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ously, to sometimes reappear under favorable conditions. It has been introduced into the Southern States of this country by soldiers returning from tropical service and will no doubt soon become endemic among us, especially when clothing is not laundered by boiling. There are constantly cases under treatment at this post.
The diagnosis and treatment will depend upon the type of the disease, whether mycotic or bacterial, and must therefore be considered under separate headings.
Pemphigus Contagiosus.-This very contagious disease, which always prevails very widely among our soldiers on first going to the Philippines, is characterized by an eruption, most marked in the crutch and axillæ, of vesicles about the size of a pea or larger, these vesicles springing from an uninflamed base, and unattended by fever or other constitutional disturbances. The fluid of the vesicles, at first clear, soon becomes turbid, about which time the vesicle is ruptured or dries up, leaving a smooth, pink, glazed surface with an edge of epidermis more or less undermined. The eruption gives rise to considerable irritation, the successive crops of vesicles running into each other and rendering the parts raw and sore.
It is distinguished from chickenpox by its distribution and the absence of constitutional symptoms, and from the mycotic dhobie by the freedom from rings, and the absence of mycotic elements as demonstrated by examining scrapings under the microscope.
The treatment consists in thorough cleanliness of the parts and of the underclothes, sponging the affected region twice a day with solution of bichloride of mercury, 1/1000, which is allowed to dry, and then followed by dusting with a powder containing equal parts of zinc oxide, boric acid and starch.
Mycotic Dhobie.-The diagnosis is easily made by observing the festooned rings with raised margins, and confirmed by finding the tricophyton elements microscopically in the scrapings. Sometimes however, when there is much inflammation these elements can not be found even when they are undoubtedly present.
The treatment consists first in keeping the parts clean and dry;
then there are several medicinal agents which are almost specific; they should be thoroughly applied once or twice a day to the edge of the rings and a little beyond, and to all the new spots. Sometimes it is necessary to first shave a hairy part. In my experience the following agents are effective in the order named: Tincture of iodine, glacial acetic acid, 5 per cent chrysophanic acid ointment, 10 per cent salicylic acid ointment, 1/500 alcoholic solution of corrosive sublimate; the last is the most painful.
DR. BOYD CORNICK, San Angelo: I want to know whether the two cases originated in or outside of this country. That is, was the disease brought from the Philippines or Cuba, or did it develop here?
DR. J. T. MOORE, Galveston: I have a case practically like the one described by Dr. Mason, but did not recognize it.
I certainly thank Dr. Mason for presenting this case to us, and I think our contributions on this subject ought to be encouraged. I believe if we were to make systematic scrapings in all skin lesions, that the general practitioner would have fewer cases to send to the skin man.
REPORT OF A CASE OF LICHEN RUBER.
JOHN W. KENNEY, M. D.,
SAN ANTONIO, TEXAS.
Lichen ruber, though not a rare disease, is not common. It will. probably not form one per cent of the skin cases treated by the general practitioner. Though divided into several varieties by many dermatologists, the identity of each is questioned by many others. A careful clinical study of any variety will always reveal a blending with another, a fact that forces some to believe that the so-called different varieties are in reality only a difference in virulence, the same difference being evident in all manner of dis
To the present-day practitioner four things are evident regarding lichen ruber: (1) It must have appealed to the lexicographer through its red color; (2) to the dermatologist as a papulo squamous disease; (3) to the patient as an intensely irritating affection; (4) to the general practitioner as an extremely obstinate disease, sometimes presenting grave constitutional symptoms and perhaps death. These four points form the chief characteristics of the disease. The painful fissures at times found where the skin folds upon itself, the infiltrated skin, the furuncles and loss of hair and nails. are only found in cases that have been much neglected. These latter symptoms would likely appear in the obstinate skin disease if allowed to progress without hindrance by treatment.
The following report of a case treated by me during the past six months illustrates the various phases of the disease better than any theoretical description:
Patient was a retired farmer 59 years of age. His constitution leaned toward the strumous. Had always considered his lungs a weak point. The first symptoms of his present illness appeared August 5, 1901, while in Oklahoma attending a town lot sale. The itching on face and extremities became very annoying. This, he
supposed, was due to the sand and dust and he sought relief by washing himself in some stagnant water near where he was located. The disease continued to get worse. He returned to his home, tried many remedies, visited Marlin and Mineral Wells and took baths at both places. Failing to get relief he came to the San Antonio hot wells and took a few baths, which aggravated his disease. September 25, 1902, he called at my office and placed himself under my care, saying that he would give me a two weeks trial. At this time he had eighteen boils scattered in an irregular manner all over him. Both arms for several inches above and below his elbows on flexor surfaces were covered with furfuraceous crusts and itched intensely; left side of abdomen was red and covered with papules. Beneath the knee joints the skin was red and fissured. A like condition was found in front of each ankle. The eyebrows and lashes were falling out and the skin of face was thickened and red. Many papules and infiltrated spots were noticeable. Peaceful sleep was unknown. Pressure of the lightest garment or the slightest exercise caused intense itching and burning. It felt good to scratch and he instinctively tried to feel good all the time. He scratched while asleep, while walking about and all the time when not thinking of my instructions to not scratch at all.
After reviewing the history of the case and taking into consideration most all manner of local and tonic treatment had been tried in vain, it was decided to adopt a systematic mode of treatment. Accordingly alkaline baths were given daily to cleanse the skin. To remove the furfuraceous matter and rough, red skin from the affected parts an application of pure carbolic acid was made. This was, of course, quickly followed by alcohol to remove the escharetic effects of the acid. Only a few days were needed to show that much good came from these applications.
Hypodermic injections of bichloride of mercury were given for their alterative effect, for their germicidal power and to relieve the apparent septic condition of the patient as evidenced by the boils, etc. The treatment caused steady improvement in the patient's general condition. The boils gradually disappeared and the
patient took on flesh. Relapses occurred often, but each was much more mild than its forerunner. The infiltrated skin, fissures and papules also gradually disappeared. Today there is but little left to tell of the patient's former miserable condition. The injections were given daily with the exception of perhaps one month up to the present time. The bichloride was administered in 20 mms. of a 2 per cent solution of phenol. This prevented all pain or inflammatory reaction from the mercury. The patient has now been allowed to return home with the advice that he continue the treatment until all trace of the disease has disappeared. The most difficult part in the management of this case was the control of the itching. All antipruritic remedies did good for awhile but soon lost their efficacy. That the itching should be relieved is self evident. It causes the patient to scratch and thereby inoculate himself with septic matter. It produces loss of sleep and consequently a nervous condition that makes life almost unbearable. So irresistible is the inclination to scratch that often the patient does not realize the harm he is doing until a raw surface is produced. These abraded surfaces are extremely difficult to heal. Perspiration, which appears whenever the patient becomes irritated, causes these raw surfaces to be very painful. To relieve this the patient will sit with some absorbent in his hand waiting to remove each drop of perspiration as it appears. This naturally adds fuel to the fire in so far as permanent relief is concerned.
To relieve this condition adrenalin chloride was applied locally and atropine sulphate administered internally. These were used as often as necessary to give relief and acted fairly well, better than anything else used in this case except the hypodermic injection of morphine sulphate, this latter being only resorted to when the pain and excessive nervous state of the patient demanded that he be given at least temporary rest and ease. The administration of an opiate is objectionable if frequently used, not only on account of the liability of the patient becoming an habitual user of the drug, but likewise because it locks the emunctories and thereby delays the elimination of the poisonous matter that undoubtedly saturates the