Treatment of Skin

Acute Radiodermatitis

noreply@blogger.com (Anonymous) — Mon, 31 Aug 2015 00:54:00 +0000

For descriptive purposes three degrees of acute dermatitis are usually designated:

First Degree Radiodermatitis. This is the mildest form of inflammatory reaction. It consists of an erythema associated with slight burning and itching, which entirely disappears after a few days or weeks, either leaving no trace or being followed by alopecia, pigmentation or slight desquamation.

Sequelae. First degree reactions are generally followed by epithelial desquamation, pigmentary changes, and temporary or permanent dryness due to impairment of the sweat and sebaceous glands or alopecia. After the course of months, usually about eighteen months subsequent to treatment, but sometimes as early as twelve months or as late as ten years, slight cutaneous atrophy accompanied by telangiectasia is likely to supervene.

Second Degree Radiodermatitis. In radiodermatitis of the second degree the erythema is more marked and the edema so intense that vesiculation results. Itching and burning are pronounced. The erythema of second degree reactions develops two or three days earlier than in the case of first degree reactions. At the beginning the color is scarlet. In the course of a few days the edema becomes intense, causing exudation, vesiculation, and erosion of the epidermis. Crusting of an impetiginous character ensues; hair in the irradiated area falls out about three weeks after exposure. The alopecia is likely to be permanent. The function of the sebaceous and sweat glands is impaired for an indefinite period in most cases. When the fingers are affected, the nails may desquamate.

The duration of second degree reactions is, as a rule, between one and three months. Several months after healing, atrophy and telangiectases are likely to ensue. It is not uncommon for the skin to assume a parchment paper appearance. In the course of time lentiginous spots and keratoses usually develop, and after years, cancer also.

Third Degree Radiodermatitis. When the reaction is severe enough to cause necrosis and ulceration, it is classified as third degree radiodermatitis. With modern methods, local injuries of this kind from x-rays rarely occur. Such a roentgen accident generally results from carelessness. On the other hand, with unfiltered or lightly filtered radium or supersoft x-rays, the necrosis which leads to ulceration is often purposeful and therapeutic.

As with the other degrees of reaction, the time of onset is inversely proportional to the magnitude of the dosage and the softness of the radiation. The reaction causes vivid erythema, edema, vesicle or bulla formation, pain, and sloughing. The pain is especially severe when cartilage, periosteum, or bone is involved. With soft radiation vesiculation always precedes ulceration by a few hours or days. With hard radiation the breaking down of tissues into an ulcer may follow an erythema and vesiculation so transient that neither is marked; consequently necrosis comes on suddenly, without much forewarning. This is especially apt to happen when cross-firing has been employed. Healing is delayed at least for months, often indefinitely. When cartilage or bone is involved it does not take place until the sequestra are removed. When healing does occur the resultant scar is dry, shiny, hairless, atrophic, telangiectatic and liable to break down spontaneously or from the slightest trauma.

Ulcerations of this character are so indolent that they frequently never heal. They are subject to secondary infection, and after years of irritation from this cause, from local remedies and motion of the injured part, cancer springs into existence.

In cases in which the reaction has been caused by penetrating radiation, the injury to the subcutaneous connective tissue is so severe that a dense, rather diffuse local sclerosis or "boardlike thickening" occurs. These sclerodermatous changes may limit the motion of articulations. The tissue is practically avascular, due to a destructive endarteritis of the vessels. Ulcerations which develop in such environments from either trophic or minor mechanical causes are naturally indolent and subject to malignant changes. In severe cases the vascular damage is so pronounced that gangrene may result.

Local Clinical Reactions

noreply@blogger.com (Anonymous) — Sat, 29 Aug 2015 00:55:00 +0000

Pigmentation following radiation is especially influenced by individual characteristics. It is common after reactions of all degrees. In brunets diffuse homogeneous tanning may ensue from a fractional unfiltered roentgen treatment. A similar small exposure may produce numberless ephelides of various sizes and depths of brownish color in those subject to freckles. In some the freckles may be of light brown color and rather large; in others they may be very dark brown or black and pinhead-sized.

Pigmentation or tanning usually disappears in a few weeks but may persist much longer. Not infrequently the hyperpigmentation endures for a few years, especially in brunets. After very severe reactions the pigmentation may be permanent.

In dark skins, especially in Ethiopian and Mongolian races, depigmentation instead of hyperpigmentation may ensue from intensive exposures. Such depigmentation is permanent. It must be particularly guarded against in the treatment of keloids, where it is customary to use fairly large doses.

Hyperpigmentation, either diffuse or in the form of ephelides, is not an important index of skin toleration, but it should not be completely disregarded in the treatment of acne and other benign dermatoses where cosmetic effects are important. Cases which show an early tendency to pigmentation should receive a little more conservative treatment than those in which this biologic reaction is not manifest.

Cutaneous Changes Representing the Transient Functional Inhibitions Which, During Fractional Treatment, Precede the Onset of True Radio-dermatitis. Although mild in character, they are of the greatest importance in roentgen therapy, because they are about the only clinical means of estimating the biologic response of normal skin structures (sebaceous and sweat glands, hair follicles, and blood vessels) to doses which are suitable for the radiotherapy of benign dermatoses.

Inhibition of Functional Activity. The mildest form of clinical reaction is a dryness of the skin caused by inhibition of the activity of the sudoriferous and oil glands. This effect—which may be temporary or permanent—is noticed chiefly in treatment with small doses over a long period at short intervals. Permanent inhibition may result from repeated fractional filtered exposures of x-rays or radium without causing an erythema.

Dryness denotes that almost an erythema dose has been administered, and serves as a warning that further radiation must be given cautiously with close observation of the skin for evidence of irritability or erythema.

Epilation. The hair is epilated by suberythema exposures of all except very soft radiation Lanugo, scalp and other hair are affected. Defluvium usually occurs sixteen to twenty-one days after the administration of an epilating dose. About the fourth week after exposure the hair ceases to fall.

Defluvium from suberythema exposures is always temporary. Even if there are mild reactions the hair will usually regrow. It is necessary to bear in mind that an erythema, however mild, may not be followed by complete regeneration. Erythemas are therefore to be avoided in cases requiring temporary epilation.

Quality of radiation also affects the character of these mild reactions. With soft radiation from beryllium window tubes and grenz rays the action is so superficial that the hair follicles are not appreciably affected. As a result, this reaction consists of a superficial erythema. It appears within a few hours after treatment and disappears in the course of one or two weeks. Erythemas from unfiltered radium may also be so superficial that they do not cause epilation. With orthodox qualities of radiations, defluvium occurs with all doses sufficient to produce an erythema.

Permanent alopecia is apt to follow severer types of radiodermatitis and even well-marked erythemas, although occasionally a few scattered coarse hairs are seen growing in atrophic, telangiectatic areas which have resulted from large doses.

