Class Book Wl^l J CopyiightN? l^t ^ COPYRIGHT DEPOSE THE READY REFERENCE HANDBOOK • OF DISEASES OF THE SKIN BY GEORGE THOMAS JACKSON, M.D. LATE PROFESSOR OF DERMATOLOGY, COLLEGE OF PHYSICIANS AND SURGEON! NEW YORK: CONSULTING DERMATOLOGIST TO THE NEW YORK INFIRMARY FOR WOMEN AND CHILDREN; MEMBER OF THE AMERICAN DERMATOLOGICAL . ASSOCIATION AND NEW YORK DERMATOLOGICAL SOCIETY, ETC. WITH 115 ILLUSTRATIONS AND 6 PLATES SEVENTH EDITION, THOROUGHLY REVISED LEA & FEBIGER NEW YORK AND PHILADELPHIA 1914 Entered according to the Act of Congress, in the year 1914, by LEA & FEBIGER, in the Office of the Librarian of Congress. All rights rooorvod MAY -2 1914 •CI.A869960 PREFACE The aim of this book has always been to furnish students and practitioners with a comprehensive yet compact exposition of dermatology. The rate of growth of the subject is in a way reflected in some statistics of its increase in size. Its first edition in 1902 contained 502 pages discussing 164 diseases. In this edition there are 726 pages describing 257 diseases. In spite of liberal pruning, rewriting, and the elimination of anything obsolete, this new issue is 32 pages longer than its predecessor. New sections have been added on acarodermatitis urticariodes, cutis verticis gyrata, eczema marginatum, eczematoid dermatitis, erythema figuratum perstans, gan- gosa, granuloma coccidioides, ground itch, hemisporosis, keratodermia gonorrhoica, leukemia cutis, lichenification, lichen nitidus, lichen planus sclerosus et atrophicus, and trypanosomiasis. Many of the old sections have been entirely rewritten. The author acknowledges with thanks his indebtedness to his friends: Dr. M. F. Engman, for an article on Vac- cines; to Dr. John A. Fordyce for one on Salvarsan; and to Dr. G. M. MacKee for one on the use of ar-rays. These gentlemen are so eminent in their respective fields that their contributions add greatly to the value of the IV PREFACE book. Hearty thanks are also due to Dr. H. Noguchi for pictures of Treponema pallida, and to Dr. H. Fox for some admirable photographs of cases. To the medical public the author expresses his appre- ciation for the kindly reception accorded the previous editions of the book and the hope that it will continue to render acceptable service. G. T. J. 11 East Forty-eighth Street, New York. DISEASES OF THE SKIN. PART I. GENERAL CONSIDERATIONS. Anatomy and Physiology of the Skin. The skin varies in thickness in different regions of the body from J to 8 mm. It is composed of three distinct layers, namely : (1) the epidermis; (2) the derma, also named the cutis vera or corium; and (3) the subcuta- neous connective tissue. At all the orifices of the body lined with mucous membrane, the latter and the skin merge into each other. The appendages of the skin are the hair, the nails, the sebaceous and the sweat glands. This complicated structure is supplied with bloodvessels, lymphatics, and nerves. Epidermis. — The epidermis scarf skin, or cuticle, is composed of four layers, called strata, namely: (1) the stratum corneum; (2) the stratum lucidum; (3) the stratum granulosum; and (4) the stratum mucosum. Of these strata, the two that most concern us are the first and the last — that is, the stratum corneum and the stratum mucosum. The other layers of the skin may, for our present purpose, be regarded as simply transition-layers through which an epithelial cell passes on its developmental way to become a fully formed corneous cell. Each of the four strata of the epidermis 2 18 DISEASES OF THE SKIN is divided again into layers, but these are of no prac- tical importance. The thickness of the epidermis varies from 0.25 to 1.65 mm., being thickest and most compact Fig. 1 Vertical section through the skin. Diagrammatic. (After Heitzmann.) ANATOMY AND PHYSIOLOGY OF THE SKIN 19 where it is subjected to the most pressure of intermittent character, as on the palms and soles. The stratum corneum, or horny layer, consists of a series of superimposed layers of flattened, elongated cells that increase in flatness from below upward. The upper layers are called scales. The cells of each layer are united to each other so much closer than the layer itself is united to those above or below it that when an effusion takes place into the stratum corneum a layer of cells in the affected area is raised and the fluid is found between two layers. The lamellated scaling met with in certain scaly diseases, such as dermatitis exfolia- tiva, in which great plates of scales are readily removable, is likewise due to this close relation between the cells of each layer. This stratum is largely a protective one, its compactness affording a fair degree of resistance to injury of the underlying, more succulent layers of the epidermis. The stratum mucosum, rete Malpighii, or mucous layer, is the deepest layer of the epidermis, and is seated upon the papillary layer of the corium. It is composed of several layers of cells, but may be considered as consist- ing of two chief layers, namely, the columnar epithe- lium and the prickle cells. The columnar epithelial cells are arranged perpendicularly to the papillae of the corium, while the prickle cells, which are polygonal in shape with spherical nuclei and with little filaments running out from their sides toward the neighboring cells, are arranged in strata over them. As the stratum granulosum, which lies above the stratum mucosum, is approached, the prickle cells become flatter, and finally lie with their long axis parallel to the general surface. The "granules" contain eleidin (Ranvier) and keratohyalin (Waldeyer), the former being a fluid and the latter a solid substance. The stratum mucosum is the most important stratum of the epidermis, and the seat of that most common of all skin diseases, eczema. From its lower part it sends down projections between the papillae of the corium, 20 DISEASES OF THE SKIN which are called interpapillary projections. Most of the pigment of the skin is situated in the lower part of the stratum mucosum. As the upper part is approached, less and less pigment is found. The pigment itself is in tl^e form of granules and of diffused coloring matter. According to Unna, the pigment is found even in the upper part of this layer, while in pathological conditions it may be located in the corium. In the so-called colored races pigment is always found in the corium, and even the horny layer is stained. From this arrangement of the cells of the epidermis it will be seen that nutrient fluids can readily work upward from below by means of the little channels formed by the interlacing of the filaments running between the cells. The epidermis has no bloodvessels. It receives its nutrition entirely from the corium. Though there are no true lymphatics in the epidermis, there are abundant lymph spaces between the cells that take their place. Nerves of the non-medullated variety have been traced between the cells of the epidermis, and have been de- scribed by some histologists as entering into the cells to end at the nucleus, though not to enter it. The final distribution of the nerves in the epidermis is not yet fully determined. Corium. — The corium is composed of white fibrous and yellow connective tissue, disposed in horizontal bundles above and in oblique bundles below. It is a very dense and tough tissue, and is pierced in all direc- tions to allow of the passage of bloodvessels, lymphatics, sweat ducts, and nerves, and affords lodgement for the hair follicles and sebaceous glands. It contains a con- siderable amount of elastic fibers, especially in regions such as about the joints where there is more or less motion. The upper part has been named the pars papillaris, and the lower part the pars reticularis corii. From its upper part it sends off a vast number of pro- jections called papillw. These vary in length, being ANATOMY AND PHYSIOLOGY OF THE SKIN 21 longest and most marked on the ends of the fingers and toes. The epidermis follows these projections and dips down between them. They are readily seen as parallel markings on the ends of the fingers. Over most of the body surface the papillae are but slightly raised, and merely give a wavy appearance to the upper edge of the corium when viewed under the microscope. As the lower part of the corium is reached the bundles of fibers are less closely crowded together, and becoming succes- sively looser, gradually pass over into the — Subcutaneous Connective Tissue. — This is a loose connec- tive tissue with large and small spaces in it, which are filled with adipose tissue. This consists of fat cells collected into lobulated masses that in some cases have about them a connective-tissue sheath. Each lobule is supplied with an afferent artery, a capillary plexus about it, and efferent veins. This part of the skin is called the panniculus adiposus, and is found everywhere except in the skin of the penis, scrotum, labia minora, eye-lids, pinna, and beneath the nails. It contributes to the roundness and beauty of the body, besides acting as a store-house for fuel against such times as the body cannot gain its proper nutriment from food, as in fevers. It also gives lodgement to the coil or sweat glands, and aids in protecting the underlying parts from injury. The lower ends of the deep hair follicles are also in this part of the skin. The subcutaneous tissue merges into the underlying fasciae of the muscles and the periosteum of the bones. Under the name of columnce adiposce, J. C. Warren has described certain prolongations of fatty tissue running up to the bases of the hair follicles. They are important in relation to the pathology of carbuncle. Bloodvessels. — The arteries which supply the skin come up from below to form a horizontal plexus in the subcutaneous tissue, from which the vessels proceed perpendicularly through the corium to form a second horizontal plexus just below the papillae. From the 22 DISEASES OF THE SKIN lower plexus small branches pass to the fat cells, sweat glands, and, according to Unna, the hair papillae. From the upper plexus branches are given off which enter the papillae of the skin. There are also branches to the hair follicles, sebaceous glands, and the tissue of the corium itself. Papillae that give lodgement to a tactile corpuscle have no arterial twig. The veins follow the same course as the arteries, but, of course, in the opposite direction. Lymphatics. — Lymph vessels are large in the subcu- taneous tissue, smaller in the upper part of the corium, and form plexuses. "Juice spaces/' filled with lymph, are found abundantly in the epidermis and papillae, about the glands of the skin, and around the muscles of the skin and the connective-tissue bundles and fat lobules. Nerves. — The skin is provided with both medullated and non-medullated nerve-fibers and motor and vaso- motor nerves. We have learned already that non- medullated nerve fibers have been traced between the cells of the epidermis, some terminating at, if not in, the nuclei of the prickle cells. It may be roughly stated that the nerves follow pretty much the same arrange- ment as the bloodvessels, forming a sort of plexus beneath the papillae and then giving off branches to the vessels, the tactile corpuscles, the papillae, the hair follicles, the sebaceous and sweat glands, and the epidermis. The tactile corpuscles (corpuscles of Meissner) are located in the papillae. They are oval or rounded bodies, and their long axis runs longitudinally. Not more than one papilla in four is supplied with one of the corpus- cles, even where they are most abundant — on the end of the index finger. They are composed, according to Unna, of large, flat connective-tissue cells, which are placed one above the other like coins in money rolls, and take up between them the terminal branches of the medullated nerves, which on entering the bodies lose their medulla and finally end between the cells. The transversely striped appearance presented by the corpuscles is due to the swollen lateral edges of the cells and the band- CO Hair Follicle and Shaft. (Darier.) t. Shaft. o. Follicle mouth, of funnel shape, co. Neck of follicle, tnu. Erector pili muscle, s. Sebaceous gland. r. Radicular portion of shaft or root, f. Connective-tissue sheath of follicle, ex. External epithelial layer, i. Internal epithelial layer. i'. Internal epithelial layer, showing eleidine (keratohyalin) contained in the deeper portion, be. Bulb of hair shaft. The extremity is open and contains the papilla, p. Papilla. g. Adipose tissue of the hypodermis. a Arteriole in cross-section. n. Nerve, be. Coils of sweat gland. ANATOMY AND PHYSIOLOGY OF THE SKIN 23 like nerve fibers that here and there appear upon the surface. The corpuscles of Krause are located in the sensory mucous membranes. They are rounded in shape and bear a close resemblance to the Pacinian corpuscles in structure. The Pacinian corpuscles are located in the subcutaneous tissues, and also in connection with the sensitive nerves. They are oval in form, visible to the naked eye, and consist in a colossal swelling-out of the sheath of Schwann, forming a thick connective-tissue capsule surrounding a much smaller cylindrical cavity filled with granular, faintly filamentous cellular substance, through the axis of which passes a sensitive nerve. As the latter enters the corpuscle it loses its medulla, and either terminates in the corpuscle or passes through it to enter one or more corpuscles. These corpuscles are most abundant in the fingers and toes, and the palms and soles. They are sup- posed to enable us to appreciate pressure or traction. Less well understood are the MerheVs touch cells in the epidermis and corium. They are ovoid in shape with nucleus and nucleolus. Motor and vasomotor nerves are also found in the skin. The former are attached to the smooth muscles of the skin and glands; and the latter to the muscles of the vessel walls, and come into action in blanching and flushing of the skin. Hair. — The hair is an epidermic structure which grows from a nipple-shaped projection, the hair papilla, situated at the bottom of a deep, slender pocket or sac- like depression in the skin which is called the hair follicle. Commencing at the papilla it is bulb-shaped. This part is called the bulb and fits over the papilla like a cap. On leaving the papilla the body of the hair is first called the root, and then as it becomes narrower the shaft. The diameter of the shaft rapidly decreases until, leaving the skin, it terminates in the point. A fully formed hair is hollow, its central cavity being called the medullary canal and filled with the medulla. This is composed of • 24 DISEASES OF THE SKIN a column of cells arranged in layers, one layer being superimposed on another. The main substance of the hair is called the cortex, and consists of long, spindle- shaped epithelial cells flattened out into fine bands which run in the long axis of the hair. This part of the hair gives it substance and strength, and in it is placed the pigment that determines the color of the hair. The outer layer of the hair is called the cuticle. It corresponds to the epidermis and consists of flattened, non-nucleated, fully cornified cells which cover the hair like scales and overlap each other like shingles. The hair follicle is located, for the most part, in the corium, but in some very strong hairs it reaches down into the subcutaneous tissue. It is always, excepting at the dorsal edge of the eye-lids, placed at an angle to the skin, and is a permanent structure that is not removed when the hair is plucked. It is composed of three layers, which are derived from the corium as it dips down to form the follicle. Between the follicle and the hair is the root sheath, which is derived from the epidermis. It is composed of two layers, which are called the external and the internal root sheaths. The whole arrangement of the hair and its sheath may be graphically conceived by regarding the hair as a blunt needle pressed against the skin. The needle would form the hair, the epidermis would form the root sheath, and the corium would be to the outside of all and form the hair follicle. Hair is found on all parts of the body excepting the palms and soles, the terminal phalanges of the fingers and toes, the glans penis, prepuce, labia minora, and the vermilion border of the lips. In form it is flattened or rounded, straight or curled. There are three main vari- eties of hair: (1) long, soft hair, as of the head and beard; (2) short, stiff hair, as of the eye-brows and eye- lashes; and (3) lanugo, or soft, downy, colorless hair, that is scattered all over the surface of the body. Nails. — The nails, like the hair, are epidermic struc- tures. They are placed on the extensor surfaces of the ANATOMY AND PHYSIOLOGY OF THE SKIN 25 terminal phalanges of the lingers and toes. Their proxi- mal end is called the root, under which is the matrix, from which they grow. On the way to their distal end they pass over the nail bed. This is separated from the matrix by a more or less convex and apparent line called the lunula. At their posterior and lateral margins they are embedded in a fold of skin that is called the nail fold. At their distal extremity they are separated from the end of the finger or toe. They are formed by the matrix, but in passing over the bed they receive a certain amount of nourishment from it, and their cells become rapidly cornified. They are slightly curved from side to side, being convex above and concave below, and are marked with fine lines. The flesh beneath the nail is the same as the skin in general, though without subcutaneous tissue. The nail takes the place of the corneous and granular layers of the skin. They are horny and trans- parent, and are composed of several layers. It has been estimated that it takes from one hundred and eight to one hundred and sixty-one days for a finger nail to grow from the lunula to the free edge, the rate of growth being more rapid in summer than in winter. It has been noted that in a case of fracture of a limb the nails of the fingers or toes may cease growing until the bone is well knit. Sebaceous Glands (Fig. 1). — These glands are of the racemose variety, and are closely related to the hairs, from two to six being attached to each hair, emptying by their ducts into the upper third of the follicle. Each gland is composed of a number of acini that empty by a common duct. They are composed of a delicate, struc- tureless capsule, the membrana propria, which continues along the duct to merge into the hair follicles. This is lined with large, although short, cubical or cylindrical epithelial cells arranged in one or two rows. These are continuous through the duct with the cylindrical cells of the outer root sheath of the hair and of the skin. The interior of the glands is filled with fatty secretion. 26 DISEASES OF THE SKIN Around the glands passes the external layer of the hair follicle. These glands occur also on the vermilion border of the lips, the labia minora, and the glans penis and prepuce, though in these locations there are no hairs. They are not found on the palms, soles, or backs of the third phalanges of the fingers and toes. The function of the sebaceous glands is to oil the hair and skin, thus rendering them soft and supple, and giving luster to the hair. This oily secretion, or sebum, is produced by the cells, which, as they reach the central part of the acini, undergo fatty degeneration. It is composed of fats, fatty acids, cholesterin crystals, debris of cells, and water. It is forced out of the glands by the constant production of new sebum. The glands are largest in the nose, cheeks, scrotum, mons veneris, labia, and about the anus. It is not settled whether the smegma is composed of exfoliated cells alone or mixed with sebaceous matter. Sweat Glands (Fig. 1). — The sweat glands are simple coil glands that are located in the lower part of the corium and in the subcutaneous tissue. Their ducts ascend through the corium in a straight or wavy line to the interpapillary spaces, where they enter the epi- dermis. The cells lining the coil are simple cubical epithelial cells. These are seated upon muscular fibers; and a connective tissue, the membrana propria, comes outside of all. An abundant net-work of bloodvessels surrounds each gland and sends off branches to its interior. The glands are also richly supplied with nerves. The duct is made up of pavement epithelium upon the membrana propria. When the epidermis is reached the membrana propria is lost, and the further tract of the duct seems to be made by the sweat working its own channel up between the epidermic cells. The duct ends as a rounded aperture on the surface of the skin that is called a sweat pore. Unna teaches that the sweat pro- duced by the coil glands is mixed with other elements while passing through the epidermis, so that the secretion PHYSIOLOGY 27 that appears at the sweat pores is not the same as that which leaves the coils. He further teaches that the office of the coil glands is not to produce sweat, but to oil the skin. This theory still needs confirmation before it can be accepted as proved. His arguments have con- siderable weight, but space will not allow of their state- ment here. It has long been known that there was a certain amount of oil in the sweat. Sweat glands are most numerous in the palms and soles. Their diameter is from 0.3 to 0.4 mm. The largest are in the axilla, where they have a diameter of 2 to 7 mm., and are very numerous. In the external meatus of the ear they secrete the so-called ear wax. Muscles. — The skin is provided with muscles, both of the striated and unstriated variety. The striated muscles are found in the face and neck. The majority of the muscles of the skin are involuntary muscles. In the scrotum they run parallel with the raphe. On the penis and about the nipple their direction is circular. The arrectores pilorum muscles are found all over the body, running in a more or less oblique direction from the bottom of several papilla? down and around a sebaceous gland to be attached to the bottom of a hair follicle. By contracting they raise the hairs to a perpendicular position and aid in pressing out the contents of the sebaceous glands.. There contraction also causes the appearance known as "goose flesh" when cold strikes the skin. Physiology. The skin is a protective, sensory, heat-regulating, and secretory organ. It offers protection to the deep parts by the pad-like structure of the subcutaneous tissue with its panniculus adiposus, and the highly resistant nature of the insensitive horny epidermis, both to physical and chemical agencies, and to the penetration of bacteria. The most vulnerable points in the skin are the pilo- 28 DISEASES OF THE SKIN sebaceous openings, and these are usually plugged with masses of sebum. The end organs of touch and temperature sensation are located in the skin, but the delicacy of these sensations varies markedly in different regions. Loss of sensation leads frequently to the formation of traumatic lesions in the anesthetic area. Little is known about the existence of trophic nerves, although the nutrition of peripheral parts seem to be influenced by the central nervous system. The skin plays a very important part in the regu- lation of the amount of heat lost by the body through evaporation, radiation, and conduction. In man 77 to 85 per cent, of the total heat loss of the body is through the skin. The regulation is effected through the blood supply and the sweat secretion. The efficiency with which the mechanism serves its purpose is evidenced by the fact that in a dry atmosphere a temperature of over 250° F. will not produce any change in the body tem- perature as long as the sweat secretion remains active. When the body surface is exposed to cold, the sweat secretion is reduced to a minimum and the skin blanched by the contraction of the cutaneous vessels, under the control of the vasomotor centre. The emptying of the vessels is assisted by the contraction of the involuntary muscles of the skin, which increase the tension and the pressure around the vessels, and produce the condition known as gooseflesh (cutis anserina) . The sweat is 99 per cent, water, and varies in amount from 600 to 1300 c.c. a day, but may rise under stimu- lation as by heat or exercise even to 400 c.c. an hour. Besides its heat regulating function, it serves also to remove small quantities of excretives from the body and to keep pliable and moisten the epidermis. The sebum, besides lubricating the skin, prevents the absorption of aqueous solutions from without, and the evaporation of fluids from within. It is always very DIAGNOSIS 29 difficult to make the skin absorb medicaments, and it is believed that such absorption takes place through the glandular orifices and mouths of the hair follicles. Diagnosis. The Lesions of the Skin. — We speak of primary and secondary lesions of the skin. By the first of these terms we mean the form assumed by the efflorescence at its first appearance. By the second of these terms we mean the subsequent changes the primary lesion under- goes of itself, or as the result of extraneous causes acting upon it. In running its course, whether influenced by treatment or not, almost every disease of the skin exhibits more than one lesion, and we can only speak of it as a macular, papular, or other disease from its most promi- nent and characteristic lesion. The primary lesions of the skin are the macule, the papule, the tubercle, the vesicle, the pustule, the bulla, the wheal, and the tumor. The secondary lesions of the skin are the crust, the scale, the excoriation, the fissure, the ulcer, and the cicatrix. These may be graphically represented, following Piffard. 1 Primary Lesions. — A macule is a spot or stain of the skin which is not raised above its surface. It may be of any size from that of a pinpoint to that of the palm of the hand, or larger. Large-sized and diffused, non- elevated lesions are usually spoken of as patches. A macule is usually round, but may be of any shape. It may be white, red, brown, black, blue, pink, or yellow, according to its cause. It may be due to hyperemia, as in erythema simplex; to a change in the pigmentation of the skin, as in lentigo and chloasma, where there is increase of pigmentation, or in vitiligo, where there is decrease of pigmentation; to a hemorrhage into the skin, 1 Cutaneous Memoranda. Wood, N. Y., 1885. 30 DISEASES OF THE SKIN as in purpura; to a development of bloodvessels in the skin, as in nevus vascularis and telangiectasis; to a parasitic growth in the skin, as in chromophytosis ; to a change in the consistency of the skin, as in morphea and xanthoma; or to the introduction of foreign matter, as in powder stains or tatoo marks. Fig. 2 LESIONS OF THE SKIN. Primary. Macule — Fig. 3 Secondary. Vesicle Pustule Bulla Wheal Tumor A Crust Scale Excoriation Fissure - V Ul( Cicatri XXX The macule may be evanescent or permanent; may remain as a macule during its existence, or may give place to a papule, vesicle, or pustule. It is the simplest of all the lesions of the skin, and is met with as a primary lesion in many of its diseases. The principal macular diseases are chloasma, chromo- phytosis, erythema simplex, lentigo, melasma, morphea, nevus simplex and spilus, purpura, scleroderma, vitiligo, and xanthoma. A papule is a circumscribed, solid elevation of the DIAGNOSIS 31 skin. In size it varies from that of a pinpoint to that of a split pea. It may be of different colors, from white as in milium, to black as in melanotic sarcoma, but is usually some shade of red. It is soft or firm to the touch. In form it may be acuminated, rounded, flattened, or umbilicated. Its base may be round, oval, or angular. It may be due to inflammation, as in eczema; to hyper- trophy of normal structures, as in verruca; to the heap- ing up of epidermic cells about a hair follicle, as in keratosis pilaris; or to the retention of sebaceous matter in a follicle, as in comedo and milium. The papule may remain as such throughout its course, and finally be absorbed; or it may change into a vesicle or pustule; or it may soften and break down. Papular diseases have received the name of lichenoid diseases, and at one time we had a goodly number of lichens. Most of these have now been placed under other headings, as it is recognized that they are but single manifestations of other diseases. Papular diseases may be scaly and itchy. The principal papular diseases are lichen tropicus, lichen ruber acuminatus and planus, lichen scrofuloso- rum, lichen pilaris or keratosis pilaris, lichen urticatus or papular urticaria, acne, comedo, milium, prurigo, syphilis, and psoriasis. Like the macule, the papule is found in many diseases that cannot be classed as papular. A tubercle or nodule may be thought of as a large papule. Like it, it is a circumscribed solid elevation of the skin, usually of a reddish color. Indeed, the differ- ence between a papule and a tubercle is mainly arbitrary and for convenience. Thus we speak of a solid lesion up to the size of a split pea as a papule, while above that it is spoken of as a tubercle. Some lesions which are usually spoken of as tubercles, such as the tubercular syphilide, may not be larger than a split pea. Stelwagon makes the good suggestion that "a papule may be a solid lesion extending upward; a tubercle a solid lesion pro- jecting both upward and downward." Quite commonly, 32 DISEASES OF THE SKIN when a lesion is larger than a cherry it is spoken of as a node. Auspitz 1 makes the distinction between a papule and tubercle on more scientific grounds, and regards a tubercle as a cell infiltration into the corium. A tubercle is not only larger than a papule, but it extends deeper into the skin. In form and color a tubercle corresponds to a papule. Tubercles may be absorbed and disappear and leave no trace; or they may break down and ulcerate and leave scars, as in syphilis; or they may remain unchanged for an indefinite period, as in molluscum. The principal tubercular diseases are: carbuncle, epithelioma, keloid, lupus vulgaris, molluscum, rhino- scleroma, and xanthoma. Tubercles form a very prominent symptom in leprosy, syphilis, and erythema multiforme. Of course, tubercular used in this sense has nothing to do with the tubercle of tuberculosis. A vesicle is a circumscribed elevation of the epidermis that contains fluid, generally serous. In size it varies from that of a pinpoint to that of a split pea. It may be unilocular, or multilocular. Its color is crystalline when only serum is present, more or less opaque and yellowish when the serum is mixed with pus, and of a reddish hue when blood is effused into it. It may be pointed, rounded, flattened, or umbilicated. Vesicles are in most cases due to inflammation, as in eczema. They may be due to simple serous effusion, as in erythema; or to the retention of sweat, as in sudamina. They have around them, in many cases, a red halo. As a rule, vesicles are superficial elevations of the epidermis, and readily rupture and pour out their contents upon the skin, forming a yellowish crust. They may be below the mucous layer of the skin. They may remain as vesicles and dry up, their contents being absorbed; or they may become changed into pustules. The principal vesicular diseases are: dermatitis venen- 1 Ziemssen's Handbuch der Hautkrankheiten. DIAGNOSIS 33 ata, dysidrosis, eczema, herpes, hidrocystoma, impetigo contagiosa, sudamina, varicella, and zoster. A pustule is a circumscribed elevation of the epidermis containing pus. In size and shape it corresponds to the vesicle, though the term pustule is applied to lesions up to the size of the finger nail. Its color is yellow and opaque; or brown or reddish if there is an admixture of blood with the pus. It either originates as a pustule or develops from a vesicle or papule. It may be superficial or deep seated. As a rule, pustules are inflammatory, and when they appear as a general eruption, as in syphilis, they indicate a strumous or broken-down condition Around each pustule there is very commonly a well- marked inflammatory areola. Pustules are prone to break down and discharge their contents upon the skin, forming a greenish crust. If located deep in the skin, they may leave scars. The principal pustular diseases are acne vulgaris, ecthyma, furunculosis, impetigo, and sycosis. Eczema, syphilis, and a few other dermatoses are often markedly pustular in character. Pustular diseases are often spoken of as impetiginous. A bulla, or bleb, may be considered as a large vesicle or pustule. It is of irregular oval shape or umbilicated. It may be as large as a split pea, or reach the size of a goose egg or larger. It rises from the skin with a slight areola or with none at all. It is either fully distended or flaccid, and does not rupture readily. It may be a bulla from the beginning, as in pemphigus; or it may be formed by the coalescence of two or more vesicles; or it may arise on an erythematous lesion, as in erythema multiforme. Its contents is usually serum, but it may change in time to pus. The only purely bullous disease is pemphigus; but bulla are met with in dermatitis, dermatitis herpetiformis, erysipelas, erythema multiforme, impetigo contagiosa, leprosy, and syphilis. A wheal is an evanescent round, oval, or elongated flat 3 34 DISEASES OF THE SKIN elevation of the skin, of a pinkish or white color, which is more or less firm to the touch. It is surrounded by a red halo. It may be as small as the head of a pin or as large as the palm of the hand. Wheals appear suddenly and disappear within a few hours. They are due to a spasm of the capillaries of a limited area of the skin and an effusion of serum into the meshes of the skin, the raised part being the site of the effused fluid, and the halo the congested vessels in the neighborhood. The whiteness of the wheal is due to the sudden effusion of the serum squeezing out the blood of the area. As the circulation becomes reestablished the serum is absorbed, the whiteness changing to pink, and then to the normal color of the skin. Of late it is declared that wheals are due to localized inflammation. The disease in which wheals are met with is urticaria. They can also be pro- duced by contact with the stinging nettle, or by sharp traumatism on skins predisposed to urticaria. A tumor is a new growth in the skin which projects more or less above its surface and dips down into the subcutaneous tissue. It may be pedunculated or sessile. Tumors vary greatly in size. Their color is often that of the surrounding skin, but it may be red, blue, or other color. They may be firm to the touch, or soft or elastic. They may become ulcerated. A tumor is rather a surgical than a dermatological lesion. Epithelioma, fibroma, and sarcoma are types of tumors. Secondary Lesions. — The secondary lesions of the skin require a much less extended description. The main distinction to be retained in the student's mind is that between a crust and a scale. This can be readily done if it is remembered that a crust is formed by the drying of some secretion or exudation upon the skin, while a scale is a dry, laminated mass of epidermis which has separated from the tissues below, the product of imperfect or perverted nutrition. Thus in vesicular eczema when the exudation dries on the skin we have a yellowish crust; while in squamous eczema we have thin DIAGNOSIS 35 scales, the horny layer of the skin not being perfectly produced. Crusts are yellow when formed of dried serum, green when derived from pus, and black when there has been an admixture of blood. Scales are whitish, grayish, yellowish, or dirty yellow. Crusts are especially characteristic of ecthyma, some forms of eczema, favus, impetigo, seborrheal dermatitis, and pityriasis steatoides. Scales are especially abundant in dermatitis exfoliativa, pityriasis simplex, pityriasis rubra pilaris, psoriasis, ich- thyosis, and some of the lichens. Excoriations are familar as scratch marks. They are superficial denudations of the skin. They are of value as a sign of itching, as scratching is their chief, though not sole cause. They frequently are followed by pig- mentation if the irritation causing the scratching is long continued. They also occur as the natural result of some diseases, such as pemphigus, without the intervention of scratching. Fissures are cracks in the epidermis extending down to the corium. They are usually located in the folds of the skin, as over the joints. They may occur about the corners of the mouth and about the anus. They occur in diseases attended by infiltration and thickening of the skin by which its elasticity is interfered with, and are especially seen in eczema, psoriasis, and syphilis. They often bleed, and sometimes are very painful. Ulcers are irregularly shaped and sized losses of substance usually with granulating surfaces. They may be quite small or of large size. They may be shallow, deep, excavated, or scooped out. Their edges may be undermined, as in tuberculosis; everted, as in epithe- lioma; or sharp cut, "punched out," as in syphilis. Their secretion may be scanty or abundant. They result either from some previous lesion or from injury. They occur in carbuncle, chancre, chancroid, ecthyma, varicose eczema, epithelioma, furuncle, lupus vulgaris, sarcoma, syphilis, tuberculosis, and sometimes after zoster, der- 36 DISEASES OF THE SKIN matitis, and some pustular eruptions. They always heal with a cicatrix, leaving a scar. Cicatrices, or scars, represent an effort of nature to heal a damage to the skin by means of connective tissue. They occur only when the corium has been injured. They may be depressed, as in smallpox; raised and puckered, as in lupus; smooth and white, as in syphilis. While ulceration usually precedes them, they occur independently of it, as in leprosy, scleroderma, and atrophoderma. Other Elements of Diagnosis. — We must observe the location, distribution, and configuration of the eruption, and note its color, and whether or not it itches. When we have done all this, and have come to a probable conclusion as to the disease before us, then is the proper time to ask the patient a few questions as to his sensa- tions and the duration of the attack. In a few cases of doubtful diagnosis the microscope will aid us. Location. — In the following lists those diseases are mentioned that occur especially in the region named, or with special frequency. In general eruptions, of course, all regions are more or less involved. Upon the face we meet with acne, adenoma sebaceum, comedo, chloasma, dermatitis venenata, erythematous eczema, epithelioma, erysipelas, herpes febrilis, hydrocy st- oma, impetigo contagiosa, lupus vulgaris and erythema- tosus, milium, nevus, rhinoscleroma, rosacea, sycosis, and xanthoma. An eruption confined to the middle third of the face, from above downward — forehead, nose, and chin — is in all probability rosacea. A pustular eruption occupying the bearded portion of the face, above a line drawn from the angle of the mouth to the angle of the jaw, is probably sycosis. Should it occupy the bearded portion of the face below that line it is probably trichophytosis barbae. If a scaly patch is found in front of the ear, it should put us on the lookout for psoriasis, which will often be DIAGNOSIS 37 found elsewhere on the body. This point may be useful in the diagnosis of a doubtful case. If a raw, or cracked, or scaly place is found behind the ear, it points to eczema. Upon the scalp we meet with alopecia, alopecia areata, dermatitis seborrhoica, eczema, favus, pediculosis capitis, pityriasis steatoides, seborrhea, and trichophytosis. If we find a patch of pustular eczema upon the back of the head and about the nape of the neck, the case is probably one of pediculosis; and if we look for the nits, we shall find them either at the site of the eruption or over the parietal region. The chest is the favorite location for chromophytosis, keloid, and seborrheal dermatitis. Upon the back we meet with acne, carbuncle, and the scratch marks due to the irritation from pediculi. If we find long, parallel scratch marks over the shoulder-blades, they are very good evidence of pediculi in the clothing. The extensor surfaces of the forearms and wrists are the favorite sites of erythema multiforme, ichthyosis, and urticaria, while the flexor surfaces give lodgement to lichen planus and scabies. The posterior surface of the elbow is a common location for psoriasis, while on the soft skin of the bend of the elbow we find eczema. . Upon the hands occur callositas, dermatitis venenata and repens, erysipeloid, pernio, and pompholyx. Upon the legs ecthyma, elephantiasis, erythema exudati- vum, ichthyosis, purpura, and ulcers are apt to occur. y A general eruption, that is one that is scattered over the whole skin, is either one of the exanthematous fevers, dermatitis exfoliativa, eczema, erythema, ichthyosis, lichen planus, lichen ruber acuminatus, mycosis fungoides, pityriasis rubra pilaris, psoriasis, scabies, or syphilis. Of these, syphilis is most marked on the sides of the chest and abdomen, and upon the face along the margin of the hair. It may also be given as a general rule, to which there are many exceptions, that syphilis occupies the flexor surfaces of the extremities and the anterior plane of the trunk, while psoriasis is found most markedly 38 DISEASES OF THE SKIN upon the extensor surfaces of the extremities and the posterior plane of the trunk. A universal eruption, that is one in which the whole skin is involved, is either eczema, dermatitis exfoliativa, erythema scarlantiniforme, ichthyosis, pityriasis rubra pilaris, psoriasis, or one of the exanthemata. Configuration. — Certain diseases assume certain config- uration, which, if noted, will sometimes assist in diagnosis. Thus we have : The circular outline and scalloped border of syphilis. The round and bald patch of trichophytosis and alopecia areata. The map-like border of psoriasis. The oval or egg-shaped lesions of erythema nodosum and the gumma of syphilis. The angular, umbilicated, flattened papules of lichen planus. The annular arrangement in herpes iris and pityriasis rosea, and in some cases of ringworm, psoriasis, syphilis, and dermatitis seborrhoica. The patches of grouped vesicles upon reddened bases located over the course of a cutaneous nerve in zoster. Color. — An eye for color is of some value in diagnosis. It is very difficult to convey by words a correct idea of the color of an eruption, but perhaps this list may prove helpful: Raw ham of syphilis. Brilliant red of erysipelas. Inflammatory red of eczema. Dark red of purpura. Bright or pinkish red of psoriasis. Brown of pigmentary diseases. Yellowish or cafe au lait of chromophytosis. Sulphur yellow of favus. Buff of xanthoma. Violaceous or dull red of lichen planus and lupus erythematosus. White of leukoderma. DIAGNOSIS 39 History. — Having carefully noted all these objective symptoms, now is the time to obtain the history of the case, either for the purpose of scientific study of its etiology and natural course, or for the purpose of clearing up some doubt as to the diagnosis. It is so easy to obtain a history of syphilis that were we influenced by the history we would be often misled. There is no reason why a patient with syphilis should not have any other skin disease. Mo cover, most people do not pay much attention to the course of their diseases, and it would be difficult for them to give a correct account of them if they would. Of course, a clear history of the initial lesions of syphilis or its presence would clear up any doubt as to an erythematous rash. The history of a scaly disease recurring at frequent intervals upon the elbows and knees would go far to determine the existence of psoriasis. In urticaria we often have to rely upon the statement of the patient or attendant as to the appear- ance of the wheals, as their presence at some time is pathognomonic, and they are usually absent when we see the patient. In these and similar ways the history is useful, but it should be entirely subordinated to the study of the objective symptoms. Pruritus. — It is important to know whether a dis- ease itches or not. This we can discover by the pres- ence or absence of scratched papules or excoriations. The itching eruptions are dermatitis herpetiformis, eczema, pediculosis, prurigo, pruritus cutaneous, scabies, and urticaria. The symptom is also present in the lichens, psoriasis, dermatitis seborrhoica and tricho- phytosis. It is markedly absent in syphilis, although an occasional case of syphilis will be encountered in which there is itching. Burning. — The sensation of burning is one the exist- ence of which we must take upon the patient's statement. It is a prominent symptom in erythema. Very often a patient will say that his eruption itches, but if he is watched he will soon begin to rub his skin gently with 40 DISEASES OF THE SKIN the heel of his hand. This indicates that the sensation is one of burning and not of itching. In itching, the nails are used, or else the rubbing is vigorous. Pain.