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Pediculosis (Synonyms: Phtheiriasis; Lousiness.)

Define pediculosis.

Pediculosis is a term applied to that condition of local or general cutaneous irritation due to the presence of the animal parasite, the pediculus, or louse.

Name the several varieties met with.

Three varieties are presented, named according to the parts involved, pediculosis capitis, pediculosis corporis, and pediculosis pubis; the parasite in each being a distinct species of pediculus.

Pediculosis Capitis.

Describe the symptoms of pediculosis capitis.

Pediculosis capitis (pediculosis capillitii), due to the presence of the pediculus capitis, occurs much more frequently in children than in adults. It is characterized by marked itching, and the formation of various inflammatory lesions, such as papules, pustules and excoriations— resulting from the irritation produced by the parasites and from the scratching to which the intense pruritus gives rise. In fact, an eczematous eruption of the pustular type soon results, attended with more or less crust formation. In consequence of the cutaneous irritation the neighboring lymphatic glands may become inflamed and swollen, and in rare cases suppurate. The occipital region is the part which is usually most profusely infested, more especially in young girls and women. In those of delicate skin, especially in children, scattered papules, vesico-papules, pustules, and excoriations may often be seen upon the forehead and neck. In some instances, however, especially in boys, there may be many pediculi present, with but little cutaneous disturbance, the itching being the sole symptom.

In addition to the pediculi, which, as a rule, may be readily found, their ova, or nits, are always to be seen upon the shaft of the hairs, quite firmly attached.

Describe the appearance of the ova.

They are dirty-white or grayish looking, minute, pear-shaped bodies, visible to the naked eye, and fastened upon the shaft of the hairs with the small end toward the root.

Is there any difficulty in the diagnosis of pediculosis capitis?

No. The diagnosis is readily made, as the pediculi are usually to be found without difficulty, and even when they exist in small numbers and are not readily discovered, the presence of the ova will indicate the nature of the affection.

Pustular eruptions upon the scalp, especially posteriorly, should always arouse a suspicion of pediculosis. The possibility of the pediculosis being secondary to eczema must not be forgotten.

What is the treatment of pediculosis capitis?

Treatment consists in the application of some remedy destructive to the pediculi and their ova. Crude petroleum is effective, one or two thorough applications over night being usually sufficient; in order to lessen its inflammability, and also to mask its somewhat disagreeable odor, it may be mixed with an equal part of olive oil and a small quantity of balsam of Peru added.

Tincture of cocculus indicus, pure or diluted, may also be applied with good results.

When the parts are markedly eczematous, an ointment of ammoniated mercury or β-naphthol, thirty to sixty grains to the ounce may be used.

Daily shampooing with soap and water, and the twice daily application of a five per cent. carbolic acid lotion, together with the use of a fine-toothed comb, is a safe and efficient method for dispensary practice; as it is, indeed, for any class of patients.

How are the ova or their shells to be removed from the hair?

By the frequent use of acid or alkaline lotions, such as dilute acetic acid and vinegar, or solutions of sodium carbonate and borax.

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.

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 mammæ 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 symptom

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?

Sulphur, balsam of Peru, styrax, and β-naphthol, singly or severally combined. In children, or in those of sensitive skin, the following:—

  ℞ Sulphur. præcip., ................................ ʒiv
   Balsam. Peruv., .................................. ʒij
   Adipis,
   Petrolati, .....................āā................ ℥iss.   M.

And in adults, or those of non-irritable skin:—

  ℞ Sulphur, præcip., ................................ ℥j
   Balsam. Peruv., .................................. ℥ss
   β-Naphthol, ...................................... ʒij
   Adipis,
   Petrolati, ..............āā......... q.s. ad. .... ℥iv.   M.

Styrax is a remedy of value and is commonly employed as an ointment in the strength of one part to two or three parts of lard.

Is one such course of treatment sufficient to bring about a cure?

Yes, in ordinary cases, if the applications have been carefully and thoroughly made; exceptionally, however, some parasites and ova escape destruction, and consequently itching will again begin to show itself at the end of a week or ten days, and a repetition of the treatment become necessary.

Does the secondary dermatitis which is always present in severe cases require treatment?

Only when it is unusually persistent or severe; in such cases the various soothing applications, lotions or ointments employed in acute eczema are to be prescribed.

Is a dermatitis due to too active and prolonged treatment ever mistaken for persistence of the scabies?

