the follicles are somewhat prominent; there is more or less alopecia,
with here and there broken, gnawed-off-looking hairs, some of which may
be broken off just at the outlet of the follicles and more or less
surrounded by a whitish or grayish-white dust. This type is produced by
the small-spore fungus--microsporon.
#Does ringworm of the scalp always present typical appearances?#
Not invariably. In some cases the patch or patches may become almost
completely bald, and in others a tendency to the formation of pustules,
with more or less crust-formation, may be seen. The affection may also
appear as small scattered spots or points.
[Illustration: Fig. 69.
Ringworm (rather inflammatory type, and produced by the trichophyton).]
The markedly inflammatory and pustular types are produced by the
large-spore fungus--trichophyton.
#What is tinea kerion?#
Tinea kerion (_kerion_) is a markedly inflammatory type of ringworm of
the scalp involving the deeper tissues, appearing as a more or less
bald, rounded, inflammatory, [oe]dematous, boggy, honeycombed tumor,
discharging from the follicular openings a mucoid secretion.
#Does ringworm of the scalp ever occur in adults?#
No. (Extremely rare exceptions.)
[Illustration: Fig. 70.
Ringworm Fungus (Trichophyton) x 450. (_After Duhring._) As found in
epidermic scrapings of ringworm, showing mycelium and spores.]
#Describe the symptoms of ringworm of the bearded region.#
Ringworm of the bearded region (_tinea trichophytina barbae_, _tinea
sycosis_, _parasitic sycosis_, _barber's itch_) begins usually in the
same manner as ringworm on other parts, as one or more rounded, slightly
scaly, hyperaemic patches. In rare instances the disease may persist as
such, with very little tendency to involve the hairs and follicles; but,
as a rule, the hairy structures are soon invaded, many of the hairs
breaking off, and many falling out. From involvement of the follicles,
more or less subcutaneous swelling ensues, the parts assuming a
distinctly _lumpy and nodular_ condition. The skin is usually
considerably reddened, often having a glossy appearance, and studded
with few or numerous pustules. The nodules tend, ordinarily, to break
down and discharge, at one or more of the follicular openings, a glairy,
glutinous, purulent material, which may dry to thick, adherent crusts.
[Illustration: Fig. 71.
Ringworm Fungus (Microsporon) x 500. (_After Duhring._) Short,
broken-off hair of scalp invaded with masses of free spores.]
The disease may be limited to one patch, or a large area, even to the
extent of the whole bearded region, becomes involved. The upper lip is
rarely invaded. Ringworm of the bearded region is due to the trichophyton.
[Illustration: Fig. 72.
Ringworm Fungus (Trichophyton) x 300. (_After Duhring._) Short, stout
hair of beard, with the root-sheath attached, showing free spores and
chains of spores.]
#To what is ringworm due?#
To the presence and growth in the cutaneous structures of a vegetable
parasite. Although the disease is contagious, individuals differ
considerably as to susceptibility. It is much more common in children
than in those past the age of puberty, ringworm of the scalp being
limited to the former (rare exceptions), and tinea sycosis being a
disease of the male adult.
Until recently the ringworm was thought to be due to but one fungus--the
trichophyton; it is now known that there are several forms of fungi, the
main forms being the small-spored (microsporon Audouini) and the
large-spored (trichophyton). Of this latter there are two main
subvarieties--endothrix and ectothrix. The small-spored fungus is found
as the cause in the majority of scalp cases; the endothrix also commonly
invades the scalp integument. The ectothrix variety is usually derived
directly or indirectly from domestic animals, and is chiefly responsible
for body-ringworm, and for suppurative ringworm, whether upon the
bearded region or elsewhere.
#What is the pathology of ringworm?#
On the general surface the fungus has its seat in the epidermis,
especially in the corneous layer; upon the scalp and bearded region the
epidermis, hair-shaft, root and follicle are invaded. The inflammatory
action may vary considerably in different cases, and at different times
in the same case.
The fungus consists of mycelium and spores. In the epidermic scrapings
it is never to be found in abundance, and the mycelium predominates,
while in affected hairs the spores and chains of spores are almost
exclusively seen, and are usually present in great profusion.
#How do you examine for the fungus?#
The scrapings or hair should be moistened with liquor potassae, and
examined with a power from three hundred diameters upward.
