an idiopathic affection and also as a consequence or accompaniment of
other diseases. The hypertrophy may consist in excessive length, width,
thickness, or all combined. In addition to the increase in size, the
nails may be abnormal as regards their shape, being twisted, conical or
curved, their surface roughened, uneven or furrowed, and may also be
attended with changes in color and consistence. If the hypertrophy
increases the width to any marked extent, the parts encroached upon
become irritated and inflamed, resulting in paronychia. At times the
matrix may be the seat of inflammation, giving rise to structural
changes in the nail-substance,--onychia. One, several, or all the
nails, both of the fingers and toes, more frequently the latter, may be
involved. Hypertrophy of the nail is met with in eczema, psoriasis,
ichthyosis, leprosy and syphilis, and also as a result of the invasion
of the vegetable parasites of tinea trichophytina and favus. The rare
diseases lichen ruber and pityriasis rubra may also involve the nails.
In syphilis infiltration of the matrix gives rise to the changes in the
nail-substance. The nails in eczema and psoriasis are thickened and
brittle, with an uneven surface. In some cases, especially those due to
the vegetable parasites (onychomycosis) softening occurs.
Treatment depends upon the cause. Both constitutional and local means
are in most cases employed. The nail should be softened and trimmed by
means of the scissors or knife. Inflammation of the surrounding tissues
is to be combated by the ordinary methods, and all sources of
irritation avoided. Ingrowing nails should be cut transversely and not
rounded, and the soft parts may be relieved of pressure and irritation
by placing a piece of lint or cotton between the nail and skin-fold. In
hypertrophy due to syphilis, psoriasis, and like diseases appropriate
constitutional treatment is essential. In onychomycosis the
parasiticides are to be applied.
Hypertrichosis.
Hypertrichosis (hirsuties), or hypertrophy of the hair, is a term
applied to unnatural growth of hair, either as regards region, extent,
age, or sex. It may be slight or excessive; thus, it may be universal,
as in the so-called hairy people (homines pilosi), or limited, as upon
a wart or nævus (nævus pilosus). The hairs themselves may be fine,
coarse or of the average thickness. The hair of the scalp, eyebrows,
axillæ, pubes, and beard in men may show excessive development either
in thickness or length. Increased activity of hair-growth may take
place in the fine downy hairs present {670} over the greater portion of
the surface. It may occur in the very young--in fact, may be
congenital--and the growth may also appear on the face, arms, and other
parts of females, resulting, of course, from a hypertrophy of the
natural lanugo hairs.
It is difficult to give any definite or satisfactory explanation of the
causes which give rise to unnatural growth of the hair. It is seen more
frequently in persons of dark complexion, and may be congenital or
acquired; if the latter, the tendency to excessive development
manifesting itself, as a rule, toward middle life. It is frequently
associated in women with other masculine peculiarities, appearing
especially at the climacteric period, and also noted in connection with
the diseases of the uterus and ovaries. It is sometimes seen in sterile
women, also on the faces of insane women. Local stimulation or
irritation will at times have a curative influence.
For general hirsuties there is no remedy. Hairy nævi, if small, may be
treated by excision, or, if large, the hairs may be removed by
electrolysis, as described below. The excessive growth seen about the
faces of women is an annoying disfigurement, and such patients will
submit to almost any treatment with the hope of relief. Extraction of
hairs and shaving are frequently employed, but give only temporary
relief. The method of removal by electrolysis is the only plan which
promises permanent success. A fine needle in a suitable handle is
attached to the negative pole of a galvanic battery, introduced into
the hair-follicle alongside of the hair to the depth of the papilla,
and the circuit made by the patient touching the sponge electrode
attached to the positive pole. At the point of insertion the parts
become blanched, and frothing appears at the aperture of the follicle,
a result of the decomposition of the tissues at the point of the
needle. The action should be continued for several seconds or longer,
and then the circuit broken by the patient removing the hand from the
sponge electrode, after which the needle is to be withdrawn. If the
papilla has been destroyed, the hair may be readily extracted by the
forceps with very little traction. In most cases, after the needle is
withdrawn, or at times even before this, a wheal-like elevation appears
at the point of insertion. In some cases the follicles may suppurate.
