thoroughly, and supplement with momentary cauterization, with caustic
potash, or with several days' use of the pyrogallic acid ointment.
During the healing process, short exposures to the Roentgen ray--about
every three to five days--is good practice.
The degenerative changes in the beginning of scurfy, seborrh[oe]ic spots
or patches seen in old people can frequently be lessened or wholly
stopped by the daily application of an ointment containing 5 to 10 per
cent. of sulphur and 2 to 5 per cent. of salicylic acid.
#What can be said of the value of the x-ray in epithelioma?#
The _x_-ray method is now much in vogue, and proves curative in many
superficial cases, and of benefit in some of the deeper-seated
varieties. In most cases it must be pushed to the point of producing a
mild _x_-ray erythema; and in some instances benefit or cure only occurs
after more active exposure, sufficient to cause an _x_-ray burn of the
second degree. The method is not attended with much risk if properly
used. The healthy parts should be protected by lead-foil. Exposure
should be two to five times weekly, at a distance of three to eight
inches, and from five to twenty minutes, employing a tube of medium
vacuum. Unfortunately the method is usually slow. The radium treatment
is essentially similar to that by the _x_-ray.
The much better plan, as already intimated, is to employ one of the
several operative or caustic methods, and supplementing, while healing,
with the _x_-ray.
#Paget's Disease of the Nipple.#
(_Synonyms:_ Malignant Papillary Dermatitis; Paget's Disease.)
#What do you understand by Paget's disease of the nipple?#
Paget's disease is a rare, inflammatory-looking, malignant disease of
the nipple and areola in women, usually of advancing years, eventually
terminating in cancerous involvement of the entire gland.
#Describe the symptoms of Paget's disease.#
The first symptoms, which usually last for months or years, are
apparently eczematous, accompanied with more or less burning, itching
and tingling. Gradually, the diseased area, which is sharply-defined,
and feels like a thin layer of indurated tissue, presents a florid,
intensely red, very finely-granular, raw surface, attended with a more
or less copious viscid exudation. Sooner or later retraction and
destruction of the nipple, followed by gradual scirrhous involvement of
the whole breast, takes place.
#What is the pathology of Paget's disease?#
Although it was thought at one time to be a cancerous disease resulting
from a continued eczematous inflammation of the parts, there is now but
little doubt that it is of malignant nature from the earliest stages.
The psorosperm-like bodies found, to the presence of which the disease
has by some authorities been attributed (psorospermosis), are now known
to be merely changed and degenerated epithelia. The morbid changes
consist of an inflammation of the papillary region of the derma, leading
to [oe]dema and vacuolation of the constituent cells of the epidermis,
followed by their complete destruction in places and their abnormal
proliferation in others (Fordyce).
#State the diagnostic features of Paget's disease.#
The age of the patient; the sharp limitation; the well-defined,
indurated film of infiltration; the peculiar, red, raw, granulating
appearance; and, later, the retraction of the nipple; and, finally, the
involvement of the deeper parts.
#What is the prognosis?#
If the disease is recognized early, and properly treated, a cure may be
anticipated; later the outlook is that of scirrhus of the breast.
#What is the treatment of Paget's disease?#
Thorough cauterization by means of caustic potash or the
galvano-cautery; or, its extirpation by means of the curette or
excision. After extirpation or cauterization, supplementary treatment by
the _x_-ray is advisable as an additional measure of precaution against
relapse.
Until the diagnosis is thoroughly established, soothing applications,
such as are employed in acute eczema, are to be advised.
#Sarcoma.#
(_Synonyms:_ Sarcoma Cutis; Sarcoma of the Skin.)
#Describe the several varieties of sarcoma.#
Sarcoma of the skin is a more or less malignant new growth, of rapid or
slow progress, characterized by the appearance of single or multiple,
variously-shaped, discrete, non-pigmented or pigmented tubercles or
tumors, of size varying from that of a shot to a hazelnut or larger. As
a rule the growths are smooth, firm and elastic, somewhat painful upon
pressure, and exhibit a tendency to ulcerate. The overlying skin is at
first normal and somewhat movable, but as the growths approach the
surface it becomes reddened and adherent; or, if the disease is of the
pigmented variety, it acquires a bluish-black color. It is now generally
believed that the most of the pigmented cases formerly thought to be of
sarcomatous nature are really carcinomatous in character.