#How is ringworm of the general surface to be distinguished from eczema,
psoriasis and seborrh[oe]a?#
By the growth and characters of the patch, the slight scaliness, the
tendency to disappear in the centre, by the history, and, if necessary,
by a microscopic examination of the scales.
#How is ringworm of the scalp to be distinguished from alopecia areata,
favus, eczema, seborrh[oe]a, and psoriasis?#
By the peculiar clinical features of ringworm on this region--the slight
scaliness, broken hair and hair stumps, with a certain amount of
baldness--and in doubtful cases by a microscopical examination of the
hairs.
In favus, although the same condition of the hair is noted, the yellow,
cup-shaped crusts, and the presence of the atrophic areas in that
disease are pathognomonic.
#How is ringworm of the bearded region to be distinguished from eczema
and sycosis?#
By the peculiar lumpiness of the parts, the brittleness of the hair,
more or less hair loss, and the history.
The superficial type of ringworm sycosis--those cases in which the
disease remains a surface disease--is readily distinguished, as the
symptoms are essentially the same as ringworm of non-hairy parts, except
that some of the hairs in the areas may become invaded and break off or
fall out.
In doubtful cases recourse may be had to microscopical examination.
#What is the prognosis of ringworm of these several parts?#
When upon the general surface, the disease usually responds rapidly to
therapeutical applications; upon the scalp it is always a stubborn
affection, and, as a rule, requires several months to a year of
energetic treatment to effect a cure. In this latter region the disease
will disappear spontaneously as the age of fifteen or sixteen is
reached. Tinea sycosis yields in most instances in the course of several
weeks or a few months.
#Is ringworm of these several parts treated with the same remedies?#
As a rule, yes; but the strength must be modified. The scalp will stand
strong applications, as will likewise the bearded region; upon non-hairy
portions the remedies should be used somewhat weaker. They should be
applied twice daily; ointments, if used, being well rubbed in, and
lotions thoroughly dabbed on.
#How would you treat ringworm of the general surface?#
By applications of the milder parasiticides, such as a ten to fifteen
per cent. solution of sodium hyposulphite; carbolic acid, five to thirty
grains to the ounce of water, or lard; a saturated solution of boric
acid; ointments of tar, sulphur and mercury, official strength or
weakened with lard; and tincture of iodine, pure or diluted.
When occurring upon the upper and inner part of the thighs (so-called
eczema marginatum), the same remedies are to be employed, but usually
stronger. Deserving of special mention is a lotion of corrosive
sublimate, one to four grains to the ounce; or the same remedy, in the
same proportion, may be used in tincture of myrrh or benzoin, and
painted on the parts.
#How would you treat ringworm of the scalp?#
By occasional soap-and-hot-water washing; by extraction of the involved
hairs, when practicable; by carbolic acid or boric acid lotions to the
whole scalp, so as to limit, as much as possible, the spread of the
disease; and by daily (or twice daily) applications to the patches and
involved areas of a parasiticide. The following are the most valuable:
the oleate of mercury, with lard or lanolin, in varying strength, from
ten to twenty per cent.; carbolic acid, with one to three or more parts
of glycerine or oil; corrosive sublimate, in solution in alcohol and
water, one to four grains to the ounce; sulphur ointment; and citrine
ointment, with one or two parts of lard. Chrysarobin is a valuable
remedy, but is to be employed with care; it may be prescribed as a
rubber plaster, or in a solution of gutta-percha, or as an ointment, ten
to fifteen per cent. strength. [beta]-naphthol in ointment form, five
to fifteen per cent. strength, is also useful. An excellent application
for beginning areas on the scalp is a solution of the red iodide of
mercury in iodine tincture, one to three grains to an ounce.
A compound ointment, containing several of the active remedies named, is
convenient for dispensary practice, such as:--
[Rx] [beta]-naphthol, ................. [dram]ss-[dram]j
Ol. cadini, ......................... [dram]j
Ungt. sulphuris, ............ q.s. ad [Oz]j. M.
In that form known as tinea kerion mild applications are demanded at
first; later the same treatment as in the ordinary type.
