writers, but the clinical features and course of the two diseases are
entirely different. Elephantiasis telangiectodes is a term that has
been given to a form of simple hypertrophy of the skin in which a
marked new growth of vascular tissue takes place. In connection with
this disease mention may be made of the condition characterizing the
so-called rubber or elastic-skin man. In this condition there is no
hypertrophy. The mobility and elasticity of the skin are probably due
to a peculiar and abnormal looseness of the subcutaneous areolar
tissue. It is to be looked upon as a congenital deformity. The
treatment of dermatolysis is by excision when this operation is
practicable.
CLASS V.--ATROPHIES.
Albinismus.
Albinismus is a term employed to designate that condition in which
there is congenital absence of the normal pigment. It may be localized
(albinismus partialis) or general (albinismus universalis). Persons in
whom it is universal are called albinos. They are characterized by more
or less complete absence of pigment in the skin, hair, iris, and
choroid. The skin is milky-white, with, usually, a pinkish tint; the
hair is white or yellowish, fine, thin, soft, and silky. The eyes are
sensitive to light, the pupils appear red and contract and dilate
continuously; oscillation of the eyeballs is noted, and also rapid and
constant winking. These individuals are usually physically and mentally
deficient, with a tendency to pulmonary disease.
Partial albinismus is seen more frequently in the negro. There may be
one or more whitish or pinkish-white patches, variable as to size and
shape, occurring upon any region. The skin is normal with the exception
of loss of pigment. The hairs existing upon the spots are blanched. The
eyes show no loss of pigment. The negroes in whom the patches occur are
termed pied, or piebald. In exceptional instances a redeposit of
pigment has been observed. Albinismus is not confined to any race or
climate, and is comparatively rare. Its causes are not known. It is
frequently inherited.
{677} Vitiligo.
Vitiligo (known also as acquired leucoderma or leucopathia) is a
disease consisting of one or more usually sharply-defined, rounded or
irregularly-shaped, variously-sized and distributed, smooth, whitish
spots, whose borders usually show an increase in the normal amount of
pigmentation. The patches may appear on any region, the backs of the
hands and the trunk being favorite localities. The disease begins by
the appearance of small pale spots, which gradually increase in size,
new patches showing themselves from time to time. They are well defined
in outline, the pale milky whiteness of the patches contrasting
markedly with the surrounding pigmented skin. The increased
pigmentation of the borders is almost an invariable accompaniment of
the disease, and may be slight or excessive, gradually becoming less
intense as the healthy skin is approached. The patches are smooth, on a
level with the surrounding skin, rounded, ovalish, or irregular. They
may be small or large, depending upon their age and also upon the
rapidity of their growth. If several coalesce, as is frequently the
case, large irregular patches are formed. The secretion of the sweat
and sebaceous glands and the sensibility of the skin are not disturbed.
With the exception of the loss of color the skin is normal. Hairs
included in the patches may or may not be whitened. There are no
subjective symptoms.
As a rule, the progress of the disease is slow, years frequently
elapsing before the patches attain a large area. In some instances,
after reaching a certain size, they remain stationary, either for a
time or permanently. In most cases, however, the disease is
progressive. In rare instances the skin has been known to become normal
again. The sole annoyance the disease occasions is the disfigurement,
and this is often striking. The spots are but little, if at all,
affected by the sun, except that they are rendered more conspicuous by
the bronzing of the normal skin which its rays cause. As a rule, the
affection first shows itself in early adult life, although it may
appear earlier or later. Both sexes, whether of a light or dark
complexion, are attacked. The general health is usually good. It is
attributed to a disturbance of innervation. Alopecia areata and
morphoea have been seen in association with it.
Anatomically, it consists of both an atrophy and a hypertrophy of the
normal pigment of the skin, the pale patch resulting from the former,
and the pigmented border from the latter. There is no textural change
in the skin. It may be mistaken for chloasma, tinea versicolor, and
morphoea. In the former diseases, when several patches are close
together, the normal skin between appears, in comparison, pale, and if
cursorily examined might be mistaken for the pale patches of vitiligo,
while the surrounding yellowish patches of tinea versicolor or chloasma
may appear as the pigmented borders. In tinea versicolor the patches
are slightly scaly. In morphoea there is always structural change.
