By E. Carlos. University of Indianapolis.

Multiple excision is successful in curing the condition in over parathyroid adenomas may occur in 4% of patients minocycline 50 mg low cost. The decision to operate order 50 mg minocycline, particu- Chief-cell hyperplasia of all glands occurs in 15-20% of larly in the elderly and those with asymptomatic dis- patients; the histological diagnosis depends on the find- ease 50mg minocycline sale, requires careful assessment [16] generic minocycline 50 mg overnight delivery. Adams function, blood pressure, and bone density at regular in- Chondrocalcinosis tervals [17, 18]. This is most likely to With the increased number of patients with primary hy- be identified on radiographs of the hand (triangular liga- perparathyroidism being diagnosed with asymptomatic ment), the knees (articular cartilage and menisci), and hypercalcemia, the majority (95%) of patients will have symphysis pubis. Affected joints, however, may be asymp- tify this early subperiosteal erosion is along the radial as- tomatic, and chondrocalcinosis noted radiographically pects of the middle phalanges of the index and middle might bring the diagnosis of hyperparathyroidism to light fingers. The combination of chon- phalanges (acro-osteolysis), the outer ends of the clavi- drocalcinosis in the symphysis pubis and nephrocalci- cle, the symphysis pubis, the sacroiliac joints, the proxi- nosis on an abdominal radiograph is diagnostic of hyper- mal medial cortex of the tibia, the proximal humeral parathyroidism. However, if no subperiosteal ero- ry disease, rather than occurring secondary to chronic re- sions are identified in the phalanges, they are unlikely to nal impairment. Subperiosteal erosions in sites other than the phalanges Brown Tumors (Osteitis Fibrosa Cystica) indicate more severe and long-standing hyperparathy- roidism, such as may be found secondary to chronic re- These are cystic lesions within bone in which there has nal impairment. Histologically, the cavities are filled with fibrous tissue and osteo- Intracortical Bone Resorption clasts, with necrosis and hemorrhagic liquefaction. Radiographically, brown tumors appear as low-density, Intracortical bone resorption results from increased os- multiloculated cysts that can occur in any skeletal site teoclastic activity in haversian canals. They are now rarely this causes linear translucencies within the cortex (corti- seen. This feature is not specific for hyper- parathyroidism, and can be found in other conditions in Osteosclerosis which bone turnover is increased (e. Osteosclerosis occurs uncommonly in primary hyper- parathyroidism [21] but is a common feature of disease secondary to chronic renal impairment [22]. In prima- ry disease, with normal renal function, it results from an exaggerated osteoblastic response following bone resorption. In secondary causes of hyperparathy- roidism, it results from excessive accumulation of poorly mineralized osteoid, which appears more dense radiographically than normal bone. In the vertebral bodies, the end plates are preferentially involved, giving bands of dense bones adjacent to the end plates with a central band of lower normal bone density. These alternating bands of normal and sclerot- ic bone give a stripped pattern described as a “rugger jersey” spine (Fig. Hyperparathy- Osteoporosis roidism: there are sub- periosteal erosions With excessive bone resorption, the bones may appear along the radial cortex reduced in density in some patients. This may particu- of the middle phalanges larly occur in postmenopausal women and the elderly, and of the terminal pha- langes of the second in whom bone resorption exceeds new bone formation, and third fingers with a net reduction in bone mass. Azotemic osteodystrophy: phosphate retention due to re- chronic renal insuffi- duced glomerular function associated with secondary hyper- ciency: bone sclerosis parathyroidism causes metastatic calcification in soft tissues of vertebral endplates around the left hip joint giving the appearance of a “rugger jersey” in the thoracic spine Hypoparathyroidism Etiology firmed by bone densitometry, which is an integral com- ponent in the evaluation of hyperparathyroidism. In Hypoparathyroidism can result from reduced or absent primary hyperparathyroidism, there is a pattern of parathyroid hormone production or from end-organ (kid- skeletal involvement that preferentially affects the cor- ney, bone or both) resistance. Bone mineral the parathyroid glands failing to develop, the glands be- density measurements made in sites in which cortical ing damaged or removed, the function of the glands be- bone predominates, e. The biochemical abnormality that creases after parathyroidectomy in primary hyper- results is hypocalcemia; this can clinically cause neuro- parathyroidism [24]. Acquired hypoparathyroidism results either from sur- Metastatic Calcification gical removal of the parathyroid glands or from autoim- mune disorders. Idiopathic hypoparathyroidism hyperparathyroidism, unless