formation of variously-sized, usually numerous, firm, immovable and
elastic fibrous tubercles containing new nerve-elements, and accompanied
by violent, paroxysmal pain. Their growth is slow and usually
progressive. Later they are painful upon pressure. They are limited to
one region.
The tumors are seated in the corium, extending into the deeper
structure, and consist of nerve-fibres, yellow elastic tissue, blood
vessels and lymphoid cells.
In the two cases reported, excision of the nerve-trunk gave, in one
instance, permanent relief; in the other the effect was only temporary.
#Xanthoma.#
(_Synonyms:_ Vitiligoidea; Xanthelasma.)
#What is xanthoma?#
Xanthoma 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.
#Name the two varieties met with.#
The macular or flat (_xanthoma planum_) and the tubercular (_xanthoma
tuberculatum_ or _tuberosum_). In some instances both varieties
(_xanthoma multiplex_) are seen in the same individual.
#Describe the clinical appearances of xanthoma planum.#
The macular or flat variety is usually seen about the eyelids. It
consists of one, several or more small or large, smooth, opaque,
sharply-defined, often slightly raised, yellowish patches, looking not
unlike pieces of chamois-skin implanted in the skin.
#Describe the clinical appearances of xanthoma tuberosum.#
The tubercular variety is commonly met with upon the neck, trunk and
extremities. It occurs as small, raised, isolated, yellowish nodules, or
as patches made up of aggregations of millet-seed-sized or larger
tubercles. The lesions may be few or they may exist in great numbers.
#What is the course of xanthoma?#
Extremely slow; after reaching a certain development the growths may
remain stationary.
#State the etiology of xanthoma.#
The causes are obscure. Jaundice not infrequently precedes and
accompanies its development, especially in the tubercular variety. The
disease is uncommon, and is usually seen in middle and advanced life,
and more frequently in women. In some cases (_xanthoma diabeticorum_) of
general xanthoma diabetes is the causative factor.
#What is the pathology of xanthoma?#
It is a benign, connective-tissue new growth, with concomitant or
subsequent, but usually partial, fatty degeneration.
#Give the prognosis of xanthoma.#
The condition is persistent, and usually irresponsive to all treatment
save destructive or operative measures.
#What is the treatment of xanthoma?#
Treatment consists, in suitable cases, of excision; in some instances,
electrolysis is serviceable. Applications of trichloracetic acid
cautiously made are sometimes of value. In that form of general xanthoma
due to diabetes the treatment of this latter condition will materially
and sometimes completely remove the eruption.
#Myoma.#
(_Synonyms:_ Myoma Cutis; Dermatomyoma; Liomyoma Cutis.)
#Describe myoma.#
The disease is rare, and consists usually of one or several
(exceptionally numerous), variously-sized tumors of the skin, made up of
smooth muscular fibres. They are flat, rounded, oval or pedunculated,
and have a smooth surface and a pale-red color; as a rule, they are
painless.
The growth is benign, and consists essentially of a new formation of
unstriped muscular fibres; but it may also be composed largely of
connective tissue (_fibromyoma_); or it may contain an abundance of
bloodvessels (_myoma telangiectodes_, _angiomyoma_); or there may be
lymphatic involvement (_lymphangiomyoma_).
#Angioma.#
(_Synonyms:_ Naevus Vasculosus; Naevus Sanguineus.)
#Give a definition of angioma.#
Angioma is a congenital hypertrophy of the vascular tissues of the
corium and subcutaneous tissue. Exceptionally it makes its appearance a
few weeks or a month after birth.
#Into what two classes may angiomata be roughly grouped?#
The flat (or non-elevated) and the prominent (or elevated).
#Describe the flat, or non-elevated, variety of angioma.#
The flat, or non-elevated, angioma (_naevus flammeus_, _naevus simplex_,
_angioma simplex_, _capillary naevus_) may be pin-head- to bean-sized; or
it may involve an area of several inches in diameter, and, exceptionally,
a whole region. It is of a bright- or dark-red color, and is met with
most frequently about the face. In some instances it extends after birth,
reaches a certain size and then remains stationary; occasionally, when
involving a small area, it undergoes involution and disappears.
The so-called _port-wine mark_ is included in this group.
