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

by Unknown

Ecthyma is characterized by the formation of one or more discrete finger-nail-sized, flat, inflammatory pustules. The pustules are usually few in number, vary in size from that of a pea to a large finger-nail, roundish or ovalish in shape, and are situated on an inflammatory base, with a marked areola of a bright-red color. In the beginning they are yellowish, but later, from an admixture of more or less blood, they become reddish, subsequently drying to brownish but slightly adherent crusts. If the crust is removed, a superficial excoriation, secreting a yellowish fluid, is disclosed. The lesions pursue an acute course, but new pustules are apt to form from time to time. The lower extremities, shoulders and back are favorite localities. The subjective symptoms are usually slight, but burning and pain may be complained of. More or less pigmentation is left to mark the site of the lesions, which sooner or later disappears. The affection is seen in both sexes and at all ages, but is more frequently met with in men.

It is a disease of the poorly-nourished and debilitated; hence it is chiefly seen in the lower walks of life. All causes that tend to reduce the tone of the general health are indirectly responsible for the disease. In such persons external irritants, such as pediculi, bed-bugs, and similar parasites, may provoke the formation of ecthymatous lesions. The affection is not contagious. The process is of a markedly inflammatory type, and tends rapidly to pus-formation. The lesion is a typical pustule, and the excoriation does not extend deeper than the papillary layer. Permanent scarring never results. In the negro, instead of increased pigmentation, loss of pigment results.

The disease is to be distinguished from simple impetigo, contagious impetigo, and the flat pustular syphiloderm. It differs from impetigo in the flat form of the lesion and the character of its crust, and in the more inflammatory nature of the process. The non-contagiousness of the affection, the character and color of the crust, the regions involved, and the course will serve to differentiate it from impetigo contagiosa. In exceptional cases of this latter disease some of the lesions bear considerable resemblance to ecthyma. A striking similarity to the large flat pustule of syphilis is often noticed in ecthyma, and it is here that difficulty in the diagnosis is most likely to be experienced. The local disturbance, such as pain and heat, is generally more marked in ecthyma. The syphiloderm is usually of slower development and runs a more chronic course; moreover, positive ulceration beneath the crusts does not occur in ecthyma. The crusts of syphilis are darker in color, and usually have a greenish hue. Concomitant symptoms of syphilis are almost always present, and are valuable in the diagnosis. Ecthyma can scarcely be confounded with pustular eczema, as the size and discrete character of the pustules and the absence of marked itching are sufficiently distinctive.

Where it is possible for the patient to follow out treatment the result is always favorable. The importance of good food and proper hygiene cannot be overestimated. Tonics may be prescribed as efficient adjuvants. Iron, quinine, nux vomica, and the mineral acids are valuable. As a rule, simple measures are sufficient in the external treatment. If the lesions are numerous and are markedly inflammatory, alkaline baths, six ounces of sodium bicarbonate or of a similar alkaline salt to the bath, will be of service. The crusts are to be removed by poultices or hot-water applications, and the excoriations dressed with an ointment of ten to twenty grains of ammoniated mercury in an ounce of oxide-of-zinc ointment. In some cases a more stimulating ointment is required. Where active stimulation is demanded, touching the parts with nitrate of silver, diluted carbolic acid or a similar agent will prove serviceable.

Miliaria.