there is associated reduced usually presents during childhood, is more common in glomerular function resulting in phosphate retention. It may be associated with latter results in an increase in the calcium phosphate pernicious anemia and Addison’s disease. There may be product, and as a consequence amorphous calcium phos- antibodies to a number of endocrine glands as part of a phate is precipitated in organs and soft tissues [25]. At an early age epiphyseal dysplasia) and acquired (juvenile chronic of onset, the dentition is hypoplastic. Rarely, soft-tissue ossifi- A rare but recognized complication of hypoparathy- cation can occur in a periarticular distribution, usually in- roidism is an enthesopathy with extraskeletal ossification volving the hands and feet. In the spine this skeletal hyperostosis resembles most closely that de- Pseudo-pseudohypoparathyroidism (Pphp) scribed by Forestier as “senile” hyperostosis [28, 29]. The ab- pain and stiffness in the back with limitation of move- normalities of metacarpal and metatarsal shortening, cal- ment. Extraskeletal ossification may be present around varial thickening, exostoses, soft-tissue calcification, and the pelvis, hip, and in the interosseous membranes and ossification are best identified on radiographs. Metastatic calcification, bowing of long bones and phatase, and on a normal body pH. Clinical features include tetany, cy of any of these substances, or if there is severe sys- cataracts, and nail dystrophy. This results in a qualitative abnormality of bone, hereditary syndromes, including Turner’s syndrome, with a reduction in the mineral to osteoid ratio, resulting acrodysostosis, Prader-Willi syndrome, fibrodysplasia in rickets in children and osteomalacia in adults. This usually involves unresponsiveness of both mature skeleton, the radiographic abnormalities predom- bone and kidneys. At skeletal maturity, when the process of en- condition is referred to as pseudohypohyperparathy- chondral ossification has ceased, the defective mineral- roidism, and the histologic and radiological features re- ization of osteoid is evident radiographically as Looser’s semble those of azotemic osteodystrophy. Many different Radiographic Abnormalities conditions can cause the same radiological abnormalities of rickets and osteomalacia. In the past, there was much Abnormalities may not be evident at birth but subse- confusion between these conditions, which had similar quently there develops premature epiphyseal fusion, cal- clinical and radiological features but different patterns of varial thickening, bone exostoses, and calcification in the progression and responses to therapies of the day. Metacarpal shorten- of the causes of confusion have been clarified with the in- ing is present, particularly affecting the fourth and fifth creased understanding during the twentieth century of the digits. This may result in a positive metacarpal sign in structure and function of vitamin D and its metabolites. In the immature skeleton, the effect of vitamin D defi- ciency and the consequent defective mineralization of osteoid is seen principally at the growing ends of bones Vitamin D Deficiency [35, 36, 39] (Fig. In the early stage, there is apparent widening of the growth plate, which is the translucent Deficiency of vitamin D may occur as a consequence of “unmineralised” gap between the mineralized metaph- simple nutritional lack (diet, lack of sunlight), malab- ysis and epiphysis. More severe change produces “cup- sorption states (vitamin D is fat soluble and absorbed in ping” of the metaphysis, with irregular and poor miner- the small bowel), chronic liver disease (which affects hy- alization. Some expansion in width of the metaphysis re- droxylation at the 25 position), and chronic renal disease sults in swelling around the ends of the affected long (in which the active metabolite 1,25 di-hydroxy D is not bones. There may be a thin result in vitamin D deficiency; the radiological features ghost-like rim of mineralization at the periphery of the will be similar, being those of rickets or osteomalacia. The margin of the epiphysis appears in- response to treatment, contributed to some of the early distinct as enchondral ossification at this site is also de- confusion. If rickets is suspected it is these to the terms “refractory rickets” and “vitamin D resistant anatomical sites that are most likely to show radiograph- rickets” being used for these conditions. Adams at the insertion of the diaphragm (Harrison’s sulcus), pro- Osteomalacia trusio acetabuli, and triradiate deformity of the pelvis, which can cause problems with subsequent parturition. At skeletal maturity, the epiphysis fuses to the metaph- Involvement of the bones in the thorax and respiratory ysis with obliteration of the growth plate and cessation tract (larynx and trachea) rarely result in stridor and res- of longitudinal bone growth. In very severe rickets, when little skele- continues throughout life in order to maintain the tensile tal growth is taking place (i.