Scarring, which is liable to take place, is to be guarded against. It
occurs more markedly in some subjects than in others. Noticeable
scarring, however, may generally be prevented if the operator is
skilful. The operation is somewhat painful, the amount of pain varying
with different persons, in some being slight, while in others it is
severe. A current from four to twelve cells of a freshly-charged
battery usually suffices.
Removal of hairs by the use of depilatories is considerably practised,
but, as they are caustic in their nature, they should be employed with
care. If prescribed, one made up of two drachms of barium sulphide and
three drachms each of oxide of zinc and starch may be recommended.
Enough water is added to the powder to make a paste, which is thinly
laid on the parts for ten or fifteen minutes. Heat of skin or a burning
sensation soon occurs, upon the advent of which the paste is
immediately to be scraped off, the parts thoroughly cleansed, and a
mild ointment applied. As with extraction and shaving, this method is
only temporary in its effects.
{671} Sclerema Neonatorum.
Sclerema neonatorum, or sclerema of the new-born, is a disease of
infancy manifesting itself usually at birth, characterized by a diffuse
stiffness, rigidity or hardness of the integument, accompanied by
coldness, oedema, discoloration, lividity, and general circulatory
disturbance. Frequently it is congenital. It usually begins on the
lower extremities, extending upward and invading the trunk, arms, and
face. The skin is reddish, purplish or brownish, glossy, and tense or
stretched, causing more or less rigidity and stiffness. The surface is
usually cold, and upon pressure oedema, together with an infiltrated
state of the tissues, is noted. When the disease is general the body
bears resemblance to a half-frozen corpse. The child is unable to move,
respires feebly, and usually perishes in a few days. The disease is
very rare. It is in most cases found associated with pneumonia or with
affections of the circulatory apparatus. The causes are obscure. After
death the condition of the skin undergoes but little change, the
induration remaining; on incision a considerable quantity of serous
fluid is poured out, when the tissues become softer and resemble
ordinary oedematous tissue. The treatment should consist of warm
applications, frictions, and like measures. The prognosis is
unfavorable.
Scleroderma.
Scleroderma, known also as sclerema and scleriasis, is an acute or
chronic disease, characterized by a diffuse, more or less pigmented,
rigid, stiffened or hardened, hide-bound condition of the skin. It was
first described by Alibert with the name sclérèmie des adultes, since
which time many cases have been recorded. The first symptoms consist of
more or less rigidity or induration of the integument, which may
increase rapidly, or, as is usually the case, slowly, until the region
affected becomes hard and bound down to the tissues beneath. In some
cases febrile symptoms, oedema, and pigmentation precede the
induration, but usually the process asserts itself insidiously, the
first symptom noted by the patient being the sclerosis. In marked cases
the skin is rigid, tight, or immovable, and is firm or positively hard
to the touch, as though frozen, but without the sensation of cold. In
some cases it may seem wooden or as though undergoing petrifaction. It
is hide-bound, and cannot be made to glide over the structures beneath,
nor can it be taken up between the fingers. The skin, owing to the
immobility, becomes set or fixed, the natural lines and wrinkles
disappearing, causing persons to look younger. The induration is
diffuse, being neither circumscribed nor defined, and generally
occupies a considerable area, the face, neck, back, chest, and upper
extremities being the regions most frequently involved. It may occupy
variously sized and shaped areas, for the most part irregular in
outline, or it may appear in the form of narrow or broad bands or
elongated patches, which usually become more or less shrunken and
sunken atrophic lesions.
The surface of the integument in scleroderma is usually on a level with
the neighboring healthy skin, except in the later stages where atrophy
has occurred, and is generally smooth and shining. Pigmentation is in
{672} most cases a marked symptom, being yellowish or brownish, in the
form of patches, giving a dirty, chloasmic appearance to the part.
