubbed into a patch denuded of scales. In Vienna a still\\nmore energetic effect is secured by using soft soap freely over the\\npatches while the patient is in the bath, then anointing him with tar,\\nand finally returning him to the bath, in which he remains for from\\nfour to six hours. For localized eruptions, green soap in combination\\nwith tar and alcohol serves a useful purpose, either in the proportion\\nof equal parts of the three ingredients, or by combining them in other\\nproportions, as, for example\\nB Saponis viridis, ^iv 120\\n01. rusci, __ _.\\nGlycerin, J aa 30\\n01. rosmarin., 3jss 6\\nSpts. vin. rectif, Oss 240\\nSig. For external use.\\nM.\\nOther combinations of service are the liquor picis alkalinus, the\\nformula for which is given in the chapter on Eczema or Wilkinson s\\nsalve, as modified by Hebra, the latter combining the remedial effects\\nof sulphur, tar, and soap, as follows\\nR\\nSulphur, sublimat,\\n01. rusci [crud. vel. rectif.], j\\naa \u00c2\u00a7ss;\\n15\\nSaponis viridis,\\nAdipis, j\\naa Sj\\n30\\nCret. prseparat.,\\nBijss\\n3\\nSig.\\nWilkinson s salve, modified.\\n5 M.\\nWhere the sensitiveness of the skin to the action of tar has not\\nbeen tested, or when the skin is particularly tender, a small quantity\\nof the Wilkinson salve may be added to any simple ointment, or Spen-\\nder s ointment of tar (see the chapter on General Therapeutics) may\\nbe substituted afterward 1 drachm (4.) of the oil of tar, or of oleum\\nrusci, to the ounce (30.) of oil of almonds or of alcohol, may be\\nemployed.\\nj When toleration is established the tar may be rubbed over the\\npatches in a pure state with a stiff brush, a procedure preferred in\\nsome parts of Germany, after which the patient either remains for\\nsome hours in bed, or is powdered with soapstone and bandaged with\\njflannel, so that when the clothing is replaced it may not adhere to the", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0303.jp2"}, "304": {"fulltext": "288 INFLAMMATIONS.\\ntar. Naphtalin, ichthyol, and carbolic acid operate in psoriasis in the\\nsame way as the tars, but are decidedly inferior to tar.\\nAbsorption of any tarry compound applied externally may result in\\ngeneral toxic symptoms, including fever, vomiting, diarrhoea, stran-\\ngury, the elimination of the toxic agent in secretions which are\\nblackened by its presence. These symptoms are usually relieved in\\nfrom twenty-four to forty-eight hours after discontinuance of the\\ndrug.\\nPyrogallol, first suggested as a remedy for psoriasis by Jarisch, is\\ninferior to chrysarobin. The fact that several deaths have been reported\\nas consequent upon the use of this acid deters many from making trial\\nof it in a painless and merely disfiguring disease. It is used in a 10\\nper cent, vaselin ointment, is effective though less rapid in effect than\\nchrysarobin, is cheaper, is odorless and painless, and it discolors to a\\nless extent the sound skin. Both remedies are capable of being\\nabsorbed from the skin-surface, and of producing constitutional symp-\\ntoms (pyrexia, strangury, and blackish evacuations) but in the case\\nof pyrogallic acid only have fatal results followed.\\nKaposi l was the first to employ beta-naphtol (the formula being\\nC 10 H 8 O) in psoriasis, as also in eczema. It may be applied in alcoholic\\nsolution. Following the employment of a 15 per cent, ointment the\\nauthor reported speedy disappearance of psoriatic patches. It did not\\nstain the skin, hair, or nails.\\nCrocker, of London, similarly uses thymol in ointment, scruple to\\ndrachm (0.66-2.) to the ounce (30.) and Williamson advises tur-\\npentine, 2 drachms (8.) to the ounce (30.) of olive-oil, with the odor\\ncorrected by the oil of lemon.\\nThe nitrate, as well as the iodides and oxides, of mercury is applied\\nby many practitioners in the form of ointment to patches of psoriasis\\nusually few in number and limited in extent. The action of these\\nagents, however, is inferior to that of those already named and the\\nrange of their availability being limited, they should be esteemed lightly\\nin the topical treatment of the disease. Other articles more recently\\nvaunted in the external treatment of psoriasis are thilanin, which\\nseems to possess some value hydracetin cacodylic acid rufigallic\\nacid, 10 per cent, in unguent form cupric oleate anthrarobin and\\ngallacetophenol, 5 to 10 per cent, in salve or in traumaticin.\\nWhen practicable, the skin affected with psoriasis should be exposed\\nto the direct action of sunlight in a sufficiently warmed apartment. By\\nthis measure alone the skin is often relieved of its eruption.\\nPrognosis. The permanent relief of psoriasis is not insured by any\\ntreatment of a grave case, though hundreds of patients are. permanently\\nrelieved by even the simplest treatment. The disease often recurs, and\\nmay do so repeatedly for the greater part of a lifetime. Permanent\\nrelief, therefore, should never be either predicted or promised in any\\ncase. Once relieved, it should be the aim of the practitioner to guard\\nagainst all possible recurrences. After relief of any obstinate or re-\\ncurrent attack, as also in all inveterate cases, the prognosis is greatly\\nimproved by removal to a climate suitable for the psoriatic patient.\\n1 Wien. med. Woch., May 28, June 4 and 11, 1881.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0304.jp2"}, "305": {"fulltext": "", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0305.jp2"}, "306": {"fulltext": "PLATE IV.\\nPityriasis Rosea.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0306.jp2"}, "307": {"fulltext": "PITYRIASIS ROSEA. 289\\nPITYRIASIS ROSEA.\\n(Pityriasis Maculata et Circinata, Herpes Tonsurans Macu-\\nlosus, Pityriasis Circtnata. Fr., Pityriasis rose de\\nGibert, Pityriasis circine et margin^.)\\nThis disorder has been recognized and described by Gilbert, Bazin,\\nHorand, and Duhring. It is non-contagious and benign in its course,\\nlasting from a few weeks to three months.\\nSymptoms. The subjects are commonly young adults, but the\\ndisease is seen in children and in middle life in both sexes. The out-\\nbreak of the malady may be preceded for a variable time by languor,\\nlassitude, inappetence, or a feeling of chilliness. Occasionally the first\\nnoticeable symptom is the occurrence of mild fever, the body-tempera-\\nture rarely rising above 102\u00c2\u00b0 F.\\nThe eruption often escapes recognition for a time after its appear-\\nance on account of its sparseness or the trifling degree of pruritus it\\narouses. When fully developed it is characterized by the conspicuous\\nappearance over large surfaces of the trunk, especially upon the integu-\\nment covering the clavicles, the ribs, and the scapulae, rarely on the\\nexposed face and hands, of numerous pinhead- to small-coin-sized, cir-\\ncumscribed, roundish or oval-shaped, slightly elevated, macular or\\nmaculo-papular lesions. These lesions may be discrete, closely set\\ntogether, or confluent, and instead of being elevated may be either on\\na level with the general surface or slightly depressed, with an annular\\nborder. They are dry, covered with furfuraceous rather adherent\\nscales, and vary in color from a yellow or tawny shade to a deep red.\\nThe infiltration is slight, and the patch is superficially situated.\\nThe fully formed disks vary in long diameter from the width of a\\nfinger-nail to three or four centimetres. The oval contour is that\\nmore often recognized as characteristic of a well-developed lesion, the\\nlong axis of the disk usually corresponding with the lines of cleavage,\\nand the terminal extremities of the oval slightly frayed by the irregu-\\nlarity with which the fine branny scales are there disposed. A tawny,\\nsalmon-shade is highly characteristic of the disease, the patch slightly\\nenlarging by peripheral extension, and leaving a relatively clear centre.\\nThe scales have often a silvery grayish color. The eruption may be\\ntolerably well generalized, but the face and other exposed parts of the\\nbody usually escape, though the scalp may be involved. In the latter\\nevent the hairs are unaffected.\\nThe variations exhibited by the exanthem in this affection are dis-\\ntinct, but are scarcely ever sufficient to mask the characteristic appear-\\nance of the oval or circular plaques over the neck, the arms, the ab-\\ndomen, or the extremities, sometimes first appearing over the latter\\nand extending thence to the trunk. At times a retiform expression is\\ngiven to the picture by coalescence of the patches. There may be\\nmoderate itching with nocturnal exacerbation, but the usual type of\\nthe disease is mild. Complete involution is usually reached in the\\n1 course of a week or a fortnight.\\nEtiology. The causes of this disease are obscure. According to\\n19", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0307.jp2"}, "308": {"fulltext": "290 INFLAMMATIONS.\\nBazin, it occurs chiefly in lymphatic and scrofulous patients. Most\\ncases occur in patients having light hair and delicate skins, who have\\nbeen enfeebled by great physical fatigue or by overtaxation in school.\\nProfuse perspiration has been assigned as a cause by Horand. Epi-\\ndemics of the disease have been reported. It is possible the disorder\\nis feebly infectious and allied to the exanthemata.\\nPathology. The histopathology of the disease has been studied by\\nUnna and by Hollmann. 1 The changes begin apparently in the papil-\\nlary body and the subpapillary layer of the cutis, and include a dilata-\\ntion of the vessels, perivascular cell-infiltration, and oedema. As the\\ndisorder progresses these changes are more marked, especially the peri-\\nvascular cell-infiltrate. The rete shows decided intracellular and inter-\\ncellular oedema and proliferation of the prickle-cells, especially in the\\ninterpapillary portions. As the disease approaches its acme minute ves-\\nicles, not visible on macroscopic examination, form beneath the horny\\nlayer, which later is exfoliated.\\nDiagnosis. The disease is to be differentiated from ringworm of\\nthe body by the absence of vesicles, the tendency to symmetrical dis-\\ntribution of the lesions, their multiplicity, the characteristic yellowish\\ncentre of the oval rather than circular patch, and the constitutional\\nsymptoms. Psoriasis differs greatly in the color, quantity, and char-\\nacter of the scales present, and in the contour of the patch. In the\\nscaling syphilodermata, the region of the body involved, the presence\\nof plantar and palmar lesions, the constitutional symptoms and history,\\nand the color of the patch, which is usually of a deeper and dirtier red\\nthan in the disease under consideration, will point to the diagnosis.\\nIn the macular syphiloderm syphilitic roseola the closer proximity\\nof the lesions will point at once to the difference, since the patches of\\npityriasis rosea are, as a rule, far more widely separated. The greasi-\\nness of seborrheic scales and the pallid hue of the integument beneath\\nwhen the former are removed differ from the congested skin beneath\\nthe dry scale in this form of pityriasis.\\nThe Treatment is expectant. Quinine, sodic salicylate, and, later,\\nferruginous tonics are indicated in most cases. Locally, tepid bathing\\nin an alkaline or bran-bath is usually grateful. This bath is to be fol-\\nlowed by the application of a dusting-powder.\\nDERMATITIS EXFOLIATIVA.\\nSome confusion, both as to the names of diseases and as to the dis-\\neases themselves, has existed in connection with the subject of all gen-\\neralized exfoliative cutaneous disorders. More investigation is needed\\nbefore definite limits can be established for several of the dermatoses\\nof this class. By some, the term dermatitis exfoliativa is held to\\nbe synonymous with pityriasis rubra. In these pages pityriasis rubra\\nis distinguished as a distinct disease, and dermatitis exfoliativa is made\\nto include the exfoliative and exudative disorders of the skin not prop-\\nerly considered in any other connection.\\nClassing these forms of exfoliative dermatitis together as for the\\n1 Arch. f. Derm. u. Syph., 1900, Band li., Heft 2.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0308.jp2"}, "309": {"fulltext": "DERMATITIS EXFOLIATIVA. 291\\nmost part of acute type, and distinguishing the chronic forms from\\nthe pityriasis rubra of Hebra, it may be said of them all that they\\npresent features of wide diversity. At one time exfoliative dermatitis\\nbegins and ends in a single patient as a well-defined, distinct, and\\nspecific disease with mild symptoms, pursuing a definite career, and of\\nbenign type in another case it occurs as a sudden or a gradual change\\nin a preexisting disorder, such as an eczema or a psoriasis (Gamberini)\\nagain, beginning in one or another of the simpler forms described above,\\nit may become chronic, and in its symptoms and appearance be indis-\\ntinguishable from pityriasis rubra.\\nSymptoms. Exfoliative dermatitis is usually ushered in with mild\\nfebrile symptoms, which are often preceded by malaise, languor, or a\\nvariable period in which the general health has been impaired. Often,\\nhowever, all prodromata are absent.\\nThe eruptive symptoms are a more or less shining and vivid redness\\nof the skin in one or several plaques which become in the course of\\na Aveek the seat of numerous fine bran-like scales. Any region of the\\nbody may be affected, though the articular folds of the skin, the genital\\nregion, the head, and the trunk are most often the seat of the disease,\\nwhich may involve consecutively one part after another until in a week\\nor a fortnight the whole body-surface is invaded. The affection may\\nbe limited to one region, or several distinct regions may simultaneously\\nbe involved, as the head and the lower limbs, or the thorax and the\\nexternal genitals. The hands and the feet are usually the last to be\\ninvaded. The eruption may appear in reddish patches of well-defined\\nor of very indeterminate outline. The skin affected may be slightly or\\napparently not at all infiltrated and raised. The itching may be slight\\nor be severe. The redness displayed in the regions affected with\\nscaling may be of the brightest crimson, erysipelatous, violaceous,\\nor purplish shade, or with a faint suggestion of yellowness. The\\nscales, which are usually formed in abundance, are commonly seen\\nloosely covering the reddish integument upon which they rest, though\\nthey are also shed in profusion when the affected surface is lightly\\nswept Avith the hand. They are always whitish, minute, and bran-\\nlike, neA T er in the so-called pastry-crust condition of the scales in\\npemphigus foliaceus.\\nIn Avell-marked cases the features may be slightly disfigured by\\ntumefaction of the lips, sAvelling of the ears, and puffiness of the eye-\\ndids. In all cases the skin is dry and is rarely moistened with a path-\\nological discharge. The scales are always AAmite, imbricated, and\\ni silvery in hue they are usually larger and coarser upon the lower\\nJ limbs than 0A T er the neck, face, and chest.\\nIn the course of the disorder the hairs may fall, and in some cases\\nBbe resulting alopecia is general. When the nails also are lost there\\njis rarely any special preexisting onychia. The mucous surfaces of the\\neyes, nose, mouth, and throat may participate in the general disorder\\nand become the seat of inflammatory and, in rare cases, even of pseudo-\\nmembranous and exulceratiA T e processes.\\nItching may be absent; when present and severe it is relieA T ed eA r en\\nbefore the complete restoration of the integrity of the skin. The itch-", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0309.jp2"}, "310": {"fulltext": "292 INFLAMMATIONS.\\ning may recur with each relapse, at which time also the fever is usually\\nrelighted.\\nIn most cases the disease is terminated in the course of two or three\\nmonths, after which convalescence from the emaciation and possible\\ncomplications (furunculosis, abscesses, etc.) may require an equal length\\nof time. Pigmentation is always present for some time after recovery.\\nEtiology. The cause of the disease is not known. It is often\\naccompanied or preceded by an acute or chronic toxaemia. Chronic\\nforms of exfoliative dermatitis may follow extensive cases of psoriasis,\\nlichen planus, or pityriasis rubra pilaris.\\nPathology. Brocq 1 has made a study of this disorder, and his\\nresults are in part confirmed by Viclal and Baxter. These observers\\nrecognized an infiltration of the papillary layer of the corium with em-\\nbryonic cells, dilatation of the papillary and subpapillary vessels, hori-\\nzontal flattening of the prickle-cells, disappearance of the stratum\\ngranulosum and stratum lucidum of the epidermis, and the appearance\\nof nuclei in the cells of the stratum corneum. According to Quinquaud, 2\\na diffuse myelitis and parenchymatous neuritis of cutaneous nerves may\\nbe responsible for these changes.\\nDiagnosis. Exfoliative dermatitis is to be distinguished from pity-\\nriasis rubra by the variety of its symptoms and course from pemphigus\\nfoliaceus by the absence of bullae and grave systemic trouble and from\\nscarlet fever by the absence of sore-throat and by a much more tardy evo-\\nlution. Though in general a disease having a cyclical career and special\\ncharacteristics it may at times be lighted into activity by a diffuse psor-\\niasis of acute type, or by a squamous eczema becoming generalized. In\\nsuch cases the diagnosis is qualified by the preexisting disorder.\\nTreatment. The disease may be mitigated by any medicament\\nwhich induces profuse sweating hence, both jaborandi and pilocarpine\\nhave been employed with success. Quinine, soclic salicylate, cod-liver\\noil, and the mineral acids are often indicated. The strength of the\\nsufferer is always to be supported by appropriate measures. Hebra s\\ndiachylon ointment, 1 part to 4 of vaselin, with from 5 to 10 grains\\n(0.33-0.66) of salicylic acid to the ounce (30.) of the whole, is usually\\ngrateful to the skin. One of the combinations of lime-water, olive-oil,\\nand zinc oxide, described in the treatment of eczema, may, however, i\\nbe employed locally.\\nPrognosis. The disorder may prove fatal in exceptional cases\\ngenerally, however, recovery may be expected. Often convalescence\\nis tedious, protracted, and complicated by the occurrence of furuncles\\nand cutaneous abscesses.\\nDERMATITIS EXFOLIATIVA INFANTUM.\\n(Keratolysis Neonatorum.)\\nUnder this title Von Bittershain 3 and others have described an\\nexfoliating non-contagious disease of the skin in infants from six days\\n1 Arch. gen. de Med., 1884.\\n2 Bull, de la Soc. anat., 1879.\\n3 Centralzeitg. f. Kinderheilk., 1878, Bd. ii. Dorland: Phila. Polyclinic, Sept.\\n26, 1896.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0310.jp2"}, "311": {"fulltext": "PITYRIASIS RUBRA. 293\\nto five weeks old, the disorder continuing from seven to ten days. It\\ndevelops as an erythema, at times as a vesico-bullous dermatosis, with\\ndryness of the skin, from which branny scales are abundantly exfoliated,\\nleaving a peculiarly dry, reddish, and fissured integument beneath. The\\nangles of the mouth and the mucous outlets generally are specially in-\\nvolved. Often buccal lesions are present. The face, the buttocks, and\\nthe limbs are chief seats of the disease. The malady lasts for about\\none week and is unaccompanied by fever it occurs more often in boys\\nthan in girls. In severe cases crusts form where rhagades exist, and\\nthere are considerable pain and constitutional disturbance. Occasion-\\nally the skin is attacked by furunculosis after the disease has existed\\nfor a week. Relapses are common, but recovery occurs in most cases.\\nThe Treatment is by soothing applications to the cutaneous surface.\\nPrognosis. The mortality is grave when the disorder induces\\nmarasmus, diarrhoea, or pneumonia.\\nPITYRIASIS RUBRA.\\n(Gr. Tvirvpov, bran.\\n(Dermatitis Exfoliativa. Ger., Rothkleie; Fr. y Pityriasis\\nRUBRA AIGU.)\\nJ Symptoms. This disease is characterized by a superficial hyperemia\\nand inflammation of the skin, declared in patches or by a diffuse red-\\nness of a vivid or lurid tint, and by an abundance of small or large,\\nlamellated, bran-like scales, which are continuously exfoliated from the\\nepidermis throughout the course of the malady. Patients rarely present\\nthemselves for observation until a considerable portion of the body-\\nsurface is involved but Kaposi states that in two patients observed\\ni| by him the disease was first noticed in the neighborhood of the articu-\\n5j lations. There are never at any time other lesions of the skin, betrayed\\nin vesiculation, pustulation, moisture, or crusting. The palmar and\\nplantar surfaces are usually less distinctly reddened than the face and\\nt the extremities, having at times even a pallid hue, but they are always\\ncovered with a scaling epidermis.\\nUnder pressure with the finger the redness subsides or assumes a\\nyellowish shade, while, as a rule, when the integument is gathered up\\nbetween the finger and thumb, no infiltration can be recognized. Ex-\\nceptions, however, have been noticed by several observers. 1 The tem-\\nperature of the skin is slightly increased. The exfoliation, as the dis-\\nease progresses, is one of its most striking characteristics, the scales\\naccumulating in large quantities in the clothing of the patient, who is\\nengaged, as a French writer has it, in the labor of stripping himself\\ninvoluntarily of his epidermis.\\nThe disease persists for months or for years, being always more\\nsevere in expression as it advances, the papery scales being shed more\\nabundantly and in larger flakes, leaving a smooth, shining, occasionally\\npurplish or even cyanotic skin. In the patients observed by Jamie-\\n1 We have reported one such case. Cf. Pityriasis Rubra, Chicago Med. Jour,\\nand Exam., Feb., 1881.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0311.jp2"}, "312": {"fulltext": "294 INFLAMMATIONS.\\nson, 1 the skin was so dark hued as to suggest the color of a mulatto.\\nGradually the patient becomes conscious of an increasing sense of\\nchilliness, as if deprived of sufficient body-covering. The itching may\\nbe absent, be moderate, or be severe. There may be instead sensations\\nof stiffness, burning, and tingling. Later the integument seems to\\nretract, as if it were insufficient to encompass the body, and becomes\\nsubject to fissure from extension and contact, while the lower extremi-\\nties may be cedematous. This retraction may be so marked that ectropion\\nof the eyelids may ensue, and wide opening of the mouth may become\\ndifficult. The hairs and the nails lose their lustre and become friable,\\nand the hairs often fall though the nails may escape.\\nThe influence of this epidermal catarrh, involving, as it does, finally,\\nevery portion of the body-surface, does not fail toward the end to be\\nfelt by the vital forces. Alternating chills and febrile processes,\\npneumonia of a low grade, colliquative diarrhoea, tuberculosis, sub-\\ncutaneous abscesses, bedsores, and even gangrene of the skin may close\\nthe scene.\\nHebra and Kaposi together had under observation about fifteen\\npatients affected with pityriasis rubra, who, with a single exception,\\ndied from its effects. It will thus be seen that the disease is rare. A\\nfew cases have been reported by British authors. Among Americans,\\nDuhring, George H. Fox, of New York, and one of us, have published\\nreports of cases. We have had under observation in all six typical\\ninstances of the affection. The disease is one of early or of middle life,\\nand affects preeminently the male sex.\\nThe progress of the disease is either rapid or slow, lasting for years\\nand at times ending with relative rapidity. In the course of a few\\ndays after its onset the entire body may be covered with the exanthem\\nyet when the disease is of long duration it may be at times partial and\\nat other times general in distribution. There are no red points visible\\nas in other forms of scarlatinoid-shaded eruption, and the color when\\nthe palms and soles are involved only appears after the thick epi-\\ndermis of those regions has been shed. Sweat may or may not be\\nsecreted in the course of the disease. The tongue is bright red in the\\nearly stages later it is covered with a brownish crust it occasion-\\nally undergoes exfoliation. There may be a secretion from the skin\\nwhich at times stains the linen. Rhagades may form, especially in the\\npalmar and plantar regions. While in the instances of this disorder\\nfirst described in Vienna there was no infiltration of the skin, this\\nchange has been observed in other typical instances, but usually not\\ndeeply implicating the corium. The nails may be separated, tilted up\\nfrom the nail-folds, softened, thinned, fissured, worm-eaten, or other-\\nwise altered. The chief systemic symptoms recorded are languor,\\nchilliness, and even severe rigors alternating with febrile temperatures\\nof recurrent type, albuminuria, diarrhoea, pulmonary oedema, icterus,\\ninterstitial pneumonia, bronchitis, and rheumatism.\\nThe cases reported by English authors are mostly instances of ex-\\nfoliative dermatitis following lichen ruber, eczema, psoriasis, and other\\nsimple dermatoses. To this class in particular belong the patients\\n1 Edinburgh Med. Jour., April, 1880, p. 879.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0312.jp2"}, "313": {"fulltext": "PITYRIASIS RUBRA. 295\\nreported as suffering from repeated attacks of the disease and those\\nalso in whom the affection is limited to but few regions of the body,\\nsuch as the palms and soles.\\nEtiology The causes of the disease are unknown. It will be seen\\nthat the fewness of cases which have been recognized has restricted the\\nfield for the study of the malady. It is more common in men than in\\nwomen, and in adults rather than in children. The cutaneous phe-\\nnomena are due in each case to some constitutional disorder which in\\nthe early stages frequently presents no other symptoms than those mani-\\nfested on the skin, the patient being apparently in good general health.\\nVisceral troubles are recognized chiefly at a late period of the malady,\\nwhen it would appear that the cutaneous mischief is sufficiently exten-\\nsive to induce them. The wide range of these disorders suggests that\\nthe cutaneous disease may result from a number of visceral maladies.\\nPathology. The researches of Hans Hebra 1 demonstrated in two\\ncases that in the earlier period of the disease there is an infiltration of\\nthe integument moderate in degree, succeeded at a later period by\\ncutaneous atrophy, in which the rete and papillae of the cor i urn disap-\\npear. The connective-tissue elements undergo sclerosis and the\\nglands and the follicles of the skin are destroyed. Pigmentation is\\nabundant.\\nBoth Hebra and Fleischmann discovered coincident pulmonary, in-\\ntestinal, or cerebral tuberculoses and Kaposi, in one post-mortem\\nexamination, established an atheromatous condition of the arteries.\\nBaxter, 2 in a patient examined by him, discovered no trace of the\\nstratum granulosum, nor was the stratum mucosum completely sep-\\narated from the stratum corneum. There was a gradual transition\\nfrom the polygonal prickle-cells below, which readily stained, to the\\nhorny cells above, which remained colorless. Flattened and faintly\\nstained nuclei lay parallel with the surface, and they could be recognized\\neven in the enormously hypertrophied stratum corneum. The papillae\\nwere enlarged the rete-pegs had pushed deeply into the corium. The\\nprickle-cells of the hair-sheaths were multiplied. The remarkable con-\\nsistency of the thickened corium at the outset of the disease was regarded\\nas chiefly due to a fluid exudate, which was observed before death.\\nMyelitis was discovered in one case by Jamieson, who has been fol-\\nlowed by others in the recognition of central and peripheral neurotic\\nalterations.\\nJadassohn found a round-cell infiltration of the papillary body and\\nthe subpapillary tissue, with increase of the nuclei of the fixed con-\\nj nective-tissue cells. The significant features of the process, as Unna\\nI points out, are the persistent hyperemia, the widespread pigmentation\\n(possibly associated with the former), and the consequent atrophy and\\ntension of the integument.\\nDiagnosis. Many cases reported as instances of pityriasis rubra\\nare not really such. The misinterpreted symptoms are often those of\\nj an unusally extensive psoriasis or a chronic squamous eczema, which\\ncommonly terminates favorably in the course of proper treatment.\\n1 Vierteljahr. f. Derm. u. Svph., 1876, Heft 4, S. 508.\\n2 Brit. Med. Jour., 1879.", "height": "4321", "width": "2388", "jp2-path": "practicaltreatis00hyde_0313.jp2"}, "314": {"fulltext": "296 INFLAMMATIONS.\\nIn lichen ruber the essential lesion is a papule, which even in the\\nlater extensive scaling of that disease usually may be recognized in\\nsome part or another of the infiltrated skin.\\nPsoriasis rarely extends over the entire surface of the body, but at\\ntimes it is thus generalized. In these exceptional forms a long history\\nof the occurrence of typical psoriatic patches may usually be obtained,\\nwhile the bleeding surface beneath the scales and the character of the\\nlatter will point to the true nature of the disease. Psoriasis occurs in\\nhealthy, pityriasis rubra in cachectic, constitutions. Extensive eryth-\\nematous or squamous eczema, apart from all other symptoms, can be\\nrecognized at once by the excessive distress occasioned by the erup-\\ntion. The patient lies in bed nursing his or her tender limbs, back, or\\nbelly. In the early stages of pityriasis rubra the patient may rise,\\ndress, and move about with an expression, not of pain, but of listless\\napathy. His scales are not scanty and adherent, but are abundant and\\nexfoliate freely. There is, from first to last, no history of moisture.\\nIn every generalized eczema, at one point or another, there always will\\nbe a surface which weeps. In its early periods pityriasis rubra can be\\ndistinguished from pemphigus foliaceus by the absence of bullae and\\nof the intolerable stench which is often emitted by the sufferer. When,\\nhowever, there is present merely a generalized exfoliative dermatitis the\\ntwo disorders may well-nigh be indistinguishable.\\nTreatment. Arsenic administered internally seems powerless in\\npityriasis rubra. Cases are on record of fatal results after the exhibi-\\ntion of this drug in prodigious quantities for long periods of time. Tar\\nexternally promises no better result. Kaposi reports a single patient\\nrelieved by the use internally of carbolic acid. Thyroid extract may\\nbe tried in chronic cases.\\nA roborant treatment, including the employment of cod-liver oil,\\niron, or quinine, is generally indicated, with externally the simplest\\nbland unguents, of which vaselin seems best tolerated. It should be\\nemployed, not merely to soothe, but also to protect the skin. The\\nclothing should be ample and un irritating, and the diet selected with\\na view to supporting the strength.\\nThe Prognosis is necessarily grave.\\nPITYRIASIS RUBRA PILARIS.\\n(Lichen-psoriasis. Fr., Pityriasis rubra pilaire.)\\nThis affection has chiefly been described in France by Devergie,\\nBesnier, Bichaud, and others. The museum of the Saint Louis Hos-\\npital is provided with illustrations in wax of every phase of the malady.\\nIn other countries it has until recently either been described under a\\ndifferent name or has wholly been ignored. Cases of the disease in\\nconsiderable number have come under the observation of experts in\\nAmerica in the past few years. It is claimed that the malady is\\nidentical with the lichen ruber acuminatus of Hebra.\\nSymptoms. The disease commonly appears as a seborrhoea sicca\\nof the hairy scalp, with and without palmar and plantar scaling", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0314.jp2"}, "315": {"fulltext": "PLATE V.\\nFig 1.\\nPityriasis rubra pilaris.\\nFig. 2.\\nPityriasis rubra pilaris.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0315.jp2"}, "316": {"fulltext": "", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0316.jp2"}, "317": {"fulltext": "PITYRIASIS RUBRA PILARIS. 297\\npatches, though the face may be first to exhibit the signs of the affec-\\ntion. The eruption may be preceded by malaise, insomnia, hyperses-\\nthetic symptoms, or by a feeling of stiffness in the skin. The first\\nsymptom is usually the occurrence of very fine desquamation soon\\nthere appear over the surfaces of the fingers, hands, forearms, elbows,\\nknees, waist, or belly, minute papules, firm, dry, and silver white, red-\\ndish brown, or rosy yellow in color. Each of these papules has evi-\\ndently been pierced by a hair, and about its apex where thus traversed\\nby the pilary filament there is a delicate sebo-corneous sheath which\\npenetrates the hair-follicle for a short distance. These papules may be\\nas minute as a millet-seed or larger, but are never of the size of a split\\npea. They become more and more numerous, and appear at times to\\ncoalesce, and may form a patch covered with fine elevations conical\\nand discrete or may be lost in the general scaling, exfoliating, eryth-\\nematous, and shining area. The apex of each conical elevation may\\ndisplay an unbroken hair or a mere stump of the same, or a black\\npoint, the surface presenting then the appearance of the shaven beard.\\nThe yellowish-red or deep-reddish patches may be the seat of pityriasic\\nscaling, or may exhibit separation of the epidermis in large, adherent\\nflakes, which especially over the elbows and the knees present the\\nappearance of psoriasis. Commonly at the borders of these patches\\nare found the initial papules of the affection, still isolated and surround-\\ning characteristic stumps, filaments, or black points of hairs, enabling\\none thus to make the diagnosis with ease. At times the eruption is\\ngeneralized; when the face is chiefly involved the slight crusts formed\\nare decidedly of the type of those described under Eczema Sebor-\\nrhoei cum. In many cases the tension of the skin which results produces\\nectropion of the lower lid. Occurring over the hairy scalp, the accumu-\\nlated scales and crusts may form a dense and resisting cap which is\\ndifficult to remove. The nails are usually grayish, yellowish, longi-\\ntudinally striated, and roughened. There may also be a coincident\\npolytrichia. Important for purposes of diagnosis are the little horny,\\nblackish, conical papillse occupying the sites of the hair-follicles on the\\ndorsal surfaces of the first and second phalanges of the fingers. These\\nusually remain distinct even when the hands are completely invaded.\\nThe course of the disease is chronic, irregular, and subject to relapses\\nand unexpected aggravations. The general health may remain unim-\\npaired; the itching is slight.\\nEtiology. The cause of the disease is unknown. It occurs rather\\nmore often in the male sex, but has been observed at all ages in both\\nsexes.\\nPathology. According to Jacquet, the papule, which is the essen-\\ntial lesion of the disease, represents merely keratinization to an unusual\\ndegree of the epithelial lining of the superior portion of the hair-pouch.\\nAll the other changes in the skin are subordinate to the epidermal affec-\\ntion. Besnier recognizes four types of the disorder, three of which are\\nprobably represented by somewhat differing processes in the corium\\nand epidermis. These types are the sebaceo-squamous, or pasty\\nform the reddish, or pityriasic the xerodermic, in which the con-\\ndition resembles that known as goose-flesh and lastly, a mixed", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0317.jp2"}, "318": {"fulltext": "298 INFLAMMATIONS.\\nform. It is in these clinical pictures that the process, if it be in fact\\nunique, may best be recognized, for in them are represented the familiar\\nchanges seen in eczema, psoriasis, keratosis (lichen) pilaris, xerosis,\\nichthyosis, and possibly a few other affections of the skin attended with\\nkeratinization of the epidermis.\\nDiagnosis. The disease is to be differentiated from all others by\\nthe characteristic papule pierced by the shaft, or segment of shaft, of\\na hair. In extensive cases of long standing the identity of the papules\\nmay be lost in the general scaling process over most of the body but\\nin nearly all cases they can be recognized on the backs of the fingers,\\nas described above. Ichthyosis is congenital pityriasis rubra is more\\nfrequently generalized, and is a grave disorder affecting the general\\nhealth while pityriasis rubra pilaris does not always interfere with the\\nsystemic condition. The disease is by many supposed to be identical\\nwith lichen ruber acuminatus. For the differences between the two\\nmaladies the chapter on the last-named disease may be consulted.\\nPsoriasis is never characterized by papules with hair-filaments in the\\ncentre.\\nTreatment. The remedies hitherto found most useful in the local\\nmanagement of this disorder are those valuable in the management of\\npsoriasis and squamous eczema. Tar, pyrogallol, chrysarobin, resorcin,\\nsalicylic acid, and the mercurials, with lotions of Van Swieten s liquor,\\nare advised, and, when an inflammatory effect is produced, the employ-\\nment of soothing lotions and salves. Fatty crusts, when these are\\nabundant, are to be removed by shampooings, as in seborrheic affections\\nof the scalp. Internally, arsenic, cod-liver oil, and carbolic acid have\\noccasionally proved advantageous. Brocq recommends for internal use\\nsodium arseniate in increasingly large doses, but no single remedy is\\nknown to be efficacious when administered internally.\\nThe Prognosis is usually favorable.\\nEPIDEMIC EXLOLIATIVE DERMATITIS.\\n[Epidemic Skin-disease (Savill).]\\nDuring the summer and autumn of 1891 an epidemic disorder with\\ncutaneous symptoms developed in several London asylums, infirmaries,\\nand hospitals, affecting about five hundred patients. The disease was\\nstudied with special care by dermatologists and medical men. The\\nbrief sketch given below is based upon an excellent monograph with\\ncolored and photographic illustrations by Savill, 1 on various communi-\\ncations made on the subject in the columns of the British Medical\\nJournal and the London Lancet for 1892, and on the description given\\nby Crocker in his treatise.\\nThe disease occurred in two distinct clinical types, one with catarrhal\\nexudation from the skin, resembling the moist forms of eczema, the\\nother dry and non-discharging, resembling pityriasis rubra, and, accord-\\ning to Crocker, indistinguishable from that disease.\\n1 An Epidemic of Skin-disease resembling Eczema and Pityriasis Kubra, by Thomas\\nD. Savill, etc. London, 1892.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0318.jp2"}, "319": {"fulltext": "EPIDEMIC EXLOLIATIVE DERMATITIS. 299\\nThe eruptive features were apparently not preceded by prodroinata,\\nbut gastro-intestinal disturbance (vomiting, diarrhoea), and in some\\ncases sore-throat, either preceded or accompanied the appearance of the\\ndermatosis. Except in patients of advanced years, there was usually\\npost-occipital and cervical adeno])athy, not to be explained as sympa-\\nthetic with a cephalic eruption. The regions most frequently involved\\nwere the upper limbs, the scalp, and the face the lower limbs less\\nfrequently.\\nThe skin-lesions were pruritic, and were irregularly grouped, acumi-\\nnate papules, with a follicular site.\\nThe stages of the exanthem, as given by Savill, w r ere\\na. A papulo-erythematous stage, lasting from three to eight days,\\nin which shot-like papules were felt beneath the skin, were dis-\\ncrete, and were seated on a reddened, thickened, even an indurated\\nor oedematous integument. In some cases the onset was in the form of\\nmarginate and circular nodose patches, resembling those seen in\\nerythema nodosum in a few cases the resemblance was to ringworm,\\nflattened papules enlarging to a circinate annular group with minute\\ncentral vesicles readily ruptured.\\nb. An exudative stage, lasting from three to eight weeks, in which\\nmacules, vesicles, or papules soon formed a confluent eruption, the\\nskin being of crimson hue, thickened, and scaling in flakes or in\\nlamellated crusts in consequence of the exudation. In the moist type\\nthe papules developed to vesicles w T ith exudation in the dry type the\\nexfoliation occurred in pure scales, pints of w T hich in some cases could\\nbe collected from a patient s skin in a day. In other cases this exfo-\\nliation was in the form of an impalpable powder it was characteristic\\nof all well-marked cases.\\nc. A stage of subsidence, in w T hich the disease proceeded to invo-\\nlution, leaving the skin at first indurated, polished, and brownish\\nin color. In many cases the new skin was raw and parchment-like,\\nsmooth, shining, and readily fissured, resembling in this respect ich-\\nthyosis. In a few instances ectropion resulted, as a sequel of conjunc-\\ntivitis. In severe cases the hair and all the nails were shed. There\\nwas a mortality of from 5 to 13 per cent., death resulting from ex-\\nhaustion with the usual signs of subsultus, shallow respiration, and\\ncoma. Complications occurred with pneumonia, gangrene, and albu-\\nminuria. A few of the attendants upon the sick (children and patients\\nof somewhat older years) were attacked but for the most part the\\npatients, and especially those succumbing to the disease, were individ-\\nuals of advanced years of both sexes, inmates admitted for the man-\\nagement of other disorders in the institutions in w T hich the disease\\nprevailed.\\nThe Etiology of the disease was not satisfactorily determined. Cocci\\nwere isolated and cultivated by Savill and Russell, but the etiological\\nimportance of these micro-organisms is yet to be demonstrated. The\\ninfluence exerted upon the disease by parasiticides was beneficial to a\\ndegree but this treatment on the whole w 7 as unsatisfactory and chiefly\\namounted to amelioration of the conditions of the skin.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0319.jp2"}, "320": {"fulltext": "300 INFLAMMATIONS.\\nPARAKERATOSIS VARIEGATA.\\nUnder this title Unna l and his assistants described two cases of\\npatients affected with a dermatosis supposed to be idiopathic, the\\ndisease occurring in the form of yellowish, reddish, or empurpled\\nmacules and flat papules constituting an eruption lasting several\\nyears, and at first affecting the neck, the chest, and the lower limbs\\nlater involving the entire surface of the body with the exception\\nof the head, the palms, and the soles. The infiltrated patches, which\\nat times contrasted with apparently sunken areas of the intervening\\nsound skin, were the seat of a pityriasic desquamation, were distinctly\\ncircumscribed, and were somewhat variegated in color, suggesting the\\nname adopted in describing the affection. Beneath the scales the\\nsurface was smooth and brilliant.\\nLICHEN RUBER.\\n(Gr. 7.SIXVV, moss.)\\n(Lichen Ruber Acuminatus, Lichen Exudativus Ruber,\\nLichen Psoriasis, Pityriasis Rubra Pilaris. Ger., Rothe\\nSCHWINDFLECHTE.)\\nUnder the term lichen ruber, Hebra was first to describe the disease\\nwhich is now recognized under this title. It is a malady rare of occur-\\nrence, and is more often recognized on the continent of Europe than\\nelsewhere. Its exact relations to lichen planus and to pityriasis rubra\\npilaris have been the subject of discussion, the results of which have\\nnot yet settled all the questions at issue. In these pages the disease is\\ndescribed as it exists in Europe, while the chapter devoted to Lichen\\nPlanus is designed to portray this affection as it exists in America and\\nas it has been investigated by American observers.\\nSymptoms. The disease is characterized by the appearance, with-\\nout prodromal symptoms, of isolated, pinhead-sized, conical, reddish,\\nscale-capped papules of considerable firmness, bright red or livid\\nin hue, and disseminated over the belly, the chest, the genitalia, the\\nextremities, and other portions of the body. In another form of the\\ndisease these lesions are lighter in color, each with a smooth surface,\\na small central depression at the apex, and a waxy appearance. The\\nnutmeg-grater effect is usually produced when the finger is passed\\nover them. The itching excited may be mild or be severe it bears\\nno relation to the extent of the exanthem.\\nThe papules rapidly multiply, forming patches which, by aggrega-\\ntion rather than by coalescence, cover large areas of the body, and,\\nlastly, its entire surface. Throughout the course of the disease indi-\\nvidual papules do not enlarge at the periphery, but they persist as\\nsuch until they are lost in a diffuse, dull-red, infiltrated patch, covered\\nwith thin, papery, grayish non-adherent scales, beneath which the\\norifices of the hair-follicles are seen to be dilated. Occasionally at the\\nborder of a patch thus formed, isolated, shining, flattened, or umbili-\\n1 Monatsehft. f. prakt. Derm., 1890, vol. xi.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0320.jp2"}, "321": {"fulltext": "LICHEN RUBER. 301\\ncated papules persist or form circles of densely packed lesions, sur-\\nrounding groups in which involution of the lesions progresses, leaving\\npigmented and atrophic areas within. At this stage of the disease the\\nresemblance of the symptoms to those displayed in pityriasis rubra\\npilaris is so striking that some authors (Kaposi included) make no dis-\\ntinction between the two.\\nWhether in the form of lesions last described, or after irregularly\\ndisposed disseminated patches have been developed, the entire integu-\\nment becomes eventually the seat of extensive infiltration, reddening,\\nand scaling. As a consequence fissures form and the distress of the\\npatient increases. Bulla? are occasionally observed.\\nThe skin of the face cracks the eyelids are everted or are thickened\\nthe skin of the palms and soles is converted into a leathery tissue the\\nnails become friable and irregular motion at the joints is excessively\\npainful on account of the inelasticity of the skin covering the articula-\\ntions the hairs are thinned and fall the extremities are maintained\\nin a position midway between flexion and extension. The integument\\nis now universally reddened, is covered with innumerable delicate or\\nwith coarse scales, and, especially upon the palmar and plantar surfaces,\\nis thickened by dense infiltration. Over the deeper fissures, extending\\nto the corium, form blackish and blood-containing crusts. Emaciation\\nprogresses pari passu with the invasion of the disease, and death may\\nresult from exhaustion, intercurrent diarrhoea, or pneumonia.\\nLichen Ruber Planus (as a variety of lichen ruber acuminatus)\\nis regarded by most writers as identical with lichen planus. Minute\\nyellowish to reddish, firm, dry papules, irregular, differing in shape but\\noften polygonal in contour, and varying in size from that of the minutest\\nlesions to those as large as a pinhead, rise from the affected surface of\\nthe skin, often at the site of a hair-follicle whence the pilary filament\\nhas disappeared. Desquamation does not occur, as a rule, while these\\nlesions are isolated when confluent there may be considerable scaling.\\nThe itching may be mild or be of the intensest grade.\\nThe eruptive symptoms may persist in discrete form as at the\\noutset, the exanthem spreading by multiplication of new lesions until\\nthe entire surface is involved. At points there may be confluence\\nwith formation of a flattish elevated plaque, light or dark reddish in\\nhue, and irregular in outline, with considerable infiltration of the in-\\ntegument. Grayish scales are then produced, often with whitish striae\\nradiating from the patch. Annular bands and also other figures w r hich\\nmay be geometrical in contour are thus formed. Occasionally there\\nare vesicles and vesico-pustules. Deep pigmentation may succeed com-\\nplete involution of the disorder. The wrists, the forearms, the belly,\\nthe lumbar region, the inferior extremities, and in men the genital\\nregions, are most often involved.\\nThe variations of the affection are: an extreme grade of exfolia-\\ntion of the epidermis in large plates from a raw, reddish surface\\nfringed with reddish or yellowish scales. On the palms and soles the\\nlesions may closely resemble a syphiloderm of these parts, even to the\\nminute pits or depressions whence the epidermis has fallen. In occa-\\nsional cases, according to Brocq, the papules exhibit blackish points in", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0321.jp2"}, "322": {"fulltext": "302 INFLAMMATIONS.\\nthe centre corresponding with the orifices of coil-glands. The disorder\\nmay affect also the mucous surfaces, as is described in the following\\nchapter. The disease even may progress for months or for years with-\\nout marked modification; or, on the contrary, the evolution may be\\nrapid, the eruptive elements large, the skin greatly infiltrated, the sheets\\nof eruption vast, and the general distress great. Bullae and vesico-\\npustular lesions are observed in rare cases.\\nMixed Forms are reported, in which all the symptoms of lichen\\nruber acuminatus and lichen ruber planus have been exhibited in one\\npatient. In some instances the one form of disease has been noted\\nto precede; in yet other cases another form. Cases are recorded\\nin which all the lesions of typical lichen ruber acuminatus and planus\\nhave been observed coincidently in one patient.\\nUnna has attempted to create yet another clinical variety of lichen\\nruber, under the title Lichen Ruber Obtusus.\\nIn a first variety the lesions are semicircular, pea-sized, flattened,\\npolished, waxy papules unprovided with scales, having a bluish-red or\\nbrownish-red depression in the centre. The itching is usually intense,\\nthe papules may coalesce, and the eruption may become generalized.\\nPigmentation has been observed after involution is completed. Occa-\\nsionally cicatrices have formed.\\nIn a second variety, the corneous form, the papules are large and\\nare seated for the most part on the extremities. The itching is\\nintense. As individual lesions increase in size the tinting becomes\\nbrownish, and over these elements form small, grayish, dry, adherent\\nscales, which give a cornified aspect to the surface. Some of the\\npapules persist without coalescence throughout the attack.\\nThese two forms are evidently merely clinical variations of the dis-\\norder described fully by authors.\\nLichen Ruber Moniliformis (Kaposi) is an odd-looking disorder\\n(of the lichen ruber class), in which numerous node-like masses are\\narranged in lines and chains resembling a jewellers necklace, with\\nflattish, punctiform papules between the nodes, and macules of a sepia-\\nbrown hue between the lesions.\\nEtiology. The cause of the disease is unknown. Both sexes seem\\nto suffer in equal proportion, though it is claimed that more men than\\nwomen are affected. The disease is transmitted neither by heredity\\nnor by contagion. In those who display the symptoms of the affec-\\ntion external irritation is capable of aggravating the eruption. The\\ndisease is chiefly encountered in middle-life, from the tenth to the\\nfortieth year, but it has been observed as early as the eighth month.\\nIt is probably a trophoneurosis. Cases have been reported following\\ntraumatism and shock. Well-marked instances of the disorder have\\nbeen recorded in persons otherwise healthy. Lassar discovered minute\\nbacilli in the lymph-spaces, but they have not been shown to be the\\ncause of the malady.\\nPathology. Lichen ruber is a paratypical keratosis of the super-\\nficial portions of the stratum corneum. It is characterized by hyper-\\ntrophy of the stratum corneum and by incomplete corneous transforma-", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0322.jp2"}, "323": {"fulltext": "LICHEN RUBER. 303\\ntion of the individual elements of that layer, which are larger and\\nmore polygonal, a feature most noticeable about the sweat-ducts and\\nthe hair-follicles. The rete is in places enlarged in consequence of\\ncell-infiltration, and in places is normal. The upper portion has an\\nuneven appearance, as the interpapillary portion pushes slightly down-\\nward, and the increase in size of the other parts is more marked. The\\npapillae are increased in dimensions, and their blood-vessels are dilated\\nand surrounded by corpuscles. The walls of the sweat-ducts are\\nformed of large cells with vesicular nuclei corneous cells are heaped\\nalso about the orifices of the hair-follicles the muscle-bundles are\\nmuch hypertrophied.\\nDiagnosis. In psoriasis the discovery of a typical scaling patch,\\noften with a clearing centre, should suffice for recognition of that dis-\\nease. The scaling in diffuse psoriasis is also much more abundant.\\nIn papular eczema the lesions do not persist as such. When these\\ntwo affections are generalized it is claimed by French observers that\\nthere is always some one area, however small, of unaffected integu-\\nment. This unaffected area is not to be found in generalized lichen\\nruber; but in such generalized cases the distinction between that\\ndisease, pityriasis rubra, or dermatitis exfoliativa may be extremely\\ndifficult if at all practicable. At an early period papules are not seen\\nin either of the last-named two disorders. The papules of syphilis\\nnever scale so generally as those in lichen ruber moreover, they\\nincrease in some cases to double their original size, and are always\\naccompanied by some other symptom of that disease. In the scaling\\nstage of pemphigus foliaceus there are bullse present or there is a history\\nof these lesions preexisting.\\nLichen ruber is to be distinguished from pityriasis rubra pilaris by\\nthe non -limitation of the former to the orifices of follicles by the later\\nperiod of its scaling by its deeper involvement of the skin by its\\ngreater diffusion over the extensor surfaces of the body by its severe\\nj grade of pruritus by its involvement of the general system by its\\nfrequent grave issue by the deep pigmentation remaining and by its\\noccasional involvement of the mucous surfaces.\\nPityriasis rosea is a much more superficial and a milder affection\\nits scales are fewer its rarer papules are smaller, and they occur\\nI chiefly at the periphery of its oval patches.\\nTreatment. Arsenic, which is of great value, can be employed\\nwith large chances of success in lichen ruber. This drug is early to\\nbe given, and persistently pushed notwithstanding neAV crops of lesions\\nuntil the desired result is obtained, and to be continued for several\\ni months after all signs of the disease have disappeared. Tonics, when\\nindicated, should always be exhibited. The diet should be generous.\\nExternal treatment is employed chiefly for the relief of pruritic sen-\\ni sations. Dusting-powders and ointments prove serviceable. The local\\nremedies employed in corresponding stages of eczema may, in brief, be\\nhere used with advantage, such as alkaline, starch-, or bran-baths, fol-\\nlowed by inunction of the skin with salves containing thymol, salicylic\\nacid, zinc oxide, bismuth subnitrate, carbolic acid, or benzoin.\\nPrognosis. The prognosis of the disease when it refuses to yield", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0323.jp2"}, "324": {"fulltext": "304 INFLAMMATIONS.\\nto treatment and tends to become generalized is necessarily grave.\\nTreatment after the occurrence of marasmus will often prove ineffec-\\ntual. The disease is said to be occasionally amenable to energetic\\ntreatment before it has advanced to the stage of inducing systemic\\nexhaustion.\\nLICHEN PLANUS.\\n(Gr. hetxvv, moss Lat. planus, flat.)\\n(Lichen Kuber Planus.)\\nSince the date of the first description (1869) of this malady by Sir\\nErasmus Wilson it has been the source of considerable discussion due\\nto the confusion which has existed in different countries respecting the\\nquestion of its identity with or distinction from lichen ruber planus.\\nLichen planus at one time was rarely reported in America, but it is now\\namong the affections occupying a second rank after those of most fre-\\nquent occurrence.\\nSymptoms. The elementary lesion of every classically developed\\neruption is a flat-topped, polygonal papule which, when studied in\\ndifferent positions so that the light falls aslant upon the surface, exhibits\\na characteristic glistening or shining top of each papule shown in no\\nother eruption.\\nThe papules exhibit a peculiar crimson or purplish shade, and when\\nthe eruption is plentiful this color is so characteristic that by it alone in\\na well-marked case the eruption may be recognized by the eye before\\nindividual lesions can be identified. The papules vary in size from\\nthe head of a small pin to the larger lesions (e. g., of so-called lichen\\nplanus obtusus in which the papules may be as large as pease or\\nbeans, and may even assume an annular form or may exhibit about the\\nflattened top a ring of minute vesicles or of still finer papules.\\nThe individual lesions are at first discrete, but they tend to form\\nirregularly arranged groups, which may assume a circular shape or that\\nof a figure with sharp angles. In no other eruption than lichen planus\\ndo eruptive elements form in distinctly straight lines and in variants\\nfrom the latter, such as, e. g., a figure representing a digit flexed at a\\nright angle. In this way are occasionally formed exceedingly odd-\\nlooking groups parallel lines, cockades with scaling crests, rings,\\nrosettes, etc.\\nAs the lesions grow older they almost invariably distinctly deepen\\nin shade, from a light-crimson to a dull-purplish hue, and still later to\\neven a darker color. In typical cases the lesions of lichen planus when\\nactually subsiding or well-nigh gone from the surface of either the chest\\nor of the belly are likely to leave a smoky and even blackish hue, which\\nis the result of the pigmentation produced when the disease is in great-\\nest activity. These sequels of the disease are naturally most conspicuous\\non the lower extremities.\\nThe eruption is usually symmetrical, though it may occur in patches\\non only one side of the body. The most frequent site of the disease\\nis the anterior surface of the forearm, but lesions may develop upon any\\nportion of the body-surface, especially the abdomen (more frequently", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0324.jp2"}, "325": {"fulltext": "LICHEN PLANUS. 305\\nits lower third), the extremities (in the point of frequency, first the\\nupper and then the lower extremity), the hands, the penis, the back,\\nthe ankles, the inner side of the knee, and the neck. A typical dis-\\nplay of symptoms is not often to be seen on the face. In rare cases l\\nthe eruption is universal.\\nWhen the papules coalesce and also, as happens in extreme cases,\\nwhen they have flattened so as to be indistinguishable before the dis-\\nease has yielded, a crimson-hued sheet or mask of the skin is seen,\\ngenerally characterized not merely by the color of the lichen-papules,\\nbut also by a silvery sheen, due to thin shining scales which do not\\ncompletely cover, but which supplement, as it were, the empurpled\\npatches, beside and over which they form. These scales are not freely\\nshed from the surface, but they are firmly attached.\\nThe greatest variation is experienced in the way of subjective sensa-\\ntions. In some patients the eruption is tolerated with but few symp-\\ntoms of annoyance. In other patients the greatest possible distress is\\noccasioned, and no subjects of scabies or of eczema suffer more. The\\neruption of lichen planus, however, is less often scratched than that of\\nother cutaneous exanthemata accompanied by severe pruritus.\\nThe disease is usually chronic in course. Patients of the better\\nclass commonly reach the end of their sufferings in the course of\\nsix months or a year. This fact seems to furnish a reasonable basis\\nfor the belief that treatment has a favorable influence upon the\\nmalady, seeing that it is not rare to discover untreated patients or\\nthose in whom the nature of the disease has been long ignored, who\\nfor two and even more years have suffered from lichen planus in cir-\\ncumscribed forms limited to a palm-sized patch over one popliteal\\nspace or a wrist while another for six years and more may have been\\naffected over an entire lower extremity or a shoulder. The disease\\nmay recur, but recurrence is an exception to the rule. In the rarer\\nacute forms noted by observers the disease may be relighted to activity\\nfrom a chronic patch or it may begin with acute symptoms.\\nLichen planus is remarkable for the exceptions it offers in individual\\ncases to the lesions seen in others. Thus, Crocker 2 describes papules\\nwith a convex instead of a concave top and cases in which the lesions\\nwere soft and compressible instead of possessing the firmness of the\\nusual lichen planus nodule. The lesions are occasionally interspersed\\nwith telangiectases, bullae, etc.\\nWhen the mucous surface is affected the disease develops in whitish\\nmacules, or striae, or flat papules, the latter aggregated on both sides\\nof the tongue, the striae running along the line of the jaws where the\\nmolar teeth come in contact. The affection in this region has unques-\\ntionably often been confounded with leukoplakia (so-called ichthyosis\\nlinguae elsewhere described. In the mouth the papules of lichen\\nplanus are in rare instances conical at the apex.\\nThe disease most often attacks young adults and the middle-aged of\\nboth sexes. In children, who suffer but rarely, the eruptive features\\nshow a striking tendency to early flattening, and they thus simulate the\\n1 Fordyce, Jour. Cutan. and Gen.-Urin. Dis., 1898, p. 444.\\n2 Diseases of the Skin, second edition, 1893, p. 300.\\n20", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0325.jp2"}, "326": {"fulltext": "306 INF LA MM A TIONS.\\nmacules of much simpler disorders of the skin. Lichen planus of the\\nface occurs much oftener in children than in adults. A few cases of the\\ndisease have been recorded in infants, and these commonly among the\\ndispensary class.\\nUpon the lower extremities a narrow fillet of typical lesions may in\\ncases extend from the heel to the trunk along the line of the sciatic or\\nother nerve. After the disease has existed for a long time, a single\\nband-like plaque of the disease may lose almost all papular features,\\nand come to resemble a deep-purplish keloid-like elevation or flat tumor\\nimbedded in the skin. When involution is complete there are usually\\nvery deep pigmentation and at times slight atrophy.\\nWhitish points and streaks are visible at times in the smaller and\\nlarger lesions, the horny scales projecting from other lesions like thorns.\\nFantastic groups occur on the body in the form of a cockade or in a\\nwhip-shaped curve; the bands of papules may also assume odd and\\nsingular figures. At times, especially when the case is one of persistent\\nand wholly discrete papules, linear bands of these lesions, one or several\\ncentimetres in length, of geometrical straightness, may be commingled\\nwith curved lines and even goitre-shaped figures.\\nWhen there are decided sheets of infiltration they are most conspic-\\nuous over the flanks and belly, but they may also be seen elsewhere,\\nas, for example, over the extremities. In these cases the very peculiar\\ncolor of the patch with indefinite outlines is characteristic, and is often\\nin brilliant contrast with the scales. The scales are of a silvery white-\\nness, very different in hue from the pearl-white or yellowish-white large\\nscales of psoriasis, and equally distinct from the branny and yelloAvish\\nfine scales of pityriasis rosea. They are by no means freely shed from\\nextensive patches, but they adhere and rarely cover the entire patch,\\nnor crop out beyond its indefinite border, but produce a species of\\nsilvery sheen over its central portions. These patches are usually\\nsymmetrical, as are commonly also the discrete papules of extensive\\ndevelopment. When either of these forms proceeds to involution the\\nscaling ceases, the infiltration subsides, and the intensely deep pig-\\nmentation left is characteristic of the disease, being often of a smoky,\\nand even of a blackish hue.\\nThe course of the disease is always toward recovery while it may\\nendure for months, it rarely lasts for years.\\nVariations in the small or the large papules are occasionally observed.\\nMinute vesicular points may be visible over their flattened surfaces, or\\nthere may be seen equally minute keloid-like processes, or reddish points,\\nupon or between them, where the vascularity of the tissues beneath is\\napparent. Only as an exception to the rule are the polygonal papules\\nclustered about the orifices of hair-follicles, as in pityriasis rubra pilaris\\nand lichen ruber. At times whitish points and streaks are left after the\\nresulting pigmentation subsides.\\nBullae have been recognized as coincident features in but a few cases.\\nOver the palms and soles the whitish spots, produced by exfoliation of\\n.the epidermis, may be the most conspicuous symptoms of the disease\\nin those regions.\\nLavergne divides all cases of lichen planus into three classes. The", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0326.jp2"}, "327": {"fulltext": "LICHEN PLANUS. 307\\nfirst is chronic lichen planus, the disease as it is known in its most\\ncommon form the second is acute lichen planus, in which the papules\\nrapidly develop and form extensive patches, thickened, painful, livid\\nred, and abundantly desquamating the third form is the lichen planus\\ncorneus of Vidal, Fournier, and Besnier. This form corresponds with\\nthe coin- or palm-sized, bluish to blackish, scaling and rugous, tumor-\\nlike plaques, usually seen on the anterior face of the leg, briefly described\\nabove.\\nHypertrophic Lichen Planus 1 is characterized by the occur-\\nrence of numerous, flat-topped, purplish and brownish-red elevations,\\ncommingled with sepia-brown pigment-spots. The warty growths may\\nbe elevated four or five millimetres above the general level of the\\nskin. They are seen usually on the legs. The penis is at times sur-\\nrounded by papillomata, some of which coalesce to a diffuse infiltration\\nand the genitalia of women, including the pubic region and hypogas-\\ntrium, may be studded with pea- to bean-sized empurpled nodules seated\\non a dull-crimson infiltrated integument.\\nEtiology. The causes of lichen planus are obscure. It is often\\ndifficult to recognize the sources of the disease, but in many cases a\\nhistory of nervous exhaustion can be obtained. Affliction, long-con-\\ntinued anxiety, and overwork, especially in cases in which mental effort\\nis required for its continuance, are frequent causes of this disorder.\\nMany patients are notably well nourished and not lacking in flesh. In\\nfact, the combination of a fair degree of nutrition of the body with\\nnervous exhaustion is to be recognized more commonly in patients\\naffected with lichen planus than in any other affection as annoying and\\npersistent.\\nOther causes cited are traumatism (dog-bite Walters), digestive\\ndisturbances, malaria, malnutrition, and diseases of the generative or-\\ngans. Different opinions are entertained respecting the frequency with\\nwhich the two sexes are attacked. General experience points to the\\nconclusions formulated by Crocker, who reports more cases among\\n(English) women than among men, as against the statistics of the\\nVienna school, which reverse the figures. The disease among the\\nnervously taxed of the well-to-do classes is encountered more fre-\\nquently in private practice than among out-patients of public charities,\\nwho suffer to a greater extent than others from cachexia and malnutri-\\ntion. Russell lately reported a case in which the disease followed am-\\nputation of four fingers of the right hand.\\nPathology. Robinson first clearly showed the pathological dis-\\ntinction between lichen ruber and lichen planus. His observations\\nhave been confirmed by those of Boeck, Kaposi, Touton, Weyl, and\\nothers.\\nThe first changes noted in the skin are increase in the lumen and a\\nsinuous condition of the capillaries supplying the one or two papilla?\\nconcerned in a single papule. The papilla?, thus largely filled with\\ndilated capillaries, contain also a network of fine connective-tissue\\n1 Cf. Fordyce and Eddoues, Jour. Cutan. and Gen.-Urin. Dis., Feb., 1897 Brit. Jour,\\nof Derm., 1898, p. 103.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0327.jp2"}, "328": {"fulltext": "308 INFLAMMATIONS.\\nfibres, and dense, round cells, which proceed to multiply. Later, more\\npapillae and also the epidermis are concerned in this process. In the\\nplaces in which white points are exhibited granules of keratohyalin\\nbecome visible. In some portions of a lichen-papule of medium devel-\\nopment the stratum corneum exhibits an external, dark, narrow, and\\nfirm layer, and beneath it are two to four rows of translucent cells\\nforming the stratum lucid am but in other parts, and in all parts when\\nfully developed, the stratum corneum breaks up into definite lamellae,\\na phenomenon seen in other disorders attended by derangement of the\\nkeratogenetic function of the skin. The external layer is dark and\\nfirm when stained next below it is a wider layer of swollen cells with\\nnuclei scarcely visible, or with relics of liberated nuclei and, still\\ndeeper, a narrow and solid layer beneath which the stratum lucidum\\nbecomes visible.\\nThe horny layer is almost entirely absent over the region occupied\\nby the cell-packed papule, below which the corium is normal. The\\nrete is centrally hypertrophied, especially in the region of the sweat-\\nducts its cells above the affected papillae are horizontally flattened,\\nand the granular layer is thickened. In some places it is difficult\\nin consequence of these changes to distinguish between the rete and\\nthe corium beneath. The cell-infiltration, composed largely of em-\\nbryonic white blood-corpuscles, extends more deeply into the corium\\nin the neighborhood of the sweat-ducts.\\nBriefly, it appears that the papule of lichen planus is the result of\\na primary hyperaemia of the papillae of the corium a secondary thick-\\nening of the lower part of the rete a tertiary flattening of the papule\\nby reason of the resulting pressure, producing thus the appearance of\\numbilication a proliferation of cells in the granular layer, as a result\\nof which the deposit of keratohyalin in whitish points or in sheets\\noccurs sufficient to produce the clinical peculiarities having that ap-\\npearance (not due, as Neumann supposed, to changes in the sweat-\\nglands) and coloration of lesions due to both vascularization and to\\nescape of blood-corpuscles.\\nDiagnosis. The diagnosis rests upon the characteristic shape, size,\\ncolor, grouping, disposition, and umbilication of the papule of lichen\\nplanus, which are features not found in any other papular disease.\\nThus, in its size, apex, color, and course the papule of papular eczema\\nis quite different from that described above, being brighter, redder,\\nmore acuminate at the apex, and much more often followed or accom-\\npanied by catarrhal symptoms. In psoriasis punctata the scales are\\nabundant and readily removed the individual lesions are increased\\nrapidly by peripheral extension, far beyond the fullest development of\\nthe papule of lichen. The papular syphiloderm is not, as a rule, pru-\\nritic, not flattened when minute, not polygonal in shape, and not cov-\\nered with a closely adherent horny scale, and it always occurs in\\npatients in whom careful investigation discloses other symptoms of the\\ndisease (mucous patches, adenopathy, etc.).\\nThe distinctions noted above in connection with lichenification of\\npatches of chronic inflammation of the skin are not to be disregarded.\\nTreatment. Roborant treatment by quinine, the mineral acids,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0328.jp2"}, "329": {"fulltext": "LICHEN PLANUS. 309\\nthe ferruginous tonics, and cod-liver oil is frequently indicated. Al-\\nthough it is claimed that arsenic actually aggravates the disease,\\nthere is general agreement with Hebra, Wilson, Duhring, and others in\\nascribing to it the most brilliant results obtained in the treatment of\\nlichen planus, results far more consistent than are obtained from the\\nsame drug in the management of psoriasis. Boeck and Taylor give 1 5\\ngrains (1.) of potassium chlorate in 4 ounces (120.) of water, fifteen\\nminutes after eating, followed in a quarter of an hour by 20 drops of\\ndilute nitric acid, swallowed in a wineglassful of water. Robinson, in\\ngeneralized hypersemic cases, praises the alkaline diuretics (potassium\\nacetate with sweet spirits of nitre), well diluted after meals. Fox\\nregards mercury as valuable in the chronic forms of the disease, for\\nwhich also he administers asafoetida. Koebner has injected both pilo-\\ncarpine and arsenic subcutaneously with success.\\nIn the way of local treatment the most important measure in acute\\ncases is complete protection of the involved surface with powders, oint-\\nments, pastes, soft dressings, or with a non-irritating protective plaster,\\nsuch as zinc oxide plaster or plaster-mull. Unna used 1 part of cor-\\nrosive sublimate, 20 parts of carbolic acid, and 500 of benzoated zinc\\noxide salve Brocq and Jacquet employ the tepid douche for from two\\nto ten minutes once and oftener in the day Vidal employs baths of\\nvinegar, 1 litre to the bath and the external application of 1 part of\\ntartaric acid to 20 of the glycerole of starch Wilson praises a mer-\\ncurial salve, 2 grains (0.13) to the ounce (30.). In all severe cases\\nattended with considerable pruritus frequent baths of warm oatmeal- or\\nbran- water should be ordered, after which the skin should be dried and\\na Lassar paste applied. When later a stronger application is tolerated\\nthe paste may be medicated with pyrogallol, ichthyol, or the dried\\nferrous sulphate. Tar, thymol, iodine, or chrysarobin may also be em-\\nployed topically with success. Weyl recommends caustic applications,\\nas also 1 or 2 parts of beta-naphtol to 90 of rectified spirits of wine\\nand 10 of glycerin. In the persistent verrucous types of the disease\\nfrom 10 grains to 2 drachms (0.66-8.) of salicylic acid to the ounce\\n(30.) of paste or plaster may be employed.\\nPrognosis. The prognosis is in general favorable, since even cases\\nof long standing are usually relieved when the subjects of the disease\\nare placed under conditions favorable for recovery. It is always to be\\nborne in mind, however, that in individual cases in which the patient\\nis neurasthenic the eruptive symptoms may persist for years, accom-\\npanied by intense itching and a consequent teasing of the nervous cen-\\ntres. In this class of subjects it is generally well to make a guarded\\nprognosis, and to pronounce upon the future with just reserve.\\nLichen Annularis (Ringed Eruption of the Extremities)\\nis a title given by Galloway 1 to a case in which several lesions having\\npale, irregular, elevated borders showing circular or circinate outlines,\\ndeveloped about the joints of the hands. The border was slightly\\nelevated, about three millimetres in breadth, smooth, and not reddened.\\nThe skin of the enclosed area was almost sound, but showed slight\\n1 Brit. Jour, of Derm., 1899, p. 221.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0329.jp2"}, "330": {"fulltext": "310 INFLAMMATIONS.\\nsigns of atrophy when the original process had undergone involution.\\nThe histological structure closely resembled that of lichen planus. The\\nlesions flattened rapidly under the application of salicylic acid in oint-\\nment. A similar case is under our observation.\\nLichenification. In certain portions of the integument, usually\\ndefinitely circumscribed and of a limited area, a significant change\\noften occurs, which has been designated by the French lichenification,\\non the ground that this is not a form of lichen planus, the term which\\nthey employ designating the change which is progressing in the skin.\\nIt is possible that this condition represents a stage intermediate between\\nchronic inflammation and a specialized dermatosis. In any event it is\\nnecessary to distinguish between the two in establishing a careful diag-\\nnosis. In such patches (marginate eczema, nevrodermite, etc.), found\\nparticularly about the flexures of the joints, the fork of the thighs, the\\nback of the neck, and elsewhere, the surface of the skin is seen to be\\nstudded with dull-reddish, closely packed, flat-topped, often polygonal\\npapules, which strongly resemble those occurring in lichen planus, and\\nyet which seem to be symptoms of the chronic inflammation present\\nrather than of an affection of distinct type.\\nECZEMA.\\n(Gr., ek tjeo, to boil forth.)\\n(Ger., Eczem; Fr., Eczema.)\\nEczema is distinctly a protean disease. It cannot, therefore, be\\ndefined or described satisfactorily in a single paragraph. It is not\\nonly protean in its clinical manifestations, but its causes are varied,\\nnumerous, and usually complex. In histological detail different types\\nof eczema vary considerably, yet all probably result from one common\\npathological process. Clinically, though a dozen successive cases of\\neczema may present wholly different pictures, yet they all have some\\ncharacteristics in common and the diagnosis in most cases is not diffi-\\ncult. It has often been described as a catarrhal inflammation of the\\nskin, but many cases of dermatitis now generally classed as eczema\\nshow no vesiculation or other evidence of discharge, and cannot properly\\nbe considered catarrhal in nature. As a rule, eczema shows at some\\ntime in its history more or less serous discharge, either in the form of\\nvesicles or in a denuded oozing surface but some cases of erythematous\\nand papular eczema persist as such throughout their entire course, aud\\nnever produce an exudate upon the surface.\\nA vexed and unsettled question among dermatologists is the rela-\\ntion of eczema to other forms of dermatitis. The study of the exact\\npathological changes in the skin has led to the inclusion under eczema\\nof conditions formerly considered distinct affections. On the other\\nhand, many writers, especially in England and France, are now endeav-\\noring to exclude from eczema every dermatitis for which a definite\\ncause can be found. Eczema is a dermatitis, and it is not possible to\\nsay for every case which title is the more appropriate. A convenient,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0330.jp2"}, "331": {"fulltext": "ECZEMA. 311\\narbitrary division, which is followed in these pages, classes under der-\\nmatitis those forms of inflammation of the skin which result from\\nrecognized, external causes, and which subside on the removal of the\\ncause. Such definite and independent affections as dermatitis herpeti-\\nformis or dermatitis repens are, of course, considered separately.\\nSymptoms. Eczema is one of the diseases of the skin of most\\nfrequent occurrence. In the statistics gathered by medical men it\\nwould seem to rank first in the order of frequency, forming from 20 to\\n40 per cent, of dermatological cases reported. It is undoubtedly true\\nthat acne is a more common affection than eczema, but as many subjects\\nof acne never deem it necessary to submit to treatment for its relief the\\nrecords of such cases do not figure in dermatological statistics. This\\nfact being noted, eczema may be regarded as the disease of the skin for\\nwhich most frequently the practitioner of medicine is consulted. By\\nas much as inflammation is the commonest accident of other organs of\\nthe body, by so much is its enveloping organ subject to the same path-\\nological process.\\nThe accepted signs of inflammation of any given tissue are usually\\nnamed as increased heat, redness, pain, and swelling. These symptoms\\nare present to some extent in every eczema though modified by the\\nanatomical peculiarities of the organ in this case affected. The surface\\ninvolved in typical eczema always shows some elevation of tempera-\\nture, it being slight in chronic, but more marked in acute, cases. Red-\\nness, varying in shade from the bright red of the acute to the dull red\\nof the chronic forms, is also true of the eczematous skin. Pain here is\\nrepresented by a sensation of itching which is almost invariably present\\nand may vary from a slight annoyance to an almost intolerable distress.\\nIt is commonly intermittent or paroxysmal in character and is usually\\nworse at night. In some instances, especially in acute and erythemat-\\nous types, the sensation of burning or smarting may be more marked\\nthan that of itching. Occasionally an eczematous skin is hypersesthetic\\nand exceedingly sensitive to contact with even the blandest substances.\\nThe degree and character of the subjective sensations in eczema depend\\nlargely upon the location, type, or severity of the disease, but also to\\nsome extent upon the general condition or peculiarities of the indi-\\nvidual. The fact that itching rather than pain accompanies inflamma-\\ntory disorders of the skin is due largely to the fact that the skin is\\nexposed to the air, and its increase in bulk is not opposed by contigu-\\nous parts. Inflammation of the inner skin of the body, that of the\\nlining membrane of the stomach or of the intestines, is generally char-\\nacterized by the occurrence of severe pain. In acute types of eczema\\nthere is often some cedematous swelling, together with slight infiltration\\nof the skin. In chronic forms the infiltration and thickening of the\\nskin are more pronounced and may be excessive.\\nf In addition to the symptoms of heat, redness, itching, or burning,\\nI and swelling or thickening of the skin, found in every case of eczema,\\nj the great majority of eczemas have certain characteristics in common.\\nThe course of the disease is capricious, not only the severity of the\\nprocess, but often the type of lesion changing frequently and rapidly.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0331.jp2"}, "332": {"fulltext": "312 INFLAMMATIONS.\\nThis is most conspicuous in children and in others having delicate\\nskins, and in those cases in which the affected areas are not protected\\nfrom atmospheric and other external influences it is unusual for any\\neczema to pursue an even course. Daily variations in severity, with or\\nwithout change or modification of type, are not uncommon. Apparent\\nrecovery is frequently followed by a relapse which may develop fully\\nin a few hours and without apparent cause.\\nAside from some cases of erythematous and papular eczema, which\\nmay persist throughout without change of type, eczema is notably a\\npolymorphic disease, presenting in irregular succession or in varied\\ncombinations erythema, papules, vesicles, pustules, crusts, scales, fis-\\nsures, excoriations, or denuded and oozing surfaces. Even in the mildest\\ncases the skin is slightly infiltrated, while in some severe, chronic forms\\nthe thickening may be excessive and deforming, or there may be hyper-\\ntrophy of all the layers of the skin producing wart-like growths\\n(Eczema Verrucostjm).\\nThe serous discharge which is present during at least a part of the\\ncourse of most eczemas is characteristic, and stiffens articles of clothing\\non which it dries. It may be imprisoned in vesicles, but more com-\\nmonly oozes from a denuded surface or from minute excoriated points\\nwhich represent abortive or ruptured vesicles.\\nLike all other inflammations, eczema may be acute or be chronic.\\nLike all others, too, the acute may precede, and the chronic may follow,\\nor the reverse may occur. The disorder, originating in subacute or\\ninsidious forms, may become chronic, and then, as the result of fresh\\nor of more severe irritation, may develop the acutest symptoms. Fre-\\nquently, as in the eczema of children, the disease may be chronic in\\nrespect to duration, yet most of the time present acute symptoms. As\\na rule, eczema does not undergo spontaneous recovery, but tends rather\\nto remain indefinitely and to extend either by involving contiguous\\nsurfaces or by developing in new areas. The disease is commonly\\nmore or less local, appearing in one or several irregular and usually ill-\\ndefined areas, but may be general or even universal. It apparently\\noccurs independently of all other disorders, the general health remain-\\ning unaffected even in severe forms of the disease or it may be but the\\nexternal expression of constitutional disturbance.\\nClinically, several types of eczema can be recognized. These types\\nrequire separate description. It should not be forgotten, however, that\\nin the majority of cases eczema is a complex process, in which two or\\nmore types are seen, either in succession or simultaneously. Though\\nseveral forms of eczema frequently coexist, it is usual for one type to\\npredominate, either throughout the course of the disease or for certain\\nperiods.\\n[A] Eczema Erythematosum. This form of the disease is most\\ncommon on the face, especially in individuals exposed to wind and\\nweather or to direct heat, but it may appear on any part of the body,\\nand is frequently seen on the palms, the soles, and in the genital regions.\\nIt begins usually as a diffuse, ill-defined area of redness, less frequently\\nas a number of coin-sized macules or erythematous spots, which may\\ncoalesce or remain more or less distinct. Swelling and infiltration are", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0332.jp2"}, "333": {"fulltext": "ECZEMA. 313\\npresent in varying degrees. In acute cases the oedema may be exces-\\nsive, sometimes closing the eyes. In the subacute forms, which are\\nthe more common, there are less oedema and more infiltration and thick-\\nening of the skin.\\nThe sensation of itching, which is so characteristic of most forms of\\neczema, is usually excessive, though it may be largely or wholly sup-\\nplanted by one of heat or of burning. This is especially true when the\\nprocess is acute in character. The color varies from a bright to a dull\\nor purplish red, depending upon the severity of the disease, its location,\\nand the peculiarities of the individual and inasmuch as the condition\\nis more frequently observed in middle-aged adults with darker hue of\\nintegument than in early life, the color of the part is often noticed to\\nbe of a dull-crimson shade. At times the coloration is irregularly dis-\\ntributed, producing a mottled appearance, bright at one point and dark\\nat another. A yellowish tinge usually indicates that the process is\\ncombined with seborrhcea, producing the combination described in\\nanother chapter as eczema seborrhoei cum.\\nThe erythematous surface is modified, as a rule, by more or less fine\\ndesquamation, which begins a few days after the occurrence of the first\\nerythema, and persists to the end of the disease. There is no discharge,\\nunless, as frequently happens, the type changes to a moist form, but\\nwhen the disease occurs on apposed surfaces, as in the axilla, under the\\nbreasts, or about the genitals, the epidermis may be destroyed by\\nmaceration and friction, and leave a denuded, oozing surface. The dis-\\nease may pursue an acute course, terminating in exfoliation and gradual\\nresolution, or changing to the papular, vesicular, pustular, or mixed\\ntypes. More frequently it persists and becomes chronic, both in the\\nintensity of the process and in its duration. The skin then becomes\\nmore infiltrated and thickened, and may present voluminous firm folds,\\nwhich are very conspicuous and often deforming. Exfoliation may be\\nso prominent a symptom as to suggest for the condition the name of\\nEczema Squamosum or Exfoliativum. The area involved is fre-\\nquently better denned than in other forms of eczema, and though the\\ncondition may remain limited to its original site for months or years,\\nit has a decided tendency to extend either contiguously or by the\\nformation of new areas. The intensity of the process may change\\nfrequently and rapidly. It is usually aggravated by exposure to\\nheat, cold, or wind, or by any condition which favors congestion of\\nthe part. Scratching of the surface involved produces a change in\\nthe symptoms which the skilled eye will promptly recognize. Minute\\nsuperficial losses of tissue are then visible here and there upon the\\nsurface; the more recent lesions having a reddened floor possibly hidden\\nbeneath a thin blood-scale, the older being surmounted by a light\\nyellowish-red crust. The scratch-lines, often recognized elsewhere, are\\nhere less evident.\\nLike all other varieties of eczema, this form is extremely liable to\\nrecrudescence and relapse. In advanced life traces of the disease may\\nbe visible for years.\\n[B] Eczema Papillosum. Under this title are classed all those forms\\nwhich have been described as Lichen Simplex, Lichen Ecze-", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0333.jp2"}, "334": {"fulltext": "314 INFLAMMATIONS.\\nmatodes, Eczema Lichenoides, etc. It is of great importance that\\nthere should be a distinct and general recognition of the fact that in\\nexceptional cases eczema may exist from first to last as a dry infiltration\\nof the integument, for there is perhaps no one of the various manifesta-\\ntions of the disease that is so frequently confounded with other widely\\ndifferent affections.\\nThe papules are acuminate, pinhead-sized or larger, colored in\\nvarious shades of red to a dark lurid shade, and are usually seated\\nupon a reddened and thickened base. They are generally discrete,\\nthough often set closely together, are accompanied by an intense form\\nof itching; and of all eczematous lesions are most likely to be irritated\\nby scratching. Their summits are torn, often to such an extent as to\\nbleed, the blood drying in minute crusts on the apices of individual\\nlesions. Existing papules may persist for weeks or may disappear\\nand be replaced by others. They may completely coalesce to form\\nirregular, thickened, elevated, pea-sized or larger patches, covered with\\nscales. The areas involved in papular eczema are often fairly well\\ndefined in outline. The extent of surface affected varies, the disease\\nbeing in some cases largely diffused over various portions of the body,\\nbut usually limited to small single patches no larger than the size of\\na small coin. Such patches, covered with a single or with several\\ngroups of reddish papules, may continue to torment the patient for\\nlong periods of time, or, being at one time relieved, may recur with each\\naggravation of the malady by the exciting cause. Papular eczema is a\\ndry manifestation of the disease, and is thus most frequently noticed\\nupon the drier portions of the integument. These parts are the surfaces\\nof the limbs, the back of the body, and, in particular, the scrotum. In\\nthe latter region the papules are large and often flattened. If the moist\\nforms of eczema are most frequently seen in early life, it is none the\\nless true that the dry forms are the most common in adult life or in\\nadvanced years.\\nIt should not be forgotten, however, that the papules here described,\\nwhen there is free exudation beneath the surface, may exhibit pin-\\npoint-sized vesicular summits which may develop into minute or larger\\npustules. A patch of papular eczema, where no vesiculation nor pus-\\ntulation has been observed, will, if sufficiently scratched, ooze with\\nmoisture, the serum escaping from the abraded surface. There are, in\\nfact, few scratched eczematous surfaces which will not moisten a dry\\nhandkerchief applied to the part. This weeping condition attracts the\\nattention of patients themselves, who complain of it in describing their\\nsymptoms. A species of relief from the pruritus is thus obtained and\\nin aggravated cases patients will scratch or rub or otherwise irritate the\\ndiseased patches, not merely for the purpose of gratifying the intense\\ndesire to assuage the itching, but also to induce serous exudation for the\\nsake of the relief it affords. The secretion when in contact with linen\\ncloths stains and stiffens them, very much as seminal fluid leaves its\\ntraces upon clothing.\\nResolution of papular eczema is accomplished after the formation\\nof scales, the tissues beneath the latter assuming more and more the\\nappearance of healthy skin.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0334.jp2"}, "335": {"fulltext": "ECZEMA. 315\\n[C] Eczema Vesicuiosum. This expression of the disease is char-\\nacterized at an early period by the formation of minute vesicles. It\\nis a matter of importance, however, to recognize the fact that the\\nvesicular, like the erythematous, is but one of several manifestations\\nof this singularly protean affection. Long after the appearance of the\\ntreatises of early English dermatologists the term eczema was very\\ngenerally limited by physicians to the vesicular phases of the disease\\nit is to the Vienna school that we are largely indebted for the recog-\\nnition of the fact that these simultaneous or successive features,\\npresented often in the same individual, really belong to one and the\\nsame malady. To limit the name eczema to-day to its vesicular variety\\nalone would be to relegate the student of diseases of the skin to the\\nmisty uncertainties of the first half-century of dermatology.\\nThe clinical features of vesicular eczema are chiefly due to the\\nacuity of the inflammatory process present, and to the consequent free\\nexudation of serum of the blood from the vesicular plexus immediately\\nbelow the pars papillaris of the corium. The involved surface usually\\nfeels at the outset hot, itchy, or unusually sensitive, and soon after\\nbecomes more or less intensely reddened, the result of hyperemia and\\nsubsequent exudation which may last for one or for several hours.\\nPoppy-seed- to grape-seed-sized vesicles then become visible on this\\nreddened base. The lesions may be closely packed together, or be\\ndiscrete, or may be so abundant as to coalesce, a frequent behavior of\\nall vesicular lesions. Each vesicle is filled with a droplet of clear\\nserum imprisoned beneath the most superficial layers of the epidermis.\\nThis vesicle is readily ruptured, and if this rupture does not speedily\\noccur as the result of accident, the lesion bursts spontaneously, and its\\nlimpid contents are then poured out upon the surface of the integu-\\nment. The quantity of the fluid thus exuded is in excess of that\\noriginally contained in the small vesicular chamber. This excess is\\ndue to the fact that the elevated, macerated, and broken epidermis\\nno longer presents an obstacle to the outflow of serum from the\\nengorged vessels beneath. Minute and even large drops of a clear fluid\\nof syrupy consistency can be seen collecting at the points where the\\nsolution of continuity has occurred. If with a slip of bibulous paper\\nthe first drop be removed, its place is visibly filled by a second. Crops\\nof new vesicles succeed the first, each crop being followed by the train\\nof symptoms described. The vesicles are usually short lived and often\\nhave disappeared before the patient is seen by the physician. In other\\ninstances the destruction of the epidermis by rubbing or scratching, or\\nby an abundant and rapidly formed exudate, allows the escape of the\\nfluid without previous vesicle-formation. The discharge dries rapidly,\\nwhen exposed to the air, in light-yellowish crusts which are rarely\\nbulky. Clothing on which the fluid dries is stained and stiffened.\\nThe weeping at many points of the surface affected is so prominent a\\nfeature of the disease that it has led several authors to describe eczema\\nas invariably a catarrhal disease of the skin. There are, without\\nquestion, forms of this disease in which the history is throughout\\nentirely different from that just described, in which no evidence of\\ndischarge can be appreciated from first to last, and yet in which, by", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0335.jp2"}, "336": {"fulltext": "316 INFLAMMATIONS.\\nartificial measures, the so-called catarrhal features can readily be\\nproduced.\\nThe contour of the affected patch or patches is seldom well defined,\\nthe pathological portions imperceptibly shading into the sound skin.\\nThe color of the area thus diseased varies according to the stage of the\\nprocess, being at one time of a vivid red, at another yellowish, and,\\nwhen covered with crusts or scales, undergoing a corresponding change\\nof hue. Infiltration of the skin occurs rapidly, so that when a portion\\nof the affected integument is pinched up between the finger and thumb\\nis is found to be thicker and less elastic than normal. This form of\\neczema may persist or recur in a single small area, or it may spread and\\nbecome diffused or even generalized. It appears commonly on the\\nflexor and other surfaces where the skin is thin.\\nThe subjective symptoms of vesicular forms of eczema are more or\\nless intense itching and often burning. In very acute forms there is\\nconsiderable soreness, the patient managing the affected part with as\\nmuch care as if it were a fractured limb. In exceptional cases, more\\nfrequently observed in children, there is a sympathetic febrile disturb-\\nance of a mild grade.\\nAs resolution approaches, all the symptoms described above gradu-\\nally decline in severity the serous discharge diminishes, the redness\\nfades, the limits of the involved area become less distinct, the crusts\\nloosen and fall, and beneath the scales which have taken the place of\\nthe oozing and broken epidermis a new and tender epithelial covering\\nis produced. As a rule, for weeks after the process has completely\\nceased the newly formed epidermis has a slightly reddened and tender\\nappearance, though complete resolution is followed by no permanent\\nsequels. Instead of undergoing resolution the condition may terminate\\nin eczema rubrum, in eczema squamosum, or in eczema pustulosum,\\nthis last form being ordinarily due to pus-infection.\\nThese then being the typical phases of vesicular eczema, clinically\\nthe picture may be quite different from that described. The types here\\ngiven are convenient for analysis and study, however much they may\\nbe commingled and obscured in the inflamed integument. Like the\\nerythematous, the vesicular forms of eczema may precede the others,\\nand, becoming chronic, may torment the suffering patient continuously\\nfor long periods of time, or may yield, only to reappear at irregular\\nintervals.\\n[D] Eczema Pustulosum (Eczema Impetiginoides, Impetigo Ec-\\nzematodes). This type may originate in one of the other forms of ec-\\nzema, in consequence of the severity or acuity of the process, or be the\\nresult of secondary pus-infection, or pustular lesions may rapidly form\\nat the onset. Usually there is first seen a crop of minute vesicles, which\\nenlarge and become distended with puriform contents. These pustules\\neither accidentally or spontaneously burst, and the fluid with which\\nthey were distended dries into yellowish-green or darker colored\\nfriable crusts. In aggravated cases the purulent matter seems to\\nform directly upon the involved surface. If the process be long\\ncontinued, infiltration occurs, and the itching, which in all varieties of\\nthe disorder is a characteristic feature, is awakened as an accompany-", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0336.jp2"}, "337": {"fulltext": "ECZEMA. 317\\ning symptom. The itching, however, is rarely of the peculiarly\\naggravated type accompanying the erythematous and papular phases.\\nPustular eczema is most frequently encountered on the head, and\\nin constitutions that do not readily resist the invasion of pus-cocci.\\nWhen existing on the scalp and the face there is most commonly\\nan involvement also of the sebaceous glands, the secretion of which,\\naltered by the periglandular inflammation, is added to that naturally\\nproduced by the exudative process. Singular shades of mixed yellow\\nand green and even black, are then to be distinguished in the re-\\nI suiting crusts, which later desiccate and fall, leaving a reddened\\nand tender new epidermis beneath. The condition is frequently seen\\non the scalp and face of infants, and is then popularly called milk-\\ncrust.\\nThe four types of eczema considered above are, as has been stated,\\nj sometimes encountered in practice as distinct and unmingled forms of\\ncutaneous disease, some of them more commonly than others. To pre-\\nsent, however, a picture of eczema as it is seen clinically it must be\\ni understood that these several forms, useful in the analytical study of\\nthe disease, often become, in actual observation, well-nigh inextricably\\ncommingled. Observation of the natural course of an attack of\\neczema, said Hebra, furnishes the most unassailable proof of the\\nconnection between its various forms. In one case an eruption of\\nvesicles begins the series of symptoms in another it is preceded by\\nthe appearance of red scaly patches or groups of papules or vesicles\\nI and papules are developed together, some of the former rapidly chang-\\ning to pustules and forming yellow gum-like crusts by the drying up\\nof their contents/ It is this constant interchange of features that dis-\\ntinguishes most eczemas from all other inflammatory affections of the\\nskin.\\nThe name Eczema Kubrum has been given to the red and angry\\nform of the disease, which, because of the free exudation of serum\\nfrom the surface, has also been termed Eczema Madidans. In\\nthis form the highly inflamed, intensely red and wounded integument,\\nI the horny layer of which has been destroyed and removed, pours\\nout freely upon the surface a thick, gummy or syrupy fluid, which, if\\ni artificially removed, leaves behind it a swollen, angry, and still dis-\\ncharging skin or, being permitted to dry where it has formed, covers\\nj the surface with large flake-like crusts, which may be thin and yellow,\\nor thick, dark-colored, and often blood-stained. The crusts may re-\\nI main but a few hours before an excessive outpouring of the fluid re-\\ni moves them. There are thus displayed in frequent and rapid alterna-\\ntion the discharging and the crusted surface. Eczema rubrum may\\nI occur on any part of the body, but especially in the flexures of joints\\nor where two surfaces come together; another common site is on\\nthe legs of elderly people or of those who stand much of the time. In\\nthis region it is exceedingly chronic and rebellious to treatment, and\\neventually is accompanied by a great degree of infiltration and thick-\\nening which may go on to hyperplasia and produce a condition simu-\\nlating elephantiasis.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0337.jp2"}, "338": {"fulltext": "318 INFLAMMATIONS.\\nEczema Squamosum, or Exfoliativum, is a type of the disease\\nmarked by more or less redness, infiltration, and exfoliation of the\\nskin. The scales are usually small, thin, whitish, and adherent. They\\nmay be scanty or quite abundant. Squamous eczema represents a low\\ngrade of inflammation, and is present as a transitory condition during\\na part of the period of resolution of all other types of the affection.\\nIt frequently persists, however, in the form of irregular, usually ill-\\ndefined, more or less infiltrated, dry, scaly patches. It is seen com-\\nmonly on the neck and face, at the border of the scalp, and on the\\nlimbs.\\nEczema Fissum, Eczema Rhagadiforme. In eczema of the\\nhand the movements of the fingers often produce fissures or cracks in\\nthe inflamed and infiltrated integument, and to those fissured forms the\\ntitles named above have been given. Fissures are observed wherever an\\neczematous disorder has so impaired the elasticity and extensibility of\\nthe skin that its necessary movements, especially about the joints, tear\\nand stretch the thickened integument. It is thus seen not only on the\\nhands, but also on the arms, the feet, and about the ankles, the resulting\\nrhagades being, at times, the most painful of all the complications of the\\nmalady. It is frequently seen about the mouth and anus. Occurring\\nupon the bodies and the hands of those who are compelled to come in\\ncontact with irritating substances, this form of the disease finds its\\nseverest expression. Mild, commingled forms of squamous and fis-\\nsured eczema occur quite commonly on the hands and faces of persons\\nwhose skin is thin, tender, and poorly nourished, or exposed to wind,\\nharsh soaps, hard water, chemicals, and other irritants. The condi-\\ntion is popularly known as Chaps or Chapping.\\nEczema Craquele is a rare form of eczema described by French\\nwriters in which a reddened surface is covered with large, thin flakes,\\nor scales, separated and outlined in polygonal areas by superficial cracks\\nor fissures. The condition usually involves a considerable surface of\\nthe skin, and is accompanied by itching and burning and in most cases\\nby hyperesthesia and an extreme sensitiveness to temperature-changes.\\nIt occurs chiefly in neurotic subjects.\\nEczema Intertrigo is a name applied to that form of intertrigo\\nwhich, surpassing the limits of hyperemia, results in an exudative\\nprocess. Reference is made to this possibility in describing the symp-\\ntoms of erythema intertrigo. In eczema intertrigo the symptoms are\\nusually those of diffused redness of surfaces of the skin in close appo-\\nsition, macerated by previous transudation of sweat, and weeping with\\nthe serum which oozes from several abraded points or patches. It\\nchiefly attacks the obese of both sexes and all ages, and in advanced\\nyears the gouty.\\nThe flexor surface of the extremities, especially in the vicinity of\\nthe joints, as well as the inframammary regions, the interdigital surfaces\\nof the feet, and the axillary and inguinal spaces, are particularly prone\\nto exhibit symptoms of this disease. In all such localities the alter-\\nnate tension and relaxation of the integument serve, when the limbs are\\nin motion, to increase the pruritus, and, correspondingly, to aggravate\\nthe disease. Often a certain proportion of symmetry can be perceived,", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0338.jp2"}, "339": {"fulltext": "ECZEMA. 319\\nthe two popliteal spaces, for example, being simultaneously affected,\\nthough each in a different degree. The parts most favorable for the\\ncomplications of intertrigo are those nearest the trunk, where moisture\\nand heat are greater, as the groins and the axilla?, while the elbow and\\npopliteal spaces are more frequently dry, exhibiting papulo-squamous\\nridges in lines at right angles to the axes of the limbs, with hypersemic\\npatches on either side.\\nEczema Verrucosum, or the wart-like form of the malady, is\\noccasionally observed, especially upon the lower extremities, in middle\\nlife or in advanced years, as the result of long-continued disease. The\\nintegument becomes thickened and so hypertrophied as to suggest the\\nappearance of warts closely packed together in a circumscribed patch.\\nEczema Sclerosum is a form of the disease most frequently\\nobserved upon the palmar and plantar surfaces, a condition referred\\nto in the paragraphs relating to Asteatosis. In eczema sclerosum is\\npresented a densely thickened inelastic integument, suggesting the con-\\ndition of tanned leather, without the occurrence of any of the other\\nlesions of eczema described above. As a consequence, the power of\\nperfect extension of the digits is impaired.\\nTuberculous Eczema of Nurslings, so called, is a term which\\nhas been applied to eczematoid eruptions about the mucous orifices of\\nthe eyes, nose, mouth, and ears, occasioned and sustained by morbid\\nconditions of, and serous discharges from, those parts (otorrhoea, rhin-\\nitis, phlyctenular keratitis, etc.), and accompanied by oedema, vesicula-\\ntion, and enlargement of lymphatic glands. The disease is character-\\nized by rebelliousness to treatment and chronicity of course. This\\ndisorder is improperly named, since tubercle-bacilli have not been rec-\\nognized in its lesions; and because the symptoms above enumerated\\nmay all be present when there is simply systemic nutritive failure and\\nwhen no tuberculosis of other organs is present.\\nEczema Diabeticorum (Fr., Diabetides).\u00e2\u0080\u0094 A singularly well-\\ndefined eczema is to be recognized about the genital organs of both\\nsexes, but more particularly of women, accompanied by the most\\natrocious pruritus, excoriations produced by scratching, and enormous\\ntumefaction of the anogenital and surrounding integument. The local\\nsymptoms are chiefly those of eczema erythematosum, the surface\\nbeing, as a rule, destitute of either vesicles or pustules. There are\\noften a profuse serous discharge, considerable infiltration, and the pro-\\nduction of inflammatory nodules over the engorged surface.\\nThese cases fall within three categories. In the first and rarest the\\npatient has saccharine diabetes of long standing, and the parts are\\nsimply irritated by the passage over them of urine charged with sugar.\\nIn the second and commoner form there is a temporary glycosuria,\\nI either produced by the local eczema or indirectly resulting from the\\nlatter, and yet due to transitory causes, since both the eczema and\\nsaccharine urine disappear with relative rapidity when the local treat-\\nment is combined with the dietary appropriate for the diabetic. In a\\n!last group the sugar-fungus (Torula cerevisice) finds a nidus in the skin.\\nEczema Folliculorum. Morris first described under this title\\na form of eczema which begins as an inflammation of hair-follicles.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0339.jp2"}, "340": {"fulltext": "320 INFLAMMATIONS.\\nEach inflamed follicle projects from the surface in the form of a red-\\ndened papule about which the skin becomes hyperemia As the\\nprocess spreads centrifugally by the involvement of adjacent follicles,\\nthe centre undergoes involution with desquamation, and a gradual\\nchange in color from red to yellow. This condition is found most fre-\\nquently on the extensor surfaces of the legs and the arms, in multiple,\\nscattered patches. The itching may be intense. This form of eczema\\nis obstinate, and usually recurs. Morris considers it parasitic in origin\\nand allied to sycosis.\\nEczema Parasiticum. Under this title is included a large num-\\nber of cases the exact relations of which to the recognized types of the\\ndisease are still indeterminate. It is well known, for example, that the\\nsurface of the human body in health is the habitat of an enormous\\nnumber of different parasites which are, for the most part, harmless or\\nare effective as agents of disease only under certain specially favorable\\nconditions of the body. Cultivation-experiments with the flora found\\non the eczematous skin have revealed a large number of parasites which\\ntogether, if not singly, may be effective in producing some of its dis-\\ntinctive features. According to Unna, eczema is in these cases a\\nchronic parasitic catarrh.\\nEczema Marginatum is considered under the head of ringworm.\\nEczema Seborrhceicum is described separately under that title.\\nAcute Eczema. An acute attack of eczema may be ushered in by\\nmalaise, chilliness, or the recognized symptoms of the febrile state. With\\nor without these prodromata the affected portion of the skin-surface\\nbecomes the seat of a burning sensation which is soon succeeded by\\nredness and swelling. This tumefaction may occur upon one or upon\\nseveral portions of the body at the same moment of time, and the dis-\\nease throughout be limited to a single area or to several spaces or it\\nmay extend from one to other or all regions. This extension may pro-\\nceed by continuous development of the disease along the surface, or an\\neczema of the thigh may suddenly be followed by an eczema of the\\nface, and this by an eczema of the scrotum. Extension of eczema by\\nthe last-described course may occur when no constitutional cause can\\nbe discovered and undoubtedly is due largely to the extraordinary\\nsensitiveness of the skin when involved in an acute attack, in con-\\nsequence of which the slightest friction, or even reflex irritation of\\nthe blood-vessels produces a new focus of the disease at a distant point.\\nThis consideration is of special importance. Patients will frequently\\npoint to an acute eczema upon several portions of the body widely\\nseparated one from another, and will urge this as an irrefutable argu-\\nment in favor of the fact that they suffer from some poison in the\\nblood/ 7\\nThe tumid and erythematous surface above described soon assumes\\nthe features of one or more of the types of eczema outlined in the\\npreceding pages. In this manner the evolution of the disease occurs,\\nand may continue for weeks, the patient, if unrelieved, being tormented\\nby the itching, and, if the disease be extensive, being prevented from\\nattending to his usual vocation. Acute eczema of severe grade will", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0340.jp2"}, "341": {"fulltext": "ECZEMA. 321\\nfrequently prostrate a strong adult, confining him to his bed-chamber\\nand often to his bed. When there is a simultaneous febrile process the\\nemaciation and adynamia are proportioned to its severity. Weeks and\\neven months may elapse before recovery can be pronounced complete,\\nsubacute patches of the disease lingering here and there upon the sur-\\nface, crust-hidden, scale-covered, occasionally oozing from recrudescence\\nof symptoms. Recovery, even when complete, leaves the patient, it\\nshould never be forgotten, with a skin sensitive to irritation and more\\nprone to a fresh attack of the disease than one long virgin of an inflam-\\nmatory process.\\nSuch is the course of an attack of acute eczema of severe grade.\\nIt must be remembered, however, that the process may be mild and\\nsubacute from the beginning, or again that a circumscribed patch of\\nskin may exhibit all the features of vesicular eczema in an acute form,\\nand under the influence of appropriate treatment may satisfactorily be\\nrelieved in the course of a few days. Lastly, acute or subacute eczema\\nmay be followed by chronic forms of the disease, the one passing into\\nstages of the other by scarcely definable gradations.\\nChronic Eczema. The symptoms and pathology of chronic eczema\\nare largely those of the acute form of the disease. The chief differ-\\nences to be noted relate to diminished intensity of the inflammatory\\naction, a marked tendency to recurrence and persistence of the process,\\nand a preponderance of scaling and infiltration as contrasted with the\\nactive secretion and crusting of acute phases. It is important, how-\\never, to remember that chronic eczema is not only the frequent sequel\\nof such acute phases, but is prone also to recurrent exacerbations of\\nacute grade, during which the serous discharges, consequent crusts, and\\nangry aspect of the affected surface do not fail to reappear. The itch-\\ning so characteristic of the malady in all its manifestations is often\\nmore annoying than in the acute phases of the disease.\\nChronic eczema may involve a limited region of the skin, or may\\ninvade the entire surface of the body from the head to the feet. Rarely\\nthus generally developed, it is more frequently observed upon circum-\\nscribed patches of the integument, as, for example, the scrotum or the\\nflexor surface of a joint, in which situation it may linger for years or\\neven for a lifetime, now better and now worse, or disappear for brief\\nperiods only to return with each recurrence of its cause.\\nEtiology. Eczema is a disease of both sexes and of all ages. Ten-\\ndencies to all disorders of the body may be inherited, but eczema, as\\nsuch, is not an inherited disease. No child was ever born into the\\nworld with an eczema. Certain individuals, however, show a peculiar\\nsusceptibility to eczema. In these persons the disease may occur with-\\nout obvious cause, and is often produced by conditions, either internal\\nor external, which are ineffective in the great majority of people. It\\nis noted elsewhere that eczema in certain instances is due to parasites\\nbut for the majority of cases it should, nevertheless, be classed with\\nnon-contagious affections.\\nIn many cases no cause of eczema can be discovered beyond the\\ncauses which operate exclusively within the skin-organ and which are\\n21", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0341.jp2"}, "342": {"fulltext": "322 INFLAMMATIONS.\\nproper to itself. These causes are necessarily obscure, and will so\\nremain until we are in possession of far more knowledge than possessed\\nat present as to the complex and inscrutably delicate processes by which\\ninnervation, nutrition, and new formation of the living matter of the\\nskin are both conserved and impaired. The autonomy of the integu-\\nment must be conceded to the extent recognized in other organs of the\\nbody. There are diseases of the liver that are referred neither to the\\nblood, to the nerves, nor to the action of poisons. There are diseases\\nof the heart that are induced by neither rheumatism nor syphilis.\\nWhen the etiology of the disorders of all the viscera is perfected that\\nof the skin displaying the lesions of eczema will assuredly be more\\ndistinct.\\nThese remarks are justified by clinical facts. Eczematous affections\\nmay occur in individuals who are in every respect superb examples of\\ngood health, and whose bodies, after the most thorough and careful\\nexamination, fail to reveal either an external or an internal cause for\\nthe disorder. It is true that in a majority of cases eczema is associ-\\nated with some disturbance of the general economy, but it occurs in\\npersons who are affected with every form of bodily ailment, those\\nsuffering from acute and chronic disorders of every viscus and system\\nof the body, and even those affected with other disorder^ of the skin.\\nJust what influence these varied systemic disorders may have upon\\neczema is not known. For the present they should be considered for\\nthe most part as either coincidences or as conditions favoring the de-\\nvelopment of diseases in general, eczema not excepted. By interference\\neither with innervation, nutrition, development, or excretion, or with\\nthe performance of other important functions of the body, as well as by\\nlocal and reflex irritation of the surface, these internal causes operate\\nby inviting, aggravating, or prolonging an eczematous attack. Among\\nsuch predisposing conditions may be named not only diseases, but also\\nphysiological states, such as pregnancy, lactation, and dentition; oc-\\ncupations necessitating inordinate fatigue of body or of mind, espe-\\ncially with the exclusion of sunlight and lastly substances foreign\\nto the body which produce an irritative action upon the mucous sur-\\nfaces, such as certain dietary and medicinal articles, intestinal par-\\nasites, and instruments or fluids introduced into the mucous canals, as,\\nfor example, the male urethra.\\nThe systemic conditions which occur most frequently with eczema\\nare those dependent upon defects in digestion, assimilation, and excre-\\ntion, such as constipation, the various forms of indigestion, rheuma-\\ntism, gout, and allied conditions. In individuals suffering from these\\ndisorders the secretions from an eczematous surface have been found\\nto contain an excess of uric acid, or have dried to form a visible crys-\\ntalline deposit of urates on the surface. In these so-called gouty\\neczemas the disease commonly occurs independently of any recog-\\nnized external cause, is symmetrical, recurrent, and it may be found\\nin several members of a family or in successive generations. In\\nsome individuals, and frequently in children, certain articles of diet\\nproduce a dermatitis which persists and spreads as an eczema. Gly-\\ncosuria and less frequently albuminuria may be discovered before or", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0342.jp2"}, "343": {"fulltext": "ECZEMA. 323\\nafter the appearance of an eczema. In the foregoing conditions, depend-\\ning upon some form or degree of malassimilation, it is probable that\\ntoxins or imperfectly metabolized food-products circulating in the blood\\nact either directly upon the excretory glands or upon the nerve-end-\\nings of the skin, or indirectly through vasomotor disturbances, or\\nthrough so-called reflex irritation. That the nervous system is\\nclosely related, etiologically and pathologically, to some forms of\\neczema is now recognized by most observers. Eczema occurs in various\\norganic and functional neuroses, in simple nervous exhaustion or debil-\\nity, in neuritis, neuralgia, or following injury to a nerve. It may even\\nfollow nervous shock. Through the action of the sympathetic and\\nvasomotor nerves various organic diseases may cause an irritation or\\ncongestion of the skin, and thus contribute one or more factors to the\\nproduction of an eczema.\\nEczema seems, in exceptional cases, to bear some relation to spas-\\nmodic asthma, either coexisting with that disease or its attacks regu-\\nlarly alternating with asthmatic paroxysms. This relation may be\\ndue to the exquisite sensitiveness of the skin, the mucous membranes,\\nand the nervous system exhibited in some patients.\\nFinally, ansemia, chlorosis, tuberculosis, scrofula, syphilis, or any\\nother systemic disorder that lowers the general vitality and that of the\\nskin, may favor the occurrence of eczema or of any other disease to\\nwhich the skin may be exposed.\\nThe external causes of eczema are identical with those of dermatitis,\\nand are chemical, mechanical, or thermal in their action. As stated\\non a preceding page, no sharp distinction can be drawn between\\neczema and any other dermatitis due to external causes, but those\\nforms of dermatitis which persist after the removal of the external\\ncause are probably due in part to, and are continued through, the\\naction of other etiological factors, and are conveniently classed with\\neczema. It is doubtful if any of the local causes of dermatitis, acting\\nfor a limited period, could produce a persisting eczema without the\\ncooperation of other conditions, either internal or external. The\\nlarge majority of all externally operating causes of dermatitis fail to\\nbe effective in the mass of individuals. Even the poison-ivy, a fertile\\nsource of the disorder in susceptible individuals, will fail to influence\\nothers. The late Professor Boeck, of Christiania, when he last visited\\nAmerica, rubbed the leaves of this plant over his hands and face\\nin repeated efforts to produce the disease, and failed of the desired end.\\nRespecting the numerous agencies operating thus externally and\\ncapable of producing the disease under consideration, they can all be\\nreferred to either solar light and heat, to contact with foreign bodies\\nin various fluid or solid states, to toxic agencies of a widely differing\\nnature, to traumatisms in varying degrees, and to the action of para-\\nsites. Many of these agencies cooperate, some include others, and\\nsome become effective by aggravating a disease which others have\\nengendered. The reader is referred to the chapters on General Etiol-\\nogy and Dermatitis for fuller consideration of this subject. It will be\\nsufficient to note here that acids, alkalies, antimonial and mercurial\\ncompounds, mustard, sulphur, castor-oil, capsicum, arnica, turpentine,", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0343.jp2"}, "344": {"fulltext": "324 INFLA MM A TIONS.\\nchloroform, ether, alcohol, and a long list of other medicaments are\\ncapable of producing eczema when applied to the skin. The same\\nstatement is true of articles manipulated in many of the trades\\nthose, for example, handled by the grocer, the baker, the confec-\\ntioner, the seamstress, the ink-manufacturer, the mason, the cook,\\nthe gardener, the laundress, the painter, the dyer, the printer, the\\ntobacconist, and the chemist. Then, too, the eczema of the person\\nexposed to severe cold, or to intense solar light and heat aided by\\nreflection from water, or even to excessive artificial heat, as the fire of\\na furnace, illustrates the action of other causes named. Pressure- and\\nfriction-eifects are exhibited in the eczema produced by contact with\\ngaiters, the edges of cuffs, trusses, crutches, and corsets.\\nScratching is a fruitful cause of eczema when the skin is affected\\nwith pruritus as a distinct disease or as a symptom of other cutaneous\\ndisorders. Thus, it is efficient in urticaria, scabies, and the prurigo\\nof Hebra in the skin bitten by lice, insects, bedbugs, and fleas (which\\neven without such interference are capable in many cases of inducing\\nthe disorder) and in the lower extremities when the skin of this region\\nis distended by varicose veins.\\nWater is capable of exercising an injurious effect upon the skin to\\nthe extent of producing an eczema whether it proceeds from the sudo-\\nriparous glands in an excessive exudation of sweat, which is not duly\\nremoved by ablution, or is applied externally as a fluid in excessively\\ncold or hot temperatures, or in the vapors of the popular Turkish and\\nRussian baths or, yet again, be rendered irritating by saline or other\\nconstituents.\\nThe causes are at times climatic, the disease being worse in most\\npeople during the cold seasons. Cold winds and sudden temperature-\\nchanges, especially from warm to cold, will often aggravate and pro-\\nlong an existing eczema.\\nThe external sources of eczematous trouble named above should be\\nregarded simply as suggestive illustrations. It should be borne in\\nmind that every contact with the external world sufficiently severe or\\nprolonged to awaken the resentment of the healthy skin may be fol-\\nlowed by the protest of the latter in the shape of an eczema and the\\nsame may be true when even the most trivial external accidents occur\\nto the sensitive skin of certain individuals especially prone to the\\ndisease.\\nThat many eczemas are modified in their course, if not indeed\\ncaused wholly or in part, by various micro-organisms is undoubtedly\\ntrue. Aside from pus-cocci found in pustular eczema, however, no\\ndefinite parasites have yet been demonstrated to be effective either in\\nthe production or in the modification of eczema. The healthy skin is\\nthe habitat of many forms of parasites, chiefly vegetable, and every\\nskin-lesion is open to infection with any one of the many micro-organ-\\nisms with which it may come in contact hence, it is probable that the\\ndisease, once begun, is modified by secondary infections of one kind or\\nanother. Secondary pus-infection is frequently recognized, and the\\nmanner in which some forms of eczema respond to antiparasitic treat-\\nment leads to the inference that some of the many micro-organisms", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0344.jp2"}, "345": {"fulltext": "ECZEMA. 325\\nfound in the lesions are active in the prolongation, if not in the produc-\\ntion, of the disease. Numerous parasites, including the morococcus of\\nUnna, have been cultivated and described as the cause of eczema, but\\ntheir etiological relations to the disease have not been demonstrated\\nsatisfactorily. 1\\nPathology. The pathological changes in eczema are those of inflam-\\nmation of the skin, varying somewhat with the acuteness or chronicity\\nof the process, and with the character and career of the exudate fur-\\nnished in each expression of the disease. In most cases there is, first.\\na circumscribed or diffused hyperemia of the affected part followed by\\ndilatation and congestion of the blood-vessels of the corium, exudation\\nof serum, diapedesis of white blood-corpuscles, and oedema.\\nThe process probably begins in the papillary layer, from which it\\nextends to the epidermis, to the deeper parts of the corium, and in\\nexceptional cases inward even to the subcutaneous tissue. The oedema-\\ntous infiltration may be quite extensive, producing marked swelling\\nover considerable areas, or it may be slight and circumscribed. At\\ntimes it appears- only about the hair-follicles, producing perifollic-\\nular papules. The cell-infiltration about the vessels of the corium is\\nformed in part of leucocytes, some of which wander outward into\\nthe rete, but is probably composed largely of young connective-tissue\\ncells.\\nThe epithelial changes in eczema vary greatly with the stage, in-\\ntensity, and type of the disease. It is not determined definitely if\\nthese changes are always dependent upon and follow the conditions\\ndescribed above in the corium, or if they are usually, or even rarely,\\nprimary in origin. It is probable that they are secondary to the vascu-\\nlar changes in the corium, though some observers, including Unna and\\nLeloir, believe that in most cases the epithelium is first affected. In\\npractically all forms of eczema there is a parenchymatous oedema of the\\nepithelial cells, especially of the transitional layers, as a result of which\\nthere is imperfect keratinization (parakeratosis) of the horny layers, the\\ncells of which contain some moisture, retain imperfect nuclei, and are\\nexfoliated in scales. In acute erythematous eczema running a brief\\ncourse the epithelial changes may be limited to this parakeratosis, but\\nin most cases they are followed by vesicle-formation in the upper part\\nof the rete. The manner in which vesicles are formed is a matter of\\ndispute. The first vesicles of acute eczema are apparently due to the\\nformation in a number of contiguous cells of a clear space between the\\nnucleus and the protoplasm, which enlarges until there is left merely a\\nmesh work filled at first with serum, and later with serum, fibrin, and\\ncellular fragments. If these spaces become filled with leucocytes as a\\nresult of more active degeneration of the cell-substance, or possibly as\\na result of secondary infection, they become pustules, the contents of\\nwhich dry on the surface, forming thick crusts. In very acute cases,\\n1 For a full discussion of the parasitic and other causes of eczema the reader should\\nconsult the Transactions of the Fourth International Congress of Dermatology, Paris,\\nAugust 2 to 9, 1900; also papers bv Morris, Brit. Jour, of Derm., October, 1898;\\nKoberts, Ibid., 1899, pp. 7 and 6Q Torok, Annal. de Derm, et de Svph., 1898, p. 1073,\\nand 1899, pp. 30 and 37 Sabouraud, Ibid., 1899, p. 305 Leredde, Ibid., 1899, p. 438\\nKromayer, Arch. f. Derm. u. Syph., July, 1900 and Kaposi, Ibid., October, 1900.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0345.jp2"}, "346": {"fulltext": "326 INFLAMMATIONS.\\nwith an abundant exudate, the horny layer may be raised from the rete\\nto form vesicles or bullae. According to Unna, vesicles in the later\\nstages of eczema are due solely to an intercellular oedema.\\nIn eczema rubrum the horny layer is raised from the rete and de-\\nstroyed without true vesicle-formation. The rete is thus exposed\\ndirectly to the air, Or is partly covered by an amorphous coating of\\ndried serum and degenerated cells.\\nIn the later stages of eczema there is more or less hypertrophy of\\nthe rete (Unna s acanthosis), with corresponding enlargement of the\\npapillae, forming papules and elevated, thickened areas. In chronic\\ncases the cell-infiltration and proliferation in the corium become very\\nconspicuous, producing the thickening of the skin so characteristic of\\npatches of chronic eczema. In these cases the papillae are larger than\\nnormal, and the vessels of the corium are dilated and surrounded by con-\\nnective-tissue cells. The process may extend to the subcutaneous fatty\\nlayer, which then loses much of its fat, and becomes dense and attached\\nto the skin. Hypertrophy of connective tissue and lymphatic obstruc-\\ntion with elephantiasic changes may follow. In these cases the sebaceous\\nand coil-glands and the hair-follicles may be partially or entirely\\ndestroyed by undergoing degeneration and atrophy.\\nThe fluid exuded in eczema, in vesiculation, or in a free discharge\\nfrom the surface, is always characteristic. Though in the earliest\\nvesicles it is a simple blood-serum, it soon becomes a yellowish-white,\\nsticky, and syrupy liquid, feebly alkaline in reaction and depositing\\nalbumin in abundance when treated with heat and nitric acid. Exposed\\nto the air, it desiccates in light-yellowish to brownish friable crusts\\nresembling honey or gum.\\nIncrease in the pigment-particles distributed to the epithelia of the\\nrete is characteristic of the chronic forms of eczema, and more espe-\\ncially of those in which the circulation is somewhat impeded by the\\ninfluence of gravity, as, for example, in the lower extremities. This\\nincreased pigmentation is true, however, of all diseases accompanied by\\nan augmented afflux of blood to any part of the body, as, for example,\\nover the surfaces of joints to which for many years stimulating embro-\\ncations have been applied.\\nThe elevation of the body-temperature in the inflamed skin is some-\\nwhat proportioned to the rapidity of the process. In acute eczema\\nsuch elevation may exceed 105.5\u00c2\u00b0 F. (41\u00c2\u00b0 C), while in chronic eczema\\nit can scarcely be appreciated.\\nThe subjective sensations in eczema are due, undoubtedly, to an\\nirritation of the nerve-endings in the corium and rete. It is not known\\nif this nerve-irritation is secondary to other pathological changes in the\\nskin, or if the nerves are primarily active in disturbing the nutrition\\nand function of other tissues.\\nDiagnosis. Though of a dozen consecutive cases of eczema no two\\nmay look alike, yet they all have some characteristics in common and\\nthe diagnosis is usually attended with little difficulty. Eczema in\\nits manifestations is such a protean disease and is, moreover, of such\\nfrequent occurrence, that it is necessary to establish a differential diag-\\nnosis between it and a large number of other cutaneous disorders. The", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0346.jp2"}, "347": {"fulltext": "ECZEMA. 327\\nmore important of these disorders are named below in alphabetical\\norder for convenience of reference, the distinctive peculiarities of each\\nbeing briefly appended. In making a diagnosis it must be remembered\\nthat eczema may coexist with any other disease of the skin, and that\\nit very frequently thus complicates such cutaneous disorders as sebor-\\nrhea, psoriasis, and scabies.\\nAcne. Acne occurs chiefly on the face, the neck, and the back of\\nthe trunk, and its pustular forms may be mistaken for eczema of the\\nsame localities but pustular acne is usually accompanied by a deeper-\\nseated infiltration than the similar lesions of eczema, and this infiltra-\\ntion is also generally limited to the sebaceous glands or the periglan-\\ndular tissue. In eczema the itching is often severe, while in acne the\\nsubjective sensations are those of heat or burning. Comedones inter-\\nmingled with the pustules of acne will aid in distinguishing the two.\\nErythematous eczema of the face is to be distinguished from Acxe\\nRosacea by the more generalized infiltration of the former, its produc-\\ntion of itching, and its greater diffusion over the face while acne\\nrosacea is limited more often to the cheeks, nose, and brow, and to the\\nregion adjacent to these parts. The patch of erythematous eczema is\\nhot, that of acne rosacea is cold, to the touch. The former is seen\\nin infancy, the latter is rare in that period of life. Acne rosacea in\\nmany cases is distinguished readily by the development of visible\\nblood-vessels in the skin of the cheeks or the nasal region. Lastly, in\\nerythematous eczema the eyelids may suffer, while in acne rosacea this\\nis the exception. In severe forms of acne the subepidermic pus-form-\\nation and the resulting scar will prove significant.\\nDermatitis. Dermatitis of artificial origin is to be distinguished\\nfrom idiopathic eczema rather by its history than by special differences\\nin the appearance or evolution of the lesions. In many cases the two\\naffections are indistinguishable. A history of traumatism or of the\\nexternal application of irritant or of toxic articles will often serve to\\ndistinguish the two. When the dermatitis has been produced by an\\nexternally applied irritant the resulting inflammation of the skin will\\noften exactly outline the area of contact. Dermatitis of artificial pro-\\nduction is usually sudden in its onset, the date of which will nearly\\ncorrespond with the time of operation of an exciting cause. The sub-\\nsidence of the symptoms after the withdrawal of the cause will also\\npoint to the nature of the affection. Eczema is also much more capri-\\ncious in its distribution and career than dermatitis.\\nErysipelas. Erysipelas is generally accompanied by febrile symp-\\ntoms in many cases bulla? appear. The affected surface is reddened,\\nmuch more swollen than in eczema, owing to the involvement of deeper\\ntissues, and it exhibits besides a characteristic shining appearance,\\nwhich is always absent in erythematous eczema. The line of demar-\\ncation between the affected and unaffected portions of the skin is\\nusually distinctly defined in erysipelas, ill defined in eczema. Erysipelas\\nis an exceedingly acute affection and spreads from one point to another\\nwith a rapidity that is never noticed in eczema the latter disease,\\nmoreover, usually exhibits under a lens its minute papules or vesicles.\\nIn eczema also, when occurring upon the face in the erythematous", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0347.jp2"}, "348": {"fulltext": "328 INFLAMMATIONS.\\nform, the scalp is usually spared, while erysipelas tends to invade the\\nscalp and the regions covered by the beard.\\nErythema. Eczema is to be distinguished from the forms of\\nerythema which are due to hyperemia only, by the presence of an\\ninflammatory process. The erythema simplex which advances to exu-\\ndation at once transgresses the artificial line of distinction between\\nthe purely congestive and the purely exudative disorders. It must,\\ntherefore, be remembered that many eczemas begin as erythemata, and\\nthat clinically the latter may represent but a stage in the morbid\\nprocess. The discharge in erythema intertrigo results from imprisoned\\nor from chemically altered sweat, and will not stiffen linen as does\\nthe serous exudation of vesicular eczema, for example. Erythema\\nmultiforme, an affection really on the border-line between the two\\npathological classes here sought to be distinguished, will be recognized\\nby the absence of severe itching and the recurrence of the disorder\\nat certain special seasons of the year while Erythema papulosum, E.\\ntuberosum, and E, nodosum display solid elevations of the skin-sur-\\nface much exceeding in size the minute lesions of papular eczema.\\nHerpes. Eczema is so associated with the occurrence of a vesicle in\\nthe minds of many that other vesicular disorders are likely to be con-\\nfounded with it. But in herpes febrilis the vesicles are usually grouped\\nabout the mucous outlets of the body, and when actually under observa-\\ntion they exceed in size the minute and transitory lesions of vesicular\\neczema. In herpes zoster, with the limitation of the eruption in the\\ncourse of a nerve to one side of the body and the production of grouped\\nvesicles of a larger size and more persistent type, there is commonly a\\nhistory of precedent or coincident neuralgic pain. The subjective sen-\\nsation in the skin is a decided burning rather than itching, and there is\\na possibility of the subsequent production of scars.\\nImpetigo. In these forms of disease pustular lesions are usually\\nisolated, do not spring from an infiltrated surface on which other lesions\\nmay be visible, and are unaccompanied by the intense pruritus which\\nis characteristic of eczema. The pustules, moreover, are larger, and\\nthe resulting crusts, as a rule, are bulkier and darker colored than\\nthose in eczema. Again, in pustular eczema the cutaneous affection\\nusually occurs in one or more patches, while in impetigo a dozen or\\nmore isolated pustules may be irregularly scattered over the entire\\nsurface of the body. In impetigo there may be a history of extension\\nof the disease from one member of a family to another.\\nLichen Planus. Papular eczema may be confounded with lichen\\nplanus, but in the latter disease the typical papule has an irregular or\\npolygonal base a flat or umbilicated apex, which is covered with a thin,\\nclosely adherent, varnished-looking scale; and a violaceous or dull-\\ncrimson hue. The papules of eczema have round or oval bases, acu-\\nminate or rounded summits, and are brighter red in color. They also\\nform more rapidly and undergo change of type more frequently than\\nthe more persistent papules of lichen planus. The patches of lichen\\nplanus are more sharply defined than those of eczema, and are usually\\nangular or linear in outline. The lesions of lichen planus on disap-\\npearing leave a characteristic brown or sepia-tinted pigmentation.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0348.jp2"}, "349": {"fulltext": "ECZEMA. 329\\nLupus Erythematosus. Lupus erythematosus greatly resembles cer-\\ntain forms of squamous eczema. The great chronicity of lupus the\\nfirm attachment of the scales the symmetrical distribution of many\\npatches upon the face; the association of some forms of the disease with\\nthe sebaceous glands the definite border of each involved area and,\\nabove all, the discovery of a cicatrix left by the morbid processes will\\nsufficiently distinguish the disorder. In eczema there are usually itch-\\ning, often vesiculation, more rapid extension of the borders of a single\\npatch, and scales much more loosely attached than in erythematous lupus.\\nThe scales of eczema are never provided, as in lupus erythematosus,\\nwith stalactitiform plugs on the inferior surface.\\nMycosis Fungoi des. Mycosis fungoi des, in its earliest stages, may\\nbe indistinguishable clinically from some forms of localized or even\\ngeneralized eczema. As a rule, however, the early erythematous and\\neczematoid lesions of mycosis fungoides can be recognized by their\\ncharacteristic gyrate outlines, assuming, as they do, the shape of a\\nkidney, horseshoe, half-moon, and other fantastic, more or less circinate,\\nforms. These figures may change frequently in form and location, or\\nmay disappear spontaneously, to return in the same or in new sites.\\nThey differ further from eczema in being located on any or every part\\nof the body, independently of external influences, and in failing to\\nrespond to treatment during months or years. After the formation of\\ncharacteristic thickened and elevated plaques the diagnosis is not\\ndifficult.\\nLupus Vulgaris. Lupus vulgaris is readily distinguished from eczema\\nby its more chronic career, by its larger papules and tubercles of dark\\nreddish-broAvn hue, and by every one of its destructive processes, none\\nof which is ever recognized in eczema.\\nPediculosis. As eczema is often induced by lice upon the head, the\\npubes, or the clothing, it is always necessary to exclude the operation\\nof such causes for both diagnostic and therapeutic purposes. Eczema\\nlimited to the pubic region or to the pubic and axillary regions should\\nsuggest careful examination of the skin and the hairs for the discovery\\nof the crab-louse. As for the pediculus corporis, it should be the rule\\nof the physician, invariable and never to be forgotten (whatever the\\nsocial position or refinement of his patient), to search in a suspected\\ncase for evidence of the parasite upon the under surface of the clothing\\nworn next the skin, at the instant of its removal and while the patient\\nsupposes him to be busied with the inspection of the cutaneous lesions.\\nThe excoriations produced by scratching wounds inflicted by body-\\nlice are usually out of all proportion to the amount of skin-disease\\npresent; and this excoriation is the most significant of all symptoms\\nnext to the discovery of the corpus delicti. Head-lice may precede or\\nmay follow eczema of the scalp, but either they or their ova (nits),\\nclinging in numbers to the hairs, will be visible to him who looks\\ncarefully for them.\\nPemphigus and Pityriasis Rubra. The large isolated bullae of pem-\\nphigus vulgaris are never seen in eczema. In pemphigus foliaceus\\nthe lesions are succeeded by the formation of pastry-like crusts, serous\\nexudation, considerable soreness, and the eventual production of an", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0349.jp2"}, "350": {"fulltext": "330 INFLAMMATIONS.\\nextensive and usually fatal exfoliative dermatitis. Marasmus gradually\\nor in some cases rapidly ensues, while, as a rule, itching and infiltration\\nare not present. The disease known as pityriasis rubra is equally rare\\nand fatal, and, though unattended with the production of bulla?, is char-\\nacterized by an abundant epidermic exfoliation itching and infiltration\\nbeing either entirely wanting or insignificant in comparison with the\\nother symptoms present. The scales, too, are papery, large, and thin\\nthere is no vesiculation and moisture, and little, if any, infiltration of\\nthe skin. The integument is, moreover, of a uniformly reddish hue.\\nBoth pemphigus foliaceus and pityriasis rubra are particularly liable\\nto be complicated with chills or with uncontrollable diarrhoea. With-\\nout question, many of the reported cases of so-called pityriasis rubra\\nare instances of squamous eczema or of simple exfoliative dermatitis.\\nHere the localization of the disease to one or more patches upon the\\nbody, the severe itching, and the distinct infiltration of the patch point\\nto the eczematous character of the disease. Observation of such patients\\nwill finally convince the physician, in many cases, that there is occa-\\nsional weeping from the surface.\\nPityriasis Rubra Pilaris. Often this disease resembles in a high\\ndegree, and it may indeed be confused with, the squamous forms of\\neczema. In general there are not found in eczema characteristic\\nlichenoid papules formed about the hair-follicles, with their hyper-\\nkeratinized cap sheathing the follicular orifice. Nor is the selection\\nof the extremities, and especially the dorsal aspect of the fingers, char-\\nacteristic of eczema. In eczema there are usually distinct marks of\\nscratching that may wholly be wanting in pityriasis rubra pilaris; and\\nthe latter has in most cases a more chronic course.\\nPrurigo. In the prurigo of Hebra, a disease exceedingly rare in\\nAmerica, there are infiltration, intense itching, and numerous minute\\nand larger papules. But this disease usually occurs within a year or\\ntwo after birth and lasts for a lifetime, extending generally over the\\ngreater part of the body, sparing only the palms and soles (which\\neczema does not), and is accompanied by inguinal adenopathy.\\nPruritus. In pruritus, often confounded with prurigo, there is itch-\\ning without lesion of the skin save that induced by the nails to relieve\\nthe sensation. Hence, pruritus without scratching will not reveal a\\ncutaneous disease, while pruritus with scratching will exhibit either\\nexcoriations or an eczema induced by the attacks made upon the skin.\\nThe latter condition, however, is rarely noted. The distinction will\\nbe clear when it is remembered, first, that pruritus is usually of a\\nparoxysmal character, being worse regularly at certain hours or seasons;\\nsecond, that pruritus not originating in a cutaneous lesion, but indirectly\\nproducing the latter by the medium of the finger-nails, never exhibits\\nas much cutaneous excoriation as the skin bitten by lice or attacked\\nwith eczema. The impressive features here are always the dispropor-\\ntion between the complaint of the patient and the visible symptoms,\\nand the vast preponderance of all lesions in those regions of the body\\nmost accessible to the hands, such as the anterior faces of the limbs,\\nthe genital region, the lower belly, etc.\\nPsoriasis. Psoriasis and eczema in typical forms are distinct.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0350.jp2"}, "351": {"fulltext": "ECZEMA. 331\\nVariations in type from one to the other furnish many obscure\\ncases.\\nThe following are the chief diagnostic points in -psoriasis: sharp\\ndefinition of contour of patch; abundance and lustrous hue of the\\nscales; absence of moisture; vascularity of tissue beneath the scales;\\nsites of election on posterior aspect of the trunk and extensor surfaces\\nof limbs; chronicity in course; uniformity of lesions; and usually\\nabsence of itching. In eczema there are an ill-defined contour usually\\nscanty scales not having a nacreous hue; a preference for the flexor\\nsurfaces of the extremities, though the disease may occur in any por-\\ntion of the body; generally, at some period in its course, a history of\\nmoisture; polymorphism, as regards lesions; and a marked intensity\\nof subjective sensations. Upon the scalp psoriasis is prone to extend\\nbeyond the hairy border in a fillet stretching across the upper portion\\nof the forehead, thence irregularly down in front of the ears; while\\neczema of the face, when the scalp is also invaded, departs boldly from\\nthe hairy parts to the lower forehead, the lips, nose, cheeks, or chin,\\nregions which are relatively spared by psoriasis. Finally, the two\\ndiseases, in doubtful cases, will generally be distinguished by carefully\\nsearching the entire surface of the body, upon some part of which in\\npsoriasis there will usually be discovered a tell-tale patch of typical\\nappearance.\\nScabies. Scabies is really an artificial eczema induced by the incur-\\nsions of the acarus scabiei, and its lesions are thus those of eczema. In\\nscabies, however, the pruritus is intense and the recently formed\\npapules, vesicles, and pustules are more distinct and isolated than in\\neczema. The discovery of the presence of the parasite, especially if\\nthere be a history of contagion, and the localization of the disease in its\\nsites of preference, will at once determine the diagnosis. Scabies never\\nattacks the scalp. Its sites of preference are in both sexes the fingers,\\nhands, wrists, and axillae; in women the breast and the nipple; in men\\nthe penis; and in children the buttocks. The presence of the acarian\\nfurrow, if the disease has existed for some time, and the appearance\\nof minute blackish dots or points upon or about the lesions, usually\\nsuffice to establish the nature of the disease.\\nSeborrhcea. Seborrhcea and eczema may coexist, either disease pre-\\nceding the other. Typical forms of each are readily distinguished.\\nIn eczema there are infiltration and much consequent itching; in seb-\\norrhcea there is neither. The scales of seborrhcea are more voluminous\\nand greasy than those of eczema, are freely shed from the surface, and\\nare seated usually upon an integument of scarcely altered hue; in\\neczema the scales are dry, scanty, and more firmly attached to an\\nhypersemic base. Seborrhcea of the hairy parts is generally symmet-\\nrically diffused; eczema, though occurring with ill-defined contour, is\\nrarely as symmetrical, usually more acute, and is seldom followed by\\nalopecia. Upon non-hairy portions of the body the same distinctions\\ncan to a great extent be observed. The crusts of eczema removed from\\nthe face generally disclose beneath them an oozing surface, while the\\nunder surface of these crusts never exhibits the stalactite-like prolonga-\\ntions which pass from the under surface of seborrhcelc crusts into the", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0351.jp2"}, "352": {"fulltext": "332 INFLAMMATIONS.\\npatulous orifices of the excretory ducts of the sebaceous glauds. In\\neczema seborrhoei cum the features of both diseases are almost com-\\npletely fused.\\nSycosis. Both the hyphogenous and the coccogenous forms of\\nsycosis are limited to the region of the beard, while eczema of\\nthe hairy portions of the face will usually be found to affect other\\nparts. In eczema the itching is severe, the exudation spreads beyond\\nthe limits of the beard, and the discharge is characteristic while in\\nboth forms of sycosis there is less oozing and the subjective symptoms\\nare trivial. The discovery of the parasite in the root or the shaft of\\nthe hair will at once distinguish the hyphogenous forms of the disease.\\nIn coccogenous sycosis each pustule is perforated by a hair. Eczema\\nlimited to the region of the beard is even rarer than the two varieties\\nof sycosis. The circumscribed indurations and tuberculations of the\\naffection produced by the trichophytons, as well as the loosening of the\\nhairs in their follicles, constitute further distinctive differences.\\nSyphilis. Several syphilitic eruptions resemble certain forms of\\neczema. In the eruptions due to syphilis, however, there is usually a\\nhistory of infection of involvement of the glands and mucous surfaces\\nof ulceration and cicatrices in advanced periods, and, especially in the\\ncase of infants with an eczema-like eruption, of a history of snuffles.\\nThe intense itching of eczema is characteristic of no one of the syphil-\\nides, and the latter are remarkable for their tendency to occur with a\\ncircular or partially circular outline, and to be covered with bulky mal-\\nodorous crusts. A point worthy of note is that compared with chronic\\neczematous affections a syphilitic eruption limited for an equal period\\nof time to one locality will often ulcerate or exhibit evidences of repair\\nby scar-tissue, no such results occurring in eczema.\\nSyphilis of the palms and soles exhibits very distinct outlines in\\nthe usually circular, circumscribed, and deeply infiltrated patches\\npresent, which are often symmetrical in development, or are at least\\nsituated on both sides of the body even if more fully developed\\nupon one limb. Syphilitic pustules upon the scalp usually rise above\\nsuperficial but well-defined ulcers. Syphilitic eruptions encircling the\\nmouth in children are less angry-looking and formidable than those of\\nsevere eczema of the same region, being often made up of flattened pap-\\nules, moist or scaling, grouped in circles about the lips, with mucous\\npatches at the angles.\\nTinea Circinata. In ringworm there should be a history of con-\\ntagion, microscopical discovery of the vegetable parasite, distinct con-\\ntour of all separate patches, and absence of marked subjective sensa-\\ntions and of discharge. These symptoms are not those of eczema. In\\nringworm of the scalp the hairs loosened in their follicles are usually\\neither brittle or are actually broken at a short distance from the scalp\\nthe scales are fine, dirty white, and not torn from the surface by the\\nfinger-nails. In eczema the hairs are unaffected, and their extraction\\nis productive of pain. In ringworm of the body the patches are dis-\\ntinctly circular, are more scaly or papular at periphery than centre,\\nand, moreover, yield with promptness to the action of a parasiticide.\\nOccurring about the thighs and anogenital region, the disease may be", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0352.jp2"}, "353": {"fulltext": "ECZEMA. 333\\ncomplicated by eczema, but the characteristic festooning of the\\nadvancing border of the patch downward along the thigh, or upward\\nover the pubes, will suggest a microscopical examination of the scales\\nscraped from the surface.\\nTinea Favosa. The large, friable, dirty crusts of an old and\\nneglected favus of the scalp might be mistaken for the crusts of\\neczema of the same part but here the exudation is slight, and there is\\nlittle scratching, as in eczema, hence no history of discharge. The odor,\\nmoreover, is characteristic. In case of uncertainty a careful search\\nwould reveal a few characteristic cup-shaped and yellow crusts, or the\\nmicroscope would demonstrate the parasitic nature of the disorder.\\nTinea Versicolor. In this disease, also, the microscope will re-\\nveal, beneath the epidermal plates, the spores and filaments of the\\nfungus which produces the ailment. From eczema the disease is\\neasily distinguished by the absence of infiltration and of any history\\nof inflammation by the very slight subjective sensation it produces\\nby its peculiar fawn- to chocolate-colored, slightly yellowish patches,\\nwhich are covered with superficial furfuraceous scales, are limited to the\\ncovered parts of the body and often to the anterior surface of the trunk,\\nand are readily removed by the action of a parasiticide.\\nUrticaria. In papular forms of the disease there may be a re-\\nsemblance to eczema. This resemblance is more marked in children,\\nas here the two diseases may be intermingled. Characteristic wheals\\noften occur by the side of eczematous patches, but, as a rule, urticarial\\nlesions are less grouped, more generally disseminated, more evanescent,\\nand much less scratched.\\nTreatment. The treatment of eczema usually presents a complicated\\nproblem. The causes of the disease are numerous, frequently obscure,\\nand when discovered are often difficult to remove. Eczema shows\\nlittle tendency to spontaneous recovery, but tends rather to persist, to\\nspread to contiguous or distant parts of the body, and to recur. Al-\\nthough many cases of the disease respond well to local treatment alone\\nif the affected surface can be given absolute rest and kept constantly\\ncovered with the desired dressing, such ideal treatment can rarely be\\ncarried out except in hospital-patients. Moreover, in many cases of\\neczema the general health of the patient must be improved before local\\ntreatment can be effective. The nutrition and functional activity of\\nthe skin depend largely upon the condition of the general system, for\\nthe skin is but one of many organs in a complex organism. It follows\\nalso that every serious disease of the skin must interfere more or less\\nwith the general health. The fear that too rapid a cure of eczema may\\nresult in disease of deeper-seated organs is baseless. The sudden\\nimprovement or disappearance of an acute eczema coincidently with the\\ndevelopment of a pneumonia or other grave disorder may be explained\\nby the rapid withdrawal of a large amount of blood from the skin-\\nsurface to the newly congested organ. The improvement in the eczema\\nis thus a result and not a cause of the deeper-seated disease.\\nThe treatment of eczema requires both local and constitutional\\nmanagement.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0353.jp2"}, "354": {"fulltext": "334 INFLAMMATIONS.\\n(A) Constitutional Treatment. In many cases internal treatment\\nmay be wholly ignored, and eczema be successfully controlled by local\\nmeasures alone, even though there be coincident systemic disease.\\nOften, however, the eczema is an external expression or result of other\\npathological conditions which must be removed before the eczema can\\nbe permanently cured. These systemic disorders vary widely, ranging\\nthrough the whole field of internal medicine, including hygiene. In\\nthese pages a few suggestions only can be given regarding the internal\\ntreatment of eczema, much being left to the practitioner s knowledge\\nof general medicine. It is often necessary not only to relieve disease\\nof other organs, but also to study the patient s temperament, habits of\\neating, drinking, bathing, sleeping, etc., before an obscure cause of a\\nstubborn eczema can be found and removed.\\nDiet. No absolute rule can be laid down regarding the diet in\\neczema. Each individual should be given the quantity and quality of\\nfood that will best nourish his body without interfering with digestion\\nand elimination. The ansemic, strumous, and poorly nourished subject\\nshould be given sufficient fresh beef, mutton, eggs, milk, cream, vege-\\ntables, and other nourishing foods. Cod-liver oil, butter, and other\\nfats, when easily digested, are of special value, as also are the various\\nmalt-preparations, particularly when digestion of the carbohydrates is\\nat fault. In the plethoric, the overfed, the gouty, and in those suf-\\nfering from faulty digestion and elimination, a diet restricted to the\\nlowest point consistent with the health of the individual is often of the\\ngreatest importance. In these cases excellent results are obtained by\\nlimiting the patient to a diet of bread and milk, or of milk alone, or of\\nmilk and seltzer-water, for several weeks. In general, the diet allowed\\nthe eczematous patient should be limited to the most digestible articles\\nof food, and should exclude those (a list of which is given in the\\nchapter on Urticaria) capable of exciting cutaneous irritation. Cooked\\nvegetables, fruits, and a small quantity of fresh meats may be per-\\nmitted but starchy articles in excess, hot breads and cakes, pastry,\\nconfectionery, cheese, pickles and pickled meats, cucumbers, cabbage\\n(both raw and cooked), parsnips, turnips, beans, oatmeal, cracked\\nwheat, pease, celery, shell-fish, salted fish and meats, pork, and veal\\nshould be avoided. Milk, when not the source of constipation, may\\nbe drunk, but not during the meal-hour. Coffee, tea, and cocoa are in\\nthe doubtful list, as they are positively injurious to some patients and\\napparently without effect in others. Tobacco should always be for-\\nbidden to male patients suffering from a serious eczematous attack.\\nAlcohol in every form is contraindicated save in condition of debility,\\nor in case of its previous habitual use in moderation by persons of\\nadvanced years. In gouty patients the dietary should be of the\\nstrictest appropriate to that condition, and in diabetic eczema the regi-\\nmen proper in glycosuria is observed with great benefit in most cases.\\nInternal Medication. There are no specifics for eczema. Such\\nremedies only should be given as are indicated by the general condi-\\ntion of the individual. Over-medication and uucalled-for dosing\\nwith blood medicines is a common error in the management of this\\ndisease. The number of patients presenting themselves for treatment", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0354.jp2"}, "355": {"fulltext": "ECZEMA. 335\\nof eczema, both in dispensaries and hospitals and in private practice,\\nwho have aggravated their condition by medicaments they have swal-\\nlowed is incredibly large. Men and women, infants and adults, those\\nwho have been under the charge of physicians, and those who have\\npurchased drugs of an apothecary at the suggestion of the latter or\\nof their friends, exhibit patches of acute or of chronic eczema aggra-\\nvated by the injudicious use of arsenic, potassium iodide, potassium\\nbromide, Donovan s solution, and other harmful preparations con-\\ntained in the various blood-purifying remedies sold m the shops.\\nThe practitioner whose patient comes to him after making trial of any\\nsuch remedies is strongly urged to set aside the operation of such mis-\\nchievous agents, and to watch the eruption carefully Avhile their effect\\nis vanishing. The result is often marvellous. The chief object of the\\nconstitutional, and also of the local, treatment of eczema is to remove\\nall sources of irritation to the inflamed skin.\\nAn attempt to relieve pruritus by the use of anodynes internally\\nis rarely necessary, and usually aggravates the disorder. Opium and\\nI its preparations increase the pruritus, though in full doses they relieve\\ntemporarily. With some patients, and especially children, full doses\\nI of quinine may relieve itching. Less frequently full doses of calcium\\nchloride, largely diluted with water, may serve the same purpose. In\\nan emergency, chloral, phenacetin, sulphonal, or even the bromides,\\nmay be given, but it must be remembered that, like opium, they are all\\nliable to aggravate the pruritus after the first anodyne effect has passed.\\nIn the management of acute eczema cooling draughts are useful\\nand in all cases occurring in patients who are plethoric, who are con-\\nstipated, or who suffer from other symptoms of imperfect excretion,\\naperients and cathartics are needed. Often a brisk mercurial purga-\\ntive in the form of blue mass or the compound cathartic pill may be\\ni ordered at the outset. Five grains of blue mass or three grains of\\ncalomel may be given each night, followed by a saline laxative in the\\nmorning, for ten clays or two weeks. A tenth of a grain of calomel\\ncombined with sodium bicarbonate may be given every half hour for\\na day or two, and then three or four times daily for two weeks or\\nlonger, if at the same time salines are used to keep the bowels freely\\nopen. The rhubarb-and-soda mixture answers well in some cases.\\nPodophyllin, or the familiar combination, nux vomica, aloes, and bella-\\ndonna, may be substituted for these articles. The saline cathartics,\\nwhether employed in medicinal formulae or in natural mineral waters,\\nsuch as the Hathorn, Carlsbad, Hunyadi Janos, or Friedrichshall, are\\nexceedingly useful in the management of most cases. The following\\nis a valuable combination often advised for cases in which both iron\\nand magnesium sulphate are indicated:\\nR\\nAcid, sulphur, dil., f3u; 8\\n6Q\\nMagnes. sulphat.,\\nlij;\\n60\\nAcid, sulphur, dil.,\\nf#j;\\n8\\nFerri sulph.,\\nBss;\\nSodii chlorid.,\\n3j;\\n4\\nCardamom, tinct. comp.,\\nf3j;\\n4\\nAq. dest.,\\nad Oss\\n240\\nM.\\nFiltra. Sig. A tablespoonful before breakfast in a tumblerful of cool or of hot\\nwater.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0355.jp2"}, "356": {"fulltext": "336 INFLAMMATIONS.\\nAn excellent remedy for some cases is from 15 to 20 drops of a fluid\\ncontaining 2 parts of the fluid extract of cascara sagrada to 1 part\\neach of glycerin and tincture of aloes, the dose to be taken at bedtime\\nor before breakfast in a small glassful of water. A full dose of castor-\\noil on retiring is an excellent remedy in many neurotic cases, and may\\nbe continued for weeks if needed.\\nIn some cases of renal derangement the alkaline diuretics are indi-\\ncated, such as potassium acetate, carbonate, or citrate, administered\\nwith nitre, squills, caffein, or lithium benzoate in from 3 to 5 grain\\n(0.26-0.33) doses before meals, and in gouty cases colchicum, Vichy\\nwater, etc. Distilled or other pure water, or in suitable cases the\\nalkaline spring-waters, taken in large quantities before meals and\\nbetween meals, are very valuable as diuretics and as a means of encour-\\naging elimination. In patients suffering from acid dyspepsia liquor\\npotassse, sodium bicarbonate, or ammonium carbonate may be required.\\nSalol and other intestinal antiseptics are often of value.\\nAloes and iron, or aloes and ergot, are indicated in special cases.\\nWhere diuretics and alkalies are both indicated the following formula\\nis often of service\\nR Magnes. sulphat.,\\nMagnes. carbonat.,\\nColchici tinct.,\\nMenth. pip. ol.,\\nAq. dest.,\\nSig. Two tablespoonfuls in a wineglassful of water every three or four hours.\\nCod-liver oil is indicated in all cases of struma and tuberculosis\\ncalcium phosphate in bronchitis iron in anaemia and chlorosis strych-\\nnine, hypophosphites, and other nerve-tonics in neurotic cases.\\nIn fleshy children affected with eczema capitis calomel internally is\\na valuable remedy, from grain to 2 grains (0.03-0.133) of calomel,\\nwith 2 to 3 (0.13-0.20) of rhubarb, rubbed up with 5 (0.33), of cal-\\ncined magnesia, may be given once in a day to an infant; or -^V of a\\ngrain (0.003) of calomel, rubbed up with sugar of milk, may be given,\\nthree times daily, for ten or twelve days. Small doses of the un spiced\\nsyrup of rhubarb, with or without magnesia, may be required for the\\nconstipation of infants, or from 1 to 3 drachms (4.-12.) each of pow-\\ndered rhubarb and sodium bicarbonate in 4 ounces (120.) of pepper-\\nmint-water, of which a teaspoonful may be administered two or three\\ntimes or oftener daily. Quinine, strychnine, syrup of ferrous iodide,\\nand wine of iron may also be used with advantage when indicated in\\nthese little patients.\\nIn full doses, and especially in children, quinine sometimes acts as\\nan antipruritic. For the same purpose calcium chloride in full doses\\nanswers well in some cases. Antimony in small doses as an alterative\\nand nerve-tonic or in large doses to reduce vascular pressure is often\\nof value.\\nBeside those enumerated above may be named the following articles,\\nwhich, after internal administration, have been reported as efficient in\\nthe hands of various authorities calx sulphurata, viola tricolor, sodium\\n^ss;\\n15\\n3j;\\n4\\nf 3ss;\\n2\\nUj;\\n2\\nfgvj;\\n180\\nM.", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0356.jp2"}, "357": {"fulltext": "ECZEMA. 337\\nhyposulphite, ichthyol, chrysarobin, tar, carbolic acid, sulphur, pilo-\\ncarpine, and turpentine.\\nArsenic, which has been so largely employed by the general prac-\\ntitioner in eczema and in other disorders of the skin, is an uncertain\\nremedy in all cutaneous diseases; it is equally uncertain in eczema,\\nand has unquestionably aggravated as many cases as it has relieved.\\nIts value in some chronic papular and squamous forms of the disease is\\nundoubted, and in small doses as a nerve-tonic it is often of value, but\\nit should never be given in acute cases or where there is any digestive\\ndisturbance. If arsenic, which certainly does possess an influence over\\nthe skin, has been demonstrated to have little or no value in the large\\nproportion of all cases of eczema, what can be said for the host of other\\ndrugs, too commonly employed for a similar purpose, that are inferior\\nto arsenic in their cutaneous effects? Sunlight, fresh air, suitable\\nclothing, and due regime as to pleasure and business, must be, for\\nmany patients, controlled by the physician. These agencies do not cure\\neczema; but they do much to aid in its management; they may do\\nmore, if neglected, to furnish sources of its aggravation. Crocker\\nadvocates counter-irritation over the spine over the nape of the neck\\nfor eczemas of the upper segment of the body over the dorso-lumbar\\nvertebrae for the lower parts. Jackson has used the ice-bag with\\nadvantage in the same way. Counter-irritation of the corresponding\\npart of the lateral half of the body for the relief of an eczematous patch\\nof long standing limited strictly to the other side may also be employed\\nin rare cases.\\n(B) Local Treatment. Local treatment is of value in all cases of\\neczema, is usually imperative, and often is the only treatment necessary.\\nThe remedies recommended for external application in the various\\nforms and phases of eczema are so numerous and varied that barely to\\nmention all would require many pages and not even the expert can\\nbe sufficiently familiar with them all to use each intelligently. A com-\\nparatively small number of remedies skilfully handled will suffice in\\nall but rare cases. It often happens that in a given type of the dis-\\nease a treatment which one physician uses with brilliant success fails\\nutterly to serve a fellow-practitioner who is equally skilful, but who is\\nless familiar with this particular method. One of the most common\\nerrors in the local treatment of eczema lies in the frequency with\\nwhich, in a difficult case, a succession of new medicaments is tried\\ninstead of studying more carefully the details of application of familiar\\nremedies. It must not be forgotten that each individual skin, like its\\npossessor, has its idiosyncrasies. A remedy that in a given type of\\nthe disease will commonly give prompt relief, may in others prove of\\nno benefit and even aggravate the condition. An idiosyncrasy may\\nexist forbidding the use of particular drugs, such as carbolic acid,\\nglycerin, resorcin, etc., or it may prevent the employment of certain\\nclasses of applications, as, for example, ointments, powders, lotions,\\netc. The choice of remedies must further be influenced in each case\\nby a consideration of the type or phase, severity, and duration of the\\ndisease, of the region and extent of surface involved, of the age, occu-\\npation, and climatic and other surroundings of the patient.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0357.jp2"}, "358": {"fulltext": "338 INFLAMMATIONS.\\nThe general objects and principles of treatment in eczema may con-\\nveniently be grouped under the following heads (1) exclusion of\\nall sources of irritation to the skin (2) relief from pruritus, burning,\\nand other morbid sensations (3) antiseptic dressing (4) reduction of\\nlocal congestion in acute, and stimulation of circulation in chronic,\\ncases (5) repair of the horny layer in acute, and destruction of the\\nthickened and abnormally keratinized horny layer in chronic, forms of\\nthe disease.\\n1. Exclusion of all Sources of Irritation. This is the\\nmost important, the most varied, and often the most difficult and\\ncomplex problem of all. Its full solution, however, will in the\\nmajority of cases fulfil all the other indications for treatment. Fre-\\nquently a simple protective dressing is all that is required more com-\\nmonly the object is not so readily attained. The irritation of the skin\\ndue to its malnutrition or to conditions of ill health must be relieved\\nin accordance with the principles of internal medicine, as has been\\nindicated in discussing the internal treatment of eczema.\\nThe exclusion of all sources of irritation necessitates, secondly, the\\navoidance of all injurious external contacts. Only gross ignorance or\\ncarelessness will overlook the fact that the inflamed skin, like the in-\\nflamed bone or the inflamed bladder, calls imperatively for rest. The\\nprevalent idea, however, is that the patient with an inflamed joint\\nretires to his couch or bed, while the patient with an eczema, if his dis-\\nease be not so formidable as to necessitate temporary withdrawal from\\nthe pursuits of business or of pleasure, belongs always to the peri-\\npatetic class. He consults a physician, swallows some medicine,\\nanoints his eczematous skin with a salve, and returns to the vocation\\nin which his complaint was begotten. The baker goes to his baking\\nthe seamstress still pushes her needle through the dyed fabrics which\\nfirst injured her hand the man with an eczema of the thigh walks the\\nstreet with his trowser-leg rubbing the affected surface the nursing-\\nmother with an eczema of the inframammary region still suffers the\\nmilk chemically altered in the heat of summer to flow over the tender\\nsurface of the breast, or in the case of her infant affected with eczema\\nstuffs the folds of a coarse diaper half laundered or yet covered with\\nthe dejection from the bowels between its thighs and over the anal\\nregion. When a patient from necessity or from choice continues in\\nthe vocation or conditions which are largely or wholly responsible for\\nthe persistence of his malady he should distinctly understand that his\\nrecovery will be much slower and more uncertain than it would be\\nwith the rest and protection that every inflamed organ demands.\\nNext is involved the exclusion of all topical irritants (in the hands\\nof either physician or patient) designed to relieve the disorder, but\\nhaving a precisely opposite effect. The number and variety of these\\nmedicaments are far from being commonly appreciated some are useful\\nin advanced stages of the disorder, and harmful in its earlier periods.\\nThese articles, which are generally ordered by persons with a limited\\nexperience in diseases of the skin, represent a long list of stimulating\\nand astringent ointments. Some are employed in sheer ignorance of\\ntheir effects, as, for example, crude petroleum, strong acids and alka-", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0358.jp2"}, "359": {"fulltext": "ECZEMA. 339\\nlies, silver nitrate, turpentine, and concentrated solutions of corrosive\\nsublimate, intended to burn out the disease.\\nLastly, the exclusion of all sources of irritation necessitates protecting\\nthe involved surface from the excoriations and other traumatisms pro-\\nduced by scratching, rubbing, and excessive washing of the eczematous\\nskin, and from the irritation caused by exposure of the inflamed sur-\\nface to the air. The various applications and protective dressings here\\nserve their purpose, but in the case of adults some restraint to pre-\\nvent rubbing and scratching is also needed in the case of infants this\\nrestraint may need to be enforced. Fixed dressings are often of great\\nvalue in immobilizing a part, or in preventing friction, bruising, or\\nother injury to the inflamed surface. A light elbow-splint to prevent\\nflexion of the joint often is of service in keeping the fingers from the\\nface. Most patients have to be repeatedly and forcibly impressed\\nwith the fact that a few minutes of scratching or rubbing, or one\\nuntimely washing of the inflamed surface, or its unnecessary expos-\\nure to the air may undo all that has been gained in several days of\\npatient and successful treatment. This exclusion of all sources of\\nirritation to the skin is essential to the proper treatment of every case\\nof eczema.\\nThe great importance of rest and freedom from irritation of all sorts\\nin eczema is well illustrated by the newborn infant, whose sensitive\\nskin responds early to its first harsh acquaintance with the outer\\nworld by an explosion of eczema. It is a fact of importance that\\nno child is born into the world eczematous. If the nervous system\\na^one were responsible for infantile eczema, such a result might occur,\\nfor that system is not only capable in intra-uterine life of producing\\nclub-foot and other deformities, but also of influencing skin-disorders.\\nIn the case of pigmentary moles visible at birth the lesions are often\\nlocated along the distribution of one or more nerves. If the blood\\nalone were responsible for eczema, the foetus surely might display its\\nlesions, as it does those of syphilis. Animal poisons, as those of\\nvariola and scarlatina, do not spare the unborn child nor is it exempt\\nfrom certain diseases of the integument that are generally regarded\\nas due solely to tissue-changes, since newborn infants are occasionally\\nseen affected with ichthyosis or sclerema neonatorum.\\nWhy is the tender skin of the foetus exempt from every form of\\neczema, and the tender skin of the infant accessible to each by such\\nvarious approaches Will it be responded that the child has begun to\\nrespire and digest for itself; that it has become suddenly strumous,\\ndartrous, rheumic, arthritic, gouty, or herpetic that its standard of\\nhealth is impaired that it is suffering from assimilative, nutritive, or\\nnervous debility, or from any one of the other numberless perturba-\\ntions to which eczema may be a scribed? AYhile nutritive and other\\nconstitutional changes undoubtedly have their influence, it would cer-\\ntainly seem that the difference between the child unborn and the child\\nborn is, as regards eczema, a difference chiefly of skin-protection and\\nskin-exposure. The former enjoys what White has aptly termed a\\nprolonged, placid, subaqueous life. Anointed with unguent and\\nimmersed in its water-bath of grateful temperature, its skin cannot be", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0359.jp2"}, "360": {"fulltext": "340 INFLAMMATIONS.\\nfretted to produce an eczema. The child, abruptly and often rudely-\\nbrought into contact with the outer world, may speedily exhibit the\\nmost formidable symptoms of the disease.\\nIf any apology be needed for the space devoted to this part of an\\nexceedingly interesting subject, it must be based upon the great fre-\\nquency of the disease, the wide diffusion of erroneous doctrines re-\\nspecting its nature and the method of its management, and the mischief\\nresulting from the too common aggravation of the malady in its earliest\\nmanifestations, due largely, on the part of both physicians and laymen,\\nto a lack of appreciation of the fact that an inflamed skin needs rest\\nand protection as much as does any other similarly affected organ of\\nthe body.\\n2. Relief of Pruritus. The itching, burning, and other sensa-\\ntions which accompany eczema are usually largely or entirely allayed\\nby the complete protection of the skin from irritation. Antipruritics\\nare, however, frequently desirable and necessary. Among the best are\\ncarbolic acid, hydrocyanic acid, camphor, menthol, and salicylic acid,\\neach in the strength of 0.5 to 2 per cent, (rarely stronger) in lotions,\\nointments, jellies, pastes, etc. Saturated solutions of boric acid, or the\\nlead-and-opium wash, answer in many acute cases. If a remedy does\\nnot relieve the itching, it should be changed for one that will, unless\\nthe fault lies in the method of application. The most common error\\nin the use of local remedies is found in the five- and ten-minute, or\\nlonger, intervals during which the skin is not protected, either as a\\nmatter of convenience or of appearance or as a result of carelessness\\nin removing and reapplying the dressings. Exposure to the air for a\\nfew seconds only of an acutely inflamed surface may be sufficient to\\narouse a violent attack of itching or burning. The relief of pruritus\\nby the use of drugs internally is considered under the head of internal\\nmedication.\\nThe necessity of relief is so imperious that at times the itching\\novershadows all other symptoms of the disease. He who has never\\nstudied the case of a man, a woman, or a child, possessed with a fuiious\\nimpulse to relieve an intense eczematous pruritus has not yet completed\\nan education in medicine. This fury, for such it really is, has been\\nlikened to the sexual orgasm, with which it is undoubtedly allied, as\\nthe two are not rarely coincident when there is severe anal or genital\\nitching. The features of the patient are drawn he is but half-\\nconscious of his ejaculations and surroundings with his nails, or other\\nobject which he employs, he attacks the too vulnerable skin with an\\nincalculable savagery. In these exaggerated paroxysms nothing but\\nblood will suffice for his relief. Not until the torn and wounded sur-\\nface oozes with red drops at every point does he emit the sigh which\\nindicates that his desire is satisfied. Men and women forcibly with-\\nheld from doing themselves this severe damage will at times exhibit\\nthe muscular spasm, facial expression, and movements of body scarcely\\ndistinguishable from the symptoms of petit mat in an epileptic seizure.\\n3. Antiseptic Dressing. It is not known to what extent eczema\\nmay be due to, or may be modified by, the various micro-organisms\\nthat come in contact with the skin, but severe cases are undoubtedly", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0360.jp2"}, "361": {"fulltext": "ECZEMA. 341\\ncomplicated and prolonged by the action of such bacteria, and it is well\\nin every case, when possible, to prevent their activity. Simple protec-\\ntion does much to accomplish this end, while, fortunately, most of the\\nremedies used as antipruritics are also more or less parasiticidal. In\\ncertain forms of the disease, such as seborrhoeal eczema, sulphur, resorcin,\\nand other parasiticides are necessary.\\n4. Belief of Local Congestion. This is accomplished by posi-\\ntion, compression, internal treatment, and largely by the removal of\\nexternal irritation. Occasionally a direct astringent action may be\\nobtained by the use of lead- water, lime-water, or by some of the rapidly\\ndrying jellies or glycerogelatin preparations. In chronic eczema pas-\\nsive congestion is removed by means of stimulating washes, soaps,\\nointments, etc.\\n5. Repair of the Epidermis. If the preceding indications are\\nfulfilled, repair takes place naturally. It may be aided and hastened\\nsomewhat in suitable cases by the use of very mildly stimulating\\nremedies, such as weak preparations of sulphur, resorcin, ichthyol,\\nthiol, tar, etc. In chronic cases with much thickening of the epidermis\\nthe abnormally and imperfectly keratinized horny layer must be de-\\nstroyed and removed before the process of repair can begin. For this\\npurpose salicylic acid in ointment is especially valuable. Other reme-\\ndies used for the purpose are tar, sulphur, resorcin, chrysarobin, pyro-\\ngallol, etc.\\nLocal Treatment of Different Types and Phases of Eczema. 1. Acute\\nand Subacute Eczema. In selecting remedies for use on the acutely\\ninflamed integument it is always best to begin with one that is mild\\nand soothing, and to make the application to a small surface only, until\\nit can be determined that the preparation is going to operate favorably\\nin the case at hand. So greatly do individuals differ in their response to\\na given remedy that it is often well to order an alternative treatment\\nin case the first does not prove satisfactory. A remedy that induces\\ncomfort and brings relief to the patient will usually do good, while\\none that irritates will almost invariably do harm. One of the most\\nimportant things to be remembered in the treatment of acute eczema is\\nthat the acutely inflamed skin does not tolerate pure water. The skin\\nshould be washed as little as possible, and this without soap and with\\nsoft water or with water that has been softened by the addition of\\nborax, soda, bran, oatmeal, gelatin, or other demulcent, as outlined in\\nthe description of baths in the chapter on General Therapeutics. Hot\\nwater thus prepared and applied either as a lotion, a bath, a fomenta-\\ntion, or by sponging (without rubbing), is frequently grateful and alle-\\nviates the itching. If employed at all, its use should immediately be\\nfollowed, as soon as the part is carefully dried, by the medicament\\nselected for topical application, such as an oily or fatty substance, or a\\ndusting-powder. In exceptional cases the continuous application of\\nthe cold pack may be of value, or, when it can be obtained, the con-\\ntinuous immersion of the inflamed surface, which has been previously\\ncovered with an ointment, in water of a constant temperature. Dur-\\ning the acute stages cleansing of the skin can usually be accomplished\\nbest by the use of olive- or other oil. For the removal of crusts and", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0361.jp2"}, "362": {"fulltext": "342 INFLAMMATIONS.\\nother accumulations a bland oil may be poured frequently over the\\nsurface with gentle inunction or be applied on lint or gauze.\\nEven the oils, however, are at times sources of irritation. They\\nare made more soothing if combined with an equal part of liquor\\ncalcis to form a liniment, as in Carron oil, constituted of equal parts\\nof linseed-oil and lime-water. For the linseed-oil, which has a ten-\\ndency to dry and form a dense coating on the surface, it is frequently\\nbetter to substitute olive-oil, oil of sweet almonds, cod-liver oil, palm-\\noil, or lard-oil, flavored very slightly with bergamot or with lavender\\nto correct the disagreeable odor. The addition of 1 per cent, of car-\\nbolic acid makes the mixture antipruritic and mildly antiseptic. A\\nthick emulsion may be formed by shaking together fresh lard and\\nlime-water. In many cases the value of these dressings is greatly\\nenhanced by surrounding the whole with oiled silk or other im-\\npermeable tissue. Such dressing should not be applied continuously\\nfor many hours at a time for fear of macerating and weakening the\\nskin.\\nPoultices. Flaxseed, linseed, starch, or other poultices may\\nin exceptional cases be applied for a few hours at a time to soften\\ncrusts and other accumulations on the surface. They should not\\nbe retained long enough to produce congestion and maceration of the\\nskin.\\nPowders are useful in acute erythematous or papular eczema, in\\nintertrigo, and occasionally in vesicular forms of the disease. Applied\\nto a discharging surface, powders tend to form coherent crusts which\\nretain secretions and are therefore irritating to the skin. In early\\nstages when the discharge is slight, powders will sometimes succeed in\\nwholly arresting the secretion. For this purpose they are of special\\nvalue in mild forms of intertrigo. To prevent friction of underwear\\nupon the skin the meshes may be filled with a fine powder. In eczema\\nof the hands the gloves may be treated in the same way. For absorp-\\ntive purposes magnesium carbonate is one of the most effective. For\\nuse on dry surfaces zinc stearate, plain or combined with boric acid,\\nsalicylic acid, thiol, acetanilid, etc., is very valuable on account of its\\nlightness, and because it will adhere to any surface over which it is\\nlightly rubbed with the hand. Among other excellent powders may\\nbe mentioned talcum, lycopodium, starch, rice-flour, cimolite, bis-\\nmuth subnitrate, zinc oxide, and calamin. The following formulae are\\ngood:\\nR Acid, boric, Z 8\\nTalc, 3^ J 24\\n01. ros., q. s. q. s.\\nR Acid, boric, \u00c2\u00a3ij 8\\nZinc stearat., \u00c2\u00a3\u00c2\u00bbij 8\\nTalc, ^ss 16\\n01. amygdal. amar., q. s. q. s.\\nM.\\nM.\\nAnderson s powder and others containing camphor relieve pruritus\\nbetter than the simpler powders, but are usually too stimulating and\\nirritating for use in acute cases. In the preparation of dusting-powders", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0362.jp2"}, "363": {"fulltext": "ECZEMA. 343\\nit is of the utmost importance that they be made impalpable by sifting\\nthem carefully through silk bolting-cloth, as they are sources of irrita-\\ntion when they contain gritty particles. Only the best and finest\\ngrades of zinc oxide, talcum, calamin, and other powders should be\\nemployed, as many of the coarser grades found in the market cannot be\\nrendered fine enough for use by any means at the command of the\\naverage chemist.\\nLotions are probably the most valuable preparations in acute and\\nsubacute eczema, and in some of the chronic forms of the disease.\\nThey are especially valuable in moist eczema, where it is necessary to\\nprotect the surface and relieve the itching, and at the same time to avoid\\nthe retention of secretions by the dressing. The chief drawback to the\\nuse of a lotion lies in the necessity of its frequent application to pre-\\nvent drying. This objection may be removed partially by the addi-\\ntion of 2 per cent, or more of glycerin or of tragacanth-mucilage.\\nThe effect of a lotion is further prolonged by the addition of some\\nimpalpable and inert or astringent powder, such as talcum, zinc oxide,\\nbismuth subnitrate, or calamin. The powder, temporarily held in\\nsuspension by shaking the lotion immediately before each application,\\nis thus left as a deposit upon the skin. A similar but less uniformly\\ndiffused effect is produced by the use of a dusting-powder immediately\\nafter the application of the lotion. In moist eczemas a better method\\nis to keep the lotion constantly applied on gauze or other material in the\\nform of wet dressings. Great care must be exercised in the removal\\nof such dressings after they have become dry, for fear of wounding the\\nskin. An effective method is to put a single layer next the surface,\\nwhich is removed but once or twice in twenty-four hours or only when\\nsoiled or stiffened by excretions, while a number of outer and thicker\\nlayers may be changed frequently in order to keep the dressing wet.\\nLotions may be sedative, astringent, or stimulating. Many and\\nvaried formulae are recommended, but few only of the most useful and\\ntypical are given here, together with some suggestions as to their\\noccasional modification. One of the most useful lotions, and one that\\nis easily procured, is the following\\nB Acid, carbolic, 9ij 2\\nZinc. oxid. 5j 4\\nGlycerin., \u00c2\u00a3ij 8\\nAq. calcis, q. s. ad o vn J s a d 240\\n66\\nM.\\nThe quantity of any one or all of the first three ingredients may be\\nincreased or diminished as desired. Where carbolic acid does not act\\nfavorably dilute hydrocyanic acid may be substituted. The zinc may\\nbe replaced partially or wholly by one of the other powders mentioned\\nabove. Tragacanth-mucilage may be used instead of glycerin, or both\\nmay be omitted and half of the lime-water be replaced by an equal\\nquantity of elder-flower water. By the use of one or more of these\\nsuggested changes may be formed the well-known Starting lotion and\\nits modifications, and the several compound zinc-oxide lotions among\\nthe most desirable are", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0363.jp2"}, "364": {"fulltext": "344 INFLAMMATIONS.\\nB\\nAcid, hydrocyan. dil.,\\n3ss-5ij\\n2-8\\nZinc, oxid.,\\nCalamin., J\\naa 3j\\n4\\nAq. calcis, j\\nAq. sambuci, j\\naa 5iv;\\n120\\nM\\nAcid, carbolic,\\n5ss-5ij\\n2-8\\nBismuth, subnit.,\\n35;\\n4\\nTragacanth.,\\ngr. xl\\n2\\n6Q\\nAq. calcis,\\n^viij\\n240\\nM\\nB\\nOccasionally neither carbolic acid nor hydrocyanic acid has the\\ndesired antipruritic effect, even when increased in strength to 5 per\\ncent., or both may be contraindicated for some reason. In such cases\\nfrom 1 to 3 per cent, of menthol, camphor, or chloral may be added,\\nwith sufficient alcohol to hold them in solution. With these additions\\nthe lotion becomes more or less stimulating and must be used in acute\\ncases with great caution.\\nThe following lead-and-opium wash is as useful as the various zinc\\noxide lotions, and in weeping cases with burning or hyperesthesia is\\nusually more acceptable.\\nB Tinctur. opii, ^ss; 15\\nLiquor, plumbi subacetat.\\ndilut., q. s. ad ^viij q. s. ad 240\\nM.\\nTo this may be added, as in the case of the zinc oxide lotion, gly-\\ncerin, boric acid to saturation, zinc oxide, or other powder to be left on\\nthe skin as a deposit, or from to 1 ounce (15. to 30.) of tincture\\nof camphor if this is well tolerated and a more decided antipruritic\\neifect is desired.\\nA saturated solution of boric acid to which has been added 2 per\\ncent, or more of glycerin or tragacanth-mucilage is an excellent appli-\\ncation in moist eczema, and especially in suppurating forms. A weak\\nsolution of potassium permanganate is both antiseptic and antipruritic.\\nBlack wash pure or diluted is effectual in many moist forms of eczema,\\nas are 1 to 10 per cent, solutions of ichthyol and thiol. Excellent\\nlotions for soothing effect are made by adding 1 to 2 drachms (4.-8.)\\nof sodium bicarbonate or biborate to a quart (1000.) of thin oatmeal-\\ngruel or of marshmallow-decoction. For a dry, irritable, and itching\\nezcema, Boeck recommends the following\\nB\\nTalc,\\nAmyli, J\\naa |ij\\n60\\nGlycerin.,\\n3yj;\\n24\\nLiq. plumb, subacet. dil.,\\nfiv;\\n120\\nM.\\nThis is to be diluted with 2 parts of water, and applied with cotton or\\na brush. This lotion is decidedly cooling, but is not indicated in moist\\neczema.\\nThe COMBINED USE OF LOTIONS AND OINTMENTS will often give\\ngood results. The black wash as recommended by Duhring, White,\\nand others is often effective in acute vesicular eczema. The part is", "height": "4344", "width": "2392", "jp2-path": "practicaltreatis00hyde_0364.jp2"}, "365": {"fulltext": "ECZEMA. 345\\nbathed for fifteen or twenty minutes two or three times a day with\\nthe wash, the sediment allowed to remain on the skin, and the whole\\ncovered with a piece of gauze or soft cloth on which has been spread a\\nthick layer of zinc oxide or other simple ointment. The lead-water\\nor the zinc oxide lotions may be used in the same way with simple\\nointments or pastes.\\nAny one of the zinc oxide lotions described above may be combined\\nwith an equal quantity of almond-, olive-, or other oil to form a Lini-\\nment. These combinations are especially good in acutely inflamed\\nsurfaces of considerable extent. As has been stated, they are also\\nuseful for cleansing the surface of crusts and other accumulations. To\\nthis end their action can be hastened and made more effective if an\\nimpermeable dressing be superimposed. For therapeutic purposes,\\nhowever, the rubber and other impermeable dressings are rarely called\\nfor in acute eczema.\\nFor subacute and indolent stages of eczema and for some acute cases\\nmildly stimulating and stronger antipruritic lotions containing tar, car-\\nbolic acid, menthol, camphor, chloral, and alcohol may be used. They\\nshould be tried cautiously and diluted at first. As a rule, they give\\nbest results when applied for a few moments several times a day, the\\npart being kept covered in the interval with an ointment or other pro-\\ntective dressing. The following formulae, which may be modified to\\nsuit individual cases, are to be recommended\\nR Acid, carbolic, 3iss-^ss; 6-15\\nGlycerin., 5ij 8\\nMenthol., Sj-^ss 4-15\\nSpirit, vin. rect., q. s. M.\\nAq. destill., q. s. ad ^viij q. s. ad 240\\nR Liq. picis alkalinus, 3ss-3ij 2-8\\nGlycerin., \u00c2\u00a3ij 8\\nAq. destill., q. s. ad ^viij q. s. ad 240\\nM.\\nLiquor carbonis detergens or Duhring s compound tincture of coal-\\ntar (these preparations are described under Chronic Eczema) may be\\nsubstituted for the liquor picis alkalinus. The fluid extract of grin-\\ndelia robusta in the strength of from 1 to 2 per cent, in water is\\nrecommended by Duhring for some forms of subacute papular eczema.\\nIt should be used with caution, as it frequently irritates the skin.\\nHutchinson recommends the following in dry, subacute eczema\\nR Liq. plumb, subacet., \u00c2\u00a3ss 2\\nLiq. carb. detergentis, \u00c2\u00a3ss 2\\nAq. destill., q. s. ad 3viij q. s. ad 240\\nM.\\nOintments are not, as a rule, well tolerated by an acutely inflamed\\nskin, and are commonly more useful in subacute and chronic eczema,\\nbut there are many exceptions to the rule, and occasionally even an\\nacute vesicular eczema is best relieved bv use of an ointment. In the", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0365.jp2"}, "366": {"fulltext": "346 INFLAMMATIONS.\\napplication of ointments care should be taken that they are properly\\nand freshly prepared, and that the debris of one dressing is carefully\\nremoved before another application is made. Strata of any ointment,\\nthe older next the skin possibly rancid and having imprisoned beneath\\nthem pus or other products of disease are a source of positive harm.\\nIn acute, and especially in weeping, eczemas an ointment is best applied\\nby spreading it evenly on gauze, lint, or other soft material, which can\\nthen be laid upon the part. The salve-muslins devised by Unna\\nfurnish an excellent substitute for ointments; they are clean and effec-\\ntive, and in every way admirable if they can be procured fresh. They\\nare, in this country, expensive, and as they deteriorate rapidly it is\\noften difficult to obtain them in proper condition for use.\\nAmong the best ointments for use on the acutely inflamed skin is\\nthe well-known diachylon ointment of Hebra. It is prepared as\\nfollows to 14 ounces of the best olive-oil are added 1 pound of water,\\nand the whole heated to boiling on a water-bath 3 ounces and 6 drachms\\nof finely powdered litharge are sifted slowly into the liquid, which is\\nthen boiled and stirred constantly until all particles of litharge have\\ndisappeared and there is formed a perfectly homogeneous mass. During\\nthe cooking water is occasionally added as required, and the whole\\nevaporated to the desired consistence. The stirring is to be continued\\nuntil the ointment is cold. While the mass is cooling 1 drop of oil of\\nroses or of oil of lavender is added to each 2 ounces of ointment.\\nWhen properly prepared the Hebra ointment is perfectly homogeneous,\\nis of a light-yellowish color, and is of the consistency of butter. It is\\ntechnically known as the Unguentum diachyli albi of Hebra. The\\nsimple ointment often becomes rancid in two or three weeks, but it may\\nbe preserved for months by the addition of 0.5 per cent, of carbolic acid\\nor formalin.\\nDuhring has modified this ointment as follows 1 part of pure dry\\nlead oxide is rubbed down with 1 part of water, and well mixed with 8\\nparts of the best olive-oil. The mixture is stirred for about two hours\\nover a water-bath near the boiling-point, and is then cooled with\\nconstant stirring until the proper consistence is obtained. The oint-\\nment has been modified by Piffard, and after him by Kaposi, in com-\\nbining equal parts of lead-plaster and vaselin. It may be imitated\\nfairly well by melting together 3 or 4 parts of olive-oil and 4 of\\ndiachylon plaster, and stirring until cool.\\nThe Hebra ointment, though useful often in full strength and even\\nto the exclusion of other pomades, may often be combined with others\\nwith manifest advantage. Thus, 1 or 2 drachms (4.-8.) of it may be\\nadded to the ounce (30.) of lard, cold-cream salve, or cerate, with or\\nwithout the addition of another drachm or two (4.-8.) of zinc oxide\\nointment.\\nThe officinal zinc oxide ointment is an acceptable preparation in\\nmany acute cases equal parts of this and the Hebra ointment make\\nan excellent combination. Any one of these ointments may be reduced\\nwith from one to three times its volume of lanolin, vaselin, or cold-\\ncream salve. The following formula gives an excellent soothing and\\nprotective ointment", "height": "4274", "width": "2377", "jp2-path": "practicaltreatis00hyde_0366.jp2"}, "367": {"fulltext": "ECZEMA. 347\\nR Bismuth, oxid., 3j 4\\nSt: aa 30\\nCerse alb., 3iij 12\\n01. ros., q. s. q. s. M.\\nOther bland and soothing ointments may be made by combining in\\nvarious proportions cold-cream salve, lanolin, vaselin, lard, and simple\\ncerate. The cerates are made sufficiently soft for gentle manipulation\\nby adding 1 or 2 drachms (4.-8. to 30.) of glycerin or oil to each\\nounce of ointment, and they may be flavored with lavender, rosemary,\\nor bergamont, as preferred. These simple bases may be stiffened and\\nrendered somewhat astringent by the addition of from 10 grains to a\\ndrachm (0.60 to 4.) or more of bismuth subnitrate or subcarbonate, zinc\\noxide, or calamin to the ounce (30.). A very thin base may be prepared\\nby mixing equal parts of lanolin, olive-oil, and glycerin. This is espe-\\ncially valuable for use on hairy surfaces. A creamy and cooling base\\nis Unna s refrigerant ointment, which contains lanolin, 10; lard, 20,\\nand rose-water, from 30 to 60 parts. Any of the above bases may be\\nmedicated as desired the most frequent addition being from 5 to 10\\ngrains (0.30-0.60) of carbolic, boric, or salicylic acid, or a similar quan-\\ntity of calomel or white precipitate to the ounce (30.) of salve. With\\nthese unguents may be named glycerole of starch, cucumber ointment,\\nemulsion of sweet almonds, decoction of Irish moss, and Hardy s\\nformula 2 parts of zinc oxide, 8 of glycerin, 30 of cold-cream salve,\\nand 15 drops of tincture of benzoin.\\nThe oleate of bismuth or of zinc is prepared by rubbing up 1 drachm\\n(4.) of the oxide of either metal with 8 (30.) drachms of oleic acid, and\\nallowing the mixture to stand for two hours. It is afterward heated\\non a water-bath, where 10 drachms (40.) of vaselin and 3 (12.) of wax\\nare dissolved in it, and the whole stirred until cold. This ointment\\nis especially useful when employed in papular forms of eczema. In\\npustular eczema ointments containing iodoform, boric acid, iodol, aris-\\ntol, or europhen are indicated.\\nPastes are especially valuable in subacute eczema, and are often\\ntolerated in acute forms of the trouble better than an ointment. A\\nthick paste is rarely indicated in moist eczema, as it prevents escape\\nof the discharge from the surface. Pastes are more cleanly and\\nadhesive, furnish better protection, are more drying, and require less\\nfrequent applications than ointments. They are formed by combining\\na simple powder with an ointment-base, and may be medicated by the\\naddition of various remedies. The following paste recommended by\\nLassar may be taken as a type\\nR Amyl.,\\nZinc, oxid.,\\nVaselin.,\\n3y;\\n8\\n3ij;\\n8\\n^ss;\\n15\\nM.\\nThe substitution of talc for the starch in the above gives a paste\\nwith less tendency to concrete in lumps on the skin. Duhring uses\\nboric acid in place of the starch, and thus produces a stiff and adherent\\npaste. A very smooth and pleasant combination, and one that is also", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0367.jp2"}, "368": {"fulltext": "Sij;\\n60\\n30\\n3j;\\nly,\\n4\\n30\\n348 INFLAMMATIONS.\\nfairly stiff and adherent, is made of equal parts of talc, zinc oxide,\\nvaselin, and lanolin. These pastes serve as bases to which various\\nmedicaments may be added. Those most commonly used in acute and\\nsubacute eczema contain boric, salicylic, and carbolic acids, in the\\nstrength of from 1 to 5 per cent. calomel, white precipitate, ichthyol,\\nand thiol in similar proportions. Other remedies may be employed\\naccording to the indications. As an adherent and drying paste Duhr-\\ning recommends\\n1 Lanolin.,\\nParaffin.,\\nCerae alb.,\\nAq. destill., ^j 30 M.\\nThe lanolin, paraffin, and wax are thoroughly mixed before the water\\nis added. A good drying and soothing paste, recommended by Morris,\\nis made of equal parts of almond- or olive-oil, lime-water, and zinc\\noxide. Unna recommends a paste prepared by mixing 1 ounce of\\nzinc oxide with 2 ounces (30.-60.) each of glycerin and mucilage.\\nTo either of these pastes may be added 1 per cent, of carbolic or\\nsalicylic acid. Other good bases are found in Elliot s bassorin-paste,\\nor Unna s gelanthum, both of which are described in the chapter on\\nGeneral Therapeutics.\\nThe Glycogelatins render excellent service in all dry forms of\\neczema, in which simply protection is required. Certain remedies may\\nalso be incorporated, such as 1 or 2 per cent, of ichthyol or thiol. A\\nconvenient formula is the following\\nR Gelatin, alb., aa ^j; 30\\nZinc, oxid.,\\nOr\\nGlycerin., ^jss 45\\nAq. destill., Jiij 90\\nB Gelatin, alb., 3ijss 10\\nZinc, oxid., 3v; 20\\nGlycerin., ^j 30\\nAq. destill., 3x; 40\\nM.\\nM.\\nThe ingredients are mixed on a hot water-bath and when cool may\\nbe cut in pieces of convenient size for use. Before application a\\nsufficient quantity is placed on a hot water-bath, or in a dish placed in\\na receptacle containing hot water, and applied with a brush. It dries\\nsomewhat slowly and it is well after two or three minutes to pat the\\nsurface with cotton or to cover it completely with gauze. By increas-\\ning the quantity of glycerin a softer and more slowly drying prepara-\\ntion is formed. By lessening the quantity of glycerin and increasing\\nthat of the zinc oxide or gelatin a firmer and more rapidly drying\\nproduct is obtained. Though these glycogelatins serve their best\\npurpose in the dry forms of the disease, there are few forms of\\neczema in which they may not at times be used with benefit. In sub-\\nacute and indolent types Pick s gelatin sublimate is useful. This is\\nprepared by mixing 30 grammes of gelatin with sufficient water to", "height": "4274", "width": "2377", "jp2-path": "practicaltreatis00hyde_0368.jp2"}, "369": {"fulltext": "ECZEMA. 349\\nliquefy it on a water-bath, and evaporating to 75 grammes 25 grammes\\nof glycerin and 5 centigrammes of corrosive sublimate are then added.\\nThe product must be melted before applying.\\nIn acute erythematous eczema Pick s Tragacanth Varnish lini-\\nmentum exsiccans is a very acceptable remedy in that it is easily\\napplied without heating, dries quickly, is clean, and distinctly cooling.\\nIt is composed of tragacanth, 5 glycerin, 2 and boiling water, 93\\nparts. To this may be added 1 or 2 per cent, of boric or carbolic acid,\\nor from 2 to 5 per cent, of some simple powder, such as zinc oxide.\\nThe tragacanth must be soaked for several hours in a part of the water\\nand thoroughly triturated before the other ingredients are added.\\n2. Subacute Eczema. Attention has already been called to the fact\\nthat no sharp line can be drawn between acute, subacute, and chronic\\neczema, the degree of inflammation in any given case varying from\\ntime to time. Most acute cases, however, are followed by a longer or\\nshorter period of subacute or chronic inflammation. In proportion as\\nthe disease progresses to the subacute or chronic stage the various\\ntopical medicaments employed may be changed in character so as to\\nproduce an astringent or stimulating effect upon the part. The utmost\\nskill and prudence, however, are needed at this juncture, and changes\\nshould be made cautiously, for it is at this time that the disorder is\\nreadily awakened to renewed activity, a turn of affairs which is espe-\\ncially annoying to the patient, and particularly so to the practitioner\\nif there be a suspicion (truth to tell, often too well founded) that the\\naggravation has been due to the treatment.\\nAgain, many cases of eczema are subacute and indolent from the\\nbeginning, yet are liable at any time to present acute manifestations\\nconsequently in beginning the treatment of an apparently subacute case\\nit is well to use mild measures first, gradually changing to those stronger\\nand more stimulating.\\nThe treatment of subacute eczema varies from that of the acute type\\nchiefly in demanding more stimulating remedies and those having a\\ngreater antipruritic effect. For this purpose many of the substances\\nalready recommended for acute eczema may be employed, but in in-\\ncreased strength. In this phase of the disorder pastes are especially\\nvaluable, as are also the glycogelatins, though occasionally lotions and\\npowders produce the best results. On the other hand, cases occur in\\nwhich ointments make the best applications. When milder measures\\nwill not succeed in a given case the stronger remedies recommended for\\nchronic eczema should be employed.\\n3. Chronic Eczema. The general principles of local treatment of\\nchronic eczema are those of the acute form of the disease except that\\nstronger and more stimulating remedies are used. It must be remem-\\nbered that many chronic eczemas are subject to acute exacerbations,\\nwhen milder and soothing treatment must be adopted for a time.\\nMoreover, chronic eczema appears in such varied phases in different\\nindividuals, and in the same individual in successive attacks, that it is\\nimpossible to select certain formulae and declare that these will be of\\nbenefit in a given type of the disease. It fs only by a careful observa-\\ntion of the general principles and objects of the treatment of eczema,", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0369.jp2"}, "370": {"fulltext": "350 INFLAMMATIONS.\\ndiscussed in the preceding pages, that the varied conditions can be\\nsuccessfully treated.\\nCleansing of the skin should be accomplished according to\\ndirections already given, by means of oils or liniments, though in\\nchronic eczema more vigorous measures can frequently be employed,\\nincluding the occasional use of soap and water, some densely infiltrated\\npatches tolerating and even being benefited by a daily washing. For\\nthis purpose a good toilet-soap, or, when the skin will permit, tincture\\nof green soap may be used. The Sarg glycerin soap is an admira-\\nble substitute for these articles when the skin is tender and where an\\nelegant toilet-preparation can be ordered. The crusts and scales once\\nremoved, subsequent topical applications can be made as required in\\neach case.\\nPowders are useful in chronic as in acute eczema for mechanical\\nprotection, to prevent friction between apposed skin-surfaces or be-\\ntween the skin and clothing. They are often of value when dusted and\\npatted over a paste, thus making a thicker and more cleanly dressing,\\nand one less likely than a paste to be rubbed off. The Anderson and\\nother antipruritic powders are frequently serviceable for application\\nduring the day, when other dressings cannot well be employed on\\naccount of the patient s occupation.\\nLotions are of less value than in acute eczema, but are often use-\\nful for temporary purposes after the skin has been unduly irritated\\nby other dressings. Stimulating lotions or solutions are sometimes\\npainted on the skin and allowed to dry, or are used for a few minutes\\neach day, the surface in the intervals being covered with an ointment.