Treatment in most cases is unsatisfactory. The functions and the state
of the general health must receive attention. In some cases arsenic
long continued proves of benefit. It is the only known remedy of any
value. The disfigurement produced by the patches can in a measure be
removed. For this purpose the darkened border should receive
appropriate applications, such as are used in the removal of patches of
chloasma. The white {678} spots sometimes may be made darker by the
application of cantharides, promoting capillary congestion.
Canities.
Canities is a term applied to grayness or blanching of the hair. Loss
of pigment in the hair may be partial or general. It may occur early in
life or, as is commonly the case, as the result of old age. The change
in color may take place throughout the entire hair or in parts. The
color varies from slight blanching to white. It is usually grayish. In
rare instances the color is to a moderate degree regained in summer.
Grayness of the hair in the young--canities præmatura--is exceptional;
in the old--canities senilis--it is constant, individuals differing
considerably, however, as to the time of life at which the change
begins. After the hair has become gray it rarely recovers its coloring
matter, although occasionally in the young, after the lapse of years,
the hair may again become dark. In those of a dark complexion the loss
of pigment occurs, as a rule, much earlier than in those whose hair is
of the lighter shades. Usually considerable time is required in the
complete change to gray or white, but authentic cases are on record in
which the change has taken place in the course of a night or within a
few days. The pathology is obscure.
Canities, as may be readily inferred, depends upon a deficient
production of pigment. The causes which gives rise to this deficiency
are not understood. Hereditary influence is often noticeable.
Conditions which impair the general nutrition, such as chlorosis,
anæmia, fevers, etc., and those that hinder the local nutrition, as
seborrhoea and inflammatory diseases of the parts, may possibly have
some influence. In sudden blanching of the hair fright, intense
anxiety, and the like are the usual causes. Treatment, whether internal
or external, has no effect in preventing the loss of pigment or in
restoring it. Dyeing, however, may be practised, and the condition
masked; but it is not to be recommended, as the skin of the scalp
becomes discolored and the nutrition of the hair interfered with.
Alopecia.
Alopecia consists of partial or complete deficiency of hair,
irrespective of cause. There are several varieties, named according to
the causes which have produced the affection. Thus, congenital alopecia
consists of a partial or complete absence of hair, either over the
entire surface or confined to a portion. In some instances there is
scantiness or irregular development. In rare cases there is complete
absence of the hair, microscopical examination failing to show the
existence of hair-bulbs. In cases of congenital deficiency there
usually exists an hereditary predisposition.
Senile alopecia and senile calvities are terms applied to the baldness
of advanced years. With the loss of hair there is usually atrophy of
the other cutaneous structures. In these cases the hairs, as a rule,
first turn gray, become dry and thin, and fall out, with no tendency to
a new growth. The condition is seen upon the scalp, beginning usually
at the crown; in {679} occasional instances other parts of the body may
also sooner or later show more or less atrophy of the hairy appendage.
Upon the scalp, the skin, which is more or less free of the hair,
becomes atrophied, smooth and glossy. The alterations in the cutaneous
structures in senile baldness consist of marked atrophy of the
sebaceous glands, of the hair-follicles and of the skin itself. The
affection is common in men, but is comparatively infrequent in women.
No satisfactory reason can be assigned for this. Idiopathic premature
alopecia is the term applied to the baldness which begins to manifest
itself about the age of twenty-five or thirty. The hairs may fall out
rapidly or the loss may take place slowly. In these cases the normal
hairs are usually replaced with finer, thinner, and shorter hairs, but
finally even these eventually cease to be reproduced, and more or less
alopecia results. There is no seborrhoea, and the skin shows no other
atrophic change. As a rule, several years elapse before the condition
becomes marked. The location affected is the same as in senile
alopecia, and the same statement may be made as to its frequency in the
two sexes. According to microscopical examination, there is an increase
in the connective tissue, compressing the blood-vessels, and thus
interfering with the blood-supply of the parts.
