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, .................. āā [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.

As an idiopathic disease it is rare, consisting simply of a brittleness and an uneven and irregular formation of the hair-shaft, with a tendency to split up into filaments (fragilitas crinium); or there may be localized swelling and bursting of the hair-shaft, the nodes thus produced having a shining, semi-transparent appearance (trichorrhexis nodosa). This latter usually occurs upon the beard and moustache.

State the causes of atrophy of the hair.

The causes of the symptomatic variety are usually evident; the etiology of idiopathic atrophy is obscure, but by many is thought due to parasitism.



What would be your prognosis and treatment in atrophy of the hair?

Symptomatic atrophy usually responds to proper measures, but always slowly; treatment is based upon the etiological factors.

For the idiopathic disease little, as a rule, can be done; repeated shaving or cutting the hair has, in exceptional instances, been followed by favorable results.



Atrophia Unguis. (Synonyms: Atrophy of the Nails; Onychatrophia.)

Describe atrophy of the nails.

The nails are soft, thin and brittle, splitting easily, and are often opaque and lustreless, and may have a worm-eaten appearance. Several or more are usually affected.

State the causes of atrophy of the nails.

The condition may be congenital or acquired, usually the latter. It may result from trauma, or be produced by certain cutaneous diseases, notably eczema and psoriasis; or it may follow injuries or diseases of the nerves. Syphilis and chronic wasting constitutional diseases may also interfere with the normal growth of the nail-substance, producing varying degrees of atrophy. The fungi of tinea trichophytina and tinea favosa at times invade these structures and lead to more or less complete disintegration—onychomycosis.



What is the treatment of atrophy of the nails?

Treatment will depend upon the cause. When it is due to eczema or psoriasis, appropriate constitutional and local remedies should be prescribed. If it is the result of syphilis, mercury and potassium iodide are to be advised. In onychomycosis—an exceedingly obstinate affection—the nails should be kept closely cut and pared, and a one- to five-grain solution of corrosive sublimate applied several times a day; a lotion of sodium hyposulphite, a drachm to the ounce, is also a valuable and safe application.



Atrophia Cutis. (Synonyms: Atrophoderma; Atrophy of the Skin.)

What do you understand by atrophy of the skin?

By atrophy of the skin is meant an idiopathic or symptomatic wasting or degeneration of its component elements.

State the several conditions met with.

Glossy skin, general idiopathic atrophy of the skin, parchment skin, atrophic lines and spots, senile atrophy, and the atrophy following certain cutaneous diseases.

Describe glossy skin (atrophoderma neuriticum), and state the treatment.

Glossy skin is a rare condition following an injury or disease of the nerve. It is usually seen about the fingers. The skin is hairless, faintly reddish, smooth and shining, with a varnished and thin appearance, and with a tendency to fissuring. More or less severe and persistent burning pain precedes and accompanies the atrophy.

Protective applications are called for, the disease tending slowly to spontaneous disappearance.

Describe general idiopathic atrophy of the skin, and give the treatment.

General idiopathic atrophy of the skin is extremely rare, and is characterized by a gradual, more or less general, degenerative and quantitative atrophy of the skin structures, accompanied usually with more or less discoloration and pigmentation.

Treatment is palliative and based upon indications.

Describe parchment skin, and state the treatment.

Parchment skin (xeroderma pigmentosum, angioma pigmentosum et atrophicum) is a rare disease, the exact nature of which is not understood. It is characterized by the appearance of numerous disseminated, freckle-like pigment-spots, telangiectases, atrophied muscles, more or less shrinking and contraction of the integument, and followed, in most instances, by epitheliomatous tumors and ulceration, and finally death. It is usually slow in its course, beginning in childhood and lasting for years. It is not infrequently seen in several children of the same family.

Treatment is palliative, consisting, if necessary, of the use of protective applications and of the administration of tonics and nutrients.

Describe atrophic lines and spots.

