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HOME PHYSICIAN AND ENCYCLOPEDIA OF MEDICINE The biggy of the late 1800's. Clearly shows the massive inroads in medical science and the treatment of disease.
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ALCOHOL AND THE HUMAN BODY In fact alcohol was known to be a poison, and considered quite dangerous. Something modern medicine now agrees with. This was known circa 1907. A very impressive scientific book on the subject. |
DISEASES OF THE SKIN is a massive book on skin diseases from 1914. Don't be feint hearted though, it's loaded with photos that I found disturbing. |
Part of SAVORY'S COMPENDIUM OF DOMESTIC MEDICINE:
19th CENTURY HEALTH MEDICINES AND DRUGS |
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3. DISEASES OF THE SEBACEOUS GLANDS
SEBORRHEA
Synonyms.—Steatorrhea; Stearrhea; Acne sebacea; Ichthyosis sebacea; Fr., Acné sebacée; Séborrhée; Ger., Schmeerfluss; Gneis.
Definition.—A functional disease of the fat-producing glands, characterized by an excessive, and perhaps abnormal, secretion of fatty matter, appearing on the skin as an oily coating, crusts, or scales.
Since the writings of Unna and others on dermatitis seborrhoica, which have led to a withdrawal of many cases (see Dermatitis seborrhoica) heretofore considered to be rightly placed under seborrhea, there is much confusion as to exactly what conditions are to be properly included in this disease. Oily seborrhea, of course, belongs here, and I believe also all those cases of fatty crusted or scaly conditions which lack all signs of inflammatory action. The division line is, however, an ill-defined one, and there is a growing belief that all cases except those of oily seborrhea show histologically evidences of inflammation.1
Symptoms.—Two varieties of seborrhea are usually found, designated, according to whether there is practically only oiliness or oiliness with scale or crust accumulation; the former is that known as seborrhœa oleosa, and the latter, seborrhœa sicca. The qualifying term “sicca,” or dry, in my judgment is in the present state of our knowledge an improper one, as those cases in which the accumulation is truly dry— not oily or fatty—are necessarily relegated to dermatitis seborrhoica. The term, as here employed, will not refer therefore to such types, but essentially to those in which there is marked or moderate oiliness, with scale accumulation or crusting added, and in which there are no inflammatory symptoms. Such cases, I believe, exist, although, com-
1 See “Dermatitis seborrhoica,” and also Jackson and McMurtry’s, article on “Seborrhœa capitis,” Jour. Cutan. Dis., 1912, p. 608.
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DISEASES OF THE APPENDAGES
pared to those belonging to seborrheic dermatitis, in relatively moder ate number.
Seborrhœa oleosa (known also as hyperidrosis oleosa (Unna, Brocq), acné sebacée fluente, stearrhœa simplex, seborrhœa simplex, etc) is observed upon the scalp and face, usually conjointly, although it may be relatively extremely slight in some cases on one or the other of these regions. On the scalp the hair and skin are noted to be. oily and greasy; the oiliness may be slight or quite perceptible, and may involve the whole region, or be mainly upon the vertex portion. The hair looks moist, sometimes glistening, and is often slightly sticky, stringy, or with a tend ency, in women, to form into uncouth-looking, slightly agglutinated locks, or there is a tendency to bunching or massing together. The skin is oily to the touch, pale, often leaden-looking, and sometimes with, apparently at least, rather patulous gland-ducts. There are no inflam matory symptoms, except in occasional cases, when there may be here and there slight hyperemia, patchy in character. Itching is rarely com plained of in the oily variety. If of long continuance, there is very often a tendency to hair loss, and in some instances finally of a more or less pronounced character.
On the face, the favorite site for the oiliness is the nose and its imme diate neighborhood; not infrequently, however, the forehead is also in volved, and occasionally other parts of the face. In fact, in all cases there is, as a rule, a slight oiliness of these several regions, or the entire face, but it may be conspicuously so only on one or two of the regions named. The skin is shiny, glistening, and the gland-ducts often patulous, and the whole face presents a pasty-looking, soiled aspect. Not infrequently the nose is somewhat congested, and usually of a sluggish red tint. In addition, in some patients, comedones and scattered acne lesions are to be seen, and in occasional instances there is a disposition shown here and there, more especially on the scalp, for the secretion to dry and cake, forming thin scaliness of dirty-gray or brownish-gray color. If in women, the malady seems to be often associated with a tendency to hypertri- chosis.