#Describe the prominent, or elevated, variety of angioma.#
The prominent variety (_venous n[oe]vus_, _angioma cavernosum_, _n[oe]vus
tuberosus_) is variously-sized, often considerably elevated,
clearly-defined, compressible, smooth or lobulated, and of a dark,
purple color; it may, also, be erectile and pulsating. The growth is
usually a single formation, and is met with upon all parts of the body.
#What is the pathology of angioma?#
It is a new growth, consisting of a variable hypertrophy of the
cutaneous and subcutaneous arterial and venous bloodvessels, with or
without an increase of the connective tissue.
#Give the treatment of angioma.#
In some instances, especially in infants, painting the parts repeatedly
with collodion or liquor plumbi subacetatis will act favorably. For
well-established, small, capillary naevi electrolysis or puncturing with
a red-hot needle or with a needle charged with nitric acid may be
employed; for "port-wine mark" frequent and closely contiguous
electrolytic punctures are occasionally followed by a slight diminution
in color. For the _prominent growths_, vaccination, the ligature,
puncturing with the galvano-cautery, and excision are variously resorted
to.
In recent years applications of liquid air and carbon dioxide have proved
of service in some cases.
#Telangiectasis.#
#Describe telangiectasis.#
Telangiectasis consists of a new growth or enlargement of the cutaneous
capillaries, usually appearing during middle adult life, and seated, for
the most part, about the face.
#To what extent may telangiectasis develop?#
It may be limited to a red dot or point, with several small radiating
capillaries (_naevus araneus_, _spider naevus_), or a whole region, usually
the face, may show numerous scattered or closely-set capillary
enlargements or new formations (_rosacea_). The latter is frequently
associated with acne (_acne rosacea_).
The etiology is obscure.
#What is the treatment of telangiectasis?#
Destruction of the vessels by electrolysis or by the knife. (See
treatment of acne rosacea.)
#Lymphangioma.#
(_Synonym:_ Lymphangiectodes.)
#Describe lymphangioma.#
Lymphangioma is a rare disease, consisting of localized dilatations of
the lymphatic vessels, appearing as discrete or aggregated pin-head or
pea-sized, compressible, hollow, tubercle-like elevations, of a pinkish
or faint lilac color, and occurring for the most part about the trunk.
It is of slow but usually progressive development, and is unaccompanied
by subjective symptoms.
A rare condition, Kaposi described as lymphangioma tuberosum multiplex,
characterized by more or less solid, somewhat cystic, pearly to pinkish
red, sometimes crowded lesions, is now known to be "benign cystic
epithelioma"; its most common site is the face. While called "benign,"
ulcerative action may eventually ensue.
Treatment, when demanded, consists of operative measures.
#Rhinoscleroma.#
#Describe rhinoscleroma.#
Rhinoscleroma is a rare and obscure disease, slow but progressive in its
course, characterized by the development of an irregular, dense and
hard, flattened, tubercular, non-ulcerating, cellular new growth, having
its seat about the nose and contiguous parts. The overlying skin is
normal in color, or it may be light- or dark-brown or reddish. Marked
disfigurement and closure, partial or complete, of the nasal orifices
gradually results. It is met with chiefly in Austria and Germany.
Treatment, consisting of partial or complete extirpation, is rarely
permanent in its results, the disease tending to recur.
#Lupus Erythematosus.#
(_Synonyms:_ Lupus Erythematodes; Lupus Sebaceus; Seborrh[oe]a
Congestiva.)
#What is lupus erythematosus?#
Lupus erythematosus may be roughly defined as a mildly to moderately
inflammatory superficial new-growth formation, characterized by one,
several, or more circumscribed, variously sized and shaped, pinkish or
dark red patches, covered slightly, and more or less irregularly, with
adherent grayish or yellowish scales.
#Upon what parts is lupus erythematosus observed?#
Its common site is the face, usually the nose and cheeks, with a
tendency toward symmetry; it is often limited to these parts, but may
occasionally be seen upon other regions, more especially the lips, ears,
and scalp. In rare instances a great part of the general surface may
become involved.
#Describe the symptoms of lupus erythematosus.#
Usually the disease begins as one or several rounded, circumscribed,
pin-head- to pea-sized lesions; slightly scaly, somewhat elevated, and
of a pinkish, reddish or violaceous color. They slowly, or somewhat
rapidly, increase in area, and after attaining variable size remain
stationary; or they may progress and coalesce, and in this manner sooner
or later involve considerable surface. The patches are sharply defined
against the sound skin by an elevated border, while the central portion
is somewhat depressed and usually atrophic. More or less thickening and
infiltration are observed. _There is no tendency to ulceration_. The
scaliness is, as a rule, scanty. The gland-ducts are enlarged, patulous
or plugged with sebaceous and epithelial matter.