— Another symptom for the establishment of which we have to rely upon the patient is that of pain. The vast majority of skin diseases, while they may cause more or less discomfort, are not painful; but sharp neuralgic pain is a prominent symptom in zoster, and occasionally in epithelioma. The presence of pain of a shooting character will be one point in the differential diagnosis between lupus and epithelioma, and in favor of the latter. We also meet with pain in neuroma, dermatalgia, and in some forms of leprosy. Microscope. — The principal use of the microscope in the hands of the general practitioner is, as far as derma- tological diagnosis is concerned, the determination of the presence or absence of fungi in hair and scales in a doubt- ful case of ringworm, favus, chromophytosis, or other parasitic disease. Happily, as between favus and ring- worm we seldom have need of the microscope for diag- nosis, their symptoms being so pronouncedly different. The dark stage illumination is of great use in the early diagnosis of syphilis in finding the spirochete . In the hands of the skilled pathologist and bacteriologist the microscope is constantly adding to our knowledge of dis- eases of the skin, and is of great value. Method of* Examination of Patients. — They should be always examined by daylight or by electric light. It is prudent to refuse to give an opinion of a case when seen in a poor light or by artificial light. If the patient is a man it is necessary to request him to strip from top to toe, if there is -the slightest need of seeing more than the ordinarily exposed parts. In the case of a woman such an inspection can seldom be made. The same end can be attained by exposing one part after another. In all cases we are justified in refusing to treat a case that we have not been given ample opportunity to examine. All examinations of patients should be made in a warm THERAPEUTIC NOTES 41 room. The contact of cold with the usually covered skin is apt to give it a mottled look that obscures the diagnosis. It is well never to give a diagnosis of an obscure case that is under local or constitutional treatment until all treatment has been suspended for a few days and the disease allowed to assume its natural appearance. Under the name of diaskop, Unna has recommended the use of a small piece of thick, clear glass, marked with a measuring scale, for the purpose of exercising pressure upon the skin under examination. This does away with the confusing redness, brings into greater prominence anatomical lesions, and enables us to take accurate measurements of them. Every patient should be regarded as possibly out of health in some way quite apart from his skin trouble, and examined as to the performance of all his bodily functions quite as carefully as if he had come to us only for the treatment of some internal disorder. Therapeutic Notes. Many new preparations are constantly being introduced by manufacturing chemists. Anyone interested in them can readily procure information from his druggist. Most of those which have approved themselves as of value will be found in the sections on treatment that follow. It is our purpose here to describe concisely the methods of using those physical agents that at present are em- ployed in the treatment of dermatoses. Aciinotherapy. — Direct sunlight has long been known as a bactericide. In most countries the hours of sunlight are short and uncertain. This led Finsen, of Copen- hagen, to introduce a method of light therapy by means of electric light. Further investigations have shown that the blue, violet, and ultraviolet rays of the spectrum are bactericidal; and that light can be made to penetrate the skin and cause reactive structural changes of a destructive nature. Since Finsen introduced his lamp, 42 DISEASES OF THE SKIN a number of lamps have been put on the market, only a few of which can be mentioned here. Finsen-light therapy is the use of an electric arc light of 60 to 80 amperes and about 70 volts concentrated by means of telescopic tubes through lenses of rock crystals upon the part to be treated. The lenses are kept cool by a stream of cold water. They permit the ultraviolet rays to pass through them. To render this light effective the blood must be pressed out of the tissues. This is done by an attendant, who presses upon the skin pieces of quartz in a special holder. Painting the skin with a 5 per cent, solution of eosin increases the penetration of the light. The exposures have to be made for from half an hour to two hours daily until reaction sets in, and repeated when the reaction caused by the treatment subsides. The amount of reaction will vary from an erythema to the production of bullae depending upon the degree of exposure. The process is tedious and expensive, months and years being required for the cure of some cases. Lupus erythematosus, lupus vulgatis, and the tubercular diseases are those in which this treatment has given the most brilliant results. None of the substitutes for the Finsen apparatus are as effective as it is. Next in efficiency is the Finsen- Reyn lamp. Iron electrode lamps are also used either with or without a quartz lens, such as the Piffard lamp. The latter is more active without the lens. A current of 12 to 25 amperes is to be usedj the lamp held from 2 to 5 inches from the area to be treated, and the exposure made from two to ten minutes daily, or every second or third day. After a number of exposures, the skin may become tanned as from sunburn. This lamp is especially useful in alopecia areata. It is said to be rich in ultraviolet rays, and is superficial in its action. Mercury vapor lamps are glass vacuum tubes contain- ing a certain amount of mercury, which is vaporized by passing through it a current of electricity. They are THERAPEUTIC NOTES 43 very rich in blue, violet, and ultraviolet rays. The Heraeus, and the Sehott lamps are types of this form of lamp. The latter is called the "uviol" lamp. The most powerful of these lamps is the Kromayer (Fig. 4). It is made of quartz inside of a metal jacket, through which a stream of water circulates to keep it cool. In the front of it are two columns of mercury. When the electric current is turned on an arc of mercurial vapor is developed. It is furnished with variously sized appli- cators, some of blue color. The operator must wear simple glass spectacles to protect his eyes. For surface action it is held at a distance of 2\ inches or more from the point of application and accurately focussed on it. Three minutes' exposures produce bulla?. Armed with a Sehott blue ultraviolet glass applicator it ma}' be pressed directly upon the skin for twenty to thirty minutes where deep action is called for. Exposures are to be repeated when the reaction subsides. It is a powerful bactericide. It has been found useful in acne, alopecia areata, derma- titis herpetiformis, chronic eczema, furunculosis, lupus ery- thematosus, nevus vasculosus, prurigo, psoriasis, rosacea, and sycosis. Radiotherapy 1 is the therapeutic application of the a>ray to the human tissues. In recent years great ad- vances have been made in technique — in the efficiency of exciting apparatus, in a>ray tubes and in instruments for accurately measuring the dose. Static machines have been discarded. Induction coils of the Ruhmkorff type are extensively employed still, but the apparatus receiving the most favor at the present moment is the interrupterless transformer; x-ray tubes can now be obtained that can withstand heavy currents for suffi- ciently long periods of time. While the expensive water- and air-cooled tubes possess obvious advantages, they are not necessary. It may be said, too, that American tubes and exciting apparatus are as good if not better 1 This section is contributed by Dr. George M. MacKee, who has done very much to advance our knowledge of the exact use of rc-rays. Fig. 4 j^dhs* otH The Kromayer lamp, a, lamp connecting plug; b, current direction indicator; c, plug connection; d, tube connection; e, winged nut for fixing lamp in fork g; f, Kromayer quartz lamp; g, fork lamp holder (may be fixed in any position) ; h, j, inlet and outlet for cooling water; k, switch; /, rheostat lever; m, line connection-; n, rheostat. THERAPEUTIC NOTES 45 than those of foreign make. The dangers of the a;-ray are so well understood now, that injury to the operator or patient is an uncommon occurrence. The operator protects himself by remaining in a lead-lined booth during the entire exposure. This booth is provided with a lead-glass window for observation, and contains the switches, rheostats, and measuring instruments. The patient is protected by the tube being placed in a lead-glass receptacle, the under surface of which con- tains an adjustable diaphragm composed of lead. In this manner only the diseased area is exposed to the ray. The estimation of the dose is based upon the deter- mination of the quality and quantity of ray employed. By quality is meant the "hardness" or penetrating ability. A "soft" or low-vacuum tube emits rays of slight penetration, rays that are absorbed to a large extent by the epidermia. A "hard" or high- vacuum tube, on the other hand, produces rays of great penetration and which are similar to the gamma rays of radium. Obviously, there must be many gradations between these extremes — and, indeed, such is the case. And, further- more, the vacuum of a tube when in action can be regulated so that a maximum of rays of any desired penetration may be obtained. Because of the desir- ability of penetrating the thickened horny layer, the oedema and congestion of the rete and papillary bodies, existing in many dermatoses amenable to .T-ray therapy, and having most of the effect exerted in the dermis, a "hard" ray is indicated in the treatment of even ap- parently very superficial conditions. Also, the latitude of safety in the case of the "hard" ray is many times greater than when a "soft" ray is employed. The quality is estimated by the combined use of the Benoist radiochromometer, the milliamperemeter and the Heinz-Bauer qualimeter. The quantity is best determined by the aid of the Holzknecht radiometer. This instrument consists of a 46 DISEASES OF THE SKIN standard color scale, which is divided into units, and with it are supplied pastilles or tablets of platino-cyanide of barium. This is a chemical combination of a green color which becomes brown upon exposure to the ar-ray. By comparing the exposed pastille with the graded color scale any number of units of a given quality may be applied. This is known as the direct method of measurement in contradistiction to the indirect method, where the dose is estimated by the amount of current used, the distance of the tube from the patient and the length of time occupied by the exposure. The latter method is falling rapidly into disuse, because it is not nearly as accurate as is the direct method. The cc-ray is now employed in a much more intensive manner than formerly. Today, very few operators give more than 6 or 8 exposures to cure an epithelioma, and some of them do not administer more than one or two treatments. Indeed, the same may be said of most of the cutaneous affections that are amenable to radio- therapy. Heretofore, however, from 50 to 200 exposures were required to obtain the same result. In other words, the maximum amount of benefit is now obtained with the minimum amount of ray — a fact of very great importance when one remembers that an excess of avray is decidedly injurious. It is impossible, in a book of this kind, to give details regarding the apparatus, the various instruments, and the methods of employing them, nor can details regarding dosage, etc., be entered into. A short bibliography 1 is 1 Schultz, The X-ray in Skin Diseases, Rebman Co., New York. Belot, Radiotherapy in Skin Diseases, Rebman Co., New York. Stein, The Holzknecht Radiometer, Med. Rec, May 20, 1911. MacLeod, The X-ray Treatment of Ringworm of the Scalp, Lancet, May 15, 1909. Hampson, The Epilation Dose, Arch. Rontgen Ray, August, 1911. MacKee and Remer, A Technique for Measuring the Quality and Quantity of the X-ray, with a Discussion Regarding the value of the Pastilles of Platino-cyanide of Barium, Am. Jour. Rontg., December, 1913. MacKee and Remer, The Massive-dose X-ray Treatment of Cutaneous Epithelioma, Med. Jour., New York, March 29, 1913. MacKee and Remer, The Single-dose X-ray Method, Jour. Cutan. Dis., 1912, xxx, p. 528. THERAPEUTIC NOTES 47 appended herewith for the guidance of those who desire to be better informed. Indications for a>ray treatment will be found throughout the book under the descriptions of various diseases. Radium exerts an action similar to the Rontgen rays. The material is still too rare and expensive for it to come into common use. The bromide salt is the one used with a radioactivity of 7000 to 200,000 units or more. It is enclosed in aluminum- or mica-covered capsules or glass tubes and retained in contact with the skin from twenty minutes to an hour or more. It is used for the destruction of new growths. It is probably inferior to the a>ray, but convenient to use in the cavities of the body and for insertion into tumors. Fig. 5 Piffard's roller electrode. High-frequency Currents. — These are electric currents of high potential and great frequency generated by a coil acting usually through an Oudin resonator. The current is applied by means of a handle into which fits a vacuum glass tube of any desired shape; or by means of a point of carbon or platinum fitting into the same handle; or by the Piffard roller electrode. When the electrode is approached to the skin a violet light fills the tube, and a shower of sparks fall upon the skin, giving rise to a tingling sensation. When the tube is in contact with the skin, tingling is not felt, and there are no sparks; but the tube feels warm. These currents are used for stimulation, as in acne, chronic 10 48 DISEASES OF THE SKIN eczema, and alopecia; to relieve pruritus; and to destroy warts and new growths. Fulguration, or high-frequency cauterization, is effected by means of the carbon or platinum point. By it warts and vascular nevi and other small growths may be destroyed. Congelation. — There are four agents used for freezing the skin for therapeutic purposes: 1 . Chloride of ethyl. — This occurs in the form of a glass bulb containing the liquid, which runs out into a capillary tube. When the bulb is held in the hand its warmth drives a fine stream of fluid out of the end of the tube, which soon congeals the part. 2. Rhigolene. — This may be sprayed on the skin with an ordinary hand atomizer. It produces a temperature of 51° below zero Fahr. Though these two have been recommended in the treatment of lupus erythematosus, they are used practically only for the production of local anesthesia, for the opening of abscesses, and for taking sections of the skin for biopsies. 3. Carbon Dioxide. — This comes in iron cylinders furnished with a stop-cock, and is familiar as a part of the fitting of a soda fountain. Boyer 1 suggests the use of Presto-fire tubes for making C0 2 snow. A tube contains sufficient to use once. They are convenient to carry. In order to use the gas, the cylinder should be slightly tipped up, and a piece of chamois skin in several thicknesses wrapped about the vent of the cylinder, so as to form a little bag. The stop-cock is then opened carefully, and the gas allowed to escape, which it does with the sound of escaping steam. In a few moments enough snow has formed in the bag, by condensation, and then the stop-cock should be closed. The snow is moulded with the fingers into a mass which may be whittled to any desired size or shape. Special apparatuses are on the market for collecting this snow. We use one invented by S. Dana Hubbard. It is made 1 Jour. Amer. Med. Assoc, 1912, vol. lviii, p. 1939. THERAPEUTIC NOTES 49 of a perforated brass plate turned up into a cylinder. This is split down the back and the two sections united by hinges. It is covered with chamois leather, and fitted with a nut that screws on to the vent of the C0 2 cylinder. If a very small lesion is to be treated it is convenient to force a little of the snow into an ear speculum. Its temperature is about 90° below zero, Fahr. The snow is simply pressed against the skin, and the depth to which the freezing is carried depends upon the length of the time it is in contact with the skin and the degree of pressure which is used. After ten seconds' pressure the skin is white and hard, a wheal forms in ten minutes, and in six to ten hours there is a circum- scribed area of inflammation with vesicles. A thin crust subsequently forms that falls without a scar. After twenty seconds a bulla will form in six to eight hours, followed by a crust that falls in ten days. After thirty seconds a dry eschar forms that falls in about three weeks without ulceration, and leaving a superficial, smooth, white scar. If deep destruction is desired, the freezing is to be repeated. 4. Liquid Air. — This is atmospheric air condensed by special machinery under great pressure and in the pres- ence of cold. Its temperature is about 312° below zero, Fahr. It looks like water. It is dispensed in specially constructed glass flasks, with double sides. between which is a vacuum. The expansion of the air is so great that the flask cannot be corked tightly, but with a loose-fitting cotton plug. The most convenient way to use the air is by means of a swab made by winding absorbent cotton on a stick. This is dipped into the liquid and pressed against the skin. Its action is simi- lar to that of carbon dioxide, but as it is three times colder its effects are attained in much less time. The actual freezing is not very painful, but the thawing out is. The pain may be somewhat mitigated by the appli- cation of cold water. Congelation is a good means for the destruction of all 4 50 DISEASES OF THE SKIN sorts of nevi. In deep port- wine marks it is of doubtful efficacy. It is one of the best methods for the treatment of lupus erythematosus. It may also be used for the destruction of senile and other warts, and small super- ficial epitheliomas. Massage is of use in stimulating hair growth in alopecia areata, and in other forms of alopecia where there is no disease of the scalp. Also in scleroderma, elephantiasis, and circulatory diseases. It sometimes does good in acne, more often harm. It may tone up flabby skin, as in wrinkles, but does no permanent good. Caiaphoresis is the passing of medicaments into the skin by moistening the positive electrode with the drug and letting the current run for five or ten minutes, using a strength of 10 ma. Cocain, iodin, and salts of copper have been so used when indicated. Bacteriotherapy or Vaccine Therapy} — Phagocytosis is probably the most active defensive process the animal body has against the invasion of microorganisms and the maintenance of active immunity. It was through the investigation of the power of the leukocytes to ingest bacteria in health as compared with disease that Wright and Douglas discovered that this power was dependent upon certain substances in the blood stream, which they called " opsonins." The opsonin seemed to prepare the bacteria in such a way that the leukocytes were enabled to ingest them. They found that the pre- paring substances or opsonins could be markedly increased by injecting into the animal body killed cultures of dead specific bacteria. By comparing the phagocytic power of an infected individual's serum with that of normal serum for the same bacteria, an index was established by Wright and his pupils, called the opsonic index, which, on account of its proved unreliability and imprac- ticability for general use, has been largely discontinued, except for accurate research. 1 Contributed by Dr. M. F. Engman, of St. Louis. THERAPEUTIC NOTES 51 The nature of the bodies called opsonins is not known, but they are probably derived from the tissue cells of the general economy stimulated to the formation of such an antibody by the bacterial products absorbed into the general circulation from the foci of infection. It is therefore necessary for an antigen or bacterial products to enter the general circulation in sufficient quantity to stimulate and not overwhelm the cells of the tissues. According to Sir A. E. Wright, primary infection occurs on account of the lessened quantity of opsonins in the blood; the opsonic content does not drop because of the infection. As opsonins are formed by the tissue cells only upon stimulation by the bacterial products of the invading microorganisms, it is obvious unless these products enter the general circulation such stimulation cannot occur and the distant tissue cells cannot send into the general blood stream the necessary assistance to the infected force — namely, the chemical antibody to prepare the bacteria for ingestion of the opsonin. If the infected foci be walled off by proliferating con- nective tissue, fibrin, broken-down tissue, and other products of inflammation, or, if the foci be in a follicle in which the walls are dense and resistant, or in any position where there is not free interchange of secretions or lymph, very little of the bacterial products escape into the blood stream and the foci do not heal and the con- ditions become chronic. In such instances the bacteria are protected from the antibodies formed in the system and the formation is therefore at a minimum. Wright and his pupils elaborated, by the investigation of these chronic, walled-off infections in the skin, a form of therapy which has proved of great value when properly used. This form of therapy is based upon the fact that by the injection of an emulsion of dead bacteria, specific for the infection, into the tissues of an infected individual, under the above conditions, the antibody formation is thereby increased, and if at the proper time the lymph 52 DISEASES OF THE SKIN be guided with its freshly formed antibodies to the in- fected foci, clinical improvement results. Unfortunately immediately after the injection and for several hours or days, a depression of antibody formation is experienced and the opsonic content of the blood is lowered, consti- tuting the "negative phase" of Wright, to be followed by a gradual rise above the normal or the " positive phase." The negative phase is greatly prolonged by a large dose of bacteria, which is an element in the failure of the method. The dose of bacteria is approximate, but is definitely controlled within certain limits. The cultures for treatment should be derived from the foci of the infected individual when possible, but in the large general run of cases, stock vaccines will prove serviceable; but in every instance the offending organism should be accurately determined. The principal points to be observed in using this form of therapy are: 1. To determine the offending organism when a "stock" vaccine can be used, and in event of failure of the stock suspension, an autogenous vaccine should be made. The latter, however, is always preferable. 2. The initial dose should be small and the size of each dose very gradually increased and interspaced according to clinical results. 3. The fresh immunizing serum should be gently guided to the various foci by means of hot applications. Bier's hyperemia, the various ultraviolet-ray lamps, sunburn, chemical agents, and such other means as will cause hyperemia or "reactionary hyperemia." 4. No manipulation or hyperemia should be encouraged during a "negative phase," therefore at least forty-eight hours should elapse between an injection and local treatment. Classification. In the present state of our knowledge it is impossible to make a satisfactory classification of skin diseases. Many attempts have been made to do this, and are still CLASSIFICATION AND NOMENCLATURE 53 being made. Hebra's classification modified is found in a great many text-books. The arrangement of this book does away with classification. The one here given follows that given by Crocker, and has proved itself, after a number of years of use, a practical one. CLASSIFICATION AND NOMENCLATURE. Class I. HYPEREMIA. II. EXUDATIONES. HEMORRHAGES. IV. HYPERTROPHIC. V. ANOMALIES OF PIGMENTATION. ATROPHIC NEUROSES. NEOPLASMATA. MORBI APPENDICUM. III. VI VII VIII IX X. PARASITE Class I. HYPEREMEE— CONGESTIONS. Most prominent primary lesion. Erythema. Erythema simplex. pernio, intertrigo, scarlatiniforme. fug ax. roseola. Class II. EXUDATIONES— INFLAMMATIONS. Erythema exudativum multiforme. Peliosis rheumatica. Erythema nodosum. Erythema nodosum elevatum diu- tinum. Pellagra. Acrodynia. Urticaria. pigmentosa. Eczema. Dermatitis repens. Impetigo contagiosa. Folliculitis. Pompholyx. Herpes. progenitalis. Zoster. Pemphigus. neonatorum. Epidermolysis bullosa. Equinia. Hydroa seu Dermatitis herpeti- formis. Most prominent primary lesion. Erythema and papules. Erythema in soft swellings. Erythema. Wheals. Persistent wheals. Multiform lesions. Epidermic denudation and fluid exudation. Vesicles and pustules. Hair-follicle pustules. Bullae and vesicles. Grouped vesicles. Bulla?. Multiple lesions. Grouped multiform lesions. 54 DISEASES OF THE SKIN Impetigo herpetiformis. Dermatitis. epidemica. Psoriasis. Pityriasis rubra sen Dermatitis ex- foliativa. Pityriasis rosea. Lichen scrofulosorum. " pilaris. " planus. ruber. " variegatus. Pityriasis rubra pilaris. Prurigo. Furunculus. Carbunculus. Abscess. Pustula maligna. Ulcus. Erysipelas. Conglomerative pustular folliculitis. Dermatitis gangrenosa. Most prominent primary lesion. Qrouped pustules. Multiform lesions. Erythema and papules. Scaly crusts on red base. Diffuse redness with large scales. Oval, scaly, red patches, with yel- lowish centre. Papules, grouped. " follicular. flat, angular. acuminate, scaly. flat, and reticulated scaly spots, acuminate, scaly. " lenticular. Phlegmonous. Loss of substance. Erythema with brawny swelling. Patches of aggregated pustules. Gangrene. Purpura. Scorbutus. Class III. HEMORRHAGIC— HEMORRHAGES. Blood extravasation. Class IV. HYPERTROPHIC— HYPERTROPHIES. Parts affected. Ichthyosis. Epidermis and papillae. Keratosis pilaris. Papules about hair follicles. Acanthosis nigricans. Epidermis and papillae. Verruca. Clavus. Cornu cutaneum. Callositas, Tylosis. Porokeratosis. Angiokeratoma. Keratosis follicularis. " pilaris. Scleroderma. Morphea. Sclerema neonatorum. (Edema " Elephantiasis. Acromegaly. Epidermis. Sweat-orifice keratosis. Folicles. Hair follicles. Corium. Whole skin. Class V. ANOMALIES OF PIGMENTATION. Chloasma. Lentigo. Albinism. Leukoderma. Melanoderma. Pigment. CLASSIFICATION AND NOMENCLATURE Class VI. ATROPHIA— ATROPHIES. Parts affected. Atrophia cutis propria. Corium. Atrophoderma senilis. Atrophoderma striatum et macu- latum. Atrophoderma pigmentosum. Ainhum. Class VII. NEUROSES— SENSORY DISEASES. Hyperesthesia. Dermatalgia. Pruritus. Anesthesia. Ulcus perforans. Morvan's disease. Class VIII. NEOPLASMATA— NEW GROWTHS. Molluscum Colloid degeneration Xanthoma Lupus vulgaris erythematosus Scrofuloderma Tuberculosis verrucosa cutis Erythema induratum Syphiloderma Lepra Rhinoscleroma Leukoplakia Keloid Fibroma Acrochordon Myoma Neuroma Nevus pigmentosus vasculosus Telangiectasis Angioma serpiginosum Angiokeratoma Rosacea Lymphangioma Dermatolysis Carcinoma Paget's disease Epithelioma Sarcoma Sarcoid Leukemia and pseudoleukemia cutis Mycosis fungoi'des Yaws Verruga peruana Furunculus orientalis Phagedena Acanthoma Degeneration. Infiltrating. Benign. f Malignant. 56 DISEASES OF THE SKIN Class IX. MORBI APPENDICUM— DISEASES OF THE APPENDAGES. A. Sweat Glands. Hyperidrosis. Bromidrosis Chromidrosis Hsematidrosis Uridrosis Anidrosis. Miliaria crystallina (sudamina) . papulosa. Hydrocystoma. B. Sebaceous Glands. Seborrhcea. Seborrheic dermatitis. Milium. Comedones. Acne vulgaris. rosacea. varioliformis. " agminata aud folliclis. Sebaceous cyst. Adenoma sebaceum. Asteatosis. C. Hair. Hypertrichosis. Atrophia. Alopecia. " areata. Concretions. Trichorrhexis nodosa. Canities. Sycosis. Folliculitis decalvans. Dermatitis papillaris capillitii. Nevus pilosus. Plica polonica. Trichiasis. Distichiasis. D. Nails. Pterygium. Onychia. Paronychia. Atrophia. Onychogryphosis. Onychomycosis. Leukopathia unguium. Most prominent primary lesion. Excessive secretion. > Altered quality. Deficient secretion. Vesicles. Inflammation. Vesicles. Excessive secretion. Multiple inflammatory lesions. Retained secretion. Inflammation. Redness and pustules. Inflammation. Aggregated and disseminated pustules. Retained secretion. Papules. Deficient secretion. Excessive growth. Defective growth. Baldness. " in patches. Growths on the hair shaft. Nodes on hair shaft. Loss of pigment. Inflammation. Alopecia with inflammation. Inflammation. Excessive growth with pigmenta- tion. Felting. Misplacement of cilia. Overlapping of nail fold. Inflammation. Defective growth. Overgrowth. Fungus growth in nail. White spots in nails. CLASSIFICATION AND NOMENCLATURE 57 Class X. PARASITI— PARASITES. A. Vegetable. Favus. Trichophytosis. Tinea imbricata. A. Vegetable. Chromophytosis (tinea versicolor) . Erythrasma. Mycetoma. Actinomycosis. Pinta. Blastomycosis. B. Animal. Scabies. Demodex folliculorum. Leptus autumnalis. Pulex penetrans. Estrus. Larva migrans. Pediculosis. Cysticercus cellulosa cutis. Dracontiasis. Parasite- -Achorion. Trichophyton. Parasite — Microsporon. Parasite — Microsporon minutissi- mum. Tumors. Discolored macules. Tumors. Parasite — At Parasite — Pediculus. " — Tenia solium. " — Filaria medinensis. PART II. THE DISEASES OF THE SKIN AND THEIR TREATMENT. Abscess. Symptoms. — Abscesses are very frequently met with as complications of diseases of the skin, such as acne, eczema, scabies, pediculosis, and other acute dermatides. As thus met with they are usually of small size, though at times, as upon the scalp of a strumous child, they may attain considerable dimensions. They form rounded swellings that are at first tense but soon become soft and fluctuating. When incised, more or less thick pus escapes. Their most frequent locations are: upon the scalp with eczema; upon the face and back with acne; about the neck arising from broken-down glands; and upon the extremities with scabies and pediculosis. Apart from a slight amount of discomfort, they do not give rise to subjective symptoms, as a rule, and are, indeed, trivial affections. Of course, this does not apply to abscesses as seen by the surgeon. They may open of themselves and discharge their contents upon the skin. More commonly they are very sluggish in their course, and must be evacuated by some surgical procedure. Cutaneous abscesses are most commonly due to micro- organisms. Diagnosis. — An abscess differs from a furuncle by not being raised into a conical mass ; not having a central core, and by being less firm to the touch. It differs from a carbuncle by an entire absence of marked constitutional disturbance, brawny infiltration, intense inflammation, and 60 DISEASES OF THE SKIN cribriform mode of opening. Kerion often resembles an abscess, but differs from it in its uneven surface and its firmness to the touch. Syphilitic gummas are sometimes mistaken for abscesses and opened. They may be recognized by their dark red color, the absence of pain and discomfort, and the history of their growth. They grow slowly, beginning below the skin. There is generally more than one present, and then they are grouped. The aspiration of the tumor will decide the question. From an abscess we obtain pus; from a gumma a little bloody fluid. Treatment. — The management of the small cutaneous abscesses that we meet with as dermatologists is simple. The cavity is to be opened, the pus allowed to escape, and the part dressed with carbolized vaselin if small, or antiseptically if larger. It is sometimes necessary to swab out the cavity with a solution of carbolic acid, either 95 per cent., if the abscess is small, or of two drachms to the ounce, if large, to destroy the abscess wall and prevent the re-formation of the abscess. Acantholysis. — A disease characterized by loosening or separation of the mucous layer of the epidermis. (See Epidermolysis.) Acanthosis Nigricans. — Under this name cases have been reported by Politzer, Janovsky, Crocker, and a few others. It occurs at any time of life, but most often between the thirtieth and fortieth year. The first symp- tom may be pigmentation of the face and neck; or an eruption of warts on the backs of the hands or thighs; or itching on the inside of the thighs or in the mouth. Later there is a dirty brown to ' bluish-gray or black discoloration of the skin and mucous membranes, with more or less papillary outgrowths and seborrheal warts. On the places that are most discolored the papillary out- growths are most marked. The skin is thickened to a greater or lesser degree, and is not scaly. The eruption is more or less general, but the regions most often affected ACARO-DERMATITIS URTICARIODES 61 are the face, neck, mucous membranes of the mouth (especially the tongue), the backs of the hands (especially the fingers), the axillse, groins, genito-anal regions, and abdomen. Keratoses of the palms and soles are often found. Women are more often affected than men. Most cases occur after the forty-sixth year. It may occur as early as the second year. Late in the disease the hair and nails are lost. The cause of the disease is unknown. Rille 1 regards it as a form of keratosis. Darier, J. Burmeister, 2 and others say that it is often due to cancer affecting the abdominal sympathetic. The prog- nosis is bad, death resulting in from eight months to two years. In some cases the duration is much longer. In children and in young adults the prognosis is better, as in them it may remain stationary for an indefinite time. A cancerous cachexia is often developed and cancerous degeneration of some abdominal organ recog- nized. Treatment thus far has been unavailing. Acaro-dermatitis Urticariodes, or Grain Itch. — Schamberg 3 and others have reported cases of this disease occurring epidemically. The eruption consists of wheals, many of which have at their summit a central pinpoint-sized vesicle, at first clear, later becoming cloudy. There may be barely elevated erythemato or papulo-urticarial lesions. The lesions vary in size from a lentil to a finger nail, and are either round, oval, or irregular in shape. They are rosy in color, rarely pinkish white. There are many excoriations. The eruption is usually profuse on the trunk, while the hands, feet, and face are often spared. Itching is pronounced, especially at night. At first there may be chilliness, a temperature of 100° to 102° F., nausea and vomiting, which may last several days, though many patients are not at all ill. The duration of the disease is from seven to ten days, the eruption beginning to fade in from twelve to thirty-six hours. 1 Wien. med. Wochenschr., 1897, xlvii, 1019. 2 Arch. f. Dermat. u. Syph., 1899, xlvii, 343. 3 Jour. Cutan. Dis., 1910, xxviii, 67. 62 DISEASES OF THE SKIN The histopathology is the same as that of urticaria. A moderate leukocytosis and eosinophilia are present in most cases, and albumin is found in the urine. Etiology. — The disease is due to irritation of the skin by the pediculoides ventricosus, a mite that invests straw. All the patients give a history of having slept on fresh straw mattresses or fresh straw. Diagnosis. — It is distinguished from urticaria by its longer duration, central vesiculation, more marked constitutional disturbances, and its epidemics in groups. Varicella runs a shorter course, its vesicles are larger and are not seated on wheals, and it lacks the intense itching. The lesions of scabies are scratched papules which are found in certain definite locations, more especially the extremities, and the disease has no constitutional disturbance. Treatment. — The clothing and mattress should be disinfected. The patient is to be given a warm bath, and his skin anointed with such an ointment as /3-naphtol, gr. xxx (2), sulphur precipitat, gr. xl (2.66), adepis benzoat, §j (32). Acne. — Synonyms: (Ger.) Finnen; (Fr.) Acne, Bouton; Stone-pock, Pimple. Acne is an inflammatory disease of the sebaceous glands and the hair follicles, characterized by an eruption of papules, pustules, or nodules upon the face, neck, shoulders, or chest, which usually begins at puberty and tends to run a chronic course. There are two varieties of acne, namely, acne vulgaris and acne indurata. Acne Vulgaris, or Simplex, is either papular or pustular in character, though usually it is a combination of the two, together with more or less comedones and a certain amount of seborrhea. Symptoms.— If only papules exist (A. papulosa), the face, shoulders, or chest will be found to be dotted more or less profusely with pinhead-sized acuminated eleva- ACNE VULGARIS 63 tions of the skin, of a pinkish to red color, and with a central opening at the summit. Very often the central openings will be filled with blackish specks. The lesions are then spoken of as A. punctata. There are many comedones present. It is rare that acne exists only in the papular form. More usually it will be found that here and there the papules are surmounted by a pustule, or a pustule has taken the place of a papule. We now have A. pustulosa. The central black point is wanting. Fig. 6 €* Acne vulgaris. By courtesy of Dr. S. I. Rainforth. In strumous subjects the pustular element preponderates over the papular, and the face may be greatly disfigured by the large number of lesions upon it. The pustules are from pinhead to small-pea size, and have an inflamed base (Fig. 6). The lesions of acne are located on the face, the shoulders and on the chest and back. True acne rarely is found below the free border of the ribs anteriorly or posteriorly. Together with the acne and the comedones we meet 64 DISEASES OF THE SKIN with milia quite commonly, and the affected parts are usually greasy to the feel, showing that the sebaceous glands sympathize in the disease. We now have a fair picture of a typical case of acne vulgaris. The face, back, neck, chest, and shoulders, or all five, are dotted over in an irregular manner with blackish points, papules, and small pustules; the skin of the nose and forehead looks shiny and feels greasy, and perhaps there are some milia scattered about the region of the eyes. At times the eyes will appear inflamed and hyperemic, especially in young, otherwise robust subjects. More commonly the complexion will have that pasty appearance indicative of what has from old times been called the strumous condition. Not unfrequently the skin is abnormally red. If the inflammatory process has been unusually severe, we may find a considerable amount of scarring. Usually acne vulgaris does not leave permanent scars. The profuseness of the eruption varies greatly. In some cases there will be but a few lesions, while in other cases they will be present in vast numbers. This form of acne generally occurs in young people. The duration of the individual lesion is short, as it soon either dries up or discharges its contents. If the papules are squeezed, vermicelli-like masses of sebaceous matter will be ex- pressed. If the papulopustules are treated in the same way, there will first be pressed out a drop or two of pus, and then more or less of a sebaceous plug. Acne Indurata is a pustular acne in which the pustules are of large size and seated upon deeply infiltrated bases. They are most commonly sparsely dispersed, and take the form of purplish " lumps " of pea to bean size, which are hard to the touch. Sometimes they are more readily appreciated by touch than by sight, being located deeply in the skin. Sometimes they take the form of cutaneous abscesses, and if by chance several are located close to one another, they may run together and form a raised, dark-red, doughy mass. When incised, these lesions ACNE IN DU RAT A 65 sometimes give exit to a large amount of thick pus. They usually leave scars, which sometimes are very dis- figuring unless they are opened very early in their course. It may be the only form of acne present, or it may be combined with acne vulgaris. This form of acne usually occurs at a more advanced age than does acne vulgaris, though it is not unfrequently met with in early life, and may persist throughout life. While occurring on the Fig. 7 Acne indurata of the back. face, the neck and back are the regions in which it is prone to develop in the most marked manner, and to be most persistent (Fig. 7). Etiology. — Acne is one of the most common of skin diseases, and its great predisposing cause is youth. The disease first shows itself about the time of puberty and manifests a tendency to disappear when the body is fully developed — that is, from the twenty-third to the 66 DISEASES OF THE SKIN thirtieth year, although it may continue much later. A few rare cases have been reported of acne at an early age. Thus, Chambard 1 met with a case in a girl, aged six and a half years. The indurated form of acne appears later than the simple form, usually after the twenty-fifth year. Both sexes are affected, but the disease is more frequent in females than in males, and in them begins at an earlier age. The period of youth is the time of great developmental activity in which the sebaceous glands take part, and it is at this time we frequently have a seborrhea of the face and other parts. In nearly every case of acne the skin of the nose is greasy and feels slippery to the touch. This greasy skin is another predisposing cause of acne. It provides a favorable soil for the growth of the bacillus acnes, which probably is the exciting cause of the disease. Individuals with thick, pasty, pale skins, with patu- lous follicular mouths, are predisposed to acne. These peculiarities of skin are met with in scrofulous subjects. The disease is less common and severe in negroes than in white people. The patulous follicular mouths give ready lodgement to foreign matters, and comedones are thus formed. This prevents the escape of the follic- ular contents, a plug is formed, and we have an acne papule or pustule. Comedones are, therefore, an exciting cause of acne. Heredity has some claim to be regarded as a predis- posing cause of acne, but the disease is so common that there is no certainty about this factor. Digestive disturbances, while not causing acne, are most active in aggravating it, as they increase the con- gestion of the skin and the seborrheal condition: These may take the form of dyspepsia, stomachal or intes- tinal; or malassimilation; or failure on the part of the liver or pancreas to perform its physiological functions; or sluggishness of the large intestine and consequent 1 Ann. de derm, et de syph., 1878-79, x, 259. ACNE INDURATA (37 constipation. Improper diet, so common in early life, is responsible for the maintenance of many cases of acne. Next to disorders of the digestive organs, those of the sexual organs are suposed to have most influence in aggravating acne. But inasmuch as most cases of acne are amenable to the influence of diet and regulation of digestive disorders without any attention being given to sexual disorders, it is probable that the latter are important etiological factors in comparatively few cases. Indeed, it is not improbable that the acne that appears on the faces of women at each menstrual period, and at that time alone, as well as the aggravation of an already existing acne, is due to the more or less pronounced disturbance of the digestive organs so frequently observed at the same time. In some cases acne does seem to be a reflex irritation from the uterus. Amenorrhea is the uterine derangement most frequently encountered, but that condition is but one evidence of a general constitu- tional disorder rather than a disease in itself. Masturbation and continence have each been blamed as excitants of acne. The former of these of itself does not cause acne, but its well-known effects on the nervous, moral, and physical condition of growing youths would sufficiently account for any part it may have in producing acne. There is absolutely no proof that continence causes acne. It is safer to say that bad sexual hygiene may cause acne, rather than to ascribe it either to masturbation on the one hand or to continence on the other. It may be stated, as a broad, general rule, that anything that lowers the general health of the patient contributes to the production of acne. We have space to enumerate only some of these exciting causes. Thus we have the vague state "general debility," anemia and chlorosis, oxaluria and uremia, rheumatism and gout, poor circu- lation, mental and physical exhaustion, and chronic 68 DISEASES OF THE SKIN malaria. J. Schutz 1 believes that deficient heart action and consequent slowness of the circulation are the under- lying causes of acne, as they lead to an alteration of the sebaceous secretion. Pathology. — Acne may begin in the hair follicles or in the sebaceous glands, and may be due either to their becoming clogged up by inspissated sebum and acting like a thorn in the flesh, or to their invasion by micro- organisms, either from without or within, which set up a suppurative perifolliculitis. The papules of acne are located in the upper part of the skin, while the pustules are deeper. In very bad cases the follicle may be entirely destroyed by the perifolliculitis and scars will be left. The sebaceous glands do not take a very active part in the process. Microorganisms are found abundantly in the suppurating gland cavities. In acne indurata we find the hair follicles enormously dilated, their orifices filled with corneous cells, and their cavities almost converted into cysts. The connective tissue about the follicles shows decided signs of inflamma- tion, and may be increased in amount. Very often the follicles are destroyed by the perifollicular, inflammation. When the perifolliculitis is severe and extensive the deep layers of the skin become involved, and we have abscess formation. According to Unna the comedo is not due to stopping up of the follicle by extraneous matter, but to a hyper- keratosis closing up the follicle mouth, and the black- head is due to degeneration of the compressed horny cells. Unna, Sabouraud, and Gilchrist each describe a special organism as the cause of acne. Unna found a flask bacillus and a diplococcus and another bacillus. Sabouraud describes still another bacillus as the cause of the disease, and believes that the invasion of the infected follicles by staphylococci of gray culture produces the pustular form Gilchrist's bacillus acnes is pyogenic. iArch. f. Dermat, u. Syph., 1900, ii, 323. ACNE INDURATA 69 It is short and thick, straight or curved, and sometimes branched. The microorganisms of Sabouraud and Gil- christ are identical. The seborrheic skin is the proper ground for infection by it. It seems evident, therefore, that the disease is parasitic, and this theory best explains the course of the disease. As one grows older the charac- ter of the skin changes, so that it is no longer a proper habitat for the organisms, just as in ringworm of the scalp, which undergoes spontaneous recovery after puberty is reached. In all pustular lesions the common forms of staphylococci are found. Diagnosis. — Acne is to be differentiated from rosacea, papular and pustular eczema, sycosis, the small pustular and tubercular syphilid, and variola. Rosacea is due to a dilatation of the bloodvessels, and is attended by hyperemia and telangiectases. If there are any pustules, they are superficial and due to local infection, and if expressed give exit to only a drop of pus. Acne is a disease of the sebaceous glands, and papules and pustules constitute the disease. They are often large, and if expressed will give exit to a plug of sebaceous matter and thick pus. Rosacea, as a rule, occupies the middle third of the face alone, the forehead, nose, and chin. Acne is scattered over the whole face, and is often found on the shoulders. Papular eczema may occur at any age; acne usually occurs between the ages of fifteen and twenty-five. Papular eczema rarely is seen on the face alone, and is prone to attack the trunk and extremities; acne often occurs on the face alone, and is never disseminated over the limbs and trunk. In eczema there is an absence of comedones; the papules are often surmounted by or change into vesicles; they tend to form patches, and the disease is very itchy, so that scratch marks are almost invariably found. When it gets well it leaves no trace on the skin. These symptoms are foreign to acne. In pustular eczema, or what has been called impetigo simplex, we have a large number of small pustules 70 DISEASES OF THE SKIN running together to form patches which rapid ly become covered with greenish or yellow crusts. The disease runs a far more acute and stormy course than does acne, and is itchy. It is very frequently met with in children, whom acne rarely affects. Sycosis is a pustular disease affecting the hair follicles alone, each pustule being pierced by a hair. Acne occurs on the non-hairy as well as the hairy parts, and, indeed, shows preference for regions supplied only with rudi- mentary hairs. Acne necrotica is especially located along the hair line, and invades the scalp, which acne never does. It also runs a more sluggish course, its papules soften at their summits, become surmounted by a small, sunken-in crust, which on falling leaves variola-like scars. The small pustular syphilid, or syphilitic acne, is a general eruption, and it is easy in most cases to obtain other evidences of syphilis, such as the remains of the initial lesion, enlarged lymphatic glands, mucous patches or the like. It is usually more uniform in its lesions, and these are plainly papulopustular. The color of the areola is more that of raw ham and less inflammatory looking than is that of acne. The lesions sometimes show a tendency to group into segments of circles, and each lesion undergoes a definite development. They sometimes leave small, smooth, white scars that may disappear in a few months. They are not confined to the chest, back, and face, but are scattered over the body. The tubercular syphilid could be mistaken for an indurated acne. With it there will usually be found other evidences of syphilis. The lesions group themselves into patches that are kidney-shaped or form segments of circles. The tubercles are dark red or raw-ham colored, surrounded by a well-marked areola, firm to the touch, and do not contain pus. They may ulcerate, or, being absorbed, leave pigmented and punched-out cicatrices, and, finally, smooth white scars. The scars left by acne indurata are puckered and more disfiguring. ACNE INDURATA 71 Variola could scarcely give rise to much doubt, as it has well-marked constitutional symptoms, and its lesions undergo a definite and characteristic development. Treatment. — In the treatment of acne we can obtain a cure most rapidly by a combination of internal and local treatment. We, therefore, begin the treatment of a case by a careful inquiry into the general condition of the patient, and endeavor to regulate any, even the slightest derange- ment of the internal organs. By so doing we may find no one of those conditions enumerated under the etiology of the affection, and the patient may consider himself as in the best condition. Further observation will probably reveal some deviation, though slight, from perfect health The relief of constitutional disorders is conducted according to the principles of general medicine, and cannot be given here. Many of the cases require cod-liver oil and iron as general measures quite apart from any evident disease This is the case in the sluggish cases occurring in strumous subjects with pasty skins. In plethoric subjects with a good deal of inflam- mation attending the acne, laxative agents such as yo" grain of calomel in tablet triturates, given three or four times a day, will aid in a cure. Whitfield recom- mends menthol in 1 to 2 grain doses after each meal to subdue gastric reflexes and flushing of the face. Diet and hygiene are to be employed rather than drugs. It is impossible here to lay down fixed principles of diet, and it is better to study each case by itself. A good rule is to cut off all sweets, pastry, and cake, and give for breakfast and luncheon, or supper, a cereal, but not oatmeal, with milk and cream, bread and butter, and fruit. For dinner, meat, vegetables, salads with plain dressing, and light puddings may be allowed. A cup of coffee may be permitted in the morning, but no tea or alcoholics. In many cases coffee should not be allowed. The food must be well masticated. It must be remembered that milk is a food, and that when 72 DISEASES OF THE SKIN other foods are partaken of freely the taking of milk at the same time may overload the stomach. The omission of milk from the dietary will be of great benefit in some cases of acne. Hot water before meals, a glass of water at meals, two hours after meals, and on going to bed are good directions for the use of beverages. Butter may be used freely, and care must be had not to restrict the diet too greatly. Many young girls almost starve themselves in the mistaken idea that a low diet will give them a fine complexion. Exercise must be insisted on, an hour or more a day being spent in walking, horseback- or bicycle-riding, rowing, or other out-door exercise. Daily bathing or dry rubbing will keep the skin in healthy condition, and Turkish baths are often beneficial. Where a shower bath is at hand it is well to have the patient stand in about four inches of warm water, and allow the shower to fall first warm and then cold; this to be followed by brisk rubbing with a coarse bath towel. Where patients either cannot or will not take a daily bath, much good will be accomplished by having them bathe the chest and back daily with cold water and then dry the skin by brisk rubbing with a coarse towel. There is no drug that can be considered as a specific in acne. Arsenic is of use only in very chronic, sluggish cases, and the more papular the case the more useful the arsenic. It should be used as the last resort, not as the first. Fowler's solution is the most frequently used prepara- tion in doses of from 3 drops (0.194) three times a day as an initial dose, gradually increased to 15 or 20 (1 to 1.33) drops or until the appearance of some symptoms of poison- ing. Piffard 1 recommends bromide of arsenic in the dose of ttTo to 5V grain two or three times a day in rather acute cases of acne. A convenient method of administration is to make a 2 per cent, solution in alcohol and give 1 or 2 minims of that in a wineglassful of water. Should 1 Jour. Cutan. and Ven. Dis., 1884, ii, 71. ACNE INDURATA 73 it cause gastric irritation the dose must be lessened. We have used this in a number of cases with good results. The sulphid of calcium, has its advocates for sluggish pustular cases. It is of doubtful value. Glycerin was advocated by Gubler 1 as a cure for acne, and is well spoken of by others. It must be given in doses of a teaspoonful three times a day increased to a table- spoonful, and is of most use in strumous cases. Ergot, either the^ fluidextract in doses of \ drachm (2) three times a day or a corresponding amount of ergotin, has many advocates. Small doses of the bichloride of mercury are sometimes curative where there is much infiltration. Iodide of 'potassium in doses of from 1 to 5 drops (0.065 to 0.33) of a saturated solution, well diluted, taken three times a day before meals, sometimes is useful in pustular acne. As acne is a local infection of the skin we have little faith in the administration of drugs for its cure except to meet symptoms. Vaccines often are most efficacious. According to Engman: "Initial dose of acne bacillus suspension, 5,000,000; interval of dose, five to seven days; gradual increase of dose to 10,000,000; hot applications dur- ing positive phase — forty-eight to seventy- two hours after each injection; opening of large, deep lesions forty- eight to seventy-two hours after injection, when the walls of the little cavities should be rubbed together or so manipulated that fresh lymph be induced into and about them; after immunity has been established, monthly or bimonthly injections should be continued for some time to prevent relapse; after immunity has been greatly improved, a reactionary inflammation produced by any of the numerous pastes is very beneficial. In treating acne vulgaris with bacterial suspensions one must be certain that the suspensions used are from cultures of the acne bacillus, as many short, thin, or fat bacilli 1 Jour, de Bruxelles, 1870. 