Chapter II: The Peculiarities of Certain Accidental Acute and Chronic Diseases (16)

The disease is met with in both sexes, in children and adults, and among {681} the wealthy and the poor. It is not a rare disease, nor is it common. Impaired nutrition as the result of functional nerve-disturbance is probably the important etiological factor, leading to the view that the affection is a trophoneurosis. It is often seen to follow neuralgias, nervous shock, and debility. Morphoea and vitiligo, both diseases of a neurotic character, are occasionally seen in association with it. In the greater number of cases no appreciable cause is discoverable. It is not parasitic, nor is it contagious. Microscopic examinations have given negative results, the skin remaining normal and the glandular structures unchanged. Atrophy of the hair shafts and bulbs, and occasionally breaking and bulging of the hairs, are usually noted. The atrophic condition of the bulbs is similar to that seen in hairs which have reached the end of their normal life.

The disease with which alopecia areata may, by the inexperienced, be sometimes confounded is tinea tonsurans, and yet the incomplete baldness, the short, stumpy, split, gnawed-off-looking hairs, the scaliness, the increased prominence of the follicular openings, and the history and course which characterize ringworm, are entirely different from the clinical signs of alopecia areata. Where there is doubt the microscope is to be employed. It is to be remembered, also, that ringworm of the scalp is not seen in individuals past the age of puberty. The peculiar clinical features of the disease will distinguish it from other forms of baldness.

TREATMENT.--The uncertainty of the duration and ultimate termination of the disease is to be kept in view in expressing an opinion. It may be stated, with a degree of positiveness, however, that in young individuals the eventual result is, as a rule, good; but occurring in persons past adult age, the prognosis as to a regrowth is not so favorable, and becomes less so as age increases. The length of time elapsing in favorable cases before the hair reappears, as already mentioned, is uncertain: it may be several months, or on the other hand, as many years. On both points proper and persevering treatment has sometimes a material influence.

Local and general measures are called for. Of the two, the general treatment is the more important, and among remedies employed arsenic stands prominent. It should be continued for months. In addition, such tonics as iron, quinine, cod-liver oil are to be advised as the case demands. In some instances potassium iodide in moderate doses is of service.

External treatment is of value, and is in most cases to be advised. The object in view is a stimulation of the vascular supply, and through this an improvement in the nutrition of the papillæ and hairs. The same remedies in various combinations are employed as in the treatment of other forms of alopecia. Rubefacients and irritants, such as alcohol, the essential oils, sulphur, tar, cantharides, corrosive sublimate and other salts of mercury, carbolic acid, iodine, turpentine, ammonia, chrysarobin, and spiritus saponatus kalinus, are variously used. They are, as a rule, employed either in alcoholic or ethereal fluids or in the form of oils or ointments. It is to be borne in mind that the scalp tolerates strong remedies. The applications are to be made once or twice daily, according to the demands of the case, and with considerable friction, employing for the application a flannel rag or mop. Such remedies as iodine, corrosive sublimate, are usually to be painted or dabbed on.

{682} Sulphur, two to four drachms to the ounce; corrosive sublimate, one to four grains to the ounce of alcohol; tar, ol. cadini, or ol. rusci, one to four drachms to the ounce of alcohol or ointment,--are all serviceable remedies. Cantharides and capsicum are stimulating, and may be prescribed as in the following formula:

Rx. Tinct. cantharidis,
Tinct. capsici, aa. fluidounce iss;
Olei ricini, fluidrachm ij;
Alcoholis, fluidrachm vj;
Spts. rosmarini, fluidrachm ij. M.

The following, containing the oil of mace, is also serviceable:

Rx. Olei myristicæ exp., fluidrachm ij;
Alcoholis,
Spiritus lavandulæ, aa. fluidounce ij. M.

Carbolic acid may be used as follows:

Rx. Acidi carbolici cryst., drachm ij;
Alcoholis, fluidounce iij;
Olei ricini, fluidrachm iv;
Spts. rosmarini, fluidrachm iv. M.

Aqua ammoniæ may sometimes be employed with benefit, as in the formula recommended by Wilson:

Rx. Olei amygdalæ dulc.,
Aquæ ammoniæ fort., aa. fluidounce ss;
Spiritus rosmarini, fluidounce ij;
Olei limonis, fluidrachm ss. M.

Blistering the affected areas by means of a cantharidal vesicating fluid, frequently repeated, sometimes proves of advantage. Friction with oil of turpentine once or twice daily may in some cases be practised with benefit; when the skin becomes sensitive it should be discontinued for a few days. Chrysarobin in ointment, 5 to 15 per cent. strength, is an active irritant which may be cautiously employed. Oleate of mercury, 10 to 30 per cent. strength, rubbed in once or twice daily, is useful in some cases, and the same may be said of the other mercurial ointments, such as citrine and white precipitate ointments. Electricity sometimes proves of service, and may be tried in obstinate cases.

Atrophia Pilorum Propria.

Atrophia pilorum propria, or atrophy of the hair, may be either symptomatic or idiopathic. As a symptomatic affection it is seen as a result of such diseases of the scalp as seborrhoea and the parasitic affections, and also following various constitutional diseases, such as syphilis and fevers, in consequence of impaired nutrition. The hairs become dry, brittle, atrophied, and exhibit a marked disposition to split up. Idiopathic atrophy of the hair is characterized in one of its forms (fragilitas crinium) by a brittle state of the hair-shaft, an irregular and uneven formation of its structure, and a tendency to separate into its filaments. It is seen about the scalp and beard, and may be slight or markedly developed. A somewhat similar condition of the hair of the beard has been described (Duhring), in which the bulb is {683} atrophied and the shaft split up, fission taking place within the follicles, causing irritation of the skin. Another form (trichorexis nodosa) of the idiopathic affection is characterized by shining, semi-transparent, rounded swellings of the hair-shaft, seen usually upon the beard and moustache. At first sight they look not unlike the ova of pediculi; one or several may be present upon a single hair. Upon close inspection they are seen to be localized swellings of the hair-structure. At these points the hairs readily break off, leaving a brush-like end; if many of these are present, which is usually the case, they give the impression that the hair has been singed. The medullary as well as the cortical substance, as determined by microscopical examination, is swollen, and in consequence of the swelling of the medullary portion the cortex is burst and split into filaments. In regard to the cause of idiopathic atrophy of the hair nothing is known, and but little can be done in the way of treatment. Shaving and cutting the hair have exceptionally been followed by a normal growth.

