Chapter 11

Hygienic and dietary measures, the administration of tonics and astringents, and, in severe cases, by relative or absolute rest.

The drugs commonly prescribed are: ergot, oil of erigeron, oil of turpentine, quinia, strychnia, iron, mineral acids, and gallic acid. _External_ treatment is rarely called for, but if deemed advisable, astringent lotions may be employed.

#Scorbutus.# (_Synonyms:_ Scurvy; Sea Scurvy; Purpura Scorbutica.)

#Describe scorbutus.#

Scurvy is a peculiar constitutional state, developed in those living under bad hygienic conditions, and is characterized by emaciation, general febrile and asthenic symptoms, a more or less swollen, turgid and spongy and even gangrenous condition of the gums; and concomitantly, or sooner or later, by the appearance, usually upon the lower portion of the legs only, of dark-colored hemorrhagic patches or blotches. The skin of the affected part may become brawny and slightly scaly, and not infrequently may break down and ulcerate. Hemorrhages from the various mucous surfaces, slight or grave, may also take place.

#State the etiology of scurvy.#

It is due to long-continued deprivation of proper food, especially of fruits and vegetables. Other bad hygienic conditions favor its development. It is seen most commonly in sailors and others taking long voyages.

#How is scurvy to be distinguished from purpura?#

By the asthenic and emaciated general condition and the peculiar puffy, spongy state of the gums. The cutaneous manifestation is more diffused, forming usually large palm-sized patches, and, as a rule, limited to the region of the ankles or lower part of the legs.

#Give the prognosis of scurvy.#

The disease is remediable, and usually rapidly so. In those instances in which the same bad hygienic conditions and the ingestion of improper food are continued, death finally results.

#What treatment would you advise in scurvy?#

Proper food, with an abundance of fruit and vegetables. Lemon or lime juice is especially valuable, and is to be taken freely. If indicated, tonics and stimulants are also to be prescribed. For the relief of the tumid, spongy condition of the gums, astringent and antiseptic mouth washes are to be employed.

The cutaneous manifestations, when tending to ulceration, are to be treated upon general principles.

#CLASS IV.--HYPERTROPHIES.#

#Lentigo.# (_Synonym:_ Freckle.)

#Describe lentigo.#

Lentigo, or freckle, is characterized by round or irregular, pin-head to pea-sized, yellowish, brownish or blackish spots, occurring usually about the face and the backs of the hands. It is a common affection, varying somewhat in the degree of development; the freckles present may be few and insignificant, or they may exist in profusion and be quite disfiguring. Heat and exposure favor their development. Those of light complexion, especially those with red hair, are its most common subjects. The color of the lesion is usually a yellowish-brown.

It is common to all ages, but is generally seen in its greatest development during adolescence, the disposition to its appearance becoming less marked as age advances.

#What is the pathology of lentigo?#

Lentigo consists simply of a circumscribed deposit of pigment granules--merely a localized increase of the normal pigment, differing from chloasma (_q. v._) only in the size and shape of the pigmentation.

#State the prognosis.#

The blemishes can be removed by treatment, but their return is almost certain.

#Name the several applications commonly employed for their removal.#

An aqueous or alcoholic solution of corrosive sublimate, one-half to three grains to the ounce; lactic acid, one part to from six to twenty parts of water; and an ointment containing a drachm each of bismuth subnitrate and ammoniated mercury to the ounce.

The applications, which act by removing the epidermal and rete cells and with them the pigment, are made two or three times daily, and their use intermitted for a few days as soon as the skin becomes irritated or scaly.

Touching each freckle for a few seconds with the electric needle, just pricking the epidermis, will occasionally remove the blemish.

#Chloasma.#

#What do you understand by chloasma?#

Chloasma consists of an abnormal deposit of pigment, occurring as variously-sized and shaped, yellowish, brownish or blackish patches.

#Describe the clinical appearances of chloasma.#

Chloasma appears either in ill-defined patches, as is commonly the case, or as a diffuse discoloration. Its appearance is rapid or gradual, generally the latter. The patches are rounded or irregular, and usually shade off into the sound skin. One, several or more may be present, and coalescence may take place, resulting in a large irregular pigmented area. The color is yellowish, or brownish, and may even be blackish (_melasma_, _melanoderma_). The skin is otherwise normal. The face is the most common site.

