experience either in dispensary or in private practice. It occurs
chiefly in children, and more especially among the poorer classes. Its
cause is obscure. By some authorities it is considered to be
contagious, this view being more generally entertained in England
(where the disease seems to be more frequently encountered than
elsewhere) than in other countries. The evidence for believing it to be
contagious, however, does not seem sufficient to warrant such a
conclusion. Inoculation has failed to develop the disease. Some
observers consider that the process has its origin in the sebaceous
glands, while others--ourselves among the number--hold that it is a
disease of the rete mucosum. It is to be regarded as a {662}
hyperplasia of the rete. If the tumor be cut into, the contents may
usually be expressed in the form of a whitish or yellowish rounded mass
of a thick or thin cheesy consistence. Under the microscope it is seen
to be composed of epithelial cells with nuclei and of peculiar rounded
or ovoidal, sharply-defined, fatty-looking bodies--the so-called
molluscum bodies, which are to be viewed as a form of epithelial
degeneration. The growth probably begins in the hair-follicles, as
originally stated by Virchow and more recently confirmed by Thin.
The disease is to be distinguished from molluscum fibrosum, from
papillary warts, and from acne. Local treatment, consisting of incision
and expression of the contents, with subsequent cauterization with
nitrate of silver, is the best procedure. They may also be ligated. As
the disease tends to spontaneous cure, the remedies employed should be
simple in character.
Callositas.
Callositas (syn., tylosis, tyloma, callus) is characterized by the
formation of a hard or horny thickened patch of epidermis, variously
sized and shaped, and of a grayish, yellowish, or brownish color. The
patches are usually coin-sized, more or less rounded in shape, grayish,
yellowish, or brownish in color, somewhat elevated, and of a dense and
firm texture. They are most common about the hands and feet, and in a
measure are protective to the more sensitive corium beneath. The
ordinary surface lines are less distinct than on the surrounding
healthy skin, into which the patch gradually merges. The thickening and
elevation may be slight or excessive, and are most marked at the
centre. The process rarely gives rise to any annoyance or pain, but
when excessive the more delicate movements of the parts are restricted.
Occasionally, from accidental injury, the underlying corium becomes
inflamed, suppurates, and as a result the thickened mass is cast off.
When occurring about the joints from motion of the parts, it may,
moreover, become fissured and painful. Pressure and friction are the
main factors in the production of a callosity--on the hands from the
use of tools and implements, and on the feet from ill-fitting shoes.
But cases are seen exceptionally in which there has been no apparent
external cause; moreover, the same amount of pressure or friction in
different individuals may give rise to different degrees of callosity;
hence there must in some cases be other causes which at times enter
into its production, as, for example, altered nerve-supply. The
epidermis is the only part involved; fissuring and suppuration, it is
true, involve the deeper structures, but these conditions are
accidental and secondary. A section of a callosity shows a thickening
of the horny layer, the corium remaining normal.
Unless the callosity is excessive or gives rise to inconvenience,
treatment is rarely demanded. When advisable, the parts are to be
softened by means of hot-water applications or poultices, solutions of
caustic potash, or sapo viridis used as an ointment; after which the
callus may be removed by scraping with a dermal curette or shaving with
a sharp knife. An excellent method of treatment consists in the
continuous application for some days of a plaster of salicylic acid of
10 or 12 per cent. strength, the same to be renewed every few days; at
the end of a week or two the {663} parts should be soaked in hot water,
and the mass will readily come away. A solution of salicylic acid in
collodion of the same strength or stronger, applied frequently for five
or six days, will often act in like manner.
Clavus.
Clavus, or corn, is a small, circumscribed hypertrophy of the horny
layer of the epidermis, painful upon pressure, situated usually about
the feet. As commonly met with, it is about the size of a pea, with a
smooth and shining surface, having a hard and horny feel. Corns are
seen most frequently upon the outer surface of the little toe, but are
often met with also upon the other toes and on the soles of the feet.