Atrophia Unguis.

Atrophy of the nail is commonly an acquired affection. It is characterized by deficient development or growth of the nail-substance, as shown by a thin, brittle, soft, crumbly or worm-eaten condition. The nail may be pale, opaque or dark in color. It may occur in consequence of injury or disease of the nerves of the part, or as a result of some general disease, as syphilis, or from general debility. Eczema, psoriasis, and allied diseases, which may be productive of hypertrophy of the nails, may also cause atrophic changes. Treatment of atrophy of the nail depends upon the cause. In simple atrophy, and also in that due to eczema and psoriasis, arsenic is of value.

Atrophia Cutis.

Atrophy of the skin, or atrophia cutis propria, in its various forms is not infrequently encountered. It may occur as an idiopathic affection, or as a symptom in connection with other well-known diseases. Thus, as an example of the former condition the well-known striæ atrophicæ may be cited, while lupus, syphilis, and tinea favosa are sometimes followed by symptomatic atrophy. Injuries to nerves are also at times followed by more or less cutaneous atrophy, usually in connection with wasting of the subcutaneous structures, the skin becoming thin, dry, shrivelled, and yellowish or brownish in color. Atrophy of the skin may be general, as in the senile form, or localized, as in morphoea. Where degenerative atrophy exists the skin is usually somewhat hardened, yellowish or whitish in color, and has a waxy, fatty appearance. In the condition known as glossy skin, generally seen upon the fingers, the skin is reddish, smooth, and shining as though varnished, the affection resembling chilblains. The hairs are usually shed, and excoriations or fissures often exist. It is accompanied with pain of a burning character.

Cases of general idiopathic atrophy of the skin have from time to {684} time been reported, the disease in almost all instances being more marked in some localities than in others, occurring in the form of more or less extensive patches. The disease originally described by Hebra and Kaposi with the name xeroderma, or parchment-skin disease, may here be referred to. The lesions consist of numerous disseminated pigment-spots, resembling freckles; telangiectases, or minute congeries of blood-vessels; atrophic macules of variable size; with more or less shrinking and contraction of skin, followed in most cases by epitheliomatous tumors and ulceration. The disease almost invariably begins in early years, is prone to show itself in several children of the same family, and lasts during life. The advanced stages of scleroderma and morphoea likewise show marked atrophic changes, which, however, will be considered in speaking of those diseases.

Senile Atrophy.--This form of atrophy, taking place as the result of old age, may be simple or degenerative, both usually occurring together. The integument becomes thin and wasted, the surface being dry, wrinkled and more or less discolored by pigmentation, with loss of hair. In degenerative atrophy the connective tissue of the corium becomes changed into a fine or coarse granular matter or into a homogeneous vitreous mass. Fatty metamorphosis and marked pigmentary deposits are also common.

Maculæ et Striæ Atrophicæ.--Atrophic streaks and spots may occur idiopathically or symptomatically. The idiopathic form is that most frequently encountered, and occurs without known cause, generally making its appearance insidiously. It is characterized by lines or streaks constituting the so-called linear atrophy, striæ atrophicæ; or by spots, maculæ atrophicæ. The streaks are more frequently met with, and consist of irregular curved or tortuous lesions, usually about a line in width and of variable length, running parallel with one another. The macules are rounded or ovalish, varying in size from a pinhead to a finger-nail. Both are smooth and glistening, and the skin is thinned and scar-like. They are slightly depressed or grooved, and possess a pinkish, whitish, or bluish-gray color. They may appear upon any region, but the abdomen, buttocks, and thighs are the favorite localities. They pursue a slow course over a period of years or a lifetime, occasioning no inconvenience. The first stage of either variety of the disease is characterized by erythema, the lesion being reddish, hyperæmic, and slightly raised or puffed. This sooner or later disappears, followed by depression and atrophy.

The symptomatic form of the affection is usually noted to take place as the result of extreme distension of the cutaneous structures. It occurs sometimes in obese subjects, and in the latter stages of pregnancy upon the abdomen and mammæ, and over large abdominal and other tumors where the skin is greatly stretched, constituting the so-called lineæ albicantes.

{685} CLASS VI.--NEW GROWTHS.[6]

[Footnote 6: Lepra (leprosy), an important disease of this class, appears, in Vol. I. p. 785, as a separate article by J. C. White.]

Keloid.

Keloid is a connective-tissue new growth, characterized by one or more irregularly-shaped, variously-sized, elevated, smooth, firm, somewhat elastic, pale-reddish, cicatriform lesions. It ordinarily begins as a nodule or tubercle, pea- or bean-sized, which slowly, usually in the course of years, increases in dimension. When fully developed, the growth appears as an ovalish, elongated, cylindrical, fungoid or crab-shaped patch, occupying usually an area of one or several inches, distinctly elevated, sharply defined, and firmly implanted in the skin. In some cases the lesion does not exceed the size of a pea or a bean. The color is usually pinkish-white. The surface is smooth, shining, and commonly devoid of hair, with no tendency to scaliness or ulceration, and generally marked by ramifying vessels. It is firm and elastic to the touch. The disease sometimes appears in the form of streaks or lines. It is seen most frequently upon the sternum, although other regions, as the neck, mamma, ear, sides of the trunk, or back are often invaded. It is more common in the colored race. The lesion is usually single, though several may coexist. Itching to a slight degree is sometimes present, and more or less pain, especially on pressure, may also exist. Depending upon the origin of the growth, whether arising spontaneously or upon the site of various injuries of the skin, keloid is termed, respectively, spontaneous, or true, and cicatricial, or false. Clinically and pathologically, both varieties are the same.