Symptomatic premature alopecia includes all those forms of alopecia
which are the result of disease, either local or general. Falling of
the hair is frequent after fevers and other systemic diseases. Mental
anxiety, nervous exhaustion, and depraved conditions of the general
health may also cause varying degrees of alopecia. In these cases the
shedding of the hair usually takes place rapidly, constituting
defluvium capillorum. With a disappearance of the exciting cause there
is usually a regrowth, but this is not always the case, as not
infrequently the baldness is permanent. Among local diseases which give
rise to baldness, chronic seborrhoea is the most important. As a result
of the seborrhoea, atrophy of the glands occurs, and alopecia sooner or
later sets in. Many other local affections, as lupus erythematosus,
erysipelas, variola, tinea tonsurans, and tinea favosa, are at times
attended with loss of hair. Syphilitic alopecia may occur at two
different periods of that disease. It is noted as one of the early
symptoms, and later as the result of the general cachexia, or in
localized patches as the result of ulceration and destruction of the
skin. The alopecia appearing as a secondary symptom of the disease may
be slight or complete baldness may take place, but in either case the
loss is rarely permanent if the patient is under proper treatment. As a
rule, in the course of a few months the hair is reproduced. The
alopecia resulting from ulcerative lesions is permanent.
The treatment of the various varieties of alopecia named depends, as
will be readily inferred, upon the etiological causes. Senile alopecia
is rarely amenable to treatment. Idiopathic premature alopecia may
frequently be benefited by therapeutic measures. The general health is
to be looked after. In these cases arsenic in moderate doses long
continued may prove of some value. The external treatment has in view
the promotion of the nutrition of the skin, which is attained by the
use of stimulating applications for the purpose of increasing the
vascular supply. The treatment of symptomatic premature alopecia is
that of the primary disease. The external remedies and formulæ which
are employed in cases {680} of alopecia for their stimulating effects
will be found in detail under the head of alopecia areata.
Alopecia Areata.
Alopecia areata (syn. area celsi, alopecia circumscripta, porrigo
decalvans, tinea decalvans) is an atrophic disease of the hairy system,
characterized by the more or less sudden appearance of one or more
circumscribed, variously sized and shaped, whitish bald patches. The
scalp is the region most frequently the seat of the disease, but other
hairy parts, especially the face in the male, are often invaded, and
even the whole surface may be involved. Occurring upon the scalp, one
or several patches may be present, which are usually rounded and
circumscribed. The hair may fall out suddenly without any previous
signs of weakening, the individual awaking in the morning to discover
an area of partial or complete baldness on the scalp; or, as is usually
the case, the loss of hair takes place insidiously or more gradually,
several days or weeks elapsing before the bald patch is of sufficient
size to attract observation. The parietal region is perhaps most
frequently involved. In most cases but a single patch appears at first,
but this usually is followed by others. The areas incline to grow
larger and larger, and, as a rule, finally coalesce, eventually the
whole scalp, with possibly the exception of a tuft or patch here and
there, being bald. In most cases, however, the patches, after reaching
a certain size, remain stationary.
The skin of the affected areas has a smooth, whitish, polished,
atrophied appearance, and is usually entirely devoid of hair or with a
few straggling long or short hairs scattered over it. The orifices of
the follicles become less appreciable, and the skin is thin, and
resembles that seen in the baldness of advanced years. The hairs
surrounding the affected area are usually found to be firmly seated in
their follicles, but if the patch has not ceased enlarging they may be
loose and readily extracted. In some cases about the border are noted a
few short atrophied hairs, resembling the short, broken-off hairs of
tinea tonsurans. At first the skin may be slightly puffed, but usually
it is on a level with the surrounding parts; later, it may be somewhat
depressed, as though atrophied. It is neither scaly nor inflamed.
Slight anæsthesia may be present. There are, as a rule, no subjective
symptoms. Involving the regions of the moustache and eyebrows, the
clinical phenomena are essentially the same as when affecting the
scalp. In those cases in which universal loss of hair results, the
process usually begins in the same way, first appearing as well-marked
areas, which rapidly increase in size; new patches are added,
coalescence results, and eventually the entire surface is involved.
After the disease has come to a standstill it may so remain
indefinitely, or lanugo hairs may appear from time to time, reach an
inch or a fraction thereof in length, may become slightly darkened, and
then fall out. Finally, in favorable cases, instead of falling out,
their growth continues; they become dark, and recovery takes place. In
these latter cases the disease may have existed several months before
signs of a permanent regrowth show themselves; on the other hand,
several years may have elapsed.
