Chapter V: Part 5

The lesions are usually limited to the extensor surfaces of the thighs and arms, especially the former. They appear as pin-head-sized, whitish or grayish elevations, consisting of accumulations of epithelial matter about the apertures of the hair follicles. Each elevation is pierced by a hair, or the hair may be twisted and imprisoned within the epithelial mass; or it may be broken off just at the point of emergence at the apex of the papule, in which event it may be seen as a dark, central speck. The skin is usually dry, rough and harsh, and in marked cases, to the hand passing over it, feels not unlike a nutmeg-grater. The disease varies in its development, in most cases being so slight as to escape attention. As a rule, it is free from itching.

#What course does keratosis pilaris pursue?#

It is sluggish and chronic.

#Mention some of the etiological factors.#

It is not an uncommon disease, and is seen usually in those who are unaccustomed to frequent bathing, being most frequently met with during the winter months. It is chiefly observed during early adult life.

#Is there any difficulty in the diagnosis?#

No. It is thought at times to bear some resemblance to goose-flesh (cutis anserina), the miliary papular syphiloderm in its desquamating stage, and lichen scrofulosus. In goose-flesh the elevations are evanescent and of an entirely different character; the papules of the syphiloderm are usually generalized, of a reddish color, tend to group, are more solid and deeply-seated, less scaly and are accompanied with other symptoms of syphilis; in lichen scrofulosus the papules are larger, incline to occur in groups, and appear usually upon the abdomen.

#State the prognosis.#

The disease yields readily to treatment.

#Give the treatment of keratosis pilaris.#

Frequent warm baths, with the use of a toilet soap or sapo viridis, will usually be found curative. Alkaline baths are also useful. In obstinate cases the ordinary mild ointments, glycerine, etc., are to be advised in conjunction with the baths.

#Keratosis Follicularis.#

#Describe keratosis follicularis.#

Keratosis follicularis (_Darier's disease_, _ichthyosis follicularis_, _ichthyosis sebacea cornea_, _psorospermosis_) is a rare disease characterized by pin-head to pea-sized pointed, rounded, or irregularly-shaped grayish, brownish, red or even black, horny papules or elevations, arising from the sebaceous or hair-follicles. They are, for the most part, discrete, with a tendency here and there to form solid aggregations or areas. Many of them contain projecting cornified plugs which may be squeezed out, leaving pit-like depressions. The face, scalp, lower trunk, groins and flanks are the parts chiefly affected. The view advanced by Darier, that the malady was due to psorosperms, is now denied, the bodies thought to be such having been demonstrated to be due to cell transformation.

As to treatment, in one instance the induction of a substitutive dermatic inflammation had a favorable influence.

#Molluscum Epitheliale.#
(_Synonyms:_ Molluscum Contagiosum; Molluscum Sebaceum; Epithelioma
Molluscum.)

#Give a definition of molluscum epitheliale.#

Molluscum epitheliale is characterized by pin-head to pea-sized, rounded, semi-globular, or flattened, pearl-like elevations, of a whitish or pinkish color.

#Describe the symptoms and course of molluscum epitheliale.#

The usual seat is the face; not infrequently, however, the growths occur on other parts. The lesions begin as pin-head, waxy-looking, rounded or acuminated elevations, gradually attaining the size of small peas. They have a broad base or occasionally may tend to become pedunculated. They rarely exist in profusion, in most cases three to ten or twelve lesions being present. When fully developed they are somewhat flattened and umbilicated, with a central, darkish point representing the mouth of the follicle. They are whitish or pinkish, and look not unlike drops of wax or pearl buttons. At first they are firm, but eventually, in most cases, tend to become soft and break down. Not infrequently, however, the lesions disappear slowly by absorption, without apparent previous softening. Their course is usually chronic. The contents, a cheesy-looking mass, may commonly be pressed out without difficulty.

#What is the cause of molluscum epitheliale?#

It is now generally accepted that the disease is mildly contagious. It occurs chiefly in children, and especially among the poorer classes. The belief in the parasitic nature of the disease is gaining ground; recently the opinion has been advanced that it is due to psorosperms (psorospermosis); but further investigations have indicated that these bodies were degenerated epithelia.

#State the pathology.#

According to recent investigations, molluscum epitheliale is to be regarded as a hyperplasia of the rete, the growth probably beginning in the hair-follicles; the so-called molluscum bodies--peculiar, rounded or ovoidal, sharply-defined, fatty-looking bodies found in microscopical examination of the growth--are to be viewed as a form of epithelial degeneration.

#What are the diagnostic points in molluscum epitheliale?#

The size of the lesions, their waxy or glistening appearance, and the presence of the central orifice.

It is to be differentiated from molluscum fibrosum, warts and acne.

#State the prognosis.#

The growths are amenable to treatment. In some instances the disease, after existing some weeks, tends to disappear spontaneously.

#What is the treatment of molluscum epitheliale?#

Incision and expression of the contents, and touching the base of the cavity with silver nitrate. Pedunculated growths may be ligated. In some cases an ointment of ammoniated mercury, twenty to forty grains to the ounce, applied, by gently rubbing, once or twice daily, will bring about a cure.

#Callositas.#
(_Synonyms:_ Tylosis; Tyloma; Callus; Callous; Callosity; Keratoma.)

#What do you understand by callositas?#

A hard, thickened, horny patch made up of the corneous layers of the epidermis.