It is often met with as the result of burns, cuts, flogging, and all ulcerative affections. Not infrequently it takes its origin in the scars of acne and variola; occasionally it is seen to develop on the lobe of the ear, taking its start at the point where the ear has been pierced. Pathologically, the lesion is a connective-tissue new growth, made up of a dense, fibrous mass of tissue, whitish in color, having its seat in the corium. The clinical features of keloid are so characteristic that no difficulty is experienced in recognizing it. The course of the disease is chronic, usually lasting throughout life; in exceptional instances spontaneous involution has been noted.

Treatment is usually negative. Removal by excision or caustics is, as a rule, followed by a return of the growth, and sometimes in an aggravated form. If its destruction or extirpation is decided upon, it should not be done while the growth is still progressive. Improvement has been reported by Vidal from multiple linear scarification. If the formation is painful, various anodyne applications may be made. Iodine, mercurial, and lead plasters may be tried with the object of promoting absorption. Painting the growth with a solution composed of potassium iodide one drachm, and an ounce each of soft soap and alcohol, followed by the application of lead plaster spread on a piece of soft leather, has been advised by Wilson. The use of lead plaster alone, applied continuously as a plaster, is sometimes followed by softening and diminution in size.

{686} Fibroma.

Fibroma (molluscum fibrosum, fibroma molluscum) is a connective-tissue new growth, characterized by sessile or pedunculated, soft or firm, rounded, painless tumors, varying in size from a pea to an egg or larger, seated beneath and in the skin. A single growth may occur, or, as is more commonly the case, they are present in large numbers, and usually scattered over the greater portion of the body, having a preference for the softer tissues,--for example, the trunk. They may be of various shapes, rounded and sunken in the skin itself or in the subcutaneous tissue, or club- or pear-shaped and pedunculated. They usually begin as soft masses in the skin. If but one tumor exists, it is apt to be pedunculated or pendulous, and to attain considerable dimensions, in some cases weighing several pounds. In these instances surface-ulceration is occasionally noted as the result of mere weight or pressure. As commonly met with, however, the growths are numerous, several hundreds existing, varying from a pea to a cherry in size, with larger ones scattered here and there. The overlying skin is normal, pinkish or reddish, or may be loose or stretched, hypertrophied or atrophied. They are unattended with pain. They may make their appearance at any age, often in childhood, and grow as a rule slowly. After reaching a certain size they are apt to remain stationary; in rare instance spontaneous involution of some of the growths has been noted to take place. The affection is not common. It is often inherited, and may show itself in several members of the same family. Those in whom it is observed are usually noted to be stunted in their physical and mental development. The general health is not involved. Opinions are divided as to whether the growths take their origin in the connective-tissue framework of the fatty tissue, in the connective tissue of the corium, or in that of the walls of the hair-sac. The developed tumors consist of a connective-tissue capsule enclosing a whitish fibrous mass, with the central portion more or less soft and pulpy, out of which may be squeezed a small quantity of yellowish fluid. Small, recent tumors are composed of gelatinous, newly-formed connective tissue, while old growths consist entirely of a dense, firmly-packed fibrous tissue.

They are to be distinguished from the tumors of molluscum epitheliale by the absence of an aperture or depression upon their summits. They can scarcely be confounded with multiple neuromata or with lipomata, as the accompanying pain of the former and the lobulated structure and soft feel of the latter are sufficiently distinctive. Their removal, if desired, may be effected by the knife, or in the case of the large and pedunculated growth by the ligature or by the galvano-cautery.

Neuroma.

Neuroma cutis, or neuroma of the skin, is characterized by the formation of variously-sized fibrous tubercles, containing new nerve-elements, having their seat primarily in the corium, and accompanied in their development by violent paroxysmal pain. It is exceedingly rare, there being but few cases recorded. It appears on the shoulders, arms, thighs or buttocks in the form of numerous, disseminated, pinhead to hazelnut in {687} size, round or ovalish tubercles or nodules, which at the outset may be either painful or painless; in the later stages, however, pain, both spontaneous and upon pressure, is a constant symptom. The growths are firm, immovable, and elastic, and are seated in the corium, extending into the deeper structures. They may be covered scantily with fine, laminated, glistening scales, as in the case reported by one of us. Anatomically, the tumors are composed of nerve-fibres, yellow elastic tissue, blood-vessels, and lymphoid cells. Excision of a portion of the nerve-trunk leading to the affected area has been practised in one case (Kosinski's) reported, with permanent relief; in another (Duhring's) the relief was merely temporary.

Xanthoma.

Xanthoma (also called vitiligoidea and xanthelasma) is a connective-tissue new growth, characterized by the formation of yellowish, circumscribed, irregularly-shaped, variously-sized, non-indurated, flat or raised patches or tubercles. Two varieties are met with. The macular, or flat form (xanthoma planum) is commonly seen upon the eyelids, looking not unlike pieces of chamois-skin inserted in the lids. This form may also be encountered occasionally on other parts of the face, as well as upon the body. The patches are smooth, opaque, usually sharply defined, and to the touch soft and apparently normal in texture; they are on a level with the surrounding integument or slightly raised, and of a creamy or yellowish color. They vary in size and shape, and may coalesce, forming a band extending across the eyelids, especially the upper lids. The tubercular form (xanthoma tuberosum) is usually met with upon the neck, trunk, and extremities, the eyelids seldom being invaded. It occurs as small, isolated nodules, or in patches slightly raised above the level of the skin, consisting of aggregations of tubercles of the size of a milletseed or larger. Both forms of the disease not infrequently occur in the same individual. After reaching a certain development it is apt to remain stationary throughout life, and with no involvement of the general health. As a rule, the lesions are few in numbers; on the other hand, rarely they may be numerous (xanthoma multiplex). The affection is usually encountered in middle and advanced life, although it is occasionally met with in the young. It is more common in women than in men. Jaundice has been frequently noticed as preceding or accompanying it, especially the tubercular variety. Pathologically, it is a connective-tissue new growth with fatty degeneration. Excision, where practicable, constitutes the sole method of treatment.