74 DISEASES OF THE SKIN are so disguised. If the staphylococcus is prominent in the smears from the lesions, 50,000,000 of these should be mixed with each dose of the acne suspension. Acne vulgaris is primarily a folliculitis and perifolliculitis, and of a very chronic character, therefore, lqcal guiding influences for the lymph is nearly always necessary." The objects of local treatment are to open up the pus- tules and papules and allow of the escape of their con- tents, to stimulate the skin to a more healthful action, and to prevent further infection of the follicles by micro- organisms. To attain the first two objects, we may employ either a quick or a slow method; to attain the last object, we employ an antiparasitic. The best pre- ventive local treatment is to keep the skin clean and its nutrition good by the use of soap and water. The patient is directed to make a thick lather on the skin with soap and warm water and to work it into the skin for a few minutes with the ends of the fingers. The soap is then to be washed off, the skin dried, and wiped off with pure alcohol. Fig. Fox's ring curette. An efficient local treatment for very profuse cases of acne is to put the skin on the stretch and scrape it some- what roughly with a large and long, blunt dermal curette with a fenestrated blade (Fig. 8). This tears off the tops of all the lesions, presses out the contents of the follicles, and stimulates the skin in a most vigorous manner. It is followed by some bleeding, which it is well to encourage by the use of warm water. Deep pustules or cutaneous abscesses, if not emptied by the curetting, should be incised. All comedones should be squeezed out. The after-treatment consists in washing the face with warm water and soap and dusting with corn starch, to which may be added oxide of zinc. Instead ACNE INDURATA 75 of this a solution of peroxide of hydrogen or of bichloride of mercury, 1 to 1000, or pure alcohol may be dabbed on. The scraping is to be repeated two or three times a week. The procedure is rough and many patients will not endure it. After the first scraping the patients do not mind it much, and the result is the attainment of a smooth skin in a comparatively short time. Twenty-four hours after the scraping we may use lotio alba, as given later, or a lotion of bichloride of mercury, 1 to 1000, or peroxide of hydrogen. The same results can be attained in a slower way by opening every pustule with an acne lancet (Fig. 9) and squeezing out every comedo. This is to be done once or twice a week and lotio alba used between times. Fig. 9 Fox's acne lance and dermal curette. Very timid patients who will allow no surgical inter- ference nor the use of vaccines may be treated according to the same principles by directing them to scrub their face thoroughly once a day with green soap or tincture of green soap, and leave the lather on. After a day or two of good scrubbing, sufficient dermatitis will be excited to cause the old skin to peel off, while the tops of many of the lesions will have been torn off and the skin will have been decidedly stimulated. Not until the skin has become scaly and feels tense to the patient should a soothing ointment be applied. Repeated applications of the soap frictions will slowly bring about improvement. Rubbing the face with fine sand or coarse corn meal will do good, but is not so elegant. Massage of the skin is of doubtful value, as it some- times seems to spread the disease. The tips of the fingers should be dipped in cold cream, and then, pressure being exerted by them, the skin of the forehead should be 70 DISEASES OF THE SKIN deeply stroked from the middle line out and over the temples. The nose should be stroked from the bridge outward and downward. The skin of the cheeks should be pinched up and rolled between the fingers and thumb. These movements facilitate the emptying of the follicles. Stel wagon makes the good suggestion that instead of manual massage a small cupping glass with one inch opening should be used. The application of the galvanic current by means of the roller electrode, or by ordinary sponge electrodes, will in some sluggish cases prove helpful. G. W. Wende 1 recommends placing the electrodes in close proximity on the face and constantly changing their position until the skin becomes reddened. The amount of current to be used depends upon the ability of the patient to bear pain. Where the skin is very sensitive the anode can be held in one place and the face gently stroked with the cathode, using 5 to 10 cells for fifteen minutes. Stelwagon speaks well of the faradic current where there is sluggish muscular tone, using it strong enough to produce slight muscular reaction. The high-frequency current has its advocates, the glass electrode being used both for sparking the individual lesions and for stimu- lating the skin by direct application to it. The x-rays have proved curative. The treatment should never cause more than a slight erythema. The single dose method should be employed. It is a dangerous method of treatment and should be used only in stubborn cases, especially in those leaving scars. The use of the Kromayer lamp is also advocated. The first exposure should be at 50 cm. distance for one or two minutes. Subsequent ones should be given in four or more days on the subsidence of the erythema, and may be at shorter distance and of longer duration. The foregoing methods may be called the mechanical treatment of acne. Where they cannot be employed either 1 Buffalo Med. Jour., 1898-99, xxxviii, 254. ACNE INDURATA 77 because the patient lives at a distance, or cannot attend frequently enough, we must resort to the chemical treat- ment. A vast number of prescriptions have been written which are "good for acne/' the majority of which con- tain sulphur in some form, and in the strength of \ drachm (2) to 1 drachm (4) to the ounce (32), and in ointment or lotion form. Sulphur in powder form is good if the patient does not mind the odor. The ordinary sulphur ointment of the Pharmacopoeia is as good a preparation as any. It may be made more elegant by adding some perfume, and more efficient by adding 2 per cent, of salicylic acid. The sulphuret of potassium may be used in the following: 1$ — Potass, sulphuret., Zinci sulphat., aa 5.1 aa 4 Aquae rosas, ad ^iv 120 M. This preparation is commonly spoken of as "lotio alba," and is one of the most useful of the compounds of sul- phur. It is to be applied two or three times a day, after being well shaken. It is often rendered more active by adding to it a drachm of precipitated sulphur, and still more so if once a day the skin is washed with green soap. We have found a modification of this lotion even more efficient, the formula of which is: 1$ — Acid, salicylici, Potass, sulphuret., Zinci. sulphat., Puli. acaciae, aa 3j 4 Aquae rosae, ad §iv 120 M. If the skin becomes inflamed from either of this, cold cream should be used for a few days. Kummerf eld's lotion composed of: i — Sulphur praecipitat., 5iv 16 Pulv. camphor, gr. x 65 Pulv. tragacanth, gr. xx 133 Aquae calcis, Aquae rosae, aa §ij 60 is a favorite of manv 78 DISEASES OF THE SKIN Mercurial preparations may be used to more advantage in some cases than those of sulphur. It should be borne in mind that a mercurial must never be applied to the skin until all traces of sulphur are removed, or vice versa, because if the precaution is forgotten the black sulphide of mercury will be formed, which will give the skin the appearance of being sowed with powder grains. A lotion of corrosive sublimate, 1 to 2000 to 1 to 1000, may be mopped on once or twice a day, or an ointment of the protiodide, as recommended by Duhring, may be used: 1$ — Hydrarg. protiodid., gr. v-xv 0.33 toll Hydrarg. ammon., gr. x-xxx 0.65 to 21 Ungt. simplicis, gj 30| M. Lassar 1 recommends the following paste- ls — /8-naphtol, 10 parts. Sulph. praecip., 50 " Vaselin., Sapo viridis, aa 25 " M. This is to be spread upon the skin to the thickness of the back of a knife-blade, and left on for fifteen to twenty minutes. It is then to be wiped off with a soft cloth, and the skin powdered with talc. The skin becomes inflamed, turns brown, and peels off. The application is to be repeated every day until the skin does peel off. Desquamation can be hastened by the application of Lassar's paste with 2 per cent, of salicylic acid. Resorcin is useful in 20 per cent, aqueous solution dabbed on the face two or three times a day until a dermatitis is caused. This is allowed to subside under cold cream, and when it has subsided the rescorcin is to be used again. Ichthyol, the ammoniosulphate, is recommeded by Unna for acne, either as a 3 to 5 per cent, ointment or as a 3 to 10 per cent, aqueous solution. As much as 15 grains (1) of it are to be taken by the mouth during the day in divided doses. A mild corro- 1 Therap. Monatshefte, 1887, No. 1. ACXE INDURATA 79 sive sublimate wash is to be applied to the face until the patient goes to bed, and then a 10 per cent, aqueous solution, or paste of ichthyol is to be kept on until morn- ing. Startin 1 has employed local steam baths by means of a steam atomizer, with success. The steaming should be kept up for twenty to thirty minutes, and tincture of benzoin used in the medicine cup. While useful in some cases it does harm in other cases. The foregoing remedies are all especially adapted to more or less sluggish cases, the type met with in the great majority of instances. In very recent and quite inflammatory cases, besides the administration of laxa- tives and the regulation of the diet, the patient should be directed to bathe the face with hot water, either with or without the addition of borax (5ij to Oj), and apply a soothing ointment. When the inflammatory symptoms subside, recourse must be had to some of the above detailed methods of treatment. Bathing of the face with hot water before the appli- cation of any lotion or ointment should be advised. In indurated acne, where cutaneous abscesses have formed and the lesions are discrete, each abscess will have to be opened up with a lancet, the contents of the abscess discharged, and carbolic acid, either pure or diluted, introduced, by means of a little cotton around the end of a sharpened bit of wood, into the abscess cavity, so as to destroy the lining membrane. Individual acne lesions can sometimes be aborted by touching them with pure carbolic acid or acid nitrate of mercury. Prognosis. — By persistent effort and careful regula- tion of all the bodily functions a great improvement can be effected, one fairly deserving the name of cure. But it is often hard to prevent the occasional appearance of a few acne lesions until the period of life in which acne usually occurs is passed. There are some cases in 1 Lancet, 1SS9, i, 934. 80 DISEASES OF THE SKIN which we can do but little because we are unable to remove the underlying cause. Acne Artificialis. — By this term is meant an inflam- mation of the sebaceous glands and hair follicles caused by drugs either applied locally or acting from within. It has three principal varieties, namely, tar acne, bromic acne, and iodic acne, and should be regarded rather as a dermatitis medicamentosa than as an acne. Tar pro- duces acne-like lesions with black points when applied locally to some susceptible skins. As a rule, papules are more abundant than pustules, but abscesses and furuncles may form. These lesions are not confined to the usual locations for acne, are particularly abundant on the extensor surface of the arms, and are recognizable by their central black points and by the fact that the patient is using tar. For its cure all that is necessary is to stop the use of the tar and to soothe the inflamed skin. None of these acnes is a true one. Bromic and iodic acne will be spoken of under drug eruptions. Deriva- tives of tar, chrysarobin and pyrogallol may also produce similar acne-like lesions when applied externally. Acne Atrophica is a term applied to the scars left by acne, and to acne necrotica. The first needs no descrip- tion; the second will be found further on. Acne Cachecticorum is rather to be regarded as a scrof- uloderm than an acne, as it probably has little to do with the sebaceous glands. It occurs in broken-down or scrofulous subjects, and is particularly prone to appear upon the extremities, though it may be disseminated over the whole body. It takes the form of small, congested or dark-red, sluggish, flat papules and papulopustules that run a slow course, break down, perhaps ulcerate, and leave small depressed cicatrices. They may aggre- gate into patches. Occurring on the fingers, these will often be congested and clubbed. The lesions may appear in crops. It occurs in children as well as in adults. It is one of the rare forms of the disease, and requires ACNE NECROTICA 81 tonic remedies, such as cod-liver oil and iron, for its cure. Acne Frontalis. — See Acne necrotica. Acne Hypertrophic a. — See Rosacea. Acne, Iodic and Bromic. — See Dermatitis medicamentosa. Acne Keloid. — See Dermatitis papillaris capillitii. Acne Keratosa. — H. R. Crocker describes this disease as an eruption of finger-nail sized, well-defined, excoriated patches covered with blood crusts located on the cheeks and chin, especially near the mouth. It leaves white, hard scars. It is usually a symmetrical eruption, but the lesions may come out singly or in very small num- bers at irregular intervals. The individual lesion begins as a red, firm, tender nodule upon which a pustule forms and dries into a scab. Embedded in the lesion are one or more horny or soft conical plugs about y\- inch long, which give rise to irritation until removed. When removed the lesion heals slowly after weeks or months. The disease is chronic, showing no tendency to recovery. Thus far, treatment has been unavailing. Acne Medicamentosa. — See Dermatitis medicamentosa. Acne Necrotica. — Synonyms: A. agminata; A. frontalis; A. varioliformis; A. pilaris; A. rodens; A. telangiec- todes; A. ulcereuse; A. arthritique; A. miliaire scrof- uleuse; Lupoid acne; Hydradenitis destruens suppurativa; Acnitis. The disease begins by the eruption of a few flattened, red, firm papules with a red border which in a few hours have pale-yellow centres looking like pustules, but which are crusts. The papules may be the size of a head of a pin or that of a lentil. The crusts are 2 to 4 mm. in diameter. At first yellow they soon become brown. If the crust is raised, it discloses a deep, cup-shaped depression with rugose walls. There is a delicate layer of pus between the crust and the bottom of the depres- sion. Left to itself, the crust falls after many weeks, 6 82 DISEASES OF THE SKIN leaving a red, dry depression, which after a time becomes white, resembling variola scars. The lesions show a ten- dency to group. If the disease occurs on hairy regions it destroys the hair. Sometimes the original crust enlarges by the formation of a second vesicle about the first, or two vesicles near each other may fuse. If scratched, they may become impetiginous. The sites of pre- dilection for the disease are the nose, temples, forehead, between the shoulder-blades, and over the breast bone. It is most often seen on the temples along the hair, and may spread on the scalp or bearded portion of the face, causing destruction of the hair. The disease may occur on the limbs. It is not seen before puberty, and continues indefinitely or by relapses in one place or in several, often symmetrical regions. A seborrhea may precede and accompany the disease. Etiology. — The cause of the disease is not deter- mined. It occurs about equally in men and women, who usually are over thirty years of age and in poor circumstances. Sabouraud believes that a seborrheal skin is the predisposing factor, and that the micro- bacillus is the cause of the disease. The Staphylococcus aureus is also found in connection with it. By some it is thought to be a tuberculid, due to the toxins of tubercle bacilli. Pathology. — J. A. Fordyce 1 finds that the disease begins in and about the hair follicles above the entrance of the sebaceous glands. As the inflammatory process extends it involves the sebaceous glands as well as the superficial portion of the derma, resulting in a necrosis of the pilosebaceous system. In one case he found enormous numbers of staphylococci in the lymph spaces and free in the tissues. Diagnosis. — In some cases the resemblance to syphilis is striking, but the extreme chronicity of it and its occur- rence along the hair line distinguish it, as well as its 1 Jour. Cutan. and Gen.-Urin. Dis., 1894, xii., 152. ACNE URTICATA S3 general course of development. It differs from acne in leaving varioliform scars, in its sluggish course, and in invading the scalp. Treatment. — The ointment of the ammoniate of mercury is efficient in many cases. Sulphur 10 per cent., salicylic acid 3 to 5 per cent., and resorcin 1 to 5 per cent., in ointment are also useful. Curetting is of service. Sabouraud thinks that for the disease when it invades the scalp the best remedy is pyrogallol, either with or without tar or sulphur, 15 per cent, in ointment, or 6 per cent, in ethereal oil. He also advocates the daily use of alcohol with a little iodin or bichloride of mer- cury for three months after the disease is apparently well. Stelwagon has found a lotion of resorcin in a saturated solution of boric acid best for non-hairy regions conjoined with ammoniate of mercury for hairy regions. Crocker speaks highly of the administration of 15 to 25 drops of chloride of iron three times a day; and also of iodide of potassium. Engrnan advocates the use of vaccines. He says: Here the staphylococcus is deep in the corium at the base of the follicle and readily acces- sible to the lymph, and therefore frequently shows clinical results after one injection. The injections in this disease should be from 50,000,000 to 100,000,000 at four days' interval. Acne Necrotisans et Exulcerans Serpiginosa Nasi is described by Kaposi as an eruption of flabby papules as large as a pin's head upon the end of the nose that soon undergo purulent or necrotic degeneration and leave deep scars. New lesions appear and in a few weeks or months the end of the nose is destroyed. Acne Punctata. — See Comedo. Acne Rosacea. — See Rosacea. Acne Scrofulosorum. — See Acne cachecticorum. Acne Urticata is the name given by Kaposi to a chronic, itching disease occurring on the face, scalp, hands, and, 84 DISEASES OF THE SKIN usually, on the extensor surfaces of the extremities. It begins as an acute eruption of bean or larger size, pale-red, very hard, wheal-like elevations, which within a few hours to four days undergo involution. They are usually scratched and broken. They leave flat, brown, cicatricial stripes corresponding to the scratches. The itching is so severe as to interfere with sleeping. There seems to be no good reason for regarding this as a distinct disease. It is really a form of urticaria. Acne Varioliformis. — See Molluscum contagiosum and Acne necrotica. Acnitis. — See Acne necrotica. Acrochordon. — See Fibroma. Acrodermatitis Chronica Atrophicans. — A rare disease that begins on the hands and slowly spreads up the arms. It begins as small crimson or purplish-red nodules look- ing like chilblains, which later become atrophic, thin, and wrinkled. Its course is chronic and the treatment unavailing. Acrodermatitis Perstans. — This disease was first de- scribed by Hallopeau. It always begins upon the ends of the fingers as more or less extensive flattened pustules deep in the epidermis. Over them the epidermis exfoli- ates, and at last an eroded surface is left. In some cases a whitlow precedes them, in some an injury, but many come spontaneously. The nails are involved in whole or in part. At last the ends of the fingers become shrunken, lose their nails, and become little conical, sclerosed stumps. From the fingers the disease extends upon the palms and backs of the hands. The feet may be involved, but less profoundly, and the disease may occur elsewhere on the body, although rarely. There may be subjective symptoms of moderate pruritus and local pain which may be severe and radiate up the arm. The disease is progressive and incurable. It is probably a neuritis. It occurs both in men and women. ACTINOMYCOSIS 85 Acrodynia, or Erythema epidemicum, is a disease closely allied to pellagra in its symptoms, that has been observed chiefly among French and Belgian soldiers, and is probably due to some defect in food supplies. It begins with gastro-intestinal irritation, to which certain neuroses soon add themselves, such as formica- tion, hyperesthesia, and anesthesia. An erythema of the hands and feet, and it may be of the whole body, followed by desquamation or by brown or black pigmenta- tion, is the cutaneous element of the disease. Recovery usually takes place, although death may occur from diarrhea. Acromegaly. — A disease characterized by overgrowth of the bones and soft tissues of the face, hands, wrists, and feet. It is a rare condition and is allied to elephan- tiasis. It is a progressive and, usually, symmetrical disease, and at times attains immense proportions involving the whole body. The skin becomes dry and harsh, yellowish and wrinkled. Fibromas may develop. Symptoms of nervous derangement are also present. The cause is unknown. The treatment is on general principles. Counter-irritation over the spine is advised. Actinomycosis. — While this is usually a disease of cattle, in which it causes tumors of the jaws, it may attack man and produce nodular tumors with fistulous openings. It is due to the invasion of the tissues by the ray fungus. Infection usually occurs by the mouth along a carious tooth, but it may take place through the digestive tract, the lungs, and, rarely, by an abrasion of the skin. The incubation period may be weeks, months, or years. The tumors bear a strong resemblance to sarcoma and are livid or bluish red. At first firm, they after a time soften and break down and discharge through a fistulous tract, at first a purulent, afterward a sanious material, in which are numerous yellow granules, from pinhead to hemp-seed size. The affected area becomes infiltrated, swollen, reddish, and studded with 86 DISEASES OF THE SKIN a number of nodules that in their turn show fistulous openings from which come the characteristic discharge. They are most often seen on the face and neck, but may occur on the chest and abdomen. The disease runs a chronic course usually without constitutional disturbance. The fungus which causes the disease in the ray fungus, or actinomyces, which consists of a central mass of inter- twining threads from w^hich branch the mycelia-like rays, hence its name. The mycelia terminate in bulbous ends. The diagnosis from sarcoma, tuberculous swellings, syph- ilis, and mycetoma is made by the location about the jaws, the fistulous openings, and especially the finding of the fungus. Its prognosis is good if taken early and properly treated. Otherwise it is bad. Iodide of potassium in 10 to 15 grain (0.66 to 1) doses, three times a day increased to 30 grains (2), should be given, and continued for some time after the patient is apparently well. It may be combined with the insertion into the sinuses of a 1 per cent, solution of the same drug. Sulphate of copper in i grain dose four times a day may be tried. Surgical procedures may be resorted to at the same time that the iodide is administered. Addison's Keloid. — See Morphea. Adenocarcinoma is a carcinoma originating in the glands of the skin, most often in the sweat glands. Adenoma. — These are glandular tumors, and are due to a proliferation of the lining cells of either the sebaceous or sweat glands. There are, therefore, two varieties: A. sebaceum and A. sudoriferum. Though met with in persons of mature years, it is not improbable that they are congenital defects. They form solid tumors from pinhead to egg size or larger. They may remain station- ary or grow; may disappear spontaneously, ulcerate, form cysts, or undergo hyaline, colloid, or fatty degenera- tion. While usually benign, they may become malignant. They tend to relapse after extirpation. Adenoma Sebaceum. (Pizzoli.) AINHUM 87 The sebaceous form is encountered most often on the face, about the nose and mouth; less frequently upon the scalp, but may occur anywhere. While usually symmet- rical in distribution, it may be unilateral.. The lesions are rounded papules varying from a pin's head to a split pea in size, and usually occur in groups. The color of these adenomas varies from pale yellow to red, when they will have fine telangiectases over them. They occur most often in women, and in early life are generally multiple, often with an uneven surface, and seated deep in the skin. Once having appeared they do not tend to change, though a few may undergo involution and leave atrophic scars. The patients usually have coarse skins, often are mentally deficient, and also frequently present comedones, nevi, fibromas, and other defects scattered about the trunk and limbs. They seem to belong rather to the class of nevus than true adenomas. Politzer has cured one case of the sebaceous variety by means of multiple scarifications. Crocker advises electrolysis. A resorcin healing paste may be tried. The sudoriferous variety occurs upon the head, neck, and extremities as dirty grayish-white, pea- to egg-sized tumors, sometimes in groups, with uneven, often knobby surface. When they develop from the coil they are called adenoma sudoriparum or spiradenoma; when from the duct, syringadenoma. They are rare lesions of the skin, difficult of diagnosis, and require extirpation or total destruction for their cure. Most cases formerly described under this heading are now regarded as cases of multiple benign cystic epithelioma, which see. Ainhum is a disease most frequently seen in the negro race, though a number of cases have been reported from India. It is seen in men more often than women, and several members of the same family have been known to be affected by it. The little toe of one or both feet is the one usually diseased, though the other toes do not always escape. It begins as a furrow on the inner and 88 DISEASES OF THE SKIN lower side of the proximal end of the toe, which gradu- ally extends outward and upward so as to encircle the whole toe at its juncture with the foot. In the mean- time the toe becomes enlarged, separates from its next neighbor, and rotates outward. When fully developed the toe wobbles about so that it interferes with walking. The whole process is unattended with ulceration, except accidentally caused, and after the disease has lasted a long time. When it occurs the toe falls off. There is little pain experienced until near the end of the disease. The fingers also rarely may be affected. It takes from one to fifteen years for the full development of the disease. The cause is unknown, though traumatism probably plays a part. The process is one of progressive degeneration and destruction of all the elements of the toe — skin, muscles, bone. In its early stage a deep incision perpendicular to the direction of the furrow may check its course. Later, amputation is required for the cure, and healing takes place rapidly. Albinism. — This is a congenital defect of pigment which may be partial or complete. The skin is milky white in color, or pinkish. If it affects the hairy parts the hair is white or yellowish white. The pupils of the eyes are red, owing to an absence of pigment from the choroid. The subjects of complete albinism are not robust. Heredity is a cause. Adrian 1 has found con- sanguinity in the parents in some cases. It occurs both in negroes and white people. There is no treatment for the disease. Aleppo Boil, Bouton, Aleppo Evil, or Oriental Sore is an ill-defined furuncular disease occurrying in Syria and the Levant, where it is endemic and widespread. One or more itchy red papules appear that, after some time, change into pea- or bean-sized pustules, grow slowly, and ulcerate indolently. Large ulcerating, granu- Dermat, Centralbl., 1906, ix, 258. ALOPECIA ADNATA 89 lating patches may form by the coalescence of neigh- boring pustules. The ulcers are sharply defined and irregular in shape, and when crusted may resemble syphilitic rupia. Healing takes place after months, leaving a pigmented and contracted scar. The ulcer may heal at one part and extend at another. The disease is painless. In uncomplicated cases the prognosis is good. The extremities and face are the parts most often affected. All ages and conditions contract the disease. One attack usually protects against subsequent infection. It is due to infection, probably by a parasite, called by Wright, "Helcosoma tropica." P. G. Woolley 1 recommends J grain doses of sulphate of copper for the treatment of the disease. Painting the papules with tincture of iodin is recommended, as is scraping out the pustules with the curette and applying nitric acid. Spraying the ulcers with distilled very hot water, and keeping them covered with dry aseptic gauze has given good results. Ulcers are to be treated on surgical prin- ciples. Alopecia. — Synonyms: Calvities; (Fr.) Alopecie; (Ger.) Kahlheit; (Ital.) Calvezza; (Sp.) Calvez; Baldness. By alopecia is meant a partial or general loss of the hair, so as to produce a noticeable thinning or a bare spot. There are four main varieties, namely: Alopecia adnata; Alopecia senilis; Alopecia prematura or presenilis; and Alopecia areata. Alopecia, Adnata is congenital baldness, and is a rare affection. Symptoms. — The newborn child is covered with long, dark hair which soon falls to give place to fine lanugo hairs; or this change has taken place before birth, the usual course of events, and at birth lanugo hairs only are present. In alopecia adnata there is not the slightest trace even of lanugo hairs either on the scalp or eyebrows. 1 Jour. Amer. Med. Assoc, 1907, xlviii, 789. 90 DISEASES OF THE SKIN In some cases the baldness is not so complete. Most cases, after months or years, recover either altogether or partially, but in some cases the hair never grows. In pronounced cases delayed dentition or deficiency of the teeth has been observed. Etiology. — The cause of the disease is arrest of the development of the hair, probably due to an error in innervation. It is hereditary in some families. Pathology. — There is a complete absence both of hair and hair papilla. There are some abortive hair follicles. Otherwise the scalp is normal. Treatment. — The treatment is mainly an expectant one. The nutrition of the child should be looked after and the scalp kept in a healthy condition. If this expect- ant plan does not satisfy the child's attendants, some of the stimulating hair lotions, as in alopecia presenilis, may be prescribed for the moral effect upon them. Alopecia Senilis is baldness occurring in advancing years. Any loss of hair commencing about the forty- fifth year and without apparent cause may be placed under this heading. Graying of the hair may have preceded it for several years or may be coincident with it. Or the hair may fall without becoming gray. The hair fall having once begun is progressive, though its rate of progress may be slow or fast. It usually shows itself first upon the vertex of the head, forming the ton- sure, which slowly increases in size and, moving forward, renders the whole top of the head bald. Or it may begin anteriorly and move backward. Or the hair on the whole top of the head may become thinned at once. Rarely are the temporal and occipital regions bald, and an island or tuft of hair is sometimes preserved for a long time in the middle frontal region. The hair fall is always symmetrical and the bare scalp is smooth, oily, shiny, and appears as if stretched. Not only does the hair fall from the scalp, but it may fall from the axilla and pubic region; these manifestations being more ALOPECIA PREMATURA 91 common in women than men. Very rarely does the beard fall. Etiology. — The cause of this form of baldness is a progressive atrophy of the scalp. Men are far more prone to the disease than are women. Treatment. — As to the treatment we can do nothing. Prophylaxis, as described under Alopecia prematura, will delay its onset. Alopecia Prematura is baldness occurring before middle life. It may be idiopathic or symptomatic. Alopecia prematura idiopathica arises without any evident disease of the scalp or disorder of the general health. It usually begins in early life, between twenty-five and thirty-five; it may begin as early as the eighteenth year. Its general course is the same as the senile form of alopecia. Very often the upper parts of the temples are earliest affected, the hair line receding. In those who part the hair in the middle, the thinning of the hair about the part may be the first thing to attract attention. The process of the hair fall is one of progres- sive thinning of the individual hairs at first, and then of the whole quantity of hair, so that strong hairs give place to lanugo hairs, and these in turn fall and leave bald places. At the same time a progressive tightening of the scalp upon the skull will be observable in some cases, the scalp having lost that cushion of fat that is under it in early life. The hair fall having begun is progressive, though years may elapse before there is absolute baldness. The tonsure may not enlarge for a long time, and then increase rapidly in size. Etiology. — The main cause of this form of baldness is heredity. Fathers and sons for generations may grow bald early, or the inherited peculiarity may have to be traced to the grandparents or some collateral line. Not all the children of one family in which baldness is hereditary are bald, but it will manifest itself in two or three of them. According to Pincus, 1 inheritance and 1 Virchow's Archiv, 1867, xli, 322. 92 DISEASES OF THE SKIN chronic eczema or an impetiginous eruption on the scalp in the years preceding puberty are the only pre- disposing causes of baldness. Insufficient or improper care of the scalp; daily sousing of the hair with water, combined with improper drying of the hair afterward; sweating o£ the head, either spontaneously or on account of the wearing of unventilated or hot head-coverings; constant mental strain, either on .account of intellectual work or of worry; the wearing of stiff, unyielding hats; gout; all diseases lowering the general nutrition, and dissipation are all put forth by reputable observers as causes of premature baldness. That women are less often bald than men probably depends upon several factors: The fatty cushion beneath their scalps is longer preserved than in men; they give more attention to the care of the hair and less often wet it; and their hats are soft, ventilated, and fit loosely. Prognosis. — The prognosis of this form of baldness is bad, and especially so if the disease is hereditary and the patient is more than thirty years of age. It is better with women than with men, as they will give more time to the care of their scalps and show less tendency to alopecia. Treatment. — We can do more for this form of bald- ness by prophylaxis than by attempts at making the hair that has fallen out grow in again. Prophylaxis should begin at the beginning of life, and should be continuous. This is of special importance in the case of children in families prone to early loss of hair. The hygiene of the scalp is the chief part of the prophyl- actic treatment. Beginning in infancy, the scalp should be gently cleansed of the vernix caseosa and other extra- neous substances that have gathered on it during the process of parturition. This should be done by the gentle use of soap and water after rubbing in a little sweet almond or other bland oil. No force should be used, and after the scalp is washed it should be patted dry ALOPECIA PREMATURA 93 with a soft, warm cloth, and a little oil or vaselin smeared over it. After the first washing it should be oiled daily and washed every second day. When the hair begins to grow, a soft brush alone should be used to arrange it, and the daily oiling may be stopped, unless sebaceous matter accumulates in cakes, in which event the oiling should be continued. Sometimes it is well to add a little sulphur to the oil or vaselin, but in most cases it is unnecessary. The slightest indication of disease of the scalp should be promptly and properly dealt with. A child's hair should be cut short, not cropped close to the head. After a girl has reached her eighth or ninth year the hair should be allowed to grow. The hair and scalp do not need to be washed more than once in two or three weeks, and for this purpose any good soap will do, with plenty of water to wash out the soap-suds. Borax with water will clean the scalp nicely, but its continuous use is injurious. The yolk of three eggs beaten up with lime-water makes an elegant shampoo. The daily sousing of the head in water should be prohibited. Deep brushing of the hair with a long- bristled brush of sufficient stiffness to warm, but not scratch, the scalp is one of the best agents we have for stimulating the hair. The brushing should be done daily and systematically. Pomades and hair lotions should be avoided unless there is some evident disease of the scalp. Women should be cautioned against pulling their hair into arti- ficial and constrained positions. It is most important that a sufficient amount of out-door exercise should be taken to aid in keeping the patient in good general condition. When the hair has begun to fall it is important that the hygiene of the scalp should be begun, if not already practised. We can do more for our cases in this way than by any other method. Many remedies have been advised for the curative treat- ment of baldness. Pilocarpin, in hypodermic injections or gr. vij 50 5ij 50 Svj 200 94 DISEASES OF THE SKIN in ointment form, has been warmly commended. Lassar 1 prescribes it as follows: 1$ — Hydrochlorate of pilocarpin, gr. xxx 2 Vaselin, 5v 20 Lanolin, ad §ij ad 60 Oil of lavender, gtt. xxv 1 66 M. It may also be used in the form of the fluidextract of pilocarpus, 10 to 15 per cent, strength, in dilute alcohol. He also advises oil of turpentine, equal parts with an indifferent oil or alcohol. Another useful formula for pilocarpin is that of Sabouraud: 1$ — Pilocarpin muriat., Aquse rosse, Alcohol, ^Etheris, Spts. lavendulse, aa 3vj 25 M. This is to be well rubbed in morning and night. Gallic acid, 3 per cent., in an oily excipient; tar; galvanism; massage; tincture of cantharides (3 j to 5 j), tincture of nux vomica (3 j to 5 j), and a lot of other irritants and essential oils have their advocates. Our experience teaches us that so-called "hair tonics" are of little value, and that the best remedies are attention to the general health of the patient, massage of the scalp, and daily systematic and deep brushing of the hair. Pilocarpin is the only drug that has shown any decided influence on hair growth. Electricity is recommended by Stelwagon, either static, by means of the crown, quite near the scalp, for five minutes; or faradic, with the metallic brush or comb. The high-frequency current, D'Arsonval, is also worthy of a trial. It should be used about three times a week, with enough vigor to produce redness of the scalp, using either the hollow glass electrode or one filled with powdered carbon. Alopecia Prematura Symptomatica is premature baldness in which there is some evident disease of the scalp or disorder of the general nutrition of the body to account 1 Therap. Monatshefte, 1888, No. 12. ALOPECIA PITYRODES 95 for it. It has four varieties: Alopecia furfuracea seu pityrodes, A. syphilitica, Defluvium capillorum, and A. follicularis. Alopecia Pityrodes seu Seborrhoica is the form most frequently met with and the one in which we can often obtain good results by treatment. In our experience 70 per cent, of all cases of loss of hair are of this variety. Symptoms. — In alopecia pityrodes we have an evident disease of the scalp to deal with — that is, dandruff. By this we mean either a seborrheal dermatitis with fatty crusts, or else pityriasis with more or less abundant scaling. In some cases the condition is one of seborrhea with extreme oiliness of the scalp and hair and no scales. In others we meet with pityriasis steatoides with abundant heaping up of fatty scales. Alopecia pityrodes has two stages: The first one lasts from two to seven years or more, and is attended with a greater or lesser amount of dandruff and by dryness of the hair. Then comes the second stage, when the hair falls more or less rapidly. Its course may be the same as that of the two previously described forms of baldness, though more commonly the whole top of the head is affected at once, the hair becoming progressively thinner in diameter and less in amount until baldness results. As the baldness increases the dandruff lessens. The disease is one of early life in a large number of cases, often occurring between the twentieth and thirtieth year. While both men and women lose their hair from dandruff, it is quite exceptional for a woman to become absolutely bald like a man. If the condition is one of seborrheal dermatitis there will be more or less redness of the scalp. While if pity- riasis steatoides is present the hair will be oily. The general course of the alopecia is the same as in the dry form. Itching is often complained of. Etiology. — The greatest predisposing cause of the hair fall is heredity. Not that one inherits baldness, 96 DISEASES OF THE SKIN but a weakness of resistance to the exciting cause, a seborrhea or pityriasis. Anything that lowers the general nutrition of the patient acts in a similar manner. The chief exciting cause is the infection of the scalp with some form of dandruff. By this it is not meant that everyone who has dandruff will become bald. But that in certain persons when the scalp becomes diseased, the hair follicles become so likewise, and after a time the hair production ceases. There is little doubt but that alopecia pityrodes is contagious, and the experiments of Lassar and Bishop 1 would seem to prove this. They succeeded in producing typical alopecia pityrodes in guinea-pigs by rubbing into their backs a pomade composed of the scales taken from the head of a student who was afflicted with the same disease. A number of observers have reported from time to time the finding of a parasite in alopecia, for an account of which the reader is referred to the sections on seborrhea and pityriasis. Treatment. — The treatment of this form of baldness must be addressed to the cure of the seborrhea or pity- riasis that causes the loss of hair and to improvement of the nutrition of the patient. Prophylaxis is here again more important than the use of remedies for promoting the growth of the hair. The treatment of seborrhea 'and pityriasis will be considered under their respective headings, and need not be here detailed. The mistake is frequently made of prescribing tincture of cantharides or other irritant because the hair falls. Of course, these things, in an already more or less inflamed scalp, only do harm. If we can succeed in curing the seborrhea or pityriasis, the hair will take care of itself. If the case comes to us before absolute baldness is established, we can feel pretty confident that we can stop, or at least delay, the fall of the hair. But we must inform our patients that it is only by long and persistent treatment that we can accomplish anything. The drugs that are of most use are resorcin, sulphur, 1 Monatshefte f. prakt. Dermat., 1882, i, 131. ALOPECIA PITYRODES 97 tar, and mercury. They should be employed until the seborrhea or pityriasis are checked. When that is accom- plished, pilocarpin and other remedies as given under alopecia prematura idiopathica are to be used. It is often well to add resorcin to the pilocarpin lotion for subsequent treatment. Resorcin may be prescribed as follows: 1$ — Resorcin, 3J 4 01. ricini, gtt. v 33 Spts. vini rect., ad giv ad 120 M. Bichloride of mercury is often added to this, 1 or 2 grains (0.06 to 0.13) to the ounce (30), such as in White's formula : 1$ — Hydrarg. bichlor., gr. iv 24 Resorcin vel., Euresol pro capillis, Spts. formicari, 01. ricini, Alcohol, 70 per cent., ad gviij 250, M. These lotions are to be applied morning and night. Tar is a good remedy, but it is objectionable on account of its odor and color. It may be used in the form of an ointment 1 or 2 drams (4 to 8) to the ounce (32) or of the same strength in an oil. Joseph's lotion is: R< — Anthrasol, gr. xlv 3 01. aurant. flor., gtt. iv Tinct. saponis viridis, gj 30 Alcohol, ad gv 150 M. Sabouraud advises: R— 01. cadini. giij . 100 Decoct, quillaquse, gj 30 Yolk of egg, No. j Aq. destil., q. s. ad gviij 250 j M. Sulphur is the most reliable remedy, in the proportion of 1 to 2 drachms (4 to 8) to the ounce, (32) and the best way of using sulphur is in unguentum aquse rosae or cold cream. A very elegant sulphur ointment is: 3ij 8 Sj 32 3j-nj 4 to 12 Sviij 250 -Cerse albse, ovij 28 01. petrolati, gv 155 Aquae rosse, giiss • 75 Sodse biborat., gr. xxxvj 2 34 Sulphur, prascipitat., 3vij 28 M 98 DISEASES OF THE SKIN This is known as "Sulphur Cream." If there is much pityriasis or seborrhea the patient should be directed to shampoo the scalp and, when it is dry, to rub in the sulphur pomade. The next three nights he should use the pomade, and then the scalp should be washed, and after drying the ointment applied. For the next ten days the ointment should be used every other day, and then the scalp washed. When this has been kept up for three months a drachm of oil of cade may be added to the sulphur pomade and used twice a week. If the smell of the tar is objectionable, the sulphur pomade alone may be continued. Further particulars in regard to the treatment of seborrheal dermatitis will be found under the section upon that subject. When there is absolute baldness it is questionable if anything will make the hair grow. Alopecia Syphilitica may be an early or late manifes- tation of syphilis; it occurs both in benign and malignant cases, and manifests itself as a more or less general and temporary hair fall, or as a localized, destructive, and permanent one. Symptoms. — The former variety occurs early in the disease, and is a thinning of the hair in irregularly shaped patches scattered over the scalp, giving to it an appear- ance similar to what would be produced by cutting the hair carelessly with a pair of dull shears. In rare cases we may have a general loss of hair from all hairy regions. The broken arch of the eye-brow is .always suggestive of syphilis. There may be some seborrheal dermatitis with this form of alopecia. Syphilitic macules may be on the scalp, but quite commonly there are none. Localized baldness is one of the later manifestations of syphilis, and is always preceded by a destructive disease of the scalp. The bald spots will vary in size with the extent of the destructive process, which may be one of absorption or ulceration. Diagnosis.