#How is ringworm of the bearded region to be treated?#
On the same general plan and with the same remedies (excepting
chrysarobin) as in ringworm of the scalp. Depilation is to be practised
as an essential part of the treatment. Special mention may be made of an
ointment of oleate of mercury, sulphur ointment, a lotion of sodium
hyposulphite ([dram]j-[Oz]j), and a lotion of corrosive sublimate (gr.
j-iv to [Oz]j). The _x_-ray has been used in ringworm of this region
with alleged success, pushing it to the production of a mild erythema
and depilation. The above methods are, however, usually successful, and
are without risk of damage.
#How is the certainty of an apparent cure in ringworm of the scalp or
bearded region to be determined?#
By the continued absence of roughness and of broken hairs and stumps,
and by microscopical examination of the new-growing hairs from time to
time for several weeks after discontinuance of treatment.
Cure of ringworm of the general surface is usually self-evident.
#Is systemic treatment of aid in the cure of ringworm?#
It is doubtful, although in children in a depraved state of health the
disease is often noted to be especially stubborn, and in such cod-liver
oil and similar remedies may at times prove of benefit.
#Tinea Imbricata.#
(_Synonym:_ Tokelau Ringworm.)
#What is tinea imbricata?#
A vegetable parasitic disease of moist tropical countries, characterized
by the formation of patches composed of concentrically arranged,
imbricated, scaly rings. It may begin at one or several points as a
brownish, slightly raised spot, spreading peripherally; the renewed
epidermis of the central part of the patch goes again through the same
process; the result is a small or large area of concentrically arranged,
imbricated, slightly scaly eruption. Several such areas fusing together
may cover a large part of the surface, the ring-like arrangement being
sometimes more or less completely lost. The malady is chronic. There may
be a variable degree of itching. The cause of the disease, which is of a
contagious nature, is a vegetable parasite closely similar to the
trichophyton. The treatment is by the parasiticides, being essentially
the same, in fact, as ringworm.
#Tinea Versicolor.#
(_Synonyms:_ Pityriasis Versicolor; Chromophytosis.)
#What is tinea versicolor?#
Tinea versicolor is a vegetable-parasitic disease of the skin,
characterized by variously-sized and shaped, slightly scaly, macular
patches of a yellowish-fawn color, and occurring for the most part upon
the upper portion of the trunk.
#Describe the symptoms of tinea versicolor.#
The disease begins as one or more yellowish macular points; these, in
the course of weeks or months, gradually extend, and, together with
other patches that arise, may form a more or less continuous sheet of
eruption. There is slight scaliness, always insignificant and
furfuraceous in character, and at times, except upon close inspection,
scarcely perceptible. The color of the patches is pale or
brownish-yellow; in rare instances, in those of delicate skin, there may
be more or less hyperaemia, and in consequence the eruption is of a
reddish tinge. The number of patches varies; there may be but a few, or,
on the other hand, a profusion. Slight itching, especially when the
parts are warm, is usually present.
#Does the eruption of tinea versicolor show predilection for any special
region?#
Yes; the upper part of the trunk, especially anteriorly, is the usual
seat of the eruption, but in exceptional instances the neck, axillae, the
arms, the whole trunk, the genitocrural region and poplitea, and in rare
cases even the lower part of the face, may become invaded.
#What course does tinea versicolor pursue?#
Persistent, but somewhat variable; as a rule, however, slowly
progressive and lasting for years.
#To what is tinea versicolor due?#
To a vegetable fungus--the _microsporon furfur_.
The affection is tolerably common, and occurs in all parts of the world.
With rare exceptions, it is a disease of adults, and while looked upon
as contagious, must be so to an extremely slight degree.
[Illustration: Fig. 73.
Microsporon Furfur x 400. (_After Duhring._) Showing mycelium in various
stages of development, groups of spores and free spores.]
#What is the pathology?#
The fungus, consisting of mycelium and spores, the latter showing a
marked tendency to aggregate, invades the superficial portion of the
epidermis.
#Is tinea versicolor readily diagnosticated?#
Yes; if the color, peculiar characters and distribution of the eruption
are kept in mind.
It is not to be confounded with vitiligo, chloasma, or the macular
syphiloderm. If in doubt, have recourse to the microscope.
#State the method of examination for fungus.#
The scrapings are taken from a patch, moistened with liquor potassae, and
examined with a power of three to five hundred diameters.
#State the prognosis of tinea versicolor.#
With proper management the disease is readily curable. Relapses are not
uncommon.
[Illustration: Fig. 74. Tinea versicolor.]
