Chapter II: The Peculiarities of Certain Accidental Acute and Chronic Diseases (15)

Cornu cutaneum (syn., cornu humanum, horny tumor) is characterized by the development of a true horny formation of variable size and shape, {664} arising from the skin. The growth bears a striking similarity to the horns of the lower animals. It is a solid, dry, harsh, somewhat brittle formation, usually more or less tapering, conical, or rounded, crooked or twisted, with a laminated, irregular, and fissured surface, and of a grayish-yellow or brownish color. Horns vary as to size and form, being a few lines or several inches in length, with a broad base, and tapering toward the end. They may be broad and flat or elongate. They have a flattened or concave base resting directly upon the skin, with the underlying and surrounding tissue normal, slightly elevated, or inflamed and undergoing epithelial degeneration. In some cases the papillæ are much enlarged and extend up into the growth. Ordinarily, there is present but one growth, but in some instances several or a dozen or more have been observed in a single case. The face and scalp are favorite regions, and to a less degree the male genitalia. As a rule, the horns are painless, but if injured more or less pain is usually experienced about the base. They rarely develop before middle age, attain a certain size, and then tend to loosen and fall off, disclosing an ulcerating base, from which a new growth is usually reproduced. Epitheliomatous degeneration is not an uncommon sequela.

Anatomically, the growth has its origin in the deeper layers of the stratum mucosum, either from that lying directly over the papillæ or from that lining the follicles and glands. It is essentially an epidermic hypertrophy, similar or closely related to warty formation. A variable degree of papillary hypertrophy, the papillæ running up into the base of the horn, is invariably present, and precedes, doubtless, the horny outgrowth. The horny cells are massed together to form columns, and in the columns themselves are concentrically arranged. Blood-vessels also appear in the base of the growth. There can be no difficulty in the diagnosis. In regard to prognosis the possibility of degeneration into epithelioma is to be kept in view. If the horn becomes detached or is knocked off, it is almost invariably reproduced. Properly managed, horns are easily removed and permanent freedom assured. The possibility of epitheliomatous degeneration, as well as their unsightliness, demands active treatment. The formation is to be detached and the base thoroughly scraped with the dermal curette, and pyrogallic acid or arsenious acid applied, as in epithelial cancer; or it may be cauterized with zinc chloride or caustic potash. The galvano-cautery is also efficient, while in some cases excision may prove the best method of treatment. If the base is properly treated, a return of the growth rarely occurs.

Verruca.

Verruca, or wart, is a hard or soft, rounded, flat, or acuminated, circumscribed epidermal and papillary formation. There are several forms of warts. The most common variety, verruca vulgaris, is seen mostly upon the hands. It is usually split-pea-sized, elevated, circumscribed, rounded, with a broad base. At first there may be epidermal hypertrophy, but later this in a measure disappears, and the hypertrophic papillæ constitute the growth and are seen as minute elevations. It is firm, hard, or horny, and the color is ordinarily the same as the {665} surrounding skin, but at times it is darker. The papillæ forming a wart are sometimes so irregularly developed as to make it appear lobulated, causing a cauliflower-like form. One, several, or great numbers may be present. Another form is verruca plana, or flat wart, differing from the ordinary wart described above in being flat and broad. It is usually the size of a split pea or finger-nail; occurs most frequently upon the back, especially in elderly people; and is usually brownish or blackish in color, constituting verruca senilis and keratosis pigmentosa. Verruca filiformis, a third variety, is a thread-like formation, usually about an eighth of an inch in length, occurring singly or in groups, and generally about the face, eyelids, and neck. Verruca digitata, another form, is mostly observed upon the scalp, and occurs as a slightly elevated formation, varying in size from a pea to a finger-nail, and marked by digitations, especially noticeable about the border.

Verruca acuminata (syn., venereal wart, pointed wart, moist wart, fig wart, pointed condyloma, cauliflower excrescence; verruca elevata) consists of one or more groups of acuminated or irregularly-shaped elevations, usually so closely packed together as to form a more or less solid mass of vegetations. At times they present an appearance of granulation tissue. In color they are usually pinkish or reddish, and are seen mainly about the genitalia, more particularly about the glans penis, on the inner side of the prepuce, and about the labia, and more rarely about the arms, axillæ, umbilicus, and toes. They are dry or moist according to the regions about which they occur and to other circumstances. The secretion from the moist formation is yellowish and of a puriform character, undergoing rapid decomposition and giving rise to a penetrating and often disgusting odor. They are seen both in men and women, especially in young people; develop rapidly, at times attaining the size of a fist; and variously resemble the cauliflower, cock's-comb, fungi, or raspberries.

The etiology of warts is not known. They are common to both sexes, and are much more frequent in the young. The various causes which, in the popular mind, are capable of producing these growths are merely conjectural, and in most instances have no foundation in fact. The acuminated wart is usually caused by irritating secretions. Anatomically, a wart consists of a connective-tissue growth as a basis, with papillary and slight epidermic hypertrophy, the interior of the growth containing vascular loops. In the acuminated or venereal wart there is considerable connective-tissue growth, the papillæ being markedly enlarged, the cells of the mucous layer highly developed, and the vascular supply abundant.

There is rarely any difficulty in the diagnosis, as the formations are well known and their characters pronounced. Prognosis is favorable; as a rule, the growths respond rapidly to treatment; at times, however, they prove obstinate. When they exist in numbers it is best to remove a part only of the whole manifestation at a time. Occasionally removal of several will be followed by spontaneous disappearance of the others. In some cases, indeed, after existing a shorter or longer period, they tend to disappear without treatment.

