time been reported, the disease in almost all instances being more
marked in some localities than in others, occurring in the form of more
or less extensive patches. The disease originally described by Hebra
and Kaposi with the name xeroderma, or parchment-skin disease, may here
be referred to. The lesions consist of numerous disseminated
pigment-spots, resembling freckles; telangiectases, or minute congeries
of blood-vessels; atrophic macules of variable size; with more or less
shrinking and contraction of skin, followed in most cases by
epitheliomatous tumors and ulceration. The disease almost invariably
begins in early years, is prone to show itself in several children of
the same family, and lasts during life. The advanced stages of
scleroderma and morphoea likewise show marked atrophic changes, which,
however, will be considered in speaking of those diseases.
Senile Atrophy.--This form of atrophy, taking place as the result of
old age, may be simple or degenerative, both usually occurring
together. The integument becomes thin and wasted, the surface being
dry, wrinkled and more or less discolored by pigmentation, with loss of
hair. In degenerative atrophy the connective tissue of the corium
becomes changed into a fine or coarse granular matter or into a
homogeneous vitreous mass. Fatty metamorphosis and marked pigmentary
deposits are also common.
Maculæ et Striæ Atrophicæ.--Atrophic streaks and spots may occur
idiopathically or symptomatically. The idiopathic form is that most
frequently encountered, and occurs without known cause, generally
making its appearance insidiously. It is characterized by lines or
streaks constituting the so-called linear atrophy, striæ atrophicæ; or
by spots, maculæ atrophicæ. The streaks are more frequently met with,
and consist of irregular curved or tortuous lesions, usually about a
line in width and of variable length, running parallel with one
another. The macules are rounded or ovalish, varying in size from a
pinhead to a finger-nail. Both are smooth and glistening, and the skin
is thinned and scar-like. They are slightly depressed or grooved, and
possess a pinkish, whitish, or bluish-gray color. They may appear upon
any region, but the abdomen, buttocks, and thighs are the favorite
localities. They pursue a slow course over a period of years or a
lifetime, occasioning no inconvenience. The first stage of either
variety of the disease is characterized by erythema, the lesion being
reddish, hyperæmic, and slightly raised or puffed. This sooner or later
disappears, followed by depression and atrophy.
The symptomatic form of the affection is usually noted to take place as
the result of extreme distension of the cutaneous structures. It occurs
sometimes in obese subjects, and in the latter stages of pregnancy upon
the abdomen and mammæ, and over large abdominal and other tumors where
the skin is greatly stretched, constituting the so-called lineæ
albicantes.
{685} CLASS VI.--NEW GROWTHS.[6]
[Footnote 6: Lepra (leprosy), an important disease of this class,
appears, in Vol. I. p. 785, as a separate article by J. C. White.]
Keloid.
Keloid is a connective-tissue new growth, characterized by one or more
irregularly-shaped, variously-sized, elevated, smooth, firm, somewhat
elastic, pale-reddish, cicatriform lesions. It ordinarily begins as a
nodule or tubercle, pea- or bean-sized, which slowly, usually in the
course of years, increases in dimension. When fully developed, the
growth appears as an ovalish, elongated, cylindrical, fungoid or
crab-shaped patch, occupying usually an area of one or several inches,
distinctly elevated, sharply defined, and firmly implanted in the skin.
In some cases the lesion does not exceed the size of a pea or a bean.
The color is usually pinkish-white. The surface is smooth, shining, and
commonly devoid of hair, with no tendency to scaliness or ulceration,
and generally marked by ramifying vessels. It is firm and elastic to
the touch. The disease sometimes appears in the form of streaks or
lines. It is seen most frequently upon the sternum, although other
regions, as the neck, mamma, ear, sides of the trunk, or back are often
invaded. It is more common in the colored race. The lesion is usually
single, though several may coexist. Itching to a slight degree is
sometimes present, and more or less pain, especially on pressure, may
also exist. Depending upon the origin of the growth, whether arising
spontaneously or upon the site of various injuries of the skin, keloid
is termed, respectively, spontaneous, or true, and cicatricial, or
false. Clinically and pathologically, both varieties are the same.