Atrophic lines and spots (striae et maculae atrophicae) may be idiopathic or symptomatic, the lesions consisting of scar-like or atrophic-looking, whitish lines and macules, most commonly seen on the trunk. They are smooth and glistening. Slight hyperaemia usually precedes their formation. As an idiopathic disease its course is insidious and slow, and its progress eventually stayed. The so-called lineae albicantes, resulting from the stretching of the skin produced by pregnancy or tumors, and from rapid development of fat, may be mentioned as illustrating the symptomatic variety.

In course of time the atrophy becomes less conspicuous.

Describe senile atrophy.

Senile atrophy is not uncommon, the atrophy resulting, as the name inferentially implies, from advancing age. It is characterized by thinning and wasting, dryness, and a wrinkled condition, with more or less pigmentation and loss of hair. Circumscribed pigmentary deposits and seborrh[oe]a, with degeneration, are also noted.

What several diseases of the skin are commonly followed by atrophic changes?

Favus, lupus, syphilis, leprosy, scleroderma and morph[oe]a.



CLASS VI.—NEW GROWTHS.

Keloid. (Synonyms: Keloid of Alibert; Cheloid.)

Give a descriptive definition of keloid.

Keloid is a fibro-cellular new growth of the corium appearing as one or several variously-sized, irregularly-shaped, elevated, smooth, firm, pinkish or pale-reddish cicatriform lesions.

Describe the clinical appearance of keloid.

The growth begins as a small, hard, elevated, pinkish or reddish tubercle, increasing gradually, several months or years usually elapsing before the tumor reaches conspicuous size. When developed, it is one or more inches in diameter, is sharply defined, elevated, hard, rounded or oval, fungoid or crab-shaped, and firmly implanted in the skin. It is usually pinkish, pearl-white, or reddish, commonly devoid of hair, with no tendency to scaliness, and with, usually, several vessels coursing over it. In some instances it is tender, and it may be spontaneously painful.

The breast, especially over the sternal region, is a favorite site for its appearance. One, several or more may be present in the single case.

What course does keloid pursue?

Chronic; usually lasting throughout life. In rare instances spontaneous involution takes place.

State the etiology of keloid.

The causes are obscure. The growth usually takes its start from some injury or lesion of continuity; for instance, at the site of burns, cuts, acne and smallpox scars, etc.—cicatricial keloid, false keloid; or it may also, so it is thought, originate in normal skin—spontaneous keloid, true keloid.

What is the pathology of keloid?

The lesion is a connective-tissue new growth having its seat in the corium.

Is there any difficulty in the diagnosis of keloid?

No. It resembles hypertrophic scar; but this latter, which is essentially keloidal, never extends beyond the line of injury.

Give the prognosis.

The growth is persistent and usually irresponsive to treatment. In some cases, however, there is eventually a tendency to spontaneous retrogression, up to a certain point at least.

What is the treatment of keloid?

Usually palliative, consisting of the continuous application of an ointment such as the following:—

[Rx] Acidi salicylici, .................... gr. x-xx Emplast. plumbi, Emplast. saponis, ... āā ....... [dram]iij Petrolati, ........................... [dram]ij. M.

An ointment of ichthyol, twenty-five per cent. strength, rubbed in once or twice daily, is sometimes beneficial.

Operative measures, such as punctate and linear scarification, electrolysis and excision, are occasionally practised, but the results are rarely satisfactory and permanent; not infrequently, indeed, renewed activity in the progress of the growth is noted to follow. The x-ray can be tried with some hope of improvement. The administration of thyroid has been thought to have a possible influence in some instances.



Fibroma. (Synonyms: Molluscum Fibrosum; Fibroma Molluscum.)

What do you understand by fibroma?

Fibroma is a connective-tissue new growth characterized by one or more sessile or pedunculated, pea- to egg-sized or larger, soft or firm, rounded, painless tumors, seated beneath and in the skin.

Describe the clinical appearances of fibroma.