Regrowth of hair usually occurs without delay. Frequently it begins to grow in two or three weeks after it has fallen. In general it may be said that regeneration takes place one to four months after treatment. However, in cases which have shown no growth in this time, some coarse hair may grow years later.

The regrowth following even small doses may differ slightly from the original. Frequently it is more profuse and occasionally it is curly in instances where it was formerly straight, or may have a slightly different color or luster. It may grow more rapidly and profusely in previously diseased areas than upon normal skin.

Irritability. The serial administration of small doses of radiation may eventually lead to a pronounced vascular irritability of the skin resembling a mild degree of dermographism. In this state, rubbing or slapping of the treated area or the application of warmth gives rise to rapid hyperemia. There may or may not be slight itching.

Skin irritability of this nature results from a larger dose than is required to produce inhibition of the sweat and sebaceous glands. It may occur with an epilating dose, especially if attempts at permanent epilation are under-taken. The greatest importance attached to this type of skin irritability lies in its significant warning that an erythema may develop at any time.

The local clinical reactions which have been described are not usually included in a definition of radiodermatitis. Inflammatory conditions of the skin produced by roentgen rays or radium rays (radiodermatitis) are best divided into (a) acute dermatitis from a single large dose or multiple large doses given at short intervals, and (b) chronic dermatitis as a sequel of acute dermatitis or from frequently repeated small doses given over a long period.

Roentgen And Radium Dermatitis

noreply@blogger.com (Anonymous) — Fri, 28 Aug 2015 00:55:00 +0000

Dermatitis due to these agents may be intentionally produced by an accurately controlled technique when warranted in the treatment of certain diseases, or may be accidentally incurred by ignorance or carelessness. Accidental "burns" from x-rays and radium were closely associated with the early use of them and, in the case of radium, first called attention to its action upon living matter. About five years after the discovery and medical use of roentgen rays, the first case of cancer arising upon chronic radiodermatitis was reported in a roentgenologist. During the succeeding few years numerous cases appeared in the literature. Although the x-ray industry has since that time grown, the dangers are now more fully recognized and precautions against them have been adopted.

Similarity Between Radium and X-ray Dermatitis. Inflammatory reactions due to x-rays and radium have many points of similarity, although the onset, course, and end results vary greatly. These variations depend upon the intensity and penetration of the radiation.

Latent Period. An interval of several days intervenes between the exposure to radiation and the onset of visible skin reaction. This interval is called the latent period. The term is applied mostly when erythema doses are used, but a similar interval exists between exposure and functional or therapeutic manifestations when fractional or suberythema doses are employed. The duration of this interval is affected largely by the quality of the radiation, the skin tolerance of the subject, and the magnitude of the dose. In general, the softer the radiation and the larger the dosage, the shorter is the latent period.

The phenomena of the latent period are difficult to explain. They belong to the field of general biology and are not a specific radiation problem. Presumably the radiation effects are immediate, and such grossly visible clinical changes as ultimately appear are tissue reactions to them.

Porphyria

noreply@blogger.com (Anonymous) — Thu, 27 Aug 2015 01:02:00 +0000

Porphyria occurs in three forms. Congenital porphyria appears early in childhood as a fault of the pigment metabolism, possibly inherited as a mendelian recessive. There is hypersensitivity of the skin to sunlight in spring and summer showing as hydroa aestivale. Blisters develop on exposed parts of the face and extremities and may heal with scarring. There is a reddish or purplish brown discoloration of the teeth and bones due to impregnation with uroporphyrin I. Large amounts of uroporphyrin are excreted in the urine giving it a reddish color and causing it to fluoresce when exposed to ultraviolet light; fluorescence of the fingernails and teeth also shows. A variety of congenital porphyria is porphyria cutanea tarda.

Porphyria cutanea tarda is a relatively rare inherited fault of pyrrole metabolism characterized by the excretion of various types of porphyrin, mostly uroporphyrin. There are two types. The erythropoietic type is a form of blood dyscrasia with the site of origin in the bone marrow. There are mutilating photosensitivity, splenomegaly, hemolytic anemia, erythrodontia, hypertrichosis and melanosis. Treatment is by splenectomy. The hepatic type arises in the liver, apparently due to a genetic enzymatic disturbance. There is no evidence of consanguinity, but there are signs of impaired liver function. Many of the patients that Brunsting reported in childhood had red hair that turned dark or black in later life. There was frequently a history in older people of the darkening of gray hair. There were blisters and crusted lesions, not always related to exposure to light. Sclerodermatous patches were often noted. There was a history of colic, hypertension, melanosis, paresis or paralysis, and aggravation by drugs and alcohol. In the hepatic type there is no hemolytic disease.

Acute porphyria manifests itself by gastrointestinal symptoms and nervous system involvement. There is often agonizing abdominal pain that may come and go rather rhythmically. It may be in the upper abdomen or in the loins and associated with vomiting, constipation, icteric tinge to the conjunctivae, anxiety, crying, perplexed syndromes, paralyses and convulsions.

There may be spotted pigmentation, but the skin is little affected and patients rarely show light sensitivity. The urine has a characteristic pink color, which does not develop immediately but is most evident after forty-eight hours. Porphyrins are excreted in excessive amounts. Uroporphyrin III is excreted in very large amounts chiefly during attacks. Smaller amounts of coproporphyrin III or I are found occasionally. Microscopically there may be patchy degeneration of the myelinated fibers of the nerve roots of the cord white matter. Petechial hemorrhages and areas of focal necrosis occur in the brain. The etiology is obscure, and no treatment has been established. Glucose and thiamine may be given intravenously.

Chronic porphyria includes those cases that cannot be classified as congenital or acute, but exhibit the clinical symptoms of both in a milder form. The face and neck have a bluish cast. In chronic porphyria the skin is sensitive to light Sclerodermatous thickening occurs in the cheeks and back of the neck. Gastrointestinal, nervous and mental symptoms occur, either singly or in combination. Acute toxic porphyrinuria caused by certain toxic substances and drugs should not be included. Chronic porphyria is characterized by excessive excretion of coproporphyrin III and I and uroporphyrin III and I. Chronic porphyria is a disturbance of metabolism with hereditary aspects, and may be latent for a long time, as in diabetes. Chronic alcoholism is often a precipitating factor. In almost all cases there is failure to demonstrate hypersensitivity to any of the fractions of the spectrum by artificial tests. The treatment of porphyria, in a broad sense, is that of cirrhosis of the liver. Intramuscular injections of 2 to 5 cc. of crude liver extract two or three times a week are beneficial.