#What is the treatment of tinea versicolor?#
It consists in daily washing with soap and hot water (and in obstinate
cases with sapo viridis instead of the ordinary soap) and application
of a lotion of--sulphite or hyposulphite of sodium, a drachm to the
ounce; sulphurous acid, pure or diluted; carbolic acid, or resorcin,
ten to twenty grains to the ounce of water and alcohol; or corrosive
sublimate, one to three grains to the ounce of water. Sulphur and
ammoniated-mercury ointments are also serviceable. The following used
alone, simply as a soap, or in conjunction with a lotion, is often of
special value:--
[Rx] Sulphur, praecip., .................... [dram]iv
Saponis viridis, ..................... [dram]xii. M.
After the disease is apparently cured, an occasional remedial application
should be made for several months, in order to guard against the
possibility of a relapse.
#Erythrasma.#
#Describe erythrasma.#
Erythrasma is an extremely rare disease, due to the presence and growth
in the epidermic structures of the vegetable parasite--the _microsporon
minutissimum_. It is characterized by small and large, slightly
furfuraceous, reddish-yellow or reddish-brown patches, occurring usually
on warm and moist parts, such as the axillary, inguinal, anal and
genitocrural regions. It is slowly progressive and persistent, but is
without disturbing symptoms other than occasional slight itching.
[Illustration: Fig. 75.
Microsporon Minutissimum x 1000. (_After Riehl._)]
Treatment, which is rapidly effective, is the same as that employed in
tinea versicolor.
#Dhobie Itch.#
Dhobie itch is a name used in certain tropical countries to designate a
somewhat peculiar itching eruption of the genitocrural and axillary
regions, and by some also a similar eruption about the feet. It consists
of a dermatitis of variable degree, usually with a festooned, irregular
border, with considerable itching. It is believed that such cases are
variously due to the trichophyton of ringworm, to the microsporon furfur
of tinea versicolor, to the microsporon minutissimus of erythrasma, and
to other parasites.
#Actinomycosis.#
#Describe actinomycosis.#
Actinomycosis of the skin is an affection due to the ray fungus, and
characterized by a sluggish, red, nodular, or lumpy infiltration,
usually with a tendency to break down and form sinuses. The affection
may involve almost any part, but its most common site is about the jaw,
neck, and face. As a rule, the first evidence is a hard subcutaneous
swelling or infiltration, which may increase slightly or considerably.
The overlying skin gradually becomes of a sluggish or dark-red color.
Softening ensues, and the diseased area breaks down at one or more
points, from which there oozes a discharge of a sero-purulent, purulent,
or sanguinolent character. In this discharge can be usually noted
minute, friable, yellowish or yellowish-gray bodies representing
conglomerate collections of the causative fungus.
The course of the malady is commonly slow and insidious. Unless systemic
pyemic infection occurs or the fungus elements find their way to the
deeper organs or structures the general health remains apparently
undisturbed.
#What is the treatment?#
The administration of moderate to large doses of potassium iodide,
conjointly with curetting or excision of the diseased mass. Local
applications of iodine solution can also be tried.
#Blastomycetic Dermatitis.#
#What do you understand by blastomycetic dermatitis?#
Blastomycetic dermatitis is a rare disease beginning usually as a small
papule or nodule, enlarging slowly, breaking down and developing into a
verrucous or papillomatous-looking area, similar in appearance to
tuberculosis cutis verrucosa. A muco-purulent or purulent secretion can
visually be pressed out from between the papillomatous elevations. It
may also present the appearance of a serpiginous lupus vulgaris or
syphiloderm. As a rule it is slow in its course. Furuncular or
abscess-like formations may develop, usually from secondary infection.
The disease is due to the invasion of the cutaneous tissues by the
blastomyces.
[Illustration: Blastomycetic dermatitis.]
Treatment consists in administration of moderate to large doses of
potassium iodide, and in the employment of antiseptic and parasiticide
applications; usually, however, radical treatment, such as employed in
lupus vulgaris, may be necessary.
#Scabies.#
(_Synonym:_ The Itch.)
#What is scabies?#
Scabies, or itch, is a contagious animal-parasitic disease characterized
by a multiform eruption of a somewhat peculiar distribution, attended by
intense itching.
