Symptoms - B

Baby birth injury

Most babies are born with a minor injury such as bruis­ing, temporary deformation of the head or face, or a swelling on the scalp. These are normal side-effects of birth and may be fairly con­spicuous if the labour was unduly prolonged or if forceps or a ventouse vacuum
extractor were used.

Forceps can cause temporary paraly­sis of the face as a result of pressure on the nerves that activate the facial muscles. The ventouse often produces a large blood swelling on the top of the scalp (called a cephalhaematoma) which is eventually absorbed. Premature babies often suffer birth injuries. Even limb fractures may occur during difficult deliveries, but healing is re­markably easy and rapid in babies and there are seldom any adverse long-term conse­quences. Bottom-first (breech) deliveries tend to cause injuries to the nerves of the arms, sometimes caus­ing temporary paralysis.

Contrary to the widely held belief, cerebral palsy is not a common consequence of birth injury, nor are epilepsy and mental retardation. These are more likely to be due to other factors not related to the
birth.

Backache
See Pain in the back.

Bad breath
The medical euphemism for had breath — halitosis — is rarely used today but bad breath is still a problem for many. It is unusual because those most concerned that
they might have bad breath usually don't, and those worst affected are usually oblivious to the fact.

All smells, pleasant or otherwise, are caused by tiny chemical molecules floating in the air. Bad-smelling breath may acquire these odorous molecules from the mouth, nose or lungs — rarely from the stomach. Food debris in the mouth, especially around the teeth, will inevitably fer­ment and produce odours, unless it is removed by regular brushing. Some foodstuffs, such as garlic, are highly efficient and persistent odour-producers when fresh, let alone when decaying. For these, the only remedy is to wait for the odour to dissi­pate. Oil of garlic, taken in Capsules, does not have the same odour as cooked or raw fresh garlic and socauses much less offence to others.

Bad breath can also be caused by:
• infection of the gums (gingivitis);
• rotten teeth;
• some degenerative conditions of the nose lining;
• sinusitis;
• tonsillitis;
• throat infections;
• pharyngeal pouch (an abnormal sac which forms at the top of the oesophagus — see Swallowing difficulty).

Added to the above, nearly everyone has slight bad breath in the morning be­cause the self-cleaning me­chanisms of the mouth also 'go to sleep' during the night. Normal tooth brush­ing will deal with this.
A few ingested substances, including some of the ingre­dients of alcoholic drinks, are partially excreted in the breath, but beware any per­sistent and genuine odour in the breath which comes from deep in the lungs. This suggests a cause arising in the body. These possible causes and types of odour include:

• diabetes - an acetone-like smell;
• kidney failure with build-up of waste products in the blood (uraemia) - a urine-like smell;
• lung abscess, lung cancer, or abnormal widening of the air passages with stagnation of secretions (bronchiectasis) - a putrid odour;
• liver failure - a mousy smell.

Forget the common notion that the state of the breath somehow reflects the condi­tion of the digestion or the function of the bowels. In general, this is nonsense. Only in rare instances, such as stomach cancer with outlet blockage and food retention, will . foul-smelling belching occur.
Many people suffer from the unjustified conviction that they have bad breath. Mostly this is no more thana mild social anxiety, but sometimes it is an indication either of depression or of ima­gined illness - (hypochon­driasis). Hypochondriacs usually exaggerate normal body activity in their own minds. Occasionally, a fixed conviction of bad breath may be a feature of a more serious obsessive or paranoid disorder. It may even result from the delusion that there is internal putrefaction. Rarely, there may be a genuine hallu­cination caused by temporal lobe epilepsy. The delusion is a false belief; the hallucination is a genuinely experienced but false sensation.

Most cases of bad breath I are easily remedied. The real answer is to remove the cause rather than try to cover up the problem with peppermint or spearmint. Antiseptic mouthwashes and antibiotic 'f lozenges are unsatisfactory 4 because they interfere with the mouth's normal bacterial content and may encourage thrush. Unfortunately, most sufferers are often unaware that they have bad breath because they get used to it,
and the majority of best friends lack the necessary moral courage to break the news.
Baldness
Common baldness is heredi­tary and affects males in early adult life. The medical term is alopecia. In toxic alopecia, which sometimes affects chil­dren, the hair loss occurs some weeks after a severe feverish illness such as scarlet fever. Baldness may also be caused by disease, anti-cancer che­motherapy or radiation and treatment with thallium com­pounds, vitamin A or the re­lated group of chemical substances known as reti­noids. Scarring alopecia may follow burns, skin atrophy, ul­ceration, fungus infection of the scalp (kerion) or skin tumours.
Alopecia areata is a form of patchy baldness, of unknown cause, often affecting only one or two small circular areas of the scalp, but sometimes af­fecting all the hair of the body. The drug minoxidil, sold un­der the trade names of Ro­gaine and Regaine, was first brought out as a treatment forhigh blood pressure. It can cause regrowth of fine fuzzy hair in many cases, but you have to keep using it and this gets expensive.
Bandy legs See Bow legs.

Bat ears
This is a lay term for a minor childhood disfigurement in which the ears are larger and more protruding than usual. The problem may not, however, seem so minor for the child who may be sub­jected to abuse from his or her peers. Children's ears are always relatively large - the ear is three-quarters grown at the age of three and almost fully grown by eight - so any unusual promi­nence is more obvious than in an adult. Should there be a significant psychological dis­advantage, the condition may easily be remedied by a sim­ple plastic surgical procedure known as otoplasty.

The skeleton of the ear is a single piece of gristle (carti­lage) of complicated shape, and this is covered with skin which is firmly stuck to the front surface but more loosely attached behind. This is conve­nient, because, to conceal the scars, the surgeon performs the operation on the back of the ear. If the prominence is due to a folding outwards of the cartilage, the aim is to thin, or weaken, it along an almost vertical line so that it can ea­sily be bent backwards to­wards the head. If the ear prominence is due solely to a large angle between the ear and the head, a different opera­tion is necessary. In this case, the skin removal behind the ear is more extensive. When this is done, the bared area includes the angle between the ear and the head. When the free edges of this area are sewn together vertically, the ear is brought close against the head and becomes less prominent. In very severe cases, where both angles are large, the two procedures may have to be combined.

Bedsores
These are often worse than most people realize. Bed‑
sores, technically known as decubitus ulcers, are especially likely in debilitated or uncon­scious patients or in people who have had a stroke or are paralysed. Unless such people are frequently moved, they suffer sustained compression of the skin against the bed or wheelchair in the areas that take the weight of the body. This leads to local loss of blood supply, local loss of feeling so that there is no pain and, eventually, local tissue death (gangrene) with ulceration. Skin can remain healthy and intact only if it has a constant supply of blood, carrying oxygen, sugars and other es­sential nutrients. Local pres­sure compresses the small skin blood vessels, so this supply is cut off. Bedsores may be very large and the ulceration may progress to complete local loss of skin with exposure of the under­lying tendons or bone.

Bedsores are most likely to affect the buttocks, the heels, the elbows and the back of the head and are particularly common in people with defective sensation from neuro­logical damage. They can be avoided by regular changes of position and by skilled nur­sing to detect and deal with early signs of trouble. Dia­betics, and those with com­promised blood supply to the limbs from arterial dis­ease, such as atherosclerosis, are especially liable and re­quire special attention. Mod­em technology has devised all kinds of ingenious beds, which, by differential air in­flation of bed segments, or movement of fluid, con­stantly alter the sites taking the body weight. If econom­ics allow, these can greatly help to reduce the risk of bed­sores, but they do not elimi­nate the need for regular passive body movement and vigilance. The skin should also be inspected daily and kept clean, dry and in good condition.

Bedwetting
This is not usually a symptom of any organic disease, but it can be. Ordinary bedwetting usually occurs during sleep. The normal child develops
adequate control early in life, but one in 10 still wets regularly at the age of five. With all children, accidents will occasionally happen, especially in times of stress, but persistent bedwetting after five is considered abnor­mal. Most children with this problem are merely slow in developing full nerve control and, unless there is some un­derlying disease, bedwetting nearly always stops before puberty.

Training to pass urine reg­ularly during the day is help­ful as is a simple, battery-operated electrical bed alarm which rings as soon as urine is passed. Avoid giving drinks last thing at night and insist on a visit to the toilet before bed. Persistent bedwetting should always be medically investigated. Possible organ­ic causes include:

• urinary infection; • kidney trouble;
• diabetes;
• sickle-cell anaemia.
The problem may also result from emotional disturbance. If no organic cause is found, counselling by a child psy­chologist is often helpful.

Black stools
If your stools turn tarry black report the matter to your doctor at once. A Black faeces (mel­aena) result from chemical change in blood released by bleeding into the stomach or upper part of the intestine. This is an important indication of disease such as gastric or duodenal ulcer. Blackening may also be caused by iron tablets taken for anemia. Red
blood in the faeces usually comes from piles (hemorrhoids) but may be a sign of colitis or cancer of the rectum or colon, especially in older peo­ple. A None of these signs should be ignored. Prudent people always take a quick look at what they have pro­duced before flushing the toilet.
Blackening and loss of the extremities
This is a rather extreme symp­tom, but it can start in a small way and the earlier it is recog­nized the better.

Death of body tissues is called gangrene. This usually occurs in an arm or leg because of an inadequate blood supply. Gangrene is commonly caused by severe arterial dis­ease, such as atherosclerosis, in which the amount of blood able to get through the narrowed and easily obstructed arteries is not enough to keep the re­moter parts alive. Diabetes also increases the possibility of gangrene, mainly because of its effect on the blood vessels, but also by encouraging infec­tion. Other important causes include:

• embolism;
• thrombosis;
• severe arterial injury; • Buerger's disease, an
obstructive arterial
condition (see below).

The rye fungus ergot can cause gangrene by inducing pro­longed tight spasm that shuts off the arteries. Mechanical obstruction to the arterial blood supply can also cause gangrene, as occurs in the bo­wel with a strangulated hernia or a gangrenous appendix.

Limb gangrene usually starts in the toes or fingers. If the dead part does not become infected, it becomes dry and turns brown or black. At the junction between the dead and living tissue there is a zone of inflammation and sometimes this is where the dead part will drop off. This form of dry gang­rene is commonest in the fin­gers and toes.

Wet gangrene occurs when flesh becomes infected and pu­trefies. Infection with anaerobic organisms, such as the com­mon, gas-producing Clostri­diurn welchii, which is present in most cultivated soils, causesthe very dangerous gas gang­rene. In this type, gas makes body tissue, especially mus­cles, swell greatly or balloon, and the gangrene spreads ra­pidly to healthy tissue. There is discoloration, a smell of putre­faction, and the affected person is gravely ill from poisoning. Gas gangrene was a major cause of death in World War I when so many deep wounds were contaminated by culti­vated soil.

The condition has nothing to do with poison gas.
Buerger's disease (also known as thromboangiitis ob­literans) is a fortunately rare disorder affecting young adult males who are heavy smokers. It is a severe inflam­mation of the medium arteries and veins of the legs, and less commonly of the arms. The inflammation causes the blood vessels to block result­ing in death of the tissues (gangrene) so that the af­fected limbs, or part of them, may have to be ampu­tated. Initially, there is pain in the hands and feet with col­our changes - white, blue then red (Raynaud's phenom­enon) in cold weather. If the sufferer stops smoking, the disease will usually progress no further. The extraordinary thing is that, even after being told about this, many suf­ferers continue to smoke - some have done so until they have lost all four limbs.