Yes.

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.

Treatment consists of tonics, if indicated, and the administration of arsenic, preferably hypodermically, and Röntgen-ray exposures, along with the application of mild antiseptics, and operative interference when necessary or advisable.

Pellagra (Synonym: Lombardian Leprosy.)

Describe pellagra.

Pellagra is a slow but usually progressive disease occurring chiefly in Italy, due, it is thought, to the continued ingestion of decomposed or fermented maize. It is characterized by cutaneous symptoms, at first upon exposed parts, of an erythematous, desquamative, vesicular and bullous character, and by general constitutional disturbance of a markedly neurotic type. A fatal ending, if the disease is at all severe or advanced, is to be expected.

Treatment is based upon general principles.

Syphilis Cutanea (Synonyms: Syphiloderma; Dermatosyphilis; Syphilis of the Skin.)

In what various types may syphilis manifest itself upon the integument?

Syphilis may show itself as a macular, papular (rarely vesicular), pustular, bullous, tubercular and gummatous eruption; or the eruption may be, in a measure, of a mixed type.

In what respects do the early (or secondary) eruptions of syphilis differ from those following several years or more after the contraction of the disease?

The early or secondary eruptions are more or less generalized, with rarely any attempt at special configuration. Their appearance is often preceded by symptoms of systemic disturbance, such as fever, loss of appetite, muscular pains and headache; and accompanied by concomitant signs of the disease, such as enlargement of the lymphatic glands, sore throat, mucous patches, falling of the hair and rheumatic pains.

State the distinguishing characters of the late eruptions.

The late eruptions (those following one or more years after the contraction of the disease) are usually of tubercular, gummatous or ulcerative type; are limited in extent, and have a marked tendency to appear in circular, semicircular or crescentic forms or groups. Pain in the bones, bone lesions and other symptoms may or may not be present.

What is the color of syphilitic lesions?

Usually, a dull brownish-red or ham-red, with at times a yellowish cast.

Are there any subjective symptoms in syphilitic eruptions?

As a rule, no; but in exceptional instances of the generalized eruptions, more especially in negroes, there may be slight itching.

Describe the macular, or erythematous, eruption of syphilis.

The macular syphiloderm is a general eruption, showing itself usually six or eight weeks after the appearance of the chancre. It consists of small or large, commonly pea- or bean-sized, rounded or irregularly-shaped, not infrequently slightly raised, macules. When well established they do not entirely disappear under pressure. At first a pale-pink or dull, violaceous red, they later become yellowish or coppery. The eruption is generally profuse; the face, backs of the hands and feet may escape. It persists several weeks or one or two months; as a rule, it is rapidly responsive to treatment.

How would you distinguish the macular syphiloderm from measles, rötheln and tinea versicolor?

Measles is to be differentiated by its catarrhal symptoms, fever, form and situation of the eruption; rötheln, by its small, roundish, confluent pinkish or reddish patches, its precursory pyrexic symptoms, its epidemic nature, and short duration; tinea versicolor by its scaliness, peripheral growth, distribution and history.

And, finally, by the absence or presence of other symptoms of syphilis.

What several varieties of the papular eruption of syphilis are met with?

There are two forms of the papular eruption—the small and large; those of the latter type may undergo various modifications.

Describe the small-papular eruption of syphilis.

The small-papular syphiloderm (miliary papular syphiloderm) usually shows itself in the third or fourth month of the disease, and consists of a more or less generalized eruption of disseminated or grouped, firm, rounded or acuminated pin-head to millet-seed-sized papules, with smooth or slightly scaly summits, and in some lesions showing pointed pustulation. Scattered minute pustules and some large papules are usually present. The eruption is profuse, most abundant upon the trunk and limbs; and in the early part of the outbreak is of a bright- or dull-red color, later assuming a violaceous or brownish tint. It runs a chronic course, is somewhat rebellious to treatment, and displays a tendency to relapse.

How would you distinguish the small-papular syphiloderm from keratosis pilaris, psoriasis punctata, papular eczema, and lichen ruber?

The distribution and extent of the eruption, the color, the grouping, with usually the presence of pustules and large papules and other concomitant symptoms of syphilis, are points of difference. Pustules never occur in the several diseases named, except in eczema.

Describe the large-papular eruption of syphilis.