#Describe the clinical appearances.#

Callosities are most common about the hands and feet, and consist of small or large patches of dry, grayish-yellow looking, hard, slight or excessive epidermic accumulations. They are somewhat elevated, especially at the central portion, and gradually merge into the healthy skin. The natural surface lines are in a great measure obliterated, the patches usually being smooth and horn-like.

_Keratosis palmaris et plantaris_ (symmetric keratodermia), as regards the local condition, is a somewhat similar affection. It consists of hypertrophy of the corneous layer of the palm and soles, usually of a more or less horny and plate-like character, but is congenital or hereditary, and not necessarily dependent upon local friction or pressure.

#Are there any inflammatory symptoms in callositas?#

No; but exceptionally, from accidental injury, the subjacent corium becomes inflamed, suppurates, and the thickened mass is cast off.

#State the causes of callositas.#

Pressure and friction; for example, on the hands, from the use of various tools and implements, and on the feet from ill-fitting shoes. It is, indeed, often to be looked upon as an effort of nature to protect the more delicate corium.

In exceptional instances it arises without apparent cause.

#What is the pathology?#

The epidermis alone is involved; it consists, in fact, of a hyperplasia of the horny layer.

#State the prognosis of callositas.#

If the causes are removed, the accumulation, as a rule, gradually disappears. The effect of treatment is always rapid and positive, but unless the etiological factors have ceased to act, the result is usually but temporary.

#How is callositas treated?#

When treatment is deemed advisable, it consists in softening the parts with hot-water soakings or poultices, and subsequently shaving or scraping off the callous mass. The same result may also be often effected by the continuous application, for several days or a week, of a 10 to 15 per cent. salicylated plaster, or the application of a salicylated collodion, same strength; it is followed up by hot-water soaking, the accumulation, as a rule, coming readily away.

#Clavus.#
(_Synonym:_ Corn.)

#What is clavus?#

Clavus, or corn, is a small, circumscribed, flattened, deep-seated, horny formation usually seated about the toes.

#Describe the clinical appearances.#

Ordinarily a corn has the appearance of a small callosity; the skin is thickened, polished and horny. Exceptionally, however, occurring on parts that are naturally more or less moist, as between the toes, maceration takes place, and the result is the so-called _soft corn_. The dorsal aspect of the toes is the common site for the ordinary variety. The usual size is that of a small pea. They are painful on pressure, and, at times, spontaneously so.

#State the causes.#

Corns are caused by pressure and friction, and may usually be referred to improperly fitting shoes.

#What is the pathology of clavus?#

It is a hypertrophy of the epiderm. Its shape is conical, with the base external and the apex pressing upon the papillae. It is, in fact, a peculiarly-shaped callosity, the central portion and apex being dense and horny, forming the so-called core.

#Give the treatment of clavus.#

A simple method of treatment consists in shaving off, after a preliminary hot-water soaking, the outer portion, and then applying a ring of felt or like material, with the hollow part immediately over the site of the core; this should be worn for several weeks. It is also possible in some cases to extract the whole corn by gently dissecting it out; the after-treatment being the same as the above.

Another method is by means of a ten- to fifteen-per-cent. solution of salicylic acid, in alcohol or collodion, or the following:--

[Rx] Ac. salicylici, ...................... gr. xxx
Ext. cannabis Ind., .................. gr. x
Collodii, ............................ f[dram]iv. M.

This is painted on the corn night and morning for several days, at the end of which time the parts are soaked in hot water, and the mass or a greater part of it, will be found, as a rule, to come readily away; one or two repetitions may be necessary. Lactic acid, with one to several parts of water, applied once or twice daily, acts in a similar manner.

Soft corns, after the removal of pressure, may be treated with the solid stick of nitrate of silver, or by any of the methods already mentioned.

In order that treatment be permanently successful, the feet are to be properly fitted. If pressure is removed, corns will commonly disappear spontaneously.

#Cornu Cutaneum.#
(_Synonyms:_ Cornu Humanum; Cutaneous Horn.)

#What is cornu cutaneum?#

A cutaneous horn is a circumscribed hypertrophy of the epidermis, forming an outgrowth of horny consistence and of variable size and shape.

#At what age and upon what parts are cutaneous horns observed?#

They are usually met with late in life, and are mostly seated upon the face and scalp.

#Describe the clinical appearances.#

In appearance cutaneous horns resemble those seen in the lower animals, differing, if at all, but slightly. They are hard, solid, dry and somewhat brittle; usually tapering, and may be either straight, curved or crooked. Their surface is rough, irregular, laminated or fissured, the ends pointed, blunt or clubbed. The color varies; it is usually grayish-yellow, but may be even blackish. As commonly seen they are small in size, a fraction of an inch or an inch or thereabouts in length, but exceptionally attain considerable proportions. The base, which rests directly upon the skin, may be broad, flattened, or concave, with the underlying and adjacent tissues normal or the papillae hypertrophied; and in some cases there is more or less inflammation, which may be followed by suppuration. They are usually solitary formations. They are not, as a rule, painful, unless knocked or irritated.

#What course do cutaneous horns pursue?#

Their growth is usually slow, and, after having attained a certain size, they not infrequently become loose and fall off; they are almost always reproduced.

#What is the cause of these horny growths?#

The cause is not known; appearing about the genitalia, they usually develop from acuminated warts. They are rare formations.

#State the pathology of cornu cutaneum.#

Horns consist of closely agglutinated epidermic cells, forming small columns or rods; in the columns themselves the cells are arranged concentrically. In the base are found hypertrophic papillae and some bloodvessels. They have their starting-point in the rete mucosum, either from that lying above the papillae or that lining the follicles and glands.