The disease is met with in both sexes, in children and adults, and
among {681} the wealthy and the poor. It is not a rare disease, nor is
it common. Impaired nutrition as the result of functional
nerve-disturbance is probably the important etiological factor, leading
to the view that the affection is a trophoneurosis. It is often seen to
follow neuralgias, nervous shock, and debility. Morphoea and vitiligo,
both diseases of a neurotic character, are occasionally seen in
association with it. In the greater number of cases no appreciable
cause is discoverable. It is not parasitic, nor is it contagious.
Microscopic examinations have given negative results, the skin
remaining normal and the glandular structures unchanged. Atrophy of the
hair shafts and bulbs, and occasionally breaking and bulging of the
hairs, are usually noted. The atrophic condition of the bulbs is
similar to that seen in hairs which have reached the end of their
normal life.
The disease with which alopecia areata may, by the inexperienced, be
sometimes confounded is tinea tonsurans, and yet the incomplete
baldness, the short, stumpy, split, gnawed-off-looking hairs, the
scaliness, the increased prominence of the follicular openings, and the
history and course which characterize ringworm, are entirely different
from the clinical signs of alopecia areata. Where there is doubt the
microscope is to be employed. It is to be remembered, also, that
ringworm of the scalp is not seen in individuals past the age of
puberty. The peculiar clinical features of the disease will distinguish
it from other forms of baldness.
TREATMENT.--The uncertainty of the duration and ultimate termination of
the disease is to be kept in view in expressing an opinion. It may be
stated, with a degree of positiveness, however, that in young
individuals the eventual result is, as a rule, good; but occurring in
persons past adult age, the prognosis as to a regrowth is not so
favorable, and becomes less so as age increases. The length of time
elapsing in favorable cases before the hair reappears, as already
mentioned, is uncertain: it may be several months, or on the other
hand, as many years. On both points proper and persevering treatment
has sometimes a material influence.
Local and general measures are called for. Of the two, the general
treatment is the more important, and among remedies employed arsenic
stands prominent. It should be continued for months. In addition, such
tonics as iron, quinine, cod-liver oil are to be advised as the case
demands. In some instances potassium iodide in moderate doses is of
service.
External treatment is of value, and is in most cases to be advised. The
object in view is a stimulation of the vascular supply, and through
this an improvement in the nutrition of the papillæ and hairs. The same
remedies in various combinations are employed as in the treatment of
other forms of alopecia. Rubefacients and irritants, such as alcohol,
the essential oils, sulphur, tar, cantharides, corrosive sublimate and
other salts of mercury, carbolic acid, iodine, turpentine, ammonia,
chrysarobin, and spiritus saponatus kalinus, are variously used. They
are, as a rule, employed either in alcoholic or ethereal fluids or in
the form of oils or ointments. It is to be borne in mind that the scalp
tolerates strong remedies. The applications are to be made once or
twice daily, according to the demands of the case, and with
considerable friction, employing for the application a flannel rag or
mop. Such remedies as iodine, corrosive sublimate, are usually to be
painted or dabbed on.
{682} Sulphur, two to four drachms to the ounce; corrosive sublimate,
one to four grains to the ounce of alcohol; tar, ol. cadini, or ol.
rusci, one to four drachms to the ounce of alcohol or ointment,--are
all serviceable remedies. Cantharides and capsicum are stimulating, and
may be prescribed as in the following formula:
Rx. Tinct. cantharidis,
Tinct. capsici, aa. fluidounce iss;
Olei ricini, fluidrachm ij;
Alcoholis, fluidrachm vj;
Spts. rosmarini, fluidrachm ij. M.
The following, containing the oil of mace, is also serviceable:
Rx. Olei myristicæ exp., fluidrachm ij;
Alcoholis,
Spiritus lavandulæ, aa. fluidounce ij. M.
Carbolic acid may be used as follows:
Rx. Acidi carbolici cryst., drachm ij;
Alcoholis, fluidounce iij;
Olei ricini, fluidrachm iv;
Spts. rosmarini, fluidrachm iv. M.