The large-papular syphiloderm (or lenticular syphiloderm) is a common form of cutaneous syphilis, appearing usually in the first six or eight months, and consists of a more or less generalized eruption of pea- to dime-sized or larger, flat, rounded or oval, firmly-seated,

more or less raised, dull-red papules; with at first a smooth surface, which later usually becomes covered with a film of exfoliating epidermis. The papules, as a rule, develop slowly, remain stationary several weeks or a few months, and then pass away by absorption, leaving slight pigmentation, which gradually fades; or they may undergo certain modifications. In most cases it responds rapidly to treatment.

What modifications do the papules of the large-papular syphiloderm sometimes undergo?

They may change into the moist papule and squamous papule.

Describe the moist papule of syphilis.

The change into the moist papule (also called mucous patch, flat condyloma) is not uncommon where opposing surfaces and natural folds of skin are subjected to more or less contact, as about the anus, the scroto-femoral regions, umbilicus, axillæ and beneath the mammæ. The dry, flat papules gradually become moist and covered with a grayish, sticky, mucoid secretion; several may coalesce and form large, flat patches. They may so remain, or they may become hypertrophic, warty or papillomatous, with more or less crust formation (vegetating syphiloderm).

Describe the squamous papule of syphilis.

This tendency of the large-papular eruption to become scaly, when exhibited, is more or less common to all papules, and constitutes the squamous or papulo-squamous syphiloderm (improperly called psoriasis syphilitica). The papules become somewhat flattened and are covered with dry, grayish or dirty-gray, somewhat adherent scales. The scaling, as compared to that of psoriasis, is, as a rule, relatively slight. The eruption may be general, as usually the case in the earlier months of the disease, or it may appear as a relapse or a later manifestation, and be limited in extent.

As a limited eruption it is most frequently seen on the palms and soles—the palmar and plantar syphiloderm. Occurring on these parts it is often rebellious to treatment.

How are you to distinguish the papulo-squamous syphiloderm from psoriasis?

In psoriasis the eruption is more inflammatory, and usually bright red; the scales whitish or pearl-colored and, as a rule, abundant. It is generally seen in greater profusion upon certain parts, as, for instance, the extensor surfaces, especially of the elbows and knees. It is not infrequently itchy, and, moreover, presents a different history.

In the syphilitic eruption some of the papules almost invariably remain perfectly free from any tendency to scale formation; there is distinct deposit or infiltration, and the lesions are of a dark, sluggish red or ham tint; and, moreover, concomitant symptoms of syphilis are usually present.

Describe the annular eruption of syphilis.

The annular syphiloderm (circinate syphiloderm) is observed usually in association with the large-papular eruption, and consists of several or more variously sized, ring-like lesions, with a distinctly elevated solid ridge or wall peripherally and a more or less flattened centre. It is commonly seen about the mouth, forehead and neck. The lesion appears to have its origin from an ordinary, usually scaleless or slightly scaly, large papule, the central portion of which has been incompletely formed or has become sunken and flattened. The manifestation is rare, and is seen most frequently in the negro.

What several varieties of the pustular syphiloderm are met with?

The small acuminated-pustular syphiloderm, the large acuminated-pustular syphiloderm, the small flat-pustular syphiloderm, and the large flat-pustular syphiloderm.

Describe the small acuminated-pustular eruption of syphilis.

The small acuminated-pustular syphiloderm (miliary pustular syphiloderm) is an early or late secondary eruption, commonly encountered in the first six or eight months of the disease. It consists of a more or less generalized, disseminated or grouped, millet-seed-sized, acuminated pustules, usually seated upon dull-red, papular elevations. The eruption is, as a rule, profuse, and usually involves the hair-follicles. The pustules dry to crusts, which fall off and are often followed by a slight, fringe-like exfoliation around the base, constituting a grayish ring or collar. Minute pin-point atrophic depressions or stains are left, which gradually become less distinct. Scattered large pustules, and sometimes papules, are not infrequently present.

Describe the large acuminated-pustular eruption of syphilis.

The large acuminated-pustular syphiloderm (acne-form syphiloderm, variola-form syphiloderm) is a more or less generalized eruption, occurring usually in the first six or eight months of the disease. It consists of small or large pea-sized, disseminated or grouped, acuminated or rounded pustules, resembling the lesions of acne and variola. They develop slowly or rapidly, and at first may appear more or less papular. They dry to somewhat thick crusts, and are seated upon superficially ulcerated bases.

It pursues, as a rule, a comparatively rapid and benign course. In relapses the eruption is usually more or less localized.