#Does epitheliomatous degeneration of the base ever occur?#

Yes.

#State the prognosis.#

Cutaneous horns may be readily and permanently removed.

#What is the treatment?#

Treatment consists in detachment, and subsequent destruction of the base; the former is accomplished by dissecting the horn away from the base or forcibly breaking it off, the latter by means of any of the well-known caustics, such as caustic potash, chloride of zinc and the galvano-cautery.

Another method is to excise the base, the horn coming away with it; this necessitates, however, considerable loss of tissue.

#Verruca.#
(_Synonym:_ Wart.)

#What is verruca?#

Verruca, or wart, is a hard or soft, rounded, flat, acuminated or filiform, circumscribed epidermal and papillary growth.

#Name the several varieties of warts met with.#

Verruca vulgaris, verruca plana, verruca plana juvenilis, verruca digitata, verruca filifortnis and verruca acuminata.

#Describe verruca vulgaris.#

This is the common wart, occurring mostly upon the hands. It is rounded, elevated, circumscribed, hard and horny, with a broad base, and usually the size of a pea. At first it is smooth and covered with slightly thickened epidermis, but later this disappears to some extent, the hypertrophied papillae, appearing as minute elevations, making up the growth. One, several or more may be present.

#Describe verruca plana.#

This is the so-called flat wart, and occurs commonly upon the back, especially in elderly people (_verruca senilis_, _keratosis pigmentosa_). It is, as a rule, but slightly elevated, is usually dark in color, and of the size of a pea or finger-nail.

#Describe verruca plana juvenilis.#

The warts are mostly pin-head in size, flat, but slightly elevated, rounded, irregular or square-shaped, and of a light yellowish-brown color. They bear resemblance to lichen planus papules. They are apt to be numerous, often becoming aggregated or fused, and occur usually in young children, and, as a rule, on the face and hands.

#Describe verruca filiformis.#

This is a thread-like growth about an eighth or fourth of an inch long, and occurring commonly about the face, eyelids and neck. It is usually soft to the touch and flexible.

#Describe verruca digitata.#

This is a variety of wart, which, especially about the edges, is marked by digitations, extending nearly or quite down to the base. It is commonly seen upon the scalp.

#Describe verruca acuminata.#

This variety (_venereal wart_, _pointed wart_, _pointed condyloma_), usually occurs about the genitalia, especially upon the mucous and muco-cutaneous surfaces. It consists of one or more groups of acuminated, pinkish or reddish, raspberry-like elevations, and, according to the region, may be dry or moist; if the latter, the secretion, which is usually yellowish and puriform, from rapid decomposition, develops an offensive and penetrating odor. The formation may be the size of a small pea, or may attain the dimensions of a fist.

#What is the cause of warts?#

The etiology is not known. They are more common in adolescent and early adult life. Irritating secretions are thought to be causative in the acuminated variety. It is highly probable that a parasitic factor will finally be demonstrated. They are doubtless mildly contagious.

#State the pathology of warts.#

A wart consists of both epidermic and papillary hypertrophy, the interior of the growth containing a vascular loop. In the acuminated variety there are marked papillary enlargement, excessive development of the mucous layer, and an abundant vascular supply.

#Give the treatment of warts.#

For ordinary warts, excision or destruction by caustics. The repeated application of a saturated alcoholic solution of salicylic acid is often curative, the upper portion being pared off from time to time. The filiform and digitate varieties may be snipped off with the scissors, and the base touched with nitrate of silver; or a ligature may be used. Curetting is a valuable operative method. The growths may also be removed by electrolysis. When warts are numerous and close together parasiticide applications can be daily made to the whole affected region. For this purpose a boric acid solution, containing five to thirty grains of resorcin to the ounce, and Vleminckx's solution, at first diluted, prove the most valuable.

Verruca acuminata is to be treated by maintaining absolute cleanliness, and the application of such astringents as liquor plumbi subacetatis, tincture of iron, powdered alum and boric acid. The salicylic acid solution may also be used. In obstinate cases, glacial acetic acid or chromic acid may be cautiously employed.

#Naevus Pigmentosus.#
(_Synonym:_ Mole.)

#Describe naevus pigmentosus.#

Naevus pigmentosus, commonly known as mole, may be defined as a circumscribed increase in the pigment of the skin, usually associated with hypertrophy of one or all of the cutaneous structures, especially of the connective tissue and hair. It occurs singly or in numbers; is usually pea-, bean-sized or larger, rounded or irregular, smooth or rough, flat or elevated, and of a color varying from a light brown to black; the hair found thereon may be either colorless or deeply pigmented, coarse and of considerable length. It is, as a rule, a permanent formation.

#Name the several varieties of naevus pigmentosus met with.#

Naevus spilus, naevus pilosus, naevus verrucosus, and naevus lipomatodes. So-called linear naevus might also be considered as belonging in this group.

#What is naevus spilus?#

A smooth and flat naevus, consisting essentially of augmented pigmentation alone.

#What is naevus pilosus?#

A naevus upon which there is an abnormal growth of hair, slight or excessive.

#What is naevus verrucosus?#

A naevus to which is added hypertrophy of the papillae, giving rise to a furrowed and uneven surface.

#What is linear naevus?#

Linear naevus is a formation usually of a verrucous character, more or less pigmented, sometimes slightly scaly, occurring in band-like or zoster-like areas, and, as a rule, unilaterally.

