Ac. acet. dilut., .................... f[dram]ij
Sodii borat., ........................ [scruple]ij
Aquae rosae, ........................... f[Oz]iv. M.
And also the following:--
[Rx] Hydrargyri chlorid. corros., ......... gr. iij-viij
Zinci sulphat.,
Plumbi acetat., ...... [=a][=a] ...... [dram]ss
Aquae, ................................ f[Oz]iv. M.
And lactic acid, with from five to twenty parts of water; and an
ointment containing a drachm each of bismuth subnitrate and white
precipitate to the ounce. Hydrogen peroxide occasionally acts well.
Trichloracetic acid, usually weakened with one or two parts water, may
be cautiously tried. The application of a strong alcoholic solution of
resorcin, twenty to fifty per cent. strength, is also valuable, as is
also a two to ten per cent. alcoholic solution of salicylic acid.
(Applications are made two or three times daily, and as soon as slight
scaliness or irritation is produced are to be discontinued for one or
two days.)
_Tattoo-marks_ are difficult to remove. Excision is the surest method.
Electrolysis, applying the needle at various points, somewhat close
together, and using a fairly strong current--three to eight
milliamperes--will exceptionally, especially when repeated several
times, produce a reactive inflammation and casting-off of the tissue
containing the pigment; a scar is left.
Several writers claim good results with glycerole of papain, pricking it
in in the same manner as in tattooing.
_Gun-powder marks._ If recent, but a day or so after their occurrence,
the larger specks may be picked or scraped out. Later, electrolysis,
using a fairly strong current, may result in their removal. Their
removal may also be satisfactorily effected with a minute cutaneous
trephine.
#Keratosis Pilaris.#
(_Synonyms:_ Pityriasis Pilaris; Lichen Pilaris.)
#What is meant by keratosis pilaris?#
Keratosis pilaris may be defined as a hypertrophic affection
characterized by the formation of pin-head-sized, conical, epidermic
elevations seated about the apertures of the hair follicles.
#Describe the clinical appearances of keratosis pilaris.#
The lesions are usually limited to the extensor surfaces of the thighs
and arms, especially the former. They appear as pin-head-sized, whitish
or grayish elevations, consisting of accumulations of epithelial matter
about the apertures of the hair follicles. Each elevation is pierced by
a hair, or the hair may be twisted and imprisoned within the epithelial
mass; or it may be broken off just at the point of emergence at the apex
of the papule, in which event it may be seen as a dark, central speck.
The skin is usually dry, rough and harsh, and in marked cases, to the
hand passing over it, feels not unlike a nutmeg-grater. The disease
varies in its development, in most cases being so slight as to escape
attention. As a rule, it is free from itching.
#What course does keratosis pilaris pursue?#
It is sluggish and chronic.
#Mention some of the etiological factors.#
It is not an uncommon disease, and is seen usually in those who are
unaccustomed to frequent bathing, being most frequently met with during
the winter months. It is chiefly observed during early adult life.
#Is there any difficulty in the diagnosis?#
No. It is thought at times to bear some resemblance to goose-flesh
(cutis anserina), the miliary papular syphiloderm in its desquamating
stage, and lichen scrofulosus. In goose-flesh the elevations are
evanescent and of an entirely different character; the papules of the
syphiloderm are usually generalized, of a reddish color, tend to group,
are more solid and deeply-seated, less scaly and are accompanied with
other symptoms of syphilis; in lichen scrofulosus the papules are
larger, incline to occur in groups, and appear usually upon the abdomen.
#State the prognosis.#
The disease yields readily to treatment.
#Give the treatment of keratosis pilaris.#
Frequent warm baths, with the use of a toilet soap or sapo viridis, will
usually be found curative. Alkaline baths are also useful. In obstinate
cases the ordinary mild ointments, glycerine, etc., are to be advised in
conjunction with the baths.
#Keratosis Follicularis.#
#Describe keratosis follicularis.#
Keratosis follicularis (_Darier's disease_, _ichthyosis follicularis_,
_ichthyosis sebacea cornea_, _psorospermosis_) is a rare disease
characterized by pin-head to pea-sized pointed, rounded, or
irregularly-shaped grayish, brownish, red or even black, horny papules
or elevations, arising from the sebaceous or hair-follicles. They are,
for the most part, discrete, with a tendency here and there to form
solid aggregations or areas. Many of them contain projecting cornified
plugs which may be squeezed out, leaving pit-like depressions. The face,
scalp, lower trunk, groins and flanks are the parts chiefly affected.