Excision by means of the curved scissors or a knife in some cases will be found the best method of dealing with them, their bases immediately after the operation being touched with nitrate of silver. {666} Caustics, such as potassa, chromic acid, nitric acid, and acetic acid, may be employed, but strong remedies should be applied with care. Touching the growths frequently with a 10 to 20 per cent. solution of salicylic acid or a salicylic-acid plaster of the same strength, constantly applied, will be found useful. Multiple flat warts may be treated with a paste of precipitated sulphur and equal parts of acetic acid and glycerin, prepared at the time of using. In obstinate and relapsing cases the internal use of arsenic has been recommended. Stimulating powders and lotions, such as calomel, burnt alum, powdered savine, solution of chlorinated soda, and carbolic acid, may be used in the acuminated variety.

Nævus Pigmentosus.

Nævus pigmentosus, commonly called mole, is a circumscribed pigmentary deposit in the skin. In addition to hypertrophy of pigment there may also be hypertrophy of one or of all of the other cutaneous structures, especially of the hair. When the surface of the nævus is normal and smooth it is termed nævus spilus; if there is a growth of hair upon it, nævus pilosus; if the connective tissue is increased, forming growths of variable dimensions, it is designated nævus lipomatodes; if the surface is rough and warty, nævus verrucosus. Moles may be congenital or acquired, usually the former. As ordinarily met with, they are rounded, of the size of a coffee-grain, the color varying from a light yellowish-brown to a chocolate or black. The trunk, neck, back and face are favorite localities. One or more may be present, usually upon different parts of the body, or in exceptional cases following nerve-tracts. When once formed there is little tendency to change. They occur with equal frequency in both sexes. Anatomically, there is found an increase in the natural coloring-matter of the skin, and in almost all cases variable degrees of connective-tissue hypertrophy. Enlargement of the papillæ gives rise to nævus verrucosus, and an increase in size and numerically of the hair-bulbs constitutes nævus pilosus.

Treatment of a nævus consists in its removal by means of caustics or the knife. The small and flat lesions may be removed with potassa or the ethylate of sodium; a 1 per cent. solution of corrosive sublimate, applied for a few hours by means of compresses, causes blistering and usually the removal of the pigment. Excision or thorough cauterization may be employed for nævus verrucosus and nævus lipomatodes. The galvano-caustic has also been advocated.

Ichthyosis.

Ichthyosis, also called xeroderma and fish-skin disease, is a chronic, hypertrophic disease, usually occupying the whole surface, characterized by dryness or scaliness of the skin, with a variable amount of papillary growth. There are two varieties of the disease,--ichthyosis simplex and ichthyosis hystrix, arbitrary divisions, however, employed to designate the milder and more severe forms respectively.

The milder variety is that which is usually encountered. In this form {667} the disorder may be so trifling in character as to give rise to simple dryness or harshness of the integument,--a condition to which the term xeroderma has been given. In others the process may be more developed, and the scales somewhat thick, having a polygonal or plate-like form. When the latter is the case, the form and size of the plates are usually determined by the natural lines or furrows of the parts. The scaling may be merely thin and bran-like or thick and horny, resembling fish-scales. In the milder forms of this variety the color of the scales may be light and pearly; when more or less thickly developed, may be dark, even olive-green or blackish. This color cannot be attributed entirely to extraneous matter, pigment-granules having been demonstrated in the scales. The amount of scaling depends somewhat upon the age of the patient, the severity of the disease, and also the frequency of ablutions. If the scales are allowed to accumulate, they may become enormously thickened. The disease is found most developed upon the extensor surfaces of the upper and lower extremities, especially the latter, the flexor surfaces in mild cases being free. The scales are firmly attached, but can usually be removed without injury to the underlying parts.

In the other variety of the disease--ichthyosis hystrix--in addition to excessive formation of scales there is marked papillary hypertrophy, at times the papillary outgrowths reaching several lines, bearing resemblance to the quills of a porcupine. This resemblance has given rise to the qualifying term hystrix. This variety of the disease is not apt to be so generalized as the milder variety. It is not infrequently seen to occur as one or more rounded, irregular or linear patches, solid, corrugated, warty or spinous in character. The patches may exist close together or widely separated or along nerve-tracts, and the other parts of the surface may exhibit the milder variety.

Ichthyosis is usually first noticed in the early months of childhood, from which time it becomes progressively worse until it reaches a certain point, and then usually remains stationary throughout life. It is common to both sexes. The scalp and face usually escape. The condition is affected favorably by warm weather, so much so that the milder forms of the disease disappear entirely during the summer, to reappear as soon as the cold season begins. Even the severer forms of the affection disappear to some extent during the warm months. This change is due to the activity of the glands in the summer, the secretions macerating the epidermis, rendering the removal easy and thus relieving the patient. Unless the affection is well marked subjective symptoms rarely exist, but slight itching is sometimes present. In the well-developed cases, however, the scales may become so thick and the hypertrophy so marked as to interfere with the natural mobility of the parts, or as a result of motion fissures may occur. The general health of patients suffering with ichthyosis is usually noted to be good.

The causes of the disease are not clearly understood. An hereditary tendency is frequently traceable. The affection is to be looked upon more in the light of a deformity than as a disease. Although it does not manifest itself, as a rule, until the end of the first or second year, it is nevertheless to be considered, in most instances at least, as born with the individual. The disease is so slight in the beginning that in view of the repeated ablutions that infants are subjected to it might {668} exist slightly in the first months of life without being noted. Race and climate have been stated as important factors in its production. It will be found, however, that where it exists in any great proportion, as in Paraguay and in the Moluccas, for various reasons intermarrying among the natives is the practice, and it is unquestionably a natural consequence that a distinctly hereditary disease should become frequent under such conditions. In this country the disease in its marked form is comparatively rare.