Myoma.

Myoma cutis, or dermato-myoma (known also as liomyoma cutis), is a rare affection, consisting of tumors of the skin composed of muscular fibres. They occur either as single or multiple tumors, varying in size from a lentil to an egg, localized in a special region, as the nipple, scrotum, labia majora, thigh, hand, or foot; or, more rarely, numerous, and scattered over the greater portion of the whole body. They are {688} either flat or pedunculated, rounded or oval in form, pale-red in color, with a smooth surface; although generally painless, they are sometimes tender upon pressure, The growth consists essentially of a new formation of unstriped muscular fibres. At times it is composed largely of connective tissue (fibromyoma), or it may contain an abundance of blood-vessels, giving rise to cavernous erectile tumors (myoma telangiectodes). The disease is benign.

Angioma.

Angioma, or nævus vasculosus, is a congenital formation composed chiefly of blood-vessels and having its seat in the skin and subcutaneous tissue. Several forms of the affection are met with, all of which, however, may be grouped under two heads--non-elevated and prominent. The former (nævus flammeus, nævus simplex, angioma simplex) is illustrated by the so-called port-wine mark, or claret-stain, known in German as feuermal, and in French as tache de feu. The prominent variety (angioma cavernosum, nævus tuberosus) may be turgescent, erectile, pulsating, tumor-like, circumscribed growths, with an uneven or rugous surface. In shape nævi are usually roundish, but may be irregular; in color, bright or dark red, violaceous, or bluish; and in size as large as a pea or a bean, or in some cases involving areas several inches in diameter. As a rule, they are single formations. They may occur on any part of the body, but are most frequently seen about the face. Their course varies. In many instances, after attaining a certain size, they remain stationary, or in some cases may retrograde or undergo spontaneous involution, this remark applying more particularly to the flat variety in early life. Ordinarily, they are permanent deformities. They become pale under pressure, and the more prominent growths are markedly compressible. Anatomically, the growth consists of a dilatation and hypertrophy of the arterial and venous blood-vessels of the corium and subcutaneous tissues, and in some instances there is increase in connective tissue. In some cases the connective-tissue hypertrophy is made up mainly from the adipose layer (angioma lipomatodes). Occasionally there may be more or less pigmentation.

In the treatment, the extent, form, and region involved are to be considered. Various methods have been advised for their removal. For pinhead-sized nævi puncturing with a red-hot needle, or with a needle charged with nitric or chromic acid, may be employed. Those of pea size may be treated by caustic applications. Sodium ethylate, as recommended by Richardson, is an efficient caustic for the more superficial forms: it should be pure and applied with a glass rod; a dry dressing is to be employed and the crust permitted to loosen itself. Painting a nævus with liquor plumbi subacetatis will, if repeated daily for several weeks or months, sometimes succeed. Caustic potash in solution, from one to two drachms in the ounce, and nitric acid, may both be cautiously used. An ointment of a drachm of adhesive plaster and nine grains of tartar emetic applied to small nævi will, according to Neumann, cause free suppuration and healing. A solution of eight grains of corrosive sublimate in a drachm of collodion is sometimes effective. Injections of astringent and irritating liquids, such as the tincture of the chloride {689} of iron and cantharidine, as formerly practised, possess no advantage over safer methods. Linear and punctate scarifications--in the latter the needles being charged with a 50 per cent. solution of carbolic acid or a 25 per cent. solution of chromic acid--have been recommended. In small formations vaccinating the nævus is often successful. The galvano-cautery and the actual cautery are both serviceable in treating the smaller nævi. Electrolysis constitutes a valuable plan of treatment. A current of from six to twelve cells is usually required. One or more platinum needles are attached to the negative pole and a single needle or charcoal point to the positive pole. Slight frothing at the points of insertion indicates that the action has been sufficient. Suppuration and sloughing should not occur if proper care is exercised. If the nævus is extensive, only a small portion is to be treated at the one sitting. In the port-wine mark this method promises the best results; the color is made much lighter, and exceptionally is made to disappear entirely. In prominent, and especially in pedunculated, tumors a ligature may be employed.

Lymphangioma.

Lymphangioma (also described as lymphangioma tuberosum multiplex) is a rare disease, characterized by numerous, scattered, pea- or bean-sized, ovalish or rounded, brownish-red, glistening, smooth, slightly-elevated tubercles, having a somewhat translucent look, occurring for the most part about the trunk. They are firm and elastic to the touch; are situated in the cutis, but are not sharply defined; they can be readily made to sink below the level of the surrounding integument, owing to their marked compressibility. At times they have a lilac or bluish tinge. The growths bear some resemblance to the large papular syphiloderm. They are generally congenital or appear in childhood. Anatomically, they consist of immensely dilated and hypertrophied lymphatic vessels. The course of the disease is slow, and evinces no disposition to malignancy. The general health is not involved.

Lupus Erythematosus.