Well-defined safe 50mg minocycline, itchy cheap minocycline 50mg, red scaling patches occur asymmetrically on the medial aspects of both groins (Fig buy cheap minocycline 50mg on line. Differential diagnosis includes seborrhoeic dermatitis or intertrigo (see page 116) where the rash is symmetrical and does not have a well-defined border generic minocycline 50 mg visa, and flexural psoriasis. Tinea pedis Ringworm infection of the feet may be: 1 vesicular, with itchy vesicles occurring on the sides of the feet on a background of erythema; 2 plantar, in which the sole is red and scaling; or 3 interdigital, in which the skin between the fourth and fifth toes in particular is scaling and macerated. Tinea pedis is very common and particularly so in young and middle-aged men, who often contract it from communal changing rooms. Tinea manuum This less common, chronic form of ringworm usually involves one palm only, which is usually dull red with silvery scales in the palmar creases. Tinea capitis Ringworm of the scalp occurs in children exclusively and is mainly due to M. It invades the scalp stratum corneum and the hair cuticle (ectothrix infection), causing pink, scaling patches on the scalp skin and areas of hair loss due to the breakage of hair shafts (Fig. Tinea unguium This condition is due to ringworm infection of the nail plate and the nail bed. He was fed up with having itchy, scaly feet and ugly, thickened toenails and sought treatment. Tinea incognito This is extensive ringworm with an atypical appearance due to the inappropri- ate use of topical corticosteroids (Fig. The corticosteroids suppress the protective inflammatory response of the skin to the ringworm fungus, allowing it to spread and altering its appearance. Treatment For ordinary ringworm of the hairy skin, an imidazole-containing preparation (such as miconazole, econazole and clotrimazole) used twice daily for a 3–4-week period is usually adequate. When multiple areas are affected in tinea unguium and tinea capitis and when topical treatment has failed for some reason, one of the following systemic drugs needs to be used. These agents are administered for 2–6 weeks except for griseofulvin, which, when given for tinea unguium of the toenails, may need to be given for 6–12 months. Candidiasis (moniliasis, thrush) This common infection is due to a yeast pathogen (Candida albicans) that resides in the gastrointestinal tract as a commensal. It is a not infrequent cause of vulvo- vaginitis in pregnant women, in women taking oral contraceptives and in those taking broad-spectrum antibiotics for acne. It is also responsible for some cases of stomatitis in infants and the cause of infection of the gastrointestinal tract and elsewhere in immunosuppressed people. It may contribute to the clinical picture in the intertrigo seen in the body folds of the obese and in the napkin area in infancy. Oral and vaginal moniliasis responds to preparations of nystatin and amiphenazole as well as to the imidazoles. Some, such as histoplasmosis, cryptococcosis and coccidioidomycosis, are widespread systemic infections, which only occasionally involve the skin. Actinomycosis, sporotrichosis and blastomycosis infect the skin and subcuta- neous tissues, causing chronically inflamed hyperplastic and sometimes eroded lesions. Sporotrichosis may produce a series of inflamed nodules along the line of lymphatic drainage. Deep fungus infections of this type produce a granulomatous type of inflammation, with many giant cells and histiocytes as well as polymorphs and lymphocytes. Madura foot is a deep fungus infection of the foot and is seen in various coun- tries of the African continent and India. The affected foot is swollen and infil- trated by inflammatory tissue, with many sinuses. The infection spreads throughout the foot, invades bone and is very destructive and disabling. Clinical features Red, sore areas, which may blister, appear on the exposed skin surface (see Fig. Yellowish gold crust surmounts the lesions that appear and spread within a few days. It is, however, not uncommon for the signs of the lesions to appear over an area of eczema. In tropical and subtropical areas, an impetigo-like disorder is spread by flies and biting arthopods. This disorder is more destructive than ordinary impetigo and produces deeper, oozing and crusted sores and is caused mostly by beta- haemolytic streptococci. There have been several outbreaks of acute glomerulonephritis following episodes of this infective disorder. Treatment Local treatment with an antibacterial wash to remove the crust and debris, as well as a topical antimicrobial compound such as betadine or mupirocin are needed in all cases and, unless the area is solitary and very small, a systemic antibiotic such as penicillin V (250 mg 6-hourly for 7 days) is also required. Erysipelas Erysipelas is a severe infective disorder of the skin caused by the beta-haemolytic Streptococcus. There is sudden onset of a well-marginated, painful and swollen erythematous area, usually on the face or lower limbs (Fig. The inflammation may be very intense and the area may become haemorrhagic and even blister. Treatment with antibiotics by mouth (penicillin V, 250 mg 6-hourly) should be rapidly effective. Cellulitis This is a diffuse, inflammatory disorder of the subcutis and skin caused by several different micro-organisms and is of variable severity. It is relatively common, particularly on the limbs, and often occurs on legs affected by venous ulceration or by lymphoedema. There is pain, tenderness, slight swelling and a variable degree of diffuse erythema. Broad-spectrum antibiotics are indicated, as the micro-organisms may be Gram negative in type (e. Cephradine and flucloxacillin (250 mg of each 6-hourly) are one suitable combination. They are much less common now than 30 or even 20 years ago, presumably because of improved levels of hygiene. Nonetheless, there are still families and individuals who are troubled by recurrent boils. In many instances, the patho- genic Staphylococcus colonizes the external nares, the perineum or other body sites and is difficult to dislodge. The lesions are localized, red, tender and painful swellings; carbuncles may be quite large, perhaps 3 or 4 cm in diameter, and rep- resent the infection of several follicles. Systemic antibiotics are required and, whenever possible, their use should be guided by the pattern of sensitivities found by culture. It is spread by farm animals and, because the micro-organism has a resistant spore form, can stay on infected land for years. Several types of skin tuberculosis were once commonly seen, but are now quite rare in developed countries.