How would you distinguish the large acuminated-pustular syphiloderm from acne and variola?

In acne the usual limitation of the lesions to the face or face and shoulders, the origin, more rapid formation and evolution of the individual lesions, and the chronic character of the disease, are usually distinctive points.

In variola, the intensity of the general symptoms, the shot-like beginning of the lesions, their course, the umbilication, and the definite duration, are to be considered.

The presence or absence of other symptoms of syphilis has, in obscure cases, an important diagnostic bearing.

Describe the small flat-pustular eruption of syphilis.

The small flat-pustular syphiloderm (impetigo-form syphiloderm) consists of a more or less generalized, pea-sized, flat or raised, discrete, irregularly-grouped, or in places confluent, pustules, appearing usually in the first year of the disease. The pustules dry rapidly to yellow, greenish-yellow, or brownish, more or less adherent, thick, uneven, somewhat granular crusts, beneath which there may be superficial or deep ulceration; where the lesions are confluent a continuous sheet of crusting forms. The eruption is often scanty. It is most frequently observed about the nose, mouth, hairy parts of the face and scalp, and about the genitalia, frequently in association with papules on other parts.

Are you likely to mistake the small flat-pustular syphiloderm for any other eruption?

Scarcely; but when upon the scalp, it may bear rough resemblance to pustular eczema, but the erosion or ulceration will serve to differentiate. Moreover, concomitant symptoms of syphilis are to be looked for.

Describe the large flat-pustular eruption of syphilis.

The large flat-pustular syphiloderm (ecthyma-form syphiloderm) consists of a more or less generalized, scattered eruption, of large pea- or dime-sized, flat pustules. They dry rapidly to crusts. The bases of the lesions are a deep-red or copper color. Two types of the eruption are met with.

In one type—the superficial variety—the crust is flat, rounded or ovalish, of a yellowish-brown or dark-brown color, and seated upon a superficial erosion or ulcer. The lesions are usually numerous, and most abundant on the back, shoulders and extremities. It appears, as a rule, within the first year, and generally runs a benign course.

In the other type—the deep variety—the crust is greenish or blackish, is raised and more bulky, often conical and stratified, like an oyster shell—rupia; beneath the crusts may be seen rounded or irregular-shaped ulcers, having a greenish-yellow, puriform secretion. It is usually a late and malignant manifestation.

How would you differentiate the large flat-pustular syphiloderm from ecthyma?

The syphilitic lesions are more numerous, are scattered, are attended with superficial or deep ulceration, and followed by more or less scar-formation. Moreover, the history, and presence or absence of other symptoms of syphilis have an important diagnostic value.

Ainhum.

Describe ainhum.

Ainhum is a disease of the African race, met with chiefly in Brazil, the West Indies, and Africa, and consists of a slow but gradual linear strangulation of one or more of the toes, especially the smallest, resulting, eventually, in spontaneous amputation. The affected toes themselves undergo fatty degeneration, often with increase in size, and are, when strangulation is well advanced, considerably misshapen. The nature of the disease is obscure.

Treatment consists, in the early stages, of incision through the constricting band; when the disease is well advanced, amputation is the sole recourse.

Tuberculosis Cutis (Synonym: Scrofuloderma.)

The most important clinical variety of this class is lupus vulgaris, which is considered above, separately, at some length.

What do you understand by tuberculosis cutis?

The term is applied to those peculiar suppurative and ulcerative conditions of the skin due to the tubercle bacilli.

How does the common type of tuberculosis cutis begin?

The most common type of tuberculous ulceration or involvement of the skin usually results by extension from an underlying caseating and suppurating lymphatic gland; or it may have its origin as subcutaneous tubercles independently of these structures. It tends to spread, and may involve an area of one or several inches.

What are the clinical appearances and behavior of this type of tuberculous ulceration?

It is usually superficial, has thin, red, undermined edges of a violaceous color, and an irregular base with granulations covered scantily with pus. As a rule, it spreads gradually as a simple ulceration, with but slight, if any, outlying infiltration. Subjective symptoms of a painful or troublesome character are rarely present. Its course is usually progressive but slow and chronic.

Other symptoms of tuberculosis are commonly to be found.

Are other forms of tuberculosis cutis met with?

A papulo-pustular eruption is sometimes observed, especially on the upper extremities and face; sluggish and chronic in character and leaving small pit-like scars; has been known as the small pustular scrofuloderma.