— The diagnosis of early syphilitic alopecia is made by observing the irregular shape of the patches DEFLUVIUM CAPILLORUM 99 and that they are not completely bald, and by the occur- rence of the broken arch of the eye-brow and the presence of other manifestations of the disease. These should arouse suspicion, and other symptoms of the disease may be found. It most resembles alopecia areata, but in that disease the patches are perfectly circular or oval and entirely bald. The baldness due to destructive forms of syphilis may be confounded with that of favus. In the latter disease the scalp preserves a reddish color for a long time, and then assumes an atrophic, smooth, cicatricial look, which is characteristic of it. The history of the two cases is very different, as in favus we do not have ulcer- ation, and we do have cupped, sulphur-yellow crusts. Favus is also more widespread and disseminated than is late syphilis of the scalp. Treatment. — The treatment of this form of baldness is that of the underlying disease. A mercurial ointment or a lotion containing bichloride of mercury may aid in hastening the new growth of the hair in the early form of baldness. The late form may be lessened by active constitutional and local treatment, according to the general principles laid down for the management of syphilis. Defluvium Capillorum is that sudden and general fall and manifest thinning of the hair which come on during or after some severe illness, such as parturition, fevers, mercurialism, and various cachexia? . Symptoms. — Rarely does it produce complete bald- ness. The fall is usually rapid and takes place during convalescence or after recovery, rather than during the course of the disease. It may not occur until from six weeks to three months after the illness. Seborrhea or pityriasis may or may not be present. Usually it is a general thinning of the hair and not a localized baldness. It rarely causes absolute baldness, and complete recovery is the'rule. 100 DISEASES OF THE SKIN Etiology. — The cause of the hair fall is the profound disturbance of the nutrition of the body, in which the hair sympathizes. Treatment. — The treatment is rather to be addressed to the patient than to the hair. If we can succeed in building up the patient's strength, the hair will take care of itself. The scalp should not be shaved. Local treat- ment is the same as in alopecia pityrodes. Alopecia Follicularis is baldness due to some disease of the scalp that either destroys the hair follicles or impairs the proper performance of their function. A history of the causative disease may be obtained, or the disease itself will be present. Impetigo; long-continued sycosis; inflammatory diseases, such as erysipelas; parasitic dis- eases, such as favus and ringworm; and destructive new growths, such as syphilis and lupus, all may cause alopecia follicularis. The etiology, diagnosis, prognosis, and treatment of this form of baldness are the same as that of the disease that gives rise to it, for which we must refer to the proper sections. Alopecia Areata. — Synonyms: Area Celsi; Area occi- dental diffluens, seu serpens, seu tyria; Alopecia cir- cumscripta; Porrigo sue tinea decalvans; Vitiligo capi- tis; Ophiasis; Phyto-alopecia; (Fr.) Teigne pelade; Pelade; (Ger.) Die kerisfleckige Kahlheit; Circum- scribed baldness. This form of baldness usually begins suddenly, the patient discovering by accident, or being told by some- one, that he has a bald spot. Sometimes, on waking in the morning, the patient is astonished to find loose hairs in his bed, and, on looking in the glass, to see that he has a bald patch on his head. In some cases the hair fall may have been preceded for days or weeks by neu- ralgic pains in the head. In other cases the patient suffers from paresthesias of various kinds, such as formication, prickling, etc. In most people there are no premonitory ALOPECIA AREATA 101 symptoms and, apart from the bald spots, no discomfort on the part of the patient, nor cutaneous lesions. The neuralgia may continue after the hair fall or it may cease. There ma}' be but one bald patch or there may be a dozen patches. A patch may be as small as a three- cent silver piece or as large as a silver dollar. If larger — and the whole head may be completely bereft of hair — the patch is formed by the coalescence of several smaller ones. A patch may attain its full size at once or it may slowly enlarge, spreading at the periphery. The patches Fig. 10 Alopecia areata. are more or less perfectly oval or circular in shape and sharply defined against the surrounding hair. Patches formed by the coalescence of other patches lose the oval outline and may have a scalloped border. The color is usually that of the normal scalp; it may be pale or hyperemic. The patch is perfectly bare and smooth, without scales, as a rule. Sometimes it is dotted over with short, broken hairs, old roots that soon fall out. Sometimes it looks as if it were depressed, an appearance due to falling out of the hair roots. Sometimes there is 102 DISEASES OF THE SKIN more or less seborrheal dermatitis of the scalp. Any or all the hairy regions of the body may be affected, the patient sometimes being entirely denuded of hair. The complete form we have met with three times in 120 private cases. To it the term malignant alopecia areata has been applied. Most often it is the scalp that suffers, especially the temporal and occipital regions. The bearded portion of the face may be affected alone. Around the border of a recent patch the hair is loosened so that it may be readily extracted. They often present the Fig. 11 n 4*\ ; Alopecia areata. appearance of an exclamation point (!), because the shaft is thick while the bulb tapers off and ends in a small knob. When the patch is fully formed the hairs about it will be firmly seated in their follicles. The sensibility of the skin may be diminished. Generally it is preserved. The course of the disease is chronic, with a strong tendency to spontaneous recovery in anywhere from three months to several years. Recovery is heralded by the 1 By the courtesy of Dr. S. Dana Hubbard. ALOPECIA AREATA 103 growth of a fine down upon the bald patch. This will fall out and be replaced by lanugo hairs that in their turn will fall out to be replaced by stronger hairs, until normal hairs grow at last, though these at first may be white. Some cases relapse year after year. This occurs in from 20 to 30 per cent, of the cases. In some cases the hair never grows beyond the lanugo stage; and in other cases the patch remains permanently bald. Ophiasis is that form of the disease which begins over the nape of the neck, or by two lateral, symmetrical, occipital patches, and spreads forward as a broad band following the lower border of the hair and ending over the ears on the forehead. Starting in this way it may involve the whole scalp. Alopecia neurotica is that form of the disease in which the patches are irregular in shape in the form of stripes, triangles, or with map-like outlines shading off into the surrounding hair. Etiology.— The subjects of the disease may be in apparently perfect health, but not infrequently they are of very nervous temperament, exhausted by over- work or nervous strain, or out of health in some way. Both sexes are affected, the female rather more than the male in our experience, while Sabouraud's statistics show the reverse proportion. It occurs very often in children. The youngest case reported by Crocker was two years of age. Cases have been seen as late as in the sixtieth year. It is rather more frequent among the poor than among the well-to-do. It is more fre- quent in some countries than in others. Syphilis, either hereditary or acquired, has been found in connection with some cases. Sabouraud 1 has noted the disease in women to follow the menopause or prolonged suppression of menstruation, as in pregnancy. He has seen it in a man with double tubercular orchitis. The disputed points in the etiology of alopecia areata 1 Annal. derm, et syph., 1913, iv, 88. 104 DISEASES OF THE SKIN are its contagiousness, and whether it is a neurosis or a parasitic disease. At the present time it is impossible to decide with absolute certainty which of the contending parties is right. Most instances of contagion have been reported by French observers whose diagnostic skill we can hardly call in question. They have reported instances in which a large number of cases have appeared in bar- racks or schools, and from there spread to neighboring towns. In England similar apparent epidemics have been reported, but as a fungus indistinguishable from the trochophyton fungus was found in the surrounding hairs they were doubtless instances of bald ringworm. It is possible that some of the French epidemics were of similar character. In this country one epidemic appar- ently of alopecia areata has been reported by Putnam. 1 The cases were examined by Drs. J. C. White and J. T. Bowen, of Boston, who agreed in the diagnosis. Nothing suggestive of trichophytosis was found. Isolated instances of apparent contagion have been reported by various physicians. We have met several times with more than one case in the same family or environment. Besnier and Doyon, 2 who believe firmly that the disease is contagious, think that it is transmitted most often by "means of the barber's utensils, especially the patent hair clippers, and that it is impossible in a great number of cases to trace the contagion. Hutchinson and some other English authorities are inclined to the belief that in many cases ringworm preceded the appearance of the bald spots at a greater or less interval. As to the parasitic origin of the hair fall, it is not yet proved. A goodly number of skilled microscopists have described a microorganism, but they do not agree among themselves. Still, it is assumed that a microorganism will be demonstrated at some time. 0. Lassar 3 thinks that 1 Arch. Pediat., 1892, ix, 595. 2 Path, et Traite des Mai. de la Peau: Kaposi. French edition, Paris, 1891. 3 Dermat, Zeitschrift, 1900, vii 809. ALOPECIA AREATA 105 the phenomenon can be best explained on the theory of a virus due to a microorganism. This leaves only the nourotic theory. Most derma- tologists believe the disease to be a trophoneurosis. It has been known to follow blows or injuries to the head, moral or mental shock, operations on the neck, and, experimentally, injury to or extirpation of the second cervical ganglion in cats. It has often been met with in association with various nervous diseases. Jacquet has asserted that carious teeth are in causal connection with many cases, and Whitfield would add eye-strain and severe infection with pediculi capitis. Perhaps the disease should be regarded rather as a symptom due to a disturbance of the nutrition of the hair depending sometimes on microbic infection, at other times on a trophoneurosis. For the present no decisive answer can be given to the question: "What is the cause?" Pathology. — Though hairs taken from the margin of an advancing area show trophic changes, there is nothing distinctive about such changes. A. R. Robinson 1 found evidences of inflammation, and some round-celled infiltration confined principally to the perivascular region. In recent cases there was a coagulation of lymph in many lymphatics, and of fibrin in a few of the large and small arteries, with, in old cases, a thickening of their walls. In recent cases the hair follicles were either without hair or contained a lanugo hair or a hair just about to fall. The hair roots, where present, showed atrophic changes. In advanced cases the sebaceous glands were degenerated or had entirely disappeared. In the worst cases there was complete atrophy of the hair follicles and of the subcutaneous fatty tissue. He also describes the presence of various cocci in the lymph spaces of the corium and the walls of a few of the vessels, which he regards as the cause of the disease. 1 Monatshefte f. prakt. Dermat., 1888, vii, 409. 106 DISEASES OF THE SKIN Diagnosis.— A typical case of alopecia areata is so peculiar that there is little danger of mistaking it for anything else. It differs from trichophytosis capitis in its sudden onset, its perfectly bare, smooth, non-scaly surface, without broken, split, and gnawed-off hairs, and in the absence of the trichophyton fungus from the hair and scales taken from the neighboring parts. In bald ringworm patches, which resemble alopecia areata, the fungus will be found in the neighboring hair, or some characteristic " stumps" will be found on the scalp. In adults, ringworm of the scalp is very rare. It differs from favus in the absence of cupped crusts at any time in its course, in the scalp not presenting that cicatricial appearance always met with in favic baldness, and in complete absence of fungus growth. The baldness due to syphilis may resemble that of alopecia areata, but other symptoms of syphilis will be present, and there will never be a history of the for- mation of well-defined oval or circular areas. Lupus erythematosus at times affects the scalp and produces cir- cumscribed bald areas; but these are not oval or round, and the skin is red and scaly, and evidently cicatrized. Alopecia cicatrisata differs from alopecia areata in not forming regular oval or round bald areas, but rather irregular ones, with clumps of hair at their borders; in having a cicatricial appearance, and in presenting, at first at least, some evidences of dermatitis or folliculitis. When the inflammatory symptoms have subsided the diagnosis is sometimes difficult. Joseph has found that if the doubtful patch is painted with chrysarobin in traumaticin it will cause the mouths of the follicles to appear as brown or black dots if the case is one of alopecia areata, but not if it is alopecia cicatrisata. Treatment. — In a disease that is essentially self- limited it is hard to estimate how much good our reme- dies do. One duty we have without perad venture, and that is, to look after the general condition of the patient. A large number of the cases require a stimulating and ALOPECIA AREATA 107 tonic treatment — iron, quinin, strychnin, arsenic, cod- liver oil, phosphorus or the hypophosphites. Children should be taken out of school and allowed to run free. Our hardest task will be to manage those nervous patients who are ever a trouble to us. The teeth and eyes should be examined and any defect corrected. As far as local treatment is concerned, it may be sum- med up in two words: patience and stimulation. As many of our parasiticides are stimulating to the skin, they may be used with benefit whether we believe in the parasitic cause of the disease or not. The stronger water of ammonia dabbed on the scalp several times a day by means of a swab, care being taken to guard the eyes, will be beneficial in some cases. It is remarkable how little reaction this powerful remedy will cause in alopecia areata. Pilocarpin, in hypodermic injections, or in ointment form, combined with sulphur ointment and well rubbed in, is at times beneficial. A good formula is: f£ — Pilocarpin. niuriat., gr. iv 26 Sulphur, colloidal, 3J 4 Adepislanae, Adepis anserini, aape. ad 5j 32 01. rosa? geran., gtt.xv The scalp may be painted with acetic acid until it whitens, and then sponged off with cold water, and this repeated ever}' three or four days. Chrysarobin, 2 to 10 per cent, in traumaticin, applied two or three times a week until inflammation is caused, is advised by Joseph. A mild ointment is used until the reaction subsides, when the chrysarobin is repeated. It may also be used in a saturated solution in chloroform and painted over with collodion when the solution dries. Hodara 1 exhibits it in a 25 per cent, mixture with ichthyol, and covers this with gauze. Care must always be taken that it does not get into the eyes. 1 Monatshefte. f. prakt. Dermat., 1909, xlviii, 508. 108 DISEASES OF THE SKIN Carbolic, acid (95 per cent.) applied every two weeks or so to small areas at a time ; bichloride of mercury, 2 to 4 grains to the ounce in alcohol,, or oleum pini sylvestris; the oleate of mercury, in the strength of 2 to 10 per cent.; blistering with cantharides, or 33 per cent, of iodin in collodion, have one and all been followed by the return of the hair. Moty 1 reports good results from hypodermic injections of bichloride of mercury, injecting 5 or 6 drops of an aqueous solution (1 to 500) into many places about each patch. In a later number of the same journal he an- nounced that he then used a 4 per cent, solution of the mercury, with a 2 per cent, solution of cocain; that he made but a single-drop injection in a medium-sized patch, and four or five injections about a large patch, and at its periphery. Pauses of four days were taken between the injections, and a cure was expected after the fourth series. Sabouraud 2 advises in single-patch cases cutting the hair short, epilating about the patch, and rubbing the patch every second day with 1 part of Bidet's vesicating liquid and 3 or 4 parts of chloroform. Every morning the whole scalp is to be rubbed with: I£— Alcohol, camphorat., 5iv 128 j Spts. terebinthinae, 5y 20' Aquae ammonise, 3J 4 M. If the patch is very large, instead of the cantharidal solution use: -Ac. acetici crystal, gr. i-iij, .065-194 Chloral., 3J 4 iEther., 5J 32 M. From time to time the patch should be shaved as the young hairs come in, w T hile the strength and the number of applications of the strong solution should be lessened. In obstinate cases he applies a blistering fluid at night to 1 Ann. de derm, et de syph., 1891, ii, 406. 2 Diagnostic et traitement de la pelade et des teignes de l'enfant. Paris, 1895. ALOPECIA AREATA 109 a limited area, opens it the next morning and paints the surface with nitrate of silver solution. The surface is to be covered with absorbent cotton. This is to be repeated every week. Lactic acid in 50 per cent, aqueous solution is highly commended by Balzer. 1 Alcohol or ether is to be used first to remove the fat from the part, and then the acid is to be rubbed in with a tampon until the scalp reddens. Use daily. If reaction is too great, omit for a few days and use borated vaselin. A cure may be expected in from two to three months. Trikresol and alcohol, equal parts, is an excellent remedy. After a few days it may produce marked reaction, the scalp becoming red and swollen. When this occurs the reaction should be allowed to subside under cold cream. When it has subsided the trikresol should be again applied. It cannot be used in extensive cases, excepting in small areas at a time. Massage is useful. Good results have been obtained by actinotherapy. The Finsen apparatus or the iron electrode or Kromayer lamp may be used. The iron electrode lamp is to be held about three or four inches from the scalp. The time of exposure is from five to ten minutes, or until the scalp reddens. The exposures are to be repeated when the reaction subsides. Exposures to the Kromayer lamp are from about three to five minutes, repeated when the reaction subsides. Electricity, using the galvanic current, is well spoken of by some; and the high-frequency current is indicated. It is advisable to pluck the loose hairs from around the patch for a zone of perhaps an eighth or a quarter of an inch. Every few days slight traction is to be made on the hairs surrounding the patch and all the loose ones pulled. Prognosis. — Even if left to itself, the chances are that the hair will grow in again. This good prognosis should 1 Monatshefte f. prakt. Dermat., 1900, xxx, 43. 110 DISEASES OF THE SKIN be guarded when the patient is past middle life and in those malignant cases in which there is complete baldness that has lasted several years. In the latter when occur- ring in girls the hair may grow when menstruation is established. Relapses are frequent. Alopecie Innominee. — See Folliculitis decalvans. Anesthesia is a loss of sensation in the skin which occurs in a number of diseases of the nervous system, notably in hysterical affections. It may be general or partial, or affect but one-half of the body. There may be loss of sensibility to pain while the tactile sense is preserved (analgesia), or intense pain with loss of ordi- nary sensibility (anesthesia dolorosa). There are many substances which, locally applied, will cause anesthesia, such as carbolic acid, cocain, aconite; and many others which will abolish sensation when taken internally. The subject belongs to the domain of the neurologist. Anatomical Tubercle. — See Tuberculosis verrucosa cutis. Angiokeratoma 1 is the name given by Mibelli to a peculiar disease of the skin of the hands, feet, and ears that has been called telangiectatic warts, or vermes telangiectasiques. Symptoms. — Angiokeratoma follows chilblains or ex- posure to cold, and affects principally the dorsal aspects of the hands and feet, though their plantar surfaces may be involved to a slight degree, and the toes also. A few cases have occurred on the scrotum. The eruption con- sists in tiny, almost imperceptible, pink points that do not disappear on pressure; of pinpoint- to pinhead- sized darker spots that can be made almost to disappear on pressure, leaving a deep-red capillary loop in the centre; and of clustered telangiectatic points forming small irregularly shaped, slightly elevated groups. These groups may be as large as a split pea or bean; they may 1 British Jour. Dermat., 1891, iii, 2.37. ANGIOKERATOMA 111 project for half a line above the surface, are hard, rough, warty looking, and of dull purplish-brown color. Pressure upon them brings out the telangiectatic character of the growths. When pricked with a needle free hemorrhage takes place. The eruption is symmetrical, as a rule, and usually affects more than one member of a family. It Fig. 12 begins in early life usually, though it may occur later. It is more common in women than in men. There are no subjective symptoms. Pathology. — J. A. Fordyce 1 found in his case that the lesions were composed of lacunar spaces filled with 1 Jour. Cutan. and Gen.-Urin. Dis., 1896, xiv, 81, 112 DISEASES OF THE SKIN blood, occupying the papillary portion of the derma. He thinks that the vascular changes are primary. Tkeatment. — The treatment that proves most bene- ficial is destruction by electrolysis. The hands and feet should be warmly covered in winter time and the circulation improved. Angioma. — See Nevus vascularis. Angioma, Infective. — See Angioma serpiginosum. Angioma Pigmentosum et Atrophicum is the name pro- posed by R. W. Taylor for the xeroderma of Kaposi, and is described in this book under Atrophoderma pigmen- tosum, which see. Angioma Serpiginosum. — It has also been named in- fective angioma and nevus lupus. This is a rare disease, of which but few cases have been reported. White 2 de- scribes the disease as beginning as minute vascular papules that slowly increase to the size of a pea and then undergo spontaneous involution in the central portions, while they spread outward in an annular form to an indefinite extent and for an indefinite period. By the end of ten years the circinate patches may be no larger than one or two inches in diameter. The margin of the rings is elevated and of uniform breadth. New foci continually develop at a distance of one-eighth to one- third of an inch beyond the older areas. These, in turn, are con- verted into rings in the same way. The lesions are firm and smooth, and of bright-red to claret color. The centre of the rings is not elevated, and remains of a dull pinkish-brown tint. There are no subjective symp- toms. White's case was on the right shoulder. Other cases have been on the arm, cheeks, and legs. Sometimes nearly if not all the cutaneous surface of the body is involved. Most of the cases develop in early life. They may start from a vascular nevus. The pathology is undeter- 1 Jour. Cutan. and Gen.-Urin. Dis., 1894, r xii, 505. ANGIOMA SERPIGINOSUM 113 mined. In White's case the growths were composed mostly of endothelial cells and the disease was thought Fig. 13 Angioma serpiginosum to be of sarcomatous nature. Electrolysis or destruction by cauterization along the borders of the areas may be Sequeira, British Jour. Dermat., 1912, xxiv, 35; 114 DISEASES OF THE SKIN used in the treatment of the disease, but the result of treatment is doubtful. Anhidrosis or Anidrosis. — By this is meant an affection of the sweat glandular apparatus attended by a diminu- tion or more or less complete suspension of its functions. It is a symptom rather than a disease. It may be local or general; temporary or permanent; symptomatic, as in fevers and diabetes; congenital, as in xeroderma; or neurotic. Some people never sweat perceptibly. In certain skin diseases, such as psoriasis, scleroderma, squamous eczema, and ichthyosis, the affected areas do not sweat. Its treatment is tonic by exercise and bath- ing. In symptomatic cases we must strive to remove the underlying cause. For congenital cases we can do nothing. Anonychia means congenital absence of the nail. Anthrax. —See Carbuncle and Pustula maligna. Aplasia Moniliformis. — See Trichorrhexis nodosa. Aplasia Pilorum Intermittens. — See Trechorrhexis nodosa. Area Celsi. — See Alopecia areata. Argyria is the blue or black discoloration of the skin and mucous membranes due to the deposition of particles of silver in the rete, sweat glands, and about the hair follicles, where it turns black by exposure to the sunlight. It used to be seen more often when silver salts were administered in the treatment of epilepsy than it is now. It occurs also in workers in metallic silver, minute par- ticles of the metal becoming fixed in the tissues. It has followed the use of nitrate of silver in laryngological treatment of other diseases. It is a permanent staining. Asteatosis or Xerosis. — This is an unnatural dryness of the skin, which is accompanied by desquamation and sometimes thickening, induration, and cracking. It is due either to an absolute or relative absence of fat and sweat glands, or to the action of substances that withdraw the fat from the skin, such as alkaline solutions. ATROPHIA PILORUM PROPRIA 115 It is often seen in old age and in combination with other dermatoses, such as ichthyosis and dermatitis exfoliativa. The treatment of idiopathic cases is by the application of oily substances. In cases artificially produced the avoidance of the cause will cure the condition. Atheroma. — See Sebaceous cyst. Atrophia Pilorum Propria. — Atrophy of the hair exists under three forms, namely, Fragilitas crinium, Trichor- rhexis nodosa, and monilethrix. In all forms the hair shaft is easily friable and splits or breaks of itself or by the slightest traction. Fragilitas Crinium. — This disease has been called scissura pilorum, and has for its distinguishing feature splitting of the hair. It may be symptomatic or idio- pathic. The cleft is usually at the free extremity, and at times runs some distance up the shaft. The split hairs are either scattered here and there through the otherwise normal hair, or all the hairs of the part are split. The disease occurs most often upon the hair of the scalp, the beard being the place next most fre- quently affected. It is a common occurrence in the long hair of women. The shaft may be split into two or more fibrillar, and these spread out from each other simply, or curve up upon themselves. The cleft may also occur in the middle of the shaft or at its exit from the follicle, and in the latter case the shaft will be split throughout its entire length, the segments either separating or holding together. Duhring 1 reported a case occurring in the beard in which the hair began to split within the bulb. Besides the splitting, the hair may show no other abnormality, but it is generally more dry and brittle than normal, and may be irregular and uneven in its contour. The bulb of the hair may be normal or atrophied. Etiology. — The cause of the idiopathic fragilitas crinium is yet undetermined. The disease is, without doubt, due to some interference with the nutrition of the 1 Amer. Jour. Med. Sci., July, 1878, p. 88. 116 DISEASES OF THE SKIN hair, probably a yet undetermined trophoneurosis. The symptomatic form is also due to interference with the nutrition of the hair, but now there is often some evident disease of the scalp like seborrheal dermatitis; or to some trouble with the general nutrition of the body, such as gout or some cachexia. Treatment.— When occurring only at the free end of long hairs they should be cut above the cleft. In all cases the scalp should be kept in good condition, as directed under Alopecia prematura and the general con- dition of the patient improved. If the disease occur in the beard, shaving would at least remove the deformity and possibly cure the disease. Trichorrhexis Nodosa. — Synonyms: Trichoclasia ; Tri- choptylose ; Clastothrix. Symptoms. — The disease most often affects the hair of the beard and moustache, and here it reaches its highest development. It is found also on the hairs of the pubic region and on the scalp and axillary hair. Raymond 1 says that he has found it on the labia majora in 60 per cent, of all women he has examined, and especially in fat women with intertrigo. He has found it also on scrotal hairs. It consists of one or more whitish or grayish, shiny, transparent nodular swellings occurring along the shaft of the hair. In people with red hair the color may be black. The number of nodes that may be present is from one to six, placed about one-half inch apart, and their size will vary with the diameter of the hair. The nodes, according to S. Kohn, 2 occur usually in the upper third of the hair. These nodes give to the hair an appear- ance not unlike that produced by the presence of the nits of pediculi. The hair is exceedingly brittle and fractures upon slight traction or spontaneously, the fracture taking place through a node and the hair fibers separating like the hairs of a brush. When many hairs in the beard are thus broken, their frayed-out ends make 1 Ann. de derm, et de syph., 1891, ii, p. 568. 2 Vierteljahr. f. Derm. u. Syph., 1881, viii. 581. ATROPHIA PILORUM PROPRIA 117 the beard look as if it were singed. Sometimes the hair fibers splinter about the node, but the two ends do not separate, and this gives an appearance like as if two small paint brushes were pushed together. Sometimes the hair presents an irregular contour and looks as if frayed along its entire length. While the fracture is usually transverse, if there should be an excessive amount of medulla present in the node it may be longitudinal. The hairs themselves are usually firmly fixed in the follicles. Fig. 14 N Trichorrhexis nodosa. (Michelson.) Etiology. — The cause of the disease may be a micro- organism, as they have been found in relation to the disease by Hodara, Essen, and others. Hodara 1 de- scribed a parasite in the hair that he named bacillus multiformis trichorrhexides. E. Spiegler 2 has succeeded in cultivating a bacillus and in reproducing the disease by inoculation with its culture. The parasitic theory of origin is not generally accepted. In many cases it seems to be purely due to lack of nutrition. It is by no means rare in the long scalp hair of women who are in poor general condition. Anderson 3 has reported a case of hereditary trichorrhexis nodosa, the disease in his patient being congenital or nearly so. By some it is regarded as purely mechanical, due to the patient's habit of handling the beard, the hair of which is abnormally dry and brittle. 1 Monatshefte f. prakt. Dermat., 1894, iv, 173. 2 Arch. f. Dermat. u. Syph., 1897, xli, 67. 3 Lancet, 1883, ii, 140. 118 DISEASES OF THE SKIN Pathology. — The microscopic examination of the affected hairs shows that in the early stage of develop- ment of the disease there are simply a spindle-formed thickening in the continuity of the shaft of the hair and a swelling of the medulla, while the cuticle is still intact. Later the cuticle becomes cleft, and the cleavage extends on all sides of the node until the brush-like appearance is produced by spreading of the separate fibers. At the same time with the cleaving of the cuticle the medulla under- goes degenerative changes and may disappear entirely. There is either no marked change in the appearance of the hair root or it is slightly atrophied. Air globules are only very occasionally found in or about the nodes. Treatment. — The treatment of the disease is very unsatisfactory. Continued shaving, followed by a satu- rated solution of boric acid, probably offers the best hope. All sorts of applications have been made to the affected parts, generally of a stimulating character, par- ticularly various forms of mercurials, but without cura- tive effect. Gamberini in his work on the hair recom- mends either bathing the part with a lotion composed as follows : 1$ — Potass, subcarb, 3ij 8 Alcohol, dil., ad giij ad 100 M. or inunctions of tannic acid or oil of cade. Schwimmer advises that an ointment of: -Zincioxid., . gr. vi.i Sulphur, loti, gr. xv 1 Ung. simp., 5hss 10 M be rubbed in in the morning and evening. Besnier finds it useful to pluck the diseased hairs and to apply to the newly formed hairs tincture of cantha- rides, pure or diluted. Sabouraud. advises using daily: -Hydrarg. bichlor., gr. iv 25 Ac. tartaric, gr. viij 50 Resorcin., gr. xv-xxx 1-2 Alcohol, Mther., aa § iss aa 50 M ATROPHIA UNGUIUM 119 A 2 per cent, solution or ointment of pyrogallol or a 3 per cent, carbolic acid ointment has been advised by others. Upon the theory that the disease is due to handling hair that is abnormally dry, Joseph forbids washing with soap and water, and advises the daily use of sweet almond oil, or castor oil with 20 per cent, of alcohol. Allied to trichorrhexis nodosa we have Monilethrix, also called aplasia pilorum intermittens, or nodose or beaded hair, in which the hair shaft is marked by alternate swellings and constrictions, the latter being colorless. The hairs are liable to fracture through the constricted portion, in this way differing from trichorrhexis nodosa. Occurring on the scalp it produces patches of hair broken off near the scalp. The disease has been met with on the legs. It is probably due to a trophoneurosis. Heredity is a prominent etiological factor. It usually begins in infancy. Keratosis pilaris is commonly present. It has been known to follow nervous shock. It begins in the hair follicle. Its cause is undetermined. Treatment is unavailing. Atrophia Unguium. — Atrophy of the nails occurs as a symptom of very many diseases of the skin, such as lichen ruber acuminatus, pityriasis rubra, psoriasis, and syphilis; or it may be caused by the invasion of the nail bed by parasites, as in favus and ringworm. It may also occur like defluvium capillorum as a sequence to some grave acute illness, such as typhoid fever or scar- latina, or some cachexia, such as diabetes. The nails may be congenitally absent or deficient, or become so without apparent cause. Injuries and certain chemicals will cause the nails to atrophy and fall. Atrophy is shown by white spots in the nails, leukopathia unguium, by loss of luster, by transverse white lines, by longitudinal or transverse furrows, by a worm-eaten appearance, or by a general thinning and breaking away of the nail- plate. In that form that is called spoon nail there is a 120 DISEASES OF THE SKIN central depression, a scooping out of the nail, the edges of which are everted. Treatment. — The treatment is most unsatisfactory. If the cause can be discovered and removed, the nail will recover. In many cases all we can do is to protect the nail by rubber cots or by the use of wax or other protective. Ointments of lead, zinc, or mercury may be rubbed in. The persistent use of sulphur ointment, combined with the administration of arsenic, will prove beneficial in those cases apparently dependent upon nerve disturbance. Atrophoderma or Atrophia Cutis. — Atrophy of the skin may be quantitative or qualitative; idiopathic or symp- tomatic; diffused or circumscribed. Crocker 1 gives this useful table: D iff u sum [Juvenilis /Pigmentosum. Atrophoderma Idiopathicum ~S Congenitalis \Albidum sSenilis Circumscriptum v (striae et maculae) Atrophoderma Symptomaticum \ f Neuriticum (glossy skin) Morborum cutis fQuantitativum. (Qualitativum. /Traumaticum. \Non-traumaticum. j Traumaticum . 1 Non-traumaticum. ( Scleroderma. Seborrhea. Lupus. I Syphilis. (Favus, etc. The symptomatic atrophies will be spoken of under their proper headings. The other forms of atrophy will be considered here. Atrophoderma Pigmentosum. — Synonyms : Xeroderma pigmentosum (Kaposi); Angioma pigmentosum et atro- phicum (Taylor); Dermatosis Kaposi (Vidal); Liodermia essentialis cum melanosi et telangiectasia (Neisser); Melanosis lenticularis progressiva (Pick) ; Lentigo maligna (Piffard); Epitheliomatose pigmentaire (Besnier). This is a very rare disease of the skin, first described by Kaposi in 1870 under the name of xeroderma, to which 1 Diseases of the Skin, London and Philadelphia, 1905. A TROPHODERMA PIGMENTOS UM 121 he subsequently added the adjective pigmentosum. It is a congenital disease; almost all cases begin before the second year of life. Symptoms. — It affects the parts most exposed to the air: the face, neck, chest, and back down to the level of the clavicles, or even the third rib, the backs of the hands, forearms, and upper arms. The hands, face, and neck are most markedly diseased, while a few cases have Fig. 15 Atrophoderma pigmentosum. (After Crocker.) occurred upon the scalp, legs, and back of the feet. It begins with erythematous patches, like those produced by sunburn. After a time brown or black freckle-like spots form upon the erythematous ones. They are from pinhead to bean size, and round or irregularly shaped. Small red spots appear among the pigmented lesions, which Taylor thought were their forerunners. This is denied by other observers. The pigmented spots 122 DISEASES OF THE SKIN in time give place to white atrophic ones, and the skin becomes too small for the underlying parts, so that it appears drawn and in some places bound down. A fully developed case presents a vast number of lentigi- nous spots interspersed with white atrophic spots and stellate and striate telangiectases. After a time, on account of the atrophy of the skin, we find ectropion, thinned alse nasi, and contracted nasal and oral orifices. There may be white atrophic spots on the mucous mem- brane of the lips. Conjunctivitis generally supervenes upon the ectropion, and the discharge from the eyes sets up ulcerations which in their turn give rise to other ulcerations. Warty growths at last appear, and these are prone to take on malignant action and be converted into epitheliomas, the patient dying at an early age from marasmus, although in some cases the course of the disease is prolonged for ten, twenty, or thirty years. At first, however, there is no disturbance of the health. Etiology. — The etiology of the disease is obscure. It is supposed by some to have its starting-point in irrita- tion of the skin by the sun or other irritant. Many of the cases begin in the summer. It is supposed by others to be a trophoneurosis. It is found in both sexes, and is peculiar in affecting several members of the same family and of the same sex, and in beginning in the first or second year of life. It may be hereditary. In a few of the cases there was a history of cancer in the family. Thus far microscopic investigations have failed to throw light on the pathology of the disease. Diagnosis. — The disease is to be differentiated from scleroderma by the peculiarity of its being limited to exposed parts, by lacking stony hardness, by occurring early in life, and by the general picture of pigmented and atrophic spots and telangiectases being intermingled. It differs from urticaria pigmentosa in not itching, in not occurring upon the trunk, in the absence of wheals, and in the presence of telangiectases and warty or epithelio- matous growths. ATROPHODERMA IDIOPATHICA DIFFUSA 123 Treatment. — Nothing has yet been found to stop the progress of the disease. The conjunctivitis is to be cared for, the ulcerations on the face healed as rapidly as pos- sible, and the warty growths and epitheliomatous nodules destroyed at an early date so as to prevent the develop- ment qf epitheliomatous or carcinomatous ulcers. A saturated solution of boric acid will do much for the eyes; the ulcers may be treated with iodoform or aristol powder or a dilute ammoniate of mercury ointment; while the warty growths should be scraped off with a curette, and touched with acid nitrate of mercury. The axray may be used as in epithelioma for the healing of the ulcers. Prognosis. — The disease is fatal, death from marasmus taking place in from ten to twenty years. Atrophoderma Albidum is the name used by Crocker for a second form of the xeroderma pigmentosum of Kaposi, which is described by the latter as beginning in child- hood, affecting, most frequently, the lower extremities and less often the forearms and hands, and characterized by thinness of the skin, which in some places is stretched and cannot readily be taken up into folds. The color of the skin is pale and white, with a delicate rosy shimmer in places, and here and there its epidermis peels off in asbes- tos-like lamella. The treatment is simply protective. Atrophoderma Idiopathica Diffusa. — Synonyms: Atrophia maculosa cutis; Acrodermatitis chronica atrophicans. Diffused idiopathic atrophy of the skin is a very rare affection. It may be congenital or acquired, general or partial. The subcutaneous tissue disappears, so that the skin lies close to the underlying parts. It is thin, pale, stretched or wrinkled, easily movable over under- lying parts, and allows the bloodvesesls to show through. In some cases thick, scaly plates form, while in others these are wanting and there is only slight scaling. The elasticity of the skin is lost, so that if it is pinched up into folds these slowly flatten out. In some cases the skin seems too small for the body, which, on the face, 124 DISEASES OF THE SKIN gives rise to ectropion and other deformities. The sensibility of the skin may not be diminished. The patients are susceptible to cold. Ulcers are prone to form upon slight injuries. The hair is destroyed. The disease is probably a trophoneurosis. By some observers it is thought that a faintly marked inflammatory process may be the starting-point of the disease. One case was ascribed to exposure to cold. 1 Nothing can be done for these cases beyond oiling of the skin if any discomfort is felt. Hardaway 2 reported two cases occurring in a brother and sister; and Ohmann-Dumesnil 3 has met with a case of atrophy of the skin and muscles of the right arm apparently following an injury to the radial nerve by means of a burn on the hand. One variety of diffused idiopathic atrophy of the skin is that called hemiatrophia facialis progressiva, in which only one-half of the face is affected and the skin becomes thinned and shrunken so that it lies close to the bones. Under this heading may also be placed the glossy skin or atrophoderma neuriticum of Paget, Weir Mitchell, and others. It commonly affects the fingers, less often the extremities, and follows upon disease or injury of nerves. It occurs also in scleroderma. The fingers become dry, red, or mottled, look glazed or as if varnished, and are shrunken. The natural lines of the skin disappear and the nails fall off. If parts covered with hair are affected, the hair falls. Its tendency is to spontaneous recovery. Atrophoderma Senilis is a true atrophy of the skin that takes place in consequence of advancing years. Other degenerative changes also are present, as a rule. It may be partial or general. The skin looks wrinkled; it is thrown into folds, is dry and sometimes scaly, and is often of darker color than normal. By pinching up the skin the thinness of it is readily appreciated. With the atrophy of the skin there are likewise loss of the subcu- 1 Pospelow: Ann. de derm, et de syph., 1886, vii, 505. 2 Trans. Amer. Dermat. Assoc, 1884. 3 Alienist and Neurologist, July, 1890. ATROPHODERMA STRIATUM ET MACULATUM 125 taneous fat, pruritus, and verruca senilis. Treatment is out of the question, beyond oiling of the skin to make the patient more comfortable. Atrophoderma Striatum et Maculatum. — By this is meant circumscribed atrophic streaks or spots. They may be idiopathic or symptomatic. The idiopathic form is far more rare than the symptomatic form. Symptoms. — The idiopathic streaks are met with most often about the thighs, buttocks, and lower anterior part of the abdomen. They are one or two lines wide, slightly curved, and from one to several inches long. There are usually several present, and then the}' are arranged parallel to one another and run in an oblique direction. The macules are isolated, from pinhead to finger-nail size or larger, occur most frequently on the extremities and lower part of the trunk, but may occur as high up as the neck, and are less common than the streaks. Both forms of lesion are depressed below the surface of the skin, and are of a pearly or bluish-white color and have a glistening, scar-like appearance. They are not primary atrophies, but succeed to an erythematous hypertrophic lesion, in this greatly resembling morphea. They give rise to no inconvenience, and are accidentally discovered. They usually are permanent, though they may become less pronounced in time. Etiology.— The etiology is abscure. By many it is regarded as a trophoneurosis. Shepherd 1 and Duck- worth 2 have reported cases of atrophic spots and lines following fevers. Symptomatic lines and macules are very common, and are caused by the stretching or rupture of the more super- ficial bundles of white and elastic fibrous tissues of the skin. If the fibers are ruptured, the striae will be most pronounced, and there will be little left of the skin but the epidermis and a thin fibrous membrane. 3 This form 1 Trans. Amer Dermat. Assoc, 1890. p. 23. 2 British Jour. Dermat., 1893, v, p. 357. 3 Taylor, R. W.: New York Med. Jour., 1886, xliii, p.l. 126 DISEASES OF THE SKIN of atrophy of the skin is seen upon the abdomen of pregnant women (lineoe albicantes) and on the breasts of nursing women. It has also occurred about the joints in young people who have grown rapidly after being con- fined in bed with an illness such as typhoid fever. Atrophic lines are not infrequently seen on the upper part of the thighs, both in men and women. In fact, anything that greatly distends the skin may give rise to them, such as abdominal ascites, obesity, ovarian or other tumors. Treatment. — The treatment of these cases is purely expectant. Both the idiopathic and the symptomatic atrophies may grow less pronounced in time. Autographism. — See Urticaria factitia. Baelz's Disease of the lip is a chronic affection of the mucous glands of the lip marked by an indolent swelling and infiltration of the periglandular tissue, and a slow ulceration from above downward. It ceases only with the destruction of the affected gland. The neighboring lymphatic glands are not implicated. A superficial catarrhal inflammation of the mucous membrane of the lips frequently accompanies the process. There is no general systemic disturbance. It has no relation either to syphilis, tuberculosis, or cancer. It is regarded as a local infection. It is readily cured by the application of tincture of iodin, which at first is used every other day, and later every day. Baker's Itch. — See Eczema. Barbadoes Leg. — See Elephantiasis. Barber's Itch. — See Trichophytosis barbae. Bazin's Disease. — See Erythema induratum. Beigel's Disease is a parasitic growth found on false hair, marked by the appearance of dirty-brown nodes on the hair shaft. It is caused by a fungus of yet undetermined species. Birth-mark. — See Nevus. BOTRYOMYCOSIS HOMINIS 127 Biskra Bouton or Biskrabeule. — See Aleppo boil. Black Tongue, Hairy Tongue, or Hyperkeratosis Linguae. — According to Stelwagon 1 this disease is most often located on the dorsum of the tongue, in front of the circum vallate papillae, but may occur elsewhere. The color is usually black, but may be yellow or blue. There may be simply discoloration, but more usually fine hair- like projections spring from the darkened patch. The disease may develop rapidly or slowly to areas of vary- ing size. After lasting for weeks, or years, it usually disappears of itself. It gives rise to no subjective symp- toms as a rule, excepting a mawkish taste, and rarely slight pain. The cause of the disease is unknown. It occurs both in children and adults, and in both sexes. Attention to the hygiene of the mouth and the use of an antiseptic mouth wash are the means for treatment. Blastomycetic Dermatitis. — See Dermatitis blastomy- cotica. Boil. — See Furunculus. Botryomycosis Hominis. — This is probably only "proud flesh" and due to staphylococcus aureus; though by some it has been thought to be caused by botryomyces. It is characterized by pedunculated rounded pea- to nut-sized red tumors with a more or less mammillated surface. They are soft and elastic to the touch, and sometimes bleed easily. Usually there is only one lesion. They are most often seen on the hands, but may occur anywhere. They usually start from a sligthly injured surface which has suppurated. They consist of a connective-tissue stroma and granulation tissue rich in bloodvessels. The epidermis over them is wanting either wholly or in part. They should be tied or cut off, and dressed with anti- septics, or curetted and the base cauterized. A better 1 Diseases of the Skin, Philadelphia, 1914. 