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Length of prophylaxis may be one of the following: • Ten years after the last episode of rheumatic fever or to adulthood purchase 50mg minocycline fast delivery, whichever is longer order minocycline 50 mg visa. Case Scenarios Case 1 History: A 16-year-old female presented to her primary care physician with history of sore throat for the past few days discount minocycline 50mg line. The patient initially described diffuse joint pain purchase 50mg minocycline mastercard, but after careful questioning, she states that there was severe bilateral knee pain and she was unable to stand. A grade 2/6 systolic murmur at the left upper sternal border was detected by auscultation with no radiation. Management: Rheumatic fever was suspected; therefore, penicillin was prescribed to eradicate acute infection and was advised to start long-term prophylaxis for rheumatic fever. Evaluation by the pediatric cardiologist revealed similar findings through history and physical examination. Echocardiography revealed normal cardiac structure and function with no evidence of mitral or aortic valve disease. Discussion: History and physical examination in this patient do not support rheu- matic fever. Joint pain alone without evidence of inflam- mation, such as swelling, redness, tenderness, etc. The heart murmur noted in this patient is consistent with an innocent heart murmur rather than a pathological murmur. The pediatric cardiologist may have chosen not to obtain an echocardiogram; however, echocardiogram may be worthwhile in cases where clinical presentation is not clear or when the cardiologist desires to document normality to avoid mislabeling a healthy child with a chronic illness. It is important to appreciate that a normal echocardiogram does not rule out rheumatic fever without cardiac involvement. Case 2 History: A 16-year-old female was referred to the cardiology clinic by her primary care physician. Over the past few days, she has had joint pain and swelling and has felt progressively tired. She first noted joint pain, swelling, and redness in her right knee that resolved just as she began experiencing similar symptoms in the left knee. Cardiac examination revealed distant S1 and S2 with a 3/6 holosystolic murmur heard best over the apical region; in addition, a 1–2/4 diastolic murmur was heard over the apical region. Transthoracic echocardiography revealed dilated left ventricle with mildly decreased systolic function. The mitral valve leaflets were thickened with moderate to severe 27 Rheumatic Fever and Rheumatic Heart Disease 323 regurgitation. Diagnosis and Discussion: This patient manifested two major Jones criteria: pol- yarthritis and carditis, thus satisfying criteria for the diagnosis of rheumatic fever and rheumatic heart disease. The time lapse between sore throat and the onset of the symptoms is consistent with the diagnosis of rheumatic fever. The migratory nature of polyarthritis in this patient is consistent with rheumatic fever. Carditis in this patient involves a valve lesion (mitral regurgitation), myocardial affliction (poor myocardial function), and pericardial disease (pericardial effusion). This young lady should be admitted to the hospital for bed rest and monitoring and for the management of pancarditis. She should receive penicillin to eradicate the streptococcal infection and be started on anti-inflammatory therapy with aspirin to reduce arthritis and