Seborrhœa Sicca.—In infants it is at birth more or less general, though variable in quantity, and constitutes the so-called vernix caseosa (also ichthyosis sebacea). It is apt to remain caked on the scalp for some months, and while it must be looked upon as physiologic, not infre quently, from irritation produced by decomposition or from harsh at tempts to remove it, an eczema may ensue. In children and adults its usual site is the scalp (seborrhœa capitis). In this form, in addition to more or less oiliness, the fatty secretion and the exfoliating epidermic scales, and some possibly from the lining membranes of the gland-ducts, tend to accumulate in an irregular, thin, or somewhat thick, soft, unctu ous, waxy-looking, gray or brownish coating. There is usually a variable amount of itching. The skin beneath the crusts is not hyperemic, but of the usual color or somewhat paler than normal, with, in some cases, a tendency here and there to slight redness and development into dermatitis seborrhoica. The gland-ducts are often somewhat stuffed with semi- solid fatty matter. The hair is greasy and oily, sometimes massed or
SEBORRHEA
1023
bunched, and practically in the same condition as noted in seborrhœa oleosa. In the crusted seborrhea there is a more decided disposition to falling of the hair and consequent alopecia. The disease varies in degree. It may be slight, with a variable amount of oiliness, and small fatty scale or crust specks or small filmy fragments, which are found on the scalp, scattered through the hair, and sometimes falling upon the shoulders. This latter illustrates one variety of the condition known as dandruff—of the oily or greasy form, in contradistinction to the dry variety, pityriasis capitis (one form of dermatitis seborrhoica).
A mild degree of crusted or scaly seborrhea is sometimes seen upon the face, occasionally alone, but more commonly in conjunction with the disease upon the scalp; its usual site is about the nose, and sometimes on the bearded region. As a rule, most cases of a greasy, scaly nature about these parts present a slightly or moderately inflammatory basis, and be long to the domain of dermatitis seborrhoica. The surface is noted to be oily, and variously coated with a pasty, dried, greasy film, or a thin, cheesy coating, and, especially about the nose, sometimes with dippings down into the glandular openings.
Rarely a similar, apparently noninflammatory, condition is noted on the chest, usually over the sternum and between the scapulae, and is generally of irregular patchy or circinate formation, with projections into the follicles. As a rule, however, an inflammatory element is added in these cases, and the picture is then that of dermatitis seborrhoica.
Crusted seborrhea is also sometimes seen upon the glans and corona of the penis, beneath the prepuce, where the secretion is usually relatively active, and, if permitted to collect, forms a flaky, irregular, thin, cheesy coating which undergoes decomposition, and causes more or less irrita tion or a positive balanitis. The same condition may arise in women, about the clitoris and vulvar folds, unless the parts are frequently cleansed, and a vulvitis results. Occasionally the pubic region, like the scalp and other hairy parts, is the seat of a flaky or thin greasy coating, conjointly with oiliness.
Etiology.—Exclusive of the seborrheic condition in the new- born and early infantile life, the malady is most frequent between the ages of fifteen and thirty, when the glandular structures are usually most active, although it is not uncommon, especially in women, toward the climacteric. It is met with in both sexes, and with, upon the whole, but little preponderance either one way or the other. Those of dark hair and complexion are the usual subjects for the oily variety. General debility, anemia, chlorosis, dyspepsia, and similar disorders are to be variously looked upon as contributory, if not causative. The disease is also noted to develop after severe constitutional diseases, especially after the various exanthemata. Scrofulosis must also be considered as furnishing a good basis for its production. Seborrhea of the nose is apparently due in some cases to intranasal pressure or obstruction (Seiler, Besnier, Doyon, and others). In some instances, it is true, the disease seems to be due to a loss of tone in the glands and skin, and to be entirely independent of any constitutional or predisposing condition. The view advanced in recent years, that the disease is of parasitic nature and con
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DISEASES OF THE APPENDAGES
tagious (Unna, Sabouraud, and others), has been steadily gaining ground, and its occurrence in several or more members in certain families bears as much upon the question of contagiousness as it does upon hereditary or family tendency.