The view advanced by Darier, that the malady was due to psorosperms, is
now denied, the bodies thought to be such having been demonstrated to be
due to cell transformation.
As to treatment, in one instance the induction of a substitutive
dermatic inflammation had a favorable influence.
#Molluscum Epitheliale.#
(_Synonyms:_ Molluscum Contagiosum; Molluscum Sebaceum; Epithelioma
Molluscum.)
#Give a definition of molluscum epitheliale.#
Molluscum epitheliale is characterized by pin-head to pea-sized,
rounded, semi-globular, or flattened, pearl-like elevations, of a
whitish or pinkish color.
#Describe the symptoms and course of molluscum epitheliale.#
The usual seat is the face; not infrequently, however, the growths occur
on other parts. The lesions begin as pin-head, waxy-looking, rounded or
acuminated elevations, gradually attaining the size of small peas. They
have a broad base or occasionally may tend to become pedunculated. They
rarely exist in profusion, in most cases three to ten or twelve lesions
being present. When fully developed they are somewhat flattened and
umbilicated, with a central, darkish point representing the mouth of the
follicle. They are whitish or pinkish, and look not unlike drops of wax
or pearl buttons. At first they are firm, but eventually, in most cases,
tend to become soft and break down. Not infrequently, however, the
lesions disappear slowly by absorption, without apparent previous
softening. Their course is usually chronic. The contents, a
cheesy-looking mass, may commonly be pressed out without difficulty.
#What is the cause of molluscum epitheliale?#
It is now generally accepted that the disease is mildly contagious. It
occurs chiefly in children, and especially among the poorer classes. The
belief in the parasitic nature of the disease is gaining ground;
recently the opinion has been advanced that it is due to psorosperms
(psorospermosis); but further investigations have indicated that these
bodies were degenerated epithelia.
#State the pathology.#
[Illustration: Fig. 31. Molluscum Epitheliale.]
According to recent investigations, molluscum epitheliale is to be
regarded as a hyperplasia of the rete, the growth probably beginning in
the hair-follicles; the so-called molluscum bodies--peculiar, rounded or
ovoidal, sharply-defined, fatty-looking bodies found in microscopical
examination of the growth--are to be viewed as a form of epithelial
degeneration.
#What are the diagnostic points in molluscum epitheliale?#
The size of the lesions, their waxy or glistening appearance, and the
presence of the central orifice.
It is to be differentiated from molluscum fibrosum, warts and acne.
#State the prognosis.#
The growths are amenable to treatment. In some instances the disease,
after existing some weeks, tends to disappear spontaneously.
#What is the treatment of molluscum epitheliale?#
Incision and expression of the contents, and touching the base of the
cavity with silver nitrate. Pedunculated growths may be ligated. In some
cases an ointment of ammoniated mercury, twenty to forty grains to the
ounce, applied, by gently rubbing, once or twice daily, will bring about
a cure.
#Callositas.#
(_Synonyms:_ Tylosis; Tyloma; Callus; Callous; Callosity; Keratoma.)
#What do you understand by callositas?#
A hard, thickened, horny patch made up of the corneous layers of the
epidermis.
#Describe the clinical appearances.#
Callosities are most common about the hands and feet, and consist of
small or large patches of dry, grayish-yellow looking, hard, slight or
excessive epidermic accumulations. They are somewhat elevated,
especially at the central portion, and gradually merge into the healthy
skin. The natural surface lines are in a great measure obliterated, the
patches usually being smooth and horn-like.
_Keratosis palmaris et plantaris_ (symmetric keratodermia), as regards
the local condition, is a somewhat similar affection. It consists of
hypertrophy of the corneous layer of the palm and soles, usually of a
more or less horny and plate-like character, but is congenital or
hereditary, and not necessarily dependent upon local friction or
pressure.
#Are there any inflammatory symptoms in callositas?#
No; but exceptionally, from accidental injury, the subjacent corium
becomes inflamed, suppurates, and the thickened mass is cast off.
#State the causes of callositas.#
Pressure and friction; for example, on the hands, from the use of
various tools and implements, and on the feet from ill-fitting shoes. It
is, indeed, often to be looked upon as an effort of nature to protect
the more delicate corium.