The growth may be single, in which case it is apt to be pedunculated or pendulous, and attain considerable dimensions; as a result of weight or pressure surface-ulceration may occur. Or, as commonly met with, the lesions are numerous, scattered over large surface, and vary in size from a pea to a cherry; the overlying skin being normal, pinkish or reddish, loose, stretched, hypertrophied or atrophied.

The tumors are painless. The general health is not involved.



What is the course of fibroma?

Chronic and persistent.

What is the etiology of fibroma?

The cause is not known. Heredity is often noted. The affection is not common.

State the pathology of fibroma.

The growths are variously thought to have their origin in the connective tissue of the corium, or in that of the walls of the hair-sac, or in the connective-tissue framework of the fatty tissue. Recent tumors are composed of gelatinous, newly-formed connective tissue, and the older growths of a dense, firmly-packed, fibrous tissue.

From what growths is fibroma to be differentiated?

From molluscum contagiosum, neuroma and lipoma; the first is differentiated by its central aperture or depression, neuroma by its painfulness, and lipoma by its lobulated character and soft feel.

Give the prognosis of fibroma.

The disease is persistent, and irresponsive to all treatment save operative measures.

What is the treatment of fibroma?

Treatment consists, when desired and practicable, in the removal of the growths by the knife, or in large and pedunculated tumors by the ligature or by the galvano-cautery.



Neuroma.

Describe neuroma.

Neuroma of the skin is an exceedingly rare disease, characterized by the formation of variously-sized, usually numerous, firm, immovable and elastic fibrous tubercles containing new nerve-elements, and accompanied by violent, paroxysmal pain. Their growth is slow and usually progressive. Later they are painful upon pressure. They are limited to one region.

The tumors are seated in the corium, extending into the deeper structure, and consist of nerve-fibres, yellow elastic tissue, blood vessels and lymphoid cells.

In the two cases reported, excision of the nerve-trunk gave, in one instance, permanent relief; in the other the effect was only temporary.



Xanthoma. (Synonyms: Vitiligoidea; Xanthelasma.)

What is xanthoma?

Xanthoma 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.

Name the two varieties met with.

The macular or flat (xanthoma planum) and the tubercular (xanthoma tuberculatum or tuberosum). In some instances both varieties (xanthoma multiplex) are seen in the same individual.

Describe the clinical appearances of xanthoma planum.

The macular or flat variety is usually seen about the eyelids. It consists of one, several or more small or large, smooth, opaque, sharply-defined, often slightly raised, yellowish patches, looking not unlike pieces of chamois-skin implanted in the skin.

Describe the clinical appearances of xanthoma tuberosum.

The tubercular variety is commonly met with upon the neck, trunk and extremities. It occurs as small, raised, isolated, yellowish nodules, or as patches made up of aggregations of millet-seed-sized or larger tubercles. The lesions may be few or they may exist in great numbers.

What is the course of xanthoma?

Extremely slow; after reaching a certain development the growths may remain stationary.

State the etiology of xanthoma.

The causes are obscure. Jaundice not infrequently precedes and accompanies its development, especially in the tubercular variety. The disease is uncommon, and is usually seen in middle and advanced life, and more frequently in women. In some cases (xanthoma diabeticorum) of general xanthoma diabetes is the causative factor.

What is the pathology of xanthoma?

It is a benign, connective-tissue new growth, with concomitant or subsequent, but usually partial, fatty degeneration.

Give the prognosis of xanthoma.

The condition is persistent, and usually irresponsive to all treatment save destructive or operative measures.

What is the treatment of xanthoma?

Treatment consists, in suitable cases, of excision; in some instances, electrolysis is serviceable. Applications of trichloracetic acid cautiously made are sometimes of value. In that form of general xanthoma due to diabetes the treatment of this latter condition will materially and sometimes completely remove the eruption.



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

Describe myoma.

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

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



Angioma. (Synonyms: Naevus Vasculosus; Naevus Sanguineus.)

Give a definition of angioma.