Occurring between the toes, the moisture and friction of the part have
a softening effect, and as a result the corns are soft and spongy,
constituting soft corns. One, several, or more may be present. When
slightly developed they cause very little disturbance or discomfort,
but if large or irritated they may become sensitive and render walking
painful. Continued pressure and friction, as from badly-fitting shoes,
are the active factors in their production. Anatomically, a corn is a
localized epidermal hypertrophy, consisting of a horny mass,
cone-shaped, with the base externally and the apex pressing upon the
rete and corium; the cone being made up of concentrically-arranged,
closely-packed layers of epidermic cells. The corium upon which this
cone-shaped mass presses may be atrophied or hypertrophied.
The first essential in the treatment is a removal of the cause. The
feet should be properly fitted. The corn is to be softened by means of
continuous or repeated soaking in hot water or by poulticing, after
which it may be pared down or extracted. Salicylic acid, either in
solution or in the form of a plaster, 15 or 20 per cent. strength,
applied for several nights, will often give relief. A well-known and
efficient formula is the following:
Rx. Acidi salicylici, gr. xxx;
Ext. cannabis Indicæ, gr. x;
Collodii, fluidounce ss. M.
Sig. Paint on every night and morning. At the end of several days or a
week the part is soaked in warm water and the epidermic mass, or
greater portion of it, is readily detached. Nitrate of silver is useful
after softening of the growth has been brought about, and is also of
advantage in the treatment of soft corns. Caustic potash, thirty to
sixty grains to the ounce of water or alcohol, is also of service, but
is to be employed cautiously. Considerable relief to the soft formation
is obtained by separating the toes with a thin layer of raw cotton. A
ring of rubber, wadding or felt should be employed to prevent pressure
and friction upon a corn, and, as this removes the exciting cause,
permanent relief may follow.
Cornu Cutaneum.
Cornu cutaneum (syn., cornu humanum, horny tumor) is characterized by
the development of a true horny formation of variable size and shape,
{664} arising from the skin. The growth bears a striking similarity to
the horns of the lower animals. It is a solid, dry, harsh, somewhat
brittle formation, usually more or less tapering, conical, or rounded,
crooked or twisted, with a laminated, irregular, and fissured surface,
and of a grayish-yellow or brownish color. Horns vary as to size and
form, being a few lines or several inches in length, with a broad base,
and tapering toward the end. They may be broad and flat or elongate.
They have a flattened or concave base resting directly upon the skin,
with the underlying and surrounding tissue normal, slightly elevated,
or inflamed and undergoing epithelial degeneration. In some cases the
papillæ are much enlarged and extend up into the growth. Ordinarily,
there is present but one growth, but in some instances several or a
dozen or more have been observed in a single case. The face and scalp
are favorite regions, and to a less degree the male genitalia. As a
rule, the horns are painless, but if injured more or less pain is
usually experienced about the base. They rarely develop before middle
age, attain a certain size, and then tend to loosen and fall off,
disclosing an ulcerating base, from which a new growth is usually
reproduced. Epitheliomatous degeneration is not an uncommon sequela.
Anatomically, the growth has its origin in the deeper layers of the
stratum mucosum, either from that lying directly over the papillæ or
from that lining the follicles and glands. It is essentially an
epidermic hypertrophy, similar or closely related to warty formation. A
variable degree of papillary hypertrophy, the papillæ running up into
the base of the horn, is invariably present, and precedes, doubtless,
the horny outgrowth. The horny cells are massed together to form
columns, and in the columns themselves are concentrically arranged.
Blood-vessels also appear in the base of the growth. There can be no
difficulty in the diagnosis. In regard to prognosis the possibility of
degeneration into epithelioma is to be kept in view. If the horn
becomes detached or is knocked off, it is almost invariably reproduced.
Properly managed, horns are easily removed and permanent freedom
assured. The possibility of epitheliomatous degeneration, as well as
their unsightliness, demands active treatment. The formation is to be
detached and the base thoroughly scraped with the dermal curette, and
pyrogallic acid or arsenious acid applied, as in epithelial cancer; or
it may be cauterized with zinc chloride or caustic potash. The
galvano-cautery is also efficient, while in some cases excision may
prove the best method of treatment. If the base is properly treated, a
return of the growth rarely occurs.