\\nOintments are the preparations most used, especially in the dry,\\nscaly forms of the disease, in which penetration of the remedy is\\ndesired. To serve this end, they should be gently rubbed into the sur-\\nface, which is later covered with more of the same ointment spread on\\ngauze or a soft cloth.\\nPastes often answer better than ointments, especially when protec-\\ntion and drying of the surface are the chief objects of treatment. In\\ncombination with powders as described above, they furnish convenient\\nand effectual applications in most cases of chronic eczema. In many\\ndry forms of the disease either plain or medicated Glycogelatins\\nform the best application. They are of special value in dispensary\\nand other cases in which the physician does not wish to entrust the\\ndressing to the patient, as a gelatin-dressing may often be left in place\\nfor several days or a week. For the application of tar, chrysarobin,\\nsalicylic acid, and a few other remedies to small areas, Collodion and\\nFluid Gutta-percha (Traumaticin) form convenient and cleanly\\nvehicles.\\nApplications in chronic eczema, as a rule, should be more antipru-\\nritic and more stimulating than in acute and subacute phases of the dis-\\nease. The remedies recommended above may be used in increased\\nstrength. This is especially true of the drugs classed as antipruritics,\\nsuch as carbolic acid, creosote, camphor, menthol, and chloral.\\nOne of the most useful remedies in chronic eczema is, Salicylic\\nAcid, It is antipruritic and is very effective in destroying thickened", "height": "4274", "width": "2377", "jp2-path": "practicaltreatis00hyde_0370.jp2"}, "371": {"fulltext": "ECZEMA.\\n351\\nareas of dry horny epidermis. It may be incorporated in the strength\\nof from 2 to 10 or even 20 per cent., in most of the ointments, pastes,\\nand plasters recommended in the preceding pages. In the glycogela-\\ntins more than 2 or 3 per cent, cannot be used without the addi-\\ntion of a fat, preferably 5 per cent, of fresh lard. For small areas of\\ninfiltration with marked thickening of the horny layer salicylic acid is\\nbest used with Duhring s modifications of Pick s salicylated soap\\nplaster. The acid has a tendency to soften the plaster if employed in\\nstrength above 5 per cent. Duhring s formulae are as follows\\nR Emplast. saponis (U. S. P.)\\nliquefact.,\\n3 j;\\n90\\nOlei olivae opt.,\\nfffj;\\n10\\nAcid, salicylici,\\n5ss;\\n2\\nFor a 5 per cent, plaster\\nR Emplast. saponis (U. S. P.),\\n5J\\n30\\nOlei olivae,\\nTT^ xxiv\\n1\\nAcid, salicylici,\\ngr. xxiv;\\n1\\nFor a 10 per cent, plaster\\nR Emplast. saponis (U. S. P.)\\nliquefact.,\\n30\\nAcid, salicylici,\\ngr. xlvnj\\n3\\nFor a 20 per cent, plaster\\nR Emplast. plumbi (U. S. P.),\\n5j;\\n30\\nCerse flavae,\\ngr. xlvnj\\n3\\nAcid, salicylici,\\ngr. cv\\n7\\nM.\\n60\\n60 M.\\n20 M.\\n20\\nM.\\nPlasters made according to the above formulae are adhesive, and are\\nfirm enough to be moulded and kept in rolls. For large surfaces they\\nshould be warmed before applying, to make them spread easily. Pesorcin\\nand other remedies may be substituted for salicylic acid, but resorcin\\nhas a tendency to stiffen the plaster and requires the addition of oil.\\nUnna s salicylated gutta-percha plaster-mulls make elegant substitutes\\nfor the above, but they are expensive and not always obtainable in this\\ncountry. They, moreover, deteriorate rapidly, and if not fresh are not\\nserviceable.\\nTar. This is one of the most valuable remedies, when tolerated by\\nthe skin, for the treatment of chronic eczema. The preparations most\\ncommonly employed are pix liquida (pine-tar), oleum rusci (oil of white\\nbirch), oleum cadinum (oil of cade), and terebinthina Canadensis (bal-\\nsam of fir). Oil of cade, as found in most of the shops, is inferior to\\noleum rusci. The tars are best applied in the form of ointments, but\\nare occasionally painted over the affected surface in a liquid state with\\na camel s-hair brush. From to 2 drachms (2.-8.) of tar, in com-\\nbination with a suitable quantity of potassium subcarbonate, are suffi-\\ncient to add to 1 ounce (32.) of ointment, the proportions suggested\\nbeing varied to suit the requirements of each case,", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0371.jp2"}, "372": {"fulltext": "352 INFLAMMATIONS.\\nIn beginning the use of tar with any individual, weak preparations\\nshould first be employed, and the strength be gradually increased until\\ntolerance of the skin is determined, as an acute dermatitis not infre-\\nquently follows the application of stronger preparations. A convenient\\nmethod is to order one jar of a fairly strong tar ointment, and another\\nof the zinc oxide, the Hebra, or other simple salve. Before the first\\napplication the patient takes a sufficient quantity of the simple oint-\\nment in the palm of one hand and mixes with it a very small propor-\\ntion of the tarry preparation. If no irritation follows this application,\\nthe amount of tar can be gradually increased with each dressing until\\nenough is used to relieve the itching and to cause the disappearance\\nof the infiltrated area, after which a simple paste or powder may be\\nemployed until the skin has regained its normal strength and resist-\\nance. If the application at any time causes an acute dermatitis, sim-\\npler remedies for a time must be substituted. To accomplish the best\\nresults, tar ointments should be well rubbed into the skin or liquid\\npreparations painted on. Sometimes it is well to permit the application\\nto accumulate until thrown off by exfoliation but more commonly,\\nand especially if there be signs of irritation, it is better to cleanse the\\nskin with oil or with soap and water, according to indications, before\\neach application.\\nThe following formulae are illustrations of the manner of compound-\\ning the various preparations of tar\\nR 01. rusci (vel cadini), 3ss-3iij 2-12\\nPotass, subcarbonat., Bj 3ss 1.33-2\\nUnguent, aq. ros., \u00c2\u00a7j 30\\nFt. ungt.\\nM.\\nFor the potassic subcarbonate to 1 drachm (2.-4.) of zinc oxide\\nmay be substituted, or from 2 to 4 grains (0.133-0.266) of red mercuric\\noxide, or yet scruple (0.66) of mild chloride. The vehicle, also,\\nof such ointments may be vaselin, lanolin, simple cerate, or ounce\\n(16.) of either in combination with an equal quantity of diachylon\\nointment.\\nOf fluid preparations may be mentioned alcoholic solutions of tar,\\nJ ounce (10.) of the latter to the pint (500.) of alcohol and in cases\\nin which the detersive action of soap is also needed sapo viridis may\\nbe added as follows\\nR\\nPicis liquidae,\\nf 3j-3ij\\n30-60\\nSapon. virid.,\\nf Sjss-Snj\\n45-90\\nGlycerin.,\\nf\\n30\\nSpt. vin. rectif.,\\nf 3vnj\\n240\\n01. rosmarin.,\\nf 3ss;\\n2\\nM.\\nSig. To be rubbed gently into the skin with a flannel rag.\\nBulkley devised an alkaline solution of tar and caustic potassa,\\nwhich is especially serviceable, as it is miscible with water in all\\nproportions, and which is constituted as follows", "height": "4274", "width": "2377", "jp2-path": "practicaltreatis00hyde_0372.jp2"}, "373": {"fulltext": "ECZEMA. 353\\nR Picis liquidse, f ^ij 60\\nPotassse causticae, ^j 30\\nAq. destillat., \u00c2\u00a7v; 150 M.\\nDissolve the potash in the water, and add slowly to the tar in a mortar\\nwith friction.\\nSig. Liquor picis alkalinus. To be used diluted as a lotion.\\nOf this solution 1 drachm (4.) or more may be added to a pint\\n(500.) of water. As an ointment, the same quantity of the solution\\nmay be added to the ounce (30.) of cold-cream salve, lanolin, or\\nvaselin. It should be remembered, however, that the caustic alkali\\nrenders this preparation exceedingly irritating to a sensitive skin, and\\nit should be employed with caution upon any untested surface.\\nAn excellent fluid preparation is Duhring s compound tincture of\\ncoal-tar, prepared according to the following formula Coal-tar\\n(1 part) should be digested with tincture of quillaja (6 parts), with\\nfrequent agitation for not less than eight days, preferably for a longer\\nperiod, and finally filtered. The resultant product is a brown-black\\ntincture which, upon the addition of water, forms a cleanly yellowish\\nemulsion, the color and certain other characters varying with the\\nvariety of coal-tar used. The strength of the tincture of quillaja\\nshould be 1 to 4 with 95 per cent, alcohol. Five to fifteen minims\\nto the ounce of water is the strength recommended for use.\\nThe formula recommended by Spender, and described in the chap-\\nter on General Therapeutics, is a useful means of testing the efficacy\\nof tar upon an eczematous surface. Olive-oil or cod-liver oil may be\\ncombined with equal parts of one of the tarry preparations and rubbed\\ninto the eczematous skin. When fluid or semifluid compounds of tar\\nare needed upon the scalp 1 drachm (4.) of the article selected may be\\nrubbed up with an equal quantity of glycerin and added to 6 ounces\\nof cologne- water (180.). Creolin is very similar in its action to tar\\nand is miscible with water.\\nHebra disclaimed any special value for sulphur in eczemas uncom-\\nplicated by the acarus scabiei, but in Wilkinson s and other ointments\\nit serves a good purpose. The following formula supplies an ointment\\nrather less severe that has practical efficacy in chronic eczema\\nB\\nPicis liquid, (vel. ol.\\nAdipis,\\nOl. olivae,\\nrusci),\\nJiv;\\nJj;\\ngss;\\n120\\n30\\n15\\nMisce et adde\\nTerebinth. Canadens.\\n^r\\nSulphur, flor.,\\naa\\noJ\\naa 6kj\\nSig\\nTo be applied three\\ntimes d\\naily\\nwith\\na soft brush.\\nM.\\nTo this formula may be added green soap if a stronger effect is\\ndesired.\\nOintments and pastes containing 10 to 30 grains (0.60-2.) of sulphur,\\nand 7 to 15 grains (0.33 to 1.) of salicylic acid in similar proportions\\noften give good results in circumscribed, infiltrated patches of eczema\\nwhich show tendencies to occasional moisture and crusting. Oint-\\nments containing from 1 to 4 per cent, of sulphur favor keratoplasia.\\n23", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0373.jp2"}, "374": {"fulltext": "354 INFLAMMATIONS.\\nIchthyol and thiol, in ointments of the strength of 10 per cent, and\\nless, or in aqueous lotions containing from 5 to 50 per cent, of the\\ndrug, are useful in localized patches of the disease, especially of the\\npapular and scaling varieties. Ammonium sulpho-ichthyol is prefer-\\nable to the natrium compound. Its influence upon the skin seems to\\nresemble both that of the tars and of chrysarobin. Unna s varnish\\ncontaining ichthyol is convenient, as it dries rapidly and is easily\\nremoved by washing. It is prepared as follows 40 parts of starch are\\nmixed with 100 parts of water, to which are added 40 parts of ichthyol\\nafter thorough trituration there are added 1J parts of a concentrated\\nsolution of albumin which should be prepared at a temperature low\\nenough to prevent coagulation.\\nOther remedies which may be added to ointments, pastes, or plasters\\nin strength varying from 1 to 10 per cent, for the treatment of chronic\\neczema are resorcin, chrysarobin, pyrogallol, calomel, and white precipi-\\ntate. Occasionally systemic intoxication has followed the use of these\\nremedies over large surfaces, and they are best adapted to employment\\non small areas. The three first named stain the skin and clothing.\\nOther preparations of mercury may be employed with advantage in\\nsome cases. The use of resorcin in seborrheal eczema is considered\\nwith that subject.\\nAn effective method of treating circumscribed thickened patches of\\neczema is the following a piece of green soap as large as a walnut is\\nspread upon a flannel rag, and rubbed into the eczematous part for\\nseveral minutes, pressing firmly the while, and from time to time\\ndipping it into water in order to produce lather. The duration and\\nfirmness of the rubbing depend chiefly upon the amount of infil-\\ntration present, but to some extent upon the general condition of the\\nskin. The production of an acute dermatitis by too severe treatment\\nshould be avoided. Following the soap-rubbing the part is washed\\nfree from suds with water, carefully dried, and the oil or ointment\\nselected for topical use immediately applied on strips of muslin, which\\nare neatly bandaged to the part. Hebra s diachylon ointment is one\\nof the best for this purpose. The soap must be rubbed in at least\\ntwice every day, so long as any excoriated points appear after its appli-\\ncation. Soap rubbed into the healthy skin will not be followed by\\nsuch effects, the part feeling clean, smooth, and comfortable after it\\nhas been washed. The contrast this offers to the eczematous part is\\nvery striking, the latter presenting numerous intensely red, raw, and\\nmoist spots. The appearance of these red, shining, moist points after\\nthe first inunction suggests to the inexperienced eye that the malady\\nhas been aggravated but they become fewer in number after each\\napplication, and finally disappear, the eczematous surface being then no\\nmore affected by the soft soap than is the surrounding healthy skin.\\nMany circumscribed patches of chronic eczema are greatly benefited\\nby daily painting with a saturated solution of pyoktanin-blue. It is\\nunproductive of pain in the majority of cases in which it is employed,\\nand, as it forms a thin scale over the surface to which it is applied, prob-\\nably serves a good purpose for the time being by the exclusion of air.\\nIt acts also as a parasiticide. When the effect is markedly beneficial", "height": "4274", "width": "2377", "jp2-path": "practicaltreatis00hyde_0374.jp2"}, "375": {"fulltext": "ECZEMA. 355\\nit leaves little to be desired in the way of local treatment. The chief\\nobjection to its employment lies in the staining it produces not only of\\nthe skin, but also of all articles brought into contact with it.\\nAnother valuable agent in the local treatment of these varieties of\\neczema is formalin, a solution representing 40 per cent, of formaldehyd.\\nIt is rarely tolerated by the skin in a strength greater than from 1 to 2\\nper cent.\\nAmong the more severe measures occasionally employed for small\\npatches of eczema which resist milder treatment may be named can-\\ntharides employed as a blister, silver nitrate in crayon or in solution,\\nfrom 3 to 60 grains to the ounce (0.20-4. to 30.), and iodine in combi-\\nnation with carbolic acid. The following formula should furnish a\\nclear vinous-red fluid, which may be applied pure or in dilution\\nR\\nSig.\\nIodin. tinct., 3ss\\n2\\nAcid, carbolic, (cryst.), 3j\\n4\\nAlcohol^ 3i J\\naa 8\\nAq. destillat., ad f^j;\\nad 30\\nIodized solution of carbolic acid.\\nM.\\nIn cases in which there is considerable pruritus, especially in obsti-\\nnate patches of papular eczema, the iodized phenol of Bellamy may be\\nsubstituted for the above. The formula is\\nB S3l;} M\\nCombine with gentle heat and add an equal part of glycerin.\\nSig. Iodized phenol to be applied twice daily with a glass rod.\\nPrognosis. Eczema is an entirely curable disease, but uncertainty\\nattends its prognosis as regards the duration of an attack and the prob-\\nability of the recurrence of a relapse. With respect to the questions\\nmost frequently asked, those relating to contagion, heredity, and\\npersistent lesion-relics, a favorable response can be made but the\\nfact remains that some forms of the disease are insignificant, some\\npersistent, and some particularly liable to relapse from very slight\\nprovocation. Only after careful weighing of all the conditions exhibited\\nby the skin and by the other organs can a reasonable probability as to\\nthe future of the disease be estimated. Eczema is a disease exceedingly\\ncommon, and one subject to aggravation by causes well-nigh innumera-\\nble. Were the physician always in position absolutely to insure his\\npatient a proper mode of living, and the exclusion of all sources of\\nirritation to the skin, the prognosis would be much more satisfactory.\\nIn hospital-patients, over whom such control is more perfectly attained,\\nthe results of treatment may be predicted with some confidence.\\nIn general, it may be said that acute eczema is more readily relieved\\nby proper treatment than are the chronic forms of the disease that\\neczema with a discoverable cause is more manageable than one the\\netiology of which is obscure that eczema of the very young and of\\nthe very old is at times particularly rebellious that the non-discharging\\nphases of the disease are rather more persistent than those accompanied", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0375.jp2"}, "376": {"fulltext": "356 INFLAMMATIONS.\\nby secretion that eczema lingering at the mucous outlets of the body\\n(auditory canal, nostrils, mouth, nipple, anus, vagina) is more obstinate\\nthan when it affects the skin of other parts (shoulder, neck, lumbar\\nregion) that eczema with constant aggravation or complications (fissure\\nof skin of hand, varicose veins of leg, apparatus for anchylosis) is\\nmore stubborn in proportion as these complications or aggravations\\ncannot, from the circumstances of each case, be set aside and, finally,\\nthat an eczema which has long existed, or has repeatedly recurred, as,\\nfor example, with every season of extremely cold or hot weather, is,\\nafter relief, very liable to return. Eczema seborrhceicum (dermatitis\\nseborrheica) affords brilliant results in all well-managed cases. The\\nparasitic eczemas are also particularly amenable to treatment.\\nTopical and Special Varieties of Eczema.\\nEczema of Children. Inflammation of the skin in infants and\\nyoung children is usually acute in type, owing to the delicate struct-\\nure of the skin and to the tendency in childhood to acute rather than\\nsubacute and chronic pathological changes in the various organs of the\\nbody; consequently the eczema of infants is commonly vesicular,\\npustular, or vesiculo-pustular in expression. Though acute in type,\\neczema of young children is frequently chronic in duration a child for\\nexample of two, three, or four years of age may have had the disease\\nin varying degrees and extent since a few weeks after its birth. In\\nthese persistent cases there may be considerable thickening and infiltra-\\ntion of the skin, and periods during which the symptoms are those\\nof a subacute or chronic process but acute manifestations recur at\\nfrequent intervals and usually predominate.\\nThe causes peculiar to eczema of childhood are found in the ease and\\nfrequency with which the delicate skin is injured by external agents,\\nsuch as soap, hard water, rough clothing, dirt, etc., together with the\\nrubbing and scratching that follow pruritus from any cause in the\\npresence of toxins in the blood, resulting from deficient elimination or\\nfrom imperfect metabolism and assimilation of food, due commonly to\\nimproper or irregular feeding in the so-called reflex irritations arising\\nfrom disorders of the alimentary tract, from dentition, and from other\\nsystemic disturbances and in the local infections of the skin with pus-\\ncocci and probably at times with other micro-organisms. That local\\ncauses are responsible, at least in part, for many cases of infantile\\neczema may be readily inferred from the fact that the disease is com-\\nmonly limited to, or most severe in, those regions (the face, scalp, neck,\\nears, wrists, and hands) which are not protected by the clothing. In\\nother instances the origin of the trouble can be directly traced to the\\nirritation produced by some rough article of clothing, or to friction\\nand secretion retained between two skin-surfaces, as in intertrigo. Con-\\nstipation, overfeeding, or an improperly constituted diet are often the\\ndirect or indirect causes of eczema. Many fat infants affected with\\neczema improve rapidly after a mere reduction of the carbohydrates in\\ntheir food. Rickets and other forms of malnutrition furnish a skin\\nlacking in vitality, and therefore predispose to disease. Catarrh and", "height": "4274", "width": "2377", "jp2-path": "practicaltreatis00hyde_0376.jp2"}, "377": {"fulltext": "ECZEMA. 357\\nother disorders of the gastro-intestinal tract are frequently accompanied\\nby eczema, due, seemingly, to reflex irritation. In strumous children,\\nadenopathy, furuncles, and conjunctivitis are frequent complications of\\neczema. Rhinitis or otorrhoea often produces a local inflammation of\\nthe skin, which may spread and persist as a pustular eczema. Sebor-\\nrheal eczema occurs as in adults, but in children is more acute, and the\\nmoist types predominate. According to statistics gathered by Crocker,\\nmore than one-third of all cases of eczema in children begin during the\\nfirst year of life.\\nSuccess in the treatment of these young patients depends, first, upon\\nthe painstaking search for, and removal of, the causes and secondly,\\nupon the care with which the principles of treatment of acute eczema,\\nalready set forth, are carried out in all details.\\nEczema of the Scalp (Eczema Capitis, Eczema Capielitii).\\nWhen the scalp is affected with eczema the symptoms differ somewhat\\naccording to the age of the patient. In adults the erythematous and\\nsquamous varieties of the disease are more common in infants and\\nchildren the pustular variety. In the former the eruption is usually\\ncircumscribed and in patches in the latter it is more diffused. In\\nthe same proportion, also, the former is generally asymmetrically and\\nthe latter symmetrically developed.\\nIn infants and children the pustules rupture early and their contents\\ndry into dirty-whitish, yellowish, or greenish crusts, matting the hairs,\\nthus serving as foci for dust-accumulation and as nests for lice, the\\ncrusts being superimposed upon a reddish, oozing, pus-covered, or\\noccasionally indolent skin, often foul-smelling, and usually complicated\\nby a seborrhoea. The so-called milk-crust is usually a compound\\nof dried pus and altered sebum. The itching is not so intense as in\\nsome other forms of the disease. Post-cervical, pre-auricular, and\\noccipital adenopathy are common, and in strumous children suppura-\\ntion of the affected glands may occur, though this is rare. The causes\\nof this form of disease are evidently associated with local conditions.\\nThe rapidly growing hairs of the scalp are in intimate association with\\nthe numerous and large sebaceous glands of the same part, which at\\ntimes unquestionably respond by an exudative process to the physio-\\nlogical stimulus they feel. The acne of the young man whose beard is\\ngrowing illustrates the same fact. Local irritants are not often wanting\\nto push the disturbed equilibrium into the scale of disease. White\\ncalls attention to the common neglect in removing the pre-natal cap\\nof cheesy material, as well as to rude and unskilful attempts to accom-\\nplish the same end. Extremes of temperature, friction, excess, neglect,\\nand absence of endeavor to wash the scalp, all these contribute to orig-\\ninate or to aggravate the disorder.\\nThe affection when complicated or induced by lice is more common\\nin children than in infants, doubtless in consequence of the greater in-\\ndependence of the former and their gregarious habits. In girls with\\nrelatively long hair the ova, or nits, of the parasite are readily distin-\\nguished, adhering closely to the hairs and accumulated especially about\\nthe occipital region. The itching is usually more annoying than in\\npustular eczema not thus complicated.", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0377.jp2"}, "378": {"fulltext": "358 INFLAMMATIONS.\\nThe erythematous and squamous forms of the disease, rather more\\ncommon in adults, originate frequently in seborrhcea when scratching\\nhas been practised or irritant applications have been made. The erup-\\ntion here usually occurs in asymmetrical patches, or it may be limited\\nto a single patch tolerably well defined in outline, often upon one side\\nof the scalp, not, as in infancy, preferring the vertex. Reference is\\nmade in the chapter on Seborrhcea to a form of eczema of the scalp oc-\\ncurring in adults in whom finger-nail-sized, circular, oozing or slightly\\ncrusted patches are generally disseminated over the affected surface.\\nThey result, as a rule, from the scratching of an obstinate seborrhcea in\\nnervous women. The reddish friable crusts indicate traumatism,\\nthe color being due to exuded blood.\\nThe diagnosis of these forms of disease has been already consid-\\nered. The disorders most commonly confused with eczema of the\\nscalp are psoriasis, seborrhcea, tinea favosa, and tinea tonsurans.\\nIn the treatment of eczema of the scalp in infants and children\\nthe first indication to be met is the removal of the accumulated\\ncrusts. When this removal is harshly accomplished it becomes a\\nfruitful source of further mischief; it is, therefore, necessary to pro-\\nceed with great gentleness. The thorough softening of the crusts\\nis all-important. For this purpose it is necessary to soak them with\\noil and to retain this substance in intimate contact with the scalp.\\nOlive- or cod-liver oil may be selected, and, if needful to correct the\\nodor or for other purpose, 1 drachm (4.) of carbolic acid may be added\\nto each pint (512.), with 2 drachms (8.) of the balsam of Peru. A\\nneat-fitting skull-cap, constructed of Lister protective or of flannel,\\nshould then smoothly be applied, and fastened in place by a light band-\\nage, never by elastic-rubber bands. After several hours of soaking\\nthe crusts should be removed with warm water and spirit-of-soap\\nwashing, and the entire process be repeated until the crusts are com-\\npletely detached. In selecting an article for subsequent medication\\nof the scalp it should be remembered that even infantile eczema will\\nproceed to a natural involution if unirritated hence oleated lime-\\nwater, or oil of sweet almonds alone, will often answer better than an\\nointment, and, even where there is considerable acuity of the inflam-\\nmatory process, lime-water alone, with possibly a small quantity of\\nglycerin added, will be effective. In other cases lime-water can be\\nmedicated better with calomel or with zinc oxide. As the discharge\\nand crusting cease ointments instead of oils and lotions may be\\nemployed. The ointment is to be gently rubbed over the surface with\\nthe tip of the finger, and the skin afterward protected with suitable\\ndressing, such as a gauze-cap. Good ointment-bases for use on the\\nscalp are lanolin, vaselin, equal parts of lanolin and oil, or equal\\nparts of glycerin, lanolin, and oil. The following remedies may be\\nincorporated in strength varying from 1 to 5 per cent. carbolic, sali-\\ncylic, and boric acids calomel, white precipitate, ichthyol, sulphur,\\nresorcin, and tar. In children and in acute cases strong preparations\\nmust not be used. When the seborrhceal element is at all pronounced\\nthe treatment is that of seborrhceal eczema.\\nIt is rarely needful to cut the hair unless nits be found, though in", "height": "4274", "width": "2377", "jp2-path": "practicaltreatis00hyde_0378.jp2"}, "379": {"fulltext": "ECZEMA. 359\\npublic charities it is a more expeditious method of arriving at the\\nend when a nurse has to dress the heads of several children in a\\nsingle ward. Lice when present may be destroyed by the application\\nof petroleum, bichloride lotions, or alcohol. The nits are removed\\nwith alcohol or with cologne-water from hairs which it is not desirable\\nto cut. In adults, especially in women, the hair should be spared,\\nwhile the patient is warned that the loss of the growth upon the scalp\\nmay be considerable. Where an obstinate seborrhcea is followed by\\neczema the latter may be succeeded by alopecia in the absence of\\nseborrhoea the hairs are usually reproduced. It is rarely necessary to\\nemploy the skull-cap in adults, since one can succeed in insuring the\\nnecessary applications by directing the attention of the patient to the\\nnecessity of care and thoroughness.\\nAs the disease in both classes of patients advances to a subacute or\\nchronic stage the treatment may be made more stimulating. In the\\ncase of infants, however, stimulating topical remedies are very rarely\\nto be employed. An eczema of the scalp that has once entered upon\\nresolution, in an infant or a child, should generally be soothed and\\nprotected.\\nMany children thus affected are in excellent general health, and\\nrequire no internal medication. The prevailing tendency among the\\nlaity and even among many practitioners to dose these little ones with\\nmercury, arsenic, iodides, and other blood medicines cannot be con-\\ndemned too severely. Frequently, however, the general health needs\\nattention. Proper nourishment, elimination, and hygienic surroundings\\nshould be sought in every case.\\nThe treatment of erythematous and chronic eczema of the scalp in\\nadults is described under eczema seborrhoeicum.\\nEczema of the Face (Eczema Faciei). Erythematous eczema\\nof the face in adults is projected prominently among the varieties of the\\ndisease by its uniformity of type. It occurs in early and in middle\\nlife and in advanced years, and is a particularly intractable ailment.\\nIn well-marked cases the forehead, cheeks, eyelids, and nose of the\\npatient are involved, exhibiting an infiltrated, usually dusky-red, often\\nsymmetrical patch of disease, the affected surface being slightly ele-\\nvated above the level of the sound skin. This surface is uniformly\\nsmooth and reddened occasionally, near the root of the nose and\\nabout the lower line of the forehead minute, closely set papules are\\nvisible. Very slight oozing, especially after irritation, may be noticed.\\nAt the height of the disease, or in its involution, exceedingly fine\\nscales form, which are scarcely perceptibly shed from the surface.\\nThe eyelids, especially the lower lids in advanced years, become puffy.\\nThe line of demarcation of the attacked surface is unusually distinct,\\nand rarely invades the scalp-border or the region of the beard. Itch-\\ning is at times intense, the patient bitterly complaining of it and\\nusually preferring to rub the face with the hands or with pieces of\\ncloth. Sometimes, however, the face is Avell scratched with the finger-\\nnails and excoriations and blood-crusts disfigure the countenance. Pa-\\ntients of intelligence usually describe the itching as paroxysmal and\\nas starting at the root of the nose, wdience it travels upward over the", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0379.jp2"}, "380": {"fulltext": "360 INFLAMMATIONS.\\nforehead and laterally to the brows, often in the line of the supraorbital\\nnerves. At the root of the nose the exudative process is most marked.\\nThe eruption is seen also in asymmetrically disposed patches of various\\nsizes, with islets of sound skin between. In typical cases the hairs of\\nthe eyebrow are reduced to a stubble by constant rubbing. In resolu-\\ntion of the symmetrical form this condition of the eyebrows is com-\\nmonly observed.\\nPatients thus affected are often those whose faces have especially\\nbeen exposed to irritation, such as locomotive-engineers, pilots of sea-\\ngoing vessels, mechanics in trades in which the hands are soiled with\\nirritants and afterward applied to the face, and women spending hours\\nof each day over the laundry-tub or the kitchen-stove. In each class\\nthe operation of the cause is made manifest by the exacerbation of the\\ndisease after exposure.\\nThe affection is most commonly mistaken for erysipelas, a disorder\\nfrom which it is readily differentiated by the chronicity of its course.\\nThe latter feature is particularly characteristic of this form of eczema,\\nwhich is rarely completely relieved after the age of sixty within a\\ntwelve-month, and which, when it has existed for a long period of\\ntime, is particularly obstinate under the best treatment, recurring with\\nexasperating frequency upon exposure of the face to atmospheric\\nchanges. The great vascularity, abundant supply of sensory nerves,\\nand necessary exposure of the face explain this peculiarity. In its\\nmanagement the lotions and dusting-powders described under the treat-\\nment of acute eczema fulfil an important part. In some cases pastes,\\nointments, plasters, or the glycogelatins give better results than lotions\\nand powders. Soothing applications should always be first employed\\nand more stimulating applications may be tried later. In many cases\\nPick s linimentum exsiccans or tragacanth-glycerin mucilage fur-\\nnishes a pleasant and effective application.\\nIn obstinate cases tar and other stimulating remedies recommended\\nfor chronic eczema should be employed. It is well to remember in the\\nmanagement of any case that while a tarry application may be well\\ntolerated over one part, as, for example, on the cheeks and near the\\nnose, in another part, as, for example, over the eyelids, a zinc-salve\\nmay better be employed in the same individual.\\nIn patients of younger years and especially in infants the face is\\nlikely to display vesicular and pustular phases of the disease, forms\\nmore often of acute eczema, and correspondingly more manageable.\\nThe itching, and especially the burning sensations, are prone to be\\nsevere and crusts rapidly form. In infants the picture presented is\\noften similar to that seen in the scalp, except that there are no hairs\\nto be matted into crusts and there is often a reddish blush at the\\nedge of the patch or where the crust has been removed, the redness of\\nthe oozing surface being somewhat more marked than the similar\\npatches on the less vascular scalp. The scratching in these little\\npatients is severe, crusts being torn off in part or wholly blood-\\ncrusted excoriations are common. In this way the area of surface\\ninvolved is clearly extended, sleep is greatly disturbed, and the irrita-\\nbility and fretfulness of the child bear heavily upon its general nutri-", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0380.jp2"}, "381": {"fulltext": "ECZEMA. 361\\ntion. In severe cases of long standing the mental tone of the little\\nsufferers becomes singularly perverted and their character unquestion-\\nably changed. The eczema of the cheeks and chin of infants is often\\nlargely due to irritation reflected from eruption of the teeth.\\nThis chain of formidable symptoms well linked together will often\\nbid defiance to the most skilled effort to impart ease to the tormented\\nskin. In such cases the harness employed by White, of Boston, fills\\nan important office a skull-cap, made of firm old cotton or linen\\ncloth, is closely fitted to the calvarium, and a mask of the same material\\nis shaped to the face with exactly placed apertures for the eyes, nose,\\nmouth, and ears. This mask is gathered in beneath the chin, and laps\\nover two inches at the back of the head it may be used only during\\nsleep, or, in aggravated cases, also during the hours of wakefulness. A\\nspecies of straight-jacket is made by passing the head of the child\\nthrough a hole in the closed end of a small pillow-case, which is\\nthen drawn down over the body and arms, and the latter confined at\\nthe sides by stitching or pinning the case together between the trunk\\nand the upper extremities. This jacket is finally secured by similar\\nmeans between the thighs. When it is necessary to imprison the\\nlower extremities they are similarly secured by pins within the pillow-\\ncase and the outer edge of such trousers can be fastened to the bed\\nor the cushion on which the child reclines. Of course, this treatment\\ndoes not preclude the employment of the washes, ointments, etc.,\\nwhich are to be neatly applied next the skin beneath the trousers\\nor the jacket. The ointment or other application is thus retained\\nin position, rest and protection from all external irritation are given\\nto the tormented skin, and its natural tendency to repair soon brightens\\nup the case.\\nFor the treatment of these cases are recommended the black wash\\nand zinc-salve treatment, the diachylon salve, Lassar paste, boric acid\\nointment, lead lotions, glycerole of starch, and other preparations and\\nmethods described in full in the treatment of acute eczema. These\\ncases are often very capricious in their course, and treatment may have\\nto be changed frequently to meet the varying conditions.\\nEczema of the Lips (Eczema Labiorum). Reference has already\\nbeen made to the obstinacy of eczema occurring near the mucous out-\\nlets of the body, a result due, probably, to the secretion furnished by\\nthe adjacent mucous tracts. The lips furnish an illustration alike of\\nthis pertinacity and aggravation. Their frequent motions in mastica-\\ntion and articulation aggravate an eczema, which is, moreover, apt to\\nbe teased by a no less frequent thrusting out of the tongue (where there\\nis no beard) to wet the parts with mucus and saliva. Vesicular, pus-\\ntular, squamous, and erythematous lesions occur at one point, or along\\nthe entire line of the lip, with frequently resulting crusts and fissures.\\nThe vermilion border of the lips commonly participates in the process.\\nThe lips become hot, and sometimes much thickened by the swelling\\nand infiltration, their mucous faces being rarely implicated. Scarlet,\\ndull-red, and other peculiarly purplish hues of the vermilion border\\nbecome visible. The parts are more picked than scratched, though\\nthe itching at times is severe. The pustular and vesicular forms are", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0381.jp2"}, "382": {"fulltext": "362 INFLAMMATIONS.\\nmore common in children. The erythematous form, its reddened out-\\nline roughened by scales evenly projected beyond the vermilion\\nborder, is rather an affection of maturer years. In many cases the\\ndisease is aggravated by nasal discharges which flow over the upper\\nlip, giving the latter an elephantiasic aspect or even the appearance\\nof an animal s snout. In eczema of the hairy lip the symptoms and\\ntreatment are those of eczema barbae.\\nThe diagnosis is between hyphogenous sycosis, herpes labialis, epi-\\nthelioma, and syphilis. The first is accompanied by loosening of the\\nhairs, caused by a vegetable parasite the second is vesicular in lesion,\\nbrief of duration, and trivial in severity the third is a disease of ad-\\nvanced years rather than of early and middle life, and is accompanied\\nby characteristic induration and ulceration and not by itching. Syphilis\\nis fond of the angles of the lips in most cases, when thus limited,\\ntypical mucous patches of the mouth can be discovered. The lesions\\nof syphilis at the angles of the mouth are seldom linear fissures, but\\nare more often definitely outlined erosions, secreting a puriform mucus.\\nPustules and resulting crusts of the lips and the nose in female children\\nare often eczematoid features due to the picking and scratching caused\\nby lice upon the scalp.\\nIn male patients the pipe, the cigarette, and the cigar, as well as the\\ntobacco chewed and expectorated, may aggravate the malady. In all\\ncases it is obstinate and calls for either emollient, stimulant, or pro-\\ntective applications. In eczema of the lips displaying acute and painful\\nsymptoms frequent fomentations of the part with soft rags dipped in\\nhot mucilaginous and alkaline waters will aid in controlling the swell-\\ning and in alleviating the pain. After such bathing some soothing\\nointment should be applied. In chronic cases, in which stimulation is\\ndemanded, this can be effected at the time of dressing, the parts being\\nsubsequently protected by collodion or other material. Carbolic acid\\nand silver nitrate are often needed for such dressing.\\nEqual parts of tincture of benzoin, alcohol, and glycerin applied\\nfrequently during the day is an excellent combination for the ver-\\nmilion border. For protecting this portion of the lip cold-cream or\\nother simple salve to which has been added enough white wax to make\\nas stiff an ointment as can be spread with the finger, is recommended.\\nA drachm (4.) of the compound tincture of benzoin with 5 to 20\\n(0.33-1.33) grains of tannin may often be added to such ointment with\\ngood results.\\nCheilitis Glandularis Aposthematosa, Myx adenitis Labi-\\nalis. This is a rare form of chronic inflammation of the lips which\\nmight be confused with eczema of this region, and which has been\\ndescribed by Volkmann, 1 Purdon, 2 and Duhring. 3\\nThe disease consists in a firm swelling, usually of the lower lip.\\nthe mucous glands of which are congested and exude a muco-purulent\\nsecretion,, which dries and forms crusts. There are few subjective\\nsensations, but the condition is chronic and rebellious to treatment.\\nDuhring states that the condition is usually associated with a depressed\\n1 Arch. f. path. Anat. u. Phys., Bd. 1, S. 142.\\n2 Brit. Jour, of Derm., Jan., 1893. 3 Cutaneous Medicine, p. 403.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0382.jp2"}, "383": {"fulltext": "ECZEMA. 363\\nstate of the nervous system. The treatment recommended consists in\\nwarm fomentations, simple lotions, and the occasional use of more\\nstimulating preparations, such as alkalies and silver nitrate.\\nEczema of the Nostrils (Eczema Narium). Eczema of the nos-\\ntrils is naturally often associated with a chronic coryza. Inasmuch as\\none of the common symptoms of hereditary syphilis is the snuffles,\\nthe physician should carefully exclude the possibility of such disorder\\nin every instance when an infant with coryza exhibits an eczema\\nof the nares or of the lips. The age of the little patient, an inspection\\nof its anal region (which should never be omitted in infantile eczema),\\nand the history of the case will throw considerable light upon this\\nimportant question.\\nWhether occurring in the adolescent or the child, the disease may\\nlinger only upon the alee in the pustular or the squamous form, or may\\nblock up the nares with crusts. In infants this obstruction enforces\\nrespiration with an open mouth, and the grasp of the nipple by the\\nlips is thus interrupted either by respiratory acts or cries of agitation.\\nThe Schneiderian membrane participates in the inflammatory process\\nand pours out its secretion upon the eczematous skin. This membrane\\nwhen inspected is seen to be either raw and succulent, or in a condition\\nanalogous to that seen in pharyngitis sicca, is dry, glazed, and free\\nfrom discharge. The nostrils are often thickened in consequence of\\ninfiltration or are fissured, especially at the lines of the nares, laterally\\nand inferiorly. In severe cases, and when the lips participate in this\\nprocess, the pouting, swollen, and distorted organs suggest the snout of\\nthe lower animals. Adults, as a result, frequently suffer from cocco-\\ngenous sycosis and furunculosis.\\nCare should be taken to exclude syphilis in making a diagnosis,\\nbearing in mind the fact that the pustular syphiloderm (which see) fre-\\nquently selects the furrow on either side of the nostrils for its evolution.\\nIn treating these cases all crusts should be removed and the parts\\ncarefully be protected. Picking of the nose in children should be\\nprevented, if needful, by the straight-jacket. Pencillings with com-\\npound tincture of benzoin, iodized phenol, silver nitrate, or collodion\\noften prove serviceable.\\nIn softening crusts oil may be freely used. For this purpose the\\nwarm carbolized oil-spray of the atomizer or a glycerin-lotion answers\\nwell. After softening and removal of the* crusts a simple ointment\\ncontaining from 5 to 20 grains (0.33-1.33) of boric acid, or from 2 to\\n10 (0.13-0.66) grains of white precipitate to the ounce (30.) may be\\nused. A weak citrine ointment is often serviceable. When the dis-\\nease extends well up the nares Neumann employs bougies made by\\ncombining 2 grains (0.133) of zinc oxide with 16 grains (1.06) of\\ncocoa-butter. Hardaway recommends equal parts of cold-cream salve\\nand glycerole of lead subacetate.\\nEczema of the Ears (Eczema Attritjm). The ears are affected\\nwith eczema, both in infancy and maturer years, rather more often in\\nwomen and children, the disease being limited to the whole or part of\\nthe organ, or extending backward over the post-auricular region, or\\ndownward over the ramus of the superior maxilla. The eczema may", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0383.jp2"}, "384": {"fulltext": "364 1NFLA MM A TIONS.\\nbe acute or be chronic, and commonly originates in seborrheic eczema\\n(which see) of the scalp or the face, but may find its origin in chronic\\nor catarrhal discharges from the external auditory meatus in the\\ngrowth of aspergillus in the same canal in exposure to temperature-\\nchanges, especially with high winds in frostbite in the irritation set\\nup by pediculi and by the auricular rim of the frame of spectacles in\\nthe toxic effect induced by the hook of cheap ear-rings and dyed bonnet\\nribbons in the traumatism of ear-piercing and in the habit of unnec-\\nessarily picking the ear to relieve it of wax or of trifling sensations of\\nirritation.\\nThe pustular and moist forms are common at the superior, inferior,\\nand posterior boundaries of the pinna, where a linear fissure is liable to\\nform in the line of the angle made by the auricle with the plane of the\\nadjacent integument. The motions impressed upon the ear by handling\\nit, or by placing the hat on the head and tying hat-strings over the ear,\\nalways tend to aggravate the disorder. Long hairs worn over the ears\\nhave a similar effect by the production of friction and the retention of\\nheat. The lobules are likely to display the erythematous and scaly\\nphases of eczema, becoming infiltrated, and having a deformed appear-\\nance and lurid-red color, the affection pursuing an indolent course.\\nThe lobules alone of both ears in young women may similarly be\\naffected, and may exhibit these phenomena for consecutive years. Often\\nthe chronic inflammation lays the foundation for a keloid growth, an\\naccident of inflammatory processes in other parts.\\nSometimes the entire auricles are uniformly dark red, infiltrated,\\nalternately weeping and scaling, and project to a noticeable extent from\\nthe side of the head in consequence of their increase in bulk. The\\nitching is usually more annoying than severe, being accompanied by a\\ncharacteristic sensation of tenseness and fulness of the part. Like the\\neczema which occurs at the other mucous outlets of the body, the affec-\\ntion in the meatus is particularly obstinate when it assumes a chronic\\nform. Symmetry to the extent of involving both ears, though com-\\nmonly to a different degree in each, is rather the rule than the exception,\\nand is doubtless due to the simultaneous operation of effective causes.\\nThe diagnosis is between erysipelas, seborrhea (which occasionally\\noccurs in the concha of the auricle), erythema simplex and multiforme,\\nand dermatitis calorica.\\nThe treatment should at first be soothing and protective by zinc salve\\nor diachylon ointment or by soothing and astringent lotions afterward\\nit should be stimulating. A firm bandaging of the ears to the head\\nmay be required to support them, to prevent irregular pressure (of the\\nhead upon the pillow), and to retain external medicaments. In chronic\\ncases stimulant applications are often well tolerated, and sulphur,\\nsalicylic acid, ichthyol, and tar ointments here play an important\\npart. Treatment appropriate to the otitis externa or the aspergillus\\nmay be required. Bulkley recommends a tannin ointment, 1 drachm\\n(4.) of tannin to the ounce (30.), deeply and thoroughly passed into\\nthe meatus on a camePs-hair brush. French authors generally advise\\nsmall tampons smeared with an ointment and left in the canal\\nBurnett employs 2 drachms (8.) of oil of tar to 1 ounce (30.) of al", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0384.jp2"}, "385": {"fulltext": "ECZEMA. 365\\ncohol. Great benefit is derived from painting the indolent surfaces\\nwith solutions of silver nitrate. The intractable forms almost invari-\\nably affect adults, in whom there is usually a history of improvement\\nunder treatment, followed by relapse due to exposure to wind, heat,\\ncold, or other sources of irritation. Many cases require the treatment\\nrecommended for eczema seborrhoeicum.\\nEczema of the Eyelids (Eczema Palpebrarum). In eczema of\\nthe eyelids the free edges of the eyelid, or the skin over the orbital\\nmargin of the tarsal cartilage, may chiefly be affected and these parts,\\nboth in children and adults. When the free edge of the eyelid is in-\\nvolved there is present a species of coccogenous sycosis, the hair-folli-\\ncles becoming inflamed and furnishing a purulent discharge which may\\nagglutinate the eyelids. The latter are thickened and swollen, become\\nthe seat of a moderate itching, are picked rather than scratched, and\\nexhibit minute crusts between, or glued to, the hairs. The disorder is\\noften accompanied by a seborrhoea of the Meibomian follicles, and is\\ndescribed by oculists under the designation of blepharitis or tinea\\ntarsi. Inasmuch as the facial expression is characteristic when\\nthe eyelids are thus involved, patients exhibiting this form of eczema\\nare usually set down as scrofulous/ though the disorder occurs in\\nmany individuals with no other sign of struma, and eczema surely is\\nnot such a sign.\\nFissures occasionally form at the commissure of the eyelids. The\\ndisorder may complicate eczema of other parts of the face. In erythe-\\nmatous eczema faciei of adults there is usually swelling with puffiness,\\nespecially of the lower eyelid. The conjunctiva may or may not be\\nimplicated. A chronic granular condition of the eyelids is not noted\\nas frequently as might be suggested by a priori reasoning.\\nThe edges of the eyelids should carefully be cleansed with a weak\\nalkaline solution and a soft camel s-hair brush whenever the eyelid is\\ninvolved, and then as carefully be dried and anointed with cold-cream\\nsalve. In acute cases the closed eyelids may be bathed frequently\\nwith warm solutions of boric acid or of borax (1 to 2 drachms [4. to\\n8.] to the pint), and strips of soft lint, soaked in the same solution,\\nor a very dilute glycerin and carbolic acid lotion may be laid over the\\nclosed lids for as long periods during the day as these remedies are\\ncomfortably tolerated. In chronic cases red mercuric oxide ointment,\\nfrom 1 grain to 10 (0.066-0.66) to the ounce (30.), with or without an\\nequal quantity of salicylic acid, is held in high esteem. Oculists, in\\nthe treatment of this affection, are fond of using an ointment of yellow\\nmercuric oxide, 1 to 3 grains (0.066 to 0.2) to the drachm (4.). In\\nplace of these mercurials the unguentum hydrargyri nitratis, 1 part to\\n6 of cold-cream salve, may be applied, or resorcin 1 part to 100 of\\nsimple unguent. Epilation of the eyelashes may be necessary. Pen-\\ncillings with solutions of silver nitrate in various strengths are also\\nuseful in chronic cases, but these solutions must carefully be confined\\nto the eyelids, and not be suffered to come in contact with the con-\\njunctiva. Excessive use of the eyes must be prohibited.\\nIn the diagnosis care must be taken to exclude syphilis, lupus, and\\npediculi. Piedra of the eyelashes must not be overlooked. Instead", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0385.jp2"}, "386": {"fulltext": "366 INFLAMMATIONS.\\nof the ordinary nits of the lash, there are in such cases jet-black, pin-\\nhead-sized masses of ivory-like hardness attached to the hairs.\\nEczema of the Beard (Eczema Baeb^:). Eczema may involve\\nthe region of the beard only, or it may exist in connection with the\\ndisease on other parts of the face.\\nIn recent cases there is no loss of hair, but in those of long standing\\nthe hairs are thinned and fail to hide completely the reddened surface\\nbeneath, covered here and there with pustules or displaying floors of\\nbroken pustules, dried inflammatory products, yellowish and greenish\\nscales and crusts. Beneath the crusts the surface is smooth, not lumpy\\nas in hyphogenous sycosis. The hair-follicles are not solely involved,\\nas in the coccogenous form of that disease, but evidently they and also\\nthe integument between them are inflamed. In chronic cases the symp-\\ntoms may be those of erythematous and scaling eczema. In recent\\neczema the hairs are not loosened in their follicles, but in chronic cases\\nsuch loosening does occur, and there is a true defluvium capillitii.\\nThe disorder is one primarily involving the skin, and secondarily the\\nhair-follicle, extending smoothly over the surface, as smoothly as an\\neczema on the cheek of a woman. There is commonly a certain\\ndegree of symmetry, to the extent at least of involving the beard in\\ndifferent degrees on both cheeks at once, or the chin on both sides\\noften the symmetry is perfect. This symmetry is rare in the several\\nsycoses of the same part.\\nThe disease is accompanied by itching, rarely so severe as upon the\\nsmooth parts of the face, is particularly obstinate, and is extremely\\ndisfiguring. When extending into the region of the beard from other\\nparts it is usually associated with eczema of the ears. When limited\\nto the region of the moustache it may be connected with an eczema\\nof the nares and a chronic nasal catarrh or be a symptom of seborrheic\\neczema.\\nThe condition is more superficial than that of hyphogenous sycosis\\nand never shows any of the deep-seated nodules found in the latter\\ndisease. From coccogenous sycosis it is differentiated with greater dif-\\nficulty, as the two conditions have many features in common. Sycosis\\nis primarily an inflammation of the hair-follicles, a distinct folliculitis,\\nand presents a characteristic pustule pierced by a hair at the mouth\\nof ,the follicle. In this disease there are also found papules and small\\ntubercles. Though there is a superficial inflammation of the follicle\\nin eczema of the beard, a distinct folliculitis is not present and there\\nare no papules or tubercles. Moreover, the skin-surface between th\\nfollicles is evenly involved in eczema, while it frequently escapes wholly\\nor in part in sycosis. Eczema quite commonly coexists on other por-\\ntions of the face, while sycosis is limited strictly to the region of the\\nbeard.\\nThe treatment of recent cases of eczema of the beard is that of sim-\\nilar phases of the disease on other parts of the body, by means of the\\nsimpler lotions and ointments, but cases of long standing are exceed-\\ningly stubborn and frequently require vigorous measures. After remov-\\ning crusts and other accumulations by soaking with oil and thorough\\nwashing with soap and water the beard must be wholly removed.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0386.jp2"}, "387": {"fulltext": "ECZEMA. 367\\nClipping short the hairs of the face will not answer, though this is\\ngenerally preferred by the patient as exposing to a less degree the\\nunsightly surface beneath. Nothing short of epilation or of shaving,\\nand repeated shaving every second day, Avill effect the desired result\\nin chronic cases. As soon as the disease is reduced practically to an\\neczema of the non-hairy parts it improves in proportion to its distance\\nfrom the mucous outlets of the body. When limited to the bearded\\ncheeks the most obstinate cases in the course of a single month may be\\nrobbed of one-half their unsightliness. The patient should be encour-\\naged by reminding him that usually it is but the first step which costs,\\neach succeeding removal of the beard being accomplished with greater\\ncomfort to himself physically and mentally. After each shaving the\\nskin should be bathed with water as hot as tolerable, and, if at night, a\\nlotion or an ointment, or the latter after the former, may be used. The\\nsalves most useful for this purpose are sulphur, 10 to 60 grains to the\\nounce (0.66-4. to 30.); diachylon ointment with salicylic acid, 5 to 10\\ngrains to the ounce (0.33-0.66 to 30.), and zinc or tar ointment.\\nRarely, the surface requires painting with weak solutions of silver\\nnitrate. As the condition improves a dusting-powder will afford\\nneeded protection during the day. The shaving should be continued\\nfor months after the disease is at an end.\\nEczema of the Genital Organs (Eczema Genitalium). In\\n1 eczema of the genital organs the disease is remarkable for the severity\\nI of the subjective sensations it occasions; for its tendency to persistence,\\nI recrudescence, and nocturnal exacerbation and for the liability to the\\n1 production of the sexual orgasm by the act of scratching. In men the\\nsurfaces most often involved are the anterior, the posterior, or lateral\\nfaces of the scrotum where they meet the thigh, though the surface of\\nthe penis, as also that of the pubes and the perineum, may be involved.\\nIn women the labia majora, more rarely the labia minora and vestibule\\nof the vagina, are affected, with occasionally extension of the disease to\\nthe same contiguous parts as in men.-\\nEczema thus located is, as a French Avriter has well said, a dry\\ndisease in a moist locality. Vesicular and pustular forms are much\\nI rarer than the erythematous, the papular, the papulo-squamous, and\\nthe erythemato-squamous. In women the moister forms are more\\nI frequent, doubtless because of the wider mucous outlet and the more\\nI extensive mucous tract in the vicinage. The labia are then heightened\\njin color, oedematous, agglutinated by crusts, and often torn viciously\\nby the finger-nails. Blood-crusted excoriations are seen in most of the\\nI severe cases. An eczema intertrigo at the labio-femoral angle is com-\\nt mon. Over the whole may be poured the normal or pathologically\\naltered secretions from uterus or vagina. The disease, however, is suf-\\nficiently common after the menopause, when there is usually physio-\\nk logical atrophy of the uterus.\\nThe typical disease in men is recognized in the thickened, reddened,\\nperhaps slightly scaling integument of the scrotum, which may also be\\nfissured, excoriated by the finger-nails, or covered with blood-crusts.\\n[(Torn papules, even tubercles and nodose swellings may be closely\\npacked together, exhibiting a lurid or even purplish hue. In aggravated", "height": "4352", "width": "2388", "jp2-path": "practicaltreatis00hyde_0387.jp2"}, "388": {"fulltext": "368 INFLAMMATIONS.\\ncases the infiltration is so great as to deform the parts, increasing the\\nthickness and deepening the normal furrows of the scrotal integument\\nto the grade of many times its normal dimensions, producing thus an\\nelephantiasic appearance. In eczema of the penis also the prominent\\nsymptoms are oedema, itching, and redness with slight scaliness.\\nIn both sexes, as before indicated, attempts to relieve the itching are\\noften as severe and prolonged as they are ingenious. Commonly no\\nrelief is obtained until a serous sweating or weeping of the thickened\\ntissues is induced by the friction. Inasmuch as the latter in severe\\ncases is frequently repeated, the physical dangers are obvious.\\nApart from this, however, the disorder has a marked tendency to\\ndisturb the mental tone and the general health. Shame deters many\\nfrom seeking speedy relief, so that cases of long standing are often\\nregistered by the physician. Though unconnected with venereal dis-\\nease of any kind, there is for many a special dread of an eczema of\\nthese parts simply because of its location. With sleep disturbed, the\\nmind agitated, and the nervous system teased by an intolerable pru-\\nritus, one can scarcely wonder at the eloquence with which many\\npatients describe their sufferings. It is a disease of middle life and of\\nadvanced years. It is rare to see a well-marked, obstinate case in a\\nchild.\\nThe causes, exciting and aggravating, of eczema of the genital region\\nare often obscure, but undoubtedly depend largely upon heat, moisture,\\nand friction. These factors are favored first, by the effect of gravity,\\nthe organs in question being situated, when the body is in the erect\\nposition, at the inferior apex of the double cone forming the trunk and\\nbeing thus subject to the force of gravity second, by the arrangement\\nof the clothing in both sexes, by which heat and friction-effects are\\nheightened third, by uncleanliness, the secretions and discharges from\\nthe adjacent mucous tracts being suffered to accumulate upon the person.\\nThe cause may lie in some disturbance of the genital organs or of the\\ngeneral nervous system. In some cases the disease is apparently reflex\\nin origin.\\nIn many eczemas of the surface, and especially those of the genital\\norgans, the urine will be found to contain albumin or sugar, and these\\nconditions have been supposed to lie at the root of the eczema. The\\ndiet of the eczematous patient with saccharine urine is of prime impor-\\ntance. In some cases, however, the eczema causes the elimination of the\\nsugar or the albumin, and not the reverse. Sugar and albumin are\\nknown to be producible in urine by external irritants, among which are\\ncutaneous diseases. Merely varnishing a portion of the skin has been\\nfollowed by these effects. If a patient with saccharine urine and severe\\ngenital eczema can be kept in bed in the recumbent position for a few\\ndays, while any soothing application productive of comfort is continu-\\nously applied to the tender and excoriated surface, the sugar will often\\nrapidly disappear from the urine. These renal symptoms are in part\\nreflex, resulting from the extraordinary irritation of the nerves distrib-\\nuted to the involved surfaces. Many cases of extensive and severe\\neczema of the genital region in both sexes occur in patients in whom\\ncareful and repeated examination of the urine fails to reveal sugar,", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0388.jp2"}, "389": {"fulltext": "ECZEMA. 369\\nbut the practitioner is urged never to omit such examination in his\\ntreatment of a typical case.\\nPatients exhibiting genital eczema with glycosuria may be separ-\\nable into two distinct classes. The first and commoner class includes\\nthose patients presenting such marked physical symptoms that the urine\\nmay be suspected before chemical examination. These patients are\\nextremely fleshy men or women given to an excessive consumption of\\nbeer. In such patients the sugar decreases pari passu with the eczema,\\nif the beer is withheld and the local irritation is judiciously treated.\\nIn a second and much graver class of patients, chiefly women, there is\\na diabetic history (often also of pulmonary tuberculosis), and the gen-\\nital eczema is manifestly an epiphenomenon. These patients are rarely\\nobese, usually the figure is that of a slender and delicate woman there\\nis little, if any, use of alcoholic beverages and the local eczema is trifling\\nin features as compared with that in the class first described. In these\\ncases, too, under the influence of an appropriate dietary and local man-\\nagement the genital eczema subsides, but the glycosuria persists often\\nto a grave issue. Genital eczema occurring with glycosuria is one of a\\ngroup of disorders named by French authors Diabetides Genitales.\\nThe diagnosis of eczema of the genital organs is between ringworm,\\nacne, pruritus, pediculosis, the venereal disorders, and herpes progenita-\\nlis. The first-named affection may occur alone or may induce or may\\nbe grafted upon the eczema. Ringworm may be recognized by the dis-\\ncovery of the microsporon or trichophyton, and is clinically distin-\\nguished by the crescentic edge of the spreading patch, its convex border\\nlooking away from the genital centre. The follicular vulvitis of\\ngynaecological authors is a genital acne and is manifestly limited to the\\nglands and the periglandular tissues. The same is true of bromine and\\niodine acne, Avhich may be developed in the same situation in both sexes.\\nGenital pruritus may beget an eczema from scratching, but it is accom-\\npanied primarily by no skin-lesion. The pubic louse is visible to the\\neye, as are also its reddish excreta and nits. The ulcers and sclerosis\\nof chancroid and primary syphilis are rarely accompanied by pruritus,\\nand, though occasionally multiple, never exhibit diffuse patches of dis-\\nease. Syphilodermata are recognizable by their characteristic features\\nand the history of an infectious disease. In herpes progenitalis there\\ni are precedent burning, smarting, or neuralgic sensations, the occurrence\\nof vesicles or groups of vesicles (lesions rare in eczema of the genitals),\\nand frequent limitation of the disorder to the mucous surfaces or to the\\nmuco-cutaneous lip by which such surfaces are bounded. In eczema\\nthese boundaries are usually respected and the disease is much more\\nstrictly cutaneous.\\nThe treatment is to be conducted on the general principles hereto-\\nfore outlined. Sponging of the genital region with alkaline water\\nas hot as can well be tolerated, followed by the blander lotions, oils, and\\nointments at night, and the use of antipruritic dusting-powders in the\\ndaytime, must not be omitted. One per cent, solutions of formalin are\\nof value. In eczema of the scrotum a suspensory bandage lined with\\nlint which is wet with a lotion, smeared with an ointment, or thoroughly\\ncovered with a powder, can usually be employed with advantage.\\n24", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0389.jp2"}, "390": {"fulltext": "370 INFLAMMATIONS.\\nThe habit of scratching must be broken up at all hazards. In chronic\\ncases treatment by soft soap and diachylon ointment will be found\\nuseful. Caustics, solutions of mercuric chloride and other mercurials,\\ncarbolic acid, and especially the tarry compounds, are often necessary.\\nThe Lassar paste also may be used with advantage.\\nThe following formulae are useful in allaying the irritation of some\\nacute and subacute cases\\nR Liniment, calcis, f ^iv; 120\\nBelladonn. extr., gr. xij\\nZinci oxid., 3ij 8\\nGlycerini, f.^ij 8\\nAq. calcis, f giv; 120\\n80\\nM.\\nSig. Lotion to be applied at night after bathing the parts with hot water.\\nR Liniment, calcis, f giv; 120\\nAcid, hydrocyanic, dil., f^j; 4\\nLiq. plumbi subacetat., f^ij 8\\nGlycerini, f \u00c2\u00a3ij 8\\nAq. ros., adf^viij; 240 M.\\nSig. Cream, for application on strips of old linen.\\nExceedingly obstinate eczema of the pubic region is benefited by\\nshaving and subsequent appropriate treatment. When complicated by\\nintertrigo the latter condition requires special relief by the interposition\\nof soft lint spread with an ointment.\\nEczema of the Anus and Anal Region (Eczema Ani). Eczema\\nof the anal region, in its etiology and characteristics, is closely allied\\nto the same disease in the genital region. The presence of ascarides\\nand hemorrhoids occasionally induces or aggravates the disorder\\nthough this complication is rarer than is commonly supposed. Multi-\\ntudes of men and women who suffer from piles never complain of\\neczema. The eczema may occur in erythematous, squamous, or papu-\\nlar form, in the order named thus exhibiting here, as in the genitals,\\na dry disease in a moist locality.\\nThe redness, infiltration, and itching may be limited to the verge of\\nthe anus, radiate from the latter in stellate lines, creep upward between\\nthe nates in the cleft, sweep forward over the perineum to the genital\\nregion, or extend laterally with intermediate intertrigo over the inner\\nface of each thigh. Rarely the buttocks are covered with the same\\nlesions. Fissures are likely to form about the anal orifice.\\nThis disease is common in infancy, when want of care in the removal\\nof the napkin is a fertile source of mischief; and also in persons in mid-\\ndle life and in advanced years, when it becomes particularly intractable.\\nThe itching is intense in the latter class, with frequent nocturnal exacer-\\nbation. Unfortunately the scratching is often reflex, and is practised\\nduring sleep, from which the patient is often aroused by his or her\\nmanipulations. Pollutions fully recognized, or occurring during pro-\\nfound sleep, or, more usually, in states of semi-consciousness, compli-\\ncate certain cases defecation becomes painful the harassed nervous\\nsystem of the sufferer is often in a deplorably wretched condition.\\nIn cases of long standing the usual congested, thickened, infiltrated,", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0390.jp2"}, "391": {"fulltext": "ECZEMA. 371\\nand almost elephantiasic appearance of the skin is presented, with\\noccasional fissures and exaggeration of the natural furrows. The part\\nmay simulate in aspect the formidable conditions discovered in passive\\npederasty. Excoriations are common around the anal verge.\\nIn the treatment of these cases the use of very hot water by\\nsponging, and the subsequent application of ointments, in some\\ncases mild but in others stimulating, have yielded the best results.\\nIn the case of infants dusting-powders and the blander ointments\\nare alone to be employed in adults, especially in chronic cases, tar\\nin some form is especially valuable. Here the Lassar paste may be\\napplied or tincture of tar be freely painted over the surface, or there\\nmay be used one of the tarry ointments, such as the Wilkinson salve,\\nof sufficient firmness to retain its form as an unguent when sub-\\njected to the heat of the part. Caustics, especially the silver nitrate\\nin crayon, are useful when there are fissures. Corrosive sublimate,\\nJ to of a grain (0.016-0.033) to 4 ounces (120.) of milk of almonds\\nSquire s glycerole of plumbic subacetate, J drachm (2.) in 2 ounces\\n(60.) of glycerin and water, or, as a substitute for the latter, soft soap\\nand diachylon plaster, are here of special service. Almond-oil, or an\\nointment containing 2 to 10 per cent, of carbolic acid, often gives\\nrelief. Duhring recommends the following\\nR\\nSulphur, preecipitat.,\\n9y;\\n2\\nm\\nNaphtol.\\nEd;\\n1\\n33\\nMorph. acet.,\\ngr.ij;]\\n133\\nZinci carb.\\n3j;\\n4\\nUngt. aq. ros.,\\nij;\\n30\\nM.\\nWhen defecation is painful the stools should be semiliquid in order\\nto insure non-aggravation of the local disorder, not, it need scarcely\\nbe remarked, with a view to eliminating any materie.s morbi by purga-\\ntion. Small tampons of cotton may be smeared with an emollient oint-\\nment and gently be inserted for a short distance within the anus.\\nTincture of benzoin, 1 part to 8 of vaselin, may be used for this pur-\\npose. Kaposi recommends cocoa-butter suppositories, containing zinc\\noxide with belladonna or opium. When complicated by true fissure\\nof the anus the sphincter ani must be stretched or divided, or dilated\\nwith medicated bougies. At night a cataplasm is applied. The parts\\nare washed frequently with tepid water, and the anal tampons are\\nsmeared with cocaine. During the day zinc oxide salve, 30 grains (2.)\\nto the ounce (30.) of vaselin, is applied, and over this are thoroughly\\nsprinkled equal parts of zinc oxide and bismuth subnitrate in fine\\npowder. Collodion medicated with 1 to 3 per cent, of salicylic acid,\\nand lotions containing 1 scruple (1.33) of silver nitrate to the ounce\\n(30.), are of great value in many cases. Besnier recommends the use\\nof a clyster after each bowel-movement, the fluid being retained for\\nonly a short time. Pencillings of fissures with crayon of silver nitrate\\nare indispensable in severe cases.\\nVeiel prefers the cautious use of chrysarobin to tar, employing the\\nlatter either in the form of spirits or as tar-diachylon, 1 part to 20,\\ngradually increasing in strength. Carbolic acid, 1 to 5 per cent., and", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0391.jp2"}, "392": {"fulltext": "372 INFLAMMATIONS.\\nglycerin, 2 to 10 per cent., in elder-flower water or in almond-emulsion,\\nare specially indicated in fleshy women when the disorder, as is often\\nthe- case, is complicated with intertrigo.\\nThe key to most cases of anal eczema is to be sought in the dietary.\\nThis disorder, in adults particularly, is likely to be a significant symp-\\ntom of gout, and without the dietetic and medicinal treatment of that\\ncondition no local applications avail. Tobacco and alcohol are invari-\\nably to be excluded in the case of patients of this class and blue pill,\\nalkalies, colchicum, and salicylates are often needed. It is in these\\nmanifestations of eczema that health-resorts furnish their best results,\\nnecessitating and inviting, as they often do, an out-door life, an appro-\\npriate regimen, and an avoidance of stimulants. Even in children and\\ninfants, when there are no ascarides in the rectum or the vulva, the\\ndietetic management of the patient should never be neglected.\\nEczema of the Nipple and Breast of Women (Eczema Mammje).\\nEczema of the mammary region is common in nursing-women either\\nfrom the irritation produced by the mouth of the infant, or, more\\ncommonly, in consequence of a galactorrhea. Eczema intertrigo is\\ncommon below and between the breasts. The eczema here is vesicular,\\nerythematous, or squamous in type, with fissures at the apex, the side,\\nor the base of the nipple. The serous ooze from the infiltrated areas\\ndries as usual into light-colored crusts. There are the characteristic\\nburning and itching. The disease may occur on one or both breasts, and,\\nespecially with a galactorrhea in the summer, may spread extensively,\\ncovering both breasts, the surface of the belly, and the intermammary\\nregion. The circumscribed forms occur also in pregnant or in unmarried\\nwomen, and are to be distinguished from scabies, which in women is\\nprone to occur upon the breast.\\nPaget s Disease, which in its early stages presents all the appear-\\nances of an eczema, is more fully described in this treatise among the\\nepitheliomata it is sufficient here to call attention to the important\\nfact that a fairly well-defined eczematoid patch, surrounding the areola\\nof the nipple or that organ only, with infiltration, itching, and possibly\\na fissure of the nipple, or a crust covering a superficial erosion, may be\\nthe sign of an epitheliomatous change already advanced either in the\\naffected part only or deeper in the galactiferous ducts of the breast itself.\\nThe treatment of mammary eczema is that of eczema in general.\\nIn severe cases with galactorrhea nothing short of weaning the child\\nand a cessation of all demands upon the breast will insure relief. Every\\neffort should be made in milder cases to avoid this dernier ressort. The\\nnipple should be thoroughly cleansed after each nursing. As a rule,\\nhot water and soap may be used for the purpose without harm and\\nusually with benefit. Any fissures existing should be then painted\\nwith compound tincture of benzoin, tincture of myrrh containing 1\\ngrain of mercuric chloride to each ounce (0.06 to 30.) or weak solutions\\n(2-15 per cent.) of silver nitrate. The whole should immediately be\\ncovered with a protective ointment or paste. The zinc oxide or dia-\\nchylon ointment spread on lint serves the purpose well. Salicylated\\nand borated pastes are sometimes preferable. Lister s borax salve often\\ndoes well", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0392.jp2"}, "393": {"fulltext": "ECZEMA. 373\\nR Acid, boracic. subtil, pulv.,\\nCerae alb., j G\\nParaffin.,\\n01. amygdal.,\\naaSss; aa 2\\nM.\\nIn some instances stronger and more stimulating remedies are\\nnecessary. Before the child takes the breast all but the simplest\\npreparations should be entirely removed with oil or other unirritating\\nagent.\\nFournier recommends a breast-plate of caoutchouc. When the\\ndisease is limited to the nipple and areola in nursing- women the glass-\\nand rubber-apparatus sold in the shops may be tried in the hope of\\nsaving the nipple from mouth-contacts in nursing. Sometimes they\\nanswer admirably often they utterly fail. Dusting-powders are valu-\\nable in mild cases, and for any intertrigo that may exist between and\\nbeneath the breasts.\\nEczema of the Umbilicus (Eczema Umbilici). This local variety\\nof the disease is briefly described in the chapter devoted to Seborrhoea.\\nIn most cases it is either induced or is aggravated by a seborrhoea fluida\\nwhich gives origin to the peculiarly nauseating odor characteristic of\\nthe disease. Generally a reddish and infiltrated, more or less annular\\npatch surrounds the umbilical depression, which may be filled with\\n1 crusts. Syphilodermata, pediculosis, and scabies in women are to be\\ncarefully excluded in the diagnosis.\\nLiquor sodae chlorinatae, carbolic acid solutions, and, in chronic cases,\\niodized phenol will be required in its management. The dressing of\\nthe navel in the newborn infant, the improperly adjusted apparatus\\nfor retention of an umbilical hernia, and the corsets or uterine sup-\\nporters of women, should not be permitted to occasion or aggravate\\nthe disease.\\nAnderson reports that in typical cases, especially of those affected\\nwith scabies, the navel is swollen and projects in the form of a small\\ntumor.\\nEczema Orurum (Eczema CrueAle). Upon the legs, where the\\nforce of gravity is more potent than in other parts of the body, aggra-\\nvated forms of eczema are found complicated with varicose veins and\\noedema, with dense infiltrations and indurations. In ancient cases the\\nfrequent elephantiasic aspect is significant, one limb being several\\ninches larger in circumference than its fellow. The skin is covered\\nfrom knee to ankle with enormous patches of eczema rubrum of an in-\\ntensely angry appearance, moist and crust-covered or is dry, glazed,\\nand of a lurid, reddish hue or is dry, horny, and ridged with irregular\\nprojections surmounted by scales resembling the rough bark of a tree\\nj or, again, with or without oedema, the integument is tense, inelastic,\\nseamed with scars of old varicose ulcers, and deeply and irregularly\\npigmented, a condition with some difficulty distinguished from syphi-\\nlitic ulceration of the same region. At its onset eczema of these parts\\nmay assume any one of its known forms. In infants in long clothing,\\nwhere the lower extremities are subjected to a higher temperature than\\nin adults, the vesicular and pustular forms are common. The exceed-\\ningly obstinate forms of eczema of the legs, especially those complicated", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0393.jp2"}, "394": {"fulltext": "374 INFLAMMATIONS.\\nwith varicose veins, are, of course, chiefly encountered in middle life\\nand in advanced years.\\nThe diagnosis is, in general, to be established by considering the\\npoints heretofore discussed. The chief difficulty lies in distinguishing\\nthe eczema associated with ancient varicose cicatrices of the leg from\\nsyphilitic scars of the same locality that have resulted from degener-\\nating tubercular syphilodermata or from gummata. In some cases, when\\nno distinct history can be obtained, there will be a doubt, since the\\nforce of gravity upon the vessels, even without varicosities, produces\\ncertain common features, notably deep pigmentation, in both classes\\nof cases. In women the sexual history is all-important, including the\\norder of succession of abortions, miscarriages, and viable infants. In\\nboth sexes the discovery of other lesions, and especially of character-\\nistic cicatrices elsewhere, must be attempted. It will be remembered\\nthat the syphilitic ulcer tends to the shape of a circle or a segment of\\na circle, and though occasionally existing as the sole lesion upon one\\nleg, it is frequently multiple, or may involve both extremities, the pig-\\nmentation in old cases occurring chiefly at the periphery of the scar.\\nVery extensive pigmentation about ancient cicatrices, especially dis-\\nposed between irregularly defined scars, is commoner in eczematous\\nforms, as the pigmentation due to syphilis though long-lived is yet the\\nmore ephemeral. With periosteal nodes the diagnosis is clear.\\nThe treatment of eczema of the legs does not differ from that of\\neczema in general, except as regards the indications to be met rela-\\ntive to the support of the parts, thus counteracting the effect of\\ngravity. In severe cases rest with the foot elevated and the leg placed\\nin the horizontal position should be maintained, and other indica-\\ntions met by the use of the various liniments, lotions, and ointments\\nalready described. For those who must pursue their accustomed\\noccupations the problem is difficult. An excellent preparation for\\nsubacute and chronic cases is found in the glycogelatins, as they\\nfurnish not only protection, but also some support. Moreover, they\\nfrequently may be left in position for a week at a time. As a rule,\\nthey are not indicated in acute cases or where there is much discharge\\nyet in some of these cases they are well tolerated and do good. A\\nmoderately firm paste is made by taking 30 parts each of white gelatin\\nand zinc oxide, 40 parts of glycerin, and 90 parts of water. The\\nmethod of preparation has been given in the preceding pages. From\\n1 to 3 per cent, of ichthyol, thiol, or salicylic acid in most cases may\\nbe added with advantage.\\nA dressing well adapted to the larger number of cases of eczema\\nof the lower limbs is disinfection of the surface and the application of\\nthe Lassar paste or other well-selected unguent or paste, followed by\\ndusting the whole area with a powder, over which may be neatly\\napplied, if desirable, a cheesecloth bandage. Often, however, this band-\\nage may be dispensed with, as in both sexes a woman s long stock-\\ning, made light and thin, such as is used in the summer season and\\nalways of white or undyed cotton, may be drawn over the limb.\\nOver this stocking may be wound, for the purpose of support, either\\na flannel bandage cut on the bias, which can, as a rule, be applied", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0394.jp2"}, "395": {"fulltext": "ECZEMA. 375\\nwithout especial skill by the inexpert, or in chronic cases that will\\ntolerate it an elastic bandage, the inner white stocking being changed\\nwith each dressing. In the case of male patients it is often desirable\\nthat the man s sock be drawn over the long white stocking below.\\nIn this way support without compression (which is the essential point)\\nmay be secured.\\nExcellent results may be obtained by the use of the pure rubber\\nbandage, applied immediately next the skin, especially in cases compli-\\ncated by oedema, ulceration, and venous varicosity. The method of its\\napplication is generally familiar to the profession. The starch bandage,\\nthe plaster-of-Paris dressing over folds of Canton flannel so arranged\\nthat it may be removed at will in the manner in which it is used by\\nsome surgeons in treatment of diseases of the joints, these and other\\nimmovable dressings may accomplish even more in obstinate cases than\\nelastic apparatus.\\nA favorite dressing in dry, papular, erythematous, and squamous\\npatches of the disease is applied as follows the parts are bathed\\nwith hot borated water for several minutes until the itching is relieved,\\nand then are carefully and thoroughly dried. The patch is then com-\\npletely covered with a dusting-powder, which, according to the indica-\\ntions of the case, is either emollient, astringent, or stimulating. Finely\\npowdered tannin with French chalk, or boric acid and starch, or bis-\\nmuth subnitrate, zinc, and starch may thus be used. Strips of cheesecloth\\nare superimposed. A snug-fitting rubber or flannel bandage cut on the\\nbias encompasses the whole. The dressing is left \u00c2\u00a371 situ as long as it\\nis comfortable, often for two or three days, when it can be removed.\\nIn properly selected cases the itching is relieved, the infiltration is\\nreduced, and the patch soon loses its hypersemic aspect. Occasionally\\nno other treatment will be required.\\nEczema of the Hands and the Feet (Eczema Manuum, Eczema\\nPedum). No more striking illustration of the significance of the\\netiology of eczema can be adduced than that to be discovered in\\nthe hands. With these organs man toils to earn his bread, and the\\neczema they display is their protest against the rude contacts which\\nare thus necessitated. Unfortunately, in too many patients the\\nimperative necessity of bread-winning forbids consent to the best\\nmethods of relief, viz., temporary disuse of these organs. The feet\\nmay be similarly attacked, and for similar reasons. All forms of eczema\\nare here seen erythematous, vesicular, papular, pustular, and squamous\\ninvolving the entire surface, or being limited to the wrists, ankles,\\ninterdigital spaces, palmar or plantar surfaces, or one or more digits\\nof either hand or foot. The motions of the part are so free that fis-\\nsures are common and often are exceedingly painful. The itching may\\nbe severe, and parts of one hand or of one foot may be extensively\\nrubbed, torn, or abraded by the other. Vesicles are frequently\\nencountered upon delicate portions of the skin, as over the dorsum and\\ninterdigital spaces, while in the denser palm and sole such lesions are\\ndeep seated and do not tend to spontaneous rupture, but on puncture a\\nclear serous or a cloudy fluid may be evacuated.\\nPalmar and Plantar Eczema is commonlv asymmetrical, but", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0395.jp2"}, "396": {"fulltext": "376 INFLAMMATIONS.\\nmay be symmetrical. The hands are more often involved than the\\nfeet. The condition is characterized by the appearance of irregular,\\nill-defined, more or less diffuse areas of dry, dead-whitish, or hypersemic,\\nindurated, and thickened integument, which may be fissured or which\\nmay produce such a tense inelasticity of the surface that the digits are\\nsemiflexed into the palm or sole.\\nCircumscribed patches of eczema, with fairly denned outline, reddish\\nin color beneath crust or scale, subacute in course, and accompanied by\\nparoxysmal itching, are of common occurrence on the dorsum and also\\non the palm or the sole. In the latter situation they may be traversed\\nby one or more painful fissures, the same being true of the fingers and\\nthe toes. Upon the back of the hand these circumscribed patches are\\nprone to pursue an indolent course, improving temporarily under ap-\\npropriate treatment and becoming aggravated by every exposure to\\nthe causes by which they were first induced.\\nThe long list of etiological factors w r hich may here be efficient can\\nscarcely be enumerated. The majority have already been considered\\nin discussing the causes of eczema in general. The influence of all\\narticles handled in the trades, occupations, and professions, as well\\nas the action of toxicants and dyes, must be remembered. Thus,\\nprinters, bakers, and masons suffer in the hands, and the wearers of\\ndyed stockings and coarse, ill-fitting shoes and boots suffer in the feet.\\nThese so-called Trade Eczemas are often due wholly to local\\ncauses and disappear promptly on removal of the latter. Such con-\\nditions should properly be classed under chronic dermatitis.\\nIn the matter of diagnosis, it should be remembered that an eczema\\nof the hands may follow a dermatitis due to the Rhus toxicodendron.\\nIn these cases the disease is found usually at the same time upon the\\nface and in the genital or mammary regions. Scabies of the hand\\nin America is rarer than eczema manuum. In scabies the vesicles\\nare firmer, more often unruptured, are fewer, are more isolated, and\\nmore intermingled with crusts, pustules, and even with bullae, which\\nlatter are rare in eczema. The discovery of the parasite or its bur-\\nrows and a history of contagion will aid in removing doubt. Numer-\\nous pustular lesions in young subjects are, however, according to\\nHebra, most commonly produced by the acarus. The occurrence of\\nthe eruption on the body elsewhere than on the hand is also to be\\nexpected in scabies, with respect to which it should be remembered\\nthat the burrow may not be visible, and that it may be wanting when\\nthe parasites are present. Psoriasis of the palms and soles is almost\\nalways accompanied by the presence in other parts of the body of\\npatches, the typical characters of which should throw light on the local\\ndisorder. They are dry, non-discharging lesions, very rarely fissured\\nas is eczema of the hands, have a distinct contour (which is rare in\\neczema), and are covered with more abundant and more lustrous scales.\\nEczema is less sharply outlined, and occurs in larger and more diffused\\nareas than either psoriasis or syphilis. The scaling syphilodermata\\nof the palms and soles occur early and late in the disease, and usually\\nafter a distinct history of infection. The lesions in syphilis are usually\\nisolated, firm, deep infiltrations, circular in outline, with very sharp", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0396.jp2"}, "397": {"fulltext": "ECZEMA. 377\\ndefinition, and they may be covered with dry, adherent, dirty-white\\nscales, beneath which the brown-and-red hue of the persistent lesion\\ncan be discovered. Superficial or deep circular excavations of tissue,\\nsingle or multiple, with punched or ragged edges, are visible. The\\neruption is rarely, like eczema, accompanied by itching or by dis-\\ncharge, but painful fissures may form. It occasionally aifects the dor-\\nsum of the hand or the foot, favorite sites of eczema manuum, but\\nalmost invariably it has in such cases swept thither from the palm or\\nfrom the sole.\\nIn both syphilis and eczema of the hand the right organ in right-\\nhanded toilers is usually most involved, even where there is apparent\\nsymmetry of distribution of lesions.\\nThe treatment demands, first, rest for the organs and a simultaneous\\ndiscontinuance of the exciting cause. In the trades the result of the\\nlatter can usually be demonstrated by the patient, who notices the dif-\\nference between the condition of the skin on Monday morning after a\\nSunday s rest and that which was distressing on the preceding Saturday\\nnight. When practicable, protection during labor must be secured by\\nthe use of gloves, neatly applied finger-cots, rubber-stalls, or bandages,\\nretaining a dressing to the part of the hand or the foot that is the seat\\nof the disease. For circumscribed, non-discharging patches on the\\ndorsum of the hand or the foot the dressing described in connection\\nwith eczema of the extremities may be applied. When the nature\\nof the labor performed is such as to render it impossible to secure\\nprotection of the hands or fingers in this w 7 ay, something may be\\naccomplished in a few cases by directing that the hand be frequently\\ndipped in a protective solution or powdered during the hours of labor.\\nThus, printers may dust their fingers with lycopodium, and individuals\\ncompelled to retain their hands in irritating solutions can anoint these\\norgans occasionally with an oily or fatty substance. Generally it may\\nbe said that an eczema of the hands is too frequently washed, and the\\nill effects of this practice are made evident not only in laundresses,\\nbut also in mothers who personally attend to the dressing of young\\ninfants. After each washing, the hands should immediately be cov-\\nered with a suitable dressing, or with a simple lotion, ointment, or\\npowder. For mild cases equal parts of tincture of benzoin, glycerin,\\nand alcohol diluted more or less with water make a serviceable and\\nagreeable application. For protection of the hands and for the reten-\\ntion of dressings the cheap white cotton gloves such as are worn by\\ninfantrymen are convenient and serviceable. They should be large\\nenough to go on over the dressings easily and should be washed as\\nsoon as soiled. When extensively and acutely involved the hand\\nshould carefully be dressed, each finger being separately wrapped in\\ngauze which has been soaked in a lotion or oil or has been spread\\nwith the selected ointment or paste, and the whole covered with a\\nbandage or other dressing.\\nThe local application must be chosen in accordance with the prin-\\nciples previously given for the treatment of eczema in general. In\\nsubacute and chronic types tarry compounds are very useful, and caus-\\ntics more than ever needful when there are fissures. The fissures may", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0397.jp2"}, "398": {"fulltext": "378 INFLAMMATIONS.\\noften with advantage be painted with compound tincture of benzoin.\\nProtective flexile collodion plays an admirable part about the finger-\\nnails where irritable seams and fissures form with overhanging fringes\\nof torn and ragged epidermis, bordered with red. In painful eczemas\\nof this region the immersion, particularly at night, of the entire hand\\nor the foot in hot borated water may be practised, followed by careful\\ndrying and dressing with the selected application.\\nWhen the epidermis of the palm is greatly thickened it should be\\nshampooed at night with green soap, pure or in spirit, with the aid of\\nhot water, followed by a salicylated soap-plaster or by a salve contain-\\ning white precipitate, 10 to 20 grains to the ounce (0.66-1.33 to 30.),\\nor some preparation of tar. For intractable cases caustic potash, in\\nthe strength of 20 to 30 per cent, solutions, can be mopped well into\\nthe thickened palm and be followed by a salve application. Van\\nHarlingen suggests:\\nR\\nHydrarg. ammoniat.,\\nBj;\\n1\\n33\\nAdipis,\\n3ss;\\n2\\nSevi benzoinat.,\\nBvij\\n10\\n01. amygd. dulc,\\nlx\\n66\\nVaselia.,\\nad 3vj\\nad 24\\nM.\\nA paste useful in many mild cases and one which dries rapidly is\\nmade of 10 parts each of glycerin, dextrin, and water. To this may\\nbe added from 1 to 3 per cent, of thiol or ichthyol. The ingredients\\nare mixed on a hot water-bath and form a sort of liniment, which may\\nbe painted on the skin. Unna s litharge-glycerin-starch paste, described\\non a preceding page, is also a valuable and effective preparation for sub-\\nacute cases. For chronic, sluggish eczema of the palms Duhring recom\\nmends an ointment composed of equal parts of mercurous nitrate\\nplumbic acetate, and zinc oxide ointments.\\nFor the fingers and hands Unna s mull-plasters, but only if freshly\\nimported, fill every requirement. These plasters may be cut int\\nstrips and be applied with neatness to every digit. Zinc oxide, sali\\ncylic acid, tar, and ichthyol mulls are all available for this purpose.\\nThe condition known as Chapping of the hands and face is, prop\\nerly speaking, a dermatitis, since it is usually dependent upon exposure\\nto wind and weather and disappears when the cause is removed. It\\nsometimes occurs, however, as a condition indistinguishable clinically\\nfrom mild eczema of this region. In those subject to this disorder care\\nshould be taken through the changeable weather of spring and autumn\\nnot to expose the skin to cold or wind, especially if the hands have\\nbeen previously immersed in water and are not perfectly dry. In\\nmany instances the trouble can be prevented by a simple oiling of the\\nskin after each washing, or instead of oil equal parts of tincture of\\nbenzoin, glycerin, and alcohol may be used. This last preparation is not\\nonly a preventive, but it often affords relief in mild cases. Severer forms\\nshould be treated as corresponding grades of dermatitis or of eczema.\\nEczema as it Affects the Nails (Eczema Unguium). There is\\nnothing characteristic of eczema in its effects upon the nails. These\\nhorny plates participate in the diseases which affect their matrices, and\\ni\u00e2\u0080\u0094", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0398.jp2"}, "399": {"fulltext": "ECZEMA. 379\\nthus exhibit nutritional changes. There is, therefore, no eczema of the\\nnail proper, but only an eczema of the digit by which the nail is affected.\\nIn well-marked cases, one, several, or all the nails of either hands or\\nfeet may lose their polish, or may become rough, punctate, furrowed\\nlaterally, and clubbed, or may present an appearance suggestive of\\nworm-eaten surfaces. They lose their uniformly smooth attachment\\nbeneath and become tilted on their beds, with marked friability of their\\ntissue. An eczematous condition of the skin at the nail-margin may\\nbe detected, where the usual redness, infiltration, and scaling, with a\\nsensation of itching, point to the nature of the trouble. Rarely the nails\\nare shed. The most misshapen will be succeeded by smooth and nat-\\nural growths of nail-substance if the disease of the matrix be completely\\nrelieved. The treatment, therefore, is the treatment of the cutaneous\\ndisease. Care must be taken to exclude psoriasis (to be generally\\nrecognized by lesions in other regions of the body), as also ringworm\\nand favus of the nails, which end can be reached by microscopically\\nexamining scales scraped from the nail-surface.\\nThe finger-tips may be held in hot water for fifteen or twenty min-\\nutes at night and the nails then shampooed as vigorously as the condi-\\ntion will permit. A soft ointment should then be applied on lint or\\nother material. Zinc oxide, white precipitate, salicylic acid, and tar\\nsalve will be found most effective for the larger number of cases.\\nOften the organs may with advantage be protected during the daytime\\nby the glycogelatins, powders, gloves, or by rubber-cots.\\nUniversal Eczema. In these cases patients should be treated in\\nbed. The diet, which is of great importance, should be of unstimulat-\\ning quality but it is not to be forgotten that in a disease involving\\nthe entire surface of the body the strength is sooner or later liable to\\nbe exhausted, and a supporting dietary, even ferruginous tonics, is often\\nrequired.\\nThe local treatment is by alkaline and bran-baths, followed by\\nlime-water-and-oil lotions, a dusting-powder, ointment, or other dress-\\ning suited to the local condition. In treating universal eczema the\\nentire surface does not usually require the same topical agents. Often\\nthere should be cold-cream salve, freshly made, for the eyelids; a\\ndusting-powder for the non -discharging or scaling surface; a salve or\\nan oleated lotion for discharging surfaces of the integument; and\\nspecial dressings for the extremities, the ears, the hands, etc.\\nEczema of the Tropics (Prickly Heat).\\n(Eczema Solare, Lichen Tropicus, Miliaria Rubra, etc.)\\nUnder these titles has been described a number of disorders, some\\nof which are more closely related to the forms of sudamen considered\\nin connection with the functional derangements of the sweat-apparatus,\\nothers of which are instances of papular eczema, associated or not with\\nprofuse sweating under the influence of severe physical exertion or of\\nhigh temperatures (solar heat). This disease is aggravated by all exter-\\nnal and internal sources of irritation, including indigestion, the use of", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0399.jp2"}, "400": {"fulltext": "380 INFLAMMATIONS.\\nalcoholic beverages, of opiates, of flannel and of chemically dyed gar-\\nments worn next the skin undue exertion in a heated medium, fatigue,\\nand obesity.\\nEtiology. The disease is more common in those subjected to rapid\\nand intense fluctuations in the temperature of the atmosphere than in\\nthose long accustomed to a relatively hot climate. It is thus exceed-\\ningly common in the northern and central parts of the United States,\\nwhere sudden changes in temperature are frequent and of wide range\\nin degree. It attacks alike individuals of both sexes and all ages, being\\noften particularly severe in the obese and in infants, whose delicate skins\\nno less than their bowels resent sudden and severe thermal changes. It,\\nmoreover, affects equally the vigorous and the debilitated. It is un-\\nquestionably seen in the severest grade among fleshy Europeans and in\\nAmericans emigrating to tropical climates who are habitually ingesting\\nalcoholic beverages in excess.\\nThe disease is characterized by the occurrence of pin-point to pin-\\nhead-sized vesicles, bright-red papules, vesico-papules, or the two as\\ncoincident and commingled symptoms. The lesions are exceedingly\\nnumerous, and may in severe cases cover almost the entire so-called\\nnon-hairy surface of the body, though they are commonly much\\nmore limited in their diffusion. They are usually acuminate and dis-\\ncrete, though often thickly set together. They are of rapid occurrence,\\nbut in consequence of persistence of the cause may be slow to disap-\\npear or may repeatedly recur. The affected region is the seat of charac-\\nteristic sensations of tingling, pricking, and burning. The attack may\\nlast for but a few days or be severe for a week or more.\\nTreatment. The local treatment of prickly heat is, in brief, that\\nof the corresponding stage of eczema. Unguents are generally to be\\navoided, as the skin rarely tolerates them, and the same may be said\\nof plasters and very cold baths. Baths or lotions (tepid, Avarm, to\\nmoderately cool, as the feelings of the patient may decide to be most\\ngrateful), medicated with alkalies, bran, gelatin, or starch, will be found\\nuseful. After each application the skin is to be dried by gently pressing\\ndry towels over the surface, not by rubbing, and is then to be thoroughly\\nprotected by a free use of one of the dusting-powders, particularly boric\\nacid and talc, or one of the zinc stearate preparations. When large\\ntracts of the skin are involved, and general baths have been ordered,\\nstarch in fine powder will often be found well suited for topical em-\\nployment.\\nLotions may also be employed, composed of lead, or of lead and\\nopium, or black wash, or alcoholic and ethereal solutions containing\\ncamphor and glycerin in the proportions given when considering the\\nsubject of acute eczema. Modifications of oleated lime-water are\\nserviceable in severe cases,\\nas,\\nfor\\nexample\\nR 01. lini,\\nf \u00c2\u00a3ij\\n60\\nParaffin.,\\nSapon. Castil., J\\naa gij;\\naa 60\\n01. bergamii,\\nq.s.;\\nq.s.\\nAq. calcis,\\nad Oj;\\nad 500\\nSig. For external use.\\nM.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0400.jp2"}, "401": {"fulltext": "ECZEMA. 381\\nThis preparation makes a demulcent creamy solution which often\\nproves grateful to the skin to it may be added zinc oxide or carbolic\\npr dilute hydrocyanic acid, as required.\\nThe general treatment of the patient is a matter of importance. The\\ncause must be removed if possible. Withdrawal from the light, heat,\\nand labor of the day, the use of unstimulating food and drink, unirri-\\ntating apparel, and rest are of great importance. Saline and acidu-\\nlated beverages are usually acceptable to the palate, and useful if not\\ndrunk too cold. The free use of lemonade, Vichy, Kissengen, Apolli-\\nnaris, or other pure water, carbonated or aerated, is useful in aiding\\nelimination and in supplying the fluids demanded by the cutaneous\\nloss through evaporation.\\nPrognosis. The disorder may be trivial or be severe, and may\\nlast bat for a few hours or for several months. It is usually relieved\\nwithout difficulty, often by domestic measures alone.\\nECZEMA SEBORRH(EICUM.\\n(Dermatitis Seborrheica.)\\nDuhring was the first observer to show that a type of inflammation\\nof the skin, to which he gave the name seborrhoea corporis, was closely\\nallied to, and usually consecutive to, seborrhoea capitis. Later, Unna l\\nadvanced the theory that a single morbid process, to which he gave the\\nname eczema seborrhoeicum, is responsible for a number of varied clin-\\nical manifestations which had previously been considered separate dis-\\norders. Under this title he includes seborrhoea sicca (or pityriasis) of\\nthe scalp, face, and body, some chronic circumscribed forms of eczema,\\nand many cases which most observers still believe are forms of psoriasis.\\nThough Unna gives to eczema seborrhoeicum a wider range than is\\naccepted by the majority of dermatologists, there is little doubt that\\nmost of the phenomena he describes under this title are intimately\\nrelated etiologically and pathologically. In America Elliott has fur-\\nnished an excellent presentation of the subject. 2 In the following\\ndescription the writings of both observers have been freely consulted.\\nSymptoms. Eczema seborrhoeicum almost invariably begins on\\nthe scalp an,d often remains limited to this region, though frequently\\nit extends to the ears, temples, forehead, neck, and adjacent parts.\\nThe disease is not uncommon on other parts of the body where the\\nsebaceous glands are large and abundant, as in the sternal, interscapular,\\ninguino-scrotal, axillary, and umbilical regions. It may appear, how-\\never, on any part of the body and in rare instances is universal. The\\ndisease is extremely variable in its course and mode of extension. It\\nmay remain confined to the scalp for years and then extend to adjacent\\nsurfaces, or appear on portions of the body distant from the scalp,\\nleaving the intervening surfaces unaffected. Such spreading of the\\ndisease may be very rapid, or so slow as to be almost inappreciable,\\n1 Monatshft. f. prakt. Derm., 1887 and The Histopathology of the Diseases of the\\nSkin, 1894.\\n2 Morrow s System, vol. iii., p. 273.", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0401.jp2"}, "402": {"fulltext": "382 INFLAMMATIONS.\\nwhile the lesions may be numerous, extensive, and acute in type, or\\nfew, scattered, and indolent in character.\\nThe affection varies considerably in appearance in its different phase\\nand especially in different regions. In the scaly form, which is the\\nmost common, there may be simply a scanty or abundant formation of\\nfine branny scales with apparently little other change from the normal\\nthough the skin may be slightly reddened, and often has the peculiar\\nyellowish color which is characteristic of the disease. The scales may\\nbe large and abundant, and heaped up in dry, adherent masses, simu-\\nlating those sometimes seen in psoriasis, but in such cases the scales\\nare usually somewhat fatty. Frequently there is a coexisting seborrhoea\\noleosa, with the formation of yellowish to brownish, soft, greasy, and\\nnon-adherent masses, suggesting crusts rather than scales, under which\\nthe skin is more or less reddened and the mouths of the follicles\\npatulous.\\nThe disease often appears in the form of oval or rounded macules\\nand patches, or as small scale-capped papules which may remain dis-\\ncrete or may coalesce to form slightly elevated plaques. The macules,\\npapules, and plaques are sharply outlined, and patches that are spread-\\ning peripherally frequently present a circinate border with a fading\\nyellowish centre. By the coalescence of several such areas poly cyclic,\\ngyrate bands may be produced. The color of the lesions is reddish or\\npinkish, modified by the yellow tinge that is nearly always present.\\nScaling and crusting in varying degrees are usually present as in the\\nmore diffuse forms described above. The lesions may occasionally be\\nmoist over all or parts of their surfaces, but the characteristic vesicles\\nand pustules of eczema are absent and the discharge when present is\\nusually distinctly greasy. A transformation to the ordinary forms of\\nmoist eczema may occur in which the characters, both clinical and his-\\ntological, of the original eczema seborrhoeicum are lost. Of the varied\\nmanifestations of the disease the scaling forms are the most common,\\nbut in a given case the type may change gradually or rapidly, and\\nmultiformity of lesions is not unusual. Itching is usually slight and\\nmav be absent.\\nOn the scalp the onset of the disorder is particularly insidious and\\noften unnoticed until attention is attracted to it by a thinning of the\\nhair, moderate or really annoying pruritus, and a scanty or abundant\\nformation of scales over more or less of the scalp. In the early and\\nmild forms the condition is practically that described under seborrhoea\\nsicca. The vertex is the usual site of the affection, but the entire\\nscalp may be involved. The scales may appear in any of the forms\\ndescribed above, but are usually fine, dry, grayish, and slightly greasy.\\nThe lowest layers of the scales are usually firmly attached to the\\nunderlying surface, which is commonly dry, lustreless, and pale, though\\nit may be slightly hypersemic. After the condition has existed for a\\ntime alopecia is noticed, while the hairs of the affected regions are dry\\nand lustreless. The condition may persist for months or years with\\nbut slight change. In more severe forms the heavier masses of scales\\nand crusts described above may form upon distinctly reddened or moist\\npatches. Seborrhoea oleosa may complicate the process with its char-", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0402.jp2"}, "403": {"fulltext": "ECZEMA. 383\\nacteristic greasy crusts and oily condition of scalp and hair. In infants\\nand occasionally in adults an acute dermatitis may supervene, involving\\nportions or all the scalp and usually extending to the adjacent portions\\nof the face. The conditions known as Milk-crust (described under\\nSeborrhoea) may well be considered a form of dermatitis seborrheica.\\nIu adults circumscribed, oval or circinate, reddened, and scaling, moist\\nor crusted patches may appear, chiefly about the temporal and parietal\\nregions, often extending to the ears and portions of the face. Occa-\\nsionally a sharply defined red band, more or less covered with scales or\\nsmall crusts, may be seen at the margin of the hair, especially on the\\nforehead and on the neck. Such bands closely resemble those of psori-\\nasis, but usuallv have a more regular and even outline, much less infil-\\ntration and thickening of the skin, and lack the characteristic scales\\nand outlying separate lesions of psoriasis.\\nThe ears and the surfaces surrounding them are, after the scalp,\\nmore frequently involved than other parts of the body. Any of the\\nabove-described types of the disease may be seen in this region, the\\nmoist and crusting forms being quite common, especially back of the\\nears, where fissures frequently occur. The disorder not rarely affects\\nto a very marked degree the lining of the external conduit of the ear,\\nblocking it with crusts and interfering seriously with audition.\\nThe beard, moustache, eyebrows, and pubes may present symptoms\\ndiffering but slightly from those in the scalp. The disorder may linger\\nabout the verge of the moustache or other parts of the beard, showing\\nits grease and scales even at a distance from the line of hairs, with a\\nwell-defined reddened surface beneath. The same occurs about the\\nline of the eyebrows. Alopecia is uncommon in any of the regions\\nexcept the eyebrows.\\nOn the face the pityriasic forms are common on the nose and\\nadjoining portions of the cheeks, the eyebrows and the region between,\\nthe eyelids and their margins, and may be exhibited on any part of the\\nface. Loss of hair from the eyebrows and eyelids is not unusual (see\\nSeborrhoea sicca). The more inflammatory moist and crusting types\\nare most frequent along the junction of the alee of the nose with the\\ncheeks, but may involve the entire nose and other parts of the face.\\nThe macular and papular types, above described, are most common on\\nthe cheeks.\\nSeborrhgea Corporis, Seborrhoea Papulosa or Lichenoides\\n(Crocker), Lichen Circumscriptum (Willan), Lichen Annulatus\\net Serpiginosus (Wilson), Flannel-rash. Upon the trunk is\\nfrequently found Unna s flower-leaf or petaloid type of the\\neruption which was first described by Duhring and to which have\\nbeen assigned by different authors the titles here enumerated. Its\\nfavorite sites are the sternum and interscapular region, but rarely it\\nspreads in more extensive areas on other parts of the trunk. In a\\nwell-marked case the lesions appear in the form of sharply outlined\\ncircles or segments of circles which enlarge centrifu^allv, often coalesc-\\ning to form patches with irregularly circinate outlines. The extreme\\nborders, which represent the early stage of the lesions, are made up of\\nvery small red papules, usually covered with fine whitish or yellowish,", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0403.jp2"}, "404": {"fulltext": "384 INFLAMMATIONS.\\ndry or fatty scales. As the border progresses the centre undergoes\\ninvolution, so that from without inward the patch may display varying\\nshades of red, brown, and yellow, while the whole surface is often the\\nseat of a furfuraceous desquamation. Round or oval, somewhat ele-\\nvated, solid lesions are frequent, and may scale slightly or be covered\\nwith yellow, greasy crusts. In less perfectly developed cases and in\\nthose modified with friction of the clothing or frequent bathing there\\nmay be simply yellowish, finely scaling patches with slightly reddened,\\nmore or less irregular borders.\\nThe eruption also occurs upon the trunk and extremities in the form\\nof macules, papules, and reddened patches which by coalescence of\\nindividual lesions may become quite large. These lesions may present\\nany degree of scaling or crusting, though there is usually a narrow\\nuncovered reddened margin. The affected areas may be dry and in\\nform, distribution, and general appearance closely simulate psoriasis;\\nor they may be somewhat moist and, as a result of irritation or of\\nexcessive exudation, may undergo a transformation to a condition indis-\\ntinguishable from that of eczema. In most cases the yellowish color\\nof the lesions is conspicuous, being most marked when the eruption is\\nfading.\\nIn the axilla and groin the eruption often begins as an erythema\\nintertrigo, and owing to the influence of heat, moisture, and friction\\nin these regions secreting patches are common. From these points\\nthe disease often spreads to the adjoining surfaces, the advancing\\nmargin of the eruption always being sharply outlined and usually of\\ncircinate contour.\\nThe dorsal surface of the hands and fingers may be involved, and\\nalso the palms, on which pea-sized and larger ill-defined scale-covered\\nmacules are irregularly distributed over the surface.\\nEtiology. In his first description of eczema seborrhceicum Unna\\nclaimed for it a parasitic origin. He has described three varieties of\\ndiplococci which he found in the lesions of this disease, beside several\\nvarieties of bacilli which were occasionally present. Of these he con-\\nsidered a mulberry-shaped coccus, which he called the m-orococcus, of\\nspecial importance, and on occasions has produced with it, by the\\ninoculation of pure cultures, one or more vesicles, but without repro-\\nduction of a patch of true eczema seborrhceicum. He also found\\nMelassez s flask-shaped bacillus in the scales.\\nElliott 1 reports on a bacteriological study by W. H. Merrill, of fifty\\ncases of eczema seborrhceicum. In all but two cases, on which a solu-\\ntion of resorcin had been freely used, bacteria of some kind were found.\\nMerrill describes two varieties of diplococci and a bacillus, all three of\\nwhich were present in thirty-one cases, while one or two of them were\\nfound in most of the remaining cases. Twelve inoculation-experiments\\nwere made, of which seven were successful; from pure cultures of the\\ncocci typical lesions of the disease were produced, from which, in each\\ncase, the special coccus was recovered and cultivated. One of these\\ncocci was decided to. be chromogenic and the cause of the yellowish\\n1 A Preliminary Bacteriological Report on Eczema Seborrhceicum, N. Y. Med.\\nJour., October 26, 1895.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0404.jp2"}, "405": {"fulltext": "ECZEMA. 385\\ncolor characteristic of the disease. These experiments, though too few\\nin number to be conclusive, would seem, when considered in connection\\nwith clinical evidence, to leave little doubt of the parasitic origin of the\\ndisease. The etiological value of the micro-bacillus of Unna and\\nSabouraud is considered in the discussion of seborrhoea. Positive\\nevidence of the transmission of the disease from one individual to\\nanother is difficult to get, though a history of probable contagion is\\nsometimes obtained.\\nLocally, heat, moisture, friction, and other forms of irritation may\\nact as predisposing causes and favor the origin and spread of the dis-\\nease. On the body it is often found in those who perspire freely and\\nwho wear woollen next the skin. On the scalp it is common in\\nthose who keep the head covered much of the time. Elliott reports\\nthat most of his cases occurred in people who lived for the most\\npart indoors, and that the affection is unusual on those who live\\nlargely in the open air. His explanation of the greater prevalence\\nof the disease in winter than in summer is that in the former season\\nmost people live indoors, with poorer ventilation, and bathe less than\\nin summer.\\nThe systemic conditions favoring the development of the disease are\\npractically those named as predisposing causes of seborrhoea.\\nPathology. Even in the mildest grades of the affection, corre-\\nsponding to the condition known as pityriasis capitis, Elliott found\\nslight inflammatory infiltration about the papillary vessels and the\\nascending branches from the subpapillary plexus, and along the hair-\\nfollicles, while in the rete there were some vacuole-like formations\\nand a few wandering cells. In severer grades the inflammatory infil-\\ntration extended to the subpapillary plexus, and in higher grades to\\nthe entire cutis, which was then somewhat cedematous. In the rete\\nvacuoles were numerous and their origin could be traced to a nuclear\\ndegeneration. Many wandering cells were present, also karyokinetic\\nfigures and areas of cell -degeneration. The horny layer was thick-\\nened and easily detached from the interfollicular spaces, but densely\\npacked in the dilated openings and necks of the follicles. The seba-\\nceous glands were apparently normal. The coil-glands in many\\ninstances were dilated and contained cast-off epithelial cells mixed with\\na granular debris, while mitosis and cell-degeneration were frequently\\nseen. Elliott found no appearance that would warrant him in believ-\\ning the coil-glands to be the source of the fatty hypersecretion. Unna,\\non the other hand, found fat in the coil-glands, and believes them to\\nbe the source of most of the fatty secretion characteristic of the dis-\\nease. He also describes an infiltration of small, free globules of fat\\nthrough all parts of the cutis and rete, inside the lymph-sacs. Elliott\\nfound no evidences of such infiltration but Ledermann announces that\\nhe has recognized it in normal epithelium.\\nUnna and Elliott agree in considering all stages of the process an\\ninflammation of a catarrhal nature, the immediate cause of which is to\\nbe found in one or more specific micro-organisms.\\nDiagnosis. From other forms of dermatitis and from simple\\neczema, eczema seborrhoeicum may be distinguished by its origin on", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0405.jp2"}, "406": {"fulltext": "386 INFLAMMATIONS.\\nthe scalp, its oily secretion and crusts, the yellowish color and sharp\\noutline of its lesions, its tendency to spread peripherally in circinate\\noutlines, and by its lack of marked subjective sensations.\\nIn some forms of the disease the diagnosis from psoriasis is diffi-\\ncult, but the location of the lesions on the flexor rather than on the\\nextensor surfaces, the oily character of the scales and crusts, the yellow-\\nish color, the greasy and scaly centre of circinate lesions undergoing\\ninvolution, and the general course of the eruption, will usually suffice\\nto distinguish the disease.\\nPityriasis rosea may present appearances identical with those of\\neczema seborrhoeicum of the trunk and extremities. The lesions in\\nthe former disease, however, do not appear on the scalp, usually have\\nill-defined, frayed-out borders, and the enlarging rings present a dry,\\nfawn-colored centre which is free from greasy scales. The affection,\\nmoreover, runs an acute course, rarely lasting more than six or eight\\nweeks.\\nTreatment. Sulphur, resorcin, salicylic acid, white precipitate, and\\nother preparations of mercury are remedies most useful in the treatment\\nof all stages of the disease. For the earlier and dry forms, stronger\\nand more stimulating preparations may be used, together with more fre-\\nquent washings of the skin, than in the acute, moist forms, which must\\nbe treated more in accordance with the principles laid down Tor the\\ntreatment of the corresponding stages of eczema. For the scalp and\\nother hairy portions of the body lotions are usually better than oint-\\nments. The lotion recommended by Elliott, containing 3 to 20 per\\ncent, of resorcin in equal parts of alcohol and water, is one of the best,\\nand should be applied two or three times daily. For the dry forms\\nof the disease a small amount of oil preferably the oil of sweet\\nalmonds to prevent the disagreeable drying effect of the lotion\\nalone, may be added. Instead of thus combining the oil with the\\nliquid, a thin ointment containing resorcin or sulphur may be\\nsubstituted for or applied after the lotion. After soap-and-water\\nwashings, which should be used often enough to prevent accu-\\nmulation of scales and crusts, an oily or fatty application is always\\ndesirable.\\nThe most serviceable ointment in the majority of cases is one con-\\ntaining from 1 scruple to 2 drachms (1.33 to 8.) of sublimated or\\nprecipitated sulphur, 10 minims (0.66) of balsam of Peru, and 1 ounce\\n(30.) of vaselin. Instead of sulphur, resorcin or white precipitate may\\nbe used. In some chronic cases with much infiltration, sulphur,\\nresorcin, and salicylic acid may be with advantage combined in the\\nsame ointment, while in a few instances the tars, pyrogallol, or chrysaro-\\nbin may succeed after the above-named preparations have failed. In\\nacute forms, in which the symptoms are more those of an acute\\neczema, pastes and ointments containing salicylic or boric acid are\\nvaluable until the acute inflammatory condition has subsided, when\\npreparations containing sulphur or resorcin should be used.\\nThe disease is usually more amenable to treatment than eczema,\\nthough recurrences are common.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0406.jp2"}, "407": {"fulltext": "PRURIGO. 387\\nDERMATITIS REPENS.\\nUnder this title Crocker first described an inflammatory disease of\\nthe skin (usually a consequence of injuries) spreading with a marginate\\nborder, and, as a rule, beginning over the upper extremities. Cases\\nhave since been reported by Garden and Nepveu. 1\\nThe inflammation spreads from a traumatism, eventually producing a\\nraw, reddish surface denuded of epidermis and oozing at several points,\\nthe serous exudate also undermining the apparently sound cuticle. The\\ndisease spreads with uninterrupted regularity, lasting for months, and\\nin cases invading the larger part of an upper extremity. The exten-\\nsion is at times from coalescing reddish papules which discharge and\\nleave thick, dirty looking crusts. There is a definite margin to the dis-\\neased patch. In cases the disease begins with the formation of blisters.\\nThe disease has. originated in cicatrices after amputation of a\\nfinger, from burns, from irritation of the feet after walking barefoot on\\nsand, and from splinters under the nail. Crocker believes that the\\ndermatitis results from peripheral nerve-irritation, and that there\\nis a secondary parasitic involvement of the part. The disease seems\\nto be an infectious dermatitis, the traumatism being simply an initial\\nfactor of the process. The parchment-like epithelium often left after\\nhealing shows that the process may be one of considerable destruction\\nof epidermal and dermal tissues, which may result in diffuse but super-\\nficial atrophy and cicatrization. The diagnosis from eczema depends\\nchiefly upon the recognition of the limited outline of the disease, the\\nentire denudation of the surface, the undermined edge, and the thinned,\\nshining epidermis left after healing. The affection is to be treated as a\\nparasitic eczema.\\nTwo cases of this disease were supposed to have originated in the\\nminute traumatisms of the finger-nails occurring when farm-laborers are\\nengaged in husking Indian corn by hand and one Avell-marked case\\nfollowed the amputation of a finger. An excellent illustration of the\\ndisease is given in a colored lithograph accompanying the report of a\\ncase by Stowers. 2\\nIn three cases treated by us success was obtained in one after employ-\\ning locally a saturated solution of pyoktanin-blue. In another case that\\nhad resisted continued and varied treatment the lesions disappeared\\nrapidly under application of a solution of sodium hyposulphite. Still\\nanother case yielded to applications of strong white-precipitate oint-\\nment. Crocker recommends a strong solution of potassic perman-\\nganate.\\nPRURIGO.\\n(Lat. prurire, to itch.)\\n(Prurigo Gravis, Prurigo of Hebra, Prurigo Ferox.)\\nPrurigo is one of those terms which in the past have led to consid-\\nerable confusion in the nomenclature of cutaneous disease. In England,\\n1 Brit. Med. Jour., December 11, 1896.\\n2 Brit. Jour, of Derm., 1896, vol. viii., No. 1.", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0407.jp2"}, "408": {"fulltext": "388 INFLAMMATIONS.\\nchiefly, it is applied with more or less looseness to disorders accompa-\\nnied by the subjective sensation of itching, such as the prurigo mitis\\nof Willan, and the disease well recognized under the title pruritus.\\nPrurigo in this loose sense represents a group of disorders due either\\nto the invasion of animal or of vegetable parasites, to disorders of\\ninternal origin, to the ingestion of drugs, or to the other causes de-\\nscribed under Pruritus.\\nThe title prurigo in this work is strictly limited to the disease\\nto which the name was originally given by Hebra, a disorder beginning\\nin earliest life and continuing throughout its duration. Once observed\\nonly or chiefly in Austria, it has now, in consequence of extensive\\nimmigration, been occasionally seen in America.\\nSymptoms. Mild and severe forms of the disease are distinguished\\nunder the terms Prurigo Mitis and Prurigo Ferox, or Agria.\\nIncessant care, judicious treatment, climatic influences, and the com-\\nforts of life commanded by wealth seem to determine the difference\\nbetween the two. In both varieties of this affection pinhead- to rape-\\nseed-sized, Arm, whitish or reddish-white papules form, chiefly and\\nprimarily upon the extensor faces of the extremities, but from these\\nlocalities gradually extending over the entire surface of the body.\\nThe itching is of the severest type.\\nThe earliest symptoms are usually displayed in the latter portion of\\nthe first year of life, in the form of an urticarial rash, which persists\\nand which is finally succeeded by typical papules. These papules are\\nminute, often subepidermic, and rapidly become covered with blood-\\nstained crusts in consequence of the induced scratching. Then ensues\\na long train of symptoms, including pustulation, fissures, excoriations,\\ndense infiltrations, crusts formed of exuded serum and dried blood,\\noedema, diffuse dark-brown pigmentation of the skin-surface in large\\nareas, and consequent adenopathy. Fully developed, the disease pre-\\nsents in general the same physiognomy in patients of different ages.\\nThe lower extremities always exhibit the severest manifestations of\\nthe disease, especially the thigh and leg as distinguished from the\\nfoot though the trunk, the forehead, the cheeks, the neck, the arms,\\nand the head may also be involved. Protected surfaces, such as the\\naxilla? and the groins, except as regards adenopathy, are free from the\\ndisease. The general health of the patient manifestly suffers from the\\ninsomnia and nervous agitation induced by the state of the integument.\\nEmaciation, malnutrition, and cachexia are common sequels. The\\nmental and moral tone of the patient thus harassed from early child-\\nhood throughout an entire life is necessarily profoundly impaired.\\nInsanity and suicide are reckoned among its remote consequences.\\nThe characteristic papules first appear about the eighteenth or nine-\\nteenth month of life, the urticarial rash up to the second year produc-\\ning merely whitish plaques upon the skin, commingled with excoria-\\ntions and occasionally a marked degree of insomnia. The minute\\npapules develop only later on the several regions of preference of the\\ndisease, at first appreciable only to the touch, later projecting from the\\nsurface and capped with a blood-scale from the scratching to which\\nthey have been subjected. Then are to be seen striated excoriations,", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0408.jp2"}, "409": {"fulltext": "PRURIGO. 389\\nbulkier crusts, pustules, dark-brownish-hued pigmentation, and a\\nrubbing off of the hairs, such as is often to be seen over the brows\\nof male patients with erythematous eczema of the face. (Edema,\\ninfiltration, and axillary and inguinal adenopathy supervene, so that\\nby the end of the second year or at the beginning of the third the pict-\\nure of prurigo is complete. At such an epoch the distinguishing\\nmarks of the disease are its selection of the extensor faces of the ex-\\ntremities and the progression of symptoms with added severity from\\nthe arms to the legs. The natural furrows of the skin are all exag-\\ngerated. In exceptional cases the lesions are seen over the face and\\nthe dorsum of the feet. Eczematous attacks may complicate any case.\\nAs a rule, the patient presents practically the same morbid portrait\\nafter maturity and even in old age as in earlier life.\\nPrurigo mitis is the same as the severer form of the disease\\nwith respect to the evolution of symptoms the only difference to\\nbe observed is in their intensity. The papules are fewer, the recru-\\ndescence rarer, the itching less intense, and the amenability to treat-\\nment more pronounced. It is to be noted of all cases that they are\\ninfluenced happily by the warm weather of the summer season and\\nby special attention to cleanliness and hygiene.\\nEtiology. The disease occurs chiefly in Austria, few cases being\\nrecorded elsewhere. A patient was exhibited at the International\\nMedical Congress in London, whom both Kaposi and Hebra recognized\\nas affected with prurigo. Wigglesworth, Campbell, and others have\\nreported cases in America. Prurigo is more often encountered in the\\nmale sex, is never contagious, and is never induced by lice but, accord-\\ning to Hebra and Kaposi, it may be grafted upon an hereditary pre-\\ndisposition. Scrofula, tuberculosis, malnutrition, misery, poverty,\\nanaemia, and filth are held to be severally favorable to its development.\\nThe disease is practically limited to the poorer classes living under\\nwretched hygienic and social conditions. The superior resources of\\nthe poorest classes in America will long protect them from the incur-\\nsion of this inveterate malady.\\nWhile typical prurigo ferox, as described by the Vienna school of\\nauthors, is of such rarity that probably less than a dozen cases have\\nbeen reported in America, the opinion is gaining ground that the same\\ndisease with milder manifestations (prurigo mitis) is much more com-\\nmon here than has been believed. Patients with severe prurigo, treated\\nby Hebra himself, have found their way to our clinic they bore unmis-\\ntakable symptoms of improvement after a residence in the United States,\\nand almost every American expert has observed cases of milder type.\\nPathology. Kaposi practically admits that, striking as is the clin-\\nical portrait of this disease, its anatomical features are indistinguish-\\nable from severe forms of obstinate papular eczema, or from other forms\\nof chronic dermatitis accompanied by hyperplasia. The microscope\\nreveals proliferation and swelling of rete-cells, cell-infiltration and\\noedema of the papillae, most marked around the vessels, and frequently\\ndilated lymph-spaces. There is a scattered deposit of pigment in the\\ncorium, and many cutaneous muscles (erectores pilorum) are thickened\\nand shortened.", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0409.jp2"}, "410": {"fulltext": "390 INFLAMMATIONS.\\nSome authors contend that the papules are solely due to traumatism\\nof the pruritic skin. Auspitz believes that the disease is in fact a\\nsensori-motor neurosis without essential lesion. Biehl 1 considers it as\\na chronic form of urticaria. Leloir and others find the prurigo-papule\\ninvariably resulting from a cystic degeneration of rete-cells, thus form-\\ning a cavity which at first contains clear serum with the addition later\\nof epithelial debris. The walls of the cyst later undergo keratinization.\\nAccording to Unna, the epithelial changes consist in a circumscribed\\ngrowth of the mouth of the follicle and its periphery, and in areas of\\nsoftening and necrobiosis of the epithelia. Most of the histological\\nchanges concern the epidermis, but the vessel-sheaths of the cutis\\nexhibit a cellular infiltration with dilated lymph-spaces, though the\\nblood-vessels are unchanged. The papillary body is oedematous at\\nfirst later, flattened as the slow thickening of the prickle-layer pro-\\nceeds. The thickening of the epidermis is most marked in the horny\\nlayer.\\nDiagnosis. Remembering the extreme rarity of prurigo in America,\\nit is to be distinguished chiefly from the various forms of papular\\neczema by the location of its lesions, by the course of the disease, by\\nthe age of the patient when it is first developed, by the great extent\\nof the eruption, and by the uniform type of its lesions. In prurigo,\\nalso, the fingers and the toes, the flexor aspects of the extremities, and\\nthe face are more or less spared. Under treatment eczema commonly\\nyields at least in some portions of the skin, while prurigo does not.\\nFrom pruritus, prurigo is readily diagnosticated by its general\\nphysiognomy and history, by its peculiar pigmentations and infiltra-\\ntions, and by the special region chiefly affected. But both diseases\\nmay complicate prurigo, especially eczema, which is then ordinarily of\\nartificial origin. In pediculosis corporis the parasites will usually be\\nfound upon the underclothing, w T hile the lesions induced by the finger-\\nnails never form closely packed papules. There is something highly\\ncharacteristic in the widely separated excoriations, the puncta from\\nwounds inflicted by parasites, and the inflamed papules seen upon louse-\\nbitten patients.\\nIn scabies the characteristic burrows of the parasites will usually\\nbe recognized, as also vesicular and pustular lesions. Urticaria can\\nbe mistaken for prurigo only in the earlier stage of the last-named\\ndisease.\\nTreatment. In Vienna, sulphur, naphtol, tar, green soap, baths,\\nand frequent anointings with oily and fatty substances have occasion-\\nally served to ameliorate the severe symptoms of the disease. Mer-\\ncury, ichthyol, salicylic acid, carbolic acid, and boric acid, and diachylon\\nand zinc ointments may also be employed upon different portions of\\nthe skin when indicated.\\nThe Wilkinson salve, representing a combination of tar, sulphur,\\nand green soap, has proved of special value in many cases. Vle-\\nminckx s solution (q. v.), followed by hot bathing and corrosive-subli-\\nmate baths, 1 drachm (4.) of the sublimate to 30 gallons of w T ater,\\nhas also been recommended. Internally arsenic has proved valueless,\\n1 Arch. f. Derm. u. Pvph 1884.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0410.jp2"}, "411": {"fulltext": "ACNE. 391\\nwhile carbolic acid has occasionally seemed beneficial. Cod-liver oil\\nand the ferruginous tonics with the bitters will naturally be indicated\\nin many patients suffering from malnutrition. A generous diet and a\\ntonic regimen are essential to the management of most cases.\\nPrognosis. The disease usually persists through life. The most\\nfavorable conditions are those in which the patient is young and sur-\\nrounded by circumstances which permit of provision for his needs. The\\ndisease is probably curable in the early years of life.\\nACNE.\\n(Gr. anvrj, a point.)\\n(Vaeus. Fr.y Acne Ger., Hautfinn t e.)\\nSymptoms. Acne is probably the cutaneous disease of most com-\\nmon occurrence, not excepting eczema. The latter affection occurs\\nupon the face as often as upon other parts of \u00c2\u00a3he body, yet it is seen\\nin persons upon the street with far less frequency than acne. Eczema,\\nhowever, is more distressing in its symptoms, and for that reason\\nphysicians are more often consulted for its relief, the disease thus\\nacquiring a statistical preponderance. Acne is more tolerable, and\\ntherefore is more tolerated and less treated, especially among the poor.\\nThe disease chiefly occurs in the second and third decades of life,\\nand is characterized in general by the occurrence of several and usu-\\nally numerous, light-red, dull-crimson or violaceous, pinhead- to small-\\nnut-sized, ill-defined papules, nodules, tubercles, or non-projecting\\nindurations of the skin, often commingled with the symptoms of comedo\\nand seborrhcea sicca. The lesions are isolated or irregularly scattered\\nover the surface, which, however thickly studded with them, never dis-\\nplays a grouping or definite arrangement of the elements of the erup-\\ntion. Many of the latter are both slightly painful and tender, though\\nupon this point there is a wide range of difference in various indi-\\nviduals, some patients tolerating with a surprising equanimity the most\\nextensive invasions of the disease. The inflammatory process, which\\nmanifestly involves the sebaceous glands and periglandular tissues,\\nmay result in suppuration of several adjacent follicles, as a conse-\\nquence of which coalescence occurs and pea- to large-nut-sized cuta-\\nneous and subcutaneous abscesses may form. In many cases, however,\\nthe suppuration is limited to the area of the individual nodule. Every\\nfeature of the disease, from the smallest papule to the largest subcuta-\\nneous abscess, may be displayed at the same moment in an affected in-\\ndividual. Under circumstances of special aggravation the disease may\\noccur in acute forms, but it is commonly chronic, the acute phases\\nbeing usually accidents of the general process.\\nThe disease occurs chiefly upon the face, but is seen also upon the\\nneck, the back and front of the chest, the genitals, and the extremities,\\nthe palms and soles alone being excepted. It is emphatically a disease\\nof the early puberal epoch in both sexes, though occasionally it is seen\\nin middle and later life. In women the symptoms of the disease are\\nusually most conspicuous at about the date of menstruation. Acne", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0411.jp2"}, "412": {"fulltext": "392 INFLAMMATIONS.\\nusually lasts for years when unrelieved, during this period being sub-\\nject to occasional exacerbations and remissions, but it commonly spon-\\ntaneously disappears as full maturity of the body is attained. It may\\npersist for years in a mild form with or without the occasional develop-\\nment of the severer grades. In severe cases in which suppuration has\\nbeen extensive it leaves indelible traces of its ravages in the form of\\nscars. The various terms used in the description of the forms of the\\ndisease refer chiefly to its external features.\\nAcne is a disorder which frequently is associated with mild or severe\\nalopecia furfuracea and seborrhoea capitis, the totality of symptoms\\ndepending upon similar causes in the susceptible subject.\\nAcne Artificialis. Various substances, either applied topically\\nto the skin or ingested, are capable of producing acneiform lesions.\\nAmong them may be named tar, which may prove an irritant whether\\nemployed externally or internally, and far more frequently the salts\\nof iodine and bromine after ingestion. Tar-acne occurs both among\\nworkers in tar and in those subjected to the action of this substance for\\nthe relief of other cutaneous disease. Pinhead- to pea-sized, reddish-\\nbrown papules then form, at the apex of each of which is perceptible\\na minute blackish punctum, produced by the lodgement of a particle\\nof the medicament in the orifice of a sebaceous follicle. Pustular\\nand furuncular lesions are, however, also produced, such as occur\\nin bromic and iodic acne. In the latter disease Adamkiewicz and\\nothers have demonstrated the presence of the drug in the contents of\\nthe pustular lesions. Chrysarobin and a number of other medicinal\\nsubstances are capable of exerting a like effect.\\nAcne Atrophica and Acne Hypertrophica are terms employed\\nto designate merely the lesion-relics of the disease. In acne atrophica\\nthere is complete atrophy of the gland-tissue, indicated by a minute\\nsunken pit in the site of the former orifice. In acne hypertrophica\\nthere are, in consequence of the periglandular exudation, a thickening\\nof the tissues about the acini, and a projection from the surface in the\\nform of persistent, pea-sized, indurated masses.\\nAcne Cachecticorum or Scrofulosorum includes the symp-\\ntoms encountered in the subjects of struma, scorbutus, marasmus,\\nchloro-ansemia, and tuberculosis. The lesions are more often developed\\non the trunk and the extremities than over the face, and are papulo-\\npustules, pinhead- to bean-sized, particularly indolent, and remarkable\\nfor their livid, purplish, lurid-red, or violaceous tint. The lesions are\\nrarely indurated more often they are seen as softish, pus- and blood-\\ncontaining nodules, sluggish of career, and leaving minute cicatrices.\\nTheir features are due entirely to the general cachectic condition of the\\nsubjects in whom they occur. Colcott Fox describes acne scrofuloso-\\nrum as it occurs in infants. 1\\nAcne Indurata. This type of the disease is less frequently ob-\\nserved than several of the other forms, but it is one which possesses\\ndistinct clinical features. Induration of the base of the acne-papule\\nmay be noted in many cases of the simple form of the malady, but\\nin others the glands seem generally to be distinguished as minute,\\n1 Brit. Jour, of Derm., November, 1895.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0412.jp2"}, "413": {"fulltext": "ACNE. 393\\nvery firm nodules, with no tendency to suppuration. The surface of\\nthe skin is often without marked change in color or heat, the indi-\\nvidual lesions exhibiting at times an unnaturally whitish aspect. They\\nare felt when the finger is passed over the surface as dense, often\\nconical projections, occasionally painful, and giving to the touch a\\nsensation suggestive of the surface of a nutmeg-grater. Comedones\\nmay often be discovered intermingled with the papules. The disease\\nwhen well marked is likely to be extensive, occurring with charac-\\nteristic expression among brunette, hairy male patients well advanced\\nto the twenty-fifth year. It is often generalized over the forehead,\\ncheeks, and chin, and the back of the neck.\\nAcne Papulosa. In acne papulosa the lesions are of a papular\\ntype, ranging in size from that of a millet-seed to that of a coffee-\\nbean, whitish or reddish in color, and varying in the amount of indura-\\ntion at the base. They are evidently due to infiltration of the peri-\\nglandular tissue, and are often commingled with pustules, papulo-pus-\\ntules, and comedones. At the apex of each papule is often distinguished\\nthe blackish point characteristic of acne punctata, or a minute, greasy,\\nyellowish- white spot, which represents the non-pigmented extremity of\\nan inspissated sebaceous plug.\\nAcne Punctata. In this variety of acne the apex of the papule\\nexhibits the characteristic blackish pun ct urn of the comedo about which\\nthe papule has formed.\\nAcne Pustulosa. This form is probably the most frequently\\nobserved of all the expressions of the disease. The lesions are apt to\\nbe commingled with papules, comedones, and intermediate phases\\nbetween the functional and inflammatory disorders of the glands. The\\npustules almost invariably originate in previously formed papules and\\nmay be large or be small, containing merely a droplet of pure pus, or,\\nwhen a true furunculosis ensues, a teaspoonful or more of pus may be\\nmingled with blood and serum. This accumulation may be evacuated\\nsurgically or accidentally, or be absorbed, or may remain for a long\\nperiod of time in a species of cyst, whence it can finally be expressed.\\nIn aggravated cases two or more of these pustulo-furuncular depots\\nmay coalesce, forming nut-sized abscesses, or, not rarely, may become\\nunited by fistulous tracts, through which there is free communication\\nof the fluid contents of two or more chambers.\\nAcne Vulgaris is a term applied by several authors to the com-\\nposite eruption which is common to many clinical cases. Here the\\nvarious lesions described above (papules, pustules, comedones, etc.)\\nare associated, usually on the face and over the shoulders, each in sev-\\neral degrees of development, often in conjunction with the scars left\\nby a prior eruption.\\nAcne Disseminata is a name given by some authors to acne vul-\\ngaris, the common inflammatory type of the disease above described.\\nAcne Kebatosa is the Acn6 cornSe of French authors. In this\\naffection cornified masses of sebum distend and project from the orifices\\nof the sebaceous glands, particularly over the neck, but also over the\\nface, the trunk, the elbows, the knees, and other portions of the body.\\nThere is some doubt whether this disease should not be classed with", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0413.jp2"}, "414": {"fulltext": "394 INFLAMMATIONS.\\nichthyosis, which it unquestionably resembles, or with keratosis pilaris.\\nBy some French authors the condition is considered an early stage of\\nkeratosis (psorospermosis) follicularis.\\nUnder this title Crocker l reports four cases in women in whom there\\nappeared on the face, chiefly about the angles of the mouth firm, painful\\ninflammatory papules, succeeded by pustules and crusts. From the cen-\\ntre of these lesions could be expressed short, soft or horny plugs which\\nwere formed evidently in the sebaceous glands or hair-follicles. On\\nremoving the plug the lesions healed slowly, in many instances leaving\\na scar. The disease was persistent, lasting in one case for forty years.\\nKeloid-acne (Dermatitis Papillaris Capillitii) is a name\\nwhich has been given to an inflammatory folliculitis and perifolliculitis,\\nleaving deep hypertrophic scars, usually, in the thick epidermis over\\nthe neck and the back of the trunk, though seen also upon the scalp\\nand face. Wisps of thick, distorted, and evidently altered hairs pro-\\nject here and there from the affected surface. Reddish, and even vas-\\ncularized nodes, tubercles, and bridges occur at irregular intervals, in-\\nterspersed with occasional acne-pustules and deep-seated, broad, even\\ngigantic comedones. Sclerotic tissue, in brief, forms about the site of\\nthe acne-process quite like cicatricial keloid of the trunk and other\\nsituations.\\nAcne Parasitica is a term which eventually will be extended to\\ninclude many of the varieties of the disease described above. Some\\nof the pustular lesions of acne result solely from dissemination of pus-\\ncocci over the face by the finger-nails or other means. The good re-\\nsults obtained by an appropriate therapy are often the fruit of a de-\\nstruction of these micro-organisms.\\nThat some of these lesions are at times infected with the bacillus\\ntuberculosis there can be no question. Not only have tubercle-bacilli\\nbeen recognized in the pustules of some forms of acne, but singular de-\\ngenerative and even ulcerative results have in rare cases been produced,\\nnot solely due to the ordinary processes distinguishable in acne.\\nAcne Urticata is described by Lowenbach 2 as occurring on the\\nscalp, face, and other portions of the body. The primary lesion, which\\nis preceded by itching and burning, is a small wheal which enlarges to\\nthe size of from 6 to 12 mm. The centre then becomes paler and de-\\npressed and shows a vesicle which dries into a crust. The crust falls,\\nleaving a small scar which in time becomes depressed and shining\\nwhite. The full development of a wheal requires from four to six\\ndays. The later stages of the process suggest acne necrotica both\\nclinically and histologically.\\nUlerythema Acneiforme is probably due in part to the toxins of\\na tubercular infection, and is assigned in this work to another chapter.\\nContagious Acne (Diekerhoff and GraAvitz) of horses (horse-pox)\\nis compared by Kaposi to contagious impetigo rather than to human\\nacne. It is characterized by an eruption of flattish, pea-sized and\\nlarger bullae, seated on an inflammatory base, and visible over the\\nregion of the mane, the back, and the shoulders.\\n1 Brit. Jour, of Derm., 1899, p. 1.\\n2 Arch. f. Derm. n. Syph., 1899, vol. xlix., p. 29.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0414.jp2"}, "415": {"fulltext": "PLATE VI\\nAene-keloid of the Back.", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0415.jp2"}, "416": {"fulltext": "", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0416.jp2"}, "417": {"fulltext": "ACNE. 395\\nEtiology. The causes of acne are numerous and in many cases\\nobscure. It is common to describe the puberal change in both sexes\\nas a frequent cause of the disease, but a physiological crisis is rarely a\\ndisease-factor unless the full and normal development of the period\\nbe prevented by accident, disease, or malnutrition, or by excessive\\ndemands upon the vital forces in other directions. With the growth\\nof the hair in both sexes at the period of puberty there is an unusual\\nactivity of the sebaceous glands, and this physiological is then the\\nmore readily perverted to a pathological activity. Thousands, how-\\never, escape acne who survive puberty. The disease, none the less,\\nis prone to appear first at this time of life, and, if not improperly\\ntreated, to disappear spontaneously when full maturity of the body is\\nattained. There is a close physiological connection between the genital\\nfunction and organs, and the appendages of the skin, not only in man\\nbut also in the lower animals (antlers of the stag, plumage of birds,\\netc.), and the disturbances of the former may be reflected to the latter.\\nThe effect of castration upon the male of many animals is displayed in\\nthe appendages of the skin. In the same way perverted sexual\\ninstincts and habits, or a poorly regulated sexual hygiene and uterine\\ndisease, are frequently associated with an acne. The most common\\ncauses of acne are associated with disturbances of the gastro-intestinal\\ntract, including constipation, dyspepsia, and malnutrition from various\\ncauses. Acne cachecticorum, struma, tuberculosis, and the cachexias,\\nand the medicinal agents capable of producing artificial acne, either by\\ningestion or after external application, have already been accused.\\nIt should not be concluded, however, that any one of these condi-\\ntions can be recognized as efficient in the majority of patients. Many\\ncases of acne occur in healthy young people of both sexes. A careful\\nrecord of many cases of the disease will exhibit in other organs no ail-\\nment common to the larger number of patients. The causes of the\\ndisease may be local, such as suffice merely to induce primarily altera-\\ntion in the consistency, quantity, or chemical character of the sebaceous\\nsecretion, and, either as a cause or result of this alteration, there ensues\\nan adenitis or a periadenitis and subsequently an infection with micro-\\norganisms.\\nThe use of cosmetics, the neglect of soap, or the use of the cheaper\\nand irritating varieties, excessive shaving on the part of the young\\nman, friction from hatbands, frizzes, bangs, and dyed veils, too\\nfrequent fingering of the face, improper compression of the neck by\\ntight collars, and a long list of other agencies may prove the immediate\\nor the remote cause of the disease. It is believed that blondes are the\\nmore frequent sufferers but this observation may have been suggested\\nby the circumstance that in those of light complexion the symptoms of\\nthe disease are more conspicuous and disfiguring. It certainly seems\\nthat young brunettes, with thick skins and abundant growth of dark\\nlauugo-hair, furnish the most obstinate cases.\\nThe cause of acne is the mechanical irritation produced by the\\ncomedo-plug which is formed by inspissation of the contents of the\\ngland and by hyperkeratosis of the neck of the follicle. An efficient\\ncause in some cases is perversion of the glandular function or excretion", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0417.jp2"}, "418": {"fulltext": "396 INFLAMMATIONS.\\nby the gland of toxic substances, in consequence of which the secretion\\nis changed in character and becomes a chemical irritant to the tissues.\\nInfection with pus-cocci or possibly with other micro-organisms is an\\nimportant factor in many cases. The micro-bacillus of Unna and\\nSabouraud is found constantly in the lesions of acne, as it is in those\\nof comedo and alopecia areata. It is believed by many that this\\nbacillus is the sole direct cause of comedo and acne.\\nPathology. The earliest stage of the acne-papule is that described\\nunder comedo. Hyperplasia of the horny layer at the follicle-neck\\nmay continue without decided inflammatory changes and produce the\\nsmall, firm, normal-colored papules of this type of acne indurata, or\\ncomplete occlusion of the duct of the gland may result in a simple\\nretention-cyst.\\nAs a rule, however, the presence of the comedo-plug excites an\\ninflammation which may be limited to the common excretory duct and\\nthe sebaceous gland, but which involves often the hair-follicles and\\nusually the tissues surrounding these structures. The pathological\\nchanges depend upon the extent and intensity of the process. In gen-\\neral, however, the inflammatory changes are of one or the other of\\ntwo types. In the first type the inflammation is subacute and per-\\nsistent, resulting in a denser infiltration of the tissues and producing\\nthe indolent, indurated papules often seen in old and stubborn acne.\\nThe process may result in hyperplasia of the connective tissue, as in\\nacne hypertrophica. In the second type of inflammation the process\\nis more acute and is followed by suppuration, which may be limited to\\nthe sebaceous gland, and produce neither scarring nor loss of the hair,\\nor may include the follicle and surrounding tissues, causing destruction\\nof the hair-papilla and the production of a permanent scar. When\\nseveral glands and the intervening tissues are involved in this sup-\\npurative inflammation small abscesses are formed, considerable tissue\\nis destroyed, and the resulting scars are large and disfiguring.\\nAccording to Kaposi, there is no question that the first stage of the\\ndisease is always an anomalous performance of secretion or excretion in\\nthe sebaceous gland. Unna takes an opposite view, citing two main\\nfeatures: first, a parakeratosis resulting in occlusion of the follicular\\norifices, and, second, the presence in the crypt-contents of a bacillus\\nwhich he believes is pathognomonic for this disease.\\nDiagnosis. The typical facies of acne vulgaris is readily recog-\\nnized by the characteristic features already described. The reddish\\npapules, pustules, comedones, and lumps in the skin of the face of\\na young subject; the evident involvement of the sebaceous glands; the\\nhistory of a chronic affection destitute of itching and, though possibly\\npicked, quite unscratched the occasional blood-crusts where lesions\\nhave been squeezed or incised, are all significant facts. The pustular\\nsyphilide of the face is not only to be differentiated by its share in the\\nhistory of an infectious disease, but also by the occurrence of charac-\\nteristic crusts, its selection by preference of the regions about the nose\\nand mouth, its evolution in groups, and its sequels in the form of super-\\nficial or deep ulcerations. Nevertheless, simple acne is common in\\nsyphilitic subjects. Potassium iodide is so frequently administered", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0418.jp2"}, "419": {"fulltext": "ACNE. 397\\nfor the relief of syphilis, and in so large a majority of cases induces\\nits artificial acne, that the latter eruption often precedes the evolution\\nof the macular syphilide, and also with frequency masks the latter by\\na commingling of lesions. Simple acne is common also among those\\nwho are veterans of syphilis. Acne certainly at times resembles variola,\\nand cases of the former have been mistaken for variola. In most\\ninstances the absence of fever and a brief delay will end any doubt.\\nTreatment. Acne is an entirely remediable disease in every case\\nproperly managed. Scars of ancient ravages of the affection are, it is\\ntrue, indelible, but even these are smoothed down in the progress of\\ntime so that they become yearly less conspicuous and disfiguring.\\nThe general treatment of acne requires a careful and exhaustive\\nstudy of the special requirements of each individual case. For most\\npatients the question of diet is of the highest moment that appro-\\npriate for the school-boy and the school-girl, or the adolescent\\nemployed in factory or on the farm or in domestic labor. All well-fed\\nsubjects of acne are benefited in a high degree by reducing the quan-\\ntity of food ingested, especially in the item of meats. A milk-diet,\\nor one composed largely of fish, fruits, and the lighter vegetables,\\nwill usually brighten up the most obstinate case. Confectionery,\\nhighly spiced food, pastry, hot bread and cakes, sugars, and fried\\narticles are all excluded with great advantage. In most cases much\\nwill be accomplished by cutting down the quantity while regulating the\\nquality of the food eaten. Alcohol is generally to be prohibited and\\nit is idle to treat a severe case of acne in a young male subject who\\ncannot for the time abandon the use of tobacco in every form.\\nAn important consideration, at the outset of treatment of a patient\\naffected with acne, relates to any local or internal medication previ-\\nously employed. A large proportion of all patients first claim the\\nattention of the physician after ingesting drugs or making topical\\napplications which have decidedly aggravated the original trouble.\\nWith or without the advice of others, such patients have often been\\nengaged for months in swallowing potassium iodide, red clover,\\nand various nostrums calculated to drive out the disease or in\\nrubbing over the skin equally noxious proprietary substances. In\\nevery such instance the skilled physician should delay active treatment\\nof the affection until the artificial acne has subsided, and the real con-\\ndition of affairs can clearly be recognized. The patient should be\\ndirected to discontinue his or her former practice, to bathe the affected\\npart with hot water at night, and after the surface is dried to apply any\\nbland unguent. By these simple measures alone many cases can be\\nimproved greatly, and some be relieved completely.\\nThe constitutional treatment of acne rests for its success upon the\\ndiscovery of the cause of the disease. Many patients certainly require\\nno internal medication, being entirely relieved by local treatment. A\\nthorough investigation of the habits of living food, diet, bathing,\\noccupation and bodily functions, according to the methods described\\nin the chapter devoted to General Diagnosis, is essential at the outset.\\nSince dyspepsia and constipation are frequent causes of the disease,\\nit is necessary to correct these disorders when present. A blue pill or", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0419.jp2"}, "420": {"fulltext": "Sy;\\n60\\nf3ij;\\n8\\n33;\\n4\\ngr. v;\\n33\\nf 3j\\n4\\nad f 3viij\\nad\\n240\\nM.\\n398 INFLAMMATIONS.\\ncalomel on several consecutive nights followed by a saline laxative in\\nthe morning is usually indicated at the outset of treatment. The\\ncascara compounds are especially valuable when it is necessary to con-\\ntinue the use of a laxative for more than a few days. Some modifica-\\ntion of Starting acid mixture, such as the following, will be found\\nsuitable for other cases\\nR Magnes. sulphat.,\\nAcid, sulphur, dil.,\\nSodii chlorid.,\\nFerri sulph.,\\nCardamom, tinct. co.,\\nAq. dest.,\\nFiltra.\\nSig. A tablespoonful in a tumblerful of water before breakfast.\\nOther cathartics, saline and alterative, will often prove service-\\nable. The mineral waters, Hathorn, Carlsbad, Hunyadi Janos, Racoczy\\nor Kissingen, a tumblerful before breakfast, are exceedingly valuable\\nin cases of habitual intestinal torpor. When there is an acid form of\\ndyspepsia the rhubarb and soda mixture, or potassium acetate in -J\\ndrachm (2.) doses, will be serviceable. Mercurous iodide in small doses\\nthree times a day is often of value in aiding elimination. Some cases\\nimprove rapidly on taking each night enough castor-oil to cause a daily\\nfree evacuation of the bowels. Salol and other intestinal antiseptics are\\neffective in some cases.\\nIn many cases of acne due to inactivity of the large intestine\\nthorough irrigations of the bowel, together with daily exercises which\\nwill strengthen the abdominal muscles and stimulate peristalsis, are\\nfollowed by complete recovery. Large quantities of pure water drunk\\nbetween meals and before meals aid greatly in the matter of elimina-\\ntion. As a rule, it is advisable to take little or no liquid especially\\nif iced with food, or for an hour after eating. The unwholesome habit\\nof rapidly bolting food without proper mastication is thus largely over-\\ncome. In many instances, however, a cup of w^arrn, but not strong,\\ntea, cocoa, or coffee at the close of the meal is an aid to digestion.\\nDaily exercise in the open air is necessary to stimulate sluggish\\nglandular systems into proper functional activity. Such exercise to be\\nof value should be carefully adjusted, both in kind and in amount, to\\nthe needs of the individual.\\nA most important part of the treatment in every case is without\\nquestion the daily bathing of the entire surface of the body (with\\nexception of the face, which requires special attention as elsewhere\\nshown and excluding the menstrual period in women) with water\\nas cool as can be tolerated, by rapid sponging, followed by brisk\\nfriction with coarse towels or with a flesh-brush until the skin is\\nglowing. Common salt may be added to this bath in the strength of\\npound of salt to each gallon of water. The results of this treatment\\nare excellent in the majority of cases, especially in those in which the\\npatient has been accustomed to the hot or Turkish bath, which may\\naggravate affections of this class.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0420.jp2"}, "421": {"fulltext": "ACNE. 399\\nIn nervous and overworked patients sufficient sleep at regular hours\\nshould be secured, and when possible short periods of rest during the\\nday should be obtained. In some of these cases the indigestion and\\nconsequently the acne can be made to disappear with no other treat-\\nment than ten minutes of complete physical and mental relaxation\\nbefore meals, and half an hour of comparative inactivity after eating.\\nIn a growing boy or girl relief of acne often can be best accomplished\\nby shortening the school-hours, and by carefully selecting studies and\\noccupation adapted to the physical and intellectual development of the\\nindividual.\\nThe sexual life of both the married and the unmarried should be\\nregulated according to the laws of hygiene. Uterine disease, when\\nthis complication exists, should receive proper treatment and this, far\\nless by topical applications than by attention to the general health, as\\npatients of this class are often chlorotic young women with menstrual\\nderangements, leading sedentary lives, or overworked at the school-desk,\\nthe sewing-machine, or the shop-counter.\\nWith the recognition of the several causes of acne, general and\\nlocal, internal medication for the relief of the disorder should be\\ndirected wholly to the general condition of the patient. Calcium sul-\\nphide, long highly esteemed in the management of acne, is set down\\nto-day as side by side with the ludicrous specimens of therapeutic\\nempiricism. Arsenic, however, is highly recommended in acne papu-\\nlosa by Duhring and Taylor. The internal employment of ergot\\nin full doses for the relief of acne has occasionally been followed by\\nexcellent results. Cod-liver oil, iron, strychnine, phosphorus, the\\nmineral acids, and the bitters are needed in chlorosis and cachexia.\\nGlycerin in teaspoonful to tablespoonftil doses three times daily has\\nproved valuable (Gubler). Pepsin, pancreatin, and other aids to diges-\\ntion are often of temporary value.\\nIn all cases, whether previously treated or not, which have been\\npurged of suspicion of an artificial element, the local treatment is of\\nprime importance, and in the perfection with which its details are\\nobserved lies the key to success. It is not the selection of one of the\\nseveral remedies of the manv advocated for the relief of the disease, nor\\nyet the successive substitution of one for another to meet any transitory\\nindication in each case, that conduces to the happiest result but it is\\nrather the use of a single method of recognized value, and its skilful\\nadaptation to the changing conditions of the disease.\\nAn effective method of local treatment is found in curetting the\\nlesions as practised by Fox, of New York. A ring-curette is drawn\\nover the affected surface so as to express the contents of the lesions and\\nto stimulate others to activity. The subsequent bleeding is encouraged\\nby sponging with hot water. All comedones are expressed, and the\\nsubsequent treatment is that suggested below.\\nIt is always necessary to evacuate the contents of pustules, to express\\nfrom the summits of papules (where are the orifices of sebaceous ducts)\\nall densely inspissated plugs of sebum, and to remove any comedones\\npresent with the aid of the comedo-extractor. In many cases this oper-\\native treatment, especially the removal of comedones, is easier and more", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0421.jp2"}, "422": {"fulltext": "400 INFLAMMATIONS.\\nsatisfactory after several days of the hot bathing and ointment-applica-\\ntions recommended in the following paragraphs. For the purpose of\\nopening the superficial and smaller purulent collections the long needles\\nused by gynaecologists are decidedly preferable to a knife, and for the\\nlarger and deeper furuncular lesions a bistoury with a delicate and very\\nnarrow blade should be used. A slight degree of skill will here repay\\nthe operator. Piffard s acne-lance is useful in this connection, as\\nalso is Volkmann s spoon (modified by Auspitz), which may be em-\\nployed in removing pathological debris. By counter-depression with\\nthe fingers the whitish-yellow or blackish orifice of the duct may be\\ndetected, and at this point the needle or the bistoury should be thrust\\nsufficiently deep to insure removal of pent-up pathological accretions.\\nShould blood flow in droplets from any of these slight wounds,\\nit is rather to be encouraged than repressed, as relieving the hyper-\\nemia and engorgement of the small periglandular phlegmon. In one\\nor several sittings all lesions requiring such interference should care-\\nfully be attacked, and immediately after each operation, preferably\\nwhile pus and blood still are oozing, the part is to be bathed for sev-\\neral minutes with water as hot as can be borne with comfort. For\\nmany reasons the hour before retiring is preferable, though not always\\npracticable, in treating such cases, as then a bland ointment can thor-\\noughly be applied and be permitted to remain until the following\\nmorning.\\nWhen one or several of these operations have largely relieved the\\nskin of its engorgement and retained inflammatory products a systematic\\nuse, at night, of the spiritus saponis alkalinus or tincture of green soap\\n(q. v.) with hot water, should for a time be practised. Many cases,\\nwhich do not require the minor surgical operation described above,\\nshould from the first be treated in the following manner. As the face\\nis the commonest seat of the disease, for the purpose of description,\\nit may be considered as the affected part\\nThe patient is seated before a basin of water, which is as hot as can\\nbe tolerated with comfort, and, with a pad of white flannel or a soft\\nsponge, the face is bathed until the skin is thoroughly moistened and\\nsoftened by the heated water and steam. From ten minutes to half an\\nhour may well be employed in this way, it being a fertile source of the\\nimprovement which follows. While the face is still wet all pustules\\nwhich have formed are emptied, and a sufficient quantity of spirit of\\ngreen soap is poured over the flannel or the sponge, with which the face\\nis then thoroughly scrubbed. Finally, the skin-surface is cleansed with\\na surplus of the water, is carefully dried, and is anointed with a sulphur\\nointment.\\nSome range may be observed in the employment of the two sub-\\nstances named. Thus, the spirit may be diluted with cologne- or rose-\\nwater, one-half or more or the soaps employed, in less imperative\\ncases, may be the best toilet-soap, Sarg s glycerin or sulphur soap.\\nThe ointment, too, may be compounded by adding from 15 grains\\nto 2 drachms (1.-8.) of sublimed sulphur and half of the same quantity\\nof resorcin to the ounce (30.) of lanolin, cold-cream salve, or vaselin.\\nIn the morning the face is to be washed with cold water.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0422.jp2"}, "423": {"fulltext": "ACNE.\\n401\\nThis operation of steaming, soaping, and anointing is to be contin-\\nued, according to the severity of the case and the tolerance of the\\npatient, nightly, or twice a day, or on alternate nights, until the face\\nis free from papules and other inflammatory lesions. After from two\\nto ten days of this vigorous treatment the face is usually unsightly,\\nreddened, slightly tumid, and often moderately furfuraeeous. To the\\npatient the skin feels tense, slightly painful, and as if made of leather.\\nWhen this artificial dermatitis is severe the hot water and ointment\\nmay be employed for a few occasions without using soap. For sensi-\\ntive skins it may be necessary to employ for a few days some of the\\nsedative lotions and ointments recommended for the treatment of acute\\neczema. When the artificial dermatitis has subsided the shampoo may\\nbe resumed. With the removal of the lesions the spirit, or other prep-\\naration of soap, may for a time be discontinued. The improvement\\nwhich follows is marked and speedy, and usually is satisfactory to the\\npatient. When this condition is reached a wider latitude of treatment\\nis permitted. Gradually the hot ablutions may be withdrawn, and the\\nuse of less stimulating lotions and ointments may be advised. Sulphur,\\nhaving the highest reputation in the disorders of the sebaceous glands,\\nis a constituent of many of the lotions thus employed. One of the best\\nis Vlerninckx s solution (see page 93), of which from 10 to 60 drops in a\\ntablespoonful of water may simply be mopped on the face and allowed to\\nremain over night, or may be applied with gentle friction and massage.\\nTaylor l advises the following\\nR\\nSig.\\nSulphuris loti,\\n3iij\\n12\\nCamphorse spts.,\\nt* 3iij\\n12\\nSodse biborat.,\\n3ij\\n8\\nGlycerin.,\\nf3yj;\\n24\\nAq. fontan.,\\nad f ^iv\\nad 120\\nM.\\nShake well and\\napply freely, leaving a\\nthin\\nfilm of powder over\\nface.\\nVarious combinations of sulphur with alcohol will be found useful.\\nThus, Kaposi recommends a paste composed of:\\nSulphur, prsecip.,\\n3ijss\\n10\\nSpts. vin. rect.,\\nf ajss\\n45\\nLavand. spts.,\\nf Sijss\\n10\\nGlycerin.,\\nttlxx;\\n1\\n33 M.\\nSig. To be spread over the face and retained during the night.\\nOr,\\nR Sulphur, nor.,\\nSpts. sapon. virid.,\\nLavand. tr.,\\nPeruv. bals.,\\nCamphor, spts.,\\nBergamot. ol.,\\nSijss\\nf3v;\\nf^ij;\\nT\u00c2\u00bblxx;\\nfflxv;\\n10\\n20\\n60\\n1\\n1\\nSig. To be applied over the face at night\\n1 American Clinical Lectures, Xew York, 1878, vol. iii., No. 10\\n33\\n33 M.\\n2(5\\ni", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0423.jp2"}, "424": {"fulltext": "402 INFLAMMATIONS.\\nDuhring recommends the following\\nR Sulphur, prsecip.,\\n3ij;\\n8\\nGlycerin.,\\nf SPij\\n_ 8\\nAlcoholis,\\nf Jj;\\n30\\nAq. calcis,\\nfgj;\\n30\\nAq. ros.,\\nf?ij;\\n60\\nSig. Shake the vial before\\nusing.\\nM.\\nResorcin, next to sulphur, is probably the most valuable remedy in\\nacne as in other sebaceous gland disorders. It may be used in the\\nabove formulae in place of sulphur, or combined with it in strength\\nvarying from 2 to 10 per cent. Ichthyol and thiol are similar in their\\naction to sulphur, and sometimes succeed when the latter fails. They\\nmay be used in ointments, in lotions, or combined with glycerin. The\\ndiscoloration produced is easily removed, as both substances are soluble\\nin water.\\nAmmoniated mercury, 2 to 15 per cent., in lanolin or other\\nsimple ointment is an effective remedy. Mercuric chloride is very\\n\u00e2\u0080\u00a2generally employed in the strength of from -J- to grain (0.008-0.033)\\nto the ounce (30.) of emulsion of bitter almonds as a lotion and the\\nprotiodide and biniodide of the metal are similarly applied in lotions\\nand unguents, in the strength of from 5 to 10 grains (0.33-0.66)\\nto the ounce (30.). One should be careful not to make use of mercu-\\nrials at the same time with a compound of sulphur, lest a chemical\\ncombination occur by reason of which mercurous sulphide (sethiops\\nmineral) be precipitated upon the skin and produce the appearance of\\ncomedo.\\nFor mild cases an excellent lotion is obtained by adding 2 drachms\\neach (8.) of simple tincture of benzoin and glycerin to 4 ounces (120.)\\nof distilled water, to which, where a more stimulating effect is desired,\\n1 ounce (30.) of cologne-water or of alcohol may be added, or 1 scruple\\n(1.33) of sulphurated potassa.\\nOccasionally rumex ointment may be used with advantage as the\\nbasis of sulphur and other salves in acne. It is prepared according to\\nthe following formula\\nR Rum. crisp, rad.,\\nAdipis,\\nCerse flav.,\\nAq. pur.,\\nWash and bruise the roots boil for two hours strain evaporate to 4\\nounces (120.) gradually add the wax and lard in a melted state; and\\nstir until cool.\\nThe English sulphur hypochloride, in ointments of the strength of\\nthose given above, and sulphurated potassa, to 1 scruple (0.66-1.33)\\nto the ounce (30.) of lotion or of ointment, are effective, but objection-\\nable on account of their odor.\\nMercurial plaster may be applied on strips of linen or iodated gly-\\ncerin (5 parts of eaoh of pure iodine and potassium iodide to 10 of\\nglycerin) may be applied with a brush twice daily until from six to\\ntwelve applications have been made. Van Harlingen employs 1\\nSix;\\n270\\nSyj;\\n180\\n3j;\\n30\\nq. s.\\nq. s.", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0424.jp2"}, "425": {"fulltext": "ACNE. 403\\ndrachm each (4.) of sulphurated potassa and zinc sulphate to 4 ounces\\n(120.) of rose-water. Fox applies drachm (2.) of chrysarobin to the\\nounce (30.) of collodion. Taylor advises from 5 to 25 grains (0.33-\\n1.6) of zinc iodide to the ounce (30.) of vaselin.\\nThe paste recommended by Lassar is useful in some cases that is,\\n1 part of beta-naphtol, 2^- parts each of vaselin and sapo viridis, and 5\\nparts of precipitated sulphur spread over the skin for from fifteen to\\ntwenty minutes, and then wiped off, when the surface is dusted with\\nFrench chalk. In obstinate cases with few lesions the touching of the\\nparts Avith pure carbolic acid or with salicylic acid, or with acid nitrate\\nof mercury, is useful, but such measures should be condemned for the\\nmajority of patients at or near puberty. A fine needle connected with\\nthe negative pole of a galvanic battery may be employed to destroy\\nsingle and indurated papules or papulo-pustules.\\nFor chronic and indolent cases one of us devised a modification of\\nthe local treatment of acne by the aid of an instrument called the\\nmassering-ball, figured on page 104. This instrument consists of a\\nstout, short handle of hard rubber, connected by means of a slender steel\\nneck with a ball set in a steel socket, the small sphere rotating within\\nthe cup of the socket, as in an ordinary ball-and-socket joint. The free\\nplay of the ball is aided by its bearing upon a smaller ball set in the\\nneck of the cup attached to the handle, which is fixed upon the socket\\nat an angle sufficiently convenient for the operator, whose eye can thus\\nbetter follow the play of the ball. The ball is constructed of hard rubber,\\nand the area of its impact upon the skin at any moment is about that\\nof the human thumb of average size similarly placed. When actually\\nin use the ball travels with ease as well along the angles of the nares\\nwith the cheeks, the bridge and root of the nose, and the regions below\\nthe symphysis menti, as over the brow, the temples, the chin, and the\\ncheeks. When necessary to cleanse the instrument the ball is detached\\nby unscrewing but the entire instrument may be boiled without\\nimpairment of its usefulness.\\nWhen ready for treatment the skin is first operated upon with\\naseptic needle ana 1 comedo-extractor until all pustules and subepidermic\\nfoci are emptied and conspicuous comedones are removed. After this\\nthe surface is rendered aseptic, either with one of the bichloride lotions\\nor with a solution of formalin (40 per cent, of formic aldehyd) in the\\nstrength of from 0.5 to 2 per cent., according to the sensitiveness of\\nthe patient s face. The massering-ball is then rotated freely over the\\nsurface, and deep pressure is made upon the affected region, with the\\nresult of bringing into view groups of previously inconspicuous come-\\ndones, which are in turn removed by the extractor or presser.\\nLastly, massage of the surface is practised with the ball by the aid\\nof a salicylated cocoanut-oil or by one of the sulphur unguents.\\nThe use of caustics in acne, though recommended, should in general\\nbe discountenanced as needless. In extreme induration of the lesions\\nthese may be rubbed with fine pumice-stone until the desired effect is\\nproduced.\\nThe powders employed in the milder forms of the affection are finely\\npowdered sulphur, which may freely be dusted over the face, and those", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0425.jp2"}, "426": {"fulltext": "404 INFLAMMATIONS.\\ncompounded in various proportions of starch, rice-flour, zinc oxide, and\\nbismuth subcarbonate.\\nRelief of acne in young male patients has been reported after the\\npassage of the urethral sound, and in both sexes by hot- and cold-\\nwater injections of the vagina and urethra.\\nPrognosis. The majority of patients, even when untreated, even-\\ntually recover. This natural involution of the disease is commonly\\nattained in proportion as the body arrives at the maturity of its devel-\\nopment and accomplishes the sum of its important functions. Appro-\\npriate treatment has, however, a satisfactory influence in hastening the\\nrecovery of a large number of all patients. A small minority suffer\\nfrom the unsightly complications and sequels of the malady (cicatrices,\\nkeloid). Exceedingly rebellious and even grave cases occur in the\\ncachectic, those long and improperly treated, and those who from\\nnecessity are continuously exposed to influences unfavorable to the\\ninvolution of the disorder, such as the subjects of epilepsy habitually\\ningesting potassium bromide, and the victims of syphilis requiring\\npersistent use of the salts of iodine.\\nACNE ROSACEA.\\n(Rosacea, Gtttta Rosea, Telangiectasis Faciei, N^vus Araneus,\\nBrandy-nose, Copper-nose. Fr., Acne Rosee, Coupe-\\nrose J Ger., KUPFERROSE, KUPFERFINNE.)\\nAcne rosacea is most often displayed upon the nose, cheeks, and\\nchin, but may occur on any part of the face, and rarely on the lateral\\nregions of the neck. It is seen usually in middle life, and occurs rarely\\nbefore the twenty-fifth year.\\nSymptoms. In the first grade there is a more or less diffuse\\npinkish or dusky, but transitory redness, involving the extremity of\\nthe nose and its contiguous parts, which coloration may extend from\\nthis region in a somewhat symmetrical figure over the cheeks and chin.\\nThe redness may be uniformly spread over the regions involved, or\\ndisplayed in irregular, ill-defined blotches which vary greatly in size\\nand shape. The spots may be roundish, radiating, stellate, linear,\\ntortuous, or of fantastic outline. The colors vary from a delicate rosy-\\npink to a deep-purplish crimson. Minute capillaries often ramify over\\nthe erythematous surface. The effect is a marked unsightliness, for\\nwhich chiefly, or only, the advice of the physician is sought, as the\\naffected parts give rise to little or no subjective sensations. Under\\npressure with the finger the color disappears, the surface seems cool\\nrather than hot, and the sebaceous glands are seen to be affected, as\\nthere is usually present either a seborrhoea oleosa or an accumulation of\\nyellowish-white, moderately inspissated sebum in the patulous orifices\\nof the gland-ducts.\\nThe disorder varies greatly with the general condition of the patient.\\nAt times it may scarcely be perceptible again, after the stimulation\\nproduced by ingested food or by alcohol, after mental excitement, a\\nparoxysm of coughing or laughing, or exposure to external irritation\\nthe lesions may be even conspicuously deforming. This condition may", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0426.jp2"}, "427": {"fulltext": "ACNE. 405\\nendure for months or for years and then disappear, or may be succeeded\\nby the second stage of the malady.\\nIn a second grade of the disease the redness becomes permanent,\\nthough subject to frequent variations in intensity, capillaries dilate\\npassively and appear as conspicuous, tortuous, straight, or anastomosing\\nlines of reddish color about the nose, cheeks, chin, or forehead. Firm,\\npurplish-red, painless, pinhead- to pea-sized nodules or papules often\\nrise from the erythematous surface, and they either display minute\\nsuperficial and tortuous blood-vessels in the integument with which they\\nare covered, or they project from a base about which such a telangiec-\\ntasis has very irregularly been developed. The lesions are apt to be\\nintermingled with those of seborrhoea oleosa or with acne vulgaris.\\nWhen fully developed, this stage of the disease, though generally not\\nproductive of marked subjective sensation, produces an exceedingly\\nconspicuous deformity.\\nIn the third stage (which is the most pronounced of the three)\\nroundish, sessile or pedunculated, lobulated or pendulous, firm, elastic,\\npinkish-red, bluish, livid, or violaceous vegetations, traversed by a finer\\nor larger network of blood-vessels, slowly develop about the affected\\npart of the face, chiefly the nose. These vegetations may be single or\\nmultiple, and in the latter case may be isolated or so closely united as\\nto be scarcely distinguishable from one another. The acneiform lesions\\nseen in the second grade of the disease may here also be apparent.\\nThe nose is often cold to the touch when bright red in hue, and it may\\nbe peculiarly oily or greasy in appearance in consequence of a seborrhoea\\noleosa of the part. The so-called brandy-drinkers wine-drink-\\ners and whiskey-drinkers noses are of this class. In some cases\\nthere is a uniform and symmetrical hypertrophy of all the soft parts\\nof the nose, which may thus attain colossal proportions. It is these\\nextreme consequences of acne rosacea to which the term Rhixophyma\\nhas been applied.\\nThe course of the disease is very slow, and in by far the largest\\nnumber of patients does not produce the exaggerated types of the\\nsecond and third grades. The lesions may persist indefinitely as indo-\\nlent symptoms of the malady in any one of its stages, or in a case in\\nwhich there has been no new growth of vessels or of tubercles may\\nproceed to spontaneous involution.\\nEtiology. The first and second grades of acne rosacea are common\\nin women either at puberty or near the period of the menopause, in\\nthose who are pregnant, or in those who suffer from utero-ovarian\\ndisease, frequent miscarriages, sterility, irregular performance of the\\nmenstrual function, or chlorosis.\\nThe disease, however, is seen in men of early and of late adult life.\\nIn both sexes it may occur in anaemic and asthenic states in both, also,\\nits association with gastro-intestinal dyspepsia, constipation, and the\\nimmoderate use of strong tea and alcoholic drinks beer, wine, and\\nspirits is a matter of common observation. According to Kaposi,\\nthe rosaceous nose of the wine-drinker is bright red; that of the beer-\\ndrinker, cyanotic or violet that of the spirit-drinker, smooth, supple,\\nfatty, and dark blue. The new growth of vessels and tubercles, with", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0427.jp2"}, "428": {"fulltext": "406 INFLA MM A TIONS.\\nthe rhinophyma of the advanced grade of the disease, is much com-\\nmoner in men than in women. In those whose faces are bronzed by\\nexposure to the weather the telangiectasic condition of the cheeks,\\nrather than of the nose, is of frequent occurrence. Veteran sailors and\\nsoldiers are thus commonly affected. Persons who have frozen the\\nnose or the cheeks on one or more occasions are similarly liable to\\ntelangiectases. Any externally or internally operating cause which\\ntends to retard the capillary circulation in the superficial portion of\\nthe skin is capable of inducing this result. Acne rosacea is at times\\nconspicuously displayed in the mulatto.\\nPathology. In the first stage of acne rosacea there is merely pas-\\nsive hyperemia. The circulation in the superficial capillary plexus is\\nretarded. Persistence of this condition for long periods of time results\\nin paresis of the capillaries, with their consequent dilatation and hyper-\\ntrophy, phenomena which characterize the second stage, the sebaceous\\ngland-disorder being a complication of the process. In the third stage\\nthe nodules are composed of newly formed gelatinous elements, which\\nlater are replaced by organized connective tissue. According to Biesia-\\ndecki, there are also dilatation and hypertrophy of the sebaceous glands,\\nwith dilatation, hypertrophy, and new growth of the superficial blood-\\nvessels, and enlargement also of those trunks which ascend from the\\ncorium. There is no marked epithelial hypertrophy (Unna).\\nThe disease, however, is viewed differently by authors. By some its\\nobvious connection with acne vulgaris is denied by others it is\\nregarded as a seborrheal eczema. According to Besnier and Doyon,\\nthis disease represents (a) superficial or deep, at first intermittent,\\nthen persistent, hypersemia (6) sebaceous hyperemia (acne-eczema), in\\nwhich there are unquestioned steatorrhea and implication of the seba-\\nceous glands with infiltration and possibly exfoliation of the skin (c)\\ndeep hypersemia with infiltration of the corium and plastic products\\nabout vessels, follicles, and perifollicular tissue (d) telangiectases, as\\ndescribed above and (e) hypertrophies of the perifollicular derma.\\nDiagnosis. Acne vulgaris is distinguished from acne rosacea by the\\nabsence of telangiectasis, and of the hypertrophic growths which char-\\nacterize the developed lesions of acne rosacea. The tubercular syphilo-\\nderm is recognizable by its tendency to ulceration and crusting and\\nby the entire absence of telangiectasis. When the tubercles of syph-\\nilis are limited to the extremity of the nose (they are usually small in\\nconsequence of the influence of treatment) they often degenerate into\\ncharacteristic, split-pea-sized, irregularly circular ulcerations, which\\nare superficial in seat and frequently isolated. They leave similarly\\nshaped and sized depressed cicatrices at the tip and neighboring parts\\nof the nose. As the process is much more rapid than in acne rosacea,\\nthese lesions, considered in connection with the absence of telangiec-\\ntasis, furnish the most significant diagnostic symptoms of the disorder,\\nfor they often occur late in the history of syphilis, in individuals in\\nmiddle life, and in varying shades of a dull-reddish color, circum-\\nstances particularly favorable for confusion regarding the identity of\\nthe two diseases.\\nZoster from involvement of the superior maxillary branch of the", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0428.jp2"}, "429": {"fulltext": "ACNE. 407\\ntrigeminus, with diffused redness of one side of the nose and efflores-\\ncence of vesicles over its tip and ala, strongly resembles acne rosacea\\nwith pustular lesions but in zoster the painful character of the dis-\\norder, its limitation to one side of the face, its transitory career, and\\nits vesicular lesions are characteristic.\\nLupus vulgaris, like syphilis, when occurring upon the nose, is to\\nbe recognized by the tendency of its papulo-tubercular lesions to ulcer-\\nation and crusting, by the absence of vascularity, and by the frequent\\npresence of characteristic cicatrices. Unlike syphilis and acne rosacea,\\nhowever, the history of lupus vulgaris usually extends from early\\nchildhood. Lupus erythematosus is characterized by a definite outline,\\nby a superficial infiltration and elevation of the border of the patch, by\\nan atrophic or scarred centre, by adherent scales, and by its symmetri-\\ncal diffusion over much larger and defined areas, commonly extending\\nfrom the bridge of the nose well on to the cheeks.\\nTreatment. So far as there can be said to be any internal treat-\\nment of acne rosacea, it is that employed in acne vulgaris but in\\nneither disease can such treatment be confidently described as effective\\nin the dispersion of the local lesions. The treatment is that of the\\npatient rather than of his disease. When alcohol has been in any\\ndegree productive of the local effects the use of spirits, wines, and beer\\nis to be interdicted but as regards confirmed rosacea this prohibition\\nwill prove to be of little avail. The disease when resulting from\\nspirit-drinking may persist after years of total abstinence.\\nThe diet should be of the character proper for the patient with\\nacne. All imbibition of hot liquids, even tea and coffee in excess,\\nshould be restricted as tending to congest the blood-vessels of the face.\\nEverything having the same result in the habits, the occupation, or the\\nclothing of the patient should be, as far as possible, deprived of\\ninfluence, as, for example, wearing of tight collars and corsets, working\\nover hot fires, etc.\\nIn many patients who are the subjects of rosacea, as distinguished\\nfrom the younger class of sufferers from acne vulgaris, there are evi-\\ndences of lithaBmia, gout, and similar conditions, requiring even stringent\\nrules in many particulars for the conduct of life. The use of sugar\\nin many of these cases is to be restricted, meat should be forbidden or\\npermitted but once in the day, and other articles of food be selected\\nwith special care. Tobacco should never be allowed to male patients\\nwith well-marked symptoms, and the daily general bath described in\\nthe preceding chapter as of importance in the treatment of acne should\\nhere also be prescribed.\\nAll gastrointestinal sources of mischief should also be set aside\\nwhen practicable. In acne rosacea, even more than in acne simplex,\\ndyspepsia and constipation are conspicuously effective factors.\\nInternally, nux vomica, ergot and ergotin, ichthyol (ammonio-sul-\\nphate), mineral acids and alkalies, and arsenic have been recom-\\nmended. Most of these drugs are valueless in removing the symptoms\\nof the disease unless their use is indicated by the general condition of\\nthe patient. In gouty patients blue pill and alkalies, though not of\\nthemselves capable of relieving the rosacea, may serve to aid the", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0429.jp2"}, "430": {"fulltext": "408 INFLAMMATIONS.\\npatient the same may be said of the use of iron in chloro-ansemic\\nwomen.\\nThe local treatment of the first grade of acne rosacea is substantially\\nthat of acne vulgaris. Stimulating lotions of green soap, formalin,\\nalcohol, mercuric chloride, or sulphur in connection with ablutions\\nin hot water, are of the highest value. In addition, the various oint-\\nments containing sulphur, resorcin, mercuric oxide, and iodides, and\\nthe continuous application of mercurial plaster should be employed if\\nnecessary.\\nVan Harlingen reports rapid results from the application, several\\ntimes in the day, of a lotion composed as follows\\nR Sulphuris prsecipit., 3j 4\\nPulv. camphorse, gr. v;\\nPulv. tragacanth., gr. x\\nAq. calcis, c z- --on\\na n r aa i ^i aa o0\\nAq. rosas, OJ\\n33\\nM.\\nFox, of New York, applies chrysarobin in traumaticin, drachm\\n(2.) to the ounce (30.) but this drug should be reserved for intractable\\ncases, as it may produce severe dermatitis. After the production of\\nthese effects, however, the benefits secured may be appreciable for\\nmonths.\\nIn the second stage of the disease the treatment is the same as in\\nthe first stage, but when all the inflammatory phenomena have yielded\\nand the causes of the local congestion have been removed, the vessels\\nand remaining nodules may be destroyed by single or by multiple\\npuncture of each with a fine cambric needle attached to the negative\\npole of a galvanic battery with six to ten elements in the circuit. This\\noperation is better than the knife, and it may be regarded to-day as\\nthe effective method of removing blemishes produced by dilated blood-\\nvessels in this stage of rosacea. The method is simple, readily exe-\\ncuted, requires no anaesthetic, and is in many ways superior to other\\nmethods, to which resort should be had when electrolysis cannot be\\nemployed. Some vessels may completely be destroyed with the pro-\\nduction of so slight a cutaneous cicatrix that in the course of a few\\nmonths it cannot be recognized by the unaided eye.\\nFor details of this simple operation the reader is referred to the\\nchapter on Hypertrichosis. For the cambric needle may often be\\nsubstituted with advantage a fine jeweler s brooch, annealed in the\\nflame of a spirit-lamp. The vessels may be entered in one or several\\nplaces, and the operation be repeated until the last thread-like evidence\\nof their existence has disappeared. The number of cells brought into\\nthe circuit must be somewhat graduated to the requirements of each\\ncase and to the locality of the skin operated upon. Fewer cells can\\nbe tolerated for the lip and alse nasi than for the root of the nose, the\\ncheeks, or the forehead. Next in value after this operation may be\\nnamed\\nBrushing the part cautiously with solutions of caustic potash, from\\n10 to 30 grains (0.66 2.) to the ounce (30.) of water; and the local\\nuse of pure carbolic, chromic, pyrogallic, and glacial acetic acids,", "height": "4352", "width": "2338", "jp2-path": "practicaltreatis00hyde_0430.jp2"}, "431": {"fulltext": "ACNE VARIOLIFORMIS. 409\\nacetum cantharidis (Taylor), sulphur iodide, or solution of mercury\\npernitrate. Before these drugs are employed, however, an effort should\\nbe made to produce exfoliation by spreading over the part a plaster\\nmade of green soap. Unna s mercurial plaster-mull is similarly\\napplied. Kaposi highly recommends the solution of iodated glycerin\\nemployed by him in acne vulgaris (q. v.), which solution is painted\\nover the part from eight to twelve times daily for three or four suc-\\ncessive days, and is immediately covered with gutta-percha tissue.\\nMultiple scarification of all new-growths after the manner of attack-\\ning lupus-nodules, erasion with a dermal curette or with a Braun spoon,\\nand surgical ablation or decortication of tumors by ligature and knife,\\nare also available. After any destructive attack upon the diseased por-\\ntions of the skin soothing lotions, fomentations, or ointments should\\nregularly be applied.\\nPrognosis. A favorable prognosis can be given in cases in which\\nthe disease occurs in its milder forms. Even in cases complicated by\\nmarked telangiectasis and hypertrophy the results of treatment are often\\nin the highest degree encouraging. Notwithstanding the most ener-\\ngetic procedures, however, the vis-a-tergo of passive hyperemia, involving\\noften the deeper and unassailed blood-vessels, may work its slow pro-\\ngress. For women the future is in general more promising than that\\nof men. With the most unfavorable prognosis, however, it is to be\\nremembered that, after all, the disease is one of deformity rather than\\nof physical discomfort.\\nACNE VARIOLIFORMIS.\\n(Acne Frontalis, Acne Rodens, Acne Necrotica, Acne Atro-\\nphica, Folliculitis Varioliformis. Ft., Miliaire Scrof-\\nULEUSE.)\\nThis disease is not to be confounded with that to which Bazin and\\nother French writers once gave the name Acne variolifo? me, viz., mol-\\nluscum epitheliale (molluscum verrucosum of Kaposi).\\nSymptoms. The disease is characterized by the occurrence over\\nthe centre or the upper portion of the forehead, the temples, or margin\\nand central portions of the scalp, of pea- to bean-sized, firm, reddish-\\nbrown papules, which become pustular at the apex, and which are\\ncommonly exceedingly indolent and often grouped. The pus of these\\nlesions desiccates in crusts which are flattish, closely adherent, and\\ni apparently depressed below the general level of the skin. On the fall\\nJ of the crusts there is left a rather deeply tinted brownish-red cicatri-\\nform lesion, somewhat resembling the cicatrix of variola, from which\\nthe disease received its name. The scar much more closely resembles,\\nhowever, the results of the involution of the pustulo-tubercular syphi-\\nloderm in groups. The subjective sensations are slight, at times there\\nis itching. The disease tends to recur and is exceedingly chronic in\\ncourse.\\nIn exceptional cases the disorder occurs in other regions than those\\nnamed above for example, over the dorsal and sternal aspects of the", "height": "4329", "width": "2395", "jp2-path": "practicaltreatis00hyde_0431.jp2"}, "432": {"fulltext": "410 INFLAMMATIONS.\\ntrunk, about the nose, and within and about the concha of the ear.\\nIn one of the authors patients (the subject of the accompanying illus-\\ntration) the disease left very disfiguring scars on the right ala of the\\nnose. The lesions are often traversed by a hairy filament. In some\\ncases the affected regions are so thickly invaded that the resulting scars\\nproduce a cribriform aspect in the integument. Occasionally the ar-\\nrangement of the lesions is linear or is circinate.\\nAcne necrotica.\\nThe variations displayed are exceptional, but worthy of note. Severe\\nconfluent, serpiginous, and very extensive developments of the malady\\nmay be seen. According to Boeck, the hue of the papulo-pustule is\\ndue to minute capillary hemorrhages, which later become invisible in\\nconsequence of tumefaction of the overlying integument.\\nEtiology. The sexes are represented nearly equally among the\\nsubjects of the disease, who are, as a rule, in or near middle life. The\\ncauses of the disease are unknown, but the microbic origin of acne\\nvarioliformis, together with necrotic granuloma and folliclis, is well-\\nnigh established.\\nPathology. Fordyce and Sabouraud state that the disease begins\\nin the upper part of the hair-follicle, from which point it extends to the\\nentire follicle and to the sebaceous gland. Various micro-organisms\\nare found in the lesions, but the active agent is apparently a staphylo-\\ncoccus. Sabouraud l believes the disease is always preceded by sebor-\\nrhoea. The inflammation usually terminates in central necrosis and\\nsubsequent scar-formation.\\nAccording to Unna, acne varioliformis is produced by a mixed\\ninfection. At first there is plugging of the lanugo-follicles with a firm\\n1 Annal. de Derm, et de Syph., 1899, p. 845.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0432.jp2"}, "433": {"fulltext": "IMPETIGO HERPETIFORMIS. 411\\nscale. Along with this is a marked perifollicular cell-agglomeration,\\npenetrated by extensively dilated lymph-spaces. Later the follicle dis-\\ntends with an abundant growth of a bacillus 1 to 1.25 fi in dimensions.\\nStill later the diplococci of seborrheic eczema are seen with colonies of\\nbacilli in the centre of the distended sac. At first the diplococci simply\\nfurnish a sero-fibrinous crust. By their active development at a later\\nstage in the depth of the tissue they lead to necrosis and subsequent\\ncicatrization. Some of these cases may be due to infection with the\\ntoxins of tubercle-bacilli. Acne varioliformis occurs in typical develop-\\nment upon the faces of the tuberculous. For further details in this\\nconnection, the paragraphs devoted to the paratuberculoses of the skin\\n(Necrotic granuloma, folliclis, etc.) should be consulted.\\nDiagnosis. The lesions are to be distinguished from the syphilo-\\nderm named above, from acne vulgaris, and from variola. The points\\nof distinction are the absence of fever, present and precedent the\\nabsence of other symptoms of syphilis the localization of the eruption\\nand the absence of intermingled comedones and other symptoms of\\nacne disseminata. The involvement of the scalp-surface is not alone\\nsufficient to distinguish it, as syphilodermata and occasionally come-\\ndones are visible in the scalp above the brow.\\nTreatment. The disease usually yields readily after the use of\\nantiseptic lotions or of ointments containing white precipitate, resorcin,\\nsulphur, mercuric chloride, formalin, or boric acid, though lesions are\\nlikely to develop after suspension of treatment. In severe cases caustics\\nor galvano-puncture may be required.\\nIMPETIGO HERPETIFORMIS.\\nKnowledge of this rare disease is limited to the reports of thirteen\\ncases observed by Hebra and Kaposi in the Vienna clinic; one by\\nHeitzmann in New York one by Pataky and a few scattered cases\\nreported by others. Of the Vienna patients, twelve were women, and\\nthe most of these were in the puerperal state.\\nSymptoms. Pinhead-sized pustules, usually closely packed in\\ngroups, filled with an opaque or a yellowish-green fluid, are discovered\\nupon the surface of the groins, the navel, the axillae, the breasts, and\\nother portions of the body. A dirty brownish-colored crust is formed\\nby rupture or desiccation of these lesions, and about this crust, single,\\ndouble, or triple concentric circlets of new and similar lesions appear in\\nsuccession, each series undergoing a similar process of involution. The\\neruption thus extends until the circlets from different foci of origin\\nunite, and extensive areas of the skin are involved. Beneath the\\ncrusts the skin is reddened, infiltrated, smooth, and covered with a\\nnew epidermis, moist as in eczema or exhibiting a denuded corium.\\nIt is never in a state of ulceration. In the course of three or four\\nmonths the eruption is well-nigh universal, the skin being swollen,\\nshining, and crust-covered, or seamed with excoriations surrounded\\nby circles of pustules. Exceptionally there are multiformity of lesions\\nand the occurrence of the disease in women who are not pregnant.\\nThe lingual mucous membrane exhibits grayish, centrally depressed", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0433.jp2"}, "434": {"fulltext": "412 INFLAMMATIONS.\\npatches, well defined in contour. Alternate rigors and febrile accesses\\nmark the periods of recrudescence when new pustules form. Delivery\\nseems to have no favorable effect upon the course of the disease\\nin pregnant women. An endometritis with peritonitis was discovered\\npost mortem in a single case. Two women only of the thirteen\\nVienna patients survived one suffered from a relapse after several\\nweeks of improvement.\\nThe Etiology and Pathology of the disease are necessarily obscure,\\nhaving in view the relatively small number of reported cases.\\nDumesnil, Marx, and Dubreuilh have examined the skin removed\\nfrom living subjects of the disease, and have discovered dilatation of the\\nblood- and lymph-vessels with swollen endothelium and embryonic\\ncells surrounding these, especially in the papillary body at the base of\\nthe pustules. Cocci were present in the pustules, which are always\\nwithin the epidermis, and there was acanthosis of the palisade-layer of\\nprickle-cells. Post-mortem evidences of nephritis, endometritis, and\\npulmonary tuberculosis have been recognized in different cases.\\nThe Diagnosis of the disease is between herpes, dermatitis herpeti-\\nformis, and pemphigus.\\nIn herpes the purely vesicular character of the lesions and the cycli-\\ncal career of the disease indicate its nature. In dermatitis herpetiformis\\nthere is commonly a distinct multiformity of lesions, and the subjects\\nof the disorder are not, in such great preponderance, pregnant women.\\nIn pemphigus the size of the bulbe and their distribution in other than\\nconcentric groups will indicate the character of the disease. Special\\ncare should be taken to distinguish impetigo herpetiformis from pem-\\nphigus vegetans. The locality primarily invaded is the same in both\\ndiseases. For details consult the paragraphs devoted to the malady\\nlast named.\\nThe Treatment is conducted on general principles, including the\\nadministration of antipyretics, and the local employment of alkaline or\\nof carbolated baths starch and other dusting-powders anodyne, carbo-\\nlated, or simple salves and coal-tar. The uterus should be relieved\\nof its contents.\\nThe Prognosis is necessarily grave.\\nPEMPHIGUS.\\n(Gr. TTEfi^i^ a bladder.\\n(Pompholyx. Ger., Blasenausschlag.)\\nWith respect to the question whether pemphigus should be regarded\\nas the name of a distinct disease or of a group of several diseases, various\\nopinions are held. At one time every dermatosis displaying blebs was\\naccounted a form of pemphigus. With increasing knowledge there\\nhas been a greater reluctance to distinguish any disease by this specific\\nterm alone merely because of the presence of a bullous exanthem, and\\nas a result a number of affections exhibiting bullous efflorescence upon\\nthe cutaneous surface have been wholly disassociated from both pemphi-\\ngus and what the French term the pemphigoid eruptions. For some", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0434.jp2"}, "435": {"fulltext": "PEMPHIGUS. 413\\nauthors there is only a chronic pemphigus for others, in order to\\nestablish a diagnosis of pemphigus, the existing lesions should repose\\ndirectly upon the skin without exhibiting a peripheral inflammatory\\nareola, or at least be the expression of a disease with periodic exacerba-\\ntions in a determined career.\\nIn many morbid conditions of the skin bullae are present, when it is\\nmanifestly improper to call the disease pemphigus. For example, these\\nlesions are exhibited typically in some forms of lepra, in inherited\\nsyphilis, often as a result of the traumatisms of insects, and of several\\ninfective processes. To assert that a disease is a pemphigus in one of\\nits varieties, it is necessary to recognize the presence of other symptoms\\nthan bullae.\\nSymptoms. The distinctions respecting the bullous dermatoses\\nestablished by Brocq are worthy of recognition. In a first class are\\nincluded, as suggested above, the bullae which are epiphenomena of some\\nmalady (e. g., erysipelas). In a second class the bullae are either the\\nmain feature or one of the main features of a disease. The second\\nclass includes both the dermatoses in which the eruptive symptoms\\nare not commonly of bullous type, but which become such under\\nspecial conditions (e. g., polymorphous erythema bullosum), and those\\neruptions to which the term pemphigus is assigned by the best\\nauthors.\\nIt is to this second class, and to the last-named subdivision of the\\nclass, that the title is assigned in the paragraphs which follow. In this\\ngroup are included (a) Acute pemphigus (b) Chronic pemphigus (c)\\nPemphigus foliaceus (d) Pemphigus of the newborn (e) Pemphigus\\nof young girls Pemphigus vegetans of Neumann.\\nIt should be understood at the outset that these are simply clinical\\ndistinctions of value for the time being. There are doubtless other\\nforms of pemphigus, some of which are named below and there are\\nunquestionably morbid conditions here described which may be classed\\nlater more appropriately with other affections.\\nAcute Pemphigus. The rarity of this disorder has led observers to\\ndeny its existence. It is seen, however, though very rarely, in typical\\nexpression chiefly in infants and in young adults.\\nPemphigus Acutus Benignus Febkilis occurs in adults, in chil-\\ndren, and in infants, but more frequently among the very young. It\\nmay be epidemic in hospitals and in other public institutions. With or\\nwithout an antecedent febrile movement, the blebs may appear before\\nor within a fortnight after birth in infants that are well nourished or\\ncachectic, more often the latter. In favorable cases the evolution of\\nthe disease is completed within three or four weeks. Any part of the\\nbody may be affected but, what is important from a diagnostic point\\nof view, the face, the hands, and the feet are often exempt. The con-\\njunctivae and mucous lining of the mouth may, however, become\\nimplicated. In some cases the pemphigus may be of hemorrhagic type.\\nUnderneath the lesions a reddish, glistening rete is exposed. The ter-\\nmination may be fatal. The greatest care is required to differentiate\\nthe disorder from syphilis, which is commonly not a difficult matter\\nsince the eruptive symptoms in syphilis are first developed, as a rule,", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0435.jp2"}, "436": {"fulltext": "414 INFLAMMATIONS.\\nat a later period, are less acute, and they invariably exist upon the\\nperson of an infant exhibiting the characteristic cachexia of lues.\\nPemphigus Acutus Malignus Febrilis is still rarer. As in the\\ncase of infants, in adults there may be marked febrile antecedents and\\nsystemic disturbance. The eruption of pea- to large nut-sized bulla?\\nmay be sparse or be abundant, covering in some cases the entire body\\nand attacking mucous surfaces. The vesicles or bulla? may be tense,\\nflaccid, and tilled with clear, serous, or puriform contents. Covering\\nthe floor of the lesion may be seen a smooth, raw, mucous layer or a\\ndiphtheritic exudation. The bullae, as a rule, are large, well formed,\\nand irregularly distributed over the body, the face, and the limbs, with\\nacuity of development. After a few hours or a few days crusts form,\\nthe latter, after their fall, leaving a slightly pigmented surface. The\\nmalignancy of this affection is at times formidable, death occurring in a\\nweek after the onset of the malady. In these cases there is usually a\\ndecided febrile movement, with vomiting, headache and other pains,\\nstupor, delirium, and great nervous anxiety. In some cases the exan-\\nthem is productive of intensely pruritic or burning sensations and\\nwhen generalized the difficulty of placing the patient in a position of\\nease greatly aggravates the nervous state.\\nPathologically the lesions are elevations of the horny layer with\\nserum, having an cedematous prickle-layer in the periphery, with a base\\nrepresented by an involuted prickle-layer permeated with leucocytes.\\nDiplococci and saprophytes are found in numbers at the base of each\\nbleb. According to Weyl, Bulkley s Herpes gestationis is an example\\nof Acute pemphigus adultorum.