Pathology.—Seborrhea, as observed in the types just described, is to be considered as a disease chiefly and probably wholly of the sebaceous glands, and functional in character. Unna and Meissner would have us believe that the coil-glands (sweat-glands) secrete the
oil, and that (Unna) the seba ceous glands are not involved in this malady, except secon darily. Unna, therefore, sug gests for the oily form the name hyperidrosis oleosa, but Beatty’s1 investigations go to show that at least in the oily form and the vernix caseosa the secretion is not a product of the sweat-glands. While it is, I believe, true that secretion from the sweat-glands does contain oil at times, at least, nevertheless, one needs but ex amine a case of seborrhea of the types here defined and the exit from the sebaceous gland- ducts of fatty secretion is at once evident. Moreover, its favorite situations are those where the sebaceous glands are most numerous and most highly developed. Sabouraud2 does not state it too strongly when he says that seborrhea has two essential symptoms— an overproduction of normal sebum and a dilatation of the sebaceous gland-duct openings. The oily secretion and the fatty collection found in the gland-ducts and also that upon the surface are chiefly composed of fatty matter, although Elliot3 found that the plugs in the ducts were composed of epidermic cells, derived from the epidermic lining of the follicular open ing, impregnated with fatty hypersecretion. Van Harlingen,4 who made some careful investigations, concludes that: “(1) The sebaceous secretion
1 Beatty, “Seborrhea,” Brit. Jour. Derm., 1894, p. 161; also “The Functions of the Glands of the Skin,” ibid., 1893, p. 97 (both valuable contributions).
2 Sabouraud, Annales de l` lnstitut Pasteur, 1897, p. 134; and Annales, 1897,
P. 257.
3 Elliot, Morrow’s System,, vol. iii (Dermatology), p. 789.
4 Van Harlingen, “The Pathology of Seborrhea “ Arch. Derm., 1878, p. 97.
Fig. 256.—Vertical section through the scalp of a newborn child suffering from sebor- rhœa neonatorum (X 250): e, Corneous layer; m, rete mucosum; s, shaft of hair; r, root of hair, cut obliquely; i, inner root-sheath; 0, outer root-sheath; f, hair-follicle; g, g, en larged sebaceous glands, with ducts; d, d, corium; v, veins in the corium (courtesy of Dr. L. Heitzmann).
SEBORRHEA
1025
is derived from fatty metamorphosis of the enchyma cells of the sebaceous glands. These cells are homologous with those of the stratum mucosum of the skin. They have nothing in common with the cells of the horny layer. (2) Seborrhea is a disease of the sebaceous glands, characterized by the pouring out of an increased quantity of sebum, more or less altered in chemical and physical composition. In comedo and seborrhœa sicca, properly so called, the secretion is condensed to a fatty consistency, while in seborrhœa oleosa it remains in an oily state. In each of these affections, however, microscopic examination shows epithelial cells in a state of more or less complete fatty degeneration, and breaking down into granular débris. Horny cells are found only adventitiously.”
Sabouraud believes that seborrhea is due to a short microbacillus.1 It is always to be found in the upper part of the hair-follicle, and a sebor- rheic cocoon which develops, containing the bacillary colony, by inter fering with the function of the hair-papillæ, gives rise to the secondary hair loss and sometimes permanent alopecia. Further evidence is, how ever, needed before Sabouraud’s conclusions can be admitted. Scham- berg2 found this bacillus in individuals who presented no trace of sebor- rhea. As the observations of Unna, Sabouraud, Brooke,3 and others show, the seborrheic process often has an influence in materially influ encing other cutaneous eruptions, notably eczema, acne, acne rosacea, syphilis, psoriasis, etc
Diagnosis.—Oily seborrhea can scarcely be mistaken for any other disease; the oily, greasy character and appearances and the region involved are sufficiently distinctive. The crusted, scaly form is to be differentiated from eczema, dermatitis seborrhoica, psoriasis, and possibly ringworm. The rather diffused character of seborrhea, the greasy, oily nature of the scaliness or crusts, the absence of all inflammatory symp toms, the usually dilated gland-ducts, containing sebaceous matter, are points of difference from those of the several diseases named; moreover, in these latter there are noted, except in eczema, rather sharp definition to the areas and inflammatory action. In eczema the inflammatory char acter is sufficient to prevent error. It is true, however, that the step from seborrhea to dermatitis seborrhoica is often a short one.