Verruca.
Verruca, or wart, is a hard or soft, rounded, flat, or acuminated,
circumscribed epidermal and papillary formation. There are several
forms of warts. The most common variety, verruca vulgaris, is seen
mostly upon the hands. It is usually split-pea-sized, elevated,
circumscribed, rounded, with a broad base. At first there may be
epidermal hypertrophy, but later this in a measure disappears, and the
hypertrophic papillæ constitute the growth and are seen as minute
elevations. It is firm, hard, or horny, and the color is ordinarily the
same as the {665} surrounding skin, but at times it is darker. The
papillæ forming a wart are sometimes so irregularly developed as to
make it appear lobulated, causing a cauliflower-like form. One,
several, or great numbers may be present. Another form is verruca
plana, or flat wart, differing from the ordinary wart described above
in being flat and broad. It is usually the size of a split pea or
finger-nail; occurs most frequently upon the back, especially in
elderly people; and is usually brownish or blackish in color,
constituting verruca senilis and keratosis pigmentosa. Verruca
filiformis, a third variety, is a thread-like formation, usually about
an eighth of an inch in length, occurring singly or in groups, and
generally about the face, eyelids, and neck. Verruca digitata, another
form, is mostly observed upon the scalp, and occurs as a slightly
elevated formation, varying in size from a pea to a finger-nail, and
marked by digitations, especially noticeable about the border.
Verruca acuminata (syn., venereal wart, pointed wart, moist wart, fig
wart, pointed condyloma, cauliflower excrescence; verruca elevata)
consists of one or more groups of acuminated or irregularly-shaped
elevations, usually so closely packed together as to form a more or
less solid mass of vegetations. At times they present an appearance of
granulation tissue. In color they are usually pinkish or reddish, and
are seen mainly about the genitalia, more particularly about the glans
penis, on the inner side of the prepuce, and about the labia, and more
rarely about the arms, axillæ, umbilicus, and toes. They are dry or
moist according to the regions about which they occur and to other
circumstances. The secretion from the moist formation is yellowish and
of a puriform character, undergoing rapid decomposition and giving rise
to a penetrating and often disgusting odor. They are seen both in men
and women, especially in young people; develop rapidly, at times
attaining the size of a fist; and variously resemble the cauliflower,
cock's-comb, fungi, or raspberries.
The etiology of warts is not known. They are common to both sexes, and
are much more frequent in the young. The various causes which, in the
popular mind, are capable of producing these growths are merely
conjectural, and in most instances have no foundation in fact. The
acuminated wart is usually caused by irritating secretions.
Anatomically, a wart consists of a connective-tissue growth as a basis,
with papillary and slight epidermic hypertrophy, the interior of the
growth containing vascular loops. In the acuminated or venereal wart
there is considerable connective-tissue growth, the papillæ being
markedly enlarged, the cells of the mucous layer highly developed, and
the vascular supply abundant.
There is rarely any difficulty in the diagnosis, as the formations are
well known and their characters pronounced. Prognosis is favorable; as
a rule, the growths respond rapidly to treatment; at times, however,
they prove obstinate. When they exist in numbers it is best to remove a
part only of the whole manifestation at a time. Occasionally removal of
several will be followed by spontaneous disappearance of the others. In
some cases, indeed, after existing a shorter or longer period, they
tend to disappear without treatment.
Excision by means of the curved scissors or a knife in some cases will
be found the best method of dealing with them, their bases immediately
after the operation being touched with nitrate of silver. {666}
Caustics, such as potassa, chromic acid, nitric acid, and acetic acid,
may be employed, but strong remedies should be applied with care.
Touching the growths frequently with a 10 to 20 per cent. solution of
salicylic acid or a salicylic-acid plaster of the same strength,
constantly applied, will be found useful. Multiple flat warts may be
treated with a paste of precipitated sulphur and equal parts of acetic
acid and glycerin, prepared at the time of using. In obstinate and
relapsing cases the internal use of arsenic has been recommended.
Stimulating powders and lotions, such as calomel, burnt alum, powdered
savine, solution of chlorinated soda, and carbolic acid, may be used in
the acuminated variety.