An ulcerative papillomatous or verrucous tuberculosis of the skin (tuberculosis verrucosa cutis) is also occasionally noted, most commonly seated upon the lower leg or the back of the hand. It may be slight or extensive. Its mildest phase is the so-called verruca necrogenica.

Describe verruca necrogenica.

Verruca necrogenica is a rare, localized, papillary or wart-like formation, occurring usually about the knuckles or other parts of the hand.

It begins, as a rule, as a small, papule-like growth, increasing gradually in area, and when well advanced appears as a pea, dime-sized or larger, somewhat inflammatory, elevated, flat, warty mass, with usually a tendency to slight pus-formation between the hypertrophied papillæ; the surface may be horny or it may be crusted. It tends to enlarge slowly and is usually persistent, but it at times undergoes involution.

State the etiology.

Heredity, insufficient and unwholesome food, impure air, and the like are predisposing. The tubercle bacillus is the immediate exciting cause.

The disease usually appears in childhood or early adult life, and not infrequently follows in the wake of some severe systemic disease. Etiologically it is identical in nature with lupus.

How is the tuberculous ulcer to be differentiated from syphilis?

By the peculiar character of the tuberculous ulceration, the absence of outlying tubercles and infiltration, together with its history, course, and often the presence of other tuberculous symptoms.

State the prognosis.

These various types of tuberculosis cutis are, as a rule, more amenable to treatment than that form known as lupus vulgaris (q. v.).

What is the treatment of these forms of tuberculosis cutis?

Constitutional remedies, such as cod-liver oil, iodide of iron or other ferruginous tonics, together with good food and pure air; phosphorus one-hundredth to one-fiftieth of a grain three times daily is also of benefit in some cases.

The local treatment consists in thorough curetting and the subsequent application of a mildly stimulating ointment. The several other plans of external treatment employed in lupus (q. v.) are also variously practised. In recent years the x-ray and Finsen light plans have, in a measure, supplanted the previous methods of treatment. They are slow, however, and might be, especially the x-ray, more satisfactorily employed as a supplementary measure.

Lymphangioma (Synonym: Lymphangiectodes.)

Describe lymphangioma.

Lymphangioma is a rare disease, consisting of localized dilatations of the lymphatic vessels, appearing as discrete or aggregated pin-head or pea-sized, compressible, hollow, tubercle-like elevations, of a pinkish or faint lilac color, and occurring for the most part about the trunk. It is of slow but usually progressive development, and is unaccompanied by subjective symptoms.

A rare condition, Kaposi described as lymphangioma tuberosum multiplex, characterized by more or less solid, somewhat cystic, pearly to pinkish red, sometimes crowded lesions, is now known to be “benign cystic epithelioma”; its most common site is the face. While called “benign,” ulcerative action may eventually ensue.

Treatment, when demanded, consists of operative measures.

Myoma (Synonyms: Myoma Cutis; Dermatomyoma; Liomyoma Cutis.)

Describe myoma.

The disease is rare, and consists usually of one or several (exceptionally numerous), variously-sized tumors of the skin, made up of smooth muscular fibres. They are flat, rounded, oval or pedunculated, and have a smooth surface and a pale-red color; as a rule, they are painless.

The growth is benign, and consists essentially of a new formation of unstriped muscular fibres; but it may also be composed largely of connective tissue (fibromyoma); or it may contain an abundance of bloodvessels (myoma telangiectodes, angiomyoma); or there may be lymphatic involvement (lymphangiomyoma).

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.

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.

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.

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 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 seborrhœa, 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.

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.

Alopecia Areata (Synonyms: Area Celsi; Alopecia Circumscripta.)

What do you understand by 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.

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 ammoniæ, and oil of turpentine. The following is a safe formula, especially in dispensary and ignorant class practice:

  ℞ β-naphthol, ...................................... ʒss-ʒj
     Ol. cadini, .................................... ʒj
   Ungt. sulphuris, ................. q.s. ad. ...... ℥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.

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 seborrhœa or seborrhœic 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:—

  ℞ Tinct. cantharidis, ............................. fʒiv
   Tinct. capsici, ................................. f℥j
   Ol. ricini, ..................................... fʒss-fʒj
   Alcoholis, ................. q.s. ad. ........... f℥iv.   M.