Hydroa Vacciniforme

noreply@blogger.com (Anonymous) — Wed, 26 Aug 2015 00:59:00 +0000

This is a vesicular and bullous disease which tends to recur each summer in childhood on uncovered parts of the body. Although both sexes are affected, the disease occurs more often in boys, beginning during the first three or four years of life and usually disappearing soon after puberty. Mild types of the disorder are characterized by papules or small vesicles (summer prurigo of Hutchinson or hydroa aestivale ), but when the eruption is severe there are bullae, impetiginous crusts, and pitted scars (hydroa vacciniforme). The lesions appear mostly on the face and the extensor aspects of the extremities and are arranged symmetrically chiefly over the nose, cheeks, ears, and dorsal surfaces of the hands. They may arise on other areas, including the cornea, and in this location cause scars that interfere with vision. Itching and burning, as well as mild constitutional symptoms, may precede the outbreak of skin lesions, which appear in crops. These begin as erythematous macules that rapidly develop into vesicles and bullae, which in the course of three or four days dry up with the formation of adherent brown crusts. Some of the bullae become umbilicated, forming a central punctum about which are the remains of the bulla; the whole surrounded by a mildly inflammatory zone, so that the appearance simulates a vaccination vesicle. Fresh crops of lesions appear at various intervals, which in summer may be so short that they are in-determinate. The itching may lead to lichenification that persists through the winter. In some cases of hydroa vacciniforme, porphyrinuria occurs so that the urine fluoresces under Wood's light. The disease in many respects resembles the congenital type of porphyria. The treatment of hydroa vacciniforme is the avoidance of exposure to sunlight and the elements and the use of nicotinic acid, quinacrine hydrochloride, and estrogens. Locally sun screens and hydrocortisone ointment are useful.

Colloid Degeneration Of The Skin

noreply@blogger.com (Anonymous) — Tue, 25 Aug 2015 03:14:00 +0000

Synonyms. Colloid milium, colloid pseudomilium, miliary colloidoma, hyaloma.

This is a rare disease which usually occurs on the face or the dorsal surfaces of the hands, but may occur at any other site. It generally begins in early childhood as cream-colored or yellowish, pinhead to split-pea-sized, rounded, pellucid papules. The lesions gradually develop and spread over the cheeks, forehead and nose, and on the backs of the hands. The papules are of a firm consistency and do not coalesce but are frequently grouped. Although they resemble vesicles, usually nothing can be expressed from them when incised. However, some authors state that small amounts of a gelatinous substance can be squeezed out. The disease causes no symptoms but is persistent and seldom disappears; although sometimes it does as in the case pictured in Figure a. This photograph was made when the patient was 8 years of age. Now at the age of 20, there is scarcely a trace of the disease. Her sister had the same condition and is likewise cured.

The exact cause of the disease is unknown but there is increasing evidence that it is provoked in some cases by severe sunburn. Colloid degeneration of the skin is to be differentiated from milium, hydrocystoma, adenoma sebaceum, syringocystadenoma, and multiple steatomata.

The histopathology of one of our cases, as described by Dr. G. F. Machacek, is typical: "These sections of skin showed a thin keratin layer which had been lifted from the underlying epidermis and which disclosed processes corresponding to the keratin within the numerous follicular funnels. The follicles were small and apparently represented follicles of lanugo hairs. The epidermis was thin. Processes of this epidermis penetrated the corium and connected with one another, thus forming roughly oval patterns. Within these enclosures there was seen a degenerated connective tissue composed of swollen bundles, separated by clefts. This tissue was pink. The areas were fairly cellular. With Congo red and methyl violet stains no evidence of amyloid was produced. Sections stained with scarlet red showed the areas of degeneration, which were enclosed within the epidermal pattern, to be a muddy brown color due to the deposition of small droplets of fat. The area of degeneration extended one-third to one-half the thickness of the corium. The corium beneath, though relatively normal in texture, was the site of edema and a moderate chronic inflammatory process, the infiltrating cells of which were chiefly mononuclear. The picture was that of so-called colloid milium but showed a definite lipid deposition such as is described under lipid proteinosis."

Xeroderma Pigmentosum

noreply@blogger.com (Anonymous) — Mon, 24 Aug 2015 02:40:00 +0000

Synonyms. Atrophoderma pigmentosum, angioma pigmentosum atrophicum, Kaposi's disease, melanosis lenticularis progressiva.

Xeroderma pigmentosum showing lentigines, atrophy, and scars, due to the removal of carcinomas. Tumors upon the corneas have already destroyed the vision. Death occurred from cancer at age of 19 years.

Xeroderma pigmentosum is a rare pigmentary and atrophic disease that begins in childhood and progresses to the early development of senile changes in the skin, which consist of ephelides, telangiectases, keratoses, papillomatous growths, and carcinoma. The disease is due to a congenital altered reaction of the epidermis to light, probably owing to some deficiency of the protective mechanism. The occurrence of two or more cases in one family is not infrequent. The predisposition may be due to a tissue defect caused by intermarriage. Porphyria may be present.

The regions most often affected are the face, neck, hands and arms, although a few lentigines may appear on other areas. The lesions are worse upon the face, particularly about the nose and eyes. As a rule, due to coalescence of the freckles, the entire face is dappled with pigmented spots of various tints of brown, mingled with white atrophic patches and telangiectases. Keratoses and vascular and epithelial neoplasms complete the picture. Some of these tumors are usually ulcerated or crusted, or they may be raised, discoid lesions or globular, crateriform, or even pedunculated growths. The effects of the disease on the eyes are most distressing. Photophobia and lacrimation are early symptoms; and keratitis with resulting opacities, and tumors of the lids and cornea generally supervene and cause a loss of vision, so that schooling and even simple games are interrupted and the child becomes pitiably dependent. Death occurs early, usually between the ages of 15 and 20. Mild forms of the disease which give no serious trouble are occasionally seen.

The symptoms of the disorder may be ameliorated by the avoidance of exposure to sunlight and by the proper treatment of the skin growths as they develop. Cortisone may be of considerable benefit. Figure shows a girl of 14 in whom the disease developed during the first year of life. At the time she came under my observation she had a pedunculated tumor hanging from the right upper eyelid and a dozen or more other growths on the face, as indicated in the photograph by the white scars which resulted from their removal.

Ephelis

noreply@blogger.com (Anonymous) — Sun, 23 Aug 2015 09:30:00 +0000

Synonym. Freckles.

Ephelides are yellowish, brownish, or black pigmented spots which occur on the skin as a result of exposure to light. They are usually produced by sunlight, being worse in the hot months, but may follow exposure to ultraviolet light from artificial sources or exposure to x-rays. The lesions may be sparsely scattered, or profuse. The condition is more common in blonds than in brunets; but mulattoes are especially subject to the disorder. Freckles are usually 1 to several millimeters in diameter and are arranged symmetrically, as a rule on exposed portions of the skin. Some grouping may be discerned; and larger spots may form due to coalescence. Although the face, neck, shoulders, and dorsa of the hands are the usual locations of freckles, unexposed areas may occasionally be affected. Freckles do not often make their appearance before the sixth or eighth year, and from then on persist throughout life, being exaggerated each summer. Coglievina has shown a coincidence between the location of the freckles and of the points representing the thermic sense in the skin. The freckles may be a biologic defensive process to protect the nerve terminal, at a particularly vulnerable point, by an extra pigmentation. Ephelides must be differentiated from lentigines, which are freckle-like nevi. Ordinary freckles develop at a later age, are lighter in color, usually most marked on exposed surfaces and are definitely related to exposure to sunlight, largely disappearing in the winter.