Angioma is a congenital hypertrophy of the vascular tissues of the corium and subcutaneous tissue. Exceptionally it makes its appearance a few weeks or a month after birth.

Into what two classes may angiomata be roughly grouped?

The flat (or non-elevated) and the prominent (or elevated).

Describe the flat, or non-elevated, variety of angioma.

The flat, or non-elevated, angioma (naevus flammeus, naevus simplex, angioma simplex, capillary naevus) may be pin-head- to bean-sized; or it may involve an area of several inches in diameter, and, exceptionally, a whole region. It is of a bright- or dark-red color, and is met with most frequently about the face. In some instances it extends after birth, reaches a certain size and then remains stationary; occasionally, when involving a small area, it undergoes involution and disappears.

The so-called port-wine mark is included in this group.

Describe the prominent, or elevated, variety of angioma.

The prominent variety (venous n[oe]vus, angioma cavernosum, n[oe]vus tuberosus) is variously-sized, often considerably elevated, clearly-defined, compressible, smooth or lobulated, and of a dark, purple color; it may, also, be erectile and pulsating. The growth is usually a single formation, and is met with upon all parts of the body.

What is the pathology of angioma?

It is a new growth, consisting of a variable hypertrophy of the cutaneous and subcutaneous arterial and venous bloodvessels, with or without an increase of the connective tissue.

Give the treatment of angioma.

In some instances, especially in infants, painting the parts repeatedly with collodion or liquor plumbi subacetatis will act favorably. For well-established, small, capillary naevi electrolysis or puncturing with a red-hot needle or with a needle charged with nitric acid may be employed; for "port-wine mark" frequent and closely contiguous electrolytic punctures are occasionally followed by a slight diminution in color. For the prominent growths, vaccination, the ligature, puncturing with the galvano-cautery, and excision are variously resorted to.

In recent years applications of liquid air and carbon dioxide have proved of service in some cases.



Telangiectasis.

Describe telangiectasis.

Telangiectasis consists of a new growth or enlargement of the cutaneous capillaries, usually appearing during middle adult life, and seated, for the most part, about the face.

To what extent may telangiectasis develop?

It may be limited to a red dot or point, with several small radiating capillaries (naevus araneus, spider naevus), or a whole region, usually the face, may show numerous scattered or closely-set capillary enlargements or new formations (rosacea). The latter is frequently associated with acne (acne rosacea).

The etiology is obscure.

What is the treatment of telangiectasis?

Destruction of the vessels by electrolysis or by the knife. (See treatment of acne rosacea.)



Lymphangioma. (Synonym: Lymphangiectodes.)

Describe lymphangioma.

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

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

Treatment, when demanded, consists of operative measures.



Rhinoscleroma.

Describe rhinoscleroma.

Rhinoscleroma is a rare and obscure disease, slow but progressive in its course, characterized by the development of an irregular, dense and hard, flattened, tubercular, non-ulcerating, cellular new growth, having its seat about the nose and contiguous parts. The overlying skin is normal in color, or it may be light- or dark-brown or reddish. Marked disfigurement and closure, partial or complete, of the nasal orifices gradually results. It is met with chiefly in Austria and Germany.

Treatment, consisting of partial or complete extirpation, is rarely permanent in its results, the disease tending to recur.



Lupus Erythematosus. (Synonyms: Lupus Erythematodes; Lupus Sebaceus; Seborrh[oe]a Congestiva.)

What is lupus erythematosus?

Lupus erythematosus may be roughly defined as a mildly to moderately inflammatory superficial new-growth formation, characterized by one, several, or more circumscribed, variously sized and shaped, pinkish or dark red patches, covered slightly, and more or less irregularly, with adherent grayish or yellowish scales.

Upon what parts is lupus erythematosus observed?

Its common site is the face, usually the nose and cheeks, with a tendency toward symmetry; it is often limited to these parts, but may occasionally be seen upon other regions, more especially the lips, ears, and scalp. In rare instances a great part of the general surface may become involved.

