ZLTJE^TTJS- 
By ISADORE DYER, Ph. B., M. D., 
Professor of Dermatology in the Yew Orleans Polyclinic; Lec- 
ti'ukh and Clinical Instructor of Dermatology, Medical De- 
partment Tulane Univ.; Dermatologist to Charity Hospital, 
etc.. New Orleans, La. 
Reprinted from the May, 1895, number of the New Orleans Medical and Surgical Journal. 
L. GRAHAM & SON. 44-46 BARONNE ST.. NEW ORLEANS. DR. DYER’S CASE OF NiEVUS UNIUS LATERIS. ZtTJE'VWJS-* 
By ISADORE DYER, Ph. B., M. D., 
Professor of Dermatology in the New Orleans Polyclinic; Lec- 
turer and Clinical Instructor of Dermatology, Medical De- 
partment Tulane Univ.; Dermatologist to Charity Hospital, 
etc., New Orleans, La. 
Reprinted from the May, i8qs, number of the Nero Orleans Medical and Surgical Journal. 
Strictly defined, a naevus is a congenital alteration of the 
skin, in which there is a localized increase in the amount of 
pigment deposit. There may be, concomitantly, hypertrophy 
of other elements of the skin, as the vascular and the connec- 
tive tissues, the nerves or even the lymphatics. 
In its limited definition, naevus pigmentosus is the term 
applied to the existing lesion, which consists in a simply exag- 
gerated pigment supply, appearing as the ordinary mole. 
These are generally quite small, in color brown or black, and 
are found in all locations, but with a predilection for the face, 
neck and back. When simple, smooth and soft, this form is 
known as “ naevus spilus.” Where the hypertrophy extends 
to the papillary part of the corium, and the mole is warty and 
rough in appearance, the name of “naevus verrucosus” is ap- 
plied. When there is additionally an excess of fat cells and 
the growth is large and dependant, the variety is styled “naevus 
lipomatodes.” On any of these there may be a hypertrich- 
iasis, or overgrowth of hair, forming the hairy mole, or 
“naevus pilosus.” 
While correctly only congenital, noevi of these types may 
* Paper read before the Mississippi State Medical Association on April 12, 1895. 2 
develop de novo after birth. Either congenital or acquired, 
however, they may grow from the start and develop consider- 
ably. They may grow from time to time, with intermissions of 
inactivity, years even being required in the final development. 
The presence of nasvi is in most instances of small patho- 
logic significance. The hairy moles and those of the warty 
or papillary character are objectionable for cosmetic reasons, 
and demand treatment. These, of course, are particularly 
undesirable on the face. 
Melanotic cancer may be ushered in by a nsevus, but this 
is uncommon enough to warrant only passing mention. 
Among the angiomata, classed in dermatology with the 
neoplasms, there is one variety separated as the vascular nasvus. 
To this variety the names of nasvus vascularis, nasvus san- 
guineus, or birth-mark, are applied. This form of birth-mark 
must be included with the nasvi, and in reali’y it is properly 
that particular kind of nasvus to which the term “mother's 
mark” is given. Vascular nasvi may be present at birth, or 
may only develop several weeks or months after birth. 
The term angioma is applied to tumors of embryologic 
rudimentary vessels which develop into blood vessels. 
The vascular nasvus may involve the capillaries, the smaller 
venous or arterial terminal branches. 
The capillary nasvus is distinctly cutaneous, and in size is 
as small as a pin’s head, or varies to the size of the palm, or 
even larger, involving large areas of the body. 
This is the form of vascular nmvus most commonly met with. 
It is usually only slightly elevated, or level with the surface of 
the skin. It is often seen as a tiny red spot with radiating 
lines made by the capillaries, the “ nasvus araneus.” The 
more diffuse variety, assuming irregular shapes, often startling 
in their resemblance to familiar objects, is known as the “port 
wine” mark or “strawberry” mark. These occur in many in- 
stances as family marks, appearing in several successive genera- 
tions. The entire side of the face may be involved. I have seen 
one case in which the entire lower lip and chin were involved. 
Vascular nasvi often begin indistinctly and spread gradually to 
cover large surfaces. On the other hand nasvi, present at birth, 
may within a few months entirely disappear spontaneously. 3 
The venous naevus is apt to be more elevated than the 
capillary. It is smooth, with protuberant surface, often lobu- 
lated, soft and compressible. Here, thin walled veins and 
small arteries are connected directly by small sinuses, without 
the intermediary capillaries, all bound together with delicate 
connective tissue. Pulsation is not infrequently present, and 
many of the venous naevi are erectile. In size, the venous 
naevi vary from the size of a large pea to a hazelnut, or even an 
orange. This kind of naevus may ulcerate shortly after birth, 
and undergo a spontaneous cure. Last year a child was 
brought to me in the midst of this process. The growth was 
located over the right loin, in size about an inch and a half in 
diameter, but fully half an inch in depth. It was ulcerating 
freely, and came away in sloughs. In two weeks’ time there 
was only a smooth, red scar about half an inch in diameter to 
mark the site of the growth. The child was 23 months old, 
had the naevus since birth, but it began ulcerating only one week 
before it was brought to me. In this same child there was a 
small venous naevus in the line of the eyebrow, just over the 
internal angle of the right eye. In size, it was as large as a small 
hazelnut. The mother was naturally distressed at the location. 