Subjective symptoms are usually wanting, although there may be numbness
or cramp-like pains, especially when the limbs are the seat of the
disease. The skin in all cases feels contracted, tightly stretched or
too short. The disease may be limited, as is generally the case, or it
may occupy the greater portion, or even the whole, of the body. It is
usually symmetrical. It pursues a variable course, at times acute, but
more frequently chronic, extending over a period of years or throughout
life. Sooner or later resolution and recovery set in, or atrophic
changes take place, characterized by a wasting or a condensation of the
integument and of the subjacent tissues, causing contraction and
deformity, which are especially marked when occurring about joints. As
a rule, the general health remains good. The disease in some cases is
accompanied by patches of morphoea, which affection is regarded by some
authors as being merely a circumscribed variety of scleroderma.
The causes are obscure. The disease is rare, and is encountered oftener
in women than in men, and occurs usually in early adult or middle life.
Sudden changes of temperature, exposure to wet or cold, and violent
impressions on the nervous system have been cited as causes. The
anatomy of the disease has been studied by various observers, but with
different results, in the majority of cases slight structural changes
only having been found. Both the true skin and the subcutaneous
connective tissue are the seat of the process, showing a marked
increase of the connective tissue, with thickening and condensation of
the fibres. The disease may be viewed as a tropho-neurosis. The
diagnosis, as a rule, presents no difficulty. From morphoea, to which
it is closely allied, it may be distinguished by its tendency to
involve large areas, occupying sometimes the greater portion or the
whole of the integument, whereas morphoea usually appears in smaller
lesions. Scleroderma manifests itself diffusely and without lines of
demarcation; morphoea is circumscribed, and in its early stage is
surrounded by a pinkish border. Scleroderma is always characterized by
stiffness or hardness, whereas morphoea is usually soft or firm. In
scleroderma the skin is merely rigid or hard in the beginning, whereas
in morphoea there is hyperæmia and only slight induration.
Concerning the treatment of this disease there is but little to be
said. Constitutional remedies, such as arsenic, quinine, and cod-liver
oil, together with the employment of stimulating oily or fatty
applications, frictions, and electricity are indicated, though it is
difficult to state their intrinsic value. The course and termination of
the disease varies. In some cases spontaneous involution sets in sooner
or later, while in other instances the process continues to progress,
and lasts throughout life.
Morphoea.
Morphoea, formerly known as keloid of Addison, is characterized by one
or more rounded, ovalish or elongate, coin-sized patches, which, as a
rule, are circumscribed and clearly defined. At first they are
hyperæmic and pinkish, becoming as the process advances pale yellowish
or whitish, {673} with a faint pinkish or lilac border made up of very
minute injected capillaries. The patch may be slightly elevated or
puffed in the beginning, but later is on a level with the surrounding
skin, or even somewhat depressed. When typically developed it is either
soft or firm to the touch, or, more rarely, leathery or brawny. The
surface is usually smooth, and may be shining and have an atrophic
appearance. Not infrequently it resembles in color and in look a piece
of cut bacon or ivory laid in the skin. Around the patch there is
usually, in addition to the hyperæmic border, more or less diffuse,
mottled yellowish or brownish pigmentation. The disease exhibits no
disposition to symmetry, but not infrequently it manifests itself over
nerve-tracts. The regions commonly invaded are the face, neck, chest,
mammæ, back, abdomen, arms, and thighs. The lesions pursue a variable
though usually chronic course, lasting, as a rule, years. There is
always a marked tendency to varied atrophic changes, which in most
cases appear early, the skin becoming thin, shrivelled, or
parchment-like, later being bound down to the tissues beneath, forming
cicatriform, keloidal lesions, which may cause contraction and
deformity, with, in some cases, wasting and general atrophy, more
particularly of the extremities.