\\nChronic Pemphigus (Pemphigus Vulgaris). The term Pemphigus\\nVulgaris is applied to the more common clinical forms of the malady,\\nand it has been employed generically by many authors to include all\\nvarieties of the disease. The title Pemphigus Diutinus has been\\nused also to designate that pemphigoid eruption in which the character-\\nistic lesions follow each other with rapidity and in profusion, fresh\\nbulla? appearing each day. Fortunately, all forms of the disease are\\nrelatively rare.\\nThe cutaneous lesions in chronic pemphigus are usually preceded by\\nfebrile symptoms and the disturbance of the economy is declared in\\ncardiac, respiratory, and gastro-intestinal derangements of function.\\nThe fever may be continuous, remittent, or intermittent, and is usually\\naggravated just before the appearance of a fresh crop of blebs.\\nThe face, the trunk, and the extremities are chiefly involved. The\\neruption first appears bilaterally, somewhat symmetrically or asym-\\nmetrically, in reddish macules of rather vivid hue, in the centre of\\neach of which appears later a whitish elevation of the epidermis sug-\\ngesting a wheal. Either upon these or upon unaffected points of the\\nskin there subsequently form tense, well-rounded or oval vesicles\\ndeveloping into bulla? varying in size from that of a pea to that of a\\nhen s egg and even larger, and in number from three to six only, to\\na hundred and more they are usually irregularly distributed (Pem-\\nphigus Disseminatus), but they may be clustered in groups, or very\\nrarely be found the younger encircling the older lesions, so as to form", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0436.jp2"}, "437": {"fulltext": "PEMPHIGUS. 415\\na circinate patch (Pemphigus Circinatus) their contents are serous\\nor bloody (Pemphigus H^emorrhagicus), or, later, purulent, the\\ncolor corresponding with that of pus. The bullae often coalesce, and,\\nwhether ruptured or not, the involution of the lesion is accomplished\\nby desiccation and crusting, the crusts being usually found to contain\\nblood, pus, epithelial debris, and the exudate from the base of the bleb.\\nBeneath such a crust there forms a new epidermis, which is usually\\nviolet, purplish, or bluish red in color, and which later displays a\\nbrownish pigmentation which may survive the disease for several weeks.\\nOccasionally the affection occurs with very mild and even insignifi-\\ncant phenomena (Pemphigus Bejstgnus). There may be no fever,\\nand very few blebs appear in some cases but a single lesion can be\\nseen (Pemphigus Solitarius). In other instances the fever is\\nintense the eruption abundant the skin \u00c2\u00a9edematous, painful, pru-\\nritic, excoriated and the underlying lymphatic glands are enlarged.\\nThis general condition with exacerbations and remissions may persist\\nfor months, and the eruption may then disappear never to return, or to\\nrecur, as it often does, in the future.\\nClinically, many of the distinctions between the varieties of pem-\\nphigus disappear. Between the benign processes just considered and\\nthe grave form of pemphigus foliaceus described below several inter-\\nmediate gradations can be observed, and even the most benign may at\\ntimes unexpectedly assume the most malignant phases. Pemphigus\\nMalignus is a name given generally to those intermediate varieties of\\nthe disease, most of which are distinguished by persistent and pros-\\ntrating fevers by cachexia, especially in infants by the occurrence\\nof diphtheritic patches upon or about the lesions, with infiltration of\\nthe derma and slough of its superficial layers or by extensive crust-\\ning, and even subsequent ulceration.\\nIn all varieties of pemphigus the lesions may be exhibited upon the\\nmucous membrane of the accessible outlets of the body.\\nChronic pemphigus exhibits the greatest variation both as to its\\nsymptoms and as to the period of their efflorescence. There may be a\\nweek or a month of immunity, followed by benign relapses or by ma-\\nlignant and rapid recurrences. The bullae may form upon an unaltered\\nor a deeply hyperaemic skin, in all sizes from that of a pea to that of\\nan orange, invading the skin and mucous surfaces including the vagina,\\nthe lesions at the base exhibiting the several features described above.\\nThe eruption is rarely generalized, and throughout the course of the\\ndisease not more than half a dozen lesions may at any moment be vis-\\nible upon the surface of the skin. Their contents may be removed by\\nj evaporation, absorption, or rupture, leaving a crust the color of which\\nis largely determined by the contents of the bleb.\\nThe areola, which may or may not be present in the several forms\\nj here described, is commonly narrow, and is fully developed only when\\nthe bleb is mature. The separate lesions may persist for days, or may\\nrupture at an earlier period, leaving behind a superficial excoriation\\nI which after healing exhibits pigment.\\nThe intercurrent disorders in the several forms of the disease desig-\\nnated may be numerous, death occurring from septicaemia, exhaustion", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0437.jp2"}, "438": {"fulltext": "416 INFLAMMATIONS.\\n(especially when a deep slough results, as in pemphigus gangrsenosus),\\nand lymphangitis, the neighboring vessels and glands exhibiting evi-\\ndence of the toxic effects produced by the cocci present. In some cases\\nthe general symptoms are absent or are insignificant, and the subjective\\nsensations are limited to a slight feeling of burning or of tension. In\\nother cases the blebs project from the affected surface and are well dis-\\ntended in still others they are flaccid, the roof partially collapsing\\nupon the serous, purulent, or bloody contents. The crusts which form\\nare rarely bulky; they are more commonly dark colored and thin.\\nPemphigus Prtjriginosus is a name applied to that grave form of\\nthe disease in which the lesions give rise to an intense pruritus. As a\\nresult of the scratching induced by the pruritus they are torn, exco-\\nriated, and commingled with the crusts and exudations of an arti-\\nfically engendered eczema. If the itching be severe, the vesico-bullge\\nmay be so torn as to be difficult of recognition. Several of the malig-\\nnant and intermediate forms may terminate fatally.\\nPemphigus Foliaceus. Pemphigus foliaceus is a rare variety of\\ndermatosis which may originate in one of the common dermatoses or in\\na grave form of pemphigus chronicus, or may, at the onset, present\\ncharacteristic features. Hallopeau and Fournier have reported cases\\nwhich began as a dermatitis herpetiformis. The lesions are flaccid\\nbullae, which are developed without a perceptible preexisting exanthem,\\nand which speedily rupture and discharge their ill-conditioned contents,\\nleaving beneath an excoriated, reddish or purplish, and at times inflam-\\nmatory surface. Often the blebs are so poorly defined that the epidermis\\nseems scarcely raised from the tissue beneath, the condition resembling\\nthat of the skin to which a blister has been applied, with the result of\\nimperfect vesication. The contents, at first pellucid or lactescent,\\nbecome later purulent or sanguinolent. When rupture of the blebs\\noccurs there form yellowish-brown crusts which acquire a feeble attach-\\nment to the centre of the floor of the original chamber, while the edges\\nremain free; these edges, visible over the affected surface, in poly-\\ncyclical or irregular outlines, incompletely hiding the raw and sodden\\nepidermis, present a characteristic picture.\\nThe disease spreads gradually until it becomes symmetrical and\\nuniversal, a peculiarity which marks it as unique among the pem-\\nphigoid eruptions, and which, in a striking degree, distinguishes it\\nfrom pemphigus vegetans and from pemphigus acutus. As the disease\\nadvances the patient lies in a pitiably helpless condition, the remaining\\nepidermis being completely undermined by the serum exuded, in\\nplaces exposing large denuded areas of skin in a condition of inflam-\\nmation of a low grade. Even, however, when the disease is fully\\ngeneralized the appetite and bowel-function are at times unimpaired.\\nIn its later stages, after it has become generalized, the pemphigoid\\norigin of the disease is not always easy of demonstration. In these\\ninstances large masses of greasy scales are exfoliated from the surface,\\nthe moisture proceeding from which is scarcely sufficient to attract\\nattention.\\nThe disease affects the mouth and throat, denuding the mucous sur-\\nfaces of the epithelium. The scalp becomes affected, as also the covered", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0438.jp2"}, "439": {"fulltext": "PEMPHIGUS. 417\\nportion of the body. The hairs remain attached for a long time, but\\neventually they are completely swept away. Over the face, at first\\nmerely reddened and scaling, occur retractive processes w T hich at times\\nproduce ectropion and consequent conjunctivitis. Over the body,\\nespecially at points pressed upon when reclining, profound ulcerations\\nmay destroy the deep skin. The palms and soles are infiltrated and\\nfissured rather than the seat of much exudation. The nails are com-\\nmonly furrowed and distorted occasionally they are shed. The sub-\\njective sensations are those of burning, smarting, and soreness, rather\\nthan of itching. If the patient be kept in the continuous water-bath,\\nthough the disease be not thereby ended, the comfort of the sufferer is\\nadmirably secured.\\nThere may be no fever, or there may be a rise of body-temperature\\nwith recurrence of lesions which, in a late stage of the disease, appear\\nin the sites of those which have been very imperfectly followed by\\nattempts at repair, a thin and glazed epidermis forming, in cases of\\nchronic type, in the sites of former bullae. In other cases the tempera-\\nture remains above normal for weeks at a time, especially in advanced\\nstages of the disease. The malady may complete its course in a few\\nmonths or may persist for years, and though not necessarily, yet is\\nunquestionably fatal in the majority of cases. Death usually results\\nfrom exhaustion occasionally an intercurrent pneumonia or diarrhoea\\nconcludes the history.\\nPemphigus Neonatorum. The disease to which this name is given\\nshould not be confused with pemphigus acutus (described above),\\nwhich may occur both in the newborn and in young adults. Pem-\\nphigus neonatorum is a term which describes an affection observed\\nexclusively in children. The lesions are ill-developed bullae, which\\nappear soon after birth in cachectic infants that have been subjected to\\nunfavorable hygienic influences. The eruption usually occurs about\\nthe lower portions of the trunk, as these are the regions requiring most,\\nand, in these unfortunate beings, receiving least care with respect to\\ncleanliness. In some cases children healthy in appearance are suddenly\\nseized with an attack, the skin, according to Fox, becoming livid, the\\nbullae being surrounded with dark areolae, and ulcers forming as a result\\nj of gangrenous complications. These are probably cases of infection\\nwith pyogenic cocci in ill-nourished infants, where the reaction of the\\ni skin is expressed in a bullous rather than in a pustular efflorescence.\\nj The subjects usually perish in a few days, but they may survive if\\nI speedily provided with a hygienic environment. Infants thus affected\\nare to be carefully distinguished from those suffering from inherited\\nj syphilis and exhibiting a bullous svphiloderm on the body.\\nThe Inherited Form of Pemphigus described by Goldscheider,\\nLegg, and others, most often noticed in summer, spring, or autumn,\\nrarely in winter, is considered under the title of epidermolysis bullosa\\nhereditaria. (See page 426.)\\nPemphigus of Young Girls (Pemphigus Vikgintjm). This disorder,\\ndescribed by Hardy 1 is characterized by the appearance upon the\\nskin of oval or rounded spots of a reddish or rosy hue upon these\\n1 Traits prat, et descript. des Mai. de la Peau, Paris, 1886, p. 268.\\n27", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0439.jp2"}, "440": {"fulltext": "418 INFLAMMA TIONS.\\nspots there later develop vesico-bullse of different sizes, which it has\\nbeen suspected are, in some subjects, instances of feigned eruption\\n(q. v.). The subjects of the disease are between the fourteenth and the\\ntwentieth year of life, unmarried, and usually menstruating irregu-\\nlarly. Others have described a pemphigus hystericus, to be recog-\\nnized in hysterical persons of the same class, alternating or correspond-\\ning with hysterical attacks, the eruption not uniformly disposed over\\nthe surface, and being transitory in duration, disappearing with relative\\nrapidity and leaving no cicatricial traces of its existence. Unna dis-\\nmisses this affection from the category of true pemphigus.\\nPemphigus Vegetans (Erythema Bullosum Vegetans). Neu-\\nmann 1 was first to describe and furnish illustrations in color of a dis-\\nease to which he gave this name, and which has since been studied by\\na number of observers. Crocker, 2 of London, published an excel-\\nlent monograph giving tabulated results in some eighteen cases and\\nat the meeting in 1891 of the American Dermatological Association\\nin Washington one of us 3 read a full account of the first case reported\\nas such in the United States, the patient having been seen in connec-\\ntion with Duhring, of Philadelphia.\\nThe onset of the disease is marked by languor, malaise, and ill-\\ndefined symptoms of impaired health, after which the morbid symptoms\\nmay first be declared in the mouth or the skin. In the former region\\nwhite patches, which are ill-developed blebs, are visible upon the mu-\\ncous surface. The detached membrane forming each spot is finally\\nloosened and leaves behind equal-sized excoriated patches, which pro-\\nduce extreme soreness of the mouth, and which as some heal are\\nsucceeded by others. In severe cases they render mastication and\\ndeglutition exquisitely painful and in patients in whom this becomes a\\nprominent feature of the case the nutrition of the body is seriously\\nimpaired.\\nThe skin-lesions may precede or may follow those in the mouth.\\nThey are commonly first seen in women about the vulva, spreading\\nover the anogenital region as closely set bullae covered with a mucoid\\nwhitish secretion, the features thus strongly resembling the appearance\\nof condylomata of the same region. In connection with the mouth-\\nlesions, the suggestion that syphilis is present is very striking, and\\nhas led to this error of diagnosis in a large number of instances\\nreported by those not expert in diagnosis. The bullous efflorescences,\\nwhich at first resemble those of other forms of pemphigus, speedily\\nexhibit in the site of their production vegetating masses, the change\\nfrom the bleb to a fungoid papillomatous growth being scarcely appre-\\nciable. The lesions tend to become grouped about the axillae, the\\ncircle at the root of the neck, the bend of the elbows, the hands, the\\nfeet, and the scalp, but they have no tendency to become universal,\\neven when extensive. A singular change in the skin, where typical,\\nwell-formed bullae have developed and healed, is a deep pigmentation\\nin puncta resembling comedones, with pin-point-sized verrucoid eleva-\\n1 Vierteljahr. f. Derm. u. Syph., 1886, Band xiii.\\n2 Pemphigus Vegetans (Neumann). London, 1890.\\n3 Jour. Cutan. and Gen.-Urin. Dis., Nov. and Dec., 1891.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0440.jp2"}, "441": {"fulltext": "PEMPHIGUS. 419\\ntions of the surface. In some regions the sequence of the closly packed\\nblebs, followed by vegetating masses, resembles that seen in pemphigus\\nfoliaceus, in which, especially over the back after long decubitus, there\\nform large, granulating erosions, exquisitely painful, and hastening the\\npatient to the end. The disease progresses in unmistakable accessions\\nof aggravation and improvement, lasting for months and occasionally\\nfor years. It is in the majority of cases eventually fatal. A few cases\\nhave been reported as cured. The authors have had two cases present-\\ning typical features of pemphigus vegetans in which recovery was com-\\nplete after two and four months, respectively, of treatment. In both\\ncases, however, the eruption appeared a few weeks after vaccination, and\\nwas evidently the result of an acute, instead of a chronic, toxaemia.\\nVariations occur, chiefly in the degree of febrile temperature, probably\\nalways reactive in the severity of the buccal lesions and in the extent\\nof the eruption.\\nEtiology. The causes of pemphigus are obscure yet the connec-\\ntion of many varieties of the disease with changes in the trophic nerves\\nand nervous centres is established by sufficient proofs. It is well\\nknown also that traumatisms and lesions of the cord have been fol-\\nlowed by bullous efflorescence upon the body-surface. At the same\\ntime (as Kaposi has well shown), on the one hand, blebs from these\\ndemonstrable causes never resemble the portraits distinguishable in\\nthe varieties of pemphigus and, on the other hand, there is no uni-\\nformity among lesions, either as to anatomical site or other features,\\nin the spinal changes to be recognized in pemphigus with a fatal issue.\\nFurther, of nine autopsies of bodies dead of pemphigus examined by\\nKaposi and Weiss, in only one w T ere changes found in the cord (diffuse\\nsclerosis). The view that these dermatoses are instances of infective\\ntrouble is, therefore, gaining ground, and it is quite probable that\\nfuture investigation will demonstrate that both the cutaneous and the\\nnerve lesions are the results of a toxic agency operating with morbid\\nresults upon each.\\nPemphigus is more frequently encountered in males, and among\\nthese in infancy and childhood, because the powers of resistance at a\\ntender age are inferior to those of a maturer epoch. The disease is\\noften observed in debilitated patients who are variously described as\\nsuffering from nervous prostration, mental worry and exhaustion,\\nneurasthenia, general debility, visceral disorders, and impair-\\nment of nutrition. In vigorous, rosy-cheeked, strong-limbed adults\\nthe disease is rare. The states in which there is marked impairment\\nI of bodily vigor are particularly favorable to the development of the\\ndisease. It occurs in hysteria and other neurotic affections, but the\\netiological relations which these bear to the disease are undetermined.\\nWe have observed one case of the disease in an adult in whom pem-\\nphigus of typical appearance occurred after mental depression, which\\nwas so greatly increased by the appearance of the exanthem as to lead\\nto suicide.\\nThere is good reason to believe that in some of its forms the\\ndisease is contagious. The bullous lesions, however, seen in syph-", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0441.jp2"}, "442": {"fulltext": "420 INFLAMMATIONS.\\nilis, lepra, and other similar disorders should not always be here\\nincluded.\\nThe contents of the bullae of acute pemphigus were found by Gibier,\\nin 1882, to contain bacteria. His observations were confirmed by\\nVidal and Roeser. Demme, 1 in 1886, found cocci both in the con-\\ntents of the bulla} and in the blood. Whiphouse 2 found diplococci\\nresembling those described by Demme and through culture and inocu-\\nlation-experiments has furnished strong presumptive evidence in favor\\nof the bacterial origin of the disease. Pernet and Bullock 3 have\\nrecorded a number of fatal cases which occurred in butchers, the\\norigin of which was traced to a local wound-infection. Other observers\\nhave searched in vain for a specific micro-organism of pemphigus either\\nin the bullae or in the blood.\\nPathology. Anatomical changes in the spinal cord have been\\nrecognized in pemphigus, as explained above, but in many cases\\ncareful search has failed to discover such changes. Dejerine and Leloir\\nfound in a case of pemphigus changes in the peripheral nerves due to\\ndegeneration.\\nBoth in the bullae and in the blood there is a marked increase in the\\nnumber of the eosinophilous cells. In this respect pemphigus corre-\\nsponds closely to dermatitis herpetiformis. The increase of the eosin-\\nophilous cells in both affections has been assigned to the effect of an\\nirritant upon the nerve-centres but more recently these cells have\\nbeen found abundantly in vesicles produced artificially upon the sound\\nskin of a healthy individual, and it is doubtful if any especial signifi-\\ncance can be attached to them.\\nMost of the bullae are superficially situated between the rete and\\nthe horny layer or in the upper part of the rete. They may be the\\nresult of an inflammation in the corium, but more probably are due\\nto a mechanical separation of the rete-cells by a sudden effusion of\\nfluid from the vessels of the derma, the papillae becoming at the same\\ntime markedly \u00c2\u00a9edematous. Unna, describing chiefly the final stage\\nof chronic pemphigus, found extensive and deep infiltration of vessels\\nin the cutis. The lymph-vessels and lymph-spaces are dilated chiefly\\nat the margin between the cutis proper and the papillary body. The\\nridge-net is hypertrophic, containing mitoses, a normal granular layer,\\nand a horny layer varying in thickness. In pemphigus foliaceus the\\nridge-net is flattened, and the suprapapillary layer is reduced to a\\nminimum, so that the altered corneous layer stretches almost imme-\\ndiately above the heads of the oedematous papillae. In general the\\n\u00c2\u00a9edematous epithelium is softened, and the prickle-borders and the\\ninterspinous spaces disappear. The epithelial cells of the coil-glands\\nare swollen that of the ducts to a less extent. The epithelial linings\\nof the hair-follicles disappear in time with the hairs. The entire process\\npoints to a persistent vascular paralysis with dilatation especially of th\u00c2\u00a7\\nsubpapillary lymph*- vessels and an oedematous swelling of the constit-\\nuents of the skin, denser in the connective tissue, and accompanied\\n1 Vierteljahr. f. Derm. u. Syph., 1886, p. 636.\\n2 London Lancet, May 2, 1896.\\n3 Brit. Jour, of Derm., 1896, pp. 157 and 205.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0442.jp2"}, "443": {"fulltext": "PEMPHIGUS. 421\\nwith softening of the epithelium. The hairs and sebaceous glands\\nplay a purely passive part.\\nDiagnosis. From what has preceded, it will be inferred that pem-\\nphigus is a name given to a disease, and not merely to bullous lesions\\nupon the surface of the skin. It is of importance to remember this\\nfact, as several authors have used the term in a purely descriptive sense,\\nthe truth being that bullae are manifestations of several disorders,\\nincluding syphilis, lepra, herpes iris, and erythema multiforme.\\nAt the outset the blebs of pemphigus can scarcely be differentiated\\nfrom those of other diseases. It is necessary for the recognition of the\\nmalady that consideration be had of all the cutaneous and other phe-\\nnomena present in the disease. In syphilis blebs are rare in the\\nadult, and relatively more frequent in infants hereditarily diseased. In\\ninfants the blebs are usually seen at birth, often upon the palms and\\nsoles, and are frequently superimposed upon an exulcerated base. The\\ncoexistence of mucous patches of the mouth, the vulva, and the anus\\nwith the other characteristic lesions and signs of grave cachexia, will\\nusually indicate the nature of the disease. The cutaneous symptoms\\nof infants thus affected are improperly designated as pemphigus. Such\\nan eruption is a bullous syphiloderm.\\nIn the bullae of lepra there is usually coexisting cutaneous anaesthe-\\nsia, and the involution of the bleb is followed by a strikingly char-\\nacteristic atrophic patch, usually pigmented and insensitive. In pem-\\nphigus foliaceus the extraordinary and usually generalized desquamation\\nwhich ensues is sufficiently distinctive, though it must be borne in\\nmind that several varieties of pemphigus may be transformed, the one\\ninto the other, by well-nigh insensible gradations. Among its graver\\nforms susceptible of such transformation may be named impetigo\\nherpetiformis, pemphigus cachecticus, pemphigus diphtheriticus, and\\npemphigus pruriginosus.\\nIn herpes iris the lesions are more vesicular than bullous and much\\nmore transitory are concentrically arranged and vary in color and\\nare situated more frequently upon the extremities, especially the backs\\nof the hands. The bullous lesions occasionally seen in urticaria and\\nerythema multiforme are to be recognized by the other characteristic\\nsymptoms of these diseases in the former, more particularly, by their\\nintermingling with typical wheals, and in the latter by the location of\\nthe eruption and its climatic or seasonal significance. Some of the\\nreported contagious forms of pemphigus, epidemics of which have been\\ndescribed by Besnier, Hervieux, and other French authors, were possi-\\nbly, as Duhring suggests, instances of impetigo contagiosa. This infer-\\n1 ence is sustained by the frequent allusion of the writers named to the\\nvaricellaform appearance of the lesions.\\nIn a large proportion of cases pemphigus vegetans has been mis-\\ntaken for syphilis, the close grouping of the lesions about the anogenital\\nregion, and their striking resemblance to condylomata, taken in con-\\nnection with the presence of erosions of the mucous membrane of the\\nmouth, being the grounds for error. With care this blunder can usually\\nbe avoided. However closely packed together may be condylomata of\\nthis region, they rarely spread, as does pemphigus vegetans, beyond the", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0443.jp2"}, "444": {"fulltext": "422 INFLAMMATIONS.\\nregions adjacent to the mucous outlets while the bullae of pemphigus\\nvegetans, when the disease is fairly advanced, are not only exceedingly\\nnumerous and closely packed together, but they spread also beyond\\nhigh toward the pubes and low over the inner faces of the\\nthighs. There is commonly a history of fever, no lymphatic adenop-\\nathy, and a distinct uniformity of lesions, each separate element being\\nof bullous type.\\nSome ingested medicaments are capable of producing bullous lesions,\\nfor example, potassium iodide such a possibility should always be\\nborne in mind when establishing a differential diagnosis. Scabies in\\ninfants and older children is occasionally characterized by the forma-\\ntion of blebs, in which case the other lesions present, as also a history\\nof contagion and the discovery of the parasite, will point to the real\\nnature of the disease.\\nLastly, the external application of cantharides, mezereon, the stronger\\nacids, alkalies, and other chemicals may be followed by blebs produced\\neither by accident or by intention with a view to feigning disease. The\\nintentional production of such symptoms is usually effected upon the\\nanterior faces of the lower extremities, regions within easy reach\\nof the right hand. Erysipelas and dermatitis calorica are also affec-\\ntions in which blebs appear, always, however, of minor significance\\nas compared with the other symptoms of disease present. The\\nsame may be said of the bullae which form upon a gangrenous integu-\\nment.\\nTreatment. The internal treatment of pemphigus is a matter of\\nimportance, as will be suggested by even a brief consideration of the\\nconstitutional states in which it occurs. Jonathan Hutchinson, of\\nLondon, 1 distinctly asserts his belief that arsenic is a specific for the\\nstate of health upon which relapsing pemphigus depends. In many\\nyears trial of this remedy he declares that, in his own practice, he\\nhas never recorded a single failure, though he makes exception, prop-\\nerly, of many infantile cases supposed to be syphilitic. This remedy\\nis certainly a valuable one, but it should be employed with caution\\nand in accordance with the rules prescribed in the chapter on Psoriasis.\\nKaposi, however, declares that he has been unable to obtain favor-\\nable results from its employment. Iron, quinine, ergot, strychnine,\\nand the mineral acids are indicated in many cases, in conjunction with\\na nutritious diet. Cod-liver oil and the malt preparations on the\\nmarket should not be neglected. Not infrequently the treatment\\nshould be directed to the relief of the anomalous performance of the\\nsexual function in women, as pemphigus has been found to occur in\\nthe hysterical and chlorotic states common as a result of functional\\ndisorder.\\nThe local treatment of the lesions should consist, first, in puncturing\\neach bleb with a fine needle, in order to give exit to its contents, which\\nshould carefully be removed from the skin with the aid of cotton- wool.\\nThen the parts are to be wholly enveloped in an antiseptic wet dress-\\ning, or freely dusted with a powder, such as zinc stearate or borated\\ntalcum. When there is considerable pyrexia, with heat and distress\\n1 Lectures on Clinical Surgery, London, J. A. Churchill, 1878, p. 49.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0444.jp2"}, "445": {"fulltext": "HYDRO A. 423\\nin the skin, the affected surface may be treated as in acute eczema,\\nwith oleated lime-water, containing opium or dilute hydrocyanic acid\\nin some such proportions as those already detailed.\\nThe ordinary lead-and-opium wash, with or without the addition of\\nzinc oxide, will also answer a good purpose. The continuous hot\\nwater-bath still enjoys among experts the highest favor in the treat-\\nment of the grave forms of pemphigus. Kaposi kept a patient day\\nand night for eight months with his body thus immersed, to the great\\nadvantage of the invalid. This continuous bath is often impracticable\\noutside a large hospital but in cases of grave pemphigus the continu-\\nous hot water-bath has been employed in private practice with the hap-\\npiest results.\\nIn pemphigus vegetans internal treatment is symptomatic, usually\\nalong the line of elimination and support locally, the continuous bath\\naffords speediest relief. If this cannot be obtained, the lesions should\\nbe cleansed thoroughly and dressed with antiseptic lotions or ointments,\\nor dusted with borated, salicylated, or camphorated powders. The\\nnumerous scalp-lesions require cutting short the hairs of the head in\\norder to make applications. Alcoholic stimulants are in most cases\\nessential.\\nPrognosis. The prognosis in mild cases of pemphigus, though\\nmuch less grave than in the malignant forms of the disease, should\\nalways be formulated with caution. Unlike several of the diseases\\nheretofore considered, the affection is one not frequently encountered\\nin persons of fair general health. The constitutional condition of the\\npatient must carefully be considered it should not be forgotten that\\nthe disease is not only one liable to relapses, but also is one in which\\nthe graver may succeed the more benign manifestations. A flaccid\\nsummit of the bleb, sanguinolent or ichorous contents, an abundant\\nefflorescence, and a rapid succession of new, after the involution of\\nmore ancient, lesions, are in general unfavorable symptoms. The same\\nmay be said of degeneration of the floor of the bleb after rupture and\\ndischarge of its contents.\\nHYDROA.\\n(Gr. vtiup, water.)\\n(HlDROA.)\\nThe term Hydroa was once extensively used as a designation of\\ncutaneous disorders characterized by the occurrence of a bullous\\nexanthem, the blebs being associated with erythematous lesions and\\nproductive of subjective sensations of itching. But since it is no\\nlonger employed by the best authors as a title of disease, it is here\\nset down merely in order to enumerate some of the affections liable\\nto be confounded under the title. The Herpetiform Hydroa of\\nT. Fox the Dermatitis Herpetiformis of Duhring the Herpes\\nCircenatus Bullosus of Wilson the Hydroa of Quinquaud the\\nHerpes Gestationis of Bulkley and the Pemphigus Pruriginosus\\nof Chan sit and Hardy, are included by some authors under the name", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0445.jp2"}, "446": {"fulltext": "424 INFLAMMATIONS.\\nhydroa. According to Quinquaud, the essential symptoms of hydroa\\nare a primary vesico-bullous exanthem a rapid evolution of symp-\\ntoms the termination of the disorder within two months as a maxi-\\nmum the occurrence of pruritus in the active periods of the disease\\nand the recognition of varieties pemphigoid, impetiginous, vesicular,\\ncircinate, regional, and of a form implicating the mucous surfaces.\\nCrocker describes a group of diseases by this name, standing mid-\\nway between erythema multiforme and pemphigus. The most of\\nthem, even on the showing of French writers including Bazin, can\\nwithout difficulty be assigned to the one class or the other.\\nOf the three varieties of hydroa proposed by Bazin, Hydroa Vesi-\\nculeux is identical with the Erythema and Herpes iris of Bateman,\\nand Hydroa Bulleux is a phase of Dermatitis herpetiformis. As a\\nresult of recent observations Hydroa vacciniforme would seem entitled\\nto consideration as a distinct disease.\\nHYDROA VACCINIFORME, SEU JESTIVALE.\\n(Hydroa Puerorum.)\\nThis form of hydroa, first described in 1855 by Bazin, has been\\nrecognized only recently. Hutchinson, Hauford, Jamieson, Boeck,\\nCrocker, 1 Bowen, 2 Graham, and others have seen and described a number\\nof cases of hydroa vacciniforme.\\nSymptoms. The disease usually begins during the first three or\\nfour years of life and gradually disappears during the few years fol-\\nlowing puberty. With but two or three exceptions the cases reported\\nhave been in boys. The disease is most active in summer, the larger\\nnumber of patients remaining free from active manifestations during\\nthe winter months. The direct cause in most cases is exposure to the\\nsun s rays, though exceptionally warm or cold winds, or even artificial\\nheat, seem sufficient to cause an outbreak.\\nThe eruption is symmetrical and is limited to the uncovered parts\\nof the body the bridge of the nose, cheeks, and ears, and the backs\\nof the hands being the parts most affected. Bazin, however, reported\\ncases in which covered portions of the body were slightly involved.\\nThe authors have under observation a case (the subject of the accom-\\npanying illustration) in which a new crop of vesicles and bulla? on the\\nface is accompanied at times by an herpetic keratitis, the resulting scars\\ninterfering considerably with vision. The disease occurs in successive\\noutbreaks, each of which lasts for two or three weeks. The intervals\\nbetween recurrences in the summer may be several weeks, or so brief\\nas practically to be wanting. The lesions first to appear are red mac-\\nules or elevations, upon which are rapidly formed vesicles or bulla?,\\nvarying in size from that of a millet-seed to that of a large pea, and\\noccurring either singly or in groups like herpes they may coalesce.\\nThese vesicles may dry in a day or two, or they may rupture and form\\na crust, but many of the larger become depressed in the centre ami\\n1 Diseases of the Skin, 1893.\\n2 Jour. Cutan. and Gen.-Urin. Dis., March, 1894.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0446.jp2"}, "447": {"fulltext": "HYDROA VACCiyiFORME, SEU jESTIVALE.\\n425\\nresemble a vaccination-vesicle. The depressed centre is black or dark\\nblue, and is surrounded by a ring of fluid, while about the whole is a\\nreddened areola. Some of the lesions may become purulent. The\\ndark centre is rapidly converted into a thick, black crust which is very\\nadherent, and which on falling leaves a depressed, reddened scar that\\neventually becomes white and practically indistinguishable from that\\nof variola. The duration of an individual lesion from its beginning\\nto the formation of the crust is three or four days. The time required\\nfor the crust to fall is variable.\\nThe eruption is usually preceded by some slight constitutional dis-\\nturbance, and by burning or pain at the site of the lesions. Itching\\nis absent, as a rule, though it was marked in Bowen s case.\\nFig. 50.\\nHydroa vacciniforme.\\nHYDROA iESTIVALE, HvDKOA PuEKORUM, SUMMER PRURIGO.\\nA type of eruption similar in appearance, history, and etiology to that\\nof hydroa vacciniforme has been described by Unna, Hutchinson, Ber-\\nliner, Graham, and others, under the names above enumerated. These\\neruptions diifer from those of hydroa vacciniforme chiefly in being\\neczematous in nature. Itching is commonly present macules and\\npapules are more numerous than the vesicles, which are not umbili-\\ncated and scarring is comparatively slight. The disease is found in\\ngirls, though less frequently than in boys.\\nThe Pathology has been studied by Bowen in two lesions taken\\nfrom a single case. In the primary stage he found merely vesicle-\\nformation in the middle layers of the rete. In a more advanced lesion\\nhe found necrosis involving the lower layers of the stratum corneum,\\nthe entire rete, and the corium nearly to the subcutaneous tissue. He\\nconcluded that the process begins as an inflammation in the epidermis\\nand upper part of the corium, followed by vesicle-formation in the\\nrete, and later by the necrosis described above. The necrosis is", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0447.jp2"}, "448": {"fulltext": "426 INFLA MM A TJONS.\\nsharply circumscribed, and, showing through the vesicles above, pro-\\nduces the black centre of the advanced lesions. Bowen further calls\\nattention to the points of similarity between this disease and those of\\nacne necrotica, or of acne varioliformis.\\nAccording to Unna, the histological facts of the disorder are an\\noedema and cellular infiltration corresponding to a vascular area of the\\nskin, the chief seat of which is the papillary body an utterly passive be-\\nhavior of the epithelium, exhibiting oedema and interepithelial blebs\\nor, more commonly, elevation with serum and, finally, the complete\\nabsence of leucocytosis.\\nThe Treatment is unsatisfactory. To prevent recurrence the patient\\nshould be guarded from exposure to the sun and in some cases from hot\\nor cold winds. Veils and coverings which exclude the light may be of\\nservice. Crocker recommends treating the eruption by opening the\\nvesicles and applying iodoform in powder or in solution in ether. After\\nremoving the crusts with carbolized oil the surfaces may be dressed with\\nan ointment containing iodoform and boric acid.\\nEPIDERMOLYSIS BULLOSA HEREDITARIA.\\n(ACANTHOLYSIS BULLOSA.)\\nThis name has been given to a rare affection or condition of the skin\\nin which there is a pronounced tendency to the rapid formation of bulla?\\nwherever the integument may be slightly bruised or rubbed. Cases\\nhave been reported by Goldscheider, Kobner, Valentine, Elliott, 1 Beatty, 2\\nBowen, 3 and others. 4 In the majority of cases reported the condition\\nhad existed from infancy or early childhood, and there was a clear his-\\ntory of heredity. Valentine reported eleven cases which occurred in\\nfour generations of the same family.\\nThe general health of individuals thus affected may be excellent and\\nthe skin remain sound so long as it is subjected to no irritation, but in\\nsome cases very slight causes (the pressure of a shoe in walking the\\ngrasping of a firm substance, such as the handle of a hammer the\\nfriction of suspenders or waistband) are sufficient to cause the appear-\\nance of firm, tense, blebs at the site of the irritation. Such bulla?\\nvary in size from that of a small pea to that of a walnut. They\\noften last some days, having a firm roof-wall are usually more or\\nless painful, especially after rupture and disappear without leaving\\neither pigmentation or scar. The predisposition to the formation of\\nnew bulla?, however, remains indefinitely. In Bowen s case the bulla?\\nwere often hemorrhagic in type and were followed by pigmentation\\nand scarring.\\nHistological studies of the lesions have thrown little light on the\\n1 Jour. Cutan. and Gen. -Urin. Dis., Januarv, 1895; Ibid., 1899, p. 539; and N.\\nY. Med. Jour., April 21, 1900.\\n2 Brit. Jour, of Derm., 1897, p. 301. He gives a resume of all previously reported\\ncases.\\n3 Jour. Cutan. and Gen. -Urin. Dis., 1898, p. 253.\\n4 Cf. Kona, Arch. f. Derm. u. Syph., 1899, Bd. 1., S. 339; Russell, Jour. Cutan.\\nand Gen. -Urin. Dis., 1900, p. 405 and Colombini, II Morgagni, 1900, No. 10.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0448.jp2"}, "449": {"fulltext": "EPIDERMOLYSIS BULLOSA BEUEDlTARIA. 427\\netiology and pathology of the process. Elliott examined portions of\\napparently normal skin from one of his patients, and found in all the\\nsections a granular degeneration of the basal layer of rete-cells and fre-\\nquently of adjoining cells. The changes were most pronounced in the\\ninterpapillary portions. This condition permits a serous effusion to\\nseparate rapidly the rete from the papillary body and produce bullae.\\nElliott suggests that the disease is due to an excessive irritability of the\\ncutaneous vascular supply, which responds to such slight stimuli as\\nordinary friction of clothing. The lower rete-cells are in consequence\\nconstantly bathed in more or less serous transudation, and degeneration\\nresults.\\nNo treatment has been found capable of insuring relief.", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0449.jp2"}, "450": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0450.jp2"}, "451": {"fulltext": "", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0451.jp2"}, "452": {"fulltext": "PLATE VII,\\nPurpura Due to Copaiba.\\n(From a painting.)", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0452.jp2"}, "453": {"fulltext": "CLASS III.\\nHEMORRHAGES\\nPURPURA.\\n(Gr. iroptyvpcoz, purple.)\\nHemorrhage into the skin may result from undue intravascular\\npressure, as in violent effort with extraordinary demand upon the circu-\\nlatory system. It may occur with a normal intravascular pressure\\nwhen there is lessened extra vascular atmospheric pressure, as after ordi-\\nnary exertion in high altitudes. It may result from disease of the\\nvascular walls (as in malnutrition). It may result also from lack of\\nsupport of the vessels due to various disorders of perivascular tissues,\\nas where the epidermis is artificially removed, or where an abscess-cavity\\nis evacuated of pus and the sac immediately fills with blood. It may\\nbe due to traumatism of the vascular wall. The discolored patches\\nwhich result from contusions of the surface of the body are illustrations\\nof this condition.\\nPurpuric eruptions occur in many and varied constitutional condi-\\ntions. They are seen in the course of measles, scarlatina, variola,\\ntyphoid, and other specific fevers in septicaemia in toxaemias due to\\nthe iodides, bromides, copaiba, belladonna, quinine, and other drugs, or\\nto other articles against which the individual has an idiosyncrasy or\\nwhich he does not properly digest and assimilate in rheumatic and\\ngouty disorders in the cachexias of renal, tubercular, malignant, and\\nother diseases and in functional and organic disorders of the nervous\\nsystem.\\nIn short, purpura occurs in such a variety of conditions that it must\\nbe considered as a symptom of these conditions, and not as a distinct\\ndisease. Moreover, its relation to these constitutional disturbances is\\nnot well understood, and a satisfactory classification of the different\\nforms of purpura based upon their etiology or pathology is not possible.\\nAs a matter of convenience the cutaneous hemorrhages are grouped\\naccording to the predominating symptom into simple, rheumatic, and\\nhemorrhagic purpuras. These groups are not sharply divided, however,\\nbut merge the one into another.\\nSymptoms. The lesions of purpura have the following character-\\nistics in common They all are due to escape of blood into the tissues\\nthey do not fade under pressure they usually appear suddenly at first\\nthey are of a bright- or deep-red color, which in a few hours or days\\nchanges to the duller and darker shades of red, purple, and brown,\\n429", "height": "4251", "width": "2380", "jp2-path": "practicaltreatis00hyde_0453.jp2"}, "454": {"fulltext": "430 HEMORRHAGES.\\nwhich in turn, beginning at the centre, slowly fade through various\\nshades of brown, green, and yellow to the normal color of the skin.\\nOn the lower extremities the pigmentation sometimes persists for years.\\nAccording to their shape, size, and arrangement, the lesions of purpura\\nare designated as petechije which are pin-point- to small coin-sized,\\nusually well-defined macules, sometimes situated about the hair-follicles\\necchymoses, which are like petechia?, except that they are larger and\\nmore irregular in shape and in distribution, sometimes covering the\\nentire surface of a limb and vibices, which are linear and band-like\\narrangements of ecchymoses. Occasionally the hemorrhage takes the\\nform of bullae (bulljs hemorrhagica), or of nut- to egg-sized, and\\neven larger, tumors (ecchymomata). At times purpura is seen in the\\nform of minute papules. In addition to the clinical forms above\\ndescribed, purpura may appear as a complication and modification of\\nthe various lesions of erythema multiforme, urticaria, and other cuta-\\nneous diseases.\\nPurpura Pulicosa is the result of the traumatisms produced by\\nfleas, lice, and bugs. The lesions are punctiform and are due to the\\nwelling up of blood into the minute punctured wound, which is sur-\\nrounded usually by a hyperaemic halo, the result of the irritation.\\nWhen the areola fades the central hemorrhagic point usually persists\\nfor a brief time. The disease is characteristically manifested upon the\\nfilthy skins of individuals long bitten by bugs and covered with\\nexcoriations and dark-colored crusts the result of scratching. Such\\ncases are often pronounced scorbutic.\\nPurpura Simplex. In this form of cutaneous hemorrhage, pinhead-\\nto pea-sized, light-red to dark-purple petechia? and small ecchymoses,\\nusually multiple and symmetrical, a few at a time or suddenly in\\nlarge numbers, appear upon various portions of the body-surface,\\nchiefly over the lower extremities, and here doubtless by preference\\nbecause of the greater effect of gravity upon the column of blood. The\\nlesions usually awaken no subjective sensation, and they may occur in\\npersons of apparently unaltered health, though rigid examination will\\noften disclose some facts having a bearing upon the etiology of the dis-\\nease. The subjects of the disorder may be asthenic, and complain of\\nunwonted lassitude and malaise. The disease may last for a fortnight,\\nand in exceptional cases may be accompanied by a rise of temperature.\\nLesions of this sort may be due solely to an ingested medicament, such\\nas arsenic, salicylic acid, or quinine. The lower extremities may be\\ncovered completely with petechia? induced by ingestion of potassium\\niodide.\\nPurpura Urticans is that form in which there is an irritability of\\nthe skin sufficient to produce wheals and other urticarial lesions that\\nare accompanied by itching in various degrees and that have a pur-\\npuric hue in consequence of circumscribed cutaneous hemorrhage.\\nPurpura Rheumatica (Peliosis Eheumatica, Arthritic Pur-\\npura, Schonlein s Disease). This variety of purpura, which has\\na striking analogy to erythema multiforme, is probably an exaggerated\\nform of some of the conditions recognized under that title. It is pre-\\nceded by the usual febrile or other premonitory symptoms associated", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0454.jp2"}, "455": {"fulltext": "PURPURA. 431\\nwith arthritic pains, especially of the knees and ankles, which may\\nbecome swollen or be affected with a hydrarthrosis. In a few days\\npetechial to ecchyrnotic, light-red to dark-purplish maculations appear\\nupon the extremities, the trunk, or the entire surface of the body, fade-\\nless under pressure, and usually with coincident relief of the arthritic\\npain. The subjective sensations are ordinarily trivial. In a fortnight\\nthe eruption may subside, its color undergoing the usual variations\\nfrom greenish to orange and light yellow; but relapses are common in\\nthe course of weeks, with recrudescence of the fever, return of\\nrheumatoid symptoms, and progressive asthenia. The purpuric spots\\nsometimes make their appearance regularly in the afternoon or evening,\\nsometimes daily and often with several days interval, accompanied by\\npain, stiffness, and swelling of joints. The arthritic symptoms are\\nextremely variable and may be slight or severe. While most common\\nin the knees and ankles, they may appear in any joints of the body.\\nAssociated with the purpura and the arthritic symptoms there are often\\nmild or severe gastro-intestinal disturbances.\\nThere are thus, in the majority of cases, three groups of symptoms,\\nthe cutaneous, the arthritic, and the gastro-intestinal. It is rare, how-\\never, for these symptoms to be equally severe in any one case, one or two\\nI of the groups being usually but slightly or not at all apparent. Fre-\\nquently one group follows another. Thus, the arthritic pains may sub-\\nside before the appearance of the purpura, or the reverse may be true.\\nThroat-lesions, acute circumscribed oedema, and urticaria are often\\nseen with one or more of the groups of symptoms above described.\\nThe intimate relation of purpura rheumatica to erythema multiforme\\nj is discussed in the pages devoted to the latter disorder. Cases are\\ndescribed in which there was coincidence of purpura rheumatica with\\nrenal hemorrhage, albuminuria, and gangrene of the soft palate. Cases\\nj are also on record in which there were cardiac involvement and grave\\ndisorders of other viscera. In Hemophilia, a disease occasionally of\\nhereditary origin and characterized by the facility with which trivial\\ntraumatisms of the body-surface are followed by incoercible hemor-\\nrhages, purpura may be the first signal of the predisposition. A young\\nman with purpuric lesions of both lower extremities, but otherwise\\napparently in good health, presented himself at the dermatological\\nclinic. There was at the time no suspicion of haemophilia, but two\\nweeks later as the result of a vaccination he bled continuously for eight\\ndays.\\nThe disease occurs in both sexes, though more often in young\\nwomen, and it is to a certain extent influenced by the changes of climate\\nand season. Its diagnosis, in consequence of its marked characteristics,\\ni coincidence of petechias and ecchymoses with rheumatoid pains, is\\nreadily effected. Duhring calls attention to the danger of confounding\\nthe disease with the macular syphiloderm, the lesions of which, how-\\never, when relatively recent, fade under pressure.\\nThe prognosis is in general favorable, though the condition may\\npersist for long periods of time, and may, in rare cases, terminate\\nfatally. The final result depends naturally upon the constitutional\\naffection with which the purpura is associated.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0455.jp2"}, "456": {"fulltext": "432 HEMORRHAGES.\\nPurpura Hemorrhagica (Morbus Maculosus Werlhoffii\\nLand-scurvy This disorder is usually ushered in with phe-\\nnomena of a febrile character, accompanied by symptoms of general\\ndepression. Subsequently ecchymoses appear upon the extremities and\\nthe trunk, both spontaneously and at points at which the integument\\nhas specially been subjected to pressure and friction. Often petechia\\nappear simultaneously upon the nasal, laryngeal, buccal, aud other\\nmucous surfaces, which may also be the seat of exhausting hemor-\\nrhages, resulting rarely in fatal collapse. A symptomatic fever is\\nusually awakened. The disease occurs equally in the robust and the\\nfeeble of all ages, and, though commonly a sporadic affection, it may\\nassume an epidemic form. Purpura hemorrhagica is slow in its course,\\nbut, as a rule, terminates favorably after the lapse of several months.\\nIn some instances the general symptoms are those of typhoid fever and\\nhemorrhage from the mucous surfaces, including those of the stomach\\nand intestines, may be severe. In yet severer cases, to which the name\\nPurpura Fulminans is applied, the symptoms are those of septicaemia\\nor of other acute and severe infection. In these cases extensive internal\\nhemorrhage may be followed by death. Many of the severer cases of\\nhemorrhagic purpura are undoubtedly due to infections the exact nature\\nof which is not understood.\\nThe lesions commonly appear first on the upper extremities, then\\nover the trunk, and finally over the lower extremities. They are\\nusually dark red or purplish in hue, varying in size from that of a pin-\\nhead to that of a bean, but they may be of the size of the palm.\\nHemorrhagic purpura is distinguished from purpura scorbutica, or\\nscurvy, by the absence of distinctive premonitory symptoms of the\\nlatter disease which always occurs among those suffering from improper\\nalimentation, vitiated air, and lack of exercise.\\nPurpura Scorbutica (Scurvy). This disorder is peculiar to those\\nwho are compelled to subsist for lengthened periods of time on improper\\ndiet, more particularly that from which fruit and fresh vegetables are\\nexcluded; to respire vitiated air; and to endure such confinement as\\nprecludes the possibility of duly exercising the body. The disorder is,\\nhence, more common among sailors, prisoners, Arctic voyagers, and men\\nsimilarly situated.\\nThe cutaneous lesions are, as in so many other forms of purpura,\\npreceded by an almost characteristic sense of languor and depression.\\nOne or several joints may then enlarge. There may be a distinct\\nfebrile action.\\nThe hemorrhages which result resemble those of purpura hemor-\\nrhagica the cutaneous lesions are petechia, ecchymoses, and painful\\necchymomata, usually first appearing on the lower extremities, that\\nmay fluctuate, open, and result in offensive ulcerations reaching to the\\nbone. Simultaneously with the cutaneous eruptions the gums become\\ninvolved, showing tumid, hemorrhagic, or ulcerative fungosities,\\nsmeared with a dirty yellowish secretion, and having a fetid exhalation.\\nThe subcutaneous connective tissue, muscles, fasciae, and viscera become\\ninvolved. The disease is accompanied by febrile and other general\\nphenomena of asthenia, and, when the causes are persistent, results", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0456.jp2"}, "457": {"fulltext": "PURPURA. 433\\nfatally. It is, however, remediable by proper treatment, though con-\\nvalescence is usually tediously prolonged.\\nEtiology. It is evident that the causes of purpura must vary with\\nthe constitutional disturbances upon which it depends. Direct infection\\nis undoubtedly the cause of many hemorrhagic purpuras. Letzerich,\\nin 1889, recognized in the spots of purpura hsemorrhagica long bacilli,\\ncultures from which injected into rabbits produced a purpura with\\nstuffing of the hepatic capillaries by colonies of the same microorganism.\\nOther investigators have since found micrococci or bacilli in the lesions\\nof purpura hsemorrhagica or in the blood. These organisms have\\nbeen cultivated and the disease reproduced in rabbits, dogs, and\\nguinea-pigs by inoculations with pure cultures. The purpuras occur-\\nring in typhoid and other specific fevers are evidently due indirectly\\nto infection. Other purpuras are evidently toxic in origin, as in drug-\\ningestion (particularly after the administration of potassium iodide),\\nanaemia, cachexia, etc.\\nThe influence of the nervous system in the origin of many purpuras\\nis unquestionably important. Purpura may occur in the course of\\nvarious functional and organic disorders of the nervous system. It\\nhas followed severe neuralgia, over-exertion, sudden fright, a fit of\\nanger, and other violent emotions. By many authors the rheumatic\\npurpuras are considered neurotic in origin. Osier suggests that the\\npurpuras, together with urticaria, angioneurotic oedema, and erythema\\nmultiforme, may depend upon some poison an alkaloid, possibly\\nthe result of faulty chylopoietic metabolism, which in varying doses in\\ndifferent constitutions excites in one urticaria, in a second peliosis rheu-\\nmatica, and in a third a fatal form of purpura.\\nPathology. The hemorrhage occurs chiefly in the corium, but also\\nat times in the subcutaneous tissue. The corium shows collections of\\nred blood-corpuscles, and later variously sized granules of blood-pig-\\nj ment which is slowly absorbed, producing the color-changes character-\\nistic of purpura. The pigment may be wholly absorbed in a few weeks\\nor persist for years. Evidences of inflammation are present in some\\ncases, there being dilatation of the papillary vessels, with some oedema\\nand perivascular infiltration of leucocytes. In a few instances endo-\\nthelial proliferation and endarteritis have been noted.\\nWilson, Fox, and others have recognized lardaceous or inflammatory\\nchanges in the vascular walls, with embolism or thrombus in others.\\nWatson Cheyne l and others have found some of the capillaries in the\\nneighborhood of the hemorrhages plugged with bacilli, and colonies of\\nthe same in the effused blood. Leloir found in a single case coagulated\\nfibrin adhering to the walls of a number of vessels of the skin.\\nExaminations of the blood have shown irregular variations from\\nnormal in the number and form of the blood-cells and in the quantity\\nof fibrin. Micro-organisms have been found in many cases. These\\nexaminations, however, have not thrown much light on the pathology\\nof purpura.\\nTreatment. The treatment of these various forms of cutaneous\\n1 Brit. Med. Jour., September 1, 1883, p. 416.\\n28", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0457.jp2"}, "458": {"fulltext": "434 HEMORRHAGES.\\nhemorrhage depends upon the nature of the cause in each case. If\\nthis be found and removed, no other treatment may be necessary. In\\ngeneral it may be said that internally the use of ergot, of ferric chloride\\nor other salt of iron, and of quinine is advisable. Oil of turpentine,\\nplumbic acetate, and dilute sulphuric acid have all been employed at\\ntimes with marked success, at others without avail, in the treatment of\\nthese cases. Hypodermatic injections of ergotin, 1 part to 2 of dis-\\ntilled water, repeated every second day, have been followed by favor-\\nable and rapid results. A generous diet, the use of wine, malt liquors,\\nand even spirits, and a strict observance of the demands of hygiene,\\nare often essential methods of relief.\\nIn the way of local treatment the gums often require an application\\nof rhatany, 1 part of the extract to 50 or 60 of lotion or equal parts\\nof tincture of cinchona and tincture of myrrh, diluted as required.\\nRest in the recumbent position is advisable, and in severe cases is\\nimperative. If hemorrhage be actually in progress, the free use of\\nhaemostatics will be required, with local application of ice. For those\\nwho are convalescent from systemic disorders accompanied by purpuric\\nlesions of the lower extremities, resorption of the extravasated blood\\nmay be hastened by the local application of stimulating spirit-lotions\\nwith friction and the pressure of the blood-column may partly be\\nrelieved by elastic bandaging of the extremities.\\nThe Prognosis has been given, as far as might be, in connection\\nwith each disorder named.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0458.jp2"}, "459": {"fulltext": "CLASS IV.\\nHYPERTROPHIES.\\nLENTIGO.\\n(Lat. lens, a freckle.)\\n(Freckles, Ephelis. Ger., Sommersprosse.)\\nSymptomSo This condition is due to excessive and irregular de-\\nposit of pigment in the skin, producing the pin head- to bean-sized\\nspots of circinate or of irregular outline, frequently grouped and even\\nconfluent, which spots are commonly designated as freckles. They\\nare most frequently seen symmetrically distributed on those parts of\\nthe body ordinarily exposed to the light and heat of the sun and to at-\\nmospheric influences, such as the face, the neck, and the backs of the\\nhands in persons of both sexes. In those individuals whose bodies\\nare to a greater extent similarly exposed they occur upon the chest, the\\nback, and over the extremities. In other persons they may be seen\\nupon parts not thus exposed, such as the penis, the scrotum, and the\\ninner surfaces of the thighs, a fact which indicates that freckles are not\\nalways the result of the operation of the agencies noted above. They\\nvary in color from light yellow, salmon, or red to the deepest brown\\nand are most noticeable in those having red hair and a delicate skin.\\nFreckles occur rarely in infancy, partly, perhaps, on account of the\\ninfrequency of outdoor exposure in tender years. They are usually\\nseen first about the age of six to eight years. They are commonly\\nobserved in mulattoes, individuals of a race particularly disposed to\\nanomalies of pigment-distribution. Once developed, the lesions may\\npersist through life without marked alteration or may fade with each\\nrecurrence of the season of winter or in milder cases may disappear.\\nThey usually share in the atrophic changes of old age, and, when per-\\nsisting to that period, may then spontaneously disappear. They are\\nnot the source of subjective sensation.\\nEtiology. Freckles are unquestionably produced and aggravated\\nat times by the action of the light and heat of the sun, as common ex-\\nperience suggests but it is evident that these forces must act upon a\\nsusceptible skin. Of a hundred sailors exposed in precisely similar\\nsituations on a long cruise, some of the number will uniformly be\\ntanned and others deeply freckled. Attention has been called\\nto the occasional occurrence of lentigo in the protected parts of the\\nskin. Exposure to sea-air and fog, with obscuration of the sun, is suf-\\nficient to produce the result.\\n435", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0459.jp2"}, "460": {"fulltext": "436 HYPERTROPHIES.\\nPathology. Freckles are due to an increased deposit of pigment\\nin definite areas of the rete mucosum of the epidermis, never in the\\ncorium. The pigment accumulates densely in and about the prickle-\\ncells, which become apparently softer and lose their spines at a later\\nstage. Unna divides pigmentations of the skin into two classes\\nhemosiderosis (due to granules containing iron) and melanosis (due\\nto pigments in which the presence of iron has not been determined).\\nIn lentigo no iron-reaction has been recognized. Lassar urges, with\\nstrong probability, that there is always a congenital predisposition to\\nthese pigment-formations that requires certain external conditions for\\ndevelopment.\\nTreatment. The treatment of lentigines is that of chloasma and\\nother pigmentations of the surface. Wertheim, of Vienna, advises\\nR Hydrarg. ammon. muriat., gr. lvj 3 75\\nBismuth, magister., gr. lij 3 50\\nUngt. glycerini, Jj 30[ M.\\nSig. To be applied every other night.\\nBulkley employs\\nR Hydrarg. chlor. corros., gr. vj [4\\nAcid, acetic, dilut., f^ij; 8\\nBoracis, \u00c2\u00a3ij 2 66\\nAq. ros., f^iv; 120 M.\\nSig. To be applied night and morning, at first with gentle brushing after-\\nward by rubbing.\\nHardaway touches each freckle with a rather stiff needle connected\\nwith the negative pole of a galvanic battery, and he finds the results\\nsatisfactory.\\nMost of the methods employed by charlatans for the removal\\nof freckles depend for their success upon thorough blistering of the\\nsurface. Inasmuch as by this process the epidermis is removed, it is\\nevident that the pigment of its cells is also removed with it, and the\\nnew epidermis is for a time free from blemish. But in all such cases\\nthe ultimate result is a deeper and more persistent pigmentation than\\nthat which was previously visible.\\nCHLOASMA.\\n(Gr. ^Aoacw, to possess a greenish color.)\\nSymptoms. In this affection the skin is either diffusely discolored\\nin various shades, or the maculations occur in patches larger than\\nthose of lentigo, fairly well denned, and irregular in contour, the so-\\ncalled liver-spots. In color they vary from a scarcely perceptible\\nstaining of the skin that requires a strong light for its detection, to a\\ndeep-yellow, a yellowish-green, a chocolate-brown, or a blackish shade\\n(Melanoderma). They may be idiopathic or symptomatic in\\ncharacter.\\nThe idiopathic varieties of chloasma are produced by all externally\\noperating agencies, in consequence of which an undue afflux of blood", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0460.jp2"}, "461": {"fulltext": "CHLOASMA. 437\\nis persistently determined to any portion of the skin. It is largely\\nfrom the blood that the pigment is derived, hence the stains produced\\nby the pigment are, to a certain extent at least, proportioned to the\\nhyperemia, stasis, or extravasation of the vascular fluid. Among these\\nexternally operating agencies may be named pressure and friction (as\\nover the part covered by the pad of a truss) traumatism (as after the\\nsevere scratching of the skin affected with lice, eczema, or scabies)\\nheat (as in diffuse tanning of the face, or sunburn following\\nexposure to the solar rays) and the toxic or irritating effect of externally\\napplied substances, such as mustard, capsicum, cantharides, and other\\narticles capable of producing either vesication or pustulation of the\\nskin-surface. Persistent or even permanent pigmentation of the skin\\nupon the face, shoulders, and bosom, especially of young women, may\\nbe produced by the repeated application of such topical medicaments.\\nThe symptomatic varieties of chloasma are the result of disorders\\neither systemic or those involving the internal organs. They occur as\\neither circumscribed or diffused, localized or generalized, spots, mot-\\ntlings, stainings, or masks of the skin, and they vary in color from\\nthe lightest to the darkest shades. One of the most common, and at\\nthe same time the most marked of these varieties, is\\nChloasma Uterinum, so called because of its frequent association\\nwith certain physiological or pathological conditions of the uterus, both\\namong married and single women. Thus, in pregnancy, sterility, hys-\\nteria, chlorosis, ovarian disorders and tumors, and functional derange-\\nments of the uterus there can be observed at times a facial discoloration\\nextending equably over the forehead and reaching nearly to the line of\\nthe hairs at the scalp, in the form of a faint or a decidedly reddish-yellow\\nor deep-brownish tinge. At other times the discoloration is macular\\nand asymmetrical, involving the eyelids, the cheeks, the lips, or the\\nchin. When the chloasma assumes the mask-like form it is usually\\nmost pronounced over the forehead, but it may involve the whole facial\\nregion, being less distinctly defined below than above. Similarly, the\\nwell-known changes occur in the areola of the nipple, along the linea\\nalba, and about the external genitalia.\\nChloasma (or Melanoderma) Cachecticorum is another of the\\nsymptomatic pigment-disorders, characterized by changes in the color\\nof the integument of the subjects of tuberculosis, syphilis, cancer,\\nchronic alcoholism, malaria, and other disorders. Its hue varies between\\na faintly defined yellow to a deep chocolate.\\nAddison s Disease, formerly thought to be due exclusively to\\nlesions of the suprarenal capsules, is of the same nature, and is charac-\\nterized by a peculiar bronzing of the skin. Overbeck and Greenhow\\nhave shown that the capsules may be destroyed wholly without\\nchanges in the skin-color resulting. The pigmentation may be gen-\\neral or be partial, and in the latter case is without definite lines of\\ndemarcation. It is commonly most pronounced over the face and neck,\\nthe scrotum, the groins, the axilla, and the nipple and areola. The\\nhairs become coarse and dark and dark or grayish-brown patches are\\nat times visible over the mucous surface of the lips, the gums, and\\nother parts of the mouth. The bronze or mulatto-like color of the", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0461.jp2"}, "462": {"fulltext": "438 HYPERTROPHIES.\\nskin is intensified by stimulation or erosion of the cutaneous surface,\\nand by exposure to light. In these cases there are generally marked\\nasthenia and a feeble pulse, with anorexia and other signs of gastro-\\nintestinal disorder. When the result is fatal there may or may not be\\nrecognized pathological alterations of the suprarenal capsules.\\nThe pigment when examined furnishes no iron-reaction.\\nHadra, of Berlin, reports a case of Addison s disease cured by extir-\\npation of a small apple-sized tubercular neoplasm of the retroperitoneal\\nglands. A suprarenal capsule was contained in the growth. 1\\nAmong the cutaneous disorders capable of producing skin-pigmenta-\\ntion may be named scleroderma, lepra, angioma pigmentosum et atroph-\\nicum, eczema (especially e. venis varicosis), and general exfoliative\\ndermatitis.\\nFrom all the above-named discolorations, which are due solely to\\ndeposition in excess of coloring-matters normally existing in the skin,\\nit is necessary to distinguish the various dyschromia which are owing\\nto the introduction into the integument of coloring substances, either\\nsupplied by other portions of the body or foreign to it. Thus, in\\nIcterus the bile may color the skin from a light-yellow to a dark-\\nchrome shade, the duration and severity of the cutaneous symptoms\\ndepending upon the nature and gravity of the hepatic disease. This\\ncondition is frequently accompanied by pruritus in various grades of\\nseverity, the exact causes of which are obscure.\\nChloasma from Ingestion of Arsenic. The administration of\\narsenic in full doses for relief of nervous disorders in adults and chil-\\ndren is frequently followed by a characteristic dull-brownish or dirty-\\ncolored discoloration of the skin of the neck and chest. In connection\\nwith these arsenical pigmentations, which are in some instances obsti-\\nnate and generalized, may occur palmar or plantar keratoses, as well\\nas those appearing elsewhere, which may be the starting-point of an\\nepithelioma.\\nArgyria. A bluish, bluish-gray, slate-colored, or bronzed colora-\\ntion of the skin may result from ingestion of silver nitrate. Argyria\\nis most commonly the result of the administration of the drug in the\\ntreatment of epilepsy, but it is said to have also resulted from the topi-\\ncal application of silver-crayons to the throat, to the conjunctivae, and\\neven to the skin. Under what form the silver produces this effect,\\nwhether as an albuminate or other salt, is not known. The deposition,\\nhowever, occurs in the form of minute particles of the metal in the\\nconnective tissue of the derma. The discolorations are most evident\\nupon the parts of the skin exposed to the light, as the face and hands\\nbut the chest and the lower extremities may be similarly stained. The\\nconnective tissue of the viscera is at times also involved, showing thus\\nthat the action of light is not essential to the production of the dys-\\nchromia. Two cases are reported as relieved by the administration of\\npotassium iodide.\\nTattooing. By the process of tattooing mineral and vegetable\\nsubstances are directly introduced into the corium by means of needles,\\n1 Medical Week, Paris, Oct., 1896.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0462.jp2"}, "463": {"fulltext": "CHLOASMA. 439\\nfor the production in the skin of various devices in colors. Individuals\\nwhose entire integument has been thus artificially covered with figures\\nof different patterns by tattooing with indigo, vermilion, and cinnabar,\\nare from time to time publicly exhibited. The results are indelible.\\nPost mortem these pigments have been discovered not only in the\\nderma, but also in the lymphatic ganglia nearest the site of their\\nintroduction.\\nAnomalous Discoloration of the Skin and the Mucous\\nMembranes. Bruce 1 describes the case of a harness-maker, the gen-\\neral surface of whose body, especially the skin of the face and of the\\nextremities, as well as the mucous surfaces, underwent a noteworthy\\nchange of color. The hue acquired was a deep and uniform cyanotic\\nshade. The symptoms in this case are believed by some to have resulted\\nfrom the employment of nitrate of silver.\\nPathology. The lentigines, ephelides, and chloasmata are all due\\nto excessive deposit of the natural pigment of the body in the rete\\nmusosum of the epidermis. Restoration of the normal color of the\\nskin is usually proportioned to the extent and depth of the deposit,\\nbut the process is always very gradual. It can well be studied in the\\nslow bleaching of the pigmentation of syphilitic cicatrices upon the\\nlower extremities. In the dyschromias due to the introduction of\\ncoloring-matters foreign to the body or foreign to the skin the corium\\nand the subcutaneous connective tissue are commonly stained.\\nThe origin of the pigment in the skin being still undetermined,\\npathologists are unsettled as to the question whether migratory pigment-\\nconveying cells are responsible for the change of color in the skin or\\nwhether the pigment-granules themselves migrate. Kaposi, Jarisch,\\nand a few others believe that pigment is formed in the rete. Unna\\nbelieves there are two distinct kinds of pigment, not however fully\\ndifferentiated, formed in the corium and carried through the lymphatic\\nspaces to the rete. Ehrmann, 2 after much careful investigation, states\\nthat there are special pigment-cells, or melanoblasts, which are formed\\nin the embryo from the mesoderm. These cells perpetuate themselves,\\nbeing thus independent of all other bodies, and are connected by long\\nprocesses or threads of protoplasm, along which the pigment flows in a\\nviscous state. The cells obtain their pigment from the haemoglobin of\\nthe blood. All pigment outside of these cells he considers hsematin-\\ndetritus. In some of these cases there is no change in the walls of the\\nblood-vessels and there are no signs of blood-extravasation.\\nDiagnosis. The diagnosis of cutaneous pigment-hypertrophies is\\nreadily effected by observing the persistence of the discoloration under\\npressure; the absence of all symptoms of hyperemia, inflammation,\\nand secondary changes in the skin, as also by the characteristic shades\\nof color presented to the eye. In tinea versicolor there is usually\\nslight furfuraceous desquamation, and the existence of a vegetable par-\\nasite is readily demonstrated by the microscope. The rare pigmentary\\nsyphilide is usually seen upon the neck and shoulders of infected women\\n1 Internat. Atlas of Rare Skin-diseases, 1892, vol. vi., 2 and 7.\\n2 Bibliotheca Medica D. II., Part VI., W. G. Fisher Co.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0463.jp2"}, "464": {"fulltext": "440\\nIIYPERTR OPHIES.\\nin the form of yellowish to brownish maculations, often arranged in an\\nirregular network. The lesion is, indeed, one of the symptomatic\\nchloasmata.\\nTreatment. In all the symptomatic pigment-anomalies the indi-\\ncations for treatment are presented by the disease which begets the\\ncutaneous disorder.\\nThe local treatment of both the idiopathic and symptomatic varieties\\nof the affection demands the use of external applications which will\\nhasten the physiological reproduction of the epidermis, substituting thus\\nnew and unpigmented for old and pigmented epithelia. This process\\nmust also be accomplished without the artificial production of such an\\nhyperemia as will tend to add to the very coloration which it is\\nattempted to relieve. The substances used for the slow accomplish-\\nment of this end are borax, sulphur, tincture of iodine, potassium and\\nsodium hydroxides (including the soaps of these alkalies), and the mer-\\ncurials. None of these substances is more generally employed than\\ncorrosive sublimate, which constitutes the basis of most of the cosmetic\\nlotions sold in the shops.\\nThe following formulae are given by White 1 for use in the evening.\\nThe preparation in each case should be left upon the affected surface\\nduring the night, and be removed by a soap-and-water washing in the\\nmorning. They are to be used for weeks in succession, but only after\\na cautious preliminary testing of the sensitiveness of the skin to their\\naction. To avoid the possibility of error, the practitioner would do\\nwell to order a poison-label upon all vials containing the sublimate\\nR Hydrarg. am. chlor.,\\nBismuth, magister.\\nAmyl.,\\nGlycerin.\\naa 3ij\\naa ^ss;\\naa 8\\naa 15\\nM.\\nR Ammon. murat.,\\nAq. Colognien.,\\nAq. dest.,\\nR Hydrarg. bichlorid.,\\nAcid. mur. dil.,\\nGlycerin.,\\nAlcoholis,\\nAq. ros., J\\nAq. dest.,\\n3ss;\\nOss;\\ngr. vj;\\nfSi;\\nfBJ;\\naa f gij\\nfgiy:\\n2\\n30\\n240\\n4\\n30\\nM.\\naa 60\\n120\\nM.\\nThe following formulae for ointments are given by Kaposi\\nR Hydrarg. ammon.,\\nSodse biborat.,\\n01. rosmarin.,\\nUngent. simpl.,\\nR Acid, boric,\\nCer. albse., j\\nParaffin.,\\n01. amygd. chile,\\naa \u00c2\u00a7ss;\\ngtts. x\\n5j;\\naa 3j;\\n3ij;\\n3j;\\naa 15\\n30\\naa 4\\n6Q\\nM.\\n8\\n30 M.\\n1 Lot. cit.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0464.jp2"}, "465": {"fulltext": "CHLOASMA. 441\\nVan Harlingen recommends\\nR Hydrarg. chlor. corros., gr. vss\\nZinci sulphatis, 2\\nPlumbi subacetat., J aa^ss, aa a\\nAq. dest.. fSiv; 120 M.\\nSig. Lotion, for external use, morning and evening.\\nOther measures advised are stimulation with alcohol, and applica-\\ntion, for several hours after, of a plaster of ammoniated mercury; 2\\nparts of magnesium carbonate and zinc oxide, 4 parts of pure kaolin\\nand glycerin, and 10 of vaselin; chloroform, 100 parts, chrysarobin,\\n15 parts (Leloir); hydrogen peroxide; diluted acetic, carbolic, muriatic,\\nand nitric acids; 1 to 2 parts of salicylic acid, in paste or powder, to\\n20 parts of base; and solutions of mercuric chloride in collodion, 1 part\\nto 30, employed with great caution.\\nThe rapid removal of pigmented patches is accomplished, in Vienna,\\nby covering the part with strips of linen dipped in an aqueous or an\\nalcoholic solution of corrosive sublimate of the strength of 4 grains\\n(0.26) to the ounce (30.), with which solution the dressing is also occa-\\nsionally moistened. Vesiculation is usually accomplished in about four\\nhours, when the serum is evacuated by puncture, and the detached epi-\\ndermis is covered with any inert dusting-powder. The resulting crusts\\nfall in about eight days. The procedure is attended with danger of\\nproducing in the end the precise deformity which it seeks to remedy, a\\ndanger explained above.\\nAnother method of removing tattoo-marks and pigmented nsevi,\\nsuccessfully employed by French dermatologists, consists in tattooing\\nthe region, previously rendered aseptic, with a solution of 30 parts of\\nzinc chloride to 40 parts of water. If properly done, the resulting\\ninflammation is slight, and after a few days there forms a superficial\\ncrust which remains about a week and then falls, leaving a slight scar\\nwhich becomes almost imperceptible. This method calls for skill and\\ncare in its application in order to obtain good results and to avoid sup-\\npuration and deep cicatrization.\\nThe internal administration of potassium iodide, recommended for\\nthe removal of argyria, has often failed.\\nPrognosis. The prognosis is in all cases uncertain. There is\\nstrong reason to believe that the local treatment of these dyschromias\\nis, in the long run, ineffective. Those methods which effectually and\\nbrilliantly accomplish the desired end are almost invariably followed\\nby deeper pigmentation than that which it was attempted to remove\\nthose operating more slowly have, probably, a less speedy, but scarcely\\nmore disguised sequel. It is likely that local treatment of these pig-\\nmented states will ere long be abandoned. The treatment intelligently\\ndirected to the cause of each discoloration is that which in the end\\nproves most satisfactory.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0465.jp2"}, "466": {"fulltext": "442 HYPERTROPHIES.\\nKERATOSIS.\\n(Gr. icepag, a horn.)\\nThe term Keratosis was first applied by Lebert to hypertrophic\\nlesions of the epidermis. It has since been made to include changes\\nin both the epidermis and the corium, and it is employed by some\\nauthors in a generic sense to embrace a number of both localized and\\ngeneral hypertrophies of these portions of the skin.\\nKERATOSIS PILARIS.\\n(Lichen Pilaris, Pityriasis Pilaris.)\\nSymptoms. This condition may be a mere temporary functional\\ndisturbance of the skin, awakening no subjective sensation, inappreci-\\nable by the patient and apparent only to the careful observer, or it\\nmay constitute a disease. Its symptoms are the occurrence of pinhead-\\nsized, pointed elevations of the skin-surface that may be described as\\npapules, though, strictly speaking, they are not such, but are consti-\\ntuted by an accumulation of horny epithelia and a small quantity of\\ninspissated sebum about the lanugo-hairs of the extensor surfaces of\\nthe extremities and trunk. These aggregations of material are usually\\nof a dirty-whitish or grayish hue, and are pierced by a lanugo-hair\\nimplanted in the follicle about which the abnormal condition exists.\\nOccasionally, however, the hairs are of the finer and shorter kind, and\\nare often coiled in or otherwise covered by the little heaps of epithelial\\ndebris. The skin of the individual thus affected is generally harsh,\\nsquamous, and dry to the touch being also, in the majority of cases,\\nlong unwashed. The color of the quasi-papules differs also with the\\ncomplexion of the individual at times the papules have a distinctly\\nreddish tinge, and they are often surmounted by a scale.\\nKeratosis of this type can scarcely be described as a morbid state.\\nThose who seek treatment for it are readily divided into two classes\\nfirst, comely young women desiring to exhibit bare arms in evening\\ntoilet second, young men suffering from the delusion that they are vic-\\ntims of a disease of the blood or of syphilis. Viewed as a whole,\\nthe subjects of the best types of this so-called disease are men and\\nwomen of exceeding vigor, with firm, well-developed muscles and\\nshapely limbs.\\nKeratosis pilaris is common in skins long uncleansed by ablution,\\nand this condition can thus be produced artificially. In some individ-\\nuals it persists for long periods of time, and awakens no concern. In\\nothers, especially in children, it speedily becomes the source of pruritus,\\nand each lichenoid papule may then be transformed into an urticarial\\nwheal, with distinct and sometimes very annoying pricking and ting-\\nling sensations, the trouble being at once relieved by a bath in warm\\nwater with soap. In still other individuals, especially in adults, an\\nexaggerated form of the disease can be recognized, the skin presenting\\na roughness to the touch suggestive of the surface of a nutmeg-grater,\\nand exhibiting numerous fine, conical, grayish, horn-tipped filaments,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0466.jp2"}, "467": {"fulltext": "KERATOSIS. 443\\nwhich several dermatologists are disposed to regard as a form of ich-\\nthyosis. Id the latter case there is doubtless a true hypertrophy of\\nthe epidermis. In the former case there is scarcely more than a me-\\nchanical accumulation of effete organic material. There can be little\\ndoubt that the malady, simple though it be in character at the onset,\\nmay become the first stage of a series of chronic cutaneous disorders.\\nTilbury Fox has reported four cases, in which the disease was well\\nmarked, under the title of Cacotrophia Folliculorum, this name\\nbeing employed to designate its peculiarities as to wide distribution\\nover the body, its implication of the deeper portion of the follicles, and\\nits congenital history. In these cases the reddish tint of the lesions is\\ndistinctly shown.\\nBrocq, who devotes an extensive chapter to this affection, describes\\na white variety, the uncolored circumpilary papules being scattered\\nover the arms, forearms, legs, and thighs, usually on the outer faces of\\nthe extremities, and three inflammatory types (a) a mild form, in\\nwhich reddish papules are disseminated among those of the white\\nclass (b) a form of medium intensity, in which the papules are gener-\\nerally rosy-red in hue (c) an intense form, in which well-marked\\nlesions occur over the surface of the chest, the lumbar and pubic re-\\ngions, and the folds of the larger articulations.\\nKeratosis pilaris on the face, as described by French writers, is\\ncharacterized by exceedingly minute, usually conical, occasionally obtuse\\npapules (each pierced by a fine hair) that develop over the brow, about\\nthe eyebrows, over the cheeks, and the inframaxillary region.\\nEtiology. Puberty and uncleanliness have been assigned as causes\\nof the disorder both conditions may in some patients be indirectly\\neffective. In certain individuals the condition seems to follow a pro-\\nlonged course of arsenic. The disease is seen frequently in persons\\nhaving peculiarly thick, coarse, usually dark-colored skins, and also\\npossessing marked muscular vigor and unusual development of most of\\nthe other bodily tissues. In brief, the disorder seems to be due often\\nto marked inherited predisposition in persons of vigorous constitution.\\nThe varieties of keratosis pilaris seen in cachectic hospital-patients, and\\nin persons who have aggravated the disease by inducing a medicamentous\\nrash upon the person, belong to a different category. Patients in the\\ntwo classes last named may be so perfectly relieved that there is no\\npredisposition to a return of the disorder, a relief not always to be\\nsecured by the others.\\nPathology. Keratosis pilaris is produced by accumulation of the\\ncells of the horny layer of the epidermis and sebaceous material about\\nthe orifices of the hair-follicles. In some cases the result is an irrita-\\ntion which produces a mild grade of chronic inflammation of the peri-\\nglandular tissue. Giovanni in twelve cases examined found atrophy\\nof the hair-papillse. Entire absence of sebaceous glands in three-fifths\\nof his cases, and very marked atrophy in the remainder, were noted\\nalso. Necrosis of the outer end of the arrectores pilorum was observed\\nin a few instances.\\nDiagnosis. The disease should readily be recognized by the pecu-\\nliarities of its seat, its course, and the nature of its symptoms. From", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0467.jp2"}, "468": {"fulltext": "444 HYPERTROPHIES.\\nichthyosis it can be distinguished by the limitation of its lesions to\\nthe orifice of the hair-follicle from the transitory condition known as\\ngoose-flesh by its persistence after the surface of the skin is thor-\\noughly warmed from papular eczema and the other lichenoid erup-\\ntions by the relatively insignificant character of the lesions, their evi-\\ndent follicular origin, and either the entire absence, or mild chronic\\ntype, of inflammatory symptoms.\\nThe disease is to be carefully differentiated from pityriasis rubra\\npilaris, in which the characteristic disorder of the scalp, the appearance\\nof plaques of disease covered with fine pityriasic scales (often upon the\\ntip of the nose and chin), exhibiting a peculiarly dark, smirched appear-\\nance, the affection of the nails, the characteristic papulae on the dorsal\\nsurfaces of the first and second phalanges of the fingers, and the evident\\nadmixture of the disease with symptoms of seborrheic type, suffice to\\ndetermine its nature.\\nThough the lesions of keratosis pilaris bear little resemblance to\\nthe papular syphilodermata, many male patients for years swallow\\nmedicaments for relief of a supposed syphilis the sole symptom of\\nwhich is a keratosis pilaris. The papular syphilodermata are not per-\\nsistent year after year, are not throughout symmetrical, and are not\\nlimited largely to the outer faces of the limbs, especially of the thighs.\\nThey are preceded by a history of infection, and invariably are accom-\\npanied by some other manifestations of the disease. They are not\\nlimited to the orifices of the hair-follicles, and are not capped by the\\npeculiar horny scaling tip of the papule of keratosis pilaris.\\nCrocker describes a Lichen Pilaris which he considers distinct\\nfrom keratosis pilaris, as in the former the follicular elevations are\\nmore pronounced and resemble spines, there is usually evidence of\\ninflammation, and the eruption tends to occur in patches instead of\\nbeing diffuse.\\nTreatment. For the subjects of this disorder in its typical forms\\nit is not sufficient merely to order a bath. The bathing should be\\nconducted systematically for years at a time.\\nAs soon as it can well be tolerated the patient should be urged to\\nbathe the entire surface of the body every morning by the use of the\\nsponge and cold fresh or salt water, following this with brisk fric-\\ntion with a coarse towel or a flesh-brush. The habitual use of this\\ncold bath continued daily for years, in persons who can tolerate it\\n(and patients affected with keratosis pilaris are usually of this class),\\naccomplishes results of the most satisfactory character, exerting, as\\nit does, a profound influence on the nutrition and healthfulness of\\nthe skin.\\nFor immediate treatment of the most of these cases, however, the\\nhot bath with soap is desirable. This bath may be repeated as often\\nas required to remove the lesions, and be followed in the more urgent\\ncases by inunction with lanolin-pomades, or the fats or oils. Salicylic\\nacid, 1 to 10 per cent, in oils or ointments, is effective in removing\\ntemporarily the horny accumulations. In the congenital and severe\\ntypes, such as those -described by Fox, cod-liver oil internally should\\nbe ordered.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0468.jp2"}, "469": {"fulltext": "KERATOSIS. 445\\nKERATOSIS SENILIS.\\nThe skin of the aged may become harsh, dry, and unusually corni-\\nfied either diffusely or in certain definite regions, such as the hands,\\nfeet, or extremities this may be regarded as the simplest form of\\nkeratosis senilis. The skin of the entire body or of the region affected\\nis then dark in color, dry to the touch, occasionally covered with fine,\\nrather adherent scales, representing merely attached and cornified cells\\nof the horny layer of epidermis, and notably unprovided with the natu-\\nral unguent of the skin.\\nIn a more advanced grade the skin undergoes changes closely allied\\nto epithelioma often, indeed, these both furnish the first symptoms of\\nepithelioma and coexist with its gravest destructive effects. The skin,\\nmore commonly of the face, the hands, or the forearms, less often of\\nthe feet, the legs, and the genital regions of the aged, is covered with\\nthin, horny, often greasy-looking, pinhead- to nail-sized and larger,\\ndark-yellowish plates or scales, between which the integument that has\\nundergone the atrophic changes in the senile skin is visible. Pig-\\nmented puncta and macules may also appear scattered irregularly over\\nthe surface, with rough, dirty-yellowish to dark-brownish granular\\naccumulations upon the skin of certain regions, such as the clefts beside\\nthe alse of the nose, the temples, etc. The appearance is suggestive\\nin some cases of a seborrhcea sicca of the face. In many patients\\nexhibiting these features a fully developed papillomatous, superficial,\\nor deep epithelioma may be present. In other patients one or more\\nvarieties of the senile wart may be visible, as described in the chapter\\non Verruca.\\nViewing the subject of senile keratosis in the light of the knowledge\\nhad upon the subject to-day, it must be admitted that the boundary-lines\\nbetween it and epithelioma are not well established. Unquestionably\\nthe exaggerated lesions of the former affection are frequently the first\\nstages of the latter disease, and in the treatment of the skin of the\\naged, conducted on the general principles already set forth, the physi-\\ncian should never lose sight of possibly serious consequences in one or\\nmore regions of the skin affected.\\nKERATOSIS FOLLICULARIS.\\n(Psorospermosis, Psorospermose folliculaire vegetante, Ich-\\nthyosis FOLLICULARIS, ACNE SEBACEE CORNEE, DARIER s\\nDisease.)\\nIn 1889 Darier l and Thibault in France White in America and\\nlater, Wickham, 2 Neisser, and others, called attention to a cutaneous\\ndisorder not previously distinguished from other maladies. Between\\ntwenty and thirty instances have been recorded. In reporting a new case\\nBo wen 3 gives a brief summary of the clinical and pathological charac-\\nteristics of the disease as described by other observers.\\n1 Annal. de Derm, et de Syph., July, 1889.\\n5 Contribution a 1 Etude des Psorospermoses Cutan^es. Paris, 1890.\\n8 Jour. Cutan. and Gen.-Urin. Dis., June, 1896.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0469.jp2"}, "470": {"fulltext": "446 HYPERTROPHIES.\\nIn the few cases reported the eruption displayed was practically\\ngeneralized, and was exhibited in greatest abundance over the limbs, the\\nfront of the chest, the inguinal and genital regions, the scalp, the face,\\nand the loins. The first lesions were firm, pinhead-sized papules, scarcely\\ndifferent in color from that of the surrounding integument, which later\\nassumed a deeper hue, and, whether flattened or hemispherical, these\\npapules were soon covered with a grayish or brownish crust, greasy to\\nthe touch and apparently prolonged into depressions beneath, much as\\nthe crust of seborrhoea sicca of the face is sunk within the orifices of\\nthe sebaceous follicles. The papules, as they increased in size and age,\\nbecame darker in hue until eventually they were a deep brown and red,\\nor even purple. A few exhibited scratch-marks and were covered with\\nhemorrhagic crusts.\\nOver the scalp the symptoms are practically those of the crusting\\nforms of seborrhoea, save that there is no tendency to loss of hair.\\nOver the face the parts chiefly involved are the temples, the inside of\\nthe concha of the ears, and the folds about the nose and lips. Here,\\nas over the parts of the trunk named above, form dark, even blackish,\\nstrata of dirty oil-crusts, spontaneously shed. Beneath each crust, as\\nindicated above, there is usually a conical spur let into an infundibular\\ndepression, the latter representing the patulous orifice of a pilo-seba-\\nceous gland. Over the backs of the hand and fingers the papules and\\ncrusts are less numerous, but the papules are closely set together and\\ntend to coalesce. In the palms and soles are numerous almost imper-\\nceptible lesions of the same type. As the disease advances to what\\nhas been described as a second stage the papules coalesce, forming\\nsmall tumors and papillomatous growths, which involve not only the\\nfollicles, but also the interfollicular tissues. Many of the follicles\\nbecome the sites of superficial ulcers, while the whole of the vegetating\\nmass is bathed in a more or less abundant, fluid, muco-purulent secre-\\ntion. The subjects of the malady often emit an offensive odor.\\nThe disease progresses gradually until large portions of the body\\nare covered. Occasionally exacerbation with rapid spreading of the\\nlesions occurs but, as a rule, the course of the affection is slow and\\nthe general health of the patient does not seem to suffer except sec-\\nondarily from the presence of ulcerating and suppurating lesions of\\nthe skin.\\nEtiology. Little is known definitely regarding the etiology of\\nkeratosis follicularis. In the majority of cases recorded it began in\\nchildhood, and in several instances in early infancy. Of twenty cases\\ncollected, thirteen were in males and seven in females.\\nThe theory first advanced by Darier, and later elaborated by Wick-\\nham and others, that this variety of keratosis, and probably also\\nPaget s disease, some superficial forms of epithelioma, and molluscum\\ncontagiosum, were due to the presence of psorosperms or coccidia?,\\nhas been abandoned even by its propounders. As a result of further\\nstudy by Bowen, Buzzi, Miethke, Boeck, Darier, and others, these\\nbodies, which closely resemble certain psorosperms, have been demon-\\nstrated to be produced by cell-transformation.\\nWhite s cases were in father and daughter, while Boeck had three", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0470.jp2"}, "471": {"fulltext": "KERATOSIS. 447\\ncases in one family. It is possible that contagion or heredity may have\\nan influence in the production of the malady.\\nPathology. The disease seems to be primarily a kyperkeratosis\\ninvolving the sebaceous follicles and the hair-follicles. The process is\\nconfined for the most part to the neck of the follicle, but in the later\\nstages it extends to the interfollicular tissues. The mouths of the pilo-\\nsebaceous ducts are dilated into funnel-shaped openings and packed\\nwith masses of horny cells produced by the hyperkeratosis. Boeck\\nand a few other observers believe, however, that the process is not\\nessentially follicular, but that it may begin outside the ducts.\\nThe rete is usually thickened and in the later stages of the disease\\nthe interpapillary processes are prolonged. Mitoses are numerous,\\nand in the lower layers of the rete are found fissures or lacunae, the\\nexact significance of which is not yet determined. In places the pres-\\nsure of the horny masses may produce thinning and atrophy of the\\nrete. About the borders of the lesions there is an abundant pigment-\\ndeposit in both the epidermis and in the corium. The only other\\nchange noted in the corium is a small amount of cellular infiltration.\\nThe glands of the skin are unaltered.\\nThe round bodies formerly supposed to be psorosperms are found in\\nthe deeper and middle layers of the rete, and at the base of the horny\\nplug filling the follicle. According to Bowen, they are swollen cells\\ncontaining a nucleus which stains deeply, and which is surrounded by\\na clear or hyaline ring of protoplasm, outside of which is a zone con-\\ntaining granules of keratohyalin, the whole being surrounded by a\\nhomogeneous, glistening membrane, which may possess a double\\ncontour. Various modifications of this type are found as a result of\\nirregular keratinization of the cells. In the upper layers, in which\\nthe process of cornification is advancing, the keratohyalin gradually\\ndisappears; but it may do so irregularly, and, losing its granular\\nappearance, may give rise to appearances closely simulating nuclei and\\nnucleoli. In the upper layers also the outer membrane may contract\\nor disappear, leaving an empty space. At the bottom of the horny\\nmass in the follicle the stratum granulosum is frequently absent, and\\nthere are seen irregular, shrunken, homogeneous cells with nuclei which\\nstain but feebly. These cells are the grains of Darier, and Bowen\\nbelieves they are cells which have become cornified without passing\\nthrough the keratohyalin stage.\\nDiagnosis. The disease is to be differentiated from moll u scum\\nepitheliale, which is never so generalized, and which always exhibits\\nan enucleable mass containing the so-called molluscous bodies.\\nThe papular forms of acne are eruptive elements which contain\\ncentrally a true corneous mass in keratosis follicularis there is a\\nsoftish comedo-like central mass. The acne-forms, further, are not\\ngeneralized. The disease bears close resemblance to some forms of\\nichthyosis, but a careful study of the history, the character, and location\\nof the lesions will usually make the diagnosis clear.\\nTreatment. So few cases of the disease have been observed that\\nthe treatment is still undetermined. While marked improvement may\\nbe obtained, no complete recovery has been reported, and with a lapse", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0471.jp2"}, "472": {"fulltext": "448 HYPERTROPHIES.\\nin treatment the unfavorable condition of the patient quickly returns.\\nThe parts are to be well cleansed by shampooings, and then dusted\\nwith borated, salicylated, and absorbent powders. The French, acting\\nupon the parasitic theory of the nature of the affection, vigorously\\nemploy parasiticides, salves containing pyrogallol or iodoform, and even\\nresort to cauterizations with zinc chloride.\\nKERATODERMIA PALMARIS ET PLANTARIS.\\n(Symmetrical Keratodermia of the Extremities, Congenital\\nKeratoma of the Palms and Soles, Ichthyosis Palmaris\\net Plantaris.)\\nA symmetrical and well-marked thickening of the palmar and\\nplantar epidermis occurs as a result of several effective causes to which\\nspecial attention has been directed, in France by Besnier and Doyon\\nin Germany by Unna and in the United States by one of the authors l\\nof this treatise in a communication, in 1887, to the American Dermato-\\nlogical Association.\\nSymptoms. Four varieties have been identified\\nIn the first variety there is symmetrical thickening of the palms\\nand soles, strictly congenital, in cases hereditary, and accompanied or\\nnot by nsevi situated upon other regions of the body. The epidermis\\nof the involved areas is greatly thickened and a delicate erythematous\\nhalo extends beyond the border of the keratosis. The latter condition\\noccasionally sweeps beyond the palmar and plantar regions to the dorsum\\nof the affected fingers, toes, hands, or feet. The nails, the teeth, and\\nthe hair are not involved.\\nThe second group includes the more common variety of symmetrical\\nkeratodermia of the extremities, erythematous in type and possibly\\nassociated with a central neurosis. Here the epidermal thickening is\\nexaggerated over the points of special pressure, though occurring inde-\\npendently of such agency, a fact well illustrated in a case in which the\\nthickening at times developed while the patient was for months\\nreclining in a hospital-bed. The disorder is worse in winter. There\\nare the usual hypersemic zone at the border-line of the keratosis, and a\\ngreat distinctness of definition of the latter with perfectly sound skin\\nbetween the islets of epidermis sclerosed at the points of pressure.\\nThere are usually a coincident hyperidrosis, and dislocation of and\\nstructural change in the nails. The keratinized sole or palm sheds its\\nhorny envelope either as a result of treatment or spontaneously and\\neven in the most pronounced cases the disorder may disappear.\\nIn a third form there are foci in which the keratosis is declared in\\nmultiple isolated points over the palmar and plantar regions, always\\nindependently of pressure and contact, due to a central trophoneurosis.\\nThe remote cause in some cases is the long-continued ingestion of\\narsenic. In a subvariety the orifices of the sweat-pores are distended\\nwith corneous plugs, resembling comedones, with concentric lamellations.\\nA fourth variety is a partial, entirely curable, and accidental kerato-\\n1 Observations on Three Cases of Symmetrical Hand and Foot Disease, Med.\\nNews, Oct. 8, 1887.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0472.jp2"}, "473": {"fulltext": "IPLATE^VIII.\\nKeratosis Punctata in a Man who had been taking\\nArsenic for a long-standing Psoriasis.\\n(From a photograph.)", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0473.jp2"}, "474": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0474.jp2"}, "475": {"fulltext": "", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0475.jp2"}, "476": {"fulltext": "PLATE IX\\nPalmar Keratosis, due to Arsenic.\\n(From a photograph.)", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0476.jp2"}, "477": {"fulltext": "ANGIOKERATOMA. 449\\ndermia of the extremities that is not to be confounded with the callosities\\ndescribed in another chapter. This form occurs at any age under the\\ninfluence of pressure to which the limbs are unaccustomed.\\nThe Diagnosis of all forms of keratosis of the palms and soles is\\nto be made from eczema, chiefly by reason of the absence of well-\\nmarked inflammatory symptoms, of vesicles, and of eczematous patches\\nin other regions of the body. Palmar and plantar syphilides are to be\\ndistinguished with great caution. These last may be asymmetrical,\\nespecially if of late type may exist where there is often a history\\nof infection or signs of lues and may often ulcerate. They have also\\nwell-defined circinate borders and the lesions are more often multiple\\nand isolated.\\nTreatment. Internal treatment is by the methods employed in\\npsoriasiform affections. Brocq advises the internal administration of\\nsodium arseniate in large doses but in this connection it should be\\nremembered that cases are reported in which keratosis of the palms\\nand soles has apparently been produced by a long course of arsenic.\\nThe local treatment is by prolonged maceration of the parts, followed\\nby shampooings with green soap in substance or tincture, followed by\\nsalicylated pastes, plasters, or solutions of salicylic acid in collodion.\\nMercurial plasters and mercuric oleates may also be used Avith advantage.\\nPotassium hydroxide in 10 to 20 per cent, strength has been applied as\\na lotion to stimulate the surface. Other formulae recommended are\\nsalicylic acid and calomel, 1 part of each to 20 parts of glycerole of\\nstarch and 1 part each of resorcin, tartaric acid, and salicylic acid, to\\n20 or 30 parts of the salve-basis.\\nANGIOKERATOMA.\\n(Keeatoangioma.)\\nThis disorder was first described in 1889 by Mibelli; 1 later, cases\\nof a similar character though differing in many details have been re-\\nported by Thibierge, Crocker, Zeisler, Pringle, Joseph, Fordyce, Cottle,\\nand others. The cases are rare and they apparently occur with wide\\ndivergence of type.\\nSymptoms. The lesions may be first recognized upon the hands,\\nwhere they resemble ordinary perniones, and are seated on the dorsal\\naspect of the fingers, especially of individuals who are much exposed\\nto low temperatures or who handle cold substances in the trades, as,\\nfor example, those who dress cold beef in winter. Both the palms and\\nthe soles may be invaded. We have had under observation a typical\\ncase in which the lesions existed exclusively on the scrotum. Other\\ninstances of angiokeratoma of the scrotum are on record by Fordyce\\nand others. Here, as over other regions of the body involved, the\\nlesions may be commingled pinhead-sized and larger, translucent,\\nhorny-capped, roundish warts, tumors, or nodules, dull purplish in\\ncolor, leaden-hued, or even chocolate-tinted, interspersed with flat\\nmacules (split-pea-sized for the most part, having a dark central\\npunctum), which are at first removable by pressure and which event-\\n1 Giorn. Ital. delle Malattie Yeneree, e della Pelle, September, 1889.\\n29", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0477.jp2"}, "478": {"fulltext": "450 HYPERTROPHIES.\\nually persist. These lesions are often mere cutaneous varices. The\\ngloboid nodules may be smooth and horny at the surface or be rough-\\nened and prickly they are never scaly. At times the varicosities of\\nvessels are commingled with both spots and nodules, transitional forms\\noccurring in some cases. The arrangement of the lesions is in general\\nirregular and asymmetrical, though there may be grouping.\\nEtiology. The patients are commonly young, but a few cases have\\nbeen reported in middle-aged subjects. There is usually a history of\\nexposure of the affected parts to cold weather or to cold substances, as\\ndescribed above. Some of the sufferers from the disorder seem to have\\nbeen subject to chilblains.\\nPathology. The first morbid change is a blood-stasis which results\\nin punctiform capillary varices in the upper vascular web of the corium.\\nSuperimposed on these varicosities lie thickened areas of the epidermis,\\nconstituting a keratomatous tumor. The epithelial ridges in the vicinity\\nof these minute wart-like bodies are compressed and thinned by the\\nectasis of the vessels. There is moderate local acanthosis, the granular\\nlayer also being increased in thickness and the lower part of the stratum\\ncorneum showing increase in elei din. At the moment of fullest evolu-\\ntion the affected papillae are transformed into small cavernous angiomata,\\nsometimes reaching upward to the epidermis, while thinned processes\\nof the latter stretch downward toward the cutis. The sweat-pores are\\nat times narrowed at others they seem to be normal.\\nThe Prognosis is favorable, as the lesions may be made to disappear\\nunder proper treatment.\\nTreatment is by stimulating lotions and liniments, as in pernio,\\nand, when required, by electrolytic destruction of the vascular warts.\\nKERATOSIS FOLLICULARIS CONTAGIOSA.\\n(Acne Sebacee Coknee.)\\nH. G. Brooke 1 described under this title a rare and apparently contagi-\\nous disorder occurring in children and occasionally in adults. Blackish\\nmacules were symmetrically developed into deeply pigmented papules\\nover the neck, the shoulders, and the extensor faces of the arms.\\nFrom these papules protruded blackish specks, which later resembled\\ncomedo-plugs and eventually developed as spike-like filaments. The\\nskin, however, was dry, never greasy, of a dirty shade of color and the\\nthorny excrescences were firmly attached to the tissue beneath. We\\nhave had under observation a young woman who exhibited precisely the\\nsame features on the extensor surfaces of the arms, forearms, thighs, and\\nlegs. Unna divides the pathological symptoms into those due to reten-\\ntion and those due to the formation of horny plugs at the sites of the\\nfollicles. The lesions are distinguishable from those of acne and comedo\\nby the absence of sebaceous cells and by their collar of horny lamellse\\nat the base. The spokes are produced by the energy of the hyperkera-\\ntosic process, which pushes the horny plug outside of and beyond the\\nfollicle, its upper segment only being concerned in the process. The\\ndisease is essentially a hyperplasia of the epithelial cells, the first evi-\\n1 Internat. Atlas of Rare Skin-diseases, 1892, xxii.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0478.jp2"}, "479": {"fulltext": "POROKERATOSIS. 451\\ndence of the operation of the external cause being apparent in the\\nstratum granulosum, the chief result being declared in the common\\nexcretory duct of the pilo-sebaceous conduit. The disease was readily\\nrelieved by applications of lard saponified with potassium hydroxide.\\nHYPERKERATOSIS STRIATA ET FOLLICULARIS.\\nH. v. Hebra l reports under this title the case of a young woman\\nwith isolated epidermal elevations, having a reddish margin, of both\\nsuperciliary arches, over the bridge of the nose, the upper lip, the\\nthroat, shoulders, and arms. The lesions w r ere flat or elevated, iso-\\nlated or confluent nodules, constituted of heaped-up epidermis, which\\ncould be removed without disturbing the papillary layer of the corium.\\nMany were bean-sized, grayish-green elevations, conspicuous over the\\nelbows, with underspreading epidermic cones buried in corresponding\\ndepressions beneath, which often bled freely when the cuticular mass\\nwas removed. Contrasting with these lesions were striated elevations\\nof epidermis extending either at an angle or along the longitudinal\\naxis of the limb. The disorder was relieved by warm-water and soap\\nbaths, followed by resorcin-vapor and salicylated plaster.\\nPARAKERATOSIS SCUTULARIS.\\nThis name has been given by Unna 2 to a rare condition occurring\\nin a vigorous man (first on the scalp), in which thick, somewhat greasy\\ncrusts enveloped bundles of hairs, the separate filaments having yel-\\nlowish and horny cuffs that were fused with the crust. Whitish scales\\nand horny cylinders w 7 ith a perpendicular projection were visible over\\nseveral portions of the face. Upon parts of the trunk were brownish\\nspots, coin- to palm-sized, exhibiting horny cones which projected from\\nthe follicular orifices. The cones were covered with horizontally\\nplaced scales. Dark-reddish, moist, and shining surfaces were ex-\\nposed on their removal. Closely examined, the horny cones after re-\\nmoval displayed several hairs which projected, one above another,\\nfrom each cone, having been extruded from their follicles at different\\ntimes. The author believes the disease to be allied to Devergie s\\npityriasis pilaris.\\nPOROKERATOSIS (Mibelli).\\n(Hyperkeratosis Excentrica (Kespighi)).\\nThis rare form of hyperkeratosis, described by Mibelli, 3 Respighi, 4\\nHutchins, 5 Gilchrist, 6 and others, begins as a minute, elevated, wart-like\\npapule which gradually enlarges peripherally to form a small plaque\\n1 Internat. Atlas of Rare Skin-diseases, 1891, v.\\n2 Ibid., 1890, i.\\n3 Ibid., 1893, vol. ix.; Monatshft. f. prakt. Derm., 1897, p. 345, etc.\\n4 Giorn. Ital. delle Malattie Veneree, e della Pelle, 1893, p. 356.\\n5 Jour. Cutan.and Gen.-Urin. Dis., 1896, p. 373.\\n6 Johns Hopkins Hosp. Bull., viii. Jour. Cutan. and Gen.-Urin. Dis., 1899, p. 149\\n(with bibliography to date, etc.).", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0479.jp2"}, "480": {"fulltext": "452 HYPERTROPHIES.\\nwith a depressed centre and a characteristic, narrow, slightly elevated\\nborder, in the form of a dike or raised seam, along the crest of\\nwhich is a depressed black line or series of black dots. This crest\\nmay be continuous or be broken at intervals, or may be surmounted here\\nand there by small conical elevations. This peculiar ridge inclosing a\\ndepressed centre can be made out in lesions that have attained a diam-\\neter of two millimetres or more. Many of the lesions do not reach a\\nsize greater than one centimetre in diameter, but some become much\\nlarger and may cover the greater portion of an extremity. The smaller\\nplaques are circular, but the larger ones may have an irregular and\\nsinuous outline.\\nWithin the border the surface in small lesions is depressed but\\ncallous, while in the larger areas it usually is thinned and atrophic,\\nbut may be of normal thickness, with sometimes a few small round\\nhorny elevations superimposed. Absence of hair and of perspiration\\nis noted in some of the areas, while in others both are present. There\\nare no evidences of inflammation, and as a rule no subjective sensa-\\ntions. Some of the lesions may fail to attain typical development and\\nexhibit a border but slightly elevated in which the furrow is the most\\nconspicuous feature or they may appear as flat horny or scaly disks.\\nThe disease began in most instances between the second and eighth\\nyear of life, but in one of Respighi s cases it first appeared at the age\\nof twenty-eight years. The lesions develop slowly, and may be limited\\nfor years to one region. The disks may be single, but usually are mul-\\ntiple and may be very numerous. They occur in any region of the\\nbody, including the mucous surfaces. We have seen the disease in\\ntypical development on the glans penis.\\nThe causes of the disease are not known. Bacteriological investi-\\ngations have given negative results. Gilchrist s eleven cases occurred\\nin four generations of one family. Two other families are reported\\nin which there were two or more cases of the disease.\\nPathologically the disease is a hyperkeratosis beginning in the\\ndeeper parts of the horny layer or in the upper portion of the rete,\\nand involving chiefly the sweat-ducts, but also the hair-follicles and\\nsebaceous glands. No inflammatory changes are found.\\nTreatment of the smaller lesions with the electrolytic needle has\\nbeen successful. Those which are larger may be excised. Recurrence\\nafter curetting was reported in one of Gilchrist s cases.\\nMOLLUSCUM EPITHELIALE.\\n(Lat. molluscus, soft.)\\n(MOLLUSCUM VeKRUCOSUM, MOLLUSCUM SEBACEUM, EPITHELIOMA\\nContagiosum, Molluscum Contagiosum (Bateman), Acn\u00c2\u00a3\\nvakioliforme (Bazin).)\\nMolluscum epitheliale, a disease first recognized in 1817 by Bate-\\nman, under the title Molluscum Contagiosum, is to be distinguished\\nfrom another, known for a long time as molluscum fibrosum. The two\\ndisorders are distinct, and are no longer to be confounded by a simi-\\nlarity in name.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0480.jp2"}, "481": {"fulltext": "MOLLUSCUM EPITHELIALE.\\n453\\nSymptoms. Typical epithelial mollusca are firm, roundish bodies,\\naveraging in size the dimensions of a pea, and in color varying from\\na waxy whitish hue, nearly that of the integument, to the dark-red tint\\nof injected masses. They are either imbedded in the skin or project\\nfrom it in smooth, firm, semiglobular, sessile or pedunculated tubercles.\\nUsually a dark-colored aperture can be detected at the apex or side of\\nthe lesion, from which, on pressure, milky and curd-like, semifluid\\ncontents can be made to exude. Occasionally, inspissated or even horn-\\nlike masses project from these orifices, as though forced out by a vis-a-\\ntergo. The disease is rare, and the lesions are usually single and iso-\\nlated, though hundreds may appear upon the person of one individual.\\nFig. 51.\\nMolluscum epitheliale. (After Allen.)\\nThey consist of semifluid collections derived from that portion of the\\nrete which lines the sebaceous glands or penetrates between the papillae\\nof the derma; or they are actual transformations of the glands into\\ncornified amorphous deposits, surrounded by thickened parietes. They\\nj may be removed by surgical procedures or be shed spontaneously or\\ninflame, and result in circumscribed abscess; or terminate by ulcera-\\ntion. More often they are insidious and slow of development, and may\\npersist for years without producing annoyance or subjective sensation.\\nThey occur on the face, the side of the neck (Fig. 51), and the nucha;\\non the penis and scrotum of men, and the breasts and labia of women;\\non the trunk on the flexor surfaces of the extremities, and the dorsal\\nsurfaces of the hands and feet. Thev are most common in children.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0481.jp2"}, "482": {"fulltext": "454\\nHYPERTROPHIES.\\nIn consequence of the depression of the centre of the little tumors\\n(which Hutchinson has happily likened to small pearl buttons) they\\nmay suggest the lesions of variola, hence they were described by Bazin\\nunder the term Varioliform acne. This title, however, is by most\\nwriters employed to designate a totally different affection, a variety of\\nacne vulgaris, to which a chapter is devoted in this work.\\nHebra, Virchow, and Nicolaysen have reported mollusca as large\\nas an orange or a small cocoanut. Microscopical examination of these\\ngigantic lesions demonstrated their identity with the smaller tumors.\\nSimilar bodies of less size have been found interspersed among\\nepitheliomata.\\nEtiology. In England where the disease was first recognized, it\\nis more frequent than on the continent of Europe. The contagiousness\\nof molluscum is experimentally established, though the lesions are\\nfeeble in propagation by contact. Retzius, Vidal, Peterson, and Wig-\\nglesworth succeeded in producing the disease by inoculation of the\\ncontents of molluscous tumors. The proofs of contagion apart from\\nexperimental inoculation rest chiefly upon the circumstance of lesions\\nbeing simultaneously or successively observed on the breast of a mother\\nand the face of her nursling, and upon the successive development\\nof mollusca in several members of one family. An interesting relation\\nwould seem to subsist between mollusca and verrucae, or ordinary warts,\\nwhich are supposed to be feebly contagious.\\nStelwagon l has accumulated and classified reports of cases and of\\ninoculations which seem to leave little doubt as to the parasitic nature\\nof the disease. Eczema, sweating (Turkish baths), pruritus, and\\nmaceration of the skin predispose to the occurrence of mollusca but\\nthere are insufficient grounds for assuming that in adults they are\\nassociated with venereal disease. They are not rarely seen in large\\nnumbers upon the scrotum of youths who have never exercised the\\nsexual function.\\nPathology. Sections through the centre of a lesion of molluscum\\nepitheliale show that it is formed by a number of diverging flask-\\nshaped lobules, the small end of each lobule\\nopening into a common central cavity. The\\nlobules are separated from each other by a\\nthin fibrous partition, which may occasion-\\nally be demonstrated to be the remains of a\\npapilla. The entire mass or group of lobules\\nis surrounded, except at the surface-open-\\ning, by a fibrous capsule, thus giving the\\nentire structure an appearance very similar\\nto that of a sebaceous gland. The belief,\\nformerly held, that the process originated in\\nthe sebaceous glands, is erroneous. Minute\\nexamination fails to find any trace of a seba-\\nceous gland in these formations. The process begins as a proliferation\\nof epithelial cells in the lower layers of the rete. The growth is con-\\nfined to the rete, from which the flask-shaped processes are pushed out,\\n1 Jour. Cutan. and Gen.-Urin. Dis., February, 1895.\\nFig. 52.\\nMolluscous corpuscles.\\n(After Kaposi.)", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0482.jp2"}, "483": {"fulltext": "MOLLUSCUM EPITHELIALE. 455\\ncausing a flattening and more or less complete disappearance of the\\nunderlying papillae.\\nEach lobule is lined with a layer of palisade-cells continuous with\\nthe same layer in the healthy rete adjoining the growth, and is filled\\nwith round and cuboidal nucleated epithelium undergoing peculiar\\nchanges. The first two or three rows of cells are usually normal,\\nbut above them the changes become gradually more marked. The\\nexact nature, sequence, and signification of these changes are in\\ndispute, but it would seem to be fairly well established that the outer\\npart of the cell shows early in the process abundant granules of kerato-\\nhyalin, and soon undergoes a cornification forming a clear ring or\\ncapsule for the cell. Within, the changes are similar to those seen\\nin amyloid or colloid degeneration. Authors describe a granular condi-\\ntion surrounding the nucleus which is usually at one end of the cell,\\nwhile the remainder of the cell-protoplasm shows vacuoles or groups\\nof small, irregularly shaped hyalin bodies, uniting to form an oval\\nmass which gradually encroaches upon and distends the cell. This\\noval homogeneous corpuscle surrounded by a horny capsule forms the\\nso-called molluscum body. These bodies accumulate at the mouths\\nof the lobules and in the small common cavity into which the lobules\\nall open, and may be pressed out upon the surface of the skin in a yel-\\nlowish or whitish semifluid or waxy mass.\\nThe more minute changes in the cells and the methods of recogniz-\\ning them are given in detail by Unna and others. The theory that the\\ndisease is caused by psorosperms has been abandoned.\\nDiagnosis. Mollusca resemble the lesions of variola more than any\\nother cutaneous phenomena. They are, however, readily distinguished\\nfrom the latter by their chronicity, their semifluid contents, the absence\\nof febrile symptoms, and the career of variolous pustules. From\\nwarts they are also differentiated by their contents, hemispherical shape,\\nand the dark punctum almost invariably present on one part or another\\nof the lesion.\\nMolluscum epitheliale in no way suggests molluscum fibrosum, with\\nwhich it has been confounded only in consequence of the similarity in\\nname. The tumors of molluscum fibrosum are solid new-growths,\\nusually occurring in great numbers upon the trunk of individuals of\\nadult years. They may attain enormous dimensions, the masses\\nreaching several pounds in weight and though in cases they degen-\\nerate by ulceration, they never enclose the curdy contents of molluscum\\nepitheliale.\\nPapillary warts are to be distinguished from mollusca, though with-\\nout question lesions are occasionally seen of a type intermediate between\\nthe two forms. Warts are to be recognized by their general papilli-\\nform character, and by their evident relation to the papillary layer of\\nthe corium overlaid by a thickened stratum corneum.\\nPhysicians are occasionally consulted by patients who have discov-\\nered mollusca upon the genitals, and who suppose these lesions to be\\nof venereal origin. An error in this respect can scarcely be committed\\nby the expert. Neither the solid papule of the initial lesion of syphilis\\nwhen observed on the skin of the penis, nor the pustule and resulting", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0483.jp2"}, "484": {"fulltext": "456 HYPERTROPHIES.\\nulcer of the chancroid, ever exhibit the waxy look of genital mollusca\\nwith their depressed puncta. In such cases the inguinal glands should\\nalways be carefully examined, remembering, however, that a forcibly\\nsqueezed and cauterized molluscum may be accompanied by sym-\\npathetic adenopathy.\\nTreatment. Molluscous tumors may be removed by ligature,\\nscissors, knife, curette, or a needle in contact with the negative pole\\nof a galvanic battery, their contents having previously been expressed.\\nIn order to diminish the pain of the trifling operation the affected sur-\\nface may first be chilled or frozen with an ethyl-chloride or ether spray.\\nBleeding is easily arrested with a pledget of lint. Occasionally after\\nremoval the point of a crayon of silver nitrate may be introduced,\\neither to check hemorrhage or to insure destruction of the cyst. Ac-\\ncording to Hebra, the return of the lesion, when this occurs, may be\\nexpected at situations previously not implicated.\\nWhen the lesions are small and numerous they may be made to\\nexfoliate by the local application of green soap. Removal of the larger\\nlesions may be followed by minute cicatrices.\\nPrognosis. The disease can always be terminated by removal of\\nthe tumors, the process to be repeated in case of recurrence.\\nCALLOSITAS.\\n(Lat. callus, hard flesh.)\\n(Keratoma, Tyloma, Tylosis.)\\nCallosities are superficial, circumscribed, dirty-white, yellowish- white\\nor darker, flattened, thickened, and horny patches of epidermis, dense\\nin structure and usually insensitive. Section of a single plaque shows\\nit to be largest at the centre and least at the periphery. Callosities\\nvary in size from that of a finger-nail to that of a section of a hen s\\negg, being at times larger they occur chiefly upon parts of the integu-\\nment subjected to long-continued intermittent pressure, as the hands\\nand feet also upon parts stretched over osseous prominences, as those\\nover the ischia. They may be complicated by hyperemia, fissure, acute\\ninflammation, or erysipelas and readily serve as foci of cutaneous dis-\\nease (eczema, psoriasis, etc.). They are commonly encountered among\\nmechanics, carpenters, shoemakers, etc. among persons wearing ill-\\nfitting shoes (heel, or ball of foot, or big toes), stockings, or surgical\\napparatus among workers in metals, acids, or heated substances and\\namong musicians (harpers, banjo-players, etc.). They are produced by\\nsuch external causes as pressure, friction, chemical agents, and heat.\\nThey can readily be distinguished from eczematous, psoriasic, and ich-\\nthyotic patches, being always limited to the sites of external contact.\\nCallosities are so characteristic of the several professions and trades\\nthat by their locality alone they point in many cases to the occupation\\nof the individual who exhibits them. Often they are, in these cases,\\nessential to the prosecution of such work and their removal would\\nonly expose a tender epidermis to the operation of an injurious pressure\\nor friction.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0484.jp2"}, "485": {"fulltext": "CLAVUS. 457\\nThe pathological features of callosities are: marked hypertrophy\\nand compaction of the stratum corneum and thickening of the stratum\\ngranulosum, the rete mucosum on the contrary being thinned by the\\npressure. The papillae are often flattened from the same cause. The\\ncorium may exhibit signs of inflammation when the callosity has been\\nconverted into a source of irritation.\\nCallosities require treatment only when they are sources of pain or\\nof discomfort. They may be removed surgically, by the knife chem-\\nically, by the destructive action of acids or alkalies rationally, by dis-\\nuse of the part to an extent sufficient to interfere with the operation\\nof the cause. When painful they may be poulticed. A nightly soak-\\ning of the callus with warm oil, kept in contact with the thickened\\nepidermis during the hours of sleep by a compress of flannel saturated\\nwith the same substance, will in the end soften the induration.\\nCallositas of the Hands, with Unusual Complications\\n(reported by Morison, 1 of Baltimore), is illustrated by the case of a\\nnegro who was a stoker. In this instance the combined effects of heat\\nand friction resulted in ulcerations beneath the callosities that event-\\nually produced necrosis and loss of some of the phalanges. This\\npatient recovered as soon as the hands were properly protected, a fact\\nthat seems to justify the assignment of this and similar cases to a class\\napart from those which follow.\\nCLAVUS.\\n(Lat. clavus, a nail.)\\n(Corn. Fr., Cor, CEil de Perdrix Ger. y Huhnerauge.)\\nCorns are hypertrophies of the horny layer of the epidermis, with\\nthe peculiarity of presenting inferiorly a coniform prolongation, which,\\nbeing pressed from without inward upon the sensitive papillse of the\\ncorium, excites pain in various degrees. Corns vary in size from that\\nof a pea to that of a large chestnut, and are dense and callous when\\noccurring upon those prominent parts of the foot on which the boot,\\nshoe, or gaiter exercises its greatest pressure. When occurring upon\\nthe lateral face of a toe in apposition with another the corn originates\\nusually from pressure through the medium of the neighboring toes. It\\nis then softer from exposure to heat and moisture. Corns are often\\nweather-sensitive, being unusually painful before, during, or after the\\noccurrence of storms, and should not be confounded with gouty or\\nrheumatic deposits below the skin.\\nHistology. Corns are composed of superimposed, and often con-\\ncentrically arranged, layers of epithelium, between which are found at\\ntimes minute hemorrhagic extravasations. They are occasionally seen\\nupon the palms of the hands. At the periphery of the corn the corium\\nis unchanged, but at the point where its central cone is pressed into the\\ndeeper structures the papillae are either atrophied or absent. A corn\\n1 Jour. Cutan. and Ven. Dis., Jan., 1886.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0485.jp2"}, "486": {"fulltext": "458 HYPEHTROPHim\\nat the periphery exhibits, according to Unna, a thickening of the\\nprickle- and granular layers. There is a central horny layer, the outer-\\nmost stratum of which gives evidence of welding. But the core\\nitself, which is composed of compressed masses of the horny layer con-\\nically pointed below, exhibits a flattened ridge-net and papillary body.\\nOften the sweat-pores are preserved, and may be traced running dilated\\nand with many windings through the epithelium deeply into the core.\\nThe granular layer here disappears, and the general flattening is so\\ngreat that the margin between the horny cells and the flattened prickle-\\nlayer is lost.\\nTreatment. Corns, when rationally treated by disuse of the feet,\\nor by the adjustment of properly fitted coverings for the same, will\\nusually fall spontaneously. They may be softened by prolonged mac-\\neration in water, by poultices, or, best of all, by oil, as in the treatment\\nof callosities. Erasion and excision may be practised, if demanded by\\nan exigency. Where the sufferer must necessarily continue the use of\\nthe foot the simplest and best treatment is as follows: The part is\\nthoroughly macerated for half an hour with water as hot as can be\\ntolerated. Then the projecting callous portion of the corn is gently\\nremoved by cutting or scraping until, as nearly as may be, the surface\\nis level with the plane of the adjacent skin. The part is then dried,\\nand the entire surface, both of the seat of the corn and the adjacent\\nintegument, is completely covered with many narrow, short, and nicely\\nadjusted strips of rubber-plaster. Burgundy pitch melted and painted\\nover the part may be applied as a substitute for the plaster. When\\nthe trifling operation and dressing are complete the patient should\\nbear firm pressure over the corn without flinching, and walk with\\ncomfort. The plaster remains until it separates spontaneously, which\\nis usually in the course of a few days. The corn is then macerated at\\nnight with an oil-poultice, as described above, and the dressing after-\\nward reapplied, usually the second time by the patient. Persistence\\nin this course is followed by complete relief if the coverings of the\\nfeet be properly fitted. Caustics are usually unnecessary when there\\nis no ulceration of the hard corn, and are in this situation frequent\\nsources of great distress. They are chiefly valuable in the treatment\\nof the soft variety, but they should always be applied with a skilled\\nhand.\\nFor this purpose acetic acid or the silver nitrate crayon may be\\nemployed. The proprietary corn-salves sold in the shops commonly\\ncontain the ointment of mercuric nitrate, which also is a useful applica-\\ntion to the soft variety of corn. The latter should be protected by the\\ninterposition of absorbent cotton or wool from contact with adjacent\\ntoes.\\nAs a rule, the ringed corn-plasters sold in the shops are inferior to\\nthe dressing with the rubber or salicylated plaster, made to cover the\\nentire corn.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0486.jp2"}, "487": {"fulltext": "CORNU CUTANEUM.\\n459\\nFig. 54.\\nCORNU CUTANEUM.\\n(Lat. eornu, a horn.)\\n(Horn. Fr., Corne de la Peau; Ger., Hauthorx.)\\nCylindrical, conical, straight or twisted, angular and otherwise\\nirregularly shaped and sized corneous eminences, single or multiple,\\noccasionally project from the scalp, forehead, nose, lips, ears, penis,\\nor extremities. The sites of preference are in the following order,\\nthe scalp, forehead, temples, nose, lower extremities, male genitals,\\nand trunk. Horns are\\nnamed from their resemb-\\nlance to the similar appen-\\ndages in horned cattle, but\\nthey widely differ from cat-\\ntle-horns, which are always\\nimplanted upon osseous\\ntissue. Human horns are\\nformed of dense and massed\\ncolumns of epithelia, often\\nresting upon prolonged pap-\\nilla?. Occasionally, on sec-\\ntion, they exhibit the con-\\ncentric arrangement of the\\nepithelia seen in corns, but,\\nunlike the latter, have re-\\nentrant basal depressions into\\nwhich the papillae below pene-\\nFig. 53.\\nVarieties of cutaneous horns.\\ntrate. At times they are implanted in a dilated follicle, in which case\\nthe glandular elements participate in their formation. At times, also,\\nthey represent a corneous transformation of the epithelia which con-\\nstitute warts. They are seen in all colors, but are often between a\\nyellowish brown and a brownish black, with fissured or wrinkled\\nor longitudinally grooved exterior, like rough bark (Fig. 53). They", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0487.jp2"}, "488": {"fulltext": "460 HYPERTROPHIES.\\nmay be painless, or, like other keratoses, become the seat of inflamma-\\ntion in various grades. They may be short or several inches in length\\n(Fig. 54). They may be shed spontaneously never to return, or may\\nshortly reappear. They occasionally develop into epitheliomata.\\nBrinton l has exhibited an anteriorly curved horn one and seven-\\neighths inches long and three-eighths of an inch in circumference, re-\\nmoved by him from the glans penis of an elderly patient. Fourteen\\ncases are on record of a similar growth in this situation. In the\\nhorn growing from the lower lip of an elderly man exhibited in\\n1886, at our clinic, the growth w T as longitudinally furrowed, and also\\nat somewhat regular intervals transversely seamed, presenting thus the\\nappearance of the joints of the sugar-cane.\\nThe Etiology is without question that of the senile wart for most\\ncases though, as with epithelioma, horns occur in infancy. They have\\nbeen recognized as starting from a sebaceous cyst.\\nPathology. Pathologically these hypertrophies are first developed\\neither within a closed atheromatous cyst or from remarkably elon-\\ngated papillae of the corium. They are made up of cornified and hy-\\npertrophied epidermal cells. According to Unna, they are all papil-\\nlary and medullated keratomata growing on a circumscribed warty\\nbase. The first stage of their development is characterized by a sim-\\nultaneous acanthosis and hyperkeratosis, dense epithelial taps reaching\\ntoward the corium. In the second stage of horn-formation the kera-\\ntosis advances and the acanthosis diminishes. Sets of horny wedges\\nsink downward into the epithelial taps and ridges, fill the spaces be-\\ntween the papillse, and are capped above by a horny cupola.\\nLebert shows that horns develop into epitheliomata in about 12\\nper cent, of cases. As horns are really metamorphoses of epidermal\\ncells similar in many features to warts, it is not surprising that the two\\noften undergo the change from benign to malignant epithelial growths.\\nIn a few cases horns have developed to an appreciable degree on epi-\\ntheliomata; but under the microscope this horny metamorphosis on a\\nsmaller scale may be recognized in a large number of epitheliomata sit-\\nuated on the back of the hands of elderly men who have been farm-\\nlaborers, sewer-builders, or workers in contact with earth.\\nTreatment. Horns may be removed by extirpation, after which\\nthe surface upon which they were implanted should completely be\\ncauterized.\\nPrognosis. In formulating a prognosis the possibility of an epi-\\ntheliomatous result should not be forgotten.\\nVERRUCA.\\n(Lat. verruca, an excrescence.)\\n(Wart. Fr., Verrue Ger., Warze.)\\nWarts are cutaneous excrescences congenital or developing after\\nbirth sessile or pedunculated pointed or flat smooth, rugous, or\\nhaving a cauliflower appearance pigmented in various shades or of\\n1 Jour. Cutan. and Gen.-Urin. Dis., 1887, p. 272.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0488.jp2"}, "489": {"fulltext": "", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0489.jp2"}, "490": {"fulltext": "PLATE X.\\nte\\nCongenital Warts.\\n(From a photograph ot one of the author s patients.)", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0490.jp2"}, "491": {"fulltext": "VERRUCA. 461\\nthe natural color of the skin soft, dense, or even corneous to the\\ntouch. They may develop slowly or rapidly, and may persist for years\\nor disappear without apparent cause. They may be single or multiple,\\nand they occur upon the hands, feet, face, scalp, neck, genitals, and\\nother parts of the body. They are usually discrete, but may be con-\\nfluent and form palm-sized and larger elevated plaques. Fox, of New\\nYork, has reported a case in which warts occurred in the lines tattooed\\non the skin of a young man.\\nThe several names given to the various forms of warts have chiefly\\na descriptive value.\\nVerruca Acuminata (Condyloma Moist Venereal Wart. Ger.,\\nSpitzen Warzen) is a filiform, papilliform, or cock s-comb-like vegeta-\\ntion. They are single or multiple at times hundreds coexist upon the\\ngenitalia and neighboring regions. In size they vary from that of a\\npin s point to that of a hen s egg, and may be larger. They are usu-\\nally moist and secreting, being frequently covered with a puriform\\nmucus of exceedingly nauseating odor. Upon the genitals they are\\nencountered upon the glans, around the frenum, and over the prepuce\\nof men and in women about the clitoris, labia, ostium vaginae, and\\nanus. They are usually of a bright-red color in these situations. When\\noccurring upon the integument they are firmer, drier, and exhibit a ten-\\ndency to luxuriant growth. In this form they may be recognized about\\nthe axillary regions, the umbilicus, the interdigital spaces of the feet,\\nand even the face. They may cover the side of the chin.\\nThe summit of these warts may be tufted, acuminate, or flattish\\non the surface of the skin, unconnected with mucous membrane, they\\nmay have the color of the unaltered integument. They are often\\nminute and numerous as well as multiple and large or they may be\\nsingle throughout, though, as a rule, they multiply when untreated.\\nTheir largest maximum development is observed in negroes, in whose\\npersons they may attain unusual proportions. There was lately exhib-\\nited at our clinic a male negro with a compound venereal wart of the\\npenis that was of the size of an orange.\\nThese warts are almost always the result of exposure of the sexual\\nparts to venereal secretions (blennorrhagic, syphilitic, leucorrhceal, etc.),\\nand, though observed in virgins, are decidedly rare in individuals of\\nboth sexes of that class. In pregnancy they often attain a large size\\nand rapid development, but, as a rule, disappear when parturition is\\ncompleted. They are contagious and furnish auto-inoculable secretions.\\nCocci and bacilli have been recognized in several varieties, thus explain-\\ning many otherwise obscure histories.\\nVerruca Acquisita is a term used to designate lesions developed\\nafter birth.\\nVerruca Congenita. Congenital warts are usually first noticed\\nseveral months after birth. They may be single or be multiple,\\nusually the latter, in which case they are arranged along the lines of\\ndistribution of the nervous trunks, the disposition of the lesions often\\nsuggesting the arrangement displayed in zoster of the trunk or other\\nregion. They are, as a rale, roundish, slightly pigmented, and scarcely\\nlarger than split pease. At times they acquire unusual dimensions.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0491.jp2"}, "492": {"fulltext": "462 HYPERTROPHIES.\\nThe neck and shoulders may be well covered with lesions of this class\\nin asymmetrical groups, the largest wart having the size of the section\\nof an egg.\\nVerruca Filiformis. This variety of wart differs somewhat from\\nthe others, not only pathologically, as is noted below, but also in its\\nclinical features. These warts are pointed growths, slender, thread-\\nlike, often pedunculated, usually covered with a smooth and apparently\\nunaltered epidermis they occur upon the face, neck, eyelids, chest,\\nand ears. Kaposi concludes that they are minute fibromata. 1\\nVerruca Dorsi Manus et Pedis (Unna) is a nsevus with\\nlesions symmetrically grouped upon the dorsal surfaces of the meta-\\ncarpi of the thumb and index finger. The lesions are flat, round, or\\npolygonal, two to six millimetres in diameter, externally presenting a\\npunctate appearance, occurring in middle or later life, and exhibiting\\nno tendency to spontaneous change. Pathologically they disclose a dis-\\ntinctive thickening of the prickle-layer from the periphery to the\\ncentre. They lack many of the characteristic microscopical features of\\nthe ordinary seborrheic wart.\\nVerruca Glabra is distinguished by its smooth surface.\\nVerruca Necrogenica is a tuberculous wart, occurring on the\\nhands of person3 who have been in contact with tubercle-bacilli, chiefly\\nas a result of handling the bodies of the dead. For details, the chap-\\nter on Tuberculosis of the Skin should be consulted.\\nVerruca Plana describes a not uncommon variety of wart which\\nis flat, smooth, and but slightly elevated. The plane warts may be\\nsingle, but are commonly multiple, and they usually vary in size from\\nthat of a pinhead to that of a small split-pea, but may be much larger.\\nThey are often grouped, and may have a polygonal outline, closely\\nsimulating the papules of lichen planus. In young people these plane\\nAvarts are usually small, multiple, often grouped; have the color of the\\nnormal skin or are slightly yellowish or whitish and are seen most\\nfrequently on the forehead, on other parts of the face, and on the backs\\nof the hands. In older people this form of wart shows less tendency to\\ngrouping than in the young, is often pigmented, and may be associated\\nwith or form the beginning of superficial epithelial changes.\\nVerruca Senilis vel Plana (Keratosis Pigmentosa). These\\nwarts are bean- to coin-sized, smooth, softish growths developed upon\\nthe face, trunk, and extremities of persons of advanced years. They\\nare flat, usually pigmented, and have a granular aspect. They are\\nreadily separable by the finger-nail, and are then found to rest upon\\na reddish granular base. As the result of external injury (caustics,\\ntraumatism) they may become the starting-point of an epithelioma.\\nVerruca Vulgaris is the form most frequently seen upon the\\nfingers and hands, as pinhead- to pea-sized, usually discolored, papilli-\\nform excrescences.\\nEtiology. Most warts are nests of micro-organisms of different\\nvarieties. The precise cause, however, is unknown but in early child-\\nhood, a period in which warts are most frequently encountered, it is\\n1 See Taylor s observations as epitomized in the chapter on Fibroma.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0492.jp2"}, "493": {"fulltext": "VERRUCA. 463\\nreasonable to conclude that they result from external contacts. It is\\nwhen the child begins to handle everything within reach that they\\nusually first appear, and then about the hands. Acuminate or condy-\\nlomatous warts chiefly occur in parts moistened with a blennorrhagic\\nsecretion, but unquestionably they may originate from contact with\\nleucorrhoeal or pathological, non-venereal discharges from the female\\ngenitals. Senile warts are more probably due to obscure changes in\\nthe nutrition of the integument. The etiological importance of the\\ncocci and bacilli which many of them furnish cannot be determined\\nat this time.\\nPathology. The process begins with downward and upward growth\\nof the rete-cells, resembling in this respect benign epithelioma. The\\ngranular layer is remarkably thickened, while the greatly hypertrophied\\nhorny layer is less compact than normal owing to imperfect keratini-\\nzation of the cells, in many of which the nucleus is still apparent.\\nThe descending rete-processes are usually pointed and turn toward\\na common centre, producing thus a shallow cup-shaped depression in\\nthe cutis.\\nThe papilla? beneath the wart are flattened, many being obliterated,\\nexcept a few at the centre of the base. These hypertrophy, become\\nelongated, and with their dilated vessels form a vascular core for\\nthe verruca. In the pointed forms the connective-tissue and vascular\\nelements are marked, while the horny layer is but slightly hyper-\\ntrophied. In verruca plana the chief change is in the rete, the horny\\nlayer being but little thicker than normal.\\nDiagnosis. It is a matter of importance to recognize the fact that\\nI many epitheliomas begin as warts therefore the verruca of those ad-\\nvanced in years should always be examined and treated with a view\\ni to this fact. A tendency, especially in the aged, for the lesion to break\\n(down into an ulcer should arouse suspicion. Warts on the face and\\nthe backs of the hands of the aged are often of this class.\\nAnother class of warts are tuberculous in character, and, whether\\noccurring in the young or the aged, are the result of infection with\\ntubercle-bacilli, a generalized tuberculosis at times originating in these\\nlesions (vide Tuberculosis Verrucosa).\\nGreat care must be had to distinguish the moist variety from syphi-\\nlitic condylomata. In the latter there is usually a history of conta-\\ngion with other syphilodermata upon the surface, such as mucous\\npatches, palmar lesions, or papules of the face. Fibroma, or mollus-\\ncum fibrosum, generally occurs in tumors of greater number, firmer\\nconsistence, and larger size. The tumor of molluscum epitheliale\\ngreatly resembles a wart, but the waxy-whitish appearance of the\\nlesion and its dark punctum at one plane or another sufficiently dis-\\ntinguish it. In exceptional cases verruca plana may in shape and\\ngrouping closely simulate lichen planus, but the location and history,\\ntogether with the absence of the typical color, the varnished appear-\\n;ance, and of the itching, characteristic of lichen planus, will make the\\ndiagnosis clear.\\nTreatment. Warts may be removed by excision, erasion, or caus-\\ntics (silver nitrate, alkalies, acids, ferric chloride, corrosive sublimate,", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0493.jp2"}, "494": {"fulltext": "464\\nHYPERTR OPHIES.\\netc.). The larger growths upon the genitalia that are often highly\\nvascular may demand the prior application of a ligature when they are\\npedunculated. Even the slender filiform warts will be found to contain\\na small vessel in each pedicle that requires cauterization after excision.\\nFig. 55.\\nVertical section of the summit of a pointed wart a, papilla containing vascular loop c, stratum\\ncorneum d, hypertrophied rete. (After Kaposi.)\\nWhen the warts cannot more readily be removed by the knife or by\\ncurved scissors the Paquelin cautery may be used. The blackened\\neschar which is left prevents hemorrhage, serves as the best subsequent\\ndressing, and is less likely to be followed by a return of the growth.\\nIn some eases it is a useful expedient to transfix the lesion in several", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0494.jp2"}, "495": {"fulltext": "VERRUCA. 465\\ndirections with the long needles used in gynaecological practice, pre-\\nviously dipped in a 50 per cent, solution of chromic acid.\\nOne may also transfix the base of the wart a sufficient number of\\ntimes with a needle connected with the negative pole of a galvanic\\nbattery, the positive pole being connected with the body of the patient\\nby the aid of a moist sponge.\\nThe formula according to w T hich are made several of the proprietary\\nwart-cures sold in the shops is as follows\\nR Acid, salicylic, 3ss\\nCannabis Indie, extr., gr. v\\nCollodion., gss 15\\n33\\nM.\\nSig. To be painted over the wart with a camel s-hair brush.\\nFor small multiple warts Morris recommends the following\\nR Glycerin.,\\n3jss\\n6\\nAcid, acetic, dil.,\\nSijss\\n10\\nSulphur, praecipit.,\\n3j;\\n4\\nM.\\nFor patches of warts Van Harlingen recommends cautiously attack-\\ning one part at a time with the following paste\\nR Pulv. acid, arseniosi, gr. vj\\nEm|\\\\as y t d hydrarg. s ad s ad 8\\n40\\nM.\\nWarts may also be treated by painting once daily with a saturated\\nsolution of potassium bichromate in boiling water. The liquid is\\napplied cold. The application is painless and leaves no scar (Louvel-\\nDulongpre).\\nFor warts not requiring operative removal local treatment generally\\nanswers well. Those about the genital region often disappear if per-\\nsistently washed with a solution of tannin in alcohol, 1 drachm (4.) to\\n3 ounces (96.), after which they are dried and thoroughly dusted with\\nboric acid, or salicylic acid with lycopodium, or burnt alum and rosin,\\nor, what is most popular, dry calomel. Alum- and lead-lotions may\\nalso be substituted for the tannin and alcohol, and for a time be kept\\nover the parts on a compress.\\nPrognosis. Warts are benignant growths in childhood and in\\nearly adult life they need not suggest grave sequels. It is far different\\nin advanced years, for, though these excrescences possess even then no\\nmalignant character, they are frequent precursors of epithelioma.\\nWhile it may justly be urged that the early lesions in such cases were\\nreally epitheliomatous and not verrucous, the fact remains that many\\nwarty formations of apparently benign character do in advanced years,\\nespecially when irritated by frequent caustic applications, undergo a\\ncancerous metamorphosis. The tuberculous wart also may become the\\nsource of general tuberculous infection.\\nMultiple Cutaneous Tumors accompanied by Intense Pru-\\nritus. Under this title Hardaway, of St. Louis, described a rare\\n30", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0495.jp2"}, "496": {"fulltext": "466 HYPERTROPHIES.\\ndisorder characterized by the occurrence of about sixty pea- to nut-\\nsized, dense tubercles and tumors covered by a thickened, scaly, and\\nexcoriated, often hemorrhagic skin. In some situations coalescence\\nhad occurred, forming thus long and narrow plaques of nearly the\\nwidth and of half the length of the finger of an adult. The lesions\\nwere seen upon the outer aspects of the arms and legs, the palms and\\nsoles, the sides of the fingers, and around the ankles, wrists, and\\nelbows. The accompanying pruritus was intense and intolerable and,\\nhaving lasted for twenty-two years, it was associated with the degree\\nof pigmentation often observed under similar conditions. The patient,\\nwho was an unmarried woman, fifty-one years of age, declared that\\nthe lesions first appeared as blisters.\\nSpecimens of these tumors, microscopically examined by Heitzmann,\\nexhibited hyperplasia of the epithelial and connective tissues. The\\npapillae were longitudinally elongated, branching, and provided with\\nnarrow capillaries. Numerous nests, greatly varying in size and con-\\ntaining inflammatory elements with considerably enlarged blood-vessels,\\nlay close beneath the papillary layer of the corium. These elements\\nshowed all stages of transition into basic substance. The deeper layers\\nof the derma were built up of very coarse bundles of connective tissue\\nand of numerous elastic fibres.\\nSynovial Lesions of the Skin. These cutaneous lesions possess\\nimportance from a diagnostic point of view. We have observed them\\nin several individuals in whom the exact nature of the disorder had\\nnot been understood. They occur in the form of wart-like projections\\nfrom the skin, pseudo-vesicles, and bullae, always over the site of bursas\\nconnected with tendons, traversing the small articulations of the hand\\nand foot. They are seen over the metatarso-phalangeal articulations\\nand in the hand most frequently over the dorsal face of the articulation\\nbetween the distal and adjacent phalanges of the index-finger and\\nthumb. The first form is that of a roundish, corneous, pea-sized wart\\nwith a yellowish centre, of long duration, usually insensitive unless\\nroughly handled. When punctured a syrupy, yellowish, or grumous\\nfluid exudes, which continues to form after repeated puncture. Split-\\npea-sized vesicles, and bullae as large as a small coin, often exceed-\\ningly painful, are also seen, especially upon the feet, with simply an\\nepidermic roof-wall. Each lesion contains the same thickened, yel-\\nlowish or whitish fluid, occasionally mingled with masses like sago-\\ngrains. In every case the contents of the lesions are supplied by a\\nsynovial bursa beneath the skin, with which the lesion is either directly\\nconnected or in communication by a short sinus. The treatment\\nrequires the complete excision or destruction of the secreting cyst-wall.\\nSidney Jones and Makins, of St. Thomas Hospital, exhibited several\\nlesions of this character to the London Pathological Society.\\nPapilloma. This term has loosely been applied to a large number\\nof cutaneous growths widely differing from each other, both histolog-\\nically and clinically. It has been made to include the vegetations of\\nsyphilis, the neoplasms of naevus, and even the tubercles of lupus.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0496.jp2"}, "497": {"fulltext": "NJEVUS PIGMENTOSUS. 467\\nThe designation papilloma is properly limited here to such circum-\\nscribed hypertrophies of portions of the skin as correspond with warts\\nin their pathological significance. These growths may be defined as\\nexcrescences from the cutaneous surface, of a size considerably larger\\nthan that of any one of the varieties of wart with the exception of\\nthe condyloma, usually presenting a luxuriant growth composed of\\nelongated papillae, blood-vessels, and enlarged rete, covered externally\\nwith a smooth epidermis like a pellicle, or, more commonly, branched\\nand tufted with the cauliflower aspect, and then usually smeared with\\na puriform mucus. The tumor increases rapidly until it attains a\\nmaximum size, and then indolently persists. Lesions corresponding\\nwith this description occur in carcinoma, syphilis, and lupus. They\\nmay develop upon any portion of the body.\\nPapilloma Area Elevatum (Beigel) is regarded by Crocker as\\nan illustration of the results of the ingestion of one of the bromine\\nsalts, and this is well corroborated by the picture presented by one of\\nour patients, in whom the face was covered with so-called papil-\\nlomatous growths as a result of the administration of the salts of\\niodine. 1\\nPapilloma Neuroticum is a term which has been applied to\\nribbon-like growths classed by some authors with ichthyosis hystrix.\\nThey properly belong, however, to the category of linear naevus.\\nlOEVUS PIGMENTOSUS.\\n(Lat. ncevus, a mask.)\\n(Pigmentary Mole. Ger., Fleckenmal Fr., Tache\\nPigment aire.)\\nAbnormal congenital pigmentations of the skin vary in color from\\na light-yellow or chocolate-brown to a blackish hue, and they may be\\nsingle, or be multiple and very numerous. They vary in size from\\nthat of a pinhead to that of tumors of large volume and are either\\novoid or circular in contour, or are so irregularly shaped as to present\\na fanciful resemblance to lower animals, whence the popular belief\\nas to their origin in maternal impressions. They occur in both sexes,\\nupon the face, neck, trunk, thighs, buttocks, and external genitals.\\nThe term N^vus Spilus is applied to those pigmentations which\\noccur in a smooth and otherwise unaltered skin N^vus Verrucosus,\\nto those which are irregular and wart-like Njevus Pilosus, to those\\nsurmounted by a growth of shorter or longer, stiff or downy, dark-\\ncolored hairs; and Njevus Mollusciformis, or Lipomatodes, to\\nthe soft or firm, more or less elevated and projecting tumors. A case\\nof unusually large congenital naevus lipomatodes associated with mul-\\ntiple pigmentary nsevi of several forms, occurring in a child observed\\nby one of us in 1883, 2 is represented among the illustrations of this\\ntreatise. The so-called white moles are similar to those described\\n1 Dermatitis Tuberosa, due to the Ingestion of the Iodine Compounds, Med.\\nNews, Oct. 13, 1888 illustrated in color from a painting in oil.\\n2 Jour. Cutan. and Ven. Dis., July, 1885.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0497.jp2"}, "498": {"fulltext": "468 HYPERTROPHIES.\\nabove, except that the pigmentation is very slight or apparently\\nwanting.\\nLinear N^vus (Morrow), 1 N^vus Unius Lateris, N^vus\\nVerrucosus, N^evus Nervosus, Njevus Lichenoides Ichthyosis\\nCornea, Ichthyosis Linearis Neuropathica, Papilloma Neu-\\nropathicum Unilaterale. Moles may be, when multiple, sym-\\nmetrically or asymmetrically developed upon the surface of the body\\nand in either case may exhibit an arrangement suggesting the control-\\nling effect of the nervous system.\\nIn a case reported by one of us 2 there were multiple monolateral\\npigmentary nsevi distributed over the left side of the trunk in the\\ncourse of the intercostal nerves, and in such a manner as strongly to\\nsuggest to the eye their correspondence in site with the lesions of\\nzoster of the same region. De Amicis 3 had previously reported a\\nsomewhat similar case. Many other cases have been recorded in\\nwhich pigmentary and verrucous nsevi, consisting of variously sized\\nand shaped lesions, were arranged in lines or streaks, usually on one\\nside only of the body, and often along the course of one or more nerves.\\nSelhorst 4 and Thibierge 5 have reported cases of this type in which\\ninvolvement of sebaceous glands produced acneiform lesions.\\nNsevi seem to occur with equal frequency in the two sexes, and\\nthough they usually appear at birth or soon after, they are sometimes\\nfirst seen at puberty or even later in life. It is possible that they may\\nbe acquired after birth, as claimed by some authors; but it is much\\nmore probable that such presumably acquired cases are instances of\\nrapid development from minute congenital pigmentary moles.\\nThe tendency of pigmentary nsevi, after attaining full evolution,\\nis to persist unchanged for a lifetime. Their increase in persons of\\ntender years is occasionally characterized by a relative rapidity of\\ngrowth. A pilary nsevus upon the cheek of an infant may extend over\\nnearly double its original area in the course of two years. In adults\\nan increase in the size of these growths is unusual but does sometimes\\noccur. Degenerative changes are possible. In the young there may\\nbe spontaneous gangrene or rapid necrosis following slight injury of the\\nnsevns. In older people there may be a malignant transformation into\\ncarcinoma or pigmented sarcoma.\\nPathology. Anatomically, pigmentary moles are readily separable\\ninto two classes first, those in which the pigment only of the skin\\nundergoes hypertrophy (nsevus spilus) second, those in which there is\\nalways hypertrophy of the epidermis, together with a varying amount\\nof hyperplasia of the papillae, vessels, glands, or hair-follicles. The\\nhistopathology thus varies greatly in different cases, depending upon\\nthe extent to which these different elements of the skin are involved.\\nThe distinction made by v. Barensprung, Gerhardt, and others between\\nthese two classes and still a third, in which the lesions are limited to\\n1 K Y. Med. Jour., Jan. 1, 1898.\\n2 Chicago Med. Jour, and Exam., Oct., 1877.\\n3 Lo Sperimentale, March, 1876.\\n4 Brit. Jour, of Derm., 1896.\\n5 Annal. de Derm, et de Syph., 1896.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0498.jp2"}, "499": {"fulltext": "ACANTHOSIS NIGRICANS. 469\\nthe cutaneous regions supplied by one or several nerves (linear nsevus,\\netc.) is more apparent than real for there is probably a trophoneurotic\\ninfluence exerted in all cases, even in the enormous tumors of a mol-\\nlusciform type. According to Demieville, the pigment-accumulation\\noccurs in the corium as well as in the epidermis, in the form of ribands\\nstretching along the lines of the blood-vessels. Kaposi holds that\\nmoles as well as nsevi result from a retained foetal impulse to develop-\\nment on the part of the cellular elements of the nsevus, which carries\\nthem beyond the normal limits of growth.\\nTreatment. Pigmentary moles very rarely spontaneously disap-\\npear. Their removal may be accomplished by excision, or by destruc-\\ntion with caustics, with the Paquelin knife, or with the needle by elec-\\ntrolysis. The last-named method is applicable only to the smaller and\\nmore superficial growths of this class. Fox 1 calls attention, in connec-\\ntion with this subject, to the need of passing the needle no deeper than\\nthe epidermis, sufficiently deep merely to blister the surface of the\\nblack spot.\\nACANTHOSIS NIGRICANS.\\nUnder this title Pollitzer and Janovsky 2 describe cases which at\\npresent it is difficult to recognize as instances of ichthyosis, of verruca,\\nor of nsevus pigmentosus. Morris, 3 Pye-Smith, Darier, Spietschka, 4\\nand others have since reported cases, numbering in all about thirty.\\nIn these patients the neck, the mouth, parts of the trunk, genito-crural\\nand anal regions, hands, axillae, and thighs displayed yellow and grayish-\\nbrown to almost black pigmented areas, covered in some places by fine\\npapillary projections, some of which were scattered and discrete, while\\nthose situated in the axillae, the groins, and the flexor surfaces of the\\njoints were grouped and coalesced to form papillomatous, vegetating\\nmasses. In places there was simple exaggeration of the natural lines\\nof the skin, in other parts there were ridges radiating from a central\\npoint. The mucous surfaces also were involved. Over the hands of\\none patient the color was deepest along the lines of the veins; and\\nthere was a glassy shimmer to the prominent normal areas of the\\ncuticle. In Morris s case the pigmentation and warty growths were\\nnot always associated, there being a few sites of pigmentation in an\\notherwise normal skin, or in which there were unpigmented warty\\ngrowths.\\nIn sections made of the skin removed from one patient there were\\nrecognized dilatation of the blood-vessels and lymph-spaces in the\\npapillary and subpapillary layers; increase of pigment-cells enormous\\nthickening of papillae and epidermis elongation and bifurcation of the\\nrete-pegs, and some suggestions of epithelial pearls. A few colonies\\nof bacilli having the shape of short, thick rods were discovered, but not\\nin all the secretions examined. In several cases the condition has been\\nassociated with abdominal carcinoma.\\n1 Electricity in Removal of Superfluous Hairs, etc. Detroit, 1886.\\n2 Internat. Atlas of Rare Skin-diseases, 1890, iv., ii.\\n3 Medico-Chirurgical Transactions, vol. lxxvii.\\n4 Arch. f. Derm. u. Syph.. 1898, Bd. xliv., S. 247.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0499.jp2"}, "500": {"fulltext": "470 HYPERTROPHIES.\\nXEROSIS.\\n(Gr. Zvpk, dry.)\\n(Xeroderma.)\\nXerosis is a term which has been applied to the disease sometimes\\nknown as Xeroderma pigmentosum, or the Melanosis lenticularis pro-\\ngressiva of Pick. Xerosis has also been used as practically equivalent\\nto ichthyosis.\\nIn these pages the term is used to describe a condition included by\\nmost authors under the title of ichthyosis, which in many cases it really\\nis but in others the appearance of the integument is to be distinguished\\nfrom that seen in the typical ichthyotic skin. The condition to which\\nthe name xerosis is here given is one intermediate between keratosis\\npilaris and ichthyosis simplex.\\nSymptoms. The sole symptoms of xerosis are cutaneous. The\\nskin of the body, in some regions more than others but at times univer-\\nsally, is to the touch dry, harsh, rough, and destitute of natural moisture\\nand unguent. Closely inspected the skin-surface is seen to be scaly,\\nexfoliation being of the character described as furfuraceous. In some\\ncases the hand passed briskly over the surface of such a skin will cause\\nseparation of scales in a scanty shower in other cases, while the sur-\\nface seems ready for the furnishing of such flakes of epidermis, one is\\nsurprised to note that they are more or less attached, and the clothing\\nof the patient is not, as in some forms of psoriasic and pityriasic dis-\\nease, covered with epidermal scales. In brief, there is not in progress\\na catarrh of the horny layer, as in some of the other disorders named\\nbut there is merely an unusual keratinic transformation of the elements\\nof that layer.\\nThe parts chiefly involved are the extremities, more particularly the\\nhands, feet, forearms, and legs but all parts of the skin may be in-\\nvolved, including the face, temples, cheeks, and even the lips.\\nThe disorder is met with in all grades, from the mildest physiological\\ndryness suggestive of so-called goose-flesh, to that state in which the\\nface only indicates an abnormal condition of the skin. The color of the\\nintegument in well-marked cases is always of a dirty-yellowish or dirty-\\nbrownish shade, suggesting an unwashed condition, and in extreme cases,\\nusually those of older patients, the skin becomes rather deeply pigmented.\\nThe affection is seen in both sexes and at all ages, being a congenital\\ncondition the first appearance of which is clearly indicated only after\\nvariable periods of time after birth. Red-haired individuals perhaps\\nfurnish the larger number of well-marked cases. The general health\\nis unaffected. Before puberty the affection in northern latitudes will\\noften be inappreciable in summer and distinct in winter. As maturity\\nis reached, however, the condition may become permanent.\\nThis disorder is described by some authors as a variety of ichthyosis\\nsimplex, but the reasons for giving it separate consideration are that\\nthe disease does not furnish the typical plate-like scales of ichthyosis\\nand one child affected with what appears at first to be merely xerosis\\nmay exhibit a typical ichthyosis before puberty, while another will go", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0500.jp2"}, "501": {"fulltext": "ICHTHYOSIS. 471\\nthrough life, the xerosis of his childhood becoming simply the extreme\\nxerosis of mature years, but never an ichthyosis.\\nXeroderma may, therefore, be regarded in one sense as a variety of\\nichthyosis, but it should not be described as a stage of the latter\\ndisease.\\nThe disorder is congenital, and is readily distinguished from all fur-\\nfuraceous scaling diseases of the skin by the absence of inflammation.\\nThe Treatment and Prognosis are those of the disease next to be\\nconsidered.\\nICHTHYOSIS.\\n(Gr. ix^vc, a fish.\\n(Fish-skin Disease, Xeroderma. Ger., Fischschuppenausschlag\\nFr.j Ichthyose ItaL, Ittiosi.)\\nSymptoms. This disorder displays a wide variation in its symp-\\ntoms. To the extremes in either direction two names are given, ich-\\nthyosis simplex and ichthyosis hystrix.\\nIchthyosis Simplex. The earliest and mildest form of ichthyosis\\nsimplex is, by many authors, held to be the condition of xerosis de-\\nscribed in the preceding pages. It will be remembered, however,\\nthat such a xerosis may persist through life without the production at\\nany time of the peculiar symptoms of the ichthyotic skin. In these\\nearlier manifestations of the disease, then, the skin of the patient can\\nmerely be described as unusually harsh to the touch, moistureless, and\\ncovered with adherent or exfoliating fine scales. The scales are not\\nmassed, imbricated, nor displayed in plaques, and usually are of a dull\\nyellowish-white color. It is rare that the practitioner is consulted for\\nthe relief of this disorder it is usually discovered when the skin is\\nexposed for other purposes (exploration, vaccination, etc.). In a still\\nmore advanced degree the scales are massed, forming grayish and\\nwhitish, polyhedral elevations or plaques, regularly outlined and\\nclosely set together, especially upon the extremities and certain por-\\ntions of the trunk elsewhere the scaliness described above may be\\npresent in a more marked degree. Variations occur, in consequence\\nof which the plaques, bordered distinctly by the natural lines and fur-\\nrows of the skin, are even depressed, centrally or completely, or they\\nassume darker shades of color viz., brownish and greenish-brown.\\nIchthyosis Hystrix. With and without the symptoms detailed\\nabove, the hypertrophy of the skin may, in circumscribed patches or\\nlarger areas, produce irregularly shaped, verrucous, corneous, corrugated,\\nwrinkled, or rugous masses, usually much darker in color than the\\npatches seen in the simple variety of the disease, and more often also\\ndiscovered in adult years. The resemblance is here rather to the\\nrough bark of a tree than to the scales of a fish. In still rarer cases\\nthe excrescences assume a spinous, acuminate, or horn-shaped form.\\nThe hand passed over the skin-surface perceives not only the excessive\\nroughness, but also the dryness of the skin. Perspiration in some\\ncases is imperceptible in the parts affected. The nails are friable and", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0501.jp2"}, "502": {"fulltext": "472\\nHYPERTROPHIES.\\nindurated the scalp is scaly and covered with hairs of exceeding\\nharshness. The palms and soles are often spared. Kaposi describes\\ncertain diffuse callosities occurring in the palmar and plantar regions\\ndiffering from ichthyotic patches elsewhere. The face is usually spared,\\nbut, when involved, only the slighter manifestations of the disease appear\\nthere minute, superficial, scaly patches of a grayish tint.\\nLater studies of the hystrix type of ichthyosis have led to a modi-\\nfication of the view formerly held. To-day many disorders to which\\nFig. 56.\\nIchthyosis hystrix.\\nthe name ichthyosis hystrix was once given are classed with congenital\\nwarts, psorospermosis follicularis, nsevus unius lateris, and other simi-\\nlar affections.\\nIchthyosis is accompanied by insignificant subjective sensations.\\nThe skin, indeed, of these patients may be free from the eczematous and\\nother complications of the less diffuse keratoses. In four ichthyotic\\npatients who were syphilitic there was a decided tendency to the pro-\\nduction of lesions of the mucous surface without cutaneous efflorescence.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0502.jp2"}, "503": {"fulltext": "ICHTHYOSIS.\\n473\\nThe extensor are usually more implicated than the flexor surfaces of\\nthe extremities.\\nVariations from the types described above are noted by observers.\\nHibert l for example, in a case of congenital circumscribed ichthyosis\\nin a young woman, discovered a growth of thick hairs, one centimetre\\nlong, over the left shoulder and arm. Weisse 2 exhibited to the New\\nYork Dermatological Society a boy, ten years old, with hemorrhagic\\nfissures in an ichthyotic skin, double ectropion, corneal opacities, claw-\\nlike fingers, attachment of the ears to the sides of the head, and a gen-\\neralized condition of the skin which became very red when warm, some\\nFig. 57.\\nd\u00e2\u0080\u0094\\nIchthyosis hystrix, vertical section a, masses developed from the stratum corneum b, cones\\nformed by the re te c, hypertrophied papillae with dilated vessels; d, dense connective tissue of\\ncorium, exhibiting numerous vessels transversely divided. (After Kaposi.)\\ndoubt however existing as to the diagnosis. Extreme types of ich-\\nthyosis are seen in the so-called porcupine, rhinoceros, or hedge-\\nhog patients. In these unfortunate beings the entire skin is con-\\nverted into a rugged, bristling, warty, quilled, or horn-like envelope,\\nsuggesting the integument of the animals named. The terms Ichthyosis\\nSerpentina, Nacrea, and Nigricans are employed to designate those con-\\nditions, respectively, in which is recognized a snake-like appearance of\\nthe skin, silvery whiteness of the scales, or a dark pigmentation.\\n1 Virchow s Archiv., September 3, 1884, Bd. xcix.\\n2 Jour. Cutan. and Yen. Dis., 1883, p. 49.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0503.jp2"}, "504": {"fulltext": "474 HYPERTROPHIES.\\nIchthyosis Congenita Harlequin Fcetus). This exceed-\\ningly rare deformity occurs as an intra-uterine modification of the skin\\nof the foetus, which is usually brought into the world as a non-viable\\nmonstrosity. The skin is represented by a thick, horny cuirass, deeply\\nfurrowed and resembling plates of armor. Large flakes of corneous\\nepidermis, but partially attached to the corium, present their broad,\\nfree edges to the outer world. The ears, eyelids, and lips are usually\\nwanting, being replaced by corneous folds suggesting in appearance\\nthe corresponding features of a mummy. The fingers and toes resem-\\nble talons and claws. Death commonly occurs in the course of a few\\ndays from inability to secure nutrition by the act of sucking and from\\nimperfect development of other organs than the skin. Bo wen l believes\\nthat some of these deformities are due to a persistence of the epitrichial\\nlayer of the foetus.\\nSherwell 2 describes a case of congenital ichthyosis of unusual in-\\nterest from the fact that at the time of the report the infant had lived\\nto be more than five months old, and seemed to be gaining in strength\\nand improving in the condition of the skin. No history of heredity or\\nof a family tendency to deformities of the skin could be obtained.\\nIchthyosis Lingua psoriasis of the tongue is a disorder\\ndescribed by the French under the title leucoplasie. It is not a variety\\nof ichthyosis. (Cf. Lichen planus of the mucous membranes.)\\nViewing ichthyosis as thus exhibited in various manifestations, it\\nis seen to be a congenital deformity rather than a disease. It may be\\npartial or general, though usually the latter, with intense manifestations\\nover the extremities, especially over the extensor aspects and relative\\nimmunity of the face, the axilla?, the groins, the flexor aspects of the\\nlimbs, the palms and soles, the glans penis, and the prepuce. Like\\nxerosis, the deformity is rarely visible at birth, but usually becomes\\napparent before completion of the first year of life. It is first man-\\nifested in the regions of election named above i. e., over the elbows\\nand the knees and here also, as in xerosis, it may for some years\\nonly be apparent in northern latitudes in winter, disappearing almost\\nwholly in the summer season. When maturity is reached the deformity\\nhas been known to disappear temporarily under the influence of inter-\\ncurrent disease (variola). One patient is said to have regularly cast a\\nslough of his integument in the autumn. The general health is usually\\nunimpaired.\\nEtiology. Ichthyosis is unquestionably a congenital disease, though\\nits first manifestations are apparent only during the second year of life.\\nIt is said to be generally hereditary, but this statement should be ac-\\ncepted with some reserve for every individual case. One ichthyotic\\npatient, married to his cousin, had by her five children entirely free\\nfrom cutaneous disease. None of his parents or grandparents was simi-\\nlarly affected. The disease occurs equally in both sexes, and is liable\\nto aggravation in cold climates and during the season of winter. The\\ngeneral vigor and development of patients thus deformed are, as a rule,\\n1 Jour. Cutan. and Gen.-Urin. Dis., 1895.\\n2 Ibid., 1894, p. 385.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0504.jp2"}, "505": {"fulltext": "ICHTHYOSIS. 475\\nunimpaired. Kaposi says The cause appears to be a local anomaly\\nof the nutrition of the skin, especially involving its epidermic and\\nfatty elements.\\nThost l describes ichthyosis occurring in four generations. Accord-\\ning to the ascertained genealogy, the ancestor first known to have suf-\\nfered from this affection had five male children who inherited it, while\\none girl and one boy were spared. One of these affected subjects had\\nfive children, of whom three males showed the anomaly, w T hile one boy\\nand one girl remained free. Another brother, of the second genera-\\ntion, had five male and three female children of these, four boys and\\ntwo girls became affected. One of the latter (of third generation)\\nbore four children, of whom three girls inherited the disease, while the\\nfourth, a boy, escaped. It appeared that the affection always showed\\nitself within a few weeks after birth, in the form of a roughness of the\\npalmar and plantar surface. With the growth of the patient the con-\\ndition constantly increased in severity, the epidermis shedding in large\\nshreds, until the disease reached its maximum by the fourteenth year.\\nThere was a marked disposition to excessive sweating, particularly in\\nthe diseased localities the sensibility of the skin remained normal.\\nMicroscopic examination showed, in addition to hypertrophied papillae,\\ngreat development of the sw r eat-glands, with marked thickening of the\\nducts. Treatment failed to give more than partial relief.\\nIn the Molucca Islands and some other isolated regions ichthyosis,\\non account of its unusual prevalence, has been regarded as an endemic\\naffection but instances of this kind are readily explained, without\\nreferring to climatic influences, by the operation of heredity and inter-\\nmarriages.\\nPathology. In the mild forms Unna describes an immediate for-\\nmation of the horny layer from the rete without the intervention of\\nkeratohyalin. It is a complete cornification, the horny cells being\\nhomogeneous and containing no nuclear remnants. In this respect\\nthe hyperkeratosis is unusual, and contrary to the belief of many\\nobservers that cornification is impossible without the intervention\\nof the keratohyalin of the granular layer. The rete is thinned more\\nfrom an atrophic condition of the cells than from an actual diminution\\nof their number, though this does occur sometimes, so that only one or\\ntwo layers of cells cover the papillary tips. The lymph-spaces are also\\nvery small. The extremities of both the rete-pegs and papillae are\\nbroad and flattened and their necks narrowed, so that they suggest a\\ndove-tailed appearance. The coil-glands possess a swollen epithelium\\nand a widened lumen resembling their excretory ducts, which exhibit\\nless functional activity. The collagenous fibres are thickened at the\\nexpense of elastic, fatty, and lymphatic structures, and there may\\nbe a chronic low grade of papillary and perifollicular inflammation\\nwithout plasma-cells and with only a few mast-cells. The follicle-\\nmouths either w r ere dilated with a broad horny plug, or were closed,\\nretaining the plug in the dilated neck. In severe forms is noted a\\nproliferating rete with reappearance of the granular layer and a deeper\\ndipping down of horny substance, the cutis containing many plasma-\\nilnaug. Diss., Heidelberg, 1880; Centralbl. f. Chir., 1881, No. 10.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0505.jp2"}, "506": {"fulltext": "476 HYPERTROPHIES.\\nand mast-cells. In these severe forms there is less superficial exfolia-\\ntion, the dryness characteristic of the mild forms is wanting, and the\\ncondition is readily transformed into the clinical crusting type known\\nas ichthyotic eczema.\\nIchthyosis hystrix has, according to Kaposi, the anatomical structure\\nof all warts. Crocker finds that the lesions differ from plane warts in\\nthat the horny formation dips down deeply along the papillae.\\nIchthyosis congenita is believed by Bo wen 1 to be due to a per-\\nsistence of the epitrichial layer of the foetus. Wassmuth 2 has pub-\\nlished the results of a study of a case of ichthyosis congenita (hyper-\\nkeratosis diffusa congenita). He found the changes limited almost\\nentirely to the epidermis, the cutis showing only an insignificant chronic\\ninflammation of low grade. As compared with normal skin, the pap-\\nillae were much more numerous, broader and flatter, with greater irregu-\\nlarity in form and size. The layers of the rete were thickened and the\\ncells of the epithelial pegs assumed a spindle form. Nearer the surface\\nthey became polygonal. A granular layer could be made out definitely\\nonly on the scalp. The horny layer varied in thickness on different\\nportions of the body, but averaged two hundred times thicker than\\nnormal. The sweat-glands were greatly increased in number, but\\notherwise normal. Deformities of the sebaceous glands were caused\\nsometimes by keratinization of the follicle-mouths. The hairs grew\\nquite normally except for their deformed shape, caused by the thick\\nand dense horny layer.\\nDiagnosis. Ichthyosis not only presents features which are so\\ncharacteristic as to be unmistakable, but also those which can be well-\\nnigh perfectly portrayed in plates. In this respect it differs from a\\nlong list of cutaneous maladies. 3\\nWhenever necessary in the establishment of a diagnosis, aid of an\\nimportant character can be obtained in the history of the disease and in\\nrecognition of the absence of the lesions and lesion-sequels exhibited in\\nthe exudative and scaling affections heretofore considered. The most\\nconspicuous characteristic of ichthyosis as distinguished from psoriasis,\\nlichen ruber, and pityriasis, is the absence of inflammatory phenomena.\\nTreatment. The younger the patient applying for relief the larger\\nare the chances of improvement and of possible recovery. Ichthyosis\\nhystrix of mature years is practically incurable. Internal treatment is\\nvalueless. External treatment is directed to softening, macerating, or\\nanointing the skin, and, so far as practicable, to preserving it in a softer\\nstate. This softening is accomplished by frequent baths, alkaline,\\nvaporous, or combined with the use of soap or green soap, and generally\\nfollowed by an anointing with vaselin, dilute glycerin, or lard. The\\nFrench, after the removal of the denser layers of the horny plates with\\nthe aid of soft soap and water, anoint the body by friction with glycer-\\nolate of starch. Almond-, cod-liver, linseed-oil, or lanolin may be\\nused after the bath. Only by the most assiduous perseverance is a\\ndesirable result obtained and permanently secured. In the severe\\n1 Jour. Cutan. and Gen.-Urin. Dis., Dec, 1895.\\n2 Beitrage zur path. Anat. und allgemein. Path., 1899, p. 19.\\n3 Cf. portrait of- the ichthyotic skin in Plate F of Duhring s Atlas.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0506.jp2"}, "507": {"fulltext": "ONYCHA UXIS. 477\\nhystrix varieties the most annoying projections and rugosities may be\\nremoved by excision, by the Paquelin knife, or, less preferably, by the\\naid of caustics.\\nSubcutaneous injections of 1 grain (0.06) of pilocarpine have been\\npractised in ichthyosis, in order to induce sweating, with a view to\\nmaceration of the skin. Van Harlingen recommends the following for\\nuse when the epidermis begins to shed after the application of soft soap\\nR\\nPotass, iodid.,\\nBj;\\nl\\n01. pedis bubuli,\\nAdipis,\\naa ^ss\\naa 15\\nGlycerin.,\\n3j;\\n4\\n33\\nM.\\nAnderson recommends the wearing of pure vulcanized India-rubber\\ngarments, a method of treatment too exhausting for all cases.\\nTaking a general survey of the therapeutic management of ichthy-\\nosis and its results, the course to be advised for the majority of patients\\nis clear. With but few exceptions, the subjects of this deformity are\\neither entirely relieved or greatly better during hot weather and in\\nmoist atmospheres. Marked exceptions to this rule, however, occur.\\nUnder these circumstances, and having regard to the essential fact that\\nthe deformity is lifelong in duration, patients should always, when prac-\\nticable, select for permanent residence a climate most conducive to the\\ncomfort of the skin. There is no step which the ichthyotic patient can\\ntake comparable in value with the selection of a suitable environment.\\nPrognosis. Having in view the facts set forth above, it will be\\nclear that in no case can a favorable result be anticipated with respect\\nto a cure of the deformity. Treatment, persistent, prolonged, and\\nproperly directed in connection with suitable climatic influences, may\\ndo much to improve the condition of the skin.\\nONYCHAUXIS.\\n(Gr. bvv^ a nail avtjea), to grow.\\nSymptoms. This may be a congenital or acquired disorder. The\\nnail-substance may be developed to an unusual extent either as an idio-\\npathic or as a symptomatic affection, and in each case the nails may simply\\nbe increased in volume, extent, or number, or may exhibit such increase\\nin connection with secondary changes. Thus, the nail may develop to\\nan extraordinary length or breadth, preserving its general character as\\nregards texture, color, and position or it may also be changed in any\\nparticular, becoming opaque, discolored, dirty yellowish, and blackish\\nor brownish rugous, furrowed, horny, and rigid thickened in one\\npart and thin, vitreous, and extremely fragile in another tilted to one\\ni side or the other on its bed or projected backward in recurved,\\nirregular lines. Finally, the matrix may be inflamed, suppurating,\\nhemorrhagic, or the seat of an excruciating pain. One or more of the\\nnails may be affected in some cases the entire twenty are similarly\\ninvolved. The conditions of hypertrophy, atrophy, and dystrophy of\\nthe nails are frequently present in a single case, and it is often difficult\\nto say which process is the most prominent,", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0507.jp2"}, "508": {"fulltext": "478 HYPERTROPHIES.\\nThe diseases in which these changes occur as symptomatic lesions\\nare numerous, since it is evident that the matrix, from which the nail\\nis produced, would scarcely enjoy immunity in the case of profound\\nalteration of the skin in its vicinage. Thus, eczema, lepra, psoriasis,\\nlichen ruber, syphilis, scarlatina, perforating disease of the foot, va-\\nriola, and other diseases are attended by changes of various grades of\\nseverity in both matrix and nail.\\nIn the condition termed Paronychia (Whitlow) one or both\\nlateral borders of the nail bury themselves deeply in the tissues adja-\\ncent, producing thus an exquisitely tender and painful state of the\\nsoft parts, which may suppurate or surround the attached flange of the\\nnail with exuberant granulations. This condition is more frequently\\nobserved in the nails of the toes, as these appendages of the skin of the\\nfeet are liable to injury from the pressure of ill-fitting boots, gaiters,\\nor shoes. In the condition described as Onychia the matrix is not\\nonly inflamed, but the nail-substance is, as a consequence, texturally\\nchanged. No strict line of demarcation, however, can be described\\nbetween the two conditions. The term Onychogryphosis has been\\nemployed to describe the contorted deformities which cause the nail to\\nresemble a claw.\\nOnychomycosis is the name given to that condition in which the\\nnail-substance is invaded by vegetable parasites. In such cases the\\nnails become opaque, discolored, and thickened, with a noticeable fria-\\nbility at the projecting border.\\nSyphilitic Onychia is the condition in which one or several of\\nthe nails may become affected, though it is quite characteristic of the\\ndisease to exhibit limitation to the extremity of a single digit. In\\nsuch a case there is usually a marked involvement of the peripheral soft\\nparts, which may be infiltrated with gummatous material, though the\\nnails may be extensively damaged when the soft parts of the fingers are\\napparently normal. The bullous syphiloderm, among the congenital\\nmanifestations of the disease, will at times form beneath or quite near\\nthe nail, thus endangering its integrity. In both forms ulcerative\\nresults are common, with secretion of a foul discharge.\\nIn the affection termed perforating disease of the foot all the\\nnails of the organ affected may exhibit a characteristic onychauxis or\\ndystrophy.\\nTraumatism (constant or intermittent pressure of shoes) may aug-\\nment the size of the nail in one or another diameter and the deformed\\ntalons resulting from gross and long-continued neglect (East Indian\\ndevotees, etc.) are illustrations of another type of hyperplasia. Super-\\nnumerary nails may be found on supernumerary fingers and toes or\\ndouble organs on a single digit or in unusual situations, as over the\\nscapula (Tulpius) or on a digital stump or in an ovarian cyst.\\nWith respect to onychauxis proper, two forms are recognized in\\nthe first, the nail-cells are more closely set together and the resulting\\nhypertrophy is declared, not in changes in bulk of the nail, but in a\\ndense, thick, opaque, glossy, grayish-white transformation of the organ.\\nThe nail is perceptibly increased in weight and becomes so solid that it\\ncannot be cut with ordinary implements. It may be also, though not", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0508.jp2"}, "509": {"fulltext": "PLATE XI.\\nSyphilis of the Nails.\\nI (From a photograph.)", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0509.jp2"}, "510": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0510.jp2"}, "511": {"fulltext": "ONYCHA UXIS. 479\\nchanged in bulk, altered in shape, its free border being curved down-\\nward or upward.\\nThe second form represents a visible hypertrophy in bulk, the nail\\nbeing enlarged in one or several diameters. Enlargement in a trans-\\nverse diameter necessarily involves the soft parts adjoining. Vertical\\nhypertrophy results in any one of the claw- or talon-like forms of\\nonychogryphosis.\\nEtiology. Onychauxis may be congenital or acquired, idiopathic\\nor symptomatic, and be due to inflammatory changes in the corium or\\nmatrix of the nail to traumatism to defective hygienic care of the\\ngeneral surface of the skin, including the nails and perhaps, in ex-\\nceptional cases, to senile influences.\\nTreatment. The treatment of the disorders of the nails described\\nabove is largely that of the maladies in which they occur. Arsenic\\nand iron are often indicated in these aifections, and their influence upon\\nthe nutrition of the nail cannot be questioned. In syphilitic onychia\\nthe constitutional treatment of the disease is essential. The cutting,\\nscraping, and trimming of the nail with the aid of the useful instru-\\nments found in the chirop Klist s case are important measures in many\\npatients.\\nThe treatment of ingrowing toenail varies with the extent of the\\ndisease. In mild cases soft threads of charpie are insinuated between\\nthe offending border of the nail and the tender surface upon which it\\npresses. Counter-pressure by plaster and the local use of a crayon\\nof silver nitrate may be at times employed with advantage. In severe\\ncases the nail mav be removed, though this is generally unwise. The\\nsoft parts are, by some surgeons, completely removed from the side of\\nthe nail by means of a thin-bladed bistoury, and the nail permitted to\\ngrow down upon one side of the extremity of the distal phalanx, thus\\nprotecting the cicatrix and radically preventing recurrence of the\\ndisease.\\nThe proper dressing of the feet in onychauxis of the toes is a matter\\nof great importance. The shoes and socks or stockings should be ad-\\njusted both as to texture and shape to the special requirements of each\\ncase. After the hypertrophied tissue is largely removed by cutting or\\nscraping the phalanx may be enveloped in a plaster-mull or salve-\\nmuslin of diachylon ointment, or with mercurial plaster, and the whole\\nbe covered with a leather or a rubber cot.\\nThe Prognosis in these disorders of the nails rests entirely upon\\nthe nature of the malady in which they occur. Idiopathic and localized\\nchanges, as also those occurring in transient cutaneous diseases (e. g.,\\nthe exanthemata), often terminate favorably. In severe constitutional\\nor grave cutaneous diseases the outlook is less promising. The diseases\\nof the nail are usually more obstinate and less amenable to treatment\\nthan the similar affections of the softer parts. In cases in which there\\nis congenital disease of the nails a prognosis should be made with\\nreserve.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0511.jp2"}, "512": {"fulltext": "480\\nHYPERTROPHIES.\\nFig. 58.\\nHYPERTRICHOSIS.\\n(Gr. virepj in excess dpi!;, hair.)\\n(Hypertrophy of the Hair, Hairiness, Hirsuties, Hyper-\\ntrichosis, Polytrichia, Trichauxis. Fr., Poils acci-\\nDENTELS.)\\nThis anomaly may be congenital, and may occur in various\\ngrades. It is common to see infants at birth with extremely long\\nhairs on the hairy part of the\\nbody, this growth being usually\\nreplaced later by shorter fila-\\nments. Universal congenital hir-\\nsuties is a rare deformity, the\\nentire body being then covered\\nwith longer or shorter downy\\nhairs of various colors.\\nAcquired hirsuties may be par-\\ntial or universal, much more com-\\nmonly the former. Thus, the\\nhairs of the scalp or the beard\\nmay acquire an enormous vigor\\nand length, reaching to the\\nground when the body is in the\\nerect position or the hypertrophy\\nof the hairs may affect the face\\nof the child or the woman and\\nin persons of the sex last named\\neither the upper lip, chin, cheeks,\\nor all portions of the body usually covered by hairs in man, may be\\nprovided with a vigorously and symmetrically developed pilary growth.\\nRemarkable instances of universal congenital hirsuties are occasion-\\nally observed. The so-called Russian dog-faced man (Andrian\\nJeftichjew) and his son were noteworthy illustrations of this anomaly.\\nIn most cases the influence of heredity is distinct and is often accom-\\npanied by defective dental development, such as entire absence of\\nmolar or of canine teeth. In all cases of hypertrichosis, whether con-\\ngenital or acquired, the parts normally unprovided with hair are not\\nthe seat of the pilosis.\\nAs the growth of the beard in man is more or less associated with\\nthe maturity of the sexual organs, so the hypertrichosis of women and\\nchildren is at times related to a precocious, perverted, or arrested func-\\ntion of the generative organs. The reported instances of menstruation\\nin female infants and children usually include a description of abnormal\\npilary development about prematurely developed pudenda; and after\\nthe climacteric period, when some women conspicuously in external\\nappearance begin to resemble individuals of the opposite sex, either\\nisolated, thick, bristle-like hairs develop over the chin or lips, or the\\nextreme hirsute condition may be reached. Duhring 1 reported one\\n^rch. of Derm., April, 1877.\\nThe Russian Doer-faced Man.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0512.jp2"}, "513": {"fulltext": "HYPERTRICHOSIS. 481\\nsuch case, which is illustrated by a lithograph representing the face of\\na woman provided with a superb beard.\\nThe influence of the sexual organs in the hypertrichosis of women is\\nwell demonstrated in the following case coming under our observation\\nA married woman, thirty-three years of age, weighing one hundred\\nand fifty pounds, mother of three healthy children, applied for relief\\nof a general and facial hirsuties which had resulted in the growth of a\\nfull beard and moustache. She had not menstruated for more than a\\nyear, and had been pronounced by an expert to be past the climacteric.\\nDuring 1884 and 1885 the hairs of the face were removed in succes-\\nsive operations by the electrolytic method described below. Menstrua-\\ntion began while she was subject to the influence of the galvanic cur-\\nrent in the operating-chair, and continued thereafter irregularly, at\\ntimes with intense pain and even menorrhagia. In 1886, after the last\\nof the operations on the face, she rather suddenly lost in weight,\\ndecreasing to one hundred pounds, and began to menstruate regularly\\nand painlessly. The hypertrichosis of the general surface then spon-\\ntaneously disappeared. In the latter part of the year she again con-\\nceived, and in March, 1887, being then free from any form of hirsuties,\\nshe brought a healthy male child into the world.\\nAs the result of the persistent application of stimulating and oily\\nliniments over a region of the body (scapula, sacrum, sciatic notch, etc.),\\nas also after traumatism by pressure or otherwise, a growth of long and\\nnumerous hairs is often produced. Care should be had in the manage-\\nment of cases of acne and rosacea in the persons of dark-skinned\\nyoung women with luxuriant hair upon the head, lest a similar growth\\nbe produced upon the chin, cheeks, or nose.\\nIn cases of hypertrichosis the hairs may be colored variously, and\\nthe hypertrophy of dow T ny hairs purely be numerical, or result in\\nincrease in the actual size of the shaft of the individual filaments. In\\nneither case do the hairs present any anatomical peculiarities of struc-\\nture. The localized congenital form of hirsuties is often characteristic\\nof certain moles, known as N-ZEVi Pilosi. The surface of pigmentary\\nmoles (N^evi Pigmentosa) is often very extensively covered with hairs\\nof a dark color. Singular anomalies have been figured in which exten-\\nsive regions (one or several limbs, the entire back, even the greater\\npart of the body) were the seat of enormous pigmented moles, covered\\nwith warts, fibromata, and other benign tumors, and clothed with a\\nthick covering of longer or shorter hairs. 1 All such cases exhibit a\\nstriking development in either symmetrically or asymmetrically dis-\\nposed areas of distribution of cutaneous nerves.\\nThe Hypertrichosis Neurotica of authors is that condition in\\nI which an excessive growth of hair has succeeded spinal paralysis and\\ni other morbid conditions of the nervous centres. Under the title Tro-\\nphoneuroses of the Skin in this work are described changes of a similar\\nkind, in which there is association of hypertrichosis with hyperidrosis,\\nchanges in the nails, and even extensive tylosis of the palms and soles.\\nPlica Polonica was formerly supposed to be a disease peculiar to\\n1 See the authors case of nsevus lipomatodes in a child, the pilary growth being at\\n1 that age undeveloped. Jour. Cutan. and Ven. Dis., July, 1885.\\n31", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0513.jp2"}, "514": {"fulltext": "482 HYPERTROPHIES.\\nPoles (whence its name), but which has long been recognized as a re-\\nsult merely of persistent neglect, filth, the invasion by parasites, and\\nconsequent exudative disorders of the scalp. When it exists the hairs\\nform a huge matted mass on the crown of the head. Hebra devotes an\\ninteresting chapter to the superstitious awe with which this accumula-\\ntion of hairs, lice, and filth has been regarded. In Alaska a number\\nof cases of plica have been observed among the natives of that region.\\nA typical case of this deformity was lately presented at our clinic.\\nNeuropathic Plica. Le Page l described a case in which tangled\\nlumps and festoons of hairs, flat, curled, looped, and inter-\\ntwined appeared on one side of the head of a girl seventeen years old,\\nwho had previously suffered from neuralgic pains in the site of the\\ngrowth.\\nEtiology. The causes of hypertrichosis are obscure. It is clear that\\nwhatever determines the blood in excess to any region of the body sup-\\nplied with hair-follicles may indirectly be the cause of hypertrophy of\\nhair, a fact demonstrated in patients who, after applying sinapisms\\nor liniments for years to the skin over the seat of a rebellious neuralgia,\\nexhibit in this region an abundant growth of hair, often several inches\\nin length. In women, whose sex renders the anomaly most deforming\\nand distressing, it is noted, as has been observed, in precocious, per-\\nverted, or arrested activity of the sexual function. It may be a racial\\npeculiarity, a family trait, an inherited anomaly, or an epiphenomenon\\nin dwarfs, monsters, individuals affected with club-foot, insanity, and\\ncongenital deformities of several kinds. The neurotic conditions\\naccompanying certain varieties of hirsuties may be inappreciable or\\nevidently be due to traumatism or be exhibited in paralyses, muscular\\natrophy, etc.\\nTreatment. To Hardaway, of St. Louis, Americans are indebted\\nfor the popularization of the method of removing superfluous hairs by\\nelectrolysis, first devised by Michel, of his city. Extensive pilary\\ngrowths are now often removed by this method without subsequent\\nreproduction of the hairs. A fine needle is introduced into the hair-\\nfollicle and gently passed down to the papilla at its base. This instru-\\nment is connected with the negative pole of a galvanic battery contain-\\ning six or more elements, the positive pole of which is in connection\\nwith a sponge-electrode held in the patient s hand, who is thus enabled\\nto make or break the circuit at will. When the current is passed a\\nfew minute bubbles of gas escape from the orifice of the follicle, and\\nwhen the hair-papilla is destroyed the hair itself is readily extracted.\\nThe dexterity acquired by practice is requisite for the proper perform-\\nance of the operation, with a view particularly to the insertion of the\\nneedle at the proper angle into the follicle. Few patients complain of\\npain. The number of hairs removed at a sitting varies with the sensi-\\ntiveness of the patient s skin. The resulting scar is quite imperceptible\\nor far less disfiguring than the hirsuties, suggesting the appearance of\\nthe male beard after shaving. Transitory macules, papules, pustules,\\nand wheals occur at the site of puncture. Care should be taken not to\\nBrit, Med, Jour., January 26, 1884, p. 160,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0514.jp2"}, "515": {"fulltext": "HYPERTRICHOSIS. 483\\ninsert the needle too deeply in the particularly vascular regions of the\\nface, as an aneurysmal tumor might be produced as a consequence.\\nEvery detail of this exceedingly simple operation has now been\\ncarefully studied by American operators, and the results, as confirmed\\nby our experience, may be given as follows\\n1. Any good galvanic battery may be employed. We use habitu-\\nally a forty-cell stationary battery, the switchboard of w T hich is so\\narranged that any number of selected cells may be brought into the\\ncircuit. A galvanometer should be placed in the circuit indicating a\\ncurrent of from one-half to four milliamperes. The number of cells\\nemployed should vary with different individuals, different parts of the\\nface, and on different days with the same individual e. g., a smaller\\nnumber is required when a patient previously operated upon returns\\nafter a somewhat long period of rest. Two to four cells only may be\\ntolerated over the tip of the nose or the upper lip near the septum nasi.\\nTwelve to twenty may be well borne, after some experimenting, on an\\ninsensitive chin.\\n2. The best needle is a carefully selected, fine jeweller s broach, its\\nshaft and point being annealed by rapid passage through the flame of\\nan alcohol lamp. It is often useful to have the point also well rounded\\non an emery-wheel. Irido-platinum needles are useful, but inferior\\nfor general work to a broach.\\n3. The needle-holder should be simply a convenient insulated\\nhandle, sufficiently long to protect all the points of the operator s right\\nhand from the current, and should be as light as possible, since a\\nheavy holder interferes with delicacy of touch. Duhring s holder,\\nwhich is of the shape of a thin lead-pencil or pen-holder, is about four\\ninches in length. The handle, or stem, is of hard rubber, through\\nwhich passes a metallic rod, acting as a conductor for transmission\\nof the current. The needle is inserted into the needle-holder proper,\\nwhich is slotted, the needle being clamped immovably by means of a\\nscrew-nut. In the other end of the stem is an insulated inserting-pin\\nattached to the cord leading to the battery. The instrument is con-\\nvenient to handle and altogether well adapted to the operation.\\n4. The patient should be seated or reclining at ease in a good light,\\nwith the handle of the electrode connected with the positive pole of the\\nbattery in one hand, ready to press the sponge into the palm of the\\nother. In this way, at the bidding of the operator, the patient makes\\nand breaks the circuit at will. The sponge attached to the holder\\nshould be wet with a solution of salt and water.\\n5. As to further details of the operation, it is well (a) to make and\\nbreak the connection only when the needle is in situ, as this diminishes\\nthe pain of the operation (6) to introduce the needle with a gentle ma-\\nnipulation (acquired only by skill and well characterized by Hard-\\naway as a catheterization of the hair-follicle), observing a certain\\ndegree of parallelism with the hair-shaft as the needle enters (c) to\\noperate leisurely, making sure that the current is not broken by sep-\\naration of the hands of the patient before the hair is completely free\\nin the follicle. This last can be ascertained by gentle traction on the\\n1 Amer. Jour. Med. Sci., July, 1881.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0515.jp2"}, "516": {"fulltext": "484 HYPERTROPHIES.\\nshaft in from twenty to forty seconds after insertion of the needle\\n(d) to operate in succession upon contiguous hairs Avhen practicable, not\\nselecting one here and one there, the latter course being productive of\\ngreater pain (e) never to use the positive pole in connection with the\\nneedle, an error which results in the production of unsightly pigmented\\nblemishes on the surface of the skin.\\nThe previous employment of preparations of cocaine both hypoder-\\nmatically and by inunction e. g., cocaine oleate to relieve or diminish\\nthe pain of the operation, may be followed by exceedingly unpleasant\\nconsequences. A dermatitis thus induced may persist for months.\\nPrince, of Boston, 1 lays stress upon the accurate regulation of the\\ncurrent by the aid of the absolute galvanometer, which we have found\\nin practice useful but not essential. Fox, 2 of New York, reports a\\ngradual decrease in the number of hairs returning after operation,\\nproportioned to the improvement in the instruments and the skill\\nof the operator. The percentage of such returns varies with these\\nconditions.\\nAll patients affected with hirsuties are not to be advised the opera-\\ntion. We have declined to operate in many cases which were not\\ndeemed to belong to the class in which the best results of the operation\\nmay be expected. Young and vigorous women, usually unmarried,\\nmay point out hairs to be removed that are merely full-developed fila-\\nments of a thick downy growth, all the hairs of which are rapidly\\npushing to equal maturity. Here the operation itself, by inducing\\nhyperemia of the skin, may simply hasten the hypertrichosis actually\\nin progress, and thus aggravate the disorder. In most cases, when an\\noperation is undertaken, both parties should fully understand the possi-\\nble issue. It is a question whether it lies within the legitimate sphere\\nof the physician to remove superfluous hairs from the habitually covered\\nbreasts and arms of women.\\nThis operation has unfortunately found its way into the hands of\\nthe unprincipled and the ignorant, who, in their efforts to extract\\nmoney from the credulous, have in some of the larger cities brought\\nelectrolysis for hypertrichosis into ill repute. The operation is, how-\\never, all that can be desired if only it be performed with sufficient\\nskill and conscientiousness but if hairs are rapidly plucked away from\\ntheir follicles while an electric current is passing merely, the return\\nof each filament is prompt and mortifying to the patient. It should,\\ntherefore, be understood as a procedure requiring ample time on the\\npart of the operator, and either fairly good vision or eyes aided by a\\nmounted lens. Not more than from forty to sixty hairs can be re-\\nmoved in an hour by an expert operator and there are few who can\\nwork with advantage more than one hour at a sitting, or more than one\\nor at most two hours in a day.\\nHairy nsevi may be removed by complete excision, but removal of\\nthe hairs by electrolysis will sometimes result in disappearance of the\\nentire growth without such operation.\\n1 The Exact Measurement of the Electric Current, and other Practical Points in\\nthe Destruction of Hair by Electrolysis.\\n2 The Use of Electricity in the Kemoval of Superfluous Hair, etc. Detroit, 1886.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0516.jp2"}, "517": {"fulltext": "HYPERTRICHOSIS. 485\\nFreund, 1 Wood, 2 and others report removal of hair with the a ray.\\nFrom six to twenty-four exposures are necessary, and in the majority\\nof cases the hair eventually returns. In a few instances the result has\\napparently been permanent. By the careful and skilful use of brief\\nexposures dermatitis and other unfavorable results may be avoided.\\nDepilatories for the removal of superfluous hairs operate by the de-\\nstruction of the filament without obliteration of the papilla. The con-\\nsequence is that the hairs are reproduced in the course of about a fort-\\nnight. Most of the compounds used for this purpose contain either\\ncalcium sulphate, arsenic sulphate, or barium sulphide, made into a\\npaste with warm water. This paste is applied over the hairy surface\\nwith a spatula, and is permitted to remain until it dries, or produces a\\nsensation of heat or burning, a period usually requiring ten minutes.\\nIt is then rapidly removed by scraping with a spatula, and the surface\\nthoroughly cleansed with warm water, after which the skin is anointed\\nwith cold-cream salve or other similar unguent.\\nOf these depilatories Duhring recommends the following\\nR Barii sulphidi, 3ij 8\\nPulv. oxid. zinc., ___... --10\\nFmv. amyl., J J M.