With the history of the other lesion, however, I advised non- 
interference, and had the gratification of seeing the gradual dis- 
appearance of the growth, which finally could scarcely be 
noticed one year later. 
Another variety of nasvus has been separated in which the 
distribution of the lesions along the course of one or more of the 
superficial nerve branches has led to the opinion that there is 
some nerve influence at fault as the etiologic factor. 
To the lesions occurring in this way the term ncevus unius 
latcris, or ncevus neuroticus is applied. Some attempts have 
been made to show the association of ncevus unius lateris with 
previous neurotic influence, as injury at or near the site of the 
lesions, shock, etc. It is certain, however, that there is a dis- 
tinct difference in the arrangement of the lesions of the varietv 
under discussion and ordinary naevi. In the case whose photo- 
graph I show you there is a distinct arrangement in herpetiform 
groups, as if a spray of pigment had been thrown on the one 
side of the face, in groups arranged along the course of the 4 
submaxillary branch of the trifacial nerve. The distribution 
to the right half of the face, the sharply defined termination of 
the groups at the mental line, and the tendency of the patient 
to the formation of pigment lesions, evidenced by the extensive 
freckling, all argue for a reflex factor. 
The lesion is like the ordinary ncevus fiigmentosus, and 
presents two varieties, the flat mole, deep brown or black in 
color, and the verrucose or warty mole. 
The necessity for treatment of nsevi must depend much 
upon the character, the location, the size and importance of 
the lesion. Simple pigmentary moles are of little serious im- 
portance, and for pathologic reasons need not be removed. 
When, however, the presence of one or more of these pro- 
duces discomfort, or disfigurement, the removal is desirable. 
Hairy moles are often unsightly, and, occurring on the nose, 
or prominently on the face, are objects of mortification, if not 
concern, to the individual so afflicted. 
With vascular growths, however, it is quite different; the 
disfigurement only adds to the possibility of the further devel- 
opment, and the danger of accidental hmmorrhage, from the 
casual breaking or spontaneous rupture of the tumor, demands 
attention. 
In any instance, then, whether from cosmetic or pathologic 
indications, there are methods of treatment of naevi which are em- 
ployed. The first observation is that to cure the lesion removal 
is necessary. The removal of pigmentary nasvi should be at- 
tended with as little inconvenience or pain as is possible. The 
pigment is usually found in the rete Malpighii, but may exist as 
deeply as in the corium. Agents employed must be directed 
accordingly. Acids, nitric or carbolic, may be used. Bichlo- 
ride of mercury in collodion, grs. v-x to the oz.ss., pyrozone 
ar.d sodium ethylate, act similarly by actually destroying the 
outer layers of the skin. Where the growth is large and per- 
mits, excision is advisable. With the papillary moles, or the 
warty moles, the curette, followed by the actual cautery, the 
Pacquelin, or the galvano-cautery, is the best treatment. Or- 
dinarily, however, electrolysis serves the purpose. To the 
negative pole of a galvanic battery a small steel needle is at- 
tached, either in a needle holder or with an insulated wire. I 5 
use for this purpose a fine jeweler’s broach. The positive pole 
carries the sponge, which is customarily held in the patient’s 
hand. The needle is introduced beneath the pigmented mole 
and the current is gradually increased until the lesion blisters. 
It requires about 8 or io milliamperes, or, if cells with switch- 
board are used, about 12 to 20 cells. Where the moles are 
hairy, a blunted broach or needle is desirable. The hairs are 
removed first by electrolysis, and then the mole. The needle 
here should be gently introduced into the hair follicle, care be- 
ing used not to pierce the follicle, the hair shaft serving as a 
guise. The current is gradually applied until there is frothing 
at the orifice of the follicle, when the hair is ready to come 
away. If there is resistance on the part of the hair, the oper- 
ation is not complete. Not more than 3 to 5 milliamperes are 
needed in this operation, one serving oftentimes. The nega- 
tive pole, of course, must be used here. 