#What is naevus lipomatodes?#

A naevus with excessive fat and connective-tissue hypertrophy.

#State the etiology of naevus pigmentosus.#

The causes are obscure. The growths are usually congenital; but the smooth, non-hairy moles may be acquired.

#Give the pathology of naevus pigmentosus.#

Microscopical examination shows a marked increase in the pigment in the lowest layers of the rete mucosum, as well as more or less pigmentation in the corium usually following the course of the bloodvessels; in the verrucous variety the papillae are greatly hypertrophied, in addition to the increased pigmentation. There is, as a rule, more or less connective-tissue hypertrophy.

#What is the treatment of naevus pigmentosus?#

In many instances interference is scarcely called for, but when demanded consists in the removal of the formation either by the knife, by caustics, or by electrolysis. This last is, in the milder varieties at least, perhaps the best method, as it is less likely to be followed by disfiguring cicatrices. In naevus pilosus the removal of the hairs alone by electrolysis is not infrequently followed by a decided diminution of the pigmentation. In recent years both liquid air and carbon dioxide have also been used successfully in the removal of these growths. Pigmented naevi, which show the least tendency to growth or degenerative change, should be radically removed, as they not infrequently lead to carcinomatous and sarcomatous growths.

#Ichthyosis.#
(_Synonym:_ Fish-skin Disease.)

#Give a descriptive definition of ichthyosis.#

Ichthyosis is a chronic, hypertrophic disease, characterized by dryness and scaliness of the skin, with a variable amount of papillary growth.

#At what age is ichthyosis first observed?#

It is first noticed in infancy or early childhood. In rare instances it is congenital (ichthyosis congenita), and in such cases it is usually severe, and of a grave type; the children are, as a rule, prematurely born, and frequently do not survive many days or weeks.

#What extent of surface is involved?#

Usually the whole surface, but it is most marked upon the extensor surfaces of the arms and legs, especially at the elbows and knees; the face and scalp, in mild cases, often remain free.

#Name the two varieties of ichthyosis usually described.#

Ichthyosis simplex and ichthyosis hystrix, terms commonly employed to designate the mild and severe forms respectively.

#Describe the clinical appearances of ichthyosis.#

The milder forms of the disease may be so slight as to give rise to simple dryness or harshness of the skin (_xeroderma_); but as commonly met with it is more developed, more or less marked scaliness in the form of thin or somewhat thick epidermal plates being present. The papillae of the skin are often slightly hypertrophied. In slight cases the color of the scales is usually light and pearly; in the more marked examples it is dark gray, olive green or black.

In the severe variety--ichthyosis hystrix--in addition to scaliness there is marked papillary hypertrophy, forming warty or spinous patches. This type is rare, and, as a rule, the surface involved is more or less limited.

#Are there any inflammatory symptoms in ichthyosis?#

No. In fact, beyond the disfigurement, the disease causes no inconvenience; in those well-marked cases, however, in which the scales are thick and more or less immovable, the natural mobility of the parts is compromised and fissuring often occurs. In the winter months, in the severer cases, exposed parts may become slightly eczematous.

#Does ichthyosis vary somewhat with the season?#

Yes. In all cases the disease is better in the warm months, and in the mild forms may entirely disappear during this time. This favorable change is purely mechanical--due to the maceration to which the increased activity of the sweat glands gives rise.

#Is the general health affected in ichthyosis?#

No.

#What course does ichthyosis pursue?#

Chronic. Beginning in early infancy or childhood, it usually becomes gradually more marked until adult age, after which time it, as a rule, remains stationary.

#What is the etiology?#

Beyond a hereditary influence, which is often a positive factor, the causes are obscure. It is not a common disease.

#State the pathology.#

Anatomically the essential feature is epidermic hypertrophy, with usually a varying degree of papillary hypertrophy also.

#Mention the diagnostic features of ichthyosis.#

The harsh, dry skin, epidermic and papillary hypertrophy, the furfuraceous or plate-like scaliness, the greater development upon the extensor surfaces, a history of the affection dating from early childhood, and the absence of inflammatory symptoms.

#How is ichthyosis to be distinguished from eczema, psoriasis, and other scaly inflammatory diseases?#

By the absence of the inflammatory element.

#What is the outlook for a case of ichthyosis?#

The prognosis is unfavorable as regards a cure, but the process may usually be kept in abeyance or rendered endurable by proper measures.

#What treatment would you prescribe for ichthyosis?#

Treatment that has in view removal of the scaliness and the maintenance of a soft and flexible condition of the skin.

In mild cases frequent warm baths, simple or alkaline, will suffice; in others an application of an oily or fatty substance, such as the ordinary oils or ointments, made several hours or immediately before the bath may be necessary. In moderately developed cases the skin is to be washed energetically with sapo viridis and hot water, followed by a warm bath, after which an oily or fatty application is made. In some of the more severe cases the following plan is often useful: The parts are first rubbed with a soapy ointment consisting of one part of precipitated sulphur and seven parts of sapo viridis; a bath is then taken, the skin wiped dry, and a one to five per cent. ointment of salicylic acid gently rubbed in.

Glycerine lotions, one or two drachms to the ounce of water, are also beneficial; as also the following:--

[Rx] Ac. salicylici, ...................... gr. x-xl
Glycerini, ........................... [dram]ss-[dram]j
Lanolin,
Petrolati, .................. [=a][=a] [Oz]ss

In severe cases of ichthyosis hystrix it may be necessary, also, to employ caustics or the knife.