\\nTo be prepared in form of an impalpable powder, which, just before\\nusing, is to be mixed with water to form a thin paste.\\nThe following are formulae devised by French authors\\nR Sodii hydrosulphit, 3iij 12\\nCalcis, _ .a\\nAmyli pulv., J aa S *l aa 40 M.\\nTo be finely triturated, and, when used, to be made in a thin paste\\nwith water. (Boudet.)\\nR Calcis, 5j 4\\nSodii carbon., 3jss 6\\nCerat. adipis, ^j 30\\nTo be applied as a depilatory in the manner of a paste.\\nM.\\nAll these formulae require caution in their use, and they should\\nrarely be intrusted to patients themselves.\\nShaving may be practised upon the hirsute face of women, and,\\nwith a similar end in view, also epilation the latter, particularly in\\ncases of hypertrophy of the hair limited in extent. Partial success\\nhas attended the thrusting into the follicles of needles previously\\n[dipped in caustic solutions, or heated in various degrees, but these\\nmethods are inferior to electrolytic destruction of the hair-papillae.\\nThe hairs may be rendered less conspicuous by bleaching them with\\nfrequent applications of hydrogen peroxide. Bulkley 3 states that a\\nthorough use of this remedy retards the growth of fine hairs.\\nx Wien. klin. Woch., September 23, 1899.\\n2 Lancet, January 27, 1900.\\n3 Jour. Amer. Med. Assoc, December, 1899.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0517.jp2"}, "518": {"fulltext": "486 HYPERTROPHIES.\\n(EDEMA NEONATORUM.\\n(Edema of the newborn is characterized by the occurrence of an\\nindurated tumefaction of the skin, most noticeable in the lower ex-\\ntremities of infants affected with impaired circulation.\\n(Edema and sclerema of the newborn have long been confused. The\\ndistinction between them was first well established in 1877, when Par-\\nrot, under the title Athrepsie, first described with clearness the\\nmorbid condition now recognized as oedema neonatorum.\\nSymptoms. The disease, which is of exceedingly rare occurrence\\nin America, is observed in infants prematurely brought into the world\\nor at term, and of feeble vitality. Between the first and the third day\\nafter birth the child is found to be drowsy and difficult to waken, with\\nthe posterior and other parts of the thighs and legs, the hands, and\\nthe genital organs pallid, cold, livid, and retaining the impress of the\\nfinger as do oedematous tissues in general. At this point recovery may\\nensue, but in severe cases the oedema spreads, always more markedly in\\nthe lower portions of the body, and the skin becomes violaceous red, deep\\nyellowish, or dirty looking. As the disease advances the integument\\nbecomes more and more difficult of indentation. Meanwhile the little\\npatient becomes more drowsy, its respirations fewer, its cry weaker,\\nand its temperature lower. Death may ensue from a pulmonary com-\\nplication, from diarrhoea, or from any intercurrent disorder. Usually\\nthe child passes into a state of coma. When recovery ensues the oedema\\nbecomes less marked and the indurated skin more and more impressi-\\nble. A few days, in satisfactorily managed cases, suffice to restore the\\npatient to a condition of health. In some instances the oedema begins\\nin other portions of the body than those named and in cases there is a\\nmarked febrile reaction.\\nEtiology. The recognized causes of the malady are prematurity\\nof delivery, exposure to severe cold soon after birth, poor hygiene,\\natelectasis of the lungs, and inability to take the nipple. Blacker, 1\\ndescribes a case, seemingly typical, in which there was no evident\\netiology. The child at five weeks was perfectly well and properly nour-\\nished, but still retained the hard oedema of the buttocks, thighs, part\\nof the arms, and chest. The mother was always well, and the preg-\\nnancy, labor, and puerperium presented no unusual features.\\nPathology. All cases show an effusion of yellow serum into the\\nsubcutaneous tissue, possibly in consequence of the enfeebled action of\\nthe heart, and the fat on excision is found to be particularly dense\\nand yellowish. Enlarged liver, pulmonary congestion, venous throm-\\nbosis, and nephritis have been recognized in a small number of cases.\\nDiagnosis. The distinction between oedema and sclerema neona-\\ntorum is not made without difficulty, the disorders greatly resembling\\neach other. In sclerema the joints, and particularly the jaws, are\\nimmobile the disease is likely to be generalized the firmness of the\\nintegument is greater and there is no tendency to an oedema chiefly\\nmarked in dependent parts of the body, as over the lower limbs.\\nThe color of the skin in the two disorders may be nearly the same.\\n1 Brit. Jour, of Derm., 1898, vol. x., p. 87.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0518.jp2"}, "519": {"fulltext": "SCLEREMA NEONATORUM. 48?\\nThe pitting on pressure of the swollen skin is highly characteristic of\\noedema neonatorum. Scleroderma does not occur in children before\\nthe close of the first year.\\nThe Prognosis is grave but with proper treatment recovery may\\noccur when the oedema is not generalized.\\nThe Treatment is that of scleroderma neonatorum.\\nSCLEREMA NEONATORUM.\\n(Gr. GK?i7fp6c hard; v\u00c2\u00a3ov f new; yevvau, to bring forth.)\\n(Scleroderma Neonatorum. Fr., Sclereme des Nouveau-nes.)\\nThis disease is not to be confused with oedema neonatorum, from\\nwhich it is wholly distinct.\\nSymptoms. At birth, or between the second and the tenth day\\nafter, the lower limbs of the child assume a livid or whitish-yellow\\nappearance, occasionally suggesting the hue of wax and they become\\nof a leathery consistency. This condition spreads gradually over the\\nlumbar region, the dorsum of the body, and the chest in front and\\nbehind, and in the course of a few days may involve the entire in-\\ntegument. When pressed upon with the finger the skin produces the\\nimpression of half-frozen tissue the face suggests a cold and rigid\\nmask the thighs in their sockets and the arms in the shoulder-joints\\nare immobile. Usually there is somewhat less firmness of the abdom-\\ninal integument. The taking of the nipple, deglutition, and even the\\nopening of the oral orifice are effected only with great difficulty,\\nand eventually become impossible. The respirations are shallow and\\nimperceptible the pulse in well-marked cases is imperceptible at the\\nwrist and the thermometer in the rectum is not raised to the lowest\\nregister of the ordinary clinical instrument. There is often no cry.\\nThere may be a coincident icterus and often sprue has been observed\\nin the mouth before the declaration of well-marked symptoms. The\\ncongenital patients are often stillborn. The majority of subjects of the\\ndisease perish before the ninth day.\\nEtiology. The immediate cause of the malady is retardation of the\\ncirculation in the cutaneous capillaries, and this may depend upon prior\\ndisease (pleuro-pneumonia, intestinal disorders) or upon conditions oper-\\nating before or at birth (congenital anomalies of lymphatics, syphilis,\\nfeeble vitality).\\nPathology. Ballantyne has observed a small-cell growth in the\\ncorium, of perivascular situation Langer ascribes the condition to ex-\\ncess of fatty acids in infants as compared with adults, with the result of\\nf producing a fat consolidation. In JNTorthrop s cases 1 no fluid escaped\\non section of the tissues, which were as semisolid as if frozen scattered\\nhemorrhages involved the alveoli, connective tissue, and lymph-spaces\\nof the lungs, but there was no collapse. According to Ballantyne, the\\ndisease is due to overgrowth of connective tissue leading to atrophy of\\nthe fat-cells and is dependent upon a trophoneurosis. Parrot recognized\\n1 Arch, of Peediat,, 1890, vol. vii.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0519.jp2"}, "520": {"fulltext": "488 HYPERTROPHIES.\\nthe fact that the connective-tissue trabecule were more numerous and\\nthicker than in other cases.\\nThe Treatment of both oedema and sclerema neonatorum is by ele-\\nvating the body-temperature (in an incubator, wrapping the entire body\\nin wool, warm water-baths, etc.), and by improving the nutrition in\\nevery possible way (sterilized milk and stimulants by the stomach-\\npump, through nose or pharynx). The body may also be well rubbed\\nwith warmed oil or camphorated alcohol. Brocq suggests friction with\\nthe warm hand from below upward.\\nSCLERODERMA.\\n(Gr. GKkrjpoQ, hard depjua, the skin.)\\n(Hide-bound Skin, Dermatosclerosis, Chorionitis, Scleriasis,\\nSclerema Adultorum. Ger., Hautsclerem; Ft., Sclero-\\nDERMIE.)\\nSymptoms. [A] Diffuse Symmetrical Scleroderma. The skin-\\nsymptoms of the disease may be preceded by prodromic pains of a\\nrheumatismal character, or by singular cutaneous sensations (pricking,\\ntingling, formication), or by muscular cramps, and neurotic sensations.\\nIn some instances, also, there are vesicles, blebs, scales, local hyperi-\\ndroses, or losses of sensibility in the skin which is about to become the\\nseat of the disorder.\\nWith and without these prodromic features the skin and subcutane-\\nous tissue, chiefly of the upper portion of the body, become symmet-\\nrically involved either in a gradually increasing induration or in an\\nobscurely defined oedema of a firm character which at first pits under\\nstrong pressure with the finger, but later becomes as indurated and tense\\nas hard leather. The integument is usually exceedingly difficult to\\npick up between the finger and thumb, and is shining, smooth, waxy,\\nor of alabaster-like hue in other cases it is of a dirty-yellowish, grayish\\nshade. This is the stage of infiltration, and when pronounced it is not\\nto be mistaken for any other condition. The face may be, both to the\\neye and the finger, mask-like, immobile in features, and expressionless.\\nThe lips are then stiffened and opened with difficulty the eyelids are\\nsimilarly but much less severely involved. The back of the neck may\\nbe firm the chest, shoulders, and arms may be either immobile or\\nmovable with difficulty the ribs are often bound down so firmly by\\nthe cuirass of leathery integument that respiration may be impeded\\nseriously. The temperature is not changed, and sweat may or may not\\nbe exuded over the affected areas. The abdominal surface is relatively\\nspared. This condition may come on insidiously, and may require\\nyears for its complete evolution at other times the progress is rapid\\nand the evolution is even subacute in type. Often the upper extremities\\nare so involved that the fingers resemble curved talons the wrists lose\\ntheir flexibility, the forearms their usefulness. So extreme is the help-\\nlessness of some patients that they require to be dressed, washed, and\\nfed, even when able to travel with relative comfort.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0520.jp2"}, "521": {"fulltext": "", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0521.jp2"}, "522": {"fulltext": "a\\nw\\no\\na)\\nCm\\nr\\nX\\nM\\n2h\\ncd\\ne\\nX\\na\\nPC\\no", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0522.jp2"}, "523": {"fulltext": "SCLERODERMA. 489\\nThe lesions are accompanied at times by other subacute disorders,\\nsuch as subcutaneous tubercles, eczema, erysipelas, canities, anidrosis,\\nzoster, and acne.\\nIn the later or atrophic stage of the affection the cedematous or\\ninfiltrated areas undergo induration and contracture. The skin becomes\\nthen more and more tightly stretched and thinned over the underlying\\nstructures, and it is no longer possible after drawing the finger over the\\nsurface to produce a yellowish- white tracing of its route that disappears\\nas the circulation slowly returns along the line. When this extreme is\\nreached the atrophic skin becomes dry, scaling, fissured, or even ulcer-\\nated the muscles may waste considerably, thus reducing a limb several\\ninches in circumference; the teeth may fall; the fingers permanently\\nbe flexed into the palm or the forearm on the arm. When the condi-\\ntion becomes to this extent grave, the patient, who before seemed to\\nenjoy a fair degree of health, suddenly experiences rheumatoid pains\\nand neuralgias, or exhibits other signs of constitutional impairment;\\nand intercurrent visceral disorders gradually bring on a marasmus\\nwhich in some of the reported cases has ended fatally with renal,\\ncardiac, or pulmonary symptoms.\\n[B] Circumscribed Scleroderma; Morphcea (Gr. /iop(fiyj, a blotch);\\nKeloid (of Addison). Circumscribed scleroderma, or morphcea, is\\ncharacterized by the occurrence of one or of several discrete, well-\\ndefined, firm, and smooth points, patches, lines, or bands, that are often\\nslightly elevated or depressed, and surrounded by a delicate violaceous\\nor lilac-tinted halo, the involution of which may be followed by macular,\\npunctate, or striate atrophy of the skin.\\nThis form of scleroderma was once held to be rare. It is, however,\\nmore commonly under observation than is usually believed. French\\nauthors distinguish between the variety displayed in plaques and that\\noccurring in bands. Some forms of the latter variety are better\\ndescribed as linese atrophica?.\\nThe patches of morphcea commonly begin as rosy or violaceous\\nmacules, which irregularly extend in area from nail-sized to larger\\npatches, either with relative rapidity or with slowness. In a variable\\nperiod of time the centre of each patch becomes whitish, while the\\nperipheral portions of the plaque retain their peculiar shade of color.\\nThere is thus formed a roundish or oval or irregularly outlined\\narea, rarely larger than a dinner-plate, with a central portion some-\\nwhat elevated, infiltrated and lardaceous or flattish, and near the\\nlevel of the adjacent skin. The blanched centre has often the hue of\\nold ivory; later, this may be commingled irregularly with a flattened\\nstreak or band, distinguished with difficulty from scar-tissue. These\\npatches may be single or multiple; in the latter event they are\\narranged, as a rule, along the line of distribution of the cutaneous\\nnerves of the trunk, along the inner faces of the thigh, more often on\\nthe lower than over the upper extremities, and asymmetrical in most\\ncases. When the tissue is pinched between the thumb and finger it at\\nfirst gives the impression of stiffness and hardness in the later stages\\nof the disease the skin may be so atrophied over the region involved\\nthat it is impossible to make this test. The surface is dry and smooth,", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0523.jp2"}, "524": {"fulltext": "490 HYPERTROPHIES.\\nor, when very carefully inspected, is seen to be traversed by exceed-\\ningly delicate lines. In some instances the plaque is dotted regularly\\nwith depressed points resembling the patulous orifices of sebaceous\\nglands of the face in certain cases of acne, the slightly discolored,\\nminute, funnel-shaped orifices contrasting thus with the dead-white\\nhue of the patch. In other cases this appearance of dotting or picking\\nout of the surface is more conspicuous at one part than another, being,\\nfor example, well shown at an advancing border, with a dead -white,\\ndepressed centre, or at both extremities of a long oval.\\nThe border of typical patches is characteristic. It is made up usu-\\nally of a narrow zone having a pinkish, lilac-tinted, or violaceous hue,\\nwhich, when closely viewed, is seen to be constituted of a plexus of\\nfine vessels. The zone may be wanting wholly, as is well shown in\\nsome cases in which the temple is involved the border further may\\nbe present in such degree as to be fully as conspicuous as the whitish\\ncentral area. In a patient presenting a palm-sized patch over the\\nsacrum, together with a few multiple spots on the side of the neck (a\\nportrait of the same having beeu made in oil), the flame-like, violet-\\nshaded areola extended for several, inches on one side away from the\\ndisk, and one of the larger vessels of which it was constituted could be\\nseen at a distance of several feet from the patient. Purplish, and\\neven blackish, hues have at times been recognized in the halo by other\\nobservers.\\nAs a rule, there are few subjective phenomena in some cases itch-\\ning, tingling, pricking, and other sensations are experienced. The\\nvariations observed in this affection are as numerous as they are strik-\\ning. The disease may be extensive or be limited to one or a few very\\nsmall spots. The names maculosa, nigra, lard ace a, alba,\\nplana, atrophica, etc., are merely descriptive of clinical features,\\nand are becoming obsolete.\\nBetween the several types of scleroderma noted above are to be\\nfound instances which it is difficult to assign to the one class or\\nthe other. Some are mixed forms in which diffuse scleroderma is de-\\nveloped in one part of the body and a circumscribed form in another\\nin other cases numerous morphoea plaques are distributed symmetrically\\nover the body or develop a generalized symmetrical scleroderma. As\\na rule, the symmetrical forms occur most extensively over the upper\\npart of the body while the more frequent unilateral plaques of mor-\\nphoea affect in greater proportion the lower limbs. Often the symp-\\ntoms of the disease resemble at the outset those described as character-\\nistic of oedema neonatorum, with pitting of an oedematous surface under\\npressure. Great variation has been noted as regards the presence,\\nabsence, or increase of sensibility. Sweat and sebum may or may not\\nbe secreted from the affected patches.\\nIn the generalized forms, whether symmetrical or not, there may\\noccur serious complications from visceral disease (cardiac, vascular, or\\nrenal) due in part to interference with the function of large areas of\\nthe skin. Arthritis is not infrequently a concurrent disorder. In\\nsome cases the mucous surfaces are involved. In other cases there are", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0524.jp2"}, "525": {"fulltext": "SCLERODERMA. 491\\norganic changes in the viscera as well as sympathetic disturbances\\nof function. Some of the visceral muscles have been recognized as\\ninvolved in scleroderma.\\nAccording to Besnier and Doyon, pigmentation is one of the most\\nimportant of sclerodermatous symptoms. Beside the pigmented dots\\nvisible over the sclerosed patches, there often exists a species of chlo-\\nasma in the form of bronzing, diffuse or in irregular islets, over the\\nneck, shoulders, and elsewhere. These pigmentations are often inter-\\nspersed with whitish patches of vitiligo.\\nThe course of circumscribed scleroderma is either chronic, lasting for\\nfrom one to ten years or more or subacute, with evolution accomplished\\nin a few days and an almost equally rapid involution or atrophy of\\nskin, subcutaneous tissue, and muscle may slowly or rapidly follow,\\nand result in the production of attachments to periosteum or in de-\\nformity due to contracture. Ulceration may ensue, and in a few in-\\nstances has occurred early in the disease. Atrophy of bone is an\\nexceptional result. In yet other cases absorption of the material con-\\nstituting the plaque is effected without sequels of any sort, few, if any,\\ntraces of the process remaining.\\nThe band-form of circumscribed scleroderma usually occurs in\\nribbon-shaped elongations stretching along a limb in its longitudinal\\naxis, or over one-half of the face. Most of these cases are distin-\\nguished by the occurrence of either an elevated ridge or furrow, or\\n(what is not very rare) an elevated ridge with a furrow on one side.\\nThe median line of the forehead is the commoner site of this anomaly\\non the face over the trunk it is best displayed on the breast. As\\nnoted above, some of the cases collated in this category are instances\\nof linese atrophicas.\\nFinlayson 1 observed in one case of scleroderma symmetrical gan-\\ngrene of the extremities, a complication related doubtless to the sym-\\nmetrical asphyxia of the extremities described by a number of English\\nauthors. The so-called glossy fingers and sclerodactylie of\\nsymmetrical distribution may belong to the same category.\\nHemiateophia Facialis. Severe grades of the disease are noted\\nby several authors, in which to a varying extent, the surface of the lateral\\nhalf of the face has been involved. Here not only the subcutaneous\\ni tissue, but also the aponeuroses, periosteum, and bones may partici-\\npate in the atrophy, a fact well illustrated in the case of Robinson s\\nI patient. 2 In this instance there was also a distinct sclerodermatous\\nlesion on the face of one thigh.\\nEtiology. About three-fourths of all cases occur in women. The\\nj young and middle-aged are generally the victims of the disorder, though\\ncases are reported between the first year of life and advanced age.\\nThe predisposing causes of the affection are rheumatism and the\\nclimatic changes to which rheumatism is most often attributed; all\\nneurotic states due to emotional influences, grief, anxiety, etc.; trau-\\nmatisms by friction, blows, and direct injuries of nerves blisters\\n1 Med. Chronicle, January, 1886.\\n2 Amer. Jour. Med. Sci., October, 1878.", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0525.jp2"}, "526": {"fulltext": "492 HYPERTROPHIES.\\nexposures to the direct action of the sun and obscure disturbances\\nof the nervous centre that are difficult to appreciate. In one case, a\\nyoung woman with a series of circumscribed patches along the inner\\nface of the right thigh, could scarcely endure the fatigue of exposure\\nof the part while an oil painting was made of the disks.; another case\\nwas that of a muscular blacksmith, who exhibited a large plaque of\\nmorphcea over the trunk.\\nThe etiological importance of the nervous system is too obvious to\\nrequire demonstration. This fact is much more distinct in the local-\\nized manifestations of the disorder, in which a region supplied by\\na single nerve or traversed by a nervous trunk is solely involved.\\nHarley, Schwimmer, and others have recognized cardiac and gastric\\ndisturbances Westphal and Eulenberg, central and peripheral changes\\nin the nervous system Heller demonstrated in one case closure of the\\nthoracic duct. Bancroft l repeatedly recognized filarise in large num-\\nbers in the blood of a young girl in Australia who was affected with a\\ncharacteristic scleroderma. Atrophy and other changes in the thyroid\\ngland have been noted by Hektoen, 2 James, 3 Uhlenhuth, 4 and others.\\nPathology. The confusion which has existed in relation to the ques-\\ntion of the identity of scleroderma and morphcea is due .to various\\ncauses. By several authors similar symptoms are described under each\\nof the two names and the symptoms described as peculiar to each are\\noccasionally seen either simultaneously or successively in the same\\nindividual.\\nMicroscopical examination of the structures involved in the disease\\nhas proved unsatisfactory. The connective tissue of the skin has been\\nfound, according to Kaposi, indurated and thickened its elastic fibres\\nmultiplied at the expense of the panniculus adiposus its muscular\\ntissue hypertrophied the pigment in the rete and corium increased\\nthe sweat-glands dilated the lumen of the blood-vessels diminished,\\nand their walls ensheathed in accumulations of what he terms lym-\\nphatic cells.\\nThe nature of the pathological process in scleroderma is unknown\\nno characteristic changes in the nervous centres have yet been appreci-\\nated. In the generalized form the two vascular systems, the sanguine\\nand the lymphatic, exhibit within and about the walls of vessels embry-\\nonic cells which become converted into fibro-plastic bodies. This\\nchange produces in parts an increase in the tunica media until it is\\ntwice its normal thickness. The lumen of the Vessels is thus obstructed\\nand at times obliterated, indicating that the essential process is an\\nendarteritis obliterans, inducing, in the areas to which each twig of\\nvessels is distributed, an exsanguinated state with a surrounding\\nhyperemia. The latter accounts for the peripheral halo of the circum-\\nscribed forms of the malady. That there is at the same time lymphatic\\nobstruction is clear, with, either from the one cause or the other, an\\noverproduction of connective tissue and elastic fibres in the areas of\\n1 Lancet, February 28, 1886, p. 380.\\n2 Centralbl. f. allgem. Path. u. path. Anat., 1897, Bd. viii., S. 673.\\n3 Scottish Med. and Surg. Jour., Mav, 1899.\\n4 Berlin. klin/Woch., 1899, No. 10.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0526.jp2"}, "527": {"fulltext": "SCLERODERMA. 493\\ninvolvement. The corium is commonly hypertrophied, at least in the\\npapillary layer while the subcutaneous tissue and panniculus adiposus\\nare proportionately thinned and even at times, as suggested by the\\nclinical features noted above, may wholly disappear. The pigment\\ncommonly vanishes from the prickle-layer the coil-glands at first are\\ndilated, and later may disappear when the atrophic stage is reached.\\nIn the late circumscribed forms the papillae of the corium may also fall\\ninto atrophy* and the superior vascular plexus of the corium may\\nundergo obliteration by thrombosis (Crocker). The compression of\\nboth glands and vessels is supposed to account for the final sclerotic and\\ncicatriform condition of the advanced cases.\\nDiagnosis. In vitiligo there is an entire absence of all structural\\ncutaneous changes and the skin has a characteristic milky-white color,\\nthe hairs of the part being also blanched. Both the pigmented\\nmacules and atrophic patches of lepra are remarkable for their anaes-\\nthetic condition, and their coincidence with, or sequence from, other\\nreadily recognized symptoms of the disease, such as tubercles, bullae,\\nulcers, and involvement of the hairs, nails, eyes, and other organs.\\nIn sclerema and oedema neonatorum the age of the patient would\\nserve to distinguish the disorders from scleroderma. In cancer en\\ncuirasse (papillary cutaneous carcinoma), chiefly of the skin of the\\nbreast in women, but encountered elsewhere, the resemblance to\\nscleroderma is striking and eminent surgeons have confounded the\\ntwo. In both affections the skin, especially that of the thorax, is\\nconverted into a dense leathery cuirass, but the distinction is made as\\nfollows first, the carcinomatous condition of the skin may be secondary\\nto a cancerous change in the breast or nipple, in which case the doubt\\nis readily removed second, if primary, the firm, isolated, and deeply\\ntinted nodules of cancer are readily distinguished, projecting from the\\ndense peripheral cutaneous infiltration third, the oedema and lymph-\\nangitis associated with cancerous involvement are most often unilat-\\neral, and are limited very distinctly to the arm on the side of the body\\nmost seriously involved fourth, the line of demarcation of the can-\\ncerous change, while indeterminate on one side, is usually at the edge\\nof advance distinguishable by tongue-like erythematous prolongations\\nof a dull-reddish hue lastly, the tendency to ulceration, the coincident\\nand resulting cachexia, the possible axillary adenopathy, and the rela-\\ntively rapid and fatal result in cases at all liable to be confused with\\nscleroderma, point severally to the truth.\\nIn ichthyosis the congenital history, the presence of ichthyotic\\nplates over the affected surface, and the general conservation of the\\nhealth of the patient suffice to identify the disease.\\nIn progressive lenticular melanoderma (angioma pigmentosum et\\ni atrophicum) the melanotic condition of the skin, in connection with\\nwarts, tumors, ulcers, and limitations of the disease to the exposed\\nparts, suffice to distinguish its character.\\nTreatment. In the management of symmetrical or generalized\\nscleroderma the influence of climate should be considered. More im-\\nprovement is secured for these patients after removal to a dry equable\\nclimate than can be obtained elsewhere. If they must remain under", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0527.jp2"}, "528": {"fulltext": "494 HYPERTROPHIES.\\nunfavorable climatic influences, the body should be well protected by\\nwoollen, over muslin, silk, lisle-thread, or balbriggan undergarments;\\nand while an outdoor life is desirable, such exposure should always be\\navoided in unfavorable weather. Internally cod-liver oil, the ferru-\\nginous tonics, and the nutrients generally are often indicated, as well as\\na roborant and generous diet. Thyroid extract has given good results\\nin a small percentage of the cases in which it has been tried. Phillip-\\nson 1 reports relief of severe diffuse scleroderma by the internal adminis-\\ntration of salol in doses of from 2 to 3 grammes daily. Hebra 2 reports\\ngood results in three cases from intramuscular injections every second day\\nof 10 minims of a 15 per cent, alcoholic solution of thiosinamin. The\\nemployment of potassium iodide, arsenic, mercury, and other remedies,\\nsuch as lithium benzoate, sodic bicarbonate and salicylate, and the alka-\\nlies, supposed to be indicated by the rheumatoid symptoms, have been\\nalike praised and condemned by men of eminence on both sides of the\\nAtlantic. Remedies of the reconstituent order should always first be\\nemployed and no resort be had to others save in emergency.\\nThe local treatment is by baths, massage, galvanism, alternate hot\\nand cold douches or the actual cautery over the spinal column. Fol-\\nlowing the daily salt-and- water or alkaline bath of a temperature suited\\nto the season of the year and the physical condition of the patient,\\ninunctions with cod-liver oil, lanolin, lard, or vaselin, neat s-foot oil\\nslightly scented, or other simple oil or ointment, may be used. To\\nthese may be added with advantage in many cases 2 to 10 per cent, of\\nthe oleate of mercury or of ammoniated mercury. In morphoea Brocq\\nemploys electrolytic puncture as in the treatment of hypertrichosis.\\nMercurial plasters are applied in the intervals of each sitting.\\nPrognosis. Symmetrical diffuse scleroderma, well treated in young\\nsubjects, usually results favorably without impairment of the general\\nhealth. When atrophic changes occur the skin may recover its supple-\\nness and pliability, but this cannot be counted upon. Deformity may\\nin either event complicate an otherwise favorable issue. In a small\\nproportion of cases the disease becomes so extensive and severe as to\\nproduce a fatal marasmus more frequently death results from inter-\\ncurrent disorders.\\nIn circumscribed patches (morphoea) the majority recover without\\nserious consequences; the few go on to sclerosis of subcutaneous\\nstructures and consequent deformity. In the most of the simpler\\ncases the disease from first to last seems to have but a local significance.\\nELEPHANTIASIS.\\n(Gr. e?J f ag elephant.)\\n(Elephantiasis Arabum, Pachydermia, Bucnemia Tropica,\\nElephant Leg, Barbadoes Leg.)\\nUnder this title has been included a group of affections differing\\nboth as to their essential cause and nature. On the one hand are to\\nx Deutsch. med. Woch., 1897, 33.\\n2 Arch./. Derm. n. Syph., 1899, vol. xlviii., No. 1.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0528.jp2"}, "529": {"fulltext": "", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0529.jp2"}, "530": {"fulltext": "PLATE XIII.\\nElephantiasis Telangiectodes of the Upper Lip and Portions\\nof the Face.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0530.jp2"}, "531": {"fulltext": "ELEPHANTIASIS. 495\\nbe recognized those disorders due to obstructive embarrassment, simple\\nor even mechanical in character, of either the venous or the lymphatic\\ncirculation and, on the other hand, obstructive embarrassment due to\\nthe presence in the vessels of a parasite, the filar ia sanguinis hominis.\\nThe symptoms of the two disorders are for the present considered\\ntogether.\\nSymptoms. The disease is more common in the tropics, where it is\\nusually of parasitic origin but sporadic cases are of occurrence in all\\ncountries, and are not very rare in portions of the United States. The\\nmost frequent seat of elephantiasis is the lower extremity of one side,\\nwhere the foot, the leg (Fig. 59), or also the thigh of the same limb,\\nmay enlarge. The penis and scrotum of men (Fig. 60), the labia and\\nclitoris of women, the upper extremities, the face, the ear, and portions\\nof the trunk may likewise become involved.\\nThe disease is insidious in its approach, and remarkably chronic in\\nits career. Usually, localized inflammations precede, as an erysipelas\\nor a dermatitis, with or without involvement of the lymphatic vessels\\nand glands. At the same time there is a condition of general fever, to\\nwhich succeeds a defervescence, with abatement of the local inflamma-\\ntion, its sequels becoming manifested in a more or less persistent\\noedema of the part lately inflamed. After intervals of days, weeks, or\\nmonths the pyrexia recurs with still greater involvement of the swollen\\ntissues, which, with each access of fever, increase in volume and gain in\\ndensity. When the elephantiasic condition is fully developed the skin\\nis tense, glossy, and blanched or discolored in various shades. Pressure\\nupon the cedematous part is followed by pitting, but the tissue beneath\\nis felt to be brawny and indurated. The parts beneath the skin are\\nperceptibly increased in volume, especially the subcutaneous tissue and\\nthe circumference of a limb thus diseased may be several times larger\\nthan that of its fellow. A lymphangitis is usually declared by painful,\\ncord-like, linear indurations of the part, associated with adenopathy of\\nthe nearest ganglia. In older cases the skin loses its glabrous aspect,\\nand exhibits eczematous, verrucous, papillomatous, seborrhceie, and even\\nichthyotic changes. Pigmentation, even to a blackish tint, may ensue\\nscaling, Assuring, and furrowing are common and the accumulation\\nof altered sweat and sebum in these depressions is the source of an of-\\nfensive stench. During the course of the disease almost all the ele-\\nmentary lesions of the skin may be displayed macules, vesicles, pap-\\nules, tubercles, pustules, blebs, ulcers, crusts, scales, excoriations, and\\nfissures. Warty growths form as large as those seen in ichthyosis hys-\\ntrix, and in some cases reddish-colored tumors spring from the hyper-\\ntrophied integument.\\nWhen fully developed in the lower extremity the unwieldy limb,\\ni with the foot, ankle, and leg massed into one huge, cumbrous cylinder,\\nbears a striking resemblance to that of the elephant, from which cir-\\ncumstance the malady first received its name among the Arabs. Loco-\\nmotion is then greatly impeded or is rendered impossible. Not less\\nstriking is the similar deformity of the genital labia of women or the\\nscrotum of the male, the latter at times hanging far below the knees\\n(Fig. 60).", "height": "4314", "width": "2402", "jp2-path": "practicaltreatis00hyde_0531.jp2"}, "532": {"fulltext": "496\\nH YPERTROPHIES.\\nThe penis disappears in rugous folds, and the urine passes along\\na gutter formed of skin transformed\\ninto quasi-mucous membrane. As a FlG 60\\nconsequence of the fissures and ex-\\ncoriations which form the lymphatic\\nchannels are finally opened, and a\\ntrue lymphorrhoea results.\\nFig. 59.\\nElephantiasis of the foot and leg.\\nElephantiasis scroti.\\nSubjectively, the disease may be regarded as productive of less dis-\\ncomfort than would be suggested by its formidable features. Pain is\\nexperienced occasionally, and during the exacerbations accompanied by\\npyrexia there is corresponding malaise. The chief subjective sensations\\nare those induced by weight and consequent tension, inseparable from\\nthe enormous masses of hypertrophied tissue.\\nIn elephantiasis of the scrotum there are frequently symptoms of\\nirritation, both systemic and in the vicinity of the affected part (nausea,\\nvomiting, inguinal pain, epididymitis, effusion into the sac of the tunica\\nvaginalis, inflammatory swelling of the spermatic cord, and at times\\nhernia). In some cases vascularization of the surface (telangiectatic\\nelephantiasis) is a prominent feature. The form described below as\\nNsevoid elephantiasis may belong either to the same category, or to\\nothers in which there is lymphangiectasis lymph-tumors, lymph-\\nscrotum and these may be due either to lymphatic obstruction or\\nto the parasite described later as of etiological importance in this\\nconnection.\\nLymph-scrotum (Varix Lymphaticus, Nevoid Elephantia-\\nsis), fully described by Wong, Carter, Fayrer, Manson, 1 and other East\\nIndian observers, is that condition in which the scrotum is more or less\\nenlarged, and, though soft and silky to the touch, presents varying\\nnumbers of lymphatic varices, which on puncture or spontaneous rupture\\ngive exit to a rapidly coagulating lymph or chyle. Several ounces of\\n1 Hirsch: Handbook of Geog. and Hist. J?ath., London, 1885, p. 328 and Tropical\\nDiseases, London, 1900, second edition.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0532.jp2"}, "533": {"fulltext": "ELEPHANTIASIS. 497\\nthis liquid may escape in an hour, and the discharge may continue to\\nthe point of exhausting the patient. The disease is produced solely by\\nthe filaria sanguinis hominis, 1 the embryo filarise being present in the\\nlymph and in the blood. The inguinal and femoral glands are usually\\nenlarged. As in elephantiasis of other organs, there may be occasional\\nfever, chills, erysipelas, and other localized inflammations. Abscesses\\nmay occur, and in many cases the condition is followed by elephantiasis.\\nAceomegaly. Cases of this rare form of elephantiasis are not\\ninfrequently reported. Typical instances of the malady have been\\nmade the subject of monographs (with illustrations of the facial and\\nmanual deformity) by Church, Hessert, 2 and Zeisler. There is sym-\\nmetrical enlargement of all the tissues, including bone. It is most\\ncommon on the face and limbs. It is believed by many that the con-\\ndition is dependent upon disease of the pituitary body.\\nCases of hypertrophy of one-half of the face are also to be assigned\\nto the group of maladies to wdiich the name elephantiasis is applied,\\nexcluding the parasitic and lymphangiectatic varieties. Kiwall s patient,\\na girl eighteen years old, with a enlargement extending from brow to\\nthroat and involving the right side of the tongue as well as the bones\\nand other soft parts, is an example of this anomaly. Crocker, Hebra\\nand Kaposi, Barwell, and others report similar instances. One such,\\nthe subject of a skilful operation by Senn, suffered from a marked\\nenlargement of one side of the face, due in part to an angiomatous and\\nin part to a connective-tissue overgrowth.\\nEtiology. The causes of elephantiasis are different in the several\\ndisorders grouped under this title. AVucherer, Lewis, and Man son\\nhave demonstrated in cases prevalent in the East and West Indies,\\nEgypt, Arabia, Abyssinia, Africa, Malabar, Barbadoes, Brazil, Mexico,\\nand parts of China, the presence in the blood of the filaria sanguinis\\nhominis. Embryos and filarial are found adhering to the walls of\\nboth lymphatic vessels and blood-vessels in elephantiasis of the tropics.\\nManson reports that in countries where elephantiasis is common the\\nmajority of the natives have filarise in their blood. The parent-worm\\nlives in a large lymph-channel and produces young in immense num-\\nbers which circulate in the blood. It is only when the parent-worm\\naborts and the ova or immature filarise are unable to pass through the\\ni lymphatic glands that the circulation is obstructed. Thus it often\\nhappens that filarise are no longer found in the blood of an individual\\nwho has developed elephantiasis. They are supposed to be introduced\\ni through the medium of the mosquito.\\nOther disturbances due to the same parasite, and only in part recog-\\nnized as elephantiasic, are the lymph-scrotum described above, chylous\\nj abscess, effusions, and vascular and hypertrophic enlargement of tissue\\nand glands in and about tumors of the sort recognized as parasitic.\\nIn other cases different causes are to be recognized. Predisposition\\n1 At the Third International Congress of Dermatology, held in London in 1896,\\ni Manson exhibited living specimens of filaria moving in the blood-vessels under the\\nmicroscope.\\n2 Med. Kecord, May 6, 1893 (reprint).\\n32", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0533.jp2"}, "534": {"fulltext": "498 HYPERTROPHIES.\\nof races or individuals, heredity, climatic influences, malaria, fatiguing\\nlabor with the feet and legs immersed in water, and filth in connection\\nwith misery, have all been cited as favoring conditions. To these\\ncauses should be added the local disorders especially common in the\\nlower extremities that have in cases proved to be points of departure of\\nelephantiasic hypertrophy, such as obstruction to the blood or lymphatic\\ncurrents by pressure of tumors, pregnancy, or neoplasms ulcers, cica-\\ntrices, and traumatisms by pressure or friction cutaneous diseases\\nsystemic affections (syphilis, tuberculosis) and osseous disease.\\nPathology. Even macroscopically the elephantiasic mass is seen to\\nbe built up of hypertrophic elements representing all the tissues of\\nwhich the part is composed. The knife with difficulty divides the\\nhomogeneous, whitish, and lardaceous mass, from which on pressure\\nexudes a fluid of similar color. The subcutaneous connective tissue is\\nfound relatively much more enlarged and sclerosed than the epidermis\\nand derma though when section is made through the rugous and warty\\nskin described above, all the elements of the papillary layer, rete, and\\nstratum corneum are seen to participate in the changes described in\\nconnection with the pathology of verruca. Here and there are loculi\\nfilled with fluid lymph. The sheaths of the blood-vessels, lymphatics,\\nnerves, and the bones, muscles, and aponeuroses are also thickened,\\nsolidified, and occasionally agglutinated, so as to be almost indistin-\\nguishable in the mass of uniformly sclerosed tissue. The pigmentation\\nof the derma is marked, the nuclei of the connective-tissue cells are\\nmultiplied, and the cutaneous glands intact, hypertrophied in their\\nepithelial linings and investments, or, at a later stage, atrophied.\\nIt is evident that in many cases, as Virchow has pointed out, the\\nearliest of the changes to be noted occur in the lymphatic glands and\\nvessels, the whitish and yellowish lymphatic fluid which then accumu-\\nlates in the tissue resulting from obstruction of the lymph-channels.\\nIn some of the remarkable cases on record the lymphatic obstruction\\nis the prominent feature of the disease, and the elephantiasic enlarge-\\nment is subordinate in gravity to the former condition. Such are, for\\nexample, the noteworthy instances in which the lymph distends mul-\\ntiple cutaneous vesicles, after rupture of one or more of which the fluid\\nstreams awav to a dangerous extent. 1\\nDiagnosis. The striking deformity which characterizes elephan-\\ntiasis will always suffice for its recognition. In the earliest stages of\\nthe disease, when there is merely cedema or an erysipelatous or eczema-\\ntous condition of the skin, it would be difficult, if not impossible, to\\ndecide as to the future of the disorder, especially in a locality in which\\nonly sporadic cases occur. A symmetrical hypertrophy of both legs\\nand both feet, developing in America, even though described as ele-\\nphantiasis, should carefully be studied before a diagnosis is made of\\nthe particular disease here considered. The same might be said of\\nelephantiasis of but one inferior extremity. A patient with an exten-\\nsive deforming induration and enlargement of the right leg and foot,!\\naccompanied by pigmentation and a well-marked warty condition of i\\n*For a fuller description of this class of cases the reader is referred to Buse/s\\nmonographs on Occlusion and Dilatation of the Lymph- channels.\\nI", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0534.jp2"}, "535": {"fulltext": "ELEPHANTIASIS. 499\\nthe skin, who had been pronounced the victim of idiopathic elephan-\\ntiasis Arabum, had received a fracture of the upper third of both bones\\nof the same leg during the previous year, and had since the accident\\nconstantly worn a tight bandage encircling the limb at the seat of the\\ninjury. The deformity rapidly disappeared under the application of a\\nroller bandage extending from the toes upward.\\nA peculiar and rare, though characteristic, deformity of the labia\\nmajora of women most commonly the labium majus of one side\\nresults from a tertiary syphilitic, gummatous infiltration which must\\nbe distinguished from elephantiasis. In cases of this kind the history\\nof the patient and the relative inferiority as to bulk of the affected\\norgan point to the nature of the disease. The syphilitic labium rarely\\nexceeds the size of a large fist.\\nA gigantic, hypertrophied mass of elephantiasic type is occasionally\\nto be discovered in the lower extremity of only one side in patients who\\nhave been for many years the victims of an unrecognized and long-\\nuntreated syphilis. Even when the leg is many times its normal size\\nand weight, and its contour lost in a thickened and roughened epidermis\\nresembling the bark of a tree, the diagnosis may be made by discover-\\ning here and there in the depth of the mass circular and characteristic\\nscars of healed gummatous ulcers.\\nTreatment. In the early stage of elephantiasis the febrile condi-\\ntion of the patient and the localized cutaneous inflammation are to be\\ntreated by the measures appropriate for the relief of these conditions.\\nQuinine, especially in malarial districts, is of the highest importance.\\nWhen the elephantiasic development is established, if the genitals are\\ninvolved the knife of the surgeon offers the best prospects. The result\\nof such interference, both in the genitalia and the extremities, has in\\nmany cases been brilliant, though the mortality of such severe opera-\\ntions is necessarily great. When the lower extremity is involved it\\nshould be maintained in a horizontal position, its ulcers if possible be\\nhealed, its excrescences removed, its circumscribed inflammations\\nresolved, and then elastic compression be carefully and skilfully main-\\ntained by means of a rubber bandage. The toes are first separately\\nenveloped, then the foot and ankle, and lastly the leg. The results are\\nsometimes highly satisfactory.\\nLigation and digital compression of the main artery supplying the\\nelephantiasic leg have occasionally been followed by transient improve-\\nment. Instrumental compression has at times resulted in severe ulce-\\nI ration and a reawakening of the erysipelatous affection. Multiple\\npunctures and incisions, made with a view to giving exit to the fluids\\ncontained in the mass, have been attended by no greater success. The\\nmain obstacle in all these surgical procedures is the lymphangitis\\nwhich so frequently complicates the situation. Xone of them promises\\nso well as nerve-stretching, which in a few isolated cases has been fol-\\nlowed by noteworthy results. Excision of a portion of the sciatic\\nnerve has also been followed by satisfactory changes. The use of the\\ngalvanic current has, when long continued, accomplished resolution of\\nj engorged masses of tissue. Elastic compression in the horizontal posi-\\ntion for all cases not warranting nerve-stretching may be regarded as", "height": "4220", "width": "2387", "jp2-path": "practicaltreatis00hyde_0535.jp2"}, "536": {"fulltext": "500 HYPERTROPHIES.\\nthe wisest course when the extremity is involved. For the local treat-\\nment of the pachydermia proper, green soap, mercurial ointment, and\\nbathing with hot or cold lotions may advantageously be employed. For\\npatients whose disease is acquired in countries where the deformity is\\nprevalent a change of climate is of the highest importance and, having\\nin view the social surroundings and habits of most victims of the dis-\\nease, it is scarcely necessary to call attention to the need of a proper\\nhygiene, diet, and tonic regimen.\\nPrognosis. The future of a patient may be regarded as most favor-\\nable when the disease exhibits an early tendency to respond favorably\\nto appropriate treatment, and when circumstances permit of a resort to\\nthe best therapeutic measures which can be adopted, such as change of\\nresidence, persistent and careful dressing of the affected part, and the\\nremoval of any exciting cause of the disease, such as neoplasm, an\\nindurated cicatrix, etc. In the severer cases a fatal result may occur\\nearly in the disease but usually life is prolonged, burdened by the\\ninconvenience of the enormous elephantiasic mass in comparison with\\nwhich the rest of the body often seems to serve as a mere appendage.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0536.jp2"}, "537": {"fulltext": "CLASS V.\\nATROPHIES.\\nLEUCODERMA.\\n(Gr. 2,evk6c 7 white dep/ua, skin.)\\n(Achromia, Leucasmus, Partial Albinism.)\\nAbsence of the pigment of the skin and hairs giving rise to con-\\nspicuous disfigurement is naturally most frequently encountered in\\nthose races of mankind Avhose skins are most abundantly provided\\nwith such pigment. The absence of pigment may be congenital or\\nacquired, and be partial or universal. Some confusion has been pro-\\nduced by the arbitrary distinction established by authors between the\\nnames intended to designate these several varieties of achromia or\\nleucopathia. In the following pages leucoderma is the name employed\\nto designate the pigment-atrophy which is partial and congenital al-\\nbinismus, that which is universal and congenital vitiligo, that which\\nis acquired.\\nIn leucoderma, the patients being most often of the colored races,\\none or several whitish or rosy-whitish patches or bands, varying in\\nsize, outline, or situation, may be seen at birth unprovided with pig-\\nment. These patches may have a symmetrical arrangement, in which\\ncase they commonly observe the areas of distribution of one or more\\ncerebral or spinal nerves or they are asymmetrical in distribution.\\nThey are usually of circular outline, and may be found upon the scalp,\\nface, nipple, breast, and genital and other regions. The hairs found\\nupon such parts are equally destitute of normal color, being usually\\nwhite. Negroes thus marked are generally termed piebald, and the\\nintegument similarly affected in persons of other races has long been\\nrecognized as the pied or piebald skin. These blemishes when\\nsymmetrical, like pigmentary nsevi, exhibit a striking analogy with the\\nsymmetrical arrangement of the spots, bands, and stripes to be recog-\\nnized in the furs of many of the lower animals. The outline of the\\npatch may be abrupt, or it may gradually shade into that of the adja-\\ncent integument. At times islands of pigmented skin are visible within\\nthe non-pigmented areas. The changes in these patches during later\\nlife may be insignificant, or they may individually increase in size with\\nage, or even multiply. Rarely they regain pigment in later life. In\\nno case is there an excess of pigment deposited at the border of the\\npatch.\\nThis condition is practically remediless.\\n501", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0537.jp2"}, "538": {"fulltext": "502 ATROPHIES.\\nALBINISMUS.\\n(Lat. albus, white.)\\n(Complete Congenital Leucoderma.) _\\nSymptoms. The term albinismus is here limited to the congenital\\nconditions of achromia induced by universal absence of cutaneous pig-\\nment.\\nThis deformity is peculiar to individuals known as albinoes\\n(Kakerlaken; Dondos), isolated instances of this anomaly occurring\\nin all races, but more frequently among those having normally a hyper-\\npigmentation of the skin, such as negroes. In the subjects of this\\nanomaly the skin has a milky-whitish, transparent, or rosy-tinted hue,\\nand is usually of delicate texture; the hairs are silky and yellowish,\\nwhitish or snowy- white in color the iris transparent or pinkish and\\nthe pupil, in consequence of defect of pigment in the choroid, is also\\nreddish or pinkish. There are, as a result, nyctalopia and heliophobia,\\nwith frequent nictitation, pupillary variations, and the semblance of\\nmyopia. The pinkish hue of the skin in these individuals is due only\\nto its translucency and vascularity. The defective condition of the\\npigment is usually unchanged throughout life but in no other respect,\\nsave as to pigment-anomaly, does the skin of the healthy albino indi-\\ncate disease.\\nMany persons thus deformed, however, are far from vigorous. It\\nhas been observed that some albinoes are physically inferior to the\\naverage of persons of the same sex, both in stature, weight, mental\\nactivities, and powers of resistance to disease. There are, however,\\nnumerous striking illustrations of the reverse of this, and we have had\\nunder observation a number of albinoes in one family in which alterna-\\ntions of non-pigmented with normally pigmented children exhibited\\nno difference whatever in sturdiness and vigor. Many enfeebled\\nalbinoes are simply illustrations of the wretchedly unwholesome life of\\npersons imported for exhibition into foreign countries.\\nEtiology. Inheritance is evidently a strong factor in the produc-\\ntion of this and similar pigment-anomalies. Alternations in birth of\\nwhite and of black children in one family have been recorded, yet it is\\nunusual to find albinoes in two succeeding generations, an occurrence\\nof no great rarity in inherited affections.\\nThe condition is remediless though it is probable that transfusion\\nwith the blood of a vigorous black-skinned African would largely\\nmodify the color-characteristics of the pure albino.\\nVITILIGO.\\n(Lat. vitium, a blemish.)\\n(ACQUIRED LEUCODERMA.)\\nSymptoms. The disorder is one observed among the several races,\\noften in the negro, and not rarely among those of Aryan descent. It\\ncommonly occurs without the slightest appreciable disorder, subjective", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0538.jp2"}, "539": {"fulltext": "VITILIGO. 503\\nor objective, save that betrayed to the eye in the color-changes of the\\nskin. One or several rounded, or very irregularly shaped, smooth, and\\nwell-defined, pale or milky-white lines, streaks, or disks appear, often\\nbordered at the periphery by an integument which assumes a light- or\\ndark-brown or chocolate shade, this hue being by contrast most notice-\\nable immediately at the contour of the patch, and imperceptibly fading\\ninto the normal color of the outlying integument. The hairs or lanugo-\\nfilaments growing from the affected area may or may not be blanched\\nmost commonly they are, a condition particularly conspicuous when, as\\nis not rarely observed, a vitiliginous disk extends from the back or the\\nside of the neck well into the scalp, in which case the outline of that\\nportion of the scalp involved is clearly defined by the whitened pilary\\ngrowth. Lesser describes a condition termed by him Poliosis Cir-\\ncumscripta Acquisita, in which the hairs were thus blanched in a\\nsingle area of an unaffected scalp, an observation which is confirmed in\\nmany cases.\\nThe most common seats of the disease are the face, the neck, the\\nbacks of the hands, the genitals, and the extremities. Upon the backs\\nof the hands the disfigurement is usually more conspicuous in summer\\nthan in winter, a circumstance which probably explains the reported\\ninstances of recurrence and total disappearance of the disease in suc-\\ncessive years. The changes are due to a deepening of the pigment in\\nthe normal areas on exposure to the sun, thus making a more striking\\ncontrast with the non-pigmented spots.\\nThe course of the affection is exceedingly slow there may be for\\nyears no apparent extension of any involved area or the achromia may\\nprogress by peripheral extension and by the coalescence of relatively\\nsmall affected areas until a large portion of the trunk, the thighs, the\\nbuttocks, or other part of the body is involved. Hall 1 reports the case\\nof a dark mulatto who became perfectly white, with the exception\\nof a patch on the chin. Levy 2 reports three instances of total disap-\\npearance of pigment. It not infrequently happens that the loss of pig-\\nment is so extensive on the face, hands, and other regions that the eye\\nof the observer is struck no longer by the unusual whiteness of the\\ninvolved patches, but this whiteness being generalized and apparently\\nthat proper to the person, the remaining normal areas appear to be\\nhyperpigmented. Patients with vitiligo frequently suppose that the\\nwhitened areas are normal, and the darker ones abnormally pigmented.\\nPatients of lymphatic temperament and blonde complexion (often\\nwomen in early adult life) will occasionally apply to a physician for\\nrelief of dark patches on the skin of the face. Examination discloses\\nfaint lines, ribbons, or streaks of pigment about one or both cheeks, the\\ntemples, or the lips. But careful scrutiny recognizes an undue white-\\nness of the skin, with exceedingly faint and irregular outline near or\\nnext to these pigmented portions of which complaint is made. In\\nthese cases care is necessary to make a diagnosis between vitiligo and\\nchloasma.\\nAs in several of the other pigmentary disorders of the skin, the\\n1 Louisville Med. News, 1880, x., p. 148.\\n2 Receuil de Mem. de M\u00c2\u00a3d. de Chir. et de Pharm. mil., 1865.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0539.jp2"}, "540": {"fulltext": "504\\nATROPHIES.\\nFig. 61.\\npatches of vitiligo may be symmetrical in distribution, with their out-\\nlines limited to the areas supplied by certain nerves. The disorder\\nshows a tendency to spread, though as a rule a\\nlimit is reached eventually beyond which the\\natrophy does not progress. In exceptional cases\\nthe parts which have lost pigment again acquire\\nit.\\nIn vitiligo, aside from the dyschromia, the\\nskin is normal. The health of the subjects of\\nthis disorder is usually unimpaired. A morbid\\nmental condition, especially in women of middle\\nlife, is often produced when the disfigurement\\ninvolves the facial region.\\nEtiology. Vitiligo occurs in both sexes and\\nin individuals of all complexions and ages,\\nthough it is commonly observed among women\\nand in early or middle life. It is at times coin-\\ncident with scleroderma, lepra, variola, and other\\ndiseases with similar cutaneous symptoms, though\\nit occurs independently of all such. Its etiology\\nmust be regarded as obscure, although there are\\nstrong probabilities that it is due to the influence\\nof perturbed innervation. It is frequently found\\nin connection with functional and organic dis-\\neases of the nervous system and with peripheral\\nnerve-lesions. The disorder is of more frequent\\noccurrence than dermatological statistics tend to\\nshow. Many persons who are the subject of\\nvitiligo of an inconspicuous part of the body do\\nnot consult a physician with regard to the nature\\nof the disease, as it occasions no physical distress.\\nPathology. The pigment normally present\\nin the deep rete-cells is absent in vitiligo-spots,\\nbut greatly increased and deepened at the bor-\\nders of the areas. In the corium are cells which\\ncontain pigment-granules. These are especially\\nnumerous at the margins of patches, where blood-\\nvessels, follicles, and glands are surrounded by\\nmany oval, stellate, and branched pigment-cells. The probable nature\\nand origin of these cells are considered with chloasma. Leloir and\\nChabins have demonstrated atrophy of the subdermal nerves in patches\\ndevoid of pigment. Other changes in the skin have not been noted.\\nDiagnosis. The diagnosis is based on the presence of achromia,\\nwith usually a hyperpigmented border, and the absence of all other\\nsymptoms or changes, such as would be found in tinea versicolor, mor-\\nphoea, lepra, or syphilis. From the chloasmata, which are always\\naccompanied by hyperpigmentation, vitiligo is readily differentiated.\\nTreatment. Much chagrin will be saved both physician and patient\\nby practically regarding vitiligo as not amenable to treatment. Patients\\noccasionally recover while under treatment, which, however, has gen-\\n\u00e2\u0096\u00a01\\nVitiligo in a negro boy.\\n(Piffard s case.)", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0540.jp2"}, "541": {"fulltext": "CANITIES. 505\\nerally contributed but little to the result. Arsenic and iron internally,\\nrecommended highly by some authors, have repeatedly failed to accom-\\nplish any appreciable results as regards dyschromia. By efforts directed\\nto the removal of the hyperpigmentation in the border of the achromic\\npatches the disfigurement may be somewhat lessened. The method of\\narriving at this end is described in connection with the treatment of\\nchloasma. It is possible that further experimentation with hypoder-\\nmatic injections of pilocarpine, that have in a limited number of cases\\nbeen followed by disappearance of the disease, may warrant a less\\nunfavorable view of the results of treatment. Savill 1 reported a\\nreturn of normal color in vitiliginous patches to which he had applied\\npure carbolic acid.\\nPrognosis. The health of the subject of the malady is not impaired.\\nThe disease is practically incurable, progressing usually until it has\\nobtained a maximum of development and then, as a rule, remaining\\nunchanged throughout life.\\nCANITIES.\\n(Lat. canus, white.)\\n(Trichoxosis Cana, Poliothrix, Hoarixess, Poliosis.)\\nSymptoms. In this anomaly the hairs appear in all shade of white-\\nness, from dirty gray or yellowish white, to a steel gray or silvery\\n1 white. This may be either a general or a partial, congenital or acquired,\\nphysiological or pathological, prematurely, rapidly, or gradually\\nacquired condition. General congenital whiteness of the hairs is seen\\nin albinismus, where pigment has never colored the filaments. Partial\\ncongenital whiteness is occasionally seen in patches, limited in size\\nand varying in color from pure white to a deeper hue, that from birth\\ndo not receive pigment in due proportion, thus contrasting with the\\npigmented filaments by which they are surrounded.\\nPhysiological decoloration of the hairs in variable shades is the\\nwell-known result of advancing years. When premature, it may\\nresult from pathological causes or be due to individual or inherited\\npeculiarities. It may occur gradually or suddenly in the former\\ncase the hairs usually pass through varying shades of gray to white,\\nand this at any period after (occasionally before) puberty, though\\ncommonly after middle life is reached. Recurrence to the darker\\nshades is rarely noted. Leonard, of Detroit, 2 cites a number of curious\\ninstances in which changes of this sort have occurred. Generally,\\nhowever, canities of advanced years is progressive and permanent,\\noccurring earliest on the temples and the beard of man, then involving\\nthe vertex of the head. Finally, the hairs of the entire body-surface\\nundergo similar pigmentary loss. Trichoxosis Versicolor (TTilson),\\nRixged Hair/ occurs in sound individuals of both sexes, the pilary\\nfilaments having the appearance of a foreign body interspersed among\\nthe hairs. Close examination reveals the presence of alternating rings\\n1 Brit. Jour, of Derm., March, 1898.\\n2 The Hair, etc. Detroit, 1880.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0541.jp2"}, "542": {"fulltext": "506 ATROPHIES.\\nof different shades of color twenty to thirty to the inch of the hair-\\nshaft.\\nIt should be remembered that the coloring of the hairs of the head\\nis, to a greater extent than is commonly appreciated, subject to varia-\\ntion from the operation of external causes. Thus, washing the hair\\nwith alkaline solutions has a bleaching effect, while profuse sweating,\\ninunction with fats, subjection to smoke, and the temperature-changes\\nof the summer have the contrary influence, the last named being pos-\\nsibly associated with increased sweating in the hot season.\\nCases of sudden blanching of the hairs, occurring, for example, in\\na single night, are sufficiently numerous and well authenticated to be\\nadmitted as among the rare possibilities of a clinical experience. Ner-\\nvous disorders, both centric and peripheral, such as long-continued\\nmental depression, melancholia, paralysis, neuralgia, and traumatism\\nof nerves or of nervous centres, may be followed by more or less rapid,\\ngeneral or partial, and permanent canities. The same result may fol-\\nlow wasting disorders, such as typhoid fever, tuberculosis, syphilis,\\nand malarial (Chagres) fever, in which cases, as distinguished from\\nthe others, pigmented hairs may eventually replace those which were\\nwhite. The first hairs springing from a patch of alopecia areata in\\nwhich repair is in progress are often white or whitish, and are replaced\\nlater by those of normal color. Cases are reported in which the pres-\\nsure of a truss or of a corset has produced patches of vitiligo and\\ncanities.\\nLandois has shown that many instances of suddenly occurring cani-\\nties depend solely upon the rapid appearance of air-bubbles in excess\\nof the average number in the hair-shaft.\\nEtiology. Whitening of the hair may be senile in origin, in which\\ncase it is customary to declare it to be physiological or be due to\\nheredity to deficient nutrition or innervation of the hair-follicles to\\nfunctional or organic nervous affections (fright, facial atrophy, etc.)\\nor to local chemical action upon the hairs. Premature canities in\\nyoung adults is often associated with the occupations of life, being\\nmuch commoner in men who from necessity have the head habitually\\ncovered and who yet lead sedentary lives.\\nPathology. The color of the hair is dependent upon the pigment\\nsituated in the matrix and between the horny cells, and upon the\\nnatural yellowish color of the dried horny cells. In source and char-\\nacter the hair-pigment is undoubtedly identical with that of the skin\\nin general. This has been considered with chloasma. Decoloration\\nof the hairs may be due to failure of supply or to removal of pigment\\nto unevenness of the hair-surface (by which light is refracted) or\\nto air-bubbles between and within the fibre-cells. In senile and pre-\\nsenile decolorations there is commonly actual diminution of pigment.\\nRapidly occurring canities is ascribed to the sudden appearance of air-\\nbubbles in quantity in the shafts of the hair. Alterations of color in\\nthe hairs are attributed to successive periods of activity and rest in the\\npigment-producing cells.\\nTreatment. The chief means of remedying premature canities is\\nby the action of dyes, which are, in the main, compounded with solu-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0542.jp2"}, "543": {"fulltext": "ALOPECIA. 507\\ntions of silver nitrate, lead acetate, and ferrous sulphate. The main\\nobjections to their use are the disagreeable coloring of the scalp which\\nresults from incautious use of the dye, and the consequent liability to\\nirritation of the surface. When applied to the hair alone these sub-\\nstances are not known to have a deleterious effect upon the health.\\nKaposi gives the following formulae for hair-dyes\\nTo obtain a black color\\nOr\\nR Argent, nitrat., gr. xv 1\\nAmnion, carb., gr. xxij 1\\nUnguent, adipis, ^j 30\\n5\\nM.\\nR Argent, nitrat., 3j 4\\nPlumb, acetat., gr. xv; 1\\nAq. Cologn., gtt. xv; 1\\nAq. ros., adf^iij; ad 90\\nTo obtain a brown shade\\nR Acid, pyrogal.,\\nAq. Cologn.,\\nAq. ros.,\\nM.\\ngr. xv\\n1\\n3ss;\\n2\\n3jss\\n45\\nM.\\nAnderson first applies a lotion of mercuric chloride, 2 grains to the\\nounce (0.133 to 30.), and follows this with a solution of sodium hypo-\\nsulphite, 1 drachm to the ounce (4. to 30.), for the production of a\\njet-black shade. In the way of constitutional treatment, he suggests\\nin cases of accidental presenile blanching strict attention to the gen-\\neral health and arsenic internally.\\nALOPECIA.\\n(Gr. al Tcri^ a fox.)\\n(Calvities, Defluvium Capillorum, Deficiency of Hair,\\nBaldness. Ger., Kahlheit.)\\nThe simple term alopecia is no longer descriptive of a disease, but\\nonly of a symptom, loss of hair, which occurs in a large number of\\nmorbid and even physiological states. For convenience of description\\nthe alopecias may be enumerated as congenital alopecia, senile alopecia,\\npremature or presenile alopecia, and alopecia areata.\\nCongenital Alopecia. In rare cases there is a partial or a complete\\nabsence of hairs at birth, in consequence of arrested development of\\nthe pilary system. Generally, however, these appendages of the skin\\nare merely of tardy appearance, their eruption being extraordinarily\\ndelayed, as in retarded dentition. In some instances the hair falls\\nafter birth and never returns. When the alopecia persists to adult\\nyears, as is rarely the case, there is usually defective development also\\nof teeth and nails.\\nIn localized congenital alopecia hairs rarely develop after maturity,\\nand here, also, abnormalities of teeth may be coincident features. In", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0543.jp2"}, "544": {"fulltext": "508 ATROPHIES.\\na case of congenital alopecia examined by Scliede l the sebaceous glands\\nwere found opening on the free surface of the skin. In the deeper\\npart of the cutis straight or convoluted hair-rudiments were visible in\\nthe tubules, without perceptible internal cavity, which corresponded\\nwith the external root-sheath.\\nSenile Alopecia. The baldness of old age, whether occurring upon\\nthe vertex so as to produce a tonsure like that of the priest, or whether\\nlimited to the frontal region, or so extensive as to involve nearly the\\nentire calvarium leaving a fringe of hairs at the occiput and temples\\nmerely, is always remarkable for its symmetry. There is, hence, a\\ncertain degree of dignity added to the appearance of the head that an\\nasymmetrical loss of hair does not produce. It may occur at varying\\nages of advanced life, and is frequently traceable to an early seborrhoea\\nsicca or alopecia furfuracea. It is much commoner in men than in\\nwomen, largely because of the difference in the manner of covering\\nthe head in the two sexes, women usually wearing an exceedingly light\\ndress for the head, while men encase the latter with tight-fitting caps\\nor hats which interfere with proper aeration of the scalp. Individ-\\nuals of the male sex, also, in consequence of their usually wearing the\\nhair short, bestow far less time upon the care and dressing of it. In\\nuncivilized races these differences are less marked, men pay great\\nattention to the ornamentation of the scalp, and senile baldness is of\\nless frequent occurrence.\\nThe bald surface, as a rule, is smooth and shining it is occasionally\\nthe seat of a seborrhoea oleosa. The hair-follicles, with their accessory\\nsebaceous glands and occasionally the skin itself, are often in a state of\\natrophy, though there may be dilatation of the sebaceous glands. There\\nis commonly blanching of the hairs, which are gradually shed, as also\\nof those which remain, though the canities is not constant. This con-\\ndition is much less frequent upon the surface covered by the beard and\\npubic and axillary hairs, where, according to Michelson, the hairs in\\nadvanced years are often denser than at other periods of life.\\nPremature or Presenile Alopecia (premature calvities) is that form of\\nacquired baldness which occurs in individuals who have not attained\\nadvanced years. Idiopathic and symptomatic forms are recognized by\\nwriters, though it is probable that a definite cause exists for cases\\noccurring in individuals under forty-five years of age.\\nThe Idiopathic variety does not originate in the diseases of the\\nscalp or of the general economy that are recognized as effective in the\\nproduction of other forms of baldness. In many cases, however,\\nclassed as idiopathic a careful search will reveal the presence of a\\nseborrhoea. It is, as with senile alopecia, more common in men than\\nin women, and is in the former sex decidedly prevalent among those\\nleading sedentary lives. The loss of hair may be produced either\\nrapidly, or, more commonly, slowly, and at any period after the puberal\\nepoch. It is always symmetrical and usually remediless, partial cal-\\nvities being the permanent result of the process. The pilary growth\\nmay gradually and evenly recede from the forehead, or, what is more\\nfrequent, recede from the temples on either side of the median line,\\n1 Arch. f. klin. Chir., Bd. xiv.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0544.jp2"}, "545": {"fulltext": "ALOPECIA. 509\\nleaving a more vigorous crop extending centrally toward the root of\\nthe nose, or produce the effect of the tonsure described above. In many\\nfamilies there is a predisposition to this premature loss of hair, usually\\nin the form of the receding temple, that may be recognized in the males\\nof succeeding generations.\\nSymptomatic Presenile Alopecia may result from a number of\\nsystemic and local conditions. Loss of hair (Defluvium Capillorum)\\nis common after typhoid and other fevers, and after other conditions\\ninterfering with the nutrition of the scalp. Frequently the hairs do\\nnot fall for some weeks after the patient has recovered from the consti-\\ntutional disturbance, but remain in their follicles until pushed out by\\nthe new hairs, or until gradually pulled out by the use of brush and\\ncomb. In these cases there is usually a general and symmetrical thin-\\nning of the hair. The loss is not permanent, as new hair gradually\\nreplaces that which has fallen. The alopecia of the early periods of\\nsyphilis is of this order, but occurs in characteristic patches. A slower\\nloss of hair is seen in many cachectic conditions such as tuberculosis,\\ndiabetes, leprosy (in which the alopecia is limited often to the eyebrows\\nand eyelids), and myxoedema.\\nOf all the local causes of alopecia, seborrhoea in some form is the\\nmost frequent.\\nAlopecia Furfuracea, Pityriasis Capitis, or Alopecia\\nPityrodes Capillitii. Losses of hair varying from moderate\\nthinning of the growth to considerable symmetrical baldness, usually\\nof the vertex, accompany the pityriasic forms of seborrhoea or eczema\\nseborrhoeicum of the scalp. The affection is exceedingly common,\\nespecially in men.\\nThe disorder, essentially chronic in course, is usually first manifested\\nin early adult life, though persons of both sexes, from tw r elve to fifteen\\nI years of age, may at these ages display typical forms of the disease.\\nAfter the condition known as Dandruff has existed for some months\\nor years the subject of the affection discovers a relatively large loss of\\nhair from the scalp, producing thinness of the growth upon the vertex,\\nnear the brow, or over the temples. The hairs, when examined in situ\\nupon the scalp, are shortened, dry, harsh, lustreless, and rarely well\\nanointed with sebum. They are rebellious to comb and brush, and\\nproject irregularly from the brushed surface. Those shed from the\\nscalp, especially of men, are found to be nearer in type to the lanugo-\\nor downy hairs than those which fall physiologically from a vigorous\\nj growth of hair in a healthy subject; that is, they are short, thin,\\npointed, and often with an indistinct medulla.\\nAt the same time the scalp is in process of incessant desquamation,\\nthe scales usually being of pityriasic type, and exceedingly abundant\\nk so long as the alopecia is not complete, after which the epidermal catarrh\\nsoon disappears. The mealy, bran-like scales are shed in a fine shower\\nupon the clothing of the patient, and, the disease being more common\\nin men than in women, its traces are often distinct upon the collar of\\nthe coat after the fingers have been passed through the hair. The\\nsame flour-like, whitish and grayish scales are distinct and plentiful\\namong the hairs to which they cling, and they can also be recognized", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0545.jp2"}, "546": {"fulltext": "510 ATROPHIES.\\nover the scalp-surface when the latter is inspected with care. Itching\\nis often marked the scalp may be scratched and torn by the nails,\\nand is, in some cases, reddened and thickened. The condition is prone,\\nsooner or later, to develop the severer phases of seborrhcea and eczema\\nseborrhoe icum.\\nOther local causes of alopecia are found in various inflammatory\\ndisorders of the scalp, such as psoriasis, eczema, etc. in morphoea, and\\nlupus erythematosus in syphilitic, tubercular, and other destructive\\nlesions in some forms of folliculitis (considered in the succeeding pages)\\nin which the follicle and surrounding tissue are destroyed by suppura-\\ntion in ringworm and favus and in traumatism, which may occur as\\na bruise or be the result of scratching or rubbing.\\nThe forms of alopecia described above as encountered upon the scalp\\nmay involve also other hairy portions of the body, as of the axilla) and\\nthe pubes and these also in variable degrees.\\nAlopecia Akeata is considered in a separate section.\\nEtiology and Pathology. The causes of congenital alopecia are\\nnot known. Senile alopecia is attributed by many to the general atrophic\\nchanges which take place in the aged. This atrophy evidently will not\\nexplain the cases, often classed as senile alopecia, occurring in men\\nunder sixty or seventy who are in all other respects vigorous and well.\\nMost cases of so-called idiopathic presenile alopecia are due to an un-\\nrecognized seborrhoea. The symptomatic alopecias should be studied\\nwith the conditions upon which they depend.\\nTreatment. In symptomatic alopecias the underlying conditions,\\nlocal or systemic, must be treated by measures appropriate to each case.\\nThe general health should always be considered, and any condition\\ninterfering with the nutrition of the scalp and hair should be removed\\nas speedily as possible.\\nLocal treatment is of importance in nearly all cases, and in general\\nis directed toward stimulating the nutrition of the hair-follicle by pro-\\nducing in its periphery a species of transitory and artificial hyperemia.\\nThis result is usually accomplished by daily brisk, but light, friction\\nof the scalp with a brush, or by massage with the fingers, aided by the\\nlocal employment of one or more of the alcoholic, oily, alkaline, and\\nother stimulating applications described below. The hat should be light\\nand well ventilated, and worn as little as possible.\\nLocal treatment may often be preceded by shampooing with either\\nthe Sarg fluid soap, or combinations of glycerin, alcohol, and sapo viridis\\nto meet the requirements of individual cases. The scalp after all such\\nshampooings should be anointed with lanolin, plain or salicylated\\nvaselin equal parts of lanolin, glycerin, and rose-water the oil of\\nbenne; or scented castor-oil. In obstinate cases the nail-brush may\\nbe used vigorously over insensitive scalps at the time of shampooing.\\nThe ointment-bases named above may often be medicated advantage-\\nously with sulphur, resorcin, chrysarobin, tar, cantharides, or mercury.\\nInstead of ointments, lotions containing cantharides, carbolic acid, cap-\\nsicum, resorcin, mercuric chloride, ammonia, or nux vomica may be used.\\nFormulae for lotions and salves to be used in this way are appended", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0546.jp2"}, "547": {"fulltext": "R\\nR\\nR\\nR\\nALOPECIA.\\nHydrarg. chlorid. corros.,\\ngr. v;\\n33\\nSpts. vin. rectif.,\\n^ij\\n60\\nAcid. acet. dil.,\\n3ij\\n8\\nGlycerin.,\\n^ss;\\n15\\nAq. ros.,\\nIvj;\\n180\\nM.\\nHydrarg. bichlorid.,\\ngr- J 1\\n20\\nTinct. cantharid.,\\n^ss\\n15\\n01. amygdal. dulc,\\n33;\\n4\\nSpts. rosmarin.,\\nl]\\\\\\n30\\nSpts. vin. rect.,\\nSy;\\n60\\nAq. destill.,\\nq-\\ns. ad \u00c2\u00a3vj\\nq. s. ad 180\\nM.\\nSulphur, prsecipit.,\\n33;\\n4\\nLanolin.,\\nGlycerin., V\\naa 3ijss\\naa 10\\nAq. rosse, J\\nM.\\nHydrarg. chlorid. mit.,\\nBiv;\\n5|33\\nHydrarg. ammon. chlor.,\\nBij\\n2J66\\nVaselin.,\\nad gj\\nad 30\\nM.\\n[Br on son.]\\n511\\nThe addition of acetic acid to a scalp-lotion seems to favor penetra-\\ntion of other remedies. Pilocarpine hypodermatically has given good\\nresults. Further suggestions regarding the details of treatment of alo-\\npecia, and the special remedies recommended for alopecia furfuracea,\\nare given under Seborrhoea sicca.\\nPrognosis. Congenital, senile, and many of the so-called presenile\\nidiopathic alopecias are practically remediless, though in the two last\\nforms further loss of hair can be prevented or greatly retarded by\\nproper treatment. The symptomatic alopecias in which there is\\ndestruction of the hair-follicle, as in lupus erythematosus, syphilitic\\nulcers, favus, and some forms of folliculitis, are permanent those due\\nto systemic disorders and to local inflammations are usually temporary.\\nIn alopecia furfuracea persistent treatment will prevent further loss of\\nhair, and in recent cases may produce a new growth.\\nALOPECIA AREATA.\\n(Lat. area, a vacant space [arere, to wither, Fox].)\\n(Poeeigo Dec al vans, Tinea Decalvans, Aeea Celsi, Aeea\\nJohnstone, Alopecia Ciecumsceipta. Fr. y Pelade.)\\nThe hair-loss is limited usually to the scalp, but may occur upon the\\nbeard, the genitalia, axillae, brows, eyelids, and the general surface of\\nthe body. Cases occur, especially in early childhood, in w T hich the\\nclosest scrutiny with a glass fails to detect a single filament of hair\\nupon any portion of the skin.\\nThe disease commonly manifests itself by the sudden and complete\\nloss of hair over a circinate, circumscribed patch, usually upon one side\\nof the scalp, so rapidly effected that a first discovery of the fact may\\nbe made at the toilet of the morning:. In other cases the loss of hair\\nis gradual, the patch attaining large dimensions in the course of two or", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0547.jp2"}, "548": {"fulltext": "512 ATROPHIES.\\nthree weeks. Less frequently an area of baldness will continue to\\nextend peripherally for many weeks. Instead of one area, there com-\\nmonly are several, which may develop simultaneously or at varying\\nintervals.\\nThe patches may be round, oval, circinate, or irregularly shaped,\\nand may vary in size from that of a small coin upward. They may\\nbe so numerous as to disfigure the entire scalp, and though they touch\\nat the borders they can scarcely be said to coalesce, as the individual\\nareas are usually recognizable. Their surface is smooth, soft, whitish,\\nand usually destitute of hairs. The affected scalp may be thinner and\\nmore lax than normal, and often is slightly depressed below the level\\nof the surrounding skin, but in rare instances it is tumid and slightly\\nreddened. As a rule, there are no subjective sensations, though the\\naffected areas may be the seat of slight pruritus, or of anaesthesia, and\\nare nearly always less sensitive to irritating applications than the sur-\\nrounding normal parts.\\nThe hairs at the periphery of patches that have attained their\\nfull development are normal in every way, and are firmly implanted in\\ntheir follicles, but at the borders of areas which are still spreading the\\nhairs are loose and fragile, often broken off near the surface, thus\\nleaving short stumps which exhibit at the bulb a spade-like extremity\\nor an attenuated point, the non-atrophied shaft thus contrasting with\\nthe wasted portion implanted below the cutaneous level. Crocker\\nlikens their shape to that of the exclamation-point. Newly formed\\nareas may be covered in greater or less degree with these character-\\nistic hairs, which, however, soon fall out.\\nThe course of the disease is variable it may persist for months or\\nyears without apparent change or new patches may form while those\\nof an older date gradually regain wholly or in part the pilary growth\\nwhich, however, may be lost repeatedly in the same area. Shifting\\nareas of baldness may in this manner invade the entire surface of the\\nscalp, which yet at any one moment of time exhibits a loss of but part\\nof its hirsute covering.\\nWhen the filaments begin to reappear there is commonly a fine,\\ndowny growth over the affected area, later replaced by a crop of\\nthicker and stronger whitish filaments, which are always succeeded, in\\ncases terminating favorably, by a growth of hairs as well colored, as\\nvigorous, and as persistent as any which were at first lost. An odd\\nappearance is often presented by patients who are improving, when the\\nstrong and white new hairs contrast vividly with the dark shade of\\nthose on the unaffected scalp.\\nThis disorder, which is more common than is generally believed by\\nphysicians, may, in some cases, at its outset be preceded or be accom-\\npanied by symptoms of ill health, such as headache, malaise, inappe-\\ntence, loss of flesh, or malnutrition. In other cases, cephalalgia,\\nparesthesia, pruritus, and formication of the skin of the scalp and\\nother regions indicate disturbance of the nervous centres. Often, how-\\never, patients of this class are in sound health.\\nAmong the unusual features of the disease may be mentioned the\\noccurrence of alopecia in bands or streaks at the site of an injury or", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0548.jp2"}, "549": {"fulltext": "ALOPECIA. 513\\nalong the course of a nerve or over the entire body, removing even\\nthe finest lanugo-hairs. Universal alopecia may occur suddenly, or as\\nthe result of a gradual thinning of the hair, or may follow the exist-\\nence of the disease in characteristic areas. This variety of alopecia,\\nwhich is fortunately rare, usually occurs after the middle period of\\nlife, but it may develop in the very young.\\nIn some instances alopecia areata is associated with other cutaneous\\ndiseases. It is not rare to discover alopecia areata in patches which\\nare also the seat of the vegetable parasites. A male patient, long\\npsoriatic, under our observation exhibited a typical seborrhcea capitis,\\nand later developed a no less typical alopecia areata.\\nThe course of the disease in young subjects is usually toward a favor-\\nable result. There is hope, as a rule, when even the downiest and\\nthinnest growth, requiring a good light and a glass for its recognition,\\ncan be appreciated. E\\\\ r en when so feebly attached that these filaments\\nare removed with ease by the fingers or a brush, and when they spon-\\ntaneously fall they may be replaced by crop succeeding crop of\\nstronger filaments, which eventually persist. In serious cases, usually\\nafter the forty-fifth year of life, and in those of long standing, there\\nmay be absolute atrophy of the hair-follicles and a resulting remediless\\nbaldness.\\nThere is some reason for believing that the disease has a stadium\\nof evolution and involution, though its exact limits are not known.\\nFew individuals fully recover the hair in less than one year. The\\nmajority attain the desired end within a period of two years. These\\nlimitations, however, apply to the asymmetrical forms of the disease\\nin the relatively young. The symmetrical alopecia areata of the\\nmiddle-aged is a far more formidable affection, though in many of\\nthese cases, when the loss is recent, proper treatment will restore the\\nhair.\\nFew diseases are the source of greater mental distress than those of\\nthe class under consideration. The prominent deformity debars the\\nsubject of the malady from social relations of many kinds, and this\\nintensifies the morbid feeling which every reflected view of the head\\nawakens. This fact is particularly true of women. The successful\\nmanagement of these cases calls often for the supporting assurances\\nof the practitioner.\\nAlopecia Circumscripta seu Orbicularis is a rare form de-\\nscribed by ISTeumann in which the areas are much depressed, are the\\nsize of a pea or smaller, and are decidedly anaesthetic. The prognosis\\nis unfavorable.\\nEtiology. The question of the parasitic or neuropathic origin of\\nI alopecia areata is still undecided, though it has been the subject of\\nextended discussion and observation. It is highly probable that many\\nof the limited, asymmetrical forms of the disease, in which the patches\\nincrease by peripheral extension, are due to parasites not yet recog-\\nnized. The efficacy of some such agency, is suggested in epidemics of\\nthe disease which have been reported both in France and in America,\\nwhere entire companies of a regiment or numbers of inmates of public\\n33", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0549.jp2"}, "550": {"fulltext": "514 ATROPHIES.\\ninstitutions, have suffered from the disease in an apparently contagious\\nform. Eichhorst, Thin, Von Sehlen, 1 Robinson/ Bowen, and others\\ndiscovered in affected patches and about the bulbs of hairs in alopecia\\nareata micro-organisms which were cultivated in generations, but\\nwhich were not shown to be effective in the production of the disease\\nde novo. In a series of three hundred cases Sabouraud found in the\\nearly stages of the disease a micro-bacillus. He obtained pure cultures,\\nwith which he produced typical areas in calves, rabbits, and guinea-\\npigs. He finds the same bacillus in comedo, acne, and seborrhoea, and\\nbelieves that alopecia areata is an acute form of seborrhoea oleosa. The\\nfrequent coincidence of alopecia areata and tinea tonsurans suggests an\\netiological relationship.\\nThe weight of evidence in favor of a neuropathic origin of some cases\\nof the disorder is great, and is very generally accepted by authorities.\\nThe sudden occurrence of extensive symmetrical or of universal alo-\\npecia can hardly be explained in any other way. Mental emotion\\n(anxiety, fright), anaemia, malnutrition, traumatism both general and\\nlocal (falls upon the head, blows inflicting lacerated wounds of the\\nscalp), and bodily injuries of the general surface have all been cited as\\neffective. The nervous symptoms which often precede or accompany\\nthe appearance of the bald patches are strikingly suggestive, and the\\noccurrence of the disease after shock of the nervous centres is signifi-\\ncant. Cases of this type are classed by Michelson and others as Alo-\\npecia Neurotica. Max Joseph produced baldness in patches upon\\nthe ears of cats and rabbits by section of the second cervical nerve\\nnear the intervertebral ganglion.\\nAlopecia areata occurs with equal proportion in the two sexes, and\\namong these irrespective of social condition. Of the partial and asym-\\nmetrical forms, the larger number of cases occurs in young subjects,\\nfrom childhood to early adult life. The severe and generalized forms\\nare more often encountered in middle-aged persons. In the latter class\\nespecially the disease is occasionally observed to follow the obscure dis-\\norders of the nervous centres due to sudden or prolonged undue excita-\\ntion. In young subjects a peculiar repugnance to the ingestion of fat\\nand meat may often be discovered.\\nPathology. The anatomical lesions in alopecia areata have not\\nbeen recognized definitely. The hairs fallen from the surface, when\\nexamined, with the microscope, are seen to be atrophied in bulb and\\nshaft, as in other forms of alopecia. Fracture of the shaft is in some\\ncases also noted, evidently an accident of the process.\\nAs a^ result of careful examination of many pathological sections,\\nGioyannini 3 and Robinson 4 believe the disease is primarily an inflam-\\nmation of circumscribed areas of the corium, and especially of the sub-\\npapillary layer. In a small patch of one week s duration Robinson\\nfound marked perivascular cell-infiltration in a limited region of the\\ncorium, the papillae being but mildly affected, while the epithelium,\\n1 Annal. de Derm, et de Syph., June, 1886.\\n2 Monatshft. f. prakt. Derm., 1889, vii., p. 409.\\n3 Annal. de Derm, et de Syph., 1891, p. 921.\\n4 Morrow s System, vol. iii., p 865.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0550.jp2"}, "551": {"fulltext": "ALOPECIA. 515\\nrete, subcutaneous tissue, and glands were normal. Some of the hair-\\nfollicles were normal, while in others no papillae could be found, and\\nthe hairs were wanting or imperfect. In cases of longer standing\\nevidences of inflammation were more marked and extensive, and there\\nwere vessels with thickened walls and narrowed lumina. In some\\ncases there was more or less atrophy of all elements of the corium,\\nwith destruction of the hair-follicles and sebaceous glands. Giovan-\\nnini, who describes an invasion by leucocytes of the hair-follicle, con-\\nsiders the process a deep-seated folliculitis.\\nSabouraud finds constantly in the early stages large numbers of\\nhis micro-bacillus surrounded by keratinized epithelium, forming a\\ncocoon-shaped mass which occupied the much dilated follicle-neck.\\nIn the later stages of the disease he finds no bacilli, but describes\\ninflammatory changes, atrophy of the follicle, and achromia of the\\nbasal layer, all of which he ascribes to the influence of local toxins.\\nDiagnosis. Alopecia areata is to be distinguished from vitiligo of\\nthe hairy portions of the surface by the preservation of the pilary\\ngrowth in the disease last named, the filaments, moreover, having\\nusually a blanched and whitened look, due to the absence of pigment.\\nFrom ringworm and favus of the scalp the disease in question is\\ndifferentiated by the suddenness of its onset the absence of stumps\\nof hairs, scales, crusts, and evidences of irritation in the involved area\\nthe whiteness, smoothness, and complete baldness of the latter and,\\nabove all, by the failure to detect with the microscope the evidence of\\nthe presence of a vegetable parasite. Ringworm and alopecia areata\\nmay coexist. In cases of so-called bald-ringworm the diagnosis\\nmust rest upon the microscopical findings.\\nThe asymmetrical patches of seborrhoea of the scalp are recognized\\nby the presence of the fatty plates pasting the hairs to the scalp-sur-\\nface, as well as by the slow and very gradual onset of the disorder.\\nOther forms of baldness than those named above are all of gradual\\nand, in their early stages, of symmetrical development. Those result-\\ning from traumatic injuries of the scalp with cicatricial results, are\\neasily determined as having such an origin.\\nTreatment. One necessarily views with distrust all treatment\\nfor that disease which in the course of months or years usually termi-\\nnates in spontaneous recovery, and in the meantime may bid defiance\\nto each and every therapeutic measure. Nevertheless, persistent and\\nhopeful management of even apparently desperate cases is occasion-\\nally rewarded by such brilliant consequences that, however slight may\\nbe the foundation for a belief in the value of the therapy employed,\\nit deserves recognition and trial.\\nThe hygienic management of every case is a matter of importance.\\nThe general condition of the nervous system should be considered and\\nmay call for changes in the habits of working, eating, resting, and\\nexercising. Tobacco in every form should be denied to subjects of the\\ndisease. Iron, quinine, nux vomica, cod-liver oil, phosphorus and the\\nhypophosphites, arsenic, and strychnine are often indicated, and used\\nwith great benefit.\\nThere are few patients who are not benefited by daily salt-and- water", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0551.jp2"}, "552": {"fulltext": "516 ATROPHIES.\\nbathing of the entire body-surface, followed by brisk friction, espe-\\ncially over the spinal region. In the case of children this treatment\\nmust be conducted by a skilled hand. When practicable the cold\\ndouche is to be preferred.\\nIn all cases in which the scalp is involved in either sex, and in\\nwhich the special hypochondriasis of the disease is developed, a wig\\nshould be worn for the sake of its moral effect upon the sufferer. Its\\nuse, however, should be limited to social occasions, visits, etc., as the\\npersistent wearing of a peruke indoors seems to lengthen the course of\\nthe disease.\\nThe indication for local treatment is to destroy any parasites that\\nmay be present and to increase the physiological afflux of blood to the\\nhair-follicles. With this end in view the affected parts are to be bathed\\ndaily in water as hot as can be tolerated, then dried, and rubbed with\\na stimulating lotion. After the lotion dries it is well to apply an oil\\nor simple ointment. The articles usually employed are alcohol, ether,\\nresorcin, formalin, turpentine, ammonia, camphor, cantharides, carbolic\\nacid, oil of mace, croton-oil, tincture of nux vomica, tincture of cap-\\nsicum, tinctiu e of aconite, castor-oil, tar, iodine, sulphur, and the mer-\\ncurials. All frequently fail. Several of these substances in combina-\\ntion seem at times to be of service.\\nThe following is a formula, the ingredients of which may be varied\\nto suit the indications in different cases.\\nR 01. ricini,\\nAcid, carbolic,\\nCantharid. tinct.,\\n01. rosmarin.,\\nSpts. vin. rectif., adf^iv; ad 120l M.\\nSig. For external use over the scalp with friction.\\nThe preparations containing sulphur, resorcin, pyrogallol, chry-\\nsophanic acid (which has the disadvantage of staining the hair), mer-\\ncuric chloride, etc., given on a preceding page in connection with the\\ntreatment of seborrhoea capitis, are often valuable.\\nFormalin in solutions of 0.5 to 2 per cent, is sometimes efficient.\\nIt should be used with care, however, as it has occasioned severe der-\\nmatitis, and in several instances has given light hair a green color.\\nJackson recommends liquor amnionic fortior, applied once or twice\\ndaily to the bald areas. Speedy return of hair in a patch of alopecia\\nareata has followed the application of pure creosote and also of tri-\\nkresol to the denuded surface, resulting in moderate vesication. The\\nspirit of turpentine and pure carbolic and acetic acids have similarly\\nbeen employed but caustic applications are to be used with caution.\\nBy many experts, having in mind the probability of a parasitic\\norigin, epilation is practised to the extent of removing all the loosened\\nhairs and a narrow zone of sound hairs about each patch. By others,\\nshaving of the patches is substituted for epilation. The remedies\\nselected for application are of the order of parasiticides for example,\\nmercurials, sulphur and its compounds, chrysarobin, pyrogallol, and\\niodine.\\nf^ss\\n3j;\\ngss;\\n15\\n4\\n15\\ngtt. xv\\nad f^iv;\\n1\\nad 120", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0552.jp2"}, "553": {"fulltext": "ALOPECIA. 517\\nRepeated blisterings of the scalp with cantharidal collodion, croton-\\noil, spirit of green soap, and petroleum have also been employed with\\nsuccess. The ointment of chrysarobin has the disadvantage of staining\\nnot only the remaining hairs, but often also the face in consequence of\\nthe frequency of a transmission to that locality through the medium of\\nthe hands. When patients, however, consent to the use of chrysarobin\\nit is worthy of trial, as its application has been followed by a vigorous\\ngrowth of new pilary filaments. Andre employed ten hypodermatic\\ninjections of pilocarpine muriate in grain (0.008) doses, which\\nresulted, in the case of a middle-aged woman affected with total sym-\\nmetrical baldness, in an abundant growth of hair. Mercuric chloride\\nhas similarly been employed.\\nFaradization of the scalp with a stiff wire-brush, pushed to the\\npoint of producing moderate hyperemia, has been followed by excel-\\nlent results.\\nWilson recommends\\nR 01. amygd. dale, f 30\\nCapsici tinct., f 3 ij 8\\nLiq. ammon. fort., f j 30\\nSpts. rosmarin., f^v; 150\\n01. limon., f 3j 4\\nM.\\nAnother stimulating application is\\nR 01. terebinth., aaf^ss; aa 15\\nOl. ricini, j\\nOrigani tinct., f Z j 4\\n01. camphorat., f \u00c2\u00a7j 30\\nLiniment, volatil., adf^iij; ad 90\\nSig. For external use with a brush until the scalp is irritated.\\nM.\\nShaving should regularly be practised when in men the region of\\nthe beard is involved, as the deformity is thus rendered less conspicu-\\nous and the bald surface should be stimulated frequently with one or\\nseveral of the topical applications named above. Alcoholic solutions of\\nresorcin (3 to 20 per cent.) or of mercuric chloride, to 1 grain (0.033-\\n0.066) to the ounce (30.), are to be well rubbed over the patch or patches\\nonce or twice daily.\\nPrognosis. From what precedes, it will be inferred that, as re-\\ngards the relief of the baldness, the asymmetrical development of alo-\\npecia areata in youth is much more favorable than the symmetrical\\nj general disease of middle life, the latter being often remediless. In\\nall cases the practitioner should actively persevere to the end. In no\\n1 case should any encouragement be given as to complete relief within\\nthe year, though such exceptionally short careers of the disease\\nare at times observed. The prognosis of the same affection of the\\nI beard is quite favorable, the disease, in young men, usually conclud-\\ning its stadium in the course of about one year, with a favorable ter-\\nmination.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0553.jp2"}, "554": {"fulltext": "518 ATROPHIES.\\nALOPECIA FOLLICULARIS.\\n(Folliculitis Decalvans. Fr., Folliculites et Perifollicu-\\nlites Destructives du Follicule Pileux, Folliculites\\net Perifolliculites Decalvantes, Alopecies Cicatri-\\ncielles Innominees, Acne Decalvante, etc.)\\nA series of closely related yet differing forms of folliculitis and\\nperifolliculitis may involve the hair-follicle and its adjacent parts, de-\\nstroying not merely the hair-bulb, but also the hair-papilla. As a\\nresult these conditions are followed by permanent alopecia and by the\\nproduction of scars. The inflammatory nature of the process is usu-\\nally though not always apparent. There is commonly a marked\\ntendency to grouping of lesions, but they may be scattered and iso-\\nlated. These disorders, studied with special care by French observers,\\nare yet but imperfectly understood, and none is perfectly distinguished\\nfrom the other dermatoses resulting in hair-loss.\\nThe following types of disorders, many of them of great rarity,\\nsome observed by but few experts, are recognized by Brocq\\n(a) Cicatricial alopecias in small irregularly disseminated plaques.\\nThese can be recognized when any scalp that has been the seat of a\\nsevere alopecia pityrodes is minutely studied. They are probably\\naccidental results of that morbid condition, and are due to infection of\\nthe follicles with cocci.\\n(6) Cicatricial alopecias of the scalp, the eyebrows, and the face,\\nin which minute glistening whitish points result, compared by Brocq to\\nthe lesions produced by destruction of the hair-papilla in electrolysis.\\nIt is possible that these lesions are due to the cause suggested for the\\nfirst group.\\n(c) False alopecia areata pseudo-pelade of French writers). In\\nthese cases the scalp about one or several hair-follicles becomes tumid\\nand reddened. The hair is loosened in its pouch, and, whether it fall\\nspontaneously or be removed by epilation, it is not replaced by another.\\nThe scalp is left whitish, smooth, ivory-like, depressed, thinned, and\\napparently atrophied, without trace of the new-formed downy hairs\\noften noticed in alopecia areata. As distinguished from the last-named\\ndisorder, the advance of the patch may be in irregular lines rather than\\nby extension of the rounded or oval circles formed in alopecia areata.\\nMinute islets of alopecia exhibit the outlying evidences of disease.\\n(d) Cicatricial alopecias with a punctiform appearance of the plaque.\\nHere there is an inflammatory involvement of the follicle and peri-\\nfollicular tissue, with redness of this special region that disappears after\\natrophy has occurred. The sequel is a depressed whitish cicatriform\\ntissue, marked here and there with pinhead-sized, reddish points where\\nthe circumpilary exudation is still in activity.\\n(e) Quinquaud s Disease 1 (Acn6 Decalvante of Pailler and Robert).\\nHere miliary abscesses, punctiform, pinhead-sized and larger, involve\\nthe follicle. The hair originally piercing these suppurative lesions is\\nloosened and falls, after which the follicle atrophies and the hair is no\\n1 Bull, de la Soc. med. des Hop., 1888.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0554.jp2"}, "555": {"fulltext": "ALOPECIA. 519\\nlonger produced. The scalp is left dead-white, thinned, depressed,\\natrophied, and cicatriform, in patches as large as those visible in alopecia\\nareata, but often irregular in outline. The follicles remain distinct and\\nare not fused into a mass they resemble the distribution of the lesions\\nin coccogenous sycosis. In some instances this special follicular alopecia\\nand scarring have progressed without suppurative involvement of the\\nfollicle, and in cases without any signs of inflammation.\\nLupoid sycosis (Brocq) Ulerythema sycosiforme (Unna).\\nSpecial attention should be directed to this affection, as it is of great\\nimportance to distinguish it from the more common variety of cocco-\\ngenous sycosis, which it strongly resembles.\\nThis disease chiefly affects the male beard (a region more accessible\\nthan the scalp to the fingers), and its early symptoms are well-nigh\\nindistinguishable from those of sycosis of the type named above.\\nThere are large and small, well-defined, follicular and perifollicular\\npustules, with redness, infiltration of the derma, scales, crusts, and\\ncharacteristic deformity but as the disease progresses the hairs are\\nremoved from the whole or a large part of the involved area, and there\\nis left, after a relatively long period, occasionally suddenly produced,\\na cicatricial or keloid-like surface, which may be smooth or highly\\nirregular.\\nIn mild cases there is left a reticulum of narrow, scar-like, whitish\\nlines, irregularly radiating over the surface, giving to the eye and touch\\nthe suggestion that they are depressed below the general level of equally\\nirregular areas of the bearded chin or cheek. These areas may or may\\nnot be provided with hairs in the former event the growth is stunted\\nby the contracture of the encircling atrophy, where a species of fibrosis\\nhas occurred.\\nIn severer cases there is left a more generalized cicatriform tissue,\\nfor the most part unprovided with hairy filaments. The process may\\nbe such as to interfere with the movements of the lips in articulation\\nand mastication. These parts, for months after the disease has accom-\\nplished its evolution, are somewhat reddened. In both forms the cen-\\ntrifugal direction of the morbid process has been observed.\\n(g) In a last group are placed a few ill-defined cicatricial alopecias,\\nbeginning often with perifollicular, rather than follicular, pustulation,\\naccompanied by redness of the affected part and the eventual formation\\nof peculiarly persistent crusts. When these crusts fall a reddish,\\nslightly scaly surface is left, followed by cicatricial atrophy and a patch\\nwith distorted and friable or fairly vigorous hairs, surrounded by an\\nelevated rim. There is little definition distinct patches of the disease\\nare rarely seen. It more often affects the beard, and may be symmet-\\nrical. It may coexist in the same subject with acne-keloid, atrophic\\nacne, and other varieties of that disorder, with which it is unquestionably\\nrelated.\\nIt will be seen from the foregoing that there has been recognized a\\nseries of interesting and important affections of the hairy parts, as yet\\nnot distinctly differentiated each from the other and the series from all\\nothers. Some of them may be found eventually to be varieties of lupus", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0555.jp2"}, "556": {"fulltext": "520 ATROPHIES.\\nerythematosus others, of tuberculous infection of the scalp. Kaposi s\\ndermatitis papillaris capillitii is without question to be recognized in\\nsome of the descriptions given. A few may be rare localized gumma-\\ntous changes produced by syphilis. All are best treated with corrosive-\\nsublimate lotions, 1 part of sublimate to 400 boric acid lotions and\\npowders and salves containing mercury, sulphur, and iodine. Galvano-\\ncauterization of the pustules and inflammatory points has successfully\\nbeen employed in some of the reported cases. All these disorders are\\nwell managed if treated in accordance with the principles suggested in\\nthe chapter on Sycosis.\\nKELOID-ACNE.\\n(Acne Keloidienne, Dermatitis Papillaris Capillitii, Pian\\nRuboide [Alibert].)\\nUnder this title Kaposi describes a disorder characterized by pinhead-\\nsized, isolated or confluent elevations of the skin-surface, with inter-\\nspersed pustules, which finally form cicatriform plaques over which the\\nhairs are either clustered in tufts or are totally absent. The pilary\\nfilaments are atrophied yet firmly fixed in their follicles, and they\\nsuffer elongation or fracture before withdrawal. The disease is encoun-\\ntered chiefly upon the nucha, the occiput, and the vertex. Papil-\\nlomatous vegetations, crust-covered, hemorrhagic, and with a foul-\\nsmelling secretion, sometimes form, and eventually retract into a scle-\\nrotic tissue.\\nOne of us has described typical cases of this disorder, 1 each of which\\nconcluded with the production of a keloid-like, cicatriform, irregularly\\nshaped but circumscribed elevation of the surface. This feature is that\\nby which it specially differs from all other sycosiform disorders; The\\ndisease seems to be due fully as much to inflammatory processes in the\\nsubcutaneous tissue between the unyielding pericranium and the thick\\nscalp as in the derma proper, and therefore it is not, strictly speaking,\\na dermatitis. Puncture, for example, of one of the pinhead-sized\\npustules commonly gives exit to the usual quantity of pus but pressure\\nupon the scalp in the periphery will at once be followed by the appear-\\nance of a still larger quantity of similar pus which evidently is expressed\\nfrom a circumscribed subcutaneous abscess. When by such pressure\\nthe abscess-cavity is emptied it slowly fills with venous blood and\\nproduces a firm, semisolid elevation of the surface that subsequently\\nundergoes sclerosis, and the starved hairs above behave in the manner\\ndescribed by Kaposi. The papules and plaques are formed in a sim-\\nilar way by the abundant supply of venous blood. The case of one\\nof the patients presented at the clinic had been erroneously diagnosti-\\ncated by a surgeon as aneurismal in character. Puncture of all such\\nsemisolid, cicatriform lesions is invariably followed by oozing of venous\\nblood in abundance. The disease is chronic in character, is particu-\\nlarly liable to relapse in crops of pilary or peripilary pustules and\\npapules, and it extends from nucha to vertex, avoiding the frontal and\\n1 Jour. Cutan. and Ven. Dis., vol. i., No. 2, p. 33.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0556.jp2"}, "557": {"fulltext": "ULERYTHEMA APHRYOGENES. 521\\ntemporal regions. Over the bald or partially bald keloid-like eleva-\\ntions there is seen, in some cases, a species of seborrhoea in the form\\nof more or less adherent, fatty crusts, with occasional characteristic\\ntufts of hairs.\\nThe disease seems to owe its special character to the anatomical\\npeculiarities of its location. It occurs preferably at the points where\\nthe venous supply of the scalp is not only greatest, but where it is also\\nin most direct connection with the large vessels beneath, and where an\\ninflammatory process in the derma or subcutaneous tissues invites with\\nreadiness a pathological afflux of blood. Such a focus, limited beneath\\nby the dense calvarium, and above by the relatively thick scalp,\\nreadily undergoes organization and sclerosis, the subsequent behavior\\nof the hairs and hair-follicles being an accident of the process.\\nAccording to Besnier and Doyon, the disorder is a papillomatous\\ndevelopment, likely to occur in this region of the scalp as a sequel of\\nepilating, cicatricial (keloid) acne, eczema, or traumatism.\\nSangster (in a paper read before the International Medical Congress\\nin London, 1881) described a pigeon s-egg-sized tumor of the scalp,\\nthat Kaposi, who was present, recognized as a case of dermatitis papil-\\nlaris capillitii.\\nTreatment. The method of treatment to be employed in this rare\\ndisease can scarcely be described as established. The affected surfaces\\nare first freed from subcutaneous abscesses by puncture and expression\\nof the contents. Then the patch is washed with hot carbolized water,\\ndusted with boric acid or iodoform, and a compress, moistened with\\nan antiseptic solution, such as corrosive-sublimate wash, is firmly\\nbandaged over the part. When pathological fluids no longer form\\nunder the scalp the patch is best epilated and anointed with a salve\\ncontaining 1 drachm (4.) of precipitated sulphur to the ounce (32.) of\\nscented vaselin, which salve may also be kept constantly over the part.\\nWhen crusts form they may be removed by shampooing with green\\nsoap.\\nInternal treatment is suggested by the constitutional condition of\\nthe patient, and it should often include cod-liver oil, the ferruginous\\ntonics, and a roborant regimen.\\nULERYTHEMA APHRYOGENES.\\nThis affection was first described by Taenzer in Unna s clinic.\\nAccording to Unna, it occurs most frequently in blondes, is usually\\nlocated in the eyebrows, from which it may spread to adjacent parts,\\nincluding the scalp, or it may appear on the extensor surfaces of the\\nupper arms. The condition may be no more than a persistent ery-\\nthema, with small, elevated, horny papules at the mouths of the hair-\\nfollicles. The hairs are finer than normal and usually are broken off\\nclose to the surface. The disease may persist for years without further\\nchange, but in the severer forms atrophy, both follicular and interfol-\\nlicular, results, so that small, depressed scars are surrounded by, or\\ncommingled with, the hypersemic areas. The resulting alopecia is per-\\nmanent and may be very marked, especially on the eyebrows.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0557.jp2"}, "558": {"fulltext": "522 ATROPHIES.\\nATROPHIA PILORUM PROPRIA.\\nAtrophy of the hair may be either symptomatic or idiopathic. Illus-\\ntrations of the first-named condition are observed in phthisis, syphilis,\\nseborrhcea, ringworm of the scalp, and in almost all general diseases in-\\nterfering with the nutrition of the pilary growth. The filaments then\\nbecome dry, lustreless, friable in both longitudinal and transverse\\ndiameters, and diminished in each dimension.\\nThere are several recognized forms of idiopathic atrophy of the hair.\\nOne of these forms exists in those long hairs which are seen to be ir-\\nregularly thinned or flattened in the shaft, and split at the point into\\ntwo or more recurving fibrillar, a condition noted, for the most part, in\\nfew hairs scattered among those of full development and vigor. This\\nespecially localized atrophy seems to be peculiar to one or more follicles\\nmerely; and is analogous to the condition in which there appears\\namong the vigorous pigmented hairs of early life a single blanched\\nfilament.\\nFRAGILITAS OMNIUM.\\nUnder this title a number of odd disorders, due to atrophy, and pro-\\nducing fragility, splitting, or curling in abnormal directions of pilary\\nfilaments, have been described by authors.\\nUndescribed form of Atrophy of the Hair of the Beard\\nof Duhring. 1 In this affection, either at the bulb or at a variable dis-\\ntance, from it but within the follicle, there is fission of the hair-fila-\\nments into from two to four stalks with coincident atrophy of the bulb\\nitself, and consequent irritation of the surface. Duhring s patient ex-\\nhibited to a marked degree the species of hypochondriasis to which the\\nsubjects of disease of the hair seem specially prone. This disorder\\nis not induced by a parasite.\\nIn 1887 a gentleman applied for advice who was in a fair condition\\nof general health, but the hairs of whose beard exhibited the symptoms\\ndescribed and figured by Duhring. Photo-micrographs of specimens of\\nthese hairs show clearly that in every case the fission of the filament\\nextended completely to the base of the follicle and produced there irri-\\ntation. The hairs over several square inches of surface were thus\\nuniformly affected, normal filaments being in such areas absent. The\\ninterfollicular spaces, however, seemed to be abnormally widened, as\\nthough in these areas such normal hairs might have fallen in conse-\\nquence of a species of alopecia. The disease was much more strongly\\nmarked on the chin than on the cheeks or the upper lip. The curl-\\ning of some of the splinters was complete and characteristic.\\nTRICHORRHEXIS NODOSA.\\n(Trichoptilosis [Devergie], Nodositas Crinium.)\\n_ Trichorrhexis nodosa, first described by Wilks and Beigel, is a con-\\ndition in which the hairs display nodose swellings along the shaft at\\nirregular distances, the beard and moustache being most often affected,\\n1 Arner. Jour. Med. Sci., July, 1878.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0558.jp2"}, "559": {"fulltext": "TRICHORRHEXIS NODOSA.\\n523\\nthough rarely there is involvement also of the hairs of the scalp, the\\naxillae, and the pubes. The hairs are brittle, and fracture usually oc-\\ncurs through the node, leaving a broom-like mass of filaments project-\\nTrichorrhexis nodosa. (After Schwimmer.)\\ning there, while the internodular portions of the shaft appear normal\\nsave for enlargement of the medulla (Fig. 62). The fragility of the\\nhair at the centre of the node seems to depend upon the tension and\\nconsequent fissure of the cortical layer, which is greatest at that point.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0559.jp2"}, "560": {"fulltext": "524 ATROPHIES.\\nThe hair-bulbs are firmly adherent in their follicles. In a form of this\\ndisease common among the women of Constantinople Hodara discov-\\nered a bacillus, with pure cultures of which he reproduced the disease\\nin a woman s hair. It is probable that the condition is always caused\\nby a definite micro-organism.\\nAccording to Brocq, trichorrhexis nodosa is not produced by spe-\\ncific bacteria upon the shafts of the hair though Spiegler l reports\\nthat when of occurrence upon the beard, bacilli and cocci, probably\\nidentical with those described by Hodara, are found in heaps, not\\nmerely on the shafts of the hairs, but in the walls and enclosed bulb of\\nthe hair-crypts.\\nTreatment is not satisfactory, as a rule. Sabouraud highly recom-\\nmends daily applications of the following\\nR Hydrarg. bichlorid., gr. iij\\nAcid, tartaric, gr. viij\\nResorcin., gr. xv-xxx; 1.00 to 2\\n20\\n40\\n00\\n00\\nM.\\nShaving has been followed in some of Kaposi s cases by good results\\nwhile Roeser 2 advocates the local employment of dilute tincture of\\ncantharides.\\nMonilethrix (Ringelhaaren Moniliform, Beaded Hairs Pili\\nAnnulati Ft., Aplasie Moniliforme Intermittente) is a somewhat rare\\ncondition first observed by Smith (as described below), and since by\\nnumbers of others, including Luce, Anderson, Crocker, Lesser, and\\nBehrend. A patient affected with this disease was exhibited at the\\nInternational Congress of Dermatology held in London in 1896. Like\\nthe forms of fragility described above, the hairs are peculiar in exhibit-\\ning along the shaft a succession of rings or nodes, between which are\\nnarrower portions of the shaft, of a color lighter than that of the pig-\\nmented nodular or annular portions. The result is a characteristic\\ncheckered appearance of the hairs. Fracture always occurs in the\\ninternodular part, the fractured extremity having a characteristic brush-\\nlike stump. These conditions are evidently due to atrophic changes in\\nthe internodular parts, with better development in the pigmented and\\nthicker portions of the shaft, the whole being due to nutritive changes\\nwhich Virchow explains as due to a periodic aplasia of the hair-papilla.\\nThe obvious symptoms are clearly the result of a profound process,\\noriginating probably in the trophic nerves.\\nNodose Swellings of the shafts of the hair. Smith, 3 of Dublin,\\nfirst reported a case of this disorder. Photo-micrographs of some of\\nthe hairs from this patient exhibit no fragility at the nodes, which\\nbeginning near the scalp are regularly displayed along the shaft, the\\nfracture being always internodular. The spherical swellings along the\\nshaft are also pigmented in a brown hue, and these pigmented nodose\\nswellings, contrasting with the non -pigmented color of the unaffected\\n1 Arch. f. Derm. u. Syph., Bd. xii., Heft 1.\\n2 Annal. de Derm, et de Syph., 1877-1878, pp. 185 et seq.\\n3 Brit. Med. Jour., May 1, 1880.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0560.jp2"}, "561": {"fulltext": "LEPOTHRIX. 525\\nportions of the shaft, give the hairs a singularly checkered appear-\\nance. No parasite is discernible in any of the specimens.\\nExpansions and Fissures of the Hairs. Michelson, under\\nthis title, discusses the abnormalities of the pilary system, instances of\\nwhich are cited above, and he concludes as to the most of them that\\nthey are not separate diseases, but are expressions of an abnormal dry-\\nness and brittleness of the hairs due to atrophy. Cases of broom-like\\nAssuring and division of the shaft into larger longitudinal splinters he\\nregards as equivalent processes, both beginning by a cuticular loss and\\noften merging into each other.\\nThis view may be sound with regard to a number of these rare affec-\\ntions but even a superficial examination of the longitudinal splinters\\nshown in Duhring s and the authors cases reveals the fact that the\\nshaft represented by the sum of all its splinters is greater than that\\nof the average hair in diameter and circumference. Even the naked\\neye can recognize this fact. The distention of the epilating-forceps in\\nseizing a single hair, in the case of our patient, was equivalent to the\\ngrasping of as many sound filaments as are represented by splinters.\\nThe therapy of these cases is not well determined. Michelson be-\\nlieves shaving to be useless, and he recommends systematic shampoo-\\ning and oiling. Arsenic internally is worth trying in all cases in\\nwhich it is not contraindicated.\\nLEPOTHRIX.\\n(Gr. tenog, scale fyu f, hair.)\\n(Trichomycosis Nodosa.)\\nThis disorder, first described in 1869 by Paxton, and since recog-\\nnized by Patteson, Pick, Babes, Barthelemy, and others, affects\\nthe hairs, chiefly of the axillae and the genital regions. The fila-\\nments are dry, brittle, roughened, and loosened in their follicles.\\nUnder the microscope the shaft is seen to be either for a great part or for\\nthe entire length ensheathed in a concretion which may here and there\\nbe interrupted by furrows a diffuse form of the affection. In a\\nnodose form there are irregularly placed spherical masses, isolated\\nfrom one another and more numerous toward the point than near the\\nimplanted extremity of the shaft. Crocker describes also circular and\\nwell-defined masses, lying upon but not surrounding the shaft, three\\ntimes the diameter of the shaft, and containing fibres of the cortex\\nthat had been split by the concretion. The fracture may be clean\\nor be brush-shaped. The nodular masses are exceedingly well attached\\nto the shaft, and reddish brown to blackish in shade. At times red-\\ndish sweat of the axillae, due to micrococci, has been a coincident\\nsymptom.\\nThe nodes are found to be made up of chains of spherical or of\\nelliptical micrococci, which penetrate the cortical layers of the hair\\nwith ease in regions of considerable moisture and sweat. The micro-\\norganisms at first obtain access by minute separations of the cuticle of\\nthe hair, and they eventually penetrate more deeply, breaking up the", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0561.jp2"}, "562": {"fulltext": "526 ATROPHIES.\\ncortical portions. While thus multiplying, a homogeneous substance,\\nsimilar to the chitine by which the louse fastens its eggs to the hair,\\nforms the bulk of the concretion in which the colonies of cocci are\\nlodged.\\nThe Treatment is by shaving and external applications of mercuric\\nchloride (1 2000).\\nPIEDRA.\\nPiedra is a term descriptive of blackish and exceedingly firm nodes,\\npartially or completely surrounding the hairs, and distributed without\\nspecial order along any part of the shaft. The nodes are of the size\\nof a pinhead, and, though occurring chiefly in the hairs of the head\\nof women, have been seen also on the scalp and the beard of men.\\nDesenne, Morris, Juhel-Renoy, and Lion have reported cases. The\\ndisease belongs to the group of hyphogenous disorders. The nodes are\\nseen to consist of masses of spores with abundant mycelium, readily\\ncultivated but never penetrating to the interior of the hair. The hair-\\nbulb remains intact, and the disease is at once relieved by shaving or\\ncutting the aifected filaments. It occurs chiefly in Cauca, Colombia,\\nbut has been recognized elsewhere. In the case of a young girl sent\\nfrom the Chicago Eye and Ear Infirmary there were numerous jet-\\nblack, horny, and dense spherical masses attached to the hairs of the\\neyelashes of each lid of both eyes.\\nBEIGEL S DISEASE.\\n(Chignon Fungus.)\\nThis affection is discovered upon false hairs, which exhibit on their\\nshafts dirty-brownish nodes, due to masses of parasites. The fungus\\nhas not definitely been distinguished. The nodes are irregularly strung\\nalong the shaft of the hair.\\nTINEA NODOSA.\\nThis disorder, first discovered by Morris and Cheadle, affects the\\nhairs of the beard or the moustache. The nodular concretions, which\\ngive the hair an irregular outline, are shown to be made up of fungus-\\nspores a little smaller than those of tinea trichophytina. The hairs are\\nbrittle and break or split.\\nThe Treatment is by shaving or clipping, with the application of\\nparasiticides.\\nATROPHIA UNGUIS.\\n{Fr., Onychatrophy.)\\nAtrophy of the nails may be a congenital or an acquired condition,\\nin which there is deficient or defective production of nail-substance.\\nThe congenital forms are usually observed when the digits are poorly\\ndeveloped, and there is at the same time a deficiency of the pilary\\ngrowth. The nails may be absent in these cases, or merely be tardy", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0562.jp2"}, "563": {"fulltext": "ATROPHIA UNGUIS. 527\\nof evolution occasionally they are seen, especially upon rudimentary\\nor coalesced digits, in defective and distorted shapes.\\nNicolle and Halipre l and C. J. White 2 report interesting cases of\\ndystrophic disorders of the nails and hair extending through several\\ngenerations of the same family. In the French cases the condition was\\nseen in thirty-six individuals in six generations. One of those affected\\nwas an idiot, another a subject of hysteria, and another of feeble intel-\\nlect. There were other evidences of a family tendency to mental and\\nnervous deterioration. The hairs in the affected individuals were\\nscanty, short, thin, light-colored, friable, and easily epilated. The\\nmost marked symptoms, hoAvever, were in the nails, which showed vari-\\nous grades of hypertrophy and atrophy, with periungual changes of an\\ninflammatory type, due probably to injury or secondary infection.\\nIn acquired atrophy the nail may be changed either in color, bulk,\\nelasticity, firmness, shape, or position. Thus, the nail may be ex-\\npanded and thin, narrow and acuminate, friable, furrowed, laminated,\\nridged, or otherwise distorted. It may uniformly or partially be\\nlustreless, or singularly striped, or even irregularly speckled.\\nThese changes in various combinations result chiefly from trauma-\\ntism, such injuries, for example, as are common to the toes in the boot\\nor shoe, and to the fingers when actively employed in the trades.\\nExcessive heat and cold and constant maceration in chemical solutions\\n(as among photographers, dyers, and druggists) often operate injuri-\\nously upon the nail-tissue. The inflammatory dermatoses, eczema,\\npsoriasis, and the like are frequent causes of atrophy and dystrophy of\\nthe nail. All serious disturbances of systemic nutrition, as are inci-\\ndent to prolonged fevers, surgical accidents, tuberculosis, ataxic con-\\nditions, etc., interfere visibly with the nutrition and development of\\nthe nail. Syphilitic changes in the nail are commonly due to gumma-\\ntous involvement of the matrix. Severe ulceration of the matrix is\\noften followed by atrophic or other distorted conditions of the nail-\\nsubstance.\\nThe Treatment of these conditions is largely that of the disorders\\nupon which they depend. The nails may often with advantage be\\nscraped to a desired smoothness, well trimmed, shampooed vigorously\\nwith green soap, employing this also over the adjacent soft parts of\\nthe digit, soaked in unguents, and then protected by wax, leather stalls,\\netc., from injurious contacts. Arsenic internally is said to be useful in\\nsome affections of this kind.\\nAchromia Unguium (Albugo, White Spots Fr. Decolor-\\nization des Ongles). This is a peculiar condition found in young\\nand healthy subjects who exhibit a number of dead-white macules on\\nj one or several of the nails, usually of the fingers. Morison, of Balti-\\nmore, reported to the American Dermatological Association 3 a case\\nillustrated with a portrait, in which linear striae, transverse to the long\\naxis of the digit, appeared on the fingers. Since then we have observed\\n1 Annal. de Derm, et de Syph., August and September, 1895.\\n2 Jour. Cutan. and Gen.-Urin. Dis., June, 1896.\\n3 Vierteljahr. f. Derm. u. Syph., 1888, vol. xv.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0563.jp2"}, "564": {"fulltext": "528 ATROPHIES.\\na group of similar cases of the disease, one the subject of a portrait in\\noil, in which this condition existed. In all of our patients, young\\npeople of each sex, the fingers of the two hands were capriciously\\nselected for exhibition of the peculiarity. It has been supposed that\\nthe presence of air in the nail-substance is responsible for the appear-\\nance. The affection is probably a trophoneurosis due to nutritional\\nchanges in the nail-matrix.\\nATROPHIA CUTIS.\\n(Gr. a, privative, and roofi}, nutrition.\\nThe skin and its appendages, in common with other organs of the\\nbody, may suffer from atrophy, either idiopathic or symptomatic in\\ncharacter, and general or partial in extent. It may result from either\\nquantitative or qualitative retrogressive changes, losing thus its nor-\\nmal dimensions, either from wasting of one or of all its normal elements,\\nor from degenerative changes in the latter, or from their complete and\\nfinal disappearance. These changes may be simultaneous. They are\\nusually effected slowly, and the results are persistent. They are fre-\\nquent concomitants of a long list of other pathological alterations\\nusually, however, the atrophy succeeds other morbid changes.\\nATROPHIA SENILIS.\\nThis is the frequently recognized cutaneous degeneration peculiar to\\nold age. The skin becomes colored in various shades of brown, either\\nuniformly or in tolerably distinct maculations over the face, the dorsum\\nof the hands, the genitalia and the anus, and the lower extremities.\\nThe skin is seamed with furrows and wrinkles, is very dry, may\\ndesquamate slightly, and, losing the cushion of fat upon which it rested\\nin earlier life, is either readily raised from the subcutaneous structures\\nor depends from them in loose folds. The hairs on the affected areas\\nmay fall or may undergo regressive changes to the lanugo-type. Pea-\\nto finger-nail-sized verruciform, dirty-yellowish accumulations of epi-\\ndermis become visible, often in numbers on the face and elsewhere,\\nor there may be small pendulous shrivelled pouches representing fibro-\\nmata that have disappeared. These epithelial growths, especially when\\nirritated, are not infrequently the beginning of malignant epithelioma.\\nIn quantitative senile atrophy the pathological changes include a\\ngeneral thinning of both corium and epidermis, as a result of which\\ntheir characteristic interdigitations largely disappear an increased\\npigmentation in the rete a shortening of the hair-follicles a dilatation\\nof the sebaceous and coil-glands, the mouths of which often become\\nblocked with epithelial detritus the obliteration of some vessels and\\nthe dilatation of others and the disappearance of the fat-cells from the\\nmeshes of the connective tissue.\\nIn degenerative atrophy there may be fatty, amyloid, vitreous, and\\nother changes of one or of several elements of the skin. Neumann\\ndescribed a senile atrophy with a granular degeneration and a vitreous\\nswelling of the connective-tissue fibres. Schmidt, Reizenstein, and", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0564.jp2"}, "565": {"fulltext": "ATROPHIA CUTIS. 529\\nUnna think these changes due to a peculiar arrangement of the elastic\\nfibres and their partial degeneration into elacin, or, in combination\\nwith the collagen, into collastin and coleascin (Unna). These\\nchanges in the elastic fibres are manifested through the peculiar stain-\\ning qualities of the latter, and in the light of modern technique are\\nexceedingly interesting, as they occur not only in atrophy, but also in\\nother cutaneous disorders.\\nSenile atrophy cannot be remedied, but it may often be prevented\\nor postponed by securing for the skin and for all the tissues of the\\nbody the best possible nutrition and hygiene, and by protecting the\\nskin from exposure to cold and other harmful influences. The nutri-\\ntion of the skin may often be improved by the proper use of bran- or\\nsalt-baths, massage, electricity, or inunctions of oil. Cod-liver oil or\\nother fats may usually be added to the diet with advantage. Care\\nmust be taken to protect all warty and other epithelial growths from\\nirritation, with a view to the prevention of malignant changes.\\nATROPHIA MACULOSA ET STRIATA.\\n(Fr., Vergetures.)\\nThese forms of cutaneous atrophy may conveniently be divided into\\nthe so-called idiopathic and the symptomatic.\\nPartial Idiopathic Atrophy of the skin occurs most frequently in\\nlinear cicatriform striae or streaks (a centimetre or more in length) de-\\nveloped chiefly about the hips, buttocks, and upper portion of the thighs\\nin persons of both sexes of adult years. Less frequently these striae\\nare observed upon the neck, the trunk, and the extremities. They are\\ninsidious of development, indelibly persistent, and appear as sensibly\\nI thinned, glistening, and often depressed lines or furrows, having a\\nwhitish hue, with an occasional blending of a very delicate purplish\\nj tint. They are usually multiple, and at times abundantly displayed,\\nrunning in various curves, for the most part at angles with the long\\naxis of the body. They occasion, as a rule, no subjective sensation.\\nMuch more rarely the atrophic areas occur in macular patches.\\nThe lesions are then fewer, more isolated, and are discovered more\\ni frequently upon the extremities, but also upon the trunk, varying in\\n\u00e2\u0096\u00a0j size from that of a coifee-bean to that of a chestnut. This form of\\natrophy often succeeds either an erythematous or a pigmented condi-\\n|j tion, which very slowly changes until there is formed a dead-white,\\nI round or oval, often insensitive patch, more or less depressed, resem-\\n1 bling coarsely a vaccine cicatrix. These areas usually show partial or\\ncomplete alopecia.\\n8F6re and Quemonne l have described two singular cases of the disease\\nobserved in Charcot s clinic. In one of these cases appeared minute,\\nwhitish, elongated cicatrices, about which there was a marked pigmen-\\ntation of the skin. They were abundant in the lumbar region. In a\\nsecond case brownish lines appeared over the breast of an unmarried\\nwoman, that gradually grew paler while others appeared over the skin\\n1 Le Progres med., Oct. 29, 1881, p. 837.\\n34", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0565.jp2"}, "566": {"fulltext": "530 ATROPHIES.\\nof the throat. Those lines which were recent had a brownish or a\\nbluish-red color others were of a dead- white hue some appeared over\\nthe lumbar region and the upper part of the buttocks but there was\\nnone over the belly, the groins, or the thighs. In both cases the regions\\nattacked were those in which there was no suspicion that the vergetures\\nresulted from overdistention of the skin.\\nThese lesions are to be distinguished from sequels of scleroderma,\\nsyphilis, and other diseases capable of leaving atrophic areas. A pre-\\nvious history of such pathological conditions would usually be obtain-\\nable. In the cases in which there is precedent telangiectasis, hyperemia,\\nor marked pigmentation of the spot, the diagnosis, as several authors\\nsuggest, is attended with some difficulty.\\nDiffuse Idiopathic Atrophy of the skin (General Idiopathic Cu-\\ntaneous Atrophy, Atrophia Cutis Universalis, Progressive\\nIdiopathic Atrophy) is usually of progressive type. In these cases\\nthe integument over large areas, such as that covering an entire limb\\nor the trunk, becomes thin, flaccid, dry, scaly, unprovided with fat,\\nand brownish or dead whitish in hue. Puncta, striae, and plaques,\\nreddish blue or reddish brown or even purplish in color, are to be\\nseen marbling the surface and occasionally leaving after disappearance\\na decided pigmentation. The process slowly advances over the regions\\naifected.\\nBronson has recorded a very unusual and interesting case of this\\nform of atrophy, with reference to the principal cases so far reported. 1\\nElliott 2 and Fordyce 3 have reported each a case of symmetrical and\\nextensive atrophy, in which the progressing change was preceded by\\nthe occurrence of a zone of capillary dilatation or cyanosis.\\nPartial Symptomatic Atrophy of the skin in its simplest form may\\nresult from traumatism (the persistent marks sometimes left on the\\nskin, for example, by a lash with a whip, insufficient to wound the\\nepidermis but capable of injuring the deeper elastic tissue) or from the\\nslow pressure of tumors (ovarian, uterine, mesenteric, etc.), by which\\nthe skin is distended. The well-known results of the stretching of the\\nskin in a first pregnancy conducted to term are linear atrophies, at first\\nof a violet tint, and later of a dead-whitish hue, that are indistinguish-\\nable, both clinically and pathologically, from idiopathic lesions of\\nsimilar aspect. These atrophies are occasionally seen over the belly\\nand thighs of male subjects with a protuberant abdomen. Small atrophic\\nscars result frequently from the mechanical pressure of inflammatory\\nand other infiltrations seen in lupus, syphilis, leprosy, and other diseases.\\nPartial symptomatic atrophy, with degeneration of the cutaneous ele-\\nments (fatty, lardaceous, waxy, etc.), is a sequel common to a long list\\nof cutaneous affections.\\nEtiology and Pathology. The causes of idiopathic atrophy are\\nnot known. It is generally considered a trophoneurosis, with possibly\\nmalnutrition as a predisposing cause. Elliott s and Fordyce s cases\\n(noted above) would suggest an origin in some circulatory disturbance.\\n1 Jour. Cutan. and Gen.-Urin. Dis., January, 1895.\\n2 Ibid., April, 1895.\\na Ibid., May, 1897.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0566.jp2"}, "567": {"fulltext": "GLOSSY SKIN. 531\\nThe histological changes are those of simple atrophy of the tissues\\nwithout degenerative changes.\\nThe causes of the symptomatic atrophies are obvious. Histological\\nexamination shows in some cases simple tearing and separation of\\nelements, especially of the elastic fibres in others an atrophy of the\\ncorium and epidermis. Unna describes a pressure-atrophy, in which\\nthe elastic tissue is torn or displaced to the margins of the area, and\\nan atrophy due to tension which differs from the preceding in that some\\nsmall fibres of elastin still are visible together with other fibres that\\nhave undergone a degeneration into elacin, in this respect resembling\\nsenile degeneration.\\nThe Treatment is prophylactic as in senile atrophy.\\nGLOSSY SKIN.\\n(Ateophodeemia JSTeueiticum.)\\nThe glossy fingers described by Sir James Paget, 1 Gull, Mitchell,\\nand others, are tapering, smooth, hairless, unwrinkled, glossy, pink,\\nand ruddy or blotched, as if with permanent chilblains. One or several\\nfingers are affected. The condition is associated with neuralgia or\\nnervous impairment indicated by abnormal sensations, as of heat or\\nintense burning. There is usually, however, a precedent or subsequent\\nneuralgic pain, with incurvation of the nails and at times a heaping\\nI up of epidermal masses beneath the free border of the nail. In conse-\\ni quence of retraction of the skin over the distal phalanges the terminal\\nextremity of the digit appears thinned and drawn away from the nail-\\nbed.\\nThe complications of this condition are changes in the sebaceous\\nglands and the coil-glands, loss of hair over the phalanges, excoria-\\ntions, and in severe cases ulceration.\\nThis disorder may be associated with grave systemic states, such as\\nlepra, or with gout and rheumatism. It is found also in those in whom\\nfor any reason the circulation is feeble and there has been exposure of\\nthe extremities to severe cold. It has likewise been noted as the result\\nSof centric and peripheral changes in the nervous system. In some\\ncases the cause is recognized as a neuritis in other cases it may more\\nproperly be classed with the trophoneuroses of the skin. The rela-\\nI tions of this and several symmetrical disorders of the hands and feet\\nto the so-called perforating ulcer of the foot, asphyxia of the\\ni extremities, symmetrical gangrene of the extremities, and so-called\\ni dying of the fingers, all manifestly trophoneurotic affections (see the\\nchapter on this subject), have not yet satisfactorily been established.\\nBlanching Ateophy of the Sein. This peculiar degeneration\\nof the integument is characterized by an unnatural whiteness or pallor\\ni of the skin-surface, with considerable tension and tenuity of the epider-\\nimis, usually limited to the extremities (the arms and palmar faces and\\ni the thighs and legs and plantar faces); moderate exfoliation occurs,\\nand the latter, in connection with the tension to which the skin is\\n1 Med. Times and Gazette, March 24, 1864.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0567.jp2"}, "568": {"fulltext": "532 ATROPHIES.\\nsubjected, is responsible for more or less painful subjective sensations.\\nThe disorder is chronic in its course, and it may originate in infancy.\\nThis condition is occasionally illustrated by persons affected with a\\nsensori-motor paralysis of one limb, when the muscles waste and the\\nfat-cells persist, multiply, or wholly disappear. The .skin of such\\nlimbs, wholly or in patches, becomes unnaturally soft and delicate, and\\nundergoes a loss of pigment and hairs, at the same time that its bulk\\nactually diminishes. The nails may participate in the process. In\\nother cases of trophic disturbance the skin shrivels and assumes, instead\\nof a whitish, a yellowish or yellowish-gray tinge.\\nMULTIPLE BENIGN TUMOR-LIKE NEW-GROWTHS OF THE SKIN.\\nUnder this title Schweninger and Buzzi 1 describe and figure lesions\\noccurring chiefly on the back, but also on the arms and the chin of a\\nmarried woman, twenty-nine years of age. These lesions were bean-\\nto coin-sized, bluish-white and slate-tinted formations, with delicate\\ntelangiectases over the surface of some. By pressure most of them\\ncould be forced into a shallow pit in the underlying tissue, the tumor\\nreturning like a ventral hernia after removal of the pressure. The\\nlarger seemed to spring from the smaller lesions, and as they increased\\nin age became flatter, less white, harder, and less compressible. They\\nproduced no subjective sensations and in no way interfered with the\\ngeneral health of the patient. The vigorous treatment adopted seemed\\nto have but little effect on the growths.\\nUnder the microscope sections of the excised skin showed that\\nelastic fibres were in every instance wholly wanting in the affected\\nportions, nor were there signs of remnants or of degeneration-products\\nof these elements. It was assumed that there had been in each locality\\na retraction of the elastic tissue, and that the resulting disease was due\\nto a disturbance of the static balance, the overgrowth developing until\\nthe equilibrium was established. A growth of new and young cells\\nwas visible about the adventitia of the vessels and most of the acces-\\nsory organs of the skin.\\nKRAUROSIS VULVAE.\\nBreisky, 2 in Austria, and Heitzmann and others 3 in America, have\\ndescribed a condition of the vulva in women, affecting particularly the\\nlabia minora, the preputium clitoridis, and the vestibulum, in which\\nthere occurs a peculiar shrinking, shrivelling, or atrophic change. The\\nlabia minora in some cases wholly disappear, shallow furrows taking\\ntheir place. The clitoris becomes hidden from view and may be rep-\\nresented by a minute depression in the membrane. The integument\\ncovering this thinned or atrophied tissue is whitish, thickened, rough-\\nened, and dry, while the surrounding parts are glossv, reddish-gray\\nor pallid in hue. In many cases the atrophic changes are preceded by\\n1 Internat. Atlas of Kare Skin-diseases, 1890-1891, v.\\ns Zeitschrift f. Heilkunde, Prag u. Leipzig, March, 1895.\\n3 Cf. Baldy and Williams, Amer. Jour. Med. Sci., 1899, p. 528, with a review of\\nthe literature.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0568.jp2"}, "569": {"fulltext": "", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0569.jp2"}, "570": {"fulltext": "PLATE XIV.\\n7 itfiHteirlk55\\nMalum Perforans Pedis, with Symmetrical Keratoma\\nof the Palms and Soles.\\n(From a water-color sketch of one of the author s patients.)", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0570.jp2"}, "571": {"fulltext": "PERFORATING ULCER OF THE FOOT. 533\\na period of congestion and intense pruritus, burning, or hyperesthesia.\\nThese subjective sensations usually disappear in the later stages of the\\ndisease. Women of all ages, from nineteen to fifty, suffer from the\\ndisorder, irrespective of coitus and pregnancy.\\nThe study of well-marked instances of this disorder indicates\\nthat for the present further investigation must be made before the\\nidentity of the disease can be accepted or its nosological position be\\nestablished. The life-history of some of the affected patients must\\nbe had in order to gain a complete knowledge of the morbid condi-\\ntion. In one patient the resemblance was very striking to certain\\nindolent epitheliomata of the penis, where a remarkable shrinking may\\nat times be produced in consequence of metamorphosis of tissue.\\nPERFORATING ULCER OF THE FOOT.\\n(Malum Perforans Pedis. Fr., Mal Perforaxt du Pied.)\\nThis disorder, first named by Vesigne has been studied by Savory\\nand Butlin, 1 Gasguel, 2 and others. The name is an unfortunate one,\\nsince many cases to be classed only in this category have neither ulcer-\\native nor perforating symptoms.\\nSymptoms. The first symptom is a proliferating thickening of the\\nepidermis like a corn, usually single, occasionally multiple, appearing\\nover a point of pressure (first or fifth metatarso-phalangeal joint, etc.).\\nInflammation and suppuration proceed beneath this thickening, spread-\\ning first to the soft parts of the sole and perhaps to the bone itself.\\nGradually a sinus forms, reaching from the side of the corn to the\\ndeeper parts involved. Meantime the skin in the neighborhood be-\\ncomes greatly thickened, heaping itself especially about the sinus.\\nThe latter is sometimes surrounded by a mass of granulations. The\\nulcer which eventually forms is circular in outline, deep, and at times\\nvery destructive in its effects.\\nThus far the lesion might be supposed to be the result merely of a\\ngreatly irritated corn, but other phenomena exhibited in differing\\ncases are quite inexplicable in this way. The nails are altered super-\\nfluous hair grows on the dorsal surface of the foot and the skin of the\\ninvolved extremity pigmentation, erythema, or eczema may occur\\nand the parts may become affected with either anidrosis or hyperidrosis.\\nThe disease has been noted as the result of spinal injury, congelation,\\nposterior spinal sclerosis, anaesthetic leprosy, alcoholic and diabetic\\nneuritis, and, in animals, after section of the sciatic nerve, the etiolog-\\nical element in these diseases being degeneration of the nerve (except\\nof the motor nerve) which supply the part. Among the concomitant\\nsymptoms ascribed to the same causes are anaesthesia, neuralgic and\\nrheumatic pains, hyperidrosis, and coldness of the feet.\\nIn a group of cases of perforating ulcer of the foot there is gen-\\nerally a symmetrical involvement of the entire sole or palm, either of\\nboth feet or of both hands and feet. The patients are often young\\nadults. The palms when involved never exhibit the translucent,\\n1 Medico-Chirnrgical Transactions, 1879, vol. lx.\\n2 These de Paris, July, 1890 a resume of ninety-one collected cases.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0571.jp2"}, "572": {"fulltext": "534 ATROPHIES.\\nyellowish, wash-leather-like appearance of the same condition of the\\nsoles, but rather suggest the dry, scaly features of the palms in certain\\nforms of erythematous eczema of these parts, but always without itch-\\ning, and with coincident plantar tylosis. The soles, however, present\\nthe typical appearance of callositas throughout the entire region, the\\ncallosity reaching somewhat upward over the heel, and in certain\\npatients relatively sparing the instep. In some cases the nails are not\\ninvolved. The feet are always as cold to the touch as in pernio.\\nPathology. \u00e2\u0080\u0094The disease is, without question, a trophoneurosis, and\\nmay be due to injury to a nerve-centre, as in tabes dorsalis to a nerve-\\ntrunk, as in syphilis or leprosy or to the terminal nerve. Of ninety-\\none cases collected by Gasguel, 1 there were in sixty-nine central and\\nin eight peripheral nerve-lesions. Histological examination has shown\\ndestruction of the myelin and axis-cylinder of twigs of nerves supply-\\ning the affected parts. According to Savory and Butlin, the sensory\\nand nutrient fibrils of the involved nerves degenerate in consequence\\nof pressure exercised upon them, by increase of the endoneurium, the\\nmotor fibrils escaping owing to their large size and thicker medullary\\nsheath, a view untenable for all cases.\\nDiagnosis. The diagnosis is between tuberculosis and simple cal-\\nlositas, a distinction readily established by the evident neurotic phe-\\nnomena seen in perforating disease of the foot.\\nTreatment. By curetting away all diseased tissue and putting the\\nfoot completely at rest the ulcer may be made to heal, but it usually\\nreappears when the patient again tries to walk. Amputation of the\\ntoe and joint aifected avails little. It is not unusual even after ampu-\\ntation of the foot for the disease to appear in the stump. A roborant\\ntreatment and mechanical devices to prevent the use of the foot are to\\nbe advised in most cases.\\nThe Prognosis is doubtful.\\nMORVAN S DISEASE.\\n(Syringomyelia, Analgesic Paralysis with Whitlow.\\nFr. y Panaris Analgesique.)\\nMorvan s disease is a paretic affection chiefly involving the upper\\nextremities, accompanied by pain and producing a series of whitlows,\\naffecting first one side of the body and then the other.\\nSymptoms. In this disorder the arm is commonly first involved,\\nthe approach of the disease being insidious and usually first noticed on\\naccount of the production of pain and some loss of nervous and mus-\\ncular power. At times the first sign of involvement is the production\\nof whitlows, which either early or late in every case are tolerably sure\\nto appear. In other instances the disease first displays an analgesia\\nsimilar to that occurring in some subjects of lepra, the attempt having\\nbeen made to establish a relation between the two diseases. In time\\natrophy of the interosseous muscles, of the flexors of the wrist, and of\\nthe tissues forming the thenar and hypothenar eminences may result.\\nThe integument of the affected limb has a bluish or empurpled look;\\n1 Loc. cit.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0572.jp2"}, "573": {"fulltext": "AINHUM. 535\\nit may be thinned or thickened, and the ^eat of fissures, vesicles, and\\nbullae, as well as of the characteristic whitlows, which vary in number\\nfrom two to four or six. Ulceration, extending as deeply as to the\\ntendinous sheaths, may result, and, as a consequence of one or more of\\nthe changes described above, the phalanges may necrose and be sepa-\\nrated from the hand.\\nTrophic changes arise in connection with the disease, pointing for\\nthe most part to an origin in disturbances of the centric nervous system.\\nAmong these disturbances may be named hyperidrosis diminution of,\\nvariability in, or complete absence of the reflexes visual changes con-\\ntracture of the fingers and a general distortion of the hand. Scoliosis\\nand arthritic complications have been recorded in a number of cases.\\nThe disease is usually protracted in its course, lasting in some cases\\nfor a quarter of a century.\\nEtiology. The affection may first develop in childhood and last\\nuntil middle life and longer, though more often it is first noticed after the\\noccurrence of puberty. Women are much less often affected than men.\\nTraumatism, malaria, and rheumatism have all been cited as possible\\ncauses of the disease. Its exact etiology is obscure.\\nPathology. Neuritis and thickening of the neurilemma have been\\ndiscovered in the nerves distributed to the affected parts as also\\nsclerosis of the posterior cornua and columns of the cord. The cavities\\nrecognized in the central canal, distended with fluid, are supposed to be\\ndue to absorption of gliomata.\\nDiagnosis. The recognition of a fully developed case of Morvan s\\ndisease is readily established by taking into consideration the paretic\\nI symptoms present, the whitlows, and the perversions of sensation,\\nI more particularly in appreciation of temperature-changes, pain, and\\ni contact with foreign bodies. Attention has already been directed to the\\nstriking resemblance between certain phenomena of anaesthetic lepra and\\nI those of both syringomyelia and Morvan s disease. With respect to\\ni the diagnostic difference between the two last-named affections, it is\\nclaimed that in most cases of syringomyelia the sense of touch remains\\nunimpaired. The time, however, is probably not distant when the two\\nwill be recognized as slightly differing manifestations of the same\\nmorbid state. Scleroderma and glossy fingers are to be differentiated\\nby the special peculiarities of each.\\nTreatment is to be conducted on the general principles, surgical and\\nmedical, relied upon for meeting the indications of each case. In gen-\\neral the hygienic and dietetic management of the patient with a highly\\nroborant regimen is conducive to recovery. Many of the subjects of\\nthe disease have been reported as relieved or even wholly cured.\\nAINHUM.\\n(From a native term, meaning to saw.\\nThis disease was first described by Clark 1 and later by J. F.\\nDa Silva Lima, 2 of Bahia, in Brazil, who collected a large number of\\ncases. In a paper presented by him, which was read by one of us before\\n1 Transactions Epiderm. Soc., 1860. 2 Arch, of Derm., 1880, p. 367.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0573.jp2"}, "574": {"fulltext": "536 ATROPHIES.\\nthe American Dermatologioul Association, in 1880, the disease was\\ndescribed as affecting usually the little toe of negroes of Africa and\\nBrazil. An indurated ring encircled the root of the digit, which pro-\\nduced, finally, a deep, narrow circular depression, the latter deepening\\ntill the toe was strangulated, and finally, in the course of from five to\\nten years, completely detached. Meantime the volume of the digit was\\ngreatly increased by development of fatty tissue at the expense of the\\ntendons, vascular elements, bones, and cartilages. This paper was\\naccompanied by the presentation of a toe affected with ainhum and\\nthe specimen was referred to a committee, which after examination\\nreported with a full description of the anatomical appearance of the\\nspecimen, that the constricting ring was probably produced artificially\\nby tying a thin ligature around the toe, which, if not continuously\\nencircling it, was worn at least for long periods of time.\\nDuhring also has published the report of a case of ainhum in which\\nmicroscopical examination was made by Wilde of a toe that was cast\\noff from the foot of a negro in West Virginia. The pathologist came\\nto the conclusion in this case also that the disease was essentially an\\ninflammatory oedema produced by ligating the toe.\\nThough the disease has since been studied by many competent\\nobservers its exact nature is still undetermined. Considering the fact\\nthat among superstitious races, especially the blacks, the most singular\\npractices of self-mutilation are observed, it is possible that in some of\\nthese cases the toe is constricted by a ligature intentionally applied\\naround it. That many of these cases occur independently of such\\nintentional mutilation there can be no doubt when the observations of\\nother competent observers are considered. Zambacho Pacha discusses\\nat length the possible relation of the disease to leprosy.\\nThe probable relation of the disease to other trophoneuroses is well\\nillustrated by a child presented at our clinic, a deaf mute who was an\\ninmate of one of the public institutions founded for the care of that\\nclass of sufferers. The patient was twelve years of age, fairly well\\nnourished, and the subject of a symmetrical palmar and plantar\\nkeratosis. The little finger of each hand in the middle of the proximal\\nphalanx was closely encircled by a tensely drawn cicatriform linear\\ngirdle, the constriction of which was rapidly working an amputation\\nof the little finger of the left hand, the right being less seriously in-\\nvolved, and some other fingers incompletely girdled by constrictions\\nexisting only on the palmar faces. Here the demonstration of the\\ncause of the amputation was clearly made, for the callous ring about\\nthe digits was manifestly in line with the equally dense callosities of\\nthe palms and soles, which differed from the former chiefly because of\\ntheir occurrence in broad plates rather than in narrow lines. A patient\\npresenting the same features was exhibited before the Fourth Inter-\\nnational Congress of Dermatology, held in Paris in 1900.\\nAinhum is seen chiefly in the natives of Africa, Brazil, West\\nIndies, and India, a few cases having been reported from the southern\\nstates of this country. Herrick 2 recently reported a case in a negro\\n1 Transactions Internat. Leprosy Conference, 1897, vol. iii., p. 45.\\n2 Phila. Med. Jour., Feb. 5, 1898.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0574.jp2"}, "575": {"fulltext": "AINHUM. 537\\nwho had lived for thirty years in Illinois. It is a disease of adults,\\nthough it has been reported in a few instances in children. Only\\nfour times is it recorded as occurring in the white race. The little toe\\nis the one usually affected, but the disease may involve the other toes,\\nor rarely the fingers. The sensibility of the toe is not lost, but there\\nis no pain unless ulceration occur at the bottom of the groove.\\nThe causes of the disease, which is probably a trophoneurosis, are\\nnot known, and its pathology is undetermined. There is marked\\natrophy of bone, the amputation occurring commonly through the\\nosseous diaphysis instead of the joint. There is marked hypertrophy\\nof the epidermis and of the papillary body. The vessels are enlarged\\nand thickened, but their calibre is diminished.\\nIncision of the constricting ring at an early period is said to relieve\\nthe disease. In most of the cases amputation is required or is effected\\nby the natural progress of the disorder.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0575.jp2"}, "576": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0576.jp2"}, "577": {"fulltext": "CLASS VI.\\nNEW-GROWTHS.\\nKELOID.\\n(Gr. XV^V, a crab s claw.)\\n(Cheloid, Kelis. Fr., Cancroide Ger., Knollenkrebs,\\nAlibert s Keloid.)\\nThe term keloid, first given to the disease by Alibert, should be\\nrestricted to it exclusively. The so-called keloid of Addison is\\nknown to-day more properly as scleroderma.\\nAuthors have described two varieties of this disease the true,\\nspontaneous/ or idiopathic form and the false, spurious, or\\ncicatricial form, which develops in the scar produced by a previous\\ntraumatism.\\nThere is no anatomico-pathological separation between the two, and\\nit is highly probable that all cases of so-called spontaneous keloid\\nare instances of development of the growth in regions of pressure,\\ncontusion, traction, or slight traumatisms that have not been recognized,\\nsuch as the wounds inflicted by mosquitoes.\\nSymptoms. The new-formations of this disease are dense, gener-\\nally elastic nodules imbedded in the corium, or projecting above the\\nlevel of the skin and firmly attached to it. They are usually very\\nslow of evolution, and, having once attained full development and\\nassumed one of the several shapes which they affect, usually persist\\nfor a lifetime. These forms are whitish or reddish, globular or semi-\\nglobular nodules, buttons, or plaques, with roundish or ovoid outline\\nlinear elevated striae, bands, ridges, resembling cords, ribbons, or tapes,\\nin irregular outline and disposition or combinations of two or more\\nof these figures. A common form over the sternum and in other situa-\\ntions where the development of the growth in every direction is not\\nimpeded, is that of a larger central mass with two or more diminishing\\nand declining prolongations bearing a remote resemblance to the body\\nand claws of a crab. The lesions vary in size from that of a small\\npea to that of a large saucer, the largest including the outlying points\\nof the limbs or radiating ridges. Over them the skin is reddish or\\nwhitish in color, smooth, hairless, and occasionally hypersensitive to\\npressure and heat. Often small blood-vessels traverse its surface. The\\ngrowth at times is also the seat of spontaneous pain.\\nThe most frequent site of the disease is the anterior surface of the\\nchest, but it is observed also upon the face, neck, ears, breast, hands,\\n539", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0577.jp2"}, "578": {"fulltext": "540\\nNEW-GROWTHS.\\nbetween the scapulae, and on the extremities (Fig. 63). Keloid is also\\nseen upon the penis of the negro. It is far more common in the colored\\nthan in the white races. Though frequently multiple, there are rarely\\nmore than a score of these growths visible at one time upon the skin\\nof one person.\\nThe overlying integument at times may wholly be uncolored in\\nthe white races, and dead whitish in color or even blackish among\\nnegroes. At other times the surface is not merely pinkish or red-\\ndish, but is vividly red in hue. The color is produced by vascular\\nconnective tissue covering the growth. The subjective sensations\\nFig. 63.\\nKeloid.\\naroused are commonly trifling or inappreciable at other times the\\ngrowths are the seat of severe pain or of burning. The usual course\\nof the disease is toward the production of tumors of a medium size,\\nafter which few changes are to be recognized. Involution and complete\\ndisappearance are rare. These results, however, have been secured in a\\nfew cases.\\nCicatricial Keloid (Scar- keloid, Hypertrophic Scar,\\nHypertrophic Cicatrix) resembles in its features the true keloid\\ndescribed above, and differs from it chiefly in the fact that the cicatricial\\nform is ordinarily preceded by scar- formation, due either to disease or to\\ninjury. It thus follows the lesions of zoster, variola, and syphilis, as also\\ntraumatisms of all sorts, including those made by surgical operations and", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0578.jp2"}, "579": {"fulltext": "KELOID. 541\\naccidents. The tumors, as a rule, spring directly from scar-tissue, and\\nafter reaching a maximum of development do not surpass the limits of\\nthe original lesions at times, however, the growths slowly develop, as\\nin spontaneous keloid, at a distance from the original site of injury or\\ndisease. Scar-keloid is often found as a firm nodule in the lobe of each\\near among women, after piercing the ears for the insertion of earrings\\nit is seen also not rarely as a result of burns, whether produced by\\napplication of caustic agents or of heat.\\nEtiology. The origin of the disease is exceedingly obscure. Neither\\nage, sex, nor previous disorder of the skin seems to have any bearing\\nupon its production. It is seen in remarkably vigorous persons (more\\noften in the negro race), but also in those who are weakly. The very\\nyoung and very old are more rarely affected.\\nThough not yet demonstrated, it is probable that eventually some\\nvarieties of keloid will be recognized as examples of cutaneous para-\\ntuberculosis, the predisposition to the development of the disease in.\\nsites of slight traumatism being related to the toxins furnished from a\\ndistant focus. The race in which its lesions are most often and most\\nvoluminously displayed is exceedingly prone to tuberculous infection\\nand the frequent recurrence of the disease after surgical excision and\\nthe peculiar lupoid aspect of certain keloid lesions are strikingly\\nsuggestive.\\nPathology. According to Langerhans, Warren, Kaposi, and others,\\nin all cases of true keloid the papillary layer of the corium and the\\ninterpapillary projections of the rete downward are intact, the new\\nformation being strictly limited to the middle and lower portions of the\\ncorium, in which there are numerous whitish, tendinous fibres of con-\\nnective tissue, dispersed for the most part parallel with the surface of\\ni the rete. In cicatricial keloid these observers find a partial or complete\\nI absence of the papillse and interpapillary processes. Babes, Crocker,\\nj and others, on the contrary, find that the papillse and rete may be\\nI normal, modified, or absent in either form. Lymph-vessels with pro-\\nliferated endothelium, compressed by longitudinal growth of the fibres,\\npass in both vertical and horizontal planes, for the most part remaining\\ni patulous. There are few spindle-cells and nucleated cells. Blood-\\nvessels are few in the centre of the tumor, but are numerous at the\\nborder and in the loose connective tissue surrounding the growth. For\\nsome distance beyond the tumor the adventitia of the vessel shows a\\nsmall-cell-growth which probably develops later into spindle-cells and\\nfibres. These, with the included tissue of the corium, form the keloid.\\nThe sebaceous glands and coil-glands, hair-follicles, and muscles are\\npushed to one side by the new growth and often are atrophied.\\nDiagnosis. The clinical distinction between keloid and cicatricial\\ni keloid is of trifling importance. The situations of the lesions of keloid,\\noften over the sternum, the in frequency of multiple tumors, its claw-\\nlike prolongations, and yellowish-white, reddish, or grayish-white\\ncolor, all point to the nature of the disease.\\nTreatment. Removal of keloid by cauterization and excision is\\nnot to be practised, as the growth commonly does not fail to reappear.\\nVidal successfully employed multiple linear scarifications. Various", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0579.jp2"}, "580": {"fulltext": "542 NEW-GROWTHS.\\nstimulating applications may also be made with a view to promote\\nresorption such as the spirit of green soap, iodated glycerin, iodine\\nin ointment and tincture, and mercurial, salicylated, and lead plasters.\\nThe employment of these remedies is subject to the danger of stimu-\\nlating the growth to greater activity. Where there is pain anodyne\\nunguents may be employed topically, such as freshly prepared bella-\\ndonna plaster, or ointments of belladonna, stramonium, and opium.\\nBy far the most elegant of these, and the one which also is capable\\nof producing an alterative effect, is the oleate of mercury and mor-\\nphine. Laurence 1 obtained good results by scarification followed for\\nseveral weeks by moderate pressure, produced with adhesive plaster.\\nUlaric and others report successful destruction of keloid with injections\\nof 5 to 20 per cent, solutions of creosote in olive oil. Electrolysis has\\ngiven good results in a few cases.\\nInternally, quinine, strychnine, arsenic, and potassium iodide have\\nbeen exhibited with varying success.\\nPrognosis. As regards the general condition of the patient the\\nprognosis is favorable. Very rarely there is spontaneous resorption of\\nthe nodule or tumor. Generally the latter may be expected to persist,\\nafter full evolution is attained, for an indefinite period of time.\\nCICATRIX.\\nA cicatrix is a new-formation of the skin, replacing connective\\ntissue which has been lost by traumatism, by ulceration, or by some\\nother pathological process. Most cicatrices, as, for example, those\\nfollowing the ulcerations of syphilis, the operations of the surgeon, or\\nthe dermatitis produced by a severe burn, are reparative in character.\\nThey vary greatly in shape, size, color, and other features. They\\nmay be smooth, glossy, shining, scaling, dull whitish in color, or pink-\\nish from vascularization of the surface. They may be linear, fan-\\nshaped, circular, corded, ridged, dotted, crateriform, or tumor-like.\\nThey may be raised above the skin, on a level with it, or depressed\\nbelow it. They may be deeply attached to periosteum or to bone, or\\nreadily be movable over the panniculus adiposus. They are of deeper\\ncolor when young, and increase in whiteness with age. They are\\nunprovided, as a rule, with hairs, or with coil- or sebaceous glands.\\nThe most insignificant cicatrices are those resulting from clean,\\nincised, and punctured wounds and lesions of similar grade. Certain\\npeculiarities of cicatrices are seen in special disorders in which they are\\nproduced. Circular, oval, reniform, horseshoe-shaped, S-shaped, and\\nfigure-of-eight-shaped scars, thin and flexible, are characteristic of\\nsyphilis. The cicatrices of variola, zona, and ecthyma are slightly dif-\\nferent each from the other, though all are of small size and depressed.\\nThose of tuberculosis and dermatitis calorica of severe grade are exceed-\\ningly irregular and often corded.\\nHypertrophy of cicatrices is the condition already described as\\nkeloid. Here there is a tumor-like development of the cicatrix, form-\\ning a ridge, button, knob, indurated fold, or puckered and irregularly\\n*Brit. Med. Jour., July 16, 1898.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0580.jp2"}, "581": {"fulltext": "CICATRIX. 543\\ncircumscribed, whitish or reddish lesions. In certain individuals these\\nlesions may follow almost every traumatism and destructive process to\\nwhich the integument is liable.\\nA case of cicatrix undergoing involution has been described by Dyce\\nDuckworth, in a man (aged fifty) who suffered from rheumatic fever\\non two occasions, ten years before the date of report. This patient\\nhad pericarditis, and was blistered over the precordia. Nine months\\nafterward lines of cicatricial growth began to form in the scar left by\\nthe blister, and they rapidly extended in two years time they were\\nstill enlarging in seven years some subsidence was noticed, and, when\\nexhibited ten years after their first formation, involution was markedly\\nprogressing. This case illustrates the frequent origin of scar-tissue,\\nits common occurrence over the sternum, and the fact of the subsidence\\nof the new-growth in the course of time. 1\\nKeloid-like cicatrix of the cheeks following acne is far from uncom-\\nmon. Its lesion is usually smoothed down in the process of time, after\\nthe disappearance of the sebaceous gland-disorder, until the deformity\\nis greatly lessened, and often scarcely noticeable.\\nEtiology. The formation of cicatrix is always preceded by destruc-\\ntion of at least a portion of the papillary body of the corium. This\\nloss of tissue may be due to various causes trauma, burns, ulcers,\\natrophy caused by pressure of new-growths, etc. Hypertrophied\\ncicatrix may result from slight but continued or frequently repeated\\nirritation of a healing surface, the repair of which is thus greatly\\ndelayed, but it occurs chiefly in the form of cicatricial keloid.\\nPathology. Histologically, scars are made up of connective-tissue\\nbundles which interlace in all directions with great irregularity. In\\nyoung scars the fibres are finer and the tissue is vascular, but as the\\nscar grows older the fibres usually become coarser and contract and the\\nvessels disappear. There is complete absence of hair-follicles, glands,\\nand furrows of normal skin. The scar-tissue proper is covered with a\\nvery thin epidermis, and Heitzmann claims that shallow and irregular\\npapillae are always present. Other observers report in scars an entire\\nabsence of both papilla? and rete-pegs.\\nDiagnosis. The distinction between hypertrophied cicatrix and\\nkeloid is one chiefly of degree and needless from a practical point of\\nview. Following the piercing of the lobule of the ear for the insertion\\nof earrings, the lesion is distinguishable by pinching the part between\\nthe fingers, when a globular-, pea- to cherry-sized mass will be felt\\nfirmly imbedded in the derma between the reflected folds of the integ-\\nument. Upon the face, after the occurrence of acne, keloid can be\\nusually seen as a puckered ridge, often transverse in direction, occu-\\npying the region of the cheek.\\nTreatment. The resources of modern surgery are to be trusted in\\nthe production of laudable cicatrices when all antiseptic precautions are\\nobserved. The treatment of pathological conditions likely to be fol-\\nlowed by cicatrices is the treatment largely of the special disease in\\nwhich such loss of tissue occurs, e. g., the ulcer left by a degener-\\nating syphilitic gumma of the skin. An irregular or disfiguring cicatrix\\n1 Brit. Med. Jour., October 8, 1881, p. 597.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0581.jp2"}, "582": {"fulltext": "544 NEW-GROWTHS.\\nmay be excised if there be sufficient tissue to permit direct union\\nof normal tissue on either side. Skin-grafting may be employed after\\nexcision of larger scars.\\nThe treatment of hypertrophied cicatrix depends upon its cause.\\nIf due to individual idiosyncrasy, the treatment is that of keloid.\\nFIBROMA.\\n(Lat. fibra, a fibre.)\\n(FlBKOMA MOLLUSCTTM, MOLLTJSCUM PENDULUM.)\\nSymptoms. Fibroma is a disease characterized usually by the\\noccurrence of numerous, roundish, softish, semisolid or solid growths,\\nvarying in size from that of a small pea to tumors of several pounds\\nweight, though more rarely the neoplasm is single. They are often\\ncalled mulluscous fibromata, as the disease was termed at one time\\nmolluscum fibrosum. When quite small they are seated within or\\nbeneath the skin, where they can be distinguished as distinctly circum-\\nscribed nodules, buttons, or plaques often slightly projecting. When\\nmore fully developed they become sessile, pedunculated, or largely\\npendulous tumors, hanging from the part to which they are attached so\\nas to resemble in shape a cherry, a nipple, a pear, or a sausage. They\\nare commonly covered with an integument that is natural in color\\nand suppleness, though the latter may be traversed by blood-vessels\\nsprinkled with comedones or patent orifices of sebaceous gland-ducts\\nthinned or thickened, or in a state of ulceration the last named being\\nusually the result of externally operating causes in tumors of large\\nsize. They are productive of no subjective sensation beyond the more\\nor less uncomfortable tension produced by the weight of those attain-\\ning a great size. When multiple they may be seen in various degrees\\nof development, covering in hundreds and even thousands the entire\\nbody, especially the scalp, face, trunk, genitals, and extremities. Upon\\nthe lids they may interfere with vision by the production of ptosis.\\nTo the touch they may be felt as softish, somewhat elastic, firm, or\\nlobulated masses, though at times nothing but a double fold of skin\\ncan be perceived, or a cord-like contained body. They are often con-\\ngenital. When closely set together upon the skin, and of small size\\nand pendulous, the features of the disease are characteristic.\\nSchwimmer distinguishes between these lesions usually congenital\\n(termed by him, soft fibroma), and the dense tumors of similar ana-\\ntomical features (termed by him, firm, or hard, fibroma). The latter\\nare circumscribed, deeply seated, very slow of development, and apt to\\ninduce changes in the tissue which surrounds them. They may undergo\\nfatty degeneration, or ossification, or calcification.\\nThe first appearance of the disease may sometimes be recognized as\\na roundish spot over which the skin is uplifted. It is of a light-pink-\\nish color. The tumor is soft and suggests to the touch a thinning of\\nthe derma beneath. By firm pressure over such lesions when they\\nhave attained about a centimetre in diameter they may be slowly\\npushed downward into the skin, and the sensation is produced to", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0582.jp2"}, "583": {"fulltext": "PLATE XV.\\nMultiple Fibroma of the Back.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0583.jp2"}, "584": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0584.jp2"}, "585": {"fulltext": "FIBROMA.\\n545\\nthe touch of a foramen in the derma. Fusion between the new-\\ngrowth and the skin over it is of early occurrence. The spherical or\\noval form of the tumor depends\\nupon the direction of the bundles\\nof the subcutaneous tissue of the\\npart invaded. The tumors may\\nundergo involution, but this result\\nis more common when the patient\\nis under thirty years of age.\\nDermatolysis is produced by great\\nactivity of the growth of one, or\\nfusion of several tumors, by which\\na flap of skin is formed.\\nSome of the tumors, usually\\nin young subjects, suggest, when\\nhandled, that they contain boiled\\nvermicelli or a number of thread-\\nworms. The soft and gelatinous\\nquality of the neoplasm in earlier\\nlife is believed to be proportioned\\nto the age of the subject, and a\\nrapid development and succu-\\nlency of structure are only con-\\nditions of imperfect evolution, and\\nare not common in older patients,\\nin whom the tumors are firmer\\nand grow more slowly.\\nWhen involution occurs after\\nmaturity of the lesions has been\\nattained the softish contents of the\\ntumors are adherent to the cutis\\nabove, and the cutaneous atrophy\\nis proportioned to the rapidity of\\ndevelopment of the growth and the\\nfirmness of its structure. Then\\nensues a purse-like pedunculation\\nof the tumor, produced by en-\\ncroachment of the skin upon its pedicle, rendering its invagination, suppos-\\nably possible before, afterward difficult or impossible. Gradually there-\\nafter the neoplasm loses its skin-connection. Eventually in many cases\\nonly fibrous cords are left, evidently attached to the connective tissue\\nbeneath, the skin-color paling as the vascular tension correspondingly\\ndiminishes. Soon the dermal foramen closes, and the involutive process\\nis at an end. Then empty and wrinkled pouches or purses of integu-\\nment are left, the further skrinkage of which produces multiple warty\\nor nipple-like elevations of tissue (under the microscope recognized as\\nfibrous structures with an epithelial envelope), much in color like the\\nvirgin nipple or the scrotum of a boy. From four months to a year\\nare requisite for the mature development of the tumors, and nearly as\\nlong a period for the completion of the process of involution. The\\n35\\nMultiple fibromata. (Gboss.)", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0585.jp2"}, "586": {"fulltext": "546 NEW-GROWTHS.\\ndermatolytic flap is permanent. Taylor believes that there is the\\nclosest possible relation between fibroma and the verrucous growths\\ncalled acrochordon and ecphyma mollusciforme.\\nDermatol ysis (Chalazodermia, Pachydermatocele, Fibroma\\nPendulum, Lax or Relaxed Skin) is a condition which, as appears\\nin what precedes, may be produced by fibroma and follow the involu-\\ntion of its lesions. In other cases it is apparently spontaneous and\\ndiffuse, but then it is probably the result of some preceding condition\\nthat has been unnoticed. The skin of patients thus affected is in a\\ncondition resembling that of the young of several of the larger among\\nthe lower animals (pups of large hounds, etc.), where enormous flaps of\\nskin may be gathered up between the fingers and extended a foot or\\nmore from the underlying tissue. On releasing such folds the skin\\nretracts to its former position. The skin in these cases is usually\\nthickened, but it may be stretched to a considerable tenuity, as in the\\ncase of a man lately exhibited in America who could cover his face\\nwith skin drawn up from the surface of the chest. The integument\\nmay be externally normal to the view or pigmented. It may be the\\nseat of molluscous tumors; and either insensitive or normally sensitive,\\nor the seat of painful sensations. Usually all the functions of the\\nintegument are preserved.\\nThe anomaly is always partial and limited to either the face (the\\nlids), the neck, the chest, the belly, or the genital region. The disease\\nmay be congenital or acquired.\\nDermatolysis, as thus recognized, is to be distinguished from the\\nlaxity of skin apparent in the senile condition and after distention from\\nthe presence of tumors, pregnancy, etc. Usually, however, in the last-\\nnamed group of cases it is the subcutaneous tissues which are relaxed\\nrather than to any unusual extent the skin itself (e. g., the mammary\\nglands of women of advanced years, and the abdominal muscles after\\ndistention of the belly).\\nEtiology. Fibroma is peculiar to neither sex and, though observed\\nin adults, is commonly first developed in childhood. It cannot be\\nclaimed as peculiar to any race, though in America negroes have prob-\\nably furnished the largest field for its observation. Hebra called atten-\\ntion to the low standard of physical and mental development of the\\nsubjects of the disease seen by him, a fact well illustrated in a case\\nrecently presented, the patient being an exceedingly myopic, poorly\\nnourished white male dwarf, whose body was literally covered with\\nfibromata from the scalp to the feet. In view of this well-established\\nclinical fact, the hereditability of the disease, which is rendered prob-\\nable by recorded observations, seems capable of explanation. It has\\nbeen noted in three successive generations and in seven children in one\\nfamily. The cause of the disease is unknown. It is, however, reason-\\nable to conclude that it is due to a vice of local development under the\\ninfluence of a constitutional predisposition.\\nPathology. Simple, soft fibroma of the skin is seen under the\\nmicroscope to be a variety of myxo-fibroma and originates in gelatinous\\nconnective-tissue elements, which undergo metamorphosis into bundles", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0586.jp2"}, "587": {"fulltext": "PLATE XVI.\\nFibroma Pendulum.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0587.jp2"}, "588": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0588.jp2"}, "589": {"fulltext": "FIBROMA. 547\\nof fibres, the tumors always exhibiting more of the formed fibrous tissue\\nin the outer, and the formative or protoplasmic material in the central\\nparts of the mass. In young tumors the fibres are delicate and form a\\nloose network containing many spindle-shaped cells. As the growth\\nbecomes older and harder the fibres become coarser and more closely\\nunited, forming compact fibrous tissue in which there are very few\\ncells. The vascular supply of fibromata is usually slight. The fibrous\\nbundles pass downward and unite with those of the derma or sub-\\ncutaneous tissue, forming thus a firm attachment for the pedicle of all\\npedunculated tumors. There is some question as to whether these\\ngrowths originate in the deep interspaces of the corium or in the con-\\nnective tissue about the hair-follicles or fat-globules.\\nA very large number of fibromata are of the so-called mixed\\nvariety. Some spring from the nerve-sheaths, and actually contain\\nnerve-filaments (neuro-fibroma) others from muscular, vascular, and\\nglandular tissues, the compound tumor receiving in this way a part of\\nits constituent elements; often warty growths form with participation\\nof epithelium in the connective tissue, constituting thus an epithelioma\\n(so-called papilloma The large pendulous tumors of nsevus lipom-\\natodes may be examples of mixed fibromata, the surface of which is\\ncomposed of pigmented and hairy skin.\\nDiagnosis. The tumors of molluscum fibrosum are to be distin-\\nguished clinically from multiple cutaneous sarcomata by the violaceous\\nor reddish color of the latter, the absence of pedunculation, the greater\\ntendency to ulceration, and their evidently malignant character. From\\ntubercles of lepra they are differentiated by the entire absence of con-\\nstitutional impairment and their general development in far greater\\nmultiplicity. The tumors of molluscum epitheliale differ in their con-\\ntents, their superficial location, and in the frequent presence of the\\ndark punctum at their summits.\\nNeuroma is usually painful lipoma less frequently multiple and\\npedunculated, and more suggestive, when handled, of a pillowy\\nsensation to the touch. Warty growths are readily distinguished by\\ntheir verrucous summits and the gummata of syphilis, by the con-\\ncomitant or prior symptoms of the existence of lues.\\nTreatment. The treatment of large single fibromata is surgical,\\ninvolving the employment of knife, ligature, 6craseur, or galvano- or\\nthermo-cauterization. Multiple lesions are often so numerous as to\\nforbid such interference. When there is a distinct vice of development\\nor inherited tendency to the disease little can be accomplished in the\\nway of treatment.\\nPrognosis. Rarely, one or more of these lesions disappear by\\nspontaneous involution. More commonly they persist after their evo-\\nlution is completed. Marasmus, tuberculosis, and a fatal result may\\noccur. One or several of the tumors may become sources of danger\\nfrom the occurrence in them of an active inflammation with resulting\\ndegeneration and septicemic consequences. The disease, however, does\\nnot in many cases shorten life. In general the prognosis of multiple\\nfibromata may be regarded as unfavorable.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0589.jp2"}, "590": {"fulltext": "548\\nNEW-GROWTHS.\\nNEUROMA.\\n(Gr. vevpov, nerve.)\\nSymptoms. But few cases of this rare disease are recorded. The\\ndescription appended is a summary of the symptoms detailed in the\\nreports of Duhring, 1 of Rump/ and of Kosinski. 3\\nThe patients were all men of middle life or advanced years, who\\nexhibited upon the shoulders, arms, thighs, or buttocks numerous dis-\\nseminated and denned, pinhead- to hazel-nut-sized, spherical or oval\\nnodules or tubercles. They were either painful, or painless at the out-\\nset and painful later. In Rump s case, which was a sample of the\\nfalse neuroma of Virchow (fibroid tumor of the nerve), there was no\\npain throughout the course of the disease.\\nFig. 65.\\nNeuroma of the skin: external appearance. (Duhring.)\\nThe nodules were not arranged along the tracts of nerves were\\nimmovable, dense, and elastic were fixed in the corium and extended\\nbelow it. They were purplish or pinkish in color and the skin\\nbetween them was unaltered, or like that enveloping the lesions, dry,\\nuneven, and desquamative. The tubercles were both tender and pain-\\nful, the pain being excruciating, paroxysmal, usually lasting in Duhr-\\ning s patient for an hour, and radiating. It was aggravated by tem-\\nperature-changes, mental emotion, and movement.\\n1 Case of Painful Neuroma of the Skin, Amer. Jour: Med. Sci., October, 1873;\\nalso supplement to the same, with cuts, October, 1881.\\n2 Arch. f. path. Anat. u. Phvs., Bd. lxxx., Heft 1.\\n3 Centralbl. f. Chir., 18 74, No. 16.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0590.jp2"}, "591": {"fulltext": "NEUROMA.\\n549\\nHistologically these tumors are composed of a mixture of fine con-\\nnective tissue with medullated and non-medullated nerve-fibres and\\nshould properly be called neuro-fibromata. Sections of the growth in\\nDuhring s case showed anatomically a connective-tissue stroma, inter-\\nwoven with fibres for the most part lying parallel with one another,\\neach fibre composed of a finely granular central substance surrounded\\nby a sheath containing numerous, elongated, oval, somewhat granular\\nnuclei. There were also yellow elastic tissue, blood-vessels with thick-\\nened and nucleated walls, and about the latter lymphoid, cell-like\\nbodies. There was entire absence of unstriated muscular and fibrillar\\nMicroscopic structure of neuroma. (Duhring.)\\nconnective tissue. The specimen represented the true amyelinic neuro-\\nmata of Virchow. In Kosinski s case non-medullated nerve-fibres and\\nconnective tissue were also discovered. In both cases exsection of a\\nportion of nerve (brachial plexus, of the one and small sciatic, of the\\nother) was followed by considerable diminution of pain and almost\\nentire disappearance of the growths. In Rump s case, which, as stated\\nabove, represented the fibromated and so-called fibro-nucleated tumors\\nof Yirchow, the nodules were strung upon the same nerve, like beads\\nupon a rosary, and were similarly displayed upon its branches.\\nSpinal, cerebral, and sympathetic fibres were all involved.\\nDuhring, in commenting upon these rare cases, calls attention to the\\ndistinction between purely cutaneous lesions and the generally solitary,\\nmovable, and painful subcutaneous tubercle.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0591.jp2"}, "592": {"fulltext": "550 NEW-GROWTHS.\\nKnauss l reports a case in a girl of eleven years. There were over\\nsixty tumors varying in size from a cherry to a hen s egg. They were\\nsituated beneath the skin, were firm and elastic, and never painful.\\nHistological examination showed them to be composed of medullated\\nand non-medullated nerve-fibres, and numerous ganglionic nerve-cells.\\nXANTHOMA.\\n(Gr. ^avQoq, yellow.)\\n(Xanthelasma, Yitiligoidea. Fr., Plaques jaunatres des\\nPaupieres.)\\nThis affection w T as described by Payer 2 under the title Plaques\\njaunatres des Paupieres; by Addison and Gull (1851) as Vitiligoidea\\nby Erasmus Wilson as Xanthelasma; and by W. F. Smith (1869) as\\nXanthoma, the name now generally accepted by writers.\\nSymptoms. -Two forms of the disease are commonly recognized\\nXanthoma planum and Xanthoma multiplex.\\nXanthoma Planum. The flat or plane forms of the disease ap-\\npear as pinhead- to finger-nail-sized plaques, either quite flat or with\\nslightly elevated borders, and covered with an apparently normal\\nintegument. In color, which may be rendered more distinct by\\nstretching the skin, they vary from light- or chrome-yellow to a\\ncoffee-and-milk shade and in shape they may be punctiform,\\nspherical, oval, elongated, or of irregular outline. They are distinctly\\ncircumscribed, and when gathered between the thumb and finger are\\nsoft and smooth, and do not produce a sensation of the presence of a\\nforeign material. The plaques, examined closely, are seen to be made\\nup of an aggregation of millet-seed-sized, yellowish nodules, each pro-\\nvided commonly with a somewhat reddish central point. The plaques\\nare most often seen upon the eyelids (Xanthoma Palpebrarum), near\\nthe inner canthus, where they may be symmetrically disposed about the\\ntwo orbits, first appearing on one side but they may invade also the\\nperiorbicular region, as also, rarely, the cheeks, the nose, the ears, and\\nthe nucha. They are rarely productive of subjective sensation, being\\noccasionally the seat of slight pruritus. This is the commoner form of\\nthe disease.\\nXanthoma Multiplex (Xanthoma Papulatum, Tubercula-\\ntum, Tuberosum) is the form in which the lesions, usually first mani-\\nfested in the sites of election and in their simplest development,- pro-\\nceed to a gradual invasion of the trunk and extremities. The regions\\nof greatest pressure, outside of the lids and cheeks, seem sites of pref-\\nerence, as, for example, over the elbows, knees, palms, and buttocks.\\nOccasionally the mucous surfaces of the mouth, of the respiratory and\\ngastro-intestinal tracts are involved, as also the surfaces of the peri-\\ntoneum, endocardium, and larger arteries. The genital region, pal-\\nate, oesophagus, spleen, trachea, and cornea have all been recognized\\nas seats of the disease. Papular and tubercular lesions may coexist\\n1 Virchow s Arch., 1898, Bd. cliii., S. 29.\\n2 Traite* prat, des Maladies de la Pean. Paris, 1836.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0592.jp2"}, "593": {"fulltext": "PLATE XVII.\\nXanthoma of the Hands, Elbows, and Knees.\\n(From a Photograph of one of the author s patients.)", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0593.jp2"}, "594": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0594.jp2"}, "595": {"fulltext": "", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0595.jp2"}, "596": {"fulltext": "PLATE XVIII.\\nXanthoma Tuberosum of the Hands.\\n(From a painting.)", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0596.jp2"}, "597": {"fulltext": "XANTHOMA. 551\\nwith the plane lesions described above, and scarcely differ from the\\nlatter save in a greater development. The lesions are whitish or yel-\\nlowish papules, plaques, and tubercles, circumscribed in contour,\\nmillet-seed- to nut-sized, and at times much larger, covered with an\\nunaltered epidermis, and determinable by palpation as having greater\\nconsistence than the flat macules. They are less frequently seen upon\\nthe lids, but occur upon the scalp, cheeks, palmar and plantar surfaces,\\nthe genital region, and about the joints of the digits.\\nIn rare cases the tubercles may coalesce to form sessile or pedun-\\nculated, nut- to hen s-egg-sized tumors which are firmer as a rule than\\nthe smaller lesions (Carj^and Chambard 2\\nThe conglomerate forms upon the skin constitute large plaques\\nresembling tumors, compounded of lesions of xanthoma tuberosum.\\nThey are distinctly circumscribed, deeply imbedded in the coriuni,\\nelevated to the extent of one-fourth of an inch above the general level\\nof the integument, and irregularly furrowed or lobulated superficially.\\nAn illustration from a photograph of xanthoma occurring in full de-\\nvelopment and in rare situations is presented in the plate appended.\\nOther cases display unusual features of this disease. In one there\\nare flattened ribbons, exhibiting xanthomatous changes in both palms,\\nstretching at right-angles to the long axis of the hand in a second\\nand somewhat rare form of the disease isolated xanthomatous papules\\nare attached somewhat regularly to the edges of the lids of both eyes,\\nthe upper and lower equally, while large pinhead-sized and equally\\nisolated yellowish masses are visible below the orbits on each cheek.\\nIn certain cases the disease is accompanied by a generalized colora-\\ntion of the skin in a yellowish shade, which has been variously inter-\\npreted as a xanthomatous dyschromia and as a true icterus. The\\nformer is the more probable explanation of the fact, as in such cases\\nthe urine and viscera have been found normal. A woman presenting\\none of the extreme phases of this icteroid xanthomatous condition of\\nthe skin was shown at the International Congress of Dermatology in\\nLondon in 1896.\\nKorach 3 has described the case of a woman twenty-five years old,\\nsuffering from chronic icterus produced by closure of the ductus\\ncholedochus. Beside the typical patches of xanthoma on the lids,\\nthe skin-surface was generally and similarly affected. Thus the\\nextensor faces of the extremities, the palms of the hands, nates, and\\nother parts w T ere extensively covered with sago-grain- to pepper-corn-\\nsized papules and tubercles of xanthoma, both flat and elevated.\\nOccasionally the tubercles exhibit a fine vascularization and when\\nthere is a coincident jaundice the skin between isolated lesions is also\\ntinted with the color of the xanthoma nodules. The jaundice, so-\\ncalled, is rather common in the multiplex forms and even when not\\nreadily recognized the skin, at first sight of normal tint, is seen to be\\nsomewhat deeply colored in a shade of reddish yellow. As a rule,\\nthere are scarcely distinguishable subjective sensations, patients coni-\\n1 Annal. de Derm, et de Syph., 1880, p. 7o.\\n2 Arch, de Phvs. norm, et path., Sept. and Dec, 1879.\\n3 Deutsch. med. Woch., 1881, No. 20.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0597.jp2"}, "598": {"fulltext": "552 NEW-GROWTHS.\\nmonly applying for relief of the resulting facial disfigurement. Occa-\\nsionally burning and pricking, and rarely even painful sensations are\\nproduced. The patient whose lesions were selected for illustration of\\nthis chapter subsequently had the tumors removed from his limbs in\\norder to relieve himself of discomfort in his work.\\nThe course of most cases is toward a maximum of development,\\nafter which the process ceases. In a few instances, usually not palpe-\\nbral, complete involution has spontaneously occurred. The variations\\nnoted in the color of the plane and elevated forms of xanthoma are\\nfrom a light-yellow to a deep-brownish and even blackish hue. Cases\\noccurring in children and infants seem to exhibit nearly the same fea-\\ntures as those seen in adults.\\nEtiology. The causes of the disease are obscure. In a few cases\\nthe lesions are first observed in early childhood, though they are\\nencountered chiefly in middle and later life. Women are rather more\\noften affected than men.\\nThe belief is growing that xanthoma is due to embryonic and local\\ncauses. Many instances are on record in which several members of a\\nfamily were affected. Torok and T. C. Fox have each reported families\\nin which members of three generations presented the disease. The\\nmother of the patient exhibiting multiple lesions upon the elbows and\\nknees, whose case was selected for illustration of these pages, presented\\nplane lesions of xanthoma near the inner canthi of the eyes. The\\nstudies of Torok 1 in this direction are instructive. The association of\\nxanthoma with disease of the liver, rheumatism, gout, ovarian disease,\\nmigraine, syphilis, carcinoma, hydatids, and other disorders cannot be\\ndenied for certain cases, but in the majority no such association can be\\nrecognized. Multiple plane lesions of the lid in a middle-aged woman\\nhave succeeded a dermatitis of that region, induced by accidental con-\\ntact with a corrosive solution of mercury.\\nPathology. The anatomy of xanthoma has been investigated spe-\\ncially by Chambard, Balzer, Touton, 2 Torok, and others. The process\\nseems to be a connective-tissue new-growth, containing cells infiltrated\\nwith fat-granules. Aside from the new-formed connective tissue and\\nendothelial cells there are seen between the interlacing fibres the char-\\nacteristic xanthoma-bodies. These are cells varying greatly in size,\\nhaving a distinct membrane, granular or fibrillated protoplasm, and\\nlarge round or oval vesicular nuclei, which vary in number from one to\\na dozen or more.\\nThese xanthoma-cells are grouped especially about and along the\\nvessels, and form globular masses in the deeper parts of the corium,\\nthough they may extend almost to the rete. They are more or less\\ninfiltrated with fat-granules, and correspond closely in structure to the\\ndeveloping fat-cells of normal connective tissue, but, as Torok has\\nshown, they never go on to the formation of a fully developed cell\\ncontaining one large drop of fat, and Unna finds they do not respond\\nto staining and other tests as do the fat-containing cells found in other\\n1 Annal. de Derm, et de Syph., Nov. and Dec, 1893.\\n2 Vierteljahr. f. Derm. u. Syph., 1885, Heft 1, S. 3, with reference to previous re-\\nports.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0598.jp2"}, "599": {"fulltext": "XANTHOMA. 553\\ntissues. There is seen also in the growth a transitional series of\\nbodies between the connective-tissue corpuscles and the characteristic\\nxanthoma-cells.\\nThe epidermis is usually unchanged, though it, together with the\\npapillary layer, may be slightly thinned, and there is frequently a\\ndeposit of a yellowish-brown pigment in the deeper layers of the rete.\\nThe growth is almost wholly confined to the deeper parts of the corium,\\nthough occasionally portions extend to the subcutaneous tissue and may\\nsurround the coil-glands and hair-follicles. The sebaceous glands may\\nbe few, but are unchanged and are not, as was formerly supposed, con-\\ncerned in the process. There is often a deposit of pigment in the corium,\\nboth free and in the cells, but the characteristic color of xanthoma is\\nundoubtedly due to the fat-granules.\\nThe icterus and hypertrophy of the liver which sometimes complicate\\nxanthoma are probably secondary and caused by the presence of the\\ngrowth in the liver or in the biliary passages.\\nPollitzer 1 has made a study of xanthoma palpebrarum, and states\\nthat this form of the disease is due to a slow fatty degeneration of\\nthe fibres of the orbicularis muscle analogous to the more rapid\\ndegeneration of muscles which sometimes follows acute infectious dis-\\neases. He finds the xanthoma-bodies to be fragments of degenerated\\nmuscle-fibres, and believes that this form of the disease has no connection\\nwhatever with the generalized forms.\\nChambard, Morris, Crocker, and a few others believe the primary\\nprocess is an inflammation which is followed by a fatty degeneration of\\nthe cells. 2 Balzer s conclusions as to the parasitic nature of the disease\\nhave not been verified by more recent investigators.\\nDiagnosis. Milia occasionally occur in groups in the form of oval\\nplaques upon the lids, but are distinguishable from xanthoma by the\\npossibility of expressing their contents.\\nThe diagnosis from all other lesions is readily made when consider-\\nation is had of the peculiar yellowish or saffron-like hue of xanthoma,\\nand the common situation, form, and general characteristics of its plane\\nor nodular lesions.\\nPollitzer has reported a case of multiple dermoid cysts in which were\\npresent the clinical appearances of xanthoma. A similar case is now\\nunder our observation.\\nTreatment. Erasion and excision are the usual methods of remov-\\ning xanthomata. Care should be taken in such operations to avoid a\\nconsequent ectropion Avhen the operation is performed upon the skin\\nof the eyelids. The Paquelin knife is objectionable on account of the\\nradiation of heat to the globe of the eye. With the tumor slipped\\nthrough an aperture in a thin sheet of asbestos paper, such as is now\\nfound in the market, this danger may be obviated.\\nThe modern method, however, of treatment by electrolysis is prefer-\\nable to others. Caustics also have been successfully employed. Besnier\\nemploys phosphorus internally, followed by turpentine, by which the\\n1 Jour. Cutan. and Gen.-Urin. Dis., 1897, p. 367.\\n2 A discussion of this question and a resume of literature are found in the Brit.\\nJour, of Derm., August, 1892.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0599.jp2"}, "600": {"fulltext": "554 NEW-GMOWTBS.\\ncourse of the disease is said to have been relieved. Wilson, with the\\nsame end in view, employed nitro-muriatic acid, arsenic, bitters, and\\nblue pill. McGuire reports the removal of xanthoma by applications\\nof monochloracetic acid.\\nPrognosis. The lesions, when not removed, are liable to persist\\nthrough life. Spontaneous involution is said to occur very rarely.\\nFrench authors who have given considerable attention to this subject\\nare disposed to believe that some cases of xanthoma tuberosum, with\\npermanent xanthochromia and involvement of the inner coats of the\\nlarger vessels, may prove serious.\\nXANTHOMA DIABETICORUM.\\n(Glycosueic Xanthoma.)\\nThis rare disorder has been well illustrated by three excellent por-\\ntraits showing the features of the malady in a case reported by Robin-\\nson. 1 Instances of the disease have been also recorded since the cases\\nof Addison and Gull (1851), by Hillairet, Morris (who was the first to\\nclaim for it an independent position in the list of cutaneous affections),\\nourselves, 2 and many others.\\nSymptoms. The lesions are usually multiple and numerous, dis-\\ncrete or confluent, and not rarely grouped, pinhead- to pea-sized, firm,\\nwell-defined, conical or acuminate papules. At the apex may be recog-\\nnized a yellowish centre with reddish areola, which may be made to\\ndisappear temporarily under pressure. The appearance when viewed\\nat some distance is suggestive of a pustule. Subjective sensations of\\nitching, pricking, etc., may be produced. The lesions are visible over\\nthe buttocks, loins, elbows, knees, and extensor faces of the limbs in\\ngeneral, the face (broAvs, nose), the scalp, about the angles and over the\\nmucous surface of the mouth, and the palms and soles. But one case\\nhas been reported as occurring on the eyelids. The eruptive lesions\\nare likely to be of sudden occurrence. After remaining upon the sur-\\nface for a few months or years they may wholly disappear without\\nleaving a trace of their existence, or the eruptive elements may in part\\nonly disappear.\\nEtiology. In seventeen out of twenty-one cases reported glycosuria\\nhas been recognized and Johnston calls attention to the fact that in\\nnearly every case the patient has been described as stout, florid, or\\nobese. The majority of the patients have been male subjects, and\\nusually in a condition of fair nutrition often they have been consumers\\nof beer in large quantities.\\nPathology. Histologically the disease does not differ essentially\\nfrom the ordinary form of xanthoma, except that the inflammatory\\nchanges are more marked, there is less connective-tissue formation, and\\nthere are fewer of the xanthoma-cells than in the common variety.\\nThe lesions, moreover, are usually found near the coil-glands and fol-\\nlicles. Torok, Johnston, and others believe the disease to be an exuda-\\n1 Internat. Atlas of Kare Skin-diseases, 1890, iv., ii.\\n2 Paintings in oil showing the lesions in two patients were exhibited to the Amer.\\nDerm. Assoc, in New York, 1898.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0600.jp2"}, "601": {"fulltext": "PLATE XIX.\\nI\\nXanthoma Diabeticorum.\\n(From a painting.)", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0601.jp2"}, "602": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0602.jp2"}, "603": {"fulltext": "COLLOID METAMORPHOSIS OF THE SKIN. 555\\ntive dermatitis terminating in a granulo-fatty degeneration which is\\nquite distinct from the heterotopic, arrested development of fat seen in\\nordinary xanthoma.\\nDiagnosis. Those who would separate this form of xanthoma from\\nall others base the difference between them upon the following points\\nin xanthoma of glycosuria the sudden evolution and involution of the\\ncutaneous lesions the firmness and solidity of the latter as distinguished\\nfrom the softness of the ordinary forms and the inflammatory character\\nof the glycosuric as distinguished from the hypertrophic changes in the\\nother variety. In xanthoma diabeticorum the yellowish apex is not at\\nfirst apparent, nor in all the lesions, and, when it exists, is due to epi-\\ndermal changes and not to those occurring in the corium as in xanthoma.\\nOther characteristic features of the xanthoma of diabetic subjects are\\nthe absence of striae and patches, the absence of jaundice and of eyelid-\\nlesions, the presence of marked subjective sensations, the grouping of\\nthe lesions about the hair-follicles (well marked in Robinson s case), and\\nthe absence of diabetes mellitus in most of the palpebral cases on record.\\nThis side of the question is presented by Johnston in reporting a case\\nand in giving a summary of the twenty other cases so far recorded. 1\\nOn the other hand, it is urged by Besnier and Doyon that the gly-\\ncosuria is simply an irritating cause which explains the differing symp-\\ntoms of xanthoma in the two classes of patients. Surveying the litera-\\nture of xanthoma, they find patients without diabetic symptoms suffering\\nfrom atrocious pruritus and most of the special features claimed as\\npeculiar to diabetic xanthoma of glycosuria. A woman, however, in\\nmiddle life, recognized as the subject of diabetes mellitus (not insipidus),\\nexamined with special care, exhibited merely the common form of sym-\\nmetrical and plane eyelid-lesions. It is difficult to determine what are\\nthe relations, if any, between these two forms of xanthoma.\\nThe Treatment of the disease, medicinal and dietetic, is largely that\\nof glycosuria. Robinson s patient recovered after the use of small\\ndoses of Fowler s solution. Local treatment may be employed as in-\\ndicated in any case.\\nThe Prognosis is favorable, all cases eventually recovering.\\nCOLLOID METAMORPHOSIS OF THE SKIN.\\n(Colloid Milium [Wagner], Hyaloma. Fi\\\\, Colloidome\\nMiliaire [Besnier] Ger., Hyalom dee Haut.)\\nRelatively few cases of this rare disorder have been reported. The\\nlesions occur chiefly on the upper two-thirds of the face, especially on\\nthe forehead and about the orbits. They consist of pinhead- to millet-\\nseed- or even split-pea-sized, sharply circumscribed, iregularly rounded,\\nflat papules, lemon yellow in color, having a peculiar glistening, trans-\\nlucent appearance suggestive of vesicles. They project but slightly\\nfrom the skin, and on puncture give exit to a soft gelatinous mass,\\nat times accompanied by a droplet of blood. Some of them may be\\nsurrounded by very slight telangiectases. They develop slowly, often\\n1 Jour. Cutan. and Gen.-Urin. Dis., October, 1S95; and Ibid., September, 1900.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0603.jp2"}, "604": {"fulltext": "556 NEW-GROWTHS.\\nin groups, the individual papules remaining distinct even when two\\nor more unite. Frequently a papule becomes depressed in the centre\\nor becomes inflamed and covered with a crust which falls and leaves a\\nshallow depression but not a true scar.\\nEtiology. The cause of the disease is not known it occurs alike\\nin men and women, usually after the forty-fifth year of age. A male\\npatient presented at our clinic was twenty-five years of age only. In\\nmost of the cases reported the individuals lived an outdoor life and\\nwere much exposed to the elements.\\nPathology. This has been studied by Balzar, Besnier, Reboul, and\\nothers. Wagner s belief that the process begins in the sebaceous\\nglands is now practically discarded. Colloid degeneration is found to\\naffect the connective-tissue and elastic fibres of the derma, which may\\nbecome involved over considerable areas. The changes are especially\\nnoticeable about the vessels and nerves and about the sebaceous and\\ncoil-glands. The glands themselves, and all the epithelial structures,\\nexcept the endothelia of the vessels, usually escape. In sections exam-\\nined by us removed from a clinical patient a few rete-cells and a few\\ncells of the coil-gland ducts were transformed into or infiltrated with\\ncolloid substance. This disease is not identical with multiple benign\\ncystic epithelioma (hidradenoma), in which the epithelial cells play an\\nimportant part.