Anatomically, a constant feature of the disease is epidermic hypertrophy. This may be slight or marked according to the severity of the process. There is usually also considerable hypertrophy of the papillæ. In some cases, in addition to these conditions the rete may found hypertrophied, the blood-vessels dilated, the hair-follicles and the sweat and sebaceous glands more or less involved. The features of the disease--the harsh, dry skin, the hypertrophy of the epidermis and papillæ, the furfuraceous or plate-like scaliness, the greater development of the affection upon the extensor surfaces, and the history--are so characteristic that a diagnosis is a matter of no difficulty. From psoriasis, scaly eczema, and the other inflammatory scaly disorders it may be distinguished by the absence of inflammation.

The prognosis of the affection, as already intimated, is unfavorable as regards its cure. In only a few cases has a cure been noted. Hebra reports two such cases, the disappearance of the affection having followed an attack of one of the exanthematous fevers. Internal treatment is very rarely, if at all, of any benefit. Some good has been stated to follow the administration of linseed oil. In a few cases under observation jaborandi in moderate doses has temporarily influenced the disease favorably, probably by increasing the action of the sweat-glands. Although the prospect of a cure is entirely unfavorable, the affection may be, in almost all cases, kept in abeyance by external measures. Oily applications, soaps, and frequent bathing are the measures to be advised. In mild cases simple baths, frequently repeated, will suffice. In others it may be necessary to make the bath alkaline by the addition of bicarbonate of sodium, three to six ounces to the bath: the patient should soak in the bath for thirty minutes or longer. Where the alkaline baths seem unsuitable or fail to benefit sufficiently, the hot bath and washing with sapo viridis may be employed. The vapor bath is particularly serviceable in these cases. Rubbing in some mild ointment, allowing it to remain a few hours or longer, and then following it with a hot bath and green-soap washing, subsequently rinsing with simple warm or hot water, and then again anointing the surface with the ointment, will be found valuable in the more severe cases. An ointment such as the following may be employed for this purpose:

Rx. Adipis benz., ounce j;
Glycerinæ, drachm j;
Ugt. petrolei, ounce j.

M. Ft. ugt.--Apply after bathing.

Or,

Rx. Potassii iodidi, scruple j;
Glycerinæ, drachm j;
Adipis benz.,
Ol. bubuli, aa. ounce ss.

M. Ft. ugt.--Apply once daily.

Or any simple oil or salve may be substituted. In the more severe cases {669} of the hystrix variety, in addition to the measures already described, it may be necessary to employ caustics, or even the knife, for the removal of the horny patches which form. For localized patches a 10 to 20 per cent. salicylic-acid plaster will be found useful. For the general scaliness the same drug in ointment form, 5 to 10 per cent., will prove of benefit.

Onychauxis.

Onychauxis (syn., onychogryphosis, hypertrophy of the nail) is seen as an idiopathic affection and also as a consequence or accompaniment of other diseases. The hypertrophy may consist in excessive length, width, thickness, or all combined. In addition to the increase in size, the nails may be abnormal as regards their shape, being twisted, conical or curved, their surface roughened, uneven or furrowed, and may also be attended with changes in color and consistence. If the hypertrophy increases the width to any marked extent, the parts encroached upon become irritated and inflamed, resulting in paronychia. At times the matrix may be the seat of inflammation, giving rise to structural changes in the nail-substance,--onychia. One, several, or all the nails, both of the fingers and toes, more frequently the latter, may be involved. Hypertrophy of the nail is met with in eczema, psoriasis, ichthyosis, leprosy and syphilis, and also as a result of the invasion of the vegetable parasites of tinea trichophytina and favus. The rare diseases lichen ruber and pityriasis rubra may also involve the nails. In syphilis infiltration of the matrix gives rise to the changes in the nail-substance. The nails in eczema and psoriasis are thickened and brittle, with an uneven surface. In some cases, especially those due to the vegetable parasites (onychomycosis) softening occurs.

Treatment depends upon the cause. Both constitutional and local means are in most cases employed. The nail should be softened and trimmed by means of the scissors or knife. Inflammation of the surrounding tissues is to be combated by the ordinary methods, and all sources of irritation avoided. Ingrowing nails should be cut transversely and not rounded, and the soft parts may be relieved of pressure and irritation by placing a piece of lint or cotton between the nail and skin-fold. In hypertrophy due to syphilis, psoriasis, and like diseases appropriate constitutional treatment is essential. In onychomycosis the parasiticides are to be applied.

Hypertrichosis.

Hypertrichosis (hirsuties), or hypertrophy of the hair, is a term applied to unnatural growth of hair, either as regards region, extent, age, or sex. It may be slight or excessive; thus, it may be universal, as in the so-called hairy people (homines pilosi), or limited, as upon a wart or nævus (nævus pilosus). The hairs themselves may be fine, coarse or of the average thickness. The hair of the scalp, eyebrows, axillæ, pubes, and beard in men may show excessive development either in thickness or length. Increased activity of hair-growth may take place in the fine downy hairs present {670} over the greater portion of the surface. It may occur in the very young--in fact, may be congenital--and the growth may also appear on the face, arms, and other parts of females, resulting, of course, from a hypertrophy of the natural lanugo hairs.

It is difficult to give any definite or satisfactory explanation of the causes which give rise to unnatural growth of the hair. It is seen more frequently in persons of dark complexion, and may be congenital or acquired; if the latter, the tendency to excessive development manifesting itself, as a rule, toward middle life. It is frequently associated in women with other masculine peculiarities, appearing especially at the climacteric period, and also noted in connection with the diseases of the uterus and ovaries. It is sometimes seen in sterile women, also on the faces of insane women. Local stimulation or irritation will at times have a curative influence.