128 DISEASES OF THE SKIN name for them is that proposed by Crocker, granuloma pyogenicum. Bricklayer's Itch. — See Eczema. Bromidrosis. — Synonym: Osmidrosis. This word means stinking sweat, which, though not elegant, is expressive. It most often affects the feet, and then is associated with hyperidrosis. It may be general, as in the negro race. The odor is not necessarily repulsive, a few cases having been reported in which it was that of violets. The axilla? are, next to the feet, the most common site of the trouble. The odors of different fevers and cachexia are usually classed under this heading, although they do not properly belong here. Strictly speaking, bromidrosis should include only those rare cases in which the sweat, when secreted, has a distinctive odor. Usually the odor in bromidrosis is not in the sweat, but in the products of decomposition, the fatty acids and the like. When the feet are the parts affected they will be found to be of a pinkish color about the soles and between the toes, or the skin will look sodden and grayish. When the hyperidrosis is well marked, and it commonly is, the feet may be so tender as to interfere with locomotion. The stench from a pronounced case is such that it is almost impossible to stay near the subject of the disease. Etiology. — The cause of general bromidrosis is either inherent in the race or unknown. Most of the cases, apart from the racial ones, have been in hysterical sub- jects. The taking of some drugs imparts their odor to the sweat. Asafetida, onions, musk, and other drugs may do this. In the usual form of the disease it is due to decomposition of the sweat in the stockings, shoes, or clothing of the individual. When the part is uncovered and kept clean, there is no odor. Thin described a parasite, that he named bacterium fetidum, as the cause of the disease. It is supposed that this bacterium can live only in an alkaline medium. The sweat is acid, BULPISS 129 and, therefore, on most feet it does not grow, but when hyperidrosis macerates the epidermis and allows of the escape of serum the acidity of the sweat is neutralized and the bacterium flourishes. Treatment. — The treatment of the general cases is of no effect. In the local cases the hyperidrosis is to be overcome, as will be described in its proper place. The special treatment directed to the cure of the odor of the feet is to wash them with soap and water two or three times a day, to put on a clean pair of stockings every morning, to ventilate the shoes thoroughly, and to dust the feet, between the toes, the stockings, and the inside of the shoes with finely powdered boric acid. Thin recommends the wearing of cork inside soles, which are to be soaked in a saturated solution of boric acid and dried before using. Another useful powder is: R — Ac. salicylici, i Pulv. alum, exsic. vel. 3 iss-ii j 6-9 Pulv. lycopodii, ad giij ad 120 | M. to be applied in the same way, twice a day. This will cause the skin to exfoliate, when the treatment may be stopped. W. Osier 1 reports one case of general bromidrosis cured by the administration of alkalies. Bulpiss 2 is a disease that occurs in Nicaragua, affecting every tribe, both sexes, and all ages, though rare in early infancy. It begins on the feet and hands, and spreads gradually; or upon the knees, or abdomen, or neck and face. Two kinds are described. In the white bulpiss there are crops of minute reddish papules, which on disappearing leave discolored spots. After a time the pigmentation fades away and leaves a dirty white, round or oval patch, with slightly elevated and partly dis- colored broad margins. In black bulpiss the patches are grayish black, and the skin is dry and shrivelled. Both 1 Montreal Med. Jour., 1896-9, xxv, 890. 2 O. Lerch: New Orleans Med. and Surg. Jour., 1894-5, xxii, 793. 9 130 DISEASES OF THE SKIN kinds jtch at night. It is contagious and probably para- sitic. It resembles if it is not identical with caraate. Bunion.— According to P. Syms, 1 a bunion is always secondary to an outward displacement of the first pha- lanx of the great toe, due to ill-fitting shoes. As a result we have a periostitis with hyperplasia, and finally exos- tosis of the metatarsal bones. The pressure between the exostosis and the shoe gives rise to an inflamed bursa, the bunion. Surgical interference and properly con- structed shoes are the only remedies. Cacotrophia Folliculorum. — See Keratosis pilaris. Calculi, Cutaneous. — See Milium. Callositas. — Synonyms: Callosity; Callus; Tylosis; Tyloma; Keratoma; (Fr.) Durillon. This is familiar to all as the callous skin of the hands met with in oarsmen, blacksmiths, and in those who follow other manual occu- pations, and is a hypertrophy of the epidermis consequent upon intermittent pressure of the skin against the under- lying bone. Constant pressure will cause atrophy. The same thickening of the skin is found upon the soles also, due to going barefoot or wearing improperly fitting shoes. This form of the disease is not infrequently met with in people who are past middle life, and sometimes is due to a flattening of the arch of the foot. In fact, it may develop anywhere under proper conditions. Treatment.— Cessation from using the hands will be followed in course of time by the disappearance of the callus. To hasten its removal we may use maceration with rubber cloth, continuously applied to the part, or soaking in hot water containing § to 1 ounce of carbonate or bicarbonate of soda to the gallon. Or a plaster of salicylic acid, or a solution of salicylic acid, 10 to 20 per cent., in ether or collodion. The action of these remedies will be aided by previously paring down the part with a sharp knife. When the soles of the feet are affected 1 New York Med. Jour., 1897, Ixvi, 448. CANITIES 131 special attention must be given to the shoes, and to rectifying any flat-foot by mechanical means. Salicylic acid and the daily soaking of the feet are the best local applications. Callus. — See Callositas. Calvities. — See Alopecia. tlancer. — See Carcinoma and Epithelioma. Canities. — Synonyms: Trichonosis cana; Trichonosis discolor; Poliothrix; Poliosis; Trichonosis poliosis; Spi- losis poliosis; Poliotes; Grayness of the hair; Whiteness of the hair; Blanching of the hair; Atrophy of the hair pigment. Grayness or whiteness of the hair may be congenital or acquired; the latter is by far the most common. The whiteness is either partial or complete. Congenital canities usually occurs in the form of tufts, sometimes in round patches, the more or less pure white hair showing conspicuously among the normal-colored mass. When the whiteness is general we have albinism, which is associated with a deficiency of pigment in the whole body. Cases of congenital canities are rare. Acquired canities may be premature or senile. Most often grayness does not begin before the thirty-fifth or fortieth year. If it occurs before this age, it may be con- sidered as premature; and when after this age as senile. Premature canities is by no means uncommon, many persons becoming gray between the twentieth and twenty-fifth year. The hair which first whitens is, as a rule, that of the temples; then follows, with more or less rapidity, that of the vertex and whole head. Some- times the beard first turns gray, but usually it changes color after the hair of the scalp. The last hair to become gray is that of the axilla and pubis. When the gray- ing is due to some passing cause, as anxiety or some diseased state, the process may cease completely upon removal of the cause. Usually the whiteness is progres- 132 DISEASES OF THE SKIN sive and permanent. As a rule, there is no change in the color of the scalp, although in some cases gray tufts are found upon pale-yellow patches of the scalp. As in alopecia, so in canities, men are more frequently affected than women. The hair in canities is usually unchanged except in color, but it may be drier and stiffer than normal. Cani- ties may exist for years without alopecia. The hair turns gray first at its root. The color at first is gray on account of the mixture of the normal color with the whiteness due to the absence of pigment. Gradually the white parts gain the ascendant, and the whole hair is blanched, becoming finally of a yellowish or snowy whiteness. The darker the hair is originally the more it is prone to turn gray. Sudden change of color of the hair from its normal hue to perfect white has been two well authenticated to allow of a doubt as to its occurrence, though it has been denied by good authorities, who have questioned the correctness of the observations reported. Ringed hair is an anomalous variety of blanching of the hair in which the affected hairs are marked by alter- nate rings, one being that of the normal color, and the next white. The occurrence of this disease is very rare, and but few cases have been reported. The hair has been known to lose its color under vary- ing circumstances. Very commonly the first hair that comes in after alopecia areata is white. Wallenburg 1 reports a case in which, after an attack of scarlatina, the patient's brown hair was entirely lost and replaced by a growth of white hair. Prolonged residence in a cold climate, with much exposure, will cause the hair to turn gray. Sometimes the hair will change its color with the season, becoming gray in winter and darker in summer. On the other hand, Cottle 2 gives prolonged residence in hot climates, with much exposure, as a cause of canities. 1 Vierteljahr. f. Derm. u. Syph., 1876, iii, 63. 2 The Hair in Health and Disease, London, 1877. CANITIES 133 Albinos, we know, are most frequent in the negro races, which inhabit the hot countries. Etiology and Pathology. — Senile canities and many cases of the premature form are due to an obscure change in the nutrition of the hair papillee which inter- feres with the production of pigment. Only this func- tion of the papilla seems to be interfered with, as the hair-forming function is in full activity, judging from the fact that the hair in many cases is in full vigor. Metchnikoff 1 says that the loss of pigment is due to the phagocytic action of certain cells that he named pigmento- phages. These are cells of the medulla that become mobile, penetrate the cortex, absorb the pigment granules, and descend with the pigment into the bottom of the follicle and the adjacent connective tissue. In cases of sudden blanching of the hair the change of color is depen- dent upon the formation of air bubbles between the hair cells of the cortical substance, the presence of the air rendering the cortical substance opaque, so that the color of the pigment is obscured. There are various agents which act as active or exciting causes of canities. Age is one of the most prominent of these. Heredity exerts marked influence upon the blanching of the hair, most of the members of certain families turning gray at an early period of life. Neuralgia of the fifth nerve, dyspepsia of various forms, sudden fear or nervous shock (producing sudden blanching of the hair), profuse and frequent hemorrhage, excesses of all kinds, chronic debilitating diseases (as syphilis, malaria, and phthisis), local diseases or injuries to the scalp, as wounds, favus, repeated epilation, prolonged shaving, and the like, have been given by various writers as causes of canities. Schwi,mmer regards it as being principally a tropho- neurosis, and finds in the occurrence of grayness in the course of neuralgia a strong argument for his theory. Treatment. — We cannot restore the color to gray hairs. In some cases of canities occurring in the course 1 Annal. de l'lnstitut Pasteur, 1901, p. 865. 134 DISEASES OF THE SKIN of neuralgias, if we can cure the neuralgia, the color will gradually return to the hair. Besnier and Doyon suggest the use of acetic acid as a promotor of pigmentation, as they have seen numerous instances of its use in alopecia areata followed by growth of hyperpigmented hair. Pilocarpin applied locally in ointment or lotion, 3 or 4 grains to the ounce, may cause white hair to darken. All that can be done for canities is to restore artifi- cially the color by means of hair dyes, and their use is to be deprecated. Happily the custom of dyeing the hair is falling out of fashion. Carbuncle. — Synonyms: Anthrax, 1 Carbunculus; (Ger.) Brandschwar, Kohlenbeule. A phlegmonous inflammation of the skin and subcu- taneous tissue, attended with sloughing. Symptoms. — This disease begins as an innocent-looking papule, which, however, is far more painful, both sub- jectively and objectively, than an ordinary papule would be. Within twenty-four hours it becomes larger, more painful, slightly raised and reddened, and is gen- erally accompanied by a good deal of constitutional dis- turbance, such as chills, fever, and nervous irritation. All the symptoms increase in severity, the inflammation extends laterally and vertically, the swelling becomes darker in color, the pain more intense, throbbing and lancinating, and the constitutional disturbance may be so severe that the patient is compelled to go to bed. Within ten days, or perhaps longer, the swelling has reached its height. It may be two or three inches or more in width, with a brawny base that is more or less sharply defined, of irregular shape, firm to the touch, and with a wide area of edematous skin about it. Now it begins to soften, not like a boil with a central point, but with the formation of a number of small pea-sized 1 Anthrax, a term that is often applied to carbuncle, should be used rather for malignant pustule or the local manifestation of splenic fever. CARBUNCLE 135 purulent points, through which sanious pus exudes, giving to the surface a cribriform appearance. Sloughing takes place through the openings, that gradually enlarge, so that at last there results an irregular, deep, excavated ulcer with firm, sharply cut, everted edges. In very bad cases the whole mass may fall out at once. The ulcer gradually fills up, heals, and leaves a scar. With the discharge of the slough the patient gradually recovers his health; but in some cases, especially in persons already debili- tated or in elderly people, the disease runs a fatal course, the patient dying of exhaustion or pyemia, or the disease runs into a typhoid condition preceding death. Death may also result from acute sepsis, or from thrombosis or embolus, especially in carbuncles on the scalp. In some cases the resulting ulceration is very large, with a corre- sponding amount of general disturbance of the system. Dry gangrene may take place. The disease is rare in children, and most common in middle and old age. Men suffer more often than women. The most frequent locations of the disease are the upper dorsal region, back, buttocks, and forearms, although it may occur anywhere. It is usually a single lesion. The duration of the whole process is six weeks or more. Etiology. — The causes of the disease are very much the same as those of boils. While carbuncle is most apt to occur in those who are not in good health, it does occur at times in apparently robust subjects. Diabetics are frequent subjects; gout and uremia have been con- sidered as predisposing causes. The frequent location of the disease about the shoulders and on the back of the neck suggests pressure as a determining cause. Microorganisms are the exciting cause of the disease, the staphylococcus pyogenes aureus, albus, or citreus, being constantly found in the tissues of a carbuncle, especially the first. Pathology. — To Warren, 1 of Boston, we owe one of the most thorough studies of the pathology of carbuncle. 1 Boston Med. and Surg. Jour., 1881, civ, 5. 136 DISEASES OF THE SKIN He declares it to be a spreading phlegmonous inflamma- tion of the subcutaneous cellular tissue. The inflam- matory cells cluster in and about the columnar adiposse and push out laterally from them, infiltrating the skin. They reach the surface by mounting up along the hair follicles and arrectores pilorum muscles. The inflamma- tion starts from a skin follicle, or sebaceous gland; ex- ceptionally from deep down in the subcutaneous tissues. Diagnosis. — Carbuncle differs from furuncle in being single; in its brawny base; in its greater painfulness and constitutional disturbance; in its flatter shape and larger size, and especially in its opening at many points and presenting a cribriform surface rather than a central core and a crater-shaped opening. Its circumscribed shape, its lancinating pain, and its multiple sieve-like openings distinguish it from diffuse phlegmonous inflam- mation of the skin. Anthrax becomes gangrenous earlier than carbuncle and its centre sinks in instead of becoming elevated. Treatment. — As the disease is an exhausting one the patient's strength is to be supported from the start and his nutrition kept up by a generous diet. Fresh air by good ventilation must be secured. If the pain is excessive, opium or morphin is indicated, especially to procure sleep. Iron is a valuable remedy all the way through, and antipyretics should be administered if the fever is high. Alcohol should be given if suppuration is free, especially if there are any signs of exhaustion. The best local treatment in mild cases is the use of carbolic acid, and this gives such good results as to leave little to be desired. The crucial incision formerly prac- tised is now considered by many modern authorities as harmful, though it certainly gives relief for the time by removing tension. In like manner the old-time method of poulticing is condemned, though it, too, contributes to the comfort of the sufferer. If the comfort of heat is desired it may be obtained by hot fomentations with a boric acid solution. For ordinary carbuncles the most CARCINOMA 137 efficient treatment is to inject them at several points with a 5 to 10 per cent, solution of carbolic acid in olive oil or glycerin, by means of an ordinary hypodermic syringe. When there are already sloughing points it is well to push into each of them a little absorbent cotton wound on the end of a wooden toothpick and dipped in carbolic acid, either pure or in 1 to 4 solution. These procedures are painful for a moment, but the pain soon ceases. Hyde and [Montgomery suggest the application of cupping glasses to draw out the pus after the carbuncles are open. The mass must then be covered with lint soaked in a weak solution of carbolic acid or in a saturated boric acid solution used hot. It is possible to abort some carbuncles by touching them with pure carbolic acid. E. O. Ashe 1 reports the cure of one case by the injection of antistreptococcic serum. Eade 2 says that it is possible to abort cases in the papular stage by continuous soaking with a solution of a mild antiseptic, such as boric or salicylic acid. Canquoin's paste and a solution of chloride of zinc, 1 to 50, have been recommended for use in the same way as the carbolic acid. Extensive carbuncles are to be treated on surgical principles by incision or erosion with a curette. The resulting raw surface, as well as that of ordinary carbun- cles, is to be dressed antiseptically with iodoform, iodol, or aristol in powder. In all but the mildest cases the autogenous or stock staphylococcic vaccines should be used as detailed under Furunculosis, which see. Carcinoma. — Epithelioma is the form of cancer that most frequently is met with in the skin. It will be described under its proper heading. Carcinoma of the scirrhous variety rarely attacks the skin. When it does it may be primary or secondary. Most commonly it is secondary to the same disease of the breast or internal organs. It may follow extirpation of the primary deposit, 1 British Med. Jour., 1898, ii, 1427. 2 Lancet, May 19, 1888. 138 DISEASES OF THE SKIN and then is prone to begin in the scar. Two varieties are described, namely: Carcinoma lenticnlare and Car- cinoma and tuberosum. Carcinoma lenticnlare generally appears on the chest in the neighborhood of the breast, and is secondary to a mammary cancer, or begins in the scar resulting from a previous operation for the removal of a cancer of the breast. It appears in the form of smooth, firm, glisten- ing, dull, white, or brownish-red or pinkish nodules raised above the surface and discrete at first. In size the nodules vary from that of a pea to that of a bean or larger. After a time the nodules run together and form a thick, indurated mass, which may involve so much of the chest as to interfere with breathing. This is the cancer en cuirasse of Velpeau. Now T the neighboring lymphatic glands are involved and the arm of the same side becomes swollen and useless. In a short time the nodules and the mass break down and ulcerate, and the patient soon dies of exhaustion. Carcinoma tuberosum is still more rare. It may occur anywhere, but is most frequently seen upon the face and hands. It takes the form of disseminated, flat or elevated, round or oval tubercles or nodules, seated deeply in the skin and subcutaneous tissues. These are of a dull-red, violaceous or brownish-red color, and may grow to the size of an egg. They do not tend to coalesce, though they may crowd closely together. They break down and ulcerate, and the patient dies just as in the lenticular variety. It usually appears in old people. In both forms there may or may not be lancinating pains, or there may be simply itching. In both, metas- tasis may take place. Carcinoma melanodes is described by most authors as a third form of carcinoma, but Robinson, Crocker, and Brocq regard it as melanotic sarcoma. It is impossible to distinguish them clinically from sarcoma, which see. Diagnosis. — The diagnosis of carcinoma is not difficult when one is aware that there is such a disease, and knows CHEILITIS EXFOLIATIVA 139 that in a given case there has been, or is, a carcinoma elsewhere. The mode of evolution of the lesions, the involvement of the lymphatic glands, and the lancinating pains, all point toward carcinoma as against a tubercular syphilide, lupus, or leprosy. Treatment. — The treatment of carcinoma of the skin is the same as that of other forms, and is quite as unsat- isfactory. Massive doses of x-rays should be tried. Chafing. — See Erythema inter tigo. Chap. — Usually a mild form of eczema or dermatitis, the affected parts being red, possibly slightly swollen, and scaly. There often is superficial cracking of the epidermis, and these cracks sometimes bleed. The parts feel sore. It is generally due to exposure to cold and affects exposed parts, as the backs of the hands and the lips. It is predisposed to by a congenital dryness of the skin, owing to a deficiency of fat in its secretions. It may be caused by the use of strongly alkaline soaps, chemicals, and other irritants. Thorough drying of the hands after washing and keeping them covered from the air will prevent its occurrence on the hands. Rubbing into the skin cold cream from time to time, during the day or night, or the use of 1 drachm (4) of glycerin in 1 ounce (32) of rose-water will prove curative. Avoiding wetting the lips, and making some greasy protecting application, such as camphor ice, will prevent the lips from being affected. Cheilitis Exfoliativa. — The vermilion border of the lower lip is the one most often affected, though the upper one may be. The lip is swollen and covered with a yellowish or brownish crust. If this is pulled off there will be exposed "a red glazed surface that may bleed. Cracking of the lips, with bleeding, may occur. A seborrheal dermatitis of the scalp may be found. It is regarded by some authorities as a seborrheal dermatitis. The cause is unknown. Its course is chronic, the disease 140 DISEASES OF THE SKIN lasting for years. The daily application of camphor ice will keep the lips comfortable. Stel wagon benefited one case by using dilute, and later pure, lactic acid every six hours for four applications and repeating in ten days, an ointment containing ichthyol and acetanilid being used in the meantime. A solution of resorein may be tried. Cheilitis Glandularis Aposthematosa, or Myxadenitis Labialis, is a disease of the lips, usually the lower one. The lip becomes gradually swollen, firm, and rather hard to the touch, and its mobility is impaired. The mucous glands become swollen and can be felt as nodular masses. A turbid mucopurulent secretion is poured out at times, and the gland ducts are more or less dilated. No pain attends the disease, which is exceedingly obstinate to treatment. Black wash is recommended in the treatment, together with the occasional application of nitrate of silver. Cheiro-pompholyx. — See Pompholyx. Chilblain. — See Dermatitis congelationis. Chloasma. — Synonyms: (Fr.) Chloasme, Panne hepa- tique, Tache hepatique, Chaleur du foie, Masque; (Ger.) Pigmentflecken, Leberflecken; (Ital.) Macchie epatiche; (Eng.) Liver spot, Moth patch, Mask. A pigmentary disease of the skin, characterized by the formation of yellowish, brownish, or blackish patches of various sizes and shapes. Symptoms. — In this disease the only alteration of the skin is in its color. The disease consists in a deposit of pigment in the rete mucosum, and occurs in the form of circumscribed or diffused patches of yellowish to black discoloration. When the color is black it is called melasma or melanoderma. The size of the patches varies greatly from a small spot up to a general bronzing of the skin. The disease may be primary or secondary, idiopathic CHLOASMA 141 or symptomatic. The idiopathic forms are most often secondary to some irritation. Thus it occurs with or in consequence of irritants applied to the skin, such as blisters or even sinapisms; prolonged scratching on account of some pruriginous disease, such as prurigo, pruritus cutaneus, chronic urticaria, scabies or pediculo- sis; exposure to the sun's rays or high winds, or even to heat, as of the furnace in iron workers, and then on exposed parts. These all cause more or less hyperemia of the skin, and besides the deposit of the pigment there is more or less discoloration from the changes taking place in the extra vasated blood. Allied to these causes and acting in the same way is the discoloration of the skin of the legs met with about old varicose ulcers and sometimes without the ulcers when there are marked varicosities. The symptomatic form may likewise be primary or sec- ondary. It is primary in that most common form of all that is known as Chloasma uterinum, or the mask, a hyperpigmentation of the skin of the face that occurs during pregnancy, or with uterine or ovarian irritation, and that is not met with after the menopause. It usually takes the shape of a diffused brownish, light or dark discoloration of the forehead alone, or also about the mouth and cheeks. Usually it extends only across the forehead and down the temples, and is either a continu- ous or interrupted patch with sharply defined borders. Sometimes it is macular in character and occurs on the eye-lids, lips, and chin. Under the same conditions there takes place a deepening of the color about the nipples and along the linea alba. The darkening of the color under the eyes of menstruating women is largely due to vascular congestion, and little, if at all, to chloasma. After a time in some women true chloasma does occur there. Primary pigmentation also occurs in certain cachexia?, such as Addison's disease, tubercular leprosy in Europeans, abdominal tuberculosis, cirrhosis of the liver, cancer of 142 DISEASES OF THE SKIN the stomach, malaria, diabetes, exophthalmic goitre, and multiple melanotic sarcoma. There is also an earthy look to the skin in secondary as well as in congenital syphilis. Primary chloasma is also seen as the result of the ingestion of arsenic. Argyria is not a chloasma, strictly speaking. Secondary symptomatic chloasma is seen as the sequela of syphilides and of lichen ruber planus; these derma- toses disappearing to leave behind them, for a greater or less length of time, hyperpigmented spots. It may occur after other diseases of the skin, but then it usually is more fugitive. It is also seen in senile atrophy of the skin. There is hyperpigmentation about the patches of leukoderma and in scleroderma. There is also a pigmentary syphilide met with upon the neck in women. Etiology. — The cause of chloasma is undetermined in most cases. One theory to account for the pigmentation following exposure to the sun is that it is due to the action of the chemical rays of the sun upon the con- stituents of the blood. We know also that in some cases of hyperpigmentation following traumatism the color is due to changes taking place in the coloring matter of the extravasated blood. That there is a relation between chloasma uterinum and the sexual organs of women we know, because the chloasma usually clears away either after parturition, the cure of the uterine disorder, or the attainment of the menopause. Diagnosis. — The diagnosis is usually easy. Discolora- tions caused by artificial means can be washed off. Chromophytosis is scaly and can be scraped off with the nail. Chromidrosis is very rare and can be washed off with chloroform or ether. Treatment. — The treatment of chloasma is very unsatisfactory. In many of the symptomatic cases removal of the cause will be followed by disappearance of the color. Our first duty is to try to find the cause and, if possible, remove it. While it is possible to remove the color, it is very prone to return. Glacial acetic and CHROMIDROSIS 143 trichloracetic acid touched on in dots will reduce the color and sometimes remove it. The same may be said of other acids, care being used not to cause too great a destruction of the skin by the stronger ones. The bichloride of mercury in 1 to 2 per cent, solution may be used for the purpose, applied repeatedly or else kept on continuously for three or four hours. This causes vesi- cation. The vesicle cover being removed the raw surface is to be dressed with a dusting powder. It is not always a safe procedure. Salicylic acid, 10 to 15 per cent., in ointment, paste, or plaster, or in saturated solution in alcohol, may do well. Resorcin, 20 per cent, in alcohol, applied repeatedly until the skin exfoliates, sometimes removes the pigmentation. Pure carbolic acid applied with a swab made of absorbent cotton on a small sharpened stick is one of the best applications. It turns the skin white, and in a few days the shrivelled epidermis falls. Unna has recommended washing the part with alcohol and applying overnight a mercurial plaster made with the ammoniate of mercury. The next day this is to be removed and the following ointment is to be applied : 1$ — Bismuthi subnit., Kaolini, aa 3iss aa 6 Vaselini, ad oiss 48 M. Brocq advises a mercurial plaster during the night, bathing morning and evening with a 3 or 5 per cent, solution of bichloride of mercury, and wearing during the day oxide of zinc or bismuth ointment. The peroxide of hydrogen will cause a temporary dis- appearance of the pigmentation. Electrolysis may be used in small patches. In all cases in which there is an underlying cause attention must be given first to it. Pkognosis. — Many of the symptomatic pigmentations disappear when the patient recovers his health. It is not well to promise a certain disappearance of the patches, as some of them are permanent. Chromidrosis. — Synonyms: Ephidrosis tincta seu dis- color; Stearrhcea or Seborrhea nigricans; Pityriasis nigri- 144 DISEASES OF THE SKIN cans; (Fr.) Cyanopathie cutanee, Melastearhee; Melan- hidrosis; Colored sweat. This is a condition in which the sweat has an abnor- mal color. Usually it affects only limited regions, espe- cially the lower eyelids. The color is most commonly blue or blue black. The subjects are most often hysteri- cal women, and many of the cases are feigned. Besides the lower eyelids the upper ones may be affected. Next in frequency the colored sweat forms on some other part of the face, but it may occur on any portion of the body, as in the axilla or groin. Besides the blue or black color, cases of yellow, green, brown, and even rose color have been reported. A few men have exhibited the phenomenon. Hoffmann 1 reports a case of blue sweat of the scrotum of a man seventy-two years old, and White 2 has met with an extensive case of yellow sweat in a man twenty years old. R. W. Taylor saw one case of apparently blue sweat that occurred in a man taking iodide of potassium, and w T as due to a reaction between the starch of his shirt and the iodine contained in the sweat. Constipation and nervous derangements are often found in the cases. The chromidrosis has been noted to grow worse with increased constipation, and become better when that condition was removed; to be more pronounced at menstrual periods, and to break out suddenly under emotional excitement. The skin may present no apparent change except the discolora- tion, or it may have an evident deposit, commonly greasy, upon it. In either case the color can be removed by wiping with a little oil, or scraped off partially with the finger nail. The condition may disappear spon- taneously or be persistent. Black pigment in the stomach contents, feces, and urine has been noted in some of the cases. Etiology. — The cause of the disease is obscure. Some instances are purely factitious. Blanchard 3 met with 1 Wien. med. Wochenschr., 1873, xxiii, 291. 2 Jour. Cutan. and Ven. Dis., 1884, ii, 293. 3 Bull, de la Soc. Franc, de derm at. et de syph., 1908, p. 39. CHROMIDROSIS 145 a case of black sweat that came after photophobia and conjunctivitis, and relapsed several times under the same conditions. It has been thought to be due to the presence of colorless indican in the sweat, which becomes blue by oxidation. This accounts for a few cases at least. Iodide of potassium is reported to have colored the sweat pink, and copper green. Diagnosis. — The diagnosis is easy because the dis- coloration can be readily removed by an oiled cloth, while that of chromophytosis does not so readily come off, and that of chloasma does not yield at all. More- over, neither of these last two conditions exhibits a blue color. Treatment.— It is important that constipation, men- strual disorders, or any derangement of health should be relieved. Locally, good results have been reported from the use of the following: 1 1$ — Ac. borici, gr. x 2 Ac. salicylici, gr. xv 3 Ungt. aquse rosae, ad Sj ad 100 M. The red sweat that occurs in the axillae more especially, and elsewhere occasionally, is not a true chromidrosis, but is due to the growth of bacteria (bacillus prodigiosus) upon the hair, as may readily be demonstrated under the microscope. The bacteria are sometimes present so abundantly as to encrust the hair. The same bacteria grown on culture media are colorless, and it is supposed that the action of the sweat upon them determines their color. At times not only are the hair and skin stained red, but also the underclothing is deeply dyed. A mild parasiticide ointment or oil combined with the use of soap and water, or a simple borax solution, will cure the disease just as in chromidrosis. Green sweat has been seen in workers in copper and those taking the same by the mouth. Yelloio siveat has been found associated with bacteria and without them. 1 Van Harlingen: Hand-book of Skin Diseases. 10 146 DISEASES OF THE SKIN Chromophytosis. 1 — Synonyms: Pityriasis versicolor; Tinea versicolor; Chloasma; Dermatomycosis furfuracea seu microsporina; Mycosis microsporina; (Ger.) Kleien Flechte; (Fr.) Pityriasis parasitaire ou versicolore. A vegetable parasitic disease, characterized by brown or cafe-au-lait colored, variously shaped and sized patches that occur chiefly upon the trunk. Symptoms. — This disease is far more common than statistical tables show it to be, as it causes so little trouble that many people never think of applying for relief. It begins as a small yellowish point, often located at the mouth of a follicle, which gradually grows into a split- pea-sized macular lesion. Many new lesions appear, and, these coalescing, patches form which may be so large as to occupy a great part of the chest or back. At first, when of small size, the patches are circular in shape, but as they grow larger they lose all definiteness of shape, though their edges are always sharply marked and sometimes raised. Annular patches sometimes form, and at other times there will be many more or less circular patches of sound skin in the midst of the diffused patch. The color is usually fawn or cafe-au-lait; it may be brown or even black. The latter is reported only from tropical countries. In warm weather and in those who sweat profusely it is no uncommon thing to see the eruption present a pinkish hue, due to hyperemia of the skin. In negroes the patches are gray or chamois- skin-like in color. The edge of the patch may be some- what raised, but the surface is not generally above that of the skin. It presents various appearances. At times it is smooth and feels greasy; at times it is dry and covered with fine branny scales; while at times it looks rough, and, viewed in the proper light, it presents an appearance resembling that of ichthyosis of mild grade. These appearances are dependent upon the amount of 1 The name of chromophytosis was proposed for this disease by Dr. F. P. Foster, and has been well received in New York, as it quite accurately defines the disease and brings it in line with trichophytosis. CHROMOPHYTOSIS 147 sweating, which, if profuse, will remove the scales, especially if the clothing rubs upon the skin. The greasy feel is imparted by the oily sebaceous matter, always marked in the region of the sternum, where chromo- phytosis most often is located. Whatever may be the apparent condition of the surface, scraping with the nail will remove a good part of the disease, showing that it is located in the upper layers of the epidermis. The patches are located chiefly upon the anterior surface of the chest and upon the abdomen. The back is also quite often affected, but not so markedly as the chest. In very extensive cases the arms and legs may show the disease, and a few cases have been reported as occurring upon the face. C. W. Allen pointed out that the disease is very often found concealed under the pubic hair. The rule is that the uncovered parts of the body are spared, and exceptions to this are very rare. The disease is not symmetrical. The number of patches varies from a few to hundreds. Left to itself it usually shows no tendency to recovery. The only subjective symptom is itching, and this is often absent, and seldom so bad as to cause the patient to seek relief on that account. Patients desire to be treated on account of the deformity, not the discomfort, of the disease. According to A. Castelani, 1 in the tropics there are three varieties of this disease. (1) Pityriasis versicolor flava, the most common, in which the patches are of various sizes, usually round, and smooth with sharply defined margins, sometimes festooned. The color varies from orange to canary yellow. Sometimes the patches have sound skin in the middle which may be intersected by yellow ribbon-like lines starting from the patches. The face, neck, chest, and abdomen are most often affected. It is only slightly scaly. It is chronic, often beginning in childhood and involving large areas. It is usually J Jour. Cutan. Dis., 1908, xxvi, 393. 148 DISEASES OF THE SKIN seen only in Ceylon and India. (2) Pityriasis versicolor alba in which the patches are very light or white. (3) Pityriasis Versicolor nigra, in which the patches are dull black and lusterless. They may be small, round, and discrete or coalescent, and often are elevated and scaly. It affects mostly the neck and upper chest. This and the yellow variety may occur at the same time. Etiology. — The cause of the disease is the lodgement and growth in the corneous layer of the skin of a vege- table parasite, the microsporon furfur. Like all other parasites of its class, this one is incapable of growth on every skin. It flourishes especially upon the skin of one who sweats freely. That consumptives were thought to be especially prone to the disease is due to the fact that their chests are exposed to the physician more often than are those of any other class of patients, and the patches discovered. The disease is contagious, but its contagion is of low grade, and it is not common for it to take place even in such intimate relations as obtain between husband and wife. Adults from twenty to forty years of age are the most common subjects, though children may have the disease. According to Besnier and Doyon, the disease is never seen in very old people. It occurs in all countries, but most often in hot climates. It attacks all classes and conditions of men, and shows no particular discrimination in regard to sex. Its growth is interrupted by malarial paroxysms, and it peels off with the des- quamation of scarlatina and measles. Pathology.— The microsporon furfur is one of the most readily demonstrated of parasites. Place a few scales upon a slide, add a drop or two of liquor potassse, tease out the material a little, put on the cover-glass, and even with a low power the picture presented opposite will be seen (Fig. 16). It consists of heaps of conidia, which are larger than those of ringworm, with any quantity of interlacing mycelia running between them. Free conidia are scattered about in the field. The fungus grows in the upper layers of the epidermis. It has been CHROMOPH YTOSIS 149 asserted that there were two kinds of fungus, one brown and the other pale red, each of which produces its own colored eruption. In 1896 T. Spietschka succeeded in making a pure culture of the fungus, inoculating an individual with it, reproducing the disease and making pure cultures from it. In the tropical form of the dis- ease, the microsporon tropicum is found in the yellow variety; the microsporon Macfadyini in the white variety ; and the microsporon Mansoni in the black variety. Fig. 16 Microsporon furfur. (After Kaposi.) Diagnosis. — If one remembers the characteristic feat- ures of the disease, yellow or cafe-au-lait, scaly patches, that can be partly scraped away and are located chiefly upon the trunk, little difficulty can arise in diagnosis. An appeal to the microscope will decide any doubtful question. Chloasma is not scaly, cannot be scraped off from the skin, and does not have spaces of normal colored skin in the midst of the patches. Leukoderma is an 150 DISEASES OF THE SKIN absence of pigment with a hyperpigmentation about it that comes up to the white spot with a concave border and is not scaly. A fading erythematous syphilids occurs not in patches, but in isolated, round macules that are neither scaly nor itchy, that are usually most numerous over the abdomen and sides of the chest, and that are very often found as a disseminated eruption occurring upon the face as well as the trunk. Erythrasma is not so scaly and occurs usually only in or about the joints. Its parasite is much smaller than that of chromophytosis. Treatment. — Anything that will cause the removal of the upper layers of the epidermis will cure chromophy- tosis when present only in slight degree. But it is best for safety to use a parasiticide. One of the pleasantest ways of curing the disease is to have the patient scrub his skin thoroughly with soap and water, preferably soft soap, and then dab on, twice a day, a saturated solution of hyposulphite of soda, letting it dry on the skin. Crocker follows this with a solution of tartaric acid 5ij (8), water §viij (250), with the idea of producing nascent sulphurous acid on the skin. Sulphurous acid, pure or dilute, is a prompt remedy. Vleminckx's solution, 1 to 3 or 6 parts of water; bichloride of mercury, 2 or 3 grains to the ounce; or, as recommended by Klotz, 1 1 per cent, solution in tincture of benzoin; sulphur ointment rubbed in thoroughly, and tincture of veratrum viride are efficacious. The danger of systemic poisoning by either the bichloride of mercury or the veratrum viride should deter us from using these remedies in extensive cases. Brocq gives the following: ~fy — Acid, salicylici, 2-3 parts. Sulphur, prsecip., 10-15 " Lanolini, 70 Vaselini, 18 " M. Chrysarobin, naphtol, boric acid, and resorcin all are good. If the disease is very limited, it can be surely and speedily destroyed by painting the spot with tincture of iodin. 1 Therap. Gaz., February, 1910. CLAVUS 151 There is only one point to be borne in mind in using any of these remedies, and that is, that they must be thoroughly used and continued for a time even after the last trace of the fungus seems to have been removed. If one spore is left behind, the disease is liable to return. Special care must be given to the cure of the disease in the pubic region. The underclothing must be boiled before it is used again. Relapses are common, as the patient's skin is susceptible to the lodgement of the fungus. The black and white varieties of the tropics are readily cured by the application of a 4 per cent, alcoholic solution of salicylic acid, followed by ungt. hydrarg. ammon. The yellow variety is obstinate to treatment, but is curable by the persistent use of turpentine applied daily, followed by a naphtol or epicairin ointment. Clavus. — Synonyms: (Fr.) Cor; (Ger.) Leichdorn, Hiihnerauge; Corn. Symptoms. — Corns are circumscribed hyperplasias of the corneous layers of the skin due to intermittent pres- sure usually from badly fitting shoes, and differing from calluses in having a central core that grows down toward the corium. They usually occur upon the toes, either over prominent joints, where they form hard corns; or between the toes, where on account of being kept moist they form soft corns. They are usually conical in shape and slightly projecting. Unless pared down they become painful on account of their central core being pressed into the cutis. They are sometimes spontaneously painful on the approach of wet weather on account of their being hygroscopic. They may suppurate. They may occur upon the palm. We have seen several cases in tennis players. The soles are sometimes affected with them, especially in people with flat-foot, and then walking is rendered very painful. Treatment. — The best treatment for corns is to wear well-fitting boots and shoes of the straight last pattern, 152 DISEASES OF THE SKIN which must be neither too large nor too small. Pointed- toed and high-heeled shoes are especially apt to cause corns. The corn may be removed by the use of a salicylic acid plaster, or by Vigier's preparation, now sold under the name of Hebra's Corn Remedy, which is composed of: 1$ — Ac. salicylici, gr. xx 1 5 Ex. cannabis indicae, gr. x 75 Alcoholis, TTlxx 1 5 iEtheris, lUlxxx 5 5 Collodion flex., ad gss 16 M which is to be painted on twice a day for three or four days ; then the feet are to be soaked in hot water, and the corn picked out. Corns may also be cut out, but the operation is at times dangerous, especially in old people. They may be pared down and pressure removed from them by means of felt rings which come for the purpose. J. F. Palmer 1 believes that cutting corns tends to increase their size, and advises soaking the feet morning and night in warm water, with or without carbonate of soda, bread poultices at night, and woollen socks with a felt ring over the corn by day. Resorcin plaster of 10 per cent, strength worn for some days will remove corns. Crocker recommeds for soft corns careful daily ablution with soap and water, painting on them spirits of cam- phor at night, and wearing lambs' wool between the toes during the day. The ointment of the nitrate of mercury and touching with nitrate of silver are recommended for soft corns. Bicarbonate of soda, the dry powder, applied to the corn and the toes kept separated with lambs' wool is a good treatment. Absorbent cotton should never be used between the toes, as it absorbs the moisture, becomes stringy, and renders matters worse. Zeisler has cured one case with x-rays. But unless well-made shoes are worn the corns will be sure to return. Corns on the hands may be removed with salicylic acid or scraped out with the dermal curette. 