Part 17
Hygienic measures are important. Chaulmoogra oil and gurjun oil internally and externally are in some instances of service. Strychnia alone, or with either of these oils, is ofttimes beneficial. Ichthyol internally, and external applications of the same drug, and of resorcin, chrysarobin, and pyrogallic acid, have been extolled. Change of climate, especially to a region where the disease does not prevail, is often of great advantage.
#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.
#Epithelioma.# (_Synonyms:_ Skin Cancer; Epithelial Cancer; Carcinoma Epitheliale.)
#What several varieties of epithelioma are met with?#
Three--the superficial, the deep-seated, and the papillomatous.
#Describe the clinical appearances and course of the superficial variety of epithelioma.#
The superficial, or flat variety (_rodent ulcer_), begins, usually on the face, as a minute, firm, reddish or yellowish tubercle, as an aggregation of such, as a warty excrescence, or as a localized degenerative seborrh[oe]ic patch. The latter lesion (known also as keratosis senilis, old-age atrophic patches), consisting of a yellowish or yellowish-brown greasy or hardened scurfy spot or patch is quite frequently the starting-point of epithelial growths. Sooner or later, commonly after months or several years, the surface becomes slightly excoriated, and an insignificant, yellowish or brownish crust is formed. The excoriation gradually develops into superficial ulceration, and the diseased area becomes slowly larger and larger. New lesions may continue, from time to time, to appear about the edges and go through the same changes.
The ulcer has usually an uneven surface, secretes a thin, scanty, viscid fluid, which dries to a firm, adherent crust. It is usually defined against the healthy skin by a slightly elevated, hard, roll-like, waxy-looking border. In rare instances there is a disposition, at points, to spontaneous involution and scar formation; as a rule, however, the ulcerative action slowly progresses.
The general health is unimpaired, the neighboring lymphatic glands are not involved, and the local condition, beyond the disfigurement, gives rise to little trouble, unless, as occasionally happens, it passes into the more malignant, deep-seated variety.
#Describe the clinical appearances and course of the deep-seated variety of epithelioma.#
The deep-seated variety starts from the superficial form, or it begins as a tubercle or nodule in the skin. When typically developed, a reddish, shining tubercle or nodule, or area of infiltration, forms in the skin or subcutaneous tissue. In the course of weeks or months superficial or deep-seated ulceration takes place; the ulcer having hardened, and, as a rule, everted edges. The surface is reddish and granular, and secretes an ichorous discharge. The infiltration spreads, the ulcer enlarges both peripherally and in depth--muscle, cartilage and bone often becoming invaded. The neighboring lymphatic gland may become implicated, pains of a burning or neuralgic type are experienced, and from septicæmia, marasmus, or involvement of vital parts, death eventually ensues.
#Describe the clinical appearances and course of the papillomatous variety of epithelioma.#
The papillomatous type usually arises from the superficial or deep-seated variety, or it may begin as a papillary or warty growth. When fully developed, it presents an ulcerated, fissured and papillomatous surface, with an ichorous discharge which dries to crusts. It is slowly progressive, and sooner or later may develop a malignant tendency.
#Upon what parts is epithelioma commonly observed?#
About the face, especially the nose, eyelids and lips; and also about the genitalia. It may involve any part.
#At what age is epithelioma usually noted?#
It is essentially a disease of middle and late life, although it is exceptionally met with in the young.
#What is the cause of epithelioma?#
The etiology is obscure. It is not, as a rule, inherited. Any locally irritated tissue may be the starting point of the disease.
#State the pathology.#
The process consists in the proliferation of epithelial cells from the mucous layer; the cell-growth takes place downward, in the form of finger-like prolongations or columns, or it may spread out laterally, so as to form rounded masses, the centres of which usually undergo horny transformation, resulting in the formation of onion-like bodies, the so-called cell-nests or globes. The rapid cell-growth requires increased nutriment, and hence the bloodvessels become enlarged; moreover, the pressure of the cell-masses gives rise to irritation and inflammation, with corresponding serous and round-cell infiltration.
#How would you distinguish epithelioma from syphilitic ulceration, wart, and lupus vulgaris?#
From syphilis it is to be differentiated by the history, duration, character of the base and edges, its comparative slow progress, its usually slight, viscid discharge, often streaked with blood, and, if necessary, by the therapeutic test.
Wart or warty growths are to be differentiated by attention to their history and course. Long-continued observation may be necessary before a positive opinion is warrantable. The appearance of any tendency to crusting, to break down or ulcerate is significant of epitheliomatous degeneration.
In lupus vulgaris the deposits are peculiar and multiple, the ulcerations are of different character, the tendency to scar-formation constant; and, with few exceptions, it has, moreover, its beginning in childhood or early adult life.
#What factors are to be considered in giving a prognosis in epithelioma?#
The variety, extent, and rapidity of the process. The superficial form may exist for years, and give rise to no alarm; whereas the deeper-seated varieties are always to be viewed as serious, and are, indeed, often fatal. Involving the genitalia, its course is often strikingly rapid. Relapses, after removal, are not uncommon.
#What is the special object in view in the treatment of epithelioma?#
Thorough destruction or removal of the epitheliomatous tissue.
#How is the destruction or removal of the epitheliomatous tissue effected?#
By the use of such caustics as caustic potash, chloride-of-zinc paste, pyrogallic acid, arsenic, and the galvano-cautery; and by operative measures, such as excision and erasion with the dermal curette, and by the _x_-ray. (See treatment of lupus vulgaris.)
In small lesions the use of an arsenical paste is a most admirable method of treatment, although somewhat painful. The paste is made of one part powdered acacia and one to two parts arsenious acid; at the time of application sufficient water is added to make a paste. This is applied thickly, and a piece of lint superimposed. A good deal of pain and inflammatory swelling ensue; at the end of twenty-four hours the part is poulticed till the slough comes away; the ulcer is then treated as a simple ulcer, under which healing takes place. Occasionally a second application is found necessary.
Upon the whole, the best method in the average case is to curette 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 Röntgen 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.
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.
#CLASS VII.--NEUROSES.#
#Hyperæsthesia.#
#What is hyperæsthesia?#
By hyperæsthesia 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.
#Anæsthesia.#
#What is anæsthesia?#
Anæsthesia 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 vulvæ_) 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 vulvæ 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 Gylcerinæ, ........................... f[dram]ij Alcoholis, ........................... f[oz]ij Aquæ, ......... 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 vulvæ_, 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 vulvæ, 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 hyperæmic 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.
#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 Schönleinii_. 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.