#What systemic treatment would you prescribe?#

Constitutional remedies are practically powerless; occasionally some good is accomplished by the internal administration of linseed oil and jaborandi.

#Onychauxis.#
(_Synonym:_ Hypertrophy of the Nail.)

#Describe onychauxis.#

Onychauxis, or hypertrophy of the nail, may take place in one or all directions, and this increase may be, and often is, accompanied by changes in shape, color, and direction of growth. One or all the nails may share in the process. As the result of lateral deviation of growth, the nail presses upon the surrounding tissues, producing a varying degree of inflammation--_paronychia_.

#What is the etiology of hypertrophy of the nail?#

The condition may be either congenital or acquired. In the latter instances it is usually the result of the extension to the matrix of such cutaneous diseases as psoriasis and eczema; or it is produced by constitutional maladies, such as syphilis.

#Give the treatment of hypertrophy of the nail.#

Treatment consists in the removal of the redundant nail-tissue by means of the knife or scissors; and, when dependent upon eczema or psoriasis, the employment of remedies suitable for these diseases. When it is the result of syphilis, the medication appropriate to this disease is to be employed.

In paronychia the nail should be frequently trimmed and a pledget of lint or cotton be interposed between the edge of the nail and the adjacent soft parts; astringent powders and lotions may often be employed with advantage; and in severe and persistent cases excision of the nail, partial or complete, may be found necessary.

#Hypertrichosis.#
(_Synonyms:_ Hirsuties; Hypertrophy of the Hair; Superfluous Hair.)

#What is meant by hypertrichosis?#

Hypertrichosis is a term applied to excessive growth of hair, either as regards region, extent, age or sex.

#Describe the several conditions met with.#

The unnatural hair growth may be slight, as, for instance, upon a naevus (_naevus pilosus_); or it may be excessive, as in the so-called hairy people (_homines pilosi_); or it may also appear on the face, arms and other parts in females, resulting from a hypertrophy of the natural lanugo hairs.

#State the causes of hypertrichosis.#

Hereditary influence is often a factor; the condition may also be congenital.

If acquired, the tendency manifests itself usually toward middle life. In women, it is not infrequently associated with diseases of the utero-ovarian system; in many instances, however, there is no apparent cause. Local irritation or stimulation has at times a causative influence.

#How is hypertrichosis to be treated?#

For general hypertrichosis there is no remedy. Small hairy naevi may be excised, or, as also in the larger hairy moles, the hairs may be removed by electrolysis.

On the faces of women, if the hairs are coarse or large, electrolysis constitutes the only satisfactory method; if the hairs are small and lanugo-like, the operation is not to be advised. It is somewhat painful, but never unbearable. In the past several years the _x_-ray has been advocated by several writers, but it requires usually numerous exposures pushed to the point of producing erythema; it is not without risk, and the hairs are said to return in some months.

#What temporary methods are usually resorted to for the removal of superfluous hair?#

Shaving, extraction of the hairs and the use of depilatories. As a depilatory, a powder made up of two drachms of barium sulphide and three drachms each of zinc oxide and starch, is commonly (and cautiously) employed; at the time of application enough water is added to the powder to make a paste, and it is then spread thinly upon the parts, allowed to remain five to fifteen minutes, or until heat of skin or a burning sensation is felt, washed off thoroughly, and a soothing ointment applied. This preparation must be well prepared to be efficient.

#Describe the method of removal of superfluous hair by electrolysis.#

A fine needle in a suitable handle is attached to the _negative_ pole of a _galvanic_ battery, introduced into the hair-follicle to the depth of the papilla, and the circuit completed by the patient touching the positive electrode; in several seconds slight blanching and frothing usually appear at the point of insertion; a few seconds later the current is broken by release of the positive electrode, and the needle is then withdrawn. Sometimes a wheal-like elevation arises, remains several minutes or hours, and then disappears; or occasionally, probably from secondary infection, it develops into a pustule.

A strength of current of a half to two milliamperes is usually sufficient; the time necessary for the destruction of the papilla varying from several to thirty seconds.

#How are you to know if the papilla has been destroyed?#

The hair will readily come out with but little, if any, traction.

#What is the result if the current has been too strong or too long continued?#

The follicle suppurates and a scar results.

#Why should contiguous hairs not be operated upon at the same sitting?#

In order that the chances of marked inflammatory action and scarring (always possibilities) may be reduced to a minimum.

#In case of failure to destroy an individual papilla, should a second attempt be made at the same sitting?#

As a rule not, in order to avoid the possibility of too much destructive action, and consequent scarring.

#Can scarring always be prevented?#

In the average case, with skill and care, the use of an exceedingly fine needle and the avoidance of too strong a current, _perceptible_ scarring (scarring perceptible to the ordinary observer or at ordinary distance) need rarely occur.

#What measures are to be advised for the irritation produced by the operation?#

Hot-water applications and the use of an ointment made of two drachms cold cream and ten grains of boric acid are of advantage not only in reducing the resulting hyperaemia, but also in preventing suppuration and consequent scarring. To lessen the chances of the latter, cleansing the parts with alcohol just before and after the operation is also of service.

#[OE]dema Neonatorum.#

#Describe [oe]dema neonatorum.#

The essential symptoms are [oe]dema and a variable degree of hardness and induration. It develops in the first few days of life, and usually upon the extremities, especially the lower. It may remain more or less limited to these parts, but, as a rule, slowly extends. The skin is of a yellowish, dusky, or livid color, and sometimes glossy or shining. There are general symptoms of drowsiness, subnormal temperature, weakened circulation, and impaired respiration, which gradually increase, and in eighty to ninety per cent. of the cases lead to death. It is believed to be similar to anasarca in the adult and to be due to like causes.