1 Clin. Jour., 1906, xxviii., 284. COLLOID DEGENERATION OF THE SKIN 153 Clavus Syphiliticus. — Under this title Lewin 1 describes certain lesions that he regards as being syphilitic. They are horny, elevated growths that occur upon the hands and feet, and are sometimes surmounted by a delicate scaly crown, and sometimes covered with scales. They are from pinhead to lentil in size; circular, oval or oblong in shape; flat or concave on top, but never convex, and appear as if wedged into the skin. At first they are pale red and soft, but later they become yellowish horn color and hard. They are usually on the palms of the hands, but may be on the soles of the feet, as well as upon all surfaces of the fingers and toes. There is no pain caused by them. There may be some itching. The lesions are met w T ith in both sexes, and occur early in the disease, and often symmetrically. Cold Sore. — See Herpes facialis. Colloid Degeneration of the Skin. — Synonyms: Colloid milium; (Ger.) Hyaloma der Haut; (Fr.) Hyalome cutane. Symptoms. — This is a very rare disease of the skin that occurs most often on the upper part of the face in the form of disseminated or grouped, discrete, trans- parent, shining, rounded, lemon-yellow elevations of the skin. They have been seen on the backs of the hands, neck, and arms. Though they look as though they were vesicles, they do not contain fluid, and when pricked give exit to only a small amount of gelatinous substance and a drop or two of blood. They vary in size from a pinhead to a split-pea. They are resistant to the touch. The course of the disease is slow. It is capable of spontaneous disappearance by absorption or inflam- mation, leaving an ill-defined mark on the skin. It affects both sexes. The youngest patient so far reported was fifteen years old. It usually occurs in adult life, and seems in most cases to be due to exposure to the weather. It is the result of a degeneration of the fibrous 1 Arch. f. Dermat. u. Syph., 1893, xxv, 3. 154 DISEASES OF THE SKIN elements of the corium. There are no subjective symp- toms, and the general health is good. Diagnosis. — It differs from xanthoma in its trans- parency and in the shining appearance and lemon-yellow color of the lesion. In xanthoma the lesions are soft and of a dull yellow. In hydrocystoma the lesions are more crystalline in appearance, and when pricked a drop of pure watery fluid escapes from them. In adenoma sebaceum the lesions are markedly vascular in places and the disease begins in early life. Treatment consists in removing them by the curette or electrolysis. Comedo. — Synonyms: Acne punctata, Acne f ollicularis ; (Fr.) Comedon, Acne punctuee, Tanne; (Ger.) Mitesser, Hautwurmer; Grubs, Fleshworms, Blackheads. A comedo is a collection of inspissated sebaceous mat- ter retained in a pilo-sebaceous gland, whose mouth is closed by a brown or black-topped plug, and appears as a pinpoint- to a pinhead-sized, slightly elevated, conical papule in the skin. Symptoms. — Comedones are met with most often upon the face, ears, back, and shoulders, and occasionally, but much more rarely, on other parts of the body. Wherever met with they present the characteristics indicated in the definition just given. They are unaccompanied by inflammatory symptoms. Just as soon as inflam- mation is caused by their presence they are converted into acne lesions^a change that they very commonly undergo. Usually they are scattered about irregularly; sometimes they are grouped in certain regions. They are single lesions in the vast majority of cases, and being pressed between the thumb-nails they are readily ex- pressed in the form either of an ovoid mass or more commonly as a filiform or worm-like mass that may be a half-inch or more in length, and has a black head that obtains for them the popular names of "fleshworms" and "blackheads." Very exceptionally they are double, COMEDO 155 lateral pressures queezing out a filiform mass with a black head at both ends, if such an expression is allowable. There may be but few, or there may be hundreds of them, so that the skin looks as if sown with grains of gunpowder. The largest are found in the ears and on the back. They give rise to no subjective symptoms. Seborrhela is frequently a marked complication. In chidren they are more apt to be grouped, and, according to Crocker, to appear on the forehead and occiput of boys, the temples in girls, and the cheeks in infants. The scalp, too, is in children the seat of the disease. Acne may follow them. Etiology. — All that has been said as to the causes of acne applies with equal force to comedones, and need not be repeated here. We would only add that Unna 1 does not accept the commonly received doctrine that the blackhead and the clogging of the follicle are largely due to extraneous matter, but teaches that they are due to the corneous layer of the skin being abnormally firm and preventing the escape of the follicle contents by growing over its mouth. The black color he believes to be analogous to the coloration of horns in cattle. He calls attention to the fact that comedones are more frequent in chlorotic girls than in coal-heavers. It is quite certain, however, that many cases of come- dones are directly due to dirt or other foreign matters stopping up the follicles. Contact with tar acts in the same way. This is supposed to be especially the case in children. Colcott Fox 2 says that in them the come- dones are found most often in the spring-time and disap- pear in the winter. The youngest case in a child is one at twelve months of age. 3 Pathology. — The pathology of the affection is the same as that of acne without the evidence of inflam- mation. We find many varieties of microorganisms in 1 Virchow's Archiv, 1880, lxxxii, 175. 2 Lancet, 1888, i, 665. 3 Crocker: Lancet, 1884, i, 704. 156 DISEASES OF THE SKIN Fig. 17 comedones. Sabouraud believes that the microbacillus is the cause of comedones. These bacilli form cocoons in the mouths of the sebaceous glands and occlude them. The demodex folliculorum, a harmless parasite, is very often found in the plugs of sebaceous matter. It is long and worm-like, with a head, a thorax with four pairs of short, conical, three-jointed feet, with minute claw-like extremities, and a long, tail-like abdomen, which tapers off into a blunt and rounded point (Fig. 17). _ Von During 1 has endeavored to show that the double comedo is always an acquired formation, and is the result of a destructive process between the ducts of two neighboring glands, so that the two ducts become one, and that the destructive process has af- fected only one gland, while the other one is still active enough to produce the comedo plug. Diagnosis. — There is little diffi- culty in recognizing the disorder. Powder grains in the skin are under the skin and cannot be squeezed out. Treatment. — The same constitu- tional conditions being met with in comedones as in acne, we need not repeat here what is said there in regard to the general treatment. The local treatment consists in press- ing out the comedones and stimulating the skin to a more healthy action. There is little use in doing the first without the second, as the comedo would be sure to re-form. The comedones come out most readily after the free use of soap and warm water. Then they may be pressed out between Demodex folliculo- rum. (After Kuchen- meister.) Monatshefte f. prakt. Dermat., 1888, vii, 401. COMEDO 157 the thumb nails, or by means of an old watch key, whose sharp edges have been worn down; or by means of a comedo presser or preferably the comedo scoop of Fox (Fig. 18). With some practice they may be removed by pressing the back of a small dermal curette against one side of the follicle mouth and making a quick turn of the end about them. Violent attempts at removal should not be made, as they may cause inflamma- tion on account of too much irritation. If the comedo does not come out readily, wait until another time. Stelwagon 1 advises the use of the faradic current two or three times a week. Also the daily use of a small cupping glass. Fig. 18 Fox's comedo scoop. Frictions with green or soft soap and water are excel- lent as a stimulating remedy, care being taken not to set up too much reaction. Hardaway recommends: 1$ — Saponis olivse prseparat., Alcoholis, aa 5j aa 25 Aquae rosse, ad 5vj 150 M. To be rubbed in with a piece of damp flannel every night. He regards the use of sulphur preparations as tending to cause comedones, and hence objectionable. Alcoholic and astringent lotions of boric acid, alum, or zinc may act well to close up wide-open pores. Sulphur and most of the preparations given under acne are useful. At times the sulphur preparations seem to increase the trouble, especially in winter time, when there is more or less coal gas in the house from stoves and furnaces, and have to be abandoned in favor of mercurials as in acne. 1 Diseases of the Skin, Philadelphia, 1914. 158 DISEASES OF THE SKIN The best prophylactic measure is the daily washing of the face with soap and water, combined with massage. Corn. — See Clavus. Cornu Cutaneum vel Humanum. — Synonyms: (Ft.) Corne de la peau; (Ger.) Hauthorn; Cutaneous horn. This is a rare disease of the skin, in which there grows a horn-like excrescence resembling, often in a most striking manner, an animal's horn. Horns vary greatly as to size. They are of very slow growth and may attain the length of a foot and a diameter of fourteen inches at the base. They are usually single, but may be multiple. They may be straight, but usually are bent or twisted; they may be laminated, striated, or fibrillated; they may be yellowish, dirty gray, green, brown, or black; they are solid and hard, but not smooth and shining like animals' horns often are; and they have rounded or truncated ends. About their base there may be some sign of inflammation. They are not painful unless pressed on. When torn or knocked off they expose a raw and bleeding surface at the base. Sometimes they fall spon- taneously or as the result of some inflammatory process. Usually they re-form. Most of them occur upon the head, nose, face, or scalp. They may occur elsewhere, as upon the extremities or male genitals. Their base may become the site of epithelioma. There is little known about their etiology. They may occur at any age and in either sex. The poorer classes are more often affected than the well-to-do. Most cases occur after the fortieth year of life. They seem to be warty growths that have undergone corneous transformation. Pathology. — In the early stages the growth may be seen to consist of a group of elongated and hypertrophied papillae, upon which the epithelial cells have undergone keratosis. At the base of the horn and in the papilla are numerous telangiectatic bloodvessels. Treatment. — The treatment consists in tearing them off, under an anesthetic if large, curetting the base, and CYST, DERMOID 159 applying a caustic, such as chloride of zinc paste, pyro- gallic acid, or acid nitrate of mercury. Craw-craw is a disease of uncertain nature, met with in the tropics, especially on the west coast of Africa. It may be papular, vesicular, or pustular, the lesions being disseminated or grouped. Itching accompanies the lesions, and crusts form from scratching. Ulcera- tion sometimes takes place. Both whites and negroes are attacked, but chiefly the latter. Several kinds of parasites have been found in connection with the disease, especially a species of filaria. The treatment consists in the removal of the crusts and erasion of the soft tissues beneath, as well as of all other lesions, and the application of an antiparasitic. Creeping Eruption. — See Hyponomoderma. Cutis Anserina, or Goose Flesh, is that condition of the skin in which, on account of the action of cold, causing a contraction of the arrectores pilorum muscles and eleva- tion of the hair follicles, it feels rough and looks as if studded over with minute papules. It is a fugitive affair, therein differing from keratosis pilaris, which, though resembling it, is constant. Cutis Verticis Gyrata is the name given by Jadassohn and Unna to a peculiarity of the scalp in which it is thrown into folds resembling the convolutions of the brain. A case is reported by K. Vignolo-Lutati 1 which apparently followed a slight injury to the scalp. He thought it was due to the development of a deep sclerotic condition in parts of the scalp producing the deep lines. Cyst, Dermoid. — These are usually single lesions, and look like fibromas. But when they are opened they give exit to sebaceous-looking matter. Hair and teeth are frequently found in them. They are supposed to be remains of fetal structures. If single, they can be excised. 1 Archiv Dermat. u. Syph., 1910, civ, 421. 160 DISEASES OF THE SKIN Cyst, Sebaceous. — Synonyms, Atheroma, Steatoma, Wen. These innocuous little tumors may occur anywhere on the body, but are most common on the scalp, face, neck, back, and scrotum. They vary in size from that of a millet seed to that of an orange. They may be rounded, flattened, or hemispherical. There will be found in many of them a small opening, out of which some of their contents may be pressed. The skin over them may be of normal color, pale on account of pressure, or red Fig. 19 Sebaceous cysts of scalp. (Hyde.) if the cyst becomes inflamed. They may be elastic and doughy to the touch, or firm, or soft, according to the condition of their contents, which may be fluid and honey- like, or cheesy. They tend to grow slowly, and give no trouble except by the deformity they cause. In excep- tional cases they may become inflamed and ulcerate. The hair is usually absent over them when they occur on the scalp. Etiology. — Most cysts are due to distention of a sebaceous gland. They occur in both sexes in adult DERMATALGIA 161 life, being rare in children. Considerable uncertainty surrounds their pathology. Diagnosis. — They must be distinguished from fatty tumors and gummata. Fatty iumors are firmer and more doughy than cysts, and are more often tabulated, occur but seldom on the scalp, and are rarely multiple. Fibro- mas are commonly multiple, are of firmer consistence, and rarely assume a lobular shape. Syphilitic gummas are more rapid in their growth, are attached to the skin, and tend to break down and ulcerate. Treatment. — The tumor is to be opened by a linear incision, and the contents emptied out, special care being taken to remove the lining membrane of the sac entire. Cysticercus Cellulosse Cutis. — At times the larvae of the tapeworm become lodged in the subcutaneous tissues and produce movable, painless, round or oval, pea- or cherry- sized tumors, with the skin raised over them. They are smooth, firm, and elastic. The larger ones may feel like wens. After about eight months (Cobbold) the animals die, and the tumors shrivel up and become hard nodules, or they may be absorbed. They simulate gummas, lipo- mas, sarcomas, carcinomas, and sebaceous cysts. In a doubtful case excision or puncture of one of the tumors will show under the microscope either one of the larvae curled up in its shell, as it were, or the hooklets in the fluid that escapes. Dandriff or Dandruff. — See Pityriasis steatodes. Darier's Disease. — See Keratosis follicularis. Defluvium Capillorum. — See Alopecia. Delhi Boil. — See Aleppo boil. Dermatalgia. — Synonyms: (Fr.) Dermalgie; (Ger.) Hautschmerz, Hautnervenschmerz; Neuralgia or Rheu- matism of the skin. By this term is meant spontaneous pain in the skin, without any appreciable alteration of the same. The pain is variously described by patients as boring, pricking, 11 162 DISEASES OF THE SKIN or burning; or numbness or coldness may be complained of. It is constant or intermittent in character and some- times so severe as to be agonizing. It may be excited by the slightest contact. It is generally sharply located in a certain region, but may be general. The hairy parts are those most often affected, as the scalp. The legs and back, and palms and soles are not infrequently involved, as may be any part. Hyperesthesia or anesthesia may be present at the same time. Deep pressure may or may not relieve it. It disappears of itself after weeks or months. Causalgia is one form of dermatalgia. The patient complains of a burning pain, and of tenderness, and the area supplied by the affected nerve may have a glossy appearance. Etiology. — It is a neurosis that may be idiopathic or symptomatic. The idiopathic form is rare, and its etiology obscure. The symptomatic form occurs in dyspepsia, locomotor ataxia, rheumatism, syphilis, malaria, diabetes, hysteria, chlorosis, and after zoster. According to Hyde, it may be a sign of the approaching menopause. The majority of its subjects are women. Diagnosis. — Dermatalgia differs from neuralgia in being more superficial and in being accompanied by hyperesthesia. It differs from hyperesthesia in being a spontaneous pain, while the latter is pain only upon contact. Treatment. — If we can remove the underlying cause we shall cure the trouble, so our remedies should first be addressed to it. In any case the patient demands something to relieve the pain. In the way of internal remedies we can use the salicylates, quinin, antipyrin, phenacetin, some form of opium, hyoscyamus, valerian, and other like drugs. Externally relief may be obtained by galvanism, blistering, a mustard leaf over the centre from which emanates the nerve (Crocker), hot or cold water in a rubber water bag, either alone or alter- nately; rubbing in oleate of morphin, menthol pencil, DERMATITIS BLASTOMYCOTICA 163 chloroform liniment, tincture of aconite, and the like. Galvanism and the high-frequency current may be tried. Dermatitis Blastomycotica. — Under the name of pseudo- lupus or blastomycetic dermatitis, T. C. Gilchrist and W. R. Stokes 1 described a disease that had been recognized for a long time and regarded as a lupus, or at least a scrofuloderm. Since the publication of their observations cases of the disease have been reported by dermatologists of the United States and Europe. Symptoms. — The disease usually begins as a split-pea- sized round papule which may change into a pustule. New lesions crop up peripherally and run together so as to form a patch; or the original lesion slowly enlarges so as to form a patch. The patch is elevated from one- eighth to three-eighths of an inch; the surface is covered by irregular papilliform elevations separated by fissures of varying depths, giving it a verrucous or cauliflower appearance. In young patches and near the border of old ones the papillary projections are fine and the surface fairly firm, dry, and wart-like. Untreated areas are covered by more or less bulky crusts, which on removal expose a papillary surface bathed with a seropurulent secretion. Some of these patches are very vascular and bleed easily. They are deep red in color. Exceptionally we find ordinary unhealthy ulcers with exuberant granu- lations. The papillomatous surface may be replaced partly with an elevated scar-like surface, pinkish white, irregular, smooth, and shining. One of the most characteristic features of the disease is the border of the patch. It slopes more or less abruptly toward the normal skin, and is sharply defined, smooth, dark red or purple, from one-eighth to three-eighths of an inch wide, and strewed over with a large number of minute abscesses. These may be superficial or deep, and 1 Johns Hopkins Hosp. Rep., 1897, viii, 46, and Jour. Cutan. and Gen.-Urin. Dis., 1897, xv, 393. 1(34 DISEASES OF THE SKIN when punctured give exit to a small amount of thick, glairy mucus or mucopus. Abscesses of the same char- acter are found elsewhere on the patch. The course of the disease is chronic. It takes several months for a patch to attain the diameter of an inch. It may remain stationary for a long time, but usually extends slowly and continuously. In course of time new patches crop up in the vicinity of the original patch or elsewhere. Patches may be as large as the palm or larger. Healing takes place in the centre of the patch by a flattening of the papillary projections, a lessening of the secretion, and the assumption of a verrucous appear- ance. Eventually it cicatrizes, producing a smooth, soft, inconspicuous scar. A recrudescence of the disease in the scar at times occurs. The disease occurs most often on the exposed parts, the face, neck, hand, wrist, and lower extremities. Some of the patients remain in fair health, some die of tubercu- losis, and some from systemic infection by the blasto- mycetes. Etiology. — Invasion of the skin by the yeast fungus is the cause of the disease. The majority of the patients are men, and most are of middle age. J. B. Kessler 1 has reported a case in a child five months old. Tuber- culosis was present in some of the patients. Pathology. — There are many miliary abscesses in most of which the fungus is found. There are also hypertrophy of the epithelial layer of the skin a large number of polymorphonuclear leukocytes, and giant cells resembling those found in tuberculosis. The parasites are found most frequently in the pus from the miliary abscesses. They have a capsule, a trans- parent zone, a central protoplasmic mass, and a vacuole within the protoplasm. The organism multiplies by budding, the buds being of all sizes, several often start- ing from the mother body at the same time. 1 Jour. Amer. Med. Assoc, 1907, xlix, 550. DERMA TI TIS B ULLOSA 165 Diagnosis. — From tuberculosis verrucosa cutis, blasto- mycetic dermatitis differs in its more rapid course, its wider spread, and the halo about it being less violet in color. But an appeal to the microscope is the only reliable means of diagnosis. Treatment. — The iodide of potassium in large doses, from 200 to 500 grains a day, exerts a remarkably ame- liorating influence on the disease, but radical destruction Fig. 20 Fig. 21 Budding organism in tissue. X 1200. Hanging drop. X 1200 Blastomycosis of the skin. (Hyde and Montgomery.) 1 of the patch by the curette or its ablation by the knife is the most reliable curative agent. The .r-rays have seemed to help some cases when used in conjunction with iodide of potassium. The prognosis is bad if blastomycotic septicemia sets in. Otherwise a cure should result if the disease is sub- jected to treatment early in its course. Dermatitis Bullosa. — See Epidermolysis. 1 Courtesy of Drs. Hyde and Montgomery. 166 DISEASES OF THE SKIN Dermatitis Calorica is the inflammation of the skin produced by heat or cold, and divides itself naturally into two divisions, viz., D. ambustionis and D. congela- tions. Dermatitis ambustionis is the effect of heat upon the skin, the source of the same being either natural, as from the sun, or artificial. According to the intensity and prolonged action of the heat and the resistance of the skin will be the damage inflicted on the skin. A slight degree of beat gives rise to a passing erythema. Burns are due to a great amount of heat, and are described for conve- nience as being of three degrees. In the first degree the skin is reddened, hot, and somewhat swollen; in the second the damage is greater and vesicles and bullae are formed; and in the third, there is complete destruction of the skin followed by gangrene. There is always considerable pain with any burn, and, if of great ex- tent, rise of temperature and shock. Extensive burns may be dangerous to life even if not of very high degree, and burns involving one-half the cutaneous surface are generally fatal. The cause of death in such cases is uncertain. One theory, as put forth by Lustgarten, 1 is that it is due to a toxin developed by the lodgement of microorganisms of putrefaction upon the eschar, prob- ably a ptomain similar to muscarin. Some of the other theories are nerve shock, ulcerations of digestive tract, nephritis, decomposition of the red-blood globules; but no one of these is satisfactory in all cases. Treatment. — The treatment of severe burns com- monly falls into the hands of the surgeon. The general condition of the patient must be cared for, as he is often in a state of shock. In simple burns the pain may be relieved by painting them with a 5 to 10 per cent, solution of cocain, and then applying carron oil, consisting of equal parts of linseed oil and lime-water, to which may be added 5 per cent, of carbolic acid, absorbent cotton 1 Med. Rec, 1891, xl, 152. DERMATITIS CALORIC A 167 being soaked with the oil laid over the burn and covered with impermeable rubber tissue. This forms an admirable dressing that may be left on for several days, if care is taken to disinfect the part thoroughly before applying it. From time to time the rubber tissue may be removed for a moment and fresh carron oil applied. If this is not at hand, the part should be dusted thickly with flour or corn starch until it is procured. Or the burns may be covered with a varnish of linseed oil and wax, contain- ing 5 per cent, of salicylic acid. Or they may be pow- dered with bicarbonate of sodium or any of the anti- septic powders. Or the bullae and vesicles may be opened and the surface painted with a 2 to 5 per cent, solution of picric acid or a solution of ichthyol in water, 1 in 1 to 1 in 4 may be painted on. Fancher 1 advises against puncturing the blisters, and in favor of spraying the part with peroxide of hydrogen, mopping with gauze and laying over it strips of gauze soaked in picric acid, 3j (4), alcohol, gij (64), water Oiss (768), and applying over all absorbent cotton and a loose roller bandage. This dressing is to be left on until soiled, and then repeated. The excess of fluid is to be drained off and the surface covered with rubber tissue or soft gauze that is to be left on for tw^o or three days. Deep and extensive burns must be treated on surgical and strictly antiseptic principles. Lustgarten, in the paper referred to, recommends the administration of atropin as a physiological antagonist to the ptomain, the removal of necrotic portions of skin, and dressing the wound with carbonate of magnesium, 1 part, and oleum rusci, 2 parts. All cases of any magnitude demand absolute rest in bed. The continuous water-bath of Hebra is excellent where it can be had. In sunburn the application of cold cream and a dust- ing powder or calamin lotion is usually sufficient. As a preventative the skin may be anointed with the grease 1 Jour. Amer. Med. Assoc, 1910, xlvi, 27. 168 DISEASES OF THE SKIN paint used by actors, preferably one of brown color. A calamin lotion, used freely, is one of the most efficient and agreeable agents for preventing sunburn. Dermatitis congelationis, or " frost-bite," is the action of cold upon the skin. Like heat, cold produces varying degrees of damage to the skin; if not very intense, the effect is an erythema — "erythema pernio," "chilblain" — which is passing. These are seen upon the hands, feet, and face as bluish or purplish-red, circumscribed patches, which are cool to the touch, but are accom- panied by a feeling of heat, smarting, itching, or burning, both while forming and when the parts again become warmed. To those predisposed to chilblains, dampness accompanied by only very moderately cool temperature is sufficient to produce them. Hutchinson speaks of the "chilblain diathesis" to indicate the condition found in these people. Their circulation is poor, and they are anemic. Greater degrees of cold at first cause the parts to become white, dead, and wrinkled. When the cold is lessened redness and swelling supervene. Longer exposure may produce bulla? and vesicles or gangrene, either on account of prolonged anemia or inflammatory reaction from too sudden warming. Fingers, toes, nose, or ears may be lost in consequence, mortification setting in. Death may result from septicemia. Treatment. — The best preventive treatment of chil- blains is the wearing of woollen coverings on the affected parts and endeavoring to improve the general health of the patient and to quicken his circulation. To the latter end we may use w T arm foot-baths, containing salt, at night, followed by frictions with alcohol. Whitfield recommends giving opium in small doses, or nitroglycerin, tfu" § r v t. i. d. He advocates the use of w T eak galvanic currents, placing, the negative pole at the nape of the neck and the positive pole in a basin of warm water, in which the hands are placed; if the feet are affected they are to be put in the water and the negative pole at the lumbar region. A current of 5 ma. is to be used for DERMATITIS EXFOLIATIVA 109 ten minutes. When they occur stimulation is necessary, for which we may use iodin, either in tincture or oint- ment; ichthyol, 20 to 50 per cent, in water or equal parts of camphor and belladonna liniment; or — I£ — 01. cajuputi, Liq. amnion, fort., aa 3 i.i aa 8 Sapo. liniment, co., ad giij ad 100 M. or simple frictions. Care should be taken in severe frost-bites not to allow the parts to become warm too rapidly, and nothing is better than rubbing them with snow while the patient is kept in a cool room. When sloughing or ulceration has begun it must be treated on surgical principles. Dermatitis Exfoliativa. — Synonyms: Pityriasis rubra (Devergie and Hebra); Eczema folicaeum seu exfoliati- vum; (Fr.) Dermatite exfoliatrice ou exfoliative general- isee, Herpetide exfoliative; Erythrodermie exfoliante. An inflammatory disease of the skin involving the whole cutaneous surface, and characterized by redness, dryness, and abundant desquamation. The terms dermatitis exfoliativa and pityriasis rubra are used interchangeably by most authorities of the pres - ent time. If one reads the description of pityriasis rubra as given by Hebra, and of dermatitis exfoliativa as given by Wilson, he will find that the chief difference between them is in prognosis, the first being spoken of as uni- formly fatal, and the second as tending to recovery in many instances. Further, there are not a few cases of general exfoliating dermatitis that follow psoriasis, eczema, pemphigus foliaceus, and lichen ruber, that present symptoms identical with those of dermatitis exfoliativa without antecedent disease. It seems justi- fiable, therefore, to divide dermatitis exfoliativa into two varieties, namely, a primary and secondary. 1. Primary dermatitis exfoliativa or Pityriasis rubra of Hebra. 170 DISEASES OF THE SKIN Symptoms. — This disease begins as one or more ery- thematous patches in the folds of the joints, upon the upper part of the chest, or elsewhere, and these patches gradually enlarge. At the same time new patches develop, and, increasing in size, join the original ones. In this way the whole surface may become red within three days, or a month or more may elapse before the whole surface is implicated. The palms and soles may be unaffected for days or weeks. The skin is dry and of a bright red at first, without thickening and infiltration, the redness lessening and leaving a yellow stain on pressure. In a few days, say from six to twelve, scaling begins and the skin becomes of a darker red; it may even become violaceous. The scales may be large, thin, grayish, attached at their upper border and loose else- where, being turned up at their edges. They may be small and adherent in the centre. The amount of scaling is so great that handfuls of scales may be gathered from the bed after a night's rest. After a few weeks the epidermis may be raised and shed from the hands and soles in the form of a continuous sheet, sometimes forming a complete cast of the part and leaving a red, dry, glazed surface. There is a marked enlargement of the glands in the groin, so that the whole packet of glands stands out prominently against the red skin. The disease is chronic and the scaling constant, though marked with exacerbations. After lasting some time there is a certain amount of infiltration of the skin, and it seems to grow too small for the body and looks stretched and shiny in places. Thus are produced ectropion and a puckered condition of the mouth. We may also find cracking about the joints and moisture in these regions. Furuncles, bullae, or pustules may complicate matters. The hair may be shed from all parts and the nails become raised from their beds and shed. The mucous membranes participate in the disturbance, the tongue becomes markedly red, the lips cracked, and the nasal secretions increased. With the ectropion there is conjunctivitis. DERMATITIS EXFOLIATIVA 171 The disease begins in some cases with a chill, followed by a fever that may rise to 104° F. Fever is present in all cases during the early period, and may continue throughout. It is sometimes continuous, with evening exacerbations; at other times it is only at night. Diar- rhea often is met with, and there may be vomiting, albuminuria, and pulmonary congestion. The patient complains of a feeling of chilliness and of pain, tender- ness, stinging, burning, or tingling of the skin. There may or may not be itching. The sensibility of the skin is preserved and the secretion of sweat may be normal, or lessened, or increased. The duration is very variable. Recovery may take place in six months or a year. In such cases relapses are the rule. Usually the course is chronic, the patient dying either in a few months or after years, by a gradual marasmus, though the end is usually hastened by pulmonary complications. Cases of localized dermatitis exfoliativa have been reported but they are rare. The tendency is for the disease to become general, though it may take years to do so. Cases of a recurrent type have been met with. Etiology. — We know very little about the causes of the disease. It is a disease of adults, and is more com- mon in men than in women. It may occur in children. It has been thought to be predisposed to by alcoholism, gout, and rheumatism. An attempt has been made to trace a relationship between it and general tuberculosis. There may be a history of scaling skin diseases in the family. Crocker inclined to the belief that a bacillus or its toxin will be found as the cause of the disease. At present we cannot speak with any certainty as to its etiology. 2. Secondary Dermatitis Exfoliativa. — A condition of the skin exactly resembling the primary form is seen from time to time to follow upon or develop from a psoriasis, eczema, pemphigus foliaceus, and lichen ruber acuminatus or planus. The too vigorous use of chrysarobin or some other drug has been known to be followed by it. These 172 DISEASES OF THE SKIN cases differ from the primary form only in their ante- cedent skin disease. Once developed they run the same course as the primary form, either becoming well quickly or falling into a chronic state from which recovery may or may not take place. The prognosis is, however, much better in the secondary than in the primary form, recovery after two or three months being frequent. Crocker states that the disease may occur in children, though it is very rare. In them it runs a more acute course and is attended by severe constitutional symptoms. It is usually of the secondary variety. Pathology. — Histological examination shows that the disease is a dermatitis, quite superficial at first, but when it has lasted some time the whole depth of the skin is involved and eventually there is new connective-tissue formation, which subsequently undergoes cicatricial contraction, with abundant pigmentation, hyperplasia of the elastic fiber bundles, and obliteration of the skin appendages (Crocker) . Diagnosis. — When the features of the disease, as laid down in the definition, are remembered, there should be no difficulty in recognizing it. No other disease involves the whole surface in a uniform dry and scaling redness. It differs from psoriasis in being universal, in an entire absence of thick, silver-white scales, and in leaving a smooth red surface when its papery scales are removed. Should it be secondary to a psoriasis, there will be no difficulty in obtaining a history of that disease. It differs from eczema in being a dry disease, with little infiltration, in its large papery scales, and in itching but slightly. Eczema may be almost universal, but some places are apt to be spared; there is always moisture of a sticky sort present somewhere or a history of the same; its scales are small and its itching intense. It differs from pem- phigus foliaceus in an absence of flaccid bullae. It differs from lichen in an entire absence of papules and in the whole course of the disease. All these diseases may be general, but it is exceedingly rare for them to become DERMATITIS EXFOLIATIVA 173 universal, and it is always possible to obtain a history of their having been present at some time in a case of secondary dermatitis exfoliativa. It is hardly likely that scarlatina could be confounded with dermatitis. A few days' watching would in any event decide the question. Treatment. — The results of treatment of this disease leave much to be desired. Many internal and external remedies have been tried, but they all are of very uncer- tain value. There is no doubt that the patient is most comfortable when the skin is well oiled, and vaselin of good quality or pure olive oil answers well for this purpose. The general health is to be watched over, iron and quinin administered, and care exercised to preserve the strength by judicious feeding without stimulation. W. H. Mook 1 found quinin given in large doses up to producing cincho- nism, that is from 40 to SO grains (3 to 5 grams) daily, cured some cases in from two to four months, and his observation has been confirmed by others. It should be tried in all cases. Diuretics may be given with the idea of relieving the congestion of the skin. Carbolic acid has been recommended, but in my hands proved worse than useless in one case. Pilocarpin, or jaborandi, is recommended by Hardaway in acute cases. Arsenic should not be given until late in the disease, if at all. Crocker recommended enveloping the body in calamin lotion, and giving bicarbonate of potassium every four hours in 20 grain doses, with 12 grains of citric acid and 3 to 5 grains of quinin, the whole taken w T hile effervescing ; and the giving of quinin in acute febrile cases. Sherwell has reported several cases cured by the continuous use of linseed oil, both internally and externally. The patient is to chew or take in milk several ounces of flaxseed in twenty-four hours. He is to be kept in bed with a rubber sheet under him, and to be saturated, as it were, in crude linseed oil. If the oil is not used abundantly, it is worse 1 Jour. Cut an. Dis., 1908, xxvi, 408. 174 DISEASES OF THE SKIN than useless. This plan of treatment worked admirably in one of our cases. C. J. White 1 reports excellent results from keeping the patient constantly covered with borated talcum powder, freely used. Thyroid extract has proved helpful in some cases. In one of ours it aggravated the disease, and the patient made a good recovery after it was stopped, and she was treated with vaselin, soda baths, and careful feeding. In the primary form, or pityraisis rubra, treatment usually only alleviates the sufferings of the patient, but does not cure the disease. Prognosis. — In those cases secondary to psoriasis, eczema, etc., the prognosis is good, but should be guarded. In the primary cases the outlook is very grave, the mortality being high. Dermatitis Exfoliativa Epidemica. — Under this name Savill 2 has reported the occurrence, in Paddington Infirmary, of a number of cases of an apparently contagious disease of the skin, that began either as a discrete papular eruption, or as erythematous blotches like erythema nodo- sum or papulosum, or as small, flat papules enlarging at the periphery and spreading like ringworm. This stage lasted three to eight days. It was followed by the second stage, which was one of exudation or desquama- tion, and lasted three to eight weeks. However the disease began, the lesions soon ran together and formed a crimson surface of thickened and indurated skin, continually shedding its cuticle in scales or flakes of various sizes, sometimes mingled with drier exudation. In the second stage it assumed either a moist type, like eczema madidans, or a dry one like pityriasis rubra. About two-thirds of the cases were of the moist variety, and almost all at some period showed slight moisture, either in the flexures of the joints or behind the ears. Continuous exfoliation was present in all the cases. The third stage was one of subsidence. By degrees the 1 Jour. Cutan. Dis., 1912, p. 705. 2 British Jour. Dermat., 1892, iv, 35. DERMATITIS EXFOLIATIVA NEONATORUM 175 inflammation lessened, leaving an indurated, thickened skin, with polished brown appearance, which was some- times raw, or parchment-like, smooth and shining, or cracked, or purpuric, especially in aged people. The disease began most often in the skin folds of the face and upper extremities; and involved either the whole body or limited areas. It generally spread by continuity. The hair and nails were all shed. The constitutional symptoms were anorexia and pros- tration. There was either no change in the body tem- perature or a slight rise in the evening during the height of the disease. Itching and burning were marked, and there was considerable suffering experienced in those cases in which the epidermis was shed. Relapses were frequent. Albuminuria was found in half of the cases, and death occurred in about 12.8 per cent, of the cases. More men than women were attacked and advanced age predisposed to it. A specific microorganism is thought to have been found in it. Clinically these cases resemble dermatitis exfoliativa, an instance of the apparent contagion of which we have met with. Its proper place has not been determined as yet. The treatment of the disease was by antiparasitic remedies, but was not very satisfactory. Painting an early patch with tincture of iodin seems to have cured it in some cases. Dermatitis Exfoliativa Neonatorum, also called Ritter's Disease and Keratolysis Neonatorum, is a disease of newborn children, first described by Ritter von Ritter- shain, 1 and said by him to be quite often seen in the foundling asylums of Prague. Symptoms. — It begins most often at the mouth as an erythema, and thence spreads to the trunk and extremities. Then the epidermis raises itself from the cutis, rumples, and spontaneously exfoliates in large folds, leaving a dry 1 Arch. f. Kinderheilkunde, 1880, i, 53. 17(3 DISEASES OF THE SKIN skin, or there may be exudation under the epidermis. It may originate anywhere on the skin. The mucous membranes may be involved. It begins usually between the second and fifth week of life, and lasts seven or eight days. Its course may be prolonged by relapses. There is no fever nor digestive disturbances. Furuncles, abscesses, or phlegmonous infiltration, with gangrenous destruction, may follow. Recovery takes place in about half the cases. It is supposed to be a pyemic condition of the skin and probably contagious. Treatment. — Special attention must be given to the nourishment of the child, and the maintenance of its body temperature. Alkaline lotions will prove beneficial in the early stage. Later a protecting ointment, such as that of oxide of zinc, or simple vaselin, or sweet oil, containing J to 1 per cent, of boric acid, followed by corn starch, will be indicated. Dermatitis Factitia. — It is a good rule to consider the possibility of malingering whenever we meet with an eruption that does not correspond to any recognized type, and at the same time is not due to the action of drugs known to have been ingested or locally applied, nor to irritants that have come accidentally in contact with the skin. Eruptions are feigned mainly by three classes of individuals, namely, soldiers, sailors, or con- victs for the purpose of shirking work; paupers for the purpose of gaining admission to hospitals; and hysterical young women for the purpose of exciting sympathy. Not only are feigned eruptions peculiar in appearance, but also it will be observed that they are usually on the left side of the body, as they are commonly due to acids applied by the right hand; or on the legs. The back is seldom the seat of these lesions. Most commonly they are irritative lesions, such as would be due to tartar emetic ointment, croton oil, nitric acid, carbolic acid, mustard, and the like. If made by acids, the lesions will often have lines radiating from the main DERMATITIS GANGRENOSA 177 mass showing where the acid has run further than in- tended. The sharp, more or less square outline is another characteristic of these lesions. Some of the lesions imitate genuine disease with amazing faithfulness. It is impossible here to give a full account of the feigned eruptions. A good list is given by Van Harlingen, 1 and to this I would refer the reader. Sycosis by tartar emetic ointment and tar; favus by means of acids; alopecia areata by means of plucking the hair; ringworm by means of depilatories; scabies by means of excoriating with a fine needle; various forms of ulcers, vesicular and pustular eruptions by means of acids and caustics; gangrene in the same way; all these and others have been simulated. In case of a suspected feigned eruption the part should be covered with an impermeable dressing, when, of course, the lesions will soon be well. Dermatitis Gangrenosa or Sphaceloderma. — Gangrene of the skin may be due to a great variety of causes. Many cases are due to purely local causes, such as burns, bruises, compression, chemical action, and the like. It is seen in the course of diabetes, albuminuria, and some cardiac diseases; with degenerative changes taking place in the vascular walls of arteries, or plugging of their lumen; and in connection with other skin diseases, as carbuncle. Besides these we have a group of little- understood cases of gangrene, due apparently to nervous influences, and occurring in connection with diseases of the nervous system. These may occur anywhere, and may be superficial or deep. They behave like surgical gangrene, and are to be treated on the same principles. Other cases have been reported as following upon some slight injury, such as running a needle into a finger. The lesions run up the arm or leg in the form of papules that soon change into flaccid vesicles, which rapidly crust and form an eschar. When the crust falls a depressed 1 Morrow's System of Gen.-Urin. Dis., Svph., and Dermat., vol. iii, New York, 1894. 12 178 DISEASES OF THE SKIN cicatrix is left. The process tends to last a long time, with many relapses. It is always to be borne in mind that gangrene occurring in hysterical women is apt to be self-imposed. If such cases are carefully noted, it will be observed that the spots appear where they can be reached most readily by the patient's right hand, or left, if she be left-handed. Treatment. — In all these forms of gangrene attention must be given to the general health of the patient and the lesions must be treated on general antiseptic principles. There are two forms of cutaneous gangrene that have received special names that must be noticed here. They are: (1) Symmetrical gangrene, or Raynaud's disease; and, (2) Dermatitis gangrenosa infantum. 1. Symmetrical Gangrene.— This was first described by Maurice Raynaud, 1 and since then has been observed by others, although it is a rare disease. It most often attacks the second and third phalanges of the fingers and toes, next most frequently the nose and ears; but any part may be affected-. The parts become pale or blue, cold and hard, and then swell. They feel numb, but the patient may experience darting or stabbing pains in them. If pricked, no blood escapes. The process may stop here and the parts may return to their normal state; or after a time, hours or weeks, they become black, a line of demarcation forms, and separation of the affected part takes place. The process may stop short of the complete destruction of the part and recovery may take place, though relapses are liable to occur. It may result simply in a peculiar induration and thinning of the fingers. The disease is symmetrical. It may involve all four extremities, but usually only two are affected. Bullae may form. The nails may fall. Occurring on other parts of the body localized patches show the same symptoms as those on the hands and feet. i Th&se do Paris, 1872, DERMATITIS GANGRENOSA 179 Etiology. — Men are more often affected than women. People of all ages are liable to it. Exposure to cold seems to be a causative factor, and not a few of its victims have been subject to chilblains or other symptoms of poor circulation. The malarial, the syphilitic, or other cachexias and the gouty habit have been supposed to be predisposing causes. It has followed various dermatoses. It is probably of neurotic origin, and due to a contraction of the arterioles. Treatment. — The internal treatment that has done best has been the administration of quinin and bella- donna. Amyl nitrite and nitroglycerin may be given. Locally, galvanism has done good. Stimulation by means of lotions of various kinds may be tried. Cold applica- tions are said to be better than hot. If gangrene has occurred it must be treated on surgical principles. Prognosis. — The outlook is not good. Death may result in those who are not robust. Even if one attack is recovered from, another is apt to occur. 