carditis. Anti-inflammatory therapy may also include steroids in this case due to the severity of carditis. Prophylaxis should continue for a minimum of 10 years or longer if there is evidence of permanent cardiac disease. Long-term therapy includes low dose (antiplatelet) aspirin and in some cases warfarin to prevent clot formation within dilated coronary arteries. The higher rate among people of Japanese ethnicity and within siblings and twins suggests both genetic and environmental factors in the pathophysiology of this disease. The epidemiologic features of the disease suggest an infectious agent(s), which is supported by temporal (winter and early spring) and spatial clustering of cases as well as sharing some clinical features with inflamma- tory diseases that have well established underlying infectious causes (e. More recent theories suggested a toxin-mediated syn- drome similar to toxic shock syndrome and the possible role of superantigens induced by certain viral or bacterial agents. Coronary artery involvement is common and leads to much of the morbidity and mortality; however, other arteries like axillary, femoral, iliac, and renal arteries can be involved as well. The acute inflammation of the coronary arteries can lead to thrombus formation and myocardial infarction. Moreover, the inflammatory changes can weaken the structure of the coronary vessels and lead to dilation and ultimately aneurysm formation. The fever is usually high and remittent and does not typically completely respond to antipyretics. It usually lasts 1–2 weeks with a mean duration of 12 days in untreated patients, but it may last up to 30 days. Desquamation around the fingers and toes (periungual desquamation) usually follows at a later stage in the second or third week of illness. Later (1–2 months after onset), deep transverse grooves in the nails (Beau’s lines) may be noted. However, the rash may be scarlatiniform, morbilliform, or urticarial; infants may have an evanescent rash involving the intertriginous areas particu- larly the perineum. Felten • Conjunctivitis: bilateral, nonpurulent conjunctivitis involving the bulbar conjunctivae and sparing the palpebral conjunctiva and the limbus area imme- diately around the cornea. Other ophthalmologic involvement like anterior uveitis, which occurs in up to 83% of cases, is usually asymptomatic. These take the form of red, cracked, and fissured lips, strawberry tongue with promi- nent fusiform papillae and diffuse oral and/or pharyngeal erythema. It typically involves the anterior cervical lymph nodes and is unilateral and with a size of ³1. In addition to the above criteria, other diagnoses with similar presentation should be excluded. This is more common in infants who are at higher risk of coronary artery complications. These are not part of the diagnostic criteria, but are helpful in making the diagnosis. Occasionally, there is transient sensorineural hearing loss and rarely facial nerve palsy. Arthralgia or arthritis involving small and large weight-bearing joints may occur in the first week of illness. Gastrointestinal manifestations including diarrhea, vomiting, and abdominal pain occur in about one-third of the patients. Hepatic involvement is usually asymptomatic, but is detected by elevated transami- nases. Hydrops of the gallbladder is less common, occurring in 15% of patients in the first 2 weeks from onset. Rare manifestations include testicular swelling, pulmonary infiltrates, and pleural effusions.