The preventive treatment is similar to that of sunburn. Freckles may be peeled off by painting lightly with phenol, followed immediately by alcohol. Great care must be exercised in doing this. Blonds are better subjects than brunets. Only a few freckles should be treated at one sitting. Absorption of phenol may cause dizziness and nephritis. A cream containing 20 per cent monobenzyl ether of hydroquinone (Benoquin ointment) may be temporarily effective. Other lotions and creams are of little benefit.

R Camphor . . . . . . . . . . . . . . . . 1.0

Salicylic acid . . . . . . . . . . . . . . 2.0

Mercury bichloride . . . . . . . . 0.06

Alcohol . . . . . . . . . . . . .q.s. ad 50.0

M. and S. Apply to freckles t.i.d., and when peeling begins, stop applying for a few days; then repeat.

R Bismuth oxychloride . . . . . . . . 8.0

Ammoniated mercury . . . . . . . 2.0

Ol. Lemon . . . . . . . . . . . . . . . . . 0.12

Cold cream . . . . . . . . . . .q.s. ad 30.0

M. and S. Bleaching cream.

Chronic Actinic Dermatitis

noreply@blogger.com (Anonymous) — Fri, 21 Aug 2015 02:47:00 +0000

During the process of aging, the skin becomes dry, thin, and inelastic due to atrophy of its appendages and elastic fibers (senile skin). In addition, pigmentary changes take place which are usually of the freckle type, but may in some persons lead to vitiligo, telangiectases, keratoses, and warty growths, which occur especially in seborrheic subjects, and have a tendency to become epitheliomatous. The skin in the back of the neck becomes thickened and tough so that the normal skin markings are exaggerated, which together with tanning produces a condition known as cutis rhomboidalis nuchae, or peasant's neck. Such alterations of the skin may appear prematurely during the third or fourth decades. Persons habitually exposed to sunlight are predisposed to such changes, which are sometimes called chronic actinic dermatitis. Light increases the maturity of the skin.

The terms "sailor's skin" and "farmer's skin" are used for similar alterations which are manifested early and severely in these respective occupations due to exposure to the elements, especially sunlight. In this country, fishermen and gardeners exhibit similar proclivities. Tropical skin is in the same category. Excessive exposure to sunlight by vacationists can slowly lead to any of the above sequelae.

Sunburn

noreply@blogger.com (Anonymous) — Thu, 20 Aug 2015 03:14:00 +0000

This common discomfort occurs principally in the early summer after exposure on the bathing beaches. Blonds are more susceptible than brunets. The individual reaction varies: in some persons a redness begins rapidly upon exposure and in a few hours assumes a scarlet tint and is associated with local burning and heat, or bleb formation; in others the reaction does not appear until the day following exposure. Mild burns provoke a hot drawn uncomfortable feeling in the skin, which is dry and erythematous. These symptoms will disappear in about twenty-four to thirty-six hours, followed by the deposition of variable amounts of pigment. Severe burns engender great discomfort, of a peculiarly insufferable character, intensely augmented by the slightest body movement. Contact with clothing or bedding is unbearable. The integument is parched and of an angry-red hue. Shock, chills, fever, nausea, tachycardia and a sense of impending dissolution may be present. This syndrome, more or less in its entirety, may persist for a day or two. Toxemia and pain will then begin to subside. Blister formation and a firm edema of the ankles, legs, face and other parts of the body may appear. Sometimes herpes simplex, solar urticaria, or lesions that resemble erythema multiforme appear repeatedly at the same site following each exposure. When the acute symptoms disappear the epidermis desquamates and the pigmentation in the skin is increased. After repeated exposures brunets develop so much pigmentation that they are protected by it against sunburn. Indeed the formation of pigment and hyperkeratosis may be so rapid and give such complete protection that tanning may be the only effect. Sunburn is caused by the ultraviolet

rays from the sun and not by the heat rays, chiefly by wavelengths between 2970 and 3030 Å. Ultraviolet sensitivity is increased by heat.

Solar urticaria has been extensively studied by Kesten and Slatkin. Whereas the erythematogenic rays of the sun are between 2,900 and 3,200 Å.U., certain bands of the spectrum in the range of ultraviolet (2,900— .3,900), visible light (3,900-7,700), and infrared ( 7,700-14,000 Å.U.) may specifically produce solar urticaria. The symptoms at first are limited to the exposed portions of the body, but later may become widespread or generalized. Syncope may supervene.

A variety of substances are known to be photosensitizers. Louis Schwartz lists the following: coal tar, pitch, asphalt, creosote oil, fluorescein, rhodamine H., bergamot, figs, buckwheat, India wheat, wild carrot, puncture weed, alsike clover, St. John's wort, bur clover, bunch grass, lady's thumb, and rabbit bush.

Although sunburn is common it cannot be regarded other than as a severe injury of the skin. It is sometimes the precursor of vitiligo, telangiectasia, herpes simplex, and lupus erythematosus, whereas infection of the blisters by pyogenic microorganisms may lead to impetigo, and infection of the hair follicles to furunculosis.

Some individuals have strange polymorphic reactions to strong sunlight. One of my patients develops nodules that last for weeks and show histologic features of lymphosarcoma. Samuel F. Rosen has a patient who regularly develops a large patch of herpes simplex on one shoulder that is followed in ten days by an attack of erythema multiforme. John Lamb described persistent indurated plaques of erythema that had the histologic features of mycosis fungoides. Papular prurigo-like eruptions and verrucous changes also occur. Arnold and Brunsting have reported changes clinically and histologically similar to colloid milium. Jessner has called attention to lymphocytic infiltrations that clinically simulate lupus erythematosus but pathologically do not show any liquefaction degeneration of the basal cell layer, follicular hyperkeratosis or other signs of lupus erythematosus. Swelling of one ear or vesiculation of the forearm may result from riding in an automobile with the window open and the forearm resting on the car door. Repeated exposures cause hyperpigmentation (tanning) and hyperkeratosis which are protective.

The prevention of sunburn is accomplished by the application of creams, ointments, oils or lotions containing physical or chemical parasols. The most effective chemical parasols are the esters of para-aminobenzoic acid, particularly the glyceryl ester, the naphthol sulfonates, benzyl salicylate, menthyl salicylate, phenyl salicylate, sodium salicylate, quinine derivatives, the ester of anthranilic acid (orthoaminobenzoic acid), and tannic acid. Zinc oxide and bismuth subcarbonate are examples of physical parasols. There is a definite relationship between chemical structure and sun-screening efficiency. The best vehicle is mineral oil or a combination of mineral, sesame and peanut oils. Glycerol monostearate and cetyl alcohol are valuable emulsifying agents. The above ingredients absorb ultraviolet radiation, and although their action is insufficient to prevent the effects of prolonged exposure to the sun completely, they do materially diminish them. Insoluble pigments in face powders are also preventive. Large hats and veils are protective, especially if the latter are red or light in color.

