sometimes called forth by gestation and by the various disorders of
menstruation, and in other instances, in either sex, by organic
diseases of the genito-urinary tract. Diseases of the kidney and of the
liver, especially jaundice, are frequently accompanied by pruritus. The
nervous system is not infrequently at fault. Gastro-intestinal
derangement, the ingestion of certain medicines (as opium), intestinal
parasites, and hemorrhoids, are all well-known causes. The disease is
strictly functional in nature, and is due to reflex nervous action.
The diagnosis rests with the subjective symptoms as given by the
sufferer. There are no primary lesions; the secondary lesions, however,
are sometimes so extensive as to suggest other diseases, especially
prurigo and eczema, but there should be no difficulty in
differentiating these diseases if their clinical features are kept in
mind. Prurigo--a disease, practically speaking, unknown in this
country--it will be remembered, is characterized by well-defined
papules, and moreover shows predilection for the lower extremities. The
subjective symptoms of pruritus often simulate those due to the
presence of lice. In all cases these parasites, whether of the head,
body, or pubes, should be carefully excluded in the diagnosis, for it
sometimes happens that pediculosis is looked upon and treated as
pruritus, the true nature of the affection being unsuspected.
Pediculosis, it must not be forgotten, is occasionally met with in the
upper walks of life, where it is at times extremely difficult to
account for the source of contagion. Inspection of the skin and of the
underclothing should be made in all suspected cases.
The treatment naturally varies with the determined or probable cause.
The local origin of the affection should, in the first place, be
inquired into. The internal remedies are to be selected with the view
of meeting the requirements of the case. The various functions of the
body should receive due attention, the bowels, in all cases tending to
constipation, being kept open by laxatives, preferably saline
preparations. The diet should be directed, all stimulating or injurious
food and drink being interdicted. Quinine, arsenic, belladonna,
strychnine, carbolic acid, tincture of gelsemium, and pilocarpine are
remedies which may be tried in obstinate cases. In all cases the cause
should be diligently sought for, for until this is discovered and
removed there can be but little hope of complete recovery. External
remedies, though extremely grateful to the patient, and of course very
useful, as a rule are only palliative. There are cases, however, in
which they prove curative. Water in the form of very hot or {713} cold
douches, and alkaline and sulphur lotions and baths, are sometimes
serviceable, employed either alone or in connection with other
remedies. In the local varieties of the disease antipruritic and
stimulating lotions are especially serviceable. One of the most
valuable remedies is carbolic acid, in the strength of from fifteen to
forty grains to the ounce, to which may be added small quantities of
glycerin and alcohol. A strong lotion consists of carbolic acid, one
drachm and a half; potassa, twenty grains; water, eight ounces. The
tarry preparations considered in eczema, especially liquor carbonis
detergens and liquor picis alkalinus, are useful, as are likewise
thymol, a few grains to the ounce of glycerin and alcohol, and oil of
peppermint. The latter remedy, pure or mixed with glycerin, may be
applied with a brush. Sometimes a simple chloral lotion is efficacious.
In like manner lotions of acetate of lead, ten to thirty grains to the
ounce; dilute hydrocyanic acid, a few drachms to the pint; hyposulphite
of sodium; chloroform; chloroform and alcohol; diluted acetic acid;
diluted ammonia-water; diluted nitric-acid; and corrosive
sublimate,--may be tried. R. W. Taylor recommends the following:
Rx. Fol. belladonnæ,
Fol. hyoscyami, aa. drachm ij;
Fol. aconiti, drachm ss;
Acidi acetici, fluidounce j. M.
This may be diluted with water a drachm to the ounce, or may be used
with equal parts of glycerin, painted on the skin or in the form of an
ointment, a drachm or two to the ounce. Tobacco, used as an infusion,
two or three drachms to the pint, is often efficacious, especially in
pruritus vulvæ. The fluid extract of conium, applied with a brush, and
iodoform in ethereal solution, applied as a spray, may likewise be
resorted to where the disease involves this region. Camphor and borax
may be mentioned as being sometimes of service, as in the following
formula:
Rx. Sodii boratis, drachm ij;
Glycerinæ, fluidrachm iv;
Spts. camphoræ, fluidounce ss;
Aquæ rosæ, ounce v. M.