In exceptional instances it arises without apparent cause.
#What is the pathology?#
The epidermis alone is involved; it consists, in fact, of a hyperplasia
of the horny layer.
#State the prognosis of callositas.#
If the causes are removed, the accumulation, as a rule, gradually
disappears. The effect of treatment is always rapid and positive, but
unless the etiological factors have ceased to act, the result is usually
but temporary.
#How is callositas treated?#
When treatment is deemed advisable, it consists in softening the parts
with hot-water soakings or poultices, and subsequently shaving or
scraping off the callous mass. The same result may also be often
effected by the continuous application, for several days or a week, of a
10 to 15 per cent. salicylated plaster, or the application of a
salicylated collodion, same strength; it is followed up by hot-water
soaking, the accumulation, as a rule, coming readily away.
#Clavus.#
(_Synonym:_ Corn.)
#What is clavus?#
Clavus, or corn, is a small, circumscribed, flattened, deep-seated,
horny formation usually seated about the toes.
#Describe the clinical appearances.#
Ordinarily a corn has the appearance of a small callosity; the skin is
thickened, polished and horny. Exceptionally, however, occurring on
parts that are naturally more or less moist, as between the toes,
maceration takes place, and the result is the so-called _soft corn_. The
dorsal aspect of the toes is the common site for the ordinary variety.
The usual size is that of a small pea. They are painful on pressure,
and, at times, spontaneously so.
#State the causes.#
Corns are caused by pressure and friction, and may usually be referred
to improperly fitting shoes.
#What is the pathology of clavus?#
It is a hypertrophy of the epiderm. Its shape is conical, with the base
external and the apex pressing upon the papillae. It is, in fact, a
peculiarly-shaped callosity, the central portion and apex being dense
and horny, forming the so-called core.
#Give the treatment of clavus.#
A simple method of treatment consists in shaving off, after a
preliminary hot-water soaking, the outer portion, and then applying a
ring of felt or like material, with the hollow part immediately over the
site of the core; this should be worn for several weeks. It is also
possible in some cases to extract the whole corn by gently dissecting it
out; the after-treatment being the same as the above.
Another method is by means of a ten- to fifteen-per-cent. solution of
salicylic acid, in alcohol or collodion, or the following:--
[Rx] Ac. salicylici, ...................... gr. xxx
Ext. cannabis Ind., .................. gr. x
Collodii, ............................ f[dram]iv. M.
This is painted on the corn night and morning for several days, at the
end of which time the parts are soaked in hot water, and the mass or a
greater part of it, will be found, as a rule, to come readily away; one
or two repetitions may be necessary. Lactic acid, with one to several
parts of water, applied once or twice daily, acts in a similar manner.
Soft corns, after the removal of pressure, may be treated with the solid
stick of nitrate of silver, or by any of the methods already mentioned.
In order that treatment be permanently successful, the feet are to be
properly fitted. If pressure is removed, corns will commonly disappear
spontaneously.
#Cornu Cutaneum.#
(_Synonyms:_ Cornu Humanum; Cutaneous Horn.)
#What is cornu cutaneum?#
A cutaneous horn is a circumscribed hypertrophy of the epidermis,
forming an outgrowth of horny consistence and of variable size and
shape.
#At what age and upon what parts are cutaneous horns observed?#
They are usually met with late in life, and are mostly seated upon the
face and scalp.
[Illustration: Fig. 32.
Cutaneous Horns. Showing beginning epitheliomatous degeneration of the
base. (_After Pancoast._)]
#Describe the clinical appearances.#
In appearance cutaneous horns resemble those seen in the lower animals,
differing, if at all, but slightly. They are hard, solid, dry and
somewhat brittle; usually tapering, and may be either straight, curved
or crooked. Their surface is rough, irregular, laminated or fissured,
the ends pointed, blunt or clubbed. The color varies; it is usually
grayish-yellow, but may be even blackish. As commonly seen they are
small in size, a fraction of an inch or an inch or thereabouts in
length, but exceptionally attain considerable proportions. The base,
which rests directly upon the skin, may be broad, flattened, or concave,
with the underlying and adjacent tissues normal or the papillae
hypertrophied; and in some cases there is more or less inflammation,
which may be followed by suppuration. They are usually solitary
formations. They are not, as a rule, painful, unless knocked or
irritated.