In addition to the usual characteristic circumscribed patches
described, there may exist distinctly atrophic lesions consisting of
small pit-like depressions resembling scars; also, reddish or bluish,
tortuous, short or long, large and minute, dilated, superficial
cutaneous blood-vessels and telangiectases, together with smooth,
glazed, whitish, slightly-depressed spots or grooved streaks--true
maculæ et striæ atrophicæ. Accompanying these various lesions there is
usually considerable diffuse or patchy yellowish or brownish
pigmentation. The process in some cases is simple as regards the
lesions, but not infrequently it is complex, being characterized, as
indicated, by a variety of lesions in different stages of evolution.
The course is chronic, extending in the majority of cases over years.
The disease in some cases eventually tends to spontaneous recovery; and
this is all the more remarkable considering that atrophy has existed.
The disease is met with more frequently in females than in males.
Impaired nerve-power is without doubt the important factor in its
production. Concerning the relation of morphoea to scleroderma, it may
be said that these affections are closely allied, and that they may
occur together. The pathological anatomy of the characteristic patches
varies with the stage of the disease. In the early stages there is
shrinkage or atrophy of the papillary layer, with condensation of the
connective tissue of the corium. Crocker further noted marked
cell-infiltration around the sebaceous glands, hair-follicles, and
vessels, and in the later stages the transformation of these cells into
fibrillar tissue, its contraction, and the consequent obliteration of
blood-vessels, with atrophy of the sebaceous and sweat glands.
Morphoea is to be distinguished from scleroderma, from vitiligo, and
from the anæsthetic patches of leprosy. In appearance morphoea and
leprosy possess features in common, and it is probable that they are
both due to the same cause--namely, perverted innervation. As a rule,
no difficulty will arise in the diagnosis, for the reason that in
leprosy other symptoms of that disease will almost invariably be
present.
To be viewed as a variety or form of morphoea, we may mention {674}
hemi-atrophia facialis, or unilateral atrophy of the face, which
affection consists of a variable degree of atrophy of the skin and
deeper structures, the cutaneous lesions being the same as those in
morphoea. The neurotic origin of the disease in this case is plain.
A general tonic treatment, with the long-continued use of such remedies
as arsenic, quinine, cod-liver oil, iodide of potassium, and
electricity, is called for, most reliance being placed upon arsenic.
Good results sometimes follow its administration. The prognosis should
always be guarded.
Elephantiasis.
Elephantiasis, or elephantiasis arabum (also called pachydermia,
Barbadoes leg, elephant leg), is a chronic hypertrophic disease of the
skin and subcutaneous tissue, characterized by enlargement and
deformity of the part affected, accompanied by lymphangitis, swelling,
oedema, thickening, induration, pigmentation, and more or less
papillary growth. The legs and genitalia, especially the former, are
favorite localities for its development; about the latter, the penis,
scrotum, and clitoris are most frequently involved. It begins with an
inflammation of the parts, erysipelatous in character, attended with
febrile disturbance, swelling, pain, heat, redness, and lymphangitis.
The inflammation may have its starting-point in a local lesion, as a
wound or scar, or, as is usually the case, manifests itself without any
apparent cause. Similar attacks occur more or less frequently, after
each of which the part remains increased in size. After a year or
longer, during which time repeated attacks may have taken place,
considerable increase in size is noted: the part is swollen,
oedematous, and hard, and the skin hypertrophied, fissured, pigmented,
and the papillæ enlarged and prominent. Later, the hypertrophy becomes
still more marked; the part is often enormously enlarged and swollen,
the skin rough, fissured, and warty. In Eastern countries the disease
assumes huge proportions. Eczematous inflammation may coexist and
complicate the appearance. The fissures may be slight or large and
deep, the normal lines and folds of the surface exaggerated, with more
or less maceration of the epidermis taking place, especially about the
folds. Ulcers sooner or later tend to form, developing usually from
varicose veins, while scales and crusts may also be present. Pain
varies, being usually marked during the inflammatory attacks.