Treatment. The application of an effective anesthetic cold cream, such as one containing 2 per cent benzocaine, is usually adequate treatment. Ice-cold compresses of milk or of carron oil or mineral oil are also helpful. Constitutional symptoms should be treated accordingly.

Cutis Marmorata ( Livedo Reticularis )

noreply@blogger.com (Anonymous) — Wed, 19 Aug 2015 02:36:00 +0000

Some persons respond to exposure to cold by developing a bluish mottling of the skin that looks like marble. This is due to passive congestion and may look like black and blue marks. A more persistent reticulated mottling is known as livedo reticularis, or as livedo annularis when the lesions are annular. In livedo racemosa the patterns of bluish red have the outline of a bunch of grapes, or may arborize like the branches of a tree. The disease occurs on the extremities from exposure to cold and is more frequent in childhood. It is also a cutaneous manifestation of caisson disease. The pattern of the eruption is determined by the anatomical arrangement of the cutaneous vessels.

Angiokeratoma Of Mibelli

noreply@blogger.com (Anonymous) — Tue, 18 Aug 2015 03:26:00 +0000

This is a rare disease which usually occurs in children. It is often preceded by chilblains and consists of red points that proliferate to form vascular growths of pinhead size, the surfaces of which in the course of time become hyperkeratotic. The lesions are dull red or purplish black, rounded papules that may be verrucous and wartlike. They may be single or multiple, and in the latter instance are usually closely grouped. Bleeding may cause the patient to seek medical advice. The dorsal aspects of the fingers and toes, and the elbows and knees, are sites of predilection. The patient often suffers from cold, cyanotic hands and feet. A history of exposure to cold, of frostbite or pernio often is obtained.

Way has described the histology which shows signs of injury to the blood vessels with hypertrophy of the stratum corneum, increase of the granular layer and dilatation of the subpapillary vessels into lacunae. The vascular or lacunar spaces frequently are not lined with endothelium, and the epidermis usually forms part of the wall of the vascular space.

Treatment. Angiokeratoma may be treated by the cautery point, electrolysis, or electrodesiccation, or refrigeration with solid carbon dioxide. There is little choice between these methods.

Erythrocyanosis Crurum

noreply@blogger.com (Anonymous) — Mon, 17 Aug 2015 11:29:00 +0000

Synonyms. Erythrocyanosis cutis symmetrica, erythrocyanosis frigida crurum puellarum, erythrocyanosis supramalleolaris.

Various other names have been given to this and similar diseases in which the chief characteristics are a slight swelling and a bluish-pink tint of the skin of the legs of young girls and women. The disease may be unilateral. Atypical varieties are common, some presenting cinnabar red spots, bullae, indurations, and lichenoid papules. There may be circumscribed deep nodules as in erythema induratum. As a rule, the affected limbs are cold to the touch. Associated menstrual disturbances, hyperhidrosis of the hands and feet, and keratosis pilaris are common. The disease is seen mostly in northern countries and is considered an endocrine disturbance in which the skin changes are brought about by exposure to cold.

Frostbite

noreply@blogger.com (Anonymous) — Sun, 16 Aug 2015 14:12:00 +0000

Synonyms. Dermatitis congelationis, congelatio.

When the soft parts are frozen and locally deprived of blood supply, the affection is termed "frostbite." The ears, nose, cheeks, fingers, and toes are most often affected. Various degrees of destruction similar to those caused by burns are encountered: (1) erythema and edema; (2) blisters and bullae; (3) superficial gangrene; (4) gangrene of skin and subcutaneous tissue; (5) gangrene of a whole part of an extremity or other parts of the body, especially the ears; (6) injury to muscles, tendons, periosteum, bone, and nerves without or with accompanying lesions of the skin; (7) chronic

relapsing lesions of the skin—e.g., chilblains and other forms of erythrocyanosis.

Frostbite or immersion foot (trench foot, shelter foot) may develop after long mild ground exposure or in a few minutes from high altitude exposure, sometimes due to carelessness of flyers in adjusting their electrically heated clothing.

Treatment. Early treatment of frostbite before swelling develops should consist of covering the part with clothing or with the warm hand or other body surface until circulation is improved. Any rubbing of the affected part should be avoided, but gentle massage of proximal portions of the extremity which are not numb may be helpful.

After swelling and hyperemia have developed, the patient should be kept in bed with the affected limb slightly flexed, elevated and at rest. Cooling of the limb by exposure to air at room temperature may relieve pain and conserve tissue damage. Protection by a cradle and further cooling by ice bags placed outside the cradle may be desirable. Heparin, in doses of 100 mg. four times a day, should be started at once and continued for a week or ten days, to protect against thrombosis and gangrene. Papaverine and hexamethonium are given to reduce vasospasm. Penicillin or other antibiotics should be given as a prophylactic measure against infection.

The treatment of immersion foot is strict bed rest, and elevation, with asepsis. Bathroom privileges are denied. The limb is protected by a cradle and is cooled at room temperature to relieve the pain.

Wet dressings with water at 41° F. ( 5° C.) to 58° F. (10° C.) are a first aid. Further treatment along the lines recommended for frostbite may be indicated. Some patients are also victims of exposure and require blood plasma or serum albumin.

Anesthetic infiltration of the lumbar and stellate sympathetic may be indicated in obdurate, severe cases of vasospasm. Relief is immediate and the infiltrations are repeated on the next two days.

Chilblain

noreply@blogger.com (Anonymous) — Fri, 14 Aug 2015 18:04:00 +0000

Synonym. Pernio.

Chilblain is a recurrent localized erythema and swelling caused by exposure to cold. In people predisposed by poor peripheral circulation even moderate exposure may produce chilblain. Acute chilblain is the mildest form of cold injury. This occurs chiefly on the hands, feet, ears and face of poorly nourished children, the onset being favored by dampness. Patients are usually unaware of the injury at first, but later burning, itching and rubor call it to their attention. The areas are bluish red, the color disappearing on pressure, and are decidedly cool to the touch, and sometimes clammy due to excessive sweating. Chronic chilblains occur repeatedly during cold weather and disappear during warm weather. The affected extremities are cold, cyanotic and often hyperhidrotic.

Treatment. The treatment is general, as well as local. The circulation should be improved by regular exercise, and a diet of high vitamin content. Niacin, 0.1 gm. t.i.d., and Rutin, 0.06 gm. t.i.d., or Banthine 0.05 gm. or Roniacol 0.05 gm. t.i.d. are used with benefit. Corticoid therapy is useful. The parts should be cleansed with water and massaged gently with some warm oil each day, and should be protected against injury and exposure to cold or dampness. If the feet are affected, woolen socks should be worn at night during the cold months. During the day two pairs should be worn, and thick boots are advisable. Electric pads should be used now and then to warm the parts. Hydrocortone ointment may be applied.