2. Dermatitis Gangrenosa Infantum (Crocker). — Syno- nyms: Varicella gangrenosa (Hutchinson); Pemphigus grangrenosus (Stokes) ; Rupia escharotica (Fagge) ; Ecthyma infantile gangreneux (Pineau); Gangrenes multiples cachectiques de la peau; Ecthyma terebrant de l'enfance (Baudouin). Under these names has been described a disease of the skin that occurs most often after varicella, but may occur after other diseases of the skin in children, such as variola, vaccinia, purpura, erythema nodosum. It consists essentially in the formation of deep or superficial round or oval ulcerations beneath a black slough, following upon a varicella or other pustule. The lesion when fully formed may be one inch or more in diameter, and three- quarters of an inch deep. The wider the slough, the deeper is the ulcer. Around the slough is a red areola. Crocker says that if the gangrene occurs while varicella is still present, it begins on the head or upper part of the body, and then looks like a vaccination pustule; while if it 180 DISEASES OF THE SKIN begins late in the course of the disease, the lesions will be located on the lower half of the body, especially on the buttocks and thighs. In the latter case the affected parts are riddled with ulcers of all sizes, shapes, and depths. If several ulcers run together, very large and irregular ones may form. If the lesions are extensive or numerous, they may cause death, very frequently by pulmonary complications. Etiology. — Infants and young children under three years of age are those affected by this disease, and most of them are girls. Debilitating diseases, predispose to the disease. In infants' hospitals cases of this sort occa- sionally occur in epidemics of varicella. It may occur independently of varicella. The disease seems to be a product of several dyscrasic conditions plus a microbic infection, several varieties of microorganisms having been found in connection with it. Treatment. — The cases are to be managed upon general principles. Tonics, fresh air, good food, and hygienic surroundings, and remedies addressed as far as may be to the underlying constitutional condition are the best means for combating the disease. Crocker recom- mends quinin and sulphocarbonate of sodium, 5 grains (0.33) every three hours, and the injection of 2 or 3 drops of a 2 to 3 per cent, solution of carbolic acid in several places about the patch, and wet boric acid lotions. Iodo- form, aristol, and antiseptic dressings are indicated. Prognosis. — The prognosis is not good in extensive cases. Death is apt to result from lung complications or pyemic infection. Dermatitis Herpetiformis. — Synonyms: Hydroa of Bazin and Tilbury Fox; Herpes phlyctenodes of Gilbert; Herpes gestationis of Bulkley; Pemphigus pruriginosus and circi- natus; Pemphigus a petites bulle, Hydroa bulleux, Herpes circinatus of Wilson; Dermatite polymorphe of Brocq. This name was first suggested by Duhring, 1 of Phila- 1 Jour. Amer. Med. Assoc, 1884. iii, 225. DERMATITIS HERPETIFORMIS 181 delphia, for a disease which is characterized by great multiformity and marked grouping of the lesions; by pruritus of varying intensity; by chronicity of course; and by a strong tendency to relapse. Symptoms. — In severe cases there may be prodromas for several days preceding the outbreak, such as malaise, constipation, fever, chills, sensations of heat or cold, or these alternating, and itching. In mild cases these are absent. The onset of the disease may be gradual or sudden — the latter not infrequently. The eruption may be diffused over the greater part of the general surface, or it may be in localized patches. Favorite sites for it are the extensor aspects of the limbs, sacral region, and over the scapulse, but the disease has not such marked sites of preference as some other diseases exhibit. Itching and burning, which are severe, precede or accompany the outbreak. It may begin as an erythematous, vesicular, bullous, pustular, or papular eruption, or by a com- bination of two or more of these, the multiformity being a characteristic, excepting in children. It shows a tendency for one variety of lesions to pass over into another, either during the attack or at some relapse. Grouping of the lesions is a marked characteristic of the disease. The relapses occur at intervals of weeks or months. All regions are invaded, the course is essen- tially chronic, and in pronounced old cases the skin is excoriated and pigmented. The mucous membranes may be involved. Dermatitis Herpetiformis Erythematosa. — This form is usually of urticarial or erythema multiforme type, and occurs either in patches or diffused. The circumscribed patches may coalesce and form larger patches with marginate outline. The color varies with the age of the lesion, becoming darker with age. There may be maculo- papules, flat infiltrations, or vesicopapules. It may con- tinue in this way for days or weeks, but usually it changes to the multiform type. There is pruritus. 182 DISEASES OF THE SKIN Dermatitis Herpetiformis Vesiculosa. — This is the form most usually met with. The vesicles are from pinhead to pea-sized, flat or raised, irregular or stellate in shape, glistening, pale yellow or pearly, firm, tensely distended, and without areola. There may be papules, papulo- vesicles, vesicopustules, and sometimes bullae. The lesions are disseminated, but aggregated into clusters of two, three, or more, or may form groups as large as a silver dollar. If the vesicles are near together, they tend Fig. 22 Dermatitis herpetiformis to run together and form blebs, which are raised and surrounded by a pale or distinct red areola, and of a puckered or drawn-up appearance. The eruption is usually profuse. All regions are affected. Severe itching and sometimes burning last until the vesicles are broken, which may not be for several days. Sometimes there is a good deal of constitutional disturbance. This is T. Fox's hydroa herpetiforme. Dermatitis Herpetiformis Bullosa. — In this form we have more or less typical bulla? filled with cloudy or serous 1 By the courtesy of Dr. S. D. Hubbard. DERMA TIT IS HERPETIFORMIS 183 fluid, from pea- to cherry-sized, irregular or angular in outline, and with or without an inflammatory base. They occur in groups, with red and puckered skin between, and Fig. 23 Hand of a person affected with dermatitis herpetiformis. 1 more or less vesicles and pustules, disseminated over the skin. All parts of the body are affected. They come out in crops at intervals, rupture in two or three days, and crust over. This is T. Fox's hydroa bulleux. 'From a replica of Baretta's model, No. 1333, in the Museum of the St. Louis Hospital, Paris. 184 DISEASES OF THE SKIN Dermatitis Herpetiformis Pustulosa. — This form is less clearly defined than the vesicular form, because vesicles, vesicopustules, and bullae often occur at the same time. It may occur uncomplicated and be pustular throughout. The pustules are acuminated, round or flat, tense or flaccid, and vary in size from a pinpoint to a twenty- five-cent piece. The large pustules generally have an areola. They tend to flatten, spread, and dry in the centre, and to group. On the trunk we may find a central pustule surrounded by a variable number of small pustules. They are opaque, and whitish or yellowish. There may be slight hemorrhagic exudation into them. They are slow of development, an attack lasting from two to four weeks. There is more marked constitutional disturbance than in the other forms. It is accompanied by heat, pricking, and itching. It sometimes precedes, follows, or alternates with the other forms. Dermatitis Herpetiformis Papulosa. — This is the rarest and mildest variety of all, and consists in small or large, irregularly shaped, firm, reddish or violaceous papules in disseminated groups, the papules being usually excoriated on account of the scratching to relieve the severe itching. Ill-defined papulovesicles are also present. Dermatitis herpetiformis multiforme is simply a combina- tion of all the preceding varieties, with the type changing from time to time. Pigmentation is a feature of this variety as well as of all the others, and occurs after the disease has lasted for some years. Etiology. — The disease occurs in both sexes, and is supposed to be a trophoneurosis. It occurs at all ages, but most commonly between thirty and sixty years of age. Our oldest patient was a woman of eighty-two. It has been met with in children three and four years of age. Little is known as to its causes. It occurs quite indepen- dently of pregnancy, and in one case became better during the same. Another case was aggravated during pregnancy, and by irregular menstruation. One case seemed to arise from a nervous shock. Most cases are DERMATITIS HERPETIFORMIS 185 seen in the subjects of nervous exhaustion of various kinds. By Bazin the gouty diathesis was considered to be a predisposing cause of hydroa, and hence possibly of dermatitis herpetiformis. Winfield has reported four cases in which sugar was found in the urine. Oc- casionally septicemia may stand in causal relation to the disease as also auto-intoxication from the intestinal tract. Pathology. — A careful study of herpetiform hydroa has been made by G. T. Elliott. 1 This is considered by Duhring as one variety of the disease under consideration. He showed that the vesicles originate in the epithelium of the sweat ducts, several being implicated at the same time, and that the ordinary signs of inflammation are present. He believes that the inflammation is secondary, and is seated in the papillary layer of the corium. De- generated nerve fibers are found, and the disease is believed to be due to trophic nerve disturbance. Laredde and Perrin 2 are of the opinion that eosinophile cells are closely related to the process of bullous formation, and that there is a vasomotor paralysis allowing of the escape of bloody or lymphatic serum into the connective tissue and the formation of bullse. They raise the question of a possible relation between renal action and the escape of eosinophile cells. T. C. Gilchrist's 3 studies show that in the early stages the vesicles are formed beneath the epidermis on account of an inflammatory process going on in the corium. He also notes the presence of the eosinophile cells. Diagnosis. — This disease must be differentiated from erythema multiforme, eczema, and pemphigus. It differs from erythema multiforme in not occurring markedly upon the backs of the hands, wrists, forearms, and feet; in its more intense itching, instead of the burning of erythema; in its chronicity and greater tendency to 1 New York Med. Jour., 1887, xlv, 449. 2 Ann. de derm, et d. syph., 1895, vi, 281. 3 Johns Hopkins Hosp. Rep., vol. i. 186 DISEASES OF THE SKIN relapse; and in its obstinacy to treatment. If the case is watched for a time, the character of the eruption will be seen to change. The vesicular form of dermatitis herpetiformis differs from vesicular eczema in having larger vesicles of angular or stellate outline, and with no disposition to rupture, and to run together to form patches; in the grouping of these vesicles in small clusters; in its herpetic character; more intense itching; greater constitutional disturbance; and greater obstinacy to treatment. The papular form differs from papular eczema in the irregularity of the size and form of the papules; their strong disposition to group and not to coalesce; their slow evolution; their appearance in crops with free intervals; the chronicity of its course; and obstinacy to treatment. It differs from herpes iris in being a general eruption, and in not having the groups of vesicles arranged in circles about a central vesicle. It differs from pemphigus in the grouping of its lesions, which are smaller than those of pemphigus; in their more inflammatory, herpetic aspect, in its intense pruritus, and in the occurrence of vesicles and pustules at the same time with the bullae. If only bullae are present, the diagnosis is difficult. Impetigo herpetiformis is always and only pustular, and never has erythematous patches, vesicles, or bullae. It develops by new lesions springing up in a circular manner about the old ones. It is unattended by pruritus, and is a grave disease, often ending fatally. Papular urticaria lacks the grouping of herpetiform dermatitis, prefers the extensor aspects of the limbs, and presents wheals. A well-marked case of dermatitis herpetiformis with erythematous patches, grouped vesicles, pustules, and bullae of stellate form, intensely pruritic and with a myriad of excoriations, is so characteristic as to admit of no doubt in diagnosis. DERMATITIS HERPETIFORMIS 187 Treatment. — This disease is one of the most rebellious to treatment. Hygienic measures, fresh air, proper and restricted diet, no meat being allowed in some cases, abstinence from all alcoholics, and relief from all nervous disturbances must be secured as far as may be. Nerve tonics may be given, such as arsenic, strychnin, cod-liver oil, hypophosphites, and quinin; alkaline diuretics, belladonna in full doses, laxatives, all may be tried. Phenacetin, 5 to 10 grains (0.33 to 0.66), three times a day, has done well in some cases. Antipyrin exerts a more powerful influence, but is not so safe. Locally Duhring has found the best treatment to be sulphur ointment containing two drachms (8) of sulphur to the ounce (32), well rubbed in with vigorous friction as in scabies. The frictions should be continued for an hour at a time. This plan is not suitable for the erythematous variety, and in some other forms cannot be used. The spinal douche acts favorably in some cases. Other authorities recommend alkaline and bran baths, dusting on starch powder, with oxide of zinc, Lassar's paste, resorcin ointment or lotion 1 to 5 per cent., liquor carbonis detergens in water, 3ij (16) to 5 y iij (250); calamin lotion, liquor picis alkalinus, tar ointment, ichthyol, 2 to 10 per cent, aqueous solutions, solutions of carbolic acid, 3j (4) to 5j (32), dabbed on. Guaiacol, 5 per cent, in ointment base, and camphor and chloral, 1 to 5 per cent., combined in ointment or lotion, control the itching. Schamberg recommends the mercurial vapor lamp. All these will afford a certain measure of relief, but the disease is apt to laugh at our efforts to drive it away. Prognosis. — The duration of the disease is indefinite. Some mild cases may recover in a short time, never to relapse. The course of the disease is essentially chronic; it may last for many years; it shows a strong tendency to relapse at longer or shorter intervals; and, as a rule, does not materially affect the patient's health. Old people and those not otherwise in good health may be worn out by the itching and the discomforts of the disease. 188 DISEASES OF THE SKIN Dermatitis, Malignant Papillary. — See Paget's Disease of the nipple. Dermatitis Medicamentosa. — By this is meant inflamma- tion of the skin due to the systemic ingestion of drugs. There are a great number of drugs that may cause erup- tions upon the skin in susceptible individuals. These effects are seen but rarely with some drugs, and quite constantly with others. The modus operandi of drugs in producing eruptions is probably not the same in all cases. Some, doubtless, act by irritating the skin while circulating in the blood; some while being excreted by the glandular apparatus; while many of them do so by direct or reflex excitation of the vasomotor nerves. Idiosyncrasy is marked in all of them. Deficient elimina- tion by the kidneys is a contributive factor in many cases. Erythema is the principal feature of nearly all drug eruptions, to which may be added vesiculation or pustulation. Two drugs, bromin and iodin, produce pustular eruptions in nearly all cases when ingested. Most drug eruptions appear with more or less suddenness, and disappear quite promptly when the drug is stopped. They are symmetrical and general in distribution as a rule. They may be universal or localized, and the extent of the eruption is in no way proportioned to the dose. The cause of all doubtful eruptions of an erythematous type should always be sought for in the ingestion of some drug. As a rule, little, if any, treatment is required for this form of dermatitis apart from stopping the drug. Sometimes the system becomes accustomed to a drug, and does not react unfavorably to it if its administration is persisted in. With most drugs this is not the case. The subject of drug eruptions is so large a one that here no more than a skeleton account can be given. A most useful classification of drug eruptions according to lesions is given by Stelwagon, 1 as follows: 1 Diseases of the Skin, Philadelphia, 1914. DERMATITIS MEDICAMENTOSA 189 Alopecia. — Boric acid and thallium acetate. Bullous. — Aconite, anacardium, antipyrin, boric acid, bromin, chloral, copaiba, cubebs, iodin compounds, iodoform, mercury, opium, phosphoric acid, quinin, and salicylates. Carbuncular (Anthacoid). — Arsenic, bromin compounds, chloral, iodin, and opium. Cyanotic. — Acetanilid and potassium chlorate. Eczematons. — Belladonna, boric acid, carbolic acid, morphin, opium, and sodium borate. Erysipelatous. — Arsenic, belladonna, conium, digitalis, ipecac, quinin, and stramonium. Erythematous. — Acetanilid, alcohol, antipyrin, antitoxin, arsenic, belladonna, benzoic acid, boric acid, bromin com- pounds, cantharides, capsicum, carbolic acid, castor oil, chinolin, chloral, chloralamid, chloroform, conium, copaiba, cubebs, dulcamara, exalgin, guaiacum, gurjun oil, hydro- cyanic acid, hyoscyamus, iodoform, lead acetate, mer- cury, opium, phenacetin, phosphoric acid, pilocarpin, piper methysticum, potassium chlorate, quinin, salicyl- ates, santonin, sodium benzoate and borate, stramonium, sulphonal, tannic acid, tar, turpentine oil, tuberculin, and veratrum viride. Erythematopapular. — Acetanilid, antipyrin, benzoic acid, copaiba, digitalis, gurjun oil, iodin compounds, iodoform, phenacetin, silver nitrate, and potassium chlorate. Epitheliomatous . — Arsenic, secondarily to keratoses. Furuncular. — Antipyrin, arsenic, bromin compounds, calx sulphurata, chloral, condurango, ergot, mercury, and opium. Gangrenous. — Arsenic, belladonna, ergot, iodin com- pounds, quinin, and salicylates. Herpetic. — Arsenic, belladonna, iodin compounds, mer- cury, and salicylates. Keratotic. — Arsenic. Morbilliform. — Antipyrin, antitoxin, belladonna, boric acid, copaiba, cubebs, opium, sodium borate, sulphonal, tar, turpentine, and tuberculin. 190 DISEASES OF THE SKIN Nodular. — Bromin and iodin compounds. Papillomatous. — Bromin and iodin compounds. Papular. — Arsenic, boric acid, bromin compounds, can- tharides, chloral, conium, copaiba, cubebs, digitalis, iodin compounds, jaborandi, mercury, opium, terebene, and turpentine oil. Papulovesicular. — C apsicum . Pigmentary. — Arsenic, antipyrin, and silver nitrate. Pruritus. — Chloral, copaiba, opium, and strychnin. Purpuric. — Antipyrin, antitoxin, arsenic, benzoic acid, calx sulphurata, chloroform, copaiba, cubebs, ergot, hyoscyamus, iodin compounds, iodoform, lead acetate, mercury, phosphoric acid, potassium chlorate, oil of sandal- wood, quinin, salicylates, stramonium, and sul phonal. Polymorphous, resembling erythema multiforme. Anti- pyrin, antitoxin, boric acid, chloral, copaiba, cubebs, coal-tar derivatives, exalgin, iodin compounds, iodoform, opium, and potassium chlorate. Psoriasiform. — Sodium borate and tuberculin. Pustular. — Aconite, antimony, antipyrin, arsenic, bro- min compounds, calx sulphurata, cod-liver oil, con- durango, ergot, hyoscyamus, iodin compounds, mercury, nitric acid, opium, salicylates, tanacetum, turpentine oil, and veratrum viride. Scarlatiniform. — Antipyrin, antitoxin, belladonna, chloral, copaiba, cubebs, digitalis, hyoscyamus, mercury, nux vomica, opiates, pilocarpin, rhubarb, quinin, salicy- lates, stramonium, strychnin, sulphonal, turpentine oil, tuberculin, and viburnum prunifolium. Ulcerative. — Arsenic, bromin compounds, chloral, iodin compounds, and mercury. Urticarial. — Alcohol, anacardium, antimony, antipyrin, antitoxin, arsenic, benzoic acid, bromin compounds, chloral, copaiba, cubebs, digitalis, dulcamara, guarana, hydrocyanic acid, hyoscyamus, iodin compounds, mer- cury, opium, phenacetin, pilocarpin, pimpinella, quinin, salicylates, salol, sodium benzoate, tannin, tar, turpentine oil, and valerian, DERMATITIS MEDICAMENTOSA 191 Vesicular. — Aconite, anacardium, antimony, antipyrin, arsenic, bromin compounds, calx sulphurata, cannabis indica, chloral, copaiba, cubebs, cod-liver oil, ergot, iodin compounds, iodoform, nux vomica, quinin, sali- cylates, sodium santonate, and turpentine oil. V esicopustular . — Antimony and antipyrin. Some of the drugs causing eruptions are: Acids: Benzoic acid and its compounds may produce an eruption of urticaria, maculopapules, or erythema. Boric acid and its compounds may cause an erythematous, psoriatic, or erythematobullous eruption. The psoriatic form is unusual. Carbolic acid causes an erythema that may be scarlatinous in character. Nitric acid, in rare cases, gives rise to a pustular eruption. Salicylic acid and salicylate of sodium produce erythematous, urticarial, vesicular, bullous, petechial, or purpuric manifestations. Tannic acid caused an erythema in one case. Acetanilid causes erythema; sometimes cyanosis. Aconite gives rise to itching, vesicular, pustular, or bullous lesions. Alcohol may cause a generalized erythema and urticaria. Amygdala amara causes erythema. Antifebrin may give rise to cyanosis. Antimony causes an urticarial or vesiculopustular eruption. Antipyrin gives rise to an erythema, consisting of small irregularly circular, slightly elevated patches, which may be discrete or confluent, and is at times followed by desquamation. Profuse sweating and itching may accompany it, and it affects the chest, abdomen, back, and extremities, especially their extensor surfaces. It may be measly in character or purpuric. It has given rise also to bullous, furuncular, and purpuric eruptions; herpes labialis; burning and necrosis of penis and scrotum. It may cause a bullous eruption of the mouth, beginning as a general or localized erythema. This eruption may occur with or without involvement of the skin. Antitoxin quite often causes an urticarial or multiform 192 DISEASES OF THE SKIN erythema. At times the eruption resembles scarlatina, and at other times measles. There are often fever and joint pains, and occasionally prostration. The eruption may not appear until several days after the administration of the toxin, and may last a week or more. Argentum nitras when used continuously may produce a grayish-black discoloration of the skin, or an erythemato- papular eruption. Fig. 24 Bromide of potassium eruption in a child. Arsenic causes erythema of scarlatinal type, papules, petechias, urticaria, vesicles, pustules, zoster, and an erysipelatous eruption. Itching may attend some of these eruptions. Grayish or brownish discolorations of the skin have followed prolonged ingestion of the drug. Boils and carbuncles have also been produced, as well as thickening of the skin of the palms and soles, and that over the knuckles, either in the form of diffused keratosis or as numerous small corns. Belladonna or atropin produces a scarlatinal eruption with or without vesicles and pruritus. As the fauces are often reddened the resemblance to scarlatina is striking. It will clear up in twenty-four hours, and the eruption is DERMATITIS MEDICAMENTOSA 193 patchy, not punctate. Moreover, there is none of the prodroma of scarlatina nor the strawberry tongue. The pupils may be dilated. Bromin in combination with potassium, ammonium, or other bases, produces the well-known "bromic acne" so commonly seen in the treatment of epilepsy It is an outbreak of dark-red inflammatory papules, papulopustules, and cutaneous abscesses that bear a close resemblance to acne, and, like it, often leave scars. It differs from acne in having a wider distribution and in occurring at all ages. This is the most common form of bromin eruption, but erythematous, urticarial, papular, ulcerative, verrucose, vesicular, and bullous eruptions have been met with. Rarer forms are papillary hyper- trophy, resembling condylomata, and large, irregular, elevated ulcers. The eruption may continue long after the administration of the drug has been stopped. It would be desirable to prevent these eruptions, but thus far there is nothing that will do so with certainty, except stopping the administration of the drug. Arsenic, sulphide of calcium, or aromatic spirits of ammonia may be tried, and diuresis maintained. Calx sulphurata gives rise to vesicles, pustules, and furuncles; rarely to petechise. Cannabis indica has caused a vesicular eruption. Cantharides gives rise to erythematous and papular lesions. Capsicum may cause erythematous and papulovesicu- lar lesions. Chinolin causes an erythema. Chloral produces erythematous, papular, urticarial, vesicular, and petechial eruptions. At times the chloral erythema bears a strong resemblance to scarlatina. Chloralamid causes a general punctate hyperemia with vesicular lesions with febrile reaction. Chloroform produces erythematous and purpuric lesions. Cinchona and quinin produce all the primary lesions 13 194 DISEASES OF THE SKIN of the skin, though most frequently an erythema of scarlatinal type, attended by congestion of the fauces and followed by desquamation. Condurango causes acne and furuncles. Conium causes an erysipelatous eruption as well as an erythematous one. Copaiba and cubebs. Their most common eruption is an erythema which is often of a scarlatinal type, but may resemble measles, and may be followed by desquamation. Outbreaks of wheals, vesicles, bullae, or petechia may occur. Pruritus may be present. The odor of the drug may usually be detected in the breath. Digitalis produces an erythema of an erysipelatous, papular, or urticarial character. Ergot, quite apart from the condition of ergotism, may cause vesicles, pustules, furuncles, and petechia. Guaiacum and gurjun oil cause eruptions like those of copaiba. Hydrargyrum gives rise to a scarlatiniform eruption, followed by desquamation, as well as urticaria, herpes, impetigo, purpura, furuncles, and ulcers. Hyoscyamus produces an itching erythematous erup- tion, with more or less edema and wheals. Purpura has also followed its use. Iodin and its compounds, like bromin, give rise to a pustular or papulo-pustular, acneiform eruption, usually upon the face, back, and upper part of the chest and arms; but often general. This is the most typical form of eruption, but an erythema limited to the face and chest or general, an urticaria, a vesicular erythema, an eczema-like eruption, a bullous form resembling pemphi- gus, as well as carbuncular, petechial/ and nodular erup- tions, may occur. Sometimes there will be more than one type present. It is supposed that iodic eruptions occur more often in cases in which the kidneys are more or less inactive. They sometimes follow the administra- tion of very small doses. It is thought that the iodide of sodium is less apt to cause cutaneous disturbances DERMATITIS MEDICAMENTOSA 195 than are the other salts of iodin. At times the system becomes accustomed to the drug, or the kidneys acting more freely relieve the skin. The trouble may be relieved or, to a large extent, obviated by administering the salt largely diluted with vichy or seltzer water, or by giving it in milk. The free use of alkaline diuretics will relieve the skin. Arsenic has also been recommended, but does no better here than in the bromin eruptions. Iodoform is sometimes absorbed from surgical dressings, and gives rise to erythema, urticaria, and purpura. Ipecac in one case caused burning heat, with an ery- sipelatous eruption. Iron is said to produce an acne; also erythematous, vesicular, and urticarial eruptions. The iodide of iron is the form that usually produces these eruptions, and it is the iodin that causes them. Morphin may cause urticaria, ulcers, a papular, vesic- ular, or pustular eruption. Nux vomica may give rise to a scarlatina-like ery- thema and a miliary eruption. Oleum morrhufle may cause an eczematous eruption or an acne. Oleum ricini may cause an itching erythema. Oleum santali may cause a general petechial eruption. Opium causes itching and an erythema resembling- scarlatina or measles in character, which though often widely distributed, is not infrequently limited to certain regions. Phenacetin may cause a general erythematous eruption. Phosphorus causes bullous eruptions and also purpura. Pilocarpin, or jaborandi, after prolonged use, may cause umbilicated papules located in the sweat glands, especially on the face and limbs. These may be topped with vesicles or pustules. PLx liquida produces an erythema. Potassium chlorate has caused a papular erythema, while bluish spots on the skin, and a general cyanosis may occur after continuous use of the drug. 196 DISEASES OF THE SKIN Quinin produces a scarlantiniform erythema, as well as urticarcial, purpuric, vesicular, and bullous eruptions. Rhubarb may cause a scarlatiniform erythema. Salipyrin has caused edema. Salol has caused urticaria. Santonin produces an urticarial or a vesicular eruption. Stramonium gives rise to an itching or burning scar- latinoid erythema, a petechial eruption, or an erysipela- tous inflammation. Strychnin may cause a scarlatiniform rash. Sulphonal produces a scarlatiniform erythema. Sulphur causes dark discoloration of the skin, and an eczematous, pustular, furuncular, or papular exanthem. Tannin may cause urticaria or erythema. Tansy has caused a varioliform eruption. Thallium acetate causes the hair to fall. Tuberculin and other serum injections may cause scarlatiniform or measles-like patches of erythema, as well as a psoriasiform eruption. Thiosinamin has caused erythema, swelling of face, and redness of fauces and mouth. Turpentine and terebene may cause scarlatiniform erythema and a papular and vesicular eruption. Veratrum viride gives rise to an erythematous eruption. Veronal has caused erythema, sometimes so profound as to be purpuric. Besides these, Hyde and Montgomery mention the following drugs as having produced eruptions: anacar- dium, benzol, chinolin, chloroform, cocain, creosote, duboisin, guarana, kava-kava, lactophenin, matico, pim- pinella, and plumbum. Treatment. — The treatment of all drug eruptions is the same, namely, stopping the use of the drug and giving alkaline diuretics. Locally, soothing remedies should be applied, such as cold cream, vaselin, and oxide of zinc ointment, or preferably alkaline lotions. DERMATITIS PAPILLARIS CAPILLITII 197 Dermatitis Papillaris Capillitii. — Synonyms: Dermatitis papillomatosa capillitii; Frambcesia; Sycosis frambcesia (Hebra); Sycosis capillitii (Rayer); Mycosis frambce- siodes, or Acne keloidique, or Pian ruboide (Albert); Acne keloid. Fig. 25 Dermatitis capillitii. Symptoms. — This is one of the rare diseases of the skin. It begins as an eruption of small-sized papules upon the back of the neck at the margin of the hair. They are of the color of the skin, or slightly red with an inflammatory halo; exceedingly hard and firm; and when pricked they give vent to a little bloody serous fluid. Increasing slowly in number and crowding to- gether, they form raspberry-like elevations with uneven, lobulated surfaces. Gradually the disease spreads later- ally and also upward upon the hairy scalp, even reaching the vertex after months and years. After a time the masses may soften a little and contain pus. At times they secrete a foul-smelling fluid, and crust. Grad- ually they become sclerosed and keloidal. Pustules may form on the hairy scalp, and little tufts of hair protrude out of them. When they become keloidal they may be bald or tufted with hair. Hairs plucked from the growths are sometimes normal and sometimes atrophied. There 198 DISEASES OF THE SKIN may be pain or tenderness, or there may he no subjec- tive symptoms. Etiology. — Men are more often affected than women. The disease may begin at any age. Negroes seem to be more subject to it than the white races. They are pecu- liarly prone to keloidal growths, and it is probable that the disease is a species of keloid starting in the follicles, such as is so frequently seen on the male negro face. The etiology is obscure. It has been suggested that it may be due to the rubbing of the shirt collar. Diagnosis.— If the characteristics of the disease are remembered, there should be no difficulty in diagnosis. In sycosis we have no hard tumors, and the large hairs are surrounded by pustules. Warts are not so hard, do not tend to increase in size, and do not become keloidal. Treatment. — It has been recommended to use sul- phur preparations in the early stages, and in the latter stages to apply a mercurial plaster for one or two weeks, alternating it with a 10 to 20 per cent, resorcin or chrys- arobin plaster. These means usually are useless. When the keloidal masses have formed they are as rebellious to treatment as keloid usually is. Destruction by elec- trolysis, and cauterization by the high-frequency current, or x-ray offer the best prospects of success. The latter must be pushed to the production of an erythema, and repeated when that subsides. Curettage and multiple scarifications may help. Prognosis. — So far as reported, the growths are benign and have no effect upon the health of the patient. They are progressive and show no tendency to spontaneous recovery. They are obstinate to treatment and prone to relapse. Dermatitis Psoriasiformis Nodularis. — See Parakeratosis variegata. Dermatitis Repens. — Crocker first described this dis- ease as a spreading dermatitis, usually following injuries, and probably neuritic in character, commencing almost DERMATITIS FROM X-RAYS 199 exclusively on the upper extremities. It begins about some slight injury, as of the finger-nails, as vesicles or a bulla which, on breaking, leave a raw and oozing surface. The border of this area is raised up by a clear or turbid exudation, and the disease spreads over the affected part with a well-defined undermined advancing edge; or extension may take place by the appearance of new vesicles or bulla just beyond the border. Occasion- ally the disease spreads without exudation. The character of the eruption suggests a parasitic complication, if not cause. The eruption resembles eczema rubrum by its raw, oozing, reddish surface, but its sharply defined, undermined, spreading edge distinguishes it. In some cases it is papular and in others bullous in character. It runs a chronic course, sometimes leaves a superficial atrophy on healing, and is obstinate to treatment. After removing any loose old skin the disease yields best to antiseptics, such as lactate of lead, hyposulphite of sodium, permanganate of potassium, 10 per cent., sali- cylic acid, boric acid, and white precipitate ointment. In very obstinate cases ,T-rays might be used. Dermatitis from Rontgen or X-Rays. — The dermatitis may not appear until some days or weeks after the exposure. The patient first notices an erythematous patch corresponding to the point of impact of the rays, attended by swelling of the skin. This is the mildest form and may soon disappear. In most cases the part is painful and the redness increases in area and assumes a purple hue. The pain when present is deep-seated and aching. Pigmentation of the skin may either precede or follow this form of dermatitis. Vesicles and sometimes bullae form, and later the central part of the patch becomes raw, moist, and tends to remain for months without healing. Or a dry slough may form which, after a time, separates and leaves an ulcer, which may not heal for years. A keratosis may develop upon the backs of the hands of those constantly using the .T-rays, and these 200 DISEASES OF THE SKIN warty growths are liable to become epitheliomatous. A sclerodermatous condition of the hands is also met with. The hairs and nails may be shed, but they are not per- manently lost, as a rule. It is not determined what the cause of the dermatitis is. There is a certain amount of idiosyncrasy shown in some cases. The placing of lead- foil over the sound skin, about the part to be operated on, will prevent burning. As the cases arise on account of too long exposure with a tube placed too near the subject, or too frequent exposures, short sittings not too near each other, filtration of the rays and the greatest possible working distance would seem to be the most rational prophylaxis. Treatment. — In the more superficial burns boric acid dressings do well. The deeper burns are very intractable. They seem to do best under wet dressings of normal salt solution, or diachylon ointment. Pusey commends the latter for the keratotic changes on the backs of the hands. In some cases the patch has been excised in the hope of obtaining a healthy surface. Dermatitis Seborrheica, or Eczema Seborrhoicum. — Symp- toms. — The starting-point of almost all cases of sebor- rheal dermatitis is the scalp; more rarely the margin of the eyelids, the axilla, bend of the elbows, or cruro- scrotal fold. Upon the scalp the disease begins as small papules, either singly or in groups. These grow per- ipherally and coalesce to form large polycyclic or ser- piginous patches, which are covered partially or com- pletely by rather coarse, loosely adherent, yellow, and distinctly greasy scales or crusts. These tend to adhere to the hairs and may mat them together. The hair is usually oily but may be abnormally dry. A pro- gressive alopecia pityroides may show itself, the scali- ness decreasing with the loss of the hair to make way for a hyperidrosis oleosa. A seborrhea may complicate matters. Under the crusts or scales the scalp may be pale or slightly reddened. In the majority of cases the disease is confined to the scalp. The scaling DERMATITIS SEBORRHOICA 201 and crusting may increase, a corona seborrhoica may form along the hair line, and the affection may extend upon the temples, over the ears to the neck, or on the nose and cheeks. Or the catarrhal symptoms may be pronounced, and a moist eczema affect the scalp and ears, and, in children, the cheeks and forehead. There is usually pruritus. It will be readily recognized that the slightest form is the pityriasis of the older authorities, the more pronounced form their seborrhea sicca, and the most pronounced form their seborrhea with dermatitis. From the scalp the disease may spread to other parts of the body, sometimes proceeding gradually from above downward; sometimes appearing in places far removed from the scalp, the intervening regions being free. Next to the head, the sternum is a favorite site for the erup- tion, where it most commonly assumes the crusted form, and most rarely the moist form. The sternum is affected secondarily to the scalp. The crusted form is in round or oval patches the size of the finger nail; these group and partly coalesce, forming patches the size of a silver half- dollar, having a scalloped border. The color is yellow, with a delicate red border. These may clear up some- what in the centre and form circles, enclosing a yellowish centre; or break and form bow-shaped figures with the convexity outward. The lesions of this form are usually covered with a greasy crust. The back especially between the scapula is similarly affected. (This is Duhring's seborrhea corporis.) In the axilla we meet most commonly with the moist form, and here it shows a tendency to spread with rapidity upon the thorax. From the shoulders it spreads down upon the arms almost always in the form of yellowish-red crusted papules, which tend to unite in patches, and also to form rings. At times it may look very much like psoriasis. It has usually a well-marked border. It shows a predilection for the flexor surfaces. The backs of the hands and fingers are often affected with a moist eczema, the trunk and arms escaping. 202 DISEASES OF THE SKIN Upon the palms and soles we find little heaped-up masses of scales corresponding to individual coil glands and resembling psoriasis guttata. Later the epidermis peels off, but there is never any moisture. The crusted form generally appears in ring or serpigi- nous patches on the trunk, buttocks, and hips. The cruroscrotal fold and the approximating surfaces of the thigh and scrotum are favorite locations for the disease, probably forming here many of the so-called cases of eczema marginatum in its dry form with festooned margins to the patches, or as an intertrigo when it is more moist. The thigh and extensor surface of the knee are but little affected, while the popliteal space and the leg often are, either in the large papular or the thick-crusted form. Upon the bearded portion of the face, when the beard is worn, we find a diffused pityriasis, or circumscribed, reddened, itchy patches. Upon the face of women and the unbearded portions of the face in men we have circumscribed, scaly, yellowish, or yellowish-gray, slightly elevated patches, mostly on the forehead, cheeks, and nasolabial fold. There may also be red papules, free from scales or with fine yellow ones, with redness of the skin between the papules. The face is the favorite location for a moist seborrheal dermatitis in children especially. The eyebrows are often involved as well as the eyelids. The latter are often swollen, and red and scaly. The vermilion borders of the lips may be affected, and the lips swell, scale, crust, and perhaps crack. The disease may attack both the outer parts of the ear and the external auditory canal. Scaliness, itching, and great increase of cerumen mark the process in the latter situation. Etiology. — Seborrheal dermatitis occurs at all ages and in both sexes, but it is especially prevalent between puberty and thirty years of age. It is more frequent in men. Though most of the patients with it seem to be in good health, careful inquiry will bring out the fact that they either are not in perfect condition or they are DERMATITIS SEBORRHOICA 203 living unhygienic lives. Elliot thinks that an in-door life favors the disease. It is in all probability a parasitic and contagious disease. The bottle bacilli of Unna and the polymorphous cocci with gray colonies of Sa- bouraud are constantly present on the scalp, and the latter's microbacilli of seborrhea is found in the mouths of the hair follicles. Its spread is favored by neglect of the hygiene of the scalp. Barber shops doubtless are distributing centres of the malady. It is quite im- possible to estimate the prevalence of the disease, as only the more pronounced cases are seen by the physician. Pathology.— According to Darier 1 the disease re- sembles psoriasis histologically. On the surface of the skin is a thick scale composed of nucleated, cornified cells, between the layers of which are masses of dried serum and leukocytes. Parakeratosis may be continuous throughout the lesion or only in places. There is acan- thosis and lengthening of the papillse. In the latter are small areas of spongiosis and abundant cellular infiltration. When these areas of spongiosis reach the horny layer, they become dry, and enter into the crust formation. There is papillary oedema and cellular infil- tration about the bloodvessels. The sebaceous glands are normal. Diagnosis. — Many cases formerly regarded as eczema are now included in seborrheal dermatitis. In diagnosis stress is laid upon the fact that the disease begins upon the scalp and spreads from there downward in a more or less capricious manner; upon the more or less absence of itching; upon the superficial character of the lesions, their tendency to take on definite forms, their yellowish color, and the greasy feeling of the crusts. In all these things the disease differs from an eczema. At times seborrheal dermatitis of the body bears so striking a likeness to pityriasis rosea that it is hard to differentiate the two. Pityriasis rosea does not occur on the scalp; 1 Precis de derm., p. 78. 204 DISEASES OF THE SKIN but as seborrheal dermatitis is of very common occur- rence on the scalp, and may be found in conjunction with pityriasis rosea; this is not of much aid in diagnosis. The rings of pityriasis rosea are not so greasy and yellow, have fawn-colored, dry centres, and lack the punctate border so often seen in seborrheal dermatitis. The papular lesions of pityriasis rosea are not so much raised as are those of seborrheal dermatitis and not so evidently related to the follicles of the skin. Pityriasis rosea commonly runs a rapid and self-limited course, whereas seborrheal dermatitis is chronic. If pityriasis rosea occurs typically upon the trunk, there is no difficulty; but when scaly ring-shaped patches occur on the limbs alone a positive diagnosis cannot be made without a good deal of study. The psoriasiform seborrheal dermatitis differs from psoriasis in occurring in locations not typical of psoriasis, and in having a more yellowish cast of color, and more greasy, yellowish scales. Many cases can be diagnosti- cated only by taking into consideration the probabilities for and against psoriasis. Seborrhea and both forms of pityriasis of the scalp are non-inflammatory. Lupus erythematosus of the scalp is an atrophic disease, while seborrheal dermatitis does not destroy the scalp. Treatment. — It is necessary to pay special attention to the scalp in every case, as that is the place of de- parture in almost all cases. In the treatment of the disease we have three useful drugs: sulphur, resorcin, and mercury. If a patient comes with the dry and scaly form of the disease, no matter whether there is or is not apparent inflammation, the best thing to prescribe is sulphur, and the most elegant prescription is: — Sulphur, prsecip., 3 iiiss 14 Cerse albse, 5iiiss 14 01. petrolati, Biiss 78 Aquae rosae, giss 46 Sodse biborat., gr. xviij 1 -Hydrarg. bichlorid., gr. j Resorcinol seu Euresol, 3j 01. ricini, 3ss Alcohol, ad §iv DERMATITIS SEBORRHOICA 205 This is known as Sulphur Cream. It is to be applied once a day for two or three days. Then the scalp is to be washed. After drying, the ointment is to be applied and repeated every other day for ten days. After wash- ing and drying, the ointment is to be applied three times a week, and so the number of applications are to be reduced until the ointment is used once or twice a week, and the head washed every two or three weeks. The efficacy of the ointment is sometimes increased by the addition to it of 2 or 3 per cent, of salicylic acid. Where there is a good deal of oiliness of the scalp, and where the use of an ointment is objected to, this prescription may be given: 1$ — Hydrarg. bichlorid., gr. j 06 4 I 2 120 j This is to be applied morning and night by means of a perforated cork, if for a man; or a medicine dropper, or tooth-brush, if for a woman. Once every few days, if the scalp becomes dry, it is well to rub in a little sweet almond oil, or an ointment containing 2 or 3 per cent, of resorcin. The strength of the resorcin in the pre- scription must be increased from time to time up to, perhaps, 10 per cent. Care must be taken not to use resorcin on blond or gray hair, as it stains the hair a green color. The lotion may cause an exfoliation of the scalp, which does no harm, and usually does not recur. As a substitute for the sulphur ointment, and in those who cannot use sulphur, this prescription will be found excellent : 1$ — Hydrarg. amnion., gr. xx-xl 1.33-2.66 Hydrarg. chlor. mitis, gr. xl-lxxx 2.66-5.33 Vaselin, ad §j ad 32 This is known as Bronson's Ointment. It is to be used in the same w T ay as the sulphur cream. Salicylic acid, 3 to 5 per cent., in the form of a lotion 20(5 DISEASES OF THE SKIN for the scalp, and of an ointment for the body; and the ammoniate of mercury ointment in full strength or diluted, are both excellent. Hodara 1 recommends in the dry forms of the disease an ointment composed of R— Chrysarobin, gr. i ad If 1.02— .1 Ichthyol, gr. § ad vj .04-. 