The multiple pigmented sarcoma (_melano-sarcoma_) appears first, usually
on the soles and dorsal surfaces of the feet, and later on the hands.
There is more or less diffuse thickening of the integument. The lesions
themselves manifest a disposition to bleed.
#State the prognosis and treatment of sarcoma.#
The disease is always more or less malignant and, as a rule, sooner or
later a fatal termination takes place. It is usually slow in its course.
Excision or extirpation, _x_-ray exposures, and the administration of
arsenic in increasing dosage (preferably by hypodermic injection) now
are generally considered the most promising in this usually hopeless
malady.
#Granuloma Fungoides.#
#Describe granuloma fungoides.#
A rare form of disease, heretofore looked upon as sarcomatous, but now
generally recognized as granuloma, and formerly described under the
names _mycosis fungoides_, _inflammatory fungoid neoplasm_, and several
others. It is characterized usually by symptoms of an eczematous,
urticarial, and erysipelatous nature, and by the sudden or gradual
appearance of pinkish or reddish, tubercular, nodular, lobulated, or
furrowed tumors or flat infiltrations, which may disappear by involution
or may be followed by ulceration; several or a larger number of the
growths present a mushroom, papillomatous, or fungoid appearance,
sometimes roughly resembling the cut part of a tomato. In most cases the
tumor stage of the malady is not reached for two or more years; in
exceptional instances, however, they appear in the first few months. The
lesions, especially in their early stages, are, as a rule, accompanied
with more or less burning and itching.
#State the prognosis and treatment of granuloma fungoides.#
The malady may last for several years or much longer, a fatal
termination, with rare exceptions, sooner or later taking place. After
the tumor stage is well established, the patient usually succumbs in
from several months to one or two years.
[Illustration: Fig. 65. Granuloma Fungoides.]
Treatment consists of tonics, if indicated, and the administration of
arsenic, preferably hypodermically, and Roentgen-ray exposures, along
with the application of mild antiseptics, and operative interference
when necessary or advisable.
#CLASS VII.--NEUROSES.#
#Hyperaesthesia.#
#What is hyperaesthesia?#
By hyperaesthesia is meant increased cutaneous sensibility. It is usually
more or less localized, and is met with as a symptom in functional and
organic nervous diseases.
#Dermatalgia.#
(_Synonyms:_ Neuralgia of the Skin; Rheumatism of the Skin; Dermalgia.)
#What do you understand by dermatalgia?#
By dermatalgia is meant a tender or painful condition of the skin
unattended by structural change. It is commonly limited to a small area,
and is usually symptomatic of functional or organic nervous disease. As
an idiopathic affection it is looked upon as of a rheumatic origin.
Treatment depends upon the cause.
#Anaesthesia.#
#What is anaesthesia?#
Anaesthesia is a diminution, comparative or complete, of cutaneous
sensibility. It is usually localized, and is met with in the course of
certain nervous affections. It is also encountered in leprosy,
morph[oe]a and like diseases.
#Pruritus.#
#What do you understand by pruritus?#
Pruritus is a functional disease of the skin, the sole symptom of which
is itching, there being no structural change.
#Describe the symptoms of pruritus.#
The sole and essential symptom is itchiness, usually more or less
paroxysmal, and worse at night. There are no primary structural lesions,
but in severe and persistent cases the parts become so irritated by
continued scratching that secondary lesions, such as papules and slight
thickening and infiltration, may result. It is much more common in
advanced life--_pruritus senilis_. In such cases, as well as in those
cases in younger and middle-aged individuals in which the itchiness
develops at the approach of cold weather and disappears upon the coming
of the warm season (_pruritus hiemalis_), the pruritus is usually more
or less generalized, although not infrequently in the latter the legs
are specially involved.
In some individuals an attack of pruritus, of variable intensity,
lasting from five to thirty minutes, comes on immediately after a bath
(_bath-pruritus_). It is usually confined to the legs from the hips
down.
#Is pruritus always more or less generalized?#
No; not infrequently the itching is limited to the genital region
(_pruritus scroti_, _pruritus vulvae_) or to the anus (_pruritus ani_).
