often without apparent cause. Alopecia areata and morph[oe]a have been
observed associated with it.
[Illustration: Fig. 36. Vitiligo.]
#State the pathology of vitiligo.#
The disease consists, anatomically, of both a diminution and increase of
the pigment--the white patch resulting from the former, and the
pigmented borders from the latter. There is no textural change, the skin
in other respects being normal.
#From what diseases is vitiligo to be differentiated?#
From morph[oe]a and from the anaesthetic patches of leprosy.
#In what respects do these diseases differ from vitiligo?#
In morph[oe]a there is textural change, and in leprosy both textural
change and constitutional or other symptoms.
#What prognosis is to be given?#
It should always be guarded, the disease in almost all cases being
irresponsive to treatment.
#What is the treatment of vitiligo?#
The general health is to be looked after, and remedies directed
especially toward the nervous system to be employed. Arsenic, in small
and continued doses, seems at times to have an influence; when there is
lack of general tone it may be prescribed as follows:--
[Rx] Liq. potassii arsenitis, ............. f[dram]j
Tinct. nucis vom., ................... f[dram]iij
Elix. calisayae, ....... q. s. ad ..... f[Oz]iv. M.
SIG.--f[dram]j t. d.
Suprarenal-gland preparations in moderate dosage long continued has
appeared in a few instances to be of some benefit.
When upon exposed parts, stimulation of the patches, with the view of
producing hyperaemia and consequent pigment deposit; conjoined with
suitable applications to the surrounding pigmented skin, with a view to
lessen the coloration (see _treatment of chloasma_), will be of aid in
rendering the disease less conspicuous. Or the condition may be, in a
measure, masked by staining the patches with walnut juice or similar
pigment.
#Canities.#
(_Synonym:_ Grayness of the Hair.)
#Describe canities.#
Canities, or graying of the hair, may occur in localized areas or it may
be more or less general; the blanching may be slight, scarcely amounting
to slight grayness, or it may be complete. It is common to advancing
years (_canities senilis_); it is seen also exceptionally in early life
(_canities praematura_). The condition is usually permanent. The loss of
pigment takes place, as a rule, slowly, but several apparently authentic
cases have been reported in which the change occurred in the course of a
night or in a few days.
#What is the etiology of canities?#
The causes are obscure. Heredity is usually an influential factor, and
conditions which impair the general nutrition have at times an
etiological bearing. Intense anxiety, fright, and other profound nervous
shock are looked upon as causative in sudden graying of the hair.
#Give the treatment.#
Canities is without remedy. Dyeing, although not to be advised, is often
practised, and the condition thus masked.
#Alopecia.#
(_Synonym:_ Baldness.)
#What do you understand by alopecia?#
By alopecia is meant loss of hair, either partial or complete.
#Name the several varieties of alopecia.#
The so-called varieties are based mainly upon the etiology, and are
named congenital alopecia, premature alopecia and senile alopecia.
#Describe congenital alopecia.#
Congenital alopecia is a rare condition, in which the hair-loss is
usually noted to be patchy, or the general hair-growth may simply be
scanty. In rare instances the hair has been entirely wanting; in such
cases there is usually defective development of other structures, such
as the teeth.
#Describe premature alopecia.#
Loss of hair occurring in early and middle adult life is not uncommon,
and may consist of a simple thinning or of more or less complete
baldness of the whole or greater part of the scalp. It usually develops
slowly, some months or several years passing before the condition is
well established. It is often idiopathic, and without apparent cause
further than probably a hereditary predisposition. It may also be
symptomatic, as, for example, the loss of hair, usually rapid
(_defluvium capillorum_), following systemic diseases, such as the
various fevers, and syphilis; or as a result of a long-continued
seborrh[oe]a or seborrh[oe]ic eczema (_alopecia furfuracea_).
#Describe senile alopecia.#
This is the baldness so frequently seen developing with advancing years,
and may consist merely of a general thinning, or, more commonly a
general thinning with a more or less complete baldness of the temporal
and anterior portion or of the vertex of the scalp.
#What is the prognosis in the various varieties of alopecia?#
In those cases in which there is a positive cause, as, for instance, in
symptomatic alopecia, the prognosis is, as a rule, favorable, especially
if no family predisposition exists. In the congenital and senile
varieties the condition is usually irremediable. In idiopathic premature
alopecia, the prognosis should be extremely guarded.