Another lotion, containing borax and morphia, may be given:
Rx. Sodii boratis, drachm iv;
Morphiæ sulph., gr. xv;
Glycerinæ, fluidounce ss;
Aquæ, q. s. ad fluidounce viij. M.
In some cases ointments prove more acceptable than lotions. Tar,
carbolic acid, thymol, and the mercurials are all valuable used in this
form, varying in strength with the locality and amount of surface to be
treated. The smaller the area, as a rule, the stronger the remedy.
Chloroform, chloral, and camphor also may be used in the form of
ointments. About one drachm each of chloral and camphor to the ounce
constitutes a good antipruritic remedy; the active ingredients are to
be rubbed together and then added to the ointment.
In pruritus of the anus one of the most valuable and neatest remedies
is carbolic acid with glycerin or olive oil, in the strength of from
fifteen to forty grains to the ounce. Very hot water applied with a
soft linen compress or sponge will usually afford temporary ease, and
may be employed from time to time in connection with other more active
{714} remedies. In some cases we have had rapid and good results from
an ointment of balsam of Peru, a drachm and a half to the ounce. Equal
parts of belladonna ointment and mercurial ointment, and a solution of
corrosive sublimate, about a quarter of a grain to the ounce, may also
be mentioned; and where there are fissures occasional pencilling with a
solution of nitrate of silver will afford relief, the latter
application, made with a piece of sponge fastened on a stick, being
also useful in pruritus vulvæ.
A long list of formulæ have been vaunted for the relief of pruritus of
the female genitalia, a few of which may be given. In addition to the
remedies already mentioned the following formulæ will sometimes prove
valuable. The fluid preparations may be used as vaginal injections or
may be applied by means of a brush, tampon or cloth, according to their
nature. Hyposulphite of sodium, a drachm to the ounce; sulphurous acid,
sufficiently diluted; alum, sulphate of zinc, tannic acid, acetic acid,
borax, and boric acid, may all be made use of in the form of
injections. In this variety of the disease, as well as in pruritus of
the anus, a 6 per cent. solution of cocaine, applied with a brush, or
the oleate used as an ointment in the same strength, may be prescribed.
The prognosis should in all cases be guarded, the ability to relieve
the disorder depending mainly upon the nature of the cause. The
majority of cases, due to no evident cause, prove obstinate. But in all
instances the patient should be encouraged to persevere in the
treatment, and the hope of an ultimate cure extended to him.
* * * * *
PRURITUS HIEMALIS.--This is a peculiar form of pruritus, characterized
by a somewhat harsh and dry state of the skin, accompanied with
smarting and burning, unattended primarily by structural change,
dependent upon atmospheric influences, and occurring chiefly in winter.
It makes its appearance usually in the late autumn, becoming worse with
the colder weather, and disappearing in the spring. The disease
manifests predilection for certain regions, notably the extremities,
especially the inner surfaces of the thighs, the popliteal spaces, and
the calves; but in a less degree it may also invade other localities.
In its milder form it is a common affection in cold climates. At times
the itching is severe, leading to scratching and excoriations, while in
other cases it merely amounts to an annoyance. It possesses the
peculiarity of manifesting itself chiefly at night, coming on during
the evening or shortly after bed is entered. The symptoms usually vary
with the weather, being better and worse as the temperature is mild or
cold. The affection in most instances repeats itself each year, and may
thus continue indefinitely or it may partly or wholly disappear. As
stated, the disorder is due to atmospheric influences, but is
aggravated by irritating underwear and scratching. It occurs in both
sexes, at all ages after puberty, and in those who bathe freely as well
as in those who make sparing use of water. It does not seem to be
influenced by the state of the general health, nor does internal
treatment affect it favorably. Among the various external remedies,
preparations containing glycerin, the petroleum ointment, carbolic acid
and tar in the form of ointments and lotions, as in eczema, and
alkaline lotions and baths,--may be mentioned as being most useful. The
simple vapor bath is also in some cases beneficial.