It is often met with as the result of burns, cuts, flogging, and all
ulcerative affections. Not infrequently it takes its origin in the
scars of acne and variola; occasionally it is seen to develop on the
lobe of the ear, taking its start at the point where the ear has been
pierced. Pathologically, the lesion is a connective-tissue new growth,
made up of a dense, fibrous mass of tissue, whitish in color, having
its seat in the corium. The clinical features of keloid are so
characteristic that no difficulty is experienced in recognizing it. The
course of the disease is chronic, usually lasting throughout life; in
exceptional instances spontaneous involution has been noted.
Treatment is usually negative. Removal by excision or caustics is, as a
rule, followed by a return of the growth, and sometimes in an
aggravated form. If its destruction or extirpation is decided upon, it
should not be done while the growth is still progressive. Improvement
has been reported by Vidal from multiple linear scarification. If the
formation is painful, various anodyne applications may be made. Iodine,
mercurial, and lead plasters may be tried with the object of promoting
absorption. Painting the growth with a solution composed of potassium
iodide one drachm, and an ounce each of soft soap and alcohol, followed
by the application of lead plaster spread on a piece of soft leather,
has been advised by Wilson. The use of lead plaster alone, applied
continuously as a plaster, is sometimes followed by softening and
diminution in size.
{686} Fibroma.
Fibroma (molluscum fibrosum, fibroma molluscum) is a connective-tissue
new growth, characterized by sessile or pedunculated, soft or firm,
rounded, painless tumors, varying in size from a pea to an egg or
larger, seated beneath and in the skin. A single growth may occur, or,
as is more commonly the case, they are present in large numbers, and
usually scattered over the greater portion of the body, having a
preference for the softer tissues,--for example, the trunk. They may be
of various shapes, rounded and sunken in the skin itself or in the
subcutaneous tissue, or club- or pear-shaped and pedunculated. They
usually begin as soft masses in the skin. If but one tumor exists, it
is apt to be pedunculated or pendulous, and to attain considerable
dimensions, in some cases weighing several pounds. In these instances
surface-ulceration is occasionally noted as the result of mere weight
or pressure. As commonly met with, however, the growths are numerous,
several hundreds existing, varying from a pea to a cherry in size, with
larger ones scattered here and there. The overlying skin is normal,
pinkish or reddish, or may be loose or stretched, hypertrophied or
atrophied. They are unattended with pain. They may make their
appearance at any age, often in childhood, and grow as a rule slowly.
After reaching a certain size they are apt to remain stationary; in
rare instance spontaneous involution of some of the growths has been
noted to take place. The affection is not common. It is often
inherited, and may show itself in several members of the same family.
Those in whom it is observed are usually noted to be stunted in their
physical and mental development. The general health is not involved.
Opinions are divided as to whether the growths take their origin in the
connective-tissue framework of the fatty tissue, in the connective
tissue of the corium, or in that of the walls of the hair-sac. The
developed tumors consist of a connective-tissue capsule enclosing a
whitish fibrous mass, with the central portion more or less soft and
pulpy, out of which may be squeezed a small quantity of yellowish
fluid. Small, recent tumors are composed of gelatinous, newly-formed
connective tissue, while old growths consist entirely of a dense,
firmly-packed fibrous tissue.
They are to be distinguished from the tumors of molluscum epitheliale
by the absence of an aperture or depression upon their summits. They
can scarcely be confounded with multiple neuromata or with lipomata, as
the accompanying pain of the former and the lobulated structure and
soft feel of the latter are sufficiently distinctive. Their removal, if
desired, may be effected by the knife, or in the case of the large and
pedunculated growth by the ligature or by the galvano-cautery.
Neuroma.