Nævus Pigmentosus.
Nævus pigmentosus, commonly called mole, is a circumscribed pigmentary
deposit in the skin. In addition to hypertrophy of pigment there may
also be hypertrophy of one or of all of the other cutaneous structures,
especially of the hair. When the surface of the nævus is normal and
smooth it is termed nævus spilus; if there is a growth of hair upon it,
nævus pilosus; if the connective tissue is increased, forming growths
of variable dimensions, it is designated nævus lipomatodes; if the
surface is rough and warty, nævus verrucosus. Moles may be congenital
or acquired, usually the former. As ordinarily met with, they are
rounded, of the size of a coffee-grain, the color varying from a light
yellowish-brown to a chocolate or black. The trunk, neck, back and face
are favorite localities. One or more may be present, usually upon
different parts of the body, or in exceptional cases following
nerve-tracts. When once formed there is little tendency to change. They
occur with equal frequency in both sexes. Anatomically, there is found
an increase in the natural coloring-matter of the skin, and in almost
all cases variable degrees of connective-tissue hypertrophy.
Enlargement of the papillæ gives rise to nævus verrucosus, and an
increase in size and numerically of the hair-bulbs constitutes nævus
pilosus.
Treatment of a nævus consists in its removal by means of caustics or
the knife. The small and flat lesions may be removed with potassa or
the ethylate of sodium; a 1 per cent. solution of corrosive sublimate,
applied for a few hours by means of compresses, causes blistering and
usually the removal of the pigment. Excision or thorough cauterization
may be employed for nævus verrucosus and nævus lipomatodes. The
galvano-caustic has also been advocated.
Ichthyosis.
Ichthyosis, also called xeroderma and fish-skin disease, is a chronic,
hypertrophic disease, usually occupying the whole surface,
characterized by dryness or scaliness of the skin, with a variable
amount of papillary growth. There are two varieties of the
disease,--ichthyosis simplex and ichthyosis hystrix, arbitrary
divisions, however, employed to designate the milder and more severe
forms respectively.
The milder variety is that which is usually encountered. In this form
{667} the disorder may be so trifling in character as to give rise to
simple dryness or harshness of the integument,--a condition to which
the term xeroderma has been given. In others the process may be more
developed, and the scales somewhat thick, having a polygonal or
plate-like form. When the latter is the case, the form and size of the
plates are usually determined by the natural lines or furrows of the
parts. The scaling may be merely thin and bran-like or thick and horny,
resembling fish-scales. In the milder forms of this variety the color
of the scales may be light and pearly; when more or less thickly
developed, may be dark, even olive-green or blackish. This color cannot
be attributed entirely to extraneous matter, pigment-granules having
been demonstrated in the scales. The amount of scaling depends somewhat
upon the age of the patient, the severity of the disease, and also the
frequency of ablutions. If the scales are allowed to accumulate, they
may become enormously thickened. The disease is found most developed
upon the extensor surfaces of the upper and lower extremities,
especially the latter, the flexor surfaces in mild cases being free.
The scales are firmly attached, but can usually be removed without
injury to the underlying parts.
In the other variety of the disease--ichthyosis hystrix--in addition to
excessive formation of scales there is marked papillary hypertrophy, at
times the papillary outgrowths reaching several lines, bearing
resemblance to the quills of a porcupine. This resemblance has given
rise to the qualifying term hystrix. This variety of the disease is not
apt to be so generalized as the milder variety. It is not infrequently
seen to occur as one or more rounded, irregular or linear patches,
solid, corrugated, warty or spinous in character. The patches may exist
close together or widely separated or along nerve-tracts, and the other
parts of the surface may exhibit the milder variety.