For general hirsuties there is no remedy. Hairy nævi, if small, may be treated by excision, or, if large, the hairs may be removed by electrolysis, as described below. The excessive growth seen about the faces of women is an annoying disfigurement, and such patients will submit to almost any treatment with the hope of relief. Extraction of hairs and shaving are frequently employed, but give only temporary relief. The method of removal by electrolysis is the only plan which promises permanent success. A fine needle in a suitable handle is attached to the negative pole of a galvanic battery, introduced into the hair-follicle alongside of the hair to the depth of the papilla, and the circuit made by the patient touching the sponge electrode attached to the positive pole. At the point of insertion the parts become blanched, and frothing appears at the aperture of the follicle, a result of the decomposition of the tissues at the point of the needle. The action should be continued for several seconds or longer, and then the circuit broken by the patient removing the hand from the sponge electrode, after which the needle is to be withdrawn. If the papilla has been destroyed, the hair may be readily extracted by the forceps with very little traction. In most cases, after the needle is withdrawn, or at times even before this, a wheal-like elevation appears at the point of insertion. In some cases the follicles may suppurate. Scarring, which is liable to take place, is to be guarded against. It occurs more markedly in some subjects than in others. Noticeable scarring, however, may generally be prevented if the operator is skilful. The operation is somewhat painful, the amount of pain varying with different persons, in some being slight, while in others it is severe. A current from four to twelve cells of a freshly-charged battery usually suffices.

Removal of hairs by the use of depilatories is considerably practised, but, as they are caustic in their nature, they should be employed with care. If prescribed, one made up of two drachms of barium sulphide and three drachms each of oxide of zinc and starch may be recommended. Enough water is added to the powder to make a paste, which is thinly laid on the parts for ten or fifteen minutes. Heat of skin or a burning sensation soon occurs, upon the advent of which the paste is immediately to be scraped off, the parts thoroughly cleansed, and a mild ointment applied. As with extraction and shaving, this method is only temporary in its effects.

{671} Sclerema Neonatorum.

Sclerema neonatorum, or sclerema of the new-born, is a disease of infancy manifesting itself usually at birth, characterized by a diffuse stiffness, rigidity or hardness of the integument, accompanied by coldness, oedema, discoloration, lividity, and general circulatory disturbance. Frequently it is congenital. It usually begins on the lower extremities, extending upward and invading the trunk, arms, and face. The skin is reddish, purplish or brownish, glossy, and tense or stretched, causing more or less rigidity and stiffness. The surface is usually cold, and upon pressure oedema, together with an infiltrated state of the tissues, is noted. When the disease is general the body bears resemblance to a half-frozen corpse. The child is unable to move, respires feebly, and usually perishes in a few days. The disease is very rare. It is in most cases found associated with pneumonia or with affections of the circulatory apparatus. The causes are obscure. After death the condition of the skin undergoes but little change, the induration remaining; on incision a considerable quantity of serous fluid is poured out, when the tissues become softer and resemble ordinary oedematous tissue. The treatment should consist of warm applications, frictions, and like measures. The prognosis is unfavorable.

Scleroderma.

Scleroderma, known also as sclerema and scleriasis, is an acute or chronic disease, characterized by a diffuse, more or less pigmented, rigid, stiffened or hardened, hide-bound condition of the skin. It was first described by Alibert with the name sclérèmie des adultes, since which time many cases have been recorded. The first symptoms consist of more or less rigidity or induration of the integument, which may increase rapidly, or, as is usually the case, slowly, until the region affected becomes hard and bound down to the tissues beneath. In some cases febrile symptoms, oedema, and pigmentation precede the induration, but usually the process asserts itself insidiously, the first symptom noted by the patient being the sclerosis. In marked cases the skin is rigid, tight, or immovable, and is firm or positively hard to the touch, as though frozen, but without the sensation of cold. In some cases it may seem wooden or as though undergoing petrifaction. It is hide-bound, and cannot be made to glide over the structures beneath, nor can it be taken up between the fingers. The skin, owing to the immobility, becomes set or fixed, the natural lines and wrinkles disappearing, causing persons to look younger. The induration is diffuse, being neither circumscribed nor defined, and generally occupies a considerable area, the face, neck, back, chest, and upper extremities being the regions most frequently involved. It may occupy variously sized and shaped areas, for the most part irregular in outline, or it may appear in the form of narrow or broad bands or elongated patches, which usually become more or less shrunken and sunken atrophic lesions.

The surface of the integument in scleroderma is usually on a level with the neighboring healthy skin, except in the later stages where atrophy has occurred, and is generally smooth and shining. Pigmentation is in {672} most cases a marked symptom, being yellowish or brownish, in the form of patches, giving a dirty, chloasmic appearance to the part. Subjective symptoms are usually wanting, although there may be numbness or cramp-like pains, especially when the limbs are the seat of the disease. The skin in all cases feels contracted, tightly stretched or too short. The disease may be limited, as is generally the case, or it may occupy the greater portion, or even the whole, of the body. It is usually symmetrical. It pursues a variable course, at times acute, but more frequently chronic, extending over a period of years or throughout life. Sooner or later resolution and recovery set in, or atrophic changes take place, characterized by a wasting or a condensation of the integument and of the subjacent tissues, causing contraction and deformity, which are especially marked when occurring about joints. As a rule, the general health remains good. The disease in some cases is accompanied by patches of morphoea, which affection is regarded by some authors as being merely a circumscribed variety of scleroderma.