The subjective symptoms of burning and itching are usually slight and
often wanting.
#What course does lupus erythematosus pursue?#
As a rule, the disease is persistent, although somewhat variable. At
times the patches retrogress, involution taking place with or without
slight sieve-like atrophy or scarring.
#State the causes of lupus erythematosus.#
The etiology is obscure. Some observers believe it to be a variety of
cutaneous tuberculosis. It is essentially a disease of adult and middle
age; is more common in women, and more frequent in those having a
tendency to disorders of the sebaceous glands. It may, in fact, begin as
a seborrh[oe]a.
#What is the pathology?#
It was formerly considered a new growth, but recent opinion tends toward
regarding it as a chronic inflammation of the cutis, superinducing
degenerative and atrophic changes. Variable [oe]dema of the prickle
layer and of the cutis is found. There is no tendency to pus formation.
[Illustration: Fig. 42. Lupus Erythematosus.]
#Is there any difficulty in the diagnosis of lupus erythematosus?#
As a rule, not, as the features of the disease--the sharply
circumscribed outline, the reddish or violaceous color, the elevated
border, the tendency to central depression and atrophy, the plugged up
or patulous sebaceous ducts, the adherent grayish or yellowish scales,
together with the region attacked (usually the nose and cheeks)--are
characteristic.
#State the prognosis of lupus erythematosus.#
The disease is often capricious and extremely rebellious to treatment;
some cases, up to a certain point at least, yield readily, and
occasionally a tendency to spontaneous disappearance is observed; a
complete cure is, however, it must be confessed, rather rare. The
disease in nowise compromises the general health. In those rare
instances of generalized disease the patient has usually died from an
intercurrent tuberculosis.
#How is lupus erythematosus to be treated?#
The general health is to be looked after and systemic treatment
prescribed, if indicated. As a rule, constitutional remedies exert
little, if any, influence, but exceptionally, cod-liver oil, arsenic,
phosphorus, salicin, quinine, or potassium iodide proves of service.
Locally, according to the case, soothing remedies, stimulating
applications and destruction of the growth by caustics or operative
measures are to be employed. (_Try the milder applications first._)
#Mention the stimulating applications commonly employed.#
Washing the parts energetically with tincture of sapo viridis, rinsing
and applying a soothing ointment, such as cold cream or vaseline.
A lotion containing zinc sulphate and potassium sulphuret thoroughly
dabbed on the parts morning and evening:--
[Rx] Zinci sulphatis,
Potassii sulphurati, .... [=a][=a] ... [dram]i-[dram]iv
Glycerinae, ........................... [minim]iv
Aquae, ................................ f[Oz]iv. M.
The calamine-and-zinc oxide lotion used in acute eczema is also often
extremely valuable.
Lotions of ichthyol and of resorcin, five to sixty grains to the ounce;
ichthyol in ointment, five- to twenty-per-cent. strength, is also
useful.
Painting the patches with pure carbolic acid; repeating a day or two
after the crusts have fallen off.
The continuous application of mercurial plaster.
Sulphur and tar ointments, officinal strength or weakened with lard, and
also the following:--
[Rx] Ol. cadini,
Alcoholis,
Saponis viridis, ..... [=a][=a] ...... [dram]iiss. M.
(This is to be rubbed in, in small quantity, once or twice daily, and
later a soothing remedy applied.)
In recent years both the _x_-ray and Finsen light have been used with
variable success. Repeated applications of the high-frequency current,
with the vacuum electrode, have also proved serviceable. Cautious
applications of liquid air or carbon dioxide have also been used with
some success in the past few years.
#When are destructive and operative measures justifiable?#
In obstinate, sluggish, and long-persistent patches, and then only after
other methods of treatment have failed. (Remember that a patch or
patches of the disease _may_ disappear in course of time spontaneously,
and occasionally _without leaving a scar_.)
#State the methods of treatment commonly used in obstinate, sluggish and
persistent patches of lupus erythematosus.#
Cauterization--with nitrate of silver, with applications of pyrogallic
acid in ointment or in liquor gutta-perchae, fifteen to thirty per cent.
strength, and with solutions (cautiously employed) of caustic potash,
and exceptionally with the galvano-cautery.