Neuroma cutis, or neuroma of the skin, is characterized by the
formation of variously-sized fibrous tubercles, containing new
nerve-elements, having their seat primarily in the corium, and
accompanied in their development by violent paroxysmal pain. It is
exceedingly rare, there being but few cases recorded. It appears on the
shoulders, arms, thighs or buttocks in the form of numerous,
disseminated, pinhead to hazelnut in {687} size, round or ovalish
tubercles or nodules, which at the outset may be either painful or
painless; in the later stages, however, pain, both spontaneous and upon
pressure, is a constant symptom. The growths are firm, immovable, and
elastic, and are seated in the corium, extending into the deeper
structures. They may be covered scantily with fine, laminated,
glistening scales, as in the case reported by one of us. Anatomically,
the tumors are composed of nerve-fibres, yellow elastic tissue,
blood-vessels, and lymphoid cells. Excision of a portion of the
nerve-trunk leading to the affected area has been practised in one case
(Kosinski's) reported, with permanent relief; in another (Duhring's)
the relief was merely temporary.
Xanthoma.
Xanthoma (also called vitiligoidea and xanthelasma) is a
connective-tissue new growth, characterized by the formation of
yellowish, circumscribed, irregularly-shaped, variously-sized,
non-indurated, flat or raised patches or tubercles. Two varieties are
met with. The macular, or flat form (xanthoma planum) is commonly seen
upon the eyelids, looking not unlike pieces of chamois-skin inserted in
the lids. This form may also be encountered occasionally on other parts
of the face, as well as upon the body. The patches are smooth, opaque,
usually sharply defined, and to the touch soft and apparently normal in
texture; they are on a level with the surrounding integument or
slightly raised, and of a creamy or yellowish color. They vary in size
and shape, and may coalesce, forming a band extending across the
eyelids, especially the upper lids. The tubercular form (xanthoma
tuberosum) is usually met with upon the neck, trunk, and extremities,
the eyelids seldom being invaded. It occurs as small, isolated nodules,
or in patches slightly raised above the level of the skin, consisting
of aggregations of tubercles of the size of a milletseed or larger.
Both forms of the disease not infrequently occur in the same
individual. After reaching a certain development it is apt to remain
stationary throughout life, and with no involvement of the general
health. As a rule, the lesions are few in numbers; on the other hand,
rarely they may be numerous (xanthoma multiplex). The affection is
usually encountered in middle and advanced life, although it is
occasionally met with in the young. It is more common in women than in
men. Jaundice has been frequently noticed as preceding or accompanying
it, especially the tubercular variety. Pathologically, it is a
connective-tissue new growth with fatty degeneration. Excision, where
practicable, constitutes the sole method of treatment.
Myoma.
Myoma cutis, or dermato-myoma (known also as liomyoma cutis), is a rare
affection, consisting of tumors of the skin composed of muscular
fibres. They occur either as single or multiple tumors, varying in size
from a lentil to an egg, localized in a special region, as the nipple,
scrotum, labia majora, thigh, hand, or foot; or, more rarely, numerous,
and scattered over the greater portion of the whole body. They are
{688} either flat or pedunculated, rounded or oval in form, pale-red in
color, with a smooth surface; although generally painless, they are
sometimes tender upon pressure, The growth consists essentially of a
new formation of unstriped muscular fibres. At times it is composed
largely of connective tissue (fibromyoma), or it may contain an
abundance of blood-vessels, giving rise to cavernous erectile tumors
(myoma telangiectodes). The disease is benign.
Angioma.