\\nDiagnosis. The disease is apt to be confounded with xanthoma,\\nhydrocystoma, adenoma sabaceum, and multiple benign cystic epithe-\\nlioma (hidradenoma). From the last-named disease the diagnosis is\\noften very difficult or even impossible without the aid of histological\\nexamination.\\nTreatment. The nodules may be removed with a sharp curette or\\nby electrolysis.\\nADENOMA OF THE SEBACEOUS GLANDS.\\n(Adenoma Sebaceum. Fr., Adenomes S^baces [Balzer and\\nMenetrier], Adenomes Sebaces Cancroidaux, Acne Can-\\nCROIDALE.)\\nThe several forms of adenoma of the sebaceous glands may be\\nassigned to two categories, the benign and the malignant.\\nAcquired Benign Growths are pinhead- to pea-sized, sessile,\\nspheroidal, oval or acuminate bodies, occasionally presenting points of\\nwhitish appearance suggestive of milium. They are situated chiefly\\nover the face (forehead, furrows beside the nose). They are always\\ncovered with an unchanged epithelium and in color present the hue of\\nthe normal skin.\\nCongenital Benign Growths are represented by the verrucous\\nand vascular nsevi of Pringle and Darier. They increase slowly after\\nbirth and attain a notable development at about the period of puberty.\\nThey also are found about the regions of the face named above, includ-\\ning the chin and the mouth. The lesions are pinhead- to bean-sized,\\nand differ from those above described chiefly in the color they present,\\nwhich varies from a yellowish white to a deep brownish red often", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0604.jp2"}, "605": {"fulltext": "ADENOMA OF THE SEBACEOUS GLANDS. 557\\nthe surface is vascularized by the presence of minute capillaries.\\nThey are sometimes discrete, often confluent, and may be commingled\\nwith comedones, acne-pustules, pigmented patches, and the lesions of\\nfacial seborrhoea. In the majority of cases other defects of the skin,\\nsuch as warts, nsevi, small papillomata, and pigment-spots, are present,\\nwhile many of the patients reported have been mentally deficient or\\nepileptic.\\nThe two forms named above are benign tabulated tumors of the\\ntype of sebaceous adenoma the last-named group being distinguished\\nby delicate telangiectases over the surface and a verrucous structure.\\nMalignant forms of Sebaceous Adenoma occur when the skin\\nis in the senile state. They begin with the symptoms of an irritable\\nacne or seborrhoea, greasy crusts being displayed here and there, par-\\nticularly over the surface of the face or comedones of unusual\\ntype or papulo-pustules that do not pursue the course of those seen\\nin earlier years. Ulceration attacks the lesion which at first seemed\\nbenign, and the issue is the development of an epithelioma.\\nEtiology. The cause of these growths is not known. The majority\\nof them are congenital, and those also which develop later in life may\\nbe congenital in origin. Most of the cases reported have been in the\\npoor and in those of defective mental development, but cases are also\\nseen in the well-to-do and intelligent.\\nPathology. The histology of these bodies has been studied by\\nPringle, Darier, Balzer, Crocker, Pollitzer, and others. There is\\nhyperplasia of the sebaceous glands, which are numerous and large.\\nBeyond this observers do not agree, and further study of the subject\\nis necessary. Pringle described an interpapillary hypertrophy Balzer\\nfound small cysts in both sebaceous and sweat-glands Crocker reported\\nan increased development of the coil-glands and hair-follicles, in addition\\nto hyperplasia of the sebaceous glands.\\nDiagnosis. The history of the disease, which begins in early life\\nand develops gradually the persistency and permanency of the indi-\\nvidual lesions situated chiefly on the middle of the face and specially\\nin the naso-labial folds the frequent occurrence of telangiectases with\\nthe papules above described and the absence of suppuration or ulcer-\\nation will usually suffice for a diagnosis. In colloid milium the lesions\\nare usually few in number, are situated chiefly on the frontal and\\norbital regions, have a peculiar yellowish, translucent appearance, and\\nare not so much modified by telangiectases. In multiple benign cystic\\nepithelioma the lesions occur on the forehead and also on the trunk.\\nBoth of the two last-named diseases, however, may so closely resemble\\nadenoma sebaceum as to render the differential diagnosis impossible\\nwithout the aid of histological examination.\\nTreatment. Neither internal remedies nor external applications\\nhave any influence upon the lesions. The treatment is, therefore,\\nsurgical and calls for the employment of the knife, the curette, or scar-\\nIification, depending upon the size, number, and location of the lesions.\\nIn several cases the latter have been removed successfully by means\\nof electrolysis.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0605.jp2"}, "606": {"fulltext": "558 NEW-GROWTHS.\\nADENOMA OF THE COIL-GLANDS.\\nAlthough the majority of cases formerly described as adenoma of\\nthe coil-glands are now classed with multiple benign cystic epithelioma,\\na few well-authenticated examples of the disorder are reported. 1\\nPerry 2 describes a case, illustrated by a chromolithograph, of a\\nwoman upon whose face and trunk millet-seed- to small pea-sized\\nnodules were visible, lasting for nearly twenty years. Upon puncture\\na clear fluid could be expressed from each. On section the coils of\\nthe sweat-glands were found enormously increased in size, and there\\nwas pigmentation of the gland-cells.\\nThe Diagnosis of this rare disorder can be made only with the aid\\nof the microscope.\\nThe Treatment is surgical, by means of the knife, curette, cautery,\\nor electrolysis.\\nMULTIPLE BENIGN CYSTIC EPITHELIOMA.\\n(Adenoma of the Sweat-glands [Perry], Epithelioma Ade-\\nnoides Cysticum [Brooke]. Fr., Cellulome \u00c2\u00a3pitheliale\\nEruptif Kystique [Quinquaud], Cystadjenomes Epithe-\\nlieux Benins [Besnier], Hydradenomes Eruptifs [Jacquet\\nand Darier], Syringo-cystadenome [ToroK] Ger., Gutar-\\ntiges Epithelioma, Verbunden mit Kolloider Degen-\\neration [Phillipson].)\\nThe name selected as the title of this chapter is that given to the\\ndisease by Fordyce, whose presentation of the subject forms 3 the basis\\nof the following description.\\nThe disease is most common on the face, neck, and upper extremi-\\nties, but may develop on any part of the body. It is characterized by\\nthe appearance of small, pearly, pale, yellow or pinkish-colored tumors\\nvarying in size from a small pin s head to that of a pea. Larger\\nlesions are exceptional. The tumors are firmly imbedded in the skin\\nand also project above the surface they are round or oval, solid and\\npainless to the touch, the larger ones being tense, lucent, and freely\\nmovable. Some of the tumors are translucent, suggesting vesicles\\nothers resemble milia and may be the seat of fine telangiectases in\\nothers there may be a central depression which in some of the larger\\nlesions of White s case produced an appearance closely resembling\\nHutchinson s crateriform epitheliomata. The lesions are discrete, and\\nare not grouped or arranged in any characteristic manner.\\nIn most cases the tumors are first noted at or before the age of\\npuberty they enlarge slowly, rarely exceeding the size of a pea, and\\ndo not ulcerate or undergo spontaneous involution. White, 4 however,\\nreports a case in a woman of forty-five on whose face were small typ-\\nical lesions of this disease, and also others in varying stages of devel-\\n1 Fordyce gives a summary of the subject in Morrow s System, vol. ih\\\\, p. 618.\\n2 Internat. Atlas of Rare Skin-diseases, 1 890-91.\\n3 Morrow s System, vol. iii., p. 620.\\nJour. Cutan. and Gen-Urin. Dis., 1894, p. 477.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0606.jp2"}, "607": {"fulltext": "MULTIPLE BENIGN CYSTIC EPITHELIOMA. 559\\nopment up to true epithelioma of rodent ulcer type. The diagnosis\\nwas confirmed by the histological examination of a number of the\\ntumors of varying sizes.\\nThe cause of the disease is not known. In Brooke s and White s\\ncases a distinctly hereditary history was obtained.\\nPathology. The views of different observers regarding the path-\\nology of this disease are largely indicated in the names given to it by\\neach. Fordyce reports that microscopical examination shows the\\ntumors to be made up of irregularly rounded, oval, and elongated\\nmasses and tracts of epithelial cells corresponding to those in the lower-\\nmost layer of the epidermis and the external root-sheath of the hair-\\nfollicle. The epithelial masses may be distinct, or made up of inter-\\ncommunicating bands and tracts, in some places resembling coil-ducts.\\nCell- nests are met with as in malignant epithelioma, enclosing horny,\\ngranular, and colloid tissue. Colloid degeneration of individual cells is\\nalso encountered in the cell-masses. The connective tissue about the\\ncell-collections is somewhat condensed, but is not the seat of any in-\\nflammatory process. It is probable that these epithelial growths\\noriginate in a downward growth and proliferation of the epidermis and\\nexternal root-sheaths of the hair-follicle, and not from the coil-glands,\\nas. was supposed by some observers.\\nTwo cases only of those so far reported have shown any tendency\\nto become malignant. It is possible that in the two cases these\\nchanges were accidents or coincidents such as occasionally occur in\\nconnection with verruca and other benign growths, but the histological\\nstructure of the small tumors closely resembles that of true epithe-\\nlioma, and, as White suggests, it is quite possible that they would all\\nin course of time show a malignant tendency, since most of the cases\\nobserved so far have been in young subjects.\\nTreatment. The treatment is wholly surgical, with knife or curette.\\nMany of the tumors are readily expressed with slight pressure, after\\nthe skin over them has been incised. Electrolysis is suitable for the\\nsmaller growths.\\nLymphangioma Tubekosum Multiplex. These rare growths\\nsupposedly of lymphatic vessels in the skin have been noted by Hebra\\nand Kaposi, Pospelow, 1 Van Harlingen, 2 and other writers. The\\nlesions in these several cases were practically identical, from a clinical\\nstandpoint, with those of multiple benign cystic epithelioma described\\nabove. By many observers the tw r o diseases are thought to be the\\nsame clinically and pathologically, but Kaposi and others maintain\\nthat they are distinct in origin and in structure, stating that sections\\nshow under the microscope rounded or oval spaces, recognizable as dis-\\ntended lymphatic vessels by the characteristic endothelium with which\\nthey were lined. Kaposi distinguishes these tubercles from all subcu-\\ntaneous cavernous tumors constituted of new-formed dilated lymphatic\\nvessels reaching toward the skin, by the limitation in the former of\\nthe neoplastic growth to the superior parts of the corium.\\n1 Y^ierteljahr. f. Derm. u. Svph., 1879, Heft 4.\\n2 Phila. Med. Times, September 24, 1881.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0607.jp2"}, "608": {"fulltext": "560 NEW-GROWTHS.\\nLEUCOKERATOSIS BUCCALIS.\\n(Leucoplasia, Leucoma, Psoeiasis Lingua, Smokees Patches\\nof the Mouth, Buccal Psoeiasis, Ichthyosis Linguae,\\nTylosis Linguae, Leucoplakia Buccalis. Ft., Leucoplasie,\\nPlaques Blanches de la Bouche.)\\nIn the year 1868 Bazin described with tolerable accuracy the several\\nconditions indicated by the names given above and since that date the\\nsubject has been enriched by a literature contributed by Debove, Kaposi,\\nSigmund, Plumbe, Mauriac, Schwimmer, Ingals, and others. The title\\nof these paragraphs is that given by Besnier and Doyon as the least\\nmisleading and the most descriptive.\\nThe disease is manifested chiefly in the mouth, by the occurrence on\\nthe inner faces of the lips and cheeks, and on the dorsum and edges of\\nthe tongue, of sharply outlined, dull-whitish, slate-colored, or silver-\\nwhitish points, disks, streaks, bands, ribbons, or patches of an irregular\\nshape, either flattened or slightly elevated above the general level of\\nthe mucous surface. The disease may occur in isolated points or in\\npinhead-sized nodules, discrete or confluent, and in cases grouped, the\\ngrouping being often in linear arrangements, following the lines indicated\\nby the streaks or the striae of similar composition.\\nThe sites of election of these lesions are the inner face of the cheek\\nin a line following that traced by the conjunction of the teeth of the\\nupper and lower jaw when approximated the gums above the upper\\ncanine teeth and lateral incisors; the sulcus beside the upper and lower\\ngums in the roof and floor of the mouth the dorsum and edges of the\\ntongue, where the arrangement is usually in lines along the longitudinal\\naxis and more rarely other parts such as the vaginal and other mucous\\nmembranes which have been involved.\\nWhen closely examined these lesions are found to be made up of a\\nhyperkeratinized epithelium, being covered by an adherent and more\\nor less dense pellicle, removable only by artificial measures and closely\\napplied to the inferior stratum of the mucosa. The lesions are rough\\nto the touch, both to the finger of the physician and to the tongue of\\nthe subjects of the disease, but are, as a rule, not painful, though at\\ntimes annoying by producing a certain degree of stiffness and immobility\\nof the parts affected. At times the membrane in the vicinity is reddened\\nand tender.\\nThese lesions are extremely chronic of evolution, requiring months\\nand often years for their full development, and resisting in a remarkable\\nway the action of topical medicaments. They may be removed without\\nrecurrence or may recur after complete and radical ablation. If\\nunmolested and not undergoing resolution (a termination somewhat\\ndoubtful of occurrence), they usually, by reason of increased density,\\ncrack or fissure at one or another point, the fissure extending to the\\nderma and arousing a local inflammatory process with the production\\nof pain and distress. The surface is then prone to exfoliate and ulcer-\\nate, and epithelioma of the mouth may result.\\nThe proportion of .the benign cases to those which result in epithelioma", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0608.jp2"}, "609": {"fulltext": "LEUCOKEBATOSIS BVCCALIS. 561\\nis not determined. Every leucokeratosis, however, may prove the initial\\nstage of an epithelioma, and the treatment of the former is, therefore, a\\nmatter of no little consequence.\\nThe Etiology of these cases is suggested by some of the names given\\nabove. The disorder occurs almost exclusively in the mouth of men,\\nand usually after middle life. Unquestionably, the irritation produced\\nby tobacco, whether used in smoking or chewing, and the influence of\\ncarious teeth or those with sharp edges after fracture irritating the edge\\nof the tongue, are all important. The resemblance of these lesions to\\nthe mucous patches of syphilis is obvious and it is believed that\\nsyphilis, when not actively efficient in the production of leucokeratosis\\nbuccalis, may be one of its indirect causes. It is, however, important\\nto note that all the symptoms here described occur in persons who have\\nnever suffered from syphilis and such symptoms are in the latter class\\nfully as intractable as in others.\\nPathology. It is not definitely known if the primary change is a\\npure hyperkeratinization of the epithelium or an inflammatory process\\nof the papillary layer. The horny layer is hypertrophied, the cells\\nretaining their nuclei. In the derma there is always more or less in-\\nflammatory infiltration, and often the papillae are partially obliterated.\\nFordyce states that overgrowth and proliferation of the interpapillary\\nprocesses are exceptional. Leloir insists that the epitheliomatous process\\nalways begins not at the level of the hyperkeratosis of the mucous\\nmembrane, but below the fissure or other lesion induced by the indura-\\ntion of the plaque or streak, indicating, in other words, that the epithe-\\nliomatous change is rather an accident than an essential part of the\\nprocess.\\nThe Diagnosis is chiefly from syphilitic lesions of the mouth, which\\nshould be recognized, as a rule, by their softness and tendency to ulcer-\\nate, as well by their situation, which is far less distinctive than in the\\ncase of leucokeratosis of the mouth. A history of infection and of\\nsymptoms of the disease in other regions of the body would usually\\nindicate the nature of the process.\\nThe only malady likely to be confounded with leucokeratosis of the\\nmouth is lichen planus and it is important to note that some confusion\\nexists on this point in several descriptions of the two diseases.\\nIn lichen planus of the inside of the lips there may be recognized\\nover the tongue, the palate, and other parts, dents, smooth or fissured\\nplaques, rings, festoons, linear striae, or disks covered by a silver-whitish\\npellicle. It is clear that the distinction between these and leucokera-\\ntosic lesions is in a high degree obscure, and for the present the most\\nthat can be done is to search with special care for other symptoms of\\ndisease upon the cutaneous surfaces of the body pointing to either\\nlichen planus or to syphilis.\\nThe Treatment of leucokeratosis of the mouth is first by abstention\\nfrom all local irritants (tobacco highly spiced, heated, acetous, and\\niced particles of food and drink), by the care of the teeth, and by the\\nemployment of soothing sprays or lotions containing potassium chlorate,\\nboric acid, balsam of Peru, iodized phenol, myrrh, borolyptol, or muri-\\nated iron.\\n36.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0609.jp2"}, "610": {"fulltext": "562 NEW-GROWTHS.\\nSilver nitrate may be applied to any ulcerated or fissured points,\\nboth in solution and by sweeping the solid crayon over the surface.\\nThe French make use of the salicylates in the same way.\\nDestruction or removal of the lesions may be secured by the employ-\\nment of caustics, chemical or galvano-cauteric by erasion with a\\ncurette or by surgical ablation. When practicable, the burr of the\\ndental engine may be used after injection of cocaine muriate. Where\\nthe patches are not too dense and extensive this has generally been\\nproductive of good results.\\nSherwell x reports complete removal of the patches by the use of\\nundiluted liquor hydrargyri nitratis. The mouth is stuffed with cot-\\nton to protect adjacent parts the solution is applied and allowed to\\nremain from fifteen to twenty minutes, after which it is neutralized with\\nsodium bicarbonate. If necessary, the application may be repeated two\\nor three times at intervals.\\nPierce 2 was successful in one case after rubbing into the patches\\npyoktanin-blue, followed immediately with an aqueous solution of\\nanilin-oil. The applications were made daily for three months.\\nThe Prognosis is fairly favorable in the case of all subjects of the\\ndisease who consent to deny themselves absolutely the luxury of tobacco-\\nusage in every form, and who can follow a prescribed hygienic and\\nmedicinal course. For all others there is danger of epithelioma.\\nMYOMA.\\n(Gr. ftvav, muscle.)\\nCutaneous myomata are divided by Besnier 3 into two classes\\nsimple myoma, or liomyoma; and dartoic myoma.\\nDaetoic Myoma is much more common than is the other form,\\nand is of chief interest to the surgeon. It is usually single, though\\noccasionally multiple, and occurs most frequently on the mamma?, the\\nlabia majora, the penis, and the scrotum. The tumor develops slowly,\\nfinally attaining a size varying from that of a small nut to that of an\\norange, and may be sessile or pedunculated. In most cases reported\\npain has been slight or absent, though it was marked in a case reported\\nby Virchow. Under the influence of cold and local irritation the tumor\\nusually contracts or may show a slow vermicular motion. Some of\\nthese tumors are composed almost entirely of non-striped muscle-\\nfibres, others are mixed with other tissues to form a Fibromyoma, an\\nAngiomyoma (Myoma Telangiectodes), or a Lymphangiomyoma.\\nSimple Myoma is rare, only eighteen cases 4 having been reported.\\nIts lesions are usually multiple and occur most frequently on the\\nupper extremities, affecting chiefly the extensor surfaces, but they\\nmay occur on other parts of the body. They begin as minute round\\n1 Jour. Cutan. and Ge,n.-Urin. Dis., 1899, p. 185.\\n2 Chicago Med. Recorder, xii.. p. 178.\\n3 Annal. de Derm, et de Syph., 1880, p. 25 and Besnier-Doyon translation of Kaposi,\\nvol. ii., p. 346, with reference to all reported cases.\\n4 For a resume of all cases reported to date, see Crocker, Brit. Med. Jour., Jan. and\\nFeb., 1897 and Roberts, Ibid., April, 1900.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0610.jp2"}, "611": {"fulltext": "ANGIOMA. 563\\nor oval macules or papules which develop slowly to the size of a small\\npea or bean, occasionally becoming larger. At first readily effaced with\\nthe finger, later they become firm and elastic to the touch, are usually\\nlimited to one or two regions of the body, where they appear in patches\\nwithout definite arrangement or grouping, and are pinkish, reddish,\\nor of the color of the normal skin. In the beginning the growths are\\nusually insensitive, but in most cases after slow evolution become painful\\non pressure and in some instances they are the seat of paroxysms of\\nsevere pain which occur spontaneously and at irregular intervals.\\nNearly all the cases reported have been in elderly people and in men.\\nSome of the tumors may undergo involution, but usually they tend to\\nincrease in size and in number. Histological examination shows that\\nthey are limited to the derma proper, and are composed chiefly of\\nunstriped muscle-fibre mixed with some elastic tissue, w T ith a few ves-\\nsels and nerves, and are frequently developed about the hair-follicle.\\nThey are probably derived from the erector pili muscles.\\nIn a case under observation multiple pinhead- to large bean-sized\\ncongenital tumors were situated near the sterno-cleido-mastoid muscle\\nof a girl nineteen years old. These were exquisitely sensitive to pres-\\nsure, were capable of slight vermicular motion when irritated, and\\nexamination of the largest, after removal, disclosed smooth muscular\\nfibres, and, in small proportion, terminal filaments of cutaneous nerves.\\nThe Diagnosis in well-marked cases is not difficult, but in some\\ninstances the recognition of the disease must depend upon a micro-\\nscopical examination. Myomata have been mistaken for xanthoma\\ntuberosum, for keloid, for lymphangioma tuberosum multiplex, and for\\nneuro-fibroma. The last-named tumors are painful from the begin-\\nning, and usually develop in the course of a nerve.\\nThe only successful Treatment is by excision.\\nANGIOMA.\\n(Gr. ayyelov, vessel.)\\nAngiomata are divided into those composed of blood-vessels and\\nthose formed of lymphatic vessels. The former are much more fre-\\nquent and variable in character.\\nSymptoms. Blood-vascular new-growths occur in three forms\\nnsevus vascuiosus, telangiectasis, and angioma cavernosum.\\nNsevus Vascuiosus (JNLevus Flammeus, Nsevus Sanguineus;\\nI Ger., Gefassmal). This term is limited to those vascular anomalies\\n1 of the skin which are either visible at birth or become developed in a\\nbrief period thereafter. They commonly occur as irregularly outlined\\nor distinctly circumscribed, smooth spots, patches, or maculations,\\nf varying in color from light red to deep violet and port wine, and are\\neither flat or very slightly elevated above the general level of the in-\\ntegument. From this type wide variations are noted, in the develop-\\nment of pea-sized papules or tubercles to tumors even of large size\\npulsating and aneurismal in character spongy or relatively firm\\nfading or more rarely persistent under pressure superficial or deeplv\\nseated venous or arterial in their connections single or numerous", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0611.jp2"}, "612": {"fulltext": "564 NEW-GROWTHS.\\nand in either case limited to a small area or involving a relatively\\nlarge surface. They are of most common occurrence upon the head,\\nbut are seen also on the trunk and extremities. Often they are the\\nsole lesions of the skin present in a single individual in other rarer\\ncases they complicate moles, warts, and lymphangiomata.\\nThe surface of these lesions is usually smooth, though it may be\\nrugous. They are generally compressible, losing their habitual color\\nwhen the blood is forcibly pressed out from the loose meshwork of\\nvessels of which they are composed, and becoming turgid and deeply\\ntinted when the blood is driven into their tissue, as in the face in the\\nact of sneezing.\\nThe course of these lesions varies with their essential character. Of\\nthe simpler varieties, the larger number increase somewhat in extent\\nand development till they have attained a maximum size, and then\\nthey either persist indefinitely or accomplish a species of involution\\nafter agglutination of the vascular walls, leaving a whitish, cicatriform,\\noccasionally pigmented surface. Others extend indefinitely, involving\\nthe neighboring mucous surfaces, subcutaneous tissue, and deeper\\nstructures, forming vast tumors, destructive not only by their tendency\\nto extension, but by their mechanical effect. Fortunately, these ex-\\ntreme developments are rare. Much more commonly vascular nsevi\\nfurnish the forms known as port-wine mark n or claret-stain,\\nwhich awaken no subjective sensations, and are usually of clinical im-\\nportance in consequence of the marked disfigurement which they\\nproduce.\\nOccasionally, especially in the case of infants but a few days old,\\nphagedena or gangrene will suddenly occur in these patches without\\nappreciable cause (probably in consequence of the occurrence of throm-\\nbus), and the entire tumor will be removed, the line of demarcation\\nof the destructive process being exactly limited to the border of the\\nangiomatous tissue. The scar resulting is superficial, and becomes\\nsmoother in course of time. In this way may occur spontaneous cure\\nof nsevi of considerable size existing on the head and genitalia of\\ninfants.\\nTelangiectasis (N^vus Araneus, Spider Cancer Tel-\\nangiectases are acquired dilatations often combined with new forma-\\ntion of blood-capillaries, which appear at periods of life other than at\\nbirth or a few months later and are, therefore, distinct from the con-\\ngenital forms of the disease. They are commonly first observed in\\nadult life and occasionally multiply with advancing years. They\\noccur in diffuse and localized forms.\\nDiffuse, generalized telangiectasis is exceedingly rare. Hillairet and\\nVidal have each observed one such case in individuals of both sexes\\nthe condition being apparently due to systemic disturbance.\\nThe localized forms are betrayed by the occurrence of flat or slightly\\nelevated, pinhead- to pea-sized macules diffuse patches linear ramifi-\\ncations of individual vessels or contorted congeries of a plexus of the\\nlatter, all exhibiting the variations in color of nsevi vasculosi, but\\nusually of pinkish or violaceous hue. They are unaccompanied by\\nsubjective sensations, are evidently non-inflammatory in character, and", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0612.jp2"}, "613": {"fulltext": "ANGIOMA. 565\\nare simple or multiple lesions chiefly upon the face, but also upon the\\nneck, the back of the hands, the thighs, and other parts of the body.\\nThey are not rarely observed in connection with other diseases. Thus\\nthey occur in the vicinity of the lesions of lupus erythematosus, sclero-\\nderma, acne rosacea, cicatrices, and about the contour or over the sur-\\nface of many malignant tumors. They may, therefore, have either an\\nidiopathic or symptomatic character.\\nThe term Rosacea, as distinguished from acne rosacea, is employed\\nto designate that condition in which the skin, of the face particularly,\\nis affected with dilatation of the capillaries. (Consult in this connec-\\ntion the chapter on Acne Rosacea.)\\nThe conditions here described as nsevus vasculosus and telangiectasis\\nare displayed in forms which, apart from the question of congenital\\norigin, offer the widest differences and the most bizarre combinations.\\nThe so-called nsevus flammeus, naevus araneus (spider-cancer), nsevus\\nvinosus, mulberry-, strawberry-, and mother-marks are all\\nexamples of these combinations.\\nThe lesions may be congenital. There is no proof that they are\\ndue to antenatal maternal impressions, though the influence of the\\nnervous system in deciding the area of limitation of the congenital\\nforms is exceedingly distinct, as, for example, the definition of a port-\\nwine mark in the skin-area supplied by one supraorbital nerve.\\nAngioma Cavernosum (Tumor Caveexosus). Cavernous angioma\\nis distinguished from the angiomatous lesions described above by the\\npeculiarities of its formation. It consists of a dense framework of new-\\nformed connective tissue, inclosing loculi or chambers of varying\\ncapacity, containing blood and communicating not only with each\\nother, but with the larger vessels in the vicinity. Whether these\\nblood-spaces originate in the fibrous felt-work of the derma which\\nlater establishes a vascular connection, or in the vessels themselves, or\\nwhether they are constituted by a mechanical dilatation of such vessels\\nin consequence of a neAV-formed connective tissue in the adventitia, has\\nnot been determined. According to Virchow, the lesions arise gen-\\nerally from coalescence and dilatation of vessels. Other causes are\\nexplained by the earlier formation of a contracted cicatricial tissue by\\nwhich vascular distortion occurs. (Rindfleisch.)\\nCavernous angiomata are said to be rarely congenital, developing\\nsoon after birth, and to be both superficial, deep, circumscribed, and\\ndiffuse. Sometimes they originate from a nsevus or superficial telan-\\ngiectasis. Often when fully formed they are distinctly encapsulated.\\nThe diagnosis is between cysts, fibromata, lipomata, and sarcomata.\\nThe rarity of this affection in dermatological practice may be explained\\nby the surgical features of many cases. In five years no instance of\\nangioma cavernosum was reported in the statistical tables of the Amer-\\nican Dermatological Association.\\nEtiology and Pathology. The causes of the several forms of\\nangioma named above are obscure. The symptomatic telangiectases\\nare undoubtedly to be explained by obstruction to the circulation occa-", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0613.jp2"}, "614": {"fulltext": "566 NEW-GROWTHS.\\nsioned by the tumor or other lesion to which they are accessory. The\\nfoundation for the vulgar belief that maternal impressions are respon-\\nsible for the so-called mother s marks is very slight. The reputed\\nresemblance of the latter to various flowers and fruits generally requires\\nfor its recognition a stretch of the imagination.\\nAnatomically, these lesions are recognized as due to dilatation and new\\nformation of venous and arterial capillaries in the superior portions of\\nthe derma, the vessels of the newly formed plexus freely communicat-\\ning with each other. Generally there is a simultaneous new formation\\nof connective tissue constituting the framework of the growth, which\\nvaries considerably in the different forms of the disease. Lobules con-\\nstituted of coils of capillary vessels are often separated by it into dis-\\ntinct masses. According to Heitzmann, the large spaces of angioma\\ncavernosum imitate the structure of the corpora cavernosa of the penis,\\nand are filled with venous blood, being separated from each other by\\na scanty fibrous connective tissue.\\nBillroth states that the new formation has its origin in the vascular\\nnetwork surrounding in basket-like forms the fat-lobules, follicles, and\\nglands of the skin. Embryonal, vascular growths spring from these,\\nand as they multiply and develop are enforced by proliferation of\\nfibrous, connective, and muscular tissue. The color depends largely\\nupon the preponderance of arterial or of venous capillaries in the new\\nformation.\\nDiagnosis. The ordinary lesions of angioma are readily recognized\\nby their color, size, shape, and obvious vascular constituents. Ander-\\nson calls attention to the importance of differentiating encephalocele\\ndue to the failure of ossification of the ethmoid and frontal bones at\\nthe root of the nose. Operations upon such tumors supposed to be\\nangiomatous in character have resulted fatally. Lobulation, great dis-\\ntention (when a child is crying), a superficial rather than deep and com-\\nplete vascularization of the smooth and glossy skin of the tumor, and\\na double pulsation, all point to frontal encephalocele.\\nTreatment. The treatment of this group of new-growths is, in\\ngeneral, limited to a series of local surgical procedures. These opera-\\ntions all have in view either the destruction of the new-growth or the\\nartificial production of an inflammation, in order to obliterate, to an\\nextent sufficient to interfere with the transmission of the blood-current,\\nthe lumen of the capillaries of which the neoplasm is composed.\\nFirst among these methods is electrolysis. One or a set of several\\nfine cambric needles, with their points at the same plane, are connected\\nwith the negative pole of an ordinary zinc and carbon battery of ten\\nto twelve cells. The points of the needles are quickly passed into the\\ntissues, and there held for a period of between ten and thirty seconds,\\naccording to the effect produced after completion of the circuit, with a\\ncurrent of from one to two milliamperes. The new-growth is thus\\nblanched in the vicinity of the needles, this effect disappearing in the\\ncourse of a few moments.\\nIn about three weeks the curative result of the operation becomes\\napparent. According to Fox, 1 of New York, the objections are that\\nl N.*Y. Med. Record, Feb. 18, 1882, p. 188.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0614.jp2"}, "615": {"fulltext": "ANGIOMA. 567\\nthe operation is sometimes painful and tedious, and may occasionally\\nresult in the production of suppuration, superficial sloughs, minute\\nkeloid-like elevations, vascular nodules, depressed scars, or superficial\\nulcers. In scores of cases, however, there is no production of re-\\nsults worse than the original disfigurement. Usually the success is\\ncomplete.\\nThe method of Sherwell l is by multiple puncture with a set of fine\\nneedles in a holder similar to that described above. These are dipped\\nin a 25 to 50 per cent, solution of chromic acid, and then made to\\npenetrate the part to be attacked. The bleeding is readily arrested\\nby pressure, and then the patch is covered with several layers of flexile\\ncollodion. This procedure is of value in circumscribed patches of super-\\nficial character and relatively limited area. By it one can succeed in\\nremoving port-wine marks with the result of producing a somewhat\\nirregular cicatriform tissue much less disfiguring than the original\\nblemish.\\nSquire s operation is done upon previously frozen patches with the\\naid of an instrument which destroys the vessels by making numerous\\ncrossed and closely spaced linear incisions, parallel to each other and\\nin a plane obliquely directed to that of the integument. Here also\\nbleeding is arrested by pressure, exerted before the circulation is re-\\nstored. The operation has been, in hands other than his own, attended\\nat times with unsatisfactory results.\\nSodium ethylate, a compound in which the radical ethyl in ethylic\\nalcohol is united with sodium, is a caustic recommended by Richard-\\nson 2 in the treatment of nsevus. It is applied by means of a brass\\nrod. A first application usually results in the formation of a dense\\ncrust under which the nsevus contracts and repeated applications are\\nmade at intervals of a few days till the desired result is obtained.\\nThe sodium ethylate should be pure, and the crusts should not be dis-\\nturbed till they fall spontaneously. In one case there was a persistent\\nredness of the resulting scar that was decidedly open to objection.\\nOther methods employed are the ligature when practicable puncture\\nwith incandescent needles topical application of caustics other than\\nthose named above, such as potassium hydroxide, nitric and carbolic\\nacids, and corrosive sublimate and total excision, the latter being\\npracticable in relatively small growths. Larger growths also can be\\nremoved and the surface covered with skin-grafts. The galvano-\\ncautery and the thermo-cautery are both valuable in the destruction of\\ncapillaries. For telangiectasis and nsevi no larger than a pea the\\nPaquelin knife is an efficient resort. The old method of multiple\\nvaccination about and upon the involved area is sometimes followed by\\ngood results, and whether in consequence of the retraction of tissue\\nunder the influence of the inflammation excited, or of the destructive\\nresults of the suppuration induced, or of an indefinite caustic effect, is\\nnot clear.\\nThese results may be partly imitated by the induction of superficial\\npustulation and suppuration through the medium of tartar emetic and\\n1 Arch, of Derm., October, 1879.\\n2 Lancet, November 9, 1878.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0615.jp2"}, "616": {"fulltext": "568 NEW-GROWTHS.\\ncroton-oil, methods which should be considered clumsy in the light of\\nrecent successes obtained by more manageable expedients.\\nInjections with carbolic acid and ferric chloride in a few cases have\\nbeen followed by fatal results, but are at times successful.\\nCoombs 1 has modified somewhat the method most in vogue, by\\npassing fine silver wires through nsevus-growths, and connecting the\\nextremities with a Bunsen battery. When the wires are heated the\\ncircuit is broken, and the ends of the wires are disconnected from the\\nbattery and united to each other, being left in situ and covered with\\nlint and plaster. The current can then be passed repeatedly without\\nreinsertion of the wires, and the latter need be withdrawn only when\\nthe cure is complete.\\nThe Treatment of angioma cavernosum requires surgical interfer-\\nence.\\nThe Prognosis in any case of angioma rests upon the method of\\ntreatment adopted for its removal. In the larger number of cases the\\nlesions, having attained a maximum development, persist without\\nfurther pathological change, constituting a deformity rather than a\\ndisease. Physiological alterations in the color of such lesions occur\\nunder the influence of changes in the circulation.\\nANGIOMA SERPIGINOSUM.\\n(Infective Angioma, N^vus Lupus.)\\nThis disease has been described and figured by Hutchinson, 2 Jamie-\\nson, Lassar, Joy, White, and others. It is one of the rarer affections\\nof the integument.\\nSymptoms. The elements of each group of lesions are bright-\\nreddish puncta, resembling grains of Cayenne-pepper, arranged in oval\\nor circular rings which are definitely outlined, and are a centimetre or\\nmore in diameter. The infective satellites are outlying points or\\npatches where the disease is spreading. This extension is usually at\\nthe outer border of one of the annular groups of lesions. The color\\nvaries from a light- to a deep-reddish hue or purple tints which are\\ndue to the vascularity of individual lesions. The color can at times\\nbe made to disappear on pressure.\\nThe parts chiefly affected are the shoulder, the leg, the elbow, the\\near, the arm, the hand, and the chest. The disease may occur in infancy\\nor adult years. Its evolution is slow, and usually unproductive of\\nsubjective sensations. Occasionally the tufts of dilated capillaries\\nwhich constitute the reddish points are not grouped in a circinate or\\nother special arrangement, but simply irregularly distributed over the\\naffected surface.\\nEtiology. The cause of the disease is unknown. In a case under\\nobservation in a female infant the lesions developed as a sequence of a\\ncongenital nsevus of the vulva. Hutchinson has made a similar obser-\\nvation. The affection has been noted more often among male patients.\\nOne case is supposed to have originated in violent muscular exercise.\\n1 Lancet, 1881.\\n2 -Arch, of Surgery, vol. i., Plate IX.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0616.jp2"}, "617": {"fulltext": "L YMPHANGIOMA 569\\nPathology. The disease, being at first but obscurely understood,\\nwas until recently supposed to be one of the several expressions of\\nlupus and was for that reason assigned one of the names given above.\\nExamination of tissue removed from a patient w T hose case was fully\\nreported by White, 1 which was in all points typical, reported upon\\nalso by Darier, Councilman, and Bowen, indicates that the disease is\\nan angiosarcoma. Darier describes it as sarcome angioplastique reticule.\\nThe corium was found well filled with small-cell infiltrations, and these\\ncells had an epithelioid nucleus. There were abundant proliferation of\\nthe endothelium and perithelium and a new formation of vessels.\\nDiagnosis. The disease is to be recognized by its vascular puncta\\nand by their special tendency to grouping and extension through a\\nserpiginous process never seen in simple telangiectases, nor in common\\nforms of nsevus vascularis.\\nThe Treatment is by surgical ablation or destructive cauterization.\\nLYMPHANGIOMA.\\nIn the present state of knowledge on this subject it is not always\\npossible to draw sharp dividing-lines between lymphatic new-growths\\non the one side and simple lymphangiectasis on the other. It is prob-\\nable that the two processes often are associated. 2\\nLymphangiectasis, uncomplicated by growth of new vessels, may\\noccur in the superficial or deep lymphatics. When superficial, pinhead-\\nto pea-sized, isolated or grouped vesicles form which have the color of\\nthe normal skin, which disappear temporarily under pressure, and which\\ndo not break easily, but on rupture give exit to a continuous or inter-\\nmittent flow of lymphatic fluid. Elliott 3 describes a case of this kind\\nin which the vesicles bordered old scar-tissue and were seemingly iden-\\ntical in character with the lesions of lymphangioma circumscriptum,\\nbut histological examination showed them to be formed by simple\\ndilatation of the lymphatic capillaries, due probably to mechanical\\nobstruction.\\nLymphangiectasis of the deeper vessels often produces no change\\nvisible on the skin, and can then only be recognized by palpation, or it\\nmay be displayed in raised, irregular cords, or in chains of nodules.\\nFollowing injuries or inflammation it may be acute, but usually it is\\nchronic, and occurs most frequently on the lower extremities and in\\nparts in which the return current of the circulation is in some way\\nimpeded. The skin may become the seat of soft nodules which may\\nrupture and form lymphatic fistules but more frequently the greatest\\nchanges occur in the deeper structures, resulting in elephantiasis, in\\nphlegmon, or in lesions of periosteum and bone, the skin of the affected\\nregion being cedematous, infiltrated, ulcerating, or cicatricial.\\nSimple Lymphangioma may occur upon any part of the body in\\nthe form of circumscribed, elastic tumors made up of enlarged lym-\\n1 Jour. Cutan. and Ven. Dis., 1894, p. 505.\\n2 For review of literature of the subject, consult Francis, Brit. Jour, of Derm., 1893,\\nand Koberts, Ibid., 1897, p. 309.\\n3 Jour. Cutan. and Gen.-Urin. Dis., 1894, p. 137.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0617.jp2"}, "618": {"fulltext": "570 NEW-GROWTHS.\\nphatics which are the result partly of dilatation of previously existing\\nvessels and partly of new-formations. The skin over such tumors\\nmay be unchanged or it may be reddened and thickened. In more\\nextensive cases there is hypertrophy of the surrounding tissues as in\\ndeep-seated lymphangiectasis. Many of the diffuse forms of lymphan-\\ngioma constitute firm or lax tumors of such size as to be termed\\nElephantiasis Lymphangiectatic a or Pachydermia Lymphang-\\niectatica. These tumors often contain large lymph-filled sacs or\\nlacunae, enveloped in hypertrophied muscular and connective tissue,\\nand an oedematous integument. Some of the elephantiasic deformities\\nof this character are fully as enormous as the extreme distortions of\\nelephantiasis proper. Upon the tongue the condition is called Mao\\nroglossia, and upon the lips Macrochilia.\\nLymphadenectasia is a name given by Virchow to tumors usually\\nin the axillary or inguinal regions, where the lymphatic vessels in the\\nlymphatic glands dilate or multiply so as to form large tumors. The\\nlymph-scrotum due to the presence of the filaria sanguinis hominis is\\ndescribed elsewhere.\\nSimple lymphangiomata may be congenital. Their cause is un-\\nknown. It is supposed that they are produced by toxic or other irri-\\ntating influences. They are often the seat of a recurrent, circumscribed\\ninflammation of erysipelatous type. Anatomically the lesions are\\nfound to consist of greatly developed lymphatic vessels and spaces,\\nlined with epithelium and enveloped in small-celled connective tissue-\\nstroma. The treatment, of the larger lesions only is surgical.\\nCystic Lymphangioma belongs to the domain of surgery. It\\noccurs in the form of multilocular cysts, usually congenital in origin\\nand most frequently situated in the neck.\\nLymphangioma Circumscriptum.\\n(Lymphangioma Cavernosum, Lymphangiectodes, Lymphan-\\ngioma Capillare Varicosum, Lupus Lymphaticus.\\nFt., Angiome Cystique.)\\nThis is practically the only form of lymphangioma entitled to spe-\\ncial consideration by the dermatologist. It is a rare form of skin-dis-\\nease and is well illustrated in the case reported by Morris. 1\\nSymptoms. The characteristic lesions are small, deep-seated ves-\\nicles generally described as resembling frog s spawn. They are usu-\\nally closely crowded in irregularly shaped groups from eight to twenty\\nmillimetres in diameter with normal skin between. These groups have\\nno regular arrangement or distribution. There are sometimes a few\\nscattered vesicles about or between the borders of the groups which\\nmay coalesce to form new patches. There are usually several of these\\ngroups, but they are confined, as a rule, to one small region of the\\nbody. The most common sites, according to Francis, who has collated\\nreports of twenty-eight cases, are on the upper parts of the extremities.\\n1 Internat. Atlas of Eare Skin-diseases, 1889, No. 1.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0618.jp2"}, "619": {"fulltext": "LYMPHANGIOMA. 571\\nIn a large majority of the cases reported the lesions occurred on the\\nleft side of the body.\\nThe vesicles are deep-seated with thick walls, and vary in size from\\nthat of a pinhead to that of a small pea. The newer and scattered\\nvesicles may be colorless or have a yellowish or pinkish tinge, but the\\nskin over the older lesions may hypertrophy and produce growths that\\nare easily mistaken for warts, and may even result in decided warty\\nprojections. Other lesions may be more or less covered with telangi-\\nectases and vascular dots or tufts which may be present to such an ex-\\ntent as to obscure the primary vesicle-formation. When punctured the\\nlesions give exit to clear, colorless fluid, which at times may be tinged\\nwith blood, the result of hemorrhage into the vesicle.\\nIn some cases the lesions and skin about them become the seat of a\\nrecurrent inflammation of erysipelatous type, 1 such as not infrequently\\ncomplicates other forms of lymphangioma. Probably as a result of\\nthese attacks of inflammation there are often infiltration, thickening,\\nand even true hypertrophy of the deeper layers of the skin, forming a\\nsort of local elephantiasis.\\nThe disease in most cases reported began in early childhood and\\ndeveloped very slowly, often remaining stationary for years. In but\\none case has spontaneous involution been reported.\\nEtiology. As the disease usually makes its appearance in infancy\\nor early childhood, it is probable that its origin is due to some con-\\ngenital defect. It has appeared a number of times in connection with\\nnsevi. It has followed surgical operations, bordering the scars pro-\\nduced by the operator; it is possible that such cases are simple lymph-\\nangiectases of the capillary vessels due to blocking of the larger\\nchannels by the scar-tissue.\\nPathology. The vesicles, or cysts, are found on section to be situ-\\nated in the upper part of the corinm. These cysts are shown to have\\nan endothelial lining and are undoubtedly dilated or newly formed\\nlymph-capillaries. Immediately about the cysts and dilated lymphatics\\nin an early uncomplicated lesion Bowen found considerable infiltration\\nof round cells, but no other changes in the corium, while the epidermis\\nwas slightly thinned. In older lesions there is hypertrophy of the\\nepidermal layers, and sometimes of the deeper parts of the corium.\\nIn other cases there are more or less dilatation and apparently new\\ngrowth of the blood-capillaries. This change in the blood-vessels may\\nbe slight or so marked as to form the chief feature of the disease both\\nclinically and pathologically. In consequence, confusing reports have\\nbeen made by different observers regarding the structure and origin of\\nthese growths, many of which seem entitled to the name of hemato-\\nlymphangioma.\\nTreatment. The treatment is surgical. The growth may be re-\\nmoved by excision or with the cautery. Electrolysis has been of service\\nin some cases and should be given further trial. In several instances\\nthe lesions have recurred after complete removal.\\n1 Cf. White s report, Jour. Cutan. and Gen.-Urin. Dis., 1894, p. 47 also Bowen s\\narticle in Twentieth Century Practice, vol. v., p. 687.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0619.jp2"}, "620": {"fulltext": "572 NEW-GROWTHS.\\nXERODERMA PIGMENTOSUM.\\n(Angioma Pigmentosum et Atrophicum, Atrophoderma Pig-\\nmentosum, Dermatosis Kaposi, Melanosis Lenticularis\\nProgressiva, Liodermia cum Melanosi et Telangiectasi.)\\nMore than seventy-five eases of this disease have been recorded\\nand these by Kaposi, Glax, Crocker, Vidal, Pick, Neisser, Geber,\\nTaylor, Duhring, White, and others. Tables have been compiled by\\nKaposi, 1 Archambault, 2 and Lukasiewicz, 3 including seventy-three\\ncases. The disease results ultimately in a diffuse idiopathic cutaneous\\natrophy, but this condition is preceded by a general hyperemia with\\nvascular dilatation the production of numerous punctiform, bright-\\nred, pinhead- to pea-sized, flat or raised telangiectases and dissemi-\\nnated, brownish, and yellowish-brown macules, varying in extent,\\nbetween which form superficial, whitish and glossy, atrophic depres-\\nsions, like the cicatrices of variola. The regions involved are, as a\\nrule, the exposed surfaces, viz., the face, ears, neck, shoulders, and\\nchest to the third ribs and even to the lumbar region, the arms and\\nback of the hands, occasionally the legs and the dorsum of the feet.\\nThe yellow r ish-brown, freckle-like spots are soon after their appearance\\nintermingled with superficial cicatriform depressions, either unnatu-\\nrally whitish in hue or of the color of the normal skin. The puncti-\\nform or linear dilatations of the vessels, usually numerous, furnish a\\nstriking contrast with the freckled and pigmented parts. In some\\nparts the skin is of parchment-like thinness in others it is furrowed,\\nlaminated, and split, as if dry or brittle. It is usually deprived of its\\nnormal suppleness, is retracted, and is often attached to the subdermic\\ntissue.\\nThe disease commonly begins in the first or second year of life, and\\nprogresses continuously. The order of occurrence of the lesions as\\ngiven by Kaposi is the freckle-like pigmentations, surmounted in the\\ncourse of a year or two by telangiectases then a gradual disappearance\\nof the latter and occurrence of the cicatriform depressions finally a j\\ndiffuse atrophy of the skin. New pigment-spots continue to form, so\\nthat a given case usually presents all types and grades of lesions.\\nObservers of these cases differ somewhat as to the order in which the\\nseveral lesions of the disease appear and Duhring thinks it possible\\nthat no definite order is observed in the evolution of the symptoms.\\nWhite, in the case under his observation, could trace no transforma-\\ntion from a pigment-macule into a telangiectatic lesion.\\nThe melanosis is at times so uniform and diffuse as to suggest the\\ndark tints of the Spanish skin, as in White s case, with a dense spat-\\ntering of a still darker hue and a blackish scrotum. The atrophic or\\nleucodermic condition of the skin may coexist with the melanoderma,\\nand present large well-defined areas totally devoid of pigment where\\nthe skin may have a pinkish tint. The ears may thus come to\\n1 Wien. med. Woch., 1885.\\n2 Dermatose de Kaposi. Bordeaux, 1890.\\n3 Arch: f. Derm. u. Syph., 1895, Band xxxiii., S. 37.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0620.jp2"}, "621": {"fulltext": "XERODERMA PIGMENTOSUM. 573\\nresemble tanned sheepskin. The skin soon becomes furrowed, con-\\ntracted, and as dry as parchment and thus is readily developed an\\neczema or a superficial degeneration, including ulceration. A species\\nof furfuraceous desquamation also occurs in patches. The faces of\\nmost patients exhibit a peculiar checkered appearance, from the uni-\\nform dissemination of the pigmented macules over the skin. Ectro-\\npion, with ulcerative keratitis, may occur. In the course of years\\nverrucous growths appear, starting usually in the pigmented spots,\\neither epitheliomatous, sarcomatous, or angiomatous in character. They\\ni may be single or many may be confined to the skin or develop in\\nthe viscera and usually lead to fatal results in a few or many years.\\nOften the general health seems, for long periods of time, to remain\\nunimpaired, the subjective sensations being slight Both sexes in\\nearly life seem equally predisposed to this disease, though the large\\nnumber of members of single families affected with its symptoms\\n3 indicates the importance of predisposition and heredity in point of\\nij etiology. It is usually manifested before the third year of life.\\nPathology. The disease probably begins as a proliferation of con-\\nJ nective tissue in the papillary layer, with involvement also of the\\nvascular endothelium, followed in some points by retraction and in\\nj others by both ectasis and new formation of vessels. By Kaposi, who\\nI has the honor of first naming and describing the disease, the irregular\\n\u00e2\u0080\u00a2I accumulation of pigment is regarded as consecutive to the vascular\\nchanges. The rete-pegs extend deeply below there are ectasis of the\\nglands and epithelial degeneration.\\nBy the French the disease is generally regarded as a pigmentary\\nI epithelioma or epitheliomatous lentigo (Quinquaud), the connection\\nI between the neoplasm and the pigment-anomaly being regarded as\\nsimilar to that recognized in melanotic sarcoma.\\nThe Etiology of the disorder is exceedingly obscure. A congenital\\npredisposition is shown by the occurrence of several cases in one fam-\\nl ily most of the patients have been females. There is a very singular\\ndisposition of the disease to select one sex in different families. In\\nforty-three cases collected by Kaposi there were six times, two four\\ntimes, three and once, seven brothers or sisters affected with the dis-\\nease. The age of the patients first exhibiting the disorder is from the\\nfirst to the second year. Schwimmer has reported a case occurring\\nin the thirty-fifth year. Unna believes it possible that the action\\nof light upon the skin has an influence in the production of the\\ndisease.\\nThe Diagnosis is chiefly from scleroderma, but as the latter always\\nbegins with induration of tissue, and as xeroderma pigmentosum\\nalways begins with either erythematous or pigmented spots, the\\nf distinction is clear. In a case of scleroderma, too, apart from its\\nonset at a later period of life, the pigmentations are late rather than\\nearly and the telangiectases are found in circumscribed scleroderma\\nj as a violet-tinted border about a patch never as points, nodules, and\\nstellate markings interspersed among pigmented spots and depressions.\\nLepra maculosa is characterized by marked anaesthesia in and about\\nthe pigmented and non-pigmented areas further, its course is toward", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0621.jp2"}, "622": {"fulltext": "574 NEW-GROWTHS.\\nmutilations of the body, and even at an early period there may be\\nvesiculation.\\nThe Treatment of the disease is limited to amelioration of the con-\\ndition of the skin by means of local applications varied to meet the\\nindications as they arise. Surgical ablation of tumors, with electrolysis\\nof smaller lesions, may be employed to prevent or postpone a fatal\\ntermination.\\nThe Prognosis is in the highest degree unfavorable, as most of the\\npatients succumb to marasmus in from ten to twenty years.\\nRHINOSCLEROMA.\\n(Gr. pig, or piv the nose, and OK?ij]p6g hard.)\\nSymptoms. A knowledge of this rare disease, first described by\\nHebra and Kaposi in 1870, has been obtained from a study of some\\none hundred cases observed by these and other authors. The follow-\\ning is a concise description of the malady as thus presented.\\nThe disease commonly begins in the septum or a single ala of the\\nnose, without inflammatory symptoms. The involved parts slowly\\nenlarge, and become finally as dense as ivory. The individual lesions\\nare flat patches, or elevated and circumscribed nodules, papules, and\\ntubercles, painful upon pressure, movable to a certain extent over\\nunderlying tissues, and covered either by a normal integument, or by\\na light or dark-red, shining, vascular epidermis. Neither hairs nor\\nglands are discernible over the lesions. As the disease progresses the\\nala3 become enlarged, flattened, and so indurated that they cannot be\\npressed together, while respiration may be impeded by stenosis of the\\nnares. The process may extend to the neighboring parts, involving\\nthus the upper and lower lips, gums, velum, epiglottis, larynx, trachea,\\nand jaws, the teeth meanwhile falling from their sockets and the soft\\npalate becoming in some cases perforated. Involution of the process\\nhas not been observed, and the lesions do not degenerate by ulceration.\\nMax Zeissl, 1 however, reports a case in which there was ulcerative\\ndestruction of the entire left nostril, as well as of the tip and right\\nala of the nose. Occasionally superficial excoriations have occurred,\\nbut very rarely a diminution in the consistency of the mass. The dis-\\nease pursues a chronic course, requiring years for its development and\\nthough the affected parts are painful on pressure they are otherwise\\nnot the seat of subjective sensation.\\nEtiology and Pathology. The disease is observed between the\\nfifteenth and fortieth years in persons of all social conditions and in\\nindividuals of both sexes, free from syphilitic, strumous, tubercular,\\nand other cachexias.\\nKaposi originally observed, as anatomical lesions of the disease, a\\ndense infiltration of the corium and its papillary layers with small,\\nclosely packed elements, which he recognized as a true new-formation.\\nHe considered this as analogous to small-cell sarcoma, inasmuch as\\nMikulicz, Geber. and Billroth have seen some of the elements of the\\n1 Wien. med. Woch., 1880, p. 621.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0622.jp2"}, "623": {"fulltext": "RHINOSCLEROMA. 575\\nneoplasm undergoing the osseous transformation common in sarcomatous\\ntumors.\\nIn 1882, however, A. von Frisch, after examining tissue removed\\nfrom lesions of rhinoscleroma in twelve patients, found in the cells\\nand between them in the interpapillary fissures of the connective tissue\\nbacteria distinctly rod-shaped, one and one-half times longer than\\nbroad. These germs were successfully cultivated, but experimental\\ninoculations with culture-fluids thus obtained were negative in results.\\nDreschfield 1 found in sections of tissue obtained from a patient of\\nPayne s numerous bacilli less slender and smaller than those occurring\\nin tuberculosis and with slightly thickened extremities. These were\\nunlike those exhibited at the Berlin Congress by Paltauf, who con-\\nsiders them closely related to Friedlander s pneumococcus. Barduzzi,\\nPellizari, Cornil, Alvarez, Lustgarten, and others have added to the\\nevidence in favor of the parasitic nature of the disease.\\nThe bacilli are found encapsulated in a colloid-like substance and in\\nseries of two and fours. They occur in the lymphatic ganglia, in the\\ngiant-cells of the neoplasm, and in protoplasmic masses corresponding\\nto these or to their degenerate nuclei. Pawlowsky, of Kieff, in 1890,\\ndemonstrated that the bacilli of the disease are pathogenic for the\\nloAver animals. Besnier and Doyon, however, pointing to the limi-\\ntation of the disease to Austria, reject a parasitic origin for the disease.\\nMibelli, who has given the subject careful study, found two kinds of\\ncells characteristic of the process one a dropsical and the other a\\ncolloid cell. He thinks these types are the result not of cell-degenera-\\ntion, but of the presence of zooglea, a mucous substance produced by\\nthe bacilli.\\nDiagnosis. The disease can hardly be mistaken for another in con-\\nsequence of its situation, the disfigurement it occasions, the ivory-like\\nelasticity and induration of the affected parts, and the rarity of ulcera-\\ntive degeneration. As distinguished from syphilis, it is known to be\\nunaffected by specific medication. Since rhinoscleroma, however, has\\nbeen by some writers assumed to be a form of syphilis, it is need-\\nI fill to distinguish clearly between the two. But as in the former\\naffection there is rarely softening of the ivory-like induration, much\\nless ulceration, which is common in syphilitic gummata, the distinction\\n|is tolerably clear. From the variety of acne rosacea of the nose known\\nlas rhinophyma, rhinoscleroma is readily differentiated by the softness\\ni and compressibility of the acneiform affection and its evident vascular\\nand glandular composition.\\nThe ulcerations of epithelioma have a more circular outline, a more\\nelevated edge, and occur in persons of a more advanced age. Keloid,\\nif found in the situation of rhinoscleroma, does not ulcerate.\\nJ Treatment. The method of relief thus far employed is a total or\\npartial extirpation of the neoplasm. Kaposi speaks of dilatation of\\nthe nares, where there is actual or threatened nasal occlusion, by means\\nof laminaria and compressed sponge. Both excision by the knife and\\ndestruction by caustics have been found to secure merely temporary\\nbenefit, as the growth is reproduced with rapidity.\\n1 Brit. Med. Jour., October 24, 1885.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0623.jp2"}, "624": {"fulltext": "576 NEW-GROWTHS.\\nPrognosis. The future of the patient is grave. The disease riot\\nonly persists and recurs after operative interference, but may endanger\\nlife by obstruction of the nostrils. ZeissPs case proved fatal ten years\\nafter the disease first appeared.\\nTUBERCULOSIS CUTIS.\\nTuberculosis is one of the most common, formidable, and destruc-\\ntive of the great scourges of the human family. It may attack either\\nprimarily or secondarily any organ or tissue of the body. The skin\\nis not rarely the seat of its ravages, and when extensively involved the\\nresults are in the highest degree disfiguring and repulsive.\\nThe consequences of tuberculous invasion of the skin are usually\\ndeclared early in life, because in those periods the skin is most easily\\ninvaded, and also because at these ages the habits and environments of\\nthe individual are conducive to the occurrence of the accident. Tuber-\\nculosis of the skin may be the result of general infection in the body\\nor may, on the other hand, be the starting-point of such infection. In\\neither event the disease is always originally acquired by infection and\\nnot by inheritance. Children are rarely, if ever, born tuberculous.\\nThe coincidence of several members of one family exhibiting evidences\\nof the disease is most readily explicable by the opportunities for infec-\\ntive accidents furnished in such families.\\nIn the pages which follow no attempt is made to revert to the\\nremarkable and instructive history of the gradual acquisitions of science\\non the subject of this disease. Neither within these limits is it desir-\\nable to indicate the several conditions which in their relations to this\\nsubject have been confused in the past, and the names of which have\\nserved as titles for chapters on cutaneous disorders. It will be sufficient\\nif the results obtained from the vast and valuable labors of the patholo-\\ngists and clinicians of the last decade be concisely set forth with a view\\nto the simplest systematic conception of the subject. 1\\nSymptoms. Tuberculosis of the skin is conveniently studied in\\nits several forms of (1) lupus vulgaris (2) tuberculosis verrucosa\\n(3) tuberculosis cutis orificialis (4) scrofuloderma.\\n1. Lupus Vulgaris.\\n(Lat. lupus, a wolf.\\nThe symptoms of lupus vulgaris are both numerous and diverse, a\\nfact which may account for the many names which have been applied\\nto its different manifestations, and which with few exceptions are\\ndescriptive merely of certain external features.\\nThe lupous infiltrate may be limited to small areas or diffused over\\nan entire region of the body. It may be first apparent in pinhead- to\\nbean-sized flattened maculations (Lupus Maculosus, Lupus Pla-\\n1 In the preparation of this chapter valuable aid has been rendered by the symposium\\non the subject prepared at the request of the Council of the American Dermatological\\nAssociation, by James C. White, of Boston John T. Bowen, of Boston and George\\nHenry Fox, of New York. Boston, 1892.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0624.jp2"}, "625": {"fulltext": "", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0625.jp2"}, "626": {"fulltext": "PLATE XX.\\nLupus Hypertrophieus of the Face.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0626.jp2"}, "627": {"fulltext": "TUBERCULOSIS CUTIS. 577\\nnus), from which may be later developed papules, tubercles, or nodules\\nof equal or somewhat greater size, rising above the general level of the\\nskin and often perceptible within its mass by palpation (Lupus\\nNodosus; Lupus Tuberculatus, Elevatus, Tumidus, Nox-exe-\\ndens, non-ulcerosus).\\nAs in syphilis in the course of which, though almost every one of\\nthe elementary lesions of the skin may be developed, there is a dis-\\ntinct predominance of the papule and tubercle, so in lupus vulgaris\\nthe type of the disorder is shown in the lupous nodule, the lupoma,\\nas it is by some authors designated.\\nThis dull-reddish, purplish-shaded lesion, scarcely as large as half\\na pea, may be the predominant symptom of a lupous patch for a period\\nof from ten to twenty years and even more. It is of a softish, almost\\nboggy consistency, yielding when pressed upon firmly with a blunt-\\npointed probe and readily penetrated by a sharper instrument. The\\nEnglish compare its contents with apple-jelly.\\nThe changes within, about, and beneath these lesions furnish prac-\\ntically the clinical pictures of lupus vulgaris. Thus there may be\\nextensive oedema, thickening, hypertrophy, hyperplasia (bouffissure),\\npachydermia, even telangiectasis, and an accompanying lymphangitis\\nor lymphadenitis (Lupus Hypertrophic us, Papillosus, QEdema-\\ntosus, Elephantiaticus, Tumidus, Exuberans, etc.). In many of\\nthese cases the prominent symptom which has suggested these names\\nto the older writers is in fact a simple inflammatory swelling, due only\\nindirectly to the lupoid involvement of the skin, a fact which can be\\nrecognized after any efficient treatment of an extensive plaque of lupus\\nof the face, the subsidence of the swelling being one of the most con-\\nspicuous of the immediate results of the treatment.\\nInvolution of the lupoma, or of tissue infiltrated with lupoid cells,\\noccurs by resorption of that material, by fibroid metamorphosis, and\\nby ulceration. These several changes separately or together furnish\\nother clinical pictures of the disease. Thus the lupus-lesion or patch\\nmay furnish scales, whitish, dirty, yellowish brown, or even glistening,\\nthe epidermis above and about becoming wrinkled. This process may\\nbe central or peripheral as respects patch or lesion, leaving eventually\\na cicatriform depression in the skin (Lupus Exfoliativus, Lupus\\nPsoriasiforme, Lupus- psoriasis When a fibrous metamor-\\nphosis occurs a sclerotic mass occupies the site of the former lupoid\\ntissue, which in some cases progresses to extension of the lupoid\\npatch in consequence of the further production of the toxin of the\\nbacilli in the site affected and in others produces cicatriform tissue\\nresembling that left after involution without ulceration of the gumma\\nof syphilis (Lupus Sclerosus, Sclereux, Fibrosus).\\nIn the degenerating forms of lupus, ulceration may begin by break-\\ning down the epidermis over the lupous tissue or by a more or\\nless rapid transformation of patch or lesions into a cheesy semi-puru-\\nlent mass of detritus. When pus is freely formed, whether super-\\nficially or deeply, crusting ensues, the debris of epidermis being entan-\\ngled with the desiccated secretions. These crusts are variously colored,\\nand differ in thickness with the severity of the degenerating process\\n37", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0627.jp2"}, "628": {"fulltext": "578 NEW-GROWTHS.\\nbeneath. The oval or circular ulcers which furnish them are usually\\nwell denned, though irregular as to the margin, shallow, thin-edged, and\\nflattish and their floors are dirty reddish or purplish, indolently gran-\\nulating, furrowed, hemorrhagic, or, when cicatrization is in progress,\\nhealthy. The destruction produced by involution of a lupous patch may\\nbe both by resorption and ulceration in the same subject and at the same\\ntime. The two processes may also coincide with an outbreak of fresh\\nlupous tubercles, which later may develop at one point or another of\\nthe patch undergoing involution, probably from emigration of bacilli\\nat the point of advance. In other cases lupus may spread by the\\nformation of fresh nodules and plaques separated by islets of sound\\nskin from those previously degenerated. When the ulceration advances\\nit may be superficial, deep, or have other peculiarities, and be subject\\nto other accidents of the ordinary process of ulceration, whence the\\nnames Lupus Serpiginosus, Profundus, Superficialis, Gan-\\ngr^enosus, Exulcerans, Rodens, etc. Lupus Crustosus and\\nBupoides are terms descriptive merely of the incrustations which\\nform in some cases. Exuberant granulations elevating the floor of the\\nulcer may produce the condition termed Lupus Fungosus, Lupus\\nFungoldes, Lupus Vegetans. Lupus Keloides indicates a cica-\\ntricial overgrowth of the scar-tissue left after any one of the several\\nconditions described above.\\nOne of the most conspicuous features of lupus vulgaris is its essen-\\ntially chronic course. It requires far more time for its complete evolu-\\ntion than either syphilis or carcinoma and in this point is best\\ncompared with lepra. For a quarter of a century a lupus-patch may\\nbe limited to a space no larger than the palm of the hand, and exhibit\\nsome evidence of activity during the greater part of that period.\\nLupus of the Face. Here the first manifestation is the so-called\\nprimary efflorescence, exhibited on one or both cheeks, nose, or cheek\\nand nose, as a dull-colored maculation or minute nodule, often long\\nunnoticed, or as a finger-nail-sized, purplish thickening of the skin.\\nExtension may then occur by multiplication of the lesions, or by\\nspreading of the single patch, the central parts wasting or cicatrizing.\\nThe contracture of the irregular scars thus resulting may produce an\\nectropion of the lid or lip, and with this is often seen the boufnssure\\nof the features already described. Crusting and ulceration may be\\nconspicuous or well-nigh absent features. Gradually the subcutaneous\\ntissues become involved.\\nThe nose, after absorption of the lupous tissue, may become shrunken\\nand retracted to a miniature of its former dimensions, its tip being\\nnoticeably reduced to a sharp point, producing thus a characteristic\\ndeformity suggesting the beak of a parrot. In other cases the point\\nbecomes bulbous, flattened, livid, and knobbed, with a thickened sep-\\ntum and distorted alse, an isolated patch or two of lupous infiltration\\nshowing in the neighborhood of the cheek on one or both sides. The\\nlast described condition may lead by degenerative processes to the first,\\nbut is more commonly noticed as a less severe and more localized\\ninvolvement of the face, which may terminate, in favorable cases,\\nwithout the severe mutilation first described.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0628.jp2"}, "629": {"fulltext": "TUBERCULOSIS CUTIS. 579\\nThe subcutaneous tissue, mucous membrane, cartilages, and bones\\nmay be destroyed and in place of the nasal organ itself there may be\\nleft eventually two ovoid cavities in the face, separated merely by the\\nposterior flange of the septum.\\nOften large portions of the skin of the head (cheeks, lips, nose, eyelids,\\nchin, ears, brow, and neck) become altered by the lupous growth. The\\nresulting thickening produces a marked and characteristic deformity,\\nreducing the openings of the mouth and lids to narrow slits, interfering\\nwith vision, speech, and mastication, and producing a marasmus from\\nthese causes alone, before there is ulceration at any point.\\nThe ravages of the disease are at times frightful in severity not\\nmerely in consequence of the destructive ulceration to which it tends,,\\nbut from the deformity left by awkward attempts at repair. The en-\\ntire surface of the head may be thus converted into a hideous travesty\\nof humanity, while yet its possessor is left with all vital organs and\\nfunctions apparently unimpaired.\\nThe upper lip, when involved, becomes first swollen, fissured, hem-\\norrhagic, and crusted and a granulating surface indicates extension of\\nthe disease to the adjacent mucous surface. Later, if the ulcer heal,\\nthe mouth, by contracture, is reduced to a repulsive-looking slit or\\nchasm in the face, permanently retracted, and either open or closed.\\nThe gums, lining membrane of the lips, velum, and hard palate may\\nalso be granulating, eroded, or whitish, when the exfoliated epithelium\\nis in situ. Ulceration and cicatrization here also produce deformities\\ninterfering with the function of the parts, aphonia, for example, result-\\ning from the operation of these causes in the larynx.\\nLupus of the Ears may be symmetrical in development, or affect\\nbut one auricle. As in eczema, a favorite point of election is the lobule,\\nwhich, with or without tumefaction of the whole organ, becomes a\\npyriform, purplish, dependent tumor, agglutinated speedily to the\\ncheek. Later, when ulceration occurs, the auricle may disappear or\\nbe reduced to a shrunken shell of its former state, the external audi-\\ntory meatus being, by the same process, occluded.\\nLupus of the Trunk is, as a rule, more extensive and less de-\\nstructive than lupus of other parts. Giant areas over the loins, hips,\\nand belly may be involved in superficial, serpiginous ulceration, the\\ncentre healing as the peripheral ring spreads. In these cases it is even\\nmore difficult than in others to insure cicatrization.\\nLupus of the Genital Region may occur in both sexes, and\\nthen, as a rule, has extended thither from affected areas of the adjacent\\nintegument. It is one of the rarest of the locations involved.\\nLupus of the Extremities is remarkable for its interference with\\nthe mobility of the smaller bones of the hands and feet, as a result of\\nrigid cicatrices, and also for the production of caries and osseous ne-\\ncrosis. Mutilating effects are thus produced by loss of phalanges, and\\nalso by shortening of the hand or foot after the destruction of bone.\\nElephantiasic enlargement of such organs as the hands and feet thus\\ncorresponds to the livid tumefaction seen occasionally in the face.\\nThickenings, ridges, knobs, nodules, warty excrescences, ulcers, crusts,\\nand callosities are often commingled, and in patients of mature years", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0629.jp2"}, "630": {"fulltext": "580\\nNEW-GROWTHS.\\nstrongly resemble some forms of vegetating and ulcerating epi-\\nthelioma.\\nLupus of the Mucous Membranes may or may not mean exten-\\nsion of the disease from an affected adjacent integument. The lupous\\nnodule, in consequence of warmth and moisture, is here transformed\\ninto a moist papillary outgrowth, or externally granulating patch which\\nmay ulcerate and cicatrize. The borders of such an affected area are\\nwell defined, and its surface is reddish and florid, quite pallid, white\\nand glistening, or of a dirty grayish-w r hite color where the investing\\nepithelium is loosened but not yet detached.\\nThe soft is more often involved than the hard palate, but these\\nparts with the tongue, larynx (epiglottis, interarytenoid fold), and\\ngums may be extensively invaded. Often for from two to five years\\nthe disorder may make no apparent advance, being limited to patches\\nof red, swollen, coarsely granulating, whitish or glistening mucous\\nmembrane, with ulcerating and cicatricial processes slowly resulting.\\nThe lymphatic glands beneath the jaw and in the subclavian region\\nmay be simultaneously enlarged. In connection with the characteristic\\nlupoid nodules grayish growths of the character of small tumors may be\\nrecognized in the larynx, with the result of partial occlusion of the rima\\nglottidis. Patients may suffer from apical pulmonary tuberculosis, pre-\\nsumed to be the result of extension of the disease from laryngeal lupus.\\nFig. 67.\\nLupus vulgaris of the leg.\\nLupus Demisclereux de la Langue. Leloir pictures and\\ndescribes the features in the case of a girl fifteen years of age, with\\nlymphatic adenopathy, typical lupoid nodules about the nose, and char-\\nacteristic parrot s beak deformity of the latter. The middle of the\\ndorsal surface of the tongue displayed smooth, pea-sized and larger\\nsclerotic nodules, grayish yellow, firm and softish, separated by fur-\\nrows, and non-ulcerative. The palate, uvula, and larynx were involved.\\nTubercle-bacilli were recognized and cultivated in series, and inocula-\\ntion of the cultures produced tuberculosis in guinea-pigs and a rabbit.\\nEsthiomene (so-called Lupus of the External Genital Organs of\\nWomen In the year 1849 Huguier published a report of cases\\n1 Internat. Atlas of Rare Skin-diseases, 1889.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0630.jp2"}, "631": {"fulltext": "TUBERCULOSIS CUTIS.\\n581\\nunder the title of esthiomene, which have been the basis of a concep-\\ntion widely prevalent since that date, that lupus of the vulva presents\\ncertain peculiarities not displayed by the same disease elsewhere. The\\nsubject has been restudied with special care by several observers, in-\\ncluding one of us, and by Taylor, of New York. Lupus is among the\\nexceedingly rare affections of the external genitalia of women, and\\nwhere existing does not in any special way differ from its manifesta-\\ntions in other regions of the body. The esthiornene of Huguier\\nand his followers is a complexus of differing disorders, including cases\\nof syphilitic sclerosis, secondary lesions, and gummata and hyper-\\ntrophies of the genital organs due to chronic chancroid, traumatisms,\\nand inflammations of a simple character aggravated by filth. It is not\\nknown to be a tuberculosis of the vulva, though it is possible that\\nsome tuberculoses may have been included in the category.\\n2. Tuberculosis Cutis Verrucosa.\\nThere are several forms of tuberculosis of the skin in which lesions,\\ndiffering both in appearance and career from those described in con-\\nnection with lupus vulgaris, have been demonstrated to be the result\\nof the encroachment of bacilli of tuberculosis or their toxins upon the\\nintegument. The lesions exhibit for the most part a verrucous or warty\\nappearance, and are well illustrated in the most distinctive clinical\\nmember of the group, the anatomical tubercle. In 1884 bacilli were\\nfirst discovered in its mass, and in the year 1886 Riehl and Paltauf\\npointed out the connection of this lesion with cutaneous tuberculosis.\\n(A) Verruca Necrogenica (Post-mortem Tubercle, Dissectiox-\\ntubercle, Anatomical Tubercle). Verruca necrogenica is a vesic-\\nulo-pustular or wart-like symptom of cutan-\\neous tuberculosis, situated usually on the hands,\\nand resulting, for the most part, from contact\\nwith the bodies of the dead.\\nThis lesion was first named verruca necro-\\ngenica by Wilks. 1 It occurs on the fingers\\n(especially on the dorsum of the thumb and of\\nthe index) of those engaged in the habitual\\nhandling or dissection of cadavers, and results\\nfrom such professional contacts, from dissection-\\nwounds, and from all accidental inoculations\\nwith tuberculous virus. Cases are reported in\\nwhich the lesion has had a non-cadaveric\\norigin. It begins at the site of an abrasion\\nor wound as a vesico-pustule, with deep-seated\\nbase and reddish or reddish-purple areola.\\nThis is productive of a burning, smarting, or\\npruritic sensation. The lesion accomplishes a\\nperiod of bursting and crusting, which may be\\nfollowed by complete involution. Several iso-\\nlated or grouped papules, nodules, or tubercles may be formed, one or a\\npatch of several being subsequently covered with villosities or undergoing\\n1 Guy s Hospital Reports, third series, vol. viii., p. 263.\\nFig. 68.\\nVerruca necrogenica. Model,\\nGuy s Mus. 193 0.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0631.jp2"}, "632": {"fulltext": "582 NEW-GROWTHS.\\natrophic changes over an area several inches in diameter. Dermatitis\\nand suppuration, very rarely ulceration, may complicate the process,\\nthough at times the first symptom of infection is an ulcer forming at\\nthe site of a cicatrix. The typical so-called anatomical tubercle is\\nindurated and horny. A pigmented verrucous papule or tubercle very\\nslowly forms, which may become fissured at one or more points. The\\ncharacteristic lesion is the thickened, indolent, more or less pigmented\\nand fissured, split-pea- to bean-sized wart, usually single, found on the\\nfinger of the anatomist. This may persist as an apparently innocuous\\nlesion for months or years, or suddenly assume a formidable aspect.\\nIn other cases grave symptoms result, either in the involvement of\\nthe deeper tissues (subcutaneous, thecal, tendinous, periosteal), or in the\\nproduction of erysipelas, pyaemia, septicaemia, or gangrene. Surgeons\\ndivide these cases into mild and acute varieties, according to the symp-\\ntoms exhibited. The records of the medical profession in almost every\\none of the large cities of every country contain the names of one or more\\neminent men whose lives have been sacrificed in this manner. In a\\nfew instances the local process has been followed by generalized tuber-\\nculosis.\\n(B) Tuberculosis Verrucosa Cutis (Biehl and Paltauf) (Lupus Scle-\\nroses, Lupus Verrucosus, Scrofuloderma Verrucosum; Fr. y\\nLupus Papillaire Veruqueux Lupus Sclereux) The lesions\\nof this form of cutaneous tuberculosis occur often on the flexor aspect\\nof the lower forearm, but also in other regions of the body, such as the\\nintegument covering the inner malleolus and the backs of the hands.\\nThe jJlaques are insensitive, brownish red, movable, small-coin- to\\npalm-sized, single or multiple, distinctly circumscribed, ovid or scal-\\nloped in outline, and usually covered with minute pustules, fine\\npointed vegetations, and thin crusts. A characteristic violaceous halo\\ncommonly surrounds the whole. When healing occurs a smooth and\\nscaling scar results. In those cases the .papillary layer of the skin is\\nchiefly involved.\\nIn the papillary layer of the corium the inflammation results in the\\nproduction of numerous minute abscesses.. Caseating nodules contain-\\ning tubercle-bacilli, giant-cells, and epithelioid cells are commingled\\nwith the abscesses. In some cases tubercle-bacilli are numerous in\\nothers their detection is difficult if not impossible, as in verruca\\nnecrogenica.\\nThe disease is to be most carefully distinguished from cutaneous\\nblastomycosis, the lesions of which it closely resembles. Here a his-\\ntological examination is essential.\\nThe disorder is said to be especially frequent of occurrence in those\\nhandling the dead or living bodies of animals.\\n(C) Other Verrucous Tuberculoses. An interesting series of morbid\\nphenomena is presented when, for special reasons (proximity of tuber-\\nculosis of organs other than the skin, accidents of position and ex-\\nposure, influences that escape detection), sites of tuberculous infec-\\ntion, whether primary or secondary in order, exhibit peculiar special\\nsymptoms\\nTuberculosis Papillomatosa Cutis (Morrow s type) is by some", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0632.jp2"}, "633": {"fulltext": "TUBERCULOSIS CUTIS. 583\\nauthors assigned to verrucous tuberculosis (B). In these cases ex-\\nuberant, soft, and florid excrescences rise to the height of one or two\\ncentimetres above the general level, closely packed together, with indi-\\nvidual elements separated by deep fissures, the whole bathed in a puri-\\nform mucus concreting in dark crusts.\\nFibromatosis Tuberculosa Cutis (Riehl). In these cases there\\nis not merely a papillomatous, but often a sclerotic growth found on\\nthe lips, nose, cheek, or about the anus or other mucous outlets of the\\nbody, interspersed with verrucous lesions, vegetations, and small shal-\\nlow ulcers. The tuberculous masses may be in the form of tumor-like\\nbodies or thickenings of the subcutaneous tissue.\\nElephantiasis Tuberculosa Cutis is a term applied to gigantic\\novergrowths of the integument complicated by lymphatic occlusion.\\nIn these cases there has usually been a blocking up of the lymph-\\nchannels by an infarction produced by leucocytes charged with tubercle-\\nbacilli.\\nTuberculosis Fungosa Cutis (Riehl). In this class of cases\\ntumors form resembling those occurring in mycosis fungoides, second-\\narily infected with tubercle-bacilli from other and usually adjacent\\norgans (bone, muscle, etc.), the reddish-brown nodules first formed\\nincreasing to the size of a hen s egg. These may surmount large areas\\nof infiltration and ulceration. Beside the tumors, minute pustules,\\nvegetations, and crusts may be seen. Eventually typical tuberculous\\nulcers form.\\nIt is chiefly important to note in this connection that accidental\\ninoculations with tuberculous material produce in different cases differ-\\nent clinical results, the essential part of the process being the transfer-\\nence of tubercle-bacilli. These infections are far more common than\\nis generally understood. They occur in both the young and the old.\\nFox, of London, has reported such instances at the ages of seventy-two\\nand eighty-two, respectively and Marmaduke Shield has seen cases of\\ngeneral tuberculosis of the aged, resulting from these accidents.\\n3. Tuberculosis Cutis Orificialis.\\nThe clinical forms included under this title are those once supposed\\nto be the sole manifestations of cutaneous tuberculosis. The title\\ntuberculosis of the skin was, in fact, applied exclusively by many\\nwriters to the lesions observed by Kaposi, Jarisch, Chiari, 1 and others.\\nThese were indolent, oval or circular, shallow, discrete, reddish-yellow,\\ngranulating ulcers, often covered with thin crusts, occurring about the\\nmucous orifices of patients affected with pulmonary tuberculosis (lips,\\nanus, and vulva) and with development of miliary tubercles in the\\nadjacent mucous tract. Tuberculous lesions of ulcerative type on the\\nalse of the nose, over the lips, and about the ears, have been recognized\\nin association with laryngeal, palatal, oral, pulmonary, and intestinal\\ntuberculosis.\\nIn the case of a patient in advanced pulmonary tuberculosis, lately\\nseen by us, there was a tuberculous ulcer near the anus, and also a\\n1 Vierteljahr. f. Derm. u. Syph. 1879.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0633.jp2"}, "634": {"fulltext": "584 NEW-GROWTHS.\\nwell-defined patch of infiltration in near proximity, highly suggestive\\nof some of the forms of lupus.\\nAcute Tuberculosis of the Skin in children has been described\\nunder different titles (dermatitis tuberculosa acuta, tuberculose pseudo-\\nulcereuse) by Heller and Gaucher. In these cases macules, vesicles,\\nbullae, papules, and pustules, terminating in deep, crusted, circinate\\nulcers, accompanied by caseation of neighboring glands, were found\\nto contain bacilli and inoculations of cultures resulted in distinct\\ntuberculous infection. These cases scarcely justify their separate classi-\\nfication. They are properly placed with the clinical forms of disease\\ntermed, for provisional purposes, scrofulosis of the skin.\\nExANTHEMATIC MILIARY TUBERCULOSIS OF THE SKIN may follow\\nthe exanthematous fevers in children. The lesions are multiple, indo-\\nlent, dull brownish-red tubercles, acuminate, situated in or near the\\ncutaneous follicles and suggesting the lesions of acne papulosa. When\\nin process of degeneration they form rounded, circular, or polygonal,\\nsharply cut ulcers having a violaceous border, an irregular, granular\\nfloor, and a scanty sero-purulent discharge. Miliary nodules are to be\\nseen both on the floor of the ulcerative surface and in the periphery\\nof the lesion. They contain tubercle-bacilli.\\nThis disorder occurs, as a rule, in those exhibiting other and unmis-\\ntakable symptoms of tuberculosis. If the lesions be solely cutaneous,\\nhealing may result.\\n4. Scrofuloderma.\\n(Lat. scrofa, a sow.)\\nThe term Scrofula, or Struma, has been long and loosely applied in\\ngeneral medicine for the purpose of designating a number of diseases\\nthe real significance of which was unknown, their points of resemblance\\nbeing greatly outnumbered by their specific differences. The researches\\nof the last twenty years have been steadily and continuously restricting\\nthis list in almost every department of medicine. Many of the dis-\\norders once supposed to be scrofulous are now known to be syphilitic.\\nIn orthopaedic surgery a number of joint-affections once believed to be\\nincontestably of strumous origin are known to be producible by\\ntraumatism exclusively. And in dermatology no less a broad advance\\nhas been made since the day when eczema, psoriasis, and acne were\\ndescribed as evidences of scrofula.\\nThe term scrofuloderm in these pages is strictly limited to those cuta-\\nneous changes which occur in distinctly scrofulous subjects, and which are\\nthe result of tuberculous infection at one point or another of the body.\\nBy the term scrofula Billroth recognized a condition in which there\\noccurs at any point in the body where irritation has been induced an\\nindolent inflammation which persists after such irritation has ceased,\\nwhich frequently terminates in suppuration and caseation, and which\\nsubsequently rarely pursues a hyperplastic career. If with this be con-\\njoined inflammation and caseous infiltration of the lymphatic ganglia,\\nor of the subcutaneous connective tissue amyloid degeneration of one\\nor several of the viscera tumefaction of the belly chronic keratitis,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0634.jp2"}, "635": {"fulltext": "TUBERCULOSIS CUTIS. 585\\nophthalmia, otorrhoea, or coryza a chronic arthritis (white swelling)\\na pasty, dirty-colored, and thick, or delicate and transparent skin\\nexhibiting cicatrices of old abscesses or ulcers, and a voluminous nose\\noverlooking thick everted lips, the general picture of the scrofulous\\npatient may be considered complete. The recognition by Robert Koch\\nof the etiological importance of the bacillus tuberculosis in tuberculous\\ndisease, and the demonstration of the presence of these micro-organisms\\nin a number of lesions heretofore regarded as scrofulous, have estab-\\nlished their scientific position beyond controversy. The word scrofu-\\nloderma should be hereafter limited in its application to lesions of the\\nskin and subcutaneous tissue occurring in the subjects of tuberculosis,\\nand due to the presence in such lesions either of tubercle-bacilli or of\\ntheir toxins, or due to a cachexia induced by tuberculous infection of\\nsome other body-organ. With the advance of knowledge on this sub-\\nject the fact has been recognized that the toxins of tuberculosis may be\\nresponsible for a series of lesions and symptoms in which tubercle-\\nbacilli cannot be demonstrated. In this way has been established a\\nclass of disorders to which Johnston has given the appropriate title\\nof the Paratuberculoses, and in which he has inscribed the scrofu-\\nlodermata.\\nThe scrofulodermata are characterized by the occurrence of path-\\nological processes in the skin, lymph-glands, or periglandular tissues,\\nwhich betray evidence of the scrofulous process. They usually begin\\nas firm, well-defined subcutaneous nodules, similar in type to the syph-\\nilitic gumma, which gradually enlarge, become attached to the skin,\\nsubsequently degenerate, exhibit characteristic ulcers, and usually ter-\\nminate by no less characteristic cicatrices Gommes Scrofuleuses,\\nGommes Scrofulo-tuberculeuses, Scrofuloma, Cold Abscess of\\nthe Skin). Pathologically they are all pyodermias, the product of\\nacute inflammatory processes, and not of the type of the granuloma.\\nThe typical scrofuloderm is encountered about the face and neck,\\nwhere the lymphatic glands have long been tumid and are either dense\\nor doughy to the touch. This condition is usually reached very slowly;\\noften months and years are required for its production. The glands\\nmay be as small as almonds or as large as the closed fist. Gradually a\\nscrofulous dermatitis ensues in the skin which is superimposed. It\\nbecomes purplish and thinned and finally yields, giving exit to a sero-\\npurulent fluid mingled with caseous matter and blood. The pus-\\ncorpuscles of this fluid examined under the microscope are seen to be\\npoor iii protoplasm. Fistulous tracts and sinuses result, which under-\\nmine and perforate the skin, resulting in the production of a chronic\\ndischarge and characteristic ulcers. The latter are far more remark-\\nable for their borders and bases than for their floors. They are usually\\nlinear, occasionally elongated and oval, almost never circular. As a\\nresult, their uneven floors, covered with pallid granulations and a\\nwatery pus, are often hidden beneath their inverted, tumid, and un-\\ncolored edges or the latter may be thinned, stretched over a fistulous\\npocket, and reddish or purplish in color. Their bases are usually\\ndeeply attached to the subcutaneous tissue, and are firm or soft, never\\ndensely indurated. The resulting crusts are thin, tenacious, reddish", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0635.jp2"}, "636": {"fulltext": "586 NEW-GMOWTHS.\\nor brownish, and, like the ulcer, often linear, rarely bulky, never\\nrupioid. The resulting cicatrices are corded, depressed in irregular\\nlines or bands, and often alternate with equally irregular nodules\\n(scrofulous gummata) where the degenerative process either has been\\narrested or is still in activity.\\nRarely, enormous ulcers originate in the manner described above,\\nwhich dissect out vast areas of subcutaneous and intramuscular tissue\\nin the neck and even the extremities, in the course of which cartilage,\\nbone, and periosteum are melted away. Usually but a few of these\\npoints of degeneration, from two to six, are exhibited in one patient.\\nAnother type of scrofulous gumma of the skin begins as a subcu-\\ntaneous nodule on the back or over the extremities of scrofulous children,\\nthe career of which is practically that outlined above. It differs chiefly\\nfrom the lesion more or less directly connected with the lymphatic\\nglands, by reason of its relation with lymphatic vessels distributed to\\na deeper and possibly distant tuberculous focus.\\nAccording to Unna, there is a dry form which originates in the\\naction of tuberculous toxin in the granuloma; and a wet form, the\\nproduct of reaction of the nutrient channels and the resulting oedema.\\nTubercle-bacilli have been recognized in a few cases only, but their\\ntoxins have given rise to the pathological changes.\\nTuberculous Dactylitis, observed generally in children, is char-\\nacterized by bulbous extremities of the fingers and toes, the skin cov-\\nering the same being at times the seat of infiltration and thickening.\\nWhite believes this process to be more common than that occurring\\nin dactylitis syphilitica.\\nSuppurative Tubercular Lymph angiectasis (Hallopeau and\\nGoupil) is a condition in which scrofulo-tuberculous gummata, in\\nsmall-nut- to egg-sized tumors, form along the lymph- vessels, of the\\nlower extremity particularly. When such a tumor breaks down it\\nfurnishes the typical picture of the scrofulous ulcer, with its cheesy and\\nwatery pus, its thin edge, and its indolent career. In these rare cases\\nbacilli have been recognized in the secretion.\\nTuberculosis Cutis Serpiginosa Ulcerativa is a term relating\\nto a rare group of lesions in which brownish-red nodules, pea- to bean-\\nsized, degenerate in the course of weeks or months until there results\\na centrifugally spreading, ovoid or roundish, even horseshoe-shaped\\nulcer, grayish yellow in hue and overspread with smaller cicatrices.\\nInstead of nodules, the first lesions may be circumscribed areas of\\ninfiltration. The involved surface may be extensive, even larger than\\nthe two palms, and may coexist with secondary foci of involvement.\\nVisceral and pulmonary tuberculosis may result. The resemblance of\\nthe large spreading patches to a serpiginous syphiloderm is striking.\\nLymphangitis Tuberculosa Cutanea (Besnier, Lejars).\u00e2\u0080\u0094 The\\nlymphatic vessels of the skin may be either primarily or secondarily\\n1 Loc. cit.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0636.jp2"}, "637": {"fulltext": "TUBERCULOSIS CUTIS. 587\\ninvaded with tubercle-bacilli, and in either event linear lesions form\\ncorresponding to the lymphatic trunks, or there develop tuberculous\\nnodules or warts, dermic or subcutaneous in situation, which event-\\nually ulcerate and discharge pus, blood, or lymph. At times a reticular\\nnetwork results, with fistulous sinuses. Several of the lymphangiectases\\nhave been demonstrated to be tuberculous in character.\\nEtiology of Tuberculosis Cutis. Accidental inoculation of tuber-\\nculosis may occur at all ages and in all sexes, the infective material\\ngaining access to the economy in the large number of instances by the\\nmedium of the lymphatics. There is, however, ampler opportunity for\\nsuch transmission among the members of any family in which pulmo-\\nnary tuberculosis exists hence the widespread belief in the heredity\\nof the disease. Attention has, however, been already directed in these\\npages to the striking fact that children are rarely born into the world\\ntuberculous and to the possibility that all cases of reputed inherited\\ntuberculosis were acquired by direct infection.\\nGiven, however, an infective micro-organism, the soil upon which\\nit may flourish most favorably is of paramount interest in an etiological\\nview. The young, the delicate, the cachectic furnish such a culture-\\nfield. With these must be included, as favoring such accidents, the\\nmode of life of the very poor, the filthy, and the degraded. Thus,\\nlupus vulgaris is originally developed in the majority of all cases\\nduring the first decade, between the third and sixth years of life\\nrarely after the thirtieth year, for the reasons above given. The sig-\\nnificant fact in this connection is that at this period of life the child\\noften deprived of the constant care of the mother by the demands\\nmade by a still younger infant, untaught in the simplest rules of clean-\\nliness, picking and scratching the face after miscellaneous contacts of\\nthe fingers with all sorts of material, is exceedinorlv liable to inoculate\\nthe skin of the face with tuberculous virus, if there be victims of such\\ndisease occupying the same apartment or house. It is significantly first\\nupon the face in these early years, and next over parts such as the\\nextremities or the genital region, to which the exposed hands have been\\ncarried, that the early symptoms of lupus vulgaris are betrayed.\\nFurther, it is noteworthy that well-marked cases are more frequent\\namong the poor, the filthy, and the degraded than among the comfort-\\nable and cleanly. The prevalence of the disease in public as con-\\ntrasted with private practice is conspicuous in all statistics.\\nAs throwing additional light upon the question of childhood-infection,\\nit is to be noted that other forms of tuberculosis occur at any period\\nof life and in both sexes, when the accident of infection operates.\\nBesnier, for example, reports a case of lupus resulting from tuberculous\\ninfection in vaccination Fournier, an instance in which a young woman\\nwas infected during the piercing of the ear for the insertion of earrings;\\nJadassohn, a case in which the tuberculous virus was inserted by tattoo-\\ning and Strauss, the history of a student who was wounded by a rapier\\nin a duel, and as a result developed lupus in the site of the wound.\\nIn verruca necrogenica and warty growths of the same nature it is\\ncontact with the bodies of the dead or with tuberculous matter in any", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0637.jp2"}, "638": {"fulltext": "588 NEW-GROWTHS.\\nform that determines the result. The aged with tuberculous lesions\\nupon the backs of the hands, middle-aged persons with other evidences\\nof cutaneous affection, actually suffer from generalized tuberculosis as a\\nresult of the accident.\\nWhat may be said of the causes of lupus vulgaris relates also to\\nscrofuloderma, which, while occurring in both sexes and at all ages, is\\nmore frequent in early life because of the susceptibility of the tissues\\nat those periods. The difference between the manifestations of scrofu-\\nloderma and those of other clinical forms of tuberculosis depends in\\nlarge part upon the attenuation of the virus, seeing that relatively\\nfewer tubercle-bacilli are to be recognized in the characteristic lesions\\nof scrofula and the results of inoculations of cultures as respects the\\nlower animals are markedly different.\\nThe soil fittest for scrofulodermatous manifestation is that where\\nwell-known agents have been most efficiently at work. All causes\\nwhich tend to impair the nutrition and vigor of the body are, to an\\nextent at least, efficient in its development, including privation from\\nsunlight, fresh air, wholesome food, exercise, and hygienic influences in\\ngeneral. It is common among prisoners, exiles, and, in this country,\\namong negroes and those of mixed blood. Consanguineous marriages\\nare said to result often in strumous offspring. Syphilis in the third\\nand fourth generations is known to be pathologically distinct from all\\nthe manifestations of scrofula. In many cases scrofuloderma is the\\nsequence of other depressing medical diseases and surgical accidents.\\nIn certain instances, especially where it is limited to the neck, and\\naccompanied merely by a cervical or submaxillary adenopathy, scrofu-\\nlosis is consistent with full vigor and nutrition of the body and all other\\nevidences of sound health.\\nPathology of Tuberculosis Cutis. Lupus vulgaris, tuberculosis\\ncutis verrucosa, and scrofuloderma, as well as tuberculosis cutis orifici-\\nalis (the one form hitherto recognized as tuberculous) are due to infection\\nwith tubercle-bacilli, and are practically identical histologically with\\ntuberculous lesions in other organs of the body. The discovery of\\nbacilli in lupous tissue, first made by Koch, has since been verified by\\nDoutrelepont, Weichselbaum, Meisels, Schuller, Lustig, and others.\\nThe striking resemblance first shown by Virchow between a caseous\\nmiliary tubercle and a lupous nodule had, even before Koch s discovery,\\npointed to an identity of origin. The result of inoculation of culture-\\nfluids has given positive results. Lenz, Hiiter, Schuller, ourselves, and\\nothers have produced tuberculosis by introducing in rabbits granula-\\ntions taken from lupous, scrofulous, and other infected patients.\\nFor a knowledge of the microscopic characters of cutaneous tuber-\\nculosis we are largely indebted to the Germans, whose opportunities\\nfor the study of the disease are unequalled. Virchow, Auspitz, Billroth,\\nLang, Kaposi, Klebs, Stilling, and Thin have amply contributed to the\\nsubject.\\nThe essential lesion in all forms of cutaneous tuberculosis is the\\nnodule of so-called granulation -tissue, containing small round cells\\ndeeply stained by coloring-agents large cells, epithelioid in type, which", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0638.jp2"}, "639": {"fulltext": "TUBERCULOSIS CUTIS.\\n589\\ncontain one or more large clear nuclei and giant-cells having a homo-\\ngeneous centre and few or many large vesicular nuclei situated for the\\nmost part along the border of the cell. Around and between these\\ncellular elements is woven a network of connective-tissue bundles.\\nIn its early stages the nodule is about the size of a millet-seed, is\\ngrayish or reddish yellow in color and translucent, is situated wholly\\nwithin the corium, is well defined in outline, and is well supplied with\\nvessels. After a shorter or longer period, depending upon the activity\\nof the process, the nodule undergoes changes. Although there is\\nmarked proliferation of the endothelium of the vessels, no new vessels\\nFig. 69.\\nSection of lupus of face. X 750 and reduced. (Delafield and Prudden.)\\nare formed, the old ones become obliterated, and there results a necro-\\nsis known as a coagulation-necrosis, or cheesy degeneration of both\\ncells and intercellular substance. In this condition the protoplasm is\\nseen as a granular or amorphous mass, while the nuclei stain but feebly,\\nif at all. Extension of the disease from the primary nodule may occur\\nin the form of other circumscribed nodules, or as a diffuse infiltration\\nof the tissues with the cell-forms above described, the small round cells\\nbeing greatly in excess of the others.\\nThe process begins in the corium and extends to the epidermis and\\nto the subcutaneous tissues, these adjacent structures being variously\\naffected in the different forms of cutaneous tuberculosis. The epidermis", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0639.jp2"}, "640": {"fulltext": "590 NEW-GROWTHS.\\nmay be hypertrophied, exfoliating, or broken through by the tubercular\\ninfiltration, producing a typical ulcer. The nodules may soften and\\nbreak down into a semifluid mass, and suppuration always the result\\nof secondary infection frequently occurs.\\nTubercle-bacilli have been recognized in all parts of the nodule, both\\nwithin and without the cells, but are usually most readily found in the\\ngiant-cells and in the outer portion of the nodule. Since giant-cells\\nand nodules of granulation-tissue are found also in other than tuber-\\nculous processes, the only pathogenic feature of the tubercle-structure\\nis the presence of the tubercle-bacillus, though the coexistence of a large\\nnumber of giant-cells and nodules or groups of epithelial cells leaves\\nlittle doubt as to the diagnosis.\\nIn Lupus Vulgaris are found the characteristics of the chronic\\nand slowly developing forms of tuberculosis. Giant-cells are numer-\\nous, the infiltration of round cells is marked, but epithelioid cells are\\npresent in comparatively small numbers, while the bacilli are very\\nscarce many sections of tissue may be examined before finding a single\\nbacillus. In lupus, more than in other forms of cutaneous tuberculosis,\\nthe proliferation of cells leads to a constructive or regenerative proc-\\ness as a result of which the lupus-nodule may be replaced by scar-tis-\\nsue, or there may be an excessive formation of new connective tissue,\\nproducing the various degrees of elephantiasis so often seen in lupus.\\nThis intermingling of new tubercular foci of infiltration with hyper-\\nplasia of connective tissue is what produces the many clinical forms\\nof the disease. When the process is extending, the new growth,\\nspreading along the vascular elements of the derma, involves finally the\\nrete and the panniculus adiposus. The nest-like agglomerations disap-\\npear; there is in their stead an irregularly diffuse infiltration, producing\\nsubsequently hypertrophic, atrophic, desquamative, suppurative, or\\nulcerative sequels. Finally, the glands of the skin may become\\ninvolved, the hairs falling from their follicles, the sebaceous glands\\neither becoming obliterated or having their acini stuffed with epi-\\ndermal masses which distend them in milium-like bodies grouped about\\na cicatricial pedicle.\\nThe epithelium is secondarily involved in lupus and may be desqua-\\nmating, atrophied, or ulcerated. Not infrequently there is marked\\nproliferation of the epithelial cells with down-growth of the inter-\\npapillary processes. True epithelioma may thus result, in which event\\nits course is usually rapid and destructive. There may be also a pro-\\nliferation of the glandular elements of the skin. Leloir describes, as\\nof rare occurrence, a colloid and a mucoid degeneration of the lupous\\ntissue.\\nIn the Verrucous forms of cutaneous tuberculosis the tuberculous\\nprocess proper usually is situated chiefly in the upper part of the\\ncorium, and there is more or less hypertrophy of the papillae and of\\nthe epidermal layers. In the well-marked cases of anatomical tubercle\\ndescribed by Biehl and Paltauf the horny layer is greatly thickened\\nand shows cells in which the nuclei stain more or less, while between\\nthe layers of the cells are seen granular masses and the dried products\\nof exudation. In places the horny layer dips down to fill the inter-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0640.jp2"}, "641": {"fulltext": "TUBERCULOSIS CUTIS. 591\\npapillary spaces. The papillae may be greatly hypertrophied and\\nbetween them the rete may send projections deeply into the corium, in\\nwhich occasionally are seen crypts filled with horny masses of epithe-\\nlium. Secondary inflammatory changes and pus-infection may occur\\nas in lupus.\\nBetween typical Verruca Necrogenica and the ordinary type of\\nlupus vulgaris transitional forms frequently are seen which make it\\nimpossible to draw a line sharply dividing these forms of cutaneous\\ntuberculosis. In verruca necrogenica a history of direct infection is\\noften obtainable and tubercle-bacilli are more numerous than in the\\nlupous nodules, though much less abundant than in tuberculosis cutis\\norificialis.\\nIn Tuberculosis Cutis Orificialis, both in the number of bacilli\\npresent and in the type of lesion, there is an analogy with miliary tuber-\\ncle of other organs. Large numbers of typical, circumscribed nodules\\nare found deep in the corium bacilli are numerous and easily demon-\\nstrated the degenerative processes go on rapidly, the tubercles break-\\ning down and coalescing to form masses of softened necrotic tissue\\nwhich soon break through the epidermis to form an ulcer. About\\nthe borders of such necrotic areas new nodules are constantly form-\\ning, and the whole process is rapid, as in acute tuberculosis of other\\ntissues.\\nThe Scrofulodermata originate in the subcutaneous tissues and\\nI involve the skin secondarily. The lymphatic glands or the tissues\\nabout the glands or lymphatic vessels become the seat of the tuber-\\nculous process, which runs a subacute course. The glands or peri-\\nglandular structures finally break down into softened necrotic masses.\\nSuch areas of necrosis may remain indolent and superficial, or, in\\ncase a gland is involved, may be deep and extend by burrowing\\nprolongations even to the bone. Sooner or later the skin over these\\nI softened masses becomes involved in a subacute inflammatory process\\nand gives way, producing the typical ulcer with soft, ragged, and\\noften extensively undermined edges. Experimental inoculations and\\nthe presence of tubercle-bacilli have demonstrated these subcutaneous\\nprocesses to be tuberculous. The number of bacilli present varies\\ngreatly, being much larger than in lupus, but much smaller than in the\\norificial forms of cutaneous tuberculosis. The relationship of the\\nscrofulodermata to lupus is occasionally shown by the formation of\\ntypical lupous nodules near the border of these scrofulous ulcers, the\\nresult no doubt of inoculation of the skin with the discharge from the\\nulcer.\\nDiagnosis of Tuberculosis Cutis. Epithelioma, though rarely\\nj resembling lupus vulgaris, is more often designated by that than by\\nany other false title. Great confusion has arisen from the looseness\\nwith which several authors have furnished illustrations of lupus\\njexedens, which were really pictures of cancer. But the latter is\\nrarely a disease of early life, and when of early occurrence may not\\npersist to adult years the reverse of which is true in the majority of\\nall cases of lupus. The nodules of lupus are absent in epithelioma,", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0641.jp2"}, "642": {"fulltext": "592 NEW-GROWTHS.\\nand the evolution of the disease slower, less painful, and, in its earlier\\nperiods certainly, of deeper situation. The ulcer of epithelioma is\\nmore often defined and single; its edges whitish, indurated, and\\neverted its floor uneven and glazed its secretion scanty and occasion-\\nally fetid its base a mass of indurated tissue. Lupous ulcers are often\\nill defined and multiple their edges soft and inconspicuous, neither\\neverted nor undermined their floors granulating and flattened their\\nsecretion relatively profuse and generally odorless their bases soft and\\npliable, though occasionally indurated.\\nTubercular, serpiginous, and ulcerative lesions of syphilis often re-\\nsemble certain forms of lupus. In any doubtful case a history of in-\\nfection, of other types of cutaneous disease, of mucous patches, of\\nadenopathy, of abortions in women, etc., should aid in the recognition\\nof syphilis. The suspected lesions should be examined carefully for\\nthe purpose of distinguishing characteristic lupous nodules in the patch\\nitself or in the periphery of any exfoliating area. In the case of an\\nadult a history of long-existing lupus may often be obtained and it is\\nworthy of note that syphilis with exceeding rarity displays for long\\nperiods of time a single exanthematous lesion or aggregation of such\\nlesions exclusively in one part of the body. Lupous ulcers, often\\nmultiple and isolated, insensitive, Well- or ill-determined in outline\\n(never reniform or horseshoe-shaped), with supple, low edges, and red-\\ndish, smooth, hemorrhagic granulating floor, covered with crusts like\\nsoiled parchment of uniform thickness, do not resemble those of syph-\\nilis. The latter are often painful, single, circular, and clean cut in\\ncontour, with firm, raised, infiltrated margins, and with offensive green-\\nish and blackish crusts, resembling oyster-shells. The cicatrices of\\nsyphilis are elegant, smooth, delicate, superficial, circular, and, after\\npigmentation has disappeared, dead white in color those of lupus\\nare irregular, indurated, deforming, yellowish white and reddish yellow.\\nAcquired syphilis is a disease of adult life lupus commonly begins in\\nchildhood.\\nThe disks of psoriasis are distinguished from flat exfoliating patches\\nof lupus vulgaris by the relatively large number of the former, by the\\nnacreous lustre of the scales, the reddish hemorrhagic surface beneath,\\nand the sites of election of the disks, usually on the extensor faces of\\nthe limbs.\\nLupus erythematosus is even more readily distinguished by its char-\\nacteristics including the absence of nodules, ulcers, and crusts, the\\nsuperficial character of the morbid process, the scaliness, and occasional\\nsymmetry of the patches. An intermediate form between lupus ery-\\nthematosus and lupus vulgaris has been described, but most cases so\\nclassed probably belong to the type called by Leloir erythematoid\\nlupus vulgaris, in which nodules are temporarily absent. In all such\\ncases typical nodules of lupus vulgaris develop sooner or later and\\nconfirm the diagnosis. The two diseases, unfortunately somewhat\\nsimilar in name, are distinct in character. The so-called intermediate\\nforms may be instances of flat and scaly epitheliomatous infiltration\\ngoing on to ulceration.\\nIn acne rosacea with a bulbous condition of the tip of the nose the", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0642.jp2"}, "643": {"fulltext": "TUBERCULOSIS CUTIS. 593\\nredness is vivid and the telangiectasia complications, with the sebor-\\nrhoeic flux, are conspicuous points of difference from lupus vulgaris.\\nThere is, further, no ulceration and little scarring, and the patients\\nhave usually suffered from the disease only after arriving at maturity.\\nThe mucous surfaces are also spared.\\nThe diagnosis of verrucous growths of tuberculous nature is to be\\nmade after an investigation of the history of each case, which often\\nincludes a record of contact with cadavers or persons capable of com-\\nmunicating the disorder. The epitheliomatous warty growths on the\\ndorsum of the hands of elderly persons are not to be confounded\\nwith tuberculous lesions. In the former there is commonly a history\\nof longer existence of the wart, and no record of suspicious con-\\ntacts while a careful search will usually determine epitheliomatous\\nmetamorphoses over the cheeks or temples of the elderly man or woman\\nwith epitheliomatous warts on the hands. In the latter, too, the\\nI facial lesions are usually multiple, fatty-looking scales, thicker in one\\n1 part than another, resembling those of a severe seborrhoea, but which\\ni are removed with difficulty, and which then leave a bleeding surface\\ni beneath.\\nIn the orificial cases it must be remembered that tuberculosis of the\\nviscera is a probable coincident disease. The microscope is usually\\nneeded for an exact diagnosis.\\nThe acneiform and sycosiform tuberculoses, necrotic granuloma,\\nlupus pernio, folliclis, and other disorders of that group, many of them\\nlocal evidences of infection of the system by the toxins of tubercle-\\nbacilli, are distinguished by their superficial situation, their tendency\\nto central necrosis, pitting and scarring, and by anomalous symptoms\\noccurring where none such was to be expected. For example, a sycosis,\\napparently simple, leaves persistent disfiguring infiltrations, with scar-\\ntissue and even ulcerative effects the acne which should resolve,\\nexhibits deep, sunken, cicatriform pits, or papules which ulcerate the\\nalopecia of the scalp, which at first seems to be of simple type, results\\nin characteristic changes of the deep tissues.\\nTreatment of Tuberculosis Cutis. The internal treatment of\\ntuberculosis cutis is practically that indicated by the condition of\\nthe patient inasmuch as no medicament is known to be capable, after\\ningestion, of relieving the victim of his local ailments. Of the articles\\nj in this category none will be more often indicated than cod-liver oil, the\\nchalybeates, creosote, the bitters, the preparations of iodine, and possibly\\nphosphorus. Iodoform and potassium iodide have been recommended\\nby JSTeisser, who employs the former in pills, each containing grain\\n(0.033). Guaiacol and creosote carbonate, either of them, in 5 grain\\n(0.33) capsules, have been used with varying degrees of success. In\\nLondon thyroid-extract has been given for cases of extensive tuber-\\ncular disease of the skin with seeming benefit, though no complete\\ncures are reported. The hypophosphites are useful in many cases.\\nArsenic and mercury are powerless to prevent extension of the disease.\\nIt is needless to add that a diet of the most generous character is to be\\nsupplied, and the rules of hygiene enforced.\\n38", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0643.jp2"}, "644": {"fulltext": "594 NEW-GROWTHS.\\nPatients of the tuberculous class manifest in the highest degree the\\nbeneficial effects of a change of residence and climate to the seashore\\nor mountains from the interior valleys or plateau-lands often the\\nreverse for those who reside by the sea or in mountainous countries. It\\nis the change which seems to produce the greatest benefit. An abun-\\ndance of pure air and a life permitting out-of-door exercise are of\\nthe highest importance. The thermal and other springs of several\\ncountries furnish resorts where the benefit received is proportioned to\\nthe salubrity of the climate rather than to the special advantages of the\\nwaters furnished. Unfortunately, a large number of the patients\\naffected with lupus and scrofuloderma are impoverished inmates of\\npublic charities or applicants to dispensaries, where these aids in the\\nmanagement of their ailments cannot be utilized.\\nThe local treatment of lupus vulgaris should have in view the\\nremoval of the morbid growth as painlessly and with as little resulting\\ndisfigurement as possible. These ends may be attained by surgical\\nmeasures and by chemical and other applications.\\nThe surgical procedure most frequently employed is curetting with\\na sharp spoon. This, with all other bloody operations in lupus vul-\\ngaris, labors under the disadvantage of the possibility that tubercle-\\nbacilli may be disseminated by the traumatism. Competent authors\\nare arrayed on both sides of this question. Small lupoid patches cer-\\ntainly may be spread after resorting to most of the surgical devices\\nemployed as remedial agents. The dermal curette is a sharp-edged\\nspoon with or without a fenestrum in the bowl to permit the escape\\nof debris. By it the lupous growth may be completely scraped away,\\nand, if necessary, caustics subsequently applied. Fox and others sub-\\nstitute for the sharp spoon the dental burr or dental excavator, though\\nthe change is not always for the better. Morris s double parallel\\nscrew-excavator is an improvement on the common burr. Often it is\\nwell to supplement the action of the spoon or excavator with the flat\\nelectrode treatment of Jackson. Gartner and Lustgarten originally\\nused as an electrode a flat silver plate attached to the negative pole of\\nthe battery, the plate being set in a hard-rubber ring. A current of\\nfrom five to eight milliamperes is employed.\\nThe ablation of the entire lupous patch by the modern methods of\\nsurgery, followed by skin-grafting with the Thiersch or Lang method,\\ngives good results, though the lupous growths may return sooner or\\nlater in the new skin. The objections to this method are chiefly that\\nit involves the production of a larger and more conspicuous scar, since,\\nas a rule, more tissue is removed by the knife than by the curette and\\nits allies. In the Lang l method the excision is made to include both\\nthe sound peripheral integument and half of the subcutaneous fat-\\ncushion beneath, the skin-grafts employed later differing from the thin\\nThiersch sheets in that they include the derma with the epidermis as\\nfar as the panniculus adiposus.\\nIn the history of medicine it is seldom that a therapeutic measure\\nhas been followed by such satisfactory and brilliant results as those\\nsecured by the method of treatment of lupus vulgaris practised by\\nx Der Lupus nnd dessen operative Behandlung. Wien, 1898.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0644.jp2"}, "645": {"fulltext": "TUBERCULOSIS CUTIS. 595\\nFinsen, of Copenhagen (phototherapy 1 The morbid patch by this\\nmethod is rendered anaemic by firm pressure with a planoconvex quartz\\nlens, framed in a brass ring carrying two small tubes with four arms\\nthrough which cold distilled water freely percolates, and through which\\nis concentrated the light from an arc-lamp of between fifty and eighty\\namperes. The exposures are continued for about an hour daily, during\\nwhich time a trained nurse in charge of the illumination presses the\\nlens firmly over the spot selected for attack. When sunlight can be\\nemployed, its rays are substituted for those supplied by the electric\\nlamp, the heat-rays being excluded and the violet and ultra-violet rays\\nalone permitted to pass. The effects of solar light are, however, less\\ndecided and satisfactory than those secured by electric illumination, and\\nas a consequence the out-of-door treatment of patients by sunlight is\\nreserved in Copenhagen for those whose skins are unusually sensitive\\nto the more vigorous and more brilliant light of operating-rooms. The\\nexposure is rarely a source of pain save when the patch attacked is very\\nnear the eye, though often followed by redness, hyperemia, inflamma-\\ntory reaction, and vesiculation.\\nPatients relieved by this method of treatment and exhibited at the\\nDermatological Congress in Paris in 1900 furnished one of the most\\ni convincing proofs of the essential value of the phototherapeutic method,\\na fact fully corroborated by us during two several visits to the Finsen\\nInstitute. From a cosmetic point of view nothing can exceed the\\nsmoothness and comeliness of the faces subjected to this treatment. As\\nwith all other methods extensively pursued for the relief of hundreds of\\npatients, there is a small proportion of failures, and a still smaller pro-\\nportion of cases in which the electric rays seem to have had a prejudicial\\neffect. No results however, at all comparable as to the number of\\npatients relieved and as to the perfection of the relief obtained, have\\nbeen secured by other methods in the local management of lupus\\nvulgaris.\\nThe objections to the method are the length of time required for\\nthe treatment (though this is gradually shortening to six months and\\nless); and the need of daily treatments in some cases two daily\\none in the morning and one also at night. The gratifying results\\nobtained, however, much more than compensate for the time required\\nto complete the work.\\nThe Roentgen rays have been employed for a similar purpose, and,\\nit is claimed, with a similar effect by Albers-Schonberg, 2 Kummell, 3\\nPusey, 4 Himmel-Kasan, 5 and others. The relatively small number of\\ncases thus far subjected to the treatment does not furnish a satisfactory\\nbasis for comparison with the Finsen method.\\nWithout question, next after the Finsen method and superior to it\\nin the matter of the rapidity with which the lupous nodules may be\\nmade to disappear, is the thorn treatment employed by Unna. The\\nthorns of the gooseberry bush are saturated in the German liquor\\n*Cf. Die Finsenche Lichtherapie, Bang, Monatslfft. f. prakt. Derm., 1898, Bd.\\nxxvii. Brit. Jour, of Derm., Sept., 1899.\\n2 Deutsch. med. Woch., Oct. 13, 1898. 3 Arch. f. klin. Chir., Bd. lvii., Heft 3.\\n4 Jour. Amer. Med. Assoc, Dec. 8, 1900. 5 Arch. f. Derm. u. Syph., Bd. 1., Heft 3.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0645.jp2"}, "646": {"fulltext": "596 NEW-GROWTHS.\\nstibii compositus, and one or more thrust firmly and deeply into each\\nlupous nodule which it has been determined to attack. The base of\\neach thorn is then cut off with a pair of fine scissors and the patch\\ncovered with a zinc oxide plaster. When the thorns are cast off a\\nsimple granulating ulcer is left which in favorable cases heals without\\ndelay.\\nThe obvious objection to each of the methods detailed above lies in\\nthe fact that an enormous proportion of lupus-patients have nasal and\\noral symptoms which cannot be reached either by the rays of solar or\\nelectric light or by Unna s thorns. The local treatment of these involved\\nmucous membranes is a matter of great importance, and is described\\nbelow.\\nHollander s hot-air treatment of lupus is accomplished by directing\\nupon the lupoid tissue through a metal tube of slender diameter a\\nstream of air at a temperature of about 300\u00c2\u00b0 C. The result is for the\\nmost part a destructive cauterization requiring complete anaesthesia.\\nThe resulting scars are formidable.\\nThe local treatment of lupus vulgaris by the aid of parasiticides is\\nbased upon the infectious character of the disease and in many cases\\nis successful. White, 1 with a view to its parasitic action, applies to the\\nlupous patches rags soaked in solutions of mercuric chloride, 1 to 2\\ngrains to the ounce (0.066-0.133 to 30.), and also applies ointments\\ncontaining the same quantity of bichloride in the ounce of salve-basis.\\nFavorable results have been also secured by freely painting lupous\\nulcers with a solution of corrosive sublimate in tincture of benzoin of\\nthe strength named. Salicylic acid, 2 to 4 per cent, solutions in castor-\\noil, and in ointments J to 1 drachm to the ounce (2.-4. to 30.) sul-\\nphurous acid, or pyrogallol in ointments of 10 per cent, to 50 per cent,\\nstrength, spread on linen rags, covered with impermeable tissue, and\\nfollowed by the use of mercurial plaster and iodoform, have all been\\nsuccessfully employed with the same object in view.\\nDecidedly inferior to these are the following methods, the first\\nnamed, most popular in Germany; the second, in France; the third,\\nto-day practically obsolete, and probably not to be revived\\nThe Paquelin knife is extensively used in Vienna. The finer\\nblades, especially manufactured for the purpose, are thrust, at a red\\nheat, again and again through the lupous tissue until it is destroyed in\\nits depth. Over the whole the larger blade is firmly passed and pressed,\\nthe blackish coal resulting being the best subsequent dressing after the\\nserous exudation ceases. Erasion is also followed by the use of the\\ngalvano- or thermo-cautery.\\nMultiple linear scarification, a modification of the Dubini-Volkmann\\nmethod, was once claimed to have changed the prognosis of the disease.\\nIt is doubtful whether anything is to be gained by either a preliminary\\nfreezing of the part or the use of cutting instruments with many blades.\\nThe incisions may be produced with a delicate bistoury held in the\\nfingers like a pen. They should be in parallel lines, closely set\\ntogether, and crossed should extend completely through the depth of\\nthe lupous growth and this is determinable after some practice by the\\n1 Boston Med. and Surg. Jour., October 29, 1885.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0646.jp2"}, "647": {"fulltext": "TUBERCULOSIS CUTIS. 597\\ncessation of the creaking resistance which the blade fails to discover in\\nnormal tissue. Further, these incisions should extend laterally beyond\\nthe borders of the lupous patch into the sound peripheral zone. The\\nbleeding is trifling and readily arrested by firmly pressing small pieces\\nof fine sponge, lint, or absorbent cotton over the part. The edges\\nof the incision unite either by granulation or by first intention and in\\nboth cases seem to serve as starting-points of the reparative process,\\nthe material for which, as already pointed out, seems to be supplied\\nfrom the lupous nests themselves. Subsequent operations, when needed,\\nrequire a previous freezing of the affected surface. In France and in\\nsome portions of the British Empire this method is still popular.\\nTreatment by chemical cauterization alone is obsolete. The various\\nacids and alkalies, particularly potassium hydroxide and lactic acid.\\nCosine s paste, silver nitrate, arsenical, mercurial, and zinc compounds,\\nand sodium ethylate have all been employed thus, and in suitably\\nselected cases have been in the past productive of fairly satisfactory\\nresults.\\nWith or without surgical interference, local applications may be\\nemployed, such as oily and fatty substances for the softening of crusts\\nstimulating dressings of tar, iodated glycerin, thymol, guaiacol (Funk),\\nichthyol, carbolized glycerin, iodized phenol, fluorine (Phillipson),\\nnaphtol, chrysarobin, and iodoform; as also the carbolated unguents\\nappropriate for the reparative phases of the ulcer left after the destruc-\\ntion of the lupous growth.\\nUnna advocates the topical application of 2 parts of beech-tar\\ncreosote to 1 part of salicylic acid, the latter for its marked effect\\nupon lupous tissue, and the former for what is supposed to be its\\nanodyne effect in obtunding the pain produced by the action of the\\nacid on the surface. That this explanation of the effect of the com-\\nbination is not wholly correct is shown by the well-known fact that\\ncreosote alone is capable of producing a curative effect upon lupous\\ntissue. In a former edition of this work, issued before the date of\\nUnna s experiments, creosote was set down as the dernier ressort of the\\nphysician in the topical management of lupus vulgaris. It can be\\nused with the greatest advantage in severe cases not only by being\\nbrushed freely over the part, but also in the combinations suggested by\\nUnna. It will be found that when employed alone it is far from hav-\\ning at first the local effect of a morphine of the skin, being produc-\\ntive, where no cocaine has been previously employed, of exquisite pain,\\nwhich, however, is usually short lived. It should be applied only with\\nthe greatest caution by the practitioner s own hands, its effects watched\\nand, if need be, counteracted, as in the local employment of potassium\\nhydroxide. Trikresol operates in a similar manner.\\nThe application of fuchsin in 1 or 2 per cent, alcoholic solutions\\npainted over the part, which has been previously scarified, is advocated\\nby Fox and others. We have employed pyoktanin-blue in some cases\\nwith satisfactory results.\\nIn some of the German hospitals the new tuberculin-R, Koch s\\nlymph, is injected, and, it is claimed, with a larger success than follows\\nthe older methods. It has not been unattended with danger, and fatal", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0647.jp2"}, "648": {"fulltext": "598 NEW-GROWTHS.\\nresults have in a few instances been recorded after its injection. In\\nother cases general tuberculosis has been induced while in yet others\\nthe degree of improvement following its employment has been inferior\\nto that more readily reached by other therapeutic measures. The dose\\nis -g-J-g- to 1 milligramme, the strength being very gradually increased\\nfrom the smaller to the largest amount named.\\nThe injection of calomel into the lupous patch has been followed by\\ngood results in the hands of Da Costa, Brouse, and Tschlenow.\\nThe treatment of verruca necrogenica and other verrucous tubercu-\\nloses of the skin is practically that of lupus vulgaris. The curette\\nmay be followed by one of the caustics advocated above, preferably by\\npyrogallol, or a combination of salicylic acid and creosote. As a rule,\\nmercurial lotions and salves are not well adapted to penetration of the\\nwarty or corneous envelope of the growth.\\nThe orificial lesions of tuberculosis cutis may, however, be well\\ntreated by these lotions, especially one in which to 2 per cent, of\\nmercuric chloride is dissolved in compound tincture of benzoin or tolu.\\nVeiel applies in all the cutaneous tuberculoses pyrogallol-vaselin in\\nthe strength of 10 per cent., spread upon lint for three or four days.\\nOne part to twenty of salicylic acid may often be advantageously\\nadded.\\nThe local lesions of scrofuloderma may require the use of hot borated\\nlotions applied temporarily, or kept permanently in contact on com-\\npresses covered by impermeable tissue. The results of surgical abla-\\ntion of enlarged lymphatic glands, broken down or threatening scrofu-\\nlous gummata, a nd the complete disinfection and aseptic treatment\\nto the point of cicatrization of the resulting wounds, furnish proofs of\\nthe progress of modern surgery.\\nIn the local management of lichen scrofulosorum Hebra recommends\\nthe topical use of cod-liver oil smeared over the lesions, with woollen\\ngarments worn outside. At present medicated pastes are preferable.\\nThe local treatment of dermatoses of the scrofulous is, in fact, that\\nindicated in each separate case.\\nThe Prognosis of tuberculosis of the skin in all its manifestations\\nis in the highest degree variable. Many patients affected with lupus\\nvulgaris, even after the production of the severest grade of deformity,\\nrecover and without further local manifestations gain a degree of facial\\ncomeliness that is marvellous. The scrofulodermata in the same way\\nare remarkably improved, in the majority of all cases, by skilful medical\\nand surgical management. In other cases systemic tuberculosis develops\\nafter even a single tuberculous infection, and grave results may occur\\neither early in life or after years of tuberculous involvement of the skin\\nand other organs. Other things equal, the prognosis in tuberculosis\\nof the skin, as compared with that of other organs, is relatively favor-\\nable, due to the sparsity of tubercle-bacilli in most cutaneous lesions,\\nthe skin being exposed too largely to external influences to form a\\ngood field for development of new colonies of bacilli. Any form of\\ntuberculosis of the skin, however, may result in systemic infection\\nand death.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0648.jp2"}, "649": {"fulltext": "DERMATOSES OF SCROFULOUS SUBJECTS. 599\\nTHE DERMATOSES OF SCROFULOUS SUBJECTS.\\n(Paratuberculoses, Johnston.)\\nIn this connection it is desirable to consider a group of cutaneous\\ndisorders which, while recognized as of occurrence among the scrofu-\\nlous, exhibit lesions which, at the present time, have very rarely been\\ndetermined to be sites of bacilli. They are supposed to be due to the\\npresence of toxins, the latter, possibly in many cases, originating in a\\ntuberculous focus in some organ of the body. Certain members of this\\ngroup have been actually begotten by tuberculous injection.\\nThe evidence, as regards some of these forms, which may be consid-\\nered, perhaps, as pseudo-tuberculoses, or paratuberculoses, is instructive.\\nThe results of inoculation of tuberculous material in different lower\\nanimals seem to establish the fact that tuberculosis cutis, lupus vulgaris,\\nand scrofuloderma differ widely in the number of bacilli that can be\\nrecognized in their respective lesions. It is, hence, argued that with\\neven fewer micro-organisms present there may exist types of tubercu-\\nlosis still further removed from those here classified.\\nIn yet other cases the demonstration has been made that the toxins\\nderived from any tuberculous focus in the human body may beget a\\ncutaneous affection uninvolved by tubercle-bacilli serious or short lived,\\nwholly or in part dependent upon the morbid state of the system.\\n[A] Lichen Scrofulosorum.\\n(Acne Cachecticorum, Acne Scroeulosorum. Ft., Folliculites\\ndes scrofuleux.)\\nThis eruption, first described by Hebra, 1 is characterized by its\\nchronicity, and the occurrence chiefly upon the trunk, back, belly, and\\nthighs, of millet-seed- to pinhead-sized, firm, flat, light- to livid-red,\\nand grouped papules. These are occasionally surmounted at the apex\\nby a minute scale, rarely by an equally small pustule. The lesions are\\nat the onset isolated later they tend to arrange themselves in coin-\\nsized patches when evolution is accomplished they are closely set\\ntogether, the surface of the skin being then of a dirty reddish -brown\\ncolor, and covered with thin scales, w T hich are readily detached. Often\\na crescentic outline can be determined in a group of aggregated\\nlesions.\\nThe course of the eruption is slow often the cutaneous symptoms\\npersist for months without apparent change, awakening little or no\\npruritus, and are followed by involution, accompanied by slight des-\\nquamation and no cicatrices. There may be recurrence.\\nIn 99 per cent, of all cases observed in Austria there was concomi-\\ntance of the general symptoms of struma named above (submaxillary,\\ncervical, and axillary adenopathy, periostitis, ulcerative dermatitis,\\netc.), with frequent complications, such as eczema of the scrotum.\\nThe disease was encountered in young tuberculous subjects between the\\nperiods of infancy and puberty, never after the twentieth year.\\n1 See his remarks before the German Surgical Society, Fourteenth Congress.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0649.jp2"}, "650": {"fulltext": "600 NEW-GROWTHS.\\nAccording to Kaposi, the disease consists in an exudative infiltration\\nof the pilo-sebaceous follicles and the perifollicular tissue. Each\\npapule represents, therefore, the orifice of a follicle, with an infiltrated\\nperifollicular annex and its apical scale or pustule is formed of a\\nmass of epithelial debris or an inflammatory exudate. Histologically,\\nthere is infiltration with lymphoid, epithelioid, and giant-cells, with a\\ncaseating area in the derma below the degenerating epidermis. The\\nbacillus of tuberculosis has been very rarely discovered and the most\\nof inoculation-experiments have been failures.\\nThe disease is readily diiferentiated from papular eczema by the\\nabsence of itching. From the miliary papular syphiloderm it differs in\\nthat the lesions of the latter, even though grouped, are always individ-\\nually distinct. The general symptoms, moreover, are strikingly differ-\\nent in the two diseases. Lichen scrofulosorum cannot be confounded\\nwith lichen planus or lichen ruber. Lichen pilaris, however, in a young\\nand lymphatic patient might readily be mistaken for the disease in\\nquestion.\\nThis scrofuloderm is rare outside of Austria.\\n[B] Erythema Induratum Scrofulosorum.\\n(Erytheme Indure des Scrofuleux, Bazin.)\\nThis disorder affects chiefly the lower extremities of young persons,\\nespecially girls, who have been accustomed to the erect posture for long\\nperiods of the day and who exhibit as well unmistakable symptoms of\\nscrofula. The special circumstances in which this form of indurated\\nerythema is produced are, primarily, a somewhat enfeebled constitu-\\ntion, and, as a secondary or exciting cause, toil in the standing posture,\\nas, for example, among laundresses and shop-girls.\\nThe symptoms are acutely developed or indolent, single or numer-\\nous, vividly red or purplish-hued, node-like patches on the front and\\ncalf of the legs or over the thighs, or even upon the upper extremities\\n(Crocker). At times a single patch extends by multiplication or by\\nspreading from an original site till a broadly infiltrated plaque is\\nformed, somewhat suggestive of the lesions of erythema nodosum.\\nThe firm induration of the node is one of its striking features. The\\nnodules may be either superficially or deeply situated painful and\\ntender or quite insensitive, the last being the rule and may undergo\\na tedious involution, or degenerate and produce ill-conditioned ulcers,\\nsecreting a thin pus and at times communicating by a fistulous tract\\nwith underlying pus-cavities. Often it is difficult to distinguish clin-\\nically between these nodes and ulcers and those of syphilis the diag-\\nnosis must then rest upon the history and concomitant lesions. There\\nis, as a rule, absence of constitutional symptoms, and especially of fever,\\nan important point in the distinction between this affection and erythema\\nnodosum. Relapses are not infrequent. The disease is rare, occurring\\nchiefly in public practice.\\nThe tuberculous nature of the lesions has not been determined defi-\\nnitely. There is often- enlargement and in some instances suppuration", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0650.jp2"}, "651": {"fulltext": "DERMATOSES OF SCROFULOUS SUBJECTS. 601\\nof the lymphatic glands of the subject of the malady. Johnston 1 and\\nAudry 2 found in their histological examinations dilated vessels, the\\nendothelium of the coiled portion of the sweat-glands swollen rarefied\\nconnective tissue with oedematous separation and disintegration of fibres\\nand an irregular infiltration along the lines of the vessels with lympho-\\ncytes and epithelioid cells. The hypoderm resembled a sponge. There\\nwere no tubercle-bacilli; no mast-cells; no giant-cells.\\nTreatment is by administration of the remedies most efficiently\\nemployed in cachexia and struma, with a generous diet, a recumbent\\nposition of the lower extremities when these are the seat of the disease,\\nand the ordinary management of chronic ulceration of the skin of the\\nlegs when such lesions are present. In a few cases potassium iodide\\nhas been given with advantage when there was no suspicion of syphilis.\\n[C] Necrotic Granuloma.\\n(Acnitis, Folliculitis, Acne Varioliformis, Acne Necrotica,\\nTuberculide, Spiradenitis, Hydros adenitis Suppurativa\\nDestruens, Idrosadenitis, Disseminate Folliculitis, Gran-\\nuloma Innominatum, Necrotizing Chilblain.)\\nIn this affection as yet but imperfectly differentiated from the\\nseveral disorders classed as paratuberculides and described under dif-\\nferent titles, deeply seated, uncolored, painless, and rounded nodules\\nform in the derma or hypoderm which persist for long periods and\\nundergo a slow process of evolution. They at last become attached\\ndeeply to the surrounding and overlying skin, assume a more or less\\nvivid, occasionally a brownish-red tint, and project slightly above the\\ngeneral level of the integument. Flattening and distinct depression\\nof the apex occur, and later central necrosis. The split-pea-sized\\nlesions are varioliform as to size and contour when seated on the hairy\\nportions of the body on the extremities the type is that of the passive\\nhyperemia of pernio. According to Johnston, the features of varioli-\\nform acne are produced when the lesions are pierced by a pilary fila-\\nment, but those of spiradenitis when the coil-glands are involved.\\nAfter separation of the dead central mass a minute pigmented pit is\\nleft. There is no tendency to coalescence. The resemblance of many\\nof the lesions to a papular syphiloderm is striking.\\nThe disease occurs in the subjects of anaemia, struma, and cachexia,\\nwith a tuberculous family history and with coincident keratitis, oste-\\nopathy, and menstrual derangements.\\nNo tubercle-bacilli have been discovered in the tissues examined.\\nThe morbid process is first distinctly recognized in the corium w T ith a\\ncell-infiltration of perivascular site spreading thence to the coil- and\\nsebo-pilary gland-systems. At first there is a moderate grade of\\noedema, which is followed by the development of giant- and epithelioid\\ncells. After an arteritis obliterans central coagulation-necrosis follows.\\nThe explanation of the process suggested by Johnston is that a non-\\nlu The Cutaneous Paratuberculoses, Phila. Med. Jour., February, 1899. The\\nauthors have made use of this essav in their discussion of this theme.\\n2 Annal. de Derm, et de Syph., 1898, t. ix., p. 208.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0651.jp2"}, "652": {"fulltext": "602 NEW-GROWTHS.\\nmicrobic infection working from within outward first betrays its influ-\\nence by the vascular changes, and thence the toxin has probably been\\nswept from a distinct focus through the blood- and lymph-streams to\\nthe point where its influence is first appreciated in the skin.\\n[D] Folliclis.\\n(FOLLICULITE DlSSEMINEE DES PARTIES GLABEES A TENDANCE\\nCicatricielle, Brocq.)\\nThis is one of the paratuberculoses of the skin, in reality a ne-\\ncrotic granuloma, described by Brocq, Barthelemy, Beauprez, Lefebvre,\\nDuCastel, 1 and others, and by them assigned to a group of affec-\\ntions which includes: acnitis, Darier s tuberculides, lupus pernio,\\nacne cachecticorum, erythema induratum, and other similar affec-\\ntions.\\nFolliclis is a rare dermatosis of strumous subjects first displayed in\\nlight-reddish, macules, which develop successively in crops and which\\nprogress to the formation of split-pea-sized, subepidermic and dermic\\nnodules at the apex of which minute vesico-pustules may form and\\nwhich furnish a thin secretion evidently exuded from the sebo-pilary\\nand sudoriparous follicles. Later, in some cases, these lesions become\\numbilicated, deeply pigmented, and when involution is completed are\\nfollowed by a minute cicatrix. They occur on the extremities, the\\nabdomen, and on the hands, in the region last named displaying eryth-\\nematous plaques with adherent scales, the symptoms here being prac-\\ntically those of lupus erythematosus.\\nHistologically no tubercle-bacilli have been recognized and attempts\\nat transmission to the lower animals have been largely failures. A\\nsmall-cell infiltration has been recognized about the follicles invaded,\\nfollowed by central necrosis and suppuration.\\n[E] Lupus Pernio (Besnier).\\nThis is an affection of the face (ala? and bridge of nose, ears, malar\\neminences) and extremities, especially the dorsal surfaces of the hands,\\nwhich is first displayed in circumscribed erythematous disks. These,\\nat one or more points, may break down into superficial ulcerations\\nwhere crusts form. There are accompanying oedema and formation of\\ntelangiectases. Upon the ears livid points are especially likely to be\\nfollowed by tissue-necrosis in split-pea-sized areas, the disease here as\\nelsewhere progressing with great indolence. The earlier symptoms are\\nsuggestive of the ordinary lesions of chilblain. There is no tendency\\nto spontaneous involution. In some instances there is a striking resem-\\nblance of the symptoms to those of Raynaud s disease. Synovitis with\\nfungus has occurred in the joints.\\nThe affection develops in persons of delicate constitution, as also in\\nthose who are tuberculous and strumous. As yet no tubercle-bacilli\\nhave been recognized in the tissues examined.\\n1 Cf. Annal. de Derm, et de Syph., 1887, p. 46 and 1888, pp. 814 and 1045.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0652.jp2"}, "653": {"fulltext": "DERMATOSES OF SCMOFULOUS SUBJECTS. 603\\nErysipelas Perstans. This affection resembles clinically toxic\\nerysipelas, though the coccus of Fehleisen is not responsible for the\\nsymptoms. The affected tissue is cedematous, of a bluish-red, occa-\\nsionally of a vividly red hue with few subjective sensations, rarely\\nan accompanying fever, and but little tendency to spread extensively\\nfrom a given point over the body-surface. It is chiefly remarkable for\\nits tendency to persistence, to frequent recurrences from slight causes,\\nand to the production of a brawny, firm, often beefy-red pachydermia,\\nespecially of the face, though also of the extremities. The affection\\noccurs in persons suffering especially from purulent foci in the nose\\n(rhinitis, polypus, lupus), in the mouth (caries of the teeth), in the lungs\\n(tubercle), or in other organs where a purulent product is deposited.\\nHistologically, like the other paratuberculoses, tubercle-bacilli are\\nwanting; there are oedema of the derma and hypoderm, a serous exu-\\ndate, proliferation of connective-tissue corpuscles, and vascular dis-\\ntention.\\n[F] Pustular Scrofuloderma\\n(Tuberculosis Suppurativa et Bullosa Acuta.)\\nIn this group of disorders the lesions occur as inflammatory papules\\nor pustules of an evident follicular origin. In some cases vesicles and\\nbullae have been commingled with the other lesions. The lesions may\\nbe small or large, few or numerous, limited to one or two well-defined\\npatches or regions, or, as is more commonly the case, diffuse or irregu-\\nlarly grouped. In some of the milder circumscribed cases the mani-\\nfestations are limited to a few scattered or grouped papules and pus-\\ntules situated about the hair-follicles. In other instances the lesions\\nare larger, may coalesce, and be covered with more or less bulky crusts\\nbeneath which ulcers may form. As a rule, the course of the disease\\nis slow and the lesions are indolent in type. Occasionally the symp-\\ntoms are more acute. In the majority of cases the folliculitis is evi-\\ndently due to a local infection with pus-cocci in tissues having but\\nfeeble powers of resistance. In some instances, however, the toxin\\nof a tuberculous focus may be responsible for the symptoms.\\n[G] Acneiform Group of Paratuberculoses.\\nAn acneiform group of paratuberculoses results from the common\\nhabit of picking and scratching the scalp, face, and beard. The finger-\\nnails in these cases are probably the carriers of pyodermic infection in\\nthe skins of strumous and tuberculous subjects. The lupoid sycosis\\nof certain writers refers to a class of cases which may be regarded as\\ndistinct from the simpler varieties of sycosis, since in the lupoid forms\\nlesions persist for several years, and finally leave atrophic and scar-\\nlike or simply wasted lines, points, or areas in the region of the male\\nbeard. Some of the disorders of the scalp termed epilating, cica-\\ntricial, unnamed, follicular and perifollicular, and neurotic\\nalopecias, may be one day assigned to this class of affections.\\nAcne Necrotica (Ulerythema Acneiforme). Under the title", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0653.jp2"}, "654": {"fulltext": "604 NEW-GROWTHS.\\nlast named Unna 1 describes and figures a disease on the face of a young\\ngirl, beginning with the production of papules in the centre of the\\ncheek, where finally developed comedone-like masses the lesions with-\\nout suppuration eventually left reticulated and pitted scars perceptibly\\nsunken and traversed by dull-white ledges between which comedones\\nwere visible. The lesions were also visible about the scalp, forehead,\\nand ear. Anatomically it appeared that inflammatory symptoms re-\\nsulted in a perifollicular cell-infiltration, with dilatation of lymph-spaces\\nand consequent changes in the epithelium, as well as in the muscular,\\nelastic, and other tissues.\\nTuberculous Eczema (Unna) is merely an exudative affection,\\nwhich may be recognized in proximity to the scrofulodermata, a process\\nawakened by the irritative effects of the latter or the disease occurs,\\nas do other affections, in scrofulous patients.\\nMelanoderma of the Scrofulous (Pigmentary Tuberculide).\\nIn some of the subjects of scrofula and tuberculosis a hyperpigmen-\\ntation of the skin has been produced strongly resembling the pigmen-\\ntary syphilide. The coloration is in varying shades of brown, and forms\\na reticulated staining of the regions about the face and neck, though\\nother parts may be involved. Between the pigmented spots lighter\\npoints and dots of a less deeply stained integument are commonly\\nvisible. The well-known influence of tuberculosis of the adrenals hi\\nthe production of pigment-changes in the skin lends color to the\\nbelief that some of these cases are due to the toxins of a tuberculosis\\nof non-integumentary tissue. Similar pigment-changes in the skin\\nhave been determined to be the result of paludism, carcinoma, syphilis,\\nand other disorders and it is reasonable to conclude that the changes\\nhere set down in some instances at least are the product of tuberculous\\ntoxins.\\nLupus Erythematosus (consult the following chapter) is by some\\nauthors classed with the disorders grouped under the title of tubercu-\\nlosis cutis or as a paratuberculosis. The evidence that it is itself a\\ncutaneous tuberculosis is wanting. That, however, it is in some cases\\na dermatosis of the scrofulous cannot be questioned.\\nLUPUS ERYTHEMATOSUS.\\n(Lat. lupus, a wolf.)\\n(Lupus Sebaceus, Lupus Superficialis, Scrofulous Ring-\\nworm, Seborrhcea Congestiva, Lupus Erythematodes,\\nLupus Non-exedens, Ulerythema Centrifugum. Ft.,\\nscrofulide erythemateuse, erytheme centrifuge.)\\nThis disease was first described by Biett under the title Erytheme\\nCentrifuge. Hebra, in 1845, described it among the seborrheas, as\\nSeborrhoea Congestiva. Its present title was given by Cazenave in\\n1850.\\nSymptoms. The disease is first exhibited in one or several rape-\\nseed- to bean-sized, slightly elevated reddish macules which do not\\n1 Internat. Atlas of Kare Skin-diseases, 1889, i.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0654.jp2"}, "655": {"fulltext": "LUPUS ERYTHEMATOSUS. 605\\nentirely fade under pressure and are covered with a grayish or yellow-\\nish and sometimes slightly greasy, adherent scale.\\nIn the ordinary Discoid form of the disease the primary lesion\\ndescribed above enlarges its periphery in the course of months or years\\nby a slowly continuous development. It may thus gain the size of a\\nsmall coin or a large saucer. The disks or patches are well denned\\nin outline, of a color varying with the complexion of the patient and\\nwith the acuteness or type of the disease, from a rosy-pinkish to a deep-\\npurplish hue. The shape is usually circular, oval, or in figures rep-\\nresenting combinations of these outlines, but it may be irregular from\\nthe junction of two or more progressing patches. Its border is red,\\nFig. 70.\\nLupus erythematosus of the face.\\nfirm to the touch and distinctly elevated, and not infrequently exhibits\\ncomedones or light adherent scales. The centre is depressed, paler in\\ncolor, and shows either adherent yellowish-gray scales or a glistening\\nunbroken epidermis. Close examination will disclose in most cases\\ndilated follicular openings w r hich may be plugged Avith dried sebaceous\\nmatter or horny epithelium. The scales vary in color, being at times\\nof a clear white or whitish yellow, and again often from concurrence\\nof comedones of a reddish or brownish tint. They are usually scanty\\nand adherent, but may be abundant, and can occasionally be seen\\nfirmly fastened to the orifice of the excretory duct of a sebaceous gland\\nby means of a horny projection from the under surface. In some cases\\nthe erythematous redness, in others the crusted surface of the disk, is", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0655.jp2"}, "656": {"fulltext": "606 NEW-GROWTHS.\\nthe most pronounced feature. In the latter there are seen at times\\npatches exhibiting almost a pure type of seborrhcea faciei.\\nThe disease is seen most frequently on the nose and cheeks, over\\nwhich it may spread symmetrically in a form that has been likened\\nby Hebra to the open wings of a butterfly. It occurs also on other\\nparts of the face, the ears, the scalp, the back of the hands and ex-\\nceptionally on other portions of the body. On the scalp the dilated\\nfollicles and comedones are especially pronounced, while the elevated\\nborder is rather less distinct than on the face. The alopecia which\\nresults is permanent. Rarely the mucous membrane may be involved,\\npresenting reddened plaques with minute excoriations, or partially cov-\\nered with a whitish exudate or with punctate scars.\\nAs the borders advance the centre not infrequently undergoes invo-\\nlution, and may show typical scars even while the outer rim is actively\\nprogressing. When the disease undergoes general involution both the\\ncentre and the border gradually become paler in color and less ele-\\nvated. Some of the patches resolve without leaving a trace of their\\nexistence, but in most instances typical scars are left. These are in-\\ndelible and characteristic. They are generally uniform and superficial,\\ncan be pinched up readily between the thumb and finger, are of a dull-\\nwhitish tint, and rendered punctate in a peculiar manner, suggesting\\nthe action of the engraver s tool in what is known as the stippling\\nprocess. They are never pigmented, puckered, radiate, stellate, corded,\\nor deeply attached.\\nThe disease is remarkably chronic in its course, lasting in cases for\\na quarter of a century or even longer, and throughout not interfering\\nwith the general health. So-called galloping cases, usually with\\nmarked visceral complications, are described by French writers. The\\ndisease varies in the subjective sensations it produces, being generally\\naccompanied by no discomfort, though at times by some itching or\\nburning. It is more common in women than in men, and is a disease\\nof adult years, usually appearing first in the third or fourth decade.\\nKaposi reports a single case in a child three years of age.\\nThough the disease usually progresses by a very slow extension of\\nthe border, it may, after remaining comparatively stationary for months\\nor years, rapidly advance for a short period and then again remain sta-\\ntionary. These periods of rapid progression usually follow or are\\naccompanied by a peculiar type of acute dermatitis suggesting a mild\\nform of erysipelas.\\nAmong the unusual features of the disease may be mentioned an\\nacute form, named by the French Eeytheme Centrifuge, which has\\nmost of the characteristics described above, except that the symptoms\\nare more acute and the vascular elements more marked. This condi-\\ntion may disappear, leaving the skin entirely normal, or it may be fol-\\nlowed by the more common type of the disorder. The reddened\\nplaque has been by several authors likened to the lesions of exudative\\nerythema, being hot to the touch, tender, raised, and manifestly cen-\\ntrifugal in its mode of extension.\\nThe Telangiectatic form is occasionally seen. Here points, spots,\\nplaques, or large disks, on the surface, chiefly of the face, usually well", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0656.jp2"}, "657": {"fulltext": "LUPUS ERYTHEMATOSUS. 607\\ndefined, present a rosy-reddish, or deep-purplish color which disap-\\npears under pressure. When examined with care the color is seen to\\nbe due to dilatation of the cutaneous vessels. The surface may be\\neither slightly cedematous, or infiltrated, and correspondingly elevated.\\nThere is an absence of scaling and of dilated follicles, but typical scars\\nnot infrequently follow the involution of this type of the disorder.\\nLupus Disseminatus. The disease occasionally occurs in a dif-\\nfuse form. As a rule, the lesions first appear on the face, but later\\nthey develop on any part of the body, and often large surfaces are\\ninvolved. The lesions are small, varying in size from that of a pinhead\\nto that of a bean, and though usually presenting characteristics similar\\nto the beginning patches of the more common type, they may assume\\natypical forms resembling the lesions of erythema multiforme, urticaria,\\nsyphilis, acute psoriasis, or pityriasis rosea. At times the subjective\\nsensations are severe (itching, burning, heat, etc.), and the patches may\\neven be the seat of vesicles, pustules, or bulla?. This form of the dis-\\nease is accompanied in most instances by such systemic disturbances\\n(arthritic, gastro-intestinal, and febrile) as occur in erythema multi-\\nforme. In rare instances there are changes suggesting erysipelas, some-\\ntimes accompanied by typhoid and other malignant symptoms. In\\nsome of these cases death has resulted.\\nLupus Pernio 1 is another unusual form in which the lesions are\\nexhibited on the fingers and toes particularly, but also on other parts\\nof the hands and feet and on the pinna of the ear, beginning as a more\\nor less persistent erythema of the type of pernio (chilblain). Like the\\nlatter disease, this erythema may disappear and reappear with the\\nseasons for several years, but eventually may persist and assume the\\ndiscoid type.\\nThe Livedo Form. A rare subvariety is recognized on the face,\\nhands, and other regions where the symptoms present the character\\nof local asphyxia. Here the influence of the trophic nerves, as in\\nother conditions with similar symptoms, is distinct. The disease begins\\nwith the production of livid spots in the regions named, which persist\\nfor months or even years, and eventually degenerate at the centre,\\nleaving a slough beneath which is an ulcer. In these cases, also, tuber-\\nculous complications may occur in the joints.\\nEtiology.\u00e2\u0080\u0094 -Lupus erythematosus is described by some writers as a\\nvariety of lupus vulgaris, but the histopathology of the former disease,\\nthe absence of tubercle-bacilli, and the negative results of many inocu-\\nlation-experiments seem sufficient to disprove such relationship. The\\ntransitional forms occasionally reported usually prove to be mild and\\nunusual types of lupus vulgaris.\\nAlthough lupus erythematosus has none of the essential character-\\nistics of a local tuberculosis, it occurs not infrequently as a dermatosis\\nof the tuberculous. Besnier was the first to call attention to the fact\\nthat lupus erythematosus is in many instances associated with general\\nor local tuberculosis. Cases in which this association occurred have been\\n1 Cf. contributions to this subject by one of us, Jour. Cutan. and Ven. Dis., 1884\\nand by Ohmann-Dumesnil, Ninth Internat, Medical Congress, 1887.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0657.jp2"}, "658": {"fulltext": "608 NEW-GROWTHS.\\nreported by a number of observers. Boeek x records forty-two cases of\\nthe common discoid type, in twenty-eight of which he found evidences\\nof present or past tuberculosis. Roth 2 collected records of two hundred\\nand fifty cases of lupus erythematosus, in one hundred and eighty-five\\nof which evidence of local or general tuberculosis could be obtained.\\nIn such cases Boeck concludes that the toxins of the tubercle-bacillus\\nact first upon the vasomotor centres of the skin and later upon that\\nportion of skin which is the seat of the vasomotor disturbance.\\nTuberculosis should thus be counted as an important factor in the\\netiology of lupus erythematosus, but that it is the sole cause or even\\nan essential factor has not been demonstrated. The disease is seen fre-\\nquently in individuals in whom there is no history or other evidence of\\ntuberculosis in any form. It occurs in conjunction with anaemia,\\nchlorosis, and other disorders. In many patients careful investigation\\nfails to discover any other evidence of ill health. By some writers the\\ndisease is considered a chronic inflammation due to a specific infection.\\nThe disease is more common in women than in men, two-thirds of\\nthe former to one of the latter, and usually appears first in the third\\ndecade of life, in this particular presenting a contrast with lupus\\nvulgaris. It may, however, first develop in childhood, middle life, or\\nold age.\\nLupus erythematosus may follow eczema seborrhoe icum, acne, undue\\nexposure to sunlight, variola, erysipelas, vesication with cantharides,\\nor the traumatism of leech-bites. It may appear where the curette\\nhas been employed in a patient with a characteristic patch elsewhere\\non the face. It occasionally develops on portions of the face and hands\\nthat have been subject to recurrent attacks of pernio.\\nPathology. Lupus erythematosus has been studied carefully by\\na number of observers, but unfortunately they do not agree either in\\ntheir histological findings or in their conclusions based upon the\\nlatter. In general it may be said that the chief changes are found\\nin the upper half or third of the corium in the form of a dense infil-\\ntration of small round cells of embryonic type, a small proportion of\\nwhich is probably the result of proliferation of the fixed cells of the\\npart. The infiltration varies greatly in extent and in density in dif-\\nferent types of lesions, but is most pronounced along the course of the\\nvessels. It is often found in slight degree in the deeper parts of the\\ncorium and subcutaneous tissue but it nowhere forms nodules as in\\nlupus vulgaris there are no giant-cells and there is no degeneration\\nof a mass of cells as in the latter disease. Individual cells here and\\nthere undergo a granular and fatty or colloid degeneration, disappear\\nby absorption, and are replaced by new cells. The connective-tissue\\nfibres are destroyed in the same way. Many of the vessels are seen\\nto be greatly distended and choked with red blood-corpuscles, others\\nshow a proliferation of their walls and in some cases an obliterating\\nendarteritis. Diifuse or localized hemorrhages are found in the upper\\npart of the cutis. By some observers the vascular changes are con-\\nsidered primary in the process. The sebaceous glands are at first\\n1 Arch. f. Derm. u. Syph., 1898, Bd. xlii., S. 71.\\n2 Ibid.,, 1900, Bd. li., S. 3.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0658.jp2"}, "659": {"fulltext": "LUPUS ERYTHEMATOSUS. 609\\nhypertrophied, affected with hypersecretion, and become filled with cells\\nand abnormal sebaceous matter. Later both they and the ducts of the\\ncoil-glands may become infiltrated, undergo degeneration and dis-\\nappear, leaving the peculiarly punctate form of scar characteristic of\\nthe disease.\\nThe epidermal layers are involved secondarily. They become\\natrophied, and the interpapillary depressions of the rete as well as the\\npapillae are largely obliterated.\\nFordyce and Holder 1 investigated a number of cases of the discoid\\ntype and describe a peculiar blocking of the capillaries with blood-cells\\nwhich they believe to be the primary change. They divide the factors\\nmaking up the histopathological complex into the round-cell infiltra-\\ntion, the peculiar degenerated condition of connective tissue, and the\\nsecondary atrophy. They find that the commonly described fatty and\\ngranular degeneration is not characteristic of the process, and recom-\\nmend that for purposes of study tissue from lupus erythematosus areas\\nbe imbedded in paraffine and stained with acid orcein.\\nRobinson, 2 after examining a number of cases and reviewing the\\npublished reports of others, states that the primary lesion, which\\nmay be seated in any part of the corium, is focal in character, and\\nwhen fully developed constitutes a new-growth, which is reticular in\\nstructure and closely connected with the lymph-channels. He con-\\ncludes that lupus erythematosus is a chronic inflammatory disease of\\nthe cutis with special histological characters, as shown by the changes\\nin the blood-vessels new blood-vessels in the affected area, lymph-\\nvessels and lymph-channels, and the new-formation of an adenoid-like\\ntissue by reticular tissue, by the presence of mononuclear and by the\\nabsence of polynuclear cells in the cell-infiltration; and that these\\nchanges must depend upon the presence of a poison generated in loco.\\nIn other words, lupus erythematosus is a local infective process a\\ngranuloma.\\nDiagnosis. The facies of the patient with lupus erythematosus of\\nthat region is Usually so characteristic that the disease is there recog-\\nnized with ease. When the hand and other portions of the body are\\ninvolved the diagnosis is somewhat less readily established. In the\\nhand the disease has a predilection for the dorsum, and invades the\\npalm usually only by extension to it from behind.\\nFrom lupus vulgaris erythematous lupus may be recognized by its\\noccurrence originally at a later period of life by its greater tendency\\nto symmetry; and by the absence of nodules, ulceration, and extension\\nto the deeper portions of the skin or underlying structures. Cases\\nundoubtedly occur in which the diagnosis is difficult, as in the type\\ncalled by Leloir lupus vulgaris erythematoide. But as in all cases\\nof lupus vulgaris typical nodules appear sooner or later, the diagnosis\\ncan eventually be established.\\nIn eczema there is usually some history of moisture in erythema-\\ntous lupus, rarely. In eczema, also, the itching is a more persistent\\nand distressing symptom but the acuteness of even chronic eczema, as\\n1 N. Y. Med. Kecord, July 14, 1900.\\n2 Trans. Amer. Derm. Assoc., 1898.\\n39", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0659.jp2"}, "660": {"fulltext": "610 NEW-GROWTHS.\\ncompared with lupus erythematosus, will suffice to distinguish the two\\ndiseases. From eczema seborrhoeicum, however, the diagnosis may be\\ndifficult and may have to depend on a therapeutic test, the latter dis-\\nease disappearing under appropriate treatment. Psoriasis is rarely, if\\never, limited to a single patch on the face it is also characterized by\\nmore lustrous and more readily exfoliating scales. Its patches are,\\nfurthermore, uniformly well covered with scales, and are of equal flat-\\nness in all parts, while those of lupus erythematosus are irregularly\\nsquamous, the scales being often clustered at the orifices of the ducts\\nof the sebaceous glands, while the rim of the patch is elevated and the\\ncentre depressed. From pernio the diagnosis sometimes can be made\\nonly after determining whether the lesions disappear during the warm\\nseason, as in pernio or persist, as in lupus erythematosus.\\nIn acne rosacea there are marked telangiectases and papulo-pustules\\nor nodules which are not found in erythematous lupus. In tinea cir-\\ncinata there may be a clearing, but never a cicatriform centre of the\\ncircular disk. The circular serpiginous syphilodermata of the face\\noccur usually with other manifestations of lues, are characterized by\\ngreater infiltration, a more rapidly progressing border formed by the\\ncoalescence of individual papules or tubercles, and in most cases the\\nsyphilitic lesions exhibit distinct signs of ulceration. The not infre-\\nquent modification or masking of a patch of the disease by an acute or\\nsubacute dermatitis (often seborrheal in character) should be borne in\\nmind.\\nTreatment. The internal treatment of this affection is not highly\\nsatisfactory often none is indicated or required. Of course, the general\\nhealth of the individual should be carefully investigated, and all defects\\nremedied if possible. The administration of potassium iodide, mercuric\\niodide, iodoform in 1 grain (0.06) doses (Whitehouse), starch iodide,\\narsenic, iodoform, ammonium carbonate, ichthyol, sodium salicylate, and\\nmany other remedies have been advocated by different writers. It is\\ndoubtful if these articles ever do good unless indicated by the patient s\\ngeneral condition, while they often do much harm. The last three\\nremedies on the list given above are said by Fox, Unna, and others, to\\nlessen the congestion of the face. When they do produce this effect it\\nis possible advantage may be derived from their use.\\nThe local treatment of the patches of the disease is of importance,\\nfor though the number of cases amenable to treatment is decidedly in\\nthe minority, the fact that even a few improve or recover under\\ntreatment is sufficient reason for attempting to remove this unsightly\\ndisorder. The number of remedies recommended for local use in\\nlupus erythematosus is enormous. White, 1 in reviewing the subject,\\nhas enumerated some fifty of those most promising, at the same time\\ncalling attention to the fact that lupus erythematosus is no exception\\nto the rule that the curability of a disease is in inverse ratio to\\nthe length of the list of the means recommended for its cure. He\\nadmits that our treatment of this disease is wholly empirical and not\\nvery hopeful. Unna 2 attempts a rational form of treatment based on\\n1 Jour. Cutan. and Gen.-Urin. Dis., 1898, p. 457.\\n2 Ibid., ,p. 465.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0660.jp2"}, "661": {"fulltext": "LUPUS ERYTHEMATOSUS. 611\\nhis conception of the etiology and pathology of the disease and of the\\naction of certain remedies. While his scheme is based largely on\\ntheories that are not yet capable of demonstration, the details of his\\ntreatment are of practical value. He calls attention in particular to the\\nfact that while the epidermis is exceedingly dry and hyperkeratotic, the\\ncutis is markedly cedematous and the seat of dilated lymph-spaces and\\nchannels, and emphasizes the dangers of stimulating a dry indolent\\nprocess into an active dermatitis.\\nFor convenience, the remedies used may be divided into three\\nclasses the soothing and astringent, the stimulating, and the destruc-\\ntive. The choice of remedies will depend largely upon the type of\\nthe disease and on the character of the individual skin. In the acute,\\ninflammatory, or vascular type soothing remedies alone should be used,\\nand on a skin which reacts readily to stimulation stronger remedies\\nare not allowable. Nor should it be forgotten that the indolent forms\\nof the disease not infrequently under treatment become acutely in-\\nflamed, and call for the temporary use of soothing measures. Inas-\\nmuch as the affection is one the involution of which occasionally is ac-\\ncomplished under the influence of mild topical applications, and is\\nsucceeded very rarely by grave sequels, the simpler measures should\\nalways be adopted first. In the way of soothing and astringent prep-\\narations, the lotions, powders, simple ointments, and pastes recom-\\nmended for the treatment of acute eczema can be employed to advan-\\ntage. The zinc oxide powders and lotions are especially to be com-\\nmended, as are also the cold-cream salve, the Hebra, and the zinc oxide\\nointments. The paste containing equal parts of lanolin, vaselin, zinc\\noxide, and talcum makes an excellent base. Boeck s liniment (talci,\\namyli, aa sijss (10.); glycerin., 3j (30.); aq. plumbi, sv (160.); and\\nUnna s pulvis cuticolor (zinc, oxid., boli rubrse, aa, 2 boli albse,\\nmagnes. carbonat., aa, 3 amyl. oryzoe, 10) are valuable preparations\\nin acute and irritable stages of the disease.\\nFrequently much can be accomplished through protection and com-\\npression of the surface by the application of collodion, the glvcogela-\\ntins, or tragacanth-jelly. Unna recommends especially for irritable\\ncasee\\nR Ichthyol. (vel ichthyol. sulfon.), 3ss 2\\nCollodii, 3v; 20 M.\\nFor more indolent cases\\nR Saponis virid., 3ss-ij 2-4\\nCollodii, 3v; 20 M.\\nTo the latter may be added 1 or 2 parts of salicylic acid.\\nUnna recommends also gelanthum as a substitute for collodion in the\\nabove formulae, for though it does not produce as much compression\\nas the latter, it is more convenient in that it may be washed off at any\\nmoment with warm water. A favorite formula with him is potass.\\nhydrat., 1 gelanthum, 1000.\\nFor the purpose of producing more or less stimulation of the sur-\\nface there may be added to the lotions, ointments, and pastes suggested", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0661.jp2"}, "662": {"fulltext": "612 NEW-GROWTHS.\\nabove, from 2 to 20 per cent, of sulphur, or from 1 to 5 per cent, of\\nsalicylic acid, white precipitate, resorcin, ichthyol, or tar. The mild\\nsalicylated soap plasters or the plaster-mulls containing the above\\nremedies in small amounts, or a reduced mercurial plaster may be\\nused where a moderate amount of stimulation is desired. Excel-\\nlent results follow the use of green soap applied as a plaster or in the\\nform of tincture. It not only cleanses the patches of the scales, but\\nalso stimulates the surface, often to the extent of inducing a repara-\\ntive process. The patch may be briskly rubbed either with soap or\\ntincture of soap in combination with hot water, after which a simple\\nointment or one containing a small amount of sulphur or other of the\\nremedies suggested above may be applied. When decided irritation\\nof the parts is produced, the soap should be discontinued and the hot\\nwater and ointment be employed alone for a time. A decidedly bene-\\nficial effect is noted occasionally after the topical application, for\\ntwenty minutes at a time, of very hot water alone. After drying, the\\nsurface should be dusted with a powder or covered with a simple oint-\\nment or paste.\\nThe following is a gentle stimulant\\nR Zinci sulphat., J __\\nPotassii sulphuret., *.\u00c2\u00abo**, aa l\\nSpts. vin. rectif., f 3iij 12\\nAq. rosse, f ^iijss 105\\nSig. To be diluted as required for external use.\\nThe following is a formula for a stronger lotion\\nR Chrysarobin., Sijss; 10\\nAcid, salicylici, s _ o\\nCalaminis pulv., j aa 3ss; aa Z\\nJEtheris, f 3j 4\\nCollodii flex., f3v; 20\\nSig. To be applied with a brush.\\nM.\\nM.\\nThe non-vascularized, indolent varieties of erythematous lupus are\\noften treated with very satisfactory results by the topical application of\\na saturated solution of pyoktanin-blue. This method has the great\\ndisadvantage of producing a deep bluish stain of the face, but the dis-\\nfigurement is willingly tolerated for a brief period by patients who have\\nlong suffered from -the facial unsightliness of the disease itself. The\\nsolution is thickly painted daily over the entire portion affected and\\nthe application usually may be made by an unskilled hand. No pain\\nis produced and no untoward effect of any kind has been noted. The\\napplications have been repeated continuously for sixty days and more\\nwith excellent results.\\nEnzymol painted over each patch several times in the day has been\\nfollowed in some cases by marked improvement.\\nHans Hebra 1 applies several times daily alcohol on cotton pads.\\n1 Wien. med. Woch., 1899, pp. 13-18.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0662.jp2"}, "663": {"fulltext": "LUPUS ERYTHEMATOSUS. 613\\nThe evaporation of the spirit and abstraction of water produce the\\nbeneficial effect.\\nFinsen s phototherapy, described under the treatment of lupus vul-\\ngaris, and the employment of the #-ray have been successful in a few\\ncases.\\nIn exceedingly obstinate cases, those especially in which the elevated\\nrim of the erythematous disk refuses to yield to the simple measures\\ndescribed, a solution of caustic potash in distilled water, 1 part to 2 or\\n4, may be gently applied with a camel s-hair brush, and the alkali\\nimmediately neutralized by the addition of dilute muriatic acid as soon\\nas the desired effect is produced. That effect, it must be remembered,\\nis superficial cauterization only. When the sero-sanguineous exudation\\nand reactive effects disappear the rim is seen to be flattened and to have\\nlost in part its violaceous blush. After such severe application, which\\nshould never be trusted to the hand of one unskilled in its use, an\\nanodyne cerate containing morphine or opium should be spread over\\nthe part.\\nIn indolent patches where decided stimulation or even a very super-,\\nficial destruction of tissue is desired, mercurial plaster, the stronger\\nsalicylated soap-plasters, and plaster-mulls are to be recommended, or\\ncreosote, carbolic acid, thilanin, chrysarobin, pyrogallol, salicylic acid\\nand pyrogallol (1 part of the first and 3 of the second to 40 parts of\\nflexible collodion, Brocq), silver nitrate, lactic acid, or Fowler s solution\\nmay be used. Two drachms (8.) each of iodine and potassium iodide\\nmixed with 4 drachms (16.) of glycerin or equal parts of chloral,\\ntincture of iodine, and carbolic acid, are recommended highly. These\\nstronger remedies, however, are to be used with great caution and only\\nin indolent cases, and then only after milder measures have failed to\\nproduce good results.\\nWhere more extensive destruction of tissue is required caustics are\\napplied, as carbolic, lactic, pyrogallic, or chloracetic acid. A strong\\nsolution of potassium hydroxide or mercuric nitrate, or an arsenical\\npaste, may be employed.\\nIn a few cases electrolysis has been of benefit. Erasion with a\\ndermal curette, as well as operation by multiple punctures or by linear\\nscarifications, is of less value than in lupus vulgaris. Erasion has in\\nsome instances been followed by involution of the disease, but also,\\nas a rule, by cicatrices that are no less disfiguring than the original\\ndisorder.\\nPrognosis. A favorable opinion with respect to the future of the\\ndisease can never safely be given though as regards the general\\nhealth and comfort of the patient there can rarely be question. At\\nthe same time the affection is capricious in its course, and may on\\noccasions, after long periods of persistence, rapidly improve under the\\nsimplest treatment. Spontaneous involution with disappearance of all\\nsymptoms is reported in some cases. The disorder is liable to relapse,\\nthough not to frequent recurrence. Its tendency to the production of\\npersistent scars should always be remembered in formulating a prog-\\nnosis.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0663.jp2"}, "664": {"fulltext": "614 NEW-GROWTHS.\\nSYPHILIS.\\n(Gr. gvq and (j ihog, a companion of swine term coined for poetical purposes by Fracastor.)\\n(Lues Venerea, Morbus Gallicus, Pox, Bad Disorder. Fr.,\\nVerole; ItaL, Sifilide Ger., Lustseuche, Krankheiten\\nder Franzosen; Span., Sifilis Swed., Radezyge.)\\nSyphilis is a chronic and infectious disease not yet actually demon-\\nstrated as having a microbic origin, but its position among the infec-\\ntious granulomata is practically established. Lustgarten, Doutrelepont,\\nand others have demonstrated the presence of bacilli (resembling those\\nfound in tubercle) in papules, nodes, chancres, and secretions from\\nsyphilitic lesions but the strict requirements of science as to proofs of\\netiological value for these particular germs have not been satisfied with\\nrespect to this disease. Whether these micro-organisms or others are\\nfinally demonstrated to be the potent agency in producing syphilis\\nwhen it is transmitted by the medium of a virus, it is at least certain\\nthat late investigations into the nature of lepra and tuberculosis lend\\nstrong support to the doctrine that the contagium of syphilis is due to\\nthe presence in its secretions of a species of bacterium.\\nSyphilis has been described as an imitator of other diseases.\\nThe manifestations of the malady are certainly protean in character,\\nand they may occur in every organ and tissue of the body. These\\nphenomena are both like and unlike the symptoms of non -syphi-\\nlitic diseases of such organs and tissues. It would, therefore, be more\\nin accordance with facts to describe syphilis as a special mode of dis-\\nease. Its phenomena differ from other pathological phenomena chiefly\\nin the syphilitic modality with w r hich they are impressed. After\\ninfection there is a different behavior of the living matter of which the\\nbody is constituted. Its mode thenceforward is temporarily changed as\\nregards the process of disease. Hence the importance of recognizing\\nthis modality in relation to disease of the skin, and of ascertaining\\nthe limits within which this influence is both originated and exhausted.\\nBicord was first to classify the phenomena of syphilis in three dis-\\ntinct stages. In the first stage, or primary syphilis, were included\\nsymptoms relating to the chancre and its accompanying adenopathy.\\nIn the second stage, lasting from the date of the onset of general\\nsyphilis during a period of about two years, were grouped symptoms\\nthat were, as a rule, superficial, symmetrical, and more or less tran-\\nsitory. In the third, or tertiary, stage the symptoms included were,\\nas a rule, asymmetrical, more profound, involving the subcutaneous\\nand deeper tissues, and invading often not merely the skin, but also\\nthe osseous, cartilaginous, and other structures of the body, including\\nthe viscera. This simple scheme when first given to the scientific\\nworld revolutionized all previous conceptions of the disease, and has\\ndominated the medical profession up to the present time.\\nBut there are objections to a continued acceptance of this scheme,\\nbased largely on its incompleteness. The distinctions it seeks to make\\nare wholly artificial, are defined by poor limits, and so often are com-\\npletely negatived that they fail to explain the most important of accidents.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0664.jp2"}, "665": {"fulltext": "SYPHILIS. 615\\nTo be consistent and to explain in part the violations of their time-\\nschedule, the French have coined such phrases as precocious/ tardy/ 7\\ngalloping/ 7 etc. Further, the mind once dominated by this scheme\\nwas educated to look for the evolution of symptoms within each of these\\nartificial stages in a determinate order, e. g. y after the occurrence of\\nmacules succeeded papules after these, pustules, tubercles, etc., a\\nprogression rarely observed in any given case.\\nThe Symptoms of syphilis are best studied, as they are clinically\\ndisplayed in distinct departures from the infection-moment, along lines\\nwhich are not fixed, but between which symptoms are intermingled with\\nvarying shades of severity. The four chief classes which may thus be\\nrecognized include most of the clinical pictures of syphilis\\nI. Benignant Syphilis, with Superficial and Transitory Symptoms.\\nIn this first class the skin-lesions of general syphilis are few and at\\ntimes are even insignificant. A macular rash, for example, over the\\nsurface of the chest and belly, lasting for a few days or for a week or\\nmore, accompanied by ganglionic enlargement, after involution, leaves\\nthe patient for the remainder of life free from obvious signs of the\\nmalady. These instances are rare.\\nII. Benignant Syphilis, with Superficial and more or less Persistent\\nSymptoms. In this class are to be catalogued most cases of the disease.\\nSome cases relapse to it from the class previously described others,\\nfewer in number, retrograde to one of the groups named below. There\\nis throughout no cachexia, and the skin-symptoms of the affection are\\nneither destructive nor deep. Their chief significance lies in the fact\\nthat they may persist or may recur until the disease, either as a result\\nof treatment or of a decline due to other causes, ceases to manifest itself\\nby any symptoms whatever.\\nIII. Malignant Syphilis, with Profound, Relapsing, or Persistent\\nSymptoms that Ultimately Resolve. In this group are collected those\\ncases in which, with persistent or with recurrent symptoms gradually\\ninvolving the deeper structures of the body, the system suffers to the\\nextent of exhibiting the signs of cachexia. Patients in this class, by\\nreason of efficient treatment or the reverse, are readily transferred both\\nto the second class and to the fourth.\\nIV. Malignant Syphilis, with Profound and Relapsing, or Persistent\\nSymptoms that are Ultimately Destructive. In this class are included\\nthe gravest forms of the disease those exhibiting deep and destruct-\\nive cutaneous lesions those implicating the viscera, bones, and other\\nstructures those interfering with the integrity of organs by reason\\nof either atrophic or degenerative changes succeeding a circumscribed\\nor gummatous involvement of tissue.\\nISTo one of the groups of symptoms named above necessarily follows\\nany other. The last-described group may occur within a few months\\nafter the appearance of so-called primary syphilis/ 7 even though\\nformerly included in the old nomenclature among those of late, or ter-\\ntiary, type. Many cases, indeed, of grave syphilis are of the type de-\\nscribed by the French as precocious 77 that is, they develop symp-\\ntoms of gravity either before or soon Lifter the healing of the chancre.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0665.jp2"}, "666": {"fulltext": "616 NEW-GROWTHS.\\nChancee.\\nEvery attack of acquired syphilis exhibits as a first symptom an\\ninfecting chancre, and every infecting chancre signifies syphilis.\\nA chancre is that modification of the sound or of the pathologically\\naltered skin or mucous membrane, preceded by a period of incubation,\\ncharacterized by sclerosis, and accompanied by adenopathy, which con-\\nstitutes the initial lesion of inevitable syphilis. Chancres usually appear\\nupon or about the genital organs simply because these organs are most\\noften exposed to the disease. These lesions may, however, occur upon\\nany portion of the surface of the body.\\nChancres appear after a period of incubation an interval of time\\nbetween the date of exposure to the disease and the manifestations of\\nits first symptom. This period averages twenty-one days, but it may\\nextend from ten days to two months and even more.\\nThe chancrous modification may involve, as stated above, the nor-\\nmal or the pathologically altered skin or mucous membrane. Upon\\npreviously sound surfaces chancres may appear, after an incubative\\nperiod, as macules, papules, tubercles, erosions, fissures, or ulcers, each,\\nor either of which, at some future period of its history is character-\\nized by a peculiar hardness of the tissues about and beneath the lesion,\\nthis condition being known as the initial sclerosis. These symptoms\\nvary according to the location of the chancre and the friction or other\\nexternal irritation to which the lesion has accidentally been subjected.\\nGenerally it may be said that all chancres tend to conform to the\\npapular type, the macule developing into the chancrous lesion, the\\ntubercle being evolved from its exceptional enlargement, the ulcer\\nfrom its degeneration, and the erosions or fissures from the accidents\\nof its less pronounced features. Occurring upon mucous or quasi-\\nmucous surfaces these lesions are influenced by heat, moisture, and\\nfriction (labia, prepuce, etc.). Here the superficial erosions are usually\\ncircular in outline, are very slightly depressed, and they rest upon\\ndelicate beds of sclerosed tissue, the so-called parchment-induration.\\nThe papule is often represented by a tolerably well-circumscribed,\\nmacular discoloration of the membrane, where coarse examination\\nwould scarcely suggest elevation of the surface, with a sclerosis of no\\ngreater extent than that of the erosion, w r ith which it probably sustains\\na close relation. As a result of heat, moisture, and friction, however,\\nthe typically dry and scaling papule constituting the chancre of the\\nintegument is here rarely encountered. More often the lesion is a\\ncircumscribed ulcer with clean-cut walls, penetrating deeply to the\\nderma or even below, with a scanty secretion and a reddish floor, rest-\\ning upon a split-pea-sized mass of sclerosed tissue. Other usual forms\\nare superficial erosions, in themselves of insignificant aspect, surmount-\\ning large nodules, tubercles, or even long linear ridges of densely\\nsclerosed tissue, undergoing repair or degenerating according to the\\ncondition of the patient and the treatment to which he has been sub-\\njected. These erosions are usually out of proportion to the size of\\nthe indurated mass upon which they rest. Such voluminous indura-\\ntions are occasionally perforated by deep conical or funnel-shaped", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0666.jp2"}, "667": {"fulltext": "SYPHILIS.\\n617\\nulcerations of formidable aspect, to which the name Hunterian\\nchancre was once applied.\\nOccurring upon cutaneous or mucous surfaces, where there has been\\na previous morbid process, the syphilitic mode is impressed upon the\\nsymptoms significant of such antecedent disease. This accident is\\nsufficiently common, and the resulting lesions are as various as are\\nthose of different diseases. Thus, a man or woman may be infected\\nwith syphilis at the site of an herpetic vesicle upon the lip or the\\nFig. 71.\\nChancre of the tongue.\\ngenitals, such vesicle being unbroken and recent, or several days rup-\\ntured or at the site of a balanitis or of a vegetation or of the soft\\ncontagious sore of the genital region best recognized under the term\\nchancroid. Or the inoculation may occur at the site of a trauma-\\ntism for example, where the frenum is slightly torn in coitus, or where\\nthe bruised knuckle of the accoucheur is exposed during the practice\\nof his art.\\nThe induration of chancres may precede, accompany, or follow the\\nlesion with which they are associated. The sclerosis may be short-\\nlived, persistent or recurrent, and in this respect may resemble the", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0667.jp2"}, "668": {"fulltext": "618 NEW-GROWTHS.\\nchancre itself, which may endure but for a few days, or be in course\\nof full evolution at the date of appearance of so-called secondary\\nsymptoms.\\nAs a consequence, the ganglia in anatomical connection with the\\nchancre become, with very rare exceptions, enlarged and specifically\\nindurated. With genital chancres there is usually double inguinal\\nadenopathy with labial chancres, submaxillary adenopathy with\\nchancres of the eyelid, pre-auricular adenopathy, etc. The glands\\nusually enlarge within a few days after the appearance of the chancre,\\nand remain in that condition for several months. They are indurated\\non one or on both sides of the body are freely movable are unattached\\nto surrounding tissues are neither painful, tender, nor inflammatory,\\nand they therefore terminate neither by suppuration nor by ulceration.\\nIt will thus be evident that the word chancre is applicable only to\\ncertain features assumed by other lesions, and is not itself descriptive\\nof a lesion differing absolutely from all others. It is indeed clear that\\nthere can be no particular chancre-lesion, since in turn the macule,\\nvesicle, pustule, papule, tubercle, erosion, vegetation, ulcer, and fissure\\nmay each become a chancre. Every other elementary lesion of the\\nskin, therefore, may assume the chancrous features in other words,\\nmay display in its morbid career the modality of syphilis. These\\nchancrous features are infection sclerosis after an incubative period\\ncoincident or consequent adenopathy (sclerosis of neighboring ganglia)\\nand, after a second incubative period, the occurrence of the symptoms\\nof general syphilis. The last-named is, of course, an historical feature,\\nnot recognizable during the greater part of the life of most chancres.\\nThe minor chancrous features are less constant and trustworthy.\\nChancres of the skin may be deeply pigmented. Some are painful\\nfrom the occurrence of inflammation some are injured by traumatism\\n(chancre of the nipple in nursing-Avomen) some, by irritants (caustic\\nimproperly applied) some, finally, are so insignificant in feature\\n(chancre of the vagina) that even the expert is readily deceived in their\\nrecognition.\\nWith or without involution and complete disappearance of the\\nchancre, the symptoms of general syphilis occur only after a so-called\\nsecond period of incubation. This period extends usually from\\nbetween the end of the first to the end of the second month after the\\nappearance of the chancre, the average being between the fortieth and\\nthe forty-fifth day. During this period the general condition of the\\npatient is that which, by subjective and objective phenomena, displays\\nsignals of the approaching distress of the economy. There are anaemia,\\nand, in cases, even chloro-ansemia wandering pains, substernal or\\nabout the articulations a cachectic appearance engorgement of the\\nsuperficial and deep ganglia occasionally a well-marked febrile pro-\\ncess, the so-called syphilitic fever and a special irritability of the\\nskin and mucous membranes.\\nThe so-called periods of incubation in syphilis do not, however,\\nreally exist. The words used to define them refer to periods of time in\\nwhich, upon gross inspection, the evolution of the disease does not seem\\nto be in progress, but in the course of which there is ample evidence that", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0668.jp2"}, "669": {"fulltext": "SYPHILIS. 619\\nthere is a gradual involvement of one portion of the body after another.\\nThus, in the second incubative period of the text-books careful\\nexamination of a patient about to display the external manifestations\\nof systemic disease discloses the fact, as suggested above, that the symp-\\ntoms are by no means latent. The glands of many parts of the body\\nbeside those in the vicinity of the initial sclerosis become tumid and at\\ntimes painful, including the tonsils and thyroid gland. The skin may\\nexhibit icteroid symptoms as a result of hepatic disturbance the excre-\\ntion of urea may be augmented or albumin may temporarily appear in\\nthe urine pains in the head, limbs, and other parts of the body may\\nproduce distress even of a severe grade the leucocytes may relatively\\nincrease in number the joints may become painful and swollen and\\nmuscular contracture with many other evidences of a morbid state of\\nthe system may indicate to the careful observer that a general process\\nof intoxication is in more or less rapid evolution.\\nAt this moment, the second incubative period of the disease being\\ncompleted, the patient is ready for an explosion of general syphilis.\\nInsidiously or suddenly, first noticed upon the skin beneath the cloth-\\ning, with rapid efflorescence over the entire body-surface after a hot\\nbath, the stimulus of liquor, or the excitement of the dance, appear\\nthe syphilodermata or syphilides or skin-symptoms of syphilis.\\nSyphilodermata (Syphilides).\\nThe skin-manifestations of syphilis are of common occurrence, are\\nnumerous as to their forms, and are of the greatest importance from a\\ndiagnostic point of view.\\nAs in syphilis of other organs, that of the skin is betrayed in symp-\\ntoms like and unlike those of non-syphilitic affections. The study of\\nthese differences is here also a study of the syphilitic mode of disease.\\nIn a treatise of this scope and these limitations it will be practicable\\nto describe merely those evidences of the syphilitic process to be recog-\\nnized in the integument.\\nLesions of the skin appear in syphilitic individuals of both sexes, in\\nall periods of life, and in all stages of the disease. These symptoms\\nare, however, much more frequent during the first two years after infec-\\ntion, subsequent to which period the symptoms of the disease are more\\ncommonly betrayed in subcutaneous lesions, or lesions which affect the\\nviscera, and the osseous, nervous, muscular, and vascular systems.\\nGeneral Characteristics of the Syphilodermata. The syphiloder-\\nmata, like chancres, are, properly speaking, modalities of such symptoms\\nas occur in diseases not syphilitic. The distinctive difference between\\nthe papules, ulcers, and other lesions of syphilis and those of lupus,\\nfor example, lies chiefly in the mode of evolution and involution. It\\nis the syphilitic behavior, rather than the syphilitic lesion, which guides\\nthe diagnostician. The syphilides, in short, resemble the lesions of\\nmost of the other diseases of the skin, and they differ also in various\\ndegrees from each one of the latter. Hence is seen the importance of\\na clear recognition of their general characteristics.\\nAbsence of Subjective Sensations. The eruptions produced by", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0669.jp2"}, "670": {"fulltext": "620 NE W- OR WTHS.\\nsyphilis are rarely attended by itching, burning, or painful sensations^of\\nany sort. This absence is frequently a positive aid in establishing a\\ndiagnosis, and, as a rule, is the more valuable the graver the lesion.\\nGreat difference, however, will be noted in this respect between differ-\\nent individuals. Occasionally considerable itching will be induced,\\nas in condylomata of the anus and syphilitic ulcers, especially of the\\nleg, may be productive of severe pain. At the same time it is a com-\\nmon experience to find a patient quite tranquil as regards all subjective\\nsymptoms, covered from head to foot with a brilliant macular syphilo-\\nderm, or exhibiting with the utmost composure a large number of\\nserpiginous ulcerations on his scalp and extremities.\\nPolymorphism, a term used to designate the coincident appearance\\nof lesions of various character upon one individual, is as true of\\nsyphilis as of other diseases, such as lepra and scabies. Viewing the\\ncutaneous and other symptoms of syphilis as a whole, this feature is\\nstrikingly significant, as it is possible to observe at one and the same\\ntime, upon the body of a single infected individual symptoms indic-\\native of pathological changes in the skin, mucous membranes, hair,\\nnails, lymphatic glands, and periosteum.\\nTo a less marked degree is this true of the syphilodermata. The\\ntype of syphilitic skin-lesions is generally papular, and such lesions\\nmay originate from macules, enlarge into tubercles, or degenerate into\\nulcers. The simultaneous coexistence of several of these forms is due\\nto their chronicity, to their tendency to recurrence, and to the changes\\nwhich they undergo.\\nCareer. The historical course of the syphilides suggests certain\\ncommon features. They are rarely accompanied by local inflammation,\\nand, with the exception of syphilitic fever, are usually unattended with\\npyrexia or with malaise. The tolerance by the general economy of an\\nextensively developed syphiloderm is highly significant of specific in-\\nfection. Again, though generally described as a chronic disease, syphilis\\nis, judged with respect merely to time, much more acute than several\\nother maladies. The syphilides have a distinct career, pursuing, even\\nwhen untreated, a natural process of evolution and involution, and\\nfew, save those upon the lower extremities where the force of gravity\\nis an important element in the fixation of all local disease, persist in\\nunvarying type for any lengthened period of time. One lesion often\\nsucceeds another by development or by degeneration and many of\\nthe untreated syphilides disappear without leaving relics of their exist-\\nence upon the surface of the skin. In these last-named particulars\\nsyphilitic cutaneous manifestations are singularly different from those\\nof lupus and of carcinoma, for example, where the lesion is usually of\\none type, and persists in one location for a period of time during which\\na syphilide would have progressed either to much more extensive\\ndamage or to permanent repair.\\nColor. There is no color peculiar to the syphilodermata that may\\nnot be seen in other diseases of the skin. It is important to recognize\\nthis fact clearly, as there are those who claim to diagnosticate the\\nsyphilides by their hue alone. The color, however, considered in\\nconnection with the other features of the syphilides, is highly char-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0670.jp2"}, "671": {"fulltext": "SYPHILIS. 621\\nacteristic, and often is sufficient to enable one at a glance to identify\\nthe disease. These color-shades are usually less brilliant than those\\nseen in other dermatoses, and they possess less of the scarlet and pink\\nquality. They are admixtures of red, yellow, and brown in various\\nproportions, frequently with a slight preponderance of the brown.\\nThey have been compared with the color of raw ham and with that\\nof copper, hues which unfortunately have been so associated with the\\nsyphilides that the no n -recognition of such tints has led to many\\nerrors in diagnosis. Pigmentation in various shades of chocolate,\\ncoffee, and black is recognized, both during the evolution and after\\ncompletion of involution of the syphilodermata. In cases in which\\nthere has been no luetic affection the color, as in syphilis, is due to\\nincrease of pigment in the part, both with and without extravasation\\nof blood. Recent syphilitic scars are usually pigmented both in centre\\nand at the periphery. In these, again, it is not so much the color as it\\nis the scar with, the color that gives special significance to such lesion-\\nrelics.\\nContour. In syphilis the contour of single elementary cutaneous\\nlesions, as also of a group of aggregated lesions, is usually circular, or\\nthere is a distinct tendency to assume such a configuration. Thus, it\\nis common to find outlines of patches, ulcers, and scars observing the\\ncurve of a segment of a circle, and the coalescence of several such\\nlesions tends to produce the serpiginous aspect. Figures resembling\\na horseshoe, a kidney, a half-moon, the letter S, and a dumb-bell are\\nthus produced. The earlier exanthems of syphilis are usually sym-\\nmetrical, the latter asymmetrical. Even symmetrically distributed\\neruptions will at times occur in annular patches, made up of maculo-\\npapular lesions arranged in a circular or a crescentic line. Patches of\\nsyphilitic eruption will often clear at the centre and develop or spread\\nat the circumference of a circle.\\nSite. No portion of the skin is free from the possibility of invasion\\nby syphilis. The disease may involve at once almost the entire integu-\\nment or it may rapidly spread from point to point, having covered\\nfinally a large area or it may appear conspicuously at distant and iso-\\nlated points of limited extent or, finally, it may be manifested exclu-\\nsively in an insignificant lesion or a group of lesions, ephemeral in\\ncourse and limited to one portion of the body. The site of a syphilitic\\neruption may be determined apparently by the capriciousness of the\\ndisease, and yet result from local irritation of the skin of infected\\nindividuals. The accumulations on the napkins of women invite the\\noccurrence of labial condylomata the lips of the infant, after contact\\nwith the nipple of the mother, become the seat of rhagades and fissures\\nwhile the tongue of the tobacco-chewer and the fauces of the tobacco-\\nsmoker acknowledge special sources of mischief.\\nThere are some sites of preference for special lesions, as, for example,\\nthe squamous syphiloderm of the palms and soles and the papules of\\nthe forehead, constituting the so-called corona veneris/\\nAmenability to Treatment. Mercury possesses a singular influ-\\nence upon the syphilodermata that is promptly perceived when the drug\\nis internally administered. This singularity rests upon the broad fact", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0671.jp2"}, "672": {"fulltext": "622 NEW-GROWTHS.\\nthat the lesions of many other cutaneous diseases not only refuse to ac-\\nknowledge the benefit of such medication, but in many cases are even\\naggravated by it. The importance of clearly recognizing the character\\nof each cutaneous disorder submitted to treatment is thus well illus-\\ntrated.\\nCharacter of Special Lesions. Certain families of symptoms\\nin syphilis exhibit characteristic features. Thus, some papular lesions\\nare surrounded at the base by a peculiar fraying of the epidermis, in con-\\nsequence of which they are encircled by a little fringe of scales resem-\\nbling in shape a collar. The scales of syphilis are usually not abun-\\ndant, but are fine, dirty whitish or occasionally brownish in color. The\\nFig. 72.\\nw\\nFacial cicatrices of tubercular syphilodermata after twenty-five years of infection.\\ncrusts of syphilis are apt to be bulky, greenish black in hue, and to\\nsurmount secreting ulcers of various depths. Such ulcers are gener-\\nally circular, or they exhibit in contour a tendency to assume the cir-\\ncular line, while the cicatrices by which they are succeeded have a sim-\\nilar configuration. The scars of syphilis are frequently smooth, delicate,\\nvery slightly depressed, unattached to subjacent tissues, and pigmented.\\nLastly, from several of the secreting lesions of syphilis, especially those\\nupon and about the anogenital region, proceeds a discharge having an\\noffensive odor and capable of communicating the disease to a sound in-\\ndividual.\\nSubjection to External Agents Capable of Exerting an\\nInfluence upon Non-syphilitic Eruptions. It is an obvious", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0672.jp2"}, "673": {"fulltext": "SYPHILIS. 