Aqua ammoniæ may sometimes be employed with benefit, as in the formula
recommended by Wilson:
Rx. Olei amygdalæ dulc.,
Aquæ ammoniæ fort., aa. fluidounce ss;
Spiritus rosmarini, fluidounce ij;
Olei limonis, fluidrachm ss. M.
Blistering the affected areas by means of a cantharidal vesicating
fluid, frequently repeated, sometimes proves of advantage. Friction
with oil of turpentine once or twice daily may in some cases be
practised with benefit; when the skin becomes sensitive it should be
discontinued for a few days. Chrysarobin in ointment, 5 to 15 per cent.
strength, is an active irritant which may be cautiously employed.
Oleate of mercury, 10 to 30 per cent. strength, rubbed in once or twice
daily, is useful in some cases, and the same may be said of the other
mercurial ointments, such as citrine and white precipitate ointments.
Electricity sometimes proves of service, and may be tried in obstinate
cases.
Atrophia Pilorum Propria.
Atrophia pilorum propria, or atrophy of the hair, may be either
symptomatic or idiopathic. As a symptomatic affection it is seen as a
result of such diseases of the scalp as seborrhoea and the parasitic
affections, and also following various constitutional diseases, such as
syphilis and fevers, in consequence of impaired nutrition. The hairs
become dry, brittle, atrophied, and exhibit a marked disposition to
split up. Idiopathic atrophy of the hair is characterized in one of its
forms (fragilitas crinium) by a brittle state of the hair-shaft, an
irregular and uneven formation of its structure, and a tendency to
separate into its filaments. It is seen about the scalp and beard, and
may be slight or markedly developed. A somewhat similar condition of
the hair of the beard has been described (Duhring), in which the bulb
is {683} atrophied and the shaft split up, fission taking place within
the follicles, causing irritation of the skin. Another form
(trichorexis nodosa) of the idiopathic affection is characterized by
shining, semi-transparent, rounded swellings of the hair-shaft, seen
usually upon the beard and moustache. At first sight they look not
unlike the ova of pediculi; one or several may be present upon a single
hair. Upon close inspection they are seen to be localized swellings of
the hair-structure. At these points the hairs readily break off,
leaving a brush-like end; if many of these are present, which is
usually the case, they give the impression that the hair has been
singed. The medullary as well as the cortical substance, as determined
by microscopical examination, is swollen, and in consequence of the
swelling of the medullary portion the cortex is burst and split into
filaments. In regard to the cause of idiopathic atrophy of the hair
nothing is known, and but little can be done in the way of treatment.
Shaving and cutting the hair have exceptionally been followed by a
normal growth.
Atrophia Unguis.
Atrophy of the nail is commonly an acquired affection. It is
characterized by deficient development or growth of the nail-substance,
as shown by a thin, brittle, soft, crumbly or worm-eaten condition. The
nail may be pale, opaque or dark in color. It may occur in consequence
of injury or disease of the nerves of the part, or as a result of some
general disease, as syphilis, or from general debility. Eczema,
psoriasis, and allied diseases, which may be productive of hypertrophy
of the nails, may also cause atrophic changes. Treatment of atrophy of
the nail depends upon the cause. In simple atrophy, and also in that
due to eczema and psoriasis, arsenic is of value.
Atrophia Cutis.
Atrophy of the skin, or atrophia cutis propria, in its various forms is
not infrequently encountered. It may occur as an idiopathic affection,
or as a symptom in connection with other well-known diseases. Thus, as
an example of the former condition the well-known striæ atrophicæ may
be cited, while lupus, syphilis, and tinea favosa are sometimes
followed by symptomatic atrophy. Injuries to nerves are also at times
followed by more or less cutaneous atrophy, usually in connection with
wasting of the subcutaneous structures, the skin becoming thin, dry,
shrivelled, and yellowish or brownish in color. Atrophy of the skin may
be general, as in the senile form, or localized, as in morphoea. Where
degenerative atrophy exists the skin is usually somewhat hardened,
yellowish or whitish in color, and has a waxy, fatty appearance. In the
condition known as glossy skin, generally seen upon the fingers, the
skin is reddish, smooth, and shining as though varnished, the affection
resembling chilblains. The hairs are usually shed, and excoriations or
fissures often exist. It is accompanied with pain of a burning
character.