Lupus erythematosus (also known as lupus erythematodes, seborrhoea congestiva, and lupus sebaceus) is a small-celled new growth, characterized by one or more circumscribed, variously sized and shaped, reddish patches, more or less covered with adherent grayish or yellowish scales. The affection usually begins as a rounded, circumscribed, pinhead- to pea-sized, slightly elevated lesion, which increases in size by peripheral extension until considerable surface is involved; or, as is often the case, the disease starts with several such spots, which grow and generally coalesce, sooner or later involving considerable surface. The spots are at first erythematous and slightly scaly, with but little elevation, later becoming thickened, with a more or less raised border sharply defined against the healthy skin, covered with small, firmly adherent yellowish or grayish scales, with enlarged and plugged or patulous follicles, the centre of the patch being somewhat depressed. The color is pinkish, reddish, or {690} violaceous. In the beginning the disease often closely resembles seborrhoea,--so much so that it was originally described by Hebra as seborrhoea congestiva. The scaling is usually scanty, but in exceptional instances may be abundant. At times the lesions show little tendency to peripheral growth, the large areas of disease resulting from the continuous appearance of new patches in proximity which run together. Occasionally the patches are small, discrete, and numerous, when the disease is apt to be disseminated over considerable surface.

Lupus erythematosus is seen most frequently about the face, one or several patches, varying in size from a pea to a silver dollar, ordinarily being present. The nose and the cheeks are favorite localities, and, seated here, the disease is apt to be symmetrical, extending from one cheek across the nose to the other cheek, in shape representing rudely the outline of a bat or butterfly with outstretched wings. The lips, ears, scalp, and other parts of the body are often affected. The progress of the disease is variable; the patches, as a rule, reach a certain size, and then remain stationary or retrogress, or, as generally happens, the central portion becomes depressed and more or less atrophied. The resulting scar is whitish, usually soft, punctate, and superficial. As old patches disappear it is not uncommon to see new patches appearing close by. It is essentially a chronic disease: the individual lesions may be acute in their course, and when such is noted, as a rule new areas of disease continue to appear in rapid succession. Ordinarily, however, the individual patches themselves are chronic in their course. The disease is not attended with ulceration. The subjective symptoms of itching and burning are usually mild in character, and sometimes are entirely wanting.

The condition of the general health is, as a rule, good. The disease is seen more frequently in women than in men, and is rarely observed before puberty, being chiefly encountered in early adult and middle age. The causes are not known. It frequently begins as a seborrhoea, but it may occur (although rarely) upon the palms of the hands, where sebaceous glands are not to be found. It is a notable fact, however, that the disease is most commonly encountered in those who are subject to disorder of these glands. It is observed more often in persons of light complexion. It is comparatively rare. The condition of the general health apparently exercises no causative influence.

Pathologically, the process is essentially a chronic inflammation of the cutis, superinducing degenerative and atrophic changes. In the majority of cases the disease originates in the sebaceous glands, but later all parts of the skin become affected. It is even authoritatively stated that it may in some instances take its start in the subcutaneous connective tissue. In some respects it has the character of a new growth, which until late years it has been considered. In the light of recent investigations, however, it seems possible that it may be a chronic inflammation leading to degenerative changes. The process never ends in the formation of pus. There is small-celled infiltration about the follicles and glands, the blood-vessels are dilated, the surrounding tissue is infiltrated with embryonic corpuscles, and the sebaceous glands are enlarged and their walls infiltrated with small cells. The whole affected area is, in fact, infiltrated with a small-celled inflammatory new growth. If retrograde changes occur, the {691} infiltration may disappear by absorption without leaving a trace. On the other hand, and as is usually the case, degenerative metamorphosis, resulting in absorption and atrophy, takes place.

There is very little difficulty in recognizing a fully-developed patch of lupus erythematosus, as its features are usually characteristic. The sharply circumscribed outline, the reddish or violaceous patch with elevated border, the tendency to central depression and atrophy, the plugged-up or patulous sebaceous ducts, the adherent grayish or yellowish scales, together with the region attacked (generally the nose and cheeks), are characters which, when taken together, are common to no other disease. Lupus vulgaris may be excluded by the absence of papules, tubercles, and ulceration. The sebaceous involvement and the peculiar atrophy and superficial scarring are, moreover, not seen in lupus vulgaris. Erythematous lupus begins, as a rule, during adult life; lupus vulgaris usually in childhood. In psoriasis the course and symptoms peculiar to that disease will distinguish it from lupus erythematosus. It is scarcely possible to confound the disease with eczema or syphilis. In some cases in the beginning of the affection it may resemble seborrhoea; in fact, it often has its starting-point in that disease. The inflammation, infiltration, sharply-defined characters, atrophy, and scarring are absent in seborrhoea.

TREATMENT.--The prognosis of lupus erythematosus, as regards the general health and welfare of the patient, is good, but respecting the disappearance and cure of the disease an opinion should always be guarded. Occasionally the patches yield readily, but, on the other hand, cases are frequently met with that prove exceedingly rebellious, responding only after long-continued treatment. Constitutional remedies are in most cases of but little value. Occasionally arsenic and cod-liver oil, used continuously for a long period, prove serviceable. Iodized starch, in the dose of one or two teaspoonfuls three times daily, has been recommended, and in some cases potassium iodide has a favorable influence.

It is to the external treatment, however, we look for positive effects. In the selection of remedial applications it is to be remembered that the patches of disease sometimes disappear spontaneously, occasionally with little or no scarring, and therefore treatment that would have as an effect marked scarring or disfigurement is to be avoided. The simplest remedy, at times useful, is soft soap, the sapo viridis of the shops. This may be used as such or in solution in alcohol, two parts of the soap to one of alcohol, constituting the well-known spiritus saponatus kalinus. It is to be energetically rubbed into the diseased parts once or twice daily. The application of the sapo viridis as a plaster is a more energetic method. After several days the soap is to be discontinued and a soothing ointment applied. In addition to its therapeutic properties, sapo viridis--or, better, its alcoholic solution--may be advantageously employed to cleanse the parts preparatory to other remedial applications. Mercurial plaster constantly applied to the patches will in some cases effect a cure. A 10 to 25 per cent. oleate-of-mercury ointment, rubbed on the parts once or twice daily, is sometimes of value.