Blackheads
See Skin spots in adolescence.
Blackout
This is not a medical term and is loosely applied to any condition in which there is loss of consciousness for a short time. Such conditions include:

• fainting;
• epilepsy;
• minor stroke;
• concussion;
• hysterical attacks.
The important thing is to try to identify possible causes. Consider these and also whether there are other symp­toms (if so, look them up).
Blackwater fever
See Fever and black urine.
Bleeding during pregnancy
You must always take seriously any vaginal bleeding occurring early in pregnancy. This is an unmistakable sign that there is a risk that you might lose the baby, and is called a threatened abortion. Often there is a slight pain, like a period pain, in the lower abdomen. Although the embryo or fetus remains alive and still attached to the wall of the womb, the bleeding indi­cates that there is a threat of separation. There is a 25 percent chance of spontaneous abortion, but more usually things settle down. If the bleeding stops, the pregnancy will continue to full term with delivery of a healthy, normal baby. In such cases, threatened abortion does not imply that there is anything wrong with the baby.

If the bleeding gets worse and the pain becomes more severe and cramping, there comes a point when you have to accept that abortion is inevitable. Inevitable abortion means that the cervix has opened and the contents of the womb are being expelled by contractions. Blood clots and membranes, enclosing the fetus, will have passed into the vagina. Sometimes bleeding from an inevitable abortion is very severe, and may even call for a blood transfusion. Often the expulsion is incomplete and a minor operation, under general anaesthesia, may be needed. This is called evacua­tion of retained products of concep­tion (ERPC). The womb is emptied by suction, and the lin­ing is carefully scraped with a sharp-edged spoon called a cur­ette.Adrugisthengiventomake the womb contract, and antibio­tics may also be necessary.

When bleeding occurs from the vagina after the 28th week of pregnancy it is known as antepartum haemorrhage. Most cases are caused by partial se­paration of the afterbirth (pla­centa) from the inside of the womb or because the placenta is not in the normal position. Usually the bleeding itself is painless but there may be pain in the abdomen. Antepartum haemorrhage is a threat to the baby and sometimes to the mother as well. So this requires immediate investigation in hos­pital. There the condition of the baby can be monitored and the mother can be treated, if neces­sary, for blood loss. Transfusion is sometimes required and, if the baby is at risk, delivery by caesarean section.

Bleeding gums
These usually occur when the gums are inflamed (gingivi­tis). This arises when normal tooth care has been neglected to the extent that plaque and tartar (dental calculus) accu­mulate around the necks of the teeth. Occasionally bleed­ing gums are due to severe vitamin C deficiency (scurvy). Inflamed gums are red, thick­ened, bulgy and will bleed even on minor tooth brush­ing. You can't get rid of tartar by brushing or flossing, but need to have your teeth scaled by your dentist or den­tal hygienist. Afterwards, re­solve to prevent plaque from forming by regular flossing.

Symptoms (A)

Absence of menstrual periods
This is called amenorrhoea and it has many causes. Menstrua­tion usually begins after the age of 11 and should be oc­curring by 16. If periods have not started by this age, see your doctor. When periods stop after they have been oc­curring regularly, it may be due to a number of factors, the commonest being preg­nancy. Stopping the contra­ceptive pill after using it for a time usually results in ab­sent periods for six to eight weeks but sometimes for much longer — even up to a year. Other causes include:
• severe emotional disturbance;
• anorexia nervosa;
• intense and prolonged
athletic activity;
• cysts or tumours of the
ovaries;
• the menopause.
The menopause may occur as early as 40 but more usually when a woman is between 45 and 50. Amenorrhoea is per­manent, of course, if the womb is removed surgically (hysterectomy).
Accident proneness
Some people are certainly more prone to accidents than others, but this is not a symp­tom of any particular disease. People who are emotionally upset and preoccupied and, as a result, less watchful than normal, have an increased ten­dency to mishaps. The same is true of aggressive men who often behave in such a way as to cause accidents to them­selves and others. Some peo­ple are just plain careless.
Ageing
Ageing is not a disease but it is sometimes blamed for symptoms that are caused by disease. Although the tis­sues of the body do gradually deteriorate with age, many of the disorders that affect el­derly people are due to other factors. These include:
• lack of exercise;
• the wrong kind of food; • too much exposure to sunlight;
• smoking;
• excessive drinking;
• conforming to expected patterns of behaviour (in a way that elderly people think they should behave rather than how they feel).
Memory need not decline se­verely with age and is usually well preserved in people who are in the habit of using their
minds. Elderly people are more conscious of normal lapses of memory than the young and are liable to wor­ry unnecessarily about these, thinking that they might be developing dementia or Alz­heimer's disease. The first real indication of either is when someone gets lost in formerly familiar areas. This is called disorientation. However, great philosophers and scien­tists have been known to get lost simply because their minds were on other things.
Sexual activity need not decline much with age. The reason some elderly people are less sexually active is of­ten only because of a lack of opportunity.
Age spots
See Skin spots in elderly people.
Agitation
This shows itself by constant, aimless, physical restlessness, and it is usually caused by anxiety. If there is a real cause for the anxiety, agita­tion is normal and is known
as reactive anxiety. But if there is no appropriate cause, agita­tion suggests an anxiety dis­order, often with an underlying physical cause, possibly alcohol or drug with­drawal. Depression in the el­derly often causes agitation. Some drugs, especially those used to treat psychiatric con­t.litions, cause constant move­ments of the body. This is called akathisia and it is not the same as agitation.
Air swallowing
Everyone swallows some air from time to time, but greedy or anxious people, or those who regularly feel the need to belch, may swallow a great deal of air. This causes a feeling of fullness that is relieved only by bringing the air up again. People who belch frequently at times other than after eating are usually air swallowers. There is no great harm in this but it can be boring for others. Air swallowing is sometimes a symptom of stomach ulcera­tion or indigestion from unsui­table diet and eating at irregular times.
Allergies
See Contact reactions.
Amnesia
See Loss of memory.
Anal protrusions
The commonest protrusions are internal piles (haemor­rhoids) that have slipped down. These cause a lot of irritation (see Itching anus).
A more major and dramatic condition causing anal protru­sion is prolapse of the rectum. This is a condition in which the mucous membrane lining of the anus (the lower part of the rectum) turns inside-out and passes out of the anus. In incomplete prolapse, only the lining of the anus appears, but in complete prolapse the whole thickness of the bowel pro­trudes as a thick cylindrical mass with the mucous mem­brane lining on the outside.
Incomplete prolapse is common in young children and usually requires no treat­ment. At the most, they will have their buttocks strapped together or be given a small injection to encourage internal adhesion of the lining. Com­plete prolapse occurs in adults, mostly in women, be­cause of weakness of the mus­cle ring around the anus (anal sphincter), or of the supporting floor of the pelvis, following childbirth. Anal surgery or haemorrhoids may also pre­dispose adults to the condition.
Prolapses are easily pushed back in but tend to recur. Complete prolapses usually require a surgical operation to tighten the anal sphincter or to fix the rectum internally.
Antisocial attitudes
People with persistent diffi­culty in getting on with others may have what is sometimes described as a bor­derline personality disorder. This is a rather vague name for a vaguely defined condi­tion, lying somewhere be­tween a social disorder and an actual mental illness. The unfortunate people in this ca­tegory may be:
• moody;
• unreasonable;
• prone to outbursts ofanger;
• incapable of forming or maintaining long-term relationships;
• addictive gamblers; • petty criminals;
• prone to self-damaging or even suicidal behaviour.
Changes of mood are rapid and often inappropriate. Psy­chiatrists argue about this condition; some say that it is a psychiatric condition calling for treatment, others claim that it is not. It seems likely that the condition arises from unfortunate early life experi­ence with lack of parental affection and the absence of consistent guidance on acceptable conduct.
People who consistently behave without regard to the rights or safety of others, and who refuse to conform to normally accepted standards of behaviour, are said to have an antisocial personality dis­order. They used to be called
psychopaths or sociopaths
and many of them are actual criminals. Antisocial personal­ity disorder almost certainly
originates early in life as a result of defective training or conditioning and often a ser­ious lack of parental affection and concern. Occasionally par­ents insist, however, that such people were 'born bad'. It is possible that there might be a hereditary element. Behaviour therapy or residence in thera­peutic communities is some­times successful in correcting the defect.
'Ants' crawling under skin See Itching.
Anxiety
No one is wholly free from anxiety, which is a normal and necessary part of life. Anxiety - an unpleasant sense of uneasiness or fear - becomes medically significant only when these fear reactions occur without obvious exter­nal cause and interfere with normal living. There is a fair range of disorders in which anxiety is the main feature. These affect about one person in 25 and include generalized anxiety disorder (previously known as anxiety neurosis),
panic attacks, phobias, post- traumatic stress disorders and obsessive/compulsive disorders. If you have an anxiety disorder you will cer­tainly be aware of the fact.
Anxiety, from whatever cause, is always associated with the release within the body of the hormone adrena­line, and with overaction of the part of the nervous system con­cerned with involuntary con­trol of the internal organs (the autonomic nervous system). As a result, there are few parts of the body that are not affected by anxiety. These effects are purely physical. They include:
• fast pulse;
• awareness of the heartbeat;
• 'butterflies in the stomach';
• dryness of the mouth; • trembling of the hands; • tightness in the chest; • sighing and
overbreathing
(hyperventilation);
• tense muscles.
Tightening the muscles per­sistently soon results in ach­ing and tiredness. (Prolonged muscle tension is a common cause of backache and neck pain.) It also affects the urin­ary system, causing frequent desire to empty the bladder, and even affects the skin, causing blushing or pallor and sweating.
Anxiety is additionally known to disrupt the intest­inal system causing:
• loss of appetite;
• a sense of fullness;
• difficulty in swallowing (sometimes);
• nausea;
• vomiting;
• belching;
• irritable bowel with frequent diarrhoea:
Abnormal anxiety features con­stant fears. These might be fear of death, serious illness, psy­chiatric breakdown, financial loss, social disasters or work inadequacy. With this anxiety comes an increased depen­dency on others, fatigue, insom­nia and frightening dreams. A strong and persistent convic­tion that one is suffering from a serious disease is common. This is called hypochondriasis - sufferers are hypochondriacs.
Anxiety is the hallmark of most neurotic disorders and, although various theories have been put forward to ex­plain it, no one really knows its cause. Anxious people de­serve every sympathy and need help. There is little evi­dence that psychoanalysis can cure anxiety, but there are effective remedies. Wise psy­chotherapy by a mature and experienced counsellor, beha­viour therapy, learning re­laxation techniques or carefully selected drug treat­ment can help greatly. The tricyclic antidepressant drugs are often useful in panic conditions. Fluoxetine (Prozac) is really only appro­priate if the condition is basi­cally a depression. It is best to
avoid the benzodiazepines - drugs like Valium — if possi­ble, because it is all too easy to get addicted. Beta-blockers can help anxiety, and much can be done to relieve the problem, especially if you have a sympathetic doctor.