Treatment consists in maintaining the body-heat, sufficient and proper nourishment and stimulation.

#Sclerema Neonatorum.#
(_Synonyms:_ Scleroderma Neonatorum; Sclerema of the Newborn.)

#What is sclerema neonatorum?#

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

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

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

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

Treatment should be directed toward maintaining warmth and proper alimentation.

#Scleroderma.#
(_Synonyms:_ Sclerema; Scleriasis; Dermatosclerosis; Morph[oe]a; Keloid
of Addison.)

#What is scleroderma?#

Scleroderma is an acute or chronic disease of the skin characterized by a localized or general, more or less diffuse, usually pigmented, rigid, stiffened, indurated or hide-bound condition.

Morph[oe]a, by some formerly thought to be a distinct affection, is now believed to be a form of scleroderma; as typically met with it is characterized by one or more rounded, oval, or elongate, coin- to palm-sized, pinkish, or whitish ivory-looking patches. In some instances such patches are seen in association with the more classic type of scleroderma just defined.

#Describe the symptoms of ordinary scleroderma.#

The disease may be acute or chronic, usually the latter. A portion or almost the entire surface may be involved, or it may occupy variously sized and shaped areas. The integument becomes more or less rigid and indurated, hard to the touch, hide-bound, and in marked cases immobile. [OE]dema may, especially in the more acute cases, precede the induration. Pigmentation, of a yellowish or brownish color, is often a precursory and accompanying symptom. The skin feels tight and contracted, and in some instances numbness and cramp-like pains are complained of.

#Describe the variety known as morph[oe]a.#

The patches (one, several, or more), occurring most frequently about the trunk, are in the beginning usually slightly hyperaemic, later becoming pale-yellowish or white, and having a pinkish or lilac border made up of minute capillaries. They are, as a rule, sharply defined, with a smooth, often shining and atrophic-looking surface; are soft, fine or leathery to the touch, on a level or somewhat depressed, and appearing not unlike a piece of bacon or ivory laid in the skin. Occasionally the patches are noted to occur over nerve-tracts. The adjacent skin may be normal or there may be more or less yellowish or brownish mottling. The subjective symptoms of tingling, itching, numbness, and even pain, may or may not be present.

#What is the course of the disease?#

Sooner or later, usually after months or years, the disease ends in resolution and recovery, or in marked atrophic changes, causing contraction and deformity. As a rule, the general health remains good.

#State the causes of scleroderma.#

The condition is to be considered as probably of neurotic origin. Exposure and shock to the nervous system are to be looked upon as influential. It is a rare disease, observed usually in early adult or middle life, and is more frequent in women than in men.

#What is the pathology?#

In typical and advanced cases both the true skin and the subcutaneous connective tissue show a marked increase of connective tissue-element, with thickening and condensation of the fibers.

#Is there any difficulty in reaching a diagnosis in scleroderma?#

As a rule, no. The characters--rigidity, stiffness, hardness, and hide-bound condition of the skin--are always distinctive.

The peculiar appearance, the course and character of the patches, of morph[oe]a are quite distinctive.

#Give the prognosis of scleroderma.#

It should always be guarded. In many instances recovery takes place, whilst in others the disease is rebellious, lasting indefinitely. The prognosis of the variety known as morph[oe]a is less unfavorable than general scleroderma, and recovery more frequent.

#What is the treatment of scleroderma?#

Tonics, such as arsenic, quinia, nux vomica, and cod-liver oil; conjointly with the local employment of stimulating, oily or fatty applications, friction, and electricity. Roentgen-ray treatment is often of value, more especially in the morph[oe]a type.

#Elephantiasis.#
(_Synonyms:_ Elephantiasis Arabum; Pachydermia; Barbadoes Leg; Elephant
Leg.)

#Give a descriptive definition of elephantiasis.#

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

#What parts are commonly involved in elephantiasis?#

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

#Describe the symptoms of elephantiasis.#

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

#What is the further course of the disease?#

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

#Are there any subjective symptoms?#

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

#State the cause of elephantiasis.#

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

#What is the pathology?#

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

#What are the diagnostic characters of beginning elephantiasis?#

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

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

#Give the prognosis of elephantiasis.#

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

#What is the treatment of elephantiasis?#

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

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

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

#Dermatolysis.#
(_Synonym:_ Cutis Pendula.)

#Give a descriptive definition of dermatolysis.#

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

#Describe the symptoms and course of dermatolysis.#

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

#What course does dermatolysis pursue?#

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

#Give the etiology.#

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

#What is the pathology?#

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

#What is the treatment of dermatolysis?#

Excision when advisable and practicable.

#CLASS V.--ATROPHIES.#

#Albinismus.#

#What do you understand by albinismus?#

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

#Describe complete albinismus.#

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

#Describe partial albinismus.#

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

#Is there any structural change in the skin?#

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

#What is known in regard to the etiology?#

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

#Does albinismus admit of treatment?#

No; the condition is without remedy.

#Vitiligo.#
(_Synonyms:_ Leucoderma; Leucopathia.)

#Give a definition of vitiligo.#

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

#Describe the symptoms of vitiligo.#

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

There are no subjective symptoms.