Injuries Due To Cold

noreply@blogger.com (Anonymous) — Thu, 13 Aug 2015 18:44:00 +0000

Injuries due to cold are more frequent and urgent in military than in civil life. Local cold injuries are divided into chilblain, frostbite and immersion foot. Whereas chilblain and frostbite occur sporadically in civil life, immersion foot and hand are encountered almost entirely in the armed forces.

Intense vasoconstriction due to the local action of cold and reflex vasoconstrictor stimulation is reinforced by the passage of cold blood through the vasomotor center. Vasoconstriction provokes tissue anoxia. Decreased muscular activity further diminishes the blood supply. Ice crystal formation does not usually occur, but when it does, necrosis ensues.

Erythema Ab Igne

noreply@blogger.com (Anonymous) — Wed, 12 Aug 2015 12:07:00 +0000

Synonym. Ephelis ab igne.

This disease is a persistent erythema and pigmentation produced by long-continued exposure to excessive heat, without the incidence of a burn. Erythema ab igne is most common on the legs from habitually warming them in front of open fireplaces, radiators or heaters. Similar changes may be produced by the hot-water bag. The disease occurs chiefly in cooks, stokers, invalids, and others exposed over long periods to the direct action of moderate heat.

Treatment of Miliaria

noreply@blogger.com (Anonymous) — Tue, 11 Aug 2015 03:28:00 +0000

For persons predisposed to miliaria, light clothing, rest and avoidance of hot humid environment and stimulating, heating foods such as alcohol and spices are advisable. Sodium chloride should also be avoided. Air conditioning with dehumidification and proper air circulation are desirable but usually unobtainable. Soothing, cool baths containing Linit starch or Aveeno oatmeal, 1 cup to the tub, may give comfort. Immersion for ten minutes in a cool bath containing 1 pound of starch and 1 teaspoonful of a 25 per cent alcoholic solution of menthol is beneficial. The starch is added to 2 quarts of water and boiled, before adding the mixture to the tub. Ice packs are necessary in severe cases to relieve the pruritus. Soap is undesirable. In adults a single fractional dose of unfiltered x-rays gives relief within three or four days.

Prantal 0.05 gm. every three hours, or Banthine 0.05 gm. every four hours is preferable to atropine, and if well tolerated may give considerable relief.

Locally hydrophilic ointment U.S.P. or Aquaphor (Duke) helps to dissolve the keratinous plugs and facilitate the normal emergence of sweat.

Mild cases in infants and adults may respond to dusting powders such as corn starch or baby talcum ( J. & J.). More severe eruptions may be relieved by shake lotions, especially if they produce desquamation. The following preparation has proved effective when applied hourly with a paint brush:

R Resorcinol . . . . . . . . . . . . . . . . . 2.0

Sulfur, precipitated . . . . . . . . . . . . 5.0

Zinc oxide . . . . . . . . . . . . . . . . . . 20.0

Starch . . . . . . . . . . . . . . . . . . . . . 20.0

Glycerin . . . . . . . . . . . . . . . . . . . . 10.0

Alcohol (95%) . . . . . . . . . . . . . . . . 35.0

Water . . . . . . . . . . . . . . . . . q.s. ad 120.0

Sulzberger recommends menthol and glycerin, each 1 per cent, salicylic acid 4 per cent, dissolved in alcohol 95 per cent. This should be dabbed on the affected areas several times a day until desquamation sets in. Shelton prefers a 4 per cent solution of tannic acid in 60 per cent alcohol (for infants 1 or 2 per cent tannic acid in 20 per cent alcohol). This is applied twice daily and allowed to dry, when the skin is dusted with talcum powder.

Miliaria

noreply@blogger.com (Anonymous) — Mon, 10 Aug 2015 12:55:00 +0000

Synonyms. Prickly heat, sudamina, lichen tropicus, strophulus.

Prickly heat is a common eruption in the tropics, and in temperate climates during the summer, and occurs as an occupational dermatitis in those exposed unduly to heat and humidity. Persons who wear woolens and flannels or unduly heavy clothing, infants and those who are plethoric or obese are predisposed to the disease. It affects chiefly the bends of the elbows, front and sides of the chest, the waistline and inframammary regions, but may appear on the backs of the hands, scalp or other regions except the palms and soles.

Miliaria crystallina is characterized by small clear superficial vesicles without inflammatory changes. Miliaria rubra appears as discrete erythematous macules associated with small papules. These lesions may become confluent. It may also show as distinct clear vesicles such as occur in miliaria crystallina but each vesicle is surrounded by a halo of erythema. Pustular miliaria is always preceded by some other skin damage which has produced injury, destruction, or blocking of the sweat duct or its orifice (pore). Pustular miliaria may occur in association with contact dermatitis, urticaria, localized neurodermatitis or intertrigo due to obesity. The pustules develop as a complication during the course of an inflammatory dermatosis, sometimes several weeks after apparent cure and discontinuance of all medication.

In the tropics prickly heat may be accompanied by severe systemic symptoms sometimes leading to collapse. These are called tropical anhidrosis or sweat retention syndrome, and are produced by blockage of the sweat gland ducts, thus interfering with the heat-regulating functions of the sweat glands.

The cause of prickly heat has been studied intensively since the stimulating discoveries by Sulzberger and his associates that tropical anhydrotic asthenia and miliaria are caused by a plugging of the sweat duct orifice by keratinous material. The depth of the obstruction and the level at which the sweat pours into the periductal tissues are important factors in determining the clinical types of miliaria. The inflammatory reaction which could occur as response to the plugging, the pressure, the sweat, and the constituents in sweat escaping into the periductal tissues or being resorbed may conceivably produce miliaria rubra without the addition of infection. However, Sams believes that the effects of persistent high atmospheric humidity plus high temperatures gradually diminish the oily, protecting sebaceous film so that perspiration no longer collects at the pores but is absorbed into the horny layer which becomes macerated and a better medium for the growth of bacteria and fungi because of hydration. Growth of these organisms produces inflammation which, together with the swelling caused by absorbed perspiration, induces closure of the pores. If pore closure is rapidly effected by acute inflammation reaction many clear vesicles (miliaria crystallina ) result. If there is a low degree of inflammatory reaction and sufficient time for growth of bacteria ensues, miliaria rubra develops, which supports the thesis of O'Brien that in miliaria rubra bacterial infection of the plugged duct plays a decisive part.

Histopathologically one finds a dilatation of the sweat ducts, the openings of which are obstructed by horny plugs. There is also periductal inflammation and signs of damage to the cells lining the duct.