Skin Diseases (5)

WEN (ATHEROMA, SEBACEOUS CYST).
A wen is an abnormally developed sebaceous or oil gland, resulting in a growth or sac filled with an oily or fatty material, usually appearing on the scalp, the neck, or the face, but sometimes on other parts of the body. The growth starts with a plugging of the gland outlet, or with some unusual activity of its secreting portion, resulting in a sac lined with the lining membrane of the gland and containing material similar to that secreted by the gland.

Growth may continue for months or years, but eventually ceases, in some cases while the tumor is still quite small. Large wens, however, are not unusual. They may be from one to several in number, and from the size of a pea to that of an orange. They may be whitish, pinkish, or purplish in color. They may be either soft, doughy, elastic, or firm to the touch.
Wens seldom show up before middle age, and almost never during the growing years of life.

They are rarely tender or painful, but may eventually become chronically inflamed and form pus. Very rarely, they may become malignant in elderly people. When located on the scalp where they are most often found the skin over a wen is usually bald, the hair follicles having either, been killed or having their activity stopped by the pressure of the growing tumor. Surgical removal of a wen is advisable, not only for the sake of appearance but also for safety. The operation is simple and safe, and is permanently successful if care is taken to remove the entire sac as well as its contents.

What to Do
Have the tumor surgically removed. Any other treatment is useless.

Parasitic Diseases

GROUND ITCH (CUTANEOUS AN CYLOSTOMIASIS).
BODY LICE (PEDICULOSIS CORPORIS).
A body louse is slightly larger than a head louse, and it is usually grayish in color. It lives in the seams of the underclothing most of the time, particularly in the regions of the back, the chest, and the waistline, laying its eggs there. The eggs hatch in about six days, the young being ready to reproduce in about two weeks. They invade the skin of the body only when they wish to feed.

The presence of body lice causes severe itching. If the clothing has recently been changed, the lice may be hard to find on the body. The itching, however, the bloody spots or streaks which result from scratching, and the location of the same are enough to indicate the nature of the disease. The parasites themselves can usually be found in considerable numbers in the seams of underclothing worn for a few days or longer. The infestation is spread by body contact, by wearing infested clothing, or by sleeping in an infested bed.
Body lice are known to be able to transmit several different infectious diseases, the most serious of which is typhus fever.

What to Do
1. Do not sleep in underwear worn during the daytime. Underwear and hose that will not be harmed by boiling should be boiled for ten minutes in soapsuds. Pressing the seams of clothing with a hot iron will kill many of the lice and their eggs.
2. A 5 percent DDT powder dusted on the inner surface of the underclothing, especially the seams, is effective.
3. The skin may be dusted lightly with a 5 percent DDT powder.

CRAB LICE (PEDICULOSIS PUBIS).
The crab louse, smaller than either the head louse or the body louse, translucent in appearance and nearly round in form, usually infests the hair covered part of the pubic region. It may, however, be found on other hairy regions of the body, though rarely on the scalp. The bite of this louse causes a sensation like a sharp pinprick. It produces intense itching and often a skin eruption, which may become severe enough to resemble eczema.

The infestation is spread by body contact as a rule most often at the time of sexual intercourse though sometimes by means of infested toilet seats. The infestation is often considered a disgrace because of its being associated with promiscuity. It is frequently mentioned in connection with venereal disease because in both cases illicit intercourse is a common method of spread.

What to Do
1. Shave or clip the hair from the infested regions, and burn this hair.
2. Wash the area or areas daily with soap and warm water. After washing, apply a 25 percent emulsion of benzyl benzoate or Kwell lotion each morning for three mornings. This kills the "nits" by dissolving them off the hair stumps.
3. Dust a 5 percent DDT powder on the affected skin areas each night for three nights. This will kill the active adult lice.
4. One week after completing the treatment program, if there are any signs or symptoms indicating that the infestation is not completely cleared up, repeat the treatment program.

HEAD LICE (PEDICULOSIS CAPITIS).
The presence of head lice on the scalp causes severe itching. Scratching, which is almost sure to occur, causes the oozing of fluid, watery at first, but later pussy or bloody. This fluid usually dries and forms crusts, but may remain sticky and mat the hair. It has a bad odor.

The lice live at the base of the hairs, near the scalp. They are quite dark in color and large enough to be seen easily with the unaided eye. During the short space of six days, a female louse can lay as many as fifty eggs. These are glued to the hair shafts and can easily be seen, being white in color.

They hatch in from three to eight days, and the young lice are able to reproduce in two weeks. Infestation from one person to another is usually spread by personal contact or by the wearing of infested headgear. Since body lice are known to transmit typhus fever and certain other diseases, some medical authorities believe that head lice may also transmit them.

What to Do
1. If any tiny white louse eggs can be seen attached to the base of hairs, usually in the region near the back of the neck, try to loosen and remove them by long continued soaking and washing with a gauze washcloth and a warm mixture of two parts of water and one part of vinegar. Then rinse and dry the scalp.
2. Dust 5 percent DDT powder on the scalp twice a day for three days.
3. One week later inspect the scalp and hair shafts carefully. If any evidence of persistent infestation or of reinfestation is seen, obtain a 1 percent gamma benzene hexachloride lotion (marketed as Kwell) and use as directed.

SCABIES (THE ITCH).
Scabies is a contagious skin disease caused by the itch mite, which bores beneath the surface of the skin, forming burrows. The disease is characterized by intense itching, especially at night, and by a form of eczema caused by scratching. The mite is yellowish-white and barely large enough to be seen by the unaided eye. The female, which is larger than the male, burrows into the skin to lay its eggs. The burrow may be either straight or crooked, is an eighth of an inch (3 mm.) or more in length, and looks somewhat like a very narrow and light pencil mark.

The itch mite seems to prefer the tenderest parts of the skin, such as the webs between the fingers, the inner surfaces of the forearms, thighs, and legs, the armpits, the breasts, the buttucks, and the navel. The face, scalp, palms, and soles are rarely attacked, but breast-fed infants are an exception to this rule. When one member of a family is infested, other members are very likely to become so.

Severe inflammation, with the development of papules, blisters, pustules, and crusts, may come as a result of infection from scratching. The disease may become fully developed within two weeks; the eggs hatch in about six days, and the parasites grow very rapidly. It may persist for months or even years if not recognized or properly treated. It is transmitted by body contact with others suffering from it, or by sleeping in an infested bed or wearing infested clothing.

What to Do
1. If the skin has infected scratch marks or pustules on it, this infection should be treated first before giving treatment for the itch itself. For this purpose, use Neosporin ointment rubbed into the affected skin four or five times a day.
2. Then every night for three nights apply an ointment such as mentioned in the next paragraph to the entire body from the level of the mouth and earlobes downward. Do not leave any area uncovered with the ointment, or the condition may recur. Be sure to apply it beneath the toenails and fingernails and all about the genital regions as well.
Many different ointments have been used in treating scabies. Some of the patent ointments have proved most effective. Among these, Eurax and Kwell may be mentioned.
3. Use the sane underclothes, nightclothes, and sheets throughout the course of the treatment.
4. The first night, before applying the ointment, scrub the entire body with soap and warm water. Each night, apply new ointment without washing off the old ointment. If it is impossible to leave the ointment on during the daytime, wash it off each morning, but continue the treatment for five days instead of three.
5. The next night following the nights of the treatment, take a thorough hot bath and change into clean sheets, nightclothes, and under clothes. All clothes used before and during the treatment should be disinfected by dry cleaning, washing in cleaning solvent, sending them to a laundry, or boiling.
6. During the treatment and every night thereafter for a week, spray the bed and mattress with some liquid such as Flit or a 5 percent DDT solution to kill any living parasites with which they may be infested.
7. Immediately after completing the course of ointment treatment outlined above, apply 1 percent phenol in calamine lotion four or five times a day as a soothing and drying lotion.
8. If the skin still feels irritated, take starch baths for half an hour once or twice a day, mixing one or two cupfuls of Linit starch in a tub of bath water.
9. One week after completing the treatment program, if it seems that the condition is not entirely cleared up, repeat the treatment with ointment, et cetera.
10. A 25 percent emulsion of benzyl benzoate may be used one night, or two successive nights, instead of the ointment for from three to five nights, but it is more likely to be uncomfortable or irritating.

Perspiratory Disorders
Three perspiratory disorders are common enough to merit discussion here: anhidrosis, or lack of sweat; bromidrosis, or foul-smelling sweat; and hyperhidrosis, or too profuse sweat.

Anhidrosis may be caused by sluggish action of the autonomic nerves. The condition may be present from the time of birth. It is a common symptom in ichthyosis, extensive psoriasis, and vitamin A deficiency. If the causative condition can be determined, the an hidrosis can sometimes be corrected, but this is often difficult. As a rule, the best that can be accomplished by way of relief is through care in adjusting to the weather. Cocoa butter, lanolin, or some other soothing creamy application may be used to relieve the dryness and harshness of the skin.

Bromidrosis is usually the result of fermentation, bacterial infection, or a chemical change in the perspiration after it has escaped from the sweat glands onto the skin surface. It is most obvious on parts of the body where perspiration is free but cannot readily evaporate, such as the armpits, or the feet if confined in poorly ventilated shoes. Certain foods, drugs, and germs give the perspiration characteristic odors, and some of these are unpleasant. As to this kind of bromidrosis, the only effective preventive measure is obvious. Bromidrosis affecting the feet or the armpits calls for more than usual care in cleanliness, with perhaps a change to better ventilated shoes or clothing.

Hyperhidrosis may affect the whole skin surface or only parts of it, such as the hands, feet, brow, et cetera. Nervous tension or fear may cause it. If small, circumscribed areas of the skin are affected, increased activity of one or more of the autonomic ganglia may be to blame. In such diseases as tuberculosis, malaria, undulant fever, exophthalmic goiter, and diabetes, profuse sweating is common at times.

When the underlying cause of the hyperhidrosis is corrected, the excessive sweating is usually checked, but this requires effective treatment of any systemic disease that may be present. X-ray treatments may be used in localized areas, but not on the whole skin surface. They work by crippling or destroying the secreting cells of the sweat glands, a result which would be disastrous if too widespread.

Cleanliness is the best method of controlling the unpleasant features of either bromidrosis or hyperhidrosis. A daily bath, with change of underclothing and hose, is recommended. A 5 percent solution of alum or zinc sulfate in 70 percent alcohol, dabbed on the surface of the skin areas especially concerned and allowed to dry on, may be helpful. A good powder for perspiring and malodorous feet is made as follows:

Salicylic acid............. 1|
Aluminum chloride............... 1|
Powdered alum ............... 3|
Starch ....................15|
Talcum powder ...............15|

Mix thoroughly Virus Diseases
COLD SORE (FEVER BLISTER, HERPES SIMPLEX).
A cold sore is a virus disease characterized by acutely inflamed areas of skin, upon which groups of small blisters appear. The sores are usually located on the face, especially the lips, but may also appear on the external genital organs or other parts of the body. The affected spots are not often large, but several of them may appear at the same time or in rapid succession.

They cause moderate stinging, itching, burning, and general discomfort; but they are only slightly tender. The blisters tend to dry up and form yellowish-brown crusts which drop off in a week or two, leaving no scars.