#What course does vitiligo pursue?#

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

#Give the etiology of vitiligo.#

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

#State the pathology of vitiligo.#

The disease consists, anatomically, of both a diminution and increase of the pigment--the white patch resulting from the former, and the pigmented borders from the latter. There is no textural change, the skin in other respects being normal.

#From what diseases is vitiligo to be differentiated?#

From morph[oe]a and from the anaesthetic patches of leprosy.

#In what respects do these diseases differ from vitiligo?#

In morph[oe]a there is textural change, and in leprosy both textural change and constitutional or other symptoms.

#What prognosis is to be given?#

It should always be guarded, the disease in almost all cases being irresponsive to treatment.

#What is the treatment of vitiligo?#

The general health is to be looked after, and remedies directed especially toward the nervous system to be employed. Arsenic, in small and continued doses, seems at times to have an influence; when there is lack of general tone it may be prescribed as follows:--

[Rx] Liq. potassii arsenitis, ............. f[dram]j
Tinct. nucis vom., ................... f[dram]iij
Elix. calisayae, ....... q. s. ad ..... f[Oz]iv. M.

SIG.--f[dram]j t. d.

Suprarenal-gland preparations in moderate dosage long continued has appeared in a few instances to be of some benefit.

When upon exposed parts, stimulation of the patches, with the view of producing hyperaemia and consequent pigment deposit; conjoined with suitable applications to the surrounding pigmented skin, with a view to lessen the coloration (see _treatment of chloasma_), will be of aid in rendering the disease less conspicuous. Or the condition may be, in a measure, masked by staining the patches with walnut juice or similar pigment.

#Canities.#
(_Synonym:_ Grayness of the Hair.)

#Describe canities.#

Canities, or graying of the hair, may occur in localized areas or it may be more or less general; the blanching may be slight, scarcely amounting to slight grayness, or it may be complete. It is common to advancing years (_canities senilis_); it is seen also exceptionally in early life (_canities praematura_). The condition is usually permanent. The loss of pigment takes place, as a rule, slowly, but several apparently authentic cases have been reported in which the change occurred in the course of a night or in a few days.

#What is the etiology of canities?#

The causes are obscure. Heredity is usually an influential factor, and conditions which impair the general nutrition have at times an etiological bearing. Intense anxiety, fright, and other profound nervous shock are looked upon as causative in sudden graying of the hair.

#Give the treatment.#

Canities is without remedy. Dyeing, although not to be advised, is often practised, and the condition thus masked.

#Alopecia.#
(_Synonym:_ Baldness.)

#What do you understand by alopecia?#

By alopecia is meant loss of hair, either partial or complete.

#Name the several varieties of alopecia.#

The so-called varieties are based mainly upon the etiology, and are named congenital alopecia, premature alopecia and senile alopecia.

#Describe congenital alopecia.#

Congenital alopecia is a rare condition, in which the hair-loss is usually noted to be patchy, or the general hair-growth may simply be scanty. In rare instances the hair has been entirely wanting; in such cases there is usually defective development of other structures, such as the teeth.

#Describe premature alopecia.#

Loss of hair occurring in early and middle adult life is not uncommon, and may consist of a simple thinning or of more or less complete baldness of the whole or greater part of the scalp. It usually develops slowly, some months or several years passing before the condition is well established. It is often idiopathic, and without apparent cause further than probably a hereditary predisposition. It may also be symptomatic, as, for example, the loss of hair, usually rapid (_defluvium capillorum_), following systemic diseases, such as the various fevers, and syphilis; or as a result of a long-continued seborrh[oe]a or seborrh[oe]ic eczema (_alopecia furfuracea_).

#Describe senile alopecia.#

This is the baldness so frequently seen developing with advancing years, and may consist merely of a general thinning, or, more commonly a general thinning with a more or less complete baldness of the temporal and anterior portion or of the vertex of the scalp.

#What is the prognosis in the various varieties of alopecia?#

In those cases in which there is a positive cause, as, for instance, in symptomatic alopecia, the prognosis is, as a rule, favorable, especially if no family predisposition exists. In the congenital and senile varieties the condition is usually irremediable. In idiopathic premature alopecia, the prognosis should be extremely guarded.

#How would you treat alopecia?#

By removing or modifying the predisposing factors by appropriate constitutional remedies, and by the external use of stimulating applications.

#Name several remedies or combinations usually employed in the local treatment.#

Sulphur ointment, full strength or weakened with lard or vaseline; a lotion of resorcin consisting of one or two drachms to four ounces of alcohol, to which is added ten to thirty minims of castor oil; and a lotion made up as follows:--

[Rx] Tinct. cantharidis, .................. f[dram]iv
Tinct. capsici, ...................... f[Oz]j
Ol. ricini, .......................... f[dram]ss-f[dram]j
Alcoholis, .... q. s. ad ............. f[Oz]iv. M.

The following is sometimes beneficial:--

[Rx] Resorcin, ............................ gr. lxxx
Quininae (alkaloid), .................. gr. xv
Ol. ricini, .......................... [minim]v-[minim]xx
Alcoholis, ........................... f[Oz]iv.--M.

Another excellent formula is:

[Rx] Resorcin, ............................ gr. lxxx-cxx
Ac. carbolici cryst., ................ gr. xx
Spts. myrciae, ........................ f[Oz]iv.--M.

And also the various other stimulating applications employed in alopecia areata (_q. v._).

