A system of practical medicine. By American authors. Vol. 4

by Unknown

Rx.	Chloralis,	scruple ij;
	Glycerinæ,	minim xx;
	Aquæ rosæ,	fluidounce iv. M.

Gentle friction should be employed in making the application. If the lotion is too drying, more glycerin may be added. An excellent application in many cases is the following:

Rx.	Acidi carbolici,	minim xxx;
	Olei ricini,	fluidrachm ij;
	Alcoholis,	fluidounce j drachm vj. M.

This may be perfumed with a few drops of any essential oil. If greater stimulation is required, then to this last combination one to three drachms each of tincture of cantharides and tincture of capsicum may be added. Liquid applications may be made as follows: An eye-dropper is filled and introduced between the hairs at different points of the scalp, and a few drops pressed out, and subsequently rubbed in by means of a piece of flannel rag; in this manner the application is brought into intimate association with the skin without to any extent soiling the hair.

Ointments are also useful. Sulphur, one or two drachms to the ounce, is one of the best. Ammoniated mercury, twenty to sixty grains to the ounce, red precipitate, five to twenty grains to the ounce, are both valuable. In some cases tannic acid, one or two drachms to the ounce, acts well; also a naphthol ointment, twenty or thirty grains to the ounce. Tar is also of decided value, and may be added to any of the above ointments or be prescribed alone in ointment, one or two drachms to the ounce. The tarry oils, as oil of white birch and oil of cade, used pure or in the form of tincture, one or two drachms to the ounce of alcohol, are also valuable. They may also be used with ointments. The treatment of seborrhoea of other parts of the body than the scalp is essentially the same, but the applications should be somewhat weaker. The sulphur preparations are the most useful.

The frequency of applications in seborrhoea will depend upon the activity of the process. Once or twice daily in the beginning may gradually be changed to once every other day, or later even less frequently. The soap-and-water washing is to be regulated in the same manner. It is advisable to intermit external treatment occasionally to see if the disease is entirely removed or merely in abeyance.

Comedo.

Comedo is a disorder of the sebaceous glands, consisting of retention of sebaceous matter, characterized by yellowish or blackish pinpoint- to pinhead-sized elevations corresponding to the orifices of the glands. The affection is seated, for the most part, about the face, neck, and upper part of the trunk; it may occur, however, wherever there are sebaceous glands. Each lesion is pinpoint to pinhead in size, whitish or yellowish, and usually with a central blackish point. There is very little elevation unless the amount of retained sebaceous matter is excessive. They may exist sparsely or in great numbers. Not infrequently the regions of the forehead, nose, and chin are studded with the lesions, other parts of the face and the shoulders showing them in smaller numbers. They may be disseminated or grouped. If they exist in profusion they give the face a soiled, greasy look, as if dirty and unwashed. Lateral pressure forces out the sebaceous matter in a thread-like form closely resembling a worm, hence the popular terms flesh-worms and grub-worms. From collection of dust and from other causes the outer ends of the sebaceous plugs become blackened, and this appearance has given rise to the term black-heads. This coloring may possibly, to some extent at least, as has been suggested, be dependent upon a chemical change caused by the action of the air on the exposed portion of the sebaceous collection. According to Unna, it is due to pigment matter, either free or contained within epidermal cells. Krause states that the bluish granules described by Unna are from extraneous sources. Seborrhoea oleosa is often seen to coexist. At times the retained secretion, either as a result of pressure or in consequence of chemical changes in the mass, excites inflammation, and acne results. It is not uncommon to find comedones and acne lesions associated together.

The affection is seen most frequently between the ages of fifteen and thirty. The lesions are sluggish, and are apt to disappear and reappear from time to time, depending upon the activity of the predisposing cause. As the patient advances in age the affection tends to spontaneous disappearance. The causes of the disorder are essentially the same as give rise to acne, a disease to which it is, as may be inferred, closely allied. Thus, disorders of digestion, constipation, chlorosis, scrofulous conditions and menstrual disturbances are often predisposing causes. In addition, the unstriped muscular fibres of the skin lack tone and contract sluggishly. The infrequent use of soap, especially in those with oily skins (seborrhoea oleosa), favors their formation. Working in a dirty or dusty atmosphere may cause mechanical obstruction of the ducts, and in consequence the formation of comedones.

Pathologically, the affection has its seat in the sebaceous glands and ducts, consisting essentially of retained secretion and epithelial cells within either the gland or duct or both. The accumulation gives rise to more or less dilatation, which usually increases the longer the comedo exists. The mass consists of epidermic cells, sebaceous matter, and sometimes cholesterin crystals, and one or more lanugo hairs. At times, also, the parasite Demodex folliculorum is found within the mass, but is not responsible in any way for the production of the lesion; it is also often found in healthy follicles. The dark points which usually mark the lesions are due to the accumulation of dirt. The process is an inactive one, occasioning usually no disturbance. The accumulation may increase until a papule is formed, or, on the other hand, may gradually relieve itself. The affection is to be distinguished from acne punctata and milium. Acne is a closely-allied disease, but is inflammatory in its nature; comedo is functional in character: the presence or absence of inflammation, therefore, is a decisive differential point between the two diseases. Milium differs from comedo in the facts that it has no open duct, no black point, and the contents cannot be squeezed out.