With a more violent flow of blood from the uterus order 50 mg minocycline overnight delivery, there are often cutting pains in the one side of the abdomen and in the groin; the cutting pain sometimes descends into the rectum and into the thigh; then she frequently cannot urinate 50mg minocycline sale, or sit down order minocycline 50 mg fast delivery, on account of her pains; after these pains the abdomen aches as if it were festering buy minocycline 50 mg mastercard. Not to mention the lesser ones (such as the itching of the pudenda and the vagina, with excoriation on the outside of the pudenda and the adjacent part of the thigh, especially in walking), hysterical states of all kinds follow the more severe cases of this troublesome flux, as also disturbances of the mind and spirit, melancholy, insanity, epilepsy, etc. Often it comes in the form of an attack, and then it is preceded by a digging in the one side of the abdomen, or by burning in the stomach, in the lower abdomen, in the vagina, or stitches in the vagina and in the mouth of the uterus, or a constrictive pain in the uterus and pressure toward the vagina as if everything were about to fall out, also at times most keen pains in the small of the back; the flatus is obstructed, causing pain, etc. Coryza at once, whenever she comes into the open air; then usually a stuffed coryza while in her room. Dry coryza and a stuffed nose often, or almost constantly, also sometimes with intermissions. Fluent coryza at the least taking of cold, therefore mostly in the inclement season and when it is wet. Fluent coryza, very often, or almost constantly, also in some cases uninterruptedly. He cannot take cold, even though there have been strong premonitory symptoms of it, simultaneously with other great ailments from the itch malady. Hoarseness, after the least amount of speaking; she must vomit in order to clear her voice. Hoarseness, also sometimes aphony (she cannot speak loud but must whisper), after a slight cold. Cough; frequent irritation and crawling in the throat; the cough torments him, until perspiration breaks out on his face (and on his hands). Cough, which does not abate until there is retching and vomiting, mostly in the morning or in the evening. Cough, causing a sensation of soreness in the chest, or at times stitches in the side of the chest or the abdomen. Often a slightly constrictive pain in the chest, which, when it does not quickly pass, causes the deepest dejection. Violent stitches in the side; with great heat of the body, it is almost impossible to breathe, on account of stitches in the chest with haemoptysis and headache; he is confined to his bed. Night-mare; he usually suddenly awakes at night from a frightful dream, but cannot move, nor call, nor speak, and when he endeavors to move, he suffers intolerable pains, as if he were being torn to pieces. Attacks of suffocation especially after midnight; the patient has to sit up, sometimes he has to leave his bed, stand stooping forward, leaning on his hands; he has to open the windows, or go out into the open air, etc. Dwindling of the breasts, or excessive enlargement of the same, with retroceding nipples. A hard, enlarging and indurating gland with lancinating pains in one of the mammae. In the small of the back, in the back and in the nape of the neck, drawing (tearing), tensive pains. Lancinating, cutting, painful stiffness of the nape of the neck; of the small of the back. In the limbs, drawing (tearing), tensive pains, partly in the muscles and partly in the joints (rheumatism). In the periosteum, here and there, especially in the periosteum of the long bones, pressive and pressive-drawing pains. After every attack, and when the inflammation is past, the joints of the hand are painful, as also those of the knee, the foot, those of the big toe when moved, when he stands up, etc. Such a tension or stretching of the muscles often then occasions long confinement to the bed, swoons, all grades of hysterical troubles,4 fever, haemoptysis, etc. Softening of the bones, curvature of the spine (deformity, hunchback), curvature of the long bones of the thighs and legs (morbus anglicus, rickets). Painful sensitiveness of the skin, the muscles and of the periosteum on a moderate pressure. It is usually woman (called a stroking woman) who makes with the tips of her thumbs passes over