623\\nerror to conclude that the exanthemata of syphilis are produced exclu-\\nsively by the operation of a systemic intoxication. Many of the pustu-\\nlar syphilodermata are the result solely of pyogenic cocci, and the\\nextension of the eruption may be by inoculation and auto-inoculation.\\nThis fact is shown not merely by the ordinary methods of demonstra-\\ntion, but also by the clinical fact that these lesions are far more frequently\\nencountered among the filthy, the neglected, and the ignorant. Often\\nsyphilodermata are commingled with seborrheic and eczematous affec-\\ntions. It is not rare to find patients applying for relief in clinical\\npractice who exhibit lesions of syphilis commingled with traces of the\\nincursions of lice and bugs, urticarial wheals, scratch-marks, and forms\\nof keratosis pilaris, due to the unwashed condition of the skin.\\nSyphiloderma Maculosum. The cutaneous lesions of syphilis, limited\\nto color-changes in more or less circumscribed areas of the skin, are\\nexhibited in two distinct forms, due respectively to anomalies in blood-\\nsupply and pigment-distribution.\\nSyphiloderma Maculosum due to Hyperemia (Erythem-\\natous Syphilide, Syphilitic Roseola). This form of macular\\nsyphiloderm is the earliest expression of systemic cutaneous syphilis,\\nand is more or less constant of occurrence, differing in this respect from\\nseveral of the other syphilides. It is often unnoticed by the patient,\\nwhose attention may first be called to it after its recognition by the\\nskilled eye of another. It occurs in coffee-bean- to filbert-sized mac-\\nules, roundish, oval-shaped, or of irregular contour, and varying in color\\nfrom a light rosy to a dull mulberry hue. In some cases these markings\\nof the skin-surface are very indistinct, requiring for their recognition\\nthe closest scrutiny in a clear light, and occasionally even then leaving\\nuncertainty in the mind of the expert. With a lens tinted in cobalt-\\nblue they may be recognized at an earlier date than if viewed with the\\nunaided eye. At times they constitute an irregular marbling of the\\nsurface, of a kind which renders it difficult to define with the eye the\\nindividual lesions composing the eruption, while the general visual\\neffect of the exanthem is distinct. The spots are not elevated above\\nthe general level of the integument, but may change in type, a papular\\nlesion developing later in the same site.\\nLike all macules of the skin due to vascular changes, those of\\nsyphilis vary in color with the complexion of the individual, with the\\n1 time which elapses after their first appearance, and with vascular\\nI changes in the superficial plexus of blood-vessels. Thus, the deeper\\nshades are usually observed in thick and muddy-tinted skins the more\\ndelicate tints upon the breast, for example, of blonde women.\\nBThe eruption usually appears between the sixth and the eighth week\\nafter the appearance of the initial sclerosis, and, when untreated, de-\\nvelops for about one week more. It persists for a variable period of\\ntime, depending upon the severity of the constitutional disorder and\\nthe treatment to which the patient is subjected. During the early\\npart of its career the hue of the lesions is lighter, and they may be\\nmade to disappear under pressure of the finger later, they are more\\ndeeply stained, and, exudation having occurred, the color of the spot", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0673.jp2"}, "674": {"fulltext": "624 NEW-GROWTHS.\\ndoes not disappear under pressure. When involution is in progress\\nthere is a slow disappearance of the eruption, which gradually fades\\nfrom view. The vascular changes in the capillaries occasioned by\\ncold, heat, and rapid cardiac contractions, influence the eruption to a\\nmarked degree. A hot bath, a dance, a glass of spirits, a fit of excessive\\ncoughing, laughter, etc., may all bring the lesions into prominence.\\nThe eruption may be limited to the skin of the belly, extending\\nsparsely over the chest, the loins, the anogenital regions, and the\\nthighs may develop over the palms, soles, forearms, and legs or, in\\nexceptional cases, may profusely cover the entire surface of the body\\n(face, ears, dorsal surfaces of the hands and feet, and skin of the penis\\nwith the progenital region). In the milder forms it is evidently sus-\\nceptible to external irritation of the skin, as it is common at the wrists\\nwhere a starched cuff is worn, over the brow in the line in contact with\\nthe hatband, and is particularly well developed in men where the\\ntrousers are reinforced (perineum and inner faces of the thighs).\\nAt times, as in the exanthematous fevers, the eruption is preceded\\nby a febrile state, with marked amelioration of symptoms when the\\nrash is fully developed while, again, it is throughout accompanied by\\nslight rise in the body-temperature, the patient having the so-called\\nbilious appearance muddy complexion, coated tongue, icteroid\\nhue of conjunctivae, and offensive condition of the breath. Wander-\\ning pains in the extremities, and especially beneath the sternum, are\\nfrequently experienced. The last-mentioned symptom is highly sig-\\nnificant, and the whole condition is probably due to the effect upon\\nthe nervous system of the circulation of the recently intoxicated blood.\\nThese pains are not those produced later in the periosteal and other\\ncomplications of the disease, and are the more significant as the erup-\\ntion itself is productive of a scarcely appreciable subjective sensation.\\nThe superficial ganglia of the body are usually engorged at the same\\ntime the fauces are congested the hairs of the scalp are slightly\\nloosened in their follicles, and in the latter region in severe cases\\npapules and pustules may form. Inasmuch as the order of sequence of\\nmost of the phenomena in syphilis is subject to a singular inversion, it\\noccasionally happens that there is concomitance of later signs of the\\ndisease, such as iritis, affection of the nails and bones, or even, in special\\nregions, of pustular, papular, or squamous syphilodermata.\\nMuch less rare is the survival of the initial sclerosis to the date of\\nthis efflorescence. This point is of considerable importance. The\\nphysician should never conclude the examination of a patient com-\\nplaining of suspicious genital lesions without carefully exploring the\\nsurface of the trunk, and also never pronounce upon an exanthem of\\nthis sort without minute inspection and palpation of the part where\\nan initial sclerosis may exist. In a diagnostic and therapeutic sense\\nthe information thus gained may be precious, and in a large proportion\\nof all cases is of a kind hidden from the knowledge of the patient.\\nRelapses occur in certain cases with limitation of the disease to parts\\npreviously affected or unaffected. At the end of the first twelve\\nmonths recrudescence of larger macules in annular groups may occur.\\nExceptional forms are noted in which darker puncta appear in the", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0674.jp2"}, "675": {"fulltext": "SYPHILIS. 625\\nmacular lesion, occasionally traversed by a hair. These puncta are\\nlocalizations of a more intensely hypersemic or exudative condition\\nabout the orifices of the ducts of the follicles.\\nThe diagnosis of this syphiloderm is readily established in view of\\nits essentially symptomatic character. From scarlatina, measles, and\\nrotheln it differs in the indolence of the rash, the absence of decided\\nelevation of body-temperature, and the order of its appearance in dif-\\nferent portions of the body, as it rarely occurs first upon the face. Ur-\\nticaria and the rashes induced by the ingestion of copaiba and other\\nmedicaments are distinguished by the marked itching of the affected\\nsurface and by their very general diffusion over the entire body, a con-\\ndition rarely observed in the syphiloderm. Tinea versicolor, usually\\nlimited to the anterior surface of the trunk, is characterized by a fawn-\\ncolored to a chocolate-colored tint, by the furfuraceous desquamation\\nwhich the patient usually describes as most noticeable after a hot bath,\\nand by the existence of the readily recognized vegetable parasites upon\\nthe scales scraped from the affected surface. Tinea versicolor is, more-\\nover, of much longer duration than a syphiloderm, and almost never\\nextends to the exposed parts of the body the face and the hands.\\nRingworm of the skin of the body is not symmetrical, and is a para-\\nsitic disease.\\nAil these distinctions, however, are not to be compared in diagnostic\\nvalue with the concomitant symptoms of syphilis that are very generally\\npresent, such as adenopathy, persistence of the initial sclerosis, and\\n[l evident involvement of other than cutaneous tissues. Such concom-\\nitant symptoms will be found occasionally with a non-syphilitic erup-\\ntion due to drugs ingested for relief of the infectious disease. The\\nmost common of these drugs is potassium iodide the eruptions it pro-\\nj duces are frequently found both commingled with the macular syphilo-\\nderm and occurring on the eve of the appearance of the latter. The\\nexistence of acneiform lesions upon the face, the neck, and the posterior\\nsurface of the trunk, a vivid erythema of the forearms, including the\\nhands, and purpura-like maculations of the face, legs, and feet, should\\nnever mislead the physician as to the character of the disorder with\\nwhich he is confronted. It is undeveloped syphilis with a dermatitis\\nmedicamentosa of the surface. Suspension of the iodide, which drug\\nfortunately is not required in the majority of cases the use of a properly\\nselected mercurial, or even (and this is often wise) abstention from all\\nmedication, will be succeeded by disappearance of the cutaneous lesions,\\nwhich may be followed later by a mild macular syphiloderm, altogether\\ninsignificant in comparison with the eruption artificially induced.\\nSyphiloderma Maculosum due to Anomalous Distribution\\nof Pigment (Pigmentary Syphilids). This eruption, if it may\\nbe so called, is occasioned by the appearance upon the body-sur-\\nface of irregularly circular, usually poorly defined, dirty-brown and\\nchocolate-tinted macules, which, as they are unconnected with vascular\\nchanges, do not disappear under pressure. The lesions occur as sparse,\\nwell-isolated dis colorations, or, more commonly after a species of con-\\nfluence, as an irregular rete or network, with relatively large inter-\\nspaces characterized by an absence of coloration. The eruption is most\\n40", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0675.jp2"}, "676": {"fulltext": "626 NEW-GROWTHS.\\ncommon upon the sides of the neck, the shoulders, and breasts of blonde\\nwomen, though it may more rarely involve the surface of the trunk and\\nthe extremities. It is often recognized, however, among Anglo-Saxons\\nof brunette type, and also among negroes, mulattoes, Indians, and per-\\nsons of the Mongolian race. It is most frequent during the first year\\nafter infection, though it may develop later.\\nIt occurs (a) as a sequel to a macular or maculo-papular syphilo-\\nderm over the parts described above and (b) ab origine, as a pigment-\\ndisorder, probably under the same influences as those productive of\\nthe chloasmata of symptomatic origin (chloasma uterinum, cachecti-\\ncorum, etc.).\\nThe color-changes observed in the skin are explained by the occur-\\nrence first, of pigmentary deposits, chiefly at the centre of the ordi-\\nnary macular or papular syphiloderm secondly, of peripheral absorp-\\ntion of such pigment-deposit with possible persistence of it for a varia-\\nble time at the centre of the lesion thirdly, of total absorption of all\\npigment from the original lesion and lastly, of peripheral hyperpig-\\nmentation of the spaces intermediate between the original macules.\\nThe eruption is an epiphenomenon of the syphilitic process, being\\nnot amenable to the treatment under which other macular syphiloder-\\nmata speedily disappear, and is an expression rather of general deteri-\\noration of the health of the skin than of specific disease.\\nThe eruption is liable to be mistaken for that condition in which\\nthere is simply an accumulation, upon a somewhat greasy skin, of\\nsecretions and dust, to be seen upon an integument long unwashed.\\nTinea versicolor has a more yellowish or fawn-colored tint, and is more\\nabundantly developed upon the front of the chest than upon the neck.\\nNeither vitiligo nor leucoderma is symmetrically disposed, as is usually\\nthe case with the pigmentary macular syphiloderm.\\nSyphiloderma Papillosum. The type of all cutaneous lesions pro-\\nduced by syphilis is to be recognized in the papule. Most of the\\nother lesions are either developed from it, transformed to it, or by\\nreversion or admixture confess that the neoplasm of syphilis in the\\nskin is essentially a more or less solid circumscribed cutaneous lesion,\\nvarying as to size and history.\\nPapules occurring in syphilis may appear as the first cutaneous\\nevidence of infection, or they may be developed from earlier macules.\\nThey may be small, large, acuminate, flat, disseminated, or in groups.\\nSmall Acuminate Miliary Papular Syphiloderm. In this\\neruption the lesions are millet-seed- to hemp-seed-sized, circumscribed,\\nglobular, acuminate, reddish and salmon-reddish, firm elevations of the\\nsurface, or minute nodules upon the skin, generally symmetrically\\ndeveloped, often over the entire body, closely set and occasionally\\ngrouped in crescentic figures. When viewed with care a minute vesicle,\\na pustule, or a scale may often be detected at the conical apex of each\\npapule, the vesicular or pustular lesions rarely developing to such an\\nextent as to become a characteristic feature of the eruption. The\\ncolor is at first, especially in blonde skins, a species of salmon and\\nred mixed; later, the darker and browner shades appear. When", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0676.jp2"}, "677": {"fulltext": "SYPHILIS. 627\\ngeneralized the eruption is well developed, especially over the posterior\\nsurface of the body, the occipitocervical and scapular regions, the but-\\ntocks, and the calves of the legs, though it is often distinct about the\\nanus and the genitalia. Like several other of the syphilodermata, its\\nearlier are more symmetrical than its later manifestations, whether\\nthese be tardy or relapsing, or both. The involution occurs by resorp-\\ntion of the plastic exudate, minute and usually scanty, dirty- whitish\\nscales encircling the base of each lesion. When the eruption has\\nproved especially persistent, marked pigmentation follows in the form\\nof brownish-red blotches, the centre of each of which displays a cicatri-\\nform relic in the form of a punctum.\\nThe eruption is often first noticed about the forehead, nose, mouth,\\nand neck, localities commonly subject to topical irritation. Thus, about\\nthe forehead in men the papules will frequently be arranged along the\\nsurface pressed by the lining of the hat and frequent fingering of the\\nface, shaving, and irritation by the edge of the collar of the shirt\\nmay determine a more speedy efflorescence at the sites of contact.\\nAbout the mouth tobacco plays the part of an excitant; about the nose\\na localized seborrhcea may be added to the syphilitic phenomena, in\\nwhich case the lesions may be covered with thin greasy crusts. The\\neruption is common during the first six months after infection, and is\\nusually fully developed after a fortnight when no treatment has influ-\\nenced its evolution. When the lesions are perforated by hairs they\\nsuggest on superficial examination a resemblance to keratosis pilaris\\nand when aggregated in patches of distinct contour they may be con-\\nfounded with psoriasis or squamous eczema. But in every case the\\ngeneral physiognomy of the disease may well be trusted for the estab-\\nlishment of a diagnosis, having in mind the color, the absence of intense\\npruritus and serous exudation, the disposition over the body as a whole\\nor in portions widely separated, and the rarely failing concomitant evi-\\ni dence of syphilitic infection.\\nLarge Acuminate Papular Syphiloderm. Lesions of the\\ncharacter above described occasionally develop to an unusual extent,\\nattaining the size of that of a coffee-bean in localities where the apex\\nof each lesion is free to push forward without coming into contact with\\nadjacent planes of the integument. Thus, about the dorsum of the\\nbody, the gluteal regions, the calves of the legs, and the extensor sur-\\nfaces of the forearms, fully developed, slightly scale-capped or scale-\\nencircled, and grouped papules may appear, often commingled with\\npustules and superficial ulcers, the polymorphic patch having a figure-\\nof-eight or S-shaped outline. These patches are often displayed by\\npatients under treatment the influence of which has interfered with the\\nfull evolution of the disease.\\nSmall Flat Papular Syphiloderm. The lesions recognized\\nunder this title differ from those just described in that they are not\\nacuminate, but are distinctly flattened at the apex, this flattening being\\nat times so pronounced that each lesion resembles a small button or a\\nplaque, the contour being roundish or oval-shaped. The lesions are\\nfrequently encountered on the face, especially near the mucous outlets,\\nover the anterior and posterior surfaces of the trunk, and on the flexor", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0677.jp2"}, "678": {"fulltext": "628 NEW-GROWTHS.\\naspects of the extremities. The palms of the hands are often affected.\\nIn color the papules exhibit the variation usual in individuals of dif-\\nferent complexions, and in the same individual as they are related to\\nthe condition of the circulation. Thus, on the face a scarcely distin-\\nguishable pink will become a deep, lurid, reddish brown from an attack\\nof sneezing, a paroxysm of laughter or of rage, and from violent exer-\\ncise. The seborrhoe ic condition noted on the face in the acuminate\\nlesions is also occasionally seen about the plaques. The same is true\\nof the scaling described above. The eruption is much less copious, as a\\nrule, than with other forms of syphilitic papules, due doubtless to the\\nfact of its frequent occurrence in those subjected to treatment. The\\npapule differs from the lesion about to be described with respect to its\\nsize, being rarely larger than small buttons while the largest papules\\nof the same variety may attain the size of large coins. The diagnosis\\nhas already been suggested.\\nLarge Flat Papular Syphiloderm. Here the resemblance of\\nthe papule to a button is even more distinct, the lesion occurring with\\na well-defined, firm, raised border, and a shallow depression in the\\ncentre, though at times, especially in moist situations, the superficies\\nof each plaque is a smooth, flat plane. The large papules commonly\\nbegin as macular lesions and rapidly develop at the periphery, this\\ndevelopment often corresponding with centric involution, by which the\\nshallow depression described above is reduced to the level of the adja-\\ncent skin and the lesion is transformed into a ring. In shape the\\npapules are circular and oval in size they vary from that of a finger-\\nnail to that of a pigeon s egg. They have the usual variation in color,\\nand may scale at the edge, or over the flat top or the depressed centre.\\nIn moist situations they frequently secrete a muco-purulent fluid which\\nis smeared over the papules and adjacent integument, and which, in the\\nvicinity of the anus or genitals, exhales an offensive odor. It is especially\\nin such situations that flat papules of the type described occasionally\\ndegenerate by fissure or by circular ulceration. Condylomata Lata\\nare flat and secreting papules of the regions named, which have a whit-\\nish appearance in consequence of the mucoid secretion with which they\\nare smeared, and which are transformed by the influence of heat, moist-\\nure, and either friction or apposition of contiguous integumentary folds.\\nPapular syphilodermata may become generalized or be limited to\\ncertain sites of preference, as the face, the neck, the flexor surfaces of\\nthe extremities, and the anogenital region. The eruption is either an\\nearly, a late, or an intermediate symptom of syphilis, occurring most\\nabundantly in young and delicate skins, where the disease has been\\nignored and therefore untreated; and most scantily in the thicker\\nintegument peculiar to middle life, where prompt resort has been had\\nto appropriate medication.\\nSyphilitic papules undergo a series of modifications under the influ-\\nence of various causes which may be enumerated as follows\\n(a) There is considerable hyperplasia of the cutaneous elements\\n(papillary layer of the corium, rete, and blood-vessels), by which the\\npapule becomes largely raised from the surface, so as to resemble a\\npapilloma, wart, or the lesions characteristic of iramboesia, In this", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0678.jp2"}, "679": {"fulltext": "SYPHILIS. 629\\nway, rarely, a portion or the entire surface of the body may be cov-\\nered with light-red or violaceous-red, non-ulcerative, vegetating growths.\\nThey secrete freely, and the discharge is liable to concrete into crusts\\nand to exhale an offensive odor.\\n(6) There is considerable hyperplasia of the elements, in conse-\\nquence of which the lesions spread laterally, while their elevation from\\nthe surface is prevented by contact with apposed surfaces. Thus is\\nformed the broad, flat, moist papule known as the vegetating mucous\\npatch, condyloma, plaque muqueuse, etc. (Fig. 73). The lesions,\\nwhen unaltered and fully developed, are of a whitish color in conse-\\nquence of the puriform mucus which covers them, and which, as with\\nso many of the syphilodermata in moist situations, is liable to exhale\\nan offensive odor. When the secretion is removed the lesion is seen\\nto be pinkish, or light or dark red in color, and to be either firm or\\nsoft, scarcely raised, and indefinite in contour, or distinctly elevated\\nFig. 73.\\nVegetating condylomata oi the vulva. (After Jullien.)\\nand well defined. Condylomata are chiefly found in moist situations\\nwhere folds of the skin are apposed, as about the perineum, the groins,\\nthe axillae, the mammae, the nates, the anus, the genitals, and the inner\\nfaces of the thighs. They may coalesce to form palm-sized patches\\nand frequently they are associated with hyperidrosis, seborrhcea oleosa,\\nand the dried products of secretion from the adjacent mucous outlets.\\n(c) In consequence of changes in the superficial layers of the epi-\\ndermis the papules may become covered with scales, either at the base\\nor the apex, more commonly the latter, forming thus the papulo-squa-\\nmous syphiloderm. The scales are of a dirty-grayish hue, often des-\\niccated, generally attached, rarely freely exfoliating. They are rela-\\ntively few, occurring where the lesions are closely set. The desqua-\\nmation may be the most suggestive feature of the patch. Beneath\\nthe scales are seen distinctly elevated brownish-red papules or merely\\nslightly elevated, dull-red or purplish-red maculations. When the\\nscales accumulate at the base of the papule they tend to surround it\\nwith a circlet or collarette of exfoliated shreds of epidermis.\\nPalmar and Plantar Syphilides. In consequence of the thick-\\nness of the epidermis in the palms and soles the papular or papulo-", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0679.jp2"}, "680": {"fulltext": "630 NEW-GROWTHS.\\nsquamous syphiloderm of these regions is presented under somewhat\\natypical forms. The dense stratum corneum of the epidermis in the\\npalms and soles is not readily raised from its underlying tissue into\\npapular forms. The pathological manifestations of this disease are\\nrather displayed in thickenings, separations, stainings, and frayings.\\nHere, therefore, are seen dull-red maculations, covered throughout,\\nor merely at the edges, by scales or epidermal shreds minute, firm,\\ncorneous thickenings, few or many, often without color in consequence\\nof the depth of the blood-vessels beneath the opaque horny layer and\\ndistinctly elevated (not flattened) and circumscribed papules, of the\\nusual livid-red color, coffee-bean- to small-nut-sized, often aggregated\\nin patches having a tendency to assume the circinate outline. Occa-\\nsionally with a pointed instrument pinhead-sized and larger deposits\\nresembling chalk may be pried from circular beds in the palms and\\nsoles where the lesions first developed. These and similar spots are\\noften covered with dirty-whitish, often tenacious, half-loosened, epi-\\ndermic flakes which are characteristic. In other cases, usually in con-\\nsequence of the motions of the hand or the foot, or the exigencies of\\ntoil, irregular angular losses of epidermis occur resembling the fracture\\nof a pane of glass. The attached portions of the epidermis project\\nat the edges only, over deep fissures, broad exulcerations, or a ham-red,\\ntender, and newly formed epidermic stratum.\\nThe eruption is frequently symmetrical in the centre of both the\\npalms and the soles, but is rarely found upon the dorsum of the hands and\\nthe feet, and then never developed typically, but always by extension\\nfrom the palmar or plantar regions it is also seen on the lateral sur-\\nfaces of the hands, feet, fingers, and toes, as well as over the wrists\\nand ankles. The exanthem is a persistent, rebellious, and usually\\nlate cutaneous symptom of syphilis, occurring often six, eight, and\\nmore years after infection. Rarely it is seen within a few months after\\nthe existence of chancre, and is then usually manifested in its simpler\\nforms.\\nThe papulo-squamous syphiloderm bears in many instances a strong\\nresemblance to the patches of psoriasis, but it can usually readily be\\ndistinguished from the latter by a consideration of the following points\\nThe syphilide, as a rule, is not generally diffused it displays sym-\\nmetry only when it involves the palms and soles, and then not invari-\\nably it is elevated at the border of the patch and it observes the\\ncontour of the segment of a circle. Psoriasis is more widely dif-\\nfused is generally symmetrical does not specially exhibit elevation\\nat the border of the patches, and the latter are rather more completely\\nthan partially circular in outline. In syphilis there is generally a his-\\ntory of infection, of other cutaneous or mucous symptoms of the dis-\\nease, and, in married women, of abortions, miscarriages, or births of\\ndiseased children, all of which symptoms are wanting in psoriasis. In\\npsoriasis there is a decided predisposition to the development of the\\ndisease about the extensor surfaces of the joints and the posterior\\naspect of the trunk the syphiloderm, though it may occupy these\\nsituations, can rarely be found thus displayed when other surfaces are\\nspared. The scales in psoriasis are more lustrous, are more freely pro-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0680.jp2"}, "681": {"fulltext": "SYPHILIS. 631\\nduced and shed, and they exist significantly at an earlier period of the\\nexanthem. With only such exceptions as prove the rule, psoriasis\\nis never strictly limited to the regions of the palms and soles. A\\nscaling palmar or plantar disease of the skin in childhood is more\\nlikely to be psoriasic, though both diseases are seen in the early periods\\nof puberty.\\nEczema is yet more readily recognized by its severe itching, its his-\\ntory of discharge and moisture, and its characteristic crusts. Ancient\\npatches of squamous eczema are often very indeterminate in outline\\nthey do not ulcerate, and they exhibit scales on the surface of a much\\nmore deeply infiltrated area. Eczema of the palms and soles, when\\nchronic, usually involves also the dorsum of the hands and the feet.\\nWhen this is not the case the eczematous infiltration, if of long dura-\\ntion, will in the vast majority of all cases be found to involve uni-\\nformly and evenly the entire palm or sole, including the palmar or the\\nplantar faces of the digits. Eczema, finally, is much more frequently\\nencountered solely upon the right hand in right-handed patients, or to\\na greater extent in that organ by reason of its preference in the per-\\nformance of function. This is less common in syphilis.\\nSyphiloderma Vesiculosum. Vesicular syphilodermata are either the\\nrarest of all cutaneous symptoms of syphilis or they do not actually\\nexist. Certain French authors describe pinhead- to pea-sized, conical,\\ngloboid or umbilicated, isolated or grouped, and crusting elevations of\\nthe epidermis, with lucid or cloudy contents, seated upon the face\\nand the genitalia. The eruption is described as an early syphiloderm,\\noften exhibiting a halo of characteristic tint, the resulting crusts being\\ngranular and somewhat lighter in color than those commonly seen in\\nthe disease. Both small and large vesicles have thus been assigned to\\nthe disease.\\nBut the larger number of the lesions are, without question, either\\nimmature pustules, eczematous lesions in syphilitic subjects, or pure\\naccidents of the syphilitic process. With regard to the first, it may\\nbe said that the pustular syphiloderm not rarely begins as a vesicular\\nlesion with regard to the second, that coincidence of so common a\\ndisease as syphilis with other cutaneous disorders is a matter of fre-\\nquent observation and with regard to the third, bearing in mind the\\nlarge quantity of potassium iodide swallowed for the relief of the dis-\\nease and its capability of exciting a vesicular eruption, it can reasonably\\nbe concluded that some, at least, of the cases of so-called vesicular\\nsyphilis have imperfectly been studied.\\nSyphiloderma Pustulosum. In some of the pustular syphilodermata\\nthe pus is neutral in others the staphylococcus pyogenes aureus and\\nalbus are present. The larger number of all pustular affections of the\\nskin, whether in syphilitic or in non-syphilitic subjects, are the results\\nof infection with pus-cocci. It is therefore not sufficient in syphilis to\\npronounce upon the question of infection only. It is necessary further\\nto explain many of the external phenomena of the disease by the acci-\\ndents to which non-syphilitic patients are subject.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0681.jp2"}, "682": {"fulltext": "632 NEW-GROWTHS.\\nThese accidents are probably of more frequent occurrence in pus-\\ntular syphilodermata than in any other lesions exhibited in the disease.\\nViewed as a whole, it is noticeable that pustules occur for the most\\npart in dispensary and hospital practice, among the impoverished, the\\nfilthy, the ill-housed, and the poorly treated. They are decidedly rare\\nin the clientele of the physician consulted chiefly by those who are\\ncleanly, well-nourished, and skilfully treated. If it were possible to\\nkeep the skin of the syphilitic subject aseptic during the management\\nof the disease, no one would expect an evolution of pustular syphilo-\\ndermata at any time throughout its course. The lesions described\\nunder this title may therefore be regarded for the most part as due to\\nthe causes suggested above, aided by picking and scratching the skin\\nto an extent capable of distributing staphylococci over its surface. In\\nother cases it cannot be denied that pustules, general of evolution and\\ncharacteristic in appearance, may develop in consequence of luetic\\ninfection only but even of this type they are rarely to be seen in the\\nbetter class of patients.\\nPustular lesions in syphilis further present a wide range of dif-\\nferences. They may vary in size from that of a pinhead to that of a\\nfinger-nail they may be acuminate, flat, hemispherical, or irregular in\\nshape they may be few or be very numerous they may be distinctly\\nlocalized or be generally dispersed they may be grouped or be dis-\\nseminated and they may occur from the first as minute vesico-pustules\\nor as pustular transformations of variously sized papules. They may\\nbe surrounded by inflammatory areolae, or may spring from an unaltered\\nintegument, or be subepidermic in situation, and scarcely project from\\nthe surface. They may be seated upon superficial or deep, or sharply\\ncut, secretory ulcers, and they are usually covered with crusts differing\\nin bulk and consistency, forming thus the pustulo-crustaceous syphilide.\\nAccording to the depth of the ulceration at the base are they followed\\nby cicatrices. Pigmentation is a frequent result. The crusts which\\nform by the desiccation of pus are usually reddish brown to greenish\\nblack in hue they occur in strata or laminae by accretions from beneath,\\nand, even when superimposed upon a moist and secreting ulcer, they\\nare adherent at the edges. They may occur early or late in the dis-\\nease, and at either epoch may constitute trifling or grave cutaneous\\nlesions. They have a marked predisposition for involvement of the\\nsebaceous and pilary follicles, and they are frequently disposed about\\nthe mucous outlets of the body.\\nSmall Acuminate Pustular Syphiloderm. This exanthem,\\nwhich is usually largely diffused over an extensive surface, probably\\nrepresents, as Jullien has suggested, a transformation from papular\\nlesions, due to pus-infection in skins that are usually unclean, irritated,\\nor the seat of diminished vitality. The eruption is certainly rare in\\npatients of the better class. The pustules are generally recognized\\nabout the pilo-sebaceous orifices, and upon minute papular lesions,\\nwhich, as undisguised elements of the eruption, may be interspersed\\namong the latter. The pustules are acuminate and contain each but a\\ndroplet of cloudy serum or pus, the desiccation of which furnishes a\\nthin yellowish or reddish-brown crust. The fall of the latter exposes", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0682.jp2"}, "683": {"fulltext": "PLATE XXI.\\n\u00e2\u0080\u00a2Large Pustolo-crustaeeous Syphiloderm of the Scalp and Body.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0683.jp2"}, "684": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0684.jp2"}, "685": {"fulltext": "SYPHILIS. 633\\nthe grayish epidermal fringe of the base occasionally seen in papules\\nof similar size.\\nThe lesions may be discrete, confluent, disseminated, or in groups\\naffecting the curve of a circle. The extremities and the trunk are\\nchiefly involved, though the disease may be well-nigh universal.\\nUnder the influence of treatment occur minute, punctiform, and pig-\\nmented cicatricial atrophic depressions which are not persistent. The\\neruption may be an early or a late secondary symptom, but usually it\\nis first seen within a few months after infection. Relapses occur when\\ntreatment has irregularly been pursued. Frequent concomitants are\\nthose symptoms of syphilis proper to the period in which they appear.\\nLarge Acuminate Pustular Syphiloderm. Under this title\\nare classed lesions that are usually coffee-bean-sized pustules, which may\\nspring from macular or smaller pustular lesions, very rarely from an\\nindurated or a papular base. They have a thin roof-wall, occurring by\\npreference where the epidermis is delicate, and they are surrounded by\\na halo. They are usually acuminate, but they may after full evolution\\nslightly flatten at the apex in consequence of partial collapse. The\\ncrusts are bulkier and darker in color than those of the lesions just\\ndescribed their bases are superficially ulcerated. The pustules form\\nslowly or rapidly, in disseminated or in grouped forms, usually at an\\nearly period of the disease, though commonly after the appearance of\\nsome syphilide of another type.\\nSmall Flat Pustular Syphiloderm. This is a relatively\\nfrequent manifestation of syphilis, occurring upon the face, the scalp,\\nthe trunk, and the flexor surface of the extremities. The exanthem\\nexhibits a decided tendency to characteristic and circular grouping\\nabout the mucous outlets of the body. Such groups are composed of\\nsmall, flat pustules, originating as reddish, macular lesions which tend\\nto dry into flattish, irregular, adherent crusts. These crusts either\\nexceed the limits of the diseased surface beneath, or are conspicuous\\nupon a dull brownish-red area of inflamed, and at times even of ulcer-\\nated aspect.\\nOften the pustules are so closely set as to become confluent, in which\\ncase a single convex crust, like a carapace, will completely cover the\\ninvolved area. Frequent sites of the exanthem are the regions about\\nthe nose and the lips, as also the chin, cheeks, and the anterior faces of\\nthe elbow- and wrist-joints.\\nThe eruption is of pustulo-crustaceous type, and it may be evolved\\nfrom either papular or macular lesions. It is rarely long untreated,\\nand is therefore not often presented for observation when in full evolu-\\ntion. It is usually amenable to judicious treatment; when followed by\\nsevere ulceration, destroying an ala of the nose or a part of the lip, the\\nj patient has usually suffered from either cachexia or neglect. In these\\ncases less severe phenomena are presented in the superficial serpiginous\\nsyphilide, the lesions extending in circinate or annular gyrations about\\na sound or a previously involved and healed centre. Thus, a circlet\\nof crusts, with underspreading superficial ulceration, perhaps alternating\\nwith pustules of various ages and reniform cicatrices, will surround the\\nelbow or traverse the scalp. The resemblance to pustular eczema is at", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0685.jp2"}, "686": {"fulltext": "634 NEW-GROWTHS.\\ntimes suggestive, but the ulceration and outline will aid in their recog-\\nnition. The lesions are usually late among the earlier symptoms of\\nthe disease, but they may be delayed for six months after infection.\\nThey indicate, as a rule, either severity of the disease, or, much more\\ncommonly, constitutional impairment.\\nLarge Flat Pustular Syphiloderm. The lesions classed under\\nthis title are fully developed forms of those described above. They\\noriginate as usually numerous, maculo-papular lesions, or as nodules or\\ntubercles which gradually deepen into pea-sized and even larger flat\\npustules, the further history of which is one of enlarging, blood-mixed,\\nreddish- and greenish-brown, also flattish, crusts with underspreading\\npus-bathed ulceration of varying extent. The superficial variety of this\\nsyphiloderm is distinguished from the deep chiefly by the extent of its\\nulcer, the size of its superimposed crust, and the lighter, dull-red areola\\nwhich encircles it.\\nThe deep variety, Mke the superficial, may be limited to the scalp,\\nface, neck, and flexor aspects of the extremities, or it may be much\\nmore widely diffused. The entire surface of the body is covered with\\ndiscrete lesions of this type in cases of unusual neglect or of profound\\ncachexia. The eruption is usually of late occurrence, but in the\\nso-called galloping syphilis of the French it may be precocious in\\ndevelopment. The lesions are at the onset nodular or tubercular and\\nbecome transformed into pus. They have each a deep infiltrated base\\nwith a dark-brown halo. Incrustation follows with the formation of a\\nconical, roundish, or oval-shaped, blackish-brown crust, beneath which\\nlies a clean-cut ulcer, the sharp edges of which are usually exactly\\nroofed by the incrustation. The crust thickens by concretions from\\nthe foul and purulent ulcer beneath, and spreads at the periphery while\\nit thickens in the centre. In this way the appearance of the stratified\\ncrust resembles that of an oyster-shell, a condition described by some\\nauthors as Rupia, a term once employed as the name of a disease.\\nThe ulcer, exposed after removal of the crust, is of characteristic\\nsyphilitic type in its deep base, foul floor, clean-cut edges, and puru-\\nlent secretion commingled with blood, at times attaining a diameter of\\nseveral inches, and having a circular, reniform, or horseshoe-shaped con-\\ntour. The degree of destruction it may produce is inversely proportioned\\nto the constitutional vigor of the subject and the treatment pursued. It\\nis usually a grave and may be a malignant exanthem, though under\\nfavorable circumstances it is amenable to judicious treatment, and may\\nbe an early, though oftener it is a late symptom of the disease. The\\npigmented scars left are characteristic and indelible.\\nSyphiloderma Bullosum. Bullae in acquired syphilis are late and\\nrelatively rare lesions. They are pea- to large-nut-sized elevations of\\nthe epidermis, filled at first with a cloudy serum, which is soon trans-\\nformed into pus, often mingled with blood. They have usually a char-\\nacteristic halo about the periphery are roundish or oval in contour\\nare usually discrete, rarely disseminated and after development they\\nproduce characteristic crusts with underlying ulcers, identical in feat-\\nures with the rupioid .sequels of large syphilitic pustules. The eruption", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0686.jp2"}, "687": {"fulltext": "", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0687.jp2"}, "688": {"fulltext": "PLATE XXII.\\nTubercular Syphiloderm, Resolutive and Serpiginous.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0688.jp2"}, "689": {"fulltext": "SYPHILIS. 635\\nis localized by preference upon the extremities, more particularly the\\nlower extremities, and is indolent in its course. It is always significant\\nof a cachectic condition in the subject of the disease. Its frequent\\noccurrence in congenital syphilis is described later. It is to be distin-\\nguished from pemphigus vulgaris by its characteristic crusts and ulcers,\\nconsidered in connection with the history and associated symptoms of\\nlues.\\nSyphiloderma Tuberculosum. In this eruption the lesions are usually\\nmultiple, flat, roundish, circumscribed, firm, light-red to dull crimson-\\nred nodules, beginning commonly as macules of a lurid hue. They\\nvary in size from that of a coffee-bean to that of a small nut, and involve\\nthe entire thickness of the skin, often also the subcutaneous tissue.\\nTheir surfaces are smooth, glazed, or desquamating and their evolu-\\ntion is peculiar in that they rarely exhibit apical pustulation or ulcer-\\native degeneration.\\nThe eruption is, with few exceptions, usually limited to one or more\\nregions of the body, as the forehead, the chin, the nucha, the buttocks,\\nand the outer surface of the thighs. It is less often disseminated than\\ngrouped. Occasionally there may be displayed upon the surface of the\\nbody but a single tubercular lesion, the recognition of its character\\nusually demanding some skill on the part of the diagnostician. When\\noccurring in groups the typical circinate appearance of the syphilo-\\ndermata in general may be Avanting, the patches having an irregular\\nboundary but at times the circular, reniform, or horseshoe-shaped out-\\nline is distinct, with an enclosed area of integument unaltered or the\\nseat of atrophic changes. At times the lesions assume a serpiginous\\ncharacter and distribution, a condition to which has been applied the\\nterm\\nSyphiloderma Tuberculosum Serpiginosum. In exceptional cases ser-\\npiginous and tubercular lesions are marked by secondary changes. They\\nmay become covered on the surface with a thin yellowish crust may\\nlose their firmness and become soft and rather more lurid red in hue,\\nfrom colloid, or rarely even suppurative, degeneration may vegetate\\nluxuriantly and become the seat, especially on the scalp, of warty\\ngrowths, smeared with a semipurulent secretion of disgusting odor\\n(syphilis papillomatosa, syphiloderma framboesioides) or finally they\\nmay ulcerate, the superimposed crusts thickening in bulk, deepening\\ninto blackish and greenish shades, and covering typical syphilitic ulcer-\\nations, with characteristic edges, floor, base, and secretion. The degen-\\neration iij the latter case may be rapid and the destruction extensive.\\nThis result is, however, of rare occurrence.\\nThe course of the eruption is indolent, months usually elapsing\\nbefore full evolution is accomplished. In untreated cases there is pro-\\nduced a generalized and symmetrical syphiloderm. It is rare, how-\\never, even in hospital and dispensary cases, to observe such develop-\\nment; the more superficial, generalized, and symmetrical are the\\nlesions, the briefer, as a rule, is the interval between such an eruption\\nand the date of infection. The later the lesions, the more are they", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0689.jp2"}, "690": {"fulltext": "636 NEW-GROWTHS.\\nasymmetrical, localized, and profound in their involvement of the deep\\ntissues. This syphiloderm rarely appears in the second, more often in\\nthe third or fourth, still more rarely in the fifth, tenth, or fifteenth year\\nof the disease.\\nResolution occurs by resorption, leaving in the site of the tubercles\\naccording to their age, size, and contents, livid and pigmented macu-\\nlations, or characteristic pigmented, atrophic, cicatriform areas. Scars\\nfollowing the ulcerative lesions are typical in color, shape, and career,\\nthe pigmentation of both cicatrix and areola blanching from centre to\\nperiphery, and leaving a delicate, dull-whitish, glazed, or slightly\\ndesquamating membranous new-growth ancient relics of this process\\nresembling in appearance thin, small coin- and larger-sized, circular\\nsheets of mica.\\nFig. 74.\\nUlcerative tubercular syphiloderm. (After Keyes.)\\nThe diagnosis is between lupus vulgaris, lepra, epithelioma, and\\npsoriasis. In lupus the age of the subject, the character of any scars\\nleft upon the body-surface, the chronicity of the disease, and the\\nabsence of a history of polymorphism, will usually point to the nature\\nof the disease. The tubercles of lepra are very much more indolent\\nthan those of syphilis, and have a characteristic oiled or varnished\\nlook, never the livid or dull-crimson color of syphilitic lesions. Set\\nupon the forehead, the tubercles of syphilis, near the line of The hairs,\\nnever give the leonine aspect of those at the lower border of the fore-\\nhead and over the eyebrow of the leper. In epithelioma the age of\\nthe subject and the history of the disease are always significant. In\\nthe early stage of epithelioma the patient is often in a condition of\\nexcellent general health, while the imprint of cachexia is distinct in\\ntubercular syphilis of the skin. In the later stages of epithelioma the\\nulcer with everted edges and eroded, hemorrhagic floor, varnished", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0690.jp2"}, "691": {"fulltext": "SYPHILIS.\\n637\\nwith a translucent secretion, is totally different from the punched-\\nout, syphilitic ulcer with its puriform secretion and discolored crusts.\\nThe deep infiltration of even the desquamating tubercular syphiloderm\\nwill distinguish it from the circular patches of psoriasis.\\nSyphiloderma Gummatosum. The gumma is a lesion peculiar to\\nsyphilis no other disease exhibits an exactly similar feature. It is\\nusually a late or so-called tertiary manifestation of the disease, and\\nis commonly observed in the form of one or relatively few, subcuta-\\nneous, strictly circumscribed, firm, w^ell-rounded, painless, and indolent\\nFig. 75.\\nSyphiloma of the vulva with gummatous changes in labia and clitoris, and languettes of anus\\naccompanying stricture of the rectum.\\ntumors or nodules which, when first observed, are scarcely larger than\\na pea. They are then covered with an unaltered integument and are\\nmovable.\\nVery slowly they may, when untreated, increase in size until they\\nattain the dimensions of a marble, of an egg, or even of bodies of a\\nconsiderably larger size. Sooner or later, when not resolved by treat-\\nment, they usually become attached, and the overlying skin is involved,\\nshowing by its livid, reddish, or purplish hue and its hypersemic\\nareola that it threatens to yield. Finally, at one or at several points\\nthe skin is so thinned as to be incapable of further resistance, the gumma\\nbursts, and a thick sanious secretion escapes, the gummy character of", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0691.jp2"}, "692": {"fulltext": "638 NEW-GROWTHS.\\nwhich has given the lesion its name. When the inflammation has\\nbeen active its secretion may be wholly or partially purulent, and in\\nthis case be furnished either by the contents of the tumor or by the\\nperipheral tissue which participates in the process. Ulcers always\\nresult, which occasionally are fistulous in type, roundish or oval in con-\\ntour, with edges clean cat, and floor purulent and extending to the\\nsubcutaneous tissue, tendons, aponeuroses, cartilage, or bone. Thin\\nand yielding bands or bridges of undermined skin often extend be-\\ntween several such solutions of continuity, and usually melt down in\\nthe presence of the destructive process. When repair is progressing,\\nwhich is decidedly the rule as regards the ultimate result, granulations\\nspring from the floor of the ulcer, the edges contract, and the gumma-\\ntous eventually exhibits the appearance of a simple ulcer, save in the\\nthinned purplish, pigmented appearance of the outlying integument.\\nThe scars are typical, bleaching from the centre, and they may be\\nattached to periosteum or bone, though this is exceedingly rare. Con-\\nsidering the depth of the process, the gumma of the skin is, as a rule,\\nsucceeded by less evidence of destruction at the height of the process.\\nAbout the neck cicatrices may be linear in shape and slightly puckered.\\nUpon the lower extremities and the trunk they are usually circular or\\noval.\\nBut one gumma may appear upon the person of a single individual,\\nand when this is the case it will usually be found upon the leg.\\nHalf a dozen or more may at times coexist. In other cases hundreds\\nform. Gummata may develop upon any part of the body, and when\\nsituated over the trunk of a nerve may become the seat of severe\\nneuralgic pain. They are amenable to skilful treatment, and they\\nmay undergo resorption, leaving little or no trace of their former\\nexistence.\\nGummata are to be distinguished from fibrous, carcinomatous, and\\nlipomatous tumors, as also from indurated and enlarged lymphatic\\nganglia. As gummata occur in very marked preponderance below\\nthe level of the knees, and are for the most part single or relatively\\nfew in- such situation, by their position alone they frequently can be\\ndifferentiated from each of the new-growths mentioned, no one of\\nwhich occurs by preference upon the lower extremities. As they are,\\nmoreover, relatively late lesions of syphilis, a history of pre-existing\\nsymptoms of that disease can usually be obtained.\\nErythanthema Syphiliticum. Under this title Bronson l de-\\nscribed a condition observed by himself in syphilitic patients. Upon a\\nwell-defined, crimson or livid, erythematous surface (face, palms, soles)\\nappeared an abundant crop of pea-sized vesico-pustules, which were con-\\nverted later into an exuding, whitish, elevated, diphtheroid patch. The\\nmultiformity of the exanthem was characteristic. In parts it suggested\\nthe hydroa bulleux of Bazin in other parts the dermatitis herpeti-\\nformis of Duhring. The fluid exudation that affected the face was not\\ncharacteristic of the evolution of the palmar and plantar lesions.\\nLater, warty, papilliform lesions appeared over the face and neck,\\n1 N. Y. Med. Record, September 4, 1886, p. 253.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0692.jp2"}, "693": {"fulltext": "SYPHILIS. 639\\nsomewhat resembling secreting condylomata, and surmounting for the\\nmost part a dusky-red or erythematous surface.\\nThis author regarded the exanthem as primarily a syphilitic product\\nbut not pathologically or etiologically a true syphiloderm. Its origin\\nwas possibly similar to that of the angioneurotic, trophoneurotic, or\\nreflex phenomena of skin-disorders in general, though possibly due to\\nbacterial invasion.\\nSyphilis of the Mucous Surfaces.\\nThe lesions of syphilis involving the mucous membranes, found\\nchiefly in the mouth, but exhibited, also, in both acquired and infantile\\ndisease, over the nasal, aural, vaginal, anal, and balano-preputial sur-\\nfaces, are strictly allied to the similar symptoms in the skin. The\\ndifferences are due to maceration of the involved surfaces, to the func-\\ntions of the organs chiefly implicated, to contact, and to apposition of\\ncontiguous parts.\\nThere is, hence, every grade of disorder from hyperemia to inflam-\\nmation and the results of the latter are both ulceration and cicatriza-\\ntion, each result being subject to the special modifications due to the\\nsyphilitic process (gummatous deposits, infiltrations, etc.).\\nIn the purely hyperemic forms there is usually at the moment\\nor soon after the outbreak of general syphilis a pharyngeal or a phar-\\nyngo-nasal blush, spreading symmetrically or irregularly over the parts,\\naccompanied often by engorgement of the tonsils, especially in persons\\npreviously subject to disorders of the same region due to other causes\\n(catarrh, follicular tonsillitis, etc.). There is then pain on swallowing,\\nand complications may arise, producing laryngeal hoarseness, cough,\\ndyspnoea, aphonia, nasal discharges, crusts blocking up the passages\\n(especially in inherited disease), and impeded transmission of air\\nthrough the nares. Similar conditions may be observed about the os\\nuteri, the peri-anal region, and others of the sites named above. This\\nmay or may not be the precursor of the severer complications mucous\\npatches, ulcers, and other symptoms of syphilis of mucous surfaces.\\nMucous Patches (Condylomata; Fr., Plaques muqueuses Ger.,\\nSchleimhautpapeln, Feigwarze) are merely syphilitic papules occurring\\nin moist situations, flattened by reason of the apposition of affected\\nsurfaces and by contacts necessitated by the functions of the parts in-\\nvolved. They form upon all mucous surfaces, but are nowhere better\\nstudied than in the mouth, where they are the most annoying and the\\nmost persistent symptoms of syphilis, complicating both the early and\\nthe later stages of the disease.\\nThe patches are roundish or oval, tumid, flattened or very slightly\\ndepressed, pale-rosy or whitish spots, moistened with mucus, either devel-\\noping as such or resulting from hyperemic plaques of the sort described\\nabove, or dispersed among or upon the latter. They often resemble\\nthe patches produced on the mucous membrane by pencilling the latter\\nwith a crayon of silver nitrate. When carefully inspected, many of\\nthem exhibit a loosened and partially detached film of membrane, cov-\\nering the tissue, beneath which a reddish, raw-looking surface appears.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0693.jp2"}, "694": {"fulltext": "640 NEW-GROWTHS,\\nThey are seen not merely upon strictly mucous surfaces, but develop\\nalso on the verge of the latter (mouth, anus, scrotum), and even on\\nmoistened cutaneous surfaces the edges of nails in infants, and in\\npersons whose hands are often macerated, between the toes, in the\\nvulvo-crural angles, etc. The condyloma is by many writers described\\nseparately, but the older authorities were by no means in error when\\nusing, as appears above, the term condyloma for both the mucous\\npatch and the flattened creamy-looking secreting papules seen often\\nabout the anus and the vulva of the subjects of syphilis, particularly\\nthose of a tender age for the condyloma is actually a flattened syph-\\nlitic papule, as is the mucous patch, the external appearances of which\\nare chiefly the result of its site and surroundings.\\nThe secretions of these lesions are at times very offensive in odor,\\nespecially about the anogenital region, but also about the mouth and\\nthe nose (infants, the filthy, and the neglected). They may become\\nfissured (edges of the tongue, tonsils, vagina), may ulcerate deeply,\\nmay be the seat of vegetations (papilloma, so-called cdhiomene of\\nthe vulva, etc.), and, in general, may furnish a highly contagious\\nsecretion. It is probable that mucous lesions are more responsible for\\nthe transmission of contact-syphilis than are chancres.\\nMucous lesions are to be distinguished with care from simple aphthous\\npatches in the mouth the result of indigestion or local disturbances\\nalso from smokers patches (leucoplakia buccalis, psoriasis linguae,\\nleucoplasie). In external features these patches may resemble one\\nanother, but in only one affection, syphilis, are there other signs of\\ninfectious disease. The chief points of difference are singleness, for\\nthe most part, of aphthous sores, and often exquisite tenderness mul-\\ntiplicity, as a rule, of mucous patches, and much less soreness, though\\nwhen ulcerated the soreness may be a conspicuous feature. Linear\\nstreaks and bands (often quite insensitive) of leucoplasie patches are\\nespecially found along the gums, on the lines of the inner cheek repre-\\nsenting contact with the approximated upper and lower teeth, and in\\nthe pocket posterior to the wisdom tooth.\\nScaly Patches, described by most authors separately, are not true\\nmucous lesions of syphilis. They occur not rarely in syphilitic subjects\\nas flattish, smooth, bluish-white or lead-white, firm, slightly indurated,\\nand roundish or highly irregular plaques. They are visible on the\\ndorsum of the tongue, on the mucous lining of the cheeks, and at the\\nangles of the mouth, where they are situated often in part on the mucous\\nsurface and in part on the skin of the lip. The thickened epidermis\\nis at times covered with adherent, not readily removed, scales between\\nwhich fissures form, and the patch, at first almost insensitive, becomes\\nexceedingly tender and painful.\\nThese patches are for the most part of the order described above,\\nthat is, leucoplasie, due chiefly to irritation of the mucous surfaces by\\ntobacco-smoke, yet occurring in syphilitic subjects, as they are preceded\\noften by typical mucous patches. They are almost exclusively seen in\\nmen. They are also rarely encountered in inherited syphilis. In the\\ndistinction sought to be made between the specific and the non-specific\\nform attention is called to the occurrence in the latter class of hard,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0694.jp2"}, "695": {"fulltext": "SYPHILIS. 641\\nuneven, and considerably thickened patches, which occasionally prolif-\\nerate, and which, extending to some depth, are eventually transformed\\ninto epitheliomatous lesions.\\nGummatous infiltrations of mucous membranes sclerosis of the\\ntongue, of Fournier) occur in both circumscribed and diffused forms,\\nsuperficial and deep. In the diffuse superficial forms both the mucous\\nand the submucous tissues are involved in a firm thickening, best studied\\non the surface of the tongue, which then becomes to the view polished\\nand smooth, at times appearing as if covered with a thin, translucent\\nvarnish. Patients exhibiting this condition will often describe a sub-\\njective sensation of slipperiness. These thickenings may involve\\nthe deeper structures by every gradation, producing eventually lobu-\\nlated masses with intervening fissures, tender, raw, and excoriated.\\nThe general face of the tongue is then, as a rule, covered with a par-\\nticularly foul, dirty-grayish coat, and it is occasionally notched at the\\nedge with deep ulcers. At times the tongue is mottled, with patches\\nof redness alternating with the yellowish white of the deposit on the\\nsurface of the membrane.\\nThe deeper gummata involve the body of the tongue, and they are\\nfelt as submucous, diffuse or circumscribed, dense thickenings (usually\\ntolerably well defined), which soften, ulcerate, and leave exposed to\\nview extensive losses of substance. The floors of these excoriations are\\ndeep ulcers, indurated, sloughy, and with membranous shreds over the\\nsurface. The fissures of the sides of the tongue described above may\\nhere also produce deeply ulcerated notches in the substance of this\\norgan. It is surprising how greatly deformities of this class are\\nrelieved after cicatrization, even when considerable loss of tissue has\\nresulted.\\nSyphiloderma Infantile, Acquisitum et H^reditarium.\\nSyphilis may be acquired by the infant child at any period after\\nbirth, as, for example, by immediate contagion from the nipple of the\\nnurse, or mediately, as by the use of utensils smeared with a secre-\\ntion capable of transmitting the disease. Such acquired infantile dis-\\nease displays, for the most part, the symptoms observed in adult years,\\nexcept that the delicate and tender skin at this early period of life\\noften exhibits the moist and secreting lesions of syphilis. The mu-\\ncous patch, the pustule, and the condyloma are here more common\\nthan the papulo-squamous symptoms of the adult. Some influence is\\nalso exerted upon the disease by the dress, habits of life, and mode of\\nobtaining nutriment, which are conditioned upon the helplessness of\\nthe young child. In this way the soiled napkin over the anogenital\\nregion, the warm covering of, and free diaphoresis from, the general\\nsurface of the skin, and the frequent contacts of the lips with the\\nnipple, suffice to determine in special regions particular local expres-\\nsions of the constitutional vice. The acquired is much less grave in\\ncharacter and portent than the inherited form of the disease.\\nHereditary syphilis, which may be displayed first in infancy or in\\nearly adult years, is always strictly transmitted by inheritance from one\\n41", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0695.jp2"}, "696": {"fulltext": "642 NEW-GROWTHS.\\nor both parents. The consideration of the disease in these pages being\\nlimited to its cutaneous manifestations, it is first to be noted that the\\ninfected foetus may prematurely be expelled dead-born with cutaneous\\nsymptoms displayed upon its body-surface. Over 90 per cent, of\\nthe products of conception affected with inherited syphilis perish in\\nabortions.\\nThis condition generally argues in favor either of intense syphilis\\nin one or both progenitors, or, more commonly, of relatively recent\\ninfection of both. Under these circumstances there are usually evi-\\ndences of the death of the foetus at some date prior to its expulsion,\\nthe skin being macerated and the epidermis raised from the corium in\\nfew or many bullous lesions, beneath which the derma exhibits a livid\\nreddish or a purplish hue.\\nWhen the infant is born with a clean skin it may be shrivelled and\\nemaciated, or be fat and present the appearance of sound health.\\nSoon after birth, however, cutaneous manifestations appear, usually\\nnot before the conclusion of the first month, more commonly during\\nthe second, rarely after the third and the fourth. The earlier the\\ndate of such explosion the more intense, as a rule, is the evidence of\\nthe disorder. The first symptoms displayed are significant of visceral\\ninvolvement, and are, in brief, those of marasmus. Emaciation pro-\\ngresses rapidly the skin seems stretched unnaturally over the facial\\nbones the expression is that of physical distress the cry becomes a\\nfretful moan the integument loses entirely the rosy hue of the healthy\\ninfant, and acquires instead a sallow or muddy tint and very peculiar\\nwrinkles or puckered lines radiate from the angles of the lips. Few\\nobservers have failed to notice the resemblance which then exists\\nbetween the faces of these emaciated little creatures and those of the\\naged of both sexes.\\nIn this complexus of symptoms, however, there is absolutely nothing\\ncharacteristic of syphilis as distinguished from other wasting diseases\\nof infancy. Chronic tubercular meningitis and the gastro-intestinal\\ndisorders of infancy in their extreme expression furnish a precisely\\nsimilar picture. This is natural enough, since all depend alike upon a\\nsimilar cause, failure of proper performance of function on the part of\\nthe viscera in consequence of morbid changes.\\nThe coryza of the syphilitic infant, however, is soon declared, and\\nspeedily gives a clue to the nature of the morbid process. The dis-\\ncharge from the nares (at first serous, later purulent) desiccates suffi-\\nciently to obstruct the nasal passages or, in consequence of the tumid\\ncondition of the membrane lining the passages, is prevented from\\nescaping. Often this discharge is furnished by a specific rhinitis chiefly\\ninvading the Schneiderian membrane. At times crusts accumulate\\nexternally about the nasal orifices, and they are seen to be similar to\\nthose which are prone to form also at the angles of the mouth. In this\\nway the characteristic snuffles of the syphilitic infant are induced,\\nin consequence of which it is obliged when nursing to release the\\nnipple from its mouth in order to respire, an act often accompanied by\\na hoarse cry. The breathing of the syphilitic infant, even when\\nasleep, or awake and undisturbed, is often sufficient to arouse a sus-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0696.jp2"}, "697": {"fulltext": "SYPHILIS. 643\\npicion as to the nature of the disease from which it is suffering. The\\nmouth, the larynx, the vulva, and the anus are often the seat of similar\\nlesions, the development of which into an obstructive tumefaction\\nsecreting more or less profusely, or into moist condylomata, will largely\\ndepend upon the seat and surroundings of the lesion.\\nThe cutaneous symptoms of inherited syphilis are macular, papular,\\npustular, bullous, or furuncular, two or more of them being at times\\ncommingled, attesting thus the identity of the disease with the poly-\\nmorphic acquired forms of maturer years. Macules early appear upon\\nthe trunk, the face, and the extremities, usually of a livid reddish hue,\\ncommingled with papules, and indeed often occur as the first mani-\\nfestation of the papules. They are irregular as to shape, and though\\noccasionally pinkish, discrete, circinate, and coffee-bean-sized, often\\nproduce a diffuse, coppery-red or violaceous, glazed, or moist and\\nsecreting surface, affecting an entire region, as the neck, the trunk, or\\nthe thighs and the genitalia. Deep excoriations and even fissures\\noccasionally form in these extensive patches, and the secretions may\\nincrust them irregularly, the general aspect of the patch somewhat sug-\\ngesting an eczematous condition, yet remarkably differing from it in color.\\nIn hereditary as in acquired syphilis the type of all the eruptive\\nsymptoms is to be sought in the papules which may spring from the\\nmacules described above, and develop into pustules, bullae, or condy-\\nlomata; and, in the former case, dull-red or violaceous papules of\\nlenticular size occur either in asymmetrical or symmetrical arrange-\\nment, being discrete or agglomerated in patches of infiltration. These\\npapules may, especially upon the buttocks, scale at the apex or, par-\\nticularly upon the palms and soles, may constitute by fusion a thickened\\ndesquamating epidermal patch or, commonly about the anogenital\\nregion, the interdigital spaces, the axilla?, and face, may become moist\\nand secrete a puriform mucus. By vegetation or by hypertrophy they\\ndevelop into flat or fissured condylomata, smeared with an offensive,\\nyellowish or yellowish-white discharge and vary in size from that of a\\nsmall coin to a lesion a centimetre or more in diameter, with correspond-\\ning variation in the degree of their elevation from the affected surface.\\nCondylomata may be few or numerous. Sometimes a child will appear\\nto be well-nigh covered with large, moist, secreting papules. Papulo-\\ncondylomata may deeply ulcerate and crust. It should be remembered,\\nin studying these symptoms, that they are those of a cachectic infant\\naffected with a grave disease. Death often interrupts the sequence of\\nthe manifestations above described. This event is usually preceded\\nby signs of apparent amelioration, shrinkage of hypertrophic growths,\\nand decoloration of hypersemic lesions and patches. Of the other\\ncutaneous symptoms of hereditary syphilis, vesicles are the rarest the\\nsmaller, occasionally seen, have a conical apex with serous contents, are\\nclosely set together about the lips, and spring from a violaceous infil-\\ntrated patch. The resulting crusts never have the reddish-yellow tint\\nof those observed in eczema, nor, after rupture, are they followed by\\nserous oozing from a wounded epidermis. The larger lesions of this\\nsort are usually transformations of papules which rapidly assume a\\npustular phase.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0697.jp2"}, "698": {"fulltext": "644 NEW-GROWTHS.\\nPustular eruptions, in this form of syphilis, may be discrete or be\\nconfluent, localized or generalized. They are particularly prone to\\noccur in groups about the mucous outlets, with maculo-papular lesions\\ndeveloped elsewhere, and they may result in ulceration, often after\\ndevelopment into bullae with pustular or sanious contents. The\\nresulting crusts are bulky and dark colored, and, especially upon the\\nface, disfiguring. The subjective sensations are insignificant, since\\nthe child does not attempt to tear the affected surface as in pustular\\neczema. The cachectic condition of the little patient is usually pro-\\nnounced when these lesions are large and numerous. They may be\\nseen in typical development by the side of the nail, occasionally involv-\\ning the matrix, and producing in this situation considerable swelling of\\nthe digit, with an ulcerative sequel which commonly results in distor-\\ntion or an ultimate loss of the nail-substance. Onychia, however, may\\nresult from perverted nutrition of the part, with increase in the fria-\\nbility of the nail-substance, loss of lustre, assumption of a dirty-grayish\\nhue, and phalangeal oedema. These changes are analogous to those\\nresulting in loss of the hair where the follicles have been improperly\\nnourished.\\nThe furuncles which form in other cases are either exaggerated\\nmanifestations of the same pyogenic tendency in the skin of the infant,\\na complication common to syphilitic and other cachectic conditions in\\nyoung children, or are the result of infection with pus-cocci, a more\\nfrequent cause. These furuncles may be few or be numerous, and they\\nare chiefly characterized by their indolence, the absence of laudable\\npus in their contents, the ulcerative condition left after their evacua-\\ntion, and the bluish or purplish condition of the integument which sur-\\nrounds their edges.\\nBullae in hereditary syphilis are early or late manifestations of the\\ndisease, and they may be represented by a single lesion on the palms\\nor soles (the site of their predilection), or they may constitute a sym-\\nmetrical generalized efflorescence. Bullae should be regarded as evi-\\ndences of a grave form of the disease, being often the precursors of a\\nfatal issue, as indicating a feeble resistance on the part of the epidermis\\nto the fluid exudate furnished from the corium beneath. In severe\\ncases the bullae are ill developed, and the integument will be seen to be\\nmarked here and there by small coin-sized and larger disks or plaques\\nof macerated epidermis, separated from the derma by a thin film of\\nserous, sanious, or purulent fluid, in quantity insufficient to raise the\\nroof above the general level of the integument. When fully developed\\nthey may be conical, rounded, flat, or flaccid, and be surrounded by an\\ninfiltrated border of dark-reddish or violaceous hue. Their color varies\\nwith the color of their contents. Their subsequent career is concluded\\nby shallow or by deep ulceration, the base of each bulla secreting a\\nsanious discharge. Crusts may form if the patient survives. A fatal\\ntermination of the disease is usually announced by flattening or collapse\\nof the blebs. The lesions may be commingled with pustules, maculo-\\npapules, condylomata, and mucous patches of the anus, the mouth, and\\nthe nares; but they are somewhat different from the other lesions\\ndescribed in that thfey may constitute a uniform efflorescence, no other", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0698.jp2"}, "699": {"fulltext": "SYPHILIS. 645\\ncutaneous symptoms being manifested. The uniformity is due to the\\nfact that bullae represent the state of feeblest resistance in the epidermis,\\nthe fluid exudate of exceedingly low grade mechanically separating the\\nrete from the tissues beneath.\\nTubercles and subcutaneous gummata may develop in hereditary\\nsyphilis, but only as late manifestations of the disease, one or more\\nyears elapsing before their appearance. Their behavior is scarcely dif-\\nferent from that of those observed in the acquired forms, although the\\ndestruction wrought by their degeneration in very late manifestations\\nmay be of the most intractable type. Usually there is a history of\\npreceding parental or inherited disease, and coincident symptoms or\\nsequels of such disease, in altered teeth (as described by Hutchinson),\\nin an ancient keratitis, or in a hopeless form of surdity.\\nMucous patches are very constant symptoms of the disease, and they\\nrepresent papules of the mucous membrane that diifer from those seen\\nin the skin only because they are moistened, macerated, and flattened\\nby juxtaposition of neighboring tissues. They are surrounded usually\\nby a lurid halo, and they may have the pearly whiteness always seen\\nwhen the epidermis of mucous membrane is wholly or partly detached\\nfrom the corium; or they may lose this protecting disk in shreds or\\npatches, and show, beneath, an engorged or ulcerated and secreting\\ntissue. They may be isolated or be broadly confluent, and be oval,\\ncircular, or decidedly linear in shape, the last-named appearance being\\ncharacteristic of patches existing at the angles of the mouth. Mucous\\npatches are to be recognized as distinct from both the parasitic and the\\nnon-parasitic forms of simple stomatitis or thrush, the parasitic form\\nbeing due to the presence of the o idium albicans. In both of the non-\\nsyphilitic disorders the mouth of the child is very generally, uniformly,\\nand symmetrically involved, the circumscribed patches being distinctly\\ndiscrete and resembling in color soft whitish or yellowish flocculi of\\ncurdled milk.\\nThe diagnosis is always greatly aided by noticing the well-nigh con-\\nstant occurrence of patches at the angles of the mouth, which has also\\nthe seamed and puckered appearance described above. Snuffles, syph-\\nilodermata, and marked cachexia, when established, leave little doubt as\\nto the nature of the malady.\\nThe future of the infant affected with hereditary syphilis is not\\nalways as dark as might be gathered from what has preceded. In\\nthis, as in the acquired, form of the disease benignancy may be in\\nrare cases a conspicuous feature of the entire process. The evolu-\\ntion of the disease may be tardy; its symptoms be few and unimpor-\\ntant; its amenability to judicious treatment speedily be demonstrated.\\n1 Still, the fact remains that the disease when inherited is far graver than\\nI when acquired, the victim of inheritance entering the world with its\\nj viscera and bones subject to profound pathologic alterations. Atten-\\ntion has been directed to the important fact of the frequency with which\\nthe syphilitic product of conception perishes.\\nEtiology. Syphilis, in the course of which appear the syphilo-\\ndermata, is produced by either accidental or intentional infection, or", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0699.jp2"}, "700": {"fulltext": "646 NEW-GROWTHS.\\nas a result of heredity. In all cases it is believed that the contagiuni,\\nwhich reaches the blood through the medium of the lymphatics,\\nis effective by reason of a virus charged with a pleomorphous but\\nas yet undemonstrated bacillus. The physiological secretions of the\\ninfected uncontaminated with pathological products are believed to be\\nincapable of acting as virus-carriers, but, especially in the recently\\ninfected, such contamination is of frequent occurrence, and is generally\\neffective in the transmission of the malady to persons not immunized\\nby previous attacks of the disease.\\nThe methods of transmission may be immediate, as in sexual con-\\ngress, in kissing, and in nursing at the nipple, by which act the child\\nmay infect the nurse with the secretion of the mucous patches in its\\nmouth or it may, instead, receive the disease from the excoriations on the\\nbreast of the nurse. The disorder may also result through the medium\\nof utensils charged with an infectious secretion, such as the needles of\\nthe tattooer wet with saliva commingled with diseased mucus, or the\\nlancet of the vaccinator covered with an intoxicated blood. Generally\\nit may be said that all the discharging and moist syphilodermata are\\nsources of danger to a sound individual, both in the acquired and\\nthe inherited forms of the disease.\\nBy these and other similar methods persons of both sexes and all\\nages may become infected.\\nHowever begotten, the syphilodermata are yet not excluded from\\nsubjection to the long list of external irritants which may in turn\\nannoy the skin. The influence of a hot bath, or the excitement and\\nperspiration of the dance, will often invite to the surface a macular\\nsyphilide which might otherwise be less fully developed friction, as\\nby the hatband over the forehead, the cuff at the wrist, and the shoe\\nupon the foot, demonstrates its influence by daily examples of deter-\\nmination of the morbid process to special localities. In the trades\\nthe hands of the syphilitic laborer betray unmistakable evidences of\\nthe irritative effect of harsh contacts the same may be said of filth,\\nsuch as the feces on the napkin of an infant that frequently provoke\\ncondylomata in the anal region. It is a mistake to suppose that syph-\\nilis, and syphilis only, is responsible for the exanthemata of that dis-\\nease in all shades, grades, and situations. Soap and water are as effi-\\ncient in preserving the skin of the syphilitic as of the sound subject\\nand the infected tobacco-chewer pays a price for his nauseous habit.\\nPoverty, misery, and wilful neglect or ignorance of the laws of hygiene,\\nare responsible for a long and lengthening list of the complications of\\nthe disease.\\nPathology. Lustgarten, Doutrelepont, and others have described\\na bacillus found in chancres and in the later syphilodermata. Von\\nNiessen, of Wiesbaden, also has cultivated an organism which is\\nclaimed to be common to all syphilitic subjects, and is said by its dis-\\ncoverer to be allied to the ray-fungus. The micro-organism is inva-\\nriably intracellular and pleomorphous. Pathological results were\\nobtained with it after inoculation of apes, pigs, and rabbits and it is\\nclaimed that signs of inherited lues were exhibited in a second gener-\\nation of the infected animals. The pathogenic value, however, of these", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0700.jp2"}, "701": {"fulltext": "SYPHILIS. 647\\nmicro-organisms has not been settled definitely. Syphilis is unques-\\ntionably an infectious disease, but the exact nature of its infecting\\nvirus is, as yet, undetermined. The agent which produces chancre is\\nundoubtedly present in many of the syphilodermata, while its toxins\\ncirculating in the blood are certainly the immediate cause of other\\nlesions. Pustules in this disease in most instances are due to secondary\\ninfection, while many of the crusted, scaling, and other unusual\\nsyphilides are the result of coexistence with syphilis of seborrheal\\neczema or other inflammatory dermatoses.\\nWhile the histological changes in syphilis cannot be considered\\npathognomonic, practically all the lesions, including chancre, show the\\nsame structure and processes, varying somewhat in extent, intensity,\\nand in minor features, due to the circumstances of location, state of\\nnutrition of the tissues, and the virulence of the infecting virus. The\\nprocesses are always chronic in career. There are always hyperemia\\nand more or less dense infiltration, chiefly about the vessels. Herzog\\nand Bieder agree that the vascular changes in syphilis chiefly concern\\nthe veins and lymphatics, the arteries being relatively free and that\\nthe vascular infection proceeds through the lymphatics from the peri-\\nvascular lymph-spaces. The inferiority of the veins in point of\\nresistance is supposed to explain the difference in susceptibility of the\\nvenous and arterial systems. After a general outbreak, either with or\\nwithout antisyphilitic treatment, hematogenous immunity is secured for\\nthe time being.\\nThe cells of the syphilitic new-growth are lymphoid in type.\\nThere is usually endothelial proliferation. In the solid lesions (papu-\\nlar, tubercular, and gummatous) the microscopical appearances are\\npractically those of tuberculosis, including the presence of giant-cells.\\nThe neoplasm is not capable of organization, but undergoes involution\\neither by fatty degeneration and absorption of the cells or by necrosis\\nand ulceration. According to Jullien, the three characteristic features\\nof all syphilides are the cell-infiltration, the inevitable destruction of\\nthis infiltrate the cells of which are incapable of organization, and the\\ncentrifugal development and retrogression of the neoplasm.\\nIn the macular syphilide the process is superficial and circumscribed.\\nThere may be simply hyperemia, stasis, and effusion of serum with\\nslight infiltration about the vessels of the papillary and subpapillary\\nlayers. These vessels are dilated, and show endothelial and perithelia!\\nproliferation. There is often a periglandular and perifollicular infiltra-\\ntion of lymphoid cells, and the coil-glands not infrequently show a\\nswollen epithelium. In the urticarial type of macule both the epi-\\ndermis and the upper part of the cutis may show oedema. In the older\\nand thickened macules the structure gradually approaches that of the\\npapule.\\nIn the several forms of the papular syphilide the cell-infiltration is\\npronounced in the papillary layer and about the vessels, but extends\\nalso to the deeper portions of the cutis. There is more dense peri-\\nfollicular and perivascular infiltration than in the macule. A few\\nepithelioid and young connective-tissue cells are seen, as also occasional\\n1 Brit. Jour, of Derm., June, 1899.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0701.jp2"}, "702": {"fulltext": "648 NEW-GROWTHS.\\ntypical giant-cells. Unna describes the new-growth as made up chiefly\\nof plasma-cells of different sizes. The papular syphilide exhibits a\\nlarger number of incomplete giant-cells, a different arrangement of the\\nplasma-cells, and more spindle-cells, together with a better preserva-\\ntion of the fibrous tissue along the lymphatics, than are seen in lupus.\\nThe firmness of the papule is due to a decided increase in fibrous tissue\\noccurring with the cellular growth. The normal structure of the\\ntissues and the dividing-line between the cutis and epidermis may be\\neffaced by the excessive multiplication and infiltration of cells. Dila-\\ntation of bloodvessels with endothelial and perithelia! proliferation\\noccurs. The coil-glands show swollen epithelium, which may multiply\\nsufficiently to block the canal or even to obliterate it.\\nThe infiltration is often most marked about the hair-follicles, and\\nmay penetrate the root-sheaths, sometimes destroying the hair-papillae\\nand sebaceous glands. There is frequently a deposit of pigment in the\\nbasal layer of the rete, and sometimes in the corium. The connective\\ntissue is rarely involved, and in the majority of papular syphilides the\\ninfiltrate is absorbed and leaves no scar. Involution of the deeper and\\nmore persistent papules, however, may be followed by atrophic scars.\\nThe epidermis is involved secondarily, and may be thickened and\\nexfoliated or thinned and atrophied. On the palms and soles the\\npapules are broad and flat, due to mechanical pressure of the natu-\\nrally thick and firm epidermis that is closely attached to the deeper\\ntissues. Here, and occasionally in other parts of the body, there may\\nbe a persistent thickening and exfoliation, due probably to a secondary\\ninflammatory process, for months or years after all traces of the origi-\\nnal cell-infiltration have disappeared. In the anal, genital, and other\\nregions where the papules are subjected to the influence of warmth,\\nmoisture, and friction, large, flat condylomata may develop in which\\nthe original histological structure of the papule may be largely obscured\\nby the secondary and extensive hypertrophy of the rete, which sends\\nbroad processes deeply down between the papillae, though over the\\napices of the latter it may be thinned. CEdema of both corium and\\nrete with dilatation of lymph-spaces and leucocytic infiltration is\\nusually pronounced.\\nMoist lesions (vesicles, pustules, bullae) are of exceptional occurrence\\nin syphilis, being seen chiefly in the very young, in the very old, in\\ncachectic subjects, or as the result of accidental and secondary infec-\\ntion. These moist lesions form, as a rule, at the apices of the papules,\\nand in some cases are caused apparently by an unusual intensity and\\nrapidity of the process. Destruction of the cells in the centre of a\\npapule may result in a pustule or superficial ulcer. The coexistence\\nof seborrhoea in some of its phases is responsible for the crusting of\\nmany of the papular and tubercular syphilides.\\nThe tubercular syphiloderm is practically identical in structure\\nwith the papule, but is larger, and is seated deeper within the derma.\\nThe connective-tissue hypertrophy is greater proportionately than in the\\npapule, the fibres of the papillae being much thickened, the blood-vessels\\nand lymph-vessels greatly dilated and their walls hypertrophied. As\\nin the papule, the epidermis is secondarily involved, and atrophic", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0702.jp2"}, "703": {"fulltext": "SYPHILIS. 649\\nchanges are of frequent occurrence. The tubercular syphiloderm is\\nslower of evolution and more persistent than the papule, hence the\\nmere mechanical pressure of the neoplasm frequently causes destruc-\\ntion and atrophy of the normal tissue, and the involution of the\\ntubercle in such cases is followed by an atrophic scar. Necrosis of\\nthe cells in the centre of the tubercle may result in the formation of a\\nsmall ulcer. Peripheral extension with coincident degeneration and\\nabsorption or necrosis and ulceration of the central portion may occur,\\nas in all syphilitic processes. The neoplasm is commonly circum-\\nscribed, but may be diffuse.\\nThe gumma corresponds closely to the tubercle in structure and in\\ncareer but is larger, and is seated chiefly in the subcutaneous tissue,\\ninvolving the skin secondarily.\\nDiagnosis. According to Justus, a diagnostic test of syphilis\\nis the sudden decrease in haemoglobin which immediately follows\\nthe inunction or injection (not the ingestion) of mercury in full\\ndoses.\\nThe syphilodermata are to be distinguished from all other cutaneous\\neruptions by their general characteristics and by the features peculiar\\nto each lesion. It must not be forgotten, however, that these lesions\\nare not essentially different in character from all others, but are to be\\nrecognized with ease or with difficulty according as they do or do not\\nbetray the syphilitic expression. No one, however expert in diagnosis,\\ncan always trust himself in a doubtful case to recognize these special\\nfeatures by a study of the eruption only, at a given moment of time.\\nNeither in respect to color, form, size, situation, disposition, or other\\npeculiarity do the syphilodermata exhibit an absolute difference from\\nnon-syphilitic affections of the skin. It is, therefore, requisite in every\\ncase to investigate in the fullest manner the history of the disease, of\\nall prior skin-lesions, of a primary sclerosis (when this can be obtained),\\nof adenopathy, miscarriages, abortions, and disorders affecting other or-\\ngans of the body, as the bones, the viscera, the organs of sense, and the\\nmucous surfaces. Often a single extra-cutaneous fact will be a valuable\\naid in establishing the diagnosis of syphilis. An eczematous infant\\nwith snuffles and a hoarse cry has been treated in vain by many a phy-\\nsician, otherwise capable of making a diagnosis, who might have been\\ngiven a clue to the nature of the disease from which the child was\\nsuffering if he had taken the pains to inspect the anus and question the\\nfather in private.\\nEvery syphilitic patient with a disease of the skin does not neces-\\nsarily exhibit syphilodermata. The course of the disease in many cases\\nis so protracted that patients have ample opportunities to contract other\\ndisorders, and their number is larger than is commonly supposed.\\nThey suffer most often from the medicamentous eruptions, especially\\nthose induced by the ingestion of potassium iodide (cf. the chapter on\\nDermatitis Medicamentosa Drug-eruptions from Salts of Iodine) they\\nare, like other men and women, bitten by bugs and lice and they\\nsuffer from eczema, acne, psoriasis, and other non-venereal disorders.\\nThis common susceptibility is less true possibly of the innocent victims\\nof the disease than of those guilty of sexual excesses in and out of the", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0703.jp2"}, "704": {"fulltext": "650 NEW-GROWTHS.\\nmarried state, many of the unmarried leading the most disordered lives,\\nand exposing themselves to the ordinary causes of disease to a degree\\nnot noted in other persons.\\nIt is always necessary, therefore, in making a diagnosis in a case\\nsupposed to be syphilitic, first, to determine ab origine the fact of\\nsyphilis; and, if that fact cannot indubitably be ascertained, to be\\ncareful that the statements of the patient are not allowed to bias the\\njudgment in pronouncing upon any eruption present; second, suppos-\\ning that such a fact is established by clinical proofs without reserve,\\nto decide whether the eruption present is produced by the existing\\nsyphilis or some other externally or internally operating cause and if\\nthis last be determined, to be careful in eliminating the syphilitic influ-\\nence from its operation.\\nIgnored syphilis is usually severe but it is without avail that dis-\\norders of a different character are treated by the methods useful in\\nsyphilis. Thousands are annually thus mistreated who might have\\nbeen spared such a calamity. The frequent occurrence, after a suspi-\\ncious exposure, of a balanitis, of an attack of progenital herpes, of\\nuninfected excoriations, of blennorrhagic discharges, and even the\\nappearance of molluscous tumors, warts, or parasitic cutaneous dis-\\norders upon the genital region, is a source of alarm and of fruitful\\nerror to the many rather than to the few.\\nThe diagnostician none the less must ever be on the alert to recog-\\nnize the symptoms of the disease in those who least suspect it. Thus,\\nmarried women complaining of a humor of the blood, men who have\\nbeen overheated and broken out with a rash, and a long list of\\npatients exhibiting upon their persons the symptoms of salt rheum,\\ntetter, scrofulous ulcers, and erysipelas are those whose speedy\\nrelief will depend upon the skill of the practitioner in recognizing\\nthe precise nature of the malady.\\nThe diagnosis of syphilitic lesions of the skin is a matter of the very\\ngreatest importance, inasmuch as the health, comfort, mental happiness,\\nand domestic relations of thousands of men and women annually depend\\nupon it alone. An error in either direction may involve the most\\nserious consequences to both physician and patient. He is but poorly\\nqualified to discharge the important duties of a general practitioner of\\nmedicine who has not carefully trained himself to establish the truth\\nin these cases, irrespective of the diagnosis of the patient and of all\\nothers who may have been consulted.\\nTreatment. The syphilodermata are to be treated by topical\\napplications intended to hasten their disappearance or involution but\\nas local manifestations of a constitutional disease, their management is\\nlargely that which looks to the relief of the latter.\\nThe treatment of syphilis, in the pages which follow, is described\\nin outline, so far as it relates to the relief of cutaneous lesions and of\\nthe systemic condition. The important modifications of therapy that\\nare required in the management of syphilis of the osseous and the\\nnervous systems, of the respiratory, gastro-intestinal, and other organs,\\nit is scarcely necessary to remark, are fully described in the standard\\ntreatises specially devoted to this subject. Among them may be named,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0704.jp2"}, "705": {"fulltext": "SYPHILIS. 651\\nas of American authorship, the works of Taylor/ of Morrow, 2 of E. L.\\nKeyes, 3 of Hyde and Montgomery/ of White and Martin, 5 and of\\nBangs and others. 6 Of those more or less recently published abroad\\nmay be named the standard treatises of Jullien, 7 of Fournier, 8 of Diday\\nand Doyon, 9 of Mauriac, 10 of Neumann, 11 and of Lang. 12\\nThe first and often the most important consideration for the prac-\\ntitioner who is in face of a syphilitic patient is the care of that patient s\\ngeneral health. Simple and natural as it may be to set down such an\\ninjunction in this connection, its importance rests upon the fact that it\\nis too often neglected. Patient and physician respectively are often\\nhurried into the precipitate ordering and swallowing of specific drugs\\nwithout regard to other as important details.\\nIt is well to hand to the patient, at the outset of all treatment for\\nsyphilis, a slip of paper on which are printed in concise and simple\\nterms a set of rules to be observed during the continuance of the dis-\\nease. For physicians who do not take similar precautions it is advisa-\\nable to enter rather fully into the explanation of certain details which\\nthe patient should be made to understand.\\nHe or she, if an adult, should, as a rule, be informed of the serious\\nnature of the disease recognized, since every infected patient has an\\ninterest in knowing this fact, and its important bearing upon his or her\\nrelations to the uninfected. To every such patient, with the assurance\\nthat the disease is often benign and productive of little discomfort and\\nin any case is curable, it should be stated that the affection is contagi-\\nous and capable of transmission to sound persons by physical contacts\\nof various characters. The patient should be instructed as to the\\nnutritious character of the diet he should select, and should be informed\\nthat an increase in body-weight while subjected to treatment is de-\\ncidedly favorable in the matter of prognosis that the starving and\\nsweating processes so highly esteemed by the charlatan and the advo-\\ncate of the virtues of the waters of certain resorts are relics of antiquity,\\nas useless in fact as they are frequent sources of peril.\\nThe bathing of the body is a matter of importance. Hot, Turkish,\\nand Russian baths, as a rule, are to be interdicted, inasmuch as they\\ntend to invite cutaneous hyperemia, and thus to favor the occurrence\\nof eruptions. Cool or tepid baths are to be employed sufficiently often\\n1 The Pathology and Treatment of Venereal Diseases. Philadelphia, 1900.\\n2 System of Genito-urinary Diseases, Syphilis, and Dermatology. New York, 1893\\n(3 vols.).\\n3 Surgical Diseases of the Genito-urinary Organs, including Syphilis. New York,\\n1888.\\n4 Syphilis and the Venereal Diseases (2d edition). Philadelphia, 1900.\\n5 Genito-urinary Surgery and the Venereal Diseases. Philadelphia, 1897.\\n6 American Text-book of Genito-urinary Diseases, Syphilis, and Diseases of the\\nSkin. Philadelphia, 1898.\\n7 Traite pratique des Maladies veneriennes. Paris, 1886.\\n8 Lecons sur la Syphilis, etc. Paris, 1873. La Syph. Hered. tard., 1886. Traite-\\nment de la Syphilis. Paris, 1895. Les Chancres extra-genitaux. Paris, 1897. Traite\\nde la Syphilis, tome i. Paris, 1898-99.\\n9 Therapeutique des Maladies veneriennes. Paris, 1876.\\n10 Lecons sur les Malad. vener. Paris, 1883 and 1895.\\n11 Syphilis. Vienna, 1896.\\n12 Vorlesung. uber Pathol, u. Therap. d. Syphilis. Wiesbaden, 1896.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0705.jp2"}, "706": {"fulltext": "652 NEW-GROWTHS.\\nfor the purpose of cleanliness, and by the sponge rather than by immer-\\nsion. Dry friction daily of the surface of the body may be ordered\\nwith advantage where the skin is still sound. The teeth, the mouth,\\nand the gums require constant care. The use of the tooth-brush with\\ncool water twice daily is a matter of importance, and the brushing\\nshould be preceded for a time, when the gums at the outset are in a\\ntender, fungous, or hemorrhagic state, by gentle friction of the teeth\\nwith the finger, covered by a handkerchief dipped in a weak spirit-and-\\nwater lotion, to which tincture of cinchona and of myrrh may be added\\nin any desired proportion. Tobacco in every form is decidedly inju-\\nrious. Often the patient should be sent to a competent dentist for the\\nextraction or the filling of carious teeth, and for the removal by the file\\nor the dental engine of all sharp, projecting edges.\\nMalt liquors, wines, and spirits should be employed solely under the\\nexplicit direction of the physician. They are exceedingly useful in\\ndebilitated subjects of a certain class, and need not be prohibited in\\ntoto to those long habituated to their use. At the same time, an im-\\nproper use of these stimulants is in the highest degree harmful. When\\nemployed at all, they should be restricted rigidly to the dining-table\\nand the hours of meals.\\nA compliance with the laws of hygiene is even more requisite for\\nthe syphilitic than the non-infected. Fresh air, social amusements,\\nexercise, the regular routine of business life, or, when this has proved\\nexhausting, the recreation of travel the claims of all these need at\\ntimes to be urged by the physician. With this the patient should be\\nencouraged to free his or her mind from needless anxiety, and to avoid\\nparticularly the company and conversation of those similarly infected,\\nwhose opinions are based too often upon ignorance or upon a knowl-\\nedge of half-truths. The literature of syphilis, for a similar reason, is\\nto be eschewed, as a mass of patients, too many of whom purchase\\ntreatises on the subject, are able only imperfectly to glean the meaning\\nof the authors consulted.\\nIt should be a rule to urge a married patient to inform the conjugal\\npartner frankly of the fact of infection, for the sake of both. When\\nthis advice is followed much future trouble is avoided, and one of the\\nobstacles to a completely favorable issue is at once set aside. Instances\\noccur in which disruption of the conjugal bond results from infec-\\ntion of one, but usually of both parties it is a striking argument,\\nhowever, in favor of the policy here urged, that cases are rare in\\nwhich a frank and honorable confession has been followed by sepa-\\nration. It may be added that in no one of the confessed cases\\nhas there been a subsequent infection of the innocent. The larger\\nnumber of married patients are husbands. Recently infected young\\nadults who have contracted a marriage-engagement should invariably\\nclaim release from such a tie for the sake of all concerned. The syphi-\\nlitic nurse must at once be taken from the sound nursling, and the\\nchild with hereditary syphilis must be suckled only by its mother, who,\\naccording to Colles s law, the exceptions to which are so few as to\\nprove the rule, always enjoys immunity against the diseased mouth of\\nher own child.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0706.jp2"}, "707": {"fulltext": "SYPHILIS. 653\\nRespecting the medicaments employed in the treatment of syphilis,\\nthere is no routine plan which in every case can advantageously be\\nfollowed. In no respect do physicians so differ from each other,\\njudged by the standard of professional skill, as in their ability to use\\na single remedy with success. He who has the largest armamentarium\\nis not always either the best equipped or the most successful. Mercury,\\niodine, iron, and quinine are the great remedial agents in syphilis, but\\nthey may vainly be used by one man in the long effort to accomplish\\nthat which another speedily and brilliantly achieves by the use of the\\nsame remedies employed with, greater skill.\\nOf the other substances vaunted as either advantageous or specific\\nin the treatment of the disease, no one possesses any claim whatever\\nto the confidence of physicians. Sarsaparilla, dulcamara, stillingia,\\nguaiacum, tayuya, mezereon, and the long list of other vegetable prep-\\narations whose virtues have thus been extolled, are for the most part\\nas harmless in themselves as they are ineffectual for the relief of the\\nmalady.\\nBefore proceeding, how T ever, to assume the responsibility of directing\\na course of treatment for syphilis with remedies of acknowledged value,\\nthe physician will do well to remember that no two cases of the disease\\nare precisely alike, and that there is the widest range between the most\\nbenignant forms encountered in private practice and the malignant\\ncases seen in hospital-wards. Some forms of the malady are so mild\\nas to constitute merely an inconvenience others are so severe as to\\ndestroy life. It is an axiom in venereal disease that more patients per-\\nish annually from blennorrhagia and its results than from syphilis.\\nThere could be no greater error than to treat by a uniform method any\\ndisease exhibiting so wide a variation in severity.\\nMercury, after the assaults upon it of generations of men of admitted\\nwisdom and candor, stands to-day unrivalled as a remedy for the relief\\nparticularly of those stages of syphilis in which the skin is involved.\\nAdministered with skill, it can be employed for years with immense\\nadvantage to the syphilitic patient, who, during a well-regulated mercu-\\nrial course, should gain in weight, improve in vigor, and exhibit a\\nhealthy color of the skin. No competent physician of to-day employs\\nit in such a manner as to induce salivation or other toxic consequences.\\nSuch effects of the remedy result from the carelessness or the ignorance\\nof the prescriber. It should be remembered that in every discussion\\nof the merits of mercury in syphilis both physicians and patients have\\nbeen guilty of the ignorance or the folly of ascribing to the remedy the\\ndisastrous effect of the disease.\\nMercury may be given by the mouth, by inunction, by subcutaneous\\ninjection, or externally by the aid of the vapor-bath. The most popular\\nmethod, and that productive of least inconvenience to all concerned, is\\nthe method by ingestion.\\nIngestion. In this mode of treating syphilis the mild chloride,\\nbichloride, bicyanide, or blue mass, of mercury may be employed effec-\\ntively. These preparations, however, are rather less adapted than others\\nfor continued employment during long periods of time, and are open to\\nthe objection of either readily undergoing rearrangement into more", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0707.jp2"}, "708": {"fulltext": "654 NEW-GROWTHS.\\nstable compounds of the metal, or of producing undesirable irritative\\neffects. With the protiodide and the biniodide an impression can be\\nproduced upon the system that can readily be proportioned to the\\nexigencies arising in every case, which can be sustained during that\\nchronic medication which Fournier declares to be requisite in every\\nchronic disease, and which can be exerted without fear of immediate or\\nof remote deleterious consequences.\\nTreatment of syphilis by the mercurial selected for use should, as a\\nrule, be begun only at the moment of evolution of constitutional symp-\\ntoms. The initial sclerosis of the disease is amenable to the action of\\nthe metal to a remarkable extent, but in a large proportion of cases the\\nchancre will cicatrize, when in an ulcerative stage, without having re-\\ncourse to general medication. Early mercurial medication may well be\\nreserved for such primary lesions as are threatening in symptoms, and\\nfor such individuals as require or demand speedy cicatrization of their\\nchancres, as, for example, those about to travel beyond the reach of med-\\nical assistance. Personal experience fully confirms the wisdom of the\\nteaching which reserves specific medication until the second period of\\nincubation has passed. No local or general treatment can avert either\\na mild or a severe explosion of symptoms after that period is completed.\\nIn experiments made to determine this question of delay there has\\nbeen either the production of strikingly irritative effects, such as a\\nmarked relapse, or unusual increase in the volume of the initial sclerosis\\nimmediately before the evolution of the first syphilodermata, or a dis-\\ntinct obstinacy in the latter to the action of the medicament employed.\\nIn the early stages of syphilis in adults the mercurous iodide may\\nbe named as one of the most trustworthy preparations. Of all classes\\nof adult patients, including strong men and adult women, there are\\nscarcely 2 per cent, who cannot take it, if the dose be proportioned to\\nindividual susceptibility. It is usually administered in pill or in tablet\\nform in doses of (0.01), -J- (0.013), (0.016), or (0.022) of a grain,\\nthree times daily, combined with the extract of gentian. The dose\\nmay be increased gradually according to the necessities of the case,\\nfrom J (0.032) to 3 (0.207), and even 4 (0.266) grains in the twenty-\\nfour hours. Many of the gelatin-coated pellets found in the market\\ncontain accurately divided doses of the salt. The sugar-coated pills\\nof Gamier and Lamoureux, containing each 1 centigramme of the\\nprotiodide, are efficient and largely employed.\\nBeginning with a minimum dose, this remedy is to be steadily\\nexhibited, and the daily quantity consumed to be gradually increased\\nuntil the degree of tolerance of which the patient is capable has been\\nascertained. Should the stools become frequent, pain be excited, or a\\nslight effect produced upon the mouth, as indicated by a metallic taste,\\nmoderate increase in the quantity of saliva, or any noticeable degree of\\ntenderness of the gums, the dosage is to be gradually diminished until\\nthese symptoms disappear. Often the withdrawal of (0.033) or\\n(0.013) of a grain daily will suffice to enable the patient to tolerate the\\nquantity thus diminished. The medication is to be faithfully continued\\nuntil the object in view is obtained, viz., relief of all symptoms of the\\ndisease.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0708.jp2"}, "709": {"fulltext": "SYPHILIS. 655\\nIn Keyes s so-called tonic treatment of syphilis the dosage is\\nincreased only on each third or fourth day, until irritative effects are\\nproduced, when, after an interval of two days, the quantity taken at\\nthe time of the production of such effects is reduced from one-half to\\none-third. This reduced quantity is termed the tonic dose, and is\\nthereafter continued throughout the treatment in nearly all conditions\\nof health or disease. l\\nIt may not be proper to administer a mercurial for weeks at a time\\nto all subjects of syphilis who are in apparently good health. With\\nthe active measures at immediate control in the vapor-bath, it is usually\\nsafe and not unwise to suspend temporarily specific medication of the\\npatient who exhibits such amelioration of symptoms as to be free from\\nexternal manifestations of the disease. Every syphilis has its periods\\nof activity and repose. Such period of repose will well be employed\\nin the administration of iron, which, as tending to relieve the distinct\\nchloro-ansemia of the disease, has its claims to recognition in the list\\nof specific remedies. No case of syphilis can be said to have been\\ntreated properly in which this remedy has not been given for at least a\\npart of the time during which the patient was under observation.\\nFerric citrate with quinine is an excellent preparation administered at\\nthe meal-hours, in a small quantity of sound sherry wine or ferrous\\niodide may be employed in syrup, or in the pills made after the formula\\nof Blancard, or in Vallet s mass. In some cases tincture of ferric\\nchloride may be employed, but the physician should be careful about\\nordering an acid preparation of any kind during the interval of a\\nmercurial course. There is no form of anaemia which responds more\\npromptly to the chalybeates than does that produced by the syphilitic\\nvirus.\\nThe mercuric iodide may be substituted for the mercurous iodide\\nwhen, for any reason, it is thought desirable, beginning with a minimum\\ndose of -g 1 grain (0.001), and increasing this gradually to (0.0016),\\nor rarely to (0.0033), either in pill or in solution. The average\\ndose of -fa (0.0016) of a grain in pill-form, administered three times\\ndaily, soon after eating, is tolerated by the majority of all patients of\\nboth sexes without consciousness of unpleasant effects.\\nFor those who prefer to use the more active and correspondingly\\ndangerous salts of the metal, calomel may be administered in 1 or 2\\ngrain doses (0.066-0.133) three times daily, in combination with an\\nopiate to prevent its action on the bowels, or in fa grain dose (0.0066)\\nevery hour. Small doses of blue mass or of gray powder may also be\\nemployed. The gray powder is most suitable for children and infants,\\nbut since the frequent discovery in the drug of the corrosive chloride,\\neither as of early or of late chemical production, the gray powder is\\nless esteemed. The decimal trituration of calomel with sugar of milk\\nis a far more suitable compound. Corrosive sublimate, in doses of\\nfrom fa (0.0033) to fa (0.005) of a grain is exhibited in pill-form or in\\nsolution, and is probably more generally employed in the treatment of\\nsyphilis than any other mercurial salt. The objections to its use are\\n1 Amer. Jour. Med. Sci., January, 1876; Phila. Med. Times, November 25, 1882,\\np. 337.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0709.jp2"}, "710": {"fulltext": "656 NEW-GROWTHS.\\nsuggested above. Though constantly employed in public charities,\\nwhere it is furnished as a cheap and a convenient substitute for the\\nmore elegant preparations in the market, it is much less frequently\\nordered for syphilitic patients in private practice. When given in\\nsolution it produces a disagreeable metallic taste in the mouth that\\nsome patients can perceive after the lapse of hours.\\nWith many physicians of wide experience it is customary to employ\\nopium, either alone or in connection with the use of mercury, for the\\nrelief of ulcerative or other lesions of syphilis. Sometimes it is\\nemployed for the purpose of relieving pain, sometimes to prevent the\\ncathartic action of the metal upon the bowels, and again because it is\\nsupposed to possess some power of arrest over the destructive action\\nof the disease. It should not, as a rule, be exhibited when by reducing\\nthe mercurial or exchanging the latter for a ferruginous dose the same\\nresult can be reached. Few syphilitic patients are in the end brought\\nto the desired termination of the disorder by the use of a remedy which\\ninterferes with assimilation and digestion such a remedy is opium in\\nall its forms. Temporary advantage is often gained by its employ-\\nment, but this may be more than counteracted by its ultimate effect\\nupon the gastro-intestinal tract.\\nInunction. Mercury is also satisfactorily introduced by the method\\nof inunction. The metal when thus employed is readily absorbed by\\nthe system, and its therapeutic value is no less evident. Inunction\\nshould be employed in every case which admits of it, since the gastro-\\nintestinal tract is thus left undisturbed, and, further, the dose of any\\nneeded chalybeate or of potassium iodide by the mouth can be regulated\\nwithout increasing or diminishing the quantity of mercury in daily use.\\nMercurial ointment compounded with lanolin is best used for this pur-\\npose, but a cleanly substitute for it is provided in the oleate of mercury\\nin the strength of 10, 15, or 20 per cent., and in the vasogen capsules.\\nFrom J to 1 drachm (2.-4.) of either the ointment, the vasogen com-\\npound, or the oleate may be rubbed into the skin at night before retir-\\ning, and the part selected for inunction be cleansed by washing in the\\nmorning. Unna for this purpose praises the mercury-salve soaps.\\nAll these preparations, if continually applied to a single portion of the\\nskin, are liable to produce a mild local dermatitis or an eczema, hence\\nit is wise to select on successive evenings a fresh portion of integument\\nfor the local application, preferably that where the epidermis is rela-\\ntively thin, as, for example, the flexor aspects of the joints. The\\npatient can thus upon one evening anoint the inner faces of the thighs\\nupon the next, the sides of the chest upon another, the loins, etc.,\\ntaking care to avoid surfaces where an induced eczema is likely to prove\\nespecially annoying, such as the scrotum, the axillae, and the groins.\\nThe ointment in some cases may be well rubbed into the soles of the\\nfeet previously soaked in warm water, after which the socks or stock-\\nings may be drawn over the feet for the night. In the case of infants\\nthe inunction is well performed by the natural movements of the child,\\nif a flannel swathing-band previously smeared with the salve be\\nwrapped about its belly, so that the mercurial preparation is kept in\\ncontact with the skin. Should local irritative effects be produced, these", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0710.jp2"}, "711": {"fulltext": "SYPHILIS. 657\\nsubside rapidly, as a rule, after a warm alkaline ablution followed with\\na bland dusting-powder. Subsequently or even before such accident in\\nthe case of infants or of patients having unusually sensitive skins the\\nmercurial salve may be mixed with equal parts of lanolin, lard, or\\nolive-oil. As some patients become disgusted with this routine, it is\\nwell at the onset to flavor the substance selected for inunction with\\nlavender, rosemary, or bergamot.\\nToo little attention has been attracted to the treatment of syphilis by\\nmercurial inunction. With this fact in view the preceding paragraphs\\nwhich describe the use of mercury by the mouth are to be understood\\nas related in all cases to the employment of the metal by the skin. It\\nis well to order inunction in all practicable cases to save the stomach\\nas much as possible to continue with the mercurial ointment nightly,\\nweekly, or less frequently, so long as there is a possibility of relapse and\\nto adjust carefully the quantity employed to the exigencies of the case.\\nIn this manner patients may be relieved of all symptoms of the dis-\\nease who have not during their treatment swallowed a dose of mercury,\\nand the permanency of whose relief may be tested during years of sub-\\nsequent observation.\\nFumigation. One of the most effective methods of administering\\nmercury is by fumigation in the vapor-bath. It is employed by many\\nexperts as the sole means of exhibiting the mercurial selected for\\nuse, but it is, for the average patient, too inconvenient for continuous\\nemployment. It should regularly be ordered, first, in all cases in\\nwhich the earliest syphilodermata are intense, generalized, and partic-\\nularly conspicuous upon the face second, in all obstinate cases in which\\nthe patients are not women nor cachectic subjects of either sex third,\\nat the outset of treatment of many ignored cases in which the syph-\\nilodermata, either more or less generalized, have proceeded to uninter-\\nrupted evolution fourth, in the severe cases of patients coming from\\nthe country to the city, who are able to remain but a brief time\\nwithin reach of advantages offered in metropolitan centres. From\\nto 1 drachm (2.-4.) of calomel, metallic mercury, the bisulphuret, the\\nblack oxide, or hydrargyrum cum creta may be employed for each\\nbath. It is common to order 1 scruple to 1 drachm (1.-4.) each of\\ncalomel and cinnabar. The patient is stripped of his clothing and\\nseated in a chair, the patient and chair being completely enveloped in\\nblankets, which are closely fastened at the neck of the bather. Beneath\\nthe chair is an alcohol lamp, surmounted by a metallic vessel containing\\nwater in ebullition, the hot vapor of which in a few moments induces\\ncopious perspiration. When this result is obtained the lamp is brought\\nbeneath a metal plate containing the substance to be volatilized. The\\npatient remains exposed to the vapor about ten minutes after this proc-\\ness of sublimation is finished, and retires at once to bed without\\ncleansing the skin, the fumigation preferably being conducted before\\nthe hours of sleep. In the morning a bath may be taken for the pur-\\npose of cleanliness. It is more convenient in the generation of the\\nvapor in this way to make use of Henry Lee s safety fumigating-\\nlamp, but the materials requisite for the production of all desired effects,\\nwith the exception of the alcohol lamp and the drug, can be procured\\n42", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0711.jp2"}, "712": {"fulltext": "658\\nNEW-GROWTHS.\\nof any skilful tinsmith. In the city male patients are often sent to\\nbath-houses, where the fumigation is conducted in the daytime and,\\nas a consequence, they rarely experience unpleasant effects, such as are\\npopularly associated with taking cold after exposure to the action\\nof mercury. In most of these establishments provision is made that\\nthe head also can be exposed to the mercurial fumes, respiration\\nbeing conducted through a tube in connection with pure air, a provision\\nuseful in certain cases of emergency and only emergency cases\\nshould be required to resort to fumigation of the head.\\nFig. 76.\\nLee s safety-lamp for fumigation.\\nThe happy effect of the mercurial vapor-bath is often marvellously\\nrapid. A generalized syphiloderm may become well-nigh indistin-\\nguishable upon the surface after four baths at intervals of two days\\neach. With this potent agency at hand, it can be understood how\\nthe skilled physician can afford to watch from week to week his\\nsyphilitic patient taking a dose of iron internally and employing in-\\nunction externally, the lesions fading slowly from the surface, all fears,\\nquieted, and nutrition sustained at a high grade. In comparison with\\nthis combined method, the swallowing of blue mass, or of calomel and\\nopium, should be regarded as a clumsy and dangerous procedure.\\nSubcutaneous Injection. The treatment of syphilis by mer-\\ncurial injection has largely been extended since its acceptance as a\\nscientific procedure. It should never be ordered save in eases specially\\nindicating its employment. With some of the other methods employed,\\ninjection provides for the exclusion of the medicament from the gastro-\\nintestinal tract, and accomplishes the desired effect with a minimum and", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0712.jp2"}, "713": {"fulltext": "SYPHILIS. 659\\nexactly mensurable dosage. The objections to its systematic employ-\\nment outside of hospitals are chiefly the need of a physician or an\\nexpert to administer the dose. The injection of mercury into the deep\\nmuscular tissue (the gluteus in its thickest part with the muscle wholly\\nrelaxed the trapezius above the upper scapular angle with equal lack\\nof tension), as well as when practised more strictly hypodermatically.\\nrequires all antiseptic precautions both as to the point where the needle\\nis inserted and as to the instrument itself. It is to be remembered\\nthat these injections have occasionally proved fatal (calomel, gray oil),\\nand grave mischief has followed, in one or two instances from visceral\\ntroubles.\\nThis method, which was first popularized by Lewin, 1 is open to the\\nserious objection, while reaping the obvious advantages, of requiring\\nthe aid of a physician for the administration of each dose. It is\\nefficient and speedy, but will probably always find largest favor in\\nthe treatment of hospital patients, who are completely subject to the\\norders of their medical attendant. At the site of the injection, too,\\nnot rarely abscesses have formed. Corrosive sublimate, (0.005)\\nor grain (0.008), dissolved in 10 or 15 minims of distilled water\\nmay be injected at a time, the operation being repeated upon about\\ntwenty occasions. Bamberger, of Vienna, reported favorable results\\nafter the injection of an albuminate or a peptone of mercury, thus\\nattempting to avoid the danger of localized abscesses, and insuring\\nspeedy absorption of the metal. All formulae, however, proposed for\\npreparation of solutions of this character have proved imperfect, both\\nin consequence of failure to obtain a pure metallic albuminate, and\\nalso from lack of permanency in the solution. Staub s formula, the\\nresult of experiments made by Hepp, 2 may be taken as a sample of the\\nrest:\\nR Hydrarg. chlorid. corros., gr. xviij 1[20\\nAmmon. chlorid., gr. xviij 1 20\\nSod. chlorid., 3j 4\\nAq. dest., f^iv; 120 M.\\nDissolve, filter, and add the white of one egg in distilled water sufficient\\nto make \u00c2\u00a7iv(120.); 15 minims of the solution contain about\\ngrain (0.005) of the sublimate.\\nOther preparations employed for hypodermatic injection are as\\nfollows\\nInsoluble salts of mercury. Here are included calomel in an aver-\\nage dose of 1 grain (.066) suspended in vaselin-oil, salt and water, or\\nmucilage and water; metallic mercury, frqm 6 to 30 grains (0.40-2.);\\noleum cinereum, mercury with liquid vaselin or lanolin, 20 to 50 per\\ncent., 0.05 to 0.1 at each injection; and the yellow and the black oxides\\nof mercury, corrosive sublimate, mercuric cyanide, and combinations of\\nthese with potassium iodide and other salts.\\n1 Die Behandlung der Syphilis mit Subcutaner Sublimat-injection, Berlin, 1869\\nalso translated by Proegler and Gale, Phila., 187?.\\n2 Traitement de la Syph. par les Inject, hypoderm. de Sublime. These de Paris,\\n1872.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0713.jp2"}, "714": {"fulltext": "660 NEW-GROWTHS.\\nThe so-called antiseptic group includes salicylate of mercury.\\nA Pravaz syringeful is injected every third day in the gluteal region\\nbeneath the muscular fasciae, of the following\\nR\\nHydrarg. salicylat.,\\ngr. xv-xxiv\\n1.-\\nMucil. acac,\\ngr. viij\\n533\\nAq. dest.,\\nf ^vss\\n165\\nM.\\nIn this group are also included carbolate of mercury; thymolate\\n(10 per cent, suspensions in fluid paraffin); and the benzoate associated\\nwith sodium chloride, 2 parts, and cocaine hydrochlorate, 1 part, in 500\\nof water.\\nThe amide group includes mercuric formamidate, 1 per cent, solu-\\ntion; glycocoll of mercury, alaninate of mercury, and succinamide of\\nmercury, the last two in 1 per cent, solutions.\\nBeside these mercurial preparations, potassium iodide and iodoform\\nhave subcutaneously been injected in a few instances, it is claimed\\nwith advantage.\\nIntravenous injections of mercury in syphilis have been practised,\\nbut, according to Marshall, 1 have not been shown to possess any ad-\\nvantages over other methods employed. Chopping, however, 2 had sat-\\nisfactory results in twenty-three days after introduction into artificially\\ndistended veins of 20 minims of a 1 per cent, solution of mercurous\\ncyanide.\\nPtyalism, stomatitis, fetor of the breath, or a fungous condition of\\nthe gums with inappetence and other characteristic symptoms of the\\nill effects of mercury, including all grades of gastro-intestinal disturb-\\nance, are rarely seen in modern practice, and they should never be per-\\nmitted to occur in a properly regulated mercurial course. When they\\nare produced, the tongue projected from the mouth is usually tumid,\\nand exhibits at its lateral borders the imprints of the inner faces of the\\nmolar teeth. Its surface is also covered in various degrees with a thin,\\ndirty-grayish coat and the odor of the breath is peculiarly offensive,\\nbeing often noticeable at a distance of several feet from the patient.\\nIn such cases the food should be liquid and nutritious, both hot and\\ncold drinks should scrupulously be avoided, and the mouth frequently\\nbe cleansed with washes containing dilute liquor sodse chlorinatse, potas-\\nsium chlorate, borolyptol, or a very weak solution of carbolic acid. In\\nparticularly severe cases, potassium chlorate may be employed to the\\nextent of 1 drachm (4.) daily. The compressed tablets of this salt,\\neach containing 5 grains (0.33), may be slowly dissolved in the mouth.\\nThe mercurial is to be suspended in all cases, and iced water is to be\\ninterdicted, gangrene having followed its use in a few cases. In\\nmilder forms tincture of myrrh and of cinchona, diluted with sweetened\\nwater, or honey and water, will be sufficient for local medication of\\nthe mouth.\\nIodine is chiefly employed in syphilis in the form of potassium\\niodide. It possesses some value, without question, in every stage of\\n1 Lancet, April 1, 1899.\\n2 Ibid,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0714.jp2"}, "715": {"fulltext": "SYPHILIS. 661\\nsyphilis, and is, therefore, indiscriminately used by many practitioners.\\nIts value, however, in so-called late secondary and tertiary\\nstages is incontestably greater than in the earlier lesions of the dis-\\nease, and its use should largely be restricted to the particular periods\\nin which these manifestations appear. Every prudent physician will\\nhesitate before ordering for a disease exhibiting cutaneous lesions a\\nremedy which will positively produce such lesions in the majority of\\nall patients ingesting it. In this connection the reader will do well to\\nconsult the chapter on Dermatitis Medicamentosa, in which the various\\neruptions produced by this drug are recorded. Thoughtful men are\\nbeginning to inquire, in the light of the present knowledge upon this\\nsubject, to what extent the syphilodermata have in the past been\\naggravated or obscured by this remedy. He would indeed be bold\\nwho should attempt to prove that the medicamentous eruptions thus\\nexcited have not, in the past, figured largely in the catalogue of the\\nsyphilodermata.\\nThe value of the iodine compounds, nevertheless, properly adjusted\\nto the age and other conditions of the disease, is incontestable. AVhether\\ngiven alone or by the so-called mixed treatment in combination\\nwith mercury, or administered internally while a mercurial is intro-\\nduced by the skin, or exhibited by alternation with the metal, in each\\nthese compounds find a special value, and may simply be indispensable.\\nPotassium iodide may be given in doses of from 5 grains (0.33) to 1-2\\ndrachms (4.-8.), well diluted with water, three or four times daily one\\nhour after eating. The larger doses should invariably be reached grad-\\nually they should never be employed except by special order of the\\nphysician, and when the patient is within easy reach of the latter;\\nand they should always be ordered with the understanding that the\\npatient shall diminish or suspend treatment in case of unpleasant\\nresults. When the remedy produces gastric distress it is often admin-\\nistered in connection with pepsine, pancreatine, or taka diastase. Often\\nthe dosage is well tolerated when given in a glassful. of milk.\\nSymptoms of iodism, other than the production of cutaneous lesions,\\nsuch as coryza, oedema of the eyelids, and faucial irritation, are\\nlikely to be the result of the first few doses of iodine ingested, and\\nthese symptoms often bear no relation to the size of the dose. In\\ncertain cases, 1 or 2 grains (0.066-0.133) will be sufficient to produce\\nthe most disagreeable toxic effects, which, if they occur before the\\nremedy be suspended, may not return with even the largest doses. In\\na few cases potassium iodide produces violent toxic effects in any dose,\\nowing to exceptional idiosyncrasy. Both ammonium chloride and\\nammonium carbonate are recommended for use in combination with\\npotassium iodide, as increasing its efficiency. Sodium, ammonium, and\\nlithium iodides possess also, without question, some influence over the\\ndisease, but they are for most cases less efficacious than the potassium\\nsalt. Of the three iodides named, lithium iodide is apparently most\\nprompt in its effects.\\nPotassium iodide is employed frequently in the well-known sirop\\nde Gibert, which though first popularized in the Saint Louis Hospital,\\nin Paris, has since extensively been employed in the United States. It", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0715.jp2"}, "716": {"fulltext": "662 NEW-GROWTHS.\\nhas slightly been modified to suit the varying tastes of many surgeons.\\nIt is ordered in the following formula\\nR Hydrargyri biniodid., gr. ss-ij\\nPotass, iodid., \u00c2\u00a7aj-viij 8-30\\nGentian, syrup, (vel\\nsyrup, glycyrrhiz.), aa f ^ij aa 60\\nAq. dest., J\\nDose. A tablespoonful in water, after eating.\\n033-0.13\\nM.\\nThe syrup of licorice disguises the taste of the drug better than most\\nof the other syrups used. With the dosage carefully regulated, a few\\ndrops (1 to 15) may be administered with advantage to children.\\nThe following are indications for the use of potassium iodide either\\nalone or by the so-called mixed method in the treatment of syphilo-\\ndermata: the occurrence (1) of late, tubercular, gummatous, or ulcer-\\native lesions (2) of formidable nervous, visceral, or other non-cutane-\\nous symptoms with early or late, mild or severe syphilodermata, as, for\\nexample, grave ulcerations of the velum or the fauces with a sym-\\nmetrical macular eruption, or coincidence of a generalized pustular or a\\npapular syphiloderm with hemiplegic, aphasic, ocular, or renal compli-\\ncations (3) of early or late manifestations which either assume the so-\\ncalled galloping type, being rapidly succeeded by more and more\\nformidable symptoms, or which exhibit the capriciousness of the disease\\nin a reversal of the usual sequence of evolution, as, for example, when\\nsymptoms commonly counted as late phenomena occur within a few\\nweeks after infection and are followed by the early symmetrical rashes\\n(4) of early or late symptoms occurring in cachectic, strumous, or other-\\nwise debilitated patients. Mercury is assuredly not a tonic in tubercu-\\nlosis commingled with syphilis.\\nKlingmuller 1 advocates in late syphilis the employment of iodipin,\\nan organic combination of iodine and sesame oil. It is employed both\\ninternally and by. subcutaneous injection.\\nThe local treatment of the initial sclerosis of syphilis by complete\\nexcision, lauded by Auspitz, has been practised (since the date of his\\npaper in 1879) by Kolliker, Zeissl, Leloir, Chadzynski, Mauriac, and\\nothers. 2 The result has proved conclusively that such operative inter-\\nference furnishes no bar to constitutional infection. Simultaneous\\nextirpation of all lymphatic glands in the vicinity of an initial sclerosis,\\nwith ablation of the latter and a mass of tissue about it, have repeatedly\\nproved unavailing to prevent the occurrence of systemic infection.\\nChancres should not be destroyed by caustic agents of any character,\\nas the caustics are liable to induce either irritative or inflammatory\\neffects which may be followed by denser induration. Ointments, as a\\nrule, are also objectionable, exception being made in the case of hemor-\\nrhagic lesions when the removal of an adherent dressing is followed by\\nunpleasant consequences. Cleanliness with soap and water is of chief\\nimportance. There are few better local applications at this period of\\nthe disease than painting with a saturated solution in water of pyok-\\n1 Berlin, klin. Woch., November 25, 1899.\\n2 See Keyes -s later communication on this subject, loc. cit.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0716.jp2"}, "717": {"fulltext": "SYPHILIS. 663\\ntanin-blue. The parts may then be dusted with a dry powder, such as\\neurophen, iodol, zinc stearate, calomel, hydronaphtol, or boric acid;\\nor be dressed with a piece of soft lint, saturated in pure or dilute lotio\\nnigra, or, even better, a spirit-lotion containing tannin and carbolic or\\nboric acid. Opiated washes or iodoform (which is an anaesthetic for\\nmany ulcerative surfaces) may be requisite in painful and ulcerative\\nlesions. When a phagedenic tendency is shown (an exceedingly rare\\ncomplication of syphilitic chancres) deep cauterization may be required,\\nand the subsequent local employment of solutions of potassic perman-\\nganate, from 2 to 10 grains (0.133-0.666) to the ounce (30.) of water.\\nWhen a primary venereal sore of any character (the initial scle-\\nrosis of syphilis or the chancroid) becomes phagedenic or gangrenous,\\nor, even in the absence of both of these calamities, extends rapidly\\nin depth or superficial area, cauterization should not be practised.\\nThe most effectual treatment of these complications in the genital\\nregion is by the employment of the continuous hot water-bath, aided\\nby antisepsis. The patient remains seated in the bath (the water being\\nof the temperature most grateful to the affected surface and with great\\ncare maintained at that degree of heat) throughout the day, or, in\\nformidable emergencies, if carefully watched, by day and night. The\\nbath is left by the patient only for the purpose of evacuating the bladder\\nor the rectum. Granulation and repair gradually take place. When-\\never the patient leaves the water the parts are dusted with iodoform or\\nwith iodol. By this invaluable means, in both hospital and private\\npractice, cicatrization of extensive ulcers which reach from the genital\\nhalf-way to the pubic region may be secured.\\nLocal treatment of the syphiloclermata may be demanded either by\\nreason of their appearance on exposed surfaces, as on the face and the\\nhands, or by reason of their obstinacy or threatening character, as\\nwhen they are rapidly ulcerating. Macular and papular lesions of\\nthe face may be treated by local applications of mercury 5 per cent,\\noleate mercurial ointment, 1 to 2 drachms (4.-8.) to the ounce (30.)\\nof cold-cream salve or of vaselin; red oxide, from 2 to 4 grains (0.133-\\n0.266) to the ounce (30.) or ammonium chloride, to 1 scruple (0.666-\\n1.33) to the ounce (30.) of ointment. Lotions of bichloride, 1 to 2\\ngrains (0.066-0.133) to the ounce (30.) of cologne, are also efficient.\\nThese preparations will each be found much more valuable if used at\\nnight before retiring, and left upon the lesions during the hours of sleep,\\nand each is well preceded by hot bathing of the surface for several min-\\nutes, as in the preparatory treatment of acne papulosa. The sulphur\\npreparations employed for the relief of that disease will at times be\\nfound useful also in the local treatment of the syphilodermata.\\nHot ablution is particularly useful in the treatment of the scaling\\nand frequently fissured lesions of the palms and soles, the pain of\\nthe local symptoms in severe cases being greatly alleviated by this\\ntreatment. After the epidermis in these parts has been well macerated,\\nthe hands or the feet should thoroughly be dried, and the mercurial,\\ntarry, or other salve be well rubbed in. The medicated mulls and\\nplasters are here of value. A glove or a stocking shctuld then be\\ndrawn over the part.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0717.jp2"}, "718": {"fulltext": "664 NEW-GROWTHS.\\nSecreting condylomata, flat papules, vegetations, etc., also require\\nbathing with soap and water, especially when situated at the mucous\\noutlets of the body or on the scalp. When the secretion is offensive in\\nodor, formalin, boric or carbolic acid, thymol, or chlorinated soda should\\nbe added to the lotion. Cleanliness, indeed, is more essential to the\\nsyphilitic patient, man or woman, than to the healthy. After the\\ncleansing or disinfecting ablution the parts should be dressed with a\\npowder, such as dry calomel, europhen, iodoform, iodol, hydro-naphtol,\\nbismuth subnitrate, zinc oxide, sodium salicylate, or starch. Vegetat-\\ning lesions of these regions may require also pencilling with a crayon\\nof silver nitrate. Ointments, as containing grease, are decidedly ob-\\njectionable local applications.\\nCrusted and ulcerative lesions, large or small, are to be treated in\\naccordance with general principles. Crusts should always be removed\\neither by the oil and soap-and-water treatment, or with a dermal\\ncurette, after which removal the underlying ulcers should be cleansed\\nthoroughly, pencilled with silver nitrate, filled with powdered boric\\nacid, iodoform, iodol, or calomel, or touched with a 5 to 20 per cent,\\nsolution of carbolic acid, and then be dressed with a dilute ointment of\\nmercuric nitrate, 1 to 2 drachms (4.-8.) to the ounce (30.). Large\\nsyphilitic ulcers are often encountered on the surface of the lower ex-\\ntremities, and in this situation elastic compression by a rubber bandage\\nwill greatly accelerate their cicatrization.\\nThe syphilodermata are in general amenable to the action of the\\nmercurial vapor-bath, which may be regarded as exerting upon them\\nboth a local and a constitutional influence. Those affecting the face\\nare thus benefited by exposure to the metallic vapor in the head-\\npiece arrangement already described. The patient may less com-\\nfortably also avail himself of the same local treatment by holding the\\nbreath and exposing the head and face for a few minutes at a time to\\nthe fumes of the mercury beneath the blanket, in the plan described\\nas practicable at the bedside.\\nIt is within reasonable bounds to assert that the syphilodermata, if\\ntreated locally by the measures described as useful in non-syphilitic\\ncutaneous affections of similar type, will proceed to a satisfactory invo-\\nlution if the general treatment be skilfully ordered.\\nThe local treatment of syphilitic lesions of the mucous surfaces is\\nboth hygienic and medicinal. Catarrhal conditions of adjacent mucous\\nsurfaces (vagina, nasal cavity) require attention. The parts should\\nbe kept free from all irritation (tobacco in all forms, iced and hot\\narticles of food and drink, condiments, acetous and alcoholic fluids\\nin the mouth coitus and irritating injections of vulva napkins that\\nhave been soiled over the anogenital regions of infants). Locally, the\\nsilver-nitrate crayon, used as a pencil, is effective in the management\\nof moist patches, applied once daily or every second or third day.\\nOccasionally stronger caustics are required, such as mercuric nitrate\\nor nitric acid. Mouth- washes containing potassium chlorate, myrrh,\\nand honey; 15 to 20 drops in water of Bellamy s iodized phenol;\\nborolyptol very dilute lotions of tincture of ferric chloride or dilute\\nmuriatic acid, a teaspoonful to a pint of sweetened water and carbo-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0718.jp2"}, "719": {"fulltext": "CHANCROID. 665\\nlated washes, are required in different cases. In very great soreness\\nand tenderness of the mouth only the blandest applications are tolerated,\\nsuch as thin flaxseed-tea, oatmeal-gruel as a wash, and gum-acacia\\nwater. A few formulae are appended\\nR Potass, chlorat., 3j 4\\nMel. despumat.,)\\nMyrrh, tinct., aa gss, ID\\nAq. dest., ad gvj ad 180 M.\\nSig. A teaspoonful in water as a wash for the mouth and throat.\\nR Acid carbolic., 3j 4\\nGlyc^rin^ aa 5ss; 2\\nSpts. vin. rectif., 3ij 8\\nAq. dest., ad fgj; ad 30 M.\\nSig. Fifteen to twenty drops as a lotion in water, for the mouth.\\nR Potass, chlorat., 3j 4f\\nAq. menth. piperit., aa ^vj aa 180l M.\\nSig. Gargle and wash for the mouth to be used slightly diluted.\\nThe internal management of these cases is that demanded by the\\ngeneral condition of the system and the stage of the disease, as ex-\\nplained in the concluding pages of this chapter.\\nPrognosis. The prognosis of syphilis is in general favorable, pop-\\nular opinion on the subject being at variance with fact. Benignant\\nsyphilis may disappear without treatment.\\nMalignant forms of the disease may, but rarely do, destroy life. The\\nelement of treatment, both as to its character and the period of its con-\\ntinuance, enters more largely into the estimate upon which a prognosis\\nrests than it does in most other disorders exhibiting cutaneous symp-\\ntoms. Syphilis untreated, whether because of failure to recognize its\\ncharacter, or of ignorance, poverty, neglect, or dissipation, is usually\\ngrave. The same may be said of syphilis occurring in strumous, tuber-\\nculous, and cachectic subjects, and in those enfeebled by age, by other\\ndiseases, by chronic alcoholism, or by sexual excesses. Hereditary\\nsyphilis is by far the gravest form, not merely because of the tender\\nage of its victims, but also because they, at the earliest period of their\\nlives, are burdened with a disease which may first attack organs essen-\\ntial to life.\\nThe majority of adult white patients, with hygienic environment,\\nsooner or later recover from the acquired disease, marry, and beget in\\nthe end sound children.\\nCHANCROID.\\nThis term has been adopted generally in America and England for\\nthe purpose of designating the virulent, local, contagious ulcer of the\\ngenitals, designated also as the simple, the soft, or the non-\\ninfecting chancre, the chancrelle of French authors. Chancroid has\\nno relation to syphilis, nor to the neoplasmata with which syphilis is\\ncommonly classified. As it is, however, a disease with which the initial", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0719.jp2"}, "720": {"fulltext": "666 NEW-GROWTHS.\\nsclerosis of syphilis may be confounded, and is also not merely a venereal\\nlesion, but one which may be encountered upon the skin as well as\\nupon mucous surfaces, it is briefly described in this connection.\\nChancroids present as distinct a uniformity of feature as the lesions\\nof vaccinia or of herpes zoster. They are thus stamped with special\\nand readily recognized characteristics, differing in this respect from\\nthe various modes in which the first lesion of syphilis may declare its\\nnature. The virus, for such it must be termed, of the disease is one\\nsui generis, and derived exclusively from lesions of like character. This\\nvirus, which is contained in a purulent secretion, is capable of trans-\\nmission by inoculation and auto-inoculation. After such successful\\ninoculation there is no period of incubation. The results of experi-\\nmental generation of the virus in human subjects indicate that the\\npathological process which it awakens can be determined within twenty-\\nfour hours after its introduction within the skin. At times, after acci-\\ndental infection, eight and ten days elapse before the lesion of the dis-\\nease is manifested, cases presumably in which the virulent secretion\\nhas remained pocketed in the orifice of a follicle or in a fold of mucous\\nmembrane, where its irritant effects have finally opened an avenue for\\nits deeper ingress. When typically developed the chancroid is seen\\nto be a pustular lesion, frequently multiple, of roundish outline, begin-\\nning as a pinhead-sized, turbid vesico-pustule, rapidly enlarging to\\na pea- or bean-sized, well-developed, projecting, yellowish, globoid\\nelevation of the epidermis, filled with greenish-yellow pus. When\\nlocated in furrows or depressions of the surface it may have a linear,\\noval, or even a dumb-bell shape, the latter in consequence of extension\\nfrom a sulcus to overlying folds. Clinically the roof-wall of this pus-\\ntule is not frequently encountered, the objective symptoms being the\\nulcers which represent the floors of separate lesions. These ulcers\\nvary with the shape of the superimposed pustules, being round, ovoid,\\nor linear, occasionally irregular in outline, with sharply defined or cut\\nedges they have an uneven, pus-bathed floor a faint pinkish areola\\na supple, non-indurated base an abundant puriform secretion and\\nare accompanied or unaccompanied by pain, according to the degree\\nof inflammation present. In consequence of the auto-inoculability of\\nthe discharge these ulcers frequently give rise to others in the vicinity,\\nas when the prepuce lies in contact with chancroids of the glans.\\nThe ulcers thus presented usually attain an average size of that of\\na pea or of a bean in the course of from ten to fourteen days they\\nthen remain in an indolent and suppurative condition, showing no ten-\\ndency to heal for a fortnight or three weeks and finally they granulate,\\nexhibiting the ordinary phases of repair. The resulting cicatrix is\\neither transitory or, more often, indelible. In exceptional cases the\\nulcer spreads widely. In the groin it may attain a diameter of several\\ninches its floor secreting scantily its edges lurid, undermined, pur-\\nplish, or ragged its color reddish, bluish, purplish, or leaden. Fis-\\ntulous tracts and sinuses, filled with an ichorous sero-pus, radiate in\\ndependent situations the base of the sore is densely indurated its\\ncareer may be prolonged for years, and induce finally a systemic\\ncachexia not different from that seen in all chronic ulcerations of", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0720.jp2"}, "721": {"fulltext": "CHANCROID. 667\\nsevere grade. In other cases the occurrence of gangrene, or phage-\\ndena, changes the features of the lesion to those of other ulcers under-\\ngoing similar metamorphosis.\\nChancroids may occur upon any exposed mucous surface of the geni-\\ntalia of both sexes, upon the integument of the penis, scrotum, labia,\\nthighs, fingers, perineum, peri-anal region, and, very rarely indeed,\\nupon the face. In consequence of their tendency to relapse, their\\nabundant contagious secretion, and their auto-inoculability, chancroids\\nare more frequently encountered than is the primary syphilitic lesion\\namong the filthy, the poor, and the classes that frequent hospitals and\\ndispensaries. Among the wealthy, the well-to-do, and the cleanly\\nthis order of frequency is reversed.\\nThe chancroid ulcer is also much more frequently complicated by\\nsurgical accidents than is the infecting lesion of syphilis. This result\\nis partly due to the prevalence of an ulcerative type in all its manifes-\\ntations, and in part to its situation. Thus, the ulcer is often accom-\\npanied by severe inflammatory symptoms, which may be aggravated\\nboth by phimosis and paraphimosis, occurring with stenosis of the\\npreputial aperture, or with a long, lax, and redundant foreskin. Pha-\\ngedena is also a formidable complication, whether of sloughing or of\\nserpiginous tendency, the lesion in each case losing its chancrous char-\\nacteristics. It is evident also that the disease may coexist with others\\nof a different character. Thus, a single point may simultaneously be\\ninoculated with chancroidal and syphilitic virus the former, without\\nan incubative period, followed rapidly by a pustular or an ulcerative\\nlesion the latter, after its incubation is complete, producing the char-\\nacteristic symptoms of an initial sclerosis. Chancroids may also be\\nfound coexisting with secondary and tertiary syphilitic lesions of the\\ngenitals, with vegetations, with blennorrhagic discharges and balanitis,\\nwith pediculi of the pubes, and with herpes progenitalis. Patients of\\nthe class exhibiting these lesions not infrequently present themselves at\\npublic dispensaries with three or more of these concurrent disorders.\\nOne of the most serious complications of the chancroid is its associa-\\ntion with a specific lymphangitis, periadenitis, or adenopathy. In this\\ncase the lymphatic trunks connected with the lesion become inflamed,\\nindurated, and irregularly corded, with the overlying integument often\\ncedematous, reddened, and painful. The infective process in these\\nvessels rarely terminates by suppuration. The bubo of chancroid is\\nmore common, and this adenopathy may be either sympathetic, resulting\\nfrom the severity of the process at the site of the lesion, or be virulent,\\ndue to the transmission of an inoculable pus to one or more of the\\nglands in near connection with the source of the trouble. These dif-\\nferent gland-complications may coexist in one person, in men more\\noften than in women, and in about one of each four or five cases pre-\\nsented to observation. When inoculable pus has been formed in a\\nneighboring gland the latter is at once converted into the seat of an\\nabscess, the pus of which, whether evacuated spontaneously or by the\\nknife of the surgeon, speedily inoculates the lips of the wound through\\nwhich exit has been obtained. The wound and contiguous abscess-\\ncavity then form a large chancroidal ulcer, usually inguinal in situation,", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0721.jp2"}, "722": {"fulltext": "668 NEW-GBOWTHS.\\nas the glands in this locality are nearest the most frequent seat of the\\nlesion. Such an inguinal ulcer discharges a greenish-yellow pus often\\ncommingled with blood; its borders are undermined, thin, livid or\\npurplish, and ragged its floor is irregular, sloughy, and often covered\\nwith nodules representing the debris of glandular structure; from it\\ndepart sinuses traversing the tissues in the vicinity, often downward to\\nthe thigh, occasionally upward over the belly. When occurring in\\nstrumous and cachectic subjects, or when long neglected or mismanaged,\\nthe resulting disorder is of the most serious character, and it may\\nsurpass in duration and severity certain of the varieties of lupus and\\nepithelioma.\\nThese facts have an important bearing. It is true that syphilis is a\\nconstitutional disease, and that it usually occurs but once in a lifetime.\\nIt is equally true that the chancroid is evidence of a local and non-\\nsystemic disorder, producing only such constitutional effects as may all\\nother local affections of chronic course and severe grade but it is a\\nblunder to suppose for these reasons that the chancroid is the milder\\nof the two maladies. Many of its consequences are much more severe,\\nand some of them even more malignant, than the average of syphilitic\\nsequels, and even, as indicated above, are worse than some forms of\\nother diseases usually classed as malignant. Greater attention should\\nbe generally directed to the truth respecting the comparative gravity\\nof the two diseases, as there is widespread ignorance of the facts.\\nThe Pathology of the chancroid, though illustrated by the re-\\nsearches of Biesiadecki, Auspitz, and Unna, is yet not understood to\\nan extent that will explain its specific character. The micro-organisms\\ndiscovered in all coccogenous lesions are usually abundant and readily\\ndemonstrable. Those recognized by Ducrey, of Naples, 1 are short,\\nthick bacilli measuring 1.46 by 0.50 fj These observations were con-\\nfirmed by Krefting, of Christiania; 2 while the bacilli discovered and\\nclaimed as pathogenic by Unna (his observations being later confirmed\\nby Quinquaud and Nicolle) occur in the form of twisted coils and\\nchains, measuring 1.25 by 0.33 fi. The etiological value of these ob-\\nservations remains to be determined.\\nAnatomically, there is disclosed by the microscope a uniform, dense\\ninfiltration of the corium with elements which undoubtedly represent\\ninflammatory metamorphosis of the connective tissue of the derma de-\\ngenerative changes where the ulceration has proceeded superficially\\nenlargement of vessels from thickening of their walls, often with\\ndiminished lumen and relatively intact rete and corium at the lateral\\nborders of the ulcer. This fully confirms the inferences suggested by\\na clinical study of the disease. Many roundish, circumscribed, clean-\\ncut ulcers with purulent floors occur upon the skin that bear no rela-\\ntion to the chancroid disease. It is the history and career of the disease\\nthat stamp it with an individuality of its own. It is not the form and\\nappearance of its pus-elements, but their power and potency, which\\nmake them singular.\\nDiagnosis. Chancroid is to be distinguished from syphilitic\\n1 Congres internat. ,de Derm, et de Syph. Paris, 1889.\\n2 Arch. f. Derm. u. Syph., 1892, Erganzungshefte, S. 41.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0722.jp2"}, "723": {"fulltext": "CHANCROID. 669\\nchancre, but no skill, however great, and no experience, however wide,\\nwill enable the diagnostician, even when typical chancroid is present,\\nto assert that syphilis will not follow, until the longest incubative\\nperiod of the initial sclerosis of the last-named disease has elapsed\\nwithout production of suspicious symptoms. The rule which neces-\\nsarily follows is imperative, and, being too frequently ignored, bitter\\ndisappointment on the part of the infected individual, and keen\\nmortification on the part of the physician, have naturally resulted.\\nNo PATIENT SUFFERING FROM A CHANCROID CAN BE PROMISED\\nIMMUNITY AGAINST SYPHILIS UNTIL TWO AND A HALF MONTHS\\nHAVE ELAPSED AFTER THE DATE OF LAST EXPOSURE. Subject\\nto this essential reserve, the diagnosis rests upon the pustular, ulcer-\\native, and discharging features of the chancroid, its failure to indu-\\nrate at the base, its auto-inoculability, its appearance without pre-\\nvious incubation, its more formidable localized expression of disease,\\nand the characteristics of the accompanying adenopathy. The short-\\nlived, superficial vesicles of herpes progenitalis, often accompanied by\\ntingling and painful sensations, with sequels in the form of equally\\nsuperficial, epidermal excoriations, are not to be confounded with chan-\\ncroids yet it must be remembered that these lesions may also precede\\nor may accompany any form of venereal disorder. Chancroids are to\\nbe distinguished also from secondary and tertiary lesions of the genitals,\\nand from non-syphilitic vegetations and molluscum epitheliale of the\\nsame region.\\nTreatment. The most effective and ultimately the most satis-\\nfactory treatment of chancroids is by asepsis patiently carried out.\\nLess satisfactory is the routine treatment by destructive cauterization\\nwith either nitric or sulphuric acid. Keyes recommends a previous\\napplication of pure carbolic acid, in order to benumb the part and\\nthus render the subsequent application less painful. If employed at\\nall, the carbolic acid should carefully be wiped from the sore before\\nthe subsequent cauterization, as the two acids will explode if suddenly\\nbrought in contact. As the slough separates the ulcer may be dressed\\nin accordance with the general principles governing the treatment of\\nsimple granulating wounds. Special care should be taken by all prac-\\nticable measures to avoid the possibilities of auto-infection. Vinous,\\ncarbolated, and opiated lotions, painting with a saturated aqueous solu-\\ntion of pyoktanin-blue, powders of boric acid, iodoform, iodol, calomel,\\nbismuth subnitrate, and starch, simple unguents, and the interposition\\nof a pledget of borated cotton between all affected and sound tissues\\nthftse measures in most cases suffice to insure relief. Pencillings with\\nsilver nitrate, though ineffective for the purposes of cauterization, often\\nanswer a good purpose in hastening repair. The prepuce may require\\ndivision or circumcision.\\nFor grave and extensive ulcerations, accompanied or unaccompanied\\nby phagedena or by gangrene, there is no treatment comparable in\\nvalue with the hot water-bath of an average temperature of 98\u00c2\u00b0 F.\\nFor the details of this method the reader is referred to the paragraph\\ndevoted to the treatment of syphilitic chancre.\\nPhimosis and paraphimosis, when complicating chancroids, require", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0723.jp2"}, "724": {"fulltext": "670 NEW-GROWTHS.\\nthe surgical treatment appropriate for the relief of those conditions.\\nFor the accompanying adenopathy in chancroid disease, before sup-\\npuration has occurred, rest is essential, with laxatives and gentle local\\ncompression. When there are great heat and tenderness a few leeches\\nmay be applied. After pus has formed it may be evacuated with an\\naspirator-needle, or by a free incision in the long axis of the swelling,\\nfollowed by curetting the abscess-cavity and by the usual antiseptic\\ndressings. Constitutional treatment by iron, quinine, cod-liver oil, and\\nthe employment of a generous diet with milk, malt liquors, or wines\\nare often required in broken-down and debilitated persons.\\nThe Prognosis, in uncomplicated cases, is generally favorable. The\\nscar left by a suppurating gland in the groin is indelible, but it becomes\\nless conspicuous with years. Sloughing and gangrenous sores leave\\ndeforming cicatrices, especially when occurring at the apex of the glans,\\nto which they usually give a peculiarly truncated shape. A just reserve\\nshould be made in all cases complicated with syphilis or extensive\\nfistulous sinuses, the latter, as mentioned above, often persisting for\\nyears.\\nLEPRA.\\n(Gr. leirpbg-, scaly.)\\n(Satyriasis, Elephantiasis Gr^ecorum, Leontiasis, Lepra\\nArabum, Leprosy. Fr. 9 Lepre, Ladrerie; Ger., Aussatz;\\nHal., Lebbra Norweg., Spedalskhed.)\\nLeprosy is a disorder that has been recognized for centuries as one\\nof the scourges of the human family. It is not known to affect the\\ninferior animals. It is to-day endemic in many countries.\\nSymptoms. In whatever form leprosy may ultimately be mani-\\nfested, its appearance is usually preceded by the prodromic symptoms\\ngenerally recognized as precursors of severe constitutional disease.\\nThese symptoms are anorexia cephalalgia chills, alternating with\\nmild or with severe febrile attacks depression gastro-intestinal dis-\\nturbances and insomnia. Their duration is exceedingly variable in\\nsome cases patients will remember that these or similar symptoms pre-\\nceded for years the earliest outbreak of lepra. In other cases but a\\nfew weeks interval occurs between the prodromic and the successive\\nstages of the disease. It is worthy of note that the character of the\\nprodromata furnishes no clue to the severity and type of the oncoming\\ndisorder. The earlier cutaneous lesions of leprosy are tubercular,\\nmacular, or bullous. They may be coincident or successive, or one or\\ntwo of these types may so far predominate that another may be either\\naltogether wanting or may possess in the general pathological history\\nbut a trifling significance. It has thus been customary to make an\\nentirely artificial distinction between cases of leprosy by assigning\\nthem to three varieties tubercular, macular, and anaesthetic. It will\\nbe understood, then, in separately considering these three forms, that\\nthe distinction between them is useful simply for purposes of clinical\\nclassification that mixed cases of the disease occur which it would be\\ndifficult to assign to .either variety exclusively and that each case", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0724.jp2"}, "725": {"fulltext": "LEPRA.\\n671\\nmerely represents a predominance of certain lesions at one patho-\\nlogical epoch. It should be noted also that the symptoms of leprosy\\nare remarkable for their polymorphism, a wide variation often exist-\\ning between the character of two or more lesions which at any given\\nmoment are apparent. This variation is largely owing to the fact\\nthat leprosy is a general and constitutional disorder, the cutaneous\\nsymptoms of which are simply its surface-markings.\\nLepra Tuberosa (Tuberculated, Nodulated, or Tegumentary\\nLeprosy). Tubercular leprosy commonly begins in the skin with\\nmacular lesions, which are bean- to tomato-sized, reddish, brownish, or\\nbronze-hued patches roundish, oval, or irregular in contour and\\noccurring upon the face, trunk, or extremities. The skin covering\\nthese lesions is either smooth and shining, as if oiled, or is moderately\\nFig. 77.\\nLepra tuberculosa. (After Danielssen and Boeck.)\\ninfiltrated and elevated. After a period ranging in duration from\\nweeks to years, tubercles (lepromata) rise from the maculations, vary-\\ning in size from that of a pea to that of a nut, though they may be as\\nlarge as a tomato. They are yellowish, reddish brown, or bronzed in\\ncolor, often shining as if varnished or oiled, are covered with a soft,\\nnatural, or slightly desquamating epidermis, roundish or irregular in\\ncontour, and are either isolated or grouped. Numbers of very small\\nand ill-determined nodules may often be recognized by careful exam-\\nination of the skin in the vicinity of those fully developed. They\\nmay be either cutaneous or subcutaneous in situation, and be softish\\nor firm to the touch. The eruption of these tubercles is usually at the\\noutset preceded by fever as well as by oedema of the region involved.\\nThe site of predilection of leprous tubercles is the face and their\\nmassing in great numbers upon this region produces the characteristic", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0725.jp2"}, "726": {"fulltext": "672\\nNEW-GROWTHS.\\ndeformity of the countenance that has given to the disease one of its\\nnames, Leontiasis (face of a lion). In such faces the tubercles are\\nranged in parallel series above the brows, down the nose, over the\\ncheeks, the lips, and the chin. In consequence of the infiltration\\nand development of the lesions the brows deeply overhang the globes\\nof the eyes, the eyelids become affected with partial ptosis, the lips\\npout, and the ears are so studded with tubercular masses as to project\\nfrom the side of the head. The trunk and extremities, including\\nthe palmar and plantar surfaces, are then usually to a less degree\\nFig. 78.\\nTubercular leprosy. (From a photograph of a leper in the Sandwich Islands.)\\ninvolved. Occasionally, indeed, with extensive development of tuber-\\ncles upon the face and ears, there may not be more than from five to\\nfifty tubercles upon the rest of the body, and these either widely dis-\\npersed and isolated, or agglomerated in a single, hard, flat, elevated\\nplaque of infiltration upon the elbow or the thigh. When confluence\\nof tubercles occurs large plaques of infiltration may form (lepromcs\\nen nappe), which are elevated and brownish or blackish in shade (mor-\\nphoea nigra). In yet other cases the condition described by Bazin as\\nleprous scleroderma occurs, in which dense infiltrations extend to both\\nthe derm and the hypoderm. The surface of these lesions is roughened,\\noften desquamating, rarely ulcerated.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0726.jp2"}, "727": {"fulltext": "LEPRA. 673\\nWith these cutaneous lesions there is often involvement of the\\nmucous surfaces, especially the velum palati and the larynx. In the\\ncase of a leper affected with the tubercular form of this disease, who\\nwas exhibited at our clinic in 1879/ there were marked gruffness and\\nhoarseness of the voice, and the larynx and velum were studded with\\npinhead- to pea-sized, ashen-hued tubercles. Others may form upon\\nthe conjunctiva and the Schneiderian membrane, the gums, the inside\\nof the cheeks, the tongue, the palate, the fauces, and the pharynx.\\nThese tubercles may degenerate into ulcers, or may undergo resorp-\\ntion and disappear, leaving pigmented atrophic depressions, or they lose\\ntheir shape in consequence of partial resorption. A large plaque may\\nflatten centrally until an annular disk is left to indicate its former site.\\nAmong the coincident symptoms of the tubercular exanthem in lepra\\nmay be named disturbance in the functions of sweat and sebaceous\\nsecretion, thinning and loss of the hair in the regions implicated (espe-\\ncially of the eyebrows) and disorders of sensibility.\\nIt should be borne in mind, however, that the course of the disease\\nis exceedingly slow, and that years may elapse before these several\\nchanges are accomplished. The malady, indeed, often appears to be\\nquiescent for months at a time, after which, with the occurrence of\\nfever, acute or subacute manifestations appear, and a relatively rapid\\nprogress is made toward a fatal conclusion. Long before the latter is\\nreached there are usually, in tubercular leprosy (Fig. 79), intermingled\\nsymptoms of anaesthetic type, such as the occurrence of bullae or of\\nanaesthetic patches with and without pigmentation. Toward the last\\nthe mutilations effected by the disease may result (Lepra Mutilans).\\nPhalanges of the fingers or toes, whole digits, an entire hand or foot\\nmay then become wholly or partially detached by ulcerative, atrophic,\\nor other degeneration of skin, bones, and ligaments, hastened or not\\nby intercurrent attacks of lymphangitis, erysipelas, septicaemia, and\\nirritative fever.\\nThe stadium of this type of the disease may extend through ten or\\nmore years. After its full development the dejected countenance of the\\nleper, with his leonine facies and general appearance of cachexia, is\\nhighly characteristic.\\nLepra Maculosa (Erythema Leprostjm, Leprous Eoseola).\\nThis form of the disease is chiefly distinguished, as its name implies,\\nby its macular lesions. These lesions have the general character of\\nthose described as preceding the appearance of the leprous tubercles.\\nThey are diffused or circumscribed, roundish or irregularly shaped,\\nand in color yellowish, brownish, or bronzed, often shining or glazed.\\nThey may be infiltrated, and may be slightly raised from, or on a level\\nwith, the adjacent tissues. At times they appear as lardaceous deposits\\nin the skin, whitish, reddish, or even blackish in color, with a telang-\\niectasic border. These patches are usually at first hyperaesthetic, but\\nfinally they become insensitive, so that a lancet can be thrust deeply\\ninto them without producing the slightest sensation.\\nThe pigment- variations in macular lepra are noticeable. At times\\n1 Chicago Med. Jour, and Exam., December, 1879, with cut showing appearance\\nof larynx.\\n43", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0727.jp2"}, "728": {"fulltext": "674 NEW-GROWTHS.\\na distinctly anaesthetic patch may readily be limited by its lack of\\nsensation and of normal color; at other times either symptom may\\nfail to correspond with the area of involvement defined by the other.\\nThus, a palm- to platter-sized, texturally unaltered area over the thigh\\nor the belly may suggest a vitiligo by its relatively slight pigmenta-\\ntion and its distinct contour, beyond which are sepia to deep chocolate\\ntints, gradually fading toward some adjacent and similarly involved\\npatch. Yet this area will often differ materially from that of vitiligo\\nin other respects. Every inch of the former may be totally insensi-\\ntive to the prick of the lancet, and, moreover, be of a dull, tawny,\\nyellowish, or parchment-like hue, never having the peculiar milky-\\nwhite tinge of vitiligo. Again, this anaesthesia may extend widely\\nbeyond the line traced by the pigment-anomaly, or even within the\\nlatter may vary, islets of skin capable of perceiving sensation being in\\ncases here and there discernible. The regions chiefly affected are the\\nexposed parts, the backs of the hands and wrists, the forehead, cheeks,\\nears, dorsum of feet, and ankles.\\nLepra Anaesthetica (Lepra Trophoneurotic a, Nerve-leprosy,\\nAtrophic Leprosy). This clinical variety, as has been described, may\\nbe commingled in its symptoms with each of the other types. With\\nand without such commingling, however, there is commonly noted after\\nexposure to cold, or after being subject to chills, first an eruption of\\nerythematous patches or of bullae, bean- to large-nut-sized, with a roof-\\nwall constituted of the entire thickness of the epidermis, filled with a\\nclear-tinted or blood-mixed serum, occurring usually upon the extremi-\\nties. The cicatrices which follow these bullae are atrophic patches, each\\noften far greater in extent than the base of the original bleb, whitish,\\nshining, glazed, or better described as of a tint suggesting the hue of\\nmica circular in outline, forming also the dumb-bell figure by coales-\\ncence or juxtaposition. These cicatrices are always anaesthetic, and\\nthey may coexist with macular and anaesthetic patches upon the trunk\\nor other portions of the body face, hands, feet, ankles, thighs rarely\\nthe palms and soles. Neither those of the one class nor of the other,\\nhowever, are disposed over the surface of the body in lines, bands, or\\ncurves corresponding with the distribution of the cutaneous nerves.\\nAsymmetry is the rule. Occasionally, however, the ulnar and other\\nnerves (median, posterior tibial, peroneal, facial, and radial) accessible\\nto the touch are tumid, tender, insensitive, or as rigid as indurated\\ncords fusiform, reddish-gray swellings may be recognized with the\\nnaked eye along the nerve-tract, with translucent and gelatinous aspect.\\nGeneral atrophic cutaneous symptoms follow the skin becomes dry\\nand harsh there is manifestly little or no sebaceous product the sweat\\nis scanty the muscles atrophy the hairs fall the lymphatic ganglia\\nenlarge the skin of the face seems tightly stretched over the bones.\\nAs a result of deforming atrophy of the eyelids epiphora and conse-\\nquent orbicular changes ensue, and the parted lips permit constant\\nescape of saliva. The fingers are half-drawn into the palm of the\\nhand the nails are distorted, and, later, ulceration occurs (Fig. 79).\\nThe ulcers are irregular, oval, roundish, linear covered with thin,\\nblackish, flattened, tenacious, never rupioid, crusts their bases are", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0728.jp2"}, "729": {"fulltext": "LEPRA.\\n675\\nsoft their floors covered with a pultaceous debris often mixed with\\nblood the whole usually insensitive to every foreign body and external\\napplication. Lastly, the symptoms of lepra mutilans may occur, digits,\\nor portions of the carpus, metacarpus, or corresponding parts of the\\nfoot, being detached from the body.\\nDeath may ensue, at any time during the course of the disease, from\\nsepticaemia, exhaustion, or any of the intercurrent affections to which a\\npatient in such a condition is particularly disposed. Thus, a leper was\\naccidentally choked to death in San Francisco by some perversion of\\nthe function of deglutition. The disease, however, in the anaesthetic\\nform is said to last from eighteen to twenty years, and is thus less\\nrapidly fatal than the tubercular variety.\\nFig. 79.\\nAnaesthetic leprosy with mutilating results. (From a photograph of a leper in the Sandwich\\nIslands.)\\nConsidering the several clinical varieties of leprosy named above,\\nand the mixed forms resulting from a commingling in some cases of\\nthe features of all varieties, the result is merely an analysis of the\\nsymptoms in an enormous clinical field. There are not, in fact, any\\nforms or varieties of this disorder there is but one disease, which ex-\\nhibits itself in widely differing manifestations, and these at one time\\nand in one country assume a predominant phase, while with a differ-\\nent environment and in another race other phenomena appear. Thus,\\nlepra tuberosa is reported in from 50 to 75 per cent, of patients affected\\nwith the disease in the north of Europe, and in from 10 to 20 per cent.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0729.jp2"}, "730": {"fulltext": "676 NEW-GROWTHS.\\nof those in tropical countries while anaesthetic lepra in the geograph-\\nical limits last named is represented by two-thirds of patients, and in\\nthe northern latitudes by less than one-third. Mixed forms are less\\noften reported than others, but as a matter of fact are the more often\\nobserved. The reason for this apparent anomaly lies in the fact that\\nreally pure cases of any form are rare. It is best to look upon the\\nexpressions of lepra as it is accepted to regard the phenomena of syph-\\nilis in each there is a single morbid principle there are in both no\\ntrue varieties and the external symptoms differ chiefly because of\\nspecial accidents of environment, of race, or of individual peculiarities.\\nLooking at the variant symptoms of lepra, a wide range occurs in\\nall stages. In the evolution of the disease there is a usual order of\\nfever, eruptive symptoms, and ulcerative or destructive sequels. In\\nthe prodromic period there are often chilliness, profuse diaphoresis, in-\\nsomnia, inappetence, diarrhoea, vertigo, and even a bullous efflorescence\\nupon the surface. These prodromata are rarely wanting, and, after\\nlasting for weeks, months, or years, are followed by sensations of chil-\\nliness, with remitting or intermitting febrile symptoms, the temperature\\nrising from 100\u00c2\u00b0 to 105\u00c2\u00b0 F. The tongue becomes of a reddish hue,\\nthe listlessness and sluggishness continue, and the typical cutaneous\\nlesions of the disease (leprous spots) appear, commonly on some portions\\nof the face, with or without oedema. In some cases the prodromic\\nsymptoms and fever and chilliness are either absent or, what is more\\nprobable, are unnoticed, and then the disease may be first recognized\\nby pains of a lancinating character, tenderness, and aching, especially\\nalong the course of the ulnar, peroneal, median, saphenous, or other\\nnerves or the result may be hyperesthesia, anaesthesia, or pricking,\\ntingling, and similar sensations in regions supplied by special nerves.\\nThe greatest variation is observed in the length of time during which\\nthese early symptoms, with more or less vagueness of expression, exist.\\nLater, tubercles, nodules, bullae, macules, hyperaesthetic and anaesthetic\\npatches appear with gradual development of other and non-cutaneous\\nsymptoms, paralysis, exaggerated tendon-reflexes, and atheromatous\\npapules upon the palpebral membranes and cornea. At times there\\nresults an ulcerative keratitis. In every large leper-hospital the number\\nof inmates, both men and women, who have become totally blind in\\nconsequence of the ravages of the disease is considerable. In many,\\ntoo, nodules appear over the chest, genital regions, and extremities, as\\nwell as upon the mucous surfaces of the mouth and respiratory tract.\\nThe voice becomes raucous, wdiile recrudescences of the disease occur\\neither along the one (tubercular) or the other (anaesthetic) line toward\\nthe final stages of degeneration and mutilation.\\nThe disease in seen in all typical forms, even in regions where leprosy\\nis least prevalent. There may be a genuine leprous pachydermia with\\nenormous increase in the volume of the hands and feet, accompanied\\nby severe onychia and paronychia, and deep ulcerations about the nails.\\nIn some cases tumefaction of an entire limb results, strongly resembling\\nan elephantiasis. The nose may be stuffed with leprous tubercles and\\na large number of cutaneous symptoms of the most varying type\\ndevelop in and upon the leprous skin as the result of secondary infec-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0730.jp2"}, "731": {"fulltext": "LEPRA. 677\\ntion, of accidents, or of invasion by pus-cocci, etc., for it must be remem-\\nbered that in most cases the leprous belong to the filthy and impover-\\nished classes of society. Thus, there are often developed eczemas,\\nerythematous and achromic and hyperchromic spots and disks, annu-\\nlar lesions resembling those seen in syphilis, bullae rapidly becoming\\ngangrenous (erytheme polymorphe lepreux bulleux et escharotique, of\\nLeloir), nodules of the usual size and hue of those in lepra (pinhead- to\\nnut-sized, pigmented, reddish brown, copper tinted, glazed, shining as\\nif oiled), and enormous infiltrations within and below the derma, even\\nthe production of large tumors of leprous tissue.\\nThe generative apparatus may seriously be involved, the uterus,\\nFallopian tubes, and ovaries being the seat of leprous nodules or diffuse\\nlepromatous infiltrations as may be also the testicles, prostate gland,\\nand penis. The breasts are also stuffed with tubercles but they, as\\nalso the other organs named, may simply waste under the influence\\nof the disease. Sexual power is retained longer than is commonly\\nbelieved. In the colored races the eruptive symptoms are tinted in\\nyellowish and reddish shades, a result due to contrast with the hue of\\npigmented skins.\\nEtiology. Leprosy is a contagious and infectious parasitic disorder\\nproduced by the bacillus leprae. This organism was discovered by\\nArmauer Hansen in 1874, and is present in large numbers in tubercular\\nforms of the disease, being relatively absent in anaesthetic lepra. It\\nstrongly resembles the bacillus of tuberculosis. These bacilli have been\\nfound in the dwellings and clothing of lepers as well as in the dust of\\napartments occupied by victims of the disease.\\nSecretions of a leprous patient containing bacilli or their spores are\\nthe usual vehicle by which the disease is transmitted. The question\\nof the inheritance of leprosy may be regarded to-day as in much the\\nsame position as that relating to the inheritance of tuberculosis no\\nfoetus, no newborn living child has been known to exhibit the symptoms\\nof either disease. Men are more often affected w T ith the disease than\\nwomen. Infection is more common after the second decade, though\\nchildren are occasionally among its victims.\\nThe geographical distribution of leprosy is widely extended. In\\ncountries where it has not previously existed\\nits appearance is invariably due to the infec- Fig-^80.\\ntion of sound individuals by lepers first ex-\\nhibiting symptoms in a country where the\\ndisease is prevalent. Neisser formulates the\\nlaw of its prevalence by stating that the\\nnumber of lepers in any country bears an\\ninverse ratio to the laws executed for the care\\nand isolation of infected persons.\\nThe disease exists in the interior and\\nthroughout the seaboard regions of Africa, Larvnx of a patient affected\\nincluding Egypt; in Arabia, Syria, Persia, Stho^ l ne fthe\\nChina, Japan, and India in the islands of\\nthe Mediterranean, Black, Caspian, and China Seas, of the Indian\\nOcean, and of the Australasian Archipelago in Norway and Sweden,", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0731.jp2"}, "732": {"fulltext": "678\\nNEW-GROWTHS.\\nIceland, Russia, Turkey in Europe, Spain, France, Portugal, Greece,\\nand Italy; and sporadically in Germany, England, and the smaller\\nEuropean States in North, Central, and South America, and the\\nWest India Islands. In America special attention has been directed\\nto the subject by the existence of the disease in an endemic form in\\nthe Sandwich Islands, with which the Pacific States sustain close com-\\nmercial relations by its occurrence among Chinese immigrants in San\\nFrancisco and other portions of California by cases reported from\\nNew Orleans by Burns, 1 Bemiss, 2 Jones, 3 Dyer, and Solomon, 4 and by\\nvarious reports of sporadic cases observed in Minnesota, Maryland,\\nIllinois, Nebraska, New York, North and South Dakota, Pennsylvania,\\nIowa, New Jersey, Ohio, Wisconsin, and other States of the Union, by\\nGronvold, Hoegh, Bendeke, Rohe, Piffard, Elsberg, Atkinson, the\\nauthors, and others. White and Graham have contributed to the history\\nof the colony of lepers in Tracadie, New Brunswick. More recently\\nMorrow, 5 of New York, and Bracken, 6 of Minnesota, have added\\nvaluable data to the statistics of the disease as it exists in this country.\\nWith this wide geographical distribution, the disease exists endem-\\nically in certain countries, and also in certain regions of the same\\ncountry, with greater frequency than in others. All attempts, how-\\never, to connect its origin with malaria, with a residence near inun-\\ndated sea-marshes, w r ith the ingestion of a diet consisting largely of\\nFig. 81.\\nFig. 82.\\nlb\\nLarynges of lepers affected with lepra tuberculosa. (Elsbeeg s cases.)\\nfish, or of a diet from which salt largely has been excluded, have failed\\nof recognized success. The disease, however, seems to spread more\\nrapidly in damp and cold, or warm and moist climates than in temper-\\nate countries. It is true that probably the larger number of all living\\nlepers are those who have been poorly fed and otherwise subjected to\\nthe most insalubrious of influences, but the disease also attacks, though\\nfar more rarely, persons whose social position and hygienic surround-\\nings are of the best. It occurs in both sexes though more frequently\\nin males and at all ages and, despite all effort to show the contrary,\\nbears no relation to syphilis. Lepers, however, become syphilitic if\\ninfected with that disease, precisely as they may and do acquire variola,\\n1 Arch, of Med., December, 1881. 2 N. O. Med. and Surg. Jour., April, 1880.\\n3 Ibid., March, 1878. 4 Trans. Louisiana State Med. Assoc, 1879.\\n5 Twentieth Century Practice of Medicine, vol. xv., p. 403.\\n6 Are National Leprosaria in the United States Desirable? Minnesota State Board\\nof Health, 1901.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0732.jp2"}, "733": {"fulltext": "LEPRA.\\n679\\nvaricella, morbilli, erysipelas, and phthisis. The Hebrew Scriptures\\nare often interpreted as showing that the disease among the Jews in\\nPalestine was regarded by them as contagious and so treated. The\\nmodern student of these writings will, however, be convinced that this\\ninterpretation is erroneous. The leprosy of the book of Leviticus not\\nonly includes lepra, as that term is understood to-day, but also psoriasis,\\nscabies, and other cutaneous affections. The leper, in the eye of the\\nMosaic law, was ceremonially unclean, and capable of communicating\\nonly a ceremonial uncleanness. Several of the narratives contained in\\nthese books bear witness to the fact that the Oriental leper was occa-\\nsionally seen doing service in the courts of kings, and even in personal\\ncommunication and contact with officers of high rank.\\nPathology. The bacillus of leprosy is a delicate rod-shaped para-\\nsite from one-half to three-fourths of the diameter of a red blood-\\ncorpuscle in length, and about one-fifth as broad as long. The bacilli\\nof leprosy are morphologically almost identical with those of tubercu-\\nlosis, but are found in affected tissues in vastly greater numbers, ap-\\npearing usually in clumps, and responding more promptly to staining\\nand decolorizing agents. These micro-organisms have been found in\\nnearly all the tissues of the body, and especially in the skin, mucous\\nmembranes, interstitial tissue of the peripheral nerves, in the cartilages,\\ncornea, spleen, liver, lymphatic glands, sebaceous glands, and hair-\\nfollicles, also less abundantly in the testicles, spermatic cords, ovaries,\\nand walls of the blood-vessels. They do not occur in the muscles,\\nspinal cord, bones, or joints, and are wanting in many secondary in-\\nflammatory lesions, such as bullae on the surface of the skin. They\\nare rarely found in the epidermis, and though it is claimed that they\\nare visible in the blood, their discovery in that fluid has not been con-\\nfirmed. The bacilli are not found in physiological secretions unless\\nthese be pathologically altered by\\nan organ or membrane affected with Fig. 83.\\nleprous infiltration. They have\\nnever been found in urine or in\\nmenstrual blood.\\nThe parasites are most numerous\\nin comparatively recent but fully\\ndeveloped nodes of the skin. Such\\na node on section shows in the\\ncentre a brownish mass or glo-\\nbus, which sometimes can be\\nshaken out of the surrounding tis-\\nsue, and which on examination\\nproves to be composed almost en-\\ntirely of masses of bacilli. Even\\nin the diffuse form of infiltration\\nthe bacilli are usually found in\\ngroups or masses, but they may be\\ndisseminated through the tissues.\\nAccording to Hansen and Looft, the bacilli are almost invariably situ-\\nated within a lepra-cell, or occasionally in endothelial cells of the\\n(P\\nBacilli of leprosy a, epithelial scale. About\\nX 1200. (From one of the authors patients.)", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0733.jp2"}, "734": {"fulltext": "680 NEW-GROWTHS.\\nvessels, or in white blood-corpuscles. Unna and others, on the con-\\ntrary, have found the bacilli without the cells. Most investigators\\nagree with the observations first cited, but think it probable that there\\nare a few free bacilli, and also some in the lymph-channels.\\nUnlike the bacilli of tuberculosis, those of leprosy apparently do\\nnot live or grow outside the living human body. Campana and Ducrey\\nobtained cultures, as they supposed, of the lepra-bacillus, but did not\\nverify their results by inoculation-experiments, and their conclusions\\nare not generally accepted. Practically, the bacillus has not yet been\\ncultivated. Attempts to inoculate lower animals with leprous tissue\\nhave given no definite results. Numerous attempts have been made to\\ninoculate human beings with leprosy, but the disease developed in only\\none of the inoculated individuals, and as he was a member of a leprous\\nfamily the result cannot be considered conclusive.\\nThe introduction into living tissues of leprous material containing\\nbacilli results simply in a local inflammation such as would be pro-\\nduced by the introduction of any inert substance. In such experiments\\nthe leprous tissue, which had been hardened for months in alcohol, was\\nequally effective with the fresh tissue. Besnier and others believe that\\nthe bacilli die with the tissue in which they have lived, and thus\\naccount for the failure of culture- and inoculation-experiments. The\\nslight viability of the bacilli is largely responsible for the usual\\nbenignity and slow progress of the disease.\\nIn tubercular leprosy the chief histological changes are seen in the\\ncorium, the nodule being made up chiefly of granulation-tissue similar\\nto that seen in lupus and syphilis but the leprous tissue is less vascu-\\nlar and consequently undergoes formative and retrogressive changes\\nless rapidly the cells are larger than in the two other diseases named,\\nand do not form in nests, as in lupus. The cells, which probably origi-\\nnate in endothelial cells of the vessels or in migrated cells, are seen in\\nvarying sizes and usually filled with bacilli to form the lepra-cells.\\nGiant-cells are also seen.\\nThe infiltration may be diffuse as well as nodular, and is most\\nmarked at first about the vessels, glands, and follicles. Later it may\\nobliterate the papillae and their line of union with the rete, and extend\\nto the subcutaneous tissue. The external and middle coats of the\\nvessels are infiltrated and thickened and their lumen narrowed. The\\nsebaceous and coil-glands and the follicles are involved early, at first\\nundergoing infiltration and hyperplasia, later degenerating and disap-\\npearing. The epidermis is involved secondarily only, and may be thus\\nthinned and atrophied or broken in the formation of ulcers.\\nIn macular and anaesthetic leprosy Hansen and Looft 1 state that\\nthe macules are, like the nodules, leprous infiltrations of the cutis,\\nconsisting of round epithelioid and spindle-cells, the latter being more\\nnumerous the greater the age of the macule. These infiltrations appear\\nto proceed from the vessels. Lepra-bacilli are always present, but are\\nmost numerous in the younger macules. In the young not as yet\\nanaesthetic macules the nerve-twigs appear unchanged; in the older\\n1 Leprosy in its Clinical and Pathological Aspects, English translation by Walker.\\nLondon, 1895.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0734.jp2"}, "735": {"fulltext": "LEPRA. 681\\nones they are usually affected. The essential nerve-changes are an\\ninfiltration of cells containing bacilli within the external sheath and\\nbetween the nerve-fibres, resulting in a gradual disappearance of the\\nlatter as a result of pressure produced by the great increase of intersti-\\ntial connective tissue. The irritation of the nerve-fibres in the early\\nstages accounts for the pains and hyperesthesia the nerve is also\\nincreased in size, often to a marked degree. Later there are atrophy\\nand shrinking of the nerve, of which many of the original fibres have\\nbeen destroyed and replaced by connective tissue, with resulting anaes-\\nthesia. The peripheral nerves are thus frequently affected, but in the\\nbrain and cord leprous changes have not been demonstrated. In a few\\ncases of anaesthetic leprosy degeneration and atrophy of the posterior\\ncolumns, posterior roots, and spinal ganglia have been demonstrated, as\\nwell as other changes probably due to an associated tuberculosis which\\nis not infrequently present.\\nRegarding the disappearance of leprous lesions and tissue, Hansen\\nand Looft say that in both the nodular and the maculo-anaesthetic forms\\nthe bacilli in the leprous products break up into granules which\\nfinally disappear, and there remains of the leprous products only a scar-\\nin which nothing leprous can be recognized. Occasionally this takes\\nplace in all the affected parts, and there remains only a widespread\\nanaesthesia, the result of the nerve-affection and in the maculo-anaes^\\nthetic form this is the regular termination of the disease. In both\\ncases the leprosy is completely healed. Jeanselme 1 concludes that\\nafter complete invasion of the subject the bacilli of lepra may utterly\\ndisappear, leaving only a sclerosis in their track.\\nDiagnosis. Apart from the history, present and previous places of\\nresidence of the subject of the disease, and the clinical symptoms\\nexhibited, the diagnosis of lepra is to be established by the presence of\\nlepra-bacilli. These organisms may be recognized in the tissues, in\\nserum obtained artificially from involved regions, in blood made to\\nexude from lepromatous nodules, and in the secretions of ulcers.\\nSpronck asserts that the agglutinating power of the serum of the\\nleprous produces a characteristic reaction in the bacilli reproduced by\\ncultures obtained by Hansen s method.\\nIn well-marked cases the recognition of leprosy is simple. In its\\nprodromic periods no suspicion of its existence would be awakened in\\ncountries where the disease is not endemic.\\nFrom syphilis, which is also a disorder the lesions of which are\\npolymorphic in character, lepra can be distinguished by its much\\ngreater chronicity its larger and brownish-yellow, glazed tubercles\\nits frequently paresthetic and anaesthetic symptoms its bullous lesions,\\nrare in acquired syphilis the far more extended areas of its erythema-\\ntous macules its blackish crusts, lacking the rupioid aspect of those in\\nsyphilis its leathery, mica-tinted cicatrices and the characteristic\\nleonine facies of its tubercular forms.\\nMorphoea and vitiligo are unattended by constitutional changes, and\\nmore particularly exhibit no hyperaesthetic nor anaesthetic symptoms in\\nthe affected patches. The atrophic and often deeply pigmented condi-\\n1 La Presse med., Dec. 15, 1900.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0735.jp2"}, "736": {"fulltext": "682 NEW-GROWTHS.\\ntion of the skin in the final stages of pityriasis rubra, associated with\\nthe emaciation and febrile condition of the patient, might for a time\\nmislead the observer who had not a full history of the case. Multiple\\nsarcomata, especially upon the face, are followed by much more rapid\\ndegeneration and a fatal result.\\nAll lesions of erythema multiforme can readily be distinguished\\nfrom those of lepra by the absence of hypersesthetic or of anaesthetic\\nsymptoms. Syringomyelia is differentiated by its display of lesions\\nonly in regions where there is also muscular atrophy by the much\\ngreater extent and lack of definition of areas of perturbed sensation\\nby diminution of the tendon-reflexes, which may be exaggerated in\\nlepra by a marked predominance of symptoms in the upper as distin-\\nguished from the lower extremities and by the frequent presence of\\nscoliosis. The nodules of lupus are not symmetrical, are far softer, and\\nare much more often grouped than those of lepra. Further, they never\\nhave the size of the larger leprous tubercles, and never have the peculiar\\npigmented, brownish, and oiled or varnished aspect of leprous nodules.\\nFinally, the diagnosis of leprosy requires not only clinical symp-\\ntoms, but also a definite contagion. Whether a history of transmis-\\nsion from one individual to another be or be not obtainable, it is certain\\nthat no person ever manifests leprous symptoms who has not been\\ninfected by some victim of the disease.\\nTreatment. One of the most important considerations relative to\\nthe therapy of leprosy is that requiring the segregation and isolation\\nof all lepers from contact with the uninfected. In some countries,\\nthose particularly where leprosy prevails, wholesome laws enforce this\\nseparation of the infected, and charitably provide also for the care of\\nthe wretched victims of the disease. In America, where leprosy, in\\nconsequence of its rarity, has not yet awakened the attention of legis-\\nlators beyond the point of forbidding the entry of infected persons,\\nthe proper care of lepers in a community only too ready to take\\nalarm even at the name of the disease is a serious matter. Many\\nof the public hospitals for the care of the sick poor refuse to receive\\nlepers. In several States of the Northwest the officers of health-\\nboards are powerless to make proper provision for the care of a leper\\nwhose case is brought to their attention. In some of the American\\ncolonies provision is made for the care of lepers, as in Hawaii.\\nThe child of a leprous woman should be removed from the mother\\nafter birth and not given another woman s breast.\\nNo remedies are known to have a directly curative effect in leprosy.\\nAs a consequence, the treatment of the disease is that suggested to the\\nintelligent practitioner by the indications in each case. Most impor-\\ntant, when the patient happens to reside in a district where the disease\\nprevails, is an immediate change of residence and climate the adop-\\ntion of a highly nutritious diet and the exhibition of roborant reme-\\ndies, including steel, quinine, cod-liver oil, and often the moderate use\\nof wines and malt liquors.\\nThe injection of antivenene and other modes of serum-therapy\\nhave not been followed by results confirmed by a sufficiently wide\\nexperience. The cinchonas and salicylates are indicated in febrile con-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0736.jp2"}, "737": {"fulltext": "LEPRA. 683\\nditions. Mercury, arsenic, the iodine compounds, hoang-nan in pills\\nof 3 grains (0.266) creosote in half-drop doses (0.033) the oil of\\ncashew-nut, gurjun balsam, chrysarobin, pyrogallol, resorcin, 10 per\\ncent, solution of salicylic acid in oleic acid (Arning) ichthyol, and\\nchaulmoogra oil, internally and externally, have all been employed\\nwith varying success by different practitioners but an unprejudiced\\nreview of the maximum of results thus obtained establishes the con-\\nviction that no one of the remedies named may be regarded as exercis-\\ning a controlling influence over the disease. Most of them have been\\nemployed by physicians sufficiently wise to enforce simultaneously the\\nmost generous tonic regimen, thus clouding with doubt a belief in the\\npart played by the medicament in the production of the result. In\\nthe case of a leper and his daughter in Nebraska, who were treated for\\nsome time with chaulmoogra oil, marked benefit was noticeable in the\\ncourse of a few months, a result probably due to the salubrious sur-\\nroundings of a farm in the country.\\nEvery secreting ulcer and open surface in the person of a leper re-\\nquires prompt and thorough disinfection with a solution of formalin\\nor mercuric chloride, or other parasiticide, in order to destroy the\\nbacilli commonly present. Baths are of great value in these cases,\\nand they may be medicated with any desired substance. In the local\\ntreatment of leprous tubercles, ulcers, and other lesions the simple\\nprinciples, dermatological and surgical, governing ordinary cases are\\nnot to be forgotten. Disinfectants, carbolic and boric acids, bland\\nunguents, inunctions, and local stimulation of the skin are as useful,\\nwhen properly applied to the leprous, as to the syphilitic, the cancer-\\nous, and the scorbutic patient.\\nPrognosis. The future of the leper is indeed dark. The disease\\nis malignant in character, and, however protracted, a fatal result is\\nusually inevitable. Still, with a change of climate and improved\\nhygienic conditions much may be accomplished. There can be no\\nquestion that the Scandinavian lepers who have removed to the United\\nStates have been greatly benefited by the change. This, indeed, was\\nthe opinion of the late Professor Boeck, who visited Minnesota, and\\nthere studied the history of eighteen leprous immigrants who had come\\nfrom Norway. He believed that the change in some cases would work\\na complete arrest of the disease. A careful study of the history of lep-\\nrosy in America will induce the belief that such a favorable result can\\nbe anticipated after residence in the Northwestern States, as well as in\\nother portions of the country.\\nThe Sartian Disease (Taschkent-geschwur) is an infectious\\ngranuloma, described by Heiman, and microscopically examined by\\nRudniew. It occurs in Taschkent, or Taschkend, a market-town of\\nAsiatic Russia, west of the Caspian Sea. The disease affects the face,\\nthe upper extremities, and the trunk, avoiding always the palmar and\\nplantar regions. Reddish macules develop into nodules, which des-\\nquamate, coalesce, degenerate, and leave crusted ulcers, which may\\ncicatrize.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0737.jp2"}, "738": {"fulltext": "684 NEW-GROWTHS.\\nFRAMBESIA.\\n(Fr. framboise, raspberry.)\\n(Yaws, Pian, Lepra Fungifera, Toboe, Polypapilloma Trop-\\nica, SCHWAMMFORMIGE, BUBA OR BOBA, BOUTON D AMBOINE\\nTonga, Coco, Framosi, Tetia, Lupani, Tono, Peruvian\\nWart, Parangi.)\\nFrambesia is an infectious disorder existing as an endemic malady\\nin certain tropical countries, and affecting for the most part individuals\\nof the African race.\\nContributions to the literature of this subject have been made by\\nPison Bontius, Hillary, Winterbottom, Schilling, Milroy, Nicholls,\\nImray, and Bowerbank. The description here given is largely bor-\\nrowed from a paper 1 on the subject contributed by Pierez to the Pan-\\nAmerican Medical Congress held in Washington in 1893.\\nSymptoms. There are two denned stages of the disease one of\\nincubation another of invasion. In the first stage there may be mod-\\nerate febrile symptoms in the second stage there are usually malaise,\\narticular pains, tenderness and fulness of the lymphatic ganglia, and an\\neruption consisting of tubercles which requires from two to nine days\\nfor complete evolution, the disease lasting from two to six months in\\nmild cases, and in severe forms for two years or more. The aggra-\\nvating influences determining the longer periods of the disease are\\nlack of hygienic surroundings, improper medicinal treatment (e. g., the\\nadministration of mercury under the supposition that the disease is\\nsyphilitic), and the dyscrasias in general. The eruptive phenomena are\\ndescribed under several heads\\n(a) Pian dartre yaws caeca in which there occurs on the face\\nand extremities a furfuraceous desquamation which is usually well\\ndefined and limited to patches ranging in size from that of a small\\ncoin to that of a pea. This desquamation may extend over the entire\\nsurface of the body. In some instances, when the scales are removed,\\npapillary projections are visible beneath.\\n(b) The yaws tubercle. The tubercle of frambesia varies in size\\nfrom that of a millet-seed to that of a small coin, covered at first with\\na thinned epidermis and later forming an excrescence of verrucous type\\nwith numerous aggregated pinkish points which furnish a secretion,\\ndesiccating later into a greenish-yellow, bulky crust, shaped like the\\nshell of the limpet and resembling in color and consistency lumps of\\nyellow beeswax. Reddish puncta, due to small hemorrhages, may here\\nand there be visible at the surface. Crusts are less likely to form\\nin regions near the mucous outlets of the body (vulva, anus), and at\\npoints subjected to friction (axilla?, groins). There may be a delicate\\nhalo about each crust. The odor is mawkish. A degree of symmetry\\nmay be perceptible. By confluence a few unusually large excrescences\\nmama pian may form. While the larger are thus coalescing and\\nenlarging other smaller tubercles may shrivel and disappear.\\n1 Transactions of the First Pan-American Medical Congress, Washington. Govern-\\nment Printing Office, 1895. -Part II., p. 1764.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0738.jp2"}, "739": {"fulltext": "FRAMBESIA. 685\\n(c) Pian gratelle guinea-corn yaws which is the rarest form of\\nall, is characterized by the development of watery-looking, light pur-\\nplish-hued tubercles destitute of crusts.\\n(d) Crapeaux crab-yaws In the secases fissures occur in the\\ntubercles which are usually located on the soles of the feet and are\\naggravated by the exposure of these organs when walking barefoot.\\n(e) Ringworm yaws. The eruption may occur in circular ridges\\nsurrounding an unaffected centre, the original lesions of this enclosed\\narea having undergone a species of shrivelling. When this process is\\ncompleted by the fall of the crusts no scars are left, the epidermis being\\npigmented as after the involution of syphilitic tubercles.\\nUnder unfavorable conditions ulceration of the tubercles occurs,\\nleaving raw patches (often on the anterior faces of the legs) ranging in\\nsize from that of a small coin to areas having a diameter of several\\ninches. Their edges are punched out in appearance the floors are\\ngranular and bright reddish in hue.\\nDiagnosis. The distinction between frambesia and psoriasis and\\neczema is readily effected by consideration of the distinctive peculiari-\\nties of the several disorders named. It is chiefly the distinction from\\nsyphilis that has engendered confusion in the past. The following are\\nimportant points of distinction syphilis often, yaws rarely, attacks the\\nmucous surfaces, the last-named disease much more rarely involving\\nthe lymphatic glands there is usually itching in the yaws eruption\\nthere is no characteristic copper color in its eruptive features yaws\\ndoes not affect the bones save in the continuity of long-standing ulcer-\\nation of the skin the subject of yaws is susceptible to indefinite auto-\\ninoculation yaws though common in children is not inherited healthy\\nparents may have infants seriously affected with frambesia lastly, the\\ntwo diseases have been noted as of concurrence in the same person.\\nEtiology. The disease is endemic in certain tropical countries,\\noccurring chiefly in the black races and especially among the filthy,\\nthough it is seen also among the whites.\\nThe disease is caused by a specific microbe a rod-shaped bacillus\\noccurring singly and also in couplets and triplets, and being about 2 p.\\nin length and 0.5 fi in breadth. It is readily cultivated in nutrient\\njelly, and is capable of transference, with production of yaws not only\\nupon the skin of man, but also upon that of the lower animals, espe-\\ncially the cat.\\nTreatment. The disease yields readily in the simpler cases to mild\\nparasiticides in severe cases tonics are required internally, such as\\niron, quinine, and strychnine.\\nThe Prognosis is favorable save in broken-down subjects.\\nPARANGI.\\nKynsey reports upon the nature of this disease, which is thus desig-\\nnated in Ceylon, where it prevails.\\nIt appears to present mixed features of syphilis, land-scurvy, yaws,\\npellagra, lupus, leprosy, scrofula, and less severe disorders, existing as\\nan endemic in certain provinces of the island. It is clear, from the", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0739.jp2"}, "740": {"fulltext": "686 NEW-GROWTHS.\\ndescription of the symptoms recorded, that the nature of the disease\\nhas not been recognized. It was first described in 1868 by Loos, and\\nis now regarded as due to numerous causes, such as malnutrition induced\\nby impure food and water, wretched hygienic surroundings, and infection\\nfrom the discharges from ulcers.\\nThere is, according to Christie, 1 an incubation-period of from two to\\neight weeks, followed by the appearance of an ulcer over any bony\\nprominence the initial sore. This period is succeeded by malaise and\\npyrexia, the premonitory fever lasting from two to eight days, and is\\nfollowed by the exanthem, which appears first over the face, and later\\nupon the body. This eruption may be vesicular, pustular, pustulo-\\ntubercular, or squamous, superficial ulcerations forming which become\\ncrusted subsequently. Rupioid, furuncular, and psoriasiform features\\nare common in the course of the malady. Condylomata may appear\\nat the anus. Ulcerations succeed later of a more formidable character,\\ninvolving the nose, palate, and cheeks the digits may be lost by gan-\\ngrene blebs occur pricking-pains are experienced there may be\\nanaesthesia of some part of the surface, associated with bronzing and\\nglazing of the skin. The patient may perish of some intercurrent dis-\\norder or from exhaustion. The duration of the disease is said to be\\nfrom two to eight years.\\nTreatment has been successful with the cautious employment of\\nmercury and potassium iodide, and strict observance of the rules of\\nhygiene.\\nDONDA NDUGU.\\nDonda ndugu Brother ulcer, or Ulcer that clings is a disease\\nexisting in Central and Eastern Africa. Christie, 2 who first described\\nit, believes it to be identical with that from which Livingstone suffered\\nin 1870.\\nThe disease is confined to the lower extremities, and it occurs among\\nthe natives chiefly in the rainy season after a march toward the coast.\\nDonda ndugu is characterized by the appearance of whitish papules\\nspringing from a boggy swelling, seen often near the toes, heel, or\\ndorsum of the foot. When incised, an extensive, deep-seated slough is\\nfound beneath the healthy tissue, bathed in an ichorous discharge.\\nSevere rapid-spreading ulcerations and death may ensue. Livingstone\\nextracted the ova of a species of maggot from such lesions in his own\\nperson but Christie failed to discover them in his cases.\\nThe Treatment is local, by the use of antiseptics after incision.\\nVERRUGA PERUANA.\\n(Peruvian Wart.)\\nThis is a specific disease, both endemic and at times epidemic, oc-\\ncurring for the most part in the mountains of Peru, and communicable\\nby inoculation. There is a prodromic febrile stage, followed by the\\nappearance on the skin of maculo-tubercular, softish, tender, henii-\\n1 See Anderson s Treatise on Diseases of the Skin.\\n2 Ibid.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0740.jp2"}, "741": {"fulltext": "", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0741.jp2"}, "742": {"fulltext": "PLATE XXIII.\\nPrefungoicT Stage of Mycosis Fungoides.\\n(From a painting.)", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0742.jp2"}, "743": {"fulltext": "MYCOSIS FUNGOIDES. 687\\nspherical tumors, which may attain the dimensions of a large nut.\\nHemorrhagic effusions occur as a result of fissures in the epidermis\\ncovering the lesions, at times in coercible and leading to fatal anaemia in\\nsevere cases. The lesions may be few or numerous may occur on the\\nseveral parts of the head and extremities (rarely on the trunk), and may\\neventually desiccate or break down into ulcerations. A fatal result may\\noccur at any stage from hemorrhage, or the disease may be relieved\\nin the course of a few months. It is said to attack whites more often\\nand with greater severity than negroes.\\nHirsch l and others have described the disease, an outline of\\nwhich is given by Crocker, who states that the mortality is from 6 to\\n10 per cent, among the natives and from 12 to 16 per cent, among\\nthe whites, or, in epidemics, 40 per cent. Bacilli have been recog-\\nnized, and may be the cause of the disorder.\\nMYCOSIS FUNGOIDES.\\n(Gr. fivKT/g, a mushroom.)\\n(Granuloma Fungoides, Granuloma Sarcomatodes, Inflamma-\\ntory Fungoid Neoplasm, Eczema Tuberculatum, Fibroma\\nFungoides, Lymphodermia Perniciosa, Sarcomatosis Gen-\\neralis. Fr., Lymphadenie Cutanee.)\\nThis disease was first described in 1814 by Alibert, as Pian fon-\\ngoide. Its symptoms resemble that affection, though not in any way\\nrelated to it.\\nThe disease is rare less than two hundred cases have been recorded\\nin literature but so many of these have been carefully observed and\\nfully reported that all the symptoms of the disorder are fully established.\\nAn attempt has been made to distinguish between two forms. There\\nis, however, but one. 2\\nSymptoms. For convenience in description the symptoms may\\nbe grouped roughly in three stages, which, however, do not always\\noccur in regular succession, and of which the first and second may\\nnever be manifested.\\nThe so-called Premycosic Stage (Erythematous Period\\n[Bazin]; Stadium Eczematosum [Kaposi]) is characterized by the\\noccurrence of a series of cutaneous phenomena of different types, which\\nhave been described as resembling, if not identical with, eczema, lichen,\\nerythema, pityriasis rubra, psoriasis, urticaria, furunculosis, and other\\ncongestive and inflammatory cutaneous affections. In a recent con-\\ntribution based on a personal experience in thirteen cases and a review\\nof the literature of forty-eight cases in which these early phenomena\\nwere described, we stated 3 that we believed, in common with a few\\nother investigators, that these early dermatoses, though differing con-\\nsiderably in clinical type, have many characteristics in common, and\\nare the varied expressions of a definite morbid process. The term Pre-\\nfungoid, employed by Morrow, would better designate this stage than\\n1 Handbook of Geog. and Hist. Pathology, vol. ii., p. 114.\\n2 Cf. Max Walters monograph, with sixteen illustrations. Stuttgart, 1899.\\n3 Jour. Cutan.and Gen.-Urin. Dis., June, 1899.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0743.jp2"}, "744": {"fulltext": "688 NEW-GROWTHS.\\nthe generally accepted term premycosic. The mischief is undoubtedly\\ndeclared with the earliest pruritic symptoms, and the skin-eruptions in\\nthe early periods of mycosis should be considered as significant expres-\\nsions of a general disease as the tumors themselves.\\nThe earliest phenomena vary greatly, and may imitate any of the\\nabove-named dermatoses. The most frequent lesions, however, are in\\nthe form of round or circinate, sharply defined, erythematous patches,\\nusually characterized by scaling and by itching. These areas are com-\\nmonly from one to six centimetres in diameter, but may be of any size,\\nand in rare instances (as in one of our cases) the redness and scaling\\nmay be universal. The lesions usually are dry but at times may be\\nmoist, crusted, or even the seat of small papules and vesicles. The color\\nvaries through the different shades of red, often combined with tints of\\nbrown or purple. As the lesions persist thickening and infiltration of\\nthe skin are noted, and the patches become more sharply outlined, more\\ndistinctly circinate in contour, and, by extending peripherally while\\nclearing in the centre, begin to assume the gyrate and fantastic figures\\nso characteristic of the disease. Itching is usually a pronounced feat-\\nure, but may be absent. The course of the lesion is capricious, even\\nmore so than in eczema. One or all of the patches may suddenly dis-\\nappear spontaneously, only to return without apparent cause in old or\\nnew sites, and after intervals of days or months. Treatment, either\\nconstitutional or local, seems to have almost no influence upon the\\ncourse of the lesions. This stage, during which the patches come and\\ngo, may last a few months or several years before the appearance of the\\nmore characteristic areas of infiltration.