Angioma, or nævus vasculosus, is a congenital formation composed
chiefly of blood-vessels and having its seat in the skin and
subcutaneous tissue. Several forms of the affection are met with, all
of which, however, may be grouped under two heads--non-elevated and
prominent. The former (nævus flammeus, nævus simplex, angioma simplex)
is illustrated by the so-called port-wine mark, or claret-stain, known
in German as feuermal, and in French as tache de feu. The prominent
variety (angioma cavernosum, nævus tuberosus) may be turgescent,
erectile, pulsating, tumor-like, circumscribed growths, with an uneven
or rugous surface. In shape nævi are usually roundish, but may be
irregular; in color, bright or dark red, violaceous, or bluish; and in
size as large as a pea or a bean, or in some cases involving areas
several inches in diameter. As a rule, they are single formations. They
may occur on any part of the body, but are most frequently seen about
the face. Their course varies. In many instances, after attaining a
certain size, they remain stationary, or in some cases may retrograde
or undergo spontaneous involution, this remark applying more
particularly to the flat variety in early life. Ordinarily, they are
permanent deformities. They become pale under pressure, and the more
prominent growths are markedly compressible. Anatomically, the growth
consists of a dilatation and hypertrophy of the arterial and venous
blood-vessels of the corium and subcutaneous tissues, and in some
instances there is increase in connective tissue. In some cases the
connective-tissue hypertrophy is made up mainly from the adipose layer
(angioma lipomatodes). Occasionally there may be more or less
pigmentation.
In the treatment, the extent, form, and region involved are to be
considered. Various methods have been advised for their removal. For
pinhead-sized nævi puncturing with a red-hot needle, or with a needle
charged with nitric or chromic acid, may be employed. Those of pea size
may be treated by caustic applications. Sodium ethylate, as recommended
by Richardson, is an efficient caustic for the more superficial forms:
it should be pure and applied with a glass rod; a dry dressing is to be
employed and the crust permitted to loosen itself. Painting a nævus
with liquor plumbi subacetatis will, if repeated daily for several
weeks or months, sometimes succeed. Caustic potash in solution, from
one to two drachms in the ounce, and nitric acid, may both be
cautiously used. An ointment of a drachm of adhesive plaster and nine
grains of tartar emetic applied to small nævi will, according to
Neumann, cause free suppuration and healing. A solution of eight grains
of corrosive sublimate in a drachm of collodion is sometimes effective.
Injections of astringent and irritating liquids, such as the tincture
of the chloride {689} of iron and cantharidine, as formerly practised,
possess no advantage over safer methods. Linear and punctate
scarifications--in the latter the needles being charged with a 50 per
cent. solution of carbolic acid or a 25 per cent. solution of chromic
acid--have been recommended. In small formations vaccinating the nævus
is often successful. The galvano-cautery and the actual cautery are
both serviceable in treating the smaller nævi. Electrolysis constitutes
a valuable plan of treatment. A current of from six to twelve cells is
usually required. One or more platinum needles are attached to the
negative pole and a single needle or charcoal point to the positive
pole. Slight frothing at the points of insertion indicates that the
action has been sufficient. Suppuration and sloughing should not occur
if proper care is exercised. If the nævus is extensive, only a small
portion is to be treated at the one sitting. In the port-wine mark this
method promises the best results; the color is made much lighter, and
exceptionally is made to disappear entirely. In prominent, and
especially in pedunculated, tumors a ligature may be employed.
Lymphangioma.
Lymphangioma (also described as lymphangioma tuberosum multiplex) is a
rare disease, characterized by numerous, scattered, pea- or bean-sized,
ovalish or rounded, brownish-red, glistening, smooth, slightly-elevated
tubercles, having a somewhat translucent look, occurring for the most
part about the trunk. They are firm and elastic to the touch; are
situated in the cutis, but are not sharply defined; they can be readily
made to sink below the level of the surrounding integument, owing to
their marked compressibility. At times they have a lilac or bluish
tinge. The growths bear some resemblance to the large papular
syphiloderm. They are generally congenital or appear in childhood.
Anatomically, they consist of immensely dilated and hypertrophied
lymphatic vessels. The course of the disease is slow, and evinces no
disposition to malignancy. The general health is not involved.
Lupus Erythematosus.