Ichthyosis is usually first noticed in the early months of childhood,
from which time it becomes progressively worse until it reaches a
certain point, and then usually remains stationary throughout life. It
is common to both sexes. The scalp and face usually escape. The
condition is affected favorably by warm weather, so much so that the
milder forms of the disease disappear entirely during the summer, to
reappear as soon as the cold season begins. Even the severer forms of
the affection disappear to some extent during the warm months. This
change is due to the activity of the glands in the summer, the
secretions macerating the epidermis, rendering the removal easy and
thus relieving the patient. Unless the affection is well marked
subjective symptoms rarely exist, but slight itching is sometimes
present. In the well-developed cases, however, the scales may become so
thick and the hypertrophy so marked as to interfere with the natural
mobility of the parts, or as a result of motion fissures may occur. The
general health of patients suffering with ichthyosis is usually noted
to be good.
The causes of the disease are not clearly understood. An hereditary
tendency is frequently traceable. The affection is to be looked upon
more in the light of a deformity than as a disease. Although it does
not manifest itself, as a rule, until the end of the first or second
year, it is nevertheless to be considered, in most instances at least,
as born with the individual. The disease is so slight in the beginning
that in view of the repeated ablutions that infants are subjected to it
might {668} exist slightly in the first months of life without being
noted. Race and climate have been stated as important factors in its
production. It will be found, however, that where it exists in any
great proportion, as in Paraguay and in the Moluccas, for various
reasons intermarrying among the natives is the practice, and it is
unquestionably a natural consequence that a distinctly hereditary
disease should become frequent under such conditions. In this country
the disease in its marked form is comparatively rare.
Anatomically, a constant feature of the disease is epidermic
hypertrophy. This may be slight or marked according to the severity of
the process. There is usually also considerable hypertrophy of the
papillæ. In some cases, in addition to these conditions the rete may
found hypertrophied, the blood-vessels dilated, the hair-follicles and
the sweat and sebaceous glands more or less involved. The features of
the disease--the harsh, dry skin, the hypertrophy of the epidermis and
papillæ, the furfuraceous or plate-like scaliness, the greater
development of the affection upon the extensor surfaces, and the
history--are so characteristic that a diagnosis is a matter of no
difficulty. From psoriasis, scaly eczema, and the other inflammatory
scaly disorders it may be distinguished by the absence of inflammation.
The prognosis of the affection, as already intimated, is unfavorable as
regards its cure. In only a few cases has a cure been noted. Hebra
reports two such cases, the disappearance of the affection having
followed an attack of one of the exanthematous fevers. Internal
treatment is very rarely, if at all, of any benefit. Some good has been
stated to follow the administration of linseed oil. In a few cases
under observation jaborandi in moderate doses has temporarily
influenced the disease favorably, probably by increasing the action of
the sweat-glands. Although the prospect of a cure is entirely
unfavorable, the affection may be, in almost all cases, kept in
abeyance by external measures. Oily applications, soaps, and frequent
bathing are the measures to be advised. In mild cases simple baths,
frequently repeated, will suffice. In others it may be necessary to
make the bath alkaline by the addition of bicarbonate of sodium, three
to six ounces to the bath: the patient should soak in the bath for
thirty minutes or longer. Where the alkaline baths seem unsuitable or
fail to benefit sufficiently, the hot bath and washing with sapo
viridis may be employed. The vapor bath is particularly serviceable in
these cases. Rubbing in some mild ointment, allowing it to remain a few
hours or longer, and then following it with a hot bath and green-soap
washing, subsequently rinsing with simple warm or hot water, and then
again anointing the surface with the ointment, will be found valuable
in the more severe cases. An ointment such as the following may be
employed for this purpose:
Rx. Adipis benz., ounce j;
Glycerinæ, drachm j;
Ugt. petrolei, ounce j.
M. Ft. ugt.--Apply after bathing.
Or,
Rx. Potassii iodidi, scruple j;
Glycerinæ, drachm j;
Adipis benz.,
Ol. bubuli, aa. ounce ss.
M. Ft. ugt.--Apply once daily.
Or any simple oil or salve may be substituted. In the more severe cases
{669} of the hystrix variety, in addition to the measures already
described, it may be necessary to employ caustics, or even the knife,
for the removal of the horny patches which form. For localized patches
a 10 to 20 per cent. salicylic-acid plaster will be found useful. For
the general scaliness the same drug in ointment form, 5 to 10 per
cent., will prove of benefit.
Onychauxis.