The causes are obscure. The disease is rare, and is encountered oftener in women than in men, and occurs usually in early adult or middle life. Sudden changes of temperature, exposure to wet or cold, and violent impressions on the nervous system have been cited as causes. The anatomy of the disease has been studied by various observers, but with different results, in the majority of cases slight structural changes only having been found. Both the true skin and the subcutaneous connective tissue are the seat of the process, showing a marked increase of the connective tissue, with thickening and condensation of the fibres. The disease may be viewed as a tropho-neurosis. The diagnosis, as a rule, presents no difficulty. From morphoea, to which it is closely allied, it may be distinguished by its tendency to involve large areas, occupying sometimes the greater portion or the whole of the integument, whereas morphoea usually appears in smaller lesions. Scleroderma manifests itself diffusely and without lines of demarcation; morphoea is circumscribed, and in its early stage is surrounded by a pinkish border. Scleroderma is always characterized by stiffness or hardness, whereas morphoea is usually soft or firm. In scleroderma the skin is merely rigid or hard in the beginning, whereas in morphoea there is hyperæmia and only slight induration.

Concerning the treatment of this disease there is but little to be said. Constitutional remedies, such as arsenic, quinine, and cod-liver oil, together with the employment of stimulating oily or fatty applications, frictions, and electricity are indicated, though it is difficult to state their intrinsic value. The course and termination of the disease varies. In some cases spontaneous involution sets in sooner or later, while in other instances the process continues to progress, and lasts throughout life.

Morphoea.

Morphoea, formerly known as keloid of Addison, is characterized by one or more rounded, ovalish or elongate, coin-sized patches, which, as a rule, are circumscribed and clearly defined. At first they are hyperæmic and pinkish, becoming as the process advances pale yellowish or whitish, {673} with a faint pinkish or lilac border made up of very minute injected capillaries. The patch may be slightly elevated or puffed in the beginning, but later is on a level with the surrounding skin, or even somewhat depressed. When typically developed it is either soft or firm to the touch, or, more rarely, leathery or brawny. The surface is usually smooth, and may be shining and have an atrophic appearance. Not infrequently it resembles in color and in look a piece of cut bacon or ivory laid in the skin. Around the patch there is usually, in addition to the hyperæmic border, more or less diffuse, mottled yellowish or brownish pigmentation. The disease exhibits no disposition to symmetry, but not infrequently it manifests itself over nerve-tracts. The regions commonly invaded are the face, neck, chest, mammæ, back, abdomen, arms, and thighs. The lesions pursue a variable though usually chronic course, lasting, as a rule, years. There is always a marked tendency to varied atrophic changes, which in most cases appear early, the skin becoming thin, shrivelled, or parchment-like, later being bound down to the tissues beneath, forming cicatriform, keloidal lesions, which may cause contraction and deformity, with, in some cases, wasting and general atrophy, more particularly of the extremities.

In addition to the usual characteristic circumscribed patches described, there may exist distinctly atrophic lesions consisting of small pit-like depressions resembling scars; also, reddish or bluish, tortuous, short or long, large and minute, dilated, superficial cutaneous blood-vessels and telangiectases, together with smooth, glazed, whitish, slightly-depressed spots or grooved streaks--true maculæ et striæ atrophicæ. Accompanying these various lesions there is usually considerable diffuse or patchy yellowish or brownish pigmentation. The process in some cases is simple as regards the lesions, but not infrequently it is complex, being characterized, as indicated, by a variety of lesions in different stages of evolution. The course is chronic, extending in the majority of cases over years. The disease in some cases eventually tends to spontaneous recovery; and this is all the more remarkable considering that atrophy has existed. The disease is met with more frequently in females than in males. Impaired nerve-power is without doubt the important factor in its production. Concerning the relation of morphoea to scleroderma, it may be said that these affections are closely allied, and that they may occur together. The pathological anatomy of the characteristic patches varies with the stage of the disease. In the early stages there is shrinkage or atrophy of the papillary layer, with condensation of the connective tissue of the corium. Crocker further noted marked cell-infiltration around the sebaceous glands, hair-follicles, and vessels, and in the later stages the transformation of these cells into fibrillar tissue, its contraction, and the consequent obliteration of blood-vessels, with atrophy of the sebaceous and sweat glands.

Morphoea is to be distinguished from scleroderma, from vitiligo, and from the anæsthetic patches of leprosy. In appearance morphoea and leprosy possess features in common, and it is probable that they are both due to the same cause--namely, perverted innervation. As a rule, no difficulty will arise in the diagnosis, for the reason that in leprosy other symptoms of that disease will almost invariably be present.

To be viewed as a variety or form of morphoea, we may mention {674} hemi-atrophia facialis, or unilateral atrophy of the face, which affection consists of a variable degree of atrophy of the skin and deeper structures, the cutaneous lesions being the same as those in morphoea. The neurotic origin of the disease in this case is plain.

A general tonic treatment, with the long-continued use of such remedies as arsenic, quinine, cod-liver oil, iodide of potassium, and electricity, is called for, most reliance being placed upon arsenic. Good results sometimes follow its administration. The prognosis should always be guarded.

Elephantiasis.