Burns

noreply@blogger.com (Anonymous) — Sat, 08 Aug 2015 16:41:00 +0000

A dermatitis of various intensity may be caused by the action of excessive heat on the skin, or if this heat is extreme the integument with underlying tissue may even be destroyed. The changes in the skin due to dry heat or scalding are so similar that they both may arbitrarily be classified into three degrees. A first degree burn of the skin results merely in an active congestion of the superficial blood vessels causing an erythema which is followed by epidermal desquamation. Ordinary sunburn is the most common example of a first degree burn. The pain and increased surface heat may be severe and it is not rare to have some constitutional reaction when the involved area is large. When the burn is of second degree there is a transudation of serum from the capillaries which causes edema of the superficial tissues. Vesicles and blebs are formed by the serum gathering beneath the outer layers of the epidermis. Complete recovery, without scar formation or other blemish, occurs in burns of both these two degrees. Third degree burns are far more serious in nature as there is actual loss of tissue of the full thickness of the skin and even some of the subcutaneous tissues; and an ulcerating wound is produced which in healing leaves a scar. Third degree burns are almost always surrounded by burned areas of lesser intensity.

All third degree burns are followed by constitutional symptoms of varied gravity, their severity depending upon the size of the involved surface, the depth of the burn, and particularly the location of the burned surface. It appears that the more vascular the involved area is, the more severe are the symptoms. There are symptoms which are the result of shock appearing within twenty-four hours after the patient is burned. These are followed by symptoms produced by toxemia from absorption of destroyed tissue on the surface of the wound. Lastly, there may be symptoms from wound infection, the result of contamination with pyogenic organisms. The symptoms of these three conditions may merge so that differentiation is difficult.

The prognosis as to life is poor in any case where a large area of skin surface is involved. It is almost hopeless if a fourth of the body surface is burned. Complicating conditions are not at all uncommon in the more severe cases of burns. In addition to the infection of the wound and surrounding cutaneous tissue with cellulitis or erysipelas, the patient may develop an acute duodenal ulcer or glomerulonephritis as well as pulmonary or meningeal lesions.

The local results of third degree burns are often unsatisfactory if not treated in a proper manner. Excessive scarring, both keloid-like scars or flat scars with contractures, may produce deformities of the joints and dysfunctions as well as chronic ulcerations due to impairment of the local circulation. Later changes of a malignant nature in the scar may result in an epithelioma. With modern plastic surgery these unfortunate end results can be prevented.

Local treatment consists of thorough cleansing of the burned area, removal of necrotic tissue, spraying with Aerosol solution of streptomycin and penicillin and the application of petrolatum gauze dressings. Penicillin and streptomycin are given intramuscularly at regular intervals to control infection. In severe cases accompanied by shock transfusions of blood, plasma, and electrolytes are given. Pain is controlled by one dose of morphine intravenously. Cortisone is recommended in serious cases. It combats shock and increases the appetite and epithelization.

First degree burns, such as sunburn, may when severe be treated with some emollient such as olive oil, or petrolatum containing 2 per cent benzocaine if there is pain; or a wet dressing of ice cold milk. The vesicles or blebs of second degree burns should not be opened but should be protected from injury as they form a natural barrier against contamination with microorganisms. If they become tense and unduly painful the fluid may be evacuated under strictly aseptic conditions by puncturing the wall with a surgical needle and allowing the blister to collapse upon the underlying wound and then applying a gauze dressing.

Electric burns are of two varieties, contact and flash. A contact burn is small in area but deep, causing some necrosis of the underlying tissues which later separates and is thrown off. Flash burns are usually large in area and are similar to any surface burn and are treated as such.

Dermatoses Due To Physical Causes

noreply@blogger.com (Anonymous) — Fri, 07 Aug 2015 16:59:00 +0000

THE BODY requires a certain amount of heat, but beyond definite limits, insufficient or excessive amounts are injurious. The local action of excessive heat causes burns or scalds, and on the other hand, undue cold causes chilblains, frostbite, and congelation. Thresholds of tolerance exist in all body structures sensitive to electromagnetic vibrations of other frequencies such as x-rays, radium rays, and ultraviolet rays. The eye, which is sensitive to vibrations within the component of the spectrum known as visible light, is an example of a special sense organ which has similar limits. The skin, which is exposed to so many external physical forces, is more subject to injuries caused by them than any other organ.

Indications for Surgical Diathermy

noreply@blogger.com (Anonymous) — Thu, 06 Aug 2015 11:13:00 +0000

The accuracy of control of the desiccating current makes it extremely valuable in the treatment of small lesions where cosmetic results are not only desirable, but essential. The spark for this work should be very fine, clean, and not feathered.

The action of desiccation is so superficial that lesions in the subcutis or at greater depth are not suitable to its action. For these deeper lesions and for thick elevated growths the coagulating current is employed. The cutting current is used alone or in conjunction with the coagulating current for the removal of malignant neoplasms.

Operative Technique of Surgical Diathermy

noreply@blogger.com (Anonymous) — Wed, 05 Aug 2015 11:44:00 +0000

It is imperative in the application of endothermy that no alcohol, ether, or other inflammable liquid be used on or near the area to be treated, as the spark will set fire to any such liquid. Inflammable or explosive anesthetics must also be avoided.

Cosmetic desiccation of superficial lesions usually requires no anesthesia. For the epilation of hypertrichosis, no anesthesia is used. For all other lesions a solution of procaine is administered by injection. Instillation of a few drops of 1 per cent procaine should be made before operations on or near the eye. Anesthesia is often obtained by infraorbital or inferior dental nerve block with 2 per cent procaine solution.

It is advisable to test the size and character of the spark upon a metal instrument before using it for treatment. The spark for most lesions should be clean, cold, regular, and should not feather.

The desiccating current may be applied to the lesion by a sewing needle directly connected with the generator by a cable. Another method is to have the patient grasp an indifferent electrode so connected, while the operator draws the current from the lesion with a sewing needle. The operator's fingers are placed in contact with the patient, and by increasing or lessening the amount of this contact, the intensity of the spark drawn from the lesion by the sewing needle may be regulated.

Coagulation and cutting generally require that the patient be in the recumbent position and receive local or general anesthesia by sodium pentothal or other noncombustibles.

The use of a bipolar current requires an indifferent electrode. This is conveniently attached by a cable to an aerial. Various forms of indifferent electrodes are used. The most satisfactory is a metal plate, measuring about 6 by 8 inches, with rounded corners. This is covered with two thicknesses of a towel soaked in hot saline solution. It is important that a strong solution of not less than 10 per cent should thoroughly saturate the towel, as weaker solutions offer resistance to the current and may induce scalding, especially if the patient is unconscious. A strong soap solution may be substituted for the saline.

The flat electrode is placed upon the trunk and so bandaged in position that the moistened towel interposed between it and the skin makes contact with the body at all points. It may be bandaged over the chest or abdomen or placed under the back or hips, where the weight of the body holds it in place. Modifications of this form of electrode may be strapped on the upper arm or hand. In minor operations a tubular electrode may be held in the patient's hand. Much loss of time and annoyance are caused by patients dropping the tubular electrode at critical moments during operations; therefore firm fixation of

the indifferent electrode to the patient is advisable. The electrodes must always be in position prior to the diathermy current being turned on, and must not be removed from contact until it is turned off. If these precautions are not taken, sparks between the body surface and the electrode will occur and are likely to burn adjoining parts. Moreover, contact by any one with the indifferent electrode or the exposed end of the active electrode or the skin of the patient may produce burns from the sparks.