#How would you treat alopecia?#
By removing or modifying the predisposing factors by appropriate
constitutional remedies, and by the external use of stimulating
applications.
#Name several remedies or combinations usually employed in the local
treatment.#
Sulphur ointment, full strength or weakened with lard or vaseline; a
lotion of resorcin consisting of one or two drachms to four ounces of
alcohol, to which is added ten to thirty minims of castor oil; and a
lotion made up as follows:--
[Rx] Tinct. cantharidis, .................. f[dram]iv
Tinct. capsici, ...................... f[Oz]j
Ol. ricini, .......................... f[dram]ss-f[dram]j
Alcoholis, .... q. s. ad ............. f[Oz]iv. M.
The following is sometimes beneficial:--
[Rx] Resorcin, ............................ gr. lxxx
Quininae (alkaloid), .................. gr. xv
Ol. ricini, .......................... [minim]v-[minim]xx
Alcoholis, ........................... f[Oz]iv.--M.
Another excellent formula is:
[Rx] Resorcin, ............................ gr. lxxx-cxx
Ac. carbolici cryst., ................ gr. xx
Spts. myrciae, ........................ f[Oz]iv.--M.
And also the various other stimulating applications employed in alopecia
areata (_q. v._).
Other measures of value are: Faradic electricity applied daily for five
minutes with a metallic brush or comb; daily massage, with the object of
loosening the skin and giving more freedom to cutaneous and subcutaneous
circulation; and the application, two or three times weekly, of static
electricity by means of the static crown electrode.
(The application selected should be gently--not rubbing--applied daily
or every second or third day, according to the case; if a lotion,
moistening the parts with it; if an ointment, merely greasing the parts.
Shampooing every one to three weeks, according to circumstances.)
#Alopecia Areata.#
(_Synonyms:_ Area Celsi; Alopecia Circumscripta.)
#What do you understand by alopecia areata?#
[Illustration: Fig. 37. Alopecia Areata.]
Alopecia areata is an affection of the hairy system, in which occur one
or more circumscribed, round or oval patches of complete baldness
unattended by any marked alteration in the skin.
#Upon what parts and at what age does the disease occur?#
In the large majority of cases the disease is limited to the scalp; but
it may invade other portions of the body, as the bearded region,
eyebrows, eyelashes, and, in rare instances, the entire integument.
It is most common between the ages of ten and forty.
#Describe the symptoms of alopecia areata.#
The disease begins either suddenly, without premonitory symptoms, one or
several patches being formed in a few hours; or, and as is more usually
the case, several days or weeks elapse before the bald area or areas are
sufficiently large to become noticeable. The patches continue to extend
peripherally for a variable period, and then remain stationary, or
several gradually coalesce and form a large, irregular area involving
the entire or a greater portion of the scalp. The skin of the affected
regions is smooth, faintly pink or milky white, and at first presents no
departure from the normal; sooner or later, however, the follicles
become less prominent, and slight atrophy or thinning may occur, the
bald plaques being slightly depressed.
[Illustration: Fig. 38. Alopecia Areata--complete hair loss.]
Occasionally, usually about the periphery and in the early stages, a few
hair-stumps may be seen.
#What course does alopecia areata pursue?#
Almost invariably chronic. After the lapse of a variable period the
patches cease to extend, the hairs at the margins of the bald areas
being firmly fixed in the follicles; sooner or later a fine, colorless
lanugo or down shows itself, which may continue to grow until it is
about a half-inch or so in length and then drop out; or it may remain,
become coarser and pigmented, and the parts resume their normal
condition. Not infrequently, however, after growing for a time, the new
hair falls out, and this may happen several times before the termination
of the disease.
#Are there any subjective symptoms in alopecia areata?#
As a rule, not; but occasionally the appearance of the patches is
preceded by severe headache, itching or burning, or other manifestations
of disturbed innervation.
#State the cause of alopecia areata.#
The etiology is obscure. Two theories as to the cause of the disease
exist: one of these regards it as parasitic, and the other considers it
to be trophoneurotic. Doubtless both are right, as a study of the
literature would indicate that there are, as regards etiology, really
two varieties--the contagious and the non-contagious. In America
examples of the contagious variety are uncommon.