Miliaria—popularly known as prickly heat or heat-rash—is an acute inflammatory disorder of the sweat-glands, characterized by pinpoint to milletseed-sized papules or vesicles, attended usually by sensations of pricking, tingling, or burning. In some cases the eruption is almost entirely made up of papular lesions, and constitutes the form of the affection known as miliaria papulosa. In other cases the lesions are vesicular in nature, and miliaria vesiculosa is typified. It is chiefly the papular form to which the name of prickly heat has been applied. This variety begins with the formation of minute elevated, acuminated, bright-red papules, occurring usually in great numbers, more or less crowded together; the individual lesions, however, remain discrete. The affection may be localized, or, as is usually the case, may involve considerable surface. In miliaria vesiculosa the lesions are in the form of vesicles the same in size as the papules, and appear as whitish or yellowish points surrounded with inflammatory areolæ. They are usually crowded so closely together as to give the skin a bright-red look (miliaria rubra). At first the vesicles are transparent and contain a clear fluid, but as they become older they appear opaque and yellowish-white (miliaria alba), and instead of the bright-red appearance the eruption has then a yellowish cast. As in the papular form of the eruption, small areas may be involved or the greater part of the entire surface. The trunk is a favorite locality. The vesicles dry up in a few days, showing no tendency to rupture, and terminate in slight desquamation. In the majority of cases the eruption consists of papular, vesico-papular, and vesicular lesions interspersed. They make their appearance suddenly, usually accompanied with considerable sweating, and if the cause has ceased to act terminate in the course of a few days. As a rule, the subjective symptoms are mild in character, nothing more than slight tingling, burning, being noted; in others, however, these may be so marked as to give rise to considerable annoyance. Individuals who are debilitated seem most prone to an outbreak. Hot weather predisposes to it; in fact, excessive heat from whatever cause is apt to provoke an attack. It is especially common in children. The affection as usually met with is essentially an inflammatory disorder of the sweat-glands, congestion and exudation taking place about the ducts, giving rise to papules or vesicles, according to the intensity of the process.

It is to be distinguished from eczema and sudamen. The papules of eczema are larger, more elevated, firmer, make their appearance more slowly, and are of much longer duration; moreover, the itching of papular eczema is usually marked. Vesicular eczema differs from miliaria vesiculosa by the larger size of the lesions, their disposition to rupture, their tendency to become confluent, and their greater itchiness, and by the general features of the eruption both as regards its appearance and duration. It is to be noted that miliaria occurring in children from the conjoint effects of warm weather and superfluous clothing may, if the exciting causes are continued, result in eczema. Sudamen may be differentiated by the absence of inflammatory symptoms.

The affection under favorable circumstances runs a rapid course, disappearing in a few days or weeks. A removal of the exciting cause will in all cases have a favorable effect. Too active treatment is to be avoided, not only as being useless but prejudicial. Undue perspiration should be guarded against. The patient is for the time to avoid exercise and to be properly clad. Refrigerating diuretics, as citrate or the acetate of potassium or simple lemon-juice diluted, may be prescribed. When the eruption is kept up or frequently recurs as a result of impaired health, tonics, as quinine, iron, and the mineral acids, will be useful. In the majority of cases local treatment alone is necessary. Dusting-powders and cooling or astringent lotions are of most value. Starch and lycopodium powder, equal quantities or with 20 to 30 per cent. of oxide of zinc added, may be used; the surface is to be kept freely powdered. Astringent lotions may be employed in place of the dusting-powder, or, what is often advisable, may immediately precede the latter, the lotion being first applied, allowed to dry on the surface, and then the powder freely dusted over. A lotion of alcohol and water and sponging with vinegar and water may be prescribed.

Pompholyx.

Under this head (and also that of Dysidrosis) a rare disease of the skin has been described, characterized by peculiar vesicles and blebs and an excoriated state of the skin, with subsequent exfoliation of the epidermis. It consists at first of deep-seated vesicular lesions, which resemble small boiled sago-grains implanted in the skin, accompanied by a variable degree of inflammation. As the lesions grow they incline to coalesce, thus forming small or large blebs showing but little if any disposition to rupture. Sooner or later the fluid is reabsorbed or exudes, the epidermis peeling off, usually in large flakes or pieces, sometimes in the form of a cast of the fingers or hand. In most cases burning sensations, tenderness, and soreness are complained of. The disease pursues a variable course. Ordinarily, the process lasts from two to eight weeks. Relapses as well as recurrences of the disease may take place. It attacks by preference the hands, more especially the palms and the sides of the fingers, from which circumstance it was originally designated cheiro-pompholyx; but it may invade the feet and also other regions.