Elephantiasis, or elephantiasis arabum (also called pachydermia, Barbadoes leg, elephant leg), is a chronic hypertrophic disease of the skin and subcutaneous tissue, characterized by enlargement and deformity of the part affected, accompanied by lymphangitis, swelling, oedema, thickening, induration, pigmentation, and more or less papillary growth. The legs and genitalia, especially the former, are favorite localities for its development; about the latter, the penis, scrotum, and clitoris are most frequently involved. It begins with an inflammation of the parts, erysipelatous in character, attended with febrile disturbance, swelling, pain, heat, redness, and lymphangitis. The inflammation may have its starting-point in a local lesion, as a wound or scar, or, as is usually the case, manifests itself without any apparent cause. Similar attacks occur more or less frequently, after each of which the part remains increased in size. After a year or longer, during which time repeated attacks may have taken place, considerable increase in size is noted: the part is swollen, oedematous, and hard, and the skin hypertrophied, fissured, pigmented, and the papillæ enlarged and prominent. Later, the hypertrophy becomes still more marked; the part is often enormously enlarged and swollen, the skin rough, fissured, and warty. In Eastern countries the disease assumes huge proportions. Eczematous inflammation may coexist and complicate the appearance. The fissures may be slight or large and deep, the normal lines and folds of the surface exaggerated, with more or less maceration of the epidermis taking place, especially about the folds. Ulcers sooner or later tend to form, developing usually from varicose veins, while scales and crusts may also be present. Pain varies, being usually marked during the inflammatory attacks.

Elephantiasis is met with in all parts of the world, but much more frequently in tropical climates, especially about the West Coast of Africa, Brazil, the West Indies, and particularly India, and to less extent in Mediterranean regions and Arabia. In our own country, and also in Europe, it is not common. It rarely occurs before puberty. Heredity has no influence, nor is it contagious. It is commonly observed among the poor and neglected.

The immediate cause of the disease is to be found in inflammation and obstruction of the lymphatics. This obstruction is, according to late investigations, probably due to the presence in the lymphatic vessels of the parasite filaria and its ova. The filaria--a microscopic thread-worm--has been found in large numbers adhering to the walls of the lymphatics and blood-vessels, but is discoverable only during certain hours {675} of the day. The parasite has also been found in lymph-scrotum, a disease closely related to, if not identical with, elephantiasis.

The great mass of the growth in the disease is made up of hypertrophic connective tissue and connective-tissue new growth. All parts of the skin and the subcutaneous tissues share in the hypertrophy. Papillary enlargement is usually a marked feature. The lymphatic glands are swollen and enlarged and the lymphatic vessels prominent. There is marked oedematous infiltration, lymphatic in character. As a result of pressure, the glandular structures of the skin are atrophied or destroyed, the fat atrophied, and the muscles degenerated. The walls of the blood-vessels are thickened.

In well-developed cases of elephantiasis the symptoms are so characteristic that the disease is readily recognized. Recurrent attacks of erysipelatous inflammation of the leg or genitalia will point, with probability, to a development of the disease, even before marked hypertrophy or the clinical features are developed. As regards the outcome of the disease, if the case comes under treatment in the early months of its development the process may be checked or held in abeyance; later, after the affection has become well established, but little more than palliation can be effected.

The inflammatory attacks are to be treated with rest in bed, hot or cold applications, lead-water, and similar measures. Quinine and iron internally, especially the former, are of value. Potassium iodide has also been well spoken of. Climatic change, especially in the early stages, may prove of marked advantage. After the acute symptoms of the erysipelatous attacks have subsided inunctions of iodine or mercurial ointments may be employed to soften the skin and promote absorption. The parts should also be firmly bandaged, either the roller bandage, or, preferably, one of rubber, being used. Instrumental compression and ligation of the main artery of the limb have been employed, at times, with diminution in the size of the part; also excision of a portion of the sciatic nerve was practised in a single case by Morton with reduction in the size of the limb, but these methods of treatment are not to be recommended. Lately, the use of the strong, constant current has been extolled as having a beneficial effect. Elephantiasis involving the genitalia is, if the disease is well advanced, to be treated by the knife, amputation of the parts being practised.

Dermatolysis.

Dermatolysis consists of a more or less circumscribed hypertrophy of the cutaneous and subcutaneous structures, characterized by softness and looseness of the skin and a tendency to hang dependently. It may be slight or extensive, and may be limited to a certain region or show itself simultaneously in several different parts. The integument is thickened, bulky, superabundant, and to a greater or less extent hangs down in folds. The hypertrophy is general over the area affected; the glandular structures, connective tissue, muscular fibres, pigment, and the subcutaneous areolar tissue share in the process. The surface is usually soft and pliable to the touch, but is uneven, in consequence of the hypertrophy of the follicles and {676} the natural folds and rugæ. As a result of the increase in pigment the skin is more or less brownish in color. The tissues may develop to an enormous size, and the redundant parts may hang down in several folds, overlapping one another and forming a cloak to the parts below.

Dermatolysis may be congenital or may not develop until after puberty. It is a simple hypertrophy involving the integument and all its component parts, especially the subcutaneous connective tissue. The causes which bring about this condition are not known. It appears to be closely allied to molluscum fibrosum, the two diseases sometimes occurring together. It is not malignant, but its presence impedes locomotion and its weight is a discomfort.

The affection is classified under the head of elephantiasis by German writers, but the clinical features and course of the two diseases are entirely different. Elephantiasis telangiectodes is a term that has been given to a form of simple hypertrophy of the skin in which a marked new growth of vascular tissue takes place. In connection with this disease mention may be made of the condition characterizing the so-called rubber or elastic-skin man. In this condition there is no hypertrophy. The mobility and elasticity of the skin are probably due to a peculiar and abnormal looseness of the subcutaneous areolar tissue. It is to be looked upon as a congenital deformity. The treatment of dermatolysis is by excision when this operation is practicable.

CLASS V.--ATROPHIES.

Albinismus.