\\nIn what may conveniently be called the second stage, or Period of\\nInfiltration (Lichenoid Period [Bazin, Vidal, Brocq, Fabre]),\\ncircinate, sharply defined, elevated plaques and nodules appear, either\\nin the site of previous lesions or independently of them. The nodules\\nare pea-sized or larger the infiltrated plaques are button-sized to palm-\\nsized, or larger, sometimes extending over the greater portion of the\\nchest, back, or abdomen. The color varies from a bright pink through\\nvarying shades of red and occasionally of brown or violet. The sur-\\nface may be smooth or verrucous, or fissured and excoriated as the\\nresult of scratching. The pruritus is usually severe, but may be absent.\\nThe shape and career of these plaques are almost, if not quite, diag-\\nnostic. They are circular or circinate, as a rule, and as a result of an\\nextending periphery and clearing centre they are constantly changing\\nin both site and contour, often moving over the surface in gyrate bands\\nor lines, or assuming half-moon, crescent, horseshoe, kidney, or other,\\noften fantastic and grotesque, shapes. Again, they disappear and re-\\nappear without apparent cause, as do the lesions of the first stage.\\nWhile in many cases these variations in site and form require several\\nmonths for completion, cases not infrequently occur in which the whole\\naspect of the disease changes in a few days. In one of our patients\\nthe lesion assumed the form of a curious network of connecting, broad,\\nflat-topped ridges, between which were corresponding valleys of nor-\\nmally colored and apparently normal integument. As a rule, the lesions\\non disappearing leave no trace of their previous existence, but they may", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0744.jp2"}, "745": {"fulltext": "MYCOSIS FUNG OWES.\\n689\\nbe followed by areas of more or less permanent pigmentation or of\\nvitiligo. More rarely, circumscribed areas destitute of pigment and re-\\nsembling leucodermatous patches, may occur in the skin where no pre-\\nceding lesion has been observed. The symptoms of this period often\\noccur with, or may be replaced by, those of the preceding stage. The\\ntwo periods together may last many years (fourteen in one case) before\\nthe appearance of tumors, though in exceptional instances they may be\\npreceded by tumor-formation.\\nIn the so-called third, or Fungoid, Stage (Mycofungoid, Neo-\\nplastic Period), which, in some instances is the first and only stage,\\nthe characteristic Tumors of the disease appear upon the face, scalp,\\nchest, and other portions of the body. They are bean- to orange-sized,\\nMycosis fuugoides.\\nor larger whitish, pinkish, pale, or dull reddish in hue, sessile or\\npedunculated, well rounded or lobulated and distinctly circumscribed.\\nWhen developing from the plaques above described they may be quite\\nflat. They may develop from any of the previously described lesions\\nor from the sound skin. They occur upon all parts of the body, upon\\nthe palmar and plantar surfaces, the arms, the forearm, the thighs, the\\nlegs, the face, and the back. Often they are in various degrees pig-\\nmented, showing purplish, brownish, or even black colors. They are\\nusually painful, and may or may not be tender. When the tumors have\\nattained maturity, and before involution has begun, their appearance,\\nespecially upon the face, is characteristic. Here they are smooth,\\nmoderately firm, globular, often lobulated, or sausage shaped, of a pecu-\\nliar reddish hue, and when numerous produce a lepra-like deformity,\\nclosing the eyes in consequence of their size or weight, producing the\\n44", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0745.jp2"}, "746": {"fulltext": "690 NEW-GROWTHS.\\nleonine brow and the elephantiasic ear. In a case reported by one of\\nus/ and illustrated in Fig. 84, the body of the patient was extensively\\ncovered with tumors of all sizes resembling those seen on the face.\\nLike the other lesions of this disorder, the tumors may disappear\\nspontaneously, while others appear or they may all disappear to return\\nafter uncertain intervals without known cause. As a rule, they leave\\nno trace of their previous existence, though they may be followed by\\npigmentation or slight atrophy of the skin. Sooner or later some of\\nthe tumors degenerate, and lead to superficial ulceration, usually fol-\\nlowed by papillary excrescences and mushroom-like growths of vary-\\ning sizes from which the disease obtains its name. At times they may\\nbe the seat of much more destructive ulceration, though with but few\\nexceptions this destruction is limited to the new-growth, and even large\\nfungoid and apparently deeply ulcerated tumors may completely dis-\\nappear and leave no trace further than pigmentation and possibly a\\nsmall atrophic scar.\\nThe general condition of the patient at first seems unaltered later,\\nwhen the tumors ulcerate, exhaustion occurs and the victim usually\\ndies as a result of febrile processes, of intercurrent disorders, of leuco-\\ncytliEemia, of cachexia, or of pyaemia. When the tumors are many\\nand ulceration extensive the appearance of the patient is repulsive in\\nthe extreme the exhalations from the body are in the highest degree\\nfetid, and the difficulty of procuring asepsis, hygienic care, and comfort\\nfor the wretched sufferer is well-nigh insurmountable. Extirpation of\\nthe tumors is usually followed by recurrence, frequently with added\\nmalignancy.\\nThe superficial and deep lymphatic glands may enlarge, and this\\nadenopathy, as in the case of the tumors, may subside to be replaced\\nlater by similar involvement of the same or other glands. Other com-\\nplications of the disease are pleuropneumonia, pulmonary tuberculosis,\\nhemiplegia, nephritis, and erysipelas.\\nThe duration of the tumor-stage is brief compared with the others\\nfrequently death occurs within a few months, though it may be post-\\nponed two or three years.\\nEtiology. The disease is more frequent in men than in women,\\noften in those of unusual weight and size, and usually occurs between the\\nthirtieth and fiftieth year of life, oftenest after the fortieth year, though\\nin a few instances it began earlier, even in childhood. Though the\\ncause of the disease is not definitely known, there can be little question\\nto-day as to its infectious character. It is probably produced by specific\\nmicro-organisms, but direct evidence of contagion and successful cul-\\nture- and inoculation-experiments are wanting.\\nPathology. The disease has been studied by many observers,\\nincluding ourselves. While the reports of different investigators at\\nfirst reading apparently vary widely, closer study of the recorded\\nobservations indicates that on the main points they agree. The early\\nlesions show on histological examination dilatation of the vessels with\\noften some endothelial proliferation, and a more or less dense cell-infil-\\ntration that is usually limited to the upper part of the corium, except\\nEdinburgh Med. Jour., 1883-1884, page 592.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0746.jp2"}, "747": {"fulltext": "MYCOSIS FVNGOIDES. 691\\nwhere it surrounds some of the deeper vessels in the forms of sheaths\\nor cuffs. Galloway and McLeod l describe in the early stages a con-\\nnective-tissue cell-infiltration not only about the vessels, but also about\\nthe hair-follicles, the sebaceous glands, the muscles of the hair-pouch, the\\nducts of the coil-glands, and occasionally along the lymphatic spaces be-\\ntween the connective-tissue fibres. They conclude that the characteristic\\ninfiltration may originate in the cells of any of these structures. The\\ninfiltration in some instances is diffuse, but sharply separated from the\\ndeeper parts of the corium by a horizontal line, and from the rete\\nabove by a narrow layer of connective tissue. In other instances the\\ninfiltration occurs in round or irregular areas, separated by bundles of\\nnormal connective tissue. Where the cells are most compact they are\\nsupported by a very delicate fibrous structure made up in part of elastic\\nfibres. Degeneration of collagenous and elastic fibres occurs in the late,\\nbut not in the early, stages of the disease. The cells forming the infiltra-\\ntion are in the main of the connective-tissue type, but in many cases they\\nand their nuclei show the greatest diversity in size, shape, and staining\\nqualities. Round, cuboidal, or irregularly shaped cells with little pro-\\ntoplasm and a deeply staining nucleus are numerous. Many of the\\nirregular bodies are apparently fragments of cells. In many places the\\ncells are so closely packed as to modify their shape and size. This mul-\\ntiformity of the cells is apparently characteristic of the disease, and\\nUnna believes that it is due to the result of two antagonistic processes\\nconstantly going on, that is, cell-multiplication and cell-destruction,\\nand that many of these odd forms are nothing more or less than cell-\\nfragments. Mast-cells, multinuclear cells, and giant-cells are seen in\\nsome lesions, but are absent in others. Mitotic figures are frequent.\\nThe papillae are enlarged, in places packed with cells, in others more or\\nless oedematous, as also are portions of the subpapillary layer. The\\nrete is everywhere hypertrophied, the interpapillary processes being\\nelongated, broadened, and frequently branched. In places the cells are\\nswollen and oedematous, with spaces between them. Mitotic figures\\nhere also are numerous, especially in the basal layers.\\nAs the lesions progress toward the tumor-stage the cells in the\\ncorium become more regular in form and size, and the rete becomes\\nmuch thinner. In the fully developed tumors the rete is usually\\nreduced to a few, sometimes but one, layers of cells, but in a few\\ninstances it dips down deeply into the growth in a way to suggest epi-\\nthelioma were it not that these epithelial processes are very slender.\\nMany of the tumors correspond closely in structure to sarcoma, others\\nshow the histological formation of granulomata.\\nNumerous micro-organisms have been seen in the tissues, and some\\nhave been cultivated, but none has yet been demonstrated to have any\\npathogenic relation to the disease. Among them may be named strep-\\ntococci in the capillaries of granulation-nodules, and staphylococci in\\ncultures from blood. Other examinations of blood, of infected tissue,\\nand of tumors were wholly negative as to the discovery of cocci.\\nIt is alleged that mycosis fungoides is a form of sarcoma. The facts,\\nhowever, that fully developed tumors disappear spontaneously, and that\\n1 Brit. Jour, of Derm., May and June, 1900.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0747.jp2"}, "748": {"fulltext": "692 NEW-GROWTHS.\\nin but few instances has involvement of viscera been reported in mycosis\\nfungoides, should, without other minor differences, be sufficient to\\nexclude the disease from the sarcoma group. In a few cases of mycosis\\nfungoides changes in the deeper organs have been found similar to those\\nwhich occur in leukaemia and pseudoleukemia, but no definite relations\\nhave been recognized between these conditions and the disease under\\nconsideration. There is a growing tendency among observers to class\\nmycosis fungoides with the infectious granulomata.\\nDiagnosis. The age, weight, and often the protuberant abdomen\\nof the patient are usually to be considered. In the early erythematous\\nstages the disease is to be distinguished especially from eczema, psoria-\\nsis, urticaria, erythema multiforme, and dermatitis exfoliativa. While\\na positive diagnosis cannot always be made at this time, in the\\nmajority of cases a careful consideration of the typical features\\njust described will leave little doubt as to the nature of the\\ndisease. The circinate contour of the lesions, their spontaneous dis-\\nappearance and reappearance, and the rebelliousness to treatment of\\n.what appears to be a mild and superficial inflammatory process, are\\nfeatures not found to the same extent in any of the other dermatoses\\nnamed above. Aside from the absence of these three marked character-\\nistics in psoriasis there is much more thickening of the plaques and\\nthere are characteristic scales, while the situation, history, and other\\nfeatures of the lesions are usually sufficient for a diagnosis in moist\\nforms of eczema the discharge and multiformity of lesions are both\\ngreater than in mycosis fungoides.\\nWhen these early lesions of mycosis fungoides appear in irregular\\npatches the diagnosis from eczema can be made only after they have\\nbeen under observation for weeks or months. In those exceptional\\ncases which begin as a generalized exfoliative dermatitis an early diag-\\nnosis is not possible.\\nAfter the appearance of infiltrated plaques, or of well-developed\\ntumors in case the other stages are absent, the diagnosis is usually\\nclear. The infiltrated areas, nodules, and smaller tumors may at\\ntimes closely simulate leprosy but the history, the absence of areas of\\nanaesthesia and other characteristics of leprosy, and the histological\\nexamination should clear up the diagnosis without difficulty. The\\ntumors are distinguished from those of sarcoma by their history and\\ncareer, and by their final formation of characteristic fungoid, super-\\nficially ulcerating masses.\\nThe Treatment is unsatisfactory.\\nThe pruritus and complicating dermatoses which may be present in\\nthe early stages may be treated locally with various soothing, protect-\\ning, and antipruritic applications (see treatment of eczema) according\\nto the indications in each case presented.\\nThe comfort of the patient is to be secured by all measures, includ-\\ning anodynes in an advanced stage of the disease, and his strength\\nshould be supported by a generous diet and tonic regimen. Arsenic\\nin full doses and by hypodermatic injection has been of apparent ser-\\nvice Koebner reported one patient cured by this treatment. Locally\\nichthyol, bismuth oleate, and many other preparations have been of", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0748.jp2"}, "749": {"fulltext": "SARCOMA CUTIS. 693\\nservice in allaying the symptoms and retarding the progress of the\\ndisease. When the affection is generalized tepid baths are productive\\nof great comfort the use of boric acid, resorcin, aristol, carbolic acid, or\\nsome similar agent is indicated by the fetor arising from the person. The\\nulcerating masses may be protected by a wet antiseptic dressing, or,\\nafter cleansing, dusted with the zinc stearate compounds, iodoform,\\naristol, or other powder, and protected by a proper dressing. Extir-\\npation of the tumors is proper when such a course will add to the com-\\nfort of the patient.\\nThe Prognosis is unfavorable. The patient may survive from a\\nfew months to a maximum of fifteen years, the average being from two\\nto four years. After the development of tumors the patient may live\\nbut a few months or at most two or three years. Three cases of re-\\ncovery are on record, one patient apparently relieved after an attack\\nof erysipelas.\\nSARCOMA CUTIS.\\n(Gr. capZ, flesh.)\\nSarcoma of the skin is characterized by the occurrence, either as pri-\\nmary or as secondary developments, of single or multiple, pea- to egg-\\nsized and larger, pigmented and non-pigmented, cutaneous and subcu-\\ntaneous neoplasms having a marked inaptitude for ulceration but malig-\\nnant in character, recurring after extirpation, and usually terminating\\nfatally with involvement of the viscera.\\nThe term sarcoma, meaning a fleshy tumor, was originally employed\\nby Virchow in the designation of this disease.\\nSymptoms. Cutaneous sarcoma is an uncommon affection, and its\\nclinical forms are not always clearly defined. In general they may be\\ndivided into two groups, though transition-forms exist.\\n(A) Melanotic Sarcoma, or Melano-sarcoma. This is the more com-\\nmon form. It may develop from a pigmentary nsevus that has been\\nirritated, or from any pigmented point upon the integument, especially\\nupon the dorsum of the hands and feet, the lower extremities, the geni-\\ntal region, and the face over the cheek or near the orbit, where it may\\noriginate from the choroid coat of the eye. In a few instances meta-\\nstatic, sarcomatous deposits on the face have been preceded by a\\ndiffuse bluish pigmentation.\\nMelanotic sarcoma may be of primary occurrence or may develop\\nas a secondary deposit. The lesions are bean- to egg-sized, usually\\nsingle or multiple, very firm or doughy, sessile or pedunculated, spher-\\noid or lobulated and varying in color from grayish brown to inky\\nblackness. The epidermis may be discolored, thinned, and intact, or\\nbe ulcerated. The nodules are often surrounded by blackish puncta\\nwdiich eventually develop into tubercles. The lesion or lesions may\\nfor a long time remain stationary, or they may rapidly be followed\\nby generalization, as a result of local irritation, either by extension\\nfrom a central point to adjacent tissue, or by transmission through the\\nlymphatics to a distance from the primary nodule.\\nIn a case lately observed the left lower extremity of a middle-aged\\nwoman was studded with split-pea-sized to marble-sized, ink-black", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0749.jp2"}, "750": {"fulltext": "694 NEW-GROWTHS.\\nmasses from the ankle to the middle of the thigh. The larger were\\nalways centres of groups of similar pinhead-sized black nodules. The\\nskin of the region affected was swollen, inextensible, inelastic, and as\\nfirm as sole-leather. The disease had extended from the ankle upward\\nin the course of a few months.\\nMelanotic sarcoma is one of the most malignant and rapidly fatal\\nof all neoplasms. Therapy is unavailing and the prognosis is grave\\nindeed, a fatal result usually occurring with rapidity after the occur-\\nrence of generalization, and commonly w T ith visceral complications by\\nreason of secondary deposits.\\nRecent studies of Unna, Gilchrist, 1 and others indicate that malig-\\nnant growths arising from pigmented moles are usually (if not always)\\ncarcinomatous rather than sarcomatous.\\nMelanotic Whitlow (Hutchinson) is described as a chronic ony-\\nchia, displaying pigmented spots, suggesting silver-nitrate stains at the\\nedge of the nail-fold, where eventually a fungus tumor forms with\\nincrease of pigment until the nail is exfoliated, and the process becomes\\ngeneralized.\\n(B) Primary Non-melanotic Sarcoma. This occurs in both localized\\nand generalized forms.\\nThe localized variety of primary non-melanotic sarcoma is rare, and\\nis seen chiefly in women. As in other sarcomata, it is often first recog-\\nnized at a point where a nsevus or other warty growth has become irri-\\ntated, usually on the extremities. At such a point there forms a firm,\\ndull-whitish nodule, having nearly the hue of the normal skin, rarely\\nvascularized, that may, after persistence without change for a variable\\nperiod, break down by ulceration and become the seat of a fungous\\nvegetation. Generalization of the process may result either spontane-\\nously or from accidental complications.\\nThe disease, when affecting the skin in multiple lesions, is character-\\nized by the appearance of several, usually at first isolated, pea- to nut-\\nsized and larger, smooth, spherical, irregular, or lobulated cutaneous or\\nsubcutaneous tumors. They may or may not at first be attached to the\\nepidermis above and to the deeper structure beneath, but they eventually\\ncontract such adhesions. Between them the skin may not be involved.\\nIn uncomplicated cases at this period the conspicuous features of these\\nlesions are (a) their whitish color, due to envelopment in an unaltered\\nepidermis (6) the history of a relatively rapid development, as distin-\\nguished from fibromata, epitheliomata, gummata, and lupous tubercles,\\n(c) the speedily declared systemic results of the growth.\\nLater, the skin between the lesions becomes swollen, infiltrated,\\npainful and, even before the tubercles desquamate, enormous tume-\\nfaction and redness of an erysipelatous type may affect the internodular\\ntissue. In this way an entire limb, only one portion of which is the\\nseat of tubercular growth, may attain an elephantiasic size, ulcerate at\\none or more points, and pour out an offensive secretion as a consequence\\nof ulceration of the inflamed integument.\\nThe disease is both rapid in course and malignant in type. In a\\n1 Jour. Cutan. and Gen.-Urin. Dis., March, 1899.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0750.jp2"}, "751": {"fulltext": "SARCOMA CUTIS. 695\\nfew weeks or months the nodules or tumors of sarcoma coalesce, degen-\\nerate by ulceration, and participate in the process going on in the in-\\nflamed and excoriated skin where they are implanted. Death results\\neither from exhaustion, intercurrent fever, or sarcomatous involvement\\nof one or of several viscera. By the same process the skin-lesions may\\nbe the product of metastasis from the lymphatic glands or the viscera.\\nThe disease occurs in this form over the chest, the extremities, and\\nthe genitalia, though all parts of the skin have been invaded.\\nIdiopathic Multiple Pigment-sarcoma (of Kaposi and others)\\nowes its coloring to cutaneous hemorrhages and not to a pigment-de-\\nposit. It occurs chiefly in male subjects (from forty to sixty years of\\nage) who have been laborers, whose hands and feet become the seat of\\nan oedema, accompanied by pruritus and other subjective sensations.\\nLater, brownish, bluish-red, or dark-purplish spots appear, out of\\nwhich develop pinhead- to pea-sized nodules, gradually increasing in\\nvolume, discrete, tender, and often grouped. They may be the seat of\\nlancinating and radiating pains. As they multiply a lardaceous infil-\\ntration progressively involves the depth of the integument, until an\\nelephantiasic condition is produced, a hand, a foot, or an entire limb\\nbecoming of cartilaginous hardness, bluish in tint, and covered with a\\nsmooth, mammillated, squamous, or rugous envelope, which may be\\nalso the site of tumors of considerable size. These tumors are fewer in\\nnumber and smaller in volume as they spread from the distal to the\\nproximal parts of the limb. They may be sessile, pedunculated, and\\ngrouped, but they are always of a deep-bluish or violaceous tint.\\nThese growths may remain for a long time stationary or they may\\nbe entirely resolved, the patient apparently securing complete recovery.\\nVery rarely they ulcerate or exhibit slight erosions. At times they\\nare covered with or surrounded by telangiectases, or by tissue exhibit-\\ning infiltration of blood. When the mucous membranes are involved,\\npoints, patches, disks, or infiltrations of a dusky-reddish or a bluish\\nshade appear on the inner side of the gums, the lips, the tonsils, or over\\nthe palate and there is visceral involvement with lymphatic and\\nvascular changes. The usual signs of physical exhaustion ensue, with\\nfever, dysenteric symptoms, haemoptysis, and marasmus. The disease\\nmay last only from three to five years, but a duration of fourteen years\\nhas been recorded. Post mortem tumors have usually been recognized\\nin the viscera. Only a few infantile cases have been recorded.\\nRemarkable instances of complete recovery from this affection are\\nmultiplying. A patient with the hands completely relieved was shown\\nat the International Dermatological Congress in London, in the year\\n1896, Kaposi having verified the diagnosis. A patient rapidly recov-\\nering from the same disorder is under our observation. It is doubtful\\nif this condition be a true sarcoma in the sense in which this term is\\ngenerally accepted.\\nRecurrent Fibroid of the Skin (Hutchinson), beginning usually\\nin the lower extremities, and tending to slow extension, to rapid and\\npersistent recurrence, and to ulceration and formation of fungous tumors,\\nwith ultimate marasmus, is set down by Crocker as a rare form of\\nspindle-cell sarcoma.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0751.jp2"}, "752": {"fulltext": "696\\nNEW-GROWTHS.\\nMultiple cutaneous and subcutaneous tumors are reported in leu-\\nkaemia and pseudoleukemia. Some of these are apparently sarcomatous\\nin nature while others evidently\\nFig. 85.\\nmycosis\\nSarcoma: spindle-cells visible in sections of\\ncutaneous nodule removed from a sarcomatous\\npatient. (About X 300.)\\nshould be classed with\\nfungoides.\\nThe Etiology of sarcoma is\\nunknown. According to Babes,\\nsarcomata are frequently congeni-\\ntal, and are not rarely found in\\nearly youth upon the eyelids, the\\nextremities, and the genitalia.\\nPathology. Sarcoma of the\\nskin may be primary, but is proba-\\nbly more often secondary to the\\ndisease in deeper organs of the body.\\nHistologically, it is a connective-\\ntissue growth, made up largely of\\nround- or spindle-cells, and corre-\\nsponds closely to the structure of\\nsarcoma in other parts of the body,\\nthe spindle-cell being somewhat\\nmore frequent than the round-cell\\ntype. Other mixed types, as fibro-sarcoma, angio-sarcoma, or lympho-\\nsarcoma, are seen occasionally. The most common type recorded is the\\nmelanotic sarcoma which has been described as developing from pig-\\nmented moles or warts. Recent investigations prove that some, proba-\\nbly the majority, of these growths should be classed with carcinoma.\\nIn the so-called idiopathic multiple pigment-sarcoma of Kaposi\\nthe pigmentation is due entirely to hemorrhage and the blood-slowing\\nwhich follows. The growth is highly vascular, containing many newly\\nformed vessels, the walls of which are very thin and often are made up\\nof the cells of the tumor.\\nFordyce l describes several cases of localized angio-sarcoma of the\\nskin in which the single tumor was identical histologically with the\\ngeneralized sarcoma of Kaposi.\\nThe Diagnosis rests upon the history, symptoms, and microscopical\\nexamination of the new-growth. Sarcoma should not be confounded\\nwith fibroma, epithelioma, gumma, or lupous nodules.\\nTreatment is unsatisfactory. Surgical ablation of these tumors is\\napt to be followed by their speedy return.\\nKoebner s injections of arsenic (usually Fowler s solution, 2 to 4\\ndrops in 1 to 2 parts of distilled water, repeated every second day for\\nmonths, with gradual increase of the dose) seem to have proved success-\\nful in two cases. 2 Wende 3 reports a case improving under this treatment.\\nArsenic, potash, and ergot, internally, and salol, camphorated naphtol,\\naristol, and bismuth subnitrate, locally, have secured only transitory\\nbenefit. Successful results, but also several deaths, are reported from\\n1 Amer. Jour. Med. Sci., Aug., 1900.\\n2 Berlin, klin. Woch., 1883, No. 2.\\n8 Jour, Cutan. and Gen.-Urin. Dis., 1898, p. 205.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0752.jp2"}, "753": {"fulltext": "CARCINOMA. 697\\ninoculation with cultures of the streptococcus of erysipelas. Favorable\\nresults have been reported in a few instances by Coley and others from\\nthe injection of the combined toxins of this streptococcus and of the\\nbacillus prodigiosus. In the majority of cases these measures are\\nunsuccessful.\\nThe Prognosis is unfavorable, a fatal issue occurring in most cases.\\nCARCINOMA.\\n(Gr. naptdvog, cancer.\\nThe term cancer has been employed both loosely and definitely in\\nthe designation of malignant cutaneous tumors. Every cancer of the\\nskin is, according to some authors, necessarily both alveolar and epithe-\\nliomatous in structure while others distinctly recognize forms of cancer\\nwhich are not epithelial. In these pages, for the sake of retaining a\\nconvenient clinical distinction, the term carcinoma, or cancer, is limited\\nto malignant growths of epithelial origin.\\nEPITHELIOMA.\\n(Epithelial Cancee, Caecinoma Epitheliale, Rodent Ulcee.\\nGer., Epithelialkeebs Fr., Canceoide.)\\nSymptoms. Three clinical varieties of epithelioma are recognized\\nthe superficial, the deep, and the papillary. They are practically no\\nmore than varying phases of a single pathological process.\\nSuperficial, or Discoid, Epithelioma is usually first displayed upon the\\nsound skin in the form of one or of several pinhead-sized papules, flat\\ninfiltrations, disks, or nodosities of a dull-yellowish, reddish, grayish,\\nor dirty wax-like hue. The growth may also have its origin in pre-\\nviously existing skin-lesions which are both numerous and different\\nfrom one another. Among the latter symptoms may be named fissures\\nand excoriations (especially those long teased by caustic applications)\\nwarts, nsevi, acneiform and molluscoid lesions and the dry or greasy\\nepidermal scales often seen at the orifices of sebaceous glands in the\\nfaces of the aged. The outline of the newly developed growth as a\\nconsequence varies, being roundish, linear, or irregular. As a result of\\naccident or traumatism (especially scratching and picking, which the\\nhistory of a large proportion of all cases includes) there forms a super-\\nficial excoriation, which may be covered with a sero-sanguineous crust\\nafter the desiccation of its scanty and ichorous secretion. In the prog-\\nress of its development it is often noticed that new foci of disease appear\\nin the immediate vicinity of the first, represented by subepidermic\\nindurated nodules, or superficial pearls resembling milia, whitish and\\nlustrous, with marked tendency to vascularization, exfoliation, and\\nsuperficial ulceration.\\nRodent Ulcee (Jacob s Ulcee, Ulcus Exedens, Noli-me-\\nTangeee, Canceoid Ulcee). The characteristics of this form of\\nsuperficial epithelioma are a roundish, fissured, or slightly angular con-\\ntour, and a reddish or reddish-brown, irregular, granulating, and mam-\\nmillated floor, covered with a thin, translucent, viscid serum, which, in", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0753.jp2"}, "754": {"fulltext": "698 NEW-GROWTHS.\\ndrying, suggests the effect of a varnish over the part. The edges of\\nthe ulcer are clean cut, indurated, everted, usually well attached, and,\\nseen in horizontal profile, irregularly indented. The symptoms are\\nslight at first the lymphatic ganglia and general health being unim-\\npaired. Its site of election is the face, particularly the eyelids, nose,\\ntemples, and lips, though the genitalia, the hands, and the feet may be\\naffected. Of two hundred and fifty cases collated by Heurtaux, in one\\nhundred and ninety the face was attacked.\\nSome English writers still describe the rodent ulcer as distinct from\\nepithelioma, chiefly by reason of its individual peculiarities. Patho-\\nlogically no distinction can be established between the two. The clin-\\nical features upon which this distinction is based are the slow or\\nintermittent development of rodent ulcer its tendency to destroy, as\\nit extends, all the tissues within reach its failure to implicate the\\nsystem by secondary deposits or metastases its rounded and often\\nwidely everted edges, or, better, lip, often distinctly vascularized its\\ngouged floor exhibiting unequal levels its slight tendency to granula-\\ntion and its feeble or negative attempts at repair. All these symp-\\ntoms are those of epithelioma, if one chooses to employ that term in its\\nlarge and proper sense. The rounded or oval excavation, often exceed-\\ningly clean cut, at times with a corded and whitish rim, producing,\\nlittle, if any, pain, is characteristic of the rodent ulcer, yet in its exten-\\nsion it may exhibit all the symptoms of a deep epithelioma.\\nUnder the title Crateriform Ulcer, Hutchinson 1 describes a form\\nof epithelioma distinguished chiefly by rapidity of invasion. Its\\nonset is by the formation of a roundish or conical mass which rapidly\\nexhibits ulceration, a central crater forming with exceedingly dense\\nwalls.\\nThe subsequent course of the lesion varies, its evolution being gen-\\nerally slow and accomplished in years. Sometimes having attained a\\nmaximum of size, the ulcer, if unmolested, long persists without appre-\\nciable change. In other cas es the base cicatrizes and the epithelioma\\ncompletely exfoliates, leaving an outlying linear ulceration which may\\npersist or spread. In yet other cases, after a persistence of from ten to\\ntwenty years, the ulcer may spontaneously close and the disease be at\\nan end. Sometimes the ulceration is very superficial and slowly\\nspreads in circles, segments of circles, or in irregular gyrate outlines,\\nthe older portions healing and cicatrizing while the border advances.\\nSuch lesions may cover considerable areas of the body and closely\\nresemble the serpiginous lesions of syphilis and lupus. In many\\ncases the papillomatous element is marked. To this form of super-\\nficial discoid epithelioma the name Paget s Disease is sometimes\\napplied, as the process is practically the same as that which attacks\\nthe nipple and breast. Finally, any one of the destructive and malig-\\nnant cancerous processes may be awakened, and the epithelioma be\\nthus transformed from the type of the superficial to that of the deep\\nvariety of the disease.\\nDeep, or Tubercular, Epithelioma. This variety may originate in the\\nmanner already described, or may be from the first characterized by\\n1 Transactions of the London Pathological Society, 1889, p. 275.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0754.jp2"}, "755": {"fulltext": "CARCINOMA. 699\\nits specific features. It commonly begins by the formation of round-\\nish, very firm, pea-sized nodosities closely set in the skin and subcu-\\ntaneous connective tissue, or be thus situated and well projected from\\nthe surface. In the course of months and years these nodules develop\\nto form a nut- or even a small egg-sized tumor, roundish, dark reddish\\nin color, and delicately vascular on its surface. This tumor may be\\na deep flattish or globoid development within the skin or be a well-\\ndefined nodule attached to it or (and this is a common form) be a\\ndense, thick, flattened plaque, a centimetre or more in diameter, its\\nwalls steeply descending to the sound skin on either hand or mode-\\nrately everted its centre depressed by atrophic changes its surface\\nshining, waxy, pinkish, or red, with ramifying capillaries. Satellites\\nmay form in its vicinity.\\nDegeneration of these forms produces in the course of time an ulcer\\neither like that described above, or one which deeply and destructively\\nencroaches upon the tissues beneath. In advanced cases the latter\\nulcer is irregular in contour, with a clean-cut, everted, indurated lip\\neroded and gouged, hemorrhagic and granulating floor; thin, viscid\\nsecretion which is foul and purulent at times when the resulting destruc-\\ntion is rapidly accomplished and a deep attached base Avhich may be\\nperforated by a crateriform exulceration extending down to or through\\nmuscles, fasciae, cartilage, and bone. The lymphatic ganglia become\\nsimultaneously involved, and a general cachectic condition is established.\\nDeath may ensue from marasmus, exhaustion, or hemorrhage in the\\ncourse of several months or from one to three years.\\nPapillary Epithelioma. The cancer in this variety assumes the form\\nof a malignant papilloma. In these cases a pedunculated or sessile,\\nnarrow or broad-based, smooth-capped, or spongy and verrucous vege-\\ntation is attached to the skin upon which it forms. It may originally\\nbe as small as a pea, but usually it increases considerably in volume,\\nbeing not rarely pigeon s-egg- and turkey s-egg-sized. The surface is\\neither dry, reddish yellow, smooth, and lustrous exfoliating, and se-\\ncreting an offensively smelling sanguineous or translucent fluid or is\\nmoist, granulating, filamentous, and intermingled with hairs, as when\\nit occurs upon the bearded cheek. Degeneration occurs later, fissures\\nforming first subsequently there appear superficial, and finally deep,\\nulcers which ultimately assume all the features of the epithelioma\\ndescribed above.\\nIn some cases the epithelioma forms a soft, hemispherical, small\\nnut- to egg-sized tumor, which upon pressure discharges numerous\\nconvoluted plugs, composed of epithelium, fatty masses, and a purulent\\nsecretion. The bases of these soft masses are remarkable for the ease\\nwith which they can be curetted and thus radically removed.\\nA careful study of well-marked cases of papillary epithelioma indi-\\ncates clearly that while ulceration often results, the centre of the mass\\nbreaking down and furnishing a typical cancerous excavation, with\\nhard and rounded or oval border, uneven base, irregular granulating\\nfloor, and offensive discharge, the picture may be wholly different.\\nOccasionally the superficial process extends widely over the brows,\\ncheeks, and chin, interspersed with raised cicatriform areas, suggesting", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0755.jp2"}, "756": {"fulltext": "700 NEW-GROWTHS.\\nthat ineffectual attempts had been made to check the disease by sur-\\ngical measures. These apparently atrophic disks, mingled with vas-\\ncular, florid, fungiform, pyriform, and oddly shaped outgrowths, are\\nreally cancerous infiltrations of the type of discoid epithelioma. They\\nmay be seen gluing the lobe of the ear to the cheek, or everting the\\nlower lid, even when superficial papillary vegetations are the predomi-\\nnant features of the disease.\\nEpithelioma of the skin occurs also with multiform features, almost\\nas numerous as the several different lesions from which a cutaneous\\ncancer may take its origin. 1 Thus, a wart, a button, a vegetation, a\\ncrack, an erosion, may result in a fissure that bleeds easily and refuses\\nto heal. After months or years there forms an epithelioma, assignable\\nto one of the clinical varieties described above. In other cases there\\nmay be a number of greasy scales upon the skin-surface resembling\\nthose seen in well-marked seborrhoea sicca and in one or two spots\\nthe removal of these scales offers to the eye a superficial erosion\\nimplicating the derma, bleeding freely, and, when undisturbed, crusting\\nand slowly spreading under the crust rather than healing. In yet\\nother cases a thin pellicle of apparently loosened epithelium, looking\\nlike a papery crust, is found, when removed, to cover three or more\\nshallow ulcers, unexpected and hidden from view by the tenacious\\npellicle which had protected them and beneath which they had indo-\\nlently and painlessly developed.\\nThese varieties or types of epithelioma may coexist in different por-\\ntions of the same integument, or the one may develop from the other,\\na malignant papillary growth springing from a superficial or a deep\\ncancerous infiltration. Familiar examples of the disease are seen upon\\nthe eyelids and contiguous portions of the nose the cheek and the\\nlower eyelid, the latter being often drawn into ectropion by a cicatri-\\nform bridle or band the nose or lip and adjacent mucous or osseous\\ntissue and the glans and prepuce where the vegetating forms are of\\nmore frequent occurrence. The vast destruction wrought by the widest\\ndevelopment and consequent degeneration of epithelioma is sufficiently\\nrecorded in the annals of both medicine and surgery. A woman sixty-\\nfour years of age was exhibited at the clinic, in the centre of whose\\nface an ulcerating epithelioma had left a wide chasm, after destroying\\nthree-fourths of the nose and upper lip, and the hard palate with all\\nthe upper teeth and the antrum. The bones at the base of the skull\\nwere exposed. This case illustrated well the occasional remarkable\\ntolerance by the system of the profoundest encroachments of epithe-\\nlioma. She was then digesting and assimilating food with fair profit,\\nand suffered chiefly from pain. She did not die until several months\\nhad elapsed, and then only as the result of hemorrhage from an ulcer-\\native opening into one of the large arteries.\\nCancer of the Head. In this region of the body nearly three-\\nfourths of all cancers of the skin are recognized. Upon the brow,\\nthe ala3 of the nose, the temples, cheeks, chin, scalp, or other part, the\\n1 Cf. Fordyce Clinical and Pathological Observations on some Early Forms of\\nEpithelioma of the Skin/ N. Y. Med. Jour., June 9 and 23, 1900.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0756.jp2"}, "757": {"fulltext": "CARCINOMA. 701\\ndisease may begin either upon or beneath entirely normal skin, or in\\nthat which has pathologically been changed. The origin of the disease\\nis usually ascribed to the picking, scratching, or shaving over a seba-\\nceous wart in an old man or in similar traumatisms of acneiform,\\nseborrhoeic, or furuncular lesions in either sex. In other cases the der-\\nmatologist, consulted with reference to some other ailment of the skin,\\ncan recognize, in persons of the age most liable to such accidents, one\\nor several pinhead-sized or larger milium-like nodules, clustered about\\nthe temples or the nose, that indicate the site of the awakened epithe-\\nliomatous change. The disease progresses slowly, spreading super-\\nficially along the alse of the nose in irregular lines, in more complete\\ncentrifugal outline over the temple and brow almost symmetrically\\nover the tip of the nose, and with odd indentations of contour in the\\ndense integument immediately in front of the tragus of the ear. The\\nvegetating forms are more common on the brow, scalp, and chin the\\nrodent-ulcer type, over the temples and cheeks. The more super-\\nficial varieties in any part of the face may slowly be converted into the\\ndeeper. The flattened, egg-sized disks of infiltration are more common\\non the cheeks and chin.\\nThe devastation produced by malignant cancer is nowhere more con-\\nspicuous than in the face. Cartilage, bone, muscle, and entire organs\\nmelt before its ravages with astounding readiness. Within a period of\\ntwo years a circumscribed flat epitheliomatous infiltration, limited for\\nmany months to one cheek, may spread to the point of destroying the\\near, eye, and inferior maxilla of one side of the face, opening into the\\nlarynx and oesophagus, and not producing a fatal result until the jugular\\nvein of the same side is opened by ulceration.\\nCancer of the Lower Lip, far more common in men than in\\nwomen on account of the tobacco-habits of the former, may arise either\\nas a minute lobule or as a circumscribed thickening on or near the\\nvermilion border, usually of one side, or as a linear, narrow, and shal-\\nlow excoriation, often protected by a thin crust, extending well along\\nthe mucous edge of the lower lip that is in contact with the upper\\nwhen the two are lightly approximated. Later, the lip may be the\\nseat of a defined tumor, small nut- to egg-sized, that may deeply in-\\nvolve the entire thickness of the lip, encroach upon the chin, loosen\\nthe teeth, destroy the gums, larynx, pharynx, tongue, and maxilla, and\\neventually produce one of the formidable and remediless chasms of the\\nlower part of the face already described.\\nCancer of the Genital Organs is submitted to the surgeon\\nmore frequently than to the dermatologist. The glans penis, the\\nclitoris, and the prepuce are occasionally the seat of a warty variety\\nbut the scrotum, labia, thighs, mons veneris, and abdominal walls, as\\nwell as the parts first named, may be involved in the superficial or the\\ndeep form of cancer. In persons of cleanly habits the superficial\\nvariety of epithelioma may persist in the genital region as indolent and\\ninnocuous as upon the face but where filth is permitted to accumulate\\nabout the part (lochial, menstrual, catarrhal secretions pus, urine,\\nfeces, etc.) the spread may relatively be rapid. The ulcer is then deep,\\nseated upon an indurated and very tender base, and has the steep,", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0757.jp2"}, "758": {"fulltext": "702 NEW-GROWTHS.\\npunched edge and hemorrhagic floor of the rodent ulcer. Ulceration\\nmay, later, open the rectum, vagina, corpora cavernosa, perineum, and\\ndeep perineal fascia, resulting in vast destruction that proves fatal by\\nexhaustion of the forces of the aged patient.\\nCancer of the Extremities, particularly of the back of the\\nhand, is at first usually papillomatous, or of the flat, superficial form.\\nIt may appear upon the left hand of right-handed patients. Its prog-\\nress is indolent, and when properly treated is much less liable to grave\\nulceration than epitheliomata in other situations. In special regions,\\nespecially on the lower extremity, where the force of gravity generally\\naggravates any ulcerative process, there may result caries, necrosis,\\nfistules, loss of phalanges, etc.\\nCancer of the Mucous Surfaces may be primary or be second-\\nary in origin. The mucous lining of the oral and nasal cavities, of the\\nvagina, the rectum, and the balano-preputial sac may thus be involved,\\neither by extension of the disease from the neighboring cutaneous sur-\\nface or by primary involvement of the mucous tissue. The most\\nimportant, by reason of statistical frequency, is cancer of the tongue\\nand buccal membrane, often having its origin in the leucoplasic stria-\\ntums, plaques, or thickenings, known as smokers patches, ichthyosis\\nlingua?, psoriasis linguae, etc. A pinhead- to pea- or bean-sized super-\\nficial excoriation is usually the first lesion to which attention is attracted,\\nreddish in color, granulating, tender, and not often very painful or the\\nbeginning is a shallow fissure at the edge or on the tip of the tongue or\\non the mucous face of the lower lip, its long axis commonly at right\\nangles to that of the organ upon which it forms. Beneath with more\\nor less rapidity (as a rule slowly) dense induration occurs, lancinating\\npains dart from the affected region toward the ear or along the jaw, the\\nsubmaxillary and other glands become tumid and tender, deglutition pain-\\nful and in severe cases well-nigh impossible or from the nasal membrane\\nthe disease extends toward the palate, pharynx, or larynx, ulceration,\\nwhen it occurs, opening up a vast chasm which represents all these\\ncavities. In the vagina and the rectum a cancerous change may begin\\nwith merely a thickening of the surface of the mucous membrane lead-\\ning in the course of time to a superficial and later to a deep ulcerative\\nprocess or, as in cutaneous epithelioma, the papillary form may be repre-\\nsented in vegetations, cauliflower-shaped, filiform, or simply warty and\\nmammillated, that eventually degenerate and furnish the most formida-\\nble of destructive results.\\nEtiology of Epithelioma. The essential causes of cancer are\\nunknown, though there can be no question that mechanical, chemical,\\nand other local irritations are often immediate excitants of its patho-\\nlogical processes in the predisposed skin. In this way the excoriations,\\nwarts, nsevi, and other lesions named above, though not in themselves\\ncancerous, may become the original sites of the disease. In this way,\\ntoo, the irritation produced upon the lips of the smoker by his pipe or\\ntobacco the local disorder about the inner canthus of the eye result-\\ning from occlusion of the lachrymal ducts the frequent teasing by\\ncaustic or other substances of the wart on an old man s hand and\\nother agencies disturbing the balance between waste and repair, aided", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0758.jp2"}, "759": {"fulltext": "CARCINOMA.\\n703\\nat times by senile atrophic changes, may result in the development of an\\nepithelioma. The possibility of the transmission of cancer by heredity\\nhas almost ceased to obtain credence in the light of modern pathology,\\nyet Broca reports sixteen deaths from cancer in one family, and Fried-\\nerich a congenital epithelioma in the child of a cancerous woman.\\nThe disease is eminently one of advanced life, being most frequent\\nafter the fortieth year, and a pathological curiosity in childhood.\\nKaposi reports one case at the tenth year. Only about 30 per cent,\\nof all cutaneous cases occur in women, a fact possibly explained by the\\nrelative infrequency of the action of local irritants in those who are\\nnot subjected to the exposures incidental to the trades and laborious\\noccupations of life. These figures, however, relate only to cancer of\\nthe skin, since, when cases of cancer of the breast and of the uterus\\nare included, the proportion of the sexes affected is almost exactly\\nreversed.\\nIn favor of the local origin of cutaneous epithelioma is the clinical\\nfact of the excellent general health of most patients in the earliest\\nstages of the malady while those affected with syphilis and tubercu-\\nlosis are usually exempt. The theory that carcinoma is due to a\\nspecific parasite and is, therefore, infectious and contagious, is gaining\\nground. No parasite has yet been demonstrated, since the protozoa-\\nlike bodies Avhich Darier and others described in cancer-cells have been\\ndemonstrated to be forms of cell-degeneration.\\nFig. 86.\\nEpithelioma (vertical section) a, d, cones of the rete projecting downward, between these\\nare seen atrophied papillse (b) ate, d, and other points are nests of epithelium; c, atrophied\\nstratum corneum. (After Kaposi.)\\nPathology. All epitheliomata have their origin in preexisting\\nepithelium. The old idea that they originated from connective tissue\\nj has been disproved. The essential feature of all forms of epithelioma\\nj| is proliferation of epithelium and its growth into the deeper tissues,\\nwhere it is not normally found and where its presence causes secondary\\ni inflammatory changes. Two pathological types of epithelioma are of\\nj interest to the dermatologist, the lobulated and the tubular.\\nIn the Lobulated form the interpapillary processes of the rete send\\ndown prolongations which subdivide and branch in all directions, the\\nbranches intercommunicating and giving off buds and processes which", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0759.jp2"}, "760": {"fulltext": "704 NEW-GROWTHS.\\nmay form new centres of growth. The origin of the growth may be\\ntraced to the interpapillary processes or to the epithelium of the seba-\\nceous glands, coil-glands, or hair-follicles; but more frequently the\\nsource cannot be determined absolutely, since the band connecting the\\ngrowth with its starting-point may have been destroyed by ulceration.\\nOn the other hand, the glands and follicles may be involved second-\\narily. Attempts have been made to classify epitheliomata according to\\nthe structure from which each originates, but there seems to be no good\\nground either clinical or pathological for such distinction. The branch-\\ning processes form variously shaped lobules, and the cells composing\\nthem assume, as the result of pressure, many shapes. Usually, how-\\never, the outer layer of a lobule is a row of cylindrical cells within\\nwhich are cuboidal prickle-cells, which toward the centre are under-\\ngoing cornification, the centre itself being composed of horny stratified\\ncells. Thus, the structure of a lobule from without inward corresponds\\nclosely with that of the normal epidermis from within outward. Some-\\ntimes the prickle-cells within the lobules show no tendency to cornifica-\\ntion. In places the lobules are compressed into globular masses having\\nconcentric layers like an onion. These bodies are the epithelial nests,\\nglobes, or pearls. The centre of such nests not infrequently shows\\ncolloid, fatty, or granular changes. In rare instances calcification of\\nthe lobule occurs.\\nThe connective tissue of the part into which the growth has pene-\\ntrated surrounds and supports the lobules, and may remain almost nor-\\nmal, or be thickened and infiltrated with round cells, or its fibres may\\nbe mixed with epithelial cells it contains blood-vessels, none of which\\npenetrates the lobules. In some cases the epithelial growth proves\\ngreatly irritating to the surrounding tissues, exciting in them marked\\ninflammatory processes. Fordyce believes the inflammation may be\\ndue in part to a pus-infection, and in one case, by using Gram s method,\\nhe demonstrated staphylococci in the inflamed tissue.\\nIn the Tubular variety of epithelioma the epithelial elements form\\nfreely anastomosing, cylindrical processes which extend vertically,\\nhorizontally, and at various angles through the cutis and often into the\\nsubcutaneous tissue. The cells are smaller than in the lobular variety\\nand do not, as a rule, undergo cornification or form nests. The\\nouter row of cells may be cylindrical and stain deeply, and as the tubu-\\nlar processes may assume shapes highly suggestive of gland -formation,\\nthis variety of epithelioma is supposed by some observers always to\\noriginate in the epithelium of a coil- or sebaceous gland. Largely\\nowing to the ease and rapidity with which the starting-point or con-\\nnecting-band may be destroyed by ulceration, it is often impossible to\\ndemonstrate the origin of the processes, but the investigations of\\nDarier, Pollitzer, Fordyce, and others have led to the belief that the\\ngrowth originates rarely in the sebaceous glands, but frequently in the\\nrete or in the epithelium of the coil-glands and hair-follicles.\\nTubular epitheliomata are, as a rule, less malignant and less rapid\\nin their course than are those of the lobular type. Transitional forms\\nare seen, however, which tend to show that the shape and mode of de-\\nvelopment of the processes depend as much upon the accident of loca-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0760.jp2"}, "761": {"fulltext": "CARCINOMA. 705\\ntion and surrounding tissue as upon the character of the epithelium\\nfrom which they originate. Rodent ulcer which some authors de-\\nscribe under a separate head is pathologically a tubular epithelioma.\\nDiagnosis. Epithelioma is to be distinguished from lupus vulgaris\\napproximately by the age of the patient, the latter disease rarely\\nappearing after the thirty-fifth year where there is no scar or a history\\nof its earlier existence. Lupus is, at an earlier period of its career,\\nmore diffuse than epithelioma its elementary forms are more dis-\\ntinctly groups of individual lesions than a homogeneous aggregation\\nits ulcers are more often bordered by outlying non-ulcerative papules\\nfurnish a more puriform discharge and, most distinctive of all, are\\nnever walled about by the firm, densely indurated, often everted lip\\nof the epitheliomatous ulcer, opening out often to a sound peripheral\\nintegument. The peculiar and often characteristic odor of the cancer-\\ndischarge is absent in lupus.\\nFrom syphilis, epithelioma is to be distinguished first, by the age\\nof the patient, syphilis being decidedly a disease of early and middle\\nlife second, by the far greater relative rapidity of the syphilitic pro-\\ncess, exception always being made of tertiary gummatous ulcers upon\\nthe lower extremities persisting for years when there are both lack of\\ninternal treatment and of local support third, by the history of the\\ndisease in each particular case and, fourth, by the characteristic\\nsyphilitic features always present in infected individuals, including\\nmultiplicity of lesions, typical cicatrices, contour of ulcers (that of\\nepithelioma is less often either reniform, horseshoe-shaped, or cres-\\ncentic), character of discharge, and general absence of pain. A very\\nimportant point to note is a marked tendency to reparative cicatriza-\\ntion in old syphilitic ulcers, partly due to exhaustion of the infec-\\ntive poison, partly to the influence of an insufficient but yet modifying\\ntreatment. This tendency is exceedingly rare in epithelioma, which is\\noften, while syphilis is rarely, a malignant disease.\\nEpithelioma of the genitals is not to be confounded with chancre,\\ngumma, or syphilitic tubercles of that region. The peculiarities of the\\nconsequent adenopathy in each case the lancinating pains of cancer\\nits much more prolonged duration and its occurrence in an aged subject,\\nwith the general history of the case, will usually point to the truth.\\nSarcoma is characterized by its far more rapid evolution, the tumors\\noften attaining their maximum of development in the course of a few\\nmonths by its occurrence by predilection in earlier life by its inapti-\\ntude for ulcerative degeneration and by its marked tendency to multi-\\nplication in contiguous or in distant portions of the body.\\nThe warts, nsevi, excoriations, and seborrheic lesions, from which\\nepitheliomata often take their origin, cannot be determined as having\\nsuch a tendency before the cancer has attained some development.\\nEvery such persistent and long-irritated lesion on the person of a male\\nsubject of advanced years should be regarded with suspicion.\\nTreatment. No internal treatment for cancer of the skin is known\\nto exert the slightest influence upon the growth.\\nThe topical treatment of epithelioma is by excision, erasion, or\\ndestruction of the growth. The first is performed by surgical ablation\\n45", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0761.jp2"}, "762": {"fulltext": "706 NEW-GROWTHS.\\nwith a bistoury, after which one of the plastic operations may be\\nrequired for either complete covering of the wound or relief of the\\nresulting deformity. The second is applicable only to the less for-\\nmidable growths, and is performed with the aid of a dermal curette.\\nThe third is effected by the use of caustics. The removal of smaller\\nepitheliomata, of the face especially, with the aid of a dermal curette,\\nshould generally be followed by the thorough application of the milder\\ncaustics, such as silver nitrate in crayon.\\nDestruction of smaller cancerous tumors of the skin may be per-\\nformed with the aid of caustics, of which potassium hydroxide, in stick\\nor in solution, is perhaps the most valuable, as its destructive action\\nmay be controlled by the topical employment of acids, and it is fol-\\nlowed by less pain than are some of the other chemical agents. Other\\ncaustic substances employed for a similar purpose are zinc chloride,\\nVienna paste, silver nitrate, arsenical paste, resorcin, fuchsin, and pyro-\\ngallol. The latter is highly recommended by Kaposi, not only because\\nits application is unproductive of pain, but also because it does not\\nattack sound tissue. It is used in an ointment of 10 per cent, strength.\\nAll such pastes and ointments should be spread upon cloths, and be\\napplied for from three to six days. Opiates may be required, in the\\ncase of several of these agents, to relieve the consequent pain.\\nAmong the formulas used for caustic purposes are the following\\nR Creasoti, ^ss; 15\\nAcid, arsenios., gr. iv\\nOpii pulv., gr. ij\\n26\\n13 M.\\nSig. For employment upon circumscribed surfaces. [Kaposi.]\\nMarsden s paste, also employed as a caustic, is made by combining\\nequal parts of gum arabic and arsenious acid with water sufficient to\\nmake a softish paste. By Robinson 1 it is preferred to others, and is\\napplied on rubber plaster.\\nCosmos paste, as modified by Hebra, is prepared as follows\\nB Acid, arsenios., gr. yj\\nHydrarg. sulphuret. rub., 3ss 2\\nUnguent, aq. ros., ^ss 15\\nSig. Arsenical paste for external use, with caution.\\n40\\nM.\\nThe method of its application is as follows the paste is spread over\\na thin sheet of lint to the thickness of a knife-blade, and the lint is then\\ncut to a shape and size corresponding with those of the tumor or ulcer\\nto be destroyed. After its close apposition with the surface to be\\nattacked the lint and paste should be covered with gutta-percha or\\nother impermeable tissue, and a compress laid over the whole. In\\ntwenty-four hours the dressing is removed, the parts washed clean, and\\nthe same application renewed. By the third or the fourth day the\\ndestruction of the cancerous growth is usually complete, and the parts\\nare ready for an emollient poultice, which should be applied for the\\n1 Treatment of Cutaneous Malignant Epitheliomata, Internat. Jour, of Surgery,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0762.jp2"}, "763": {"fulltext": "CARCINOMA. 707\\nthree or four days during which separation of the slough occurs.\\nThe simple ulcer left is to be treated on general principles. The\\ndanger of arsenical poisoning is here reduced to a minimum the treat-\\nment being very effectual where patients consent to the delay as to time\\nand to the severe pain which it occasions.\\nThe thermo- and galvano-cautery may also be often advantageously\\nused for destruction of the growths. The advantages of the thermo-\\ncautery are the transitory character of the induced pain the coal-like\\ndressing left upon the attacked surface and the elegance of the result-\\ning scar. Both measures find their highest value when employed after\\nincision or erasion.\\nWhatever method be employed, thoroughness is essential in attack-\\ning all portions of the new-growth and it is well to encroach some-\\nwhat upon the unaffected contiguous structure. The subsequent dress-\\nings should be made with simple or carbolated unguents, to which one\\nof the salts of morphine may be added in case of continuous pain.\\nThe eschar usually separates in the course of a few days, leaving a\\nsimple granulating wound which may soundly cicatrize, and the\\nepithelioma be thus radically relieved. In other cases the disease reap-\\npears in the ulcer or cicatrix, or, by recurrence of cancerous nodules, in\\nthe previously sound integument. Even after these recurrences\\nprompt destruction of the new-growth may finally be successful.\\nBut little confidence is placed upon any external treatment which\\ndoes not effect complete destruction of the neoplasm. Yet there are\\nthose who highly esteem some of the procedures which are less radical\\nin their aim, and which it is proper to mention here.\\nLeveque, 1 Vidal, 2 Bergeron, 3 Euthyboule, 4 and others claim large\\nsuccess in the treatment of epithelioma by potassium chlorate. Locally,\\nthe part is frequently touched with a saturated solution of the salt in\\nglycerin and warm water, after which a simple ointment-dressing is\\napplied. Vidal administers also the same drug internally in doses of\\n1J drachms (6.) in syrup and water before meals. It is possible that\\nany remedial effect obtained from such measures should be attributed\\nto the fomentations employed. Latterly, benzole and pyoktanin-blue\\nhave been reported as valuable topical applications to small-sized\\nepitheliomata.\\nInjections of solutions containing cupric sulphate, iodine, alcohol,\\nI acetic acid, silver nitrate, sodium chloride, and hydrochloric acid\\nI have been practised, it is claimed, with some success certainly at\\nI times with fatal results. This method is unquestionably inferior to\\nj others described above.\\nPrognosis. In general, the prognosis of cutaneous cancer is grave.\\nThe relative degree of gravity largely will be proportioned to the variety,\\nform, size, career, and complications of the growth in each case. The\\nvariety in which only pearls form in the skin is the most benign,\\nas the lesions are usually isolated, and may, when unirritated, undergo\\nspontaneous exfoliation. In other cases the disorder for from fifteen\\ni to twenty years seems to make no progress of any sort. The malignity\\n1 Glasgow Med. Jour., 1881. 2 Loc. cit.\\n3 Bull. Acad, de Med., Paris, 1873. These de Paris, 1877.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0763.jp2"}, "764": {"fulltext": "708 NEW-GROWTHS.\\nof a cancerous growth is usually proportioned to the quantity of epi-\\nthelium as compared with the connective tissue present the more\\nabundant the latter, the more favorable the prognosis. Naturally, also,\\nthe deeper and the more destructive the growth, the fewer are the\\nchances of ultimate recovery. Excessive pain and adenopathy are\\nunfavorable symptoms in any case. Koch x gives statistics of the\\nresults of operations, at the Erlangen Clinic, for the removal of\\nepitheliomata of the lower lip, in one hundred and thirty-one patients\\nexhibiting primary lesions. One hundred and fifteen of these were\\nfor the time cured four had speedy relapse; and three were, at\\nthe date of writing, suffering from recurrence of the disease.\\nPAGET S DISEASE.\\n(eczematoid epitheliomatosis of the nlpple, malignant\\nPapillary Dermatitis, Cutaneous Psorospermosis.)\\nThis disorder was first described in 1874, by Paget, 2 and has since\\nattracted the special attention of a number of English, French, and\\nAmerican observers, including Thin, Duhring, Malassez, Darier, Wick-\\nham, and others.\\nAt the onset the disease suggests an eczematous involvement of the\\nareola of the nipple, usually of one breast only, in women between\\nforty and sixty years of age. According to Besnier and Doyon, the\\nearliest change is without question a choking of the lacunas of the\\nnipple with corneous cells, and this either without the operation of any\\nknown cause or as a consequence of a localized eczema, a gal actor rhcea,\\nor other irritant. When early recognized the surface is intensely red\\nand granulating, exuding copiously a clear viscid secretion, and pro-\\nducing subjective sensations of heat and burning, with intense or with\\nmoderate itching. The definition is distinct, the tissue is indurated,\\nand the tenderness and pain are usually well marked and distressing.\\nA conspicuous feature of the disease is the circumscribed infiltration\\nof the skin and subcutaneous tissue, which on palpation suggests a\\nlarge-sized coin or button let into the substance of the areola and sur-\\nrounding parts.\\nWhen the disease has progressed to this point a cancerous infiltra-\\ntion of the breast is usually recognized, at least after its removal,\\nthough even with great care it may not always be possible to distin-\\nguish it before ablation of the gland. Crocker, however, holds to the\\nbelief that the disease of the nipple may endure for years without\\nresulting retraction and development of scirrhns of the breast. The\\nFrench recognize three stages, that in which the disease is limited, re-\\nspectively, to the nipple, the areola, and the breast, the latter, of course,\\nsucceeding but not replacing the earlier. In all cases there is no at-\\ntempt at repair and when abandoned to its course the ultimate result,\\nafter five to eight or more years, is a profound ulceration with destruc-\\ntive effects most noticeable in the region of primary invasion, the entire\\n1 Centralbl. f. Chir., 1881, No. 40.\\n2 St. Bartholomew s Hospital Reports, 1874, p. 87. See also the paragraphs in this\\ntreatise devoted to this subject under the title of Eczema.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0764.jp2"}, "765": {"fulltext": "CARCINOMA. 709\\nbreast having become cancerous. Cases of Paget s disease affecting\\nother parts of the body have been reported. In such cases the process\\nis identical with that of superficial discoid epithelioma described on a\\npreceding page.\\nPathology. Darier and Wickham, in a series of papers published\\nduring 1889 and 1890, attempted to show that this disorder was to be\\nincluded in a list of morbid processes which they described under the\\ntitle of Psorospermosis/ a group of affections of parasitic origin. But\\nlater investigations have shown that the so-called psorosperms are\\nin fact simple alterations of epithelium that may be recognized in other\\naffections as well as in Paget s disease of the nipple.\\nIn the earlier stages the histopathology is that of a chronic derma-\\ntitis. Epithelial proliferation and thickening progress, however, and\\nin the later stages the structure is that of a discoid epithelioma.\\nDiagnosis. There are few cases in which the raw and exuding sur-\\nface may be mistaken for an eczema. The latter, when occurring upon\\nthe surface of the breast and of the nipple, is far more common during\\nearlier periods of womanhood than after the fortieth year, and is seen\\nchiefly among those giving the breast to sucklings. Eczema is never,\\nunder any circumstances, capable of producing in this region the\\ncharacteristic button- or large-coin -sized induration beneath the deep-\\nred, raw, granulating surface of the cancerous infiltration.\\nThe Treatment of Paget s disease should always have in view the\\npossibility of cancerous involvement of the gland that usually occurs,\\nthough a number of cases are on record in which relief by other than\\nradical measures was secured. Caustics should never be employed all\\nirritants are to be avoided. Soothing applications, as in corresponding\\nstages of eczema, the pastes, zinc and calamin lotions, diachylon and\\nother soothing salves, are indicated and often prove serviceable. The\\nemployment of parasiticides meets with little favor now that the psoro-\\nspermosis theory of the disease is abandoned. Mercurial lotions fol-\\nlowed by powders of aristol or hydronaphtol (1 100), and a weak\\nointment of pyrogallol or of iodoform are also extolled. Complete era-\\nsion of the morbid tissue may be successful, but ablation of the entire\\nbreast is demanded in most of the typically developed cases.\\nThe Prognosis is not always grave. Cases are reported as relieved\\nby local measures, which are always worth a judicious trial but inef-\\nfectual measures may permit involvement of the breast eventually call-\\ning for ablation of the entire gland.\\nCANCER OF THE CONNECTIVE TISSUE.\\nThis is rare as a primary cutaneous manifestation, but appears gen-\\nerally as secondary to a cancerous involvement of other organs, as of\\nthe female breast. It is termed also Scirrhous, Hard, Fibrous, or\\nLenticular Cancer. It occurs either upon the skin covering a\\nbreast which has previously been transformed into a cancerous mass,\\nor as a cutaneous relapsing lesion after extirpation of the latter. Its\\nsymptoms are pea- to bean-sized, densely firm, shining nodules, vary-\\ning in color or a more or less diffuse infiltration of the skin, of similar", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0765.jp2"}, "766": {"fulltext": "710\\nNEW-GROWTHS.\\ncharacteristic hardness, associated often with hyperemia of a purplish-\\nred shade.\\nCancer en Cuirasse. When the cancerous infiltration is widely dif-\\nfused and densely indurated, involving a large portion of the integu-\\nment of the thorax, the condition is termed by the French cancer en\\ncuirasse (Fig. 87), a title first given by Velpeau. The malady is\\nstriking in its peculiarities, and in the highest degree serious. The\\nintegument of a large portion of the chest, usually more in front, but\\nalso behind, and even a part of the anterior abdominal wall, is con-\\nverted into a dense, leathery envelope, often so compressing the chest-\\nwall as seriously to impede respiration. The edges of the infiltration\\nare poorly defined save at the lines where tongue-like prolongations\\n(languettes) of dull-reddish hue indicate the advance of the scirrhous\\nFig. 87.\\nCancer en cuirasse, chiefly involving the right side of the chest.\\nprocess over the skin. The lymphatic circulation is obstructed, the\\nglands enlarge, and, what is almost pathognomonic of the disorder, the\\nupper extremity, especially the forearm, usually of the side chiefly in-\\nvolved, becomes enormously swollen and cedematous. The nipple may\\nor may not be retracted the breasts, one or both, are firmly bound down\\nto the chest-wall by the cuirass of dense skin, hard, smooth or rough,\\nshining, and either reddened in dull hues or of normal tint, here and\\nthere traversed by vessels, and breaking down into ulcerations, usually\\nfirst about the nipple, but also elsewhere. The process is one of the more\\nrapid of the scirrhous metamorphoses of the body, as a fatal result is\\nusually reached in a few months, though years have in some cases\\nelapsed before death resulted. One of our patients, an unmarried woman\\nwith breasts in the virgin state, perished in the course of a few months,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0766.jp2"}, "767": {"fulltext": "CARCINOMA. 711\\nthe cancer having originated in the skin. Milium-like masses, as large\\nas grains of wheat, undergoing fatty degeneration in the centre and\\nreadily expressed like comedones, are occasionally present.\\nWe have had several cases of this disorder under observation, two\\nbeing made the subject of a paper, 1 with illustrations of the clinical\\nappearances and morbid condition of the tissue. One of the patients\\nwas a man. An instance of widely disseminated lenticular cancer of\\nthe skin (illustrated by portrait), described by Morrow, 2 occurred in a\\nhealthy-looking woman as a secondary phenomenon after removal of\\nprimary cancer of the breast. Whether the nodules be, as to cutaneous\\nmanifestations, primary or secondary, the symptoms are generally the\\nsame. The lesions are closely set, shining, firm, reddish papules, infil-\\ntrations of a dull-reddish hue, miliary and pigmented deposits, tubercles\\nvarying in size, subcutaneous nodules, and secondary results in the way\\nof formidable ulcers, crusts, and fungous growths.\\nThe prognosis is serious.\\nPathologically, the several forms of carcinoma above described are\\nepitheliomatous, since the fibrous stroma always contains, in the centre\\nof narrow alveoli, a relatively small number of epithelial bodies. The\\ngrowth is usually slow of development, but in the end is accompanied,\\nas are other cancerous tumors, by adenopathy, pain, and ulcerative\\nchanges, which induce an inevitable cachexia. As with the other varie-\\nties, relapse after extirpation is common, and the prognosis is propor-\\ntionately grave.\\nTuberose Carcinoma is a rare manifestation of the disease, occur-\\nring in the form of multiple, firm, peanut- or egg-sized, roundish nodules,\\nwhich break down by ulcerative processes into deep losses of tissue. It\\nis frequently accompanied or followed by cancerous involvement of\\nother organs. It occurs chiefly upon the face, hands, arms, and chest,\\nthough also upon other portions of the skin of persons of advanced\\nyears, either as a primary or a secondary cancerous manifestation.\\nGurnard 3 reports a cancer of this variety, remarkable for the smallness\\nof the existing nodules, which varied in size from that of a hempseed\\nto that of a pea. They covered the entire thorax, the back, and the\\nright arm and had here and there broken down into ulcers. One of\\nthe latter was as large as the hand.\\nMelanotic or Pigmented Carcinoma is that form in which both\\nthe epithelium and connective-tissue framework of the cancer are richly\\nsupplied with blood-vessels, and, probably, as a consequence of trans-\\nudation from the latter, with an abundance of pigment-granules in\\ngroups and clusters. These growths usually begin as hempseed- to\\npea-sized, single or numerous, soft or dense nodules, which may develop\\nin time into tumors of considerable size, and which are stained in\\nvarious shades from a grayish-brown or a slate color to a dead black,\\n1 Amer. Jour. Med. Sci., March, 1882.\\n2 Jour. Cutan. and Yen. Dis. June, 1884, p. 1.\\n3 Union Med., February 5, 1881.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0767.jp2"}, "768": {"fulltext": "712 NEW-GROWTHS.\\nthe pigment being occasionally displayed irregularly in streaks or bands\\nover the surface of the growth. They occur over any portion of the\\nsurface, often upon the extremities and the genitals, starting frequently\\nfrom benign pigmentary lesions, such as nsevi and moles. Anatomically,\\nthe pigment is found to be deposited both between the cells and in the\\nprotoplasm of the cells themselves.\\nIn a few instances the disease is limited to single melanotic growths\\nof this character. The cancer is apt to develop into the papillary form,\\nfurnishing thus fungoid vegetations which have a noteworthy tendency\\nto degenerate into ulcers. Often such verrucous masses are seen sur-\\nrounded by grayish or blackish papules, or by a diffuse cancerous\\ninfiltration of the integument they also exhibit irregular pigmentation\\nof the surface. The disease often appears in the viscera, in the form of\\ndisseminated cancerous nodules, each highly vascular, and exhibiting\\nin varying quantity granules of pigment. The growth has usually a\\nrelatively rapid course and malignant career. Relapses are frequent,\\nthe amount of pigment usually increasing with each relapse.\\nRecent investigations (Cf. melanotic sarcoma) indicate that the\\nmajority if not all of the malignant pigmented growths which spring\\nfrom moles and nsevi, and which in the past have been considered to be\\nsarcomatous, are in fact instances of pigmented carcinoma.\\nEndothelioma of the skin has been reported in a few cases. In\\nthe three cases reported by Spiegler, 1 and in the three cases collected\\nby him from literature, numerous tumors, varying in size from a pin to\\nan orange, were located on the scalp. In some of the cases pea-sized\\ntumors were seen also upon the face, neck, back, and chest. The course\\nof the growths was comparatively benign. In Fordyce s case 2 a pea-\\nsized tumor formed at the border of a lupous scar on the forearm. The\\nhistological structure of these growths is that of a small-cell epithe-\\nlioma, except that the cells are grouped about dilated blood-spaces, and\\ntheir origin from the endothelium of the blood-vessels can be demon-\\nstrated.\\n1 Arch. f. Derm. u. Syph., 1899, Bd. 1., S. 163.\\n2 Amer. Jour. Med. Sci., August, 1900.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0768.jp2"}, "769": {"fulltext": "CLASS VII.\\nSENSORY DERMATO-NEUROSES\\nA large number of skin-diseases are more or less dependent on\\nneuropathic conditions, and could probably be classed as sensory, motor,\\nvasomotor, or trophic dermato-neuroses. Morris 1 and Leloir, 2 and a\\nfew others attempt such a classification but in the large majority of\\nthese dermatoses the neuropathic element is not so well understood as\\nare some other features according to which most authors classify these\\naffections. In this chapter are considered only the sensory dermato-\\nneuroses, that is, those disorders in which there is disturbance of sensation\\nwithout other recognized changes in the skin.\\nThese purely sensory dermato-neuroses are commonly described under\\nfour headings hyperesthesia, anaesthesia, dermatalgia, and paresthesia\\n(including pruritus).\\nBronson 3 calls attention to the fact that cutaneous sensation is complex\\nand made up of a number of elements which he describes as common\\nsensation (or mere subjective feeling), including the sense of pain the\\nsense of temperature the sense of touch, including the pressure-sense\\nand the sense of contact and a special sense of a higher order, which\\nis exercised in feeling for or of a definite object, and which he terms\\nthe sense of Pselaphegia. This sense includes and is dependent\\nupon the preceding elements, and is ranked with the special senses of\\nseeing, hearing, and smelling. Any one of the above-named senses\\nmay be exaggerated, defective, or perverted, while the others remain\\nnormal, or all may be involved simultaneously.\\nHYPERESTHESIA.\\n(Gr. vwep, above ala Tjcic, sensibility.\\nHyperesthesia is an exaggerated sensitiveness to external impressions.\\nIn this condition the abnormal sensations are aroused by contact with\\nan external body, and do not arise spontaneously, as in dermatalgia\\nand in paresthesia. The distinction between these conditions may\\noften be difficult to recognize, since two or more of them may coexist\\nor the hyperesthesia may be so excessive that the slightest unrecognized\\ncurrent of air is sufficient to produce a marked sensation. Finally, in\\nsome forms of hyperesthesia abnormal sensations may result from\\nirritation due to mental or emotional causes. It is evident that this\\n1 Diseases of the Skin. London, 1898.\\n2 Twentieth Century Practice, vol. v.\\n5 Morrow s System, vol. iii., p. 725 and N. Y. Med. Kecord, Oct. 18, 1890.\\n713", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0769.jp2"}, "770": {"fulltext": "714 SENSORY DERMATO-NEUROSm.\\nlast type of hyperesthesia can be differentiated with difficulty, if at all,\\nfrom paresthesia.\\nCutaneous sensation may be exaggerated as a whole, but the senses\\nmost commonly involved are those of contact and common sensation,\\nincluding the sense of pain. In mild cases there is merely an unusual\\nsensitiveness to contact with foreign bodies, such as the clothing, but\\nin severer forms the light touch of a feather or slight currents of air\\nover the skin may be almost intolerable. In the condition known as\\nHypekalgesia the sense of pain is greatly exaggerated, while the\\nsense of touch is diminished. As a result, the slightest contact with\\nan object causes great pain, but the nature of the object causing the\\npain is not recognized so distinctly as in health. In some instances it\\nis the temperature-sense alone that is involved, as a result of which\\nthe surface is exceedingly sensitive to cold, or, more rarely, to heat.\\nHyperesthesia, involving one or all of the senses mentioned above,\\nmay be mild or severe, and may be limited to very small areas, as in\\ntabes or leprosy to certain regions or to one side of the body, as in\\nhysteria or it may include the entire surface, as in disease of the\\ncord, in neurasthenia, and in other disorders of the nervous system.\\nThe causes of hyperesthesia are found in various functional and\\norganic disorders, central or peripheral, of the nervous system.\\nIn connection with the hyperesthesie may be mentioned a condition\\nwhich cannot be considered pathological in itself, though it is often\\ndependent upon pathological states. Reference is made to the unusual\\ndevelopment and acuity of the touch-perception, or sense of pselaphegia,\\nas a result of which contact with a foreign body gives the perceptive\\ncentres a more delicate and complete impression of that body than\\nwould normally be obtained. This unusual sensitiveness of the touch-\\nperception is seen frequently in the blind, and may even be cultivated.\\nIt occurs also in the hypnotic state in intoxication from alcohol, or\\nfrom cannabis indica in hysteria and some other mental and nervous\\ndisorders and in conjunction with the other forms of hyperesthesia.\\nTreatment is that of the nervous disorder upon which the hyper-\\nesthesia depends.\\nDERMATALGIA.\\n(Neuralgia Cutis.)\\nIn this morbid state the integument becomes the seat of painful\\nsensations, which may or may not be associated with a hyperesthetic\\ncondition. This disorder is much more frequently partial than general,\\nbeing in the larger number of cases a local expression of some disease\\nof the nervous centres or tracts. It is observed usually in middle life,\\nand in women more than in men. Its symptoms vary in severity from\\na slight burning to a state of torture that defies description. In charac-\\nter the pain is differently described as comparable to that produced by\\nfriction, incision, penetration, contusion, or burning of the integument,\\nas also to the passage over the part of streams of very hot or of cold\\nwater, or the electric current. With this there is commonly associated\\nan undue sensitiveness to contact with foreign bodies. The skin pre-\\nsents no objective signs of disease. The disordered sensations may be", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0770.jp2"}, "771": {"fulltext": "HYPERESTHESIA. 715\\nlimited to the scalp, the region of the spine, or the palmar and plantar\\nsurfaces. In the latter situation it is often significant of some ob-\\nscurely developed systemic disease, such as syphilis, rheumatism, or\\nlocomotor ataxia. In a middle-aged woman a persistent dermatalgia\\nof the interscapular region was associated with confirmed gastric dys-\\npepsia. In other cases the disorder is dependent upon disturbance of\\nthe uterine function. It is occasionally observed as one of the rare\\nsignals of the occurrence of the menopause.\\nIt is to be noted that the severe dermatalgia associated with dis-\\norders of the uterus in women is occasionally succeeded by a cutaneous\\nlesion. In a middle-aged dysmenorrhceic patient under observation a\\npea-sized hemorrhagic bulla appeared over the forehead after several\\nweeks of frontal suffering. Buck 1 also reports dermatalgia of the\\nbrows and wrists in a young woman who had frequently miscarried,\\nfollowed by recurrent formation of a vesicle which accomplished its\\ncareer of rupture, crusting, and erosion in a stadium of from five to\\nseven days.\\nDiagnosis. The disease is to be differentiated from hyperesthesia\\nof the skin, with which it frequently is associated and from which it\\noften cannot be distinguished with certainty, as it is not possible always\\nto exclude slight sources of external irritation and further the diagnosis\\nmust be based largely upon the observations and statements of the\\npatient. Painful affections of deeper parts, muscular, nervous, apo-\\nneurotic, and visceral, must also be excluded. Severe pain limited\\nstrictly to the skin of the lumbar region, with hyperesthesia, may pre-\\ncede the occurrence of perinephritic abscess.\\nThe Treatment is to be directed to the disorder of which, in the\\ngreat majority of cases, the dermatalgia is merely a local symptom.\\nQuinine, the salicylates, iron, arsenic, and zinc phosphide are often\\nindicated. Temporary relief, however, may be afforded by the local\\napplication of a rubber bag filled with very hot or very cold water\\nsometimes by an alternation of the two, each for a few moments at a\\ntime. Sponging the part with very hot water is also useful, continued\\nfor longer periods, and followed by swathing in cotton-batting covered\\nwith Lister protective. In some cases the anodynes also may be used\\n1 topically with advantage especially cocaine, opium, aconite, belladonna,\\nj or stramonium in oily combinations. In some cases relief is had by\\npainting the parts with Squibb s mercuric oleate and morphine. The\\nskin should generally, in the interval of application, be protected by a\\ndusting-powder and the clothing worn next the skin should be of an\\nj unirritating character.\\nErythromelalgia is a term given by Mitchell to a condition in\\nwhich the fingers or toes are the seat of burning or aching pain fol-\\nlowed by areas of redness. Other observers report cases occurring in\\nconnection with multiple sclerosis, tabes, myelitis, meningitis, traumatic\\nneuroses, and other nervous disorders. Mitchell and Spiller 2 found a\\nperipheral neuritis in one case.\\n1 Phila. Med. and Surg. Eeporter, Jan. 18, 1881, p. 677.\\n2 Ainer. Jour. Med. Sci., January, 1899-", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0771.jp2"}, "772": {"fulltext": "716 SENSORY DERMATO-NEUROSES.\\nANESTHESIA.\\n(Gr. a, privative aiodqcig, sensibility.\\nIn cutaneous anaesthesia one or all of the elements of cutaneous\\nsensation may partially or wholly be lost.\\nAnalgesia, or insensibility to pain, may exist while the tactile\\nsense remains unimpaired, or the reverse may be true. Thermo-\\nanesthesia may alone be manifested, and sometimes is limited to heat\\nalone or to cold alone. A curious illustration of this occurred in the\\nperson of a leper, whose hands were in all parts sensitive to the prick\\nof a lancet and to contact with heated substances yet who exposed\\nthem for hours without protection to an atmospheric temperature of\\nten degrees below zero without even slight discomfort.\\nThe tactile sense is involved more frequently than in hyperes-\\nthesia, and usually is absent in all cases of anaesthesia. It, however,\\nmay be retained unimpaired with loss of one or all of the other elements\\nof cutaneous sensation, as sometimes occurs in anaesthetic leprosy or\\nsyringomyelia. The failure to appreciate some one or more properties\\n(such as form, size, weight, density, and smoothness or roughness) of\\nforeign bodies may be psychical in origin.\\nIllustrations of cutaneous anaesthesia are furnished in the anaesthetic\\npatches of leprosy, which may or may not exhibit textural skin-\\nchanges centric and eccentric paralyses syphilitic, hysterical, and\\nataxic disorders partial or complete anaesthesia of artificial production\\nthe several toxic narcoses traumatism of nerves by pressure, wound,\\nor contusion the local anaesthesia induced by cold, frigorific mixtures,\\nand substances capable of benumbing the sensitiveness of the skin\\ncoma, of whatever origin; and a number of idiopathic cutaneous dis-\\norders, including several of the atrophies, scleroderma, and morphoea.\\nPARESTHESIA.\\nIn paraesthesia there is a perversion of sensibility, as a result of\\nwhich a given stimulus produces a sensation different from that which\\nit would produce in health. One or all of the elements of cutaneous\\nsensation may be involved. Contact with a warm object may give a\\nsensation of cold or of pain. Derangement of the tactile sense may\\ngive erroneous impressions of the size, weight, roughness or smooth-\\nness, firmness, or other qualities of an object. Many other perversions\\nof sensation occur, all dependent upon central or local disorder of the\\nnervous system. Sensations may be delayed for some seconds after\\ncontact, or may persist after the latter has ceased.\\nThere may be an error of location, as when the patient refers the\\npoint of contact to the wrong place or to the wrong side. The paraes-\\nthesia may be largely or wholly subjective, and frequently gives rise to\\nthe sensation of heat or cold, formication, tickling, dripping or pouring\\nof liquids of various temperatures, etc.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0772.jp2"}, "773": {"fulltext": "PARESTHESIA. 717\\nPRURITUS.\\n(Lat. prurire, to itch.)\\nSymptoms. Pruritus is a common form of paresthesia which is to\\nbe distinguished not only from prurigo, a rare disease of the skin\\nalready described, but also from the symptomatic sensation of itching\\nwhich is occasioned by a number of cutaneous disorders, such as\\neczema, scabies, and the dermatoses produced by pediculi.\\nIlebra was first to recognize the independent character of the dis-\\nease here considered but it is to be regretted that he did not give to\\nit a name distinct from that which is also applied to a symptom com-\\nmon to several maladies of the skin.\\nPruritus is characterized by a sensation of itching not produced\\noriginally by cutaneous lesions. It may be general or be partial. In\\neither form it begins usually by a tickling, pricking, crawling, or itch-\\ning sensation in the skin, which solicits the sufferer to rub, press, scratch,\\nor otherwise irritate the affected integument. It usually occurs by\\naccesses in the day or the night, much more often the latter, occasion-\\nally both and these accesses most frequently occur under the immedi-\\nate stimulus of some internal or external cause. Thus, moral emotions,\\na draught of cool air, the warmth perceived when in bed, the pressure\\nof clothing, and often the substances applied externally with a view to\\nthe relief of the pruritus, suffice to determine a crisis. However firmly\\nthe sufferer may determine to avoid injury to the person, in well-marked\\ncases the impulse to scratch becomes well-nigh irresistible and in the\\nhighest degree tormenting. From the milder, the patient will thus fre-\\nquently be teased to inflict the severer injuries upon the skin. Brushes,\\ncombs, coarse cloths, and even metal instruments are employed in severe\\ncases for the purpose of assuaging temporarily the local distress.\\nThe objective cutaneous symptoms which may be presented are all\\nsecondary, and invariably result from self-inflicted injury. In some\\ncases they do not appear, the statements of the patient being the sole\\nbasis for the recognition of the disease. This absence may be the con-\\nsequence of unwonted self-control, or of the mildness of the malady,\\nor of the transitory character of the lesions produced. Thus, the skin\\nmay be reddened during a nocturnal paroxysm under the manipulation\\nof the sufferer, and the transitory hyperemia disappear in the daytime\\nwhen the skin is submitted for inspection. Not rarely, however, the\\nintegument resents the treatment to which it is subjected, by displaying\\nwheals, hypersemic blotches, reddened papules, excoriations, charac-\\nteristic scratch-lines, and the minute blood-crusts which indicate\\nthat the papillary layer of the derma has been reached and slightly\\ntorn. Dermatitis in varying degrees, and even eczema, may result, and\\nstill further add to the subjective distress. Skins that for years have\\nbeen the seat of a persistent pruritus leading to traumatisms of the epi-\\ndermis frequently show smaller or larger areas of deep pigmentation.\\nCases are reported by Leloir and others in which a pruritus was fol-\\nlowed by a dermatitis not due to traumatism, and persisting for con-\\nsiderable periods of time or until relieved by treatment directed to the", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0773.jp2"}, "774": {"fulltext": "718 SENSORY DERMATO-NEUROSES.\\ncondition of the nervous system. These cases are called by the French\\nNeurodermia, or Neurodermatitis, and are probably due to vaso-\\nmotor or other neurotic disorders.\\nSenile Pruritus is a term often loosely applied to any form of the\\ndisease occurring in the aged, in whom it is very common. In the\\nlarge majority of cases, however, careful search will disclose causes\\nidentical with those found earlier in life. Among the most common of\\nthese causes are defective digestion, metabolism, assimilation, and\\nelimination, with the resulting hepatic, nephritic, circulatory, arthritic,\\nand neurotic disorders so frequently seen in those advanced in years.\\nSenile pruritus proper is that form of the disease due to atrophic and\\ndegenerative changes in the skin and other tissues of the aged, and is\\npractically remediless.\\nPruritus Hiemalis is considered at the close of this chapter.\\nThe localized forms of pruritus, albeit the abnormal sensation is in\\nthem limited to certain regions of the body, may occasion fully as much\\ndistress as those in which a larger part of the integument is affected.\\nThey are of more frequent occurrence than the generalized forms. Pru-\\nritus of the anus, of the scrotum, of the vulva, of the vagina, of the\\nscalp, of the nose, of the mouth, of the axillae, are all localized forms\\nof the disease, two or more of which may coexist or may develop in\\nsuccession.\\nPruritus Narium is a frequent symptom of irritation of the Schnei-\\nderian membrane. It is thus a common precursory or an attendant\\nphenomenon of rose- or hay-asthma and in some individuals announces\\nthe systemic effect after ingestion of opium and its alkaloids. It occurs\\nalso in children as a result of pediculosis of the scalp. It may result,\\nfurther, from the irritation awakened by intestinal parasites.\\nPruritus Genitalium is often an exceedingly severe and dis-\\ntressing affection. As the parts in question are apt to be rubbed and\\nscratched in efforts to secure relief of the itching sensation, there may\\nbe produced orgastic effects and pollutions, the moral results of which\\nare degrading. The scrotum, the labia majora and minora, the penis,\\nthe clitoris, and the adjacent cutaneous and mucous surfaces may be the\\nseat of the pruritus. Search should always be made in these cases for\\nascarides of the rectum or of the vagina, for saccharine and albuminuric\\nurine, and uterine or ovarian affections. A perverted sexual hygiene\\nmay lie at the root of these disorders. In severe cases the violence\\nwith which the parts are attacked suggests frenzy on the part of the\\npatient, who at times is never content until the scrotum or other parts\\nare bathed in blood. The thickening, erosions, and excoriations of the\\nregions attacked are conspicuous features of the disease.\\nPruritus Ani. This is a disorder of adults of both sexes, and it\\nmay coexist with pruritus of the genital region. There is usually noc-\\nturnal exacerbation. The anus may become infundibuliform from in-\\nduration its mucous surface excoriated its cutaneous borders seamed,\\npuckered, eroded, and fissured. It is often complicated with, because\\nthe origin of, an eczema the lesions of which reach upward over the\\ncoccyx or forward to the genital region over the perineum. Hemor-\\nrhoids, fistula in ano, ascarides, chronic prostatitis, rectal impaction", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0774.jp2"}, "775": {"fulltext": "PARESTHESIA. 719\\nand fissures, proctitis, unnatural practices, gout, alcoholism, albumin-\\nuria, or diabetes may each be responsible for its occurrence.\\nPruritus Palmje et Plants is a rare form of this disorder, in\\nwhich the itching is limited to the palms and soles. It may complicate\\ngout, malaria, hyperidrosis, and asthma.\\nPruritus Linguae is reported in a few instances. It usually is\\ndue to a central neurosis, to glycosuria, or other systemic disease.\\nIn all severe forms of pruritus cutaneus the general health per-\\nceptibly fails. Whether the prolonged insomnia arises from nocturnal\\nexacerbations to which there are but few exceptions or from the per-\\nversion of nutrition incident to the continuous teasing of the nervous\\nsystem or yet from the hypochondriacal state into which some patients\\nare plunged by their sufferings, such an issue is often to be expected.\\nIt is, in fact, a complication that may merit, as much as the disease\\nitself, the attention of the physician.\\nEtiology. The causes of pruritus are numerous, and the necessity\\nfor the discovery of the particular cause in each patient often makes the\\nlargest demands upon the practitioner. The disease may occur at all\\nperiods of life and in both sexes, but its aggravated forms are peculiar\\nto middle life and advanced years. It is always secondary to some\\ndisturbance of the nervous system. It is frequently the symptom of one\\nof several internal disorders, such as malarial affections, tuberculosis,\\ncarcinoma of the viscera, disorders of the liver or kidneys (especially\\njaundice, B right s disease, and diabetes), and disturbances of the ali-\\nmentary canal, including those due to intestinal worms, hemorrhoids,\\nand dietetic or medicinal ingesta. It is common in the gouty, the\\nrheumatic, and the neurotic, and undoubtedly is due often to auto-\\nintoxication. It is often reflex in character, and may be associated with\\nalmost every one of the functional, and not a few of the organic, dis-\\norders of the uterus and ovaries. The same may be said of its depend-\\nence upon the genito-urinary diseases of the male sex, including stone\\nin the bladder, stricture of the urethra, disorders of the testes and epi-\\ndidymis, and perverted sexual hygiene. Through the reflex sympathy\\nof one part of the skin with other regions it is not at all unusual for\\none point of pruritus to be the exciting cause of new foci of the dis-\\norder, even at some distance from the original seat of itching. A\\npredisposing cause may often be found in hyperesthesia, either inherited\\n(or acquired (sometimes as a result of long-continued inflammatory der-\\nmatoses, such as eczema), as a consequence of which insignificant exter-\\nnal irritants cause pruritus. Bronson thinks a diminished tactile sense,\\nwhich implies an imperfect conduction of sensory impressions, is often\\nja. predisposing cause.\\nLastly, moral emotions of a depressing character play an important\\n|part in the etiology of pruritus. Mental distress occasioned by bereave-\\nment, separation from relatives, misfortune of all sorts, and anxieties\\nrs to the future, often find physical expression in the disease.\\nPathology. The disease is essentially a functional disorder of the\\nnerves of sensation supplied to the skin, and of itself is incapable of", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0775.jp2"}, "776": {"fulltext": "720 SEXSORY DERMATO-NEUROSES.\\nproducing objective symptoms. This fact can, in some cases, be clin-\\nically demonstrated, as the seat of the pruritus, even though exhibit-\\ning artificially produced lesions, will, when protected from external\\ninjury, speedily regain its normal appearance, the pruritus no less con-\\ntinuing. It is probable, though not certain, that the nerves also in\\nthis disease undergo no structural change, but merely convey to the\\nperiphery a perverted sensation that is often reflected from some cen-\\ntric point of disturbance.\\nDiagnosis. The recognition of general pruritus is usually not diffi-\\ncult, though the secondary results of the disease are apt to be less\\ncharacteristic than its early phenomena. The complaint of the patient,\\nthe absence of cutaneous disease sufficient to explain the symptoms,\\nand especially the discovery of an efficient cause in some visceral or\\nsystemic disorder, are all significant.\\nOne of the most constant features of general pruritus is visible only\\nwhen the clothing of the patient is entirely removed. It then becomes\\nevident to the eye that the affected regions are, in the order of fre-\\nquency, those most accessible to the hands. The posterior are much\\nless involved than the anterior body-surfaces. The small of the back\\nand interscapular regions are usually untouched. The tibial regions\\nof the legs and the forearms suffer more than the calves and the upper\\narms. The lower belly and inner faces of the thighs are punished\\nmore severely than the breast and outer faces of the thighs and the\\nhips. The clavicular regions are more excoriated than the back of the\\nneck. There is no more diagnostic sign of pruritus than this, and it\\nis one too often ignored by the practitioner, who prescribes under these\\ncircumstances for a disease of the blood.\\nIt must be admitted, however, that when the disease is localized\\nand complicated, as it frequently is, by an eczema or a dermatitis,\\ndoubt may arise. Attention should then be paid to the history of the\\ndisorder, which may reveal the fact that the pruritus preceded for some\\ntime the cutaneous symptoms, and may disclose even more. Intelli-\\ngent patients will often assure the physician of the real nature of the\\nmalady, by voluntarily remarking that the skin-symptoms disappear\\nupon the region that is not scratched, though the pruritus continues.\\nIn all cases the influence of externally operating agencies should care-\\nfully be eliminated.\\nPrurigo, with its infiltrated skin, its primary papules, and its severe\\nitching, beginning in early infancy and commonly persisting through\\nlife, can scarcely be confounded with pruritus cutaneus.\\nTreatment. The degree of success to be obtained in the treatment\\nof pruritus cutaneus is largely proportioned to the skill with which the\\ncause of the disease is recognized and remedied. Taking into consid-\\neration the number of systemic and visceral disorders which may in\\ndifferent cases be responsible for the skin-symptoms, it is clear that an\\nexhaustive study of the mental and physical history of each patient\\nwill be essential at the outset of treatment. The cause once recognized,\\nthe treatment should be directed to the special disorder discovered and\\nthis largely requires the skill of the general practitioner. The gastro-\\nintestinal tract, the kidneys, the liver, the bladder, the uterus, the", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0776.jp2"}, "777": {"fulltext": "PARESTHESIA. 721\\nI- prostate gland, the rectum, and indeed any one of the viscera, may\\nL require therapeutic management. All internal causes of cutaneous\\nirritation should as far as possible be removed, and to this end atten-\\ntion should particularly be directed to any medication to which the\\npatient may have been subjected, and which may have aggravated the\\nL complaint, and also to the diet, which should be regulated in accord-\\nL ance with the principles given under Urticaria (page 194) and Eczema\\n(page 346).\\nIn atonic conditions strychnine, iron, and other tonics are indicated.\\nThe nutrition of the nerves and of the skin can often be improved by\\nthe judicious use of cod-liver oil and other fats.\\nThe attempt to relieve pruritus by the internal use of sedatives is\\n1 not to be commended except in extreme cases. The narcotics, while\\nthey may give temporary relief, tend to relax the skin and in the end\\nto aggravate the disorder. This is especially true of the preparations of\\nopium. The bromides, antipyrin, phenacetin, sulfonal, or even chloral\\nmay be given for brief periods in extreme cases, but always with the\\nunderstanding that any one of these remedies, after temporary relief,\\nI may aggravate the condition for which it was given. Furthermore,\\nI there are strong reasons for refusing to employ in pruritic disorders\\nj preparations containing opium, cocaine, cannabis indica, conium, and\\nj other drugs intended to relieve the subjective sensations by internal\\nmedication. Many well-nigh incurable cases of the cocaine-habit\\nj, have been begotten by treatment of this sort when the patient, often a\\nt nervous woman with an intolerable pruritus vulvae, is in a condition\\nI peculiarly susceptible to the action of remedies of this class. The\\nlatter should always be regarded as the last resort of the practitioner,\\nI and a confession of weakness in not discovering the special cause\\neffective in the case with which he is for the time confronted.\\nCathartics and laxatives and an abundant supply of pure water\\ninternally employed as directed for relief of acute eczema (pp. 335, 336),\\nas well as diaphoretics and diuretics, are often of value in eliminating\\ntoxins to which pruritus may be due in depleting the cutaneous ves-\\nsels and possibly in a reflex way by diverting irritation to other\\nregions. Jaborandi and pilocarpine have thus been employed to ad-\\nvantage. In children full doses of quinine sometimes relieve pruritus,\\nwhile in adults large doses of calcium chloride occasionally will accom-\\nplish the same result. Cannabis Indica and gelsemium at times are\\neffective, but should be prescribed with great caution.\\nThe indications for local treatment are to protect the skin from all\\nsources of irritation and to relieve the itching. Hyperesthesia of the\\nskin is common in pruritus, either as a predisposing cause or as a result\\nof long-continued pruritus. In consequence very slight external irri-\\ntation may suffice greatly to aggravate the itching, and every precaution\\nshould be taken to protect the skin from exposure of all kinds. First\\nin importance is the clothing. The garments worn next the skin should\\nbe of cotton, lisle-thread, linen, or silk, never of wool, and the meshes\\nshould be filled with an impalpable powder to reduce to a minimum\\nthe friction of the garments on the skin. All other clothing should\\nbe as light as possible and yet be warm enough for protection. If the\\n46", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0777.jp2"}, "778": {"fulltext": "722 SENSORY DERMA TO-NEUROSES.\\npatient live in a climate where sudden changes in temperature are com-\\nmon, the clothing should be regulated accordingly. The object is to\\nkeep the skin at an even temperature and to protect it from sudden\\nchanges. In cases in which the pruritus is due largely to the hyper-\\nesthesia the itching may be entirely relieved by dusting the surface\\nwith a simple powder and completely covering it with a layer of cotton-\\nwool or other protective dressing.\\nHot baths, unless specially indicated, and the too free use of soap\\nmay render the skin unduly sensitive. The bran, oatmeal, alkaline,\\nand other demulcent baths recommended in the chapter on General\\nTherapeutics are those most generally useful. After the bath the\\nsurface should be patted (not rubbed) dry and covered with a dusting-\\npowder or other selected application. When the skin is free from ex-\\ncoriations and other lesions the cold douche, alternate hot and cold\\ndouching or sponging, or even the cold salt-water sponge may be used\\nto improve the tone and vigor of the skin. For localized pruritus hot\\nbaths of four or five minutes duration, followed by drying and the\\nimmediate application of a protective dressing, are often grateful and\\nbeneficial. The water should be as hot as can be tolerated, and to it\\nmay be added borax or sodium bicarbonate.\\nScratching is a common source of irritation and one that is difficult\\nto set aside. Until this is accomplished, however, relief cannot be ob-\\ntained, as whenever the skin is scratched or rubbed there is produced\\na local hyperemia, or even a dermatitis, which adds to the cutaneous\\nirritation, not only at the site of the rubbing, but also by reflex action\\nin other regions of the body. It is not sufficient to tell the patient not\\nto scratch the surface must be protected by proper dressings, and the\\nitching relieved by the use of antipruritics. Bronson suggests that\\npatients be allowed to obtain relief at times by firmly pressing upon\\nthe surface or by gently drawing over it an oiled or a wet cloth.\\nThe substances which have been employed topically for the relief of\\npruritus cutaneus are almost without number, a fact warranting the\\nconclusion, corroborated with every wide clinical experience, that each\\noccasionally fails to afford the desired relief. That preparation, more-\\nover, which is at one time of the highest value, at another period in\\nthe history of the same case will disappoint. Attempts to secure relief\\nby such topical applications should, however, always be made, and will\\noften be followed by gratifying results.\\nThe sedative and antipruritic lotions, liniments, and dusting-powders\\ndescribed on pages 342-345, together with their methods of prepara-\\ntion and application, are valuable and sufficient in most cases. They\\nmay be further modified by the addition of substances recommended in\\nthe following paragraphs. The dusting-powders are of special value\\nin furnishing mechanical protection. When a decided antipruritic\\neffect is desired the Anderson, or a similar, powder may be used. In\\nsome localized forms of pruritus more complete protection with oint-\\nments, pastes, or even the glycogelatins, may be secured.\\nOf all antipruritics, carbolic acid easily takes first place. In most\\nof the lotions recommended above it is used in strength of 1 to 5 per\\ncent. In oils or liniments it may be used much stronger. Bronson", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0778.jp2"}, "779": {"fulltext": "PARESTHESIA. 723\\nuses it even to 25 per cent., stating that it is much more slowly ab-\\nsorbed than in aqueous solutions, and therefore less likely to produce\\nsystemic effects. A favorite formula with him is the following\\nR\\nAcid, carbolic,\\noj-y\\n4-8\\nLiq. potass.,\\n33;\\n4\\n01. lini,\\n3j;\\n30\\nM.\\nIt is to be shaken before using, and may be scented with bergamot.\\nThese stronger preparations of carbolic acid, even in the oils, should\\nbe used over only small areas, for fear of toxic effects.\\nOther remedies that may be used in lotion, oil, liniment, ointment,\\nor paste, in strengths varying from 1 to 5 per cent, or more are\\nsalicylic acid, hydrocyanic acid, menthol, camphor, thymol, salol, creo-\\nsote, chloral, and chloroform. Two or more of these remedies may be\\ncombined in the same lotion. Morphine, atropine, and cocaine may be\\nadded to lotions with occasional advantage.\\nOintments and pastes are irritating to many pruritic skins, but at\\ntimes are more acceptable than the lotions and oils.\\nChloral-camphor, a pungent, syrupy liquid obtained by triturating\\nan equal amount of the two substances in fine powder, is an anti-\\npruritic remedy of value in certain cases if applied in a salve contain-\\ning 1 drachm (4.) to the ounce (30.) of salve, and is comparable in its\\naction to phenol-camphor, described in the chapter on General Thera-\\npeutics. Among other remedies occasionally of service are ichthyol,\\nresorcin, and mercuric chloride. Bronson speaks highly of hydrogen\\nperoxide. The preparations of tar are not well tolerated as a rule, but\\nin some instances are exceedingly valuable. The liquid preparations\\n(page 352) are to be preferred. In atonic cases, with diminution of\\nthe tactile sense, the use of electricity over the spine has been followed\\nby good results.\\nIn Senile Pruritus the progressive atrophy and degeneration of\\ntissues may be checked or retarded by management proper to each\\ncase. Locally, electricity or hot and cold douches may aid in stimu-\\nlating the skin to renewed vigor.\\nTreatment of the regional forms of pruritus is that above de-\\nscribed, with such modifications in the dressings as may be necessitated\\nby the special location.\\nIn anogenital pruritus the hot bath described above at night is\\nespecially to be recommended. Exception should be made here to the\\nrule with regard to the exclusion of tars generally from the treatment\\nof pruritus, as in the distressing itching of the scrotum and the anus\\nthey are often essential. The tincture of tar, oil of cade, and oil of\\nwhite birch will here often be needed. Fissures and areas of infiltra-\\ntion may be painted with compound tincture of benzoin or solutions of\\nsilver nitrate containing gr. x to 3j (0.66\u00e2\u0080\u00944.) to the ounce. The scrotum\\nwhen attacked usually requires the use of a suspender, or suspensory bag,\\nlined with soft lint or with borated cotton, which may be covered with\\na dusting-powder, wetted with a lotion, or smeared with an unguent.\\nFor pruritus of the vulva Wiltshire recommends decoctions of\\n1 Brit. Med. Jour., March 5, 1881, p. 328.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0779.jp2"}, "780": {"fulltext": "724 SENSORY DERMATO-NEUROSES.\\nalmond-meal, marshmallow, slippery-elm, and rice and in case of\\nfailure of the latter, an infusion of tobacco 2 ounces (60.) to the pint\\n(480.). Vaginal injections of hot water, and tampons or cocoa-butter\\nsuppositories medicated with opium, belladonna, or carbolic acid, are also\\navailable. Mercuric chloride lotions [gr. J\u00e2\u0080\u0094 j to 3j (0.016-0.06 to 30.)]\\nare recommended by many writers.\\nIodoform, oleate and muriate of cocaine, the latter in from 2 to 4\\nper cent, solutions 1 ounce (30.) of the fluid extract of coca, to 2 or\\n4 (64.-128.) of water and linseed oil (especially for pruritus ani), are\\nalso recommended.\\nJullien recommends in pruritus of the vulva\\nR\\nSig.\\nZinc, oxid.,\\n3vj\\n24\\nAcid, salicylic,\\ngr. xv\\n1\\nGlycerin.,\\n3vj;\\n24\\nApply as required.\\nM.\\nCheron, in pruritus of the vulva attending the menopause,\\nsuccessfully used\\nR Veratriae, gr. iij\\nAxung., lj; 30\\n20\\nM.\\nHe also administers in pill-form y^ grain of veratria rubbed up\\nwith licorice.\\nSquibb s formula is\\nR Acid, tannic, 9j 1\\nSpts^vin/rectif.,} 15\\nAq. dest.. ad f ^iv ad 120\\nSig. Apply morning and evening on a rag.\\n33\\nM.\\nLastly, it should not be forgotten that many cases of intractable\\npruritus are best managed when the attention of the patient is diverted\\nfrom the malady by the distraction incident to travel, aided by change\\nof scene and climate.\\nPrognosis. Pruritus senilis is usually an intractable disorder, and\\nwhen dependent upon senile alteration of the cutaneous tissues is in-\\ncurable. For all other forms of the disease a prognosis should be\\nformulated with reserve. Under the influence of systematic and ap-\\npropriate treatment the happiest results are often obtained. Other\\ncases, especially those associated with hypochondriasis, may bid defi-\\nance to all medicinal measures. Relapse of the local forms of the\\nmalady, especially of that of the anogenital region, is common. In\\nmany of these patients the treatment serves merely to palliate the\\ndisorder, which recurs with every renewal of the cause.\\nPruritus Hiemalis (Prurigo Hyemalis, Frost Itch,\\nWinter Prurigo). Under the first title Duhring 1 described a harsh\\n1 Phila. Med. Times, January 10, 1874. See also a later but independent observa-\\ntion by Hutchinson Lectures on Clinical Surgery, 1878, vol. i., pt. 1, p. 100; and Brit.\\nMed, Jour., 1875, ii., p. 773.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0780.jp2"}, "781": {"fulltext": "PARESTHESIA. 725\\nand pruritic condition of the skin, essentially unattended by structural\\nalteration, invading all surfaces of the body, but chiefly the inner\\nfaces of the thighs, the calves of the legs, and the neighborhood of the\\njoints of the lower extremities, usually occurring in the autumn and\\ncontinuing until the following spring. It possesses many features in\\ncommon with the forms of pruritus already described, including varia-\\nbility in the subjective sensations awakened, nocturnal exacerbation,\\nand the absence of primary eruption. The secondary results are also\\nsimilar, being sequels of self-inflicted injury in the form of roughness,\\nperifollicular redness and papulation, torn and fractured hairs, excori-\\nations, blood-crusts, and, in severe cases, an induced dermatitis. It,\\nhowever, abates in severity with a rise of atmospheric temperature,\\nthough there is occasionally noted persistence of the distress after such\\nweather-changes. The affection, moreover, is one which occurs in\\npersons otherwise enjoying perfect health, in those of every social\\ngrade, irrespective of the [character of the clothing worn and of the\\nhabitual use or the neglect of the bath. It is, without question, a dis-\\nease of northern climates, more particularly of those where the varia-\\ntions of temperature between the extremes of the summer and of the\\nwinter range between 30\u00c2\u00b0 F. and 100\u00c2\u00b0. The description by Duh-\\nring presents a picture (with an accuracy verified by clinical observa-\\ntion) which justifies the recognition of the disease as a form of cutaneous\\npruritus. Its treatment is that detailed above, the author named lay-\\ning stress upon emollient unguents, glycerin in the form of lotion or\\nointment, and alkaline baths. The dusting-powders, when employed\\nafter the tepid bath, have proved more serviceable than any fat-con-\\ntaining substance.\\nPrairie Itch. This is a popular term applied largely in the\\nWestern, Northwestern, and Southern States of America to a cutaneous\\naffection productive of itching sensations. It is supposed to be the dis-\\norder popularly described also as the Texas Mange, Ohio\\nScratches, Swamp Itch, Lumberman s Itch, etc. A para-\\nsitic origin has been claimed for it by several observers who also\\ninsist upon its contagious character and its curability by parasiticides.\\nPersonal experience has led to the conviction that these terms are\\nloosely applied to a group of cutaneous symptoms of diverse origin.\\nThe most frequent by far is a pruritus, of the kind described above as\\npruritus hiemalis, occurring in the autumn, winter, or spring of the\\nyear, and aggravated by the coarse and cheaply dyed woollen under-\\ngarments of the poor and hard-working inhabitants of lumber-camps,\\nmining-districts, etc. With these causes in full operation, there is often\\naggravation after swallowing drugs for relief of the pruritus, based upon\\nthe idea of purifying the blood.\\nWith these pruritic cases occur those of undoubted scabies, for the\\nstudy of which the reader is referred to the chapter devoted to that\\nsubject. The proportion between the purely pruritic and parasitic\\ncases of this class cannot definitely be determined. It probably varies\\nin different places and seasons, the proportion of cases of scabies\\nincreasing in the lumber-camps when they are reinforced by newly", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0781.jp2"}, "782": {"fulltext": "726 THYROID CACHEXIA.\\narrived immigrants infested with acari. It decreases to probably not\\nmore than from 1 to 2 per cent, of all skin-diseases in the interior vil-\\nlages and towns of the West and Northwest where there has been no\\nimmigration for some length of time, and where, after the first onset of\\nsharply cold weather in the autumn, a large part of the inhabitants\\nsuffer from pruritic sensations in various degrees.\\nA review of the somewhat scanty literature of this subject 1 suggests\\nthe conclusion that the disorder popularly designated as prairie itch,\\netc., is far more rare in Europe than in America. It is possible that\\nthe situation of those parts of the United States where this group of\\nskin-affections seems to prevail (at a great distance from proximity to\\nthe seashore, and still further separated from the Gulf-stream) may play\\nan important part in the extraordinary sensitiveness of the skin to\\nclimatic changes. Certain it is that a great number of these affections\\nare entirely relieved by removal to a suitable climate, more particularly\\nto one of the Eastern, Southern, or extreme Western States.\\nTreatment. The therapy of this affection is that of pruritus,\\nalready described, save where a parasite is recognized as the efficient\\ncause, as in cases of scabies.\\nThe Prognosis is favorable, though the disease is at times intracta-\\nble, persisting or recurring with repeated thermometric variations until\\nthe warm season is at hand.\\nMYXEDEMA.\\n(Gr. fJ-v^a humor olSe u to swell.\\n(Cretinoid (Edema, Cachexia Strumipriva, Cachexia Thy-\\nroidea. Fr. y Cachexie pachydermique.)\\nThis disorder was first described by Sir William Gull, 2 in 1873\\nand it has since been studied, both abroad and in this country, by many\\nobservers.\\nA complete description of the disease and a resume of literature are\\nfound in the report of the Clinical Society of London for 1888, and in\\nMurray s elaborate contribution to the same subject, in the Twentieth,\\nCentury Practice of Medicine, vol. iv., 1895. The report embodies the\\nresults of the researches of a committee including Ord, Horsley, and\\nothers specially appointed by the Society to investigate the subject.\\nSymptoms. The disease occurs in both acute and chronic manifes-\\ntations, usually after the fortieth year, and in women more often than\\nin men. It may, however, first be noticed in childhood.\\nAt the outset there is observed a gradually occurring persistent and\\nremediless anaemia, succeeded in turn by mental hebetude, sluggish-\\nness of body-movements, and a characteristic change in the integument.\\n1 See two papers by one of us, entitled On the Affections of the Skin Induced by\\nTemperature-variations in Cold Weather, Chicago Med. Jour, and Examiner, March,\\n1885, and February, 1886. Obersteiner: Wien. med. Woch., 1884, No. 16. Brodie:\\nPeninsular Jour, of Med., 1853-54, vol. i., p. 506. Jones: Kansas City Med. Index,\\n1886, with views of several Western physicians. Clark Med. Age, 1886. Payne\\nBrit. Med. Jour., May 3, 1887.\\n2 Trans. Clin. Soc. London, 1874, vii., p. 170.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0782.jp2"}, "783": {"fulltext": "MYXCEDEMA. 727\\nThe skiu becomes dry, rough, yellowish, waxy, translucent, and firm, and\\nrefuses to pit on moderate pressure. The surface involved is commonly\\nthe seat of a fine furfuraceous desquamation, the mucous membranes\\noften participating in the morbid process. In the cheeks there is\\nusually perceptible a brawny redness defined at times as a sharply\\ncircumscribed, pinkish flush, due to distention of the minute capillaries,\\nextending quite to the lower eyelids, which may, as in Ball s cases, be\\nwrinkled, boggy, and swollen. The eyes, for this reason, seem smaller\\nthan natural and more widely separated. In consequence of the swelling\\nand immobility of the features the facies is characteristic the broad,\\nthick nose swollen, pendulous, or even everted lips expressionless\\neyes and leathery cheeks, producing upon the observer the impression\\nof a mask. The skin of the other regions of the body participates in\\nthese changes, the backs of the hands, for example, becoming wrinkled\\nor distended, the palms dry and fissured, the feet participating in the\\nsame morbid process, the hair falling in nearly 90 per cent, of cases\\neven to the production of extreme baldness, the nails becoming discol-\\nored, grooved, and cracked, and the teeth often carious, fragile, or\\nwholly lost. The mucous membrane of the mouth (gums, palate,\\npharynx) becomes tumid and fungous.\\nIn the triangles at the side of the neck, and also at its back, are\\nbolsters of fat. The hair of the head becomes harsh and scanty\\nalopecia may be complete. Pigment-alterations readily occur; moles\\nincrease in size and the general tint of the skin may vary from that\\nof dry parchment to the hue of Addison s disease. The gait is waddling\\nand uncertain. The thyroid gland atrophies. Anaesthesia is of common\\noccurrence. The tongue, uvula, and fauces are often so thickened and\\nimmobile as to make speech slow and indistinct. The temperature is\\nusually subnormal, the mental faculties seriously impaired, the sight\\nand hearing altered, digestion vitiated, and the muscular strength\\ngreatly reduced.\\nThe course of the disease is chronic, lasting for years, and termin-\\nating usually in a state of marasmus with fatal issue.\\nEtiology.\u00e2\u0080\u0094 The cause of myxoedema is imperfectly understood,\\nthough its association with abolition of the thyroid gland (after patho-\\nlogical change or ablation) is generally admitted. Stokes reports ten\\ncases of acute myxoedema following thyroidectomy. In these cases,\\nbeside the rapid occurrence of the symptoms enumerated above, there\\nwere convulsive seizures of an epileptiform character. Of four hundred\\nand eight complete thyroidectomies analyzed in the Clinical Society s\\nreport, in sixty-nine myxoedema developed. The result did not occur\\nwhen a part of the gland was left. The influence of heredity is distinctly\\nshown in cases reported by Ball, Ord, Saville, and Taylor. The disease\\naffects women more often than men, in the proportion of seven to one.\\nChildren are attacked, but the malady is more common in individuals\\nbetween thirty-five and fifty years of age.\\nIt is undetermined what relations, etiological or other, subsist between\\nthe members of an interesting group of maladies, all characterized by\\ncutaneous changes or dystrophy of the appendages of the skin, and total\\nor partial abolition of the functions of the thyroid gland. In this group", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0783.jp2"}, "784": {"fulltext": "728 THYROID CACHEXIA.\\nare to be named not merely myxoedema, but also myxedematous cretin-\\nism, acromegaly, and Graves s disease. These maladies are denomi-\\nnated by some authors the thyroid cachexias.\\nPathology. In nearly all cases examined the thyroid gland is\\nfound to be markedly reduced in size and its glandular structure\\nseriously impaired by substitution of fibrous connective tissue for the\\nepithelial cells lining its secreting acini. At first there is a small\\nround-cell proliferation, which gives place to changes resulting even-\\ntually in a firm thickening of both the gland and its capsule. The\\nlumen of the arteries becomes obstructed and, in cases, new-formed\\nlymphatic tissue is found surrounding the atrophied lobules.\\nExamination of affected regions of the skin discloses slight epider-\\nmal atrophy, replacement of connective-tissue trabecule with fine\\nnucleated fibrillar, a small-cell infiltration in the upper part of the\\ncorium, and an endarteritis obliterans similar to that recognized in the\\nthyroid gland. The epithelium of the coil- and sebaceous glands is the\\nseat of swelling and proliferation, which eventually produces occlusion\\nof the lumen of these emunctories and explains largely the cutaneous\\nsymptoms of the malady. The hair-follicles and the nerves (fibrosis\\nof hair-pouch, perineuritis) may or may not be invaded by a similar\\nprocess.\\nDiagnosis. Cases of myxoedema are readily distinguished from\\nthose of elephantiasis by the generalization of the symptoms, the nervous\\nstate of the patient, the fat-deposits, and the condition of the thyroid\\ngland. Acromegaly involves the bones in lepra there are commonly\\nanaesthetic symptoms or characteristic tubercles.\\nThe Treatment of myxoedema has hitherto aimed at amelioration of\\nthe symptoms by the employment of roborant and tonic measures alka-\\nline and sulphur baths electricity and massage. The later method of\\ntreatment, however, is by thyroid-grafting, by administration of thyroids,\\nand by hypodermatic injection of from 5 to 15 minims of liquid extract. 1\\nWhether there be employed the gland itself of the sheep, the liquid\\nextract, or the powder skilfully prepared by evaporation, or Vermeh-\\nren s extract precipitated by alcohol, the results are satisfactory in so\\nlarge a proportion of cases that the prognosis of this group of disorders\\npresents no longer an element of gravity. The headache, faintness,\\nloss of weight, neuralgias, and even albuminuria, with other symptoms\\nimmediately following the employment of the thyroids named above,\\ndo not seem to have an adverse influence upon the remoter benefits\\nreceived from the treatment.\\n1 Cf. Feeding Thyroids in Myxoedema, by J. J. Putnam Amer. Jour. Med. Sci.,\\nAugust, 1893.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0784.jp2"}, "785": {"fulltext": "CLASS VIII.\\nPARASITIC AFFECTIONS.\\nThe disorders due to invasion of the skin by parasites possess many\\nfeatures in common with those already described. In them, as in others,\\nare observed the hyperaemic and exudative processes which result in\\nsurface-lesions of similar type and career. They differ, however, from\\nother affections of the integument in that they are all induced by para-\\nsites of either vegetable or animal origin and are, as a consequence,\\ncommonly characterized by certain special features. They involve the\\nskin and its appendages, their symptoms being at times displayed\\nchiefly in the integument proper, and at other times in one or more of\\nthe cutaneous appendages, according to the mode of propagation and\\nattack, peculiar in each case to the parasite present. They are all in\\ndifferent degrees contagious and, being induced by local and tangible\\ncauses, are usually relieved by external treatment. Their importance\\nin cutaneous medicine rests not only upon the facts named above, but\\nalso upon the too general misconception regarding their nature, since\\nthere are many patients treated by internal remedies ingested vainly\\nfor long periods of time, who suffer from parasitic disorders often\\nremediable by very simple local measures.\\nIt should not be forgotten, however, that, distinct though these mal-\\nadies be in an etiological sense, they are yet often practically com-\\nmingled with others. Thus, an eczematous scalp in a child may by\\naccident become the habitat of lice and the eczema induced originally\\nby the acarus scabiei may persist long after destruction of the parasite.\\nThe term tinea, derived from a Latin word meaning a moth or\\nworm, has by common consent been adopted as a generic designation\\nof the cutaneous disorders induced by the presence of vegetable organisms.\\nDISORDERS DUE TO VEGETABLE PARASITES.\\nTINEA FAVOSA.\\n(Lat. favus, a honeycomb.)\\n(Honeycomb Ringworm, Porrigo Favosa, Favus. Fr., Teigne\\nFaveuse; Ger., Erbgrind.)\\nSymptoms. Favus aifects chiefly the scalp, but it also occurs upon\\nthe glabrous portions of the skin and upon the nails. In the former\\nsituation it is usually first recognized by the development of minute,\\nsubepidermic, yellowish or reddish puncta, visible through the trans-\\nlucent stratum corneum at the site of implantation of the hairs. A\\n729", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0785.jp2"}, "786": {"fulltext": "730 PARASITIC AFFECTIONS.\\ncircle of delicate vesicles may surround these spots. Puncture with\\na needle usually gives exit to puriform matter. In the course of a\\nfortnight or more these lesions cover themselves with pin-head to\\npea-sized and somewhat larger, friable, circular, and elevated crusts,\\nhaving the yellowish tinge of the lemon or of sulphur, and a concavo-\\nconvex shape, with the free concave face of the disk exposed. At\\nthe centre of the umbilication thus presented to the eye one or several\\nhairs usually make exit to the surface. The inferior surface of this\\ndisk, or scutulum, rests upon the scalp, which is either moist and\\ndeprived over a circumscribed area of its epidermis, or is smooth, dry,\\nreddened, and tender. When the crust is removed by traction upon\\nthe hairs or otherwise a minute cup-shaped depression is left at the\\npoint where the lowest level of the favus crust was in intimate con-\\nnection with the epidermis.\\nThe subsequent features of the crusts, the hairs, and the scalp are\\nsubject to variation. The crusts may acquire a brownish or a greenish\\ntinge by admixture with dirt or with dried pus may coalesce (favus\\nsquamosus); or may, by gradual desiccation, exchange the yellowish\\nhue for the dirty-whitish shade of old mortar, a substance which they\\nthen resemble in dryness and friability. The hairs invaded both in\\nthe sheath and shaft may lose their lustre become fragile appear as\\nfractured relics of longer filaments readily be extracted from their\\nfollicles and finally be shed, leaving hair-sacs destined to atrophy and\\nincapable of reproducing a pilary growth. The scalp may first be the\\nseat of an extensive hyperemia or exudation going on to the forma-\\ntion of pus, when the fungus is a source of acute irritation in conse-\\nquence of its active development. Later, when its destructive work\\nmay be said to have been accomplished, the scalp-surface is bald, irreg-\\nularly atrophied, or disfigured with cicatrices, which at first are of a\\ndeep-red color, but which gradually fade, while here and there remain\\ntufts of hair that have survived the attack.\\nThe lesions may be discrete or be confluent, and may vary in either\\ncase. Occasionally but a few small and ill-developed crusts form upon\\nthe surface. The entire scalp is not often covered with a confluent\\nfavus-crust. The disease is usually chronic in its course. Untreated,\\nit may undergo spontaneous involution after total destruction of all\\nhairs and production of general follicular atrophy, but this is rare.\\nIt may last for fifteen or twenty years, and even longer. It is often\\naccompanied by adenopathy.\\nThe disease usually awakens a noteworthy degree of itching, and,\\nas a result, it is not rare to find the favus-crusts torn and broken by\\nthe comb or the nails.\\nThe yellowish disks of the disease occur also in typical development,\\nthough more rarely, upon the surface of the face (including the bearded\\ncheeks, lips, and chin), and upon the trunks and extremities. Fox, of\\nNew York, has photographed a patient s knee which was covered on its\\nextensor aspect with favus-crusts.\\nWhen the nails are invaded, light or deep-yellowish, circumscribed\\nspots become visible through the nail structure, and by extension of\\nthese, in consequence of the growth of the parasite, the nail-tissue", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0786.jp2"}, "787": {"fulltext": "TINEA FAVOSA. 731\\nmay be thickened, irregularly split, laminated, separated from its\\nmatrix, or atrophied. The complication is rare, and is supposed to be\\ndue to transfer of the parasite from the scalp to the hands in the act of\\nscratching. When it exists the epidermis fringing the nail is usually\\nalso involved.\\nUpon the so-called non-hairy portions of the body favus occurs\\nin the same forms as elsewhere, the localities in the order of frequency\\nbeing those most exposed to the hands charged with the parasite, or to\\nother sources of the disease, viz., the hands (chiefly the backs and nails),\\nthe upper and lower extremities, and the shoulders. It is a striking\\nfact that favus may exist for years on the scalp without spreading. At\\na single clinic we have exhibited five patients affected with favus, all\\nscalp-cases, the eldest, a male, twenty-five years of age, who had suffered\\nfrom the disease for twenty years without occurrence of the lesions\\nelsewhere.\\nIn favus of the body-surface, outside the scalp, there is often a re-\\nsemblance to ringworm in the production of circular patches with an\\nactive border made up of vesicles or of papules, which may have a\\nfavus scutulum as a centre or several of these cups may irregularly\\nbe spread over circles of scaling patches. In these cases there is often\\nan acuity of symptoms not observed in scalp-cases and coincident\\ngastrointestinal signs of irritation, vomiting, etc., which Kundrat be-\\nlieves may originate in favus of the mucous surfaces of the oesophagus\\nand gastro-intestinal tract.\\nThe odor of fully developed favus is so characteristic that by it\\nalone a diagnosis has been established. It is usually compared to the\\nodor of mice also to that of the urine of cats. It should not be\\nconfounded with the peculiarly disgusting odor of neglected scalps\\naffected with lice or covered with pustules and filth. The disease not\\ninfrequently coexists with other cutaneous, parasitic, and non-parasitic\\ndiseases, as, for example, seborrhoea, eczema, and tinea tonsurans.\\nFavus of the Nail (Fa vie Onychomycosis). Rarely one or\\nseveral of the nails may be the seat of the fungus, and either the entire\\nbody of the nail or but a part of it. The lesions are maize-yellow\\npoints or macules where the substance of the organs is eroded, fissured,\\nor split into striations changes quite like those induced by other causes.\\nThe connections of the nail with the underlying nail-bed and nail-folds\\nare loosened, wholly or in part, while the matrix still holds the nail\\nfirmly in position.\\nEtiology. Favus is always produced by the presence and develop-\\nment of the vegetable organism which is named after its discoverer, the\\nachorion Schonleinii (Fig. 88). The disease is contagious simply because\\nthe parasite which produces it is capable of transmission from man to\\nman, as also from animals to man, and vice versa. It is often conveyed\\nto man from mice, cats, dogs, rabbits, fowls, and ponies but when\\nderived from the lower animals is most often transmitted from mice to\\ncats and from cats to man. It shares with other diseases originating\\nfrom vegetable parasites the peculiarity of attacking certain individuals", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0787.jp2"}, "788": {"fulltext": "732\\nPARASITIC AFFECTIONS.\\nspecially predisposed to such invasion, either by reason of physical\\npeculiarities of organization or because of accidental and fortuitous cir-\\ncumstances. It is most common from infancy to the thirtieth year of\\nlife. It is less common in the United States, Austria, and England\\nthan in France, Scotland, and Poland. It is said by Bergeron 1 to be a\\ndisease of the country, while tinea trichophytina prevails in the cities.\\nThis statement is corroborated by general experience. Favus is more\\ncommon in public than in private practice, and the larger number of\\nclinical patients with favus come to the city from the country.\\nAchorion Schonleinii a, spores b, c, sporophores. (After Cornil and Ranvier.)\\nEvidences of contagion are exhibited in those cases in which several\\nmembers of the same household are affected with the disease but in\\nother cases the absence of a history of contagion after exposure indi-\\ncates the relative difficulty experienced in propagating the contagious\\nelement in the case of favus. Thus, one individual exposed among\\na dozen who are diseased will fail to exhibit favus-crusts and the\\nlatter by no means form in all situations of the same body where the\\nfungus can be discovered by the microscope. Aubert, 2 indeed, presents\\nan argument in favor of the production of the disease by traumatism,\\nthe resulting wounds, excoriations, etc., becoming by accident the seat\\nof the disease. It is not very rarely discovered under poultices and\\nfomentations.\\nOccasionally favus occurs in special localities with such development\\namong men and the inferior animals as to constitute an epidemic.\\nGirard 3 reports thus the simultaneous existence of the disease among\\nsixteen cows and four children in the village of Nantoin, in France.\\nIt is propagated also upon the skin of rats and mice, from which it is\\ntransmitted to man, often through the medium of the domesticated cat\\nand dog.\\nPathology. Under the microscope the fungus is readily recognized\\nin the root-sheaths, the bulbs, and the shafts of the hairy filaments near\\n1 Etude sur la Geographie et la Prophylaxie des Teignes. Paris, 1865.\\n2 R61e de Traumatism dans l Etiologie de la Teigne faveuse, Annal. de Derm, et\\nde Syph., April, 1881.\\n3 Lyon med., August 18, 1880, p. 547.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0788.jp2"}, "789": {"fulltext": "TINEA FAVOSA. 733\\nthe scalp. At a distance of about two inches from the bulb the para-\\nsite ceases to appear in the tissue of the hair. It is also seen upon the\\nfree surface of the skin. The favus-crust, softened by the addition of\\na little water or solution of potassium hydroxide, may be placed upon\\nthe slide of the microscope without other preparation for its study. The\\nhairs may be examined in the same manner or they may be stained by\\nthe methods given for staining the ringworm fungi. Under a good\\none-fourth- or one-sixth-inch objective the vegetation is seen to be\\ncomposed of intricate masses of mycelium and spores in great\\nquantity.\\nQuincke 1 attempted to distinguish between three varieties of the\\nfavus fungus, designated respectively as a, ft, and y. Elsenberg, Krai,\\nPick, Unna, and others have, however, arrived at different conclusions\\nupon the same subject, some recognizing but two of Quincke s forms\\nothers, two separate forms not corresponding with the a, or y form\\nof Quincke and still others, corresponding with none of those pre-\\nviously described. The majority of observers agree that there is but\\none achorion fungus, displaying itself in several forms both under the\\nmicroscope and clinically, all differences being due to accidental influ-\\nences (varying amount of heat, moisture, and friction in the involved\\nsurface).\\nThe threads of the fungus usually preponderate, and appear as nar-\\nrow, flattened, ramifying, short or elongated, linear cells or tubes,\\nwhich may be simple and empty, or be divided more or less regularly\\nby transverse partition-walls, transforming the longer and simple into\\nshorter and compound cells. The latter often contain in their cavities\\nsporules clinging to either side, in which case the mycelial threads are\\ntermed spwophores. These sporules are the vegetative part of the\\ncryptogamous fungus, and develop by multiple subdivision into cells,\\nwhich may also themselves similarly increase in number, or by the\\nproduction, at the terminal extremities of certain mycelial threads,\\nof spores or conidia. The conidia are encapsulated or are strung\\nlike beads upon a necklace, and they appear as round, oval-shaped,\\nangular, or very irregularly contoured bodies, often provided with\\npartition-walls like mycelium, constituting thus compound cells. At\\nthe same time an amorphous granular matter can usually be distin-\\nguished in the mass of the fungus. The hyphse vary in width from\\n0.0023 to 0.0030 mm.; and the spores from 0.0023 to 6.0052 mm.\\nExamination of the invaded scalp reveals, according to Unna, 2 the\\npresence of the fungus at the lower border of the upper three-fourths\\nof the root-sheaths, where chains of conidia appear among the histo-\\nlogical elements. His view is that the cuticle of the hair offers a rela-\\ntive resistance to the growth of the vegetation that the latter first\\npenetrates the stratum corneum and the follicular orifice, and then\\nstretches, upon the one hand, into the cortex and medulla through the\\ncuticle of the hair and, on the other hand, passes to the inner root-\\nsheaths, the outer remaining always intact. In the epidermis the\\nfungus is found chiefly between the superficial and deep portions of the\\n1 Monatshft. f. prakt. Derm., 1889, Bd. viii.. S. 49.\\n2 Vierteljahr. f. Derm. u. Syph., Bd. vii., S. 170.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0789.jp2"}, "790": {"fulltext": "734 PARASITIC AFFECTIONS.\\nstratum corneum. The superior pars vascularis of the corium exhibits\\nenlarged vessels surrounded by inflammatory elements.\\nWhen the nail is involved the parasite may be recognized in the\\ndebris produced by scraping the nail-substance often also in the epi-\\ndermis bordering the nail. The fungus exhibits here the same micro-\\nscopical features as upon the scalp, though in consequence of the denser\\nstructure of the nail-substance its vegetation is usually less luxuriant.\\nDiagnosis. The clinical recognition of favus is based upon the\\npresence of the characteristic, yellowish, cup-shaped crusts, which in\\nall typical cases are isolated, each pierced by a pilary filament and each\\nsituated in a well-marked depression of the surface of the scalp. In\\nthe disseminated form the disks of conglomerated scutella with defined\\nand frequently festooned edges, friable, yellowish or yellowish white\\nin color, and greatly differing as to their bulk and contour, are com-\\nmonly suggestive of the nature of the disorder. In yet other irregu-\\nlarly formed crusts the affected area seems to be covered with a plaster-\\nlike mass irregularly distributed and of uneven thickness over an\\nenormous patch of disease which may be practically coextensive with\\nthe entire scalp-surface. Incidentally there may be a history of con-\\ntagion and a peculiar odor emanating from the scalp. The secondary\\neffects upon the hairs, hair-follicles, and skin are also, when present,\\nsignificant. White, of Boston, in an essay on the Vegetable Para-\\nsites, and Diseases caused by their Growth upon Man, calls attention\\nto the stage in which the disease is likely to be mistaken for ringworm.\\nIt exists before the formation of the crust, and may be characterized\\nby hyperemia, vesiculation, or papulation, often unnoticed beneath the\\nhairs of the scalp. In doubtful cases the microscope will usually estab-\\nlish the diagnosis, though Bodin, Morris, Sabouraud, and other\\nobservers think it is not always possible to draw a sharp line between\\nfavus and ringworm, and that cases occur in which it is impossible\\nwith the means now at our disposal to make a differential diagnosis\\nwith precision. 1\\nAubert, 2 in the absence of the clinical features named above, lays\\nstress upon an intense redness of the scalp where the hairs have been\\ncut and the crusts removed, this color being limited to the portions at-\\ntacked by the disease. The hairs also, as a result of disintegration\\nof their elements, are infiltrated with air, and look opaque and black by\\ntransmitted light by reflected light they appear polished and stratified,\\nas if constituted of layers of tissue. It should not be forgotten that\\nin exceptional cases favus-crusts coexist upon the body with other dis-\\neases of prior or of subsequent origin, as indicated. The disease should\\nnot be confounded with seborrhoea, pustular eczema, or psoriasis of the\\nscalp, none of which exhibits the special features of a parasitic fungus.\\nTreatment. The first indication in the treatment of favus is to\\ncleanse the affected surface from all crusts and scales that may be\\npresent. For this purpose the scalp (if this be, for example, the\\naffected part) is first shorn of its hair with scissors, and is then thor-\\n1 For literature of this subject consult the references tabulated with the introductory\\nparagraphs on Bingworm.\\n2 Annal. de Derm, et de Syph., 2e. ser., ii., p. 34,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0790.jp2"}, "791": {"fulltext": "TINEA FAVOSA. 735\\noughly soaked with olive-, cod-liver, or other oil, or with glycerin.\\nAfter this treatment all the crusts are scraped away with a spatula,\\nand the scalp is washed clean with hot water and soap, spirit of green\\nsoap being here preferably used. The scalp should then again be\\nanointed with oil or be covered with an emollient poultice. Once thor-\\noughly cleansed by repeated soakings with oil and by ablutions, it is\\nnecessary to resort either to the topical employment of parasiticides\\n(agents capable of destroying the fungus) or to epilation (extraction\\nof the hairs). Often both measures are required. Without further\\ntreatment the scalp, however completely freed from all evidences of\\nthe disease, will not fail to show fresh favus-crusts in a fortnight or\\nsomewhat longer time.\\nEpilation is practised with the aid of epilating-forceps. These for-\\nceps should be constructed with an easy spring that will not tire the\\nfingers of the operator with blades that are sufficiently broad to grasp\\na few hairs at once and with smooth or but slightly serrated faces of\\nthe blades, as otherwise the hair is liable to fracture in the grasp of the in-\\nstrument. The surface to be operated upon should previously be anointed\\nwith vaselin or with olive-oil, and the hairs entirely be removed, a suf-\\nficient number, covering a definite space, upon successive days.\\nThe tediousness of this process has led to several devices by which\\nit is sought to do away with its necessity. Originally the calotte\\nwas employed for the removal of the hairs it was made by smearing\\na disk of leather with pitch, and applying it over the scalp. When\\nthe calotte was subsequently removed by a brisk twitch with the\\nhand the hairs which adhered were forcibly uprooted en masse;\\nthose remaining being adherent in their sacs in consequence of the\\nfact that they had not been invaded by the fungus. As a substi-\\ntute for this procedure, Bulkley employed adhesive masses or sticks,\\nwhich can be melted and be made to adhere at once to large numbers\\nof the hairs. When cold they can be withdrawn from the surface\\nwith the hairs attached. These sticks are from two to three inches in\\nlength, and from one-fourth to three-fourths of an inch in diameter.\\nThe hair is first clipped so as to be about one-eighth of an inch in\\nlength. The end of the stick is then heated in an alcoholic flame,\\nand quickly placed upon the scalp. It is thus left in place until cold,\\nand is removed by bending it over and drawing upon the hairs suc-\\ncessively with slight rotation. When free it is found thickly set with\\nthe extracted filaments, which may be burned off in the alcohol flame,\\nthus destroying both the hairs and any adherent fungous masses. The\\nstick is then carefully wiped clean with paper, after which it is again\\nready for use. The formula for the mass of which these sticks are\\ncomposed is as follows\\nR Cerse flavae, 3iii 12\\n16\\n24\\n44\\n45 M.\\n1 Favus and its Treatment by a New Method of Depilation Arch, of Derm.,\\nApril, 1881, vii., No. 2.\\nCerse flavae,\\n3hj\\nLaccse in tubulis,\\n3iv;\\nKesinae,\\n3vj\\nPicis Burgundicae,\\n3xj;\\nGummi dammar.,\\nBjss;", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0791.jp2"}, "792": {"fulltext": "736 PARASITIC AFFECTIONS.\\nThe parasiticides in greatest favor are corrosive sublimate in solu-\\ntion in the strength of from 1 to 4 grains (0.066-0.266) to the ounce\\n(30.) formalin (1 to 4 per cent.) sodium hyposulphite in saturated\\nsolution pure or diluted sulphurous acid spirit of green soap chry-\\nsarobin, pyrogallol, tar, croton-oil boric, carbolic, and salicylic acids\\npetroleum, chloroform, ether, creosote, and oil of cloves. The addi-\\ntion of acetic acid to liquid applications, or washing the surface with\\nvinegar immediately before applying the parasiticide, favors penetration\\nof the remedy. Ointments are also useful containing mercury (citrin\\nointment, yellow sulphate, or white precipitate), naphtol, benzol, thy-\\nmol, sulphur, pyrogallol, salicylic and carbolic acids. Chrysarobin\\nis effective in an ointment, though objectionable on account of the\\nstaining of the scalp, and, almost inevitably, of the face also. Lenz-\\nberg generates sulphur-fumes in a dish of red-hot coals attached to a\\nframe (made of wood or of pasteboard) close to the head of the patient.\\nBy means of a paper cap the fames are collected and retained (from\\nfive to ten minutes) in contact with the patient s hair. During ten\\nyears trial of this plan he has never been compelled to resort to\\nepilation.\\nOne or more of the methods may be needed, either at the same time\\nor by repetition or alternation, until the fungus is entirely destroyed,\\nthe requisite period usually extending over three months. Treatment\\nshould then be discontinued in order to test the result by observation.\\nIf, in the course of a fortnight or more, a relapse occurs, treatment is\\nto be promptly renewed. Upon the non-hairy portions of the body\\nparasiticides thoroughly applied usually insure radical relief. When\\nthe nail is involved, it should be cut short and carefully scraped or be\\nsoftened by repeated applications of a strongly alkaline lotion, after\\nwhich a parasiticide may be employed in ointment or lotion.\\nIn general, it may be remarked that patients long affected with\\nrebellious favus may need a roborant course of treatment and nu-\\ntritious diet. Cleanliness here, as in all the parasitic disorders, is\\nimportant. As adjuvants in the treatment of the scalp and nails it is\\nwell to remember that continuous applications of a parasiticide are\\naided by caps or cots of impermeable material superimposed upon rags\\nsaturated with the medicament employed. For use in this manner, and\\nespecially for the nails, Sabouraud recommends a solution containing 1\\ngramme of iodine and 2 grammes of potassium iodide in a litre of dis-\\ntilled water. 2\\nPrognosis. The prognosis is generally favorable to the ultimate\\ntermination of the disease in all cases for even the most rebellious\\nand untreated forms are relieved when the hair-follicles atrophy. Upon\\nthe non-hairy portions of the body the disorder is rarely severe if\\npromptly and efficiently treated. Upon the scalp the prognosis is pro-\\nportioned to the extent, severity, and period of prior invasion of the\\ndisease. Early and vigorous treatment of the scalp in healthy children\\nis usually followed by satisfactory results. In long-neglected subjects\\nof the disorder the result may be a remediless and characteristic bald-\\n1 Der prakt. Arzt., February, 1881.\\n2 See paragraphs at the close of the chapter on Ringworm.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0792.jp2"}, "793": {"fulltext": "", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0793.jp2"}, "794": {"fulltext": "PLATE XXIV.\\nFig. 1.\\nPortion of a Hair showing the Mierosporon Audouini.\\n(From]a photo-micrograph.)\\nFig. 2.\\nPortion of a Hair invaded by the Trichophyton,\\nEndo-Eetothrix. x SOO.\\na, a Chains of spores in focus, b A chain situated further within the hair, and hence not in focus.\\n(From a photo-micrograph.)", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0794.jp2"}, "795": {"fulltext": "TINEA TR1CH0PHYTINA. 737\\nness, the affected surface being provided with scanty wisps of stunted\\nand uncolored hairs. Neglect, filth, and systemic malnutrition are the\\nmost unfavorable elements in any case.\\nTINEA TRICHOPHYTINA.\\n(Gr. dpltj, hair vt6v, a vegetation.)\\n(RlNGWOEM.)\\nRingworm is a disease of the hairs and hair-follicles of the scalp\\nand the beard, as also of the non-hairy portions of the body. In each\\ncase it is produced by the presence of a vegetable fungus. Until re-\\ncently all forms of ringworm, both of the hairy and non-hairy portions\\nof the body, were supposed to be produced by a single fungus, the\\ntrichophyton. In 1891 Furthmann and Neebe first advanced the idea\\nthat there were two or more fungi responsible for the various mani-\\nfestations of the disease. Within the last few years a number of in-\\nvestigators, headed by Sabouraud, in a series of researches, have more\\ndefinitely settled the etiological value of these fungi. 1 There are at\\nleast two distinct and unrelated forms capable of producing the\\nappearances classed as ringworm the Microsporon Attdouini, or\\nsmall-spored fungus, and the Trichophyton, or large-spored fungus.\\nOf the latter, several varieties are recognized. The microsporon appears\\nunder the microscope chiefly in the form of a large number of round\\nspores, irregularly grouped or massed about the follicular portion of the\\nhair. Mycelial threads, large and branching, are also seen, chiefly within\\nthe hair. The sheath of spores surrounding the hair is often continued\\nupward about the latter for one-sixteenth or one-eighth of an inch\\nabove its exit from the follicle, and in this situation can be recognized\\nby the unaided eye as a whitish or grayish coating of the hair.\\nThe mycelial threads of the microsporon are all within the hair\\nproper, and after repeatedly dividing and subdividing they terminate\\non the outer surface of the shaft in fine filaments, at the extremities of\\nwhich are the spores, which in this fungus are external. In France\\nthe microsporon is responsible for about 60 per cent, of all cases of\\nringworm of the scalp in children. The fungus is not found in ring-\\nworm of the beard or of the body except in the form of small, irreg-\\nularly outlined, slightly reddened, and furfuraceous patches, occurring\\non the face and neck in children having ringworm of the scalp occa-\\nsionally on the skin of adults who come in contact with such children.\\n1 Sabouraud Les Trichophyties humaines, with Atlas. Paris, 1894. Diagnostic et\\ntraitement de la pelade et desteignes de l enfant. Paris, 1895. Adamson Brit. Jour,\\nof Derm., July, Aug., and Dec., 1895. Morris: Practitioner, Aug., 1895. Ringworm\\nand the Trichophyton. London, 1896. Fox and Blaxall: Brit. Jour, of Derm., July,\\nAug., Sept., and Oct., 1896. Transactions of Third International Congress of Derma-\\ntology, London, Aug. 4 to 8, 1896. Papers by Sabouraud, Rosenbach, and Morris.\\nRosenbach Ueber die tieferen eiternden Schimmelerkrankungen der Haut. Wies-\\nbaden, 1894. Leslie Roberts Brit. Therap. Jour., Sept. 29, 1894. Jour. Path, and\\nBact., Aug., 1895. This observer classifies the fungi according to their ability to digest\\nhorny tissues. M. Fadyen Jour. Path, and Bact., April, 1895. Jamieson: Brit.\\nMed. Jour., Aug. 20, 1893. Bodin: Des Teignes tondantes du cheval et leur inocula-\\ntions humaines. Paris, 1896. Mibelli Annal. de Derm, et de Syph., 1895, p. 733.\\nCharles J. White Jour. Cutan. and Gen.-Urin. Dis., Jan., 1899.\\n47", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0795.jp2"}, "796": {"fulltext": "738 PARASITIC AFFECTIONS.\\nSuch lesions of the skin do not at all resemble ordinary ringworm, as\\ntheir outlines are irregular and ill denned, and they rarely persist for\\nmore than a few days at a time. Iu France the microsporon is rarely,\\nif ever, found in kerion.\\nThe trichophyton is composed of spores which vary greatly in size,\\nbut which, as a rule, are considerably larger than those of the micro-\\nsporon. They are frequently cuboidal, oval, or irregularly rounded\\nbut their chief characteristic lies in the arrangement in lines or chains\\nextending up and down the hair-shaft. The mycelium is found without\\nbut never within the hairs. The trichophyton occurs in three varie-\\nties the endothrix, in which the spores occur wholly within the ecto-\\nthrix, in which the spores are distributed wholly without and the endo-\\nectothrix, in which the spores are partly within and partly without the\\nhair. The endothrix, like the microsporon, is found only in ring-\\nworm of the scalp of children, though it also may produce transient,\\ninconspicuous, irregular, furfuraceous, and slightly reddened patches\\non the face and neck of children affected with this form of ringworm.\\nOn the scalp the endothrix produces lesions which are often distinctly\\ndifferent from those caused by the microsporon. These differences are\\nnoted in the clinical description of tinea tonsurans. The ectothrix and\\nthe endo-ectothrix apparently are derived either directly or indirectly\\nfrom the domestic animals, and are responsible for ringworm of the\\nbody, of the beard, and of all suppurating forms of the disease. By\\nmeans of culture-experiments a number of subvarieties of the tricho-\\nphyton are differentiated, many of which, however, are not generally\\naccepted. These varied appearances are looked upon by some as the\\nresult largely or wholly of differences in the media and circum-\\nstances of cultivation. It is well known that slight modifications of\\nthe culture-media produce marked changes in the character of a fungus-\\ngrowth.\\nIn London, Morris, Fox, Adamson, and others find that the micro-\\nsporon is responsible for more than 90 per cent, of all cases of ring-\\nworm of the scalp in children, and that it also occurs in some cases of\\nringworm of the body, and even in some of the suppurating forms of\\nthe disease, as kerion. The trichophyton is comparatively rare in Lon-\\ndon. On the other hand, Mibelli states that the microsporon is almost\\nunknown in some parts of Italy, and it would seem to be equally rare\\nin some portions of Germany. In Boston Dr. Charles J. White found\\nthe microsporon in 139 out of 279 cases of ringworm examined. The\\ndifferent varieties of these fungi seem to have a definite geographical\\ndistribution.\\nTo prepare a hair for examination, it may be placed between a\\nslide and cover-glass in a solution of potassium hydroxide. Sabouraud\\nuses a 25 to 40 per cent, solution, which is admirable for rapid work,\\nbut which quickly disintegrates the hair. Adamson employs a 5 or 10\\nper cent, solution, which clears the hair slowly in the course of one or\\nseveral hours. By making frequent examinations of the specimen the\\nobserver can arrest the destructive action of the solution at any stage\\ndesired, and thus better preserve the relative position of the fungus to\\nthe hair. Many attempts have been made to stain the fungi, which\\ni", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0796.jp2"}, "797": {"fulltext": "TINEA TRICHOPHYTINA. 739\\nunfortunately show an affinity for the same stains as does the cortical\\nlayer of the hair. A satisfactory method has been devised by\\nMorris and his laboratory assistant, Calhoun. It is a modification of\\nthe Gram and Weigert stain for bacilli, and gives good results. The\\nhair is first washed with ether to remove fatty debris it is then put for\\none or two minutes in the Gram iodine solution, and after drying is\\nstained for from one to five minutes in gentian-violet and anilin-water.\\nIt is again dried and treated for a minute or two with the iodine solu-\\ntion, and for an equal length of time in anilin-oil containing pure iodine,\\nafter which it is cleared with anilin-oil, washed in xylol, and mounted\\nin Canada balsam. Coarse, dark hairs and spores within the hairs\\nrequire more time for staining than do fine, light-colored hairs and the\\nfungus-elements situated without the hair.\\nWhile microscopical examination will often suffice to distinguish\\nthe microsporon from the trichophyton, or even for recognition of some\\nof the varieties of the latter, the finer and often disputed points of\\ndifference can be appreciated only by means of culture-experiments,\\nthe details of which require fuller description than can here be\\ngiven.\\nRecent studies of the ringworm fungus, though interesting from\\nan etiological standpoint, have added little knowledge of practical\\nvalue in treatment of the disease, nor have they furnished a basis for a\\nnew and scientific classification of the different forms of ringworm.\\nAs the several regions of the body, when invaded by the parasite,\\ndisplay lesions which are more or less peculiar to itself, it is usual to\\nconsider each separately. Ringworm of the body is, therefore, desig-\\nnated Tinea Circinata of the scalp, Tinea Tonsurans of the\\nbeard, Tinea Sycosis.\\nTinea Circinata.\\n(Herpes Tonsurans, Ringworm of the Body. Ger., Scheerende\\nFlechte Fr.j Herpes circine, Tricophytie.)\\nSymptoms. Ringworm of the body displays different symptoms\\naccording to the temperature in which the vegetation flourishes and\\nthe various external irritants to which the skin where it has once been\\nimplanted is subjected.\\nThe macular form of the disease is characterized by the occurrence\\nof one or of several pea- to large coin-sized, circumscribed, reddish\\ncircles, usually paling under pressure, often at the general level of the\\nintegument, occasionally slightly raised above it, forming then a flat-\\ntened disk. The centre of the circle may be paler, or indeed to the\\nnaked eye be unaffected, transforming the patch to an annular lesion,\\nfrom which circumstance it originally received the name ringworm.\\nIt develops within certain limits, rarely exceeding five or six inches in\\ndiameter, by peripheral extension and is usually characterized at the\\nouter border by slight, whitish, furfuraceous desquamation. This form\\nof lesion is usually seen upon exposed surfaces of the body where there\\nis less heat, moisture, and friction than upon other parts, as, for exam-", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0797.jp2"}, "798": {"fulltext": "740 PARASITIC AFFECTIONS.\\npie, the forehead and neck in moderate atmospheric temperatures.\\nFrom it may be developed the other forms described below. The\\ndisease may recur within the peripheral border; in this way occasionally\\ntwo, three, or more concentric rings or parallel bands of crescentic\\noutline may be visible in a single patch of disease. Frequently a ten-\\ndency to a peculiar formation, often that of concentric circles, is found\\nin every patch existing at the same time in a given case. It is possible\\nthat the various types are produced by different species of the fungus.\\nThe subjective sensations are a trifling degree of itching or of burning.\\nShould these rings extend to the beard or the scalp, the circinate may\\ncoexist with the other varieties of the disease.\\nThe vesicular lesions of ringworm appear as such at the onset, or\\nthey rise from the macular lesions described above. In the former\\ncase pin-point-sized, transitory, and superficial vesicles or vesico-\\npapules spring from a central point or focus, or speedily shrivel until\\nthey are represented merely by minute, whitish, branny scales. To\\nthese lesions others succeed, always at the periphery, and to these again\\nyet others, the rosy or the reddened base on which they rest being\\nsometimes slightly in advance toward the outlying skin. The enlarg-\\ning circlets of disease proceed in their course to an evolution similar to\\nthat observed in the macular forms. The difference, due to a more\\nactive development of the fungus, is noted not merely in the type of\\nthe lesion, but also in the slightly exaggerated pruritic sensations\\nthat are awakened. Rarely, both of the forms described are pre-\\nsented with acute symptoms and extensive development, in multiple\\npatches spreading over the face, neck, trunk, and extremities, accom-\\npanied by a slight febrile movement and moderate tumefaction of\\nthe affected surfaces. As a rule, the eruption is trifling, and may, in-\\ndeed, be limited to a single ring, or to a few circlets about the neck,\\nterminating in the branny desquamation described but in the severer\\nforms the evolution of the disease may persist for months and crusts\\nform, the fall of which leaves annular pigmentations of temporary\\nduration.\\nThe papular and rare pustular forms of the disease observe the same\\npeculiarities with respect to the clearing of the centre, the annular\\nappearance of the advancing area of involvement, and the production\\nfinally of scales and crusts. They represent, however, either a much\\nmore luxuriant vegetation of the fungus, or the irritation of the affected\\npart by friction and heat, or, what is probable, the cooperation of the\\ntwo. They are, hence, most commonly observed upon the back, the\\nbelly, the intermammary and inframammary regions, and the inner\\nfaces of the thighs and arms, in which localities they occasionally\\noccur with chronic manifestations. The papules are light- or dull-red-\\ndish, pinhead-sized and larger, solid elevations, roundish, oval-shaped,\\nirregular, or confluent, forming eventually bean- to coin-sized, raised\\ndisks with a pale, exfoliating, or actively inflamed centre, the so-called\\nNUMMULAR ERYTHEMA, or DISCOID TRICHOPHYTIC ERYTHEMA of\\nFrench authors. Some of the cases of Conglomerate or Agminate\\nFolliculitis are due to the trichophyton. The itching in these forms\\nis sometimes severe and the process may display central recrudescence,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0798.jp2"}, "799": {"fulltext": "TINEA TRICHOPHYTINA. 741\\nas noted above. Pustules found at the periphery have the size and\\ndistribution of the other lesions described. They represent merely\\nan aggravated exudative process awakened by the fungus and the\\nscratching incident to the pruritic sensations excited.\\nEczema Marginatum, Tinea Trickophytina Cruris. Partly\\nbecause of the controversy which the subject aroused, special attention\\nwas once directed to this variant of the disease which Hebra was first\\nto describe. It is most marked upon those portions of the body which\\ncome in contact with the saddle when a rider is mounted on a horse\\nthat is, the perineum and the inner faces of the thighs, the region\\nmarked by the reinforcing patch in the trousers of the cavalry-\\nman. The disease, as encountered here, occurs in both sexes. It is\\ncharacterized by extensive exudation in bright or lurid patches, with a\\nvery distinctly defined, raised border, showing a sharp contrast with\\nthe healthy skin beyond, from which peculiarity it has its name. It\\nmay extend laterally over the groins upward over the pubes, and back-\\nward over the sacrum, being generally defined at the periphery by a\\ncrescentic outline. The centre may be paler and less involved, or\\nactively irritated, while the periphery still extends in one or more\\nannular festoons down the inner side of the thigh or upward over\\nthe regions indicated. The itching is severe the course of the dis-\\nease is obstinate, persistent, and subject in a remarkable degree to\\n1 relapse in the same locality. The fungus is always present, whether\\n1 occurring as a cause or an epiphenomenon of the disorder. The dis-\\nease was rightly named by Hebra, and it deserves special recognition\\nJ under whatever title it may be classified. It is a true eczema, with\\nspecial features, complicated by the development of the trichophyton,\\nand, as is now well known, often by other representatives of the der-\\nmatological flora. It is aggravated by heat, the moisture of sweat,\\nand the friction of apposed surfaces of the skin in contact with\\neach other and the clothing. After detecting the fungus in scales\\nscraped from the surfaces thus involved, one is always in such cases\\nimpressed with the characteristic clinical peculiarities of the disease.\\nIt is usually of symmetrical distribution, due to the circumstances of\\nits development, and in this respect differs from the other manifesta-\\ntions of the disease. The condition may occur in milder or even\\nsevere forms in the axilla or about the breasts of women or about\\nthe umbilicus. In such cases it is indistinguishable clinically from\\na disorder described by Vidal under the title Circinate and Mar-\\nginate Pityriasis (pityriasis circine et margine), which he regards as\\ndue to the microsporon anomceon, or dispar.\\nTinea Trichophytina Unguium (Onychomycosis). When the\\nnails are affected they become friable, opaque, and lamellated and\\nare clinically indistinguishable from nails secondarily changed in favus,\\neczema, psoriasis, and similar disorders of the integument. One or\\nseveral of the nails of both the feet and hands may be involved.\\nWhen all the nails of both extremities are invaded the disease is rarely\\nof parasitic origin. The microscope is requisite for establishing the\\ndiagnosis in the latter case, the parasite being detected in the frag-\\nments procured by scraping the nail.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0799.jp2"}, "800": {"fulltext": "742 PARASITIC AFFECTIONS.\\nEtiology. Tinea circinata is caused by the presence of the parasite,\\nthough the parasitic invasion may be an accident of other cutaneous\\ndisorders. The trichophyton was first discovered in 1844 by\\nGruby though Malrnsten, whose name is often associated with that\\nof the fungus, became identified with its recognition by his observa-\\ntions during the succeeding year. As a contagious disease it ranks\\nhigher in the scale than favus, being much more readily communicated,\\nand, as a result, much more common. Occurring upon the non-hairy\\nportions of the body, it is often spontaneously removed by the desquam-\\native process which it excites in the skin.\\nThough the fungus is the essential cause of the disease, its develop-\\nment is greatly favored or retarded by external influences. Attention\\nhas already been called to its luxuriance under the influence of heat\\nand moisture. It is, therefore, much more severe and rebellions to\\ntreatment in tropical countries. It occasionally occurs in epidemic\\nforms. Thus, Gerlier 1 gives the details of such an epidemic in Fer-\\nney Voltaire, where twenty-six cases of the disease came under his\\nobservation. In some of these instances the lesions were pustular,\\nin other tuberculo-pustular. Aggravated forms of the disease often\\noriginate in the lower animals, the severest and most rebellious\\ntypes being derived usually from the horse. Tinea circinata oc-\\ncurs much more frequently in children than in adults, presumably\\nfrom the relatively tender condition of the epidermis in these subjects.\\nIt is particularly liable to occur in men whose skins are especially\\nmoistened, as in those who work in atmospheres saturated with steam.\\nSeveral members of a single household will often display ringworm\\nof the body at the same time, having transmitted it the one to the\\nother. The need of an appropriate soil for the germination of the\\nfungus is shown by the fact that some individuals are predisposed to\\nits invasion. It is, however, encountered in both sexes and in all\\nsocial conditions.\\nPathology. The seat of the fungus in tinea circinata is between the\\nstrata of the epidermis, more particularly in the lower layers of the\\nstratum corneum and in the superior layers of the rete. Here the\\ntrichophyton can be recognized with the microscope, at an early stage\\nof the disease, in the form of spores only in the course of a few\\nweeks exhibiting characteristic mycelium. The latter is much more\\nscantily developed than in favus much less branched and articular\\nand the threads more slender. Like the elements in favus, however,\\nthese are jointed and divided into compound cells by partition-walls.\\nThe spores are also often strung like beads on a necklace. The former\\nmeasure 0.0018 to 0.0026 mm.; and the latter, 0.0021 to 0.0035 mm.\\n(Duhring).\\nAfter the fungus has found its way to the surface of the skin favor-\\nable to its development it penetrates the layers of the epidermis in\\nevery direction from the central point of invasion, the circle thus pro-\\nduced being characteristic of many forms in both the higher and the\\nlower vegetable life. The irritation excited by the presence of this\\nforeign body produces all the subsequent symptoms of a mild grade of\\n1 Lyon m\u00e2\u0082\u00acd., April 24, 1881, p. 590, and May 2, p. 7.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0800.jp2"}, "801": {"fulltext": "TINEA TR1CH0PHYT1NA.\\n743\\nsuperficially seated inflammation erythema, exudation, minute vesicles,\\npapules, and, in severe grades, tubercles and pustules. The desquama-\\ntive symptoms represent, in a sense, the natural effort at relief;\\nthis effort, as noted above, being often successful when the spores and\\nsporophores are thrown off with the effete, horny plates of the epi-\\ndermis. When the nails are affected the fungus can be discovered\\nin detritus of the nail-tissue which has been macerated in dilute\\nliquor potassse. Sabouraud states that only the different species\\nof trichophyton, ectothrix pure, or endo-ectothrix, are found in ring-\\nworm of the glabrous skin and of the nails, though the trichophyton\\nendothrix and the microsporon Audouini may be found occasionally\\nin small, irregular, transient, reddened, slightly furfuraceous areas\\noccurring on the face, neck, and other parts of the body during the\\ncourse of ringworm of the scalp.\\nFig. 89\\nEpidermis invaded by trichophyton a, inferior portion of the stratum corneum b. superior\\nportion of the rete. Both exhibit long mycelial threads, with a few ramifications and a small\\nnumber of spores. (Kaposi.)\\nDiagnosis. Ringworm of the body is to be distinguished, clinically,\\nfrom eczema, psoriasis, seborrhoea, lupus erythematosus, herpes iris, and\\nsyphilis. All the varieties of eczema are noted for their greater degree\\nof itching and infiltration, their much less defined border, coarser\\nscales, decided absence of a circular contour and of a history of con-\\ntagion. Psoriasis does occur in circular and annular patches, often\\nwith a clear centre and insignificant, subjective sensations but its scales\\nare lustrous and the tissue beneath them readily bleeds, showing\\ndeeper implication of the skin. The disease is often symmetrical in\\ndisposition occurs by preference upon certain regions of the body\\nwhere ringworm is relatively infrequent and its history is that of a\\nchronic disorder. Seborrhoea of the skin exhibits greasy or fatty crusts,\\nwhich are never characterized by the peculiarly branny scales seen in", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0801.jp2"}, "802": {"fulltext": "744 PARASITIC AFFECTIONS.\\nringworm of the body. (The distinction between these disorders on\\nthe scalp is given under Tinea tonsurans.) Lupus erythematosus is\\noften symmetrical, generally chronic, and is characterized by the develop-\\nment of multiple annular patches, enlarging centrifugally from a clear-\\ning centre. Herpes iris can be distinguished, first, by its predilection\\nfor the extremities second, by the color- variegations which it displays\\nand which are never seen in ringworm of the hands. Syphilis is mul-\\ntiform in its lesions, usually preceded by a history of infection and\\nits distinctly circular patches, enlarging at the periphery, all exhibit\\neither atrophic, ulcerative, or distinctly crusted lesions which suffice\\nfor diagnostic purposes.\\nPityriasis rosea is not characterized by vesicles is often symmet-\\nrical in development occurs in oval rather than in distinctly circular\\npatches and exhibits a characteristic tawny-yellowish shade of color\\nnot seen in ringworm. In eczema marginatum the elevated border and\\ninfiltration of the diseased surface, its situation (groins, armpits, pubes,\\netc.), its curved outlines, and the occurrence of fresh rings within the\\nolder, point to the nature of the trouble, which is practically a coexist-\\nence of ringworm and dermatitis.\\nBut the microscopical discovery of the parasite is the chief, and,\\nindeed, the essential, method of diagnosis in tinea circinata. With\\na good fourth- or fifth-inch objective the spores and mycelium are\\nreadily recognized in the scales scraped from the affected surface\\nand moistened with dilute liquor potassse. Care should be had in\\ndistinguishing the fungous elements from cotton- or wool-fibres, fat-\\nglobules derived from previously applied unguents for the cure of the\\ndisease, sebum, pus, and the nuclei of epithelia. All confusion of this\\nsort can be avoided by a careful study of the anatomical peculiarities of\\nthe trichophyton, recalling especially the parallelism seen in the double\\ncontours of the threads, their jointed appearance, their contained\\ngranules, and the necklace-like or beaded arrangement of many spores.\\nTreatment. The indications in the treatment of ringworm of the\\nbody are the removal of the superficial layers of the epidermis, by\\nwhich means the spores and mycelium are thrown off from the surface\\nand, if possible, the simultaneous destruction of the latter. Upon the\\ndelicate skins of infants and children the simpler remedies are first to\\nbe employed. Scrubbing each patch with spirit of green soap, or merely\\nsoap and water, will often suffice for its obliteration. The topical ap-\\nplication of tincture of iodine is a common and usually an effective\\nremedy. The same may be said of dilute acetic, boric, and carbolic\\nacids, or of a 1 or 2 per cent, solution of formalin. A solution of acetic\\nacid used with or immediately before other parasiticides is said to favor\\npenetration of the latter. Morris s solution of thymol, 1 drachm to 2\\ndrachms (2.-8.) of chloroform and 6 drachms (24.) of olive-oil, is equally\\navailable. One may also use thymol in ointments, drachm (2.) to\\nthe ounce (30.) of simple unguent, with good effect. A 1 to 2 per cent,\\nsolution of formalin is often effective. Of the mercurials, ammoniated\\nmercury, 1 scruple (1.33) to the ounce (30.) of ointment corrosive sub-\\nlimate, 1 to 2 grains (0.066-0.133) to the ounce (30.) of solution and\\n1 Lancet, 1881, pp. 164 and 241.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0802.jp2"}, "803": {"fulltext": "TINEA TRICHOPHYTINA. 745\\nthe ointment of mercuric nitrate, 1 drachm (4.) to the ounce (30.) of\\nvaselin, are valuable. Sulphurous acid, from a freshly opened can, and\\nsaturated solutions of sodium hyposulphite are as eifective as any of\\nthe parasiticides, and are often used with advantage as lotions, to be\\nfollowed by an appropriate unguent, always providing against chemical\\ndecomposition of the ingredients of the latter. Sulphur- and tar-con-\\ntaining lotions and unguents are useful in more obstinate cases.\\nChrysarobin and pyrogallol, in ointment, from 5 to 10 grains (0.33-\\n0.66) to the ounce (30.), are brilliantly effective in all these cases, sub-\\nject, however, to the disadvantage incidental to the staining and irri-\\ntative effects they produce. They should be used with caution upon\\nthe skins of children, and always tentatively at the onset. In cases of\\nringworm of the face of male adults, close to the beard or the scalp, one\\nmay employ these remedies with a view to insure non-invasion of the\\npilary follicles by the fungus, the prompt destruction of which may\\nbecome then a matter of urgency. Wilkinson s ointment recommended\\nby Kaposi is also useful in the treatment of aggravated forms of ring-\\nworm of the body, but it should be restricted to such forms. For other\\nand more urgent reasons potassium hydroxide solutions should be re-\\nserved for exceedingly intractable cases. Sometimes a combination of\\nseveral of the simpler remedies named above may be serviceable, as in\\nthe following formulae\\nR Lac. sulphur., 3ijss; 10\\nSapon. virid. spts., _ 94\\nLavandul. tr., aa 3v J aa\\nGlycerin., 3 SS 2 M.\\n[Kaposi.]\\nR lodin. pur., Jij 601\\n01. picis [sp. gr. 0.853], j 30) M.\\nMix with care, gradually.\\nR Creasoti, tt\\\\,xx; 1\\n01. cadini, f 3iij 12\\nSulphuris prsecip., f giij 12\\nPotass, bicarb., 3j 4\\nAdipis, ^j 30\\n33\\nM.\\nTo be used in obstinate ringworm of adults.\\n[Van Harlingen.]\\nR. W. Taylor applies mercuric chloride, 4 grains to the oiuice\\n(0.26-30.) in tincture of myrrh. Perry, of California, uses the bichlor-\\nide in one-half the strength last named, dissolved in sulphuric ether.\\nFoulis, of Edinburgh, recommends iodine dissolved in oil of turpentine\\nor benzin, the fluids named penetrating with greater ease than others\\nto the deeper portions of the skin.\\nOther articles advised are oleates of mercury and copper, croton-oil,\\n[glacial acetic acid, cantharidal collodion, petroleum, and pyroligneous\\nacid (Thomas).\\nThe thorough application of the remedy selected for use, upon\\nthe integument freed from scales by scrubbing with soap and water,\\nis a matter of importance. When a solution of sodium hyposulphite", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0803.jp2"}, "804": {"fulltext": "746 PAUASITIC AFFECTIONS.\\nis employed, the previous application of vinegar and water by\\nsponging renders the agent more effective, for evident chemical\\nreasons. Over-treated skins, or those to which too strong a parasiti-\\ncide has been applied, require subsequent relief of the induced irrita-\\ntion by the simpler bland dressings. The inert dusting-powders, even\\nwhen not thus indicated, are often useful when there is distinct\\nvesiculation and in simple cases they may be the sole remedies re-\\nquired, as then the disease is self-limited in duration.\\nThe internal treatment of patients affected with ringworm, by means\\nof tonics and roborant measures, may be demanded by the systemic\\ncondition, but it has no recognized influence over the disease itself.\\nWhen the nails are involved, they should be thoroughly scraped\\nand then kept moist by wearing the rubber cots sold for the use of\\nsportsmen, fishermen, and others. In this way a partial maceration of\\nthe nail-substance is secured, and the action of any one of the para-\\nsiticides named above is greatly aided. One of the solutions most\\nuseful in the treatment of the nails is that recommended by Sabouraud,\\ncontaining 1 gramme of iodine and 2 grammes of potassium iodide in\\na litre of distilled water.\\nPrognosis. The disease is often self-limited, and is generally\\nunder the simplest treatment satisfactorily relieved. Eczema margi-\\nnatum, especially in the crural region, may be obstinate, because it is an\\neczema as well as a parasitic disease, and, therefore, subject to the re-\\nlapsed and chronic phases of the first-named disorder. Other intract-\\nable forms of the malady do, however, occasionally occur in adults,\\nusually in tropical climates and tropical temperatures.\\nTinea Tonsurans.\\n(Ringworm of the Scalp, Herpes Tonsurans, Tinea Tondens.\\nGer., Scheerende Flechte Fr., Teigne Tondante.)\\nRingworm of the scalp is a disease chiefly of children, and occurs\\nmost frequently among those congregated in public institutions. The\\ngregarious habits of children and the frequency and intimate character\\nof contacts in their amusements and studies greatly increase the\\nchances of contagion when one of their number is affected with ring-\\nworm of the scalp. As a consequence, the early recognition and\\nrelief of the disease furnish problems among the most imperious pre-\\nsented to the general practitioner as well as to the dermatologist.\\nImportant considerations relating to the segregation and education\\nof children are wrapped up with the question of treatment. Nor\\nshould the physician, examining and giving advice about the scalp of\\na number of children, forget that his hands may transmit the disease\\nto those as yet unaffected.\\nSymptoms. The differences to be particularly noted between ring-\\nworm of the body and ringworm of the scalp depend largely upon the\\nfact that in the latter the fungus makes its way to the hair-follicles\\nand there finds the nutriment for its multiplication and development.\\nThe symptoms usually first observed are circumscribed, small coin-sized,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0804.jp2"}, "805": {"fulltext": "TINEA TRICHOPHYTINA. 747\\nroundish patches upon the scalp, wholly or partly covered with minute,\\nwhitish, slate-colored, grayish, or dirty-yellowish scales. Sometimes\\nthe formation of the scales can be observed as they develop upon a\\nhypersemic and reddened area. Still more rarely, pin-point-sized,\\ntransitory vesicles or pustules precede. The hairs upon such a patch\\nseem irregularly clipped short near the surface or, as it is frequently\\nstyled, nibbled oif, thus producing the effect of partial baldness in\\nthe involved area. Among them may often be found lustreless, dry,\\nlong and fragile hairs, which break upon slight traction or flexion.\\nThe patches may increase in number and spread individually in area\\nuntil, in the course of weeks or months, the entire scalp is invaded.\\nIn the older patches young and downy hairs may here and there be\\nseen, pushing up the stumps left by those that have fallen. One or\\nmore of various phases of the disease may be presented in its subse-\\nquent evolution. Thus, a single patch may extend to the size of that\\nof a large coin or of the palm, and the disease be throughout limited to\\nthat area. Again, as set forth above, almost the entire scalp may be\\ncovered with relatively small or enlarging patches, or, even without the\\nI occurrence of any distinct patch, isolated hairs or tufts of hairs here\\n1 and there over the entire scalp may exhibit evidence of impairment.\\nThe hairs, instead of starting from the patch, may be twisted,\\nimbricated, or matted, and be covered with grayish scales. The disease\\nmay be acute or be chronic in its course. Instead of assuming the dry\\nand squamous type described, acute and exudative symptoms may de-\\nvelop, in which event the rare vesicular and pustular lesions are suc-\\nceeded by the exudation of a gummy secretion and the formation of\\ncrusts. Lastly, there may be produced the variety known as kerion,\\nwhich is described below.\\nPruritus, in various grades of severity, though usually mild, is in-\\nduced by the disease and often the patches are altered in appearance\\nby the traumatisms produced by the finger-nails and the comb. When\\nthe scalp is very generally invaded by the squamous form of the dis-\\norder its appearance is very similar to that noted in diffuse seborrhoea,\\nchronic eczema, and psoriasis of the scalp, except that the hairs are\\nless pasted to the surface are more lustreless, friable, and contorted\\nin shape and much more often are represented by stubble or stumps.\\nThe disease may occur coincidently with ringworm of the body, and\\nindeed at times there may be detected a ring, half of which on the\\nneck presents the typical aspect of tinea circinata, and the other half\\ninvolving the scalp exhibits the features here described.\\nStowers, 1 Sangster, 2 as also Hutchinson, Tay, Hillier, Baker, and\\nothers, have recorded cases in which the disease coexisted with alopecia\\nareata. Geber asserts that after exfoliation of patches of ringworm the\\nscalp may, in cases, become absolutely bald, smooth, and glossy. This\\ncondition may exist from the beginning in the Bald Tinea Tonsurans\\nof Liveing, which is often mistaken for alopecia areata, an error readily\\ncorrected by the recognition of scaling patches with hairs exhibiting\\nunder the microscope evidences of the existence of the fungus. It is\\nto be remembered that in all such persistent scaling patches left after\\n1 Lancet, 1881, p. 326. 2 Ibid., 1880, p. 303.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0805.jp2"}, "806": {"fulltext": "748 PARASITIC AFFECTIONS.\\ntreated or untreated ringworm of the scalp the possibility of contagion\\nis not averted.\\nThe Disseminated Ringworm of Alder Smith affects isolated\\nhairs or small groups of hairs scattered over the scalp, a broken stump,\\nor a group, or a relatively small number, of lustreless, dry, and friable\\nhairs furnishing the only evidence of the disease.\\nRingworm produced by the microsporon Audouini can often be\\ndistinguished clinically from that produced by the trichophyton. In\\nthe former the patches are single or few in number, are rounded\\nor oval in outline, may be of considerable size, are usually slightly\\nreddened and furfuraceous, and are more or less covered with hairs\\nwhich are lustreless, dirty looking, broken off at irregular distances\\nfrom the surface, and easily epilated between the thumb and finger\\nin considerable numbers. Moreover, in this form a grayish or\\nwhitish sheath (composed of spores) is seen encircling each hair\\nand extending from one to three millimetres above its exit from\\nthe follicle. In patches of riugworm produced by the trichophyton,\\naccording to these observers, the patches are much more numerous, but\\nare very small and irregular in outline, and instead of being covered\\nby hairs and broken stumps of hairs, usually show a number of black\\ndots at the mouths of the follicles caused by the breaking of the hair at\\nor beneath the surface of the skin. In this latter form of ringworm\\nthe scalp itself is usually normal or nearly so, scaling not being usual\\nand, instead of forming patches, the disease may affect isolated hairs\\nor small groups of hairs. The disseminated ringworm and the\\nbald tinea tonsurans mentioned above are probably produced by\\nthe trichophyton, and not by the small-spored fungus. It is un-\\ndoubtedly true that the clinical differences mentioned above can be\\nnoted in some cases, and the diagnosis made at once from a simple\\ninspection of the affected areas. In the majority of cases, however,\\nthe clinical features are not sharply marked, and the diagnosis must\\nrest upon microscopical examination, or even upon culture-experiments.\\nLastly, it is to be noted that in tinea tonsurans at times the efforts\\nof nature are successful in obtaining spontaneous relief. With the\\ndefluvium capillitii and exfoliating epidermal plates the fungus may\\nfinally be removed the resulting alopecia be followed by a growth of\\nhealthy pilary filaments and, even though years be required for this\\nlong process, in the end no trace of the disease be discernible.\\nEtiology. Ringworm of the scalp is produced by the fungus recog-\\nnized in the etiology of tinea circinata, the trichophyton, or by the\\nmicrosporon Audouini. 1 Ringworm is frequently observed in children\\nof both sexes, especially in those gathered together in schools and\\npublic charities, where it may spread very generally from one to\\nanother, and require months and years for its extermination. It is a\\nhighly contagious disease, but yet requires unquestionably a suitable\\nsoil for its development. White 2 calls attention to the fact that when\\nthere is ringworm on the face of an adult, even of rebellious form, in\\nthe course of which the beard may extensively be affected, the scalp is\\nusually spared. Ringworm in the scalp of the adult and the aged is,\\n1 See introductory paragraphs on Ringworm. 2 Loc. cit.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0806.jp2"}, "807": {"fulltext": "TINEA TRICHOPHYTINA.\\n749\\nindeed, among the rarest of cutaneous accidents. Among the methods\\nof transmission in children are the use upon the head of the unaffected\\nof brushes, combs, wearing-apparel, sponges, towels, etc., which have\\nbeen employed upon persons exhibiting ringworm of the body or the\\nhead. It must be remembered that tinea circinata may transmit tinea\\ntonsurans and it is by tracing the course of the two forms of the dis-\\nease that the sources of contagion can be ascertained in any series of\\ncases. The disease is one rather prevailing in cities than in the country\\nin this respect it differs from favus.\\nPathology. The disease is produced in consequence of invasion\\nof the scalp and follicles, bulbs, and shafts of the hair by the fungus\\nalready described.\\nUnder the microscope the hairs are seen to be greatly altered\\nin advanced cases (Fig. 90). The bulbs are distorted, misshapen,\\nFig. 90.\\nHair invaded by the trichophyton.\\nor withered, and often stuffed with spores which greatly predomi-\\nnate over the mycelium. At times the base of the bulb will show\\na brush-like expansion, and in this respect resembles the free ends of\\nthe stumps of the hairs above, which have a jagged, bristle-like appear-\\nance, from division of the shaft into many filaments between which\\nspores in abundance are visible. The shaft is often longitudinally split\\nwhere the parasitic growth has mechanically forced apart its elements,\\nand its cuticle may be peeled off or curled above and below away\\nfrom the axis, with spores protruding at such points. Conidia can\\nbe discovered much further upward along the hair and distant from\\nthe scalp than in favus often, indeed, upon its free surface. Occa-\\nsionally a few mycelial threads may be recognized, either longitudinally\\nor transversely arranged as regards the axis. It is probable, however,\\nthat the relative preponderance of spores and mycelium in these fila-\\nments is determined by the stadium of the disease in any given case.\\nIn the earlier stages of the affection the elongated threads may be dis-\\ncovered in larger quantity, and, as they interfere less with the integrity\\nof the fibrous tissue, the hair usually at these times may be extracted", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0807.jp2"}, "808": {"fulltext": "750 PARASITIC AFFECTIONS.\\nfrom its follicle without fracture. Later, the threads disappear and the\\nconidia are infiltrated throughout every portion of the shaft, which\\nthen breaks often upon the slightest traction. One unaccustomed to\\nmicroscopical examinations with a view to the detection of the parasite\\nshould be careful not to mistake for these threads the delicate lines\\nwhich traverse the surface of the shaft exposed to the objective, and\\nwhich represent the edges of the cuticle of the hair. In doubtful cases\\nthe hair should be examined in liquor potassse and after staining by the\\nmethods given in the first pages devoted to the subject of ringworm.\\nThe scales found upon the affected scalp also exhibit traces of the para-\\nsite under the microscope, though to a less extent than the invaded\\nhairs. In exceptional cases, however, the epidermis of the scalp seems\\nto suffer as much as that of the non-hairy portions of the body.\\nAs to the mode of invasion, it is still disputed whether the spores\\nfind access to the fundus of the follicle between the shaft and the\\nfollicular wall, or by penetrating the cuticle of the hair-shaft at the\\nlevel of the epidermis. It is possible that invasion may occur in both\\nways.\\nDiagnosis. The recognition of a typical patch of ringworm of the\\nhead is simple. The branny scales, clumps of hairs, and distinct con-\\ntour of the invaded area are always in the highest degree suspicious\\nsymptoms. It has been stated, however, that the general development\\nof tinea tonsurans over the scalp produces a condition very like that\\nseen in other diseases. In this case the microscope must be employed\\nfor a decision as to the nature of the process. The whole vertex has\\nbeen unnecessarily epilated in seborrhoea sicca when no parasite could\\nbe found but in seborrhoea there is usually a symmetry of involvement\\nwhich even aggravated cases of ringworm of the head fail to assume\\nand even though pasted down, atrophied, changed in color, and loos-\\nened in their follicles, the hairs are rarely broken off near the scalp in\\nseborrhoea. In seborrhoea, psoriasis, and squamous eczema of the scalp\\nthere is, moreover, no history of contagion the scales are in each\\ndisease different in color and character and the hairs in the two affec-\\ntions last named are firmly fixed in their follicles, and only in severe\\ncases present nutritional changes. The diseases, moreover, are usually\\nchronic in their course. In any doubtful case, apart from microscopical\\nevidence, thorough removal of all scales from the scalp by shampooing\\nwith green soap and hot water will reveal the nature of the disease\\npresent.\\nAlopecia areata, as has been noted above, may coexist with ring-\\nworm, but it is pathologically distinct from it. The patches in the\\nfirst-named disease are uniformly smooth, and the hair falls from them\\nen masse without scaling or other traces of previous involvement of the\\nregions affected. Blackish points or dots may, however, be distributed\\nover the areas which characterize this form of alopecia, and which cer-\\ntainly constitute suspicious symptoms in any case. In this event one\\nmay at times be able to pick out with a fine needle this blackish point\\nfrom the patent follicular orifice, and find it to be a particle of dust\\naccidentally lodged in the depression. It is not, as in comedo, free\\npigment that has found its way to the surface nor, as in ringworm, is", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0808.jp2"}, "809": {"fulltext": "TINEA TRICHOPHYTINA. 751\\nit the stump of a hair on a level with the surface of the scalp. In favus\\nthe cup-shaped crust will sooner or later betray the character of the\\ndisease to the naked eye.\\nConfirmatory evidence as to the nature of the disease will often be\\nfurnished by a careful search for the source from which it was derived\\nand for obvious reasons this should always be attempted. Ringworm\\nof the body occurring upon the individual patient affected with tinea\\ntonsurans, or upon other members of the same household, and suspi-\\ncious mangy patches upon horses, dogs, cats, rabbits, white mice, or\\nother animals with which the child may have been in contact, should\\nalways receive attention.\\nTreatment. The indication for the relief of the disease is the de-\\nstruction of the parasite and there can be no question that this may be\\naccomplished in some cases without having recourse to epilation. The\\nparasiticides named in connection with ringworm of the body, if thor-\\noughly applied in simple cases, after clipping or shaving the hair and\\nefficient scrubbing of the patch with spirit of green soap and water,\\nwill occasionally be followed by permanent relief. Prominent among\\nthese parasiticides may be named formalin (1 to 5 per cent, in aqueous\\nsolution), pyroligneous acid, sulphurous, acetic, salicylic, and boric acids,\\nsaturated solutions of sodium hyposulphite, acetum cantharidis, tincture\\nof iodine Crocker s ointment containing thymol, 1 part to 4 Morris s\\nsolution of thymol in chloroform and olive-oil (see Tinea circinata)\\nand ointments of boric acid and sulphur, of each 1 drachm (4.) to the\\nounce (30.) of vaselin, and chrysarobin, the action of the latter being\\ncarefully limited to the patch of disease by the aid of a skull-cap.\\nEpilation, however, is a valuable, and often an essential, method of\\ntreating the disease, and it may be practised as recommended when\\nconsidering the treatment of favus. The scalp in each case should\\nfirst be oiled, and be cleansed by the soap-shampoo, and after the epi-\\nlation is performed an appropriate parasiticide should be employed.\\nThe calotte, made by spreading pitch-plaster upon leather or muslin, is\\na clumsy substitute for epilation in order to remove the hairs, but the\\nsticks recommended by Bulkley may be employed, the formula for the\\npreparation of which has already been given. In each case the epila-\\ntion should remove a zone of sound hairs encircling the diseased patch,\\nthat the encroachments of the fungus may in every possible way be\\n1 limited. It should not be forgotten, however, in the treatment of\\ntinea tonsurans by both epilation and parasiticides that in chronic\\ni cases these methods in the hands of the most expert have failed for\\nconsecutive months to relieve radically the disease that even the most\\ninveterate cases, in the course of time and as adult years are reached,\\nare spontaneously relieved without permanent alopecia and that no\\nremedy or procedure is ever justifiable which is capable of either pro-\\nducing follicular atrophy or an effect worse than that wrought by the\\ndisease itself.\\nCoster s paste is popular among English practitioners, including\\nStowers, Fox, Liveing, and others. It contains 2 drachms (8.) of\\niodine in crystals, dissolved in oil of tar and is painted over the\\npart at intervals of a few days. It is most useful in circumscribed", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0809.jp2"}, "810": {"fulltext": "752 PARASITIC AFFECTIONS.\\npatches of the disease. Among other remedies employed, some of\\nwhich have been described in connection with ringworm of the body,\\nmay be named mercuric chloride, ammonio-chloride, red oxide, oleate,\\nand ointment of mercuric nitrate epispastics pure carbolic acid\\nand carbolated glycerin sulphur, chloroform, ether, tar in ointment,\\nand Wilkinson salve.\\nTo be effectual the treatment pursued must be persistent and thor-\\nough, and always be accompanied by frequent washings and soapings\\nof the affected part.\\nThe induction of suppuration in the hair-follicles (or a species of\\nartificial kerion), by the aid of electrolysis and croton-oil liniment, has\\nbeen praised by Alder Smith and Wyndham Cottle, of London, and\\nlater, in a modified form, by Magee Finny, of Dublin. By the process\\nof Finny, 100 parts of the oil are mixed with 50 each of cocoa-butter\\nand white wax. Sticks are made of this compound which can thor-\\noughly be rubbed into the part affected. By both methods it is claimed\\nthat no pain is produced, nor is permanent alopecia the result. A so-\\nlution of salicylic acid is applied after each treatment, and a subsequent\\npoultice may also be needed. In these cases the parasite is destroyed\\npresumably by the suppuration excited. As in the case of ringworm\\nof the body, tinea tonsurans is not remediable by internal treatment.\\nSuch internal medication, however, may be indicated by the systemic\\ncondition of young patients, and should be in each instance such as\\nthat condition suggests. 1\\nPrognosis. The prognosis in every judiciously treated case of\\ntinea tonsurans is favorable, since all patients ultimately recover\\nfrom the disease per se. Under the best treatment many cases prove\\nextraordinarily tedious, month after month passing without marked\\nimprovement. The disease, however, in a large proportion of cases\\namong children surrounded by proper hygienic conditions, especially\\nas regards cleanliness, is readily relieved.\\nTinea Keeion (Kerion Celsi, from xypiov, a honey-comb).\\nThe occurrence of active and usually circumscribed inflammation in\\na portion of the scalp affected with ringworm is at times followed by\\ncertain peculiar features. This complication of ringworm was recog-\\nnized early in the history of medicine by Celsus, whose name has\\nsince been associated with its lesions. Tilbury Fox, in 1866, was first\\nto recognize its identity with tinea tonsurans and it has since been\\nthe subject of a number of papers by Tanturri, Maiocchi, Schilling,\\nBarduzzi, Auspitz, and Wilson. In the United States Atkinson 2 has\\nmade it the subject of a memoir.\\nThe symptoms are the occurrence of acute inflammation, usually\\ncircumscribed, though occasionally diffuse, in a portion of the scalp,\\nwhere a tumor forms which may project a considerable height above\\nthe general level. In time the appearance presented is suggestive of\\nanthrax benigna, since from the tumid orifices of numerous distended\\nfollicles a viscid, semitransparent, puriform fluid exudes. The latter\\n1 See also paragraphs on page 758.\\n2 Arch, of Derm., January, 1881, vol. vii., No. 1.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0810.jp2"}, "811": {"fulltext": "TINEA TRICHOPHYTINA. 753\\nis characteristic. The hairs loosen and fall. When the view of\\nthe lesion is not obscured by the pilary growth it appears as a\\nflattened hen s-egg- to turkey s-egg-sized, boggy, semiglobular tumor,\\nits surface congested, reddened, glazed, and often exhibiting other evi-\\ndences of inflammation, with split-pea-sized, pustule-like lesions dis-\\ntributed over its surface, or, when these have ruptured, exhibiting the\\ngaping apertures described above, from which a gummy secretion is\\npoured in varying quantities. Modification of this condition occurs,\\nsuch as the production of a true subcutaneous abscess with fistulous\\nsinuses. The sensations awakened are usually painful the course of\\nthe disease is chronic. It may begin with the usual symptoms of ring-\\nworm of the head, though often there is no history of the latter. The\\ncomplication is a rare one.\\nThe parasite may and may not be found in patches of kerion,\\naccording to the acuity of the present or the precedent inflammatory\\nprocess. If the latter be of high grade, and suppuration result, the\\nfungus is destroyed, a result the attainment of which has been at-\\ntempted in the production of artificial kerion by means of croton-\\noil for the relief of tinea tonsurans. In the earlier stages repre-\\nsented by deep-seated follicular inflammation, with pustulation of the\\nhair-shafts, the latter may be seen microscopically to be invaded with\\nspores.\\nThe treatment is either by the milder parasiticides or by the methods\\nproper for the relief of ordinary phlegmonous inflammation of the scalp,\\naccording to the stage of the kerion. The pus-cocci present in some\\nof these cases require boric-acid lotions and bichloride washes.\\nTinea Sycosis; Hyphogenous Sycosis.\\n(Tinea Barbae, Sycosis Parasitica, Mentagra Parasitica,\\nRingworm of the Beard, Barbers Itch. Ger., Para-\\nsitare Bartfinne; Fr., Trichophytie Sycosique.)\\nSymptoms. The disease is best studied at its onset in the beard of\\na blonde subject with relatively fine, downy hairs, where are presented\\nthe typical features of tinea circinata, ringworm of the body. One or\\nseveral, reddish, pea- to small-coin-sized rings become visible, with pin-\\npoint-sized vesicles, branny scales, and often, indeed, no other lesion\\nsave a hypergernic, scarcely elevated margin at the periphery. The\\nhairs over the patch may be fragile, and clusters of pilary filaments here\\nand there betray evidences of change. AVith proper treatment the dis-\\norder may not progress beyond this point.\\nIn some cases the very slight degree of itching awakened by the\\nprocess just described may be intensified, and large plaques form, a\\nportion of which may extend from the region of the beard over the\\nface and neck, or viae versa. When fully developed a phlegmonous\\ndisorder is produced which bears some analogy to the kerion just de-\\nscribed, and which may so actively progress that it is first seen in\\ntypical development. The skin is congested and reddened, with sub-\\nepidermic (or debris of ruptured) pustules at the orifice of the pilary\\nfollicles, and is studded irregularly with firm, pea- to nut-sized papules\\n48", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0811.jp2"}, "812": {"fulltext": "754 PARASITIC AFFECTIONS.\\nand tubercles. The tubercles are usually aggregated in masses or lumps\\nwhich involve the skin and subcutaneous tissue, and they are firm,\\noften tender and painful, rarely boggy and furuncular. When pierced\\nthey give exit to a characteristic, muciform, gluey, yellowish, and sticky\\nfluid, puriform yet differing from pure pus, that rapidly dries into\\ncrusts. These composite lesions are usually circumscribed in a given\\narea of involvement, very rarely covering the region of the beard in\\nsymmetrical disposition, more often limited to one cheek or to the\\ncheek and chin.\\nThe hairs in the invaded region are involved as in ringworm of the\\nscalp. These filaments break near the surface of the integument, leav-\\ning ragged stumps or they spontaneously fall after being loosened in\\ntheir follicles. The ease with which they may be epilated is one of the\\nmost characteristic features of the disease they are slipped out of their\\nfollicles as readily as if they had been oiled or, as Anderson writes,\\nas easily as a pin can be pulled out of a pin-cushion. They are then\\noften whitish because enveloped in the fungus producing the disease.