Describe the symptoms of lupus erythematosus.

Usually the disease begins as one or several rounded, circumscribed, pin-head- to pea-sized lesions; slightly scaly, somewhat elevated, and of a pinkish, reddish or violaceous color. They slowly, or somewhat rapidly, increase in area, and after attaining variable size remain stationary; or they may progress and coalesce, and in this manner sooner or later involve considerable surface. The patches are sharply defined against the sound skin by an elevated border, while the central portion is somewhat depressed and usually atrophic. More or less thickening and infiltration are observed. There is no tendency to ulceration. The scaliness is, as a rule, scanty. The gland-ducts are enlarged, patulous or plugged with sebaceous and epithelial matter.

The subjective symptoms of burning and itching are usually slight and often wanting.

What course does lupus erythematosus pursue?

As a rule, the disease is persistent, although somewhat variable. At times the patches retrogress, involution taking place with or without slight sieve-like atrophy or scarring.

State the causes of lupus erythematosus.

The etiology is obscure. Some observers believe it to be a variety of cutaneous tuberculosis. It is essentially a disease of adult and middle age; is more common in women, and more frequent in those having a tendency to disorders of the sebaceous glands. It may, in fact, begin as a seborrh[oe]a.

What is the pathology?

It was formerly considered a new growth, but recent opinion tends toward regarding it as a chronic inflammation of the cutis, superinducing degenerative and atrophic changes. Variable [oe]dema of the prickle layer and of the cutis is found. There is no tendency to pus formation.



Is there any difficulty in the diagnosis of lupus erythematosus?

As a rule, not, as the features of the disease—the sharply circumscribed outline, the reddish or violaceous color, the 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 (usually the nose and cheeks)—are characteristic.

State the prognosis of lupus erythematosus.

The disease is often capricious and extremely rebellious to treatment; some cases, up to a certain point at least, yield readily, and occasionally a tendency to spontaneous disappearance is observed; a complete cure is, however, it must be confessed, rather rare. The disease in nowise compromises the general health. In those rare instances of generalized disease the patient has usually died from an intercurrent tuberculosis.

How is lupus erythematosus to be treated?

The general health is to be looked after and systemic treatment prescribed, if indicated. As a rule, constitutional remedies exert little, if any, influence, but exceptionally, cod-liver oil, arsenic, phosphorus, salicin, quinine, or potassium iodide proves of service.

Locally, according to the case, soothing remedies, stimulating applications and destruction of the growth by caustics or operative measures are to be employed. (Try the milder applications first.)

Mention the stimulating applications commonly employed.

Washing the parts energetically with tincture of sapo viridis, rinsing and applying a soothing ointment, such as cold cream or vaseline.

A lotion containing zinc sulphate and potassium sulphuret thoroughly dabbed on the parts morning and evening:—

[Rx] Zinci sulphatis, Potassii sulphurati, .... āā ... [dram]i-[dram]iv Glycerinae, ........................... [minim]iv Aquae, ................................ f[Oz]iv. M.

The calamine-and-zinc oxide lotion used in acute eczema is also often extremely valuable.

Lotions of ichthyol and of resorcin, five to sixty grains to the ounce; ichthyol in ointment, five- to twenty-per-cent. strength, is also useful.

Painting the patches with pure carbolic acid; repeating a day or two after the crusts have fallen off.

The continuous application of mercurial plaster.

Sulphur and tar ointments, officinal strength or weakened with lard, and also the following:—

[Rx] Ol. cadini, Alcoholis, Saponis viridis, ..... āā ...... [dram]iiss. M.

(This is to be rubbed in, in small quantity, once or twice daily, and later a soothing remedy applied.)

In recent years both the x-ray and Finsen light have been used with variable success. Repeated applications of the high-frequency current, with the vacuum electrode, have also proved serviceable. Cautious applications of liquid air or carbon dioxide have also been used with some success in the past few years.

When are destructive and operative measures justifiable?