Albinismus is a term employed to designate that condition in which there is congenital absence of the normal pigment. It may be localized (albinismus partialis) or general (albinismus universalis). Persons in whom it is universal are called albinos. They are characterized by more or less complete absence of pigment in the skin, hair, iris, and choroid. The skin is milky-white, with, usually, a pinkish tint; the hair is white or yellowish, fine, thin, soft, and silky. The eyes are sensitive to light, the pupils appear red and contract and dilate continuously; oscillation of the eyeballs is noted, and also rapid and constant winking. These individuals are usually physically and mentally deficient, with a tendency to pulmonary disease.

Partial albinismus is seen more frequently in the negro. There may be one or more whitish or pinkish-white patches, variable as to size and shape, occurring upon any region. The skin is normal with the exception of loss of pigment. The hairs existing upon the spots are blanched. The eyes show no loss of pigment. The negroes in whom the patches occur are termed pied, or piebald. In exceptional instances a redeposit of pigment has been observed. Albinismus is not confined to any race or climate, and is comparatively rare. Its causes are not known. It is frequently inherited.

{677} Vitiligo.

Vitiligo (known also as acquired leucoderma or leucopathia) is a disease consisting of one or more usually sharply-defined, rounded or irregularly-shaped, variously-sized and distributed, smooth, whitish spots, whose borders usually show an increase in the normal amount of pigmentation. The patches may appear on any region, the backs of the hands and the trunk being favorite localities. The disease begins by the appearance of small pale spots, which gradually increase in size, new patches showing themselves from time to time. They are well defined in outline, the pale milky whiteness of the patches contrasting markedly with the surrounding pigmented skin. The increased pigmentation of the borders is almost an invariable accompaniment of the disease, and may be slight or excessive, gradually becoming less intense as the healthy skin is approached. The patches are smooth, on a level with the surrounding skin, rounded, ovalish, or irregular. They may be small or large, depending upon their age and also upon the rapidity of their growth. If several coalesce, as is frequently the case, large irregular patches are formed. The secretion of the sweat and sebaceous glands and the sensibility of the skin are not disturbed. With the exception of the loss of color the skin is normal. Hairs included in the patches may or may not be whitened. There are no subjective symptoms.

As a rule, the progress of the disease is slow, years frequently elapsing before the patches attain a large area. In some instances, after reaching a certain size, they remain stationary, either for a time or permanently. In most cases, however, the disease is progressive. In rare instances the skin has been known to become normal again. The sole annoyance the disease occasions is the disfigurement, and this is often striking. The spots are but little, if at all, affected by the sun, except that they are rendered more conspicuous by the bronzing of the normal skin which its rays cause. As a rule, the affection first shows itself in early adult life, although it may appear earlier or later. Both sexes, whether of a light or dark complexion, are attacked. The general health is usually good. It is attributed to a disturbance of innervation. Alopecia areata and morphoea have been seen in association with it.

Anatomically, it consists of both an atrophy and a hypertrophy of the normal pigment of the skin, the pale patch resulting from the former, and the pigmented border from the latter. There is no textural change in the skin. It may be mistaken for chloasma, tinea versicolor, and morphoea. In the former diseases, when several patches are close together, the normal skin between appears, in comparison, pale, and if cursorily examined might be mistaken for the pale patches of vitiligo, while the surrounding yellowish patches of tinea versicolor or chloasma may appear as the pigmented borders. In tinea versicolor the patches are slightly scaly. In morphoea there is always structural change.

Treatment in most cases is unsatisfactory. The functions and the state of the general health must receive attention. In some cases arsenic long continued proves of benefit. It is the only known remedy of any value. The disfigurement produced by the patches can in a measure be removed. For this purpose the darkened border should receive appropriate applications, such as are used in the removal of patches of chloasma. The white {678} spots sometimes may be made darker by the application of cantharides, promoting capillary congestion.

Canities.

Canities is a term applied to grayness or blanching of the hair. Loss of pigment in the hair may be partial or general. It may occur early in life or, as is commonly the case, as the result of old age. The change in color may take place throughout the entire hair or in parts. The color varies from slight blanching to white. It is usually grayish. In rare instances the color is to a moderate degree regained in summer. Grayness of the hair in the young--canities præmatura--is exceptional; in the old--canities senilis--it is constant, individuals differing considerably, however, as to the time of life at which the change begins. After the hair has become gray it rarely recovers its coloring matter, although occasionally in the young, after the lapse of years, the hair may again become dark. In those of a dark complexion the loss of pigment occurs, as a rule, much earlier than in those whose hair is of the lighter shades. Usually considerable time is required in the complete change to gray or white, but authentic cases are on record in which the change has taken place in the course of a night or within a few days. The pathology is obscure.

Canities, as may be readily inferred, depends upon a deficient production of pigment. The causes which gives rise to this deficiency are not understood. Hereditary influence is often noticeable. Conditions which impair the general nutrition, such as chlorosis, anæmia, fevers, etc., and those that hinder the local nutrition, as seborrhoea and inflammatory diseases of the parts, may possibly have some influence. In sudden blanching of the hair fright, intense anxiety, and the like are the usual causes. Treatment, whether internal or external, has no effect in preventing the loss of pigment or in restoring it. Dyeing, however, may be practised, and the condition masked; but it is not to be recommended, as the skin of the scalp becomes discolored and the nutrition of the hair interfered with.

Alopecia.

Alopecia consists of partial or complete deficiency of hair, irrespective of cause. There are several varieties, named according to the causes which have produced the affection. Thus, congenital alopecia consists of a partial or complete absence of hair, either over the entire surface or confined to a portion. In some instances there is scantiness or irregular development. In rare cases there is complete absence of the hair, microscopical examination failing to show the existence of hair-bulbs. In cases of congenital deficiency there usually exists an hereditary predisposition.