Cold sores often appear as a complication accompanying disease in which fever is a prominent symptom. Sometimes they develop in conjunction with a severe cold, influenza, pneumonia, sun exposure, or menstruation; or they may manifest themselves without any such condition being present.

They may be unusually severe, causing feverishness and weakness, with soreness and swelling of the lymph nodes near the area where they are located. Indigestion or any toxic condition or chronic infection may also bring on a crop or a series of crops of cold sores.

What to Do
1. Eat sparingly for a few days, depending chiefly on fruits and liquids.
2. Dab a 1:500 solution of aluminum acetate or spirits of camphor on the sore frequently.
3. If attacks are persistent or frequently repeated, have a physician, preferably a skin specialist, study the case to find the cause if possible. There are several methods of treatment which he may use, among them being the use of vaccines. Repeated applications of smallpox vaccine sometimes prove effective, for some reason not clearly understood.
4. If the cold sores are obviously a complication of some other existing disease, the treatment should be directed to the underlying condition, and the above directions may not all be suitable.

SHINGLES (HERPES ZOSTER)
Shingles is an acute and painful in flammatory virus disease affecting the skin overlying one or more sensory nerve trunks and the nerve trunks themselves. It is characterized by groups of small blisters on inflamed red skin areas.

The skin eruption breaks out in crops, each succeeding crop tending to locate nearer the end of the related nerve trunk than did the preceding crop. The groups of blisters, each with a red base, dry and form crusts after a week or two. When the crusts fall off, scars are sometimes left. The blisters sometimes become pustules before drying. In severe cases they may turn into small spots of gangrene.

The pain, neuralgic in character, may develop before the blisters appear; and it may persist for weeks, months, or years after all signs of the eruption are gone. This is especially true of elderly people, and outstandingly so when the forehead and face are involved.

The nerves which supply the skin of the chest are most likely to be affected. The eruption in a typical attack of shingles appears on one side of the chest, spreading from near the spinal column around almost to the breast bone.

Nerves on both sides of the body, or more than one nerve on the same side, may be affected, with correspondingly widespread eruption. Occasionally nerves that supply the skin of the neck, arms, abdomen, or thighs are attacked; but second in frequency to the chest, shingles tends to appear on one side of the forehead and face, following the course of the supraorbital branch of the trigeminal nerve.

Shingles is usually less severe in young persons than in old. Overwork, general debility, damp and chilly weather, or the absorption of certain drugs, particularly certain compounds of arsenic, or contact with a case of chicken pox, favor development of the disease. The specific cause, however, is a virus which affects both the nerve roots and the skin over them. One attack of shingles gives a high degree of immunity. Second attacks are rare.

What to Do
1. In severe cases, bed rest is important.
2. Take a simple and easily digestible diet, including an abundance of fluids.
3. An electric heating pad, or the light and heat from an ordinary strong incandescent light globe, applied to the painful area or areas will relieve some of the pain of shingles. The light globe should be held as close as possible without making the skin feel unbearably hot.
4. Applying 1 percent phenol in calamine lotion will help to dry up the blisters. Do not use ointments of any kind on the eruption.
5. It is best to consult a physician in all cases of shingles, but especially in severe cases. Pain may be so distressing that more relief will be needed than home treatments can give. A physician may give treatments that will shorten the course of the disease and help to prevent complications. Cortisone given early may prevent the persistent neuralgic pain.

WART (VERRUCA).
A wart is an overgrowth of certain structures of the. skin. There is conclusive evidence that warts are caused by a virus, and they are contagious under certain circumstances. They appear most commonly in the early years of life, rarely after the age of twenty; but they sometimes persist for years. While they must be distinguished from skin cancer, there is no proof that they never become cancerous.

Though the largest and most troublesome warts occur on the soles of the feet or the external genital organs, they are most common on the hands. Small, slender, threadlike forms occur on the neck, the eyelids, and the bearded areas. This latter form may be spread by shaving.

What to Do
1. If located where they are readily accessible, common seed warts or flat
warts may be safely treated by repeated applications of the following:

Salicylic acid ............. 4|
Acetone .............15|
Flexible collodion.............. 15 |
Mix thoroughly

CAUTION: Take care not to smear this paste on the healthy skin.
2. A 3 percent solution of salicylic acid in 40 percent alcohol may be used in the same way, with the same caution.
3. If the wart is large, not readily accessible, subject to irritation, or has persisted a long time, have it removed by a physician, preferably a skin specialist.

Skin Diseases (4)

Metabolic Diseases
SEBORRHEA.
Seborrhea is a functional disorder of the sebaceous glands, resulting in more than the normal amount of oil secretion, and characteristically giving the skin a shiny, greasy appearance, sometimes accompanied by acne. A comparatively dry form of seborrhea, characterized by accumulations of cheesy material consisting of oil mixed with dead epithelial cells and other tissue debris, may occur at any time in life.

The simple, oily form, however, is found more often during adolescent years, and especially in Negroes. It is probable that altered fat metabolism underlies the disturbed action of the glands; and, if tested, the thyroid gland is often found to be less than normally active. Acne, blackheads, oily dandruff, and seborrheic dermatitis often, but not always, accompany seborrhea. Seborrhea itself does not cause any physical discomfort and does not affect the general health. It is objectionable chiefly on account of the oily appearance of the skin.

What to Do
1. Cleanse the skin frequently with such fat solvents as soap and water, alcohol, or one of the newer detergents.
2. Take a diet low in fats, starches, and sweets.
3. Apply lotio alba to the face at bedtime.
4. In the morning, apply a powder made as follows:

Sulfur ppt. .............2|
Talcum powder.............. 28|
Mix thoroughly

5. Have a basal metabolism test made under a physician's supervision. If it shows the thyroid action is sluggish, take thyroid tablets as he may direct, but do not take them otherwise.
6. In severe or persistent cases, consult a skin specialist. He can give X-ray treatments, which are usually effective.

Miscellaneous Skin Ailments

BALDNESS, FALLING HAIR (ALOPECIA).
Loss of hair, alopecia, or baldness, may occur in patches or over the entire body. It may be caused by hormone imbalance, seborrheic dermatitis (dandruff), syphilis, or other bacterial, fungous, or virus infections. The type and time of onset of ordinary baldness, however, are largely hereditary. Baldness may also be caused by acute fevers, certain drugs or chemicals taken internally or applied to the skin surface, X-ray or other burns, disturbed action of certain glands (particularly the thyroid or pituitary), or emotional shock.

Nothing effective can be done about common baldness of a hereditary nature. Discovering the causes of other types of baldness in any individual case may be difficult. Local treatments of the scalp or hair in such cases, however, are likely to be useless until the causes are found. Some of the possible causes are diseases or abnormalities which need treatment as a protection to present or future health; therefore it is especially important that they be discovered and treated, whether or not the treatment brings about improvement in the condition of baldness.

There is some basic cause, though not always curable, which accounts for the baldness; and money spent on advertised "hair growers" is likely to be wasted unless this basic cause is found and can be corrected. In many cases finding the cause and treating it will call for a physician's attention; and even a physician may not be able to bring about much improvement.

What to Do
1. Do not expect a cure if common baldness of a hereditary nature has already developed.
2. The following program may have some value in delaying the onset or in slowing the progress of the condition:
Twice a week for oily scalps, or once a week for dry scalps, wash the scalp and hair with warm water and mild soap, rinsing and drying the hair thoroughly. Then apply a little bay rum.
. Gentle massage may help, unless the scalp is very oily.
Avoid the use of others' combs or brushes.
3. Take a diet low in fats, sweets, and starches. Supplement with vitamin A not more than 25,000 units to the tablet or capsule one tablet or capsule with breakfast each morning, and with some standard preparation of vitamin B complex.
4. If you are not sure the baldness is of the common hereditary type, have a physician make a study of the possible causes, and correct them if possible.

BEDSORE (DECUBITUS ULCER).
A bedsore is an ulceration of the skin and underlying tissue that occurs typically in debilitated patients who are confined to bed and remain in one position so long that pressure on the skin areas that bear the patient's weight deprives them of their normal blood supply. Gradually an involved area becomes dark in color, the skin breaks down, and an ulcer results. Prevention is much to be preferred, for cure is tedious and difficult.

What to Do
Prevention:
1. Turn a bed patient frequently.
2. Use padding or inflated rubber rings to diffuse the pressure of body weight, particularly over the bony prominences.
3. If the patient has edema (swollen tissues), give attention to the appropriate means of removing the edema.
4. Maintain strict cleanliness of the skin.
5. After bathing the skin, use mild stimulation, such as gentle massage with lubricating cream, or an alcohol rub, to increase blood circulation.
6. Use talcum powder and proper clothing to protect the skin from friction against the bed sheets. Treatment once a bedsore has developed:
1. Use a special air mattress designed for this purpose, in which adjacent areas are alternately inflated and deflated automatically by mechanical means.
2. Clean and dress the ulcer daily, using sterile saline solution and sterile dressings.
3. Antibiotic ointments may sometimes hasten healing.
4. Make sure that the patient is receiving a balanced, adequate diet.

CALLOUS (CALLOSITAS).
A callous is merely a patch of thickened and hardened epidermis, caused by long-continued pressure or friction. It is uncommon for a callous to be either very tender or very painful, or even to cause any marked discomfort. For a permanent cure, the cause must of course be removed.

What to Do
1. As far as possible, relieve the affected area from pressure or friction.
2. At bedtime apply a bit of the following mixture to the affected area only and cover with adhesive:

Salicylic acid ......... 3|
Lactic acid ...........3|
Flexible collodionq.s. ad ..........15|

An alternative is to apply small pads of cotton or gauze that have been dipped in 40 percent salicylic acid.
3. In the morning remove the adhesive and scrape off the softened skin tissue.
4. Continue (2) and (3) until the callous has been reduced to the thickness of normal skin.

CORN (CLAVUS).
A corn is similar to a callous in texture and has similar causes; but while a callous may be found on any one of several different parts of the skin surface, a corn is almost always on a foot, and usually on a toe, possibly on several toes. A corn is less broad than a callous, and is conical in shape with the apex of the cone directed inward. This shape accounts for the pain felt when pressure is applied to a corn. So-called "soft corns" are usually located between the toes where they are kept moist and softened by the perspiration.

What to Do
1. Wear comfortable, broad-toed, "foot-form" shoes, made of soft and pliable leather, with heels not too high.
2. Surround the corn with a felt ring or corn protector. (These can be bought in almost any drugstore.) Each day, for three to five days, apply to the corn the mixture described under Callous, "What to Do," (2). Then soak the part for fifteen minutes in warm water and try to lift or pick the corn out. If it cannot be completely removed from its bed, continue the application for a day or two longer, and then try again. (Sometimes the application of this mixture will eventually make the tissues sore, even though a corn protector is worn continually. If this happens, the treatment should be temporarily discontinued.)
3. If the above treatment does not succeed, the corn may have to be surgically removed.

FRECKLES.
Freckles are merely spots of skin in which more than the usual amount of normal pigment has developed or has been deposited. They cause no distress and do no harm, except to the appearance of the skin. In many cases they are most numerous in childhood and tend to become less numerous or to disappear completely in later years.