#Does the skin undergo any alterative or destructive changes?#
Microscopical examination of the skin of the diseased area shows little
or no alteration in its structure beyond slight thinning.
#How do you distinguish alopecia areata from ringworm?#
The plaques of alopecia areata are smooth, often completely devoid of
hair, and free from scales; while those of ringworm show numerous broken
hairs and stumps, desquamation, and usually symptoms of mild
inflammatory action. In doubtful cases recourse should be had to the
microscope.
#What is the prognosis in alopecia areata?#
The disease is often rebellious, but in children and young adults the
prognosis is almost invariably favorable, permanent loss of hair being
uncommon. The same holds true, but to a much less extent, with the
disease as occurring in those of more advanced age. In extensive
cases--those in which the hair of the entire scalp finally entirely
disappears, and sometimes involves all hairy parts--the prognosis is
unfavorable. Only exceptionally does recovery ensue in such instances.
The uncertain duration, however, must be borne in mind; months, and in
some instances several years, may elapse before complete restoration of
hair takes place. Relapses are not uncommon.
#How is alopecia areata treated?#
By both constitutional and local measures, the former having in view the
invigoration of the nervous system, and the latter a stimulating and
parasiticidal action of the affected areas.
#Give the constitutional treatment.#
Arsenic is perhaps the most valuable remedy, while quinine, nux vomica,
pilocarpine, cod-liver oil and ferruginous tonics may, in suitable
cases, often be administered with benefit.
#Name several remedies or combinations employed in the external treatment
of alopecia areata.#
Ointments of tar and sulphur of varying strength; the various mercurial
ointments; the tar oils, either pure or with alcohol; stimulating
lotions, containing varying proportions, singly or in combination, of
tincture of capsicum, tincture of cantharides, aqua ammoniae, and oil of
turpentine. The following is a safe formula, especially in dispensary
and ignorant class practice:
[Rx] [beta]-naphthol, ..................... [dram]ss-[dram]j
Ol. cadini, .......................... [dram]j
Ungt. sulphuris, .......... q. s. ad ... [Oz]j M.
The cautious use of a five to twenty per cent. chrysarobin ointment is
of value. Painting the patches with pure carbolic acid or trikresol
every ten days or two weeks sometimes acts well; it should not be
applied over large areas nor used in young children. Galvanization or
faradization of the affected parts may also be employed, and with,
occasionally, beneficial effect. Stimulation with the high-frequency
current by means of the vacuum electrode is also of value. When
practicable, the Finsen light can be applied with hope of benefit and
cure.
#Atrophia Pilorum Propria.#
(_Synonym:_ Atrophy of the Hair.)
#What do you understand by atrophy of the hair?#
An atrophic, brittle, dry condition of the hair, and which may be either
symptomatic or idiopathic.
#Describe the several conditions met with.#
As a symptomatic affection, the dry, brittle condition of the hair met
with in seborrh[oe]a, in severe constitutional diseases, and in the
various vegetable parasitic affections, may be referred to.
As an idiopathic disease it is rare, consisting simply of a brittleness
and an uneven and irregular formation of the hair-shaft, with a tendency
to split up into filaments (_fragilitas crinium_); or there may be
localized swelling and bursting of the hair-shaft, the nodes thus
produced having a shining, semi-transparent appearance (_trichorrhexis
nodosa_). This latter usually occurs upon the beard and moustache.
#State the causes of atrophy of the hair.#
The causes of the symptomatic variety are usually evident; the etiology
of idiopathic atrophy is obscure, but by many is thought due to
parasitism.
[Illustration: Fig. 39. Trichorrhexis Nodosa. (_After Michelson._)]
#What would be your prognosis and treatment in atrophy of the hair?#
Symptomatic atrophy usually responds to proper measures, but always
slowly; treatment is based upon the etiological factors.
For the idiopathic disease little, as a rule, can be done; repeated
shaving or cutting the hair has, in exceptional instances, been followed
by favorable results.
#Atrophia Unguis.#
(_Synonyms:_ Atrophy of the Nails; Onychatrophia.)
#Describe atrophy of the nails.#
The nails are soft, thin and brittle, splitting easily, and are often
opaque and lustreless, and may have a worm-eaten appearance. Several or
more are usually affected.