Prognosis and Treatment.—The. prognosis of seborrhea is favorable, although it must be said that the disorder is sometimes obstinate, and that there is a strong disposition to recurrence. In moderately severe and in severe cases of seborrhea of the scalp, of pro-
1 Tiéche, Archiv, 1908, vol. xcii, p. 125 (with brief review and some references), has made some investigation as to the micro-organisms of the scalp, taking tissue from the scalps of dead bodies as soon after death as possible. He found the Malassez spores in 48 cases—96 per cent.; in 44 per cent, seborrhea bacilli were present in numbers, ab normal forms in 20 per cent.; hyphæ and spores, having considerable resemblance to microsporon furfur, were found in 10 cachectic subjects. A table showing the relation ship of bacterial and fungous growths to soil (subjects) is added.
2 Schamberg, “Remarks on the Microbacillus of Seborrhea,” Jour. Cutan. Dis., 1902, p. 99.
3 Brooke, “The Relations of the Seborrheic Processes to Some Other Affections of the Skin,” Brit. Jour. Derm., 1889, p. 247; see also literature reference to Sabouraud’s papers in connection with acne; also paper by W. Anderson, “On Seborrhea and its Results,” ibid., 1900, p. 276; and by R. W. Taylor, “The Seborrheic Process and the Early Syphilitic Eruptions,” Jour. Cutan. Dis., 1890, p. 161 (with 2 good cuts).
65
1026
DISEASES OF THE APPENDAGES
tracted duration, loss of hair is not an unusual sequence, although in most cases, if not too long neglected, a regrowth may be looked for.
In some instances of seborrhea local treatment alone is required; in most cases, however, the general condition is below the normal stand ard; constitutional remedies are to be administered according to indica tions. Chlorosis, anemia, and digestive disturbances certainly seem to have a strong predisposing influence, if not directly causative; and a removal of any of these several conditions will often have a favorable action upon the disease, or make it more promptly responsive to suitable local measures. Iron, strychnin, quinin, cod-liver oil, digestives, and laxatives are, therefore, to be prescribed according to the indications in the individual case. Arsenic may be tried in rebellious cases; and ichthyol (the ammonio-sulphate), in doses of 5 to 15 grains (0.3-1.) three times daily, is highly praised by Elliot for the oily variety. A vaccine1 made from the microbacillus might be tried in obstinate cases. In instances in which the disease is practically limited to the nose, the possibility of intranasal pressure or obstruction should be eliminated, or, if present, appropriate treatment recommended.
In the management of seborrhea frequent washing with soap and water is usually necessary, in order that the parts can be kept free from the oiliness or crusting, and for this purpose a mild toilet soap can be used, or in those of sluggish, non-irritable skin the tincture of green soap. In obstinate scalp cases to the latter can be added 10 to 30 grains (0.65-2.) of resorcin to the ounce (32.). The frequency of the washing depends upon the severity of the disease and the character of the remedies em ployed; if the oil or fatty accumulation is rapid, once every two or three days would be required for the scalp and once daily for the face. In fact, the face requires such washing as a routine measure once daily, and preferably at bedtime and before the application of the selected remedy. When salves are employed, a certain amount of added messiness results, especially upon the scalp, and cleansing becomes more frequently neces sary. After the disease becomes less active the scalp can be washed every three to ten days; as a rule, however, frequent shampooing, con joined with remedial applications once or twice daily, is often necessary in the scalp cases, especially those of the markedly oily variety. As the condition improves treatment can be less frequent and gradually inter mitted, or applications made at intervals of several days. In the removal of the greasy collection in infants care is to be taken that the skin be not irritated, for it is an easy matter in these cases to start up eczema; strong soaps should not be used, and if the crusting is adherent, as it often is on the scalp, it can be softened by oil applications, or, if persistent, with starch poultices.