What to Do
1. Avoid exposure to sunlight and strong wind.
2. Small amounts of the following peeling lotion may be painted on the affected spots three times a day:

Mercuric chloride.............. |1
Camphor gum ..............2|
Salicylic acid............. 4|
Rubbing alcohol q.s. ad............ 90|

An alternative is to use 5 percent ammoniated mercury ointment, which is a good bleaching agent in this case.
3. If the skin becomes uncomfortably irritated, stop the use of the lotion and apply rose water ointment several times a day for relief.

GRAY HAIR.
Grayness of the hair is usually the natural result of aging, coming from a failure of pigment formation in the hair follicles. It may, however, be a symptom of endocrine disturbances, most often of the thyroid gland. It is known to accompany hyperthyroidism occasionally and to disappear after adequate treatment, the hair then regaining its natural color. In some cases of premature grayness, which is often familial, there are a few gray hairs in childhood, a sprinkling during adolescence, and complete grayness between the ages of twenty-five and thirty years.

While worry, overwork, grief, anxiety, and nervous strain are contributing factors in the graying of the hair, stories of overnight blanching or whitening of the hair are contrary to physiological and anatomic facts. The graying of the hair is a slow process. In some cases early graying of the hair accompanies anemia, especially pernicious anemia.

The streak of white hair on the brow which many consider attractive is sometimes congenital and permanent, but is often acquired following the disease alopecia areata. It is typical for regrowth of hair following this disease to be white at first, but it usually regains its normal color after a time.
The person who chooses to conceal grayness of the hair by using hair dyes needs to be careful. Dyes which contain silver nitrate, pyrogallic acid, or paraphenylenediamine may be dangerous to the health; and if hair dyes are to be used at all, they should first be tested for skin sensitivity.

What to Do
1. Try to determine the causes for the graying of your hair. Some of these may possibly be removed or corrected.
2. Do not waste time or money on any so-called "anti-gray-hair" vitamins. Calcium pantothenate, formerly marketed in this way, is use¬less for adult humans, and is quite unlikely to be needed for children.

HAIR, SUPERFLUOUS (HYPERTRICHOSIS, HIRSUTISM).
Hypertrichosis is too heavy a growth of, hair on normally hairy skin areas, or a visible growth on areas where such growth should not occur.

It is usually either an inherited tendency, an evidence of imbalance in thyroid, pituitary, suprarenal, or sex-gland activity, or a result of tumors of these glands. Nothing can be done about heredity, but glandular activity can in some cases be brought back to normal and tumors can sometimes be removed. As a result of such treatment, a return to normal hair growth and distribution can sometimes be accomplished.

Hypertrichosis is no greater a sign of glandular abnormality in women than in men. It is only our idea of what is pleasing in appearance that makes most women ashamed of superfluous hair and many men proud of it.

What to Do
1. Have a dermatologist make a careful study, if possible, with the aim of detecting any abnormal glandular activity that may be present.
2. Hair-removing creams (chemical depilatories) may be used safely
186
if the directions are followed carefully. They may be somewhat irritating to the skin.
3. The only completely safe way to remove unwanted hair is to have a registered electrologist remove it hair by hair by the use of an electric needle.
4. Contrary to what most people think, shaving of unwanted hair is safe and inexpensive and does not cause the hair to grow faster or coarser.

ITCHING, GENERAL (PRURITUS).
Itching in itself is not a disease, but a symptom of many different diseases or abnormal conditions. Permanent relief, obviously, can be obtained only by avoiding or correcting the causes; but the simple measures described below should give at least temporary relief in most cases where skin eruption or other signs of disease do not appear. Some diseases not primarily skin diseases have itching as a symptom, diabetes mellitus being one of them.

What to Do
1. Take a diet low in fats, sweets, starches, and spices. Drink plenty of water. Avoid alcohol, coffee, and tea.
2. Bran, starch, or vinegar should be added to the bath water in the case of any warm, cleansing bath. Experience will prove which works best. Following the bath, the skin should be dried without harsh rubbing. Baths should not be more frequent than necessary.
3. Wear underclothing that will not irritate the skin. Launder it with care, making sure that all traces of alkali and soap are rinsed out.
4. Try applying 1 percent phenol in calamine lotion three times a day to the itching areas, if not too extensive. If this proves too drying to the skin, substitute for it a lotion made as follows:

Menthol............ 1|
Phenol .......... 2|
Glycerin........... 15|
Alcohol, 35% q.s. ad.......... 240|

In the use of any lotion for the relief of itching, take care not to let any of it get into the eyes. This will not be difficult unless it is the skin of the eyelids that is itching.
5. Most important of all, try to find out the cause of the itching and avoid, treat, or correct it. This may call for the aid of a physician, especially in the case of persistent itching in the genital or anal regions.

ITCHING IN THE ANAL REGION (PRURITUS ANI).
Pruritus ani is a persistent itching, frequently with redness, maceration, and fissuring of the skin, occurring in the skin around the rectal outlet. The itching sometimes becomes so distressing as to demand vigorous treatment. It tends to be worse at night. There are many possible causes for this condition, but the commonest is an infection of the superficial skin layers by a yeastlike organism called "monilia" (candida) . The constant moisture between the buttocks lessens the normal firmness of the skin. Germs and the yeastlike organisms, being always present, have a chance to grow in this softened skin.

Pruritus ani may accompany dermatitis from soap or douches, diabetes mellitus, diarrhea, intertrigo, leukorrhea, lichen simplex, seborrheic dermatitis, and nervous tension. Whatever the cause of the itching, the most important local treatment factor in controlling it is to keep the skin clean and dry. It may be necessary to keep a pad of dry absorbent cotton between the buttocks for this purpose.

What to Do
1. Avoid the use of soap, but keep the skin about the rectal outlet clean by washing it gently but thoroughly with warm water after each bowel movement and drying after each washing. Repeat at other times, if necessary, to total at least two bathings daily. Soft, wet tissue or cotton rather than toilet paper should be used as an aid in washing.
2. The washing after the bowel movement can be made more thorough by taking a small, half-pint (225 c.c.) plain warm water enema after the movement but before the washing.
3. After the washing and drying, apply a lotion made as follows:

Phenol ..............1|
Glycerin ............15|
Rose water q.s. ad......... 120|

4. After the lotion has dried, apply a generous amount of powder, and repeat the application of powder every two hours. A good powder is made as follows:


Salicylic acid ........2|
Talcum powder ..........58|
Mix thoroughly.

5. Each night at bedtime apply a small amount of a salve made as follows:

Salicylic acid ........... 1|
Sulfur ppt. ............2|
Cold cream q.s. ad............ 60|

6. If the above treatment does not bring permanent relief within one week, have a physician make special studies to determine the underlying cause of the condition and to prescribe more appropriate remedies.

LIVER SPOT (CHLOASMA).
Chloasma manifests itself as medium-sized yellowish-brown patches or spots on the skin, more frequently seen in women than in men or children. These spots are most common in elderly people, in this respect being opposite to freckles, which in other respects they resemble. They are skin areas in which the normal skin pigment is considerably increased in quantity.

The pigmented areas are usually somewhat rounded and have well-defined margins, but they may become numerous enough and close enough together to merge and produce irregular shapes.

The appearance of these spots does not indicate any disease or ill health, and they cause no discomfort. The common name "liver spot" is not accurate there are no skin pigmentations directly caused by either the normal or the abnormal action of the liver, except the yellowing caused by jaundice. Known causes of liver spots include sun exposure, pregnancy, and the use of birth-control tablets, perfumes, skin oils, and certain medicines.

What to Do
1. If possible, have a thorough medical study made to detect any possible underlying disease or glandular disorder which may have caused the appearance of the pigmented spots on the skin. Such a disease or disorder may respond to treatment; and, if it does, the spots may clear up. That such a disease or disorder may be found, however, is not very likely.
2. In the usual case, with no real cure possible, the spots may be given the same treatment as that suggested for freckles.

STASIS DERMATITIS AND STASIS ULCER.
This disease involves a deterioration of the tissues of the skin in the legs which follows an interference with or slackening of the flow of blood through the veins of the legs. The condition frequently develops over a period of several years, often in the wake of known disease of the veins of the legs, such as varicose veins or thrombophlebitis. The skin itches, becomes reddened, and sometimes swells. Small injuries heal slowly, and the healed areas are scarred and pigmented (brown) . As the condition worsens, injured areas fail to heal and ulcers form.

What to Do
1. Avoid standing in one position for long periods of time.
2. When seated, elevate the legs to the level of the hips.
3. In stubborn cases, elevate the foot of the bed about four inches above the level of the head of the bed to facilitate the return of blood from the legs during sleep.
4. If the veins of the leg are prominent, use elastic bandage or elastic hose to minimize the stagnation of blood in the veins.
5. Engage in exercise requiring the use of the legs as the general condition may permit.
6. Use leg baths with contrasting hot and cold water (three minutes of hot followed by a few seconds of cold, then repeat, up to fifteen minutes per treatment) two or three times per day.
7. Take precautions against bumps and injuries to the skin of the legs.
8. If an ulcer develops, a physician must use surgical techniques for removing fragments of dead tissue from the base of the ulcer. Use antibiotic ointment or powder to minimize infection. Cover with a "pressure sandwich" type of dressing, gently applied, to minimize the stagnation of blood in the area.

VITILIGO (LEUKODERMA).
Vitiligo is a condition in which spots on the skin completely lose their normal pigment, or from birth have no pigment. The cause is not known, except that a hereditary tendency has been noticed in many cases. The condition, however, often accompanies psoriasis or arthritis. There is no known cure, but it is comforting to know that vitiligo causes no physical distress and does not harm the general health. The white patches on the skin are especially subject to sunburn, and tanning of the surrounding skin makes them more noticeable.

What to Do
1. Avoid exposure to sunlight or tanning of the skin in the areas where the white spots are located. Use a sun-screening lotion before going into the sunlight.
2. Avoiding tea, coffee, and carbonated drinks, and taking a diet high in vitamin B complex has been recommended on general principles, but there is no guarantee that doing so will make any difference in the appearance of the spots.
3. Consult a dermatologist, who may use a medication especially recommended for the disease.

WHITEHEAD (MILIUM).
Milia, or whiteheads, are small, comparatively firm masses of sebaceous material, similar to blackheads but never infected, and covered by the outer layer of the skin instead of extending up to or above the surface. They are usually located on the eyelids, cheeks, or temples, causing slight elevations of the skin which may be felt as tiny, hard nodules.
The development of whiteheads is hard to explain, but they are painless and harmless, though when numerous they give the affected skin areas an unattractive appearance. They are usually associated with acne in teenagers or with aging skin in mature individuals.

What to Do
After sterilizing the affected skin area with 2 percent tincture of iodine, shell out the small masses by carefully opening the tops of the small nodules with a sterilized needle and gently squeezing them out. A blackhead remover will be helpful in this.

Nail Disorders
Nearly all abnormalities of the nails result from one or another of the following: congenital defects, accidental damage to the nail bed, bacterial infections, fungous infections, or some dis¬ease that affects the entire body or the skin in the region of the nails.

Those abnormalities caused by systemic diseases usually correct themselves when these diseases are successfully treated. Until a study of the individual case is made by a physician, preferably a skin specialist, not much can be done about nail disorders of this sort.