Senile alopecia and senile calvities are terms applied to the baldness of advanced years. With the loss of hair there is usually atrophy of the other cutaneous structures. In these cases the hairs, as a rule, first turn gray, become dry and thin, and fall out, with no tendency to a new growth. The condition is seen upon the scalp, beginning usually at the crown; in {679} occasional instances other parts of the body may also sooner or later show more or less atrophy of the hairy appendage. Upon the scalp, the skin, which is more or less free of the hair, becomes atrophied, smooth and glossy. The alterations in the cutaneous structures in senile baldness consist of marked atrophy of the sebaceous glands, of the hair-follicles and of the skin itself. The affection is common in men, but is comparatively infrequent in women. No satisfactory reason can be assigned for this. Idiopathic premature alopecia is the term applied to the baldness which begins to manifest itself about the age of twenty-five or thirty. The hairs may fall out rapidly or the loss may take place slowly. In these cases the normal hairs are usually replaced with finer, thinner, and shorter hairs, but finally even these eventually cease to be reproduced, and more or less alopecia results. There is no seborrhoea, and the skin shows no other atrophic change. As a rule, several years elapse before the condition becomes marked. The location affected is the same as in senile alopecia, and the same statement may be made as to its frequency in the two sexes. According to microscopical examination, there is an increase in the connective tissue, compressing the blood-vessels, and thus interfering with the blood-supply of the parts.

Symptomatic premature alopecia includes all those forms of alopecia which are the result of disease, either local or general. Falling of the hair is frequent after fevers and other systemic diseases. Mental anxiety, nervous exhaustion, and depraved conditions of the general health may also cause varying degrees of alopecia. In these cases the shedding of the hair usually takes place rapidly, constituting defluvium capillorum. With a disappearance of the exciting cause there is usually a regrowth, but this is not always the case, as not infrequently the baldness is permanent. Among local diseases which give rise to baldness, chronic seborrhoea is the most important. As a result of the seborrhoea, atrophy of the glands occurs, and alopecia sooner or later sets in. Many other local affections, as lupus erythematosus, erysipelas, variola, tinea tonsurans, and tinea favosa, are at times attended with loss of hair. Syphilitic alopecia may occur at two different periods of that disease. It is noted as one of the early symptoms, and later as the result of the general cachexia, or in localized patches as the result of ulceration and destruction of the skin. The alopecia appearing as a secondary symptom of the disease may be slight or complete baldness may take place, but in either case the loss is rarely permanent if the patient is under proper treatment. As a rule, in the course of a few months the hair is reproduced. The alopecia resulting from ulcerative lesions is permanent.

The treatment of the various varieties of alopecia named depends, as will be readily inferred, upon the etiological causes. Senile alopecia is rarely amenable to treatment. Idiopathic premature alopecia may frequently be benefited by therapeutic measures. The general health is to be looked after. In these cases arsenic in moderate doses long continued may prove of some value. The external treatment has in view the promotion of the nutrition of the skin, which is attained by the use of stimulating applications for the purpose of increasing the vascular supply. The treatment of symptomatic premature alopecia is that of the primary disease. The external remedies and formulæ which are employed in cases {680} of alopecia for their stimulating effects will be found in detail under the head of alopecia areata.

Alopecia Areata.

Alopecia areata (syn. area celsi, alopecia circumscripta, porrigo decalvans, tinea decalvans) is an atrophic disease of the hairy system, characterized by the more or less sudden appearance of one or more circumscribed, variously sized and shaped, whitish bald patches. The scalp is the region most frequently the seat of the disease, but other hairy parts, especially the face in the male, are often invaded, and even the whole surface may be involved. Occurring upon the scalp, one or several patches may be present, which are usually rounded and circumscribed. The hair may fall out suddenly without any previous signs of weakening, the individual awaking in the morning to discover an area of partial or complete baldness on the scalp; or, as is usually the case, the loss of hair takes place insidiously or more gradually, several days or weeks elapsing before the bald patch is of sufficient size to attract observation. The parietal region is perhaps most frequently involved. In most cases but a single patch appears at first, but this usually is followed by others. The areas incline to grow larger and larger, and, as a rule, finally coalesce, eventually the whole scalp, with possibly the exception of a tuft or patch here and there, being bald. In most cases, however, the patches, after reaching a certain size, remain stationary.

The skin of the affected areas has a smooth, whitish, polished, atrophied appearance, and is usually entirely devoid of hair or with a few straggling long or short hairs scattered over it. The orifices of the follicles become less appreciable, and the skin is thin, and resembles that seen in the baldness of advanced years. The hairs surrounding the affected area are usually found to be firmly seated in their follicles, but if the patch has not ceased enlarging they may be loose and readily extracted. In some cases about the border are noted a few short atrophied hairs, resembling the short, broken-off hairs of tinea tonsurans. At first the skin may be slightly puffed, but usually it is on a level with the surrounding parts; later, it may be somewhat depressed, as though atrophied. It is neither scaly nor inflamed. Slight anæsthesia may be present. There are, as a rule, no subjective symptoms. Involving the regions of the moustache and eyebrows, the clinical phenomena are essentially the same as when affecting the scalp. In those cases in which universal loss of hair results, the process usually begins in the same way, first appearing as well-marked areas, which rapidly increase in size; new patches are added, coalescence results, and eventually the entire surface is involved. After the disease has come to a standstill it may so remain indefinitely, or lanugo hairs may appear from time to time, reach an inch or a fraction thereof in length, may become slightly darkened, and then fall out. Finally, in favorable cases, instead of falling out, their growth continues; they become dark, and recovery takes place. In these latter cases the disease may have existed several months before signs of a permanent regrowth show themselves; on the other hand, several years may have elapsed.