{715} CLASS VIII.--PARASITES.
Tinea Favosa.
Tinea Favosa, or favus, is a contagious, vegetable parasitic disease,
due to the achorion Schönleinii, characterized by discrete or confluent
pea-sized, circular, pale-yellow, friable, cup-shaped crusts, usually
perforated by hairs. It is seen commonly upon the scalp, and at times
on other hairy regions, involving the hairs and hair-follicles (tinea
favosa pilaris), or the non-hairy portions of the integument may be
attacked (tinea favosa epidermidis), and cases are occasionally met
with in which the nails are the seat of the disease (tinea favosa
unguium). The scalp is the usual seat. It begins as a more or less
circumscribed, superficial inflammation, with slight scaling, followed
by the appearance of one or more yellowish points underneath the
superficial epidermis and surrounding hair-shafts. They increase in
size, and reach the dimensions of small peas, constituting the
so-called favus cups, favi, or favus scutula. They are sulphur-colored,
friable, circumscribed, round or oval, with depressed centres, and each
pierced with a hair. In their early stage they are bound down to the
skin by a layer of epidermis, which surrounds and envelops their
periphery. The crusts are elevated from a half to several lines above
the surrounding skin, distinctly umbilicated, and if detached an
excavated, reddened, atrophied or suppurating surface is disclosed.
The crusts are composed of closely-packed, concentrically-arranged
layers, and although they are at first discrete, sooner or later, from
increase in number and size, they coalesce, and then their peculiar
features are scarcely, if at all, distinguishable, irregular masses of
thick, yellowish-white, mortar-like crusts taking their place. If
removed, the surface is usually found atrophied, dry or inflamed and
moist, and hairless. The hair-shafts are soon involved, the nutrition
of these structures impaired, and in consequence the hairs become dry,
lustreless, brittle, break off or fall out, and eventually the papillæ
are entirely destroyed. Pustules and suppuration are in some instances
noted about the borders and beneath the crusts. The pressure of the
growing fungus gives rise to atrophy of the skin, which may be seen as
depressed, firm, shining, cicatricial-looking areas. The general
surface may also be attacked, either together with the scalp or alone.
On non-hairy regions, however, the disease is rarely persistent. If the
nails are invaded, they become thickened, yellowish, opaque, and
brittle. Favus is usually attended with itching, especially when
occurring upon the scalp. The odor of the crusts is peculiar, and may
be likened to that of mice or stale straw. Upon the scalp the disease
is always chronic, if untreated lasting indefinitely.
It is more common in children than in adults, and is seen almost
exclusively among the poor. It is comparatively rare in this country.
It is contagious. The disease is also encountered in the lower animals,
from which doubtless it is not infrequently contracted. The affection
is due solely to the growth in the upper layers of the skin of the
achorion Schönleinii. This vegetable parasite grows luxuriantly, and
constitutes almost entirely the whole mass of the crusts. It can be
readily seen by subjecting a small portion of the crust, moistened with
diluted liquor potassæ, {716} to microscopical examination, a power of
three to five hundred diameters sufficing. It consists of both spores
and mycelium. The mycelium is composed of pale-grayish or pale-greenish
narrow, flat threads or tubes branching and anastomosing in all
directions. The spores are small, variable as to size, round, oval,
flask- or dumb-bell-shaped, and are to be seen in abundance in the
meshes of the mycelium. Intermediate forms between the spores and
mycelium are always present. The hair-follicles and hair-shafts are
found to be more or less invaded. If the nails are attacked, the fungus
can be easily detected in a section or in scrapings, the mycelium
predominating.