#To what may pruritus often be ascribed?#
To digestive and intestinal derangements, hepatic disorders, the uric
acid diathesis, gestation, diabetes mellitus, and a depraved state of
the nervous system.
Pruritus vulvae is at times due to irritating discharges, and pruritus
ani occasionally to hemorrhoids and seat-worms.
#Is there any difficulty in the diagnosis of pruritus?#
No. The subjective symptom of itching without the presence of structural
lesions is diagnostic. In those severe and persistent cases in which
excoriations and papules have resulted from the scratching, the history
of the case, together with its course, must be considered. Care should
be taken not to confound it with pediculosis. In this latter the
excoriations usually have a somewhat peculiar distribution, being most
abundant on those parts of the body with which the clothing lies closely
in contact. (See Pediculosis corporis.)
In pruritus of the genitocrural region the possibility of pediculi being
the cause must be kept in mind; an examination of the parts for the
parasite or for ova (attached to the hairs) would prevent error. (See
Pediculosis pubis.)
#What prognosis would you give in pruritus?#
In the majority of cases the condition responds to proper treatment, but
in others it proves rebellious. The prognosis depends, in fact, upon the
removability of the cause. Temporary relief may always be given by
external applications.
#How would you treat pruritus?#
With systemic remedies directed toward a removal or modification of the
etiological factors, and, for the temporary relief of the itching,
suitable antipruritic applications. In obscure cases, quinia, salophen,
lithia salts, calcium chloride, belladonna, nux vomica, arsenic,
pilocarpine, and general galvanization may be variously tried. Alkalies
prove useful in many cases.
Exceptionally, the relief furnished by external treatment is more or
less permanent.
#Name the important antipruritic applications.#
Alkaline baths; lotions of carbolic acid ([dram]j-[dram]iij to Oj), of
resorcin ([dram]j-[dram]iv to Oj), of liquor carbonis detergens
([Oz]j-[Oz]iv to Oj), and liquor picis alkalinus ([dram]j-[dram]iv to
Oj), used cautiously. One or several ounces of alcohol and one or two
drachms of glycerin in each pint of these lotions will often be of
advantage, as the following:--
[Rx] Ac. carbolici, ....................... [dram]j-[dram]iij
Gylcerinae, ........................... f[dram]ij
Alcoholis, ........................... f[oz]ij
Aquae, ......... q.s. ad .............. Oj. M.
Various dusting-powders, alone or in conjunction with the lotions.
And in some cases, especially those in which the skin is unnaturally
dry, ointments may be used, such as equal parts of lard, lanolin, and
petrolatum, to the ounce of which may be added from five to thirty
grains of carbolic acid, three to twenty grains of thymol, ten to thirty
minims of chloroform, or two to ten grains of menthol.
#What external applications are to be used in the local varieties of
pruritus?#
In _pruritus ani_ and _pruritus vulvae_, in addition to the various
applications above, a cocaine ointment, one to ten grains to the ounce,
a strong solution of the same (gr. v-xx to [Oz]j), and an ointment
containing ten to thirty minims of the oil of peppermint to the ounce;
sponging with hot water, often affords temporary relief.
In pruritus vulvae, moreover, astringent applications and injections of
zinc sulphate, alum, tannic or acetic acid, in the strength commonly
employed for vaginal injections, are at times curative.
In bath-pruritus weak glycerine lotions, and an ointment containing a
few grains of thymol and menthol to the ounce sometimes give moderate
relief. Turkish baths are sometimes free from subsequent pruritus.
#CLASS VIII.--PARASITIC AFFECTIONS.#
#Tinea Favosa.#
(_Synonym:_ Favus.)
#What is tinea favosa?#
Tinea favosa, or favus, is a contagious vegetable-parasitic disease of
the skin, characterized by pin-head to pea-sized, friable, umbilicated,
cup-shaped yellow crusts, each usually perforated by a hair.
#Upon what parts and at what age is favus observed?#
It is usually met with upon the scalp, but it may occur upon any part of
the integument. Occasionally the nails are invaded. It is seen at all
ages, but is much more common in children.