Elephantiasis is met with in all parts of the world, but much more
frequently in tropical climates, especially about the West Coast of
Africa, Brazil, the West Indies, and particularly India, and to less
extent in Mediterranean regions and Arabia. In our own country, and
also in Europe, it is not common. It rarely occurs before puberty.
Heredity has no influence, nor is it contagious. It is commonly
observed among the poor and neglected.
The immediate cause of the disease is to be found in inflammation and
obstruction of the lymphatics. This obstruction is, according to late
investigations, probably due to the presence in the lymphatic vessels
of the parasite filaria and its ova. The filaria--a microscopic
thread-worm--has been found in large numbers adhering to the walls of
the lymphatics and blood-vessels, but is discoverable only during
certain hours {675} of the day. The parasite has also been found in
lymph-scrotum, a disease closely related to, if not identical with,
elephantiasis.
The great mass of the growth in the disease is made up of hypertrophic
connective tissue and connective-tissue new growth. All parts of the
skin and the subcutaneous tissues share in the hypertrophy. Papillary
enlargement is usually a marked feature. The lymphatic glands are
swollen and enlarged and the lymphatic vessels prominent. There is
marked oedematous infiltration, lymphatic in character. As a result of
pressure, the glandular structures of the skin are atrophied or
destroyed, the fat atrophied, and the muscles degenerated. The walls of
the blood-vessels are thickened.
In well-developed cases of elephantiasis the symptoms are so
characteristic that the disease is readily recognized. Recurrent
attacks of erysipelatous inflammation of the leg or genitalia will
point, with probability, to a development of the disease, even before
marked hypertrophy or the clinical features are developed. As regards
the outcome of the disease, if the case comes under treatment in the
early months of its development the process may be checked or held in
abeyance; later, after the affection has become well established, but
little more than palliation can be effected.
The inflammatory attacks are to be treated with rest in bed, hot or
cold applications, lead-water, and similar measures. Quinine and iron
internally, especially the former, are of value. Potassium iodide has
also been well spoken of. Climatic change, especially in the early
stages, may prove of marked advantage. After the acute symptoms of the
erysipelatous attacks have subsided inunctions of iodine or mercurial
ointments may be employed to soften the skin and promote absorption.
The parts should also be firmly bandaged, either the roller bandage,
or, preferably, one of rubber, being used. Instrumental compression and
ligation of the main artery of the limb have been employed, at times,
with diminution in the size of the part; also excision of a portion of
the sciatic nerve was practised in a single case by Morton with
reduction in the size of the limb, but these methods of treatment are
not to be recommended. Lately, the use of the strong, constant current
has been extolled as having a beneficial effect. Elephantiasis
involving the genitalia is, if the disease is well advanced, to be
treated by the knife, amputation of the parts being practised.
Dermatolysis.
Dermatolysis consists of a more or less circumscribed hypertrophy of
the cutaneous and subcutaneous structures, characterized by softness
and looseness of the skin and a tendency to hang dependently. It may be
slight or extensive, and may be limited to a certain region or show
itself simultaneously in several different parts. The integument is
thickened, bulky, superabundant, and to a greater or less extent hangs
down in folds. The hypertrophy is general over the area affected; the
glandular structures, connective tissue, muscular fibres, pigment, and
the subcutaneous areolar tissue share in the process. The surface is
usually soft and pliable to the touch, but is uneven, in consequence of
the hypertrophy of the follicles and {676} the natural folds and rugæ.
As a result of the increase in pigment the skin is more or less
brownish in color. The tissues may develop to an enormous size, and the
redundant parts may hang down in several folds, overlapping one another
and forming a cloak to the parts below.
Dermatolysis may be congenital or may not develop until after puberty.
It is a simple hypertrophy involving the integument and all its
component parts, especially the subcutaneous connective tissue. The
causes which bring about this condition are not known. It appears to be
closely allied to molluscum fibrosum, the two diseases sometimes
occurring together. It is not malignant, but its presence impedes
locomotion and its weight is a discomfort.