Lupus erythematosus (also known as lupus erythematodes, seborrhoea
congestiva, and lupus sebaceus) is a small-celled new growth,
characterized by one or more circumscribed, variously sized and shaped,
reddish patches, more or less covered with adherent grayish or
yellowish scales. The affection usually begins as a rounded,
circumscribed, pinhead- to pea-sized, slightly elevated lesion, which
increases in size by peripheral extension until considerable surface is
involved; or, as is often the case, the disease starts with several
such spots, which grow and generally coalesce, sooner or later
involving considerable surface. The spots are at first erythematous and
slightly scaly, with but little elevation, later becoming thickened,
with a more or less raised border sharply defined against the healthy
skin, covered with small, firmly adherent yellowish or grayish scales,
with enlarged and plugged or patulous follicles, the centre of the
patch being somewhat depressed. The color is pinkish, reddish, or {690}
violaceous. In the beginning the disease often closely resembles
seborrhoea,--so much so that it was originally described by Hebra as
seborrhoea congestiva. The scaling is usually scanty, but in
exceptional instances may be abundant. At times the lesions show little
tendency to peripheral growth, the large areas of disease resulting
from the continuous appearance of new patches in proximity which run
together. Occasionally the patches are small, discrete, and numerous,
when the disease is apt to be disseminated over considerable surface.
Lupus erythematosus is seen most frequently about the face, one or
several patches, varying in size from a pea to a silver dollar,
ordinarily being present. The nose and the cheeks are favorite
localities, and, seated here, the disease is apt to be symmetrical,
extending from one cheek across the nose to the other cheek, in shape
representing rudely the outline of a bat or butterfly with outstretched
wings. The lips, ears, scalp, and other parts of the body are often
affected. The progress of the disease is variable; the patches, as a
rule, reach a certain size, and then remain stationary or retrogress,
or, as generally happens, the central portion becomes depressed and
more or less atrophied. The resulting scar is whitish, usually soft,
punctate, and superficial. As old patches disappear it is not uncommon
to see new patches appearing close by. It is essentially a chronic
disease: the individual lesions may be acute in their course, and when
such is noted, as a rule new areas of disease continue to appear in
rapid succession. Ordinarily, however, the individual patches
themselves are chronic in their course. The disease is not attended
with ulceration. The subjective symptoms of itching and burning are
usually mild in character, and sometimes are entirely wanting.
The condition of the general health is, as a rule, good. The disease is
seen more frequently in women than in men, and is rarely observed
before puberty, being chiefly encountered in early adult and middle
age. The causes are not known. It frequently begins as a seborrhoea,
but it may occur (although rarely) upon the palms of the hands, where
sebaceous glands are not to be found. It is a notable fact, however,
that the disease is most commonly encountered in those who are subject
to disorder of these glands. It is observed more often in persons of
light complexion. It is comparatively rare. The condition of the
general health apparently exercises no causative influence.
Pathologically, the process is essentially a chronic inflammation of
the cutis, superinducing degenerative and atrophic changes. In the
majority of cases the disease originates in the sebaceous glands, but
later all parts of the skin become affected. It is even authoritatively
stated that it may in some instances take its start in the subcutaneous
connective tissue. In some respects it has the character of a new
growth, which until late years it has been considered. In the light of
recent investigations, however, it seems possible that it may be a
chronic inflammation leading to degenerative changes. The process never
ends in the formation of pus. There is small-celled infiltration about
the follicles and glands, the blood-vessels are dilated, the
surrounding tissue is infiltrated with embryonic corpuscles, and the
sebaceous glands are enlarged and their walls infiltrated with small
cells. The whole affected area is, in fact, infiltrated with a
small-celled inflammatory new growth. If retrograde changes occur, the
{691} infiltration may disappear by absorption without leaving a trace.
On the other hand, and as is usually the case, degenerative
metamorphosis, resulting in absorption and atrophy, takes place.