In obstinate, sluggish, and long-persistent patches, and then only after other methods of treatment have failed. (Remember that a patch or patches of the disease may disappear in course of time spontaneously, and occasionally without leaving a scar.)

State the methods of treatment commonly used in obstinate, sluggish and persistent patches of lupus erythematosus.

Cauterization—with nitrate of silver, with applications of pyrogallic acid in ointment or in liquor gutta-perchae, fifteen to thirty per cent. strength, and with solutions (cautiously employed) of caustic potash, and exceptionally with the galvano-cautery.



Operative—scarification, either punctate or linear, and erosion with the curette. (See treatment of lupus vulgaris.)



Lupus Vulgaris. (Synonyms: Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the Skin.)

What do you understand by lupus vulgaris?

Lupus vulgaris is a cellular new growth, characterized by variously-sized, soft, reddish-brown, papular, tubercular and infiltrated patches, usually terminating in ulceration and scarring.

Upon what region is lupus vulgaris usually observed?

The face, especially the nose, but any part may be invaded. The area involved may be small or quite extensive, usually the former.

At what age is the disease noted?

In many cases it begins in childhood or early adult life, but as it is persistent and tends to relapse, it may be met with at any age.

Describe the earlier symptoms of lupus vulgaris.

The disease begins by the development of several or more pin-head to small pea-sized, deep-seated, brownish-red or yellowish tubercles, having their seat in the deeper part of the corium, and which are somewhat softer and looser in texture than normal tissue. As the disease progresses, variously-sized and shaped aggregations or patches result, covered with thin and imperfectly-formed epidermis.

What changes do the lupus tubercles or infiltrations undergo?

The lesions, having attained a certain size or development, may remain so for a time, but sooner or later retrogressive changes occur: the matured papules or tubercles, or infiltrated patches, slowly disappear by absorption, fatty degeneration, and exfoliation, leaving a yellowish or brownish pigmentation, usually with more or less atrophy or cicatricial-tissue formation—lupus exfoliativus; or disintegration and destruction result, terminating in ulceration—lupus exedens, lupus exulcerans. This latter is the more usual course.

Describe the clinical appearances and behavior of the lupus ulcerations.

They are rounded, shallow excavations, with soft and reddish borders. In exceptional instances exuberant granulations appear—lupus hypertrophicus; or papillary outgrowths are noted—lupus verrucosus. The ulcerations secrete a variable amount of pus, usually slight in quantity, which leads to more or less crust formation; later, however, cicatricial tissue, generally of a firm and fibrous character, results.



In what manner does the disease spread?

The patches spread by the appearance of new tubercles, or infiltrations at the peripheral portion. New islets and areas of disease may continue to make their appearance from time to time, usually upon contiguous parts.

Are the mucous membranes of the mouth, throat and larynx ever involved?

In some instances, and either primarily or secondarily.



Is the bone tissue ever involved in lupus vulgaris?

No.

What course does lupus vulgaris pursue?

It is slowly but, as a rule, steadily progressive. Several years or more may elapse before the area of disease is conspicuous.

What is the cause of lupus vulgaris?

It is now known to be due to the invasion of the cutaneous structures by the tubercle bacillus; in short, a tuberculosis of the skin. It is not infrequently observed in the strumous and debilitated. It is entirely independent of syphilis.

What is the pathology of lupus vulgaris?

According to recent investigations, the infiltrations of lupus are due chiefly to cell-proliferation and outgrowth from the protoplasmic walls and adventitia of the bloodvessels 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 (Robinson).

State the diagnostic features of lupus vulgaris.

In a typical, developed patch of lupus are to be seen:—cicatricial formation, usually of a fibrous and tough character; ulcerations; the yellowish-brown tubercles and infiltration; and the characteristic soft, small, yellowish or reddish-brown, cutaneous and subcutaneous points and tubercles.

How does the tubercular syphiloderm differ from lupus vulgaris?