#Describe the symptoms of favus of the scalp.#
The disease begins as a superficial inflammation or hyperaemic spot, more
or less circumscribed, slightly scaly, and which is soon followed by the
formation of yellowish points about the hair follicles, surrounding the
hair shaft. These yellowish points or crusts increase in size, become
usually as large as small peas, are cup-shaped, with the convex side
pressing down upon the papillary layer, and the concave side raised
several lines above the level of the skin; they are umbilicated,
friable, sulphur-colored, and usually each cup or disc is perforated by
a hair. Upon removal or detachment, the underlying surface is found to
be somewhat excavated, reddened, atrophied and sometimes suppurating. As
the disease progresses the crusting becomes more or less confluent,
forming irregular masses of thick, yellowish, mortar-like crusts or
accumulations, having a peculiar, characteristic odor--that of mice, or
stale, damp straw. The hairs are involved early in the disease, become
brittle, lustreless, break off and fall out. In some instances,
especially near the border of the crusts, are seen pustules or
suppurating points. _Atrophy_ and more or less actual _scarring_ are
sooner or later noted.
Itching, variable as to degree, is usually present.
#What is the course of favus of the scalp?#
Persistent and slowly progressive.
[Illustration: Fig. 66.
Achorion Schoenleinii X 450. (_After Duhring._) Showing simple mycelium,
in various stages of development, and free spores.]
#What are the symptoms of favus when seated upon the general surface?#
The symptoms are essentially similar to those upon the scalp, modified
somewhat by the anatomical differences of the parts.
The _nails_, when affected, become yellowish, more or less thickened,
brittle and opaque (_tinea favosa unguium_, _onychomycosis favosa_).
#To what is favus due?#
Solely to the invasion of the cutaneous structures, especially the
epidermal portion, by the vegetable parasite, the _achorion
Schoenleinii_. It is contagious. It is a somewhat rare disease in the
native-born, being chiefly observed among the foreign poor. The nails
are rarely affected primarily.
It is also met with in the lower animals, from which it is doubtless not
infrequently communicated to man.
#What are the diagnostic features of favus?#
The yellow, and often cup-shaped, crusts, brittleness and loss of hair,
atrophy, and the history.
[Illustration: Fig. 67. Epilating Forceps.]
#How would you distinguish favus from eczema and ringworm?#
From eczema by the condition of the affected hair, the atrophic and
scar-like areas, the odor, and the history. From ringworm by the
crusting and the atrophy. In this latter disease there is usually but
slight scaliness, and rarely any scarring.
Finally, if necessary, a microscopic examination of the crusts may be
made.
#State the method of examination for fungus.#
A portion of the crust is moistened with liquor potassae and examined
with a power of three to five hundred diameters. The fungus, (achorion
Schoenleinii), consisting of mycelium and spores, is luxuriant and is
readily detected.
#State the prognosis of favus.#
Upon the scalp, favus is extremely chronic and rebellious to treatment,
and a cure in six to twelve months may be considered satisfactory; in
neglected cases permanent baldness, atrophy, and scarring sooner or
later result. Although favus of the scalp persists into adult life, it
becomes less active and, finally, as a rule, gradually disappears,
leaving behind scarred or atrophic bald areas.
Upon the general surface it usually responds readily to treatment,
excepting favus of the nails, which is always obstinate.
#How is favus of the scalp treated?#
Treatment is entirely local and consists in keeping the parts free from
crusts, in epilation and applications of a parasiticide.
The crusts are removed by oily applications and soap-and-water washings.
The hair on and around the diseased parts is to be kept closely cut,
and, when practicable, depilation, or extraction of the affected hairs,
is advised; this latter is, in most cases, essential to a cure. Remedial
applications--the so-called parasiticides--are, as a rule, to be made
twice daily. If an ointment is used, it is to be thoroughly rubbed in;
if a lotion, it is to be dabbed on for several minutes and allowed to
soak in.
#Name the most important parasiticides.#
Corrosive sublimate, one to four grains to an ounce of alcohol and
water; carbolic acid, one part to three or more parts of glycerine; a
ten per cent. oleate of mercury; ointments of ammoniated mercury,
sulphur and tar; and sulphurous acid, pure or diluted. The following is
valuable:--
[Rx] Sulphur, praecip., .................... [dram]ij
Saponis viridis,
Ol. cadini, ....... [=a][=a] ......... [dram]j
Adipis, .............................. [Oz]ss. M.