In almost every case where the inflammatory symptoms are marked the following lotion will prove palliative, and in some cases of the mild and superficial form of the disease it has in time effected a cure: {692}

Rx. Zinci sulphatis,
Potassii sulphidi, aa. drachm ij;
Aquæ, fluidounce iij;
Alcoholis, fluidounce j.

The salts are to be dissolved separately in the water, and then mixed, and after reaction the alcohol is to be added. Properly made, the resulting lotion is without odor, contains a whitish sediment, which when agitated gives the lotion a milky appearance. It is to be shaken, and the parts dabbed with it for from fifteen to thirty minutes twice daily, allowing it to dry on. Sulphur ointment and alcoholic sulphur lotion, such as are used in the treatment of acne, are also sometimes serviceable. Tincture of iodine, either alone or with an equal part of glycerin, painted over the parts once or twice daily until a coating forms, in some cases proves useful. The same may be said of the following formula:

Rx. Iodinii,
Potassii iodidi, aa. drachm iv;
Glycerinæ, drachm j.

M.--Sig. Paint over the part until a coating is produced. Painting pure carbolic acid over the patches is sometimes followed by good results. A mixture that is serviceable as a stimulant is the following:

Rx. Olei cadini,
Alcoholis,
Saponis viridis, aa. drachm iij.

M.--Sig. Rub into the patches night and morning.

Stronger applications are often necessary if the disease fails to yield to the simpler remedies. Pyrogallic acid in ointment, from forty to ninety grains to the ounce, and chrysarobin in the same strength, are serviceable. The latter is a dangerous remedy to use about the face, occasioning at times a violent conjunctivitis with oedema. Pyrogallic acid is safer, and sometimes proves more satisfactory when applied in flexible collodion or liquor gutta-perchæ than in ointment form, as in the following formula:

Rx. Acidi pyrogallici, drachm j;
Liquor. gutta-perchæ, fluidrachm iv.

M.--S. Apply with a brush. This is to be painted over the patches several times daily until considerable reaction takes place or a crust forms, then discontinued, and as soon as the crust is removed or falls off the application is to be repeated. If there is much scaling, thirty grains of salicylic acid may be added to the above formula. In most cases it is advisable as soon as the crust forms to remove it, and immediately to resume the pyrogallic-acid painting. Cantharidal blistering fluid, repeatedly applied, has been recommended. Nitrate of silver, either in stick or strong solution, is a comparatively safe caustic, and is at times useful. Treatment by linear scarifications, especially in obstinate, sluggish, and infiltrated patches, is often valuable. The scar left is, as a rule, insignificant. Erasion with the curette is a method that sometimes proves of advantage in the severer and deeper-seated forms of the disease. Although in almost all instances stimulating or active treatment is demanded and well borne, there are cases occasionally met with in which, on account of the inflammation and pain, soothing applications must, for a time at least, be employed. These cases, it will be found, are aggravated by stimulating remedies.

{693} Lupus Vulgaris.

Lupus vulgaris (known also as lupus exedens, lupus vorax) is a cellular new growth, characterized by variously-sized, soft, reddish-brown patches, consisting of papules, tubercles, and flat infiltrations, eventually terminating in ulceration and cicatrization. The disease appears differently as seen in the several forms and stages of its development. All the varieties usually begin in one and the same way.

The primary lesions are pinhead- to small pea-sized, deep-seated, brownish-red or yellowish papules, having their seat in the deeper part of the corium. They are softer and looser in texture than normal tissue, and as the disease progresses form variously sized and shaped patches. They may be so closely aggregated as to form flat infiltrations. The patches tend to be round, serpiginous, or ill defined. As the papules increase in size they may be distinctly recognized both by the eye and by passing the finger over the surface; later even reaching the size of small peas. The lesions having attained a certain size or development and being covered with imperfectly-formed epidermis, may so remain for a time, or retrogressive changes may immediately occur. They may disappear by absorption, fatty degeneration taking place, leaving a desquamating, atrophic or cicatricial tissue--lupus exfoliativus--or disintegration and destruction of the diseased skin may occur, resulting in ulceration--lupus exedens, or exulcerans. This latter is the usual course of the disease. The ulcerations are rounded, shallow excavations with soft and reddish borders. If the ulcerations are the seat of exuberant granulations, the condition is known as lupus hypertrophicus. Papillary outgrowths may occur in the healing ulcers, and a rough, verrucous condition results--lupus verrucosus.

The lesions of lupus are seldom painful. The ulcers secrete a slight or moderate amount of pus which forms crusts. Soft or firm cicatricial tissue finally results. In almost all cases of long standing the several stages of the disease may be recognized, each lesion, whether the first or the last, going through a similar course, either of absorption and exfoliation or ulceration and cicatrization. The deeper parts may be involved in the process, subcutaneous connective tissue, cartilage, and mucous membrane being liable to invasion. The mucous membrane of the mouth, gums, velum and larynx may even be primarily the seat of the lupus infiltration, considerable destruction eventually resulting. The face, especially the nose, is the most common site of the disease. Occurring about the eye, the process may eventually destroy that organ. The ears are likewise frequently attacked. Not infrequently the extremities, and occasionally the trunk, are invaded. The disease begins, as a rule, in childhood. It is always a destructive process, usually resulting in disfiguring cicatrices.

The causes of the disease are obscure. Although it usually appears in early life, it is never congenital. Heredity has little if any influence. It is comparatively rare in this country, less so in England and Ireland, but is more common in Austria, Germany and France. It is most generally observed among the strumous and debilitated, but is also frequently seen in those who enjoy all the advantages of life and who are otherwise in average health. It is entirely distinct and independent of syphilis. The French consider it a scrofuloderm (scrofulide), and yet in many cases there {694} is clinically a considerable difference. On the other hand, cases are met with in which its close relationship, if not identity, with the scrofulodermata is not to be questioned. The view that it is a tuberculosis of the skin due to the same cause as at present advanced for tuberculosis of the lungs--the bacillus--has lately been suggested. The disease attacks both sexes, but is somewhat more common in women than in men.