The tubercular syphiloderm is much more rapid in its course, the ulceration is deeper and the discharge copious and often offensive; the scarring is soft, and, compared to the amount of ulceration, but slightly disfiguring; and it is, for obvious reasons, a disease of adult or late life. The history, together with other evidences of previous or concomitant symptoms of syphilis, will often aid in the differentiation.

How does epithelioma differ from lupus vulgaris?

The edges of the epitheliomatous ulcer are hard, elevated and waxy; the base is uneven, the secretion thin, scanty and apt to be streaked with blood; the ulceration usually starts from one point, and is often painful; the tissue destruction may be considerable; there is little, if any, tendency to the formation of cicatricial tissue; and, finally, it is usually a disease of advanced age.

In what respects does lupus erythematosus differ from lupus vulgaris?

Lupus erythematosus has no papules, tubercles or ulceration.

How does acne rosacea differ from lupus vulgaris?

Acne rosacea is characterized by hyperaemia, dilated vessels, papules, pustules, the absence of ulceration, and a different history.

State the prognosis of lupus vulgaris.

Lupus vulgaris is always a chronic disease, often exceedingly rebellious to treatment, and one that calls for a guarded opinion. Relapses are not uncommon.



The general health usually remains good, but in some instances death by tuberculosis of the lungs has been noted.

Is external or internal treatment called for in lupus vulgaris?

Always external, and not infrequently constitutional also.

What is the constitutional treatment?

The general health must be cared for; good, nutritious food, fresh air and out-door exercise, together with, in many cases, the administration of such remedies as cod-liver oil, potassium iodide, iron and quinine, are of therapeutic importance. Tuberculin may be tried in severe and obstinate cases, but its use is not without danger.

State the object of local treatment.

The destruction or removal of the diseased tissue.

May milder methods of treatment sometimes prove beneficial and even curative?

Exceptionally, mercurial plaster, corrosive-sublimate lotion and ointment (gr. j to [Oz]j), a plaster containing five to fifteen per cent. of salicylic acid and creasote, repeated paintings with carbolic acid, and the constant application of lead plaster containing twenty per cent. of ichthyol, are valuable.



Of the milder methods, those most in vogue to-day are the Finsen light and x-ray. Either proves extremely valuable in some cases, but the Finsen method is the favorite method.

What methods are commonly employed for the rapid removal or destruction of lupus tissue?

Cauterization, scarification, erasion and excision are variously practised; the particular method depending, in great measure, upon the extent of the disease, the part involved, and other circumstances.

Name the several caustics, and state how they are employed.

Pyrogallic acid, used as an ointment:—

[Rx] Ac. pyrogallici, ..................... [dram]ij Emplast. plumbi, ..................... [dram]j Cerat. resinsae, ...................... [dram]v. M.

It is applied for one or two weeks. Every several days the parts are poulticed, the slough thus removed, and the ointment reapplied, and so on until the diseased tissue has been destroyed. It is useful in those cases in which a mild and comparatively painless caustic is advisable. In most cases several repetitions of this plan are necessary.

Arsenious acid, employed as an ointment—

[Rx] Ac. arseniosi, ...................... gr. xx Hydrarg. sulphid. rub., ............. gr. lx Ungt. aquae rosae, .................... [Oz]i.—M.

It is painful but thorough; it is spread on lint and renewed daily. The action is usually sufficient in three days, and the parts are then poulticed until the slough comes away, after which a simple dressing is employed. Its application is advisable for a small area only—not more than four square inches—as absorption is possible.

Galvano-cautery.—The diseased tissue is destroyed by numerous punctures with a red-heated point or by linear incision with a red-heated knife. It is often a practicable and satisfactory method. The Paquelin cautery and liquid air and carbon dioxide also have their advocates.

Describe the operative measures employed in the removal of lupus tissue.

Linear Scarification.—The parts are thoroughly cross-tracked, cutting through the diseased tissue, and subsequently a simple salicylated ointment applied. The operation is repeated from time to time, and as a result the new growth undergoes retrogressive changes, and cicatrization takes place.