#Into what two general classes may the various examples of chloasma be grouped?#

Idiopathic and symptomatic.

#What cases of chloasma are included in the idiopathic group?#

All those cases of pigmentation caused by external agents, such as the sun's rays, sinapisms, blisters, continued cutaneous hyperæmia from scratching or any other cause, etc.

#What cases of chloasma are included in the symptomatic group?#

All forms of pigment deposit which occur as a consequence of various organic and systemic diseases, as the pigmentation, for instance, seen in association with tuberculosis, cancer, malaria, Addison's disease, uterine affections, and the like. In such cases, with few exceptions, the pigmentation is usually more or less diffuse.

#What is chloasma uterinum?#

Chloasma uterinum is a term applied to the ill-defined patches of yellowish-brown pigmentation appearing upon the faces of women, usually between the ages of twenty-five and fifty. It is most commonly seen during pregnancy, but may occur in connection with any functional or organic disease of the utero-ovarian apparatus.

#What is argyria?#

Argyria is the term applied to the slate-like discoloration which follows the prolonged administration of silver nitrate.

#State the pathology of chloasma.#

The sole change consists in an increased deposit of pigment.

#Give the prognosis of chloasma.#

Unless a removal of the exciting or predisposing cause is possible, the prognosis is, as a rule, unfavorable, and the relief furnished by local applications usually but temporary.

#If constitutional treatment is advisable, upon what is it to be based?#

Upon general principles; there are no special remedies.

#How do external remedies act?#

Mainly by removing the rete cells and with them the pigmentation; and partly, also, by stimulating the absorbents.

#Are all external remedies which tend to remove the upper layers of the skin equally useful for this purpose?#

No; on the contrary some such applications are followed by an increase in the pigment deposit.

#Name the several applications commonly employed.#

Corrosive sublimate in solution, in the strength of one to four grains to the ounce of alcohol and water; a lotion made up as follows:--

[Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij Ac. acet. dilut., .................... f[dram]ij Sodii borat., ........................ [scruple]ij Aquæ rosæ, ........................... f[Oz]iv. M.

And also the following:--

[Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij Zinci sulphat., Plumbi acetat., ...... [=a][=a] ...... [dram]ss Aquæ, ................................ f[Oz]iv. M.

And lactic acid, with from five to twenty parts of water; and an ointment containing a drachm each of bismuth subnitrate and white precipitate to the ounce. Hydrogen peroxide occasionally acts well. Trichloracetic acid, usually weakened with one or two parts water, may be cautiously tried. The application of a strong alcoholic solution of resorcin, twenty to fifty per cent. strength, is also valuable, as is also a two to ten per cent. alcoholic solution of salicylic acid.

(Applications are made two or three times daily, and as soon as slight scaliness or irritation is produced are to be discontinued for one or two days.)

_Tattoo-marks_ are difficult to remove. Excision is the surest method. Electrolysis, applying the needle at various points, somewhat close together, and using a fairly strong current--three to eight milliampères--will exceptionally, especially when repeated several times, produce a reactive inflammation and casting-off of the tissue containing the pigment; a scar is left.

Several writers claim good results with glycerole of papain, pricking it in in the same manner as in tattooing.

_Gun-powder marks._ If recent, but a day or so after their occurrence, the larger specks may be picked or scraped out. Later, electrolysis, using a fairly strong current, may result in their removal. Their removal may also be satisfactorily effected with a minute cutaneous trephine.

#Keratosis Pilaris.# (_Synonyms:_ Pityriasis Pilaris; Lichen Pilaris.)

#What is meant by keratosis pilaris?#

Keratosis pilaris may be defined as a hypertrophic affection characterized by the formation of pin-head-sized, conical, epidermic elevations seated about the apertures of the hair follicles.

#Describe the clinical appearances of keratosis pilaris.#

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 papillæ. 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 papillæ 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 papillæ and some bloodvessels. They have their starting-point in the rete mucosum, either from that lying above the papillæ 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 papillæ, appearing as minute elevations, making up the growth. One, several or more may be present.

#Describe verruca plana.#