As a rule, favus is easily recognized. The small, pale, yellow, friable
cup- or saucer-shaped crusts and the peculiar odor are sufficiently
characteristic. In some chronic cases, where the crusts are merged into
a mass, perhaps mixed with dirt and pus, it resembles pustular eczema;
but the condition of the hair, the atrophic patches, and the odor will
serve as distinguishing points. Tinea tonsurans can scarcely be
confounded with this disease, as it is wanting in the peculiar
crust-formation and the tendency to scarring. In doubtful cases the
microscope is to be employed.
Favus of the scalp is not only a chronic disease, but is also
rebellious to treatment. In neglected cases permanent baldness,
atrophy, and scarring sooner or later occur. On the non-hairy portions
of the body it is rarely obstinate; involving the nails, it is slow to
yield. The first step in the treatment of a case of favus of the scalp,
the common seat of the disease, is a removal of the crusts. This is
readily accomplished by saturating the parts with simple or carbolized
oil, and subsequently washing with soap and hot water. The hair on and
around the patches is to be clipped as a preliminary measure; keeping
the hair of the entire scalp cut short facilitates treatment, but is
not essential. The hairs in the diseased areas are then to be carefully
extracted by means of the broad-bladed forceps. This part of the
treatment, epilation or extraction of the hairs, is indispensable if
the eventual result is to be successful and permanent. Before
epilating, the surface to be operated upon is to be anointed with a
simple oil. After the operation a parasiticide is to be thoroughly
applied, so that it may penetrate the hair-follicles. The whole surface
involved is thus treated. Another plan of epilation is that in which
the hair is drawn with some force between the thumb and an ordinary
tongue-spatula, those that are diseased and loose coming out, while
those that are sound remain. In this method the hair is not clipped.
The plan is more simple and less tedious than forceps epilation, but is
not so satisfactory, as the hairs are more likely to break off, and,
moreover, many that are diseased are left unextracted.
Whatever parasiticide is used should be well and thoroughly applied to
the affected areas. Those that have the greatest penetrating power are
to be selected. Corrosive sublimate, three or four grains to the ounce
of alcohol or ether; a 25 per cent. oleate-of-mercury ointment;
carbolic acid and glycerin, one part of the former to three or more of
the latter,--may be mentioned as among the most useful. Tar, sulphur,
and ammoniated mercury and citrine ointments, of officinal strength or
weakened; sulphurous acid; a solution of hyposulphite of sodium, a
drachm to the ounce,--are also efficient parasiticides. Chrysarobin, in
ointment or in chloroform, a drachm to the ounce, has been well spoken
of, but must be used {717} cautiously. After several weeks' treatment
applications may be suspended for a week or more, so that the condition
may again be determined. In ordinary well-developed cases from three to
six months' active treatment is required for a removal of the disease.
Favus of the non-hairy portions of the surface requires, after a
removal of the crusts, the application of a mild parasiticide, the
disease, as a rule, readily yielding. In favus of the nail as much as
possible of the affected portion is to be pared or cut away, and a
simple parasiticide applied once or twice daily. In those who are
debilitated and ill-nourished favus may possibly be rendered less
obstinate by suitable internal treatment, with proper nourishment and
pure air.
Tinea Trichophytina.
Tinea trichophytina, or ringworm, is a contagious vegetable parasitic
disease, due to the trichophyton, its clinical characters varying
according to the part invaded. It is a common disease, more frequent in
children than in adults, and is met with to a varying extent in all
countries. It is contagious, but individuals vary as regards
susceptibility. The fungus (the trichophyton) consists of spores and
mycelium. The latter consists of long, slender, delicate,
sharply-contoured, pale-grayish, straight or crooked, branching,
ribbon-like threads, containing spores and granules. They are
remarkable for their length. The spores are round, small, highly
refractive, grayish or pale-greenish bodies, and are either single or
arranged in rows, which may be isolated or joined to mycelium. The
appearances of the disease, and to a certain extent its treatment, are
so different when affecting the general surface, the scalp or the
bearded region that separate descriptions are called for. When seated
upon the general surface the disease is commonly known as tinea
circinata (tinea trichophytina corporis); on the scalp, tinea tonsurans
(tinea trichophytina capitis); on the bearded region, tinea sycosis
(tinea trichophytina barbæ).