Such a study is strongly urged, since some of the possible causative diseases such as syphilis or psoriasis should never go without treatment. This is especially true of syphilis, which may easily be present without the victim's knowledge and which may have disastrous later results.

Brittleness of the nails may be caused by sluggish thyroid action, hypochromic anemia, or long use of fingernail polish. A basal metabolism test is advised to determine whether or not the action of the thyroid is sluggish. Thyroid tablets will improve the nails if their brittleness is due to sluggish thyroid action, but they should never be taken without a physician's supervision. A blood count, with careful study of the blood cells, will either prove or rule out hypochromic anemia. If the use of fingernail polish is the cause, discontinuing its use will be curative. Anointing the nails nightly with olive oil or castor oil wi!1 help toughen them, especially if dressings are applied to keep the oil from being rubbed off during sleep. The following cream, which should also be applied every night, is better than oil in some cases:

Lanolin..................... 1|
White wax .................. 1|
White petrolatum................ 3|
Triethanolamine.............. 4|
Water q.s. ad ..............30|


NAIL DISEASES.
The four involvements of the fingernails or toenails shown here relate to other skin diseases or in the case of koilonychia to a systemic disease.

Onychomycosis is considered else where in the chapter under "Ringworm of the Nails." The patient should not attempt self-treatment of this disease because it is difficult to arrest. The physician may have to remove a considerable portion of the affected nail or nails and then prescribe medicated applications more potent than for usual manifestations of fungous disease.

The nails become involved in at least 15 percent of the cases of psoriasis The treatment of psoriasis of the nails is the same as for the disease in general.

Eczema often affects the nails when this disease involves the hands or feet. In such cases soothing lotions frequently prove helpful. The more heroic forms of treatment such as X ray or the corticosteroids are used only, of course, under the physician's supervision.
Koilonychia is usually associated with some such disease as anemia, thyroid disorder, or syphilis. It responds to the treatment of the parent disease.

INGROWING TOENAIL.
In this condition the skin and flesh at one or both corners of a nail, usually the nail of a great toe, become tender and often inflamed. Shoes that are either too short or too narrow across the toes may cause this trouble. High heels may also cause it by throwing the foot forward so that the toes are pushed into and pinched by the pointed front of the shoe. A faulty method of trimming the nails may also cause in growing toenails. The nails should be cut straight across and left long enough so there is no flesh in front of the corners. If they are cut short, especially if rounded at the corners, the skin and flesh are pressed inward in front of these corners, and as the nail grows it cuts into the skin and flesh and makes the trouble.

What to Do
1. As a preventive measure, cut the toenails as suggested above.
2. If a toenail is already ingrown, proceed as follows:
Apply a strip of adhesive plaster, drawing it around under the toe and attaching the ends so as to pull the skin and flesh away from the corners and edges of the nail.
Gently pack a small amount of oiled cotton or a bit of oiled gauze under the buried edge and corner of the nail.
If the toe is inflamed, give alternate hot and cold foot baths twenty minutes night and morning.
Cut a V-groove in the nail near the sore side and parallel to it, going as deep as possible without drawing blood.
If all these treatments fail, consult a physician, who can cure the condition by a simple operation.

PARONYCHIA.
This is a staphylococcal infection of the skin at a nail margin, commonly called a "run-around." It should be treated in the same way as a boil .If the pocket of infection is unusually deep and painful, however, it is advisable to have a physician open and drain it, rather than wait for it to open of itself.

A pus pocket in this location seems to be partly buried under the nail and thus unusually difficult to drain unless thoroughly opened. Furthermore, the tips of the fingers are so richly supplied with nerve endings that they are extremely sensitive to pain. A small paronychia may cause as much misery as a large boil located elsewhere.

Neoplastic Diseases
CANCER (CARCINOMA) OF THE SKIN.
Skin cancers are new growths of epithelial cells of the skin, tending to spread into surrounding tissues, or giving rise to the transfer of such cells from one organ or part of the body to another. Some skin cancers begin as small scaly or warty spots called keratoses, from which thick scales tend to loosen and fall off from time to time.

Others begin as waxy pimples or small, whitish, blackhead like nodules. Since they are of various types, it requires special training and experience to tell one type from another, or to tell whether or not some suspicious growth or nodule on the skin is really cancerous. Many that are cancerous are mixed or intermediate in type, so are not characteristic of either type.

Cancers which begin as scaly or warty spots tend to grow rather rapidly, becoming both broader and deeper and eventually forming large ulcers that bleed easily. These ulcers are surrounded by narrow zones of hard tissue.

As they become larger, malignant cells often spread from them through lymph channels to surrounding and underlying structures. Rarely they spread through the bloodstream to distant parts of the body, especially the lungs. In the early stages, both pain and itching are slight or entirely absent, which may cause one to ignore the condition until it has spread far enough and deep enough to be really dangerous.

Later there is more or less pain. After an extensive spread has taken place, no treatment can save life. Fortunately, the growth or spread is not so rapid that a really watchful person cannot seek for examination and treatment in time. Skin cancer is about 98 percent curable when treated properly.

Cancers that begin as waxy pimples or whitish or blackheadlike nodules are inclined to grow very slowly as a rule, forming small and comparatively shallow ulcers in the centers of broad, firm nodules. Causing very little pain, such cancers may spread over considerable areas before they begin to travel through lymph or blood channels. They are therefore less dangerous than the other type, but it is still not safe to let them go untreated.

Overexposure of the skin to sunlight is the principal cause of skin cancer, especially if the skin is dry, harsh, and of a complexion that does not easily tan. Repeated or continuous irritation of any kind also has a causative influence. Pipe smokers' cancer of the lip is a common form caused by irritation by pipe stems. Irritation by soot, paraffin, tar, or lubricating oils of petroleum origin is especially likely to cause cancer of the skin. Tampering with the waxy pimples or the nodules will hasten their malignant development.

Skin cancer occurs most frequently on the face or on the skin of other exposed parts of the head. The neck, back of the hands, and genital regions are also fairly common sites of skin cancer. Other areas of the body surface are rarely affected.

What to Do
1. If some waxy pimple or scaly or warty spot appears on the skin, does not itch, yet persists more than one to three months, consult a physician, preferably a dermatologist, without further delay. Let him make a study to determine whether or not the spot is, or may become, cancerous. Nothing short of complete destruction or removal of the seemingly simple but possibly malignant growth is safe; and the sooner, the better. The physician may use X rays, surgery, or cautery in treatment.
2. Do not try caustics, pastes, or ointments on your own responsibility or on the recommendation of others.

KELOID.
Keloids are overgrowth of scar tissue or of tissue similar to that in scars, which continue to grow and form nodules or irregular tumors. They usually result from injury such as burns, surgery, or disease, the new growth of tissue persisting and often involving adjoining healthy skin. Keloids, however, are not malignant, and they do not endanger life.

The tendency to form keloids seems to run in families and is more common in Negroes than in people with fair skin. They may cause mild pricking and burning sensations, and they are often tender and painful. They are difficult to treat successfully since they tend to recur after removal. Surgery is the simplest method of removal, but it is also the method most likely to result in recurrence. X-ray and carbon-dioxide applications are usually helpful in flattening the keloid tumor and relieving the tenderness.

What to Do
1. Do not try home treatment. It will not succeed.
2. Consult a skin specialist if possible. He may use surgery, radium,
X rays, carbon-dioxide snow, or other methods of removing or destroying the growth; but he cannot guarantee complete and permanent success.

LIPOMA (FATTY TUMOR).
A lipoma is a benign and painless tumor made up of fat cells and developing in or close beneath the skin. There is little danger that a lipoma a soft, slowly growing, freely movable tumor will ever become malignant; but it may become the seat of gangrene or of fat necrosis. Even though this may not happen, if such tumors are large or numerous they may cause awkwardness of motion, discomfort from weight or from irritation, and a very ugly appearance. Surgical removal is simple and safe.

What to Do
1. Do not try home treatments. They will prove useless.
2. If the tumor is large enough to cause discomfort, to interfere with normal body movements, to be sore on account of irritation, or is located where it is unsightly, have it removed by a surgeon.

Skin Diseases (3)

LICHEN PLANUS.

Lichen planus is an inflammatory skin disease characterized by small, fre­quently angular, violet-colored, raised spots with flat, shiny tops, occurring singly or in patches, and appearing chiefly on the flexor surfaces of the wrists, on the ankles, genitals, and lips, and on the mucous membranes of the mouth or vagina.

In some cases the eruption may appear elsewhere, or even become generalized, but the face and scalp are rarely attacked. If the rash is found on one limb or one side of the body, the opposite limb or side of the body will also show it. Sometimes the mucous membranes only are af­fected. Cases are not uniform in ap­pearance. Spots on mucous membranes are characteristically covered with a lacy network of white lines.

Though the onset is sometimes grad­ual and the course chronic, in the typi­cal acute case of the disease there is usually a general feeling of illness im­mediately before the rash begins to ap­pear. Then within one or two days the eruption is complete, the slightly raised, red or light-purplish spots usually caus­ing intense itching.

The exact cause of lichen planus re­mains unknown, but it is believed that mental or physical strain or a general run-down condition may give rise to it. It may be accompanied by a considerable degree of general debility, and it will often call for the attention of a skin specialist for recognition as well as treatment.

What to Do

1. Give the patient the benefit of good, plain food, hygienic living, and, when possible, outdoor life with freedom from worry or care.

2. Apply the following lotion fre­quently and remove it by using any convenient kind of oil.


Sol. coal tar ......................12|
Zinc oxide ........................24|
Starch ...........................24|
Glycerin ..........................36|
Water q.s. ad ..............120|

3. In severe or persistent cases, consult a skin specialist, who can give more effective treatments as needed.

LICHEN SIMPLEX CHRONICUS (LOCALIZED NEURODERMA­TITIS).

Lichen simplex is a chronic skin dis­ease characterized by a slight inflam­mation but much itching. The eruption occurs in comparatively large patches, of which there may be from one to sev­eral present on the back of the neck, the inner surfaces of the thighs, the external genital organs, the ankles, eye­lids, and ear canals.

The affected skin areas are dry, thickened, leathery, and pigmented. The condition may be a late stage of any chronic or irritative skin inflammation, or it may develop on normal skin. It often affects people of Oriental extraction and women past forty. Scratching gives temporary re­lief, but the itching is likely to return later in a more intense form. The itch­ing causes the skin to swell, and this produces more itching. The disease tends to be very persistent, but it may disappear from one area without any apparent reason, only to appear in an­other.

What to Do

1. Avoid stress or emotional up­sets.

2. Avoid scratching the affected areas.

3. Avoid the use of soap.

4. Try applying the following lo­tion four times a day:

Menthol.................... 1|
Phenol ..................2|
Glycerin .................15|
Alcohol, 35%, q.s. ad ..............240|

5. Consult a skin specialist if pos­sible. The most effective treatments or remedies cannot be given in the home or by people without medical training.

LUPUS ERYTHEMATOSUS.

Lupus erythematosus is a chronic, nontuberculous, inflammatory disease of the skin, characterized by dusky red disklike patches, which do not tend to form nodules or ulcers. The patches are covered with dry scales and crusts which tend to adhere; but if they fall off, they leave dull-white scars.