In the treatment of vascular nasvi, electrolysis is likewise 
of service, but more particularly in superficial capillary varieties, 
when these are limited in area. The treatment of the vascular 
naevus is aimed at the absorption and atrophy of the blood 
vessels or at the destruction of them. Astringent applications, 
causing contraction, as the liquid plumbi subacetatis, may serve 
in the insignificant, superficial varieties. It is applied saturated 
on cloths. Collodion, alone or with ergot or tannin, and trau- 
maticin are used to produce contraction. Mechanical com- 
pression may serve, especially over the bony parts. A piece 
of wood or metal is firmly bound over the naevus, or held in 
place with adhesive plaster. Puncturing or slitting small 
telangietic naevi often suffices. This is done either with a 
scalpel or with an ordinary needle. In large patches, linear 
scarification is done with a fine and sharp scalpel, or with a 
scarifier. Multiple puncture with several needles in a cork or 
a piece of wood is employed at times. The indications, how- 
ever, are met in most cases by the agent which will produce a 
plugging of the vessels, by setting up an inflammation; by 
caustics or the actual cautery, destroying the lesion; finally, by 
actual removal with the knife, the ligature, or by other method. 
Where it is thought advisable to resort to a complete removal 
by operative methods, care should be taken to ascertain the ex- 6 
istence or absence of the haemorrhagic tendency in the patient. 
Where there are no such contra-indications, the knife is per- 
missible. A free incision should be made, to allow for even 
union, and deep stitches must be taken, after all the larger 
vessels have been tied. It is often well to use the cauterv for 
the smaller and intangible vessels. There are two methods 
for using the ligature. First of all, it is a good plan in smaller 
nasvi to circumscribe the growth with a single or double silk 
ligature, drawing tightly and tying on opposite side of the 
growth, when the double ligature is used. If larger nrnvi, the 
ligation is applied at a point a little remote from the growth. 
An incision is made above the vein, or small artery, and a cat- 
gut ligature is applied, the wound closed. In either instance 
the growth begins to pale after several days. In superficial nasvi 
the whole patch grows bluish in color. Here and there a spot 
grows white where the area has been absorbed, and finally, in 
the successful cases, the whole patch likewise grows whiter 
and whiter. Often it is advisable to ligate a few days or weeks 
before the excision, especially in the deep-seated lesions. 
When the cautery is employed several methods maybe followed. 
A fine platinum needle maybe attached to the galvano-cautery, 
raised to a red heat, and several introductions made. Multiple 
punctures more or less deep can be likewise made with the 
same instrument. Linear cauterization may as well be em- 
ployed with the needle or small platinum knife. The Pacque- 
lin cautery will serve the same purpose. 
Caustics act as the cautery does, by producing an eschar, 
and finally a slough. With caustics, however, the slough is apt 
to be more extensive than with the cautery. When this method 
is decided upon, care must be exercised with the agent used. 
Freshly prepared ethylate of sodium, pyrozone, chloride 
of zinc in solution, nitric acid, the acid nitrate of mercury are 
among the caustics employed. All of these act in much the 
same way, producing actual destruction, followed by crusting, 
and a more or less superficial scar, which gradually fades. 
Vaccination serves in locations where an irregular scar is 
no objection. The slight bleeding need not be stopped, except 
by a temporary compress. The injection of pure carbolic acid 
or the tincture of iodine is followed quite often by gratifying 7 
results. Little scarring remains, plugging of the vessels is 
rapidly obtained, and the operation is less painful and of 
shorter duration than with other methods. The injection of a 
i per cent, solution of chloride of zinc is used for the same 
purpose. The perchloride of iron may be used by injection, 
or, as is frequently indicated in the more elevated growths, 
silk threads, saturated with the perchloride solution, are passed 
in several directions through the naevus. 
Except in small naevi, the treatment is never highly satis- 
factory, and the methods employed may have to be changed 
several times before the whole of the growth is removed. It 
is always well to impress upon the patient the necessity of per- 
severance in the matter. Dr. Geo. H. Fox reported the suc- 
cessful removal of an extensive naevus of the face by electroly- 
sis, but it required nearly two years to accomplish this (your, 
of Cut. and Gen. Urin. Dis., May, 1894). 
It requires a goodly amount of moral and physical courage 
on the part of the patient to submit to the pain of the operation, 
which is repeated at each sitting, when electrolysis is used. 
This method, however, promises most from the cosmetic stand- 
point, as it leaves but little evidence of the procedure. Most 
times, too, the treatment is demanded for purely cosmetic 
reasons. The diagnosis of naevus presents no difficulties, and 
the prognosis is always a favorable one, except where the pos- 
sibility of a degeneration and a slough may endanger life on 
account of a proximate blood vessel of importance. 
Notwithstanding the multitude of methods in vogue, the 
treatment of naevus is still far from satisfactory, and the field is 
yet large enough to admit of acceptable suggestions.