* * * * *
TINEA CIRCINATA, or ringworm of the body, is characterized by one or
more circular or irregularly-shaped, variously-sized, inflammatory,
slightly vesicular or squamous patches. It usually begins by the
formation of one or more roundish, slightly-elevated, sharply-limited,
somewhat scaly, hyperæmic spots, which in some cases show minute
papules or vesicles, especially about the periphery. As the process
advances, usually in the course of a few days, the inflammation is more
marked and the scaliness increased. The patches assume, as a rule, a
distinctly annular character, and as they grow by extending
peripherally, their centres clear up, so that when fully developed they
are usually about an inch in diameter, and consist of a more or less
normal central area, then an intermediate pale-reddish scaly portion,
and the red, elevated, and scaly or papulo-vesicular or vesicular
border defined against the healthy skin. In rare instances
vesico-pustules may form. There may be one, several, or many patches
present, but as a rule they are not numerous. After attaining a certain
size they may remain stationary for a short time or may begin to
disappear spontaneously. Where two or more are in close proximity, they
may increase in size, gradually coalesce, and form gyrate or {718}
irregularly-shaped lesions. At times, instead of the typical annular
patches, the disease may appear in the form of disseminated, small,
reddish, slightly scaly, ill-defined spots, which may appear and
disappear rapidly, the patient rarely being free of lesions. Although
any portion of the general surface may be invaded, there are certain
regions of predilection, as the face, neck, and backs of the hands. It
is commoner in children than in adults.
Involving surfaces that are in close contact, as the axillæ, between
the buttocks, and the inner surfaces of the thighs, it tends to spread
extensively, is more inflammatory, and often proves rebellious to
treatment. Invading these parts, the condition, under the impression
that it was an eczema, was described by Hebra as eczema marginatum. It
is most common, however, about the thighs, and seated here is termed
tinea circinata cruris. It begins usually in the same manner as
ringworm on other regions, but on account of the heat, moisture, and
friction of the parts its characters become changed. The patch becomes
inflamed, slightly elevated, coalescing with similar patches, until the
greater part of the inner surface of the thighs and buttocks may be
involved. The groins and mons veneris may also be invaded. When fully
developed it is characterized by extensive, irregularly-shaped,
inflammatory patches, with at times a slightly moist surface, and is
usually well defined against the surrounding healthy skin by a more or
less raised border, which may show papules or vesicles. Sometimes
beyond the general area involved may be seen more or less typical
ringworm patches. As met with in this country, it is usually mild in
character. In Southern Europe it is encountered more frequently, is of
a severer type, and is often intractable. It is met with usually in
adults. Relapses are not uncommon.
The course of ringworm of the general surface may be acute or chronic.
It may disappear in a few weeks, or, on the other hand, may continue
indefinitely. As commonly met with in this country, it is, as a rule,
readily responsive to treatment. It is frequently seen in association
with ringworm of the scalp. Itching in variable degree is usually
present. Invading the nails, the affection is designated tinea
trichophytina unguium. These structures become dry, opaque, dirty white
or yellowish, thickened, of irregular shape, bent, soft, or brittle and
laminated, the changes taking place especially about the free border.
The nails of the toes are seldom affected. As a rule, not more than two
or three of the finger-nails are attacked. It is commonly associated
with chronic ringworm on other parts of the body.
The fungus (trichophyton) in tinea circinata has its seat in the
epidermis, especially in the corneous layer. The first effect of its
invasion is hyperæmia, subsequently inflammation, usually mild in
character, with more or less scaling. A microscopical examination, with
a power of two to five hundred diameters, of scales from the periphery
of a patch, moistened with liquor potassæ, will show both mycelium and
spores, the latter comparatively few in number. In fact, the fungus in
ringworm of the body is rarely to be found in abundance. In tinea
trichophytina unguium the substance of the nail is invaded, scrapings
of which will show the fungus, usually the mycelium, generally but few
spores being present.