The following is sometimes beneficial:—

  ℞ Resorcin, ........................................ gr. lxxx
   Quininæ (alkaloid), .............................. gr. xv
   Ol. ricini, ...................................... ♏v-♏xx
   Alcoholis, ...................................... f℥iv.  M.

Another excellent formula is:

  ℞ Resorcin, ........................................ gr. lxxx-cxx
   Ac. carbolici cryst., ............................ gr. xx
   Spts. myrciæ, ................................... f℥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.)

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 præmatura). 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.

Vitiligo (Synonyms: Leucoderma; Leucopathia.)

Give a definition of vitiligo.

Vitiligo may be defined as a disease involving the pigment of the skin alone, characterized by several or more progressive, milky-white patches surrounded by increased pigmentation.

Describe the symptoms of vitiligo.

The disease may begin at one or more regions, the backs of the hands, trunk and face being favorite parts; its appearance is usually insidious, and the spots may not be especially noticeable until they are the size of a pea or larger. The patches grow slowly, are milky or dead white, smooth, non-elevated, and of rounded outline; the bordering skin is darker than normal, showing increased pigmentation. Several contiguous spots may coalesce and form a large, irregularly-shaped patch. Hair growing on the involved skin may or may not be blanched.

There are no subjective symptoms.

What course does vitiligo pursue?

The course of the disease is slow, months and sometimes years elapsing before it reaches conspicuous development. It may after a time remain stationary, or, in rare instances, retrogress; as a rule, however, it is progressive. Exceptionally, the greater part, or even the whole surface may eventually be involved.

Give the etiology of vitiligo.

Disturbed innervation is thought to be influential. The disease develops often without apparent cause. Alopecia areata and morphœa have been observed associated with it.

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 morphœa and from the anæsthetic patches of leprosy.

In what respects do these diseases differ from vitiligo?

In morphœa 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:—

  ℞ Liq. potassii arsenitis, ........................ fʒj
   Tinct. nucis vom., .............................. fʒiij
   Elix. calisayæ, ............... q.s. ad. ........ f℥iv.   M.
 SIG.—fʒj 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 hyperæmia 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.

Dermatolysis (Synonym: Cutis Pendula.)

Give a descriptive definition of dermatolysis.

Dermatolysis is a rare disease, consisting of hypertrophy and looseness of the skin and subcutaneous connective tissue, with a tendency to hang in folds.

Describe the symptoms and course of dermatolysis.

It may be congenital or acquired, and maybe limited to a small or large area, or develop simultaneously at several regions. All parts of the skin, including the follicles, glands and subcutaneous connective and areolar tissue, share in the hypertrophy; and this in exceptional instances may be so extensive that the integument hangs in folds. The enlargement of the follicles, natural folds and rugæ gives rise to an uneven surface, but the skin remains soft and pliable. There is also increased pigmentation, the integument becoming more or less brownish.

What course does dermatolysis pursue?

Its development is slow and usually progressive. It gives rise to no further inconvenience than its weight and consequent discomfort.

Give the etiology.

The etiology is obscure. It is considered by some authors as allied to molluscum fibrosum, and, in fact, as a manifestation of that disease, ordinary molluscum tumors sometimes being associated with it. It is not malignant.

What is the pathology?

The disease consists of a simple hypertrophy of all the skin structures and the subcutaneous connective tissue.

What is the treatment of dermatolysis?

Excision when advisable and practicable.

Albinismus

What do you understand by albinismus?

Congenital absence, either partial or complete, of the pigment normally present in the skin, hair and eyes.

Describe complete albinismus.

In complete albinismus the skin of the entire body is white, the hair very fine, soft and white or whitish-yellow in color, the irides are colorless or light blue, and the pupils, owing to the absence of pigment in the choroid, are red; this absence of pigment in the eyes gives rise to photophobia and nystagmus. Albinos—a term applied to such individuals—are commonly of feeble constitution, and may exhibit imperfect mental development.

Describe partial albinismus.

Partial albinismus is met with most frequently in the colored race. In this form of the affection the pigment is absent in one, several or more variously-sized patches; usually the hairs growing thereon are likewise colorless.

Is there any structural change in the skin?

No. The functions of the skin are performed in a perfectly natural manner, and microscopical examination shows no departure from normal structure save the complete absence of pigment.

What is known in regard to the etiology?

Nothing is known of the causes producing albinismus beyond the single fact that it is frequently hereditary.

Does albinismus admit of treatment?