Punctate Scarification.—By means of a simple or multiple-pointed instrument numerous closely-set punctures are made, and repeated from time to time, usually with the same action and result as from linear scarification.

Erasion.—The parts are thoroughly scraped with a curette, and a supplementary caustic application made, either with caustic potash or several days' use of the pyrogallic-acid ointment. The result is usually satisfactory.

The dental-burr is also useful in breaking up discrete tubercles.

Excision.—This is an effective method if the disease consists of a small pea- or bean-sized circumscribed patch.

Of these various operative methods those now most favored are erasion and excision, punctate and linear scarification methods are now rarely employed.



Tuberculosis Cutis.[D] (Synonym: Scrofuloderma.)

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

What do you understand by tuberculosis cutis?

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

How does the common type of tuberculosis cutis begin?

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



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

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

Other symptoms of tuberculosis are commonly to be found.

Are other forms of tuberculosis cutis met with?

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



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

Describe verruca necrogenica.

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

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



State the etiology.

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

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

How is the tuberculous ulcer to be differentiated from syphilis?

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

State the prognosis.

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

What is the treatment of these forms of tuberculosis cutis?

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

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



Ainhum.

Describe ainhum.

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

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



Mycetoma. (Synonyms: Fungous Foot of India; Madura Foot; Podelcoma.)

Decribe mycetoma.

It is a disease involving usually the foot, and is met with chiefly in India. It is characterized by swelling and the formation of tubercular or nodular lesions which break down and form the external openings of sinuses which lead to the interior of the affected part. These discharge, and are studded with, whitish granules or black, roe-like masses, mixed with a sanious or sero-purulent fluid. The whole part is gradually disintegrated, the process lasting indefinitely. Its nature is obscure; it is thought to be due to a fungus.

Treatment consists in the early stages, when the disease is limited, of thorough curetting and cauterization; later, after the part is more or less involved, amputation, at a point well up beyond the disease, becomes necessary. Potassium iodide internally may exert a favorable influence.



Perforating Ulcer of the Foot.

Describe perforating ulcer of the foot.

Perforating ulcer of the foot is a rare disease, consisting of an indolent and usually painless sinus leading down to diseased bone. The external opening, which is through the centre of a corn-like formation, is small, and may or may not show the presence of granulations. The affected part is commonly more or less anaesthetic and of subnormal temperature. One or several may be present, either on one or both feet. The most common site is over the articulation of the metatarsal bone with the phalanx of the first or last toe. The disease is dependent upon impairment or degeneration of the central, truncal or peripheral nerves.

What is to be said in regard to the prognosis and treatment?

Treatment, which is, as a rule, unsatisfactory, consists in the maintenance of absolute rest, and the use of antiseptic and stimulating applications. Amputation is also resorted to, but even this is at times futile, as a new sinus may appear upon the stump.



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

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

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

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

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

State the distinguishing characters of the late eruptions.

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

What is the color of syphilitic lesions?

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

Are there any subjective symptoms in syphilitic eruptions?

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

Describe the macular, or erythematous, eruption of syphilis.

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

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

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

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



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

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

Describe the small-papular eruption of syphilis.

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



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

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

Describe the large-papular eruption of syphilis.

The large-papular syphiloderm (or lenticular syphiloderm) is a common form of cutaneous syphilis, appearing usually in the first six or eight months, and consists of a more or less generalized eruption of pea- to dime-sized or larger, flat, rounded or oval, firmly seated, more or less raised, dull-red papules; with at first a smooth surface, which later usually becomes covered with a film of exfoliating epidermis. The papules, as a rule, develop slowly, remain stationary several weeks or a few months, and then pass away by absorption, leaving slight pigmentation, which gradually fades; or they may undergo certain modifications. In most cases it responds rapidly to treatment.



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

They may change into the moist papule and squamous papule.

Describe the moist papule of syphilis.

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



Describe the squamous papule of syphilis.

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