Chrysarobin is a valuable remedy, but must be used with caution; it may
be employed as an ointment, five to ten per cent. strength, as a rubber
plaster, or as a paint, a drachm to an ounce of gutta-percha solution.
Formalin, weakened or full strength, has been extolled. Some observers
have experimentally tried the effect of _x_-ray exposure with alleged
good results, pushing the treatment to the point of producing
depilation; if used great caution should be exercised.
#How is favus upon the general surface to be treated?#
In the same general manner as favus of the scalp, but the remedies
employed should be somewhat weaker. In favus of the nail frequent and
close paring of the affected part and the application, twice daily, of
one of the milder parasiticides, will eventually lead to a good result.
#Is constitutional treatment of any value in favus?#
It is questionable, but in debilitated subjects tonics, especially
cod-liver oil, may be prescribed with the hope of aiding the external
applications.
#Tinea Trichophytina.#
(_Synonym:_ Ringworm.)
#What is tinea trichophytina?#
Tinea trichophytina, or ringworm, is a contagious, vegetable-parasitic
disease due to the invasion of the cutaneous structures by the vegetable
parasite, the trichophyton, or the microsporon Audouinii.
#Do the clinical characters of ringworm vary according to the part
affected?#
Yes, often considerably; thus upon the scalp, upon the general surface,
and upon the bearded region, the disease usually presents totally
different appearances.
#Describe the symptoms of ringworm as it occurs upon non-hairy portions
of the body.#
Ringworm of the general surface (_tinea trichophytina corporis_, _tinea
circinata_) appears as one or more small, slightly-elevated,
sharply-limited, somewhat scaly, hyperaemic spots, with, rarely, minute
papules, vesico-papules, or vesicles, especially at the circumference.
The patch spreads in a uniform manner peripherally, is slightly scaly,
and tends to clear in the centre, assuming a ring-like appearance. When
coming under observation, the patches are usually from one-half to one
inch in diameter, the central portion pale or pale red, and the outer
portion more or less elevated, hyperaemic and somewhat scaly. As commonly
noted one, several or more patches are present. After reaching a certain
size they may remain stationary, or in exceptional cases may tend to
spontaneous disappearance. At times when close together, several may merge
and form a large, irregular, gyrate patch.
Itching, usually slight, may or may not be present.
Exceptionally ringworm appears as a markedly inflammatory pustular
circumscribed patch, formerly thought to be a distinct affection and
described under the name of _conglomerate pustular folliculitis_. It
consists of a flat carbuncular or kerion-like inflammation, somewhat
elevated, and usually a dime to silver dollar in area. The most common
seats are the back of the hands and the buttocks. The surface is
cribriform, and a purulent secretion may be pressed out from follicular
openings.
[Illustration: Fig. 68.
Tinea trichophytina cruris--so-called eczema marginatum--of unusually
extensive development. (_After Piffard._)]
#Describe the symptoms of ringworm when occurring about the thighs and
scrotum.#
In adults, more especially males, the inner portion of the upper part of
the thighs and scrotum (_tinea trichophytina cruris_, so-called _eczema
marginatum_) may be attacked, and here the affection, favored by heat
and moisture, develops rapidly and may soon lose its ordinary clinical
appearances, the inflammatory symptoms becoming especially prominent.
The whole of this region may become involved, presenting all the
symptoms of a true eczema; the border, however, is sharply defined, and
usually one or more outlying patches of the ordinary clinical type of
the disease may be seen.
#Describe the symptoms of ringworm when involving the nails.#
In ringworm of the nails (_tinea trichophytina unguium_) these
structures become soft or brittle, yellowish, opaque and thickened the
changes taking place mainly about the free borders. Ringworm on other
parts usually coexists.
#Describe the symptoms of ringworm as it occurs upon the scalp.#
Ringworm of the scalp (_tinea trichophytina capitis_, _tinea tonsurans_)
begins usually in the same manner as that upon the general surface, but,
as a rule, much more insidiously. Sooner or later, however, the hair and
follicles are invaded by the fungus, and in consequence the hair falls
out or becomes brittle and breaks off. The follicles, except in
long-standing cases, are slightly elevated and prominent, and the patch
may have a puffed or goose-flesh appearance. In addition, there is
slight scaliness.
#Describe the appearances of a typical patch of ringworm of the scalp.#