Anatomically, the process is a chronic inflammation, consisting essentially of small-cell infiltration, affecting primarily the corium, eventually spreading to other parts. The epithelial structures are usually involved in the first stages of the disease. Recent lesions are rich in vessels, the vascularity when retrogressive changes take place rapidly decreasing, beginning at the centre of the nodule. The cutaneous tissues undergo cicatricial contraction, a part, however, being organized into coarse connective tissue. In addition to the formation of the nodular mass, the cell-infiltration is found to spread along the vessels of the corium and papillæ, and also into the deeper portions of the skin. The papules may be so close and the cell-infiltration so extensive that a large area of disease results and undergoes the same changes as an individual lesion. The sweat and sebaceous glands are involved. Sometimes epithelial hyperplasia takes place, the epithelial outgrowth from the rete dipping down and joining similar outgrowths from the cells of the sweat-glands and hair root-sheaths, forming an epithelial network which may become a histological basis for the development of epithelioma. The occurrence of this latter disease in lupus tissue, in association or as a sequela, has been noted by several observers. According to the latest investigations the infiltration of lupus is due chiefly to cell-proliferation and outgrowth from the protoplasmic walls and adventitia of the blood-vessels and lymphatics. The fibrous-tissue network, vessels, and a portion of the cell-infiltration are thus produced, the fixed and wandering connective-tissue cells of the inflamed stroma of the cutis being responsible for the other portion of the new growth.

DIAGNOSIS.--Ordinarily, the features of lupus vulgaris are so distinctive as to render a diagnosis a matter of no difficulty. The characteristic soft, small, reddish-brown subcutaneous papule--the primary efflorescence of the disease--is generally to be found, especially about the periphery of the patch, and when present is diagnostic. At times, however, it bears resemblance to syphilis, epithelioma, lupus erythematosus, and acne rosacea.

It is chiefly in the serpiginous forms of the late tubercular and ulcerative syphilodermata that the resemblance to lupus vulgaris is sometimes very close. There are several points of difference. Syphilis is much more rapid in its course, marked ulceration following frequently within a few weeks or months of its appearance. With lupus, on the other hand, years may elapse before the same amount of destruction results. In lupus there are usually several points of ulceration; in syphilis, one or several, which incline to coalesce. The ulcers of lupus are apt to be superficial, whereas those of syphilis are usually deep, with a punched-out appearance. Lupus papules are small, soft and but slightly elevated, and frequently reappear in the scars left by the disease; the papules or tubercles of syphilis are larger, more elevated, firm and harder, and are seldom seen in the scar or track of the disease. The secretion of the {695} syphilitic ulcer is abundant, purulent and offensive, and the crusts thick, often oystershell-like, and of a greenish or blackish color; the secretion of lupus ulceration is slight, odorless, the crusts thin and scanty and of a reddish or reddish-brown color. The scar of lupus is generally hard, shrunken, yellowish, and more or less distorted, while that of syphilis is soft and, compared to the amount of ulceration, but slightly disfiguring. The bone-structures are not involved in lupus; they may be in syphilis. The two diseases have different histories: lupus generally begins in childhood and runs a slow and chronic course; syphilis is usually seen after adolescence or adult age, and progresses more rapidly. In syphilis, moreover, other evidences of the disease may usually be found.

Lupus vulgaris differs from epithelioma in several important points. The edges of the epitheliomatous ulcer are hard, elevated, and waxy; the base is uneven, and the secretion is thin, scanty, and apt to be streaked with blood; the ulceration usually starts from a single point; it is often painful; the tissue-destruction may be considerable; and, finally, epithelioma is, as a rule, a disease of advanced age. Lupus vulgaris differs essentially in all these particulars.

As a rule, there is no difficulty in differentiating lupus vulgaris from lupus erythematosus. The absence of papules, tubercles and ulceration is sufficiently distinctive. Lupus erythematosus is, moreover, a superficial disease, pinkish or violaceous in color, showing itself in circumscribed patches covered with thin adherent scales, and with usually evident involvement of the sebaceous glands. It rarely begins before adult age, whereas lupus vulgaris, as a rule, first appears in childhood. Attention to the ordinary characters of acne rosacea--the hyperæmia, the dilated vessels, comedones, acne papules and pustules, its advent at or after maturity, and the history--will prevent an error in diagnosis.

TREATMENT.--Lupus vulgaris is always a chronic disease, and one that calls for a guarded opinion as to treatment. Although it be removed, relapses are prone to occur, and new papules may show themselves even about the scar resulting from treatment. If it is localized the chances of permanent cure are more favorable. The deformity attending and following the disease is often great,--contraction of joints, destruction of cartilages, and sometimes partial closure of the orifices resulting. The general health is usually good. Death by tuberculosis of the lungs has been noticed in some cases.

Treatment has in the main two objects,--to limit the development or spread of the disease and to remove the morbid tissue that is already present. In accomplishing the former constitutional treatment is occasionally useful; although much cannot usually be attained in this way, yet from our own observations we are convinced that in some cases the disease may be favorably influenced and its spread limited. Cod-liver oil, administered in full doses and for a long period, is sometimes of decided value. Potassium iodide is another remedy which at times proves serviceable. Iodoform in half-grain doses three times daily has been recommended, as have also muriate of lime, in the dose of twenty grains three times a day, and calx sulphurata, in small doses. Hygienic measures are to be enforced, and a generous, nutritious diet advised.