\\nIn either event the resulting gradual thinning or removal of the hairs\\nrenders the disease of the surface more conspicuous and deforming. At\\nthe edge of a patch thus exposed, deformed, lustreless, contorted, flat-\\ntened, twisted, or split hairs may be found. Occasionally the features\\nof the patch are changed in consequence of the unusual degree of sup-\\npuration excited. In this case the pustules burst and their contents\\nconcrete into dry crusts about the stumps of shafts of surviving hairs,\\nfrom which circumstance the disease has received its name (sycosis,\\nauxov, a fig). Rarely, a conglomerate crust covers the entire region\\nwith an excoriated, inflamed, and secreting surface beneath.\\nFormidable cases of tinea sycosis have occurred in the persons of\\nfarmers, where the disease was long untreated and unrecognized.\\nSome severe types of the disease have been produced after shearing\\nsheep having diseased pelts. In these cases the cheeks, lips, and chin\\nare the seat of nut- to fist-sized and larger cutaneous and subcutaneous,\\nsoft, boggy, and pus-filled tumors, accompanied by excessive soreness\\nof the entire throat and neck, the hair falling from the follicles in large\\nmasses, and as if lubricated to facilitate their escape.\\nEtiology. The disease is always produced by the trichophyton. 1\\nWhite, of Boston, has called special attention to the frequency of its\\norigin in the barber-shop, a fact which common experience verifies. It\\nis usually the irregular visitor to these establishments who is first to\\nsupply the germs of the disease. No individual proprietorship in cup,\\nsoap, brushes, and razor can secure against the danger of infection the\\nperson whose razor is drawn over a common strop, whose cheek is\\nhandled by unwashed fingers which have recently been passed over an\\ninfected face, or whose beard is combed, brushed, or rubbed with the\\nimplements and towels in common use at these establishments. The\\nremedy is twofold first, the full beard should be worn without shav-\\ning, as it is rare to find bearded patients of this class affected with tinea\\nsycosis second, where the whole or any part of the beard is to\\nbe removed every adult male should shave himself. The physician\\n1 See introductory paragraph on Ringworm.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0812.jp2"}, "813": {"fulltext": "TINEA TRICHOPHYTINA.\\n755\\nshould, in this connection, for medico-legal reasons be upon his guard\\nagainst hastily deciding both as to the nature of the disease of his\\npatient and the source from which it was derived. Of the first, he can\\nbecome certain by his microscopical investigations of the second, he\\ncan only be sure by obtaining possession of facts far beyond the reach\\nof the average practitioner. A medical gentleman once sent for exami-\\nnation some hairs from the beard of a male patient affected with tinea\\nsycosis. Before receiving a report confirming the diagnosis this phy-\\nsician was sued by the barber in whose establishment the disease had\\nbeen probably acquired, on the ground of libel.\\nIt is difficult to determine the frequency of the disease from sta-\\ntistics. The affection is certainly relatively rare, yet more common\\nthan is often supposed to be the case. It is of somewhat irregular\\noccurrence, months often passing without a case coming under obser-\\nvation, after which several may be noted in rapid succession.\\nFig. 91.\\nFilaments and spores of the trichophyton from the beard of a patient affected with tinea sycosis.\\nThe disease, being contagious, is one affecting men in all stations\\nof life, and these usually at a period rather under than over the fortieth\\nyear. More men with light hair and eyes, and light-brown, reddish,\\nor sandy beard are affected than those having darker shades of hair\\nand eyes. Morris has called attention to the fact that tinea tonsurans 1\\noccurs more frequently in blonde than in brunette subjects.\\nPathology. The disease is essentially a follicular and perifollicular\\ninflammation induced by the irritative effects of the fungus, precisely\\nas in the case of tinea tonsurans. The difference between the clinical\\naspects of the two diseases may be explained in part by the habitual\\ncovering of the scalp with caps and hats while the face is left exposed\\nand by the occurrence of tinea sycosis in adult years, while tinea ton-\\n1 Lancet, 1881, pp. 164 and 241.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0813.jp2"}, "814": {"fulltext": "756 PARASITIC AFFECTIONS.\\nsurans is predominantly a disease of childhood. As a result of the\\ninduced inflammation, vesicles, pustules, papules, and tubercles are\\nformed, while the perifollicular inflammation may invade all portions\\nof the skin and subcutaneous tissues, gluing together the plastic nod-\\nules formed about the individual hair-sacs into the lumpy masses char-\\nacteristic of the disease. The invasion of the hair-follicles and hairs\\nby the fungus is accomplished as in the case of ringworm of the scalp.\\nUnder the microscope spores and mycelium are visible, the forms pre-\\nponderating at the time when the disease first comes under observation,\\nbut probably preceded in most cases by abundance of thread-like forms.\\nThe identity of the disease with some forms of ringworm of the body\\nand scalp does not, however, rest merely upon microscopical observa-\\ntion, but is demonstrable by established clinical facts. Not only may\\nringworm be seen to spread from the face to the beard, but tinea ton-\\nsurans and tinea circinata may also transmit tinea sycosis, and the\\nreverse. A physician had ringworm of the bearded chin and cheek\\nderived from the face of a child under his care. He subsequently\\ngave tinea circinata to his wife, who suffered on the face and shoulder,\\nand she, in turn, communicated tinea tonsurans to her daughter. 1\\nDiagnosis. The distinction between coccogenous and hyphogenous\\nsycosis is of chief importance in this connection and, necessarily, the\\nmicroscope must be employed to settle the question definitely. The\\ndiseases, however, differ in their clinical features. The coccogenous\\nform always fails to exhibit the nodules, tubercles, and composite cuta-\\nneous and subcutaneous agglutinations of the disease produced by the\\nfungus. The process in the former is more superficial, and it exhibits\\nto the eye a more vivid redness as a result of the cutaneous hyperemia.\\nOwing to the same cause, the frequent pus-containing lesions are de-\\nveloped and elevated above the general level of the integument they\\nare less commonly subepidermic crypts filled with characteristic mucoid\\npuriform contents. The region of the bearded upper lip, so often\\ninvolved in cases of nasal catarrh, is often spared by the tri-\\nchophyton. When this parasite is present the hairs are characteris-\\ntically loosened, distorted, and otherwise changed. This condition\\nis not seen in the coccogenous disease exception, however, in this\\nparticular is to be noted in some long-standing cases of the latter.\\nWhen the affection has persisted for many years (and one may often\\nsee patients thus affected) the thinned and starved condition of the\\npilary growth is a striking symptom, the scanty lustreless hairs\\noften scarcely sufficing to conceal the deforming redness and pustula-\\ntion of the surface from which they spring. The diffuse symmetrical\\naffection of the hairy face, extending over both cheeks and chin, is\\nmore frequently connected with the presence of pus-cocci. Lastly, the\\nhyphogenous, as a rule, is less painful and tender than the other form\\nof sycosis, and, furthermore, is, without question of rarer occurrence.\\nWith respect to syphilis, it is to be noted that the papular or the\\npustular syphiloderm developed in the region of the beard is, almost\\nwithout exception, to be discovered in other parts of the body, especi-\\nally the scalp. Ringworm of the scalp and the beard existing at the\\n1 See introductory paragraphs on Ringworm.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0814.jp2"}, "815": {"fulltext": "TINEA TRICHOPHYTINA. 757\\nsame time in one individual is rare. In syphilis there is usually an\\noffensive odor to the abundant crusts shallow ulcers are also prone\\nto form beneath the pustules and there is often a history of infection\\nor a hint of the nature of the disease in its polymorphic character.\\nEczema of the bearded region may extend to or from other portions\\nof the face, as in a case in which it sweeps -from the ear above. The\\npresence of a stalactitic crust depending from the lobe of the ear of\\nan affected side would at once furnish a clue to the nature of the\\ndisease in the beard. In eczema the interfollicular region is invaded,\\nnot deeply, as in tinea, but superficially, as in coccogenous sycosis.\\nThe itching is severe the hairs are not involved the infiltration is\\ndiffuse the outline is indeterminate and a halo of redness spreads\\nfrom the affected part to the non-hairy surface in the vicinity.\\nTreatment. The treatment of tinea sycosis is generally conducted\\nas in tinea tonsurans. It is customary to begin by anointing the\\naffected surface with an oily or fatty substance, and to follow this with\\na shampoo of soap and warm water for the removal of crusts, after\\nwhich shaving and epilation are practised on alternate days and para-\\nsiticides employed locally. For softening the crusts the spray of an\\natomizer may be used.\\nEpilation of the male beard is often essential for removal of the\\ndisease, but the results of the treatment suggested below in the end\\nmay be satisfactory.\\nThe patient for two successive days keeps the affected part macerated\\nwith almond- or olive-oil. On the evening of the third day the sham-\\npoo with soap is employed, and the skin is washed free from crusts and\\nscales. The part is then cleanly shaved. This operation is at first\\npainful, but gradually becomes less distressing. After shaving, the\\naffected surface is bathed for ten minutes with borated water as hot as\\ncan be tolerated, by which means the inflammatory condition of the\\nperifollicular tissues is, in a brief time, considerably reduced. While\\nthe bathing is in progress all subepidermic pustules or points where a\\nmucoid fluid is coming to the surface are opened w T ith a fine aseptic\\nneedle. A solution of sodium hyposulphite is then sponged freely\\nover the affected surface for several minutes and allowed to dry\\nthis solution may contain 1 drachm (4.) to the ounce (30.), or even\\nmore. After a thorough and final washing with hot water the tender\\nskin is carefully dried and gently smeared with a sulphur ointment\\ncontaining 1 to 2 drachms of sulphur (4.-8.) to the ounce (30.) of\\nvaselin, often with the addition of from J to J (0.016-0.033) grain of\\nmercuric sulphide. The patient then retires to bed. In the morning\\nthe unguent is washed off with soap and water, the sodium-solution\\nis reapplied, and a borated or a salicylated powder is thoroughly dusted\\nand kept over the part during the day. In the evening the shaving\\nmay be repeated or not, according to the vigor with which the beard\\nis reproduced, but on the second day shaving is imperative. As soon\\nas the pustulation ceases and the tubercles have manifestly diminished\\nin size the ointment at night is superseded by the use, at that time\\nalso, of the dusting-powder. Whether the shaving is practised nightly\\nor on alternate nights, ablution with very hot water and with solution", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0815.jp2"}, "816": {"fulltext": "758 PARASITIC AFFECTIONS.\\nof sodium hyposulphite is continued nightly until the inflammation\\nexcited by the fungus is practically limited to the follicles that are\\ninvaded. The dusting-powder is to be thoroughly and constantly\\nemployed after the ointment is discontinued. With care and patience\\nthese measures may save many patients the annoyance of epilation\\nand they should be continued for several weeks after apparent relief\\nof the disease.\\nThe treatment may be varied to suit the needs of individual cases.\\nKaposi highly recommends, for example, 1 per cent, solutions of cor-\\nrosive sublimate locally and the other parasiticides considered here-\\ntofore in connection with the treatment of ringworm may serve also a\\ngood purpose. In some cases an ointment of thymol may be used with\\nmanifest advantage in others, a substitute may be found in Morris s\\nsolution of the same in chloroform and oil (the formula for this has\\nalready been given). In still other cases spirit of green soap with\\nsulphur, finely powdered sulphur, boric, acetic, and carbolic acids, or\\nother topical applications of recognized value may be employed.\\nWhen resort is had to epilation, and this is essential in all severe\\ncases, the hairs should be thoroughly removed from their follicles over\\nevery lumpy nodule, and even over every suspicious patch covered\\nwith scales. A zone should be cleared about each such papule. The\\nresults are prompt and in the highest degree satisfactory.\\nPrognosis. This disease is always remedied sooner or later, though\\nit is at times tedious in its progress and characterized by relapses.\\nPrecautions to be Observed in the General Management of\\nTinea Favosa and Tinea Trichophytina. The physician consulted\\nin the case of a patient affected with either of the diseases thus far\\nconsidered as resulting from the presence of a vegetable parasite should\\nbear in mind that they are the most contagious of their class. He may\\nnot only himself suffer from the disease which he is attempting to\\nrelieve in another, but may also convey it to others, or be consulted\\nby others of his patient s family actually infected during the course of\\nthe treatment pursued.\\nGenerally, it may be said that the hands of the physician should\\ncarefully be washed after each manipulation of the part, and preferably\\nwith a weak disinfecting solution. In the case of children the lining\\nof all caps, hoods, and other coverings of the head should be removed\\nand destroyed by burning and fresh linings made of tissue-paper re-\\nnewed daily while paper-caps of the same or of similar material should\\nbe worn when indoors. Brushes, combs, towels, and articles of cloth-\\ning should never be used in common by two or more individuals.\\nWhen practicable, infected individuals should occupy separate beds\\nand the bed-covering, clothing, toilet-apparatus, and dressing or other\\nmaterials which have been in contact with a diseased surface should be\\nimmersed in boiling water before they are again employed for any use\\nin common. Thin recommends covering every diseased patch, after\\nthe treatment appropriate to itself, with an adhesive and impermeable\\ndressing, for the sake, not of the patient, but of those with whom the\\nlatter may be brought in contact and the suggestion is both wise and", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0816.jp2"}, "817": {"fulltext": "TINEA IMBRICATA. 759\\npracticable. A man infected with ringworm of the beard in a barber-\\nshop which he has visited but once, will often, when directed by his\\nphysician to shave, resort to some other establishment, where he is well\\nknown, and where he has more confidence in the cleanliness of the\\noperators. In this way he often thoughtlessly spreads the disease of\\nwhich he is the victim. It is well to send patients who cannot shave\\nthemselves to a particular barber, who, being instructed in the manner\\nof shaving so as to insure immunity, generally fails to spread the\\ndisease in any case.\\nTINEA IMBRICATA.\\n(Tokelau Ringworm, Burmese Ringworm, Bowditch-island\\nRingworm, Lafa Tokelau, La Peta, Cascadoe, Gune,\\nHerpes Desquamans. Fr., Herpes Tonsurans Desqua-\\nMATIF.)\\nThis disorder was first described in 1844 by Fox, and has since\\nbeen studied by Turner, Manson, MacGregor, and Roux. One of the\\nbest clinical descriptions is given by Crocker.\\nSymptoms. The disease is first declared, after artificial inoculation,\\nby a period of delay incubation lasting about nine days, after\\nwhich minute reddish points appear, arranged for the most part in\\nsemicircles, the former rapidly developing into papules producing an\\nintolerable pruritus. The growth thenceforward is reported to be at\\nthe rate of from five to ten millimetres each week. In a brief time\\nlamellae of epidermis are detached, their free border being directed to\\nthe centre of the circular disk, the patch or patches when fully de-\\nveloped being represented by concentric rings, about five millimetres\\napart, suggesting a resemblance to watered silk. The scales may be\\nas large square as half a centimetre, with curling edges Avhich later\\nbecome horny and much darker in color. It is said that the hand\\npassed over such patches from the circumference to the centre recog-\\nnizes a smoothness of the surface, but when the motion is reversed,\\nfrom centre to periphery, the scales are raised and resist the fingers.\\nThe appearance of the older patches suggests a skin covered with\\nclay. The process of production of the concentric rings is reported\\nto be, first, by the elevation of a central point of the epidermis and\\nthe formation there by the fungus of a brownish mass then by sep-\\naration of the epidermis at the central point, with persistence for a\\ntime of attachments at the border then by liberation of the attached\\nedge by friction or otherwise and finally by exposure of the corium.\\nJust beyond this line a brownish rim declares the line of advance of\\nthe fungus beneath the epidermis. When the ring thus formed has\\nattained a diameter of about five millimetres, a brown point again\\nappears centrally, and there is a repetition of the process originally\\nobserved in the primary ring.\\nAll portions of the body may be affected but the scalp and face\\nseem usually to be spared when the hairy parts (scalp, pubes, axillae)\\nare involved the disease spares the follicles, and its management is\\nthus declared to be correspondingly facile. Though the hairs them-", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0817.jp2"}, "818": {"fulltext": "760 PARASITIC AFFECTIONS.\\nselves are not invaded, they are said to fall when the disease extends\\nover the hairy regions of the body. When the disease spontaneously\\ndisappears from any portion of the integument there are left persistent,\\ndeep-colored rings or circles where the scaling originally occurred.\\nEtiology. The disease is always produced by contagion it occurs\\nat all ages and in both sexes, especially in children and is chiefly\\nencountered in tropical climates.\\nPathology. According to Koniger (who was not a dermatologist)\\nand Manson, the disease is produced by a special fungus, the tinea\\nimbricata, which invades the epidermis without involving the hair-\\nfollicles, its oval or rectangular spores being more numerous than the\\nmycelium, while the threads are long, straight, or gently curved. It\\nis not yet determined that this parasite is not a development of the,\\ntrichophyton peculiar to certain tropical regions but Manson s state-\\nment, that inoculation of the same individual with both tinea imbricata\\nand tinea trichophytina produces each disease separately, seems toler-\\nably conclusive on this point.\\nThe Diagnosis from Giant Ringworm, Boatman s Ringworm,\\nDhabie s Itch, Majee s Dad forms of trichophyton as it occurs\\nin luxuriant vegetation upon the smooth portions of the body in\\ntropical countries is readily made. In these forms of ringworm the\\ncentral area clears, while in tinea imbricata the central part of the\\npatch is made up of concentric rings.\\nTreatment. The scales are readily removed with soap and water\\nor by alkaline baths, and chrysarobin, pyrogallol, or iodine ointment is\\nwell rubbed into the part. In some cases strong lotions are employed\\nof the same chemical constitution.\\nThe Prognosis is favorable.\\nTINEA VERSICOLOR.\\n(Pityriasis Versicolor, Dermatomycosis Furfuracea, Mycosis\\nMicrosporia, Chloasma. Ger., Kleinenflechte.)\\nSymptoms. The eruption in this disorder occurs in the form of\\nfew or of many, irregular, roundish, circumscribed or reticulated\\nmacules, pinhead- to small-coin-sized, rarely occupying an area the\\nsize of the palm or larger. In color it varies from the most delicate\\nbuff or fawn shade to a reddish, deep-brown, and even blackish hue.\\nThe surface of each lesion, when closely inspected, is usually seen to\\nbe covered with furfuraceous scales. If the scales are not visible,\\nslight erasion with the finger-nail or the curette will demonstrate the\\nfact that the superficial layers of the stratum corneum are, in the site\\nof each lesion, readily separable from the tissues beneath. The eruption\\nis most common upon the anterior surface of the thorax but it is also\\ndisplayed upon the neck, the dorsum, the abdomen, and the other\\nregions of the trunk, and the flexor aspects of the upper extremities\\n(the hands only excepted). It is rarely seen upon the lower extremi-\\nties still more rarely on the face never on the hands and feet. The\\neruption is either unproductive of sensation or is accompanied by a\\nmild pruritus. Patients usually declare that after profuse sweating,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0818.jp2"}, "819": {"fulltext": "TINEA VERSICOLOR. 761\\nbathing in warm water, or brisk friction of the surface minute epi-\\ndermal rolls separate from the affected area. The disease may linger\\nfor years upon the surface of the body.. It has a special tendency in\\nsusceptible individuals to recur after removal.\\nThe eruption is occasionally encountered in extreme development.\\nIn a young married woman who had been the subject of the disease for\\nmany years the entire trunk, the axillse, the groins, the upper portion\\nof the thighs, the neck to the level of the high collar worn, and the\\nupper extremities to the wrists, were encased in a uniform sheet or\\ncuirass of chocolate-tinted epidermis in a condition of exfoliation in\\nfinger-nail-sized lamellated flakes. Even in these extreme cases the\\ntendency of the disease to avoid surfaces exposed to the light is dis-\\ntinctly manifested. Unna l describes an anomalous feature of the dis-\\nease, in which the maculations occur in annular form with a clearing\\ncentre. Rarely, also, a very few irregularly distributed macules may\\nbe seen as the sole evidences of the existence of the parasite. Thus, a\\npatient may exhibit a small-coin-sized patch on the surface of the chest,\\nanother on the shoulder, and possibly a third over the deltoid region\\nof one arm. These are generally cases partially relieved of a more\\ndiffuse eruption. More commonly the slightest manifestation of the\\nmalady is an irregular, vertically arranged, somewhat narrow band of\\nlesions immediately over the sternum, and visible beneath the hairs of\\nthat region in the adult male, or upon the intermammary sulcus of\\nwomen. The face, hands, palms, soles, hairs, hair-follicles, and nails\\nare usually exempt.\\nEtiology. The disease is produced by a vegetable mould, discov-\\nered in 1846 by Eichstedt, to which Robin gave the name Microsporon\\nfurfur. In capabilities for contagion it is far inferior to the vegetable\\nparasites already described, and it illustrates well a point to which at-\\ntention already has been directed, viz., that these fungi flourish only\\nin soils suitable for their germination and fructification. Members of\\none family are said to communicate the disease occasionally, the one\\nto the other and Lancereaux 2 reports that in this way he accidentally\\ninfected himself from scales collected for examination from a patient\\nin hospital, and afterward unwittingly transmitted the affection to his\\nwife. The disease occurs in both sexes, rarely before puberty and after\\nmiddle life, and in persons of every social condition, irrespective of\\npersonal cleanliness. It is exceedingly common, more so, indeed, than\\nstatistics are capable of demonstrating, inasmuch as hundreds who are\\nannually annoyed by it never seek professional advice. In physical\\nexaminations made with a view to the enlistment of men for military\\nservice, as also of government pensioners, the disease is often recog-\\nnized upon the persons of those who pay no attention to its pres-\\nence. Being concealed by the clothing and unproductive of much dis-\\ncomfort, many subjects of tinea versicolor endure its presence with\\ncomplacency.\\nBy some it has been supposed that the fungus selects the chest of\\nthe phthisical as its habitat, a supposition doubtless based upon the\\n1 Vierteljahr. f. Derm. u. Syph., 1880, Nos. 2 and 3.\\n2 Traite d Anatoraie pathol., xi., p. 265. Paris, 1875.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0819.jp2"}, "820": {"fulltext": "762\\nPARASITIC AFFECTIONS.\\nfact that tuberculous men and women, more than all others, expose\\nthe chest to the view of medical men in order to permit of its auscul-\\ntation and percussion.\\nPathology. The Microsporon Furfur (Fig. 92) is readily recog-\\nnized with the aid of the microscope, as it exists in luxurious profusion\\nupon every affected surface. The scales may be scraped from the skin,\\nand at once be examined, when innumerable clustered spores and short\\nthreads become visible the former highly refractive and resembling in\\ntheir circular and oval contours droplets of oil. Their aggregation in\\nclusters is distinctive of this among the other forms of cryptogamic\\nvegetation. They measure 0.0023 to 0.0084 mm., while the hypha?\\nvary in diameter from 0.0015 to 0.0038 mm. (Duhring). Among the\\nlatter, sporophores are distinguishable, with contained conidia and\\nFig. 92.\\nMicrosporon furfur. (After Kaposi.)\\nterminal elements emerging at one extremity or the other of the spore-\\ncase. Both elements are more readily stained by eosin and methyl-\\nviolet than those of the trichophyton or of favus.\\nOne of the strongest arguments against the claim for the identity\\nof all the vegetable parasites is furnished by the history of this inter-\\nesting mould. It never by any possibility invades the hairs or the\\nhair-follicles, though it may be seen flourishing at the orifice of a fol-\\nlicular duct, and even beneath a vigorous pilary growth upon the chest\\nof a male subject. It avoids light and air and singularly refuses to\\nencroach even upon certain covered portions of the body, preferring, in\\nits extreme development, to linger unobtrusively at the neck near the\\nverge of the collar.\\nDiagnosis. In this disease, as in all parasitic affections of vege-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0820.jp2"}, "821": {"fulltext": "TINEA VERSICOLOR. 763\\ntable origin, the microscope may be required to decide the diagnosis\\nin any case in which doubt arises. In its simpler manifestations the\\nrecognition of the affection is readily assured. The location of the\\neruption, its irregular reticulations, its characteristic yellowish or fawn-\\ntinted shades of color due to the nature of the fungus, and the exfolia-\\ntion of the epidermis which it excites by its superficial penetration of\\nthe outer layer of the stratum corneum, producing thus a mealy, branny,\\nflaky, or roll-like exuvium, are all significant. None of the chloas-\\nmata due to pigment-changes in the skin, however much they may\\nresemble tinea versicolor in color, share with it this peculiarity of des-\\nquamation. Chloasma may involve, moreover, the face tinea versi-\\ncolor almost never. Vitiligo occurs upon the scalp tinea versicolor\\nvery rarely. The macular syphiloderm may be mistaken for the dis-\\nease under consideration, but, when developed to such an extent as to\\nrival tinea versicolor in its diffuseness, the syphiloderm will creep out\\nover the face, the hands, and the feet, and will be accompanied by\\nadenopathy, alopecia, mucous patches, palatine hyperemia, or will fur-\\nnish evidence of a polymorphic tendency. Often, indeed, with such\\nan eruption, the survival of the initial sclerosis will at once betray the\\nnature of the disease. These are important considerations, since in the\\nmere matter of subjective sensation, color, shape, and size of lesion\\nthere may be marked resemblance between the two. Patients exhibit-\\ning the lesions of tinea versicolor may suffer from syphilis and many\\nhaving the former disease, in consequence of a suspicious exposure\\nbelieve they are infected with lues, and yet indeed are not. These\\nincidents serve to illustrate the importance of making an accurate diag-\\nnosis in every case of cutaneous disease.\\nThe most common error committed in this connection, however, is\\nbased upon the fancied resemblance in color between the patches of\\ntinea versicolor and either the liver itself or the color-changes which\\ndisease of that viscus is capable of producing in the skin. The exist-\\nence of liver-colored spots in the skin is, hence, erroneously attrib-\\nuted to hepatic disease. Few patients consult physicians for relief of\\nthis disorder who have not a belief in the internal origin of the disease.\\nTreatment. A single method of relieving tinea versicolor is recom-\\nmended for the simple reason that it invariably is successful. It\\nrequires merely vigorous and intelligent cooperation on the part of\\nthe patient. A hot bath is taken, if possible, for three nights in suc-\\ncession, and when the surface is well macerated in hot water the\\naffected skin is scrubbed either with the cheap yellow soap of the\\nshops, or with sapo viridis in substance or in tincture. When the\\ndisease is extensively developed this process is aided by friction with\\na flesh-brush or with a coarse towel. The skin is then washed clean\\nwith a surplus of hot water, and dried, after which the affected patch\\nis first moistened with vinegar and water, or dilute acetic acid, and\\nafterward well sponged with a solution of sodium hyposulphite, 1\\ndrachm (4.) to the ounce (30.) being usually sufficient. As a rule,\\nthe greater part of the eruption is removed with the third application.\\nIf there be recrudescence in isolated patches, as is often the case, or\\noutlying areas which have withstood the parasiticide employed, they", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0821.jp2"}, "822": {"fulltext": "764 PARASITIC AFFECTIONS.\\nshould subsequently be attacked with a solution of mercuric chloride,\\n1 to 2 grains (0.066-0.133) to the ounce (30.). Other measures, how-\\never, are popular with physicians, and among them may be named the\\ntopical use of boric, carbolic, or sulphurous acid tincture of iodine\\nsulphur in bath, ointment, or lotion calomel in ointment the alkalies\\nin bath or lotion potassium sulphide in bath chrysarobin, pyrogallol,\\ntar, Wilkinson s salve, and the other parasiticides employed in the\\ntreatment of ringworm of the body. The inner clothing should not be\\nworn after treatment until it has been immersed in boiling- water.\\nThe following formula is also recommended\\nR\\nHydrarg. chlorid. corros.,\\nSaponis viridis,\\nSpts. vin. rectif.,\\n01. lavandul.,\\nRj;\\nf3j;\\nl\\n60\\n120\\n4\\n33\\nM.\\n1 Anderson\\nPrognosis. The disease can readily be relieved by simple treatment.\\nRelapses often occur, and require to be radically treated. Untreated,\\nthe disease may continue for years without the slightest impairment of\\nthe general health. It is probable that when untreated the parasite\\nundergoes spontaneous exfoliation in advanced years, a period when\\npresumably the fungus fails to find in the epidermis the nutriment upon\\nwhich it thrives.\\nERYTHRASMA.\\n(Gr. epvdpdc, red.)\\nBurckhardt first described this disorder in 1869, but it received its\\nname in 1862 from von Baren sprung. It has since been studied and\\ndescribed by Balzer, Riehl, Koebner, Pick, and others.\\nSymptoms. The disease first appears in punctiform to palm-sized,\\nroundish, definitely circumscribed maculations, presenting a sharp con-\\ntrast in color with that of the adjacent integument. This hue varies\\nsomewhat according to the location of the patches. The younger lesions\\nmay exhibit a vivid redness over the entire macules or over their borders\\nonly. The older lesions exhibit a yellowish or a brownish tinge. These\\ncolors are compounds of ordinary erythematous redness and yellowish\\nor brownish discoloration of the horny layer of the epidermis.\\nThe macules are circular or rosette-shaped, or they display very irreg-\\nular outlines. They are not raised to any extent above, the general\\nlevel of the skin, though the finger passed over the surface can recognize\\na slight elevation of the border, due to hyperemia, and subsequent\\nmoderate, flour-like furfuraceous desquamation, most conspicuous also\\nat the periphery. Vesiculation and papulation do not occur. The\\ncolors recognized in different patches may be light reddish-brown, pale\\nreddish-yellow, and light or dark orange.\\nThe eruption is most commonly encountered where apposed surfaces\\nof the skin come in contact, as in the axilla?, the groins, the cleft of\\nthe anus, and the regions where the scrotum touches the thigh it\\noccurs, however, in typical expression on both sides of the chest. The\\neruption spreads slowly and in serpiginous outline until the affected", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0822.jp2"}, "823": {"fulltext": "EBYTHBASMA.\\n765\\nsurfaces are completely invaded. It is much more chronic in its course\\nthan the other dermato-mycoses, lasting for months and years without\\napparent change.\\nEtiology. Erythrasma is produced by the growth, in the superficial\\nlayers of the epidermis, of the fungus described below. Men are much\\nmore often affected than women children not at all. The youngest\\npatient whose case is recorded was sixteen years old the oldest,\\nfifty-five.\\nPathology. The fungus termed Microsporon Mixtjttssimum\\n(Fig. 93), to which the disease is attributed, is chiefly remarkable for the\\nextraordinary delicacy and fineness of its threads and its very minute\\nspores. The threads are either simple cylindrical bodies of variable\\nsize, or they may exhibit partition-septa they may divide dichotomously,\\nFig. 93.\\nMicrosporon minutissimum, from patches of erythrasma.\\nand may terminate in hooked or knobbed expansions. They are inex-\\ntricably interwoven when occurring in large masses. The largest\\ntransverse diameter is 0.6 p. in length the mycelium presents the\\ngreatest variation. Bacteria and heaps of zoogloea are visible among\\nthe scales. The granules are piled into irregular heaps, according to\\nBurckhardt, and they give a dusty appearance to the epidermal cells\\non which they lie often the outline of these granules is indistinct.\\nAccording to the same observer, the breadth of the hyphse is yjVo mm.\\nand the length from y 1 to ^J-^ mm.\\nPasquale de Michele 1 discovered the leptothrix in cases of supposed\\nerythrasma and this is but another of the proofs that in all diseases\\nof this class, as in so-called eczema marginatum/ there are few in-\\nstances in which a single mould-fungus develops on the body-surface.\\n1 Annal. de Derm, et de Syph., 1891, p. 776.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0823.jp2"}, "824": {"fulltext": "766 PARASITIC AFFECTIONS.\\nThe entire flora deriuatologica of Unna may be effective in more cases\\nthan is commonly believed.\\nDiagnosis. From all ordinary chloasmata and pigment-macules the\\nspots of erythrasma are distinguishable by the ease with which the\\nsuperficially embrowned epidermal layers are removed by erasion.\\nTinea versicolor is distinguished from erythrasma with greater difficulty\\nbut the latter occurs in different situations by preference, its patches are\\nmore vividly red, and the parasite, under the microscope, presents\\ndistinctive features.\\nThe Treatment is that of tinea versicolor and the Prognosis is\\nfavorable, subject to the disappointments arising from frequent relapses.\\nLA PERLECHE.\\nUnder this title, Justin Lemaistre l describes a contagious disease\\nobserved by himself in more than three hundred children of Limoges.\\nIt is not rarely recognized in the skin-clinics of the Paris hospitals.\\nThe malady is characterized by dryness, smarting, cracking, and exco-\\nriation of the lips, the epithelium of which becomes blanched, mace-\\nrated, and readily detached. Hemorrhagic and painful fissures form\\nin the direction of the commissural folds. Often plaques are visible,\\nsuggesting mucous patches. The disease lasts for from fifteen days to\\na month, with possible recurrence which may lead to a year s suffering.\\nThe disease is of parasitic origin, communicated by drinking from\\ncups used by infected persons. Lemaistre attributes the disease to a\\nstreptococcus plicatilis which he has cultivated in Pasteur flasks. The\\nmicrobes were originally found on the borders of epithelial cells of\\nthe lips of infected children. The parasite lives in the form of a\\nmicrococcus in stagnant water, wells, and springs. The disease is one\\nof uncleanliness, and is readily prevented by appropriate hygiene.\\nMYRINGOMYCOSIS.\\n(Otomycosis.)\\nThe spores of aspergillus (niger, flavus, fumigatus), being conveye\\nto the external ear, occasionally develop there, especially if they come\\nin contact with fatty substances introduced for purposes of medication.\\nThere can then be recognized in the canal whitish masses, covered\\nwith grayish-white, yellowish, greenish, brownish, or blackish spots.\\nIn the normal ear this vegetation cannot flourish its occupancy of\\nthe canal is conditioned on a maceration of the epidermis due to some\\nantecedent inflammatory or other affection.\\nExamination of the debris removed from the ear reveals the inter-\\nlaced hyphse of the vegetation with spores and occasional flower-like\\nmasses which constitute the sporangium of the fruit-capsule of the\\naspergillus, this last containing the receptaculum and radiating sterig-\\nmata bearing the conidia. Diffuse inflammation, otorrhcea, and eczema\\nof the part may result. There is usually some deafness, with a sensa-\\ntion of ringing in the ears, and at times a thin serous discharge from\\n1 Le Progres raid., October, 1884.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0824.jp2"}, "825": {"fulltext": "CARATES. 767\\nthe external auditory meatus. Lowenberg 1 recommends for the de-\\nstruction of the mould the injection of dilute alcohol into the canal and\\nthe subsequent insufflation of boric acid in powder.\\nCARATES.\\n(Pinta Disease, Mae de los Pintos, Spotted Sickness, Cute,\\nCaeaate, Cativi, Quirica. Fr. y Cakates.)\\nUnder one or more of the titles given above has been described by\\nHirsch, Iryz, and others a group of maladies characterized by the pro-\\nduction on the surface of the body of superficial areas of involvement\\nranging in hue from a yellowish-white to a dark chocolate color, vary-\\ning with different individuals and exhibiting varying shades upon one\\naffected subject, having a tendency to peripheral extension over the\\nface and extremities, and in general, except the palms and soles, upon\\nregions exposed to the air, and due to a vegetable fungus developing\\nin the superficial layers of the integument.\\nThe patches of the disease appear commonly over the exposed\\nrather than over the protected body-surfaces, as, for example, over the\\ncheeks, the nose, the forehead, and the temples, in circular or ovoid\\nvariously sized plaques having a yellowish or purplish or brownish\\nshade of color. They are often intensely pruritic.\\nThough displayed for the most part asymmetrically, these patches\\nmay cover the entire surface of the body and even invade the mucous\\nmembranes of the alimentary tract. When confluence occurs large\\nareas of the skin may be involved, displaying then the usual features\\nof hyperkeratinization, with pityriasic, occasionally larger and coarser\\nscales, infiltration, occasional Assuring, and complete or partial color-\\nchange and loss of hair. In final evolution the symptoms are highly\\nsuggestive of other dermatoses, such as trichophytosis, favus, some of\\nthe forms of lupus, and erythematous eczema. There may be ulcer-\\native complications. The disease occurs at all ages and in both sexes\\nis more common among the poor and the neglected is rare among the\\nwhites and may endure for years.\\nEtiology and Pathology. The effective parasite is of the asper-\\ngillus family, fine filaments giving rise to hyphse which terminate in\\nclubs surrounding chaplets of spores. Sterigmata encircle the sporu-\\nlating elements. The color of the fungus varies according to the hues\\nof the invaded integument. The fungus is found chiefly in the super-\\nficial layers of the epiderm, but may also in advanced cases be recog-\\nnized in the rete.\\nThe Diagnosis is between macular leprosy, tinea versicolor, the sev-\\neral forms of leucoderma and vitiligo, and the varieties of ringworm,\\npityriasis rubra pilaris, and keratosis the recognition of the effective\\nfungus being decisive.\\nThe Treatment is by parasiticides, the mercurials, sulphur, chry-\\nsarobin, pyrogallol, and potassic permanganate.\\nThe Prognosis is favorable save in cases that prove refractory\\nunder treatment.\\n1 Oaz. hebd. de Med. de Paris, 1880, 2me s6r., xvii., p. 579.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0825.jp2"}, "826": {"fulltext": "768 PARASITIC AFFECTIONS.\\nMYCETOMA.\\n(Gr. pvK7jg a fungus.)\\n(Madura Foot, Fungus Foot of India, Podelcoma, Tubercular\\nDisease of the Foot, Endemic Degeneration of the Bones\\nof the Foot, Morbus Pedis Entophyticus, Ulcus Grave.)\\nFrom the date of the earliest description of this disorder by Eyre\\nin 1806 to a recent date Indian physicians chiefly contributed to the\\nliterature of this disease. Among them may be named Brett (1840),\\nJille (1842), Ballingall (1855), Vandyke Carter (1859), Berkeley\\nand Biddie (1862), Hirsh (1863), Lewis and Cunningham (1875), and\\nstill more recently Layet, Liboroux, Bocarro, Bassini, Huntley, Sur-\\nveyor, Boyce, Gemy, Vincent, and Kanthack.\\nThe disease chiefly occurs in India, but is reported to have been\\nobserved also in China, Africa, Syria, and, in isolated cases, in a few\\ncountries of Europe.\\nThe record of its first recognition on the American Continent is\\nembodied in the apparently unsupported statements of Ruelle, 1 who\\nreports that Collas observed one case at La Reunion Grail and\\nGrand-Mourrel, each one case in Guiana and Layet one in Chili and\\nanother in Valparaiso. McQuestin 2 saw three cases affecting native\\nMexicans in the Civil Hospital of Hermosillo, and Kemper 3 reported\\na case which for some years w T as thought to be the first occurring in\\nthe United States, but a critical examination of the description of the\\nacute symptoms presented by his patient raises doubt respecting the\\naccuracy of the diagnosis. Charles T. Parkes reported that he had\\nsuccessfully operated upon a patient suffering from mycetoma in the\\ncity of Chicago. The disease had, however, been contracted in India.\\nThe first case certainly known to have originated in North America,\\nin which no question exists as to the diagnosis, was reported by Adami\\nand Kirkpatrick. 4 The subject was a French Canadian. Soon after\\nthe appearance of this report one of us in connection with Senn and\\nBishop published the record of an undoubted case of mycetoma 3 occur-\\nring in a native of Iowa who had never been outside of his native State\\nbefore visiting the city of Chicago. The lesions of the disease, as\\nexhibited in the foot removed from this patient, are depicted on the\\naccompanying plate. Since then Pope and Lamb, 6 Wright, 7 and\\nArwine and Lamb 8 have published full reports of undoubted cases\\nwith demonstration of the fungus and its subsequent artificial culti-\\nvation. This record of five cases of Madura foot in North America\\nincludes the history of four men and of one woman.\\n1 Contribution a 1 etude du Mycetome, Bordeaux, 1893, p. 13 etseq.\\n2 Pacific Med. and Surg. Jour., 1873, pp. 652-555.\\n3 American Practitioner, 1876.\\nTrans. Assoc. Amer. Phys., 1895, vol. x., p. 92.\\n5 A Contribution to the Study of Mycetoma as it Occurs in America, Jour. Cutan\\nand Gen.-Urin. Dis., January, 1896.\\n6 N. Y. Med. Jour., 1896, vol. lxiv., p. 386.\\n7 Trans. Assoc. Amer. Phys., 1898, vol. xiii., p. 471.\\n8 Amer. Jour. Med. Sci., Oct., 1899, p. 393.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0826.jp2"}, "827": {"fulltext": "r \\\\-it\\\\. i i-j ^wv v\\nFi\\n%s", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0827.jp2"}, "828": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0828.jp2"}, "829": {"fulltext": "C ABATES.\\n769\\nSymptomatology. There are two varieties of mycetoma the\\nblack, and the white, red, or ochroid. Some doubt exists as to whether\\nall are produced by one fungus, seeing that no intermediate forms\\nbetween the varieties thus distinguished have yet been recognized. The\\npart principally affected in most of the Indian and in the American cases\\nis the foot, and this chiefly of persons walking barefoot but the hand,\\nFig. 94.\\nOsseous lesions in mycetoma.\\nthe shoulder, the knee, the scrotum, and other regions have been at-\\ntacked. As distinguished from the lesions of actinomycosis, it is note-\\nworthy that the regions of the jaw and the neck are usually spared.\\nIn a typical case the foot is involved by progressive spread of the\\ndisease from the site of a trifling traumatism which often at first heals,\\nand is followed later by the development, near the site of the wound, of\\n49", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0829.jp2"}, "830": {"fulltext": "770 PARASITIC AFFECTIONS.\\na button or nodule which both increases slowly in volume and is later\\nsurrounded by similar lesions. The progress of the disease is exceed-\\ningly chronic, as ten and many more years have not rarely been re-\\ncorded as required for its complete evolution.\\nIn fully developed cases, when the foot is involved, the organ is\\nseen to be largely increased in volume, producing a bulging of the\\nparts posterior to the digits over the dorsum above, and below over\\nthe plantar region, giving the sole a convex appearance. Over the\\ntumid parts the skin is beset with numerous pea- to nut-sized iso-\\nlated nodules, elevated to the extent of several millimetres above\\nthe general level, each pierced with a fistulous channel extending\\nfrom without to the deeper structures. At times these fistulous tracts\\nlead only to the soft parts and especially to muscular tissues at others\\nthe surface of the bone is reached and the osseous tissue is eroded by\\nthe growth of the parasite and the coccogenous infection which results\\nfrom long exposure of the parts to the air. It is through these fistulous\\norifices that in different cases exit is given to a blackish fish-roe-like\\nsubstance, or to a whitish material, or even still more rarely, as indi-\\ncated above, to a reddish substance.\\nIn place of nodules or papules, the skin may be the seat of pustules,\\nof vesicles, of bullae, or even of abscesses. When but relatively small\\norgans of the body are invaded, such as a finger or a toe, it becomes\\nclear that the tumefaction is not due chiefly to a hypertrophy either\\nof the integument or the bones.\\nEtiology. The disease, though of more common occurrence in\\nIndia than elsewhere, may develop in other lands. The relatively fre-\\nquent involvement of men is probably due to the greater exposures of\\nthe bare feet in persons of that sex. The disease is produced by a\\nvegetable parasite, which obtains access to the tissues, as far as is known,\\nusually through, a traumatism.\\nPathology. The effective parasite in Madura foot is the actino-\\nmyces Madurse (streptothrix Madurse of Vincent oospora Indica\\nof Kanthack), a mycelium with branching threads, hyphse of some-\\nwhat greater thickness, and ovoid spores measuring 1.5 by 2 p..\\nTwo forms of granules have been recognized the melanoid, or\\nblack variety, which are irregularly shaped and which coarsely\\nresemble gunpowder and the ochroid, or pale variety, charac-\\nterized by whitish or grayish-yellow bodies somewhat resembling\\nfish-roe. The clinical symptoms of the two varieties are simi-\\nlar. Hektoen distinguishes the pale form of mycetoma by the title\\nactinomycelial, and the black as the hyphomycelial, the character of the\\nblack organism having been demonstrated by the successful cultivation\\nof the fungus in the case reported by Wright. Under the microscope\\nthe lobate-reniform masses constituting the grains are seen to be\\nformed by a dense centrally placed mycelium with peripheral filaments\\nwhich radiate uniformly from within outward, and which may or may\\nnot terminate in clubs, these last being probably the resultant of the\\ninterplay of force between the outspreading fungus on the one hand and\\nthe resisting power of the tissues on the other.\\n1 N. Y, Med. Jour., May 26, 1900.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0830.jp2"}, "831": {"fulltext": "ACTINOMYCOSIS OF THE SKIN. 771\\nIn the three areas to be equally recognized on section of the\\ngrains, the central exhibits delicate filamentous threads radially\\narranged the marginal zone longer, more distinct, and somewhat more\\nslender threads while the radial zone, separated from the last by a\\nnarrow space, exhibits a few granular threads, but for the most part\\nappears to be made up of a granular tissue, the mycelium of degener-\\nated hyphse surrounded by a reticulum. Outside of the fungous mass\\nare closely packed leucocytes, new-formed vessels having walls infil-\\ntrated with proliferating cells, few or numerous giant-cells, and in\\nmany of the lymph-spaces adjacent to the fungi large numbers of\\namorphous granular masses, refractive and yellowish brown in color,\\nwhich Carwell believes to be hemosideria. The bones when denuded\\nof tissue are found to be honeycombed with finely carved seams,\\ndepressions, furrows, and pits, leaving delicate spicula of osseous tissue\\nprojecting between the excavations wrought by the growth of the para-\\nsite. It is possible to find, as Adami suggests in the study of his case,\\nintrusive organisms, the result of exposure for so long a period of time\\nof the deeper tissues to the atmosphere. Cultures are made in bouillon\\nand potato-infusion showing a hyphomycete with loug branching threads\\nand transverse septa.\\nThe fungus differs from that of actinomyces in that the former\\nreacts indifferently to, while the rays of actinomyces are brilliantly\\ncolored by, acid fuchsin.\\nDiagnosis. The disease in all cases of long standing is readily\\nrecognized by the characteristic deformity it produces, by the escape of\\nfish-roe-like particles in the black variety, and in others by the dis-\\ncharge of the elements of the fungus, w T hich can be determined by the\\nmicroscope. The nodes or papules visible externally in all well-marked\\ncases, each perforated with a sinus leading downward to the deeper\\nstructures, and the painlessness for the most part of the involved\\norgan, are all characteristic.\\nAs distinguished from actinomycosis, it is well to remember that in\\nmycetoma there is never involvement of the viscera the disease is\\nexceedingly chronic all systemic symptoms are absent and the\\naffection is common in countries where actinomycosis is practically\\nunknown.\\nTreatment. The disease is radically treated by surgical ablation\\nof the affected organ or by erasion of tissue. Even after evolution of\\nthe disease for years recovery in cases so treated is satisfactory.\\nACTINOMYCOSIS OF THE SKIN.\\n(Gr. clktIq^ and ^k-VC, mushroom.)\\nLumpy-jaw/ Ger., Aktinomykose Fr. Actinomycose.)\\nThis disease was first recognized in 1887 as due to a parasite which\\nHarz described, from its gross appearances, as the ray-fungus,\\noccurring in the jaws of cattle. It has since been recognized in man,\\nand still later, by Majocchi, as of occurrence in the skin.\\nSymptoms. In actinomycosis this parasite usually effects entrance\\nthrough a carious tooth, and the skin when implicated is, as a rule,", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0831.jp2"}, "832": {"fulltext": "772 PARASITIC AFFECTIONS.\\nsecondarily involved. Such skin-lesions are more often displayed I\\nabout the face and neck, more particularly the lateral surfaces of the\\nneck beneath the jaw, where deep subcutaneous nodes, tumors, or\\nswellings, often firm to the touch, livid in hue, thinning at one or at\\nseveral points after involvement of the integument, finally burst, form-\\ning pustular tracts and giving exit to a serosanguineous or bloody and\\npurulent fluid, containing yellowish masses in which the fungus may be\\nrecognized. The orifices of the sinus or sinuses after such discharge\\nare usually beset with cutaneous and subcutaneous nodules and uneven\\nlumps, some softened, others firm and indurated, usually reddish or\\npurplish in hue, tender, painful, and often accompanied by pains else-\\nwhere, particularly in mastication, in deglutition, and in certain move-\\nments of the head on the neck.\\nThe onset of the disease is insidious, and it is said to occupy\\nmonths and even years. The nearer to complete evolution of the dis-\\nease the more rapid, as a rule, is the development of its symptoms.\\nIn exceptional cases the malady attacks the fingers, the hands, and\\nother parts of the body. Rarely, secondary actinomycosis of the\\nlymphatic glands occurs. Pringle reported a case in which large areas\\non the back, lumbar region, and hip were affected secondarily after\\ninvolvement of deeper organs. 1 Lymphatic metastasis is, however!,\\nrare, due, as is believed, to the large size of the fungus-granules as\\ncompared with the lumen mi the lymphatic vessels.\\nEtiology. As in mycetoma, more men than women are attacked as\\na result of special exposure a few of the affected have been occupied\\nwith cattle and horses others having carious teeth may have been\\ninfected by accidents of contact or in the operations of dentistry.\\nMurphy, of Chicago, had a case of this disease in the person of a\\nwoman whose dog had died with a large swelling under the jaw. In\\nmost instances there have been submaxillary lesions and carious teeth.\\nThe general dispersion of the ray-fungi in the atmosphere, water, and\\nupon the soil is held to explain in large measure the occurrence of the\\ndisease in man. Beards of barley, bits of stone, vegetable fragments,\\netc., have been found in actinomycotic lesions.\\nPathology. Typical actinomycosis is produced by invasion of\\nthe human body by typical pathogenic ray-fungi (actinomyces), the\\norganisms differing from the atypical acid-proof ray-fungi/ 7 which in\\na few instances have produced disease both in man and animals sug-\\ngestive of certain forms of tuberculosis.\\nThe typical pathogenic organisms form long branching threads\\nwith stellate radiations, from which the title actinomyces receives its\\nname. The atypical forms are distinguished by the absence of\\nspore-bearing hyphse and by their resemblance in polymorphous de-\\nvelopment to certain of the bacteria.\\nThe granules which form in human actinomycosis are yellowish or\\ngrayish clumps. When closely examined these are found to be a circlet\\nof club-shaped masses radiating from a network of mycelial threads,\\nthe ends of which eventually undergo hyaline degeneration or gelatini-\\nzation. The growth of the parasite in the tissues results in the forma-\\n1 Medico-Chirurgical Transactions, vol. lxxviii.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0832.jp2"}, "833": {"fulltext": "ACTINOMYCOSIS OF THE SKIN. 773\\ntion of granulation-tissue which may undergo purulent disintegration\\nand there may be extension of the process by hematogenous metamor-\\nphosis, rarely by secondary actinomycosis of the lymphatic glands and\\nvessels, by dissemination by phagocytes of mycelial fragments, and\\nlastly by secondary mixed infections with the pyogenic micro-organisms.\\nDiagnosis. All supraclavicular and submaxillary lesions consti-\\ntuted of dark-reddish tumors or swellings, subcutaneous in origin,\\nshould carefully be differentiated from actinomycosis. Scrofuloderma\\nis to be recognized by the general condition of the patient (actinomy-\\ncosis may occur in vigorous young adults) by the absence of pro-\\nnounced gumma and lymphoma gomme scrofuleuse and by failure\\nof recognition of the parasite, which is not easy of detection. The\\noccupation of the subject of the disease (as a farrier, stable-boy, or\\ndrover) may furnish a clue to the origin of some cases. Care should\\nalways be taken, in making a diagnosis, to exclude cases of swellings\\ndischarging pus, practically limited to the skin immediately over the\\nlower jaw, with sinuses leading to the bone beneath, in which the dis-\\norder is exclusively due to a carious fang of one of the lower central or\\ncanine teeth. All these may be relieved by extraction of the offending\\ntooth.\\nThe Treatment has been until recently by surgical procedures, era-\\nsion, antisepsis by mercuric chloride, boric acid, and dressings with anti-\\nseptic gauze. Gautier has employed with success an electro-chemical\\nmethod of treatment, by the use of platinum needles and injections of a\\n10 per cent, potassium iodide solution. Two needles are inserted, one\\nconnected with each pole of the battery, and a current of fifty milli-\\namperes is passed a few drops of the iodine solution are injected during\\nthe flow of the electricity, the patient being anaesthetized. Before\\nattempting surgical measures potassium iodide given internally should\\nbe tried, since it has proved successful in a number of cases. Pringle s\\ncase, mentioned above, improved under the iodide, though the patient\\nwas never able to take the remedy in large doses, and eventually died\\nfrom amyloid disease. Morris reported a case which under the in-\\nfluence of the iodide lost its characteristics and the fungus gradually\\ndisappeared. Other cases are reported in which recovery followed\\nadministration of the iodide.\\nPrognosis.\u00e2\u0080\u0094 It was held until lately that the prognosis was favor-\\nable only in case of thorough and prompt removal of all diseased tissue.\\nIn other cases a fatal result was anticipated.\\nSchlange, however, at the Congress of German Surgeons held in\\n1890, called attention to the fact that of nearly two hundred patients\\nunder his observation (over one-half traced since 1886), forty were com-\\npletely cured for more than two years and in eighty the disease re-\\nmained limited to the head and neck. After thirteen years of involve-\\nment one patient at the date of the report was alive. All extensive\\noperations for relief of the malady are now abandoned. Potassium\\niodide is effective in some cases, and is worthy of a trial in all. Even\\nactinomycosis of the lungs and viscera is susceptible of spontaneous\\nrecovery. Cases apparently hopeless have recovered in five and six\\nyears. Intestinal complications are grave.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0833.jp2"}, "834": {"fulltext": "774 PARASITIC AFFECTIONS.\\nBLASTOMYCOSIS OF THE SKIN IN MAN.\\n(Blastomycetic Dermatitis, Saccharomycosis Hominis, Derma-\\ntitis Blastomycotica. Ger. y Hefenmykose.)\\nBlastomycosis of the skin in man is a disorder induced by the pres-\\nence in the skin of a vegetable organism belonging to the family of the\\nyeast-plant, characterized by a slow progression from one point to\\nanother of the integument, the sites of invasion being for the most part\\ncharacterized by vegetations and minute wart-like elevations of the\\nsurface, which may break down into ulcerations capable of producing\\ngrave destruction of tissue.\\nThe invasion of the body of animals by a blastomyces had been\\nrecognized and carefully studied before cases of evolution of the dis-\\nease in the human family had been determined. The dermatoses it is\\ncapable of producing in man have been recorded in a group of cases\\nby Gilchrist, Busse, Buschke, Wells, Hessler, Hektoen, Stelwagon,\\nDyer, and others, including ourselves. 1 Of about a score of recorded\\ncases occurring in man but one or two have been recognized outside of\\nAmerica.\\nSymptoms. The disease commonly begins with the production of\\na split-pea-sized papule which may later assume a pustular character,\\nelevated, circular in outline, and extending slowly by multiplication\\nor enlargement either in one linear or in several directions. In some\\ncases the field traversed assumes permanently a verruciform aspect,\\nthe patch or patches being covered with raised and isolated filiform\\nprojections one to four millimetres in height, each capped with a crust\\nformed by desiccation of sero-pus. The papillomatous character of\\nthe patch, with a somewhat reddened and exactly defined peripheral\\nborder, is strongly suggestive of verrucous tuberculosis. When fully\\ndeveloped the affected area may include the larger part of the surface\\nof a limb or the greater part of the facial region. The patch of this\\nsize is often covered with a malodorous puriform secretion smeared over\\nflorid vegetations, here and there commingled with false membranes,\\nand has a sharply defined and distinctly elevated ridge, more pre-\\ncipitous on the side of the normal skin. In some cases ulceration pro-\\ngresses between the papilliform vegetations and beneath the crusts.\\nThe destruction of tissue resulting may in exceptional cases be grave,\\n1 Bibliography. Anthony-Herzog, Jour. Cutan. and Gen.-Urin. Dis., January,\\n1900. Brayton, Indiana Med. Jour., 1900, p. 403. Buschke, A., Ueber Hautblasto-\\nmykose, Verhandl. der VI. Deutschen Dermatol. Congress, 1898. Busse, O., Die\\nHefen. als Krankheitserreger, Berlin, 1897. Coates, Medicine, February, 1900.\\nCurtis, Annal. de l Inst. Pasteur, 1896, p. 449. Dyer, Jour. Cutan. and Gen.-Urin.\\nDis., January, 1901. Gilchrist, T. Caspar, Duhring s Cutaneous Medicine, Part L,\\np. 156, Phila., 1895; Johns Hopkins Hosp. Rep., 1896, vol. i., pp. 269 and 291. Gil-\\nchrist-Stokes, Jour. Exper. Med., 1898, vol. iii., No. 1. Hessler, Bobert, Indiana\\nMed. Jour., August, 1898. Hektoen, Jour. Exper. Med., vol. iv., No. 3; Jour. Amer.\\nMed. Assoc, December 2, 1899. Hyde-Hektoen, Brit. Jour, of Derm., November, 1899.\\nHyde-Pvicketts, Jour. Cutan. and Gen.-Urin. Dis., January, 1 901 report of two cases\\nand review of subject, with tabulation of all cases to date. Montgomery, Jour. Cutan.\\nand Gen.-Urin. Dis., January, 1901. Montgomery-Bicketts, Ibid., same date, two\\ncases. Owens-Eisendrath -Beady, Annals of Surgery, November, 1899. Stelwagon,\\nAmer. Jour. Med. Sci., February, 1901. Welles, H. Gideon, Preliminary Keport of\\na Case of Blastomycetic Dermatitis, Jour. Amer. Med. Assoc, March 26, 1898.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0834.jp2"}, "835": {"fulltext": "PLATE XXVI,\\nBlastomyeetie Dermatitis.\\n(From a photograph.)", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0835.jp2"}, "836": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0836.jp2"}, "837": {"fulltext": "BLASTOMYCOSIS OF THE SKIN IN MAN.\\n775\\nthe eyelids, for example, being destroyed and other organs seriously\\nimplicated.\\nAreas of several months duration usually show in the centre, or in\\npatches irregularly placed between the verrucous portions, an elevated,\\nfirm though not indurated scar- tissue varying from a sixteenth to a\\nquarter of an inch in thickness. This tissue is reddish, pink, or white\\nin color, and contains numerous pinhead-sized abscesses, which are\\nusually deep-seated and filled with a gummy or cheesy material in\\nwhich the blastomyces are readily demonstrable. In some cases as the\\ndisease advances it leaves in its wake a remarkably thinned, whitish,\\natrophic integument looking like a delicate scar.\\nFig. 95.\\nBlastomycosis.\\nIn Busse s case, which terminated fatally, the occurrence of a blasto-\\nmycotic septicemia seems to have been demonstrated. The parts chiefly\\ninvolved in the patients whose records have been published were the\\near, the forehead, the cheek, the brow, the temple, the eyelids, the\\nnose, the lips, the neck, the scrotum, the thigh, the leg, and the dorsum\\nof the fingers, of the hand, and of the wrist. In one of our cases the\\ndisease was limited to the lower lip, producing a tumor that resembled\\nan ordinary epithelioma. The clinical histories point with clearness to\\nthe fact of transference of the effective germs of the disease from point\\nto point by the medium of the hands.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0837.jp2"}, "838": {"fulltext": "776 PARASITIC AFFECTIONS.\\nEtiology. The patients have sometimes a good family history\\nothers have been cachectic a few only have given an unmistakable\\nhistory of tuberculosis in the family. None has been shown to suffer\\nfrom syphilis. Of seventeen patients, four only were women. The\\naverage age of the infected was forty-three years. The essential agent\\nin the production of the disease is the yeast-fungus.\\nPathology. Histologically the lesions resemble those of verrucous\\ntuberculosis or of superficial epithelioma, yet differ from both. The\\nsurface, on which are seen irregular masses of debris consisting of pus,\\nblood- and epithelial cells, and various bacteria, is marked by irregular\\npapilliform projections, between which are corresponding depressions.\\nThe horny layer may be destroyed or it may extend in thickened\\nmasses between distorted papillse.\\nThe rete is everywhere the seat of excessive hyperplasia, producing\\nbranching down-growths varying greatly in size and shape. Polymor-\\nphonuclear leucocytes are scattered throughout the epithelium, both\\nbetween and within the cells, and occur often in small collections which\\nform the beginning of miliary abscesses. These abscesses are charac-\\nteristic of the process, and are found in all parts of the hyperplastic\\nepithelium, in places breaking through to the surface. They contain\\nleucocytes, nuclear fragments, detached epithelial cells, epithelial detritus,\\nred blood-corpuscles, the organisms peculiar to the disease, and in many\\ncases giant-cells. The epithelial cells surrounding the abscesses are\\nflattened, but appear to take no active part in the process. The epithe-\\nlium is separated from the corium in most places by a distinct layer of\\ncolumnar cells, in which mitoses are seen occasionally. The rete-cells\\nin general are large and appear swollen, the prickles being very con-\\nspicuous and the intercellular spaces increased. Premature cornification,\\nmore or less complete, occurs in scattered individual cells, in groups of\\ncells, and occasionally in isolated epithelial whorls. Single giant-cells,\\nsurrounded by a few leucocytes, are sometimes seen in the epithelium at\\nsome distance from the corium.\\nThe corium is the seat of subacute, chronic, and occasionally of\\nacute inflammatory changes. Miliary abscesses occur, especially in\\nacute lesions. The infiltration consists chiefly of leucocytes, endothelial\\ncells, and plasma-cells, and is sometimes very dense. The number of\\nmast-cells and giant-cells varies in different cases. Tubercle-like\\nnodules are found in some instances. In several cases sections showed\\nnumerous hyalin bodies which varied greatly in size, and occurred\\nchiefly in plasma-, giant-, and new connective-tissue cells.\\nThe appendages of the skin apparently play but a passive part in\\nthe process.\\nThe blastomycetes are found in miliary abscesses, between the epithe-\\nlial cells and in the corium, and are always surrounded by more or\\nless evidence of inflammation. They are rarely found within the cells.\\nThe giant-cells, however, usually contain one or more of the parasites.\\nThe number present in the tissue varies greatly. In some cases a dozen\\nor more can be seen in a single field of the microscope, while in others\\nthey are found with difficulty. They occur usually in pairs of unequal\\nsize, but also singly and in groups. They are readily seen in sections", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0838.jp2"}, "839": {"fulltext": "", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0839.jp2"}, "840": {"fulltext": "PLATE XXVII.\\nVertical section from a typical lesion.\\na, hyperplasia of rete b, abscesses in epithelium; c, infiltration of cutis, x 55.\\nBudding organism in\\ntissue, x 1200.\\nHanging drop, x 1200.\\nBLASTOMYCOSIS OF THE SKIN.\\n(From photo-micrograph)", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0840.jp2"}, "841": {"fulltext": "BLASTOMYCOSIS OF THE SKIN IN MAN 777\\nstained with hematoxylin and eosin or other common stains, but methy-\\nlene-blue is best for showing the different parts of the organism. The\\nfungus is easily demonstrated by placing fresh or hardened sections, or\\npus, in a strong solution of potassium hydroxide, or in equal parts of\\nliquor potassse and glycerin the organisms then appear as doubly con-\\ntoured, highly refractive, bodies.\\nWhen well stained, the parasite is seen to be a round, oval, or\\nslightly irregular body, having a well-defined, double-contoured, homo-\\ngeneous capsule, and a finely or coarsely granular protoplasm, which is\\nseparated from the capsule by a clear space of varying width. The\\ncapsule resists the prolonged action of strong alkalies and acids. The\\nprotoplasm often contains a clear vacuole, which varies greatly in size\\nin different bodies. Mature organisms have a diameter of from 7 to 20\\nH, though smaller and larger forms are seen occasionally.\\nBudding forms are seen in all stages of development *the capsules\\nand clear space are pushed out apparently by the protoplasm to form\\noval buds, which grow to about one-half the size of the mother-cell\\nbefore separating from the latter. Organisms in pairs of unequal size\\nare more common than budding forms.\\nCultures of blastomyces are recorded in nine of the cases so far\\nreported, and have been obtained from the pus and from tissue. Asso-\\nciated with the blastomyces in several cases have been found various\\nbacilli and cocci, none of which has been demonstrated to have any\\ndefinite relation to the process. In two cases repeated inoculations of\\nmedia with pus from one of the lesions gave rise to pure cultures of the\\nblastomyces, showing that it was pyogenic.\\nThe organisms in the different cases have varied in minor details,\\nand in several instances have been modified considerably by varying the\\nculture-media and other conditions of growth.\\nInoculation-tests have been largely unsuccessful, but in several in-\\nstances subcutaneous injection of pure cultures of the blastomyces has\\nresulted in the production of a local abscess, or of an inflammatory\\ngranulation-tissue, from which the fungus could be recovered. The\\norganisms in four cases l have been inoculated in animals with the pro-\\nduction of tubercular-like nodules, or other inflammatory areas, in the\\nlungs, kidneys, and other organs, from which the fungus has been recov-\\nered and cultivated.\\nAn effort has been made by certain Italian investigators to establish\\na relationship between blastomyces and malignant tumors, but such a\\nrelationship is far from being satisfactorily demonstrated.\\nDiagnosis. Blastomycosis of the skin in man is to be distin-\\nguished chiefly from verrucous tuberculosis. The exact distinction\\nbetween the two can be established only after microscopical examination\\nof the tissue and pus, or by cultures and animal inoculations. In\\ngeneral the disks of lupus verrucosus as compared with patches of\\nblastomycotic infection are more slow of evolution, are more often\\nlimited to relatively small areas, are found with greater frequency\\nabout the lower forearm and the ankle, and are surrounded by a more\\ndefinitely violet-tinted halo. Other disorders to be excluded by con-\\n1 Gilchrist-Stokes Curtis Hyde-Hektoen Montgomery-Ricketts.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0841.jp2"}, "842": {"fulltext": "778 PARASITIC AFFECTIONS.\\nsideration of their characteristic features are lupus vulgaris and other\\nof the tuberculoses and paratuberculoses of the skin, the vegetating\\nforms of syphilis, and protozoan infection, which, it is now believed,\\nmay be a variant of blastomycosis.\\nThe Treatment is by radical destruction of the affected part with\\nthe aid of the curette or by the internal administration of potassium\\niodide in full doses, a measure which has been productive in some cases\\nof brilliant results. Bevan is to be credited with first employing this\\nmethod of treatment in one of our cases. Blastomycotic. septicaemia is\\nto be combated by the usual energetic measures generally employed in\\nsuch complications.\\nThe Prognosis may at times be exceedingly serious. Good results\\nshould follow early and energetic internal and local treatment. Two\\nof our cases treated with the iodide have apparently recovered com-\\npletely.\\nRefractory Subcutaneous Abscesses Caused by a Sporo-\\nthrix are reported in two cases by Schenck, 1 and Hektoen and Per-\\nkins. 2 In both cases infection occurred on the index finger, and\\nproduced subcutaneous nodules and abscesses along the lymphatics of\\nthe arm.\\nDISEASES DUE TO ANIMAL PARASITES.\\nSCABIES.\\n(Lat. scabere, to scratch.)\\nThe Itch. Fr., Gale Ger., Kratze.)\\nSymptoms. Scabies is a disease of polymorphic symptoms, which\\nmay be viewed as an artificial eczema or dermatitis, produced by the\\ninvasion of the itch-mite (Fig. 96). The objective symptoms differ\\naccording to the extent to which the skin is primarily invaded by the\\nparasite, or is secondarily injured by traumatism and severe scratching\\nof its surface.\\nProminent among the objective symptoms is the cuniculus, or acarian\\nfurrow, an elongated gallery excavated in the epidermis by the female\\nacarus soon after her impregnation by the male. The male does not\\nenter the skin, but is lodged beneath the crusts or other exuviae which\\ngather upon its surface. This cuniculus, or furrow, is a whitish or a\\nyellowish, slightly arciform, linear lesion, with regular parallel borders\\ncovered with dots or specks of blackish aspect, representing faeces of\\nthe mite. The furrow (Fig. 97) terminates at the upper extremity by\\na vesicle, pustule, or exfoliation of the surface at the site of an infun-\\ndibuliform depression and at the deeper extremity by a whitish and\\nyellowish, shining and salient point, representing always the acarus.\\nThis is the most characteristic symptom of scabies.\\n1 Johns Hopkins Hosp. Bull., Dec, 1898.\\n2 Jour. Exper. Med., 1900, vol. v., No. 1.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0842.jp2"}, "843": {"fulltext": "SCABIES.\\n179\\nThe head of the gallery, where the parasite first entered the skin,\\nis usually whitish, and is more elevated than the tail, where the\\nacarus rests after laying its dozen or more of eggs. At times the entire\\ncuniculus forms an elevated ridge, rather than a thread-like depression,\\nwith white dots along its summit. When the roof of the vesicle at\\nthe head is torn off by scratching the effect is to produce a reddened\\nspot at its site, surrounded by a whitish moat running around the\\nentrance of the gallery.\\nFig. 96.\\nFemale acarus fecundated (ventral surface). An ovum arrived at maturity is visible within the\\nbody. (After Kaposi.)\\nWhen the burrow exists it can be recognized most perfectly in the\\ninterdigital spaces and on the skin of the penis as a tangential line,\\nrunning from a vesicle, papule, or pustule to a distance of from one-\\neighth of an inch to an inch. It resembles a beaded, dotted, yellowish\\nor blackish thread, the color being more pronounced in comparison\\nwith a fresh-colored and washed skin, and less marked in contrast with\\na soiled surface being, in a soiled and subsequently washed integu-\\nment, most conspicuous in proportion as the small puncta have served\\nto entrap particles of dirt. The cuniculus may be curved, angular,", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0843.jp2"}, "844": {"fulltext": "780 PAHASITIC AFFECTIONS.\\nor tortuous and occasionally may be seen well-nigh completely cov-\\nered by a bulla, pustule, or vesicle extending its entire length. In\\nthese cases, however, the female always penetrates beyond the periph-\\neral wall of such lesion, working her gallery beyond it and more\\ndeeply, lest she be lifted by the exudation out of reach of the succulent\\nrete where she feeds.\\nHebra points to the fact that between two parallels, one drawn\\nthrough the nipples and another at a short distance above the knees,\\non the anterior face of the body, can be recognized the greater part of\\nthe eruptive lesions in every case of scabies.\\nThe disease is indeed one peculiar to those classes which are the\\nfamiliars of filth and poverty, occurring among these at all ages and\\nin both sexes. As a matter of accident, it may appear, though rarely,\\nin individuals of high social station. It is much more common in\\nScotland, Austria, Prussia, Sweden, Norway, France, and the Orient,\\nthan in America. During the late Civil War it prevailed with rela-\\ntive frequency among the masses of Americans associated in regiments\\nwith foreigners who had been but a short time in the country and\\nsteadily decreased after that time. But few cases until lately were\\nseen annually in the public clinics of our large cities, though here and\\nthere, chiefly among newly arrived immigrants, isolated nests of\\nthe disease were discovered. The later influx of immigrants to the\\nUnited States (notably the Columbian Exposition of 893), however,\\nin the last few years, has again brought the disease into prominence\\nby reason of its greatly increased frequency.\\nIn consequence of the irritation produced by the parasite and the\\ntraumatisms of scratching the region invaded may exhibit all the symp-\\ntoms of acute and chronic eczema including vesicles, pustules, wheals,\\nsmall papules, hyperemia of the skin upon which these rest, crusts\\nformed by dried serum, pus, and blood, excoriations, fissures, and, in\\ncases of long standing, pigmentation of the skin where the disease\\nhas existed. These lesions may coexist, several appearing at the same\\ntime upon the skin of an affected individual small vesicles and pus-\\ntules, with perhaps a few short cuniculi visible upon their summits\\nexcoriations larger and longer cuniculi interspersed between inflam-\\nmatory papules a tumid skin, evidently the seat of a mild grade of\\ndermatitis and crusts here and there, beneath which male and young\\nacari are ensconced such is the composite picture of a typical erup-\\ntion in scabies.\\nIt will be remembered that the acarus family find nutriment, shelter,\\nand all they require on the person of the individual whose skin they\\ninhabit, and there is no inducement for them to colonize at the instant\\nof the first opportunity offered. The transfer of a male acarus alone,\\nfrom one person to another, would not insure a generation of the young\\nand the unimpregnated female could not alone do more. As for the im-\\npregnated female, Hebra, on several occasions, failed to induce scabies\\nwhen one such female only was transferred intentionally to a sound\\nskin and was seen to penetrate it. Lastly, the eggs alone would not\\nsuffice, for they have to be nicely planted within the epidermis in\\norder to be hatched safely to maturity. In brief, only the more inti-", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0844.jp2"}, "845": {"fulltext": "SCABIES.\\n781\\nFig. 97.\\nmate contacts of the bed at night, and the application of nails charged\\nwith acari of both sexes,\\nespecially the young, are to\\nbe regarded as most effective\\nfor the transmission of the\\ndisease. This fact explains\\nwhy nearly seven men are\\nfound to be affected with\\nscabies to one woman.\\nWomen, as a rule, are more\\ninclined to sleep alone, or\\nwith those only to whom\\nthey have family ties while\\nlaborers, boys, apprentices,\\nand persons of that class,\\nincluding those who are\\nstrangers to each other, at\\ntimes occupy the same beds,\\nespecially in large cities,\\nwhere they are often hud-\\ndled together at night like\\nswine.\\nThe female acarus may\\nbe recognized always at the\\nterminal extremity of her\\ngallery, for it is now known\\nthat she does not in her life-\\ntime leave it for any pur-\\npose, as was at one time\\ntaught. The intruder here\\nshows as a minute, whitish,\\nclearly defined dot, present-\\ning a contrast in this partic-\\nular with the blackish feces\\nin the gallery behind, and\\nmay in a good light, by a\\nperson of some dexterity\\nand fair eyesight, be ex-\\ntracted on the point of a\\ncambric needle from her\\nlodging-point. It is impor-\\ntant to know that this para-\\nsite may be recognized by\\nthe unaided human eye.\\nIts characteristic tortoise-\\nlike body exhibits most of\\nits anatomical peculiarities under a glass enlarging the figure but one\\nhundred diameters.\\nThe regions affected by the eruption are the sides and roots of the\\nfingers and toes the flexor aspects of the wrist-joints the feet (and\\nAcarian furrow, from the lumbar region. The female\\nacarus is visible at the terminal extremity of the furrow\\nwith ventral surface exposed, and containing a mature\\novum: tAvo ova, next her, have been laid during the\\nday the third exhibits traces of the embryo the twelfth\\nexhibits a mature larva (a) twelve empty shells are also\\nseen between these the feces are represented by black\\npoints. (After Kaposi.)", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0845.jp2"}, "846": {"fulltext": "782 PARASITIC AFFECTIONS.\\nespecially in women, the delicate skin of the feet near the instep,\\npartly dorsal, partly plantar in situation) the palms (especially of\\nwomen and children) and the dorsal surfaces of the hands the but-\\ntocks (more particularly in those who are seated in the trades and occu-\\npations of life) the extensor faces of the joints the belly the penis\\nand scrotum in men the anterior folds of the axillae the nipples and\\nbreasts of women the elbows and knees, rather than the popliteal\\nspace and bend of the elbow and the anal region. Scabies, prurigo,\\nand pruritus are alike in this, that in each the face and posterior aspect\\nof the body display the fewest of any lesions visible. In general, por-\\ntions of the body subjected to constant pressure by the clothing, as, for\\nexample, the regions pressed by the corset of the woman and the waist-\\nband of the trousers in man, are sites of predilection. In other cases\\nthe disease is encountered in the axillae, the groins, and, as a matter of\\nrare exception, over the entire surface of the body.\\nThe itching of scabies is occasionally severe, and has, in fact, con-\\nferred upon the disease its familiar English title, the itch. This\\nsensation is usually worse at night, when the parasite is rendered active\\nby the heat of the body in bed, retained by the bed-clothing. It differs\\nsomewhat in different cases, being at times the cause of but little com-\\nplaint. There is nothing characteristic, however, in the occurrence of\\nthis symptom, as equally severe pruritus accompanies eczema uncon-\\nnected with parasites.\\nThe itching which results from the epidermic tunnelling in progress\\nis often noticeably more severe than would be suggested by the moder-\\nate number of skin-lesions visible. When these lesions (puncta, vesi-\\ncles, pustules, blebs, papules, resulting crusts, furrows, excoriations,\\netc.) are found upon the hands the itching becomes so great that the\\ninfested person scratches also the accessible parts of the skin, where\\nthere were originally no acari, such as the inner side of the thighs, the\\nlower belly, etc., as Hebra suggests, simply because they are handy.\\nHence it is that the picture comes to resemble that of all pruritic and\\nscratched skins.\\nSeveral artificial forms of this polymorphic affection are occasion-\\nally noted. In children the face may become diseased after contact\\nwith the breast of the mother or the buttocks after contact with the\\nflexor aspect of the nurse s arm. Large vesicles, and even rupioid\\nbullae, may result from the irritation 01 their tender skins. Again,\\nin subjects predisposed to eczema for any reason the invasion of the\\nparasite in one region of the body, possibly a region of preference, may\\noriginate an eczema in another locality whither the parasite has not\\nwandered. In other cases the most aggravated forms of eruption are\\nseen, usually in persons of filthy habits who have long suffered from\\nthe malady. Thus, extensive epidermal callosities form, filled with\\ndebris of dead parasites unable to find nutriment longer in the corni-\\nfied rete or extensive greenish and blackish crusts cover colonies of\\nacari which survive beneath them for generations of their race. The\\nnails in such extreme cases may be involved. The so-called Scabies\\nNorvegica, or Norwegian itch, belongs to this class. Hessler 1\\nJ Med. News, May 13, 1893.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0846.jp2"}, "847": {"fulltext": "SCABIES. 783\\nreported a case in which the entire surface of the body was covered with\\nlarge, thick scales, which were shed freely and were riddled with acarian\\nfurrows. By counting the number of parasites in a scale of a given\\nsize he calculated that the man had upon his person at one time not\\nless than 2,000,000 mites and 7,000,000 eggs.\\nAs a rule, the disease does not advance to severe grades. The\\nparasites having gained lodgement in the skin produce characteristic\\nsymptoms of the disease in the average of cases, and, though un-\\nrecognized and persisting for weeks, are the sources of so much\\nannoyance that treatment of some sort is instituted which is apt to\\nrestrict extension of the malady, certainly in America, within mod-\\nerate limits. Usually after lodgement is effected a week or a fortnight\\nelapses before the first characteristic furrow is formed, though the\\npruritus is of earlier occurrence. The extension of the disease by the\\nmaturing and ravages of young acari requires a few weeks more, so\\nthat in the course of from two to three months the evolution of the\\nmalady may be considered complete. In the course of about three\\nmonths more the disease, unchecked, may become generalized.\\nEven the animal parasites elect the soil upon which they thrive, and\\nindeed, after such election, thrive well or ill according to the conditions\\npresent. This is not only exemplified in the matter of individual sus-\\nceptibility, but in the conditions of health of an affected person. Thus,\\nin puerperal and typhoid fevers and other grave states of systemic dis-\\nturbance the parasites perish in the skin and the eruption disappears\\nclassical symptoms may recur in convalescence if one or more acari have\\nsurvived with sufficient vigor to reproduce their kind.\\nEtiology. The disease is produced only by the acarus scabiei (or\\nSarcoptes Scabiei), and is thus contagious, the parasites being intro-\\nduced upon the surface of one individual mediately or immediately\\nfrom the skin of another infested man or an animal. All persons are\\nsupposed to be susceptible to the disease, but the difficulty of intention-\\nally transmitting it by contagion is greater than that of inducing the\\nleech to fasten itself indiscriminately upon any given skin. The brief\\nshaking of the hand or transient personal contacts of the daytime are\\nin many cases insufficient for contagion. Few practitioners of medi-\\ncine suffer after careful examination of a patient. When a patient\\naffected with scabies is exhibited at the clinic he is minutely and with-\\nout ill results examined by dozens of students. It is probable that\\nthe contacts of the night incidental to the occupation of the same bed,\\nor the use of gloves and other articles of apparel containing parasites\\nor their ova, are essential to transmission of the disease.\\nPathology. The pathology of the eruption induced by the parasite\\nis that of the various phases of exudation. The differences between\\nscabies and all other eruptions of similar type depend, in the case of\\nthe former, upon the peculiarities of the exciting cause of the disease.\\nIn the description of this, the acarus scabiei, aid has been derived from\\nthe chapter devoted to this subject by Kaposi.\\nThe female acarus (Fig. 96), visible as a yellowish- white dot at the\\ncul-de-sac of her subcutaneous gallery and removed thence on the point\\nof a fine needle, is visible to the naked eye, but is best examined under", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0847.jp2"}, "848": {"fulltext": "784 PARASITIC AFFECTIONS.\\nthe microscope. The body is oval, with a short projecting head and a\\nconvex dorsum transversely corrugated, with short spinous processes\\nprojecting for the most part backward, a direction largely followed also\\nby the eight long bristles which are most noticeable at the posterior\\nextremity of the trunk. The posterior portion of the dorsum also\\nexhibits a series of recurved, short, hook-like projections, arranged\\ncircle-wise, about the anovaginal orifice.\\nThe flat ventral surface exhibits eight short claws or legs, four ante-\\nrior and four posterior. The former are set near the head, and are\\nprovided each with hairs and a long pedunculated sucker the latter\\nare armed solely with long, straight bristles. All the eight legs have\\nfive articulations. The head is oval in shape, and is provided with\\nfour pairs of mandibles and six palpi. There are two ventral outlets\\nand a stomach, intestines, ovaries, muscles, and even mature ova can\\nbe recognized internally.\\nThe males are smaller than the females and fewer in number. They\\ndiffer also in this, that the posterior extremities are provided with suck-\\ners and stalks, as are the anterior extremities of the female. Situated\\nbetween the stalks and the median line is a horseshoe-shaped mass of\\nchitin ensheathing a fork-shaped penis. They are said to die in the\\ncourse of from six to eight days after copulation. The latter survive\\nfrom twenty to sixty days.\\nThe female alone, as has already been said, penetrates the epidermis.\\nThis act she accomplishes by inserting the head first into the tissues of\\nthe skin, the body disappearing afterward, and depositing behind, in\\nthe course of her progression downward, one or two eggs daily until\\nfrom twenty to fifty have been laid. The eggs are oval, their longi-\\ntudinal axes placed transversely to the cuniculus. In the two or three\\neggs found nearest the female only a yellowish color can be distin-\\nguished in the third to the fifth, traces of the embryo are recogniza-\\nble the sixth to the ninth contain larva? and in the oldest the head\\nand front legs can be discerned. When mature the shell of the ovum\\nis ruptured, usually between the third and sixth day, and the 7 oung\\nacarus reaches the surface of the skin either by making exit at the\\noriginal point of entry of the mother or by rupture of the roof of the\\nburrow. It subsequently buries itself in the skin for a brief time while\\nthe process of casting its slough is completed. There are three of\\nthese periods of existence. Before the first period is accomplished the\\nyoung acarus is provided with but two pairs of posterior extremities,\\ntwo anal bristles, and ten dorsal spines. After the first period it is\\nan octopod with four oval bristles and twelve dorsal spines. At the\\nsecond period it gains two dorsal spines, and after the third it pos-\\nsesses fourteen. The acarus survives but a few days when removed\\nfrom the skin and immersed in liquids which protect it from the air,\\nsuch as water, oil, etc.\\nTransmission to man of the acarus peculiar to the horse, cat,\\nsheep, rabbit, elephant, etc., may be accomplished but the colony\\nunder these circumstances rarely thrives. The same is true of the\\nhuman acarus when transferred to the lower animals.\\nDiagnosis. The diagnosis of scabies must rest upon the recognition", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0848.jp2"}, "849": {"fulltext": "SCABIES. 785\\nof its special features described above. There are no lesions peculiar\\nto the disease save the cuniculi, or furrows, made by the parasites, and\\nthey, it will be remembered, do not appear until one or two weeks have\\nelapsed after infestation. They may also be obliterated or be concealed\\nby excoriations when the finger-nails plough them open, or by pustu-\\nlation and subsequent crusting when the irritation induced is excessive.\\nI In every well-marked case, however, cuniculi can be discovered, if not\\non the fingers, wrists, or forearms, at least on the penis, the breast near\\nthe nipple, or upon some other covered portion of the body. With care\\nand a little dexterity a fine cambric needle can then be forced into the\\nfurrow well down to and a little beyond its remote cul-de-sac, and the\\nJons et origo malorum be thence extracted and placed under the ob-\\njective of the microscope.\\nNext to the cuniculus and its inmate or inmates, the two most\\nimportant diagnostic features of scabies are the polymorphism of the\\neruption and the sites of its most frequent occurrence. These sites\\nmay be described as the most important of the two. Few skilled\\nI diagnosticians would fail to entertain a suspicion of scabies in a case of\\nsupposed eczema, existing upon the fingers, wrists, and penis only,\\nor upon the breast of a mother, and the face and buttocks of her infant,\\nor the arms of its nurse.\\nAt the same time it is a matter of great importance to remember\\nthat eczema is often attended with very severe itching that this sen-\\nsation may be intensely aggravated after retiring to bed at night that\\nj eczema is often limited to the hand it is not rarely characterized by\\ninterdigital vesicles and pustules and is, indeed, in America very\\nI much the more frequently encountered of the two diseases. The popular\\nconception of scabies holds to the belief that the disease is exceedingly\\ncommon that every severe itching with a cutaneous exanthem is pro-\\nduced by insects or worms in the skin, and that transient casual\\nI contacts are abundantly capable of transmitting the offending parasite.\\nMany more cases of simple eczema are supposed to be scabies than the\\nI reverse. There are few villages in this country which cannot lay claim\\nto an itch, often known by a name of local significance. Among\\nthese provincial titles may be counted the prairie itch of the West.\\nThese affections are, as a rule, forms of eczema quite unconnected with\\nthe existence of a parasite, and incurable generally by the parasiticides\\ntoo often employed to kill the disease. In all such instances the\\nabsence of the characteristic features of scabies described above, the\\nabsence of a history of contagion, and the presence of that of an alter-\\nnating relief and aggravation of the symptoms, will point to the char-\\nacter of the malady. In the severe pruritic affections of the West and\\nthe Northwest of America, described in the chapter devoted to the\\nseveral forms of pruritus, it is noticeable that the patients are often\\ncleanly those who are careful as to the hygiene of the body. Scabies\\nis really a filth-disease, and is best recognized among the filthy classes.\\nOf diagnostic importance is the relative rarity of scabies among other\\ncutaneous affections, pruritus included, observed in the United States.\\nThe Statistical Committee of the American Dermatological Asso-\\nciation from July 1, 1877, to January 1, 1898, reported 318,500 cases\\n50", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0849.jp2"}, "850": {"fulltext": "786 PARASITIC AFFECTIONS.\\nof skin-diseases of all kinds occurring in the United States and\\nCanada. Of this number, 11,560 were instances of scabies, a per-\\ncentage of 3.66 to the total number of affections tabulated. The influ-\\nence of temporary increase of population and the crowding together of\\npersons in large centres, many of whom came from foreign countries,\\nis well illustrated by the statistics of scabies in the year following the\\nColumbian Exposition held in the city of Chicago. During the year\\nof the fair (1893) 901 cases of scabies were reported in the United\\nStates. During the year 1895, however, but two years afterward, the\\ntotal number of scabies was but 383, the proportion to all cutaneous\\ndisorders being 2.531.\\nTreatment. The treatment of scabies has in view the destruction\\nof the parasite and the relief of the cutaneous disorder which the former\\nhas induced. Ordinarily these two indications are fulfilled at the same\\ntime. The destruction of the parasite is usually followed by relief of\\nthe resulting cutaneous lesions and the skin, freed from the burrowing\\nacari, is no longer tormented by the scratching, which in extreme cases\\nis not only irresistible, but is also an important element in the aggra-\\nvation of the lesions. In other cases, however, the resulting eczema or\\ndermatitis persists after the removal of the original cause of the disease,\\nand it demands special attention. Care should always be had to avoid\\ntreating the delicate skin of the infant with the severer remedies effi-\\ncacious upon the thicker integument of the adult.\\nSulphur, in all its forms and various combinations, has long held\\nthe highest esteem in the treatment of the disease. Other remedies,\\nhowever, of acknowledged efficacy are employed with satisfactory\\nresults, most of them owing their usefulness to the strong odor they\\nemit. Among these remedies may be named carbolic acid, petroleum,\\nnaphtol, the oils of cloves, cinnamon, rosemary, and mint tar, balsam\\nof Peru, and balsam of tolu styrax, staphysagria, Vleminckx s solu-\\ntion (heretofore described), and sapo viridis.\\nSulphur is commonly employed in the form of an ointment, 1 to 2\\ndrachms (4.-8.) to the ounce (30.), thoroughly rubbed, first into the\\naffected patches, especially between the individual fingers (or toes),\\nabout the wrists, over the palm and dorsum of the hand, into the axilla?,\\nabout the nipples, penis, buttocks, or other invaded parts, and, finally,\\nover the cutaneous surface in general, the head alone excepted. If\\nno severe eczematous complications exist, the inunction is well preceded\\nby a warm soap or a warm soft-soap-and-water bath but in the event\\nof such complication the bath should be deferred as decidedly injurious\\nin the inflamed condition of the skin.\\nThe first inunction is preferably performed at night, after which the\\npatient retires to bed enveloped in woollen underclothing or wrapped in\\na blanket. It is neither wise nor necessary to induce sudation by these\\nmeasures, for the skin is best retained in simply a greasy condition,\\nunmacerated by sweat. In England it is customary to bathe on the\\nensuing morning, but it is preferable to defer the bath until the cure is\\ncomplete, however disagreeable the condition of the integument may be\\nto the sufferer. The sulphur-inunctions are thus repeated for three\\nsuccessive nights, a thorough warm water-and-soap bath being finally", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0850.jp2"}, "851": {"fulltext": "SCABIES.\\n787\\nemployed for the purpose of cleanliness. The clothing meantime\\nshould either be thoroughly disinfected with sulphur, be immersed in\\nboiling water, or be subjected in a stove or furnace to a dry heat\\ncapable of destroying all acari and ova which may adhere to it.\\nIn France, the routine treatment of scabies is always preceded by a\\nthorough friction for twenty minutes with soft soap, special attention\\nbeing as usual directed to the invaded areas. This operation is at once\\nfollowed by a bath in warm water, during which the surface is also\\nthoroughly scrubbed for from thirty minutes to an hour. Lastly, the\\nparasiticide is well rubbed on for fifteen minutes, the patient is redressed\\nin the underclothing (disinfected during the progress of the bathing),\\nand the final cleansing of the skin with water is practised within\\ntwenty-four hours.\\nWhen a resulting eczema demands attention it is to be treated in\\naccordance with the general principles considered in the chapter devoted\\nto that subject. In this case the dusting-powders, the oleated lime-water,\\nand the zinc, diachylon, and even more stimulating ointments, may be\\nemployed with advantage. Generally, after a vigorous course of exter-\\nnal treatment with sulphur, the patient should be instructed to defer\\nany further topical applications to the skin for a week or more, in order\\nito test the efficacy of the method pursued.\\nSherwell 1 finds sulphur in powder as efficacious as in ointment and\\nless disagreeable. He directs the patient, after a soap-and-water bath,\\nto rub gently over the body half a teaspoonful of sulphur lotum, and to\\ndust the same amount between the sheets of the bed occupied at night.\\nThe bath, the powdering of the body and bed, and a change of clothing\\nare repeated every two or three days. In the average case one week\\nof such treatment is sufficient.\\nOne of the following formulas may be substituted for the ordinary\\nsulphur ointment\\nB Sulphur, flor., 3xij\\nPotass, subcarb., 5vj\\nAdipis, ^ix\\nHardy s modification of Helmerich s ointment.\\nB Styracis liq.,\\nPetrolei, j\\n01. olivae, J\\nBalsam. Peru v.,\\nSpts. sapon. virid.,\\nB Potass, sulphuret.,\\nSapon. alb.,\\n01. oliv.,\\n01. thym.,\\nB Sulphur. su*blim.,\\nBalsam. Peruv.,\\nAdipis,\\nf3j;\\naa f ,^ss;\\nfgijss;\\nf3v;\\n3v;\\n3xx;\\nf3iv;\\ngtt. xv\\naa \u00c2\u00a3ss\\n1j;\\nFor use especially in the scabies of children.\\n1 Jour. Cutan. and Gen-Urin. Dis., 1899, p. 494.\\n48\\n24\\n270\\nM.\\n4\\naa 15\\n10\\n20\\nM.\\nKaposi.]\\n20\\n80\\n16\\n1\\nM.\\nJadelot.]\\naa 2\\n30\\n[I\\nM.\\nhihring.]", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0851.jp2"}, "852": {"fulltext": "788 PARASITIC AFFECTIONS.\\nHebra s modification of Wilkinson s salve, Vleminckx s solution,\\nand balsam of tolu are employed for the same purpose.\\nKaposi s naphtol formula is\\nB Naphtol., 15 parts\\nSapon. virid., 50 parts\\nCret. alb. pulv., 10 parts;\\nAxung., 100 parts. M.\\nMcCall Anderson much prefers, on account of its pleasant aroma\\nM.\\nR Styracis liquid., f^j 30\\nAdipis, ^ij 60\\nMelt and strain.\\nor Schultze s modification of Pastav s formula\\nR Styracis liquid.,\\nSpts. rectificat.,\\n01. olivEe,\\nFt. liniment.\\nfgj;\\n30\\nf 3ij\\n8\\nf3j;\\n4\\nM.\\nPrognosis. Scabies is a curable disease, even after persistence for\\nlong periods of time. When, however, complications exist, or severe\\neczema continues after the efficient action of a parasiticide, the patient\\nmay experience delay before attaining complete restoration to health.\\nDEMODEX FOLLICULORUM.\\n(Steatozoon, ok Acarus, Folliculorum. Ger., Haarsackmilbe.)\\nThis parasite was discovered in 1841 by Henle. It is a microscopic\\ncreature in the form of an elongated and jointed worm, with head separated\\nfrom the thorax, and eight legs, four on each side, each leg with three\\narticulations, and terminating in three small hooklets. The posterior\\nextremity of the body is a vermiform appendage, terminating in a\\nconical point (Fig. 98).\\nThe demodex folliculorum is found long after birth upon the free\\nsurface of the integument, those parts of the skin particularly where\\nthe sebaceous glands are large, and on patients affected with acne or\\nseborrhoea oleosa, as well as upon those free from all evidences of dis-\\nease. It is encountered also in the substance of the comedo-plug, where\\nat times from five to twenty may be discovered in a single follicle. A\\ndemodex, which is considered to be a variety of that discovered upon\\nthe skin of man, infests dogs, mice, and other lower animals and may\\nin the latter be the source of disease characterized by furuncular lesions,\\nabscess, and even fatal results. None of these parasites is, however,\\nknown to be transmissible to man.\\nIt has never been demonstrated to be an etiological factor in any\\ndisease of the skin, though De Amicis 1 and Majocchi 2 report cases of\\npigmentation of the skin due apparently to this parasite.\\n1 Giorn. Ital. delle Malattie Veneree, e della Pelle, 1898, fasic iii. also, Brit. Jour,\\nof Derm., January, 1899. 2 Ibid.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0852.jp2"}, "853": {"fulltext": "PULEX 1RMTANS.\\n789\\nPULEX PENETRANS.\\n(Rhyncoprion Penetrans, Sarcopsylla Westwood, Nigua,\\nChigoe, Jigger, Sand-flea.)\\nThe Sand-flea is a minute, brownish-red, egg-shaped parasite\\nwhich penetrates the skin of man and of the lower animals, including\\nrats and mice. It is encountered chiefly in tropical countries, but is\\nsaid to exist in northern latitudes, even in some of the Southern States\\nof the United States. Fecundated females only attack the skin, in\\nman usually about the toes or near the nails, entrance being effected\\nwith scarcely painful pricking sensations. In the course of from five\\nto ten days a painful oedema with pustulation follows, occasionally ac-\\ncompanied by lymphangitis or severer symptoms in the\\nform of gangrenous abscesses. These sequels are said\\nto result from distention of the ovary of the parasite,\\nwhich may exceed fivefold the original dimensions of the\\ninsect.\\nThe Treatment of the disease is by extraction of the\\nflea with the aid of a heated needle, whereby it is simulta-\\nneously destroyed. The resulting wound may be cau-\\nterized or dressed antiseptically.\\nFtg. \u00c2\u00a38.\\nPULEX IRRITANS.\\nThe Flea which specially attacks man is a brownish-\\nred insect having a laterally compressed body, an oral\\nhaustellum, serrated soft mandibles, a tongue sheathed\\nin an inferior labium, and a pair of labial, four-jointed\\npalpi. Each of the triple segments of the thorax bears\\na pair of five-jointed, double-clawed legs. The male is\\nfrom 2 to 5 mm. in length and 1 to 2 mm. in breadth,\\nthe female being nearly twice that size. The female de-\\nposits her eggs in any fissure, crevice, fold of garment,\\nor furniture which may be accessible, from which the lar-\\nvae are produced in a week. The nympha is enfolded\\nin a cocoon, but only the mature insects prey upon man.\\nAccording to Geber, the insect injects an irritating fluid\\ninto the skin at the moment of attack. The lesion it produces is a\\nhemorrhagic punctum, followed by a transitory hypersemia and a hem-\\norrhagic exudation which may persist for a few hours.\\nThe central punctum, or point, distinguishes the wound produced by\\nthe insect from macules of simple erythema but care should be taken\\nwhen fever is present to exclude the symptomatic erythemata. The\\nsite of the wound may become an urticarial wheal.\\nMixed cases of flea-bites with wounds produced by bugs and lice are\\noften seen in the lowest classes applying for relief to public charities\\nand the deeply pigmented skins they exhibit, often with purpuric\\nlesions distributed over the lower extremities, and commingled with\\nsyphilitic eruptions, are in the highest degree confusing. The practi-\\nDemodex follicu-\\nlorum.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0853.jp2"}, "854": {"fulltext": "790 PARASITIC AFFECTIONS.\\ntioner should always be on his guard in pronouncing on these cases,\\nespecially if the purpuric blotches occur in the cachectic or in those suf-\\nfering from other diseases than those of the skin.\\nFILARIA MEDINENSIS.\\n(Dracunculus Medinensis, Guinea-worm.)\\nSymptoms. The lesions due to invasion of the skin by the dra-\\ncunculus Medinensis are first observed at the point where the worm is\\nabout to make exit, which point may be at a considerable distance from\\nthat where it entered, and the exit may be made after an interval of\\nseveral weeks or months. This approach to the surface for the pur-\\npose of securing exit is accomplished only when the worm is quite\\nmature. After some local sensation of tension or of itching, a pea-\\nsized to small-nut-sized vesico-papule forms, superficial or subdermic\\nin situation, which, after accidental or intentional rupture, gives exit\\nto a clear serous fluid in which the un colored head of the worm may\\nbe recognized. The head, which is surrounded by a quantity of leuco-\\ncytes, appears either at once or in the course of a brief time, producing\\nslow and sinuous movements by alternate contractions and elongations.\\nThe entire worm and its young may then wholly be extruded in the\\ncourse of a week or more or the head may be withdrawn and another\\nswelling form at another part of the surface, the first meantime closing\\nor, in unskilfully managed cases, the worm may be torn so that the\\nhead only is removed, and then a severe lymphangitis with inflammatory,\\nsuppurative, and even gangrenous symptoms may supervene, produc-\\ning, in fact, the train of symptoms now well recognized in connection\\nwith septicaemia. In some cases, however, the body may be discharged\\nlater than the head, after the mechanical separation of the latter, with-\\nout serious consequences. The escape of embryos into the adjacent\\ntissue is also regarded as a grave complication.\\nThe chief sites of exit are the foot particularly the heel the leg,\\nthigh, buttocks, scrotum, hands, trunk, neck, and face. There is usu-\\nally but one worm in a single subject of the disease, but the number\\nmay be indefinitely large in persons exposed.\\nEtiology. The disease is produced by the ingestion of water con-\\ntaining the larvae of the parasite. Though denied, it seems highly\\nprobable that it may also obtain access by a traumatism inflicted at a\\ndate prior to that of invasion. The fact that nearly two-thirds of all\\ncases occur in the foot is not without significance. Young filarise have\\nbeen seen penetrating the microscopic crustacese in fresh water, the\\nlater ingestion of which in drinking-water is supposed to be effective\\nin the production of the disease.\\nThe disorder due to the guinea-worm is endemic in India, Arabia,\\nand Persia it is also found in Egypt, Africa, and portions of South\\nAmerica, but with greater rarity.\\nPathology. The female alone invades the human body it is a\\nfiliform and uniformly cylindrical body, from one-half to one metre long\\nand two or three millimetres thick. The head is convex, with a central", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0854.jp2"}, "855": {"fulltext": "PULEX IRR1TANS. 791\\noral orifice surrounded by four papilla?. It is viviparous, the embryos\\nnumbering millions, each embryo measuring 0.08 mm. in length and\\n0.0025 mm. in thickness, with a head somewhat thicker than the body,\\nno buccal orifice, and a pointed tail. In from ten to a maximum of\\nfifteen months the maturity of the female which has been impregnated\\nis attained, and the parasite finds its way from muscles or other\\ntissues in which she has been lodged or to which she has travelled to\\nthe surface of the body.\\nThe Diagnosis (to be made in countries where the disease is\\nendemic) is based upon the discovery of the worm.\\nTreatment. The usual method of treatment by the natives of the\\ncountries named is to secure carefully the head when it appears, and\\nto tease out the worm very gently day after day until the entire body\\nis extracted, securing the accessible portion by winding it about a bit\\nof stick or of paper. Continuous irrigation of the wound is both recom-\\nmended and practised where the disease is common. Tincture of\\nasafoetida has also been employed to destroy the parasite.\\nManson, 1 who has given the subject much study, has entered a pro-\\ntest against winding out the guinea- worm, stating that at best this\\nprocess merely shortens by a feAV days the duration of treatment in case\\nthe parasite is properly situated in the tissues without twists or turns,\\nor if it has arrived at a stage of life when, having discharged its young,\\nit is ready to come out spontaneously. If, as is often the case, the worm\\nis twined and twisted among the tissues, and if she is still emitting her\\nyoung, she will resist traction, a process which will often result in rup-\\nture. In consequence of rupture at this time myriads of young escape\\ninto the tissues, producing violent inflammation, which is frequently\\naccompanied by secondary infection and possibly by sepsis. To de-\\ntermine if the worm is ready to come out spontaneously, the opening\\nof the tumor may be douched for a number of minutes at a time, several\\ntimes a day, by dripping cold water over it. When under the influence\\nof this douching the worm no longer emits young careful winding out\\nis not objectionable.\\nThe treatment Manson recommends for trial in all cases is one first\\nemployed by a French naval surgeon, \u00c2\u00a3mily. The swelling produced\\nby the worm when she approaches the skin and before she has pierced\\nit is injected in several places with a solution of mercuric chloride\\n(1 1000). This kills the worm, which may be subsequently absorbed,\\nor if cut dow T n upon a day or two later her body can easily be with-\\ndrawn. In case the head of the worm be already protruding, the solu-\\ntion may be injected directly into her body, which is easily removed the\\nfollowing day. A number of cases have been treated in this way\\nsuccessfully, and with no disagreeable results in the way of pain or\\ninflammation. This method also reduces the time of treatment from\\nnot less than four weeks to the much shorter period of four or five\\ndays.\\nThe Prognosis is favorable, save in cases in which septicemic symp-\\ntoms develop as a consequence of coccogenous infection.\\n1 Brit. Jour, of Derm., Feb., 1896.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0855.jp2"}, "856": {"fulltext": "792 PARASITIC AFFECTIONS.\\nCRAW-CRAW.\\nPapulose Filarienne.\\nThis rare affection was originally described in 1875 by Silva Aranjo.\\nIt has since been studied by Nielly, 1 O Neill, Manson, and others.\\nIt occurs only on the West Coast of Africa, chiefly among the\\nnegroes, in whom papules, vesicles, pustules, and vesico-pustules appear\\nas single, multiple, and disseminated or grouped lesions accompanied\\nwith severe pruritus. The scratching of the affected part is excessive,\\nand the crusting at times is a prominent feature of the disorder. As a\\nwhole, the disease assumes an inflammatory aspect and is superficial in\\nsituation. The regions involved are the arms, forearms, and hands, the\\nfeet and legs, and several portions of the trunk.\\nBy removal of the crusts and erasion of the soft tissue beneath, it\\nis said that in some cases the disease has been brought to an end.\\nOther observers, after removal with a knife of the apex of selected\\nlesions, have recognized a nematode filarial parasite, of the dimensions\\nof y^-g- by -^sVg- of an inch, displaying two blackish points near its head\\nwhich are said to distinguish it from jilaria Medinensis. The parasite\\nof craw-craw is apparently related to the latter, and is supposed to\\nbelong to the family Anguillulidce or Anguillulce, a class of parasites\\ndiscovered in some portions of Europe among the lower animals.\\nCYSTICERCUS CELLULOSE CUTIS.\\nCysticerci have been recognized in the skin and subcutaneous tissues\\nby fiokitansky, Lewin, Guttmann, SchifF, F6rr6ol, Duguet, and other\\nobservers. In these cases one or many oval or roundish, firm, elastic,\\ncutaneous or subcutaneous, pea- to walnut-sized tumors, isolated or\\ndisseminated, unproductive of pain, project from the general level, and\\nare enveloped by an unaltered integument. They occur upon the trunk\\nand the extremities. They remain in this condition without change\\nfor years; and may accompany cysticerci of the brain and other por-\\ntions of the body, productive of the serious disturbance of the economy\\nwhich such invasion may determine. If the skin-tumors be opened\\nand their contents examined, the parasite (which is the scolex or hydatid\\nof taenia solium) will be recognized as an ampulliform sac, with a\\ncephalic appendage, reentrant or projecting, and provided with four\\nsuckers and a coronal of hooklets. By no external characteristics could\\nsuch tumors be distinguished from others of similar size and external\\nappearance. Only in the rare cases of nervous complication could a\\nsuspicion arise based upon the real character of the disorder. Respect-\\ning this matter, however, the diagnostician is in no worse position than\\nwhen called upon to recognize cysticerci of the viscera. Cysticerci of\\nthe liver are distinguished during life, and subsequently removed by\\noperative procedures.\\nThe Diagnosis is from gumma, lipoma, epithelioma, and sarcoma.\\nThe first occurs only in the syphilitic the second has a peculiarly\\nuneven surface and firm feeling the third is largely facial in situation\\nand the last is of a malignant character and relatively rapid career.\\n1 Bull, de T Acad, de M\u00c2\u00a3d. de Paris, 1882, p. 395.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0856.jp2"}, "857": {"fulltext": "LEPTUS. 793\\nECHINOCOCCUS.\\nWeyl and Geber state that the parasite, echinococcus (larva or hydatid\\nof the taenia echinococcus of the dog), not mentioned in dermatological\\ntreatises, is found in the human skin. Of 336 cases reported by\\nDavaine, the parasite occurred thirty times in muscular and subcuta-\\nneous tissues, more often in women than in men. The softish, fluctuat-\\ning tumors or vesicles produce a disagreeable sensation of tension, and\\nthey undergo fatty or other metamorphosis after the death of the encap-\\nsulated parasite, that usually occurs in from one to two years. Explora-\\ntion of the superficially seated fluctuating tumor, covered with unaltered\\nintegument, usually demonstrates its nature.\\nDISTOMA HEPATICUM.\\nKuchenmeister l reports three instances in which the embryos of the\\nlarge liver-fluke were encapsulated in subcutaneous tissue. The tumors\\nwere painful or painless, and occurred on the head, trunk, and extrem-\\nities.\\nLEPTUS.\\n(Leptus Autumnalis, Harvest-bug, Mower s Mite.\\nFr., Eouget.)\\nThe leptus (Figs. 100 and 101) is a minute, reddish or yellowish-red\\ninsect of the family Trombidce, visible to the naked eye, and found in\\nsummer and autumn clinging to bushes and grasses. It is found both\\nin America and in Europe. It attacks man only after its accidental\\nlocation upon the skin, where it perishes in the course of a few hours.\\nIn such situations, however, it induces considerable irritation, betrayed\\nin erythematous, urticarial, papular, and even eczematous symptoms,\\naccompanied by pruritus of various grades. The parts chiefly affected\\nare the ankles, legs, arms, and feet. The mite may be seen in the skin as\\nan orange-reddish or brick-reddish point, which represents often the body\\nof the insect, its head being buried in the aperture of a follicle beneath.\\nExamined after extraction, it is seen to have a relatively large cephalic\\nextremity. It has a short, cylindrical, and conical haustellum, composed\\nof fused double maxillae and two strong, hooked, five-jointed palpi,\\nwhich can be rolled up. There are also two hatchet-like mandibles.\\nIt has a well-rounded or oval body 0.3558 mm. long and 0.32 mm.\\nbroad, provided with three pairs of legs. It is found upon the lower\\nlimbs, and also upon the scalp and every other part of the body.\\nAccording to Duhring, children are especially liable to its encroach-\\nments. The disorder is relieved by the application of balsam of Peru\\nin olive-oil, carbolated oil, spirit of camphor, or other mild stimulant\\nor parasiticide.\\nThere are several species of leptus {leptus Americanus, leptus irri-\\ntans) and other insects living on shrubs and grasses that, especially in\\nthe months of July and August, attack the human skin.\\n1 Loc. cit.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0857.jp2"}, "858": {"fulltext": "794\\nPARASITIC AFFECTIONS.\\nThe Leptus Americanus (krithoptes monunguiculosus Fig. 99) is\\nnamed by Weyl and Geber as the larva of a mite that annoys laborers\\nin barley. It is yellowish white, oblong or oval in form, averaging\\nFig. 99.\\nLeptus Americanus.\\n0.022 mm. in length. There is a protrudible tubular haustellum,\\nenclosed by serrated mandibles. On each side are five-jointed palpi.\\nThere are four pairs of feet two on the cephalo-thorax two, abdom-\\ninal in situation\u00e2\u0080\u0094 all articulated to the epimeres. The tarsus of the\\nFig. 100.\\nFig. 101.\\nLeptus. (After Kuchenmeister.)\\nRouget.\\nfirst part terminates in hooked claws the others have haustellum disks\\non stems. Between the first and second pairs are swinging clubs, indi-\\ncating the larval condition.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0858.jp2"}, "859": {"fulltext": "LEPTUS. 795\\nDipterous Larvae in and beneath the Human Skin.\\nThere is no dipterous insect peculiar to man alone, but a number of\\ncases are on record in which the ova of several species of oestrus have\\nbeen deposited in the skin, and larvae subsequently been formed. The\\noestrus bovis, or gad-fly, in the most common of these. Usually, after\\nthe ova are deposited by the insect, a painful swelling occurs which\\nmay change from one point to another. When suppuration is induced\\nthe larvae can be removed by pressure upon the boil. Walter Smith, 1\\nof Dublin, has described such a case in which the swelling upon the\\nankle of a girl, twelve years old, moved to the elbow, and there dis-\\ncharged a white grub nearly an inch in length. Birdsall 2 described a\\nFig. 102. Fig. 103.\\na\\nOEstrus a, the larva, natural size; b, Larvae removed from the body of a child,\\nsome of the segments seen under a lens, Of the exact size, after several days in alco-\\nand showing the lines of minute projec- hoi a, as seen from side b, as seen from\\ntion; c and d, the terminal ends of the beneath,\\ninsect. (After Abraham.)\\nspecimen sent him from Gaboon, on the West Coast of Africa, in which\\ntwo worms escaped from between the middle and the ring fingers of\\none hand another, workman having had a similar accident occur upon\\nthe leg. The fly the ova of which had been deposited in these two\\ncases was said to attack the gorilla and members of a native tribe\\nengaged in capturing these animals were reported as being commonly\\ntroubled in the same way. The worms sent to Birdsall were respec-\\ntively one-fourth and one-half of an inch in length and about one-\\neighth of an inch in thickness.\\nAbraham, of Dublin, also examined and reported upon a similar\\ncase, the specimen having been sent to the editor of the London Medi-\\ncal Press and Circular, from Portsalon, Letterkenny.\\nSeveral specimens illustrating these accidents have been sent to the\\nauthors. The larvae represented in Fig. 103 were removed from the\\nbody of an infant in Nebraska. The muscidoe (flesh, house, stable,\\ndung, and other flies) have unarmed maxillae, and are unable to wound\\nthe uninjured skin. The pregnant female seeks, therefore, to deposit\\nher ova where the larvae, equally unprovided with developed jaws, can\\nmost readily secure nutriment. Hence, open wounds and the tender\\nskins of newborn infants when exposed in the summer season, are\\nliable to become the depots of such ova.\\n1 See Report of Internat. Med. Congress, Arch, of Derm., January, 1882.\\n2 N. Y. Med. Eecord, March 18, 1882, p. 298.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0859.jp2"}, "860": {"fulltext": "796 PARASITIC AFFECTIONS.\\nThe ova of other species of muscidce and oestridce (according to\\nGeber, of the former, Lucilia Ccesar, in America Stomoxis Calcitrans,\\nin Africa and Sareophila Wohlfarti, in Russia of the latter, Derma-\\ntobia Noxalis, Cuterebra, and Hypodermd) are occasionally found in the\\nskin and subcutaneous tissue. Severe cases are reported from Texas,\\nin which larvae were expelled in great number from the nares after\\ninhalation of chloroform.\\nIXODES.\\n(Wood-tick.)\\nSeveral species of tick are recognized, such as the Rhipicephalus\\nAnnul atus (cattle- tick), Amblyomma Am eric anus, Ixodes Uni-\\npunctatus, and Ixodes Ricinus (wood-beetle), the last named being\\nmore common in Europe. In America wood-ticks are found in\\nwooded districts, especially where pine- and fir-trees are growing.\\nThe female attacks the human skin by thrusting into it her beak,\\narmed on either side with a maxillo-labial projection having recurved\\nhooklets, the mandibles also presenting similar obstacles to the forcible\\nextraction of the head. After suction of the blood from beneath, the\\nbody of the tick swells to the size of that of a pea or small bean, and\\nmay remain for several days in this position. At such times the para-\\nsite may be mistaken for a small pedunculated tumor. Forcible\\nattempts at extraction of the intruder are liable to detach the mandibles\\nfrom the body, and thus leave them as the source of future irritation\\nand even disagreeable inflammatory symptoms in the site of the punc-\\ntured wound. On applying over the tick a drop of spirit of turpen-\\ntine or benzine the head is spontaneously retracted and the body falls\\nfrom its position. Soldiers on the plains of the United States accom-\\nplish the same end with the juice of tobacco. The sensation produced\\nat the moment of the insertion of the beak of the insect is said to be\\nso trifling as often to pass unnoticed.\\nPEDICULOSIS.\\n(Lat. pediculus, a little foot.)\\n(Phtheiriasis, Morbus Pediculosis, Lousiness.)\\nSymptoms. Lice belong to the order Rliynchotta subdivision Par-\\nasites family, Pediculidce. They are apterous, provided each with\\ntwo eyes, and have an oral appendage capable of both inflicting wounds\\nand producing suction. The lice infesting the human body are recog-\\nnized as belonging to three varieties, those of the head, of the body,\\nand of the pubes. Of the disorders to which they give rise, it may be\\nsaid in general that the lesions presented differ according to the region\\ninvaded, to the multiplicity of the intruders, and to the length of time\\nduring which their ravages have been inflicted. Such lesions, however,\\nare those which have been already studied in connection with eczema,\\nurticaria, and the similar disorders resulting from external irritation.\\nTheir special peculiarities in pediculosis are owing solely to the nature\\nof the exciting cause and to the mode of its operation.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0860.jp2"}, "861": {"fulltext": "PEDICULOSIS.\\n797\\nFig. 104.\\nFig.\\nPediculosis Capillitii.\\n(Parasite, the Head-louse.)\\nThe head-louse (Fig. 104) is usually of a grayish color, but differs\\nslightly with the hue of the hair on the part which it frequents. Its\\nhead presents indistinctly the outline of a trefoil,\\nand is provided with two hairy antennae (each of\\nfive articulations) and with two eyes. Its thorax is\\nrelatively narrow, with six tracheal stigmata and\\nthree hairy legs on either side, the legs being pro-\\nvided with tarsal hooklets. The abdomen is di-\\nvided into seven segments, defined by blackish\\nindentations on either side. The males are fewer\\nand smaller than the females, and they present\\nupon the dorsum an ano-\\ngenital orifice and a large\\nconoidal penis and testes.\\nThe females are provided Pedicuius capiiiitii-maie.\\n(Alter Ktjchenmeister.)\\nwith ovaries and with an\\nanal aperture in the terminal abdominal seg-\\nment. Coupling is performed with the male\\nbeneath.\\nThe ova or nits (Fig. 105) are w T hitish\\nbodies of oval contour, that are glued to the\\nhairs by a cylindriform sheath of chitin which\\ncompletely encases each filament. They are de-\\nposited in series, as the female traverses the hair\\nfrom its insertion to its distal extremity, so that\\nthe oldest are in general the nearest to the scalp.\\nThe young escape from the ova in from three\\nto eight days, and arrive at maturity in from\\neighteen to twenty days. A single female, ac-\\ncording to Kaposi, can lay fifty eggs in six days,\\nand thus in eight weeks have a progeny of five\\nthousand lice.\\nHead-lice usually limit their habitat to the\\nscalp, though, rarely, in elderly men with long\\nhair reaching to a full beard, they may encroach\\nupon the latter. They infest every portion of\\nthe scalp, but find the region of the greatest pro-\\ntection upon the occiput. They are found upon\\nchildren and adults of both sexes, but are best\\nfurnished with lodgement upon the scalps of girls\\nand of women covered with long and luxuriant\\nhair. The lesions observed upon a scalp thus\\ninhabited vary according to the age and vigor\\nof the colony. They are few or numerous,\\ndiscrete or confluent pustules or bullae the surfaces are excoriated\\nby scratching and oozing with serum, pus, or blood the crust varying\\nOva of head-louse attached\\nto hair 1, 2, 3, ova a, a, chi-\\ntinous cylinder surrounding\\na pilary filament; b, chiti-\\nnous sheath of nearly matnre\\novum. (After Kaposi.)", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0861.jp2"}, "862": {"fulltext": "798 PARASITIC AFFECTIONS.\\nin character according to the nature of the desiccated exudate and\\nsebaceous matters. Often the picture presented is a conglomerate of an\\nartificial eczema and seborrhoea.\\nThe ova, or nits, are usually abundant upon the hairs of an\\ninfested head, and will scarcely escape the attention of a close obser-\\nver. They are not to be mistaken for the exfoliated, epithelial, and\\nfatty plates seen in seborrhoea sicca, disseminated among the hairs and\\noften perforated by hairy filaments, since the former are firmly glued in\\nposition and resist the bristles of the hair-brush. The peculiarly nause-\\nating odor of the louse-infested, pustule- and crust-covered scalp is not\\nto be confounded with that due to favus of the same region.\\nIn aggravated cases the post-cervical ganglia express, by their in-\\ncrease in size, the degree to which the local irritation has been pushed.\\nThe itching is usually severe, and in cases of long persistence in chil-\\ndren may produce the usual systemic symptoms of prolonged local\\nirritation. Children and patients of impoverished health and with\\npoor hygienic surroundings are believed to exhibit the disease in severer\\ngrades than others but this, if indeed a fact, must at least in part be\\ndue rather to the more favorable conditions for development and\\nmultiplication of the parasites that are presented in filth-accumula-\\ntion and lack of cleanliness. In the public charities of large cities\\nchildren affected with pediculosis capillitii are presented every week\\nwho come from the lowest social grades of the population and from the\\nfilthiest quarters. In these children it is not observed that the general\\nhealth of the patients is a factor in the severity of the affection.\\nThe Diagnosis of pediculosis capillitii is a matter of importance\\nhowever simple of accomplishment, since many cases of supposed\\npustular eczema of the scalp have vainly been treated by one\\nphysician with internal remedies addressed to the systemic vice\\nassumed to be responsible for the disease which another has relieved\\nafter the discovery of a few head-lice. The hairs should always be\\nraised and separated, the scalp carefully be inspected, and the presence\\nof any parasites, and especially ova or nits fastened to the hairs, be\\nascertained. Whether the lice have preceded or followed the eczema-\\ntous state (and each of these conditions may be noted) is a matter of\\nminor importance. Pustules about the nares and lips, especially of\\nyoung girls, are often significant of pediculi of the occipital region, the\\nlesions being due to picking and scratching the face under an impulse\\nto relieve pruritic sensations of the scalp induced by the presence there\\nof lice.\\nTreatment. The indications in the treatment of pediculosis capil-\\nlitii are the destruction of all parasites with their ova, and the relief\\nof the induced inflammatory condition of the scalp. Generally, re-\\nmoval of the former is followed by spontaneous disappearance of the\\nlatter. For the destruction of the lice the most popular remedy in\\nthe United States is petroleum (not kerosene), pure or with equal parts\\nof balsam of Peru (which gives it an agreeable odor), poured over the\\nscalp in quantity sufficient to cover it without overflow upon the brow,\\ntemples, and neck. It should be rubbed in with a piece of white\\n(undyed) flannel, At the end of from twelve to twenty-four hours the", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0862.jp2"}, "863": {"fulltext": "PEDICULOSIS.\\n799\\nlice are destroyed, and the ova are rendered incapable of development.\\nThis treatment is followed by a thorough shampoo with tincture of green\\nsoap, or with toilet-soap and hot water after this operation the scalp\\nmay require a bland unguent, such as vaselin, or a small quantity of\\nscented castor-oil, either pure or in combination with spirit of wine.\\nKaposi employs petroleum as a parasiticide in combination with olive-\\noil and balsam of Peru 5 parts of the first, 2^- parts of the second, and\\n1 part of the third. Cutting the hair of women and children is unnec-\\nessary, as patience and gentleness with the use of the comb will dis-\\nentangle the most matted masses after the lice have been destroyed.\\nOther remedies are employed locally for a similar purpose, of which\\nthe most popular are staphysagria, 1 drachm (4.) of the powdered seeds\\nto the ounce (30.) of vaselin, but especially in decoction tincture of\\ncocculus indicus carbolic acid in oil or water sabadilla the ethereal\\noils and mercurials in ointment and solution, including the mercuric\\noleates. In cases in which but a few parasites have found their way\\nto the scalp, and that recently, nothing more is requisite than careful\\nuse of a fine-tooth comb, scrubbing the scalp with a strongly scented\\nalcoholic perfume, and final bathing with soap and hot water.\\nThe ova adhering firmly to the hairs can be removed by soda or\\nborax lotions, alcoholic solutions, or dilute acetic acid, which are sol-\\nvents for the gluey material by which the nits are secured in place.\\nPediculosis Corporis.\\n(Pediculosis Vestimenti. Parasite, the Body-louse.)\\nThe parasite in this disorder inhabits exclusively the clothing worn\\nnext the body. In anatomical peculiarities it resembles the pediculus\\ncapillitii already described, being, however, larger in size, the females\\nalso larger than the males. The thorax is separated from the abdo-\\nmen, the latter being hairy, yellowish at the margins,\\nand provided with eight segments. The eyes are\\nblack and very prominent in both sexes and the\\nperiods requisite for the maturing of the ova and\\nyoung are those named respectively in connection\\nwith head-lice. In color they vary from a dirty\\nwhite to a light-grayish hue when undistended with\\nblood. In the reverse of this last-named condition\\nthey may be recognized as having a dull-reddish or\\na purplish color, when they are also more indolent\\nin their movements. They measure from 2 to 3 mm.\\nin length and 1 to 1.5 mm. in breadth. The female\\nlays from seventy to eighty eggs, from which the\\nyoung are produced in from three to eight days, and\\nare capable of reproduction in a fortnight more.\\nThey inhabit the seams of undergarments, where\\ntheir ova are also deposited but in coarse woollen\\nor flannel shirts they find sufficient shelter in the\\nmeshes of the material of which the clothing is made this they leave\\ntemporarily, solely for the purpose of obtaining nutriment from the\\nFig. 100.\\nPediculus corporis\\nfemale. (After\\nKtfCHENMEISTER.)", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0863.jp2"}, "864": {"fulltext": "800 PARASITIC AFFECTIONS.\\nskin of their host, and hence are not recognized upon the free surface\\nof the integument. Upon rapid removal of the clothing of an infested\\nindividual a few lice may occasionally be encountered, hastily seeking\\na place of refuge, though this is rather the exception to the rule. It\\nthus may happen that a louse-bitten patient will not exhibit the source\\nof his trouble to his physician after a recent and complete change of\\nclothing. The greater then the importance of being able to recognize\\nthe clinical features of the malady in the absence of the parasite. This\\nrecognition is comparatively easy to one who has made himself familiar\\nwith the symptoms of the disorder.\\nThe manner in which the louse is enabled to supply itself with the\\nblood of man has been studied by Swammerdam, Landois, Schjodte,\\nand Tilbury Fox. The last-named author has summarized the ob-\\nservations of the others, and the results he gives may briefly be de-\\nscribed as follows\\nSwammerdam s original view that the louse is not provided with\\nmandibles by which it can inflict a wound, but with a haustellum by\\nwhich the blood is sucked up to the head of the parasite, is confirmed\\nby Schjodte. This observer, examining the head of the louse from\\nbehind with reflected light, discovered that the parts of the head re-\\nsembling mandibles in appearance were really situated beneath its skin.\\nHe applied to the integument lice which previously had been starved,\\nand watched each as, with retracted limbs, arched back, and head in-\\nclined obliquely downward, it repeatedly projected forward and re-\\ntracted through the extreme end of its head a small, dark, narrow\\norgan, by which it was firmly held in place. A triangular blood-red\\npoint soon became visible in front of the eyes, rapidly and alternately\\ncontracting and dilating, and followed by energetic peristalsis of the\\ngastro-intestinal tract. If the head then be cut off in front of the eyes,\\nand the haustellum carefully be extracted, the latter can be recognized\\nas a brownish protrusion, armed with terminal recurved hooks, from\\nwhich depends a delicate membranous tube varying in length. It\\nseems that the mouth is like that in the rhyncotta generally, but differs\\nin the circumstance that the labium is capable of being retracted into\\nthe upper part of the head, and has a fold in it when so retracted. In\\norder to strengthen this part, a flat band of chitin is placed on the\\nunder surface and it is thinner in the middle in order that it may bend\\nand fold a little when the skin is not extended by the lower lip. The\\nlatter consists of two hard lateral pieces, of which the fore-ends are\\nunited by a membrane, so that they form a tube, of which the internal\\ncovering is a continuation of the elastic membrane on the top of the\\nhead. Inside its orifice are a number of small hooks, which assume\\ndifferent positions according to the degree of the protrusion and if\\nthis be pushed to its highest point, they form a collar of hooks curved\\nbackward like barbs. The pediculus first inserts its labium into a\\nsweat-pore and protrudes the lip. When the hook is securely attached\\nto the parts around then the first pair of setae (the real mandibles trans-\\nformed) are protruded, and these are toward the point invested by a\\nmembrane so as to form a closed tube, from which again is exserted a\\nsecond pair of setae or maxillae, which form a tube and end in four", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0864.jp2"}, "865": {"fulltext": "PEDICULOSIS. 801\\nsmall lobes placed crosswise. The whole forms a membranous tube,\\nalong the walls of which retiform mandibles and maxilla? are placed as\\nlong, narrow bands of chitin. This tube can be lengthened or shortened\\nat pleasure.\\nThis explanation of the mode in which the louse attacks the skin is\\nprobably true of each of the varieties which infest the human body.\\nFox well suggests that the invaded follicle, after the withdrawal of\\nthe haustellum, becomes the seat of a circumscribed hemorrhage. None\\nof the anatomical peculiarities described above, however, completely\\nexplains the characteristic pruritus of pediculosis corporis, for it can\\nscarcely be questioned that it is not merely at the moment of attack or\\npenetration that the suffering of the victim is greatest. The pruritic\\ncondition of the louse-wound persists, indeed usually attains its maxi-\\nmum, after withdrawal of the pediculus, and is without doubt greater\\nthan that awakened by merely mechanical puncture of the epidermis.\\nAnyone who will compare the skin of a louse-infested patient with that\\nof one who has been subjected to the acupuncture process employed\\namong the lower classes of Germans, and by them known as baun-\\nscheidtismus, can convince himself of this fact.\\nThe lesions seen on the skin thus invaded are proportioned, as in\\npediculosis capillitii, to the size and age of the colony of parasites.\\nExcoriations, usually linear, occasionally circumscribed, varying in\\ndepth and length, radiate irregularly from each louse-wound, and they\\nmay be commingled with minute papules, transitory wheals, or, in rare,\\naggravated cases, with the typical signs of diffuse eczema. All are\\nproduced by scratching in order to relieve the pruritus. Crusts, often\\ncomposed of desiccated blood, rarely of serum or pus, minute and cap-\\nping the wounded follicle, or linear and coextensive with the excoria-\\ntions produced by scratching, are generally conspicuous. In older cases\\nthese lesions are followed by the usual sequel, pigmentation, the latter\\nbeing a partial indication of lousiness which has long been tolerated.\\nIn America it is rare to note the severe and intense forms of the\\nmalady, resulting from long-continued neglect of the skin, that occur\\nin Germany. In these cases follow dermatitis, rupioid crusts, furun-\\ncles, abscesses, carbuncles, and ulcers, resulting in serious implication\\nof the skin which may persist for weeks after the clothing has been\\nfreed from lice, and finally leave a deep-tinted, diffuse pigmentation of\\nthe skin-surface, suggesting that of the negro or of the patient affected\\nwith Addison s disease.\\nThe Diagnosis is a matter of importance. Patients will visit physi-\\ncians, claiming that they have suffered from a humor of the blood/\\nwho have been swallowing drugs for a long period of time, in the vain\\nhope of obtaining relief, with lice, at the very moment of uttering the\\ncomplaint, crawling over their persons. Even those of good social\\nposition and cleanly habits will occasionally suffer after accidental\\ncontacts in the tram-car or railway-carriage, the hotel, the theatre,\\nor other places of public resort. There are certain points to be\\ncarefully noted in this connection. Excoriations over the nucha,\\nabout the shoulders, loins, buttocks, and external faces of the thighs,\\nall visible at the same time, are highly suspicious symptoms as an\\n51", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0865.jp2"}, "866": {"fulltext": "802 PARASITIC AFFECTIONS.\\neczema, when equally diffuse, is sure to be accompanied at some point\\nby perfectly classical features and generalized pruritus is exceedingly\\nrare, its localized varieties concerning chiefly the regions about the\\nmucous outlets of the body. There is a picture highly suggestive of\\npediculosis exposed to the eye when the trunk of an infested patient\\nis viewed from behind. The lesions are more discrete, more irregularly\\ndistributed, and more intermingled with long scratch-marks, reaching,\\nfor example, quite over the point of one shoulder, than in most dis-\\norders with which pediculosis vestimenti could be confounded. Here\\nand there minute blood-specks tell a significant tale. When clinical\\npatients exhibit syphilodermata interspersed among characteristic lesions\\nof pediculosis corporis the students themselves in such cases can ordi-\\nnarily point out the particular symptoms referable to the separate dis-\\norders present.\\nIn private practice it is usually advisable, for obvious reasons, to\\nsecure the corpus delicti before informing the sufferer of the nature of\\nhis or her complaint. In the case of male patients it is well to take a\\nposition in the rear, and when the underclothing is drawn well up from\\nthe shoulders a careful scrutiny of it may be made while the applicant\\nfor relief supposes that attention is directed instead to his person.\\nThe Treatment of the disorder concerns largely the clothing. The\\nlatter requires immersion in boiling water, or it may be wrapped in\\npaper and subjected to a temperature in an oven (160\u00c2\u00b0-175\u00c2\u00b0 F.)\\nsufficient to destroy the lice and their ova. In case of recurrence of\\nthe malady the clothing is to be again subjected to the same process.\\nUsually the resulting irritation of the skin promptly subsides. When\\nseveral members of one family suffer all clothing worn must be sub-\\njected to similar treatment. If the skin has been unusually tormented\\nby scratching, warm alkaline baths will afford some comfort, and they\\nmay be followed by a bland unguent or by one of the dusting-powders.\\nFor immediate use, before the clothing can be rid of the intruders, a\\nsmall cheesecloth bag containing sulphur in stick or in powder may be\\nworn beneath the underclothing, or the powder may be dusted in the\\nclothing and rubbed over the body or a parasiticide ointment may be\\nordered as recommended by Duhring, prepared by adding 2 drachms\\n(8.) of freshly powdered staphysagria to the ounce (30.) of hot lard,\\nstrained and cooled. The surface of the skin may also be anointed with\\ncarbolic acid dissolved in oil or in water.\\nPediculosis Pubis.\\n(Crab-louse. Parasite, the Pubic Louse. Fr., Morpion.)\\nIn this disorder the genital region is chiefly involved, though in\\nexceptional cases all the hairy portions of the skin may be invaded,\\nincluding the eyebrows, the eyelashes, the axillae, and the moustache\\nand beard, the hairy chest, and the hairy legs of men. The body\\nof the pubic louse (Fig. 107) is smaller than either of those described\\nabove. Its head is also attached more closely to its thorax, having a\\nshape which is compared with that of a violin. The thorax is not", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0866.jp2"}, "867": {"fulltext": "PEDICULOSIS. 803\\ndistinctly separated from the abdomen, and of the six stout legs with\\nwhich the louse is provided, the second and third pairs are conspicuously\\npowerful and armed with relatively large hooks at the tarsal extremity.\\nThe resemblance of the latter to the claws of a crab has given to this\\ncreature the common name of crab-louse. The lateral abdominal\\nindentations are much less distinct than in the other varieties and\\nthe blackish marginal marks of body- and head-lice are here scarcely\\napparent. The abdomen is also much elongated, having a more rounded\\ncontour. The pubic louse is provided on its lateral borders with eight\\nshort conical feet, terminating in bristles. It is also distinguished from\\nthe others of its family by the length of its anal bristles and by the\\npeculiar shield-shaped carapace which covers nearly one-half of the\\ndorsum. The male is from 0.8 to 1 mm. long, and from 0.5 to 0.7\\nmm. wide, being thus from 1 to 1.5 mm. smaller than the female.\\nThe pubic louse is much more inactive than the others, and does not\\nordinarily escape its pursuer. It buries its head deeply in a follicular\\norifice, and steadies itself in this position, where it may remain for\\nsome time, by grasping the adjacent hairs with its short and powerful\\nclaws. A moderate degree of force is required for its dislodgement\\nfrom this favorite position, and when removed its grasp of the hair to\\nwhich it clings is so firm that the latter usually slides for its entire\\nlength through the claw of the louse. Occasionally it may be found\\ncreeping over the skin or clinging to hairs at a distance from the skin-\\nsurface. The pyriform ova are smaller\\nthan those of the head-louse, though hav- FlG 107\\ning a similar color, and are, like the lat-\\nter, attached to the hairs by a firm chiti-\\nnous glue.\\nPubic lice are usually acquired during\\nthe contacts incidental to the sexual act\\nare, hence, more frequently encountered\\namong adults but may, without question,\\nbe transmitted mediately by occupation\\nof beds and covering which have been\\nused by infested persons. They are thus,\\nthough rarely, found in children of both\\nsexes.\\nThe lesions induced are those produced Pe dicuins pubis. 7 (After schmarda.)\\nby the wounds inflicted by the parasites\\nand by constant scratching, though these are rarely severe. In a few\\ncases one may see a severe eczema follow the ravages of the lice, but\\nin such event the complication is chiefly owing to unnecessarily severe\\nself-treatment of the disorder, patients, being often morbidly anxious\\nin their efforts to rid themselves of the pests.\\nThe Diagnosis of pediculosis pubis is between eczema and pruritus\\ngenitalium. The disease last named is, in both sexes, accompanied by\\nitching, and that often of intense grade but when this is diffuse and\\nsymmetrical in distribution it is not limited particularly to the hairy\\nparts. Eczema of the genitals is not often produced by parasites of\\nthat region, and it may readily be recognized by its characteristic fea-", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0867.jp2"}, "868": {"fulltext": "804 PARASITIC AFFECTIONS.\\ntures. Both disorders are often, indeed, limited to symmetrical patches\\nupon the side of the scrotum or one labium. The discovery of the\\nparasite, however, in pediculosis pubis is always essential, and requires\\nmerely careful inspection and a good light. The lice may be recognized\\neither at or near the point of implantation of the hairs, which also dis-\\nplay ova except in very recently infested individuals. The reddish\\nexcrement of the parasites mingled with scratch-marks and excoriated\\npapules of small size may also be observed. Patients are often made\\naware of their condition by a sensation of crawling over the parts.\\nScratching of the pubic region in adults of both sexes should awaken\\nsuspicion of the disorder.\\nTreatment. The disease is commonly treated by the topical appli-\\ncation of mercurial ointment, which is a disagreeable and rather filthy\\nmedicament for this locality. The 10 per cent, oleate may be substi-\\ntuted for it, or, even preferably, corrosive sublimate in solution, from\\n3 to 4 grains (0.2-0.268) to the ounce (30.). Petroleum and olive-oil\\nwith balsam of Peru, in the proportions given above in connection\\nwith the subject of pediculosis capillitii, are an effective combination.\\nStaphysagria, carbolic acid, cocculus indicus, or one of the other sub-\\nstances used in the disorders occasioned by the animal parasites,\\nmay be substituted if desired. It is usually better to defer bathing\\nuntil the remedy selected for the destruction of the lice has been ap-\\nplied on several occasions, after which a warm water-and-soap ablu-\\ntion will commonly end the trouble. It is needless to clip the\\npubic hairs. Should an eczematous disorder remain, it requires appro-\\npriate treatment, including hot bathing and the blander lotions and\\nunguents.\\nVagabonds Disease. This is a term given to the condition of\\nthe skin recognized among tramps, inmates of poorhouses, and the\\nfilthy and neglected in general. The skin of such persons is often\\ndensely indurated, harsh, dry, and deeply pigmented, in consequence\\nof much scratching and a consequent hyperemia. This condition is\\nproduced chiefly by phtheiriasis but is often a resultant of the incur-\\nsions of several parasites, including those of the bed and of the cloth-\\ning. It is also a consequence of persistent neglect of the bath.\\nPediculi and Acari transferred to Man from the Lower\\nAnimals rarely thrive in such uncongenial soil, but as a matter of\\nexception they occasionally survive such transfer. Thus Goldsmith, 1\\nof Vermont, reports the case of a woman affected with intense pruritus,\\nwho after sweating profusely observed numbers of pigeon- or hen-lice\\nemerging from the sweat-pores. Megnin 2 reports similar cases under\\nthe title Prurigo Dermanyssique, the dermanyssus avium, or gallinoe,\\nbeing the acarus infesting domesticated fowls. The disorder is said to\\nbe at times epidemic in the vicinity of aviaries and pigeon-cotes, but is\\nalways of trifling severity.\\n1 Louisville Med. News, December 31, 1881, p. 320.\\n2 Les parasites et les maladies parasitaires chez l homme, les animaux domestiques,\\netc. Paris, 1880.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0868.jp2"}, "869": {"fulltext": "CIMEX LECTULARIUS. 805\\nCIMEX LECTULARIUS.\\n(ACANTHIA LeCTULARIA, BUGS, BEDBUGS.)\\nStrictly speaking, the bedbug is not a parasite of man, but finds its\\ncongenial habitat in the bed, bedding, and bed-covering, and the walls\\nand floors of apartments occupied by persons of both sexes and all\\nages. It infests also furniture, including chairs, sofas, and the cushions\\nof seats occupied in public vehicles and hotels. From the cracks,\\ncrevices, seams, folds, or other protected points where it has found\\nlodgement, it emerges usually at night, for the purpose of securing its\\nnutriment in the blood of its victims. It is a pest as ancient as the\\nday in which Dioscorides wrote.\\nThis insect has a rusty or reddish color, this differing slightly ac-\\ncording as it is or is not distended with blood. It is an apterous\\nmember of the order Cimicid^e. It is provided with a blunt-pointed\\nhead, broadly attached to the thorax; two long, slender antennae;\\nand a three-jointed haustellum capable of projection and retraction\\nbeneath the head. There are three pairs of long, slender legs by which\\nit is enabled to accomplish rapid movements. The abdomen is broad\\nand flattened, and oval in shape, with nine segments. The parasite\\nemits a disgusting odor, which is much more distinct when it is\\ncrushed.\\nThe wound inflicted by this bug is accomplished with or without the\\nconsciousness of its victim, who in the former case is made aware of a\\ntransitory prick or sting. Soon after, decidedly pruritic, burning, or\\nstinging sensations are experienced, and the wound becomes the seat\\nof an urticarial wheal. The lesion then, examined soon after the inflic-\\ntion of the wound, is seen to be small pea- to bean-sized, and in the\\nform of an elevated and circumscribed button or papulo-tubercle,\\neither whitish in the centre or exhibiting there also the hyperemia\\nwhich distinguishes its peripheral zone. After the lesion has begun to\\nsubside and lose its acute features, which may not occur for several\\nhours if it be irritated by rubbing or scratching, a minute reddish\\nI punctum may be seen marking the original site of the wound.\\nThe lesions are usually multiple even when but a single assailant\\nhas been present, the insect taking apparent delight in obtaining its\\nnutriment from several distinct points upon one surface. In this way\\nat times its course upon the integument may for a short distance be\\ntraced. In cases in which the pests are numerous, as in filthy dwell-\\nings, prisons, ships, and barracks, and when infants have been attacked,\\nthe resulting eruption is often greatly masked by the scratching and re-\\nsulting excoriations of the skin-surface. In this way vesicles, pustules,\\ncrusts, purpuric blotches, and even skin-infiltrations may be found,\\ninstead of the rosy or light-reddish typical wheals of recent cases in\\npatients with fair, clean skins.\\nThe Diagnosis is a matter of importance, and upon it may hang a\\nprofessional reputation. Physicians are often consulted respecting these\\nlesions by patients who believe themselves to be suffering from hives,\\nhumors, exanthemata, and even from syphilis. The insect attacks", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0869.jp2"}, "870": {"fulltext": "806 PARASITIC AFFECTIONS.\\nthe parts of the body to which access is easy as the patient sits or\\nreclines on the back or side, including the buttocks, the thighs, the\\nshoulders, the loins, and the neck, in that order of frequency, rather\\nmore largely than the legs, much less frequently the scalp, the face, and\\nthe genitalia. The eruption is not to be confounded with urticaria ab\\ningestis, which is more apt to be symmetrical in disposition.\\nTreatment. The eruption is best relieved by the topical application\\nof spirit of camphor, alcohol, weak carbolated lotions, or solutions of\\nboric acid, 1 drachm to the pint (5. to 500.) Untreated,, it disappears\\nspontaneously when the source of the disorder is removed. The most\\neffective treatment is by prophylaxis, with soap, corrosive sublimate\\nsolutions in alcohol, and hot water employed over all accessories of the\\ndwelling-house inhabited by the insects. Once discovered to be present,\\ninfested furniture should be scrubbed in all its crevices with a saturated\\nsolution of corrosive sublimate in alcohol, and bed-clothing be immersed\\nin boiling water.\\nCULEX PIPIENS, Etc.\\nOther insects which may persistently or only occasionally attack the\\nhuman skin are the mosquito and gnat (Culex Pipiens) midges\\n(Simulia) bees (Apes Melliferje) and wasps (Vespid^). They\\nproduce by their bites or stings various cutaneous lesions, including\\nurticarial wheals, papules, ecchymoses, and in rare cases even ecchymo-\\nmata. The lesions produced by the flea are found more often on the\\nlegs, the neck, or other covered portions of the body. Those of the\\nmidge and mosquito are seen on the face, the hands, and exposed parts\\nthough, when numerous and voracious, these insects will penetrate the\\nclothing for the purpose of obtaining blood. Severe eruptive lesions\\nare often seen in America on the faces and extremities of infants and\\nchildren exposed during the night to the incursions of these marauders.\\nThe skin-symptoms are usually treated locally by aqua ammonia? or\\nspirit of camphor.\\nThe bodies of immigrants newly arrived during the summer season\\nin America, from countries where the mosquito is either rare or does not\\nexist, often present singular and even formidable evidences of the attacks\\nof these insects. The skin, unaccustomed to such depredations and\\nquite unprotected, will often be found greatly swollen, and of a light-\\nreddish hue suggestive of erysipelas. Here and there bullae are con-\\nspicuous, which add to the resemblance to the last-named disease. The\\nfeatures, in consequence of the tumefaction, vesiculation, and papulation,\\nmay be so swollen as to present a conspicuous deformity and the fore-\\narms, and even the arms, seem greatly increased in size from the same\\ncause. The feet and legs also may, in the unconsciousness of sleep, be\\nexposed in hot weather to the depredations of these marauders, and in\\nthe same way the back, the buttocks, and, rarely, even the genitalia may\\npresent the same signs of inflammation. The matter of chief moment\\nis the correct diagnosis of such cases, as many patients seeking relief under\\nsuch circumstances have been treated for disorders with which they\\nwere not affected.", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0870.jp2"}, "871": {"fulltext": "PROTOZOA AND SPOROZOA. 807\\nPROTOZOA AND SPOROZOA.\\nThe relations sustained by some forms of protozoa to diseases of the\\nskin and of other organs in man are as yet undetermined. The so-called\\npsorosperms observed by a number of investigators in Darier s disease,\\ncarcinoma, molluscum fibrosum, Paget s disease, herpes zoster, and\\nvaricella have been demonstrated clearly to be bodies produced by cell-\\ntransformation. It is well known, however, that the livers and other\\norgans of rabbits and of some other animals often contain coccidise (a\\nsubclass of sporozoa), and several instances of peculiar forms of disease\\nin man have been reported in which protozoa were satisfactorily demon-\\nstrated. Psorospermosis of internal organs of man is described by\\nOsier 1 and by Blanchard. 2\\nCases of protozoan infection of the skin and other organs are re-\\nported by Wernicke, 3 Pixford and Gilchrist, Psodas, 4 and D. W. Mont-\\ngomery. 5 In one case the course of the disease was chronic, and the\\ncutaneous lesions were almost identical clinically and histologically with\\nsome of the verrucous types of tuberculosis. The patient died finally\\nof a general infection which was in every way similar to a tubercular\\ninfection, but careful search failed to reveal tubercle-bacilli, while pro-\\ntozoa were found in great numbers in lesions of the skin and of other\\norgans. Successful, though not entirely satisfactory, inoculations were\\nmade on rabbits and dogs. The protozoa and the histology of the le-\\nsions in the cases have been studied by Gilchrist, who has published\\nthe results of his labors in the Johns Hojikins Hospital Reports, vol. i.,\\n1896. This report contains also Comparisons of Two Varieties of\\nProtozoa and the Blastomyces with the so-called Parasites in Certain\\nLesions of the Skin/ with a full bibliography.\\nRecent studies have shown that under certain conditions blastomyces\\nmultiply by sporulation. This fact removes one of the chief reasons\\nfor making a distinction between blastomycotic and protozoic infection\\nof the skin. (Cf. Chapter on Blastomycosis.)\\n1 Principles and Practice of Medicine, p. 1080, 2d edition. New York, 1895.\\n2 Bouchard s Traite de Pathologie generale, tome ii., p. 682. Paris, 1896.\\n3 Ann. de Circ. Med. Argent., Buenos Aires, 1890, vol. xii., p. 391.\\n4 Abst. in Monatshft. f. prakt. Derm., Bd. xxvii., S. 593.\\n5 Brit. Jour, of Derm., October, 1900.", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0871.jp2"}, "872": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0872.jp2"}, "873": {"fulltext": "INDEX.\\nABSCESSES caused by sporothrix, 77.\\nAcanthia lectularia, 805\\nAcantholysis bullosa, 426\\nAcanthosis nigricans, 469\\nAcari from lower animals, 804\\nAcarus folliculorum, 139, 788\\nhordei, 794\\nscabiei, 783\\nAchromia, 501\\nunguium, 527\\nAcne, 391\\nalbida, 142\\nartificialis, 392\\natrophica. 392, 409\\ncachecticorum, 392, 590\\ncancro idale, 556\\ncontagious, 394\\ncornee, 393\\ndecalvarite, 518\\ndiagnosis, 396\\ndisseminata, 393\\netiology, 395\\nfrontalis, 409\\nhypertrophica, 392\\nindurata, 392\\nkelo idienne, 520\\nkeratosa, 393\\nnecrotica, 409, 601\\npapulosa, 393\\nparasitica, 394\\npathology, 396\\nponctuee, 137\\nprognosis, 404\\npunctata, 393\\npustulosa, 393\\nrodens, 409\\nrosacea, 404\\ndiagnosis, 406\\netiology, 405\\npathology, 406\\nprognosis, 409\\nsymptoms, 404\\ntreatment, 407\\nrosee, 404\\nscrofulosorum, 392, 599\\nsebacea, 124\\nsebacee cor nee, 445\\nfluente, 125\\nsymptoms, 391\\ntar, 287\\ntreatment, 397\\nurticata, 394\\nvarioliform e, 409, 452\\nvarioliformis, 409, 601\\ndiagnosis, 411\\netiology, 410\\nAcne varioliformis, pathology, 410\\nsymptoms, 409\\ntreatment, 411\\nvulgaris, 393\\nAcneiform para-tuberculoses, 603\\nAcnitis, 601\\nBarthelemy, 123\\nAcrodynia, 187\\npathology, 188\\nprognosis, 188\\ntreatment, 188\\nAcromegaly, 497\\nActinomycosis of skin, 771\\ndiagnosis, 773\\netiology, 772\\npathology, 772\\nprognosis, 773\\nsymptoms, 771\\ntreatment, 773\\nAcute circumscribed oedema, 198\\neczema, 320\\nidiopathic oedema, 198\\nnon-inflammatory oedema, 198\\nAddison s disease, 437\\nAdenoma of coil-glands, 558\\nof sebaceous glands, 556\\nacquired benign, 556\\ncongenital benign, 556\\ndiagnosis, 557\\netiology, 557\\nmalignant, 557\\npathology, 557\\nsymptoms, 556\\ntreatment, 557\\nof sweat-glands, 558\\nsebaceum, 556\\nAdenom.es sebaces cancro idaux, 556\\nAden ulcer, 238\\nAgminate folliculitis, 740\\nAinhum, 535\\nAlbinism, partial, 501\\nAlbinismus, 502\\netiology, 502\\nsymptoms, 502\\nAlbinoes, 502\\nAlbugo, 527\\nAleppo evil, 237\\nAlkalies, 88\\nAlopecia, 507\\nareata, 511\\ndiagnosis, 515\\netiology, 513\\nfalse, 518\\npathology, 514\\nprognosis, 517\\nsymptoms, 511\\n809", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0873.jp2"}, "874": {"fulltext": "810\\nINDEX.\\nAlopecia areata, treatment, 515\\ncircumscripta, 511\\ncongenita], 507\\netiology, 510\\nfollicularis, 518\\nfurfuracea, 509\\nneurotica, 514\\norbicularis, 513\\npathology, 510\\npityrodes capillitli, 509\\nprematura, 508\\nidiopathic, 508\\nsymptomatic, 509\\npresenile, 508\\nprognosis, 511\\nsenile, 508\\nsymptoms, 507\\ntreatment, 510\\nAlopecies cicatrieielles innominees, 518\\nAmblyomma Americanus, 796\\nAnsesthsesia, 716\\nAnalgesic paralysis, with whitlow, 534\\nAnatomy of the skin, 17\\nAnderson s dusting powder, 179\\nAngiokeratoma, 449\\ndiagnosis, 450\\netiology, 450\\npathology, 450\\nprognosis, 450\\nsymptoms, 449\\ntreatment, 450\\nAngioma, 563\\ncavernosum, 565\\ndiagnosis, 566\\netiology, 565\\ninfective, 568\\npathology, 565\\npigmentosum et atrophicum, 572\\nprognosis, 568\\nserpiginosum, 568\\ndiagnosis, 569\\netiology, 568\\npathology, 569\\nsymptoms, 568\\ntreatment, 569\\nsymptoms, 563\\ntreatment, 566, 568\\nAngiome cystique, 570\\nAngiomyoma, 562\\nAngio-neurotic oedema, 198\\ndiagnosis, 199\\nsymptoms, 198\\ntreatment, 199\\nAnguillulse, 792\\nAnguillulidse, 792\\nAnidrosis, 118\\ntreatment, 118\\nAnimal parasites, 778\\nAnomalous discoloration of skin, etc., 439\\nAnthemata, 60\\nAnthrax, 233\\ndiagnosis, 234\\netiology, 233\\npathology, 234\\nprognosis, 235\\nsimplex, 229\\nAnthrax, symptoms, 235\\ntreatment, 234\\nAntiseptic baths, 94\\nApes melliferse, 806\\nAplasie moniliforme intermittente, 524\\nArea Celsi, 511\\nJohnstoni, 511\\nArgyria, 438\\nArrectores pilorum, 35\\nArsenic, 86\\nArthritic purpura, 430\\nAsphyxia, local, 219\\nAsteatose, 136\\nAsteatosis, 136\\npathology, 136\\nprognosis, 137\\nsymptoms, 136\\ntreatment, 136\\nAtrophia cutis, 528\\nmaculosa et striata, 529\\npilorum propria, 522\\nsenilis, 528\\nunguis, 526\\ntreatment, 527\\nAtrophoderma pigmentosum, 572\\nAtrophodermia neuriticum, 531\\nAtrophy of hair of beard, undescribed\\nform, 522\\nof skin, 528\\nblanching, 531\\netiology, 530\\nidiopathic, diffuse, 530\\npartial, 529\\npathology, 530\\nsymptomatic, partial, 530\\ntreatment, 531\\nAussatz, 670\\nAutographism, 190\\nAuto-infection, 65\\nBACILLOGENOUS sycosis, 240\\nBad disorder, 614\\nBaldness, 507\\nBarbadoes leg, 494\\nBarbers itch, 240, 753\\nBartfinne, 241\\nBeaded hairs, 524\\nBed-bugs, 805\\nBees, 806\\nBeigel s disease, 526\\nBiskra bouton, 237\\nBlasenausschlag, 412\\nBlastomycosis of skin, 774\\ndiagnosis, 777\\netiology, 776\\npathology, 776\\nprognosis, 778\\nsymptoms, 774\\ntreatment, 777\\nBlattern, 157\\nBlebs, 56\\nBlood-vessels, 29\\nBloody sweat, 123\\nBlutschware, 226\\nBoatman s ringworm, 760\\nBoba, 684", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0874.jp2"}, "875": {"fulltext": "INDEX.\\n811\\nBoil, 226\\nBouton d Amboine, 684\\nd Orient, 237\\nBowditch Island ringworm, 759\\nBrandy-nose, 404\\nBromhidrosis, 119\\nBromidrosis, 119\\netiology, 119\\npathology, 119\\nsymptoms, 119\\ntreatment, 120\\nBrother ulcer, 686\\nBucnemia tropica, 494\\nBug, 805\\nBulb-corpuscles, 34\\nof hair, 39\\nBullae, 56\\nhemorrhagica?, 430\\nBullous eruption, peculiar, 266\\nBurmese ringworm, 759\\nButton, Biskra, 237\\nGafsa, 237\\noriental, 237\\nCACHEXIA strumipriva, 726\\nthyroidea, 726\\nCachexie pachydermique, 726\\nCallositas, 456\\nof hands, with complications, 457\\nCallosities, 456\\nCalvities, 507\\nCancer of connective tissue, 709\\nen cuirasse, 710\\nepithelial, 697\\nof extremities, 702\\nof genitals, 701\\nhard, 700\\nof lower lips, 701\\nmucous surfaces, 702\\nCancroid ulcer, 697\\nCancro ide, 539, 697\\nCanities, 505\\netiology, 506\\npathology, 506\\nsymptoms, 505\\ntreatment, 506\\nCanker rash, 152\\nCaraate, 767\\nCarates, 767\\nCarates, 767\\ndiagnosis, 767\\netiology, 767\\npathology, 767\\nprognosis, 767\\nsymptoms, 767\\ntreatment, 767\\nCarboncle, 229\\nCarbuncle, 229\\nCarbunculus, 229\\ndiagnosis, 231\\netiology, 231\\npathology, 231\\nprognosis, 233\\nsymptoms, 230\\ntreatment, 232\\nCarbunkel, 229\\nCarcinoma, 697\\nepitheliale, 697\\nlaterosa, 711\\nmelanotic, 711\\npigmented, 711\\nCascadoe, 759\\nCathartics, 88^\\nCativi, 767\\nCauses, external, 66\\ninternal, 63\\nCellulome epitheliale eruplif kystique, 558\\nChalazodermia, 546\\nChancre, 616\\nChancroid, 617, 665\\ndiagnosis, 668\\npathology, 668\\nprognosis, 670\\nsymptoms, 666\\ntreatment, 669\\nChapping, 318, 378\\nChaps, 318\\nCharbon, 233\\nCheilitis glandularis aposthematosa, 362\\nCheiro-pompholyx. 269\\nCheloid, 539\\nChemical and other irritation, 68\\nChicken-pox, 165\\nChignon-fungus, 526\\nChigoe, 789\\nChilblain, necrotizing, 601\\nChilblains, 176, 206\\nChloasma, 760\\nfrom arsenic, 438\\ndiagnosis, 439\\netiology, 439\\npathology, 439\\nprognosis, 441\\nsymptoms, 436\\ntreatment, 440\\nuterinum, 437\\nChorionitis, 488\\nChromidrose, 120\\nChromidrosis, 120\\nChromocrinia, 122\\nChronic eczema, 321\\npustular dermatitis in peripheral\\npatches, 217\\nCicatrices, 59\\nCicatrix, 542\\ndiagnosis, 543\\netiology, 543\\nhypertrophic, 540\\npathology, 543\\nsymptoms, 542\\ntreatment, 543\\nCimex lectularius, 805\\ndiagnosis, 805\\ntreatment, 805\\nCircumscribed and persistent oedema, 199\\nClass L, 111\\nII., 147\\nIII., 428\\nIV., 435\\nV., 501\\nVI., 539\\nVII., 713", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0875.jp2"}, "876": {"fulltext": "812\\nINDEX.\\nClass VIII., 729\\nClassification, 109\\nClavus, 457\\nhistology, 457\\ntreatment, 457\\nCleavage of skin, 22\\nClimate, 67\\nClothing, 67\\nClou, 226\\nde Biskra, 237\\nCoco, 684\\nCod-liver oil, 88\\nCoil, 43\\nCoil-duct, cysts of, 117\\nCoil-glands, 43\\nCold abscess of skin, 585\\nCold-sores, 255\\nCollodion, 101\\nColloid metamorphosis of the skin, 555\\ndiagnosis, 556\\netiology, 556\\npathology, 556\\ntreatment, 556\\nmilium, 555\\nCollo idome miliare, 555\\nColumnar adiposse, 21\\nComedo, 137\\ndiagnosis, 140\\ndouble, 138\\netiology, 138\\npathology, 139\\nprognosis, 142\\nsymptoms, 137\\ntreatment, 140\\nCondyloma, 461\\nCondylomata, 639\\nCones fibreux, 21\\nConfluent variola, 162\\nCongelatio, 206\\nCongenital fibrosebaceous disease, 145\\nConglomerate folliculitis, 740\\nConglomerative pustular perifolliculitis,\\n253\\netiology, 254\\npathology, 254\\ntreatment, 254\\nConsecutive lesions, 56\\nContagious acne, 394\\nCopper-nose, 404\\nCor, 457\\nCorn, 457\\nCome de la peau, 459\\nCornu cutaneum, 459\\netiology, 460\\npathology, 460\\nprognosis, 460\\ntreatment, 460\\nCorpuscles of Krause, 34\\nof Meissner, 33\\nmolluscous, 454\\nPacinian, 31\\ntactile, 33\\nof Vater, 31\\nof Wagner, 33\\nCortex of hair, 40\\nCosme s paste, 706\\nCouperose, 404\\nCow-pox, 167\\nCrab-louse, 802\\nCraw-craw, 792\\nCretinoid oedema, 726\\nCrustse, 57\\nCrusts, 57\\nCulex pipiens, 806\\nCute, 767\\nCuterebra, 796\\nCuticle, 25\\nCuticula, 25\\nCutis, 21\\ntestacea, 128\\nvera, 21\\nCyanhidrosis, 121\\nCystadenomes epithelieux benins, 558\\nCyst, sebaceous, 144\\nCystic lymphangioma, 570\\nCysticercus cellulosse cutis, 792\\ndiagnosis, 792\\nCysts of the coil-ducts, 117\\npainless dermoid, 146\\nDACTYLITIS, tuberculous, 586\\nDandruff, 124\\nDarier s disease, 445\\nDartre, 255\\nhumide, 247\\nDecolorization des ongles, 527\\nDefluvium capillorum, 507, 509\\nDelhi boil, 237\\npathology, 238\\nsymptoms, 237\\ntreatment, 238\\nDemodex folliculorum, 788\\nDepilatories, 485\\nDerma, 21\\nDermanyssus avium, 804\\ngallinse, 804\\nDermatalgia, 714\\ndiagnosis, 715\\nDermatite, 200\\nDermatitis, 200\\ncalorica, 204\\ntreatment, 205\\nchronic pustular, in patches, 21\\ncontusiformis, 181\\nexfoliativa, 290, 293\\ndiagnosis, 292\\nepidemic, 298\\netiology, 292\\ninfantum, 292\\nprognosis, 293\\ntreatment, 293\\npathology, 292\\nprognosis, 292\\nsymptoms, 291\\ntreatment, 292\\ngangrenosa, 217\\ninfantum, 218\\nherpetiformis, 265, 423\\ndiagnosis, 268\\netiology, 267\\npathology, 267\\nprognosis, 269", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0876.jp2"}, "877": {"fulltext": "INDEX.\\n813\\nDermatitis herpetiformis, symptoms, 265\\ntreatment, 268\\nmalignant, papillary, 708\\nmedicamentosa, 207\\ndiagnosis, 215\\npapillaris capillitii, 394, 520\\nrepens, 387\\nscarlatiniformis recidivans, 175\\nseborrhoeica, 381\\ntraumatica, 200\\nvenenata, 201\\ndiagnosis, 203\\netiology, 201\\nsymptoms, 201\\ntreatment, 203\\nDermatobia noxalis, 796\\nDermatolysis, 546\\nDermatomycosis fnrfuracea, 760\\nDermatosclerosis, 488\\nDermatoses of the scrofulous, 599\\nDermatosis Kaposi, 572\\nDesquamative scarlatinoid erythema, 175\\nDevelopment of skin, 19\\nDhabie s itch, 760\\nDiabetic gangrene, 218\\nDiagnosis, general, 72\\nscheme of, 79\\nDiet in eczema, 334\\nDipterous larvae, 795\\nDiscoid trichophytic erythema, 740\\nDiseases due to animal parasites, 778\\nDisorders of glands, 111\\nof sebaceous glands, 124\\nof sweat-glands, 111\\nDisseminate folliculitis, 601\\nDisseminated ringworm, 748\\nDistoma hepaticum, 793\\nDiuretics, 88\\nDonda ndugu, 686\\ntreatment, 686\\nDondos, 502\\nDracunculus Medinensis, 790\\nDrug-eruptions, 207\\nDyes, 507\\nDysidrosis, 269\\nECCHYMOMATA, 430\\nEcchymoses, 430\\nEchinococcus, 793\\nEcthyma, 251\\ndiagnosis, 252\\netiology, 252\\ngangrenous, infantile, 218\\npathology, 252\\nprognosis, 253\\nsymptoms, 251\\ntreatment, 253\\nEczem, 310\\nEczema, 310\\nacute, 320\\nani, 370\\nof anus, 370\\naurium, 363\\nbarbae, 366\\nof beard, 366\\nof breast, 372\\nEczema capillitii, 357\\ncapitis, 357\\nof children, 356\\ncraquele, 318\\ncrurale, 373\\ncrurum, 373\\ndiagnosis, 326\\ndiet in, 334\\nof ears, 363\\nerythematosum, 312\\netiology, 321\\nexfoliativum, 313, 318\\nof eyelids, 365\\nof face, 359\\nfaciei, 359\\nof feet, 375\\nfissum, 318\\ngenitalium, 367\\nof genital organs, 367\\nof hands, 375\\nimpetiginodes, 316\\nintertrigo, 318\\nlabiorum, 361\\nlichenoides, 314\\nof lips, 361\\nmadidans, 317\\nmammae, 372\\nmanuum, 375\\nmarginatum, 320, 741\\nof nails, 378\\nnarium, 363\\nof nipple, 372\\nof nostrils, 363\\npalpebrarum, 365\\npapulosum, 313\\nparasiticum, 320\\npathology, 325\\npedum, 375\\nprognosis, 355\\npustulosum, 316\\nrelief of pruritus in, 340\\nrhagadiforme, 318\\nrubrum, 317\\nof scalp, 357\\nsclerosum, 319\\nseborrhoi cum, 320, 381\\ndiagnosis, 385\\netiology, 384\\npathology, 385\\nsymptoms, 381\\ntreatment, 386\\nsol are, 379\\nsquamosum, 313, 318\\nsymptoms, 313\\ntreatment, 333\\nconstitutional, 334\\nlocal, 337\\nof tropics, 371\\ntuberculatum, 687\\ntuberculous, 604\\nof nurslings, 319\\numbilici, 373\\nof umbilicus, 373\\nunguium, 378\\nuniversal, 379\\nverrucosum, 312, 319", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0877.jp2"}, "878": {"fulltext": "814\\nINDEX.\\nEczema, vesiculosum, 315\\nEczematoid epithelioinatosis of nipple, 708\\nEiterpusteln, 251\\nElectrolysis for removal of hairs, 483\\nElephantiasis, 494\\nArabum, 494\\ndiagnosis, 498\\netiology, 497\\nGrsecorum, 670\\nlymphangiectatica, 570\\npathology, 498\\nprognosis, 500\\nsymptoms, 495\\ntreatment, 499\\ntuberculosa cutis, 583\\nElephant leg, 494\\nEndemic degeneration of bones of foot, 768\\nEndothelioma, 712\\nEphelis, 435\\nEphidrosis, 111\\ntin eta, 120\\nEpidemic erythema, 187\\nexfoliative dermatitis, 298\\netiology, 299\\nherpetic fever, 256\\nskin-disease, 298\\nEpidermis, 25\\nEpidermolysis bullosa hereditaria, 426\\nEpilation, 245\\nEpithelial cancer, 697\\nEpithelial krebs, 697\\nEpithelioma, 697\\nadenoides cysticum, 558\\ncontagiosum, 452\\ndeep, 698\\ndiagnosis, 703\\ndiscoid, 697\\netiology, 702\\nmultiple benign cystic, 558\\npapillary, 699\\npathology, 703\\nprognosis, 707\\nsuperficial, 697\\nsymptoms, 697\\ntreatment, 705\\ntubercular. 698\\ntubular, 736\\nEpitrichial layer, 28\\nEquinia, 235\\netiology, 236\\npathology, 236\\nprognosis, 236\\nsymptoms, 235\\ntreatment, 236\\nErbgrind, 729\\nErectores pilorum, 35\\nEruptions, feigned, 216\\nErysipel, 220\\nErysipelas, 220\\nambulans, 221\\nchronic, 222\\ndiagnosis, 224\\netiology, 220\\nLombardy, 186\\npathology, 223\\nprognosis, 225\\nErysipelas, symptoms, 220\\ntreatment, 224\\nErysipele, 220\\nErysipeloid, 226\\ntreatment, 226\\nErythanthema syphiliticum, 638\\nErythanthemata, 60\\nErythema, 171\\nab igne, 172\\nannulare, 180\\nbullosum, 181\\nvegetans, 418\\ncaloricum, 172\\ncircinatum, 180\\ndesquamative scarlatiniform, 175\\ndiagnosis, 173\\ndiscoid trichophytic, 740\\nepidemic, 187\\nfiguratura, 181\\nfugax, 173\\ngangrenosum, 173\\nhypersemicum, 172\\ninduratum, 181\\nscrofulosorum, 600\\nintertrigo, 177\\ndiagnosis, 178\\netiology, 178\\nsymptoms, 177\\ntreatment, 179\\niris, 181\\nlseve, 173\\nleprosum, 673\\nmarginatum, 181\\nmultiforme, 180\\ndiagnosis, 184\\netiology, 183\\npathology, 184\\nprognosis, 185\\nsymptoms, 180\\ntreatment, 185\\nnodosum, 181\\nnummular, 740\\npapulatum, 181\\npapillosum, 181\\nparatrimma, 173\\npernio, 176\\ndiagnosis, 177\\ntreatment, 177\\npunctatum, 175\\nscarlatiniforme, 175\\ndiagnosis, 176\\netiology, 176\\nsymptoms, 175\\ntreatment, 176\\nscarlatinoid, 175\\nsimplex, 172\\nsymptomatic, 174\\nsymptoms, 172\\ntraumaticum, 172\\ntreatment, 173\\ntuberculatum, 181\\ntuberculosum, 181\\nurticatum, 181\\nvariolous, 157\\nvenenatum, 173\\nvesiculosum, 181", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0878.jp2"}, "879": {"fulltext": "INDEX.\\n815\\nErytheme, 172\\ncentrifuge, 604\\nindure dies scrofuleux, 600\\ninfectueux, 175\\nnoueux, 181\\nErythrasrna, 764\\ndiagnosis, 766\\netiology, 765\\npathology, 765\\nsymptoms, 764\\ntreatment, 766\\nErythromelalgia, 715\\nEsthiomene, 580, 640\\nEtiology, general, 63\\nExanthemata, 60, 147\\nExanthematic miliary tuberculosis of skin,\\n584 _\\nExcoriations, 57\\nExternal treatment, 92\\nJTfARCIN, 235\\nFarcy, 235\\nFat-columns, 21\\nFavic onychomycosis, 731\\nFavus, 729\\nof nails, 731\\nsquamosus, 730\\nFeigned eruptions, 216\\nFeigwarze, 639\\nFetid sweat, 119\\nFe.uerguertel, 258\\nFibres, medullated, 31\\nnon-medullated, 31\\nFibroid of skin, recurrent, 695\\nFibroma, 544\\ndiagnosis, 547\\netiology, 546\\nfungoides, 687\\nhard, 544\\nmolluscum, 544\\npathology, 540\\npendulum, 546\\nprognosis, 547\\nsoft, 544\\nsymptoms, 544\\ntreatment, 547\\nFibromatosis tuberculosa cutis, 583\\nFibromyoma, 562\\nFibrosebaceous disease, congenital, 145\\nFicosis, 241\\nFilaria Medinensis, 790\\ndiagnosis, 791\\netiology, 790\\npathology, 790\\nprognosis, 791\\nsymptoms, 790\\ntreatment, 791\\nsanguinis hominis, 497\\nFilth, 68\\nFinsen s phototherapy, 595\\nFischschuppenausschlag, 47 1\\nFish-skin disease, 471\\nFissures, 58\\nFlannel-rash, 383\\nFleckenmal, 467\\nFlower-leaf seborrhoea, 127\\nFlux, sebaceous, 124\\nFoUiclis, 602\\nFolliculite disseminee des parties glabres\\ntendence cicatricielle, 602\\nFolliculites des scrofideux, 599\\net perifolliculites decalvantes, 518\\net perifolliculites destructives du follicule\\npileux, 518\\nFolliculitis, 601\\nagminate, 740\\nbarbae, 241\\nconglomerate, 740\\ndecalvans, 518\\ndisseminate, 601\\nexulcerans, 123\\nand perifolliculitis, 254\\nvarioliformis, 409\\nFoot, endemic degeneration of bones of. 768\\nfungus, of India, 768\\nMadura, 768\\ntubercular disease of, 768\\nFragilitas crinium, 522\\nFrambesia, 684\\ndiagnosis, 685\\netiology, 685\\nprognosis, 685\\nsymptoms, 684\\ntreatment, 685\\nFramosi, 684\\nFreckles, 172, 435\\nFrost itch, 724\\nFungus foot of India, 768\\nFurunculus, 226\\ndiagnosis, 228\\netiology, 227\\npathology, 228\\nprognosis, 229\\nsymptoms, 227\\ntreatment, 228\\nGAFSA button, 237\\nGale, 778\\nGangrene, diabetic, 218\\nmultiple, 218\\nin infants, 218\\nspontaneous, 218\\nsymmetrical, of extremities, 219\\nGangrenous infantile ecthyma, 218\\nGefdssmal, 563\\nGeneral diagnosis, 72\\netiology, 63\\npathology, 70, 72\\nprognosis, 82\\nsymptomatology, 51\\ntherapeutics, 84\\nGiant ringworm, 760\\nswelling, 198\\nwheals, 54, 190\\nGibert svrup, 661\\nGlanders, 235\\nGlands, coil, 43\\ndisorders of, 111\\nmeibomian, 42\\nsebaceous, 41\\nsebiparous, 41\\nTysonian, 42", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0879.jp2"}, "880": {"fulltext": "816\\nINDEX.\\nGlandulae ceruminosse, 42\\nGlossy skin, 531\\nGlycerin, 96\\nGlycerolates, 96\\nGlyceroles, 96\\nGlycogelatins, 99, 348\\nGlycosuric xanthoma, 554\\nGnats, 806\\nGommes scrofuleuses, 585\\nscrofulo-tuberculeuses, 585\\nGoose-flesh/ 410\\nGranular layer, 27\\nGranuloma fungoides, 687\\ninnominatum, 601\\nsarcomatodes, 687\\nGrutum, 142\\nGuinea-worm, 790\\nGummata, 637\\nGune, 759\\nGutartiges epithelioma, 558\\nGutta rosea, 404\\nTTAAESACKMILBE, 788\\nHfematidrosis, 123\\nHsemophilia, 431\\nHair-bulb, 39\\ncortex, 40\\ndeficiency of, 507\\ndyes, 507\\nfollicle, 37\\nmedulla, 40\\nnodes of, 524\\nringed, 505\\nroot, 39\\nshaft, 40\\nsheaths, 37\\nHairiness, 480\\nHairs, 36\\nbeaded, 524\\nexpansions of, 525\\nfissures of, 525\\nmoniliform, 524\\nHarlequin foetus, 474\\nHarvest-bug, 793\\nHautentzundung, 200\\nHautfinne, 391\\nHauthorn, 459\\nHautrothe, 172\\nHautsclerem, 488\\nHebra s ungt. diachyl. albi, 346\\nHedge-hog skin, 473\\nHemiatrophia facialis, 491\\nHemizona, 258\\nHemorrhages, 428\\nHemorrhagic variola, 161\\nHenle s layer, 38\\nHeredity, 63\\nHerpes circinatus bullosus, 266, 423\\ncircine, 739\\ndesquamans, 759\\nfacialis, 255\\nfebrilis, 255\\ngeneralized, 256\\ngenitalis, 256\\ngestationis, 266, 269, 423\\niris, 181, 266\\nHerpes labialis, 255\\nmenstruation, 257\\nphlyctsenoides, 266\\nprseputialis, 256\\nprogenitalis, 256\\nsimplex 255\\npathology, 257\\nsymptoms, 255\\ntreatment, 257\\ntonsurans, 739, 746\\ndesquamatij) 759\\nmaculosus, 289.\\nzoster, 258\\ndiagnosis, 264\\netiology, 262\\npathology, 262\\nprognosis, 265\\nsymptoms, 258\\ntreatment, 264\\nHerpetiform hydroa, 423\\nHerxheimer s spiral fibres, 25\\nHide-bound skin, 488\\nHidradenitis suppurativa, 123\\netiology, 124\\npathology, 124\\ntreatment, 124\\nHidroa, 423\\nHidrocystoma, 117\\nHirsuties, 480\\nHives, 188\\nHoariness, 505\\nHoneycomb ringworm, 729\\nHorn, 459\\nHorny layer, 28\\nHorse-pox, 394\\nHiihnerauge, 457\\nHuxley s layer, 38\\nHycdom der Haul, 555\\nHyaloma, 555\\nHydradenitis destruens suppurativa, 123\\nHudradenomes eruplifs, 558\\nHydroa, 266, 423\\nsestivale, 424, 425\\nbulleuoc, 424\\nherpetiform, 423\\npuerorum, 424, 425\\nvacciniforme, 424\\npathology, 425\\nsymptoms, 424\\ntreatment, 426\\nvesiculeux, 181, 424\\nHydrocy stoma, 117\\ndiagnosis, 118\\netiology, 117\\npathology, 117\\nsymptoms, 117\\ntreatment, 118\\nHydrosadenitis disseminata suppurativa\\n(Dubreuilh), 123\\nsuppurativa destruens, 601\\nHydrosis, 111\\nHyperesthesia, 713\\ndiagnosis, 715\\ntreatment, 715\\nHyperhidrosis, 111\\nHyperidrosis, 111", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0880.jp2"}, "881": {"fulltext": "INDEX.\\n817\\nHyperidrosis, etiology, 112\\npathology, 113\\nprognosis, 114\\nsymptoms, 111\\ntreatment, 113\\nHyperkeratosis excentrica, 451\\nstriata et follicularis, 451\\nHypertrichiasis, 480\\nHypertrichosis, 480\\netiology, 482\\nneurotica, 481\\nsymptoms, 480\\ntreatment, 482\\nHypertrophic lichen planus, 307\\nHypertrophies, 435\\nHypertrophy of hair, 480\\nHyphogenous sycosis, 240, 753\\nHypoderm, 20 t\\nHypoderma, 796\\nTCHTHYOL, 102\\nA Ichthyose, 471\\nIchthyosis,\\ncongenita, 474\\ncornea, 468\\ndiagnosis, 476\\netiology, 474\\nfollicularis, 445\\nhystrix, 471\\nlinearis neuropathica, 468\\nlinguae, 474, 560\\nnacrea, 473\\nnigricans, 473\\npathology, 475\\nprognosis, 477\\nsebacea, 128\\nserpentina, 473\\nsimplex, 471\\nsymptoms, 471\\ntreatment, 476\\nIdiopathic multiple pigment sarcoma,\\nIdrosadenitis, 60\\nIdrosis, 111\\nIgnes sacer, 258\\nImpetigo, 247\\ncontagiosa, 248\\nbullosa, 248\\ndiagnosis, 250\\neczematodes, 316\\netiology, 249\\nherpetiformis, 411\\ndiagnosis, 412\\netiology, 412\\npathology, 412\\nprognosis, 412\\nsymptoms, 411\\ntreatment, 412\\npathology, 249\\nstrepto-coccogenata circinata, 249\\nsymptoms, 247\\ntreatment, 250\\nIncubation-periods in syphilis, 618\\nInfective angioma, 568\\nInflammations, 147\\nInflammatory fungoid neoplasm, 687\\nIngesta, 65\\n52\\n695\\nI Initial rashes, variolous, 157\\nInsects, wounds by, 237\\nj Instruments, 107\\nInternal causes, 63\\ntreatment, 86\\nIntertrigo, 177\\nIodine, 88\\nItch, the, 778\\nbarbers 753\\nDhabie s, 760\\nfrost, 724\\nlumbermen s, 725\\nNorwegian, 782\\nprairie, 725\\nswamp, 725\\nItch-mite, 778\\nIttiosi, 471\\nIxodes, 796\\nAmericanus, 796\\nbovis, 796\\nmarginatus, 796\\nricinus, 796\\nunipunctatus, 796\\nJACOB S ULCEE, 697\\nJ Jigger, 789\\nTfAHLHEIT, 507\\nKakerlaken, 502\\nKelis, 539\\nKeloid, 539\\nAddison s 489\\nAlibert s, 539\\ncicatricial, 540\\ndiagnosis, 541\\netiology, 541\\npathology, 541\\nprognosis, 542\\nsymptoms, 539\\ntreatment, 541\\nKeloid-acne, 394, 520\\ntreatment, 521,\\nKerato-angiona, 449\\nKeratodermia palmaris et plantaris 448\\ndiagnosis, 449\\nsymptoms, 448\\ntreatment, 449\\nKeratolysis neonatorum, 292\\nKeratoma, 456\\nKeratosis, 442\\nfollicularis, 445\\ncontagiosa, 450\\ndiagnosis, 447\\netiology, 446\\npathology, 447\\nsymptoms, 446\\ntreatment, 447\\npigmentosa, 462\\npilaris, 442\\ndiagnosis, 443\\netiology, 443\\npathology, 443\\nsymptoms, 442\\ntreatment, 444\\nsenilis, 445\\nKerion, 752", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0881.jp2"}, "882": {"fulltext": "818\\nINDEX.\\nKerion Celsi, 752\\nKleinenflechte, 760\\nKnollenkrebs, 539\\nKolbenkorperchen, 34\\nKoplik s sign, 148\\nKrankheiten der Franzbsen, 614\\nKratze, 778\\nKraurosis vulvae, 532\\nKrithoptes rnonunguiculosus, 794\\nKrustenflechte, 247\\nKuhpocken, 167\\nKupferfinne, 404\\nKupferrose, 404\\n7 ADBER1E, 670\\nia/*a Tokelau, 759\\nLand scurvy, 432\\nLangerhans cells, 27\\nLanolin, 101\\nLa perleche, 766\\nLa peta, 759\\nLa rosa, 1 86\\nia rose, 220\\nLassar paste, 96, 347\\nLead-and-opium wash, 344\\nLebbra, 670\\nLentigo, 435\\netiology, 435\\npathology, 436\\nsymptoms, 435\\ntreatment, 436\\nLeontiasis, 670, 672\\nLepothrix, 525\\ntreatment, 526\\nLepra, 271, 670\\nansesthetica, 674\\nArabum, 670\\ndiagnosis, 681\\netiology, 677\\nfungi fera, 684\\nmaculosa, 673\\nmutilans, 673\\npathology, 679\\nprognosis, 683\\nsymptoms, 670\\ntreatment, 682\\ntrophoneurotica, 674\\ntuberosa, 671\\nLepre, 670\\nLepromes en nappe, 672\\nLeprosy, 670\\natrophic, 674\\nLombardy, 186\\nnerve, 674\\nnodulated, 671\\ntegumentary, 671\\ntrophoneurotic, 674\\ntuberculated, 671\\nLeprous roseola, 673\\nLeptus, 793\\nAmericanus, 794\\nautumnalis, 793\\nLesions, consecutive, 56\\nunclassified, 60\\nLeucasmus, 501\\nLeucoderma, 501, 502\\nLeucoderma, acquired, 502\\ncomplete, 502\\ncongenital, 502\\nLeucokeratosis buccalis, 560\\ndiagnosis, 561\\netiology, 561\\npathology, 561\\nprognosis, 562\\nsymptoms, 560\\ntreatment, 561\\nLeucoma, 560\\nLeucoplakia buccalis, 274, 560\\nLeucoplasia, 560\\nLeucoplasie, 560\\nLichen annularis, 309\\nannulatus, 383\\ncircumscriptus, 383\\neczematodes, 313\\nexudativus ruber, 300\\nplanus, 304\\ndiagnosis, 308\\netiology, 307\\nhypertrophicus, 307\\npathology, 307\\nprognosis, 309\\nsymptoms, 304\\ntreatment, 308\\npsoriasis, 296, 300\\nruber, 300\\nacuminatus, 300\\ndiagnosis, 303\\netiology, 302\\nmoniliformis, 302\\nobtusus, 302\\npathology, 302\\nplanus, 301\\nprognosis, 303\\nsymptoms, 300\\ntreatment, 303\\nscrofulosorum, 599\\nserpiginosus, 383\\nsimplex, 313\\ntropicus, 379\\nurticatus, 189\\nLichenification, 310\\nLiodermia cum melanosi et telangiectasi,\\n572\\nLiquor picis alkalinus, 352\\nLocal asphyxia, 219\\nLombardy erysipelas, 186\\nleprosy, 186\\nLouse, body, 799\\ncrab, 802\\nhead, 797\\npubic, 802\\nLousiness, 796\\nLucilia Csesar, 796\\nLues venerea, 614\\nLumberman s itch, 725\\nLunula, 49\\nLupani, 684\\nLupoid sycosis, 240, 242, 519\\nLupus crustosus, 578\\ndemisclereux de la langue, 580\\ndisseminatus, 607\\nof ears, 519", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0882.jp2"}, "883": {"fulltext": "INDEX.\\n819\\nLupus elephantiaticus, 577\\nelevatus, 577\\nerythematodes, 604\\nerythematosus, 604\\ndiagnosis, 609\\ndiscoid form, 605\\netiology, 607\\nlivedo form, 607\\npathology, 608\\nprognosis, 611\\nsymptoms, 604\\ntelangiectatic form, 606\\ntreatment, 610\\nexfoliativus, 577\\nof extremities, 579\\nexuberans, 577\\nexulcerans, 578\\nof face, 578\\nfibrosus, 577\\nfungosus, 578\\ngangrsenosus, 578\\nof genital organs of women, 580\\nof genital region, 579\\nhypertrophicus, 577\\nkeloides, 578\\nlymphaticus, 570\\nmaculosus, 576\\nof mucous membranes, 580\\nnodosus, 577\\nnon-exedens, 577, 604\\nnon-ulcerosus, 577\\noedematosus, 577\\npapillaire verruqueux, 582\\npapillosus, 577\\npernio, 602, 607\\nplanus, 576\\nprofundus, 578\\npsoriasiforme, 577\\n-psoriasis, 577\\nrodens, 578\\nrupioides, 578\\nsclereux, 577, 582\\nsclerosus, 577, 582\\nsebaceus, 604\\nserpiginosus, 578\\nsuperficialis, 578, 604\\nof trunk, 579\\ntuberculatus, 577\\ntumidus, 577\\nvegetans, 578\\nverrucosus, 582\\nvulgaris, 576\\nLustseuche, 614\\nLymphadenectasia, 570\\nLymphadenie cutanee, 681\\nLymphangiectasis, 569\\nLymphangiectodes, 570\\nLymphangioma, 562, 569\\ncapillare varicosum, 570\\ncavernosum, 570\\ncircumscriptum, 570\\netiology, 571\\npathology, 571\\nsymptoms, 570\\ntreatment, 571\\ncystic, 570\\nLymphangioma, simple, 569\\ntuberosum multiplex, 560\\nLymphangitis tuberculosa cutanea, 586\\nLymphatic vessels, 30\\nLymphodermia perniciosa, 687\\nLymph-scrotum, 496\\nMACULJE, 52\\nMadura foot, 768\\nMajee s dad, 760\\nMalabar ulcer, 238\\nMai de los pintos, 767\\nMaliasmus. 235\\nMalignant papillary dermatitis, 708\\npustule, 233\\nMai perforant du pied, 533\\nroxo, 186\\nMalum perforans pedis, 533\\nMama pian, 684\\nMange, Texas, 725\\nMarine baths, 94\\nMarsden s paste, 706\\nMaseru, 147\\nMassering ball, 403\\nMatrix of nail, 49\\nof root-sheath of hair, 38\\nMcCall Anderson s dusting-powder, 179\\nsalve, 95\\nMeasles, 147\\nMedulla of hair, 40\\nMeibomian glands, 42\\nMelanoderma cachecticorum, 437\\nof scrofulous, 604\\nMelano-sarcoma, 693\\nMelanosis lenticularis progressiva, 572\\nMelanotic carcinoma, 711\\nsarcoma, 693\\nMentagra, 241\\nparasitica, 753\\nMercury, 87\\nMerkel s touch-cells, 34\\nMidges, 806\\nMiliaire scrofuleuse, 409\\nMiliaria cystallina, 115\\nrubra, 379\\nMiliary fever, 116\\nMilium, 142\\ndiagnosis, 143\\netiology, 142\\npathology, 143\\nprognosis, 144\\nsymptoms, 142\\ntreatment, 143\\nMineral waters, 91\\nMitesser, 137\\nMoist venereal wart, 461\\nMole, pigmentary, 467\\nMoles, white, 467\\nMolluscous corpuscles, 454\\nMolluscum contagiosum, 452\\nepitheliale, 452\\ndiagnosis, 455\\netiology, 454\\npathology, 454\\nprognosis, 456\\nsymptoms, 453", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0883.jp2"}, "884": {"fulltext": "820\\nINDEX.\\nMolluscum epitheliale, treatment, 456\\npendulum, 544\\nsebaceum, 452\\nverrucosum, 452\\nMonilethrix, 524\\nMoniliform hairs, 524\\nMorbilli, 147\\ndiagnosis, 150\\npathology, 149\\nprognosis, 151\\nsymptoms, 148\\ntreatment, 150\\nMorbus Gallicus, 614\\nmaculosus Werlhoffii, 432\\npediculosis, 796\\npedis entophyticus, 678\\nMorphoea, 489\\nMorpion, 802\\nMorvan s disease, 534\\ndiagnosis, 535\\netiology, 535\\npathology, 535\\nsymptoms, 534\\ntreatment, 535\\nMorve, 235\\nMosquito, 806\\nMothers marks, 565\\nMower s mite, 793\\nMucous layer, 26\\npatches, 639\\nMulberry-marks, 565\\nMultiple benign cystic epithelioma, 558\\npathology, 559\\ntreatment, 559\\ncutaneous tumors, pruritic, 465\\ngangrene of skin, 218\\nMuscidse, 796\\nMuscles, 35\\nMuscular fibres, 35\\nnon-striated, 35\\nstriated, 35\\nmembranes, 36\\nMycetoma, 768\\ndiagnosis, 771\\netiology, 770\\npathology, 770\\nsymptoms, 769\\ntreatment, 771\\nMycosis fungoides, 687\\ndiagnosis, 692\\netiology, 690\\npathology, 690\\nprognosis, 693\\nsymptoms, 687\\ntreatment, 692\\nmicrosporina, 760\\nMyoma, 562\\ndartoic, 562\\ndiagnosis, 563\\nsimple, 562\\nsymptoms, 562\\ntelangiectodes, 562\\ntreatment, 563\\nMyringomycosis, 766\\nMyxadenitis labialis, 362\\nMyxcedema, 726\\nMyxoedema, diagnosis, 728\\netiology, 727\\npathology, 728\\nsymptoms, 726\\ntreatment, 728\\nN^EVI pigmentosi, 481\\npilosi, 481\\nNsevoid elephantiasis, 496\\nNsevus araneus, 404, 564\\nflammeus, 563\\nlicheno ide, 468\\nlinear, 468\\nlipomatodes, 467\\nlupus, 5G8\\nmollusciformis, 467\\nnervosus, 468\\npigmentosus, 467\\npathology, 468\\ntreatment, 469\\npilosus, 567\\nsanguineus, 563\\nspilus, 467\\nunius lateris, 468\\nvasculosus, 563\\nverrucosus, 567\\nvinosus, 565\\nNail-bed, 49\\n-fold, 49\\n-lunula, 49\\n-matrix, 49\\nNails, 48\\natrophy of, 527\\nwhite spots of, 527\\nNojuolo, 157\\nNatal sore, 237\\nNecrotic granuloma, 601\\nNecrotizing chilblain, 601\\nNerves, 30\\nNervous papillae, 24\\nNesselfieber, 188\\nNesselsuch, 188\\nNettle-rash, 188\\nNeuralgia cutis, 714\\nNeurodermatitis, 718\\nNeurodermia, 718\\nNeuroma, 548\\nNeuropathic plica, 482\\nNevrodermite, 310\\nNew-growths, 539\\nof skin, multiple benign tumor-li\\n532\\nNigua, 789\\nNodose swellings of shafts of hairs, 424\\nNodositas crinium, 522\\nNoli-me-tangere, 697\\nNon-striated muscular fibres, 35\\nNorwegian itch, 782\\nNummular erythema, 740\\nOBJECTIVE symptoms, 51\\nOccupation, 67\\nOdorous emanations from skin, 47\\n(Edema, acute circumscribed, 198\\nidiopathic, 198\\nnon-inflammatory, 198\\nke,", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0884.jp2"}, "885": {"fulltext": "INDEX.\\n821\\n(Edema, circumscribed, 199\\nneonatorum, 486\\ndiagnosis, 486\\netiology, 486\\npathology, 486\\nprognosis, 487\\nsymptoms, 486\\ntreatment, 487\\npersistent, 199\\nOehl s stratum lucidum, 27\\nGEU de perdrix, 457\\nGEstridse, 796\\nOhio scratches, 725\\nOnychalrophie, 526\\nOnychauxis, 476\\netiology, 479\\npathology, 479\\nprognosis, 479\\nsymptoms, 477\\ntreatment, 479\\nOnychia, syphilitic, 478\\nOnychomycosis, 478, 741\\nfavic, 731\\nOriental button, 237\\nulcer, 237\\nOsmidrosis, 119\\nPACHYDEKMATOCELE, 546\\nPachydermia, 494\\nlymphangiectatica, 570\\nPacinian corpuscles, 31\\nPaget s disease, 372, 708\\ndiagnosis, 709\\npathology, 709\\nprognosis, 709\\nsymptoms, 708\\ntreatment, 709\\nPainless dermoid cysts, 146\\nPalmar eczema, 375\\nPanaris analgesique, 534\\nPanniculus adiposus, 21\\nbutton, 237\\nPapillae, nervous, 24\\nvascular, 24\\nPapilloma, 466\\narea elevatum, 467\\nneuropathicum unilaterale, 468\\nneuroticum, 467\\nPapulae, 53\\nPapules, 53\\nPapulose filarienne, 792\\nPapulo-tubercles, 55\\nParesthesia, 716\\nParakeratosis scutularis, 451\\nvariegata, 300\\nParangi, 684, 685\\ntreatment, 686\\nParasitse, 796\\nParasitdre Bartfinne, 753\\nParasites, animal, 778\\nParasitic affections, 729\\ndiseases, 68\\nParatuberculoses, 599\\nacneiform, 603\\nPars papillaris, 22\\nreticularis, 22\\nPasta v s formula, 788\\nPaste, Lassar s, 347\\nMorris s, 348\\npencils, 101\\nPastes, 96\\nPatches, mucous, 639\\nscaly, 640\\nPathology, general, 72\\nPeculiar skin eruption of pregnancy, 266\\nPediculi from lower animals, 804\\nPediculidae, 796\\nPediculosis, 796\\ncapillitii, 797\\ndiagnosis, 798\\ntreatment, 798\\ncorporis, 799\\ndiagnosis, 801\\ntreatment, 802\\npubis, 802\\ndiagnosis, 803\\ntreatment, 804\\nvestimenti, 799\\nPediculus capitis, 797\\ncorporis, 799\\npubis, 803\\nPelade, 511\\nPeliosis rheumatica, 430\\nPellagra, 186\\netiology, 186\\npathology, 186\\nprognosis, 187\\nsymptoms, 186\\ntreatment, 187\\nPemphigus, 412\\nacute, 413\\nacutus benignus febrilis, 413\\ncontagiosus adultorum, 248\\nmalignus febrilis, 414\\naigu prurigineux, 266\\nbenignus, 415\\nchronic, 414\\ncircinatus, 266, 415\\ncompose, 266\\ndentinus, 414\\ndiagnosis, 421\\ndisseminatus, 414\\netiology, 419\\nfoliaceus, 416\\ngangraenosus, 218\\nhaemorrhagicus, 415\\nhaereditarius, 417\\nhystericus, 269\\nmalignus, 415\\nneonatorum, 417\\npathology, 420\\nprognosis, 423\\npruriginosus, 416, 423\\nprurigineux, 266\\nsolitarius, 415\\nsymptoms, 413\\ntreatment, 422\\nvegetans, 418\\nvirginum, 417\\nvulgaris, 414\\nof young girls, 417\\nPemphigus-like dermatitis, fatal, 266", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0885.jp2"}, "886": {"fulltext": "822\\nINDEX.\\nPerforating ulcer of foot, 533\\ndiagnosis, 534\\npathology, 534\\nprognosis, 534\\nsymptoms, 533\\ntreatment, 534\\nPerifolliculitis, 254\\nPeriodic swelling, 198\\nPernio, 176\\nPeruvian wart, 684, 686\\nPetaloid seborrhcea, 127\\nPetechia?, 430\\nPetite verole, 157\\nPhagedena tropica, 238\\nPhlegmona diffusa, 239\\nprognosis, 240\\ntreatment, 240\\nPhlyctense, 55\\nPhlyctenular, 55\\nPhototherapy, Finsen, 595\\nPhtheiriasis, 796\\nPhymata, 55\\nPhysiological crises, 65\\nPhysiology of skin, 17\\nPian, 684\\ndartre, 684\\nrubo ide, 520\\nPick s gelatino-sublimate, 348\\nsalicylated soap-plaster, 351\\ntragacanth varnish, 349\\nPiebald skin, 501\\nPiedra, 526\\nPigment, 34\\nPigmentary mole, 467\\nPili annulati, 524\\nPinta disease, 767\\nPityriasis capitis, 509\\ncircinata, 289\\ncircine et margine, 289\\nmaculata et circinata, 289\\nrosea, 289\\ndiagnosis, 290\\netiology, 289\\npathology, 290\\nsymptoms, 289\\ntreatment, 290\\nrosee de Gihert, 289\\nrubra, 293\\naigu, 293\\ndiagnosis, 295\\netiology, 295\\npathology, 295\\npilaire, 296\\npilaris, 296, 300\\ndiagnosis, 298\\netiology, 297\\npathology, 297\\nprognosis, 298\\nsymptoms, 296\\ntreatment, 298\\nprognosis, 296\\nsymptoms, 293\\ntreatment, 296\\ntabescentium, 128\\nversicolor, 760\\nPlantar eczema, 375\\nPlaque muqueuse, 639\\nPlaques blanches de la bouche, 560\\njaundtres des paupieres, 550\\nPlaster-mulls, 100\\nPlasters, 100\\nPlica neuropathica, 482\\nPolonica, 481\\nPocken, 157\\nPocks, the, 157\\nPodelcoma, 768\\nPoils accidentels, 480\\nPoison-ivy, 202\\nPoliosis, 505\\nPoliothrix, 505\\nPolyidrosis, 111\\nPolypapilloma tropica, 684\\nPolytrichia, 480\\nPomphi, 53\\nPompholyx, 269, 412\\ndiagnosis, 270\\npathology, 270\\nsymptoms, 270\\ntreatment, 271\\nPorcupine skin, 473\\nPore, sweat, 44\\nPorokeratosis, 451\\nPorrigo contagiosa, 248\\ndecalvans, 511\\nfavosa, 729\\nlarvalis, 248\\nPoultices, 101\\nPowders, 100\\nPox, horse, 394\\nPrairie itch, 725\\nprognosis, 726\\ntreatment, 726\\nPrecautions in management of tineae, 758\\nPrickle-layer, 26\\nPrickly heat, 379\\nPrognosis, general, 82\\nProtozoa, 807\\nPrurigo, 387\\nagria, 388\\ndermanyssique, 804\\ndiagnosis, 390\\netiology, 389\\nferox, 387\\ngravis, 387\\nHebrse, 387\\nhyemalis, 724\\nniitis, 388\\npathology, 389\\nprognosis, 391\\nsummer, 425\\nsymptoms, 388\\ntreatment, 391\\nwinter, 724\\nPruritus, 717\\nani, 718\\ndiagnosis, 720\\netiology, 719\\ngenitalium, 718\\nhiemalis, 718, 724\\nlinguae, 719\\nnarium, 718\\npalmse et piantae, 719", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0886.jp2"}, "887": {"fulltext": "INDEX.\\n823\\nPruritus, pathology, 719\\nprognosis, 724\\nrelief of, in eczema, 340\\nsenile, 718\\nsymptoms, 717\\ntreatment, 719\\nPselaphagia, 713\\nPseudo-atheroma, 144\\nPseudo-pelade, 518\\nPsora, 271\\nPsoriasis, 271\\nbuccal, 560\\ndiagnosis, 278\\netiology, 274\\nlinguae, 274, 560\\npathology, 276\\nprognosis, 288\\nsymptoms, 271\\nof the tongue, 474\\ntreatment, 281\\nPsorospermose foUiculaire vegetante, 445\\nPsorospermosis, 445, 708\\nPulex irritans, 789\\npenetrans, 789\\nPurpura, 428\\narthritic, 430\\netiology, 433\\nfulminans, 432\\nhsemorrhagica, 432\\npathology, 433\\nprognosis, 434\\npulicosa, 430\\nrheumatica, 430\\nscorbutica, 432\\nsimplex, 430\\nsymptoms, 428\\ntreatment, 433\\nurticans, 430\\nurticata, 190\\nPustulae, 55\\nPustular scrofuloderm, 603\\nPustule maligne, 233\\nPustules, 55\\nfrom wounds of reptiles and insects, 237\\nQUININE, 89\\nQuinquaud s disease, 518\\nQuirica, 767\\nRADEZYGE, 614\\nRanvier s stratum, 27\\nRash, rose, 172\\ninitial varieties, 157\\nRashes, scarlet, 175\\nRaynaud s disease, 219\\nReptiles, wounds by, 237\\nRete Malpighianum, 26\\nMalpighii, 26\\nmucosum, 26\\nRete-pegs, 23\\nRhagades, 58\\nRhinoceros skin, 473\\nRhinophyma, 405\\nRhinoscleroma, 574\\ndiagnosis, 575\\netiology, 574\\nRhinoscleroma, pathology, 574\\nprognosis, 576\\nsymptoms, 574\\ntreatment, 575\\nRhyncotta, 796\\nRhynocoprion penetrans, 789\\nRinged eruption of extremities, 309\\nhair, 505\\nPingelhaaren, 524\\nRingworm, 737\\nof beard, 240, 753\\nboatman s, 760\\nof body, 739\\nBowditch Island, 759\\nBurmese, 759\\ndisseminated, 748\\ngiant, 766\\nhoneycomb, 729\\nof scalp, 746\\nscrofulous, 604\\nTokelau, 759\\nyaws, 714\\nRisipola Lombarda, 186\\nRodent ulcer, 697\\nRoot of hair, 39\\nRoot-sheath, inner, 38\\nouter, 38\\nRosacea, 404, 565\\nRoseola scarlatiniforme, 175\\nsyphilitic, 623\\nvariolous, 157\\nRose rash, 172\\nRothe Schwindfiecht, 300\\nRotheln, 151\\nsymptoms, 151\\ntreatment, 152\\nBothMeie, 293\\nRothlauf, 220\\nBotzkrankheit, 235\\nPougeole, 147\\nBouget, 793\\nRubella, 153\\nRubeola, 147\\nRnmex ointment, 402\\nRupia escharotica, 218\\nSACCHAROMYCOSIS hominis, 810\\nSalicylated soap plaster, 351\\nSalol, 89\\nSalt baths, 94\\nSalve muslins, 100\\npencils, 101\\nSand flea, 789\\nSarcoma cutis, 693\\ndiagnosis, 696\\netiology, 696\\npathology, 696\\nprognosis, 697\\nsymptoms, 693\\ntreatment, 696\\nidiopathic, multiple pigmented, 695\\nmelanotic, 693\\nprimary non-melanotic, 694\\nSarcomatosis generalis, 687\\nSarcophila Wohlfarti, 796\\nSarcopsylla Westwood, 789", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0887.jp2"}, "888": {"fulltext": "824\\nINDEX.\\nSarcoptes scabiei, 783\\nSartian disease, 683\\nSatyriasis, 670\\nSavill s disease, 298\\nScabies, 778\\ndiagnosis, 784\\netiology, 783\\nNorvegica, 782\\npathology, 783\\nsymptoms, 778\\ntreatment, 786\\nScales, 56\\nScaly patches, 640\\nScar, hypertrophic, 540\\nkeloid, 540\\nScarf-skin, 25\\nScarlatina, 152\\nanginose, 154\\ndiagnosis, 156\\netiology, 155\\npathology, 155\\nprognosis, 157\\nseptic, 154\\nsymptoms, 152\\ntoxic, 155\\ntreatment, 156\\nScarlatine, 152\\nScarlatiniform typhus, 155\\nScarlatinoid erythema, 175\\nScarlet fever, 152\\nrash, 152, 175\\nScars, 59\\nScharlach, 152\\nScheerende flechte, 739, 746\\nScheme of diagnosis, 79\\nSchleimhautpapeln, 639\\nSchmeerfluss, 124\\nSchonlein s disease, 430\\nSchultze s plaster formula, 788\\nSchuppenflechte, 271\\nSchwammformige, 684\\nScirrhous cancer, 741\\nSclerema adultorum, 458\\nneonatorum, 487\\netiology, 487\\npathology, 487\\nsymptoms, 487\\ntreatment, 507\\nSclereme des nouveau-nes, 487\\nScleriasis, 488\\nScleroderma, 488\\ncircumscribed, 489\\ndiagnosis, 493\\ndiffuse symmetrical, 488\\netiology, 491\\nneonatorum, 487\\npathology, 492\\nprognosis, 494\\nsymptoms, 488\\ntreatment, 493\\nSclerodermic, 488\\nScratches, Ohio, 725\\nScratching, 66\\nScrofulide erythemateuse, 604\\nScrofuloderma, 584\\nverrucosum, 582\\nScrofuloma, 585\\nScrofulous melanoderma, 604\\nringworm, 604\\nScurvy, 432\\nland, 432\\nSeasons, 66\\nSebaceous cyst, 144\\ncystic disease, rare results of, 146\\nflux, 124\\nglands, 41\\ndisorders of, 124\\nsecretion of, 42-\\nSebiparous glands, 41\\nSeborrhagia, 124\\nSeborrhcea, 1 24\\ncongestiva, 604\\ncorporis, 383\\ndiagnosis, 130\\netiology, 128\\nlichenoides, 383\\nneonatorum, 128\\noleosa, 125\\npapulosa, 383\\npathology, 129\\nprognosis, 135\\nsicca, 125\\nsquamosa, 128\\nsymptoms, 124\\ntreatment, 131\\nSeborrhee, 124\\ndepilante, 242\\nSensory dermato-neuroses, 713\\nShaft of hair, 40\\nShampooing, 132\\nShingles, 258\\nSifilide, 614\\nSifilis, 614\\nSimulia, 806\\nSirop de Gibert, 661\\nSkin, anatomy, 17\\natrophy of, 528\\ncleavage of, 22\\ndevelopment of, 19\\nhide-bound, 488\\nlax, 546\\nodors of, 47\\nphysiology of, 17\\nrelaxed, 546\\ntrue, 21\\nSmall-pox, 157\\nSmokers patches, 274, 560\\nSnuffles in syphilis of infants, 642\\nSoaps, 94\\nover-fatty, 95\\nSolar light and heat, 66\\nSpedalskhed, 670\\nSphaceloderma, 217\\nSpider cancer, 564\\nSpiradenitis, 601\\n(Unna), 123\\nSpiral fibres, Herxheimer s, 25\\nSpitzblattern, 165\\nSpitzen warzen, 461\\nSplenic fever carbuncle, 233\\nSpontaneous gangrene of the skin, 218\\nSporothrix, abscesses caused by, 778", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0888.jp2"}, "889": {"fulltext": "INDEX.\\n825\\nSporozoa, 807\\nSpots, 52\\nSpotted sickness, 767\\nSquamae, 56\\nStains, 52\\nSt. Anthony s fire, 220\\nStartin s acid mixture, 131\\nSteatoma, 144\\ndiagnosis, 145\\npathology, 144\\nprognosis, 145\\nsymptoms, 144\\ntreatment, 145\\nSteatorrhea, 124\\nSteatozoon folliculorum, 788\\nSteorrhcea, 124\\nStili dilubiles, 101\\nunguentes, 101\\nStinkender Schweiss, 119\\nStinking sweat, 119\\nStomoxis calcitrans, 796\\nStratum corneum, 28\\ndisjunctum, 28\\ngranulosum, 27\\nlucidum, 27\\nmucosum, 26\\nsubcutaneum, 20\\nStrawberry-marks, 565\\nStriated muscular fibres, 35\\nStrophulus albidus, 142\\nSubcutaneous tissue, 20\\nSubjective symptoms, 51\\nSudamen, 115\\ndiagnosis, 116\\netiology, 116\\npathology, 116\\nsymptoms, 115\\ntreatment, 116\\nSudatoria, 111\\nSuette miliaire, 116\\nSulphur baths, 93\\nSuppurative tubercular lymphangiectasis,\\n586\\nSwamp itch, 725\\nSweat, 46\\nbloody, 123\\nfetid, 119\\nstinking, 119\\nSweat-glands, adenoma of, 558\\ndisorders of, 111\\nSweat-pore, 44\\nSweating, greenish, 122\\nphosphorescent, 122\\nrosy, 122\\nsickness, 116\\nSwelling, giant, 198\\nperiodic, 198\\nSycosiform dermatoses, 240\\nSycosis, 240\\nbacillogenous, 240\\ndiagnosis, 244\\netiology, 243\\nhyphogenous, 240, 753\\nlupoid, 240, 519\\nnon -parasitic, 241\\nparasitica, 753\\nSycosis, pathology, 243\\nprognosis, 246\\nstaphylogenes, 241\\nsymptoms, 241\\ntreatment, 244\\nvulgaris, 241\\nSymmetrical gangrene of extremities, 219\\netiology, 220\\npathology, 220\\nprognosis, 220\\ntreatment, 220\\nSymptomatic erythema, 174\\nSymptomatology, general, 51\\nSymptoms, objective, 51\\nsubjective, 51\\nSynanthemata, 60\\nSynovial lesions of the skin, 466\\nSyphilides, 619\\nerythematous, 623\\npalmar, 629\\npigmentary, 625\\nplantar, 629\\nSyphilis, 614\\ndiagnosis, 649\\netiology, 645\\ngalloping, 615\\niodine in, 660\\nmercury in, 653\\nfumigation, 657\\ningestion, 653\\ninunction, 656\\nsubcutaneous injection, 658\\nof mucous membrane, 639\\npathology, 640\\nprecocious, 615\\nprimary, 615\\nprognosis, 665\\nsecondary, 614\\nsymptoms, 615\\ntardy, 615\\ntertiary, 615\\ntreatment, 650\\nSyphilitic fever, 618\\nonychia, 478\\nroseola, 623\\nSyphiloderma bullosum, 634\\ngummatosum, 637\\ninfantile, 641\\nacquisitum, 641\\nhaereditarium, 641\\nmaculosum, 623\\ndue to anomalous pigmentation,\\n623\\ndue to hypersemia, 623\\npapular, 626\\nacuminate, large, 627\\nsmall, 626\\nflat, large, 628\\nsmall, 627\\npapulosum, 626\\npustular, 631\\nacuminate, large, 633\\nsmall, 632\\nflat, large, 634\\nsmall, 633\\ntuberculosum, 635", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0889.jp2"}, "890": {"fulltext": "826\\nINDEX.\\nSyphiloderma tuberculosum serpiginosum,\\n635\\nvesiculosum, 631\\nSyphilodermata, 619\\ngeneral characteristics, 619\\nSyringo-cystadenome, 558\\nSyringomyelia, 534\\nATTACHE pigmentaire, 467\\nTactile corpuscles, 33\\nTan, 172\\nTar acne, 287\\nbaths, 94\\nTaschkent-geschwur, 683\\nTattooing, 438\\nTeigne faveuse, 729\\ntondante, 746\\nTelangiectasis, 564\\nfaciei, 404\\nTetia, 684\\nTexas mange, 725\\nTherapeutics, general, 84\\nThermal changes, 66\\nTinea barbae, 753\\ncircinata, 739\\ndiagnosis, 743\\netiology, 742\\npathology, 742\\nprognosis, 746\\nsymptoms, 739\\ntreatment, 744\\ndecalvans, 511\\nfavosa, 729\\ndiagnosis, 534\\netiology, 731\\npathology, 732\\nprognosis, 736\\nsymptoms, 729\\ntreatment, 734\\nimbricata, 759\\ndiagnosis, 760\\netiology, 760\\npathology, 760\\nprognosis, 760\\nsymptoms, 759\\ntreatment, 760\\nkerion, 752\\nnodosa, 526\\nsycosis, 753\\nprognosis, 758\\ntreatment, 757\\ntondens, 746\\ntonsurans, 746\\ndiagnosis, 750\\netiology, 748\\npathology, 749\\nprognosis, 752\\nsymptoms, 746\\ntreatment, 751\\ntrichophytina, 737\\ncruris, 741\\nunguium, 741\\nversicolor, 760\\ndiagnosis, 762\\netiology, 761\\npathology, 762\\nTinea versicolor, prognosis, 764\\nsymptoms, 760\\ntreatment, 763\\nToboe, 684\\nTokelau ringworm, 759\\nTono, 684\\nTouch-cells (Merkel), 34\\nTraumaticin, 101, 350\\nTraumatism, 68\\nTreatment, external, 92\\ninternal, 86\\nTrichauxis, 480\\nTrichomycosis nodosa, 525\\nTrichonosis cana, 505\\nversicolor, 505\\nTrichophytie, 739\\nsycosique, 753\\nTrichophytosis barbae, 240\\nTrichoptilosis, 522\\nTrichorrhexis nodosa, 522\\ntreatment, 524\\nTrombidae, 793\\nTrue skin, 21\\nTubercles, 54\\nTuberculae, 54\\nTubercular disease of foot, 768\\nTuberculide, 601\\nTuberculosis cutis, 576\\nacute, 584\\ndiagnosis, 591\\netiology, 581\\nexanthematic miliary, 584\\norificialis, 583\\npathology, 588\\nprognosis, 598\\nserpiginosa ulcerativa, 586\\nsymptoms, 576\\ntreatment, 593\\nverrucosa, 581, 582\\nfungosa cutis, 583\\npapilloraatosa cutis, 582\\nsuppurativa et bullosa acuta, 603\\nTuberculous dactylitis, 586\\neczema, 604\\nof nurslings, 319\\nTuberose carcinoma, 711\\nTumor cavernosus, 565\\nTumores, 55\\nTyloma, 456\\nTylosis, 456\\nlinguae, 560\\nTysonian glands, 42\\nULCER, Aden, 238\\nbrother, 686\\ncancroid, 697\\nJacob s, 697\\nMalabar, 238\\noriental 237\\nrodent, 697\\nUlcer that clings, 686\\nUlcera, 58\\nUlcers, 58\\nUlcus exedens, 697\\ngrave, 768\\nUlerythema acneiforme, 394", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0890.jp2"}, "891": {"fulltext": "INDEX.\\n827\\nUlerythema aphryogenes, 521\\ncentrifuguni, 604\\nsycosiforme, 240, 242, 519\\nUnclassified lesions, 60\\nUnguentum diachyli albi, 346\\nUnna s refrigerant ointment, 347\\nUrticae, 53\\nUrticaire, 188\\nUrticaria, 188\\nannularis, 189\\nbullosa, 189\\ndiagnosis, 192\\netiology, 190\\nevanida, 190\\nfigurata, 189\\nhemorrhagica, 190\\npapulosa, 189\\npathology, 192\\nperstans, 190\\npigmentosa, 196\\ndiagnosis, 198\\netiology, 197\\npathology, 197\\nsymptoms, 196\\ntreatment, 198\\nprognosis, 196\\nsymptoms, 188\\ntreatment, 193\\ntuberosa, 190\\nvesiculosa, 189\\nTTACCINAT10N, 167\\nVaccine, 167\\nVaccinia, 167\\ngeneralized, 170\\npathology, 170\\ntreatment, 170\\nVaccinial eruptive fever, 170\\nVagabond s disease, 804\\nVaricella, 165\\ndiagnosis, 166\\ngangrenosa, 218\\npathology, 166\\nsymptoms, 165\\nVariola, 157\\nconfluent, 162\\ndiagnosis, 163\\netiology, 162\\nhemorrhagic, 161\\npathology, 163\\nprognosis, 163\\nsymptoms, 157\\ntreatment, 164\\nVariolette, 165\\nVarioloid, 160\\nVariolous erythema, 157\\nroseola, 157\\nVarix lymphaticns, 496\\nVarnishes, 99\\nVarus, 391\\nVascular papillae, 24\\nVasogen, 101\\nVenereal wart, 461\\nVerbunden mit Kolloider Degeneration, 558\\nVergetures, 529\\nVerole, 614\\nVerruca, 460\\nacquisita, 461\\nacuminata, 461\\ncongenita, 461\\ndiagnosis, 463\\ndorsi manus et pedis, 462\\netiology, 462\\nfiliformis, 462\\nglabra, 462\\nnecrogenica, 462, 581\\npathology, 463\\nplana, 462\\nprognosis, 465\\nsenilis, 462\\nsymptoms, 460\\ntreatment, 463\\nvulgaris, 462\\nVerrue, 460\\nVerruga Peruana, 686\\nVesicles, 55\\nVesico-pustules, 56\\nVesiculae, 55\\nVespide, 806\\nVessels, blood-, 29\\nlymphatic, 30\\nVibices, 430\\nVisceral causes of disease, 65\\nVitiligo, 502\\ndiagnosis, 503\\netiology, 503\\npathology, 503\\nprognosis, 505\\nsymptoms, 502\\ntreatment, 503\\nVitiligoidea, 550\\nWARREN S fat columns, 21\\nWart, 460\\ncures, 465\\nmoist, 461\\nvenereal, 461\\nWarze, 460\\nWasps, 806\\nWasserpocken, 165\\nWater, 89, 92\\nWen, 144\\nWheals, 53\\nWhite moles, 467\\nWilkinson s salve, 287\\nWinter prurigo, 724\\nWorm, Guinea-, 790\\nXANTHELASMA, 550\\nXanthelasmoidea, 196\\nXanthoma, 550\\ndiabeticorum, 554\\ndiagnosis, 555\\netiology, 554\\npathology, 554\\nprognosis, 555\\nsymptoms, 554\\ntreatment, 555\\netiology, 552\\nglycosuric, 554\\nmultiplex, 550\\npalpebrarum, 550", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0891.jp2"}, "892": {"fulltext": "828\\nINDEX.\\nXanthoma papulatum, 550\\npathology, 552\\nplanum, 550\\nprognosis, 554\\nsymptoms, 570\\ntreatment, 553\\ntuberculatum, 550\\ntuberosum, 550\\nXeroderma, 470, 471\\npigmentosum, 572\\ndiagnosis, 573\\netiology, 573\\npathology, 573\\nprognosis, 574\\nsymptoms, 572\\ntreatment, 572\\nXerosis, 470\\nprognosis, 471\\nsymptoms, 470\\nXerosis, treatment, 471\\nX-ray dermatitis, 66\\nY\\nAWS, 684\\ncaeca, 684\\nZONA, 258\\nZoster, 258\\nabdominalis, 261\\nbrachialis, 261\\ncapillitii, 260 _\\ncollaris, 261\\nfacialis, 261\\nfemoralis, 261\\nfrontalis, 260\\nnuchse, 261\\nophthalmicus, 260\\npectoralis, 261", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0892.jp2"}, "893": {"fulltext": "", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0893.jp2"}, "894": {"fulltext": "", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0894.jp2"}, "895": {"fulltext": "", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0895.jp2"}, "896": {"fulltext": "o\\nwis ,v\\ni 00\\nC;\\nO\\n,0\\nv\\n\u00e2\u0080\u00a2J\\n\u00c2\u00abV\\nc^\\n1 B p\\n\u00e2\u0080\u00a2^o\\nA-\\n4\\n.0 o\\nO i\\n^r", "height": "4305", "width": "2369", "jp2-path": "practicaltreatis00hyde_0896.jp2"}, "897": {"fulltext": "0 J s\\nX v", "height": "4290", "width": "2394", "jp2-path": "practicaltreatis00hyde_0897.jp2"}, "898": {"fulltext": "LI RA-n 01 ONGRESS\\nDDD5b03130fl\\nMONH\\nMBQHfli\\n\u00e2\u0096\u00a0h\\nwaum\\nH\\ni\u00c2\u00bb\\nH\\n\u00e2\u0080\u00a2\u00c2\u00ab*a\\n^r-\\nn H", "height": "4407", "width": "2573", "jp2-path": "practicaltreatis00hyde_0898.jp2"}}