#State the causes of atrophy of the nails.#
The condition may be congenital or acquired, usually the latter. It may
result from trauma, or be produced by certain cutaneous diseases,
notably eczema and psoriasis; or it may follow injuries or diseases of
the nerves. Syphilis and chronic wasting constitutional diseases may
also interfere with the normal growth of the nail-substance, producing
varying degrees of atrophy. The fungi of tinea trichophytina and tinea
favosa at times invade these structures and lead to more or less
complete disintegration--_onychomycosis_.
[Illustration: Fig. 40. Atrophy of the Nails.]
#What is the treatment of atrophy of the nails?#
Treatment will depend upon the cause. When it is due to eczema or
psoriasis, appropriate constitutional and local remedies should be
prescribed. If it is the result of syphilis, mercury and potassium
iodide are to be advised. In onychomycosis--an exceedingly obstinate
affection--the nails should be kept closely cut and pared, and a one- to
five-grain solution of corrosive sublimate applied several times a day;
a lotion of sodium hyposulphite, a drachm to the ounce, is also a
valuable and safe application.
#Atrophia Cutis.#
(_Synonyms:_ Atrophoderma; Atrophy of the Skin.)
#What do you understand by atrophy of the skin?#
By atrophy of the skin is meant an idiopathic or symptomatic wasting or
degeneration of its component elements.
#State the several conditions met with.#
Glossy skin, general idiopathic atrophy of the skin, parchment skin,
atrophic lines and spots, senile atrophy, and the atrophy following
certain cutaneous diseases.
#Describe glossy skin (atrophoderma neuriticum), and state the treatment.#
Glossy skin is a rare condition following an injury or disease of the
nerve. It is usually seen about the fingers. The skin is hairless,
faintly reddish, smooth and shining, with a varnished and thin
appearance, and with a tendency to fissuring. More or less severe and
persistent burning pain precedes and accompanies the atrophy.
Protective applications are called for, the disease tending slowly to
spontaneous disappearance.
#Describe general idiopathic atrophy of the skin, and give the treatment.#
General idiopathic atrophy of the skin is extremely rare, and is
characterized by a gradual, more or less general, degenerative and
quantitative atrophy of the skin structures, accompanied usually with
more or less discoloration and pigmentation.
Treatment is palliative and based upon indications.
#Describe parchment skin, and state the treatment.#
Parchment skin (_xeroderma pigmentosum_, _angioma pigmentosum et
atrophicum_) is a rare disease, the exact nature of which is not
understood. It is characterized by the appearance of numerous
disseminated, freckle-like pigment-spots, telangiectases, atrophied
muscles, more or less shrinking and contraction of the integument, and
followed, in most instances, by epitheliomatous tumors and ulceration,
and finally death. It is usually slow in its course, beginning in
childhood and lasting for years. It is not infrequently seen in several
children of the same family.
Treatment is palliative, consisting, if necessary, of the use of
protective applications and of the administration of tonics and
nutrients.
#Describe atrophic lines and spots.#
Atrophic lines and spots (_striae et maculae atrophicae_) may be idiopathic
or symptomatic, the lesions consisting of scar-like or atrophic-looking,
whitish lines and macules, most commonly seen on the trunk. They are
smooth and glistening. Slight hyperaemia usually precedes their
formation. As an idiopathic disease its course is insidious and slow,
and its progress eventually stayed. The so-called _lineae albicantes_,
resulting from the stretching of the skin produced by pregnancy or
tumors, and from rapid development of fat, may be mentioned as
illustrating the symptomatic variety.
In course of time the atrophy becomes less conspicuous.
#Describe senile atrophy.#
Senile atrophy is not uncommon, the atrophy resulting, as the name
inferentially implies, from advancing age. It is characterized by
thinning and wasting, dryness, and a wrinkled condition, with more or
less pigmentation and loss of hair. Circumscribed pigmentary deposits
and seborrh[oe]a, with degeneration, are also noted.
#What several diseases of the skin are commonly followed by atrophic
changes?#
Favus, lupus, syphilis, leprosy, scleroderma and morph[oe]a.
#CLASS VI.--NEW GROWTHS.#
#Keloid.#
(_Synonyms:_ Keloid of Alibert; Cheloid.)
#Give a descriptive definition of keloid.#
Keloid is a fibro-cellular new growth of the corium appearing as one or
several variously-sized, irregularly-shaped, elevated, smooth, firm,
pinkish or pale-reddish cicatriform lesions.