External remedies are essential in every case, and constitute the only plan of treatment to be relied upon. Removal of the diseased tissues by {696} caustics or operation is the method practised. In the earlier stages of the disease or before adopting radical measures it is advisable to make an attempt to bring about absorption by the employment of stimulating applications. Equal parts of tincture of iodine and glycerin, or one part each of iodine and potassium iodide and two parts of glycerin, may be painted over the parts daily or every other day. Mercurial plaster, renewed once or twice a day and kept constantly applied, is valuable in some cases. Corrosive sublimate in the form of a lotion or ointment, one-half to two grains to the ounce, has lately been advised. Cashew-nut oil applied with friction has been recommended for the non-ulcerative form. Tar and sulphur ointments may also be employed. Chrysarobin, either in the form of an ointment or as a solution in liquor gutta-perchæ, has also been advised.

For the radical treatment of the disease there are numerous caustics in use, but there are some which are more positive in their effect and whose action may be controlled. Nitrate of silver, pyrogallic acid, arsenic, caustic potash, the curette, scarifier, and the actual and galvano-cautery are all valuable. Nitrate of silver is best used in stick form. The lesions are forcibly pierced and bored with the stick, and thoroughly cauterized. The operation is to be repeated every three or four days. It is a safe remedy, and is especially useful about the face, as the scars left are soft and smooth. Pyrogallic acid in the form of an ointment or plaster, from 15 to 25 per cent. strength, is often of great value. It is a mild and safe caustic; it is usually painless and leaves a smooth, soft scar. The ointment should be stiff and adhesive, and kept applied constantly for several days or more, renewing twice daily. The following formula serves well:

Rx. Acidi pyrogallici, drachm ij;
Emplastri plumbi, drachm j;
Cerati resinæ comp., drachm v.

M.--Sig. Apply as a plaster. In winter the lead plaster may be omitted. The remedy may also be applied in liquor gutta-perchæ, but is not so satisfactory. The tissues become soft and blackish, and then the parts are to be poulticed and the slough removed; and if the diseased tissue is not sufficiently destroyed the dressing is to be renewed. Subsequently the ulcer is dressed with mercurial ointment or a simple salve. Healing should take place in the course of a few weeks. Iodoform is well spoken of. In deep-seated infiltration the upper epidermic layers should first be removed by a solution of caustic potassa. The iodoform is then put on and a layer of cotton is applied over it, and the dressing remains undisturbed for a week. The lupus nodules are soon destroyed. Several repetitions of the remedy may be necessary. Excepting the preliminary application of the potassa the method is painless.

A solution of caustic potash is sometimes employed for the destruction of the lupus deposit. It is thorough in its action, but is painful and must be used with great caution. The cicatrices left after the use of this caustic are apt to be large and hard. In the application, as soon as the diseased tissue has been thoroughly destroyed by the caustic, the further action may be stopped by neutralizing the alkali with diluted acetic acid. Arsenic in the form of paste is another valuable caustic. It has the advantage of sparing the healthy, and even the cicatricial, tissues. Hebra's modification of Cosme's paste is an eligible formula: {697}

Rx. Acidi arseniosi, scruple j;
Hydrargyri sulphuret. rub., drachm j;
Ugt. simplicis, ounce j.

M. Ft. ugt.--Sig. Spread upon a piece of kid or cloth and apply as a plaster. The paste is to be applied for two or three days consecutively, at the end of which time the parts are somewhat swollen and painful. The lupus nodules are seen as black, necrosed spots. Poultices are then applied until the slough comes away, usually in a day or two; subsequently a mild, stimulating ointment is employed. Rapid cicatrization usually takes place, and the cicatrices are, as a rule, satisfactory. The chief objection to arsenical applications is the intense pain that usually develops soon after the remedy is applied. In other respects the method has its advantages.

Acetate of zinc in crystal form, repeatedly applied to the lesions, has been advised. It is painful at the time of application, but the pain may be somewhat relieved by washing the parts with water. Red iodide of mercury in the form of a strong ointment (equal parts of the salt and a fatty base), applied upon a piece of kid or cloth, will have a speedy caustic effect. There are other caustic remedies which may be mentioned. Chloride of zinc, with an equal part of chloride of antimony and sufficient hydrochloric acid to dissolve the zinc chloride, and enough powdered licorice added to make a paste, and applied as a plaster, is an efficient caustic. It produces an eschar in twelve to twenty-four hours. The parts are then dressed with a simple ointment, and healing allowed to take place. It is a strong caustic, and is destructive to healthy as well as diseased tissue. The same may be said of Vienna paste, consisting of equal parts of lime and potassa. The latter mixture is made into a paste at the time of application by adding alcohol. It is not to be applied more than five to ten minutes, and its further effects are to be counteracted by the application of acetic acid. In the application of such powerful and destructive caustics it is advisable to protect the adjacent skin with strips of adhesive plaster. Salicylic acid has lately been recommended in the form of an ointment of the strength of one to two drachms to the ounce. It is thickly spread on linen and applied continuously. The remedy is a mild one and acts slowly. Mention may also be made of lactic acid, applications of which, it is stated, have been productive of beneficial results.

Of late years the mechanical removal of the lupus deposits has been largely practised. In small patches excision of the entire diseased area has been recommended, but as considerable healthy tissue is necessarily removed with it, and the resulting scar is deep and disfiguring, it is not to be advised. Excision followed by transplantation of healthy skin has also been advocated. An excellent method of removal is by means of the dermal curette, or scraping-spoon. It is one that answers well in many cases. The diseased tissue should be thoroughly scraped out. It is painful, and it is often necessary to operate under ether. The healthy tissues are unyielding and cannot be readily scraped away, so that only the morbid deposit is removed. As it is difficult to remove the new growth from the interstitial spaces, we are in the habit of supplementing the operation with a caustic, either cauterizing lightly with caustic potash, or, what is advisable in the greater number of cases, {698} applying the pyrogallic-acid ointment for several days following the curetting. This method--the curetting and subsequent cauterization--has, on the whole, proved satisfactory.