#Describe the symptoms of scabies.#
The penetration and presence of the parasites within the cutaneous
structures besides often giving rise to several or more complete or
imperfectly formed _burrows_, excite varying degrees of irritation, and
in consequence the formation of vesicles, papules and pustules,
accompanied with more or less intense itching. Secondarily, crusting,
and at times a mild or severe grade of dermatitis, may be brought about.
The parasite seeks preferably tender and protected situations, as
between the fingers, on the wrists, especially the flexor surface, in
the folds of the axilla, on the abdomen, about the anal fissure, about
the genitalia, and in females also about the nipples, and hence the
eruption is most abundant about these regions. The inside of the thighs
and the feet are also attacked, as, indeed, may be almost every portion
of the body. The scalp and face are not involved; exceptionally,
however, these parts are invaded in infants and young children.
#Is the grade of cutaneous irritation the same in all cases of scabies?#
No; in those of great cutaneous irritability, especially in children,
the skin being more tender, the type of the eruption is usually much
more inflammatory. In those predisposed a true eczema may arise, and
then, in addition to the characteristic lesions of scabies, eczematous
symptoms are superadded; in long-persistent cases, indeed, the burrows
and other consequent lesions may be more or less completely masked by
the eczematous inflammation, and the true nature of the disease be
greatly obscured.
#What do you mean by burrows?#
Burrows, or _cuniculi_, are tortuous, straight or zigzag, dotted,
slightly elevated, dark-gray or blackish thread-like linear formations,
varying in length from an eighth to a half an inch.
[Illustration: Fig. 76.
Burrow, or cuniculus, greatly magnified. (_After Kaposi._) Showing the
mite, ova, empty shells and excrement.]
#How is a burrow formed?#
By the impregnated female parasite, which penetrates the epidermis
obliquely to the rete, depositing as it goes along ten or fifteen ova,
forming a minute passage or burrow.
#Upon what parts are burrows most commonly to be found?#
In the interdigital spaces, on the flexor surface of the wrists, about
the mammae in the female, and on the shaft of the penis in the male.
#Are burrows usually present in numbers?#
No. Several may be found in a single case, but they are rarely numerous,
as the irritation caused by the penetration of the parasites leads
either to violent scratching and their destruction, or gives rise to the
formation of vesicles and pustules, and consequently their formation is
prevented.
#What course does scabies pursue?#
Chronic and progressive, showing no tendency to spontaneous
disappearance.
#To what is scabies due?#
To the invasion of the cutaneous structures by an animal parasite, the
sarcoptes scabiei (_acarus scabiei_). The male mite is never found in
the skin and apparently takes no direct part in the production of the
symptoms.
[Illustration: Fig. 77. Fig. 78.
Sarcoptes scabiei x 100.
(_After Duhring._) Female. Ventral surface. Male.]
The disease is contagious to a marked degree, and is most commonly
contracted by sleeping with those affected, or by occupying a bed in
which an affected person has slept. It occurs, for obvious reasons,
usually among the poor, although it is now quite frequently met with
among the better classes.
#State the diagnostic features of scabies.#
The burrows, the peculiar distribution and the multiformity of the
eruption, the progressive development, and usually a history of
contagion.
#How do vesicular and pustular eczema differ from scabies?#
Eczema is usually limited in extent, or irregularly distributed, is
distinctly patchy, with often the formation of large diffused areas; it
is variable in its clinical behavior, better and worse from time to
time, and differs, moreover, in the absence of burrows and of a history
of contagion.
#How does pediculosis corporis differ from scabies?#
In the distribution of the eruption. The pediculi live in the clothing
and go to the skin solely for nourishment, and hence the eruption in
that condition is upon covered parts, especially those parts with which
the clothing lies closely in contact, as around the neck, across the
upper part of the back, about the waist and down the outside of the
thighs; _the hands are free_.
#State the prognosis of scabies.#
It is favorable. The disease is readily cured, and, as soon as the
parasites and their ova are destroyed, the itching and the secondary
symptoms, as a rule, rapidly disappear.
#How is scabies treated?#
Treatment is entirely external, and consists of a preliminary
soap-and-hot-water bath, an application, twice daily for three days, of
a remedy destructive to the parasites and ova, and finally another bath.
Inquiry as to others of the family should be made, and, if affected,
treated at the same time. The wearing apparel should be looked
after--boiled, baked, or sulphur-fumigated.
#What remedial applications are employed in scabies?#