[Illustration: Fig. 43. Single Scarifier.]
[Illustration: Fig. 44. Multiple Scarifier.
(_As modified by Van Harlingen._)]
Operative--scarification, either punctate or linear, and erosion with the
curette. (See treatment of lupus vulgaris.)
#Lupus Vulgaris.#
(_Synonyms:_ Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the
Skin.)
#What do you understand by lupus vulgaris?#
Lupus vulgaris is a cellular new growth, characterized by
variously-sized, soft, reddish-brown, papular, tubercular and
infiltrated patches, usually terminating in ulceration and scarring.
#Upon what region is lupus vulgaris usually observed?#
The face, especially the nose, but any part may be invaded. The area
involved may be small or quite extensive, usually the former.
#At what age is the disease noted?#
In many cases it begins in childhood or early adult life, but as it is
persistent and tends to relapse, it may be met with at any age.
#Describe the earlier symptoms of lupus vulgaris.#
The disease begins by the development of several or more pin-head to
small pea-sized, deep-seated, brownish-red or yellowish tubercles,
having their seat in the deeper part of the corium, and which are
somewhat softer and looser in texture than normal tissue. As the disease
progresses, variously-sized and shaped aggregations or patches result,
covered with thin and imperfectly-formed epidermis.
#What changes do the lupus tubercles or infiltrations undergo?#
The lesions, having attained a certain size or development, may remain
so for a time, but sooner or later retrogressive changes occur: the
matured papules or tubercles, or infiltrated patches, slowly disappear
by absorption, fatty degeneration, and exfoliation, leaving a yellowish
or brownish pigmentation, usually with more or less atrophy or
cicatricial-tissue formation--_lupus exfoliativus_; or disintegration
and destruction result, terminating in ulceration--_lupus exedens, lupus
exulcerans_. This latter is the more usual course.
#Describe the clinical appearances and behavior of the lupus ulcerations.#
They are rounded, shallow excavations, with soft and reddish borders. In
exceptional instances exuberant granulations appear--_lupus
hypertrophicus_; or papillary outgrowths are noted--_lupus verrucosus_.
The ulcerations secrete a variable amount of pus, usually slight in
quantity, which leads to more or less crust formation; later, however,
cicatricial tissue, generally of a _firm and fibrous_ character,
results.
[Illustration: Fig. 45. Lupus of Arm.]
#In what manner does the disease spread?#
The patches spread by the appearance of new tubercles, or infiltrations
at the peripheral portion. New islets and areas of disease may continue
to make their appearance from time to time, usually upon contiguous
parts.
#Are the mucous membranes of the mouth, throat and larynx ever involved?#
In some instances, and either primarily or secondarily.
[Illustration: Lupus Vulgaris.]
[Illustration: Lupus Vulgaris.]
#Is the bone tissue ever involved in lupus vulgaris?#
No.
#What course does lupus vulgaris pursue?#
It is slowly but, as a rule, steadily progressive. Several years or more
may elapse before the area of disease is conspicuous.
#What is the cause of lupus vulgaris?#
It is now known to be due to the invasion of the cutaneous structures by
the tubercle bacillus; in short, a tuberculosis of the skin. It is not
infrequently observed in the strumous and debilitated. It is entirely
independent of syphilis.
#What is the pathology of lupus vulgaris?#
According to recent investigations, the infiltrations of lupus are due
chiefly to cell-proliferation and outgrowth from the protoplasmic walls
and adventitia of the bloodvessels and lymphatics. The fibrous-tissue
network, vessels and a portion of the cell infiltration are thus
produced, the fixed and wandering connective-tissue cells of the
inflamed stroma of the cutis being responsible for the other portion of
the new growth (Robinson).
#State the diagnostic features of lupus vulgaris.#
In a typical, developed patch of lupus are to be seen:--cicatricial
formation, usually of a fibrous and tough character; ulcerations; the
yellowish-brown tubercles and infiltration; and the characteristic soft,
small, yellowish or reddish-brown, cutaneous and subcutaneous points and
tubercles.