#What course do cutaneous horns pursue?#
Their growth is usually slow, and, after having attained a certain size,
they not infrequently become loose and fall off; they are almost always
reproduced.
#What is the cause of these horny growths?#
The cause is not known; appearing about the genitalia, they usually
develop from acuminated warts. They are rare formations.
#State the pathology of cornu cutaneum.#
Horns consist of closely agglutinated epidermic cells, forming small
columns or rods; in the columns themselves the cells are arranged
concentrically. In the base are found hypertrophic papillae and some
bloodvessels. They have their starting-point in the rete mucosum, either
from that lying above the papillae or that lining the follicles and
glands.
#Does epitheliomatous degeneration of the base ever occur?#
Yes.
#State the prognosis.#
Cutaneous horns may be readily and permanently removed.
#What is the treatment?#
Treatment consists in detachment, and subsequent destruction of the
base; the former is accomplished by dissecting the horn away from the
base or forcibly breaking it off, the latter by means of any of the
well-known caustics, such as caustic potash, chloride of zinc and the
galvano-cautery.
Another method is to excise the base, the horn coming away with it; this
necessitates, however, considerable loss of tissue.
#Verruca.#
(_Synonym:_ Wart.)
#What is verruca?#
Verruca, or wart, is a hard or soft, rounded, flat, acuminated or
filiform, circumscribed epidermal and papillary growth.
#Name the several varieties of warts met with.#
Verruca vulgaris, verruca plana, verruca plana juvenilis, verruca
digitata, verruca filifortnis and verruca acuminata.
#Describe verruca vulgaris.#
This is the common wart, occurring mostly upon the hands. It is rounded,
elevated, circumscribed, hard and horny, with a broad base, and usually
the size of a pea. At first it is smooth and covered with slightly
thickened epidermis, but later this disappears to some extent, the
hypertrophied papillae, appearing as minute elevations, making up the
growth. One, several or more may be present.
#Describe verruca plana.#
This is the so-called flat wart, and occurs commonly upon the back,
especially in elderly people (_verruca senilis_, _keratosis pigmentosa_).
It is, as a rule, but slightly elevated, is usually dark in color, and
of the size of a pea or finger-nail.
#Describe verruca plana juvenilis.#
The warts are mostly pin-head in size, flat, but slightly elevated,
rounded, irregular or square-shaped, and of a light yellowish-brown
color. They bear resemblance to lichen planus papules. They are apt to
be numerous, often becoming aggregated or fused, and occur usually in
young children, and, as a rule, on the face and hands.
#Describe verruca filiformis.#
This is a thread-like growth about an eighth or fourth of an inch long,
and occurring commonly about the face, eyelids and neck. It is usually
soft to the touch and flexible.
#Describe verruca digitata.#
This is a variety of wart, which, especially about the edges, is marked
by digitations, extending nearly or quite down to the base. It is
commonly seen upon the scalp.
#Describe verruca acuminata.#
This variety (_venereal wart_, _pointed wart_, _pointed condyloma_),
usually occurs about the genitalia, especially upon the mucous and
muco-cutaneous surfaces. It consists of one or more groups of
acuminated, pinkish or reddish, raspberry-like elevations, and,
according to the region, may be dry or moist; if the latter, the
secretion, which is usually yellowish and puriform, from rapid
decomposition, develops an offensive and penetrating odor. The formation
may be the size of a small pea, or may attain the dimensions of a fist.
#What is the cause of warts?#
The etiology is not known. They are more common in adolescent and early
adult life. Irritating secretions are thought to be causative in the
acuminated variety. It is highly probable that a parasitic factor will
finally be demonstrated. They are doubtless mildly contagious.
[Illustration: Fig. 33.
Verruca Acuminata--about the anus. (_After Ashton._)]
#State the pathology of warts.#
A wart consists of both epidermic and papillary hypertrophy, the
interior of the growth containing a vascular loop. In the acuminated
variety there are marked papillary enlargement, excessive development of
the mucous layer, and an abundant vascular supply.
#Give the treatment of warts.#
For ordinary warts, excision or destruction by caustics. The repeated
application of a saturated alcoholic solution of salicylic acid is often
curative, the upper portion being pared off from time to time. The
filiform and digitate varieties may be snipped off with the scissors,
and the base touched with nitrate of silver; or a ligature may be used.