The patches have definite borders. They may include one or more small scarred areas, in which enlarged and empty hair follicles can be seen. The right and left sides are usually both affected, and about equally. The nose, cheeks, and ears are most often affected; and the most characteristic distribution is in a "butterfly" pattern. The eruption may sometimes appear on the scalp or the arms.

This disease usually begins after pu­berty and before age thirty, but it tends to persist throughout the remainder of life if not successfully treated. Its causes are not definitely known. It has been observed to develop following sunburn, the external factor being ex­posure to sunlight.

Chronic infections apparently help to cause it in many cases. An occasional acute case, where the eruption spreads rapidly over a considerable area, may be associated with a hidden or general infection and may prove fatal. As a rule the chronic disease is not accompanied by a feel­ing of illness, and rarely by any dis­comfort. It is persistent, and because long and faithful treatment is required for a cure, in no case can a cure be guaranteed.

While the chronic form is rarely a menace to life, it is the cause of some physical and much mental dis­tress, chiefly on account of its looks and scarring.

Rarely, lupus erythematosus occurs in a disseminated form, either before, during, or after the appearance of skin manifestations, with a great variety of acute symptoms due to the involvement of many different organs and sys­tems. This variety of the disease tends to prove fatal, but the attacks are likely to present such distressing symptoms that a physician is almost certain to be called. Even the best physician, how­ever, may find it a difficult diagnostic problem and an ailment hard to treat.

What to Do

1. Live a hygienic life, giving care­ful attention to a simple diet, abun­dant in vitamins, especially vitamin B complex. For potatoes, substitute white or brown rice, noodles, maca­roni, spaghetti, or barley. Avoid tea, coffee, chocolate, spices, tobacco, and alcoholic liquors, especially beer. Drink coffee substitutes or milk.

2. Avoid exposure to sunlight and all strong light, and take no X-ray or light treatments.

3. For the first few days, apply 1 percent phenol in calamine lotion three times a day. Later, use this lo­tion morning and noon and apply lo­tio alba at night. Remember, how­ever, that no ordinary remedy is likely to be curative.

4. A dermatologist may prescribe antimalarial drugs, cortisone liquids and creams, or other remedies im­possible or unsuitable for use in home treatment.

PEMPHIGUS.

Pemphigus is an acute or chronic skin disease characterized by blisters which appear on the skin and mu­cous membranes. These develop sud­denly, often on apparently normal skin, and are accompanied by constitutional disturbances of varying severity and by itching and burning sensations.

The blisters may vary in size from that of a pea to that of an egg. Their number varies from a few to scores, and they may appear singly or in crops. The walls of the blisters are thin and tense, and they enclose a clear fluid similar to blood serum. This fluid later becomes turbid or bloody.

When a blister breaks, a crust usually forms. The blis­ters may also appear on the mucous membranes of the mouth, throat, or va­gina. Sometimes they are intermingled with other types of skin eruptions, which may for a time make diagnosis difficult; but eventually the blisters be­come so prominent a part of the picture that the true nature of the disease be­comes evident.

Without proper treatment, pemphi­gus is almost always fatal. Its course may extend over several months or even years, or it may end in death within a few weeks. This is especially true of a very severe form of the dis­ease well known in the central part of South America, where it is called fogo selvagem, which makes its victims more miserable than almost any other malady they could possibly have. Fogo selvagem (savage fire, or Brazilian wildfire) differs from other forms of pemphigus in that it frequently attacks youth and even children.

The acute form of pemphigus may be caused by some infective agent, pos­sibly a virus, but the identity of this agent remains unknown, and it may not be the same in all cases. The chronic form is believed by some authorities to be of intestinal origin, but there is in­sufficient proof of this theory. Pemphi­gus is a disease of adult life, and it of­ten affects Hebrews and people of Eastern European extraction.

What to Do

1. If pemphigus is suspected, seek expert medical help at once. Life may be in danger, and home reme­dies or treatments alone have no chance of success.

2. Try to build up the general health. Take a liberal diet, rich in vitamins, especially vitamin D. Take plenty of rest. In severe cases, rest in bed on an air or water mattress may be necessary.

3. Carefully open the blisters and let out the fluid. Then dust the af­fected skin thickly with the follow­ing powder:

Zinc stearate ...............20|
Powdered starch ...............20|
Talcum powder .....................20|

Mix thoroughly

4. Soak or bathe the affected skin areas of the patient in a 1:5,000 so­lution of potassium permanganate in water for at least an hour every day.

5. Cortisone is the most effective remedy for pemphigus and may even be lifesaving. Of course its use must be carefully supervised by a physi­cian.

NOTE —In the Penfigo Adventist Hospital of Campo Grande, Mato Grosso, Brazil, pemphigus is treated with a medicine called Jamarsan. This treatment effects a cure in about 77 percent of the cases.

PITYRIASIS ROSEA.

Pityriasis rosea is an inflammatory disease. It is sometimes classed among the virus diseases because it runs a definite course of about six weeks and seems to build up an immunity, but the virus has not been definitely discov­ered.

Second attacks are rare. It is not contagious. It will subside of itself eventually, in three to six months, even if untreated. It deserves attention here chiefly for two reasons: (1) It is fairly common, and (2) those who have it may fear that it is something serious. Unrelieved fear may do more harm than the disease itself.

This disease manifests itself as nu­merous small, oval, yellowish or fawn-colored, sometimes pinkish or reddish, slightly scaly spots or patches, scat­tered over more or less of the trunk and those parts of the limbs adjacent to it. As a rule, a single comparatively large patch appears first somewhere near the waistline. This is called a herald or mother patch. The general eruption comes a week or two later. The long diameter of the patches lies in the di­rection of the natural wrinkles of the skin.

Dry, crinkly scales usually form on the patches, beginning in their centers. The larger patches may clear in their centers, forming rings, which are not, however, raised as much at the edges as are those of ringworm of the body, with which it may be easily confused. Mild itching is usually the only symptom, and the eruption disappears in a matter of weeks or months, leaving nei­ther scar nor any other sign of perma­nent damage. In fact, the symptoms are so mild and the ordinarily visible parts of the skin surface so rarely affected that the eruption may be present for several days before its presence is no­ticed.

What to Do

1. If pityriasis rosea is suspected, consult a skin specialist if possible, not because the disease is serious, but for two other reasons: (1) The erup­tion somewhat resembles that of other more serious diseases, and its true nature needs to be known. (2) A short course of cortisone, administered by the physician will usually clear up the eruption promptly.

2. If the eruption is noticeably un­comfortable, which is not often true, use starch baths, mixing one to two cupfuls of Linit starch to a tub of bath water.

POISON IVY (CONTACT DERMA­TITIS, POISON OAK).

What we are discussing here is an acute inflammation of the skin, typical cases of which are caused by contact with poison ivy or sumac in the East and poison oak in the West. There are other plants in other parts of the world that cause similar skin inflammation by contact, and there are substances other than plants that may cause a similar in­flammation.

The inflamed, swollen, and intensely itching skin areas, thickly covered with tiny blisters in the early stages, are so familiar to most people that recogni­tion of the condition is often easy. Characteristically there are linear blis­ters associated with scratch marks.

The substance causing ivy or oak poisoning is a waxy or resinous material which can be dissolved by strong soapsuds or rendered harmless by strong oxidizingagents. Extracts of poison ivy or poison oak have been prepared for use as vac­cines. These vaccines seem to have af­forded some protection to a number of people, but for others they have proved useless.

There are so many substances caus­ing inflammation of the skin by contact that it is impossible to discuss them all here. Some affect a large proportion of all persons exposed to them, while oth­ers only occasionally cause trouble. It is usually a matter of individual sensi­tivity to the particular material in ques­tion.

Fur, feathers, leather, various dyes, some of the plastics, and numer­ous drugs and chemicals are common offenders. The effect may vary from a slight and temporary reddening of the skin with mild itching to a severe in­flammation with blisters and pustules that may not clear up for months.

Skin specialists always keep in mind the possibility of contact dermatitis when a puzzling skin eruption comes to their attention. The same treatments and preventive measures are of value in most cases of this type of skin inflam­mation. Avoiding further contact with the offending substance is obviously the most important preventive mea­sure.

What to Do

1. If contact with the offending poison is recognized within a few minutes of the time it occurs, much of the poison can be removed or de­stroyed by washing the endangered skin areas with strong soapsuds, or by painting them with a 1:500 solu­tion of potassium permanganate in water. Later, avoid the use of soap. (Note: The recommended perman­ganate solution is a strong one, and it may deeply, though not perma­nently, stain the skin.)

2. During the stage of blisters and oozing, use cold (never hot) wet dressings as much of the time as practicable. For the dressings, use eight to ten layers of gauze, fluffed and crumpled, then wet with one or other of the following solutions: (1) saturated solution of aluminum ace­tate (Burow's solution) diluted 1 to 15, (2) saturated solution of mag­nesium sulfate (Epsom salts), or (3) 1 percent solution of zinc sulfate. Ap­ply the wet dressings over the entire affected skin areas, cover with waxed paper, oiled silk, or plastic to keep in the moisure, and bind on snugly with bandages. The dressings should be kept wet, and the room kept warm enough to protect the patient from chilling.

3. When the blisters have dried and the oozing ceased, apply 1 per­cent phenol in calamine lotion three times a day.

4. As a preventive measure before going into places where there is dan­ger of contact with poison ivy or poison oak, apply to the skin a van­ishing cream to which 5 percent of sodium perborate powder has been added. If you must stay in such a place very long, wash away the medicated cream and make a fresh application about every three hours.

PRICKLY HEAT (HEAT RASH).

Prickly heat is characterized by a red rash with many very tiny blisters ap­pearing on the skin surface, most often affecting babies and stout per­sons, particularly those of fair com­plexion.

The name is well descriptive of this familiar condition, for the skin feels both prickly and hot. The chief external causes of the rash are hot weather and the wearing of too much or too warm clothing. The use of alco­holic liquor encourages prickly heat to develop.

With proper treatment, the rash should clear up in a week or less; but in severe cases with a large part of the body surface involved, body tem­perature regulation may be interfered with because the sweat gland outlets may have been damaged, and there may be a fatal outcome.

What to Do

1. Avoid the use of soap in cleans­ing the affected skin areas. Use thin starch water instead.

2. Apply the following lotion four times a day:

Menthol .......................1|
Phenol .......................2|
Glycerin .....................15|
Alcohol, 35%, q.s. ad ................240|

3. Keep the affected areas cool and dry, as far as possible. When the acute stage of the rash is past, keep these areas thickly dusted with corn­starch.

4. If the causes of prickly heat cannot be avoided, dabbing on a small amount of a 10 percent solu­tion of tannic acid in alcohol twice a day may toughen the skin and help prevent further attacks; but this does not always succeed, and should never be done for more than a week at a time.

PSORIASIS.

Psoriasis is sometimes an acute, but much more often a chronic, inflamma­tory skin disease, characterized by dry, well-defined, reddish patches, fairly large and covered with an abundance of silvery scales. The patches are most commonly found on the scalp, the knees, the elbows, or the sacral region. Much of the trunk, however, may be involved, and, in severe cases, no part of the body surface is exempt from the eruption.