#How does the tubercular syphiloderm differ from lupus vulgaris?#
The tubercular syphiloderm is much more rapid in its course, the
ulceration is deeper and the discharge copious and often offensive; the
scarring is soft, and, compared to the amount of ulceration, but
slightly disfiguring; and it is, for obvious reasons, a disease of adult
or late life. The history, together with other evidences of previous or
concomitant symptoms of syphilis, will often aid in the differentiation.
#How does epithelioma differ from lupus vulgaris?#
The edges of the epitheliomatous ulcer are hard, elevated and waxy; the
base is uneven, the secretion thin, scanty and apt to be streaked with
blood; the ulceration usually starts from one point, and is often
painful; the tissue destruction may be considerable; there is little, if
any, tendency to the formation of cicatricial tissue; and, finally, it
is usually a disease of advanced age.
#In what respects does lupus erythematosus differ from lupus vulgaris?#
Lupus erythematosus has no papules, tubercles or ulceration.
#How does acne rosacea differ from lupus vulgaris?#
Acne rosacea is characterized by hyperaemia, dilated vessels, papules,
pustules, the absence of ulceration, and a different history.
#State the prognosis of lupus vulgaris.#
Lupus vulgaris is always a chronic disease, often exceedingly rebellious
to treatment, and one that calls for a guarded opinion. Relapses are not
uncommon.
[Illustration: Fig. 46.
Galvano-cautery Needle, Knife and Spiral Points. (_As devised by
Besnier._)]
The general health usually remains good, but in some instances death by
tuberculosis of the lungs has been noted.
#Is external or internal treatment called for in lupus vulgaris?#
Always external, and not infrequently constitutional also.
#What is the constitutional treatment?#
The general health must be cared for; good, nutritious food, fresh air
and out-door exercise, together with, in many cases, the administration
of such remedies as cod-liver oil, potassium iodide, iron and quinine,
are of therapeutic importance. Tuberculin may be tried in severe and
obstinate cases, but its use is not without danger.
#State the object of local treatment.#
The destruction or removal of the diseased tissue.
#May milder methods of treatment sometimes prove beneficial and even
curative?#
Exceptionally, mercurial plaster, corrosive-sublimate lotion and
ointment (gr. j to [Oz]j), a plaster containing five to fifteen per
cent. of salicylic acid and creasote, repeated paintings with carbolic
acid, and the constant application of lead plaster containing twenty per
cent. of ichthyol, are valuable.
[Illustration: Fig. 47. Double Curette.]
Of the milder methods, those most in vogue to-day are the _Finsen light_
and _x-ray_. Either proves extremely valuable in some cases, but the
Finsen method is the favorite method.
#What methods are commonly employed for the rapid removal or destruction
of lupus tissue?#
Cauterization, scarification, erasion and excision are variously
practised; the particular method depending, in great measure, upon the
extent of the disease, the part involved, and other circumstances.
#Name the several caustics, and state how they are employed.#
_Pyrogallic acid_, used as an ointment:--
[Rx] Ac. pyrogallici, ..................... [dram]ij
Emplast. plumbi, ..................... [dram]j
Cerat. resinsae, ...................... [dram]v. M.
It is applied for one or two weeks. Every several days the parts are
poulticed, the slough thus removed, and the ointment reapplied, and so
on until the diseased tissue has been destroyed. It is useful in those
cases in which a mild and comparatively painless caustic is advisable.
In most cases several repetitions of this plan are necessary.
_Arsenious acid_, employed as an ointment--
[Rx] Ac. arseniosi, ...................... gr. xx
Hydrarg. sulphid. rub., ............. gr. lx
Ungt. aquae rosae, .................... [Oz]i.--M.
It is painful but thorough; it is spread on lint and renewed daily. The
action is usually sufficient in three days, and the parts are then
poulticed until the slough comes away, after which a simple dressing is
employed. Its application is advisable for a small area only--not more
than four square inches--as absorption is possible.
_Galvano-cautery._--The diseased tissue is destroyed by numerous
punctures with a red-heated point or by linear incision with a
red-heated knife. It is often a practicable and satisfactory method. The
Paquelin cautery and liquid air and carbon dioxide also have their
advocates.
#Describe the operative measures employed in the removal of lupus tissue.#
_Linear Scarification._--The parts are thoroughly cross-tracked, cutting
through the diseased tissue, and subsequently a simple salicylated
ointment applied. The operation is repeated from time to time, and as a
result the new growth undergoes retrogressive changes, and cicatrization
takes place.