No; the condition is without remedy.

Elephantiasis (Synonyms: Elephantiasis Arabum; Pachydermia; Barbadoes Leg; Elephant Leg.)

Give a descriptive definition of elephantiasis.

Elephantiasis is a chronic hypertrophic disease of the skin and subcutaneous tissue characterized by enlargement and deformity, lymphangitis, swelling, œdema, thickening, induration, pigmentation, and more or less papillary growth.

What parts are commonly involved in elephantiasis?

Usually one or both legs; occasionally the genitalia; other parts are seldom affected.

Describe the symptoms of elephantiasis.

The disease usually begins with recurrent (at intervals of months or years) erysipelatous inflammation, with swelling, pain, heat, redness and lymphangitis; after each attack the parts remain somewhat increased in size, although at first not noticeably so. After months or one or two years the enlargement or hypertrophy becomes conspicuous, the part is chronically swollen, œdematous and hard; the skin is thickened, the normal lines and folds exaggerated, the papillæ enlarged and prominent, and with more or less fissuring and pigmentation.

What is the further course of the disease?

There is gradual increase in size, the parts in some instances reaching enormous proportions; the skin becomes rough and warty, eczematous inflammation is often superadded, and, sooner or later, ulcers, superficial or deep, form—which, together with the crusting and moderate scaliness, present a striking picture. There may be periods of comparative inactivity, or, after reaching a certain development, the disease may, for a time at least, remain stationary.

Are there any subjective symptoms?

A variable degree of pain is often noted, especially marked during the inflammatory attacks. The general health is not involved.

State the cause of elephantiasis.

The etiology is obscure. The disease rarely occurs before puberty. It is most common in tropical countries, more especially among the poor and neglected. It is not hereditary, nor can it be said to be contagious. Inflammation and obstruction of the lymphatics, probably due, according to late investigations, to the presence of large numbers of filaria (microscopic thread-worms) in the lymph channels and bloodvessels, is to be looked upon as the immediate cause.

What is the pathology?

All parts of the skin and subcutaneous connective-tissue are hypertrophied, the lymphatic glands are swollen, the lymph channels and bloodvessels enlarged, and there is more or less inflammation, with œdema. Secondarily, from pressure, atrophy and destruction of the skin-glands, and atrophic degeneration of the fat and muscles result.

What are the diagnostic characters of beginning elephantiasis?

Recurrent erysipelatous inflammation, attended with gradual enlargement of the parts.

The appearances, later in the course of the disease, are so characteristic that a mistake is scarcely possible.

Give the prognosis of elephantiasis.

If the case comes under treatment in the first months of its development, the process may probably be checked or held in abeyance; when well established, rarely more than palliation is possible.

What is the treatment of elephantiasis?

The inflammatory attacks are to be treated on general principles. Quinia, potassium iodide, iron and other tonics are occasionally useful; and, especially in the earlier stages, climatic change is often of value. Between the inflammatory attacks the parts are to be rubbed with an ointment of iodine or mercury, together with galvanization of the involved part.

In elephantiasis of the leg, a roller or rubber bandage, or the gum stocking, is to be worn; compression and ligation of the main artery, and even excision of the sciatic nerve, have all been employed, with more or less diminution in size as a result. In elephantiasis of the genitalia, if the disease is well advanced, excision or amputation of the parts is to be practised.

Eczematous inflammation, if present, is to be treated with the ordinary remedies.

Sclerema Neonatorum (Synonyms: Scleroderma Neonatorum; Sclerema of the Newborn.)

What is sclerema neonatorum?

Sclerema neonatorum is a disease of infancy, showing itself usually at or shortly after birth, and is characterized by a diffuse stiffness and rigidity of the integument, accompanied by coldness, œdema, discoloration, lividity and general circulatory disturbance.

Describe the symptoms, course, nature and treatment of sclerema neonatorum.

As a rule the disease first manifests itself upon the lower extremities, and then gradually, but usually rapidly, invades the trunk, arms and face. The surface is cold. The skin, which is noted to be reddish, purplish or mottled, is œdematous, stiff and tense; in consequence the infant is unable to move, respires feebly and usually perishes in a few days or weeks. In extremely exceptional instances the disease, after involving a small part, may retrogress and recovery take place.

The disease is rare, and in most cases is found associated with pneumonia and with affections of the circulatory apparatus.

Treatment should be directed toward maintaining warmth and proper alimentation.

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