Curetting is a valuable operative method. The growths may also be
removed by electrolysis. When warts are numerous and close together
parasiticide applications can be daily made to the whole affected
region. For this purpose a boric acid solution, containing five to
thirty grains of resorcin to the ounce, and Vleminckx's solution, at
first diluted, prove the most valuable.
Verruca acuminata is to be treated by maintaining absolute cleanliness,
and the application of such astringents as liquor plumbi subacetatis,
tincture of iron, powdered alum and boric acid. The salicylic acid
solution may also be used. In obstinate cases, glacial acetic acid or
chromic acid may be cautiously employed.
#Naevus Pigmentosus.#
(_Synonym:_ Mole.)
#Describe naevus pigmentosus.#
Naevus pigmentosus, commonly known as mole, may be defined as a
circumscribed increase in the pigment of the skin, usually associated
with hypertrophy of one or all of the cutaneous structures, especially
of the connective tissue and hair. It occurs singly or in numbers; is
usually pea-, bean-sized or larger, rounded or irregular, smooth or
rough, flat or elevated, and of a color varying from a light brown to
black; the hair found thereon may be either colorless or deeply
pigmented, coarse and of considerable length. It is, as a rule, a
permanent formation.
#Name the several varieties of naevus pigmentosus met with.#
Naevus spilus, naevus pilosus, naevus verrucosus, and naevus lipomatodes.
So-called linear naevus might also be considered as belonging in this
group.
#What is naevus spilus?#
A smooth and flat naevus, consisting essentially of augmented
pigmentation alone.
[Illustration: Fig. 34. Linear Naevus.]
#What is naevus pilosus?#
A naevus upon which there is an abnormal growth of hair, slight or
excessive.
#What is naevus verrucosus?#
A naevus to which is added hypertrophy of the papillae, giving rise to a
furrowed and uneven surface.
#What is linear naevus?#
Linear naevus is a formation usually of a verrucous character, more or
less pigmented, sometimes slightly scaly, occurring in band-like or
zoster-like areas, and, as a rule, unilaterally.
#What is naevus lipomatodes?#
A naevus with excessive fat and connective-tissue hypertrophy.
#State the etiology of naevus pigmentosus.#
The causes are obscure. The growths are usually congenital; but the
smooth, non-hairy moles may be acquired.
#Give the pathology of naevus pigmentosus.#
Microscopical examination shows a marked increase in the pigment in the
lowest layers of the rete mucosum, as well as more or less pigmentation
in the corium usually following the course of the bloodvessels; in the
verrucous variety the papillae are greatly hypertrophied, in addition to
the increased pigmentation. There is, as a rule, more or less
connective-tissue hypertrophy.
#What is the treatment of naevus pigmentosus?#
In many instances interference is scarcely called for, but when demanded
consists in the removal of the formation either by the knife, by
caustics, or by electrolysis. This last is, in the milder varieties at
least, perhaps the best method, as it is less likely to be followed by
disfiguring cicatrices. In naevus pilosus the removal of the hairs alone
by electrolysis is not infrequently followed by a decided diminution of
the pigmentation. In recent years both liquid air and carbon dioxide
have also been used successfully in the removal of these growths.
Pigmented naevi, which show the least tendency to growth or degenerative
change, should be radically removed, as they not infrequently lead to
carcinomatous and sarcomatous growths.
#Ichthyosis.#
(_Synonym:_ Fish-skin Disease.)
#Give a descriptive definition of ichthyosis.#
Ichthyosis is a chronic, hypertrophic disease, characterized by dryness
and scaliness of the skin, with a variable amount of papillary growth.
#At what age is ichthyosis first observed?#
It is first noticed in infancy or early childhood. In rare instances it
is congenital (ichthyosis congenita), and in such cases it is usually
severe, and of a grave type; the children are, as a rule, prematurely
born, and frequently do not survive many days or weeks.
#What extent of surface is involved?#
Usually the whole surface, but it is most marked upon the extensor
surfaces of the arms and legs, especially at the elbows and knees; the
face and scalp, in mild cases, often remain free.
#Name the two varieties of ichthyosis usually described.#
Ichthyosis simplex and ichthyosis hystrix, terms commonly employed to
designate the mild and severe forms respectively.
#Describe the clinical appearances of ichthyosis.#