#Describe the clinical appearance of keloid.#
The growth begins as a small, hard, elevated, pinkish or reddish
tubercle, increasing gradually, several months or years usually elapsing
before the tumor reaches conspicuous size. When developed, it is one or
more inches in diameter, is sharply defined, elevated, hard, rounded or
oval, fungoid or crab-shaped, and firmly implanted in the skin. It is
usually pinkish, pearl-white, or reddish, commonly devoid of hair, with
no tendency to scaliness, and with, usually, several vessels coursing
over it. In some instances it is tender, and it may be spontaneously
painful.
The breast, especially over the sternal region, is a favorite site for
its appearance. One, several or more may be present in the single case.
#What course does keloid pursue?#
Chronic; usually lasting throughout life. In rare instances spontaneous
involution takes place.
#State the etiology of keloid.#
The causes are obscure. The growth usually takes its start from some
injury or lesion of continuity; for instance, at the site of burns,
cuts, acne and smallpox scars, etc.--_cicatricial keloid, false keloid_;
or it may also, so it is thought, originate in normal skin--_spontaneous
keloid, true keloid_.
#What is the pathology of keloid?#
The lesion is a connective-tissue new growth having its seat in the
corium.
#Is there any difficulty in the diagnosis of keloid?#
No. It resembles hypertrophic scar; but this latter, which is
essentially keloidal, never extends beyond the line of injury.
#Give the prognosis.#
The growth is persistent and usually irresponsive to treatment. In some
cases, however, there is eventually a tendency to spontaneous
retrogression, up to a certain point at least.
#What is the treatment of keloid?#
Usually palliative, consisting of the continuous application of an
ointment such as the following:--
[Rx] Acidi salicylici, .................... gr. x-xx
Emplast. plumbi,
Emplast. saponis, ... [=a][=a] ....... [dram]iij
Petrolati, ........................... [dram]ij. M.
An ointment of ichthyol, twenty-five per cent. strength, rubbed in once
or twice daily, is sometimes beneficial.
Operative measures, such as punctate and linear scarification,
electrolysis and excision, are occasionally practised, but the results
are rarely satisfactory and permanent; not infrequently, indeed, renewed
activity in the progress of the growth is noted to follow. The _x_-ray
can be tried with some hope of improvement. The administration of
thyroid has been thought to have a possible influence in some instances.
#Fibroma.#
(_Synonyms:_ Molluscum Fibrosum; Fibroma Molluscum.)
#What do you understand by fibroma?#
Fibroma is a connective-tissue new growth characterized by one or more
sessile or pedunculated, pea- to egg-sized or larger, soft or firm,
rounded, painless tumors, seated beneath and in the skin.
#Describe the clinical appearances of fibroma.#
The growth may be single, in which case it is apt to be pedunculated or
pendulous, and attain considerable dimensions; as a result of weight or
pressure surface-ulceration may occur. Or, as commonly met with, the
lesions are numerous, scattered over large surface, and vary in size
from a pea to a cherry; the overlying skin being normal, pinkish or
reddish, loose, stretched, hypertrophied or atrophied.
The tumors are painless. The general health is not involved.
[Illustration: Fig. 41. Fibroma. (_After Octerlony._)]
#What is the course of fibroma?#
Chronic and persistent.
#What is the etiology of fibroma?#
The cause is not known. Heredity is often noted. The affection is not
common.
#State the pathology of fibroma.#
The growths are variously thought to have their origin in the connective
tissue of the corium, or in that of the walls of the hair-sac, or in the
connective-tissue framework of the fatty tissue. Recent tumors are
composed of gelatinous, newly-formed connective tissue, and the older
growths of a dense, firmly-packed, fibrous tissue.
#From what growths is fibroma to be differentiated?#
From molluscum contagiosum, neuroma and lipoma; the first is
differentiated by its central aperture or depression, neuroma by its
painfulness, and lipoma by its lobulated character and soft feel.
#Give the prognosis of fibroma.#
The disease is persistent, and irresponsive to all treatment save
operative measures.
#What is the treatment of fibroma?#
Treatment consists, when desired and practicable, in the removal of the
growths by the knife, or in large and pedunculated tumors by the
ligature or by the galvano-cautery.
#Neuroma.#
#Describe neuroma.#