The active electrode is screwed into the end of a holder connected by a

flexible cable to the instrument. It is very small and may be of various shapes and sizes. For coagulation it may be the shape of a disk or ball, a knife blade, or a needle. When the lesions are superficial and small, a ball or a flat circular disk-shaped electrode is preferable to a needle. This placed in contact with the lesion, with the current turned on, causes destruction to a depth of 2 Or 3 cm., depending on the time and the strength of the current. This method avoids any traumatism from the insertion of a needle. The length of the knife blade or needle to be used as the active electrode depends upon the thickness of the area under treatment. The point of the electrode is inserted into the lesion as deeply as necessary to coagulate the entire mass thoroughly. Unless the electrode is promptly applied to the tissue, sparks from it will produce undesirable charring. Enough current should be used sufficiently long to blanch the entire mass and the marginal tissue to a dark gray. Care should be exercised in coagulating tissues close to bone or cartilage because if the periosteum or perichondrium is destroyed, healing is delayed. When indicated, however, the bony structure can be completely destroyed and removed.

The cutting current may be applied with a needle, a small knife blade, or various sized wire loops. The large wire loops are useful for the snaring of papillomatous growths, and the smaller ones make possible the making of biopsies without bleeding. The needle and small knife blade are specially adapted to the removal of portions of the tongue, or for the circumvallation of local malignant growths of the skin or mucous membrane. The technique for building a barrier of a coagulated, impermeable wall in the healthy tissues around and beneath malignant growths is described under the terms "circumvallation." Before any application to the cancer is made directly, a wall of coagulation and necrosis is made surrounding the growth completely. The wall of coagulated tissue seals the blood and lymph channels about the lesion, as well as beneath it, thus isolating the growth from the surrounding structures and mechanically preventing the dissemination of viable cells and subsequent metastasis. After the lesion has been isolated, as outlined, tissue may be safely taken for microscopic examination since all blood and lymph drainage from the affected part has been cut off. The tumor itself is then coagulated, after which the destroyed mass is removed.

When large blood vessels are encountered in the use of the cutting current, the electrode may be pushed directly into the bleeding vessel, or the vessel may be grasped with forceps and the electrode applied to the forceps at any place between the fingers and the bleeding. The current then courses down the forceps and extensively coagulates the bleeding vessel.

Secondary hemorrhages do not often occur, but have happened in isolated instances. When work is done in close proximity to large blood vessels a preliminary ligation is advisable.

Pain and charring are proportionate to the heat of the spark. After-pain is minimal due to the blocking of the sensory nerve supply by the cutting current. Observance of the rules of asepsis and the use of isotonic solutions for injection decrease postoperative edema and the chances of infection, which sometimes is responsible for after-pain. Charring is invariably objectionable, as it forms a superficial carbon barrier over the treated area which restricts the deep action of the current and later delays healing.

As a measure of precaution it is best to remove the desiccated, coagulated,

or charred areas because they favor secondary infection, except where the destruction is very superficial. In this case, for cosmetic purposes less scarring seems to result if the thin, desiccated layer is left in place, and kept soft by the application of creams. For removal of the destroyed areas, the curet, forceps, and scissors or the cutting current is used. The purpose of dressings is to keep the wound clean, relieve after-pain and swelling, and keep the edges soft. For immediate postoperative use borated Vaseline is desirable. Treated lesions should be cleansed morning and night, or oftener, with pieces of cotton soaked in boric acid solution. The frequency is indicated by the amount of discharge. Hemor-rhage may be caused by dry, sticky dressings. Collodion dressings should never be employed, as the oozing which usually follows treatment makes them ineffective and favors secondary infection. The formation of hard crusts should be prevented. Occasionally, as a complication of healing, exuberant granulation tissue develops. It should be removed by silver nitrate.

Current and Apparatus of Surgical Diathermy

noreply@blogger.com (Anonymous) — Tue, 04 Aug 2015 11:27:00 +0000

Desiccation produces destruction by a drying up of the part or lesion. The Oudin current is of relatively low amperage and high voltage, in which the return flow of current from the patient to the machine is probably through electromagnetic waves, so that the terms monoterminal" and "uniterminal" which have been applied to it are in a sense misleading. Desiccation is accomplished by the application of this type of current through a metallic needle touching or inserted into the tissues. The high voltage, low amperage, and the number and character of the oscillations produce a very superficial destruction. Coagulation is generated by a rapidly oscillating biterminal low voltage current of high amperage of sustained and damped oscillations especially produced for the purpose. One terminal is connected to an indifferent electrode and the other is attached to the active electrode which is held against or inserted into the diseased tissue. Desiccation does not necessarily mean treatment with a uniterminal current, and coagulation with a biterminal, because heavy uniterminal currents may produce some coagulation and mild biterminal currents may cause only desiccation.

Cutting is produced by a continuous undamped oscillating current. Undamped oscillations are of equal intensity and amplitude. In some machines used for cutting, continuous undamped oscillations are obtained by the introduction of a radio tube. Other machines approximate continuous undamped oscillations by a proper balance of the induction coils, spark gap, and the capacity of the condenser.

SURGICAL DIATHERMY

noreply@blogger.com (Anonymous) — Mon, 03 Aug 2015 15:27:00 +0000

SURGICAL diathermy, or endothermy, is a method of destruction depending in major part upon the localized production of heat generated by the resistance of tissue to the passage of a high frequency electrical current, which produces a violent agitation of molecules. Medical diathermy is characterized by the stimulating action of heat so produced, whereas surgical diathermy is distinguished by the destructive action of such heat.

In accordance with the type and strength of the current, and the method of application, a variety of tissue effects are manifested. Fulguration is destruction by flashing. The monoterminal Oudin current is applied by means of a pointed electrode that is held at a distance from the skin, causing the sparks to jump through the air to the tissue. Electrodesiccation is the use of a similar current applied by means of a needle which is inserted into the skin before the current is turned on. The current is turned off before the needle is withdrawn, no sparking being permitted. Electro-coagulation is tissue coagulation by the use of the biterminal d'Arsonval current with one active needle electrode and one dispersing large metal electrode placed as near the part to be treated as possible. It is an intense, penetrative and rapid process by which the tissues become devitalized to an amorphous necrotic mass. Carbonization (charring ) is the reduction of the tissue into a residue of carbon. Searing is a general term applied to the edges of tissues treated with cutting currents, and comprehends any of the preceding degrees of destruction. Brushing is when the cutting current is used as a monopolar current without the indifferent electrode for searing the surface. This is specially useful in the treatment of moles.