The silvery scales which characterize this disease keep falling off continually a fact which helps in its recognition. If the scales are rubbed off forcibly, blood may ooze from "bleeding points" on the inflamed skin beneath.

No clear evidence exists that psoria­sis is infectious, and it is not conta­gious. Sometimes mild itching accom­panies this disease, but it does not cause any feeling of general illness. It is often worse in cold seasons.

While usually chronic and persistent, psoria­sis will sometimes disappear for some time without treatment, though usually recurring later.

Many ointments, lotions, and other remedies have been recommended for the treatment of psoriasis, but as yet none of them has succeeded in bring­ing about more than temporary improvement or relief. General improve­ment in health habits offers the most hope for the psoriasis victim, but X-ray and quartz-light treatments are often helpful.

What to Do

1. Take a low carbohydrate diet. Avoid tea, coffee, tobacco, and espe­cially alcoholic beverages. Avoid ex­posure to cold.

2. Eat freely of fruits and vegeta­bles. Be sure that the diet contains an abundance of vitamins. To obtain enough of vitamins A and D with­out taking too much fat or oil, some rich source of these vitamins, such as halibut-liver oil, should be taken in moderate amounts.

3. If constipation is present, do not use mineral oil to control it.

4. In any possible acute stage, avoid all irritating applications. The following lotion can be recom­mended for use twice a day or of­tener:

Cornstarch.................. 24|
Zinc oxide................. 24|
Glycerin ....................12|
Limewater q.s. ad ................. 120|

5. After the acute stage is past, or in any ordinary subacute case which has no acute stage, remove the scales from the spots by using warm water, mild soap, and a soft brush. Avoid causing any considerable amount of bleeding. Then every evening apply 3 percent crude coal tar ointment or the following lotion:

Sol. coal tar.............. 12|
Zinc oxide .............24|
Starch ............. 24|
Glycerin ..............36|
Water q.s. ad ...............120|

In the morning, scrub or wash away any remnant of the ointment or lotion.

(Caution: If the eruption is on the scalp, apply nothing but 5 percent ammoniated mercury ointment.)

6. In the chronic stage, apply 5 percent ammoniated mercury oint­ment twice a day.

7. In either the subacute or the chronic stage, expose the affected skin areas to sunlight as much as possible, avoiding sunburn, and re­membering that prior use of tar-con­taining preparations increases the sensitivity of the skin to sunlight. After exposure to sunlight, soften the skin areas with a little olive oil.

8. X-ray or quartz-light treatments may be very beneficial, but they must be given by, or according to the or­ders of, a physician; and he may be able to prescribe other useful reme­dies.

9. Remember that psoriasis is sel­dom really cured, but can often be controlled.


SAVAGE FIRE.

SEBORRHEIC DERMATITIS (DAN­DRUFF).

Seborrheic dermatitis is a very com­mon affliction, characterized by mild itching and free oily scaling, usually found on the scalp, but sometimes af­fecting the face, neck, chest, armpits, groins, or genital regions. It is included in the list of inflammatory skin condi­tions, first, because of its outward re­semblance to certain other inflamma­tory conditions, second, because of a constant though very mild inflamma­tion of the skin, and, third, because no proof exists that any infection is pri­marily involved.

Called "dandruff" when located on the scalp, it is so common that few peo­ple are completely free from it. When it appears on the body elsewhere, the eruption is more likely to be character­ized by more or less oily crusts instead of dry scales. The skin beneath the crusts is somewhat thickened and mildly inflamed. The only unpleasant sensation is the mild itching.

A hereditary tendency, hormone im­balance, nutritional states, and emo­tional stress are possible causative factors. If any factor of infection is in­volved, it is probably secondary, and the causative organism or organisms cannot yet be definitely classified as ei­ther bacteria or fungi. Seborrheic dermatitis tends to persist for a period of years, though it may come on in successive attacks, each of which may last from weeks to years.

What to Do

1. Take a diet low in fats, sweets, starches, spices, and hot drinks.

2. Try to build up the general health by means of a program of all good health habits, including proper diet.

3. Take some standard preparation of vitamin B complex, preferably one containing an ample proportion of vitamin B.

4. If possible, have a basal metabo­lism test made. If the metabolism is much below normal, take thyroid tablets as directed by a physician. Do not take them on your own re­sponsibility.

5. For "dry" dandruff on the scalp, proceed as follows:

Shampoo three times a week for four weeks afterward once a week until a satisfactory cure is accom­plished. Once a week, at bedtime, after a shampoo, apply Pragmatar ointment, which contains salicylic acid and sulfur and is available at any drugstore.

The following morning, wash away all traces of the ointment with mild soap and warm water, massag­ing the scalp well. After the wash­ing and massage, rub into the scalp a little of the following lotion:

Phenol ............. |5
Castor oil .................1|5
Salicylic acid 2 Alcohol, 70% q.s. ad...................... 120|

6. For "oily" dandruff, proceed as in (5) above, but make the morning washing rather brief and avoid all massage.

7. Though the condition is not primarily infectious, germs may bepresent and may make the condition worse, so sterilize your comb at least once a week. Use no hairbrush, be­cause a hairbrush cannot be steri­lized.

8. If the skin of the face or the body is affected, try the following:

Alternate nights at bedtime, rub in 5 percent sulfur ointment.

On the in-between nights, apply lotio alba.

9. X-ray or quartz-light treat­ments given by a skin specialist may be beneficial to change the chemistry of the skin and to discourage the growth of any bacteria that may be present. Some of the most effective remedies also are obtainable only by a physician's prescription.

SUNBURN.

Sunburn is an inflammation of the skin characterized by burning and red­ness, due to overexposure to the rays of the sun. It needs little discussion; but sometimes one forgets that the red­ness and burning do not develop until some time after the exposure and that sunlight reflected from a glass or wa­ter surface can burn as well as direct sunlight. A person cannot tell by feel­ing alone at the time whether or not he is overexposing his skin. Every expo­sure to the sun produces some damage to the skin, especially to fair-skinned individuals.

Certain diseases that may be pres­ent, and a considerable number of drugs taken orally or applied to the skin, make the skin more sensitive to sunlight. Fair-skinned, blue-eyed peo­ple are more sensitive to it than dark-skinned. Severe sunburn over a large part of the skin surface is more danger­ous than many people realize. It is well to remember that in extreme cases it can cause crippling or even death.

In severe cases involving a large fraction of the skin surface, there is likely to be pain, swelling, blistering with later peeling, a gastrointestinal upset, and considerable fever for sev­eral days. A toxic condition develops, probably because of some decomposi­tion of the deeper skin tissues damaged by the sun's rays. If crippling devel­ops later, it is likely to be the result of stiffening and contracture of damaged tendons. A still later possible effect is permanent hardening of the skin, or even skin cancer.

What to Do

1. Apply continuous wet dressings of a saturated solution of aluminum acetate (Burow's solution) diluted with twenty times its volume of cold water. Continue until the pain and smarting are permanently relieved.

2. A similar effect, may be ob­tained by getting into a lukewarm starch bath, prepared by stirring one or two cupfuls of Linit starch into a tub of bath water.

3. If large areas of skin are in­volved, and if the burning is severe, bed rest and the attention of a physi­cian may be necessary.

4. The following sunburn oint­ment is recommended for applica­tion before exposure to the sun's rays:

Zinc oxide.................. 2|
Glycerin ..................4|
Quinine hydrochloride.................. 6|
Rose water ointment................. 30|

5. Even more protection is af­forded by a heavy coat of standard zinc oxide ointment thickly dusted with talcum powder, but to apply this over large areas of skin is not convenient.

Malformations

HEMANGIOMA (BIRTHMARK, VASCULAR NEVUS).

The ordinary birthmark of reddish or purplish color is composed of a mass or network of tiny blood vessels in the skin. In the simplest case the skin is smooth and normal in every respect ex­cept for the excessive number of the blood vessels in it. In more severe cases, the skin may be thickened or the area may show one or more "blood blis­ters." The birthmark may even be an irregular and unsightly tumor mass of one or more lobes.

The unsightliness, however, is the chief disadvantage. Such tumor masses rarely become can­cerous, but they may occasionally ul­cerate. They do not injure the general health unless they become infected, which does not often happen. As a gen­eral rule, treatment begun early in life is more likely to give satisfactory re­sults than if begun later, so whatever is to be done should not be too long de­layed. A large majority of birthmarks, especially the flat ones, will disappear by age six even if not treated.


What to Do

1. Do not try any home remedies.

2. Skin specialists can use carbon-dioxide snow, electrodesiccation, quartz light with pressure, radium, X rays, cautery, injections, or other methods of treatment that are effec­tive.

ICHTHYOSIS (FISHSKIN DISEASE, XERODERMA).

Ichthyosis is characterized by dry­ness, roughness, and thick, adherent scaliness of the skin. The outer layer or epidermis of the skin is thick and may show numerous shallow cracks, the surface tending to peel in rather large scales. In mild cases there is merely a persistent dryness and rough­ness of the skin surface.

This condition appears early in life, and seems to run in families. Sluggishness of the thyroid gland is found in many cases.

Ichthyosis affects only the outer layer of the skin and does not harm the gen­eral health. In occasional cases, how­ever, the ability to perspire is lessened, and the afflicted person tends to become more readily feverish or over­heated than he normally would. In most cases, the chief disadvantage is the more or less unsightly appearance, but, fortunately, the face, hands, and feet are rarely noticeably affected. Dur­ing warm weather, mild cases will show improvement and the skin may appear practically normal. Dry air and cold weather make the condition worse.


What to Do

1. Do not expect a real cure, be­cause the skin of the affected person is permanently short of sweat and oil glands.

2. Daily, but especially after each bath, apply some bland oil or oint­ment, such as petrolatum, cocoa but­ter, or oil of sweet almonds. Petro­latum to which 1 to 3 percent of salicylic acid has been added has some advantages over plain petrola­tum.

3. Bathing should be restricted, as it adds to the dryness already pres­ent.

4. When a bath is taken, the wa­ter should be soft, preferably water that is naturally soft.

5. Use soap sparingly. It is ad­visable, however, to use it on body folds when bathing.

6. A basal metabolism test should be made under a physician's direc­tion. If it indicates a sluggish action of the thyroid gland, thyroid tablets should be taken as the physician di­rects. Do not take them otherwise.

MOLE (NEVUS).

Moles are usually present at birth or appear early in life. In time they may grow and become considerably larger. In color most of them resemble the surrounding skin. Although they may never make trouble aside from their unsightliness, some of them may be­come cancerous, spreading cancerous cells through the bloodstream to other parts of the body, giving rise to a con­dition that may prove fatal. Moles

which are black, bluish-black, or grayish-blue and flat, especially those lo­cated where they are exposed to irrita­tion, are most likely to become malignant. Any mole which shows signs of irritation or which begins to grow rapidly, whatever its color, should be considered suspicious.

Moles showing any signs or symp­toms suggesting possible developing malignancy should be promptly re­moved. Small moles can often be ef­fectively treated by using an electrical instrument that kills and dries the tis­sue.

What to Do

1. Do not attempt self-treatment.

2. Have a physician, preferably a skin specialist, remove the growth, particularly if it is dark-colored, be­gins to change color or grow, or be­gins to feel tender or irritated. He will know what to do and how to do it.