the shoulder blades toward the shoulders or along the spine, sometimes also from the pit of the stomach along below the ribs, only they usually exert too strong a. A crawling, or whirling, or an internally itching restlessness, especially in the lower limbs (in the evening in bed or early on awaking); they must be brought into another position every moment. Burning pains in various parts (frequently without any change in the usual external bodily temperature). Coldness, repeated or constant of the whole body, or of the one side of the body; so also of single parts, cold hands, cold feet which frequently will not get warm in bed. Frequent flushes of heat, especially in the face, more frequently with redness than without; sudden, violent sensation of heat during rest, or in slight motion, sometimes even from speaking, with or without perspiration breaking out. Warm air in the room or at church is exceedingly repugnant to her, makes her restless, causes her to move about (at times with a pressure in the head, over the eyes, not infrequently alleviated by epistaxis). Often burning, jerking, lancinating, but often also indescribable, are these pains which communicate a similar intolerable excessive sensitiveness to the mind. These pains thus affect chiefly the upper parts of the body, or the face (tic douloureux), or the skin of the neck, etc. Varices, varicose veins in the lower limbs (varices on the pudenda), also on the arms (even with men), often with tearing pains in them (during storms), or with itching in the varices. Chilblains (even when it is not winter) on the toes and fingers, itching, burning and lancinating pains. Boils (furuncles), returning from time to time, especially on the nates, the thighs, the upper arms and the body. Ulcers on the thighs, especially, also upon the ankles and above them and on the lower part of the calves, with itching, gnawing, tickling around the borders, and a gnawing pain as from salt on the base of the ulcer itself; the parts surrounding are of brown and bluish color, with varices near the ulcers, which, during storms and rains, often cause tearing pains, especially at night, often accompanied with erysipelas after vexation or fright, or attended with cramps in the calves. Tumefaction and suppuration of the humerus, the femur, the patella, also of the bones of the fingers and toes (spina ventosa). Eruptions, either arising from time to time and passing away again; some voluptuously itching pustules, especially on the fingers or other parts, which, after scratching, burn and have the greatest similarity to the original itch-eruption; or nettle- rash, like stings and water-blisters, mostly with burning pain; or pimples without pain in the face, the chest, the back, the arms and the thighs; or herpes in fine miliary grains, closely pressed together into round, larger or smaller spots of mostly reddish color, sometimes dry, sometimes moist, with itching, similar to the eruption of itch and with burning after rubbing them. They continually extend further to the circumference with redness, while the middle seems to become free from the eruption and covered with smooth, shining skin (herpes circinatus). The moist herpes on the legs are called salt- rheum; or crusts raised above the surrounding skin, round in form, with deep-red painless borders, with frequent violent stitches on the parts of the skin not yet affected; or small, round spots on the skin, covered with bran-like, dry scales, which often peel off and are again renewed without sensation; or red spots of the skin, which feel dry, with burning pain; somewhat raised above the rest of the skin. Liver spots, large brownish spots which often cover whole limbs, the arms, the neck, the chest, etc. Yellowness of the skin, yellow spots of a like nature around the eyes, the mouth, on the neck, etc. Dryness of the (scarf ) skin either on the whole body with inability to perspire through motion and heat, or only in some parts. Many remain only a short time and pass away to give place to another symptom of psora. Perspiration comes too easily from slight motion; even while sitting, he is attacked with perspiration all over, or merely on some parts; e. Daily morning sweats, often causing the patient to drip, this for many years, often with sour or pungent-sour smell.

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