Other measures of value are: Faradic electricity applied daily for five minutes with a metallic brush or comb; daily massage, with the object of loosening the skin and giving more freedom to cutaneous and subcutaneous circulation; and the application, two or three times weekly, of static electricity by means of the static crown electrode.

(The application selected should be gently--not rubbing--applied daily or every second or third day, according to the case; if a lotion, moistening the parts with it; if an ointment, merely greasing the parts. Shampooing every one to three weeks, according to circumstances.)

#Alopecia Areata.#
(_Synonyms:_ Area Celsi; Alopecia Circumscripta.)

#What do you understand by alopecia areata?#

Alopecia areata is an affection of the hairy system, in which occur one or more circumscribed, round or oval patches of complete baldness unattended by any marked alteration in the skin.

#Upon what parts and at what age does the disease occur?#

In the large majority of cases the disease is limited to the scalp; but it may invade other portions of the body, as the bearded region, eyebrows, eyelashes, and, in rare instances, the entire integument.

It is most common between the ages of ten and forty.

#Describe the symptoms of alopecia areata.#

The disease begins either suddenly, without premonitory symptoms, one or several patches being formed in a few hours; or, and as is more usually the case, several days or weeks elapse before the bald area or areas are sufficiently large to become noticeable. The patches continue to extend peripherally for a variable period, and then remain stationary, or several gradually coalesce and form a large, irregular area involving the entire or a greater portion of the scalp. The skin of the affected regions is smooth, faintly pink or milky white, and at first presents no departure from the normal; sooner or later, however, the follicles become less prominent, and slight atrophy or thinning may occur, the bald plaques being slightly depressed.

Occasionally, usually about the periphery and in the early stages, a few hair-stumps may be seen.

#What course does alopecia areata pursue?#

Almost invariably chronic. After the lapse of a variable period the patches cease to extend, the hairs at the margins of the bald areas being firmly fixed in the follicles; sooner or later a fine, colorless lanugo or down shows itself, which may continue to grow until it is about a half-inch or so in length and then drop out; or it may remain, become coarser and pigmented, and the parts resume their normal condition. Not infrequently, however, after growing for a time, the new hair falls out, and this may happen several times before the termination of the disease.

#Are there any subjective symptoms in alopecia areata?#

As a rule, not; but occasionally the appearance of the patches is preceded by severe headache, itching or burning, or other manifestations of disturbed innervation.

#State the cause of alopecia areata.#

The etiology is obscure. Two theories as to the cause of the disease exist: one of these regards it as parasitic, and the other considers it to be trophoneurotic. Doubtless both are right, as a study of the literature would indicate that there are, as regards etiology, really two varieties--the contagious and the non-contagious. In America examples of the contagious variety are uncommon.

#Does the skin undergo any alterative or destructive changes?#

Microscopical examination of the skin of the diseased area shows little or no alteration in its structure beyond slight thinning.

#How do you distinguish alopecia areata from ringworm?#

The plaques of alopecia areata are smooth, often completely devoid of hair, and free from scales; while those of ringworm show numerous broken hairs and stumps, desquamation, and usually symptoms of mild inflammatory action. In doubtful cases recourse should be had to the microscope.

#What is the prognosis in alopecia areata?#

The disease is often rebellious, but in children and young adults the prognosis is almost invariably favorable, permanent loss of hair being uncommon. The same holds true, but to a much less extent, with the disease as occurring in those of more advanced age. In extensive cases--those in which the hair of the entire scalp finally entirely disappears, and sometimes involves all hairy parts--the prognosis is unfavorable. Only exceptionally does recovery ensue in such instances.

The uncertain duration, however, must be borne in mind; months, and in some instances several years, may elapse before complete restoration of hair takes place. Relapses are not uncommon.

#How is alopecia areata treated?#

By both constitutional and local measures, the former having in view the invigoration of the nervous system, and the latter a stimulating and parasiticidal action of the affected areas.

#Give the constitutional treatment.#

Arsenic is perhaps the most valuable remedy, while quinine, nux vomica, pilocarpine, cod-liver oil and ferruginous tonics may, in suitable cases, often be administered with benefit.

#Name several remedies or combinations employed in the external treatment of alopecia areata.#

Ointments of tar and sulphur of varying strength; the various mercurial ointments; the tar oils, either pure or with alcohol; stimulating lotions, containing varying proportions, singly or in combination, of tincture of capsicum, tincture of cantharides, aqua ammoniae, and oil of turpentine. The following is a safe formula, especially in dispensary and ignorant class practice:

[Rx] [beta]-naphthol, ..................... [dram]ss-[dram]j
Ol. cadini, .......................... [dram]j
Ungt. sulphuris, .......... q. s. ad ... [Oz]j M.

The cautious use of a five to twenty per cent. chrysarobin ointment is of value. Painting the patches with pure carbolic acid or trikresol every ten days or two weeks sometimes acts well; it should not be applied over large areas nor used in young children. Galvanization or faradization of the affected parts may also be employed, and with, occasionally, beneficial effect. Stimulation with the high-frequency current by means of the vacuum electrode is also of value. When practicable, the Finsen light can be applied with hope of benefit and cure.

#Atrophia Pilorum Propria.#
(_Synonym:_ Atrophy of the Hair.)

#What do you understand by atrophy of the hair?#

An atrophic, brittle, dry condition of the hair, and which may be either symptomatic or idiopathic.

#Describe the several conditions met with.#

As a symptomatic affection, the dry, brittle condition of the hair met with in seborrh[oe]a, in severe constitutional diseases, and in the various vegetable parasitic affections, may be referred to.