The chief remedies to be employed in the external treatment of seborrhea are resorcin, sulphur, ammoniated mercury, salicylic acid, and boric acid. Resorcin is the most valuable, and is prescribed more frequently and satisfactorily as a lotion, 1 to 10 per cent, strength,
1 Savill, Practitioner, March, 1911, p. 392, reports a cure of a chronic case of sebor- rhœa oleosa of the scalp with vaccine made from the culture of the microbacillus of Sabouraud.
SEBORRHEA 1027
made up with 1 part alcohol and 3 to 6 parts water, or in some cases, especially on the scalp, the pure alcoholic solution seems best. If too drying, glycerin can be added to the aqueous lotion, and castor oil to the alcoholic one—a few minims to the ounce (32.). In those of very light or gray hair, if used, it should be carefully and in scanty quantity; if used freely, the hair becomes wet with it and there often results a dirty or dingy-looking staining. Resorcin may also be used in ointment form, made up with vaselin or cold cream, of about the proportion of 20 to 60 grains (1.3-4.) to the ounce (32.). Both as a lotion and ointment the weaker strength should be tried first, and then the proportion increased —for occasionally this drug is found to act as an irritant. Sulphur is applied in but one form to the disease as it occurs upon the scalp—as an ointment, from ½ to 2 drams (2.-8.) of precipitated sulphur to the ounce (32.) of petrolatum or benzoated lard. Ammoniated mercury, in a strength of from 20 to 60 grains (1.3-4.) to the ounce (32.) of ointment, is likewise a valuable application—upon the whole probably less generally useful than the sulphur ointment, but colorless and more elegant. Sali cylic acid may also be employed alone in the form of an ointment, from 10 to 30 grains (0.65-2.) to the ounce (32.), but it is more frequently employed with sulphur or ammoniated mercury in compound ointments.
As a rule, the lotions are much more efficacious for the oily form than are ointments, and probably also in the crusted variety, but in the latter, when scale accumulation is at all rapid, ointments are often demanded, and, indeed, in some instances, act more satisfactorily. A good plan in these cases is to use a lotion up to within a day or two of the time for shampooing, and then to employ a pomade, resuming the lotion after the shampoo. Upon the whole, petrolatum is a good base for the scalp, and often somewhat improved by 1 or 2 drams (4.-8.) of cacao- butter to the ounce (32.); for the face, cold cream can take the place of the petrolatum. Davis commends highly a “stearoglycerid ointment" as the ointment base,1 as not being greasy and readily washed off. In addition to the lotions already named which may be used for the disease upon the face, the sulphur lotions employed in acne are also of service in some instances; they are to be tried in weak proportion at first, as this remedy sometimes irritates in these cases. Carbolic acid as a lotion is also useful in seborrhea of the scalp, but has the disadvantage of odor; it can be prescribed in 1 to 3 per cent, strength, preferably in alcohol, and to which, if found too drying, a few minims of castor oil can be added. A lotion of corrosive sublimate is also sometimes of service, both for scalp and face cases, and of either variety; it may be used in the strength of 1 or 2 parts to 1000, and either alone or with the resorcin lotion as a base.
In the treatment of the disease about the glans penis and vulva frequent ablutions—twice daily at least—should be enjoined. The milder lotions of boric acid and resorcin have special application on these parts. Also weak lotions of zinc sulphate and tannic acid; of the former, 1 to 3 or more grains (0.065-0.2) to the ounce (32.), or of the latter, a saturated solution. A compound lotion, using the boric acid solution 1 See treatment of Alopecia for formula.
1028 DISEASES OF THE APPENDAGES
as a basis, with the zinc sulphate added, and if there are any abrasions, with the addition of 10 or 15 grains (0.65-1.) of finely powdered zinc oxid or bismuth subnitrate to the ounce (32.), often acts satisfactorily.
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