1 Vaselin, ad giij ad 100 | M. which is to be applied at night and removed with cold cream in the morning. If reaction occurs, the ointment should not be used until it subsides. On the scalp the chrysarobin may be used in the same strength in alcohol, with the addition of a little castor oil. At times very obstinate patches of psoriasiform seborrheal eczema will be met with on the scalp, especially at the margin of the hair over the forehead. The best application for these is a 10 per cent, solution of chrysarobin in a 50 per cent, aqueous solution of ichthyol. This was first used by Dr. C. T. Dade, of New York. The prescriptions given for use on the scalp may be used for the disease elsewhere on the body, but these ointments are to be preferred to lotions. Prognosis. — There is practically no permanent cure of the disease, as it affects the scalp, because of the multitude of hair follicles that are the hosts of the parasite. By constant care of the scalp the disease is readily held in check, but when the scalp is neglected, a relapse is to be expected. The disease occurring on the body is usually easily cured, though relapses are common. Dermatitis Traumatica. — This term is used to comprise all inflammations of the skin that are due to traumatic influences, such as blows, rubbing, and the like. It presents the usual signs of inflammation to a greater or less extent, even up to gangrene, according to the degree of traumatism and the susceptibility of the individual skin. The irritation of the skin due to scratching is a common instance of this form of dermatitis. Under 1 Monatshefte f. prakt. Dermat., 1899, xxix, 264. DERMATITIS VEGETANS 207 certain circumstances it easily develops into an eczema. The chafing of the skin met with in horseback-riding, in those unaccustomed to the exercise, is another common instance. Treatment. — The treatment of this form of dermatitis should be soothing, such as by the free use of dusting powders, alkaline lotions, or mild ointments, such as that of the oxide of zinc. Unna 1 recommends for the preven- tion of the dermatitis due to horseback-riding, that the part should be smeared with a weak resorcin or ichthyol ointment. Dermatitis Vegetans. — Synonym: Pyodermatitis vege- tans (Hallopeau). This disease is thought by some to be an anomalous form of pemphigus vegetans, and by others as belong- ing to herpetiform dermatitis. But as it lacks the gravity of the former, and yields readily to antiseptic cleanliness, and, moreover, as a number of cases begin as eczematous lesions, it is, at least, in many cases an independent disease. G. W. Wende 2 has reported ten cases occurring in infants, six of which developed in the course of eczema. They occurred on the face, scalp, wrists, arms, and legs. In his cases the disease began as papulopustules, which soon dried up or rup- tured. On the red base thus formed vegetating masses developed. They were from split pea to walnut size or larger, and elevated from one-quarter to one inch above the level of the skin. They often showed miliary pustules, especially at their borders, exuded purulent fluid on pressure, and presented a warty appearance when the crusts or scales were removed. Microscopic examina- tion showed staphylococci. Balzer, Gougerot, and Burnier 3 found in a similar case the mycoderma pulmoneum. Their case ran a slow course with relapses, and in places left cicatrices. 1 Monatshefte f. prakt. Dermat., 1888, No. 21. 2 Jour. Cut. Dis., 1911, xxix, 473. 3 Ann. derm, et syph., 1912, cxi, 461. 208 DISEASES OF THE SKIN It is very probable that this form of dermatitis may arise secondarily to several diseases, and is due to some hitherto undiscovered cause. The treatment is cleanliness by the use of peroxide of hydrogen, and the application of ammoniate of mercury, or other antiseptic ointment or lotion. Dermatitis Venenata. — Redness, swelling, and heat, fol- lowed or attended by the formation of a vast number of small, closely crowded vesicles that may remain isolated or run together and form bullae, are the symptoms that constitute this form of dermatitis, the cause of which is always some sort of irritant applied to the skin. The irritant is usually of a chemical nature, and quite com- monly is derived from plants. Rhus Poisoning. — The most frequent cause of derma- titis venenata is contact of the susceptible skin with the leaves of the rhus toxicodendron, the poison ivy, and the rhus venenata, the poison sumach, and the rhus diversi- loba, the poison oak. The mildest degree of irritation is an erythema. Commonly the reaction is more marked. The patient first experiences a little burning or itching, and attention being drawn to the part, it is found to be reddened and swollen. In some cases we may have wheals. In a few hours papules, then vesicles will form and perhaps bullae . The swelling may be intense, so as, on the face, completely to close the eyes, and on the scrotum to give the appearance of an immense hydro- cele. The vesicles may be present in a countless multi- tude. The acute developing symptoms may last several days, and then gradually subside. The vesicle contents either dry up or discharge upon the skin. The parts crust, the swelling and redness slowly disappear, and the skin once more becomes normal. The parts most usually affected are the hands and face in both sexes, the penis in the male and the breast in the female — that is, those parts that come in direct contact with the poison, or to which it is most liable to be conveyed by the hands. DERMA TI TIS V EN EN A TA 209 In some rare cases, and in extremely sensitive individuals, the whole body may be affected, and there may be grave constitutional disturbances. These bad cases are met with, for the most part in children whose legs are uncov- ered, and whose resistance to the poison is not great. Most persons, perhaps, are not susceptible to the poison. Fig. 26 Dermatitis venenata from poison ivy. 1 Some few are so susceptible that even having the wind blow on them from over one of the plants, especially on a warm day when the sap is flowing, will cause the dermatitis. Negroes are almost immune. It is not true that the dermatitis will relapse after an interval of time, but it has been observed that an eczema 1 From a photograph by Dr. H. W. Blanc, of New Orleans. 14 210 DISEASES OF THE SKIN may follow the dermatitis, and that this may show a certain amount of periodicity in its outbreaks. White says that while the poison may be most active in the flowering season, it is sufficiently active in all seasons, and that the poison resides not only in the leaves, but also in the wood, bark, and fruit. The disease is not contagious after the parts have been well washed. Pathology. — The cause of dermatitis venenata when due to ivy or dogwood is toxicodendric acid. According to S. F. Acree and W. A. Syme, 1 it is a poisonous tar, gum, or wax, which is non-volatile and a complex sub- stance of a glucoside nature. It is easily oxidized by permanganate of potassium; and precipitated into an insoluable lead compound by acetate of lead. Diagnosis. — The eruption differs from that of eczema in seeking the inner sides of the fingers, the hands, face, breast, and genitals; in the greater amount of swelling that commonly attends it; in the vast number of crowded together, " lurid" vesicles; and in the occasional occur- rence of the eruption in the early stage in streaks, sugges- tive of striking against the plant. A history of having been in the country will sometimes be an aid in diagnosis. Erysipelas of the face sometimes needs to be differen- tiated. If the hands or genitals are affected at the same time with the face, that will decide in favor of derma- titis venenata. Besides this, erysipelas almost always is attended by constitutional disturbances, and it spreads with a raised border. Treatment. — : A susceptible person should always scrub his hands and face with hot soapsuds if he has been exposed to poisoning. It is well to do this once as soon as redness appears. Morris 2 advises the appli- cation of alcohol after the soap. A saturated solution of bicarbonate of soda, that can be procured anywhere, will afford relief promptly. The parts are to be kept constantly covered with lint or absorbent cotton con- 1 Jour. Biolog. Chem., March, 1907. 2 Jour. Amer. Med. Assoc, 1911, lvii, 102. DERMATITIS VENENATA 211 tinuously saturated with it, or with lime-water. At night we cannot use this if the patient sleeps, as the cotton or the lint dries. So it is better at this time to use some simple ointment, as cold cream, oxide of zinc, or diachylon diluted one-half, the last being the best. This treatment commends itself on account of its efficacy, cheapness, safety, and accessibility. Ichihyol in aqueous solution from 10 to 40 per cent, strength is highly com- mended by some. White recommends black wash [calomel, 3j (4); aq. calcis, Oj (500)], applied for half an hour at a time two or three times a day. He cautions against the danger of using it in extensive cases. As a substitute for it he gives: 1$ — Zinci oxid., 3iv 16 Ac. carbol., 5j 4 Aq. calcis, ad Oj ad 500 M. Sugar of lead in solution is a well-known remedy, and is efficacious but dangerous. Morrow 1 recommends: 1$ — Sodii hyposulphitis, 5j 32 Glycerini, gss 16 Aqua?, ad gviij ad 250 M. Acree and Syme recommend a 1 per cent, aqueous solution of permanganate of potassium used as hot as can be borne for half an hour. They say the staining of the skin can be removed by soap and water. They caution against the use of alcohol, which tends to spread the poison. The following formula may be tried: -Zinci oxidi, Magnesise carbonat., aa 3J Aristol, 5ij Aquse rosae, ad giv 120 M. It sometimes aborts the disease when used early. After the acute stage has passed the case should be treated like an eczema. If the constitutional disturbance is marked, the patient should be cared for upon general medical principles. 1 Jour. Cutan. and Ven. Dis., 1886, iv, 180. 212 DISEASES OF THE SKIN While the poison oak, or ivy, causes the symptoms most often spoken of as dermatitis venenata, there are a number of other plants that will produce like, if not so severe, symptoms. Of the commoner ones we find the oleander, Jack-in-the-pulpit, skunk cabbage, bitter orange, May apple, arnica, burdock, golden rod, and common daisy. The Japanese primrose, a favorite house plant, poisons many. The irritation is thought to be caused by needle-shaped crystals, and large and small thrombic prisms in the secretion exuding from and covering the glandular hairs of the leaves. 1 But space will not allow of a complete list of these. Goa powder and its derivative chrysarobin, produce a marked dermatitis in addition to the mahogany-staining of the skin. The action of croton oil, mustard, stinging nettle, and oil of turpentine is well known. Tar may excite a general dermatitis or an acne-like inflammation of the follicles called "tar acne," the follicles of the skin being stopped up and their mouths filled with a plug of black tar. A somewhat similar eruption is seen in workers in flax and paraffin. Workers in picking and packing peaches may have an eczematous dermatitis develop upon the wrists, forearm, neck, and upper part of the chest. A great number of chemicals produce dermatitis of varying degree. Pyrogallic acid produces a burning and inflammation, and covers the part with a black coating on account of its oxidation. Xot only does it destroy diseased tissue, but it may cause also sloughing of the sound skin. Chloroform will blister if prevented from evaporating. This peculiarity is sometimes employed for vesication. The strong acids destroy the skin, as also arsenic. Sulphur, iodin, iodoform, creolin, mercurial preparations, chloride of zinc, bichromate of potash, and caustic potash cause varying degrees of dermatitis. Electricity will redden and inflame the skin, and not a few cases of dermatitis have resulted from wearing 1 Foerster: Jour. Amer. Med. Assoc, 1910, lv, 642. DERM ATOLY SIS 213 clothing dyed with anilin dyes. It is said that the brown-tail moth coming in contact with the skin will cause an eruption like dermatitis venenata. Its hairs contain an irritant poison. Dermatitis Verrucosa. — Occasionally we see cases marked by patches which are circumscribed, raised, with their surfaces presenting a markedly uneven, papillomatous or warty appearance. There is a narrow zone of redness about the patches. A drop or two of serum may ooze from them, or thick pus. Pressure upon them will usually force out pus. There may be only one patch, or several patches. Commonly they will be on the same part of the body. The patients are usually in poor physical condition. They may be the subjects of other skin diseases, such as chronic eczema. They do not complain of itching. The disease seems to be due to streptococcic or staphylococcic infection, and to yield best to snug bandaging with the ammoniate of mercury ointment, or salicylic acid ointment; or to wet dressing of antiseptic character. At times the disease is very intractable. It is probably allied to dermatitis vegetans. Dermatolysis. — Synonyms: Chalazodermia; Cutis laxa seu pendula; Pachydermatocele, Loose skin. This term is applied to two entirely different diseases of the skin. In one we have folds of loose, thickened skin, and subcutaneous tissue that sometimes form huge masses hanging down from the side of the face, trunk, or any part of the body. The skin is soft and does not appear altered, excepting that it is pigmented to a certain extent. This form is really a species of fibroma. True dermatolysis is a yet more rare affection, in which, owing to some defect in the attachments of the skin, it can be pulled away from the body like the skin of a cat. The "Elastic-skin Man" is an instance of this. There have been several of these freaks. The one mentioned could pull the skin from his chest up to his eyes. The condi- 214 DISEASES OF THE SKIN tion is congenital, but can be increased by cultivation. There are no other changes in the skin itself. Treatment. — The treatment of the first variety is by excision before it becomes too large. Dermographia. — See Urticaria factitia. Dhobie Itch. — According to Stelwagon, in the tropics, during the warm weather the fungi of ringworm, chromo- phytosis, and erythrasma cause a dermatitis of the axilla, crotch, and feet, which is characterized by a more or less pronounced festooned border. The patches are very pruritic, and when scratched become raw. Boils and abscesses, the result of secondary infection, often com- plicate matters. With the advent of the cooler weather, the disease tends to recovery, and is well in winter time. Treatment. — The treatment is cleanliness of the patient and the use of antiseptics, such as boric acid, salicylic acid, bichloride of mercury, and the like. Diabetic Eruptions. — According to Brocq, they may be divided into two great classes: (1) Those in direct relation to alterations in the general economy, such as pruritus, chronic papular urticaria, acne cachecticorum, erythema, lichen, eczema, herpes, ecthyma, furuncle, carbuncle, xanthelasma, gangrene. (2) Dermatoses due directly to the contact of the secretions of the body charged with sugar, and more especially eczema of the genitals caused by contact with the urine. Kaposi 1 has described a bulloserpiginous gangrene of diabetics which begins as a disseminated eruption of bullae upon the extremities. The bullae dry up in the centre into a black crust, while at the periphery there is a ring of fluid pushing up the epidermis. When the crust is removed, sphacelated skin is exposed, which separates and leaves a red, granulating surface. The penis is a favorite site for this form of gangrene. It must be treated on general surgical principles. 1 Wien. med. Presse, 1883. DISTICHIASIS 215 Diphtheria of the Skin. — Diphtheria of the skin takes the form of ulcers, which at first are small and superficial. Later they become confluent, large, of irregular shape, with scalloped borders running out into the sound skin. Their edges are slightly infiltrated, intensely red, here and there undermined, but usually perpendicular. Their floor is covered with a grayish-white, adherent diphther- itic membrane. They have only a slight odor. When cleaned they heal rapidly. There is slight constitutional disturbance, with temperature not high. They may occur without the presence of diphtheria elsewhere, and are most often seen in the crotch where intertrigo is present. Diphtheria bacilli are found in the ulcers. Sometimes the disease may rapidly spread over large surfaces, when the skin becomes bathed with a serous discharge, assumes a grayish or blackish tint, and has a putrid odor. Pustules and bullse may occur with the Loeffler bacilli found in them. Diagnosis. — Hospital gangrene differs from diphtheria in having ulcers covered with a dirty grayish-green to blackish membrane, many millimeters thick, which is gelatinous, pasty, and looks like the result of burning with an acid. They are surrounded by a bright inflam- matory zone, and have a foul odor. High fever and severe constitutional disturbance accompany them. There are no diphtheria bacilli present. Ecthyma infantile always begins as a pustule; the ulcers formed are more superficial, oval, and without diphtheritic membrane. Ulcus molle is crater-form, with undermined edges. It is inflammatory, swollen, and without diphtheritic mem- brane. Treatment. — The ulcers are to be cleaned with anti- septics and antitoxin administered. Distichiasis.— This is a congenital or acquired con- dition of the cilia, in which they grow in two distinct rows, the inner row being directed inward so as to scrape the cornea. According to Michel, generally the outer 216 DISEASES OF THE SKIN third of the upper lid is affected alone, the deformity is symmetrical and bilateral, and of embryonic origin. Electrolysis offers the best method of relief. These cases belong to the ophthalmic surgeon. Dracontiasis. — See Guinea-worm disease. Drug Eruptions. — See Dermatitis medicamentosa. Duhring's Disease. — See Dermatitis herpetiformis. Dysidrosis. — See Pompholyx and hidrocystoma. Ecphyma Globulus is described by H. L. Purdon 1 as a contagious disease occurring in Ireland. It begins as a tubercle which, after a time, softens and is replaced by a raspberry-like tumor. All parts of the body may be affected excepting the hands and feet. It is chronic in its course, but can be cured by application of the nitrate of silver. Ecthyma. — Synonyms: Furunculi atonici; Phylzacia agria; (Ger.) Eiterpusteln; (Fr.) Furoncles atoniques; (Ital.) Rogna grossa. A cutaneous eruption of deep-seated pustules, with hard, elevated, reddened bases, attended by the forma- tion of thick, greenish or dark-colored crusts, and followed either by cicatrices or dark pigmented spots. Symptoms. — As usually described, the disease consists in an outbreak of one or more round, flat pustules, whose covers are not fully distended, and which have an inflammatory areola. In size they vary from that of a split pea to that of a finger nail, or larger. At first they are white or yellow. Subsequently they may or may not become reddish from the admixture of blood. They may dry up, forming a crust which, on falling, leaves a healthy surface. Or they may rupture spontaneously or be broken, and form a thick greenish or blackish crust, under which is a raw or superficially ulcerated surface, which on heal- 1 Dublin Jour. Med. Sci., 1897, ciii, 486. ECTHYMA 217 ing leaves a pigmented or slightly cicatricial spot. In subjects in bad hygienic surroundings quite deep ulcers may result. These pustules are usually discrete, but they may group. They are both painful and tender. Any part of the body may be affected, but they are most often seen on the extremities, especially the legs, where the hair is coarse, the shoulders, and the back. The course of the disease may be acute, each pustule lasting five or ten days, and the whole disease lasting about tAvo weeks; but generally it is chronic, and kept up by the outbreak of fresh crops. There is more or less itching, soreness, and pain. It is both contagious and auto-inoculable. Febrile symptoms may accompany or precede the outbreak of the disease, but, as a rule, they are absent. It is, in all probability, only contagious impetigo modified by the character of the soil upon which it is planted. Etiology. — Dirt, want, bad hygienic surroundings, the strumous diathesis, or a broken-down, cachectic condition brought on by intemperance or dissipation, all predispose to the disease. It is quite often seen in the genus " tramp." It follows, not infrequent lv, upon scratching on account of pediculi and scabies. It is most often seen in adults, and is rare in children. Like in all other purulent diseases, pus cocci, both staphylo- cocci and streptococci, are found in the pus, and are the contagious element in the disease which is carried from place to place to produce new foci of infection. Sabouraud teaches that it is the streptococcus of Fehl- eisen that is the specific causative microorganism, staphylococci being also present secondarily. Diagnosis. — Ecthyma differs from eczema in having much larger and deeper pustules, which are discrete and not confluent, in the marked areola about the pustules, and in the absence of all other signs of eczema. It differs from impetigo contagiosa in its pustules being deeper; in their location upon the extremities rather than upon the face and hands; in not having that flabby, bullous look of a burn of the second degree, so common to impetigo; 218 DISEASES OF THE SKIN in having thick greenish or blackish crusts, and no straw-colored stuck-on crusts; occurring in more or less debilitated adults and not in otherwise healthy children. But all these alleged differences can be readily explained away by the difference in the character of the soil on which the contagious principle is implanted. Ecthyma- tous pustules are often seen in connection with impetigo contagiosa. From impetigo it differs principally in its being a deeper and more inflammatory process, and in occurring in debilitated subjects. It resembles the large, flat, pustular syphiloderm; but its crusts are not heaped up into oyster-shell-like masses, as in syphilis, and when they are removed they leave a more superficial, and not so punched-out an ulcer. There are more signs of inflam- mation than in syphilis, also pain and sometimes itching, and an entire absence of other symptoms or history of syphilis. It differs from furuncle in having no central core, and in not being so deep a lesion nor so painful. Treatment. — The first thing to be done in these cases is to obtain cleanliness, proper hygienic surroundings, and complete abstinence from alcoholics. If there is a general debility, tonics must be given, and the dietary improved. Locally, all crusts must be removed with soap and water, the lesions dressed with an ointment containing some antiseptic such as: 1$ — Hydrag. ammon., gr. xx 1 [32 Ungt. zinci oxidi, Sj 32 1 M. and the parts enveloped in a bandage, where such can be applied. An ointment or oil containing 10 (0.64) or 15 (1) grains of salicylic acid to the ounce (32) will also answer well. If ulcerations have formed, they should be treated as will be indicated under Ulcers. Eczema. — Synonyms: (Ft.) Dartre vive, ou humide, eczema; (Ger.) Ekzem, Hitzblatterchen, Flechte, nas- sende Flechte, Salzfluss; Salt rheum, Tetter, Humid tetter, Scall, Scald, Heat eruption. ECZEMA 219 A non-contagious inflammatory disease of the skin, sometimes acute, more often chronic, attended with itching, desquamation or loss of the cuticle, and usually with the exudation of serous or seropurulent fluid either beneath the cuticle or upon the denuded surfaces. It may present erythema, papules, vesicles, or pustules, and its lesions show a decided disposition to run together and form infiltrated patches. Symptoms. — This is a most protean disease. There are seven prominent symptoms of the disease : 1. Redness. 2. Itching. 3. Infiltration. 4. Tendency to moisture. 5. Crusting or scaling. 6. Cracking of the skin. 7. Tendency of the lesions to run together and form patches. In every case there will be four or five of these symp- toms present at the same time; or perhaps all of them. Eczema begins suddenly, and most often without any constitutional disturbance. Should slight fever and malaise be present, they are accidental, or an expression of that condition of the system that predisposes to the disease, and not part of the disease itself. Very often the first thing that attracts the patient's attention is itching; and when he examines the skin he finds it reddened, and either scaly, or covered with papules, vesicles, or pustules; or moist. The tendency of eczema in all forms is to form patches, which are infiltrated to a greater or lesser extent; ill defined; shade off imperceptibly into the surrounding skin, so that it is hard to say where they end, with outlying lesions about them; irregular in shape; of all sizes, some- times involving nearly the whole cutaneous surface; sometimes swollen, and of dark-red color; sometimes with a shade of yellow. Beginning by a few lesions, the disease increases more or less rapidly in extent, and it is 220 DISEASES OF THE SKIN by the running together of the individual lesions that the patches are formed. It may clear away after a short time, or it may last weeks or months, or become chronic, showing little tendency to recovery. There is no con- stant rule as to the course of the disease, though many cases occur and recur at certain seasons of the year; it may be in the summer, spring, autumn, or winter. Any or all parts of the skin may be affected, but it has a predilection for the flexures of the joints, the face, the scalp, and the sulcus behind the ear. There may be but a single patch or many patches. It commonly affects both sides of the body, but with no marked symmetry. The subjective symptoms are itching, burning, and a feeling of heat and tension. Of these, the most constant is itching, which is present in all cases, and is often so great as to cause the patient to excoriate the skin by scratching. It is subject to exacerbations and remissions. The latter may be complete or incomplete. Burning and tension are experienced for the most part only at the beginning of the attack or during some exacerbation of a subacute or chronic case. The old definition of the disease was that it is a vesicular one. It is well to disabuse the mind of this impression at the start, as there is a form of the disease that is dry throughout — the erythematous form. Though even here the vesicles, though unseen, are present deep in the skin. There are five forms of eczema, known as the erythematous, papular, vesicular, pustular, and squa- mous. Eczema madidans is but a convenient term to describe a very moist eczema. Eczema rimosum or rhagadiforme is but an eczema in which there is crack- ing of the skin, especially about the joints. Before discussing each of these forms by itself, it is necessary to understand that no one of them, excepting perhaps eczema erythematosum, is clear cut and unchang- ing. On the contrary, the disease may begin as a papu- lar erythema; upon the papules vesicles may form, which will run together and soon break down of themselves ECZEMA 221 and form a weeping patch; the subsequent lesions may then be pustules, and the final stage through which all varieties pass before recovery is the squamous. It is common to see several varieties at the same time. Eczema erythematosum is most often encountered upon the face of an adult, though it may occur elsewhere and in children. Beginning as one or more ill-defined red patches, it soon forms a continuous patch by the coales- cence of the smaller ones. Sometimes the whole face is involved, sometimes there are several patches. The inflammation at first is often attended by oedema to such an extent that the eyes are nearly closed if the disease is in their neighborhood. The acuteness of the inflam- mation subsides soon. The patient experiences great dis- comfort on account of the itching and the burning and stiffness of the skin. The skin feels harsh, dry, and thickened; it is swollen; its color is bright or dull red; there are a slight amount of small adherent scales and many small excoriations. If it occurs on contiguous folds of the skin, there may be moisture. Upon the face vesicles and papules may develop, but they are exceptional. After lasting for a time the symptoms may subside and recovery take place, the patches fading away altogether and not in the centre alone. It may assume a chronic form and last for years. It is seen at times upon the body in the form of very superficial, pale-red, scaly, round, circumscribed patches, and constitutes one form of the so-called parasitic eczema. Eczema Papillosum. — This is the lichen simplex of the old writers. It consists in an eruption of pinpoint to pinhead-sized, bright or dull-red, acuminate, discrete, grouped, or perhaps confluent papules. They are often in relation to the hair follicles. Very frequently the papules are capped by vesicles. The papules may remain discrete throughout their course, with an occasional small confluent patch to betray the nature of the disease, but, as a rule, they tend to run together and form patches. These patches are frequently no larger than a silver 222 DISEASES OF THE SKIN dollar in size and fairly well denned. This is one of the most itchy varieties of this pruritic disease, and the scratching consequent upon it produces excoriations, and, breaking down the vesicles and papules, gives exit to the serum and converts the patch into a moist one. This variety is located preferably on the extensor aspects of the limbs. The life of the individual papule is com- paratively long — days or weeks. It is often obstinate to treatment. Eczema vesiculosum is the most common and most characteristic form, and consists in an eruption of pin- point to pinhead-sized, rounded or acuminate vesicles that appear upon a reddened surface in immense numbers. Prickling and tingling precede the outbreak; intense itching and more or less swelling attend it. The vesicles group, and perhaps coalesce, and soon rupture of them- selves, and discharge a clear, sticky, mucilaginous fluid that possesses the quality of stiffening and staining linen, and dries into a light-yellow crust. The vesicles rupture so early that it is rare for the physician to see a case with the vesicles intact. New vesicles form about the patch, and break down; the discharge continues from the sites of the vesicles, and the crust continuously forms. A raw surface is exposed when the crusts are removed. Sometimes when the crust is prevented from forming on account of friction, there is a weeping surface, which has been called eczema madidans or rubrum. Eventually the discharge ceases, the hyperemia lessens, scaling takes place, and after a time the skin returns to its normal condition. This form of eczema seeks the soft parts of the skin, the flexures of the joints, the flexor surfaces of the limbs, and behind the ears. It may involve the whole or nearly the whole cutaneous surface. After it has lasted a little while in a part the skin is evidently thickened. With it papules and pustules very generally are found. Eczema Pustulosum. — Like the pustular syphilid, this form of eczema occurs in more or less broken-down, ECZEMA 223 cachectic, delicate, or strumous subjects. It is possible that there is no pustular form of the disease, what is so-called being only a secondary infection with the pus organisms. It is the most common form of eczema met with in children, and in them occurs by preference on the face and head. The eruption consists of small pustules that may start as pustules or develop from vesicles. They are present in large numbers, and tend to break down and form patches covered with greenish crusts. If blood is drawn by scratching, the crust will be blackish. They are somewhat larger than the char- acteristic vesicles, and have a fondness for hairy parts, though any part of the body may be affected. This and the previous form often merge into each other. It may develop from any of the other forms of the disease on account of infection by pus cocci. It is not so itchy as the other forms. It may change into an eczema madidans, and it passes through the squamous stage on the way to recovery. While the above described forms of eczema are in some cases fairly well marked, in very many cases several forms will be present at the same time. Thus we may see erythematous patches here, while there vesicles may form which change into pustules, while scattered about are numerous papules. Eczema squamosum is the final stage through which all forms of eczema pass on their way to recovery. In it the skin is dry, red, and covered with thin, papery, flat, large or small scales. Itching is pronounced. It is a con- dition of the skin in which the formation of its corneous layer falls short of perfection. The disease may continue in this stage for an indefinite time, a chronic eczema with occasional exacerbations. Then it may pass away entirely and the skin become quite well; or some local injury may cause an acute outbreak of eczema. The skin in this form is more or less thickened, and deep cracks are liable to form about the joints, because the infiltra- tion of the skin interferes with its elasticity, and it breaks 224 DISEASES OF THE SKIN instead of stretching when the joint is extended. While the patches are usually ill defined, in some cases they will be round, and with well-marked borders. This form is spoken of as orbicular eczema. Eczema may be acute, subacute, or chronic — terms that apply not to the length of time that the disease has lasted, but to the symptoms it presents. In acute eczema there are the usual signs of inflammation — heat, redness, and swelling. There may be constitutional symptoms of fever, chills, prostration, and the like. This stage is usually of short duration, and passes over into the sub- acute stage. Now the swelling lessens or disappears, but there is an active evolution of lesions, papules, veiscles, or pustules, as the case may be. After a time the chronic stage is reached, when the disease takes the form of red- dened, infiltrated, scaly patches. It is prone to take on acute symptoms under slight irritations. In severe attacks of eczema the patient may be confined to bed and greatly prostrated. In the great majority of cases while the patient suffers much discomfort, he does not feel ill. It predisposes to ulceration upon the legs when combined with varicose veins, and then is named eczema mricosum. This must not be confounded with a some- what similarly sounding name, eczema wrrucosum, which is a rare form, in which the skin takes on a warty appear- ance on account of a hypertrophy of the papillae. Etiology. — Like its symptoms, its causes are numer- ous. It may arise from purely local causes, but even then it is probable that we should assume in most cases a pre- disposition on the part of the skin. Thus we have eczema of the hands in washerwomen. Perhaps for a score of years they had washed in water from the same source and with the same kind of soap without eczema. Then under the same local conditions, but with some unknown internal constitutional state, an eczema breaks out. Of external irritants, we have the sun, water, intense artificial heat, acids, alkalies, traumatism, rubbing of apposed surfaces or chafing by the clothing, parasites — ECZEMA 225 in fact, just the same things as will cause a dermatitis, only now the action goes further, and a catarrhal con- dition of the skin results. Cold has an undoubted in- fluence on the skin, and eczema is more common in winter than in summer, and is generally aggravated by extremely low temperature, even when the patient keeps in the house. It has been observed that children with eczema grow worse when it is cold and a high wind is blowing, even though they are not exposed directly to these conditions. Vaccination may act as a local cause. Of the internal or predisposing causes, perhaps the most common and active is some digestive or intestinal disturbance — it may be dyspepsia or malassimilation, or derangement of the liver, or constipation. At other times the kidneys are at fault. Diabetes and B right's disease both predispose to eczema. Chlorosis and anemia, uterine disorders and the menopause, and the strumous diathesis are at times active factors. Derangements of the nervous system are exciting causes; now and again we meet with cases which appear suddenly after some nervous shock. Rheumatism and gout and varicose veins are other predisposing causes. To most of these internal causes some external irritation must be added before the eczema appears. The French school of dermatology has long held to its theory of diathesis, and has taught that the dartrous diathesis is the cause of eczema. A vulnerability of the skin is necessary for the production of an eczema, and many patients may fairly be regarded as eczematous, just as others may be spoken of as gouty, or rheumatic, or psoriatic. This peculiarity or tendency of the skin may be inherited, and insofar eczema may be regarded as hereditary. The disease occurs in all ages, conditions, races, and both sexes, and is the dermatosis we are most often called upon to treat. It is especially common in children. In Bulkley's tables, out of 3000 cases, 676 occurred under 15 226 DISEASES OF THE SKIN five years of age; and of these, 520 were in children under three years. Of the remaining cases, 1234 were between the ages of twenty and fifty, and were divided about equally in each decade. About one-third of all skin diseases are eczema. These many etiological factors indicate that it is probable that our present eczema is a too composite disease, and it is for this reason that attempts are con- stantly made to take away certain members of the family and form them into separate diseases. Thus far no microorganism has been demonstrated as the cause of the disease, though the pus cocci are found in the pustular form. The vesicles of eczema are sterile, which is evidence against the disease being parasitic. Staphylococci are doubtless the cause of pustulation, which may be a matter of secondary infection. Unna teaches that there are two other varieties of the disease: one due to reflex nervous irritation, such as is seen during dentition of infants, and one dependent upon the tubercular diathesis. Pathology. — Eczema is a catarrhal inflammation of the skin, analogous to that of the mucous membrane, which has its seat principally in the papillary layer of the skin and in the rete. This superficial location of the disease is the reason why the skin is left unmarked after the disease has been recovered from. In chronic eczema there is marked cell infiltration of the corium, producing the characteristic thickening of the skin. The subcuta- neous tissues may be affected by this infiltration. The papillae, bloodvessels, and lymphatics are considerably enlarged. In advanced cases the skin appendages may suffer obliteration. The sticky yellow exudate of eczema is made up of serum containing in solution or suspension the detritus of degenerated rete cells. This secretion when dry forms the peculiar gummy yellow glaze or crusts. A trophoneurosis is supposed by many to be the cause of the disease when not due to local irritants, and Crocker quotes Marcacci as having found changes in the sympathetic in a fatal case of universal eczema. ECZEMA 227 Diagnosis. — If the six prominent symptoms of eczema are remembered, namely, redness, itching, infiltration or thickening, exudation or tendency to moisture, crusting or scaling, and cracking, it will be a great aid in diagnosis. To them should be added the tendency the disease evinces to locate in the folds of the joints, between apposed surfaces of skin and behind the ears, and the peculiar, mucilaginous quality of the exudate, which stiffens and stains linen and glues the hair together. Fortunately, a diagnosis of eczema will fit one out of every three cases. Here will be given the general diag- nosis, reserving for the sections on regional eczema the diagnosis of special forms when necessary. Dermatitis is often distinguished with difficulty from eczema, and frequently passes over into it. As a rule, it runs a more rapid course, its vesicles are longer pre- served, bullae are apt to form, there is burning rather than itching, and it heals readily on removal of the cause, which usually is evident. Dermatitis exfoliativa is, when fully developed, a uni- versal eruption, while eczema is very rarely so. It is also dry; and has abundant large scales; while eczema will exhibit moisture somewhere, and does not scale so abundantly. For further points in diagnosis, see under dermatitis exfoliativa. Erysipelas is attended by fever and marked constitu- tional disturbances, has a sharply defined border, ad- vances steadily at its margin, and forms a swollen, deep- red patch upon which large vesicles and bullae form. The margin of eczema is ill defined, fading off into the surrounding skin; its vesicles are pinpoint- to pinhead- sized; itching is always present; and there is little or no constitutional disturbance. Eczema has a dry, rough surface in the erythematous form, while erysipelas has at first a smooth and shining one. Erythema burns rather than itches; its redness can be entirely squeezed out by pressure, leaving a whitish spot, and returns promptly when the pressure is removed. 228 DISEASES OF THE SKIN In eczema pressure will cause the redness to disappear, but it will leave a yellow stain in its place. Erythema lacks the itching, exudation, scaling or crusting, and cracking of eczema, is prone to appear upon the back of the hands and wrists, and is symmetrical. Herpes febrilis resembles eczema only in having vesi- cles upon a red surface. It occurs usually in a single patch upon the face; its vesicles are discrete, and show little tendency to run together; its course is short, and it pains or burns, but does not itch. Zoster occurs in the form of a number of herpetic patches following the course of a nerve, and occupying only one side of the body — symptoms that are entirely foreign to eczema. Impetigo contagiosa occurs for the most part upon the face, hands, and exposed parts. Its pustules are large, flat, and discrete, not small and acuminate. Its crusts are thin and stuck on; not greenish and thick, as in eczema. It is a vesicopustular disease, and often pre- sents large vesicles or bullae that look like burns of the second degree. Lichen planus presents papules that are flat, smooth, umbilicated, and angular, and has a peculiar violaceous hue when its lesions are sufficiently numerous to simulate eczema. Eczematous papules are round and acuminate and bright red. They are constantly coming and going, while those of lichen planus are constant and last for a considerable time. Lupus erythematosus occurs in sharply defined patches which are exceedingly chronic; its scales are adherent; its color is peculiar to it; and it produces atrophy of the skin. Eczema presents none of these symptoms. Mycosis fungoides in its early stage is often indistin- guishable from eczema. Usually its patches assume a half-moon, horseshoe, or kidney shape. A circular patch with a small round patch, bull's eye, in the centre is characteristic. These may disappear, to reappear in the same or other locality. They also fail to respond to ECZEMA 229 treatment. The diagnosis is at times difficult until the characteristic elevated patches appear. Pemphigus foliaceus presents raw surfaces that bear some resemblance to eczema rubrum; but its large bullae and pastry-like crusts, coupled with the generally bad condition of the patient, sharply differentiate it. Phthiriasis, or pediculosis, shows parallel scratch marks over the shoulders, and excoriations about the waist and on the limbs where the seams of the clothing come. If on the head, the lesions will be on the occiput, and nits will be found on the hair of that region or of the temples. The eruption to which they give rise is an eczema, but the cause of it is evident. Pityriasis rubra pilaris has elevated papules about the hair follicles of the back of the fingers, and is not particu- larly pruritic. It forms well-defined patches that feel like nutmeg graters and present no secondary changes. Pruritus cutaneous has no lesions, properly speaking, and the excoriations met wfth are not in patches, but scattered all over the body at intervals and irregularly. The itching is more paroxysmal than it is in eczema, and is the only symptom that it has in common with eczema. Psoriasis, when occurring in typical round or oval, sharply defined patchs, with silvery scales, offers no difficulty in diagnosis from a typical eczema. From circumscribed eczema, that occurs occasionally, it may be diagnosed by the color — of a brighter red; by the scaling, that is whiter, thicker, and more laminated; and by finding characteristic patches either of the one or the other disease elsewhere on the body. When psoriasis occurs in large areas it is diagnosed from squamous eczema by its sharply defined border; its marginate form; its brighter red; its more abundant, thicker, and whiter scales; its fondness for the extensor surfaces of the limbs, while eczema seeks the flexor aspects and the flexures of the joints; its uniform character and constant dryness, against the polymorphous character of eczema and its 230 DISEASES OF THE SKIN moisture; and its history of frequent relapses, always of the same sort and always on the elbows and knees. Rosacea occupies the middle third of the face from above downward, attacking the forehead, nose, and chin; while eczema affects the whole or part of the face, but never occurs on these limited regions alone; it burns rather than itches; it shows telangiectases, and its red- ness and occasional discrete, sluggish, superficial pustules are very different from either the dry, harsh, scaly, red- ness of an erythematous eczema, or the crusted surface of a pustular eczema. Scabies may be diagnosed from eczema, by its loca- tion upon the anterior surface of the wrists, between the fingers, and upon the abdomen and buttocks, of both sexes, and upon the nipples and breasts of women and the penis of males. In children the feet are often affected. The presence of cuniculi is diagnostic, but they are hard to find in some cases. The eruption in scabies is at times an eczema; but it is important to recognize, where pos- sible, the cause of an eczema in order to cure it. Syphilis like eczema is a protean disease; but it does not itch, and that is an important point in differential diagnosis. It is true that occasionally a papular or crusted pustular syphilid does itch, but the occurrence is so rare that it need not here be taken into account. The early syphilids are general eruptions, whether macular, papu- lar, or pustular, and the efflorescences never run together to form patches, though they may show more or less grouping. When the other symptoms of syphilis are present, such as the initial lesion, mucous patches, and alopecia, there can be no difficulty. It is the later manifestations of the disease that offer difficulties in diagnosis, and especially the grouped papular lesions that occur on the palms in the form of scaly patches. In some cases a diagnosis is impossible. The most suggestive symptom of syphilis is the occurrence of the disease upon the palm of one hand alone. The patch will have a wavy outline; will be scaly, but not moist or crusted; will often show healthy ECZEMA 231 skin in the middle; and there are apt to be isolated, scaly, dark-red papules somewhere in the neighborhood. The finding of scars of old lesions, or some other evi- dence of syphilis, will aid us. In any doubtful case the Wassermann test should be made. Trichophytosis corporis when in disk-shaped patches that have not formed rings bears at times so close a resem- blance to eczema that it is difficult to make a diagnosis at once; but in a short time the centre of the disk will clear up and the annular ringworm patch will declare itself. Eczema does not have annular patches. Urticaria, when it has induced itching and has been scratched, looks like an eczema. We recognize it by the finding of the wheals, or the history of them, and by the isolated, scattered distribution of the excoriations and papules. Some cases of papular urticaria can only be diagnosed after prolonged observation. Treatment.— While not a few cases of eczema arise from purely local causes, and require only external treat- ment, in most cases the patient is not in good condition, and he needs treatment quite apart from his skin disease. It is well for us to begin the treatment of a case by regard- ing it as one of a sick man rather than a sick skin, and striving to remedy any disorder of the general health we may find. Fresh air, exercise, and attention to diet, here, as in general medicine, are" more to be relied on than drugs. Diet is of special importance. Piffard 1 found that 56 per cent, of his cases of eczema were carnivorous — that is, ate meat three times a day and but little bread and vegetables; 40 per cent, omnivorous, and but 4 per cent, herbivorous. Many of the patients eat too much and exercise too little. Many suffer from distress of stomach after eating certain articles. Some eat too little, and that of improper sort. The indications for treatment are therefore obvious. The greatest difficulty 1 Materia Medica and Therapeutics of the Skin. Wm. Wood & Co., New York, 1881. 232 DISEASES OF THE SKIN we have to contend with is the objection most people have to dieting of any sort. In an acute eczema of any considerable extent it is always best to put the patient on a restricted and simple diet, and of these, where milk is well borne, a milk diet is the best. Two or more quarts of milk may be taken during the day in divided doses, with dry toast or toasted crackers and the cereals, excepting oatmeal. A diet of rice, plain boiled, and milk answers admirably in some cases. After a few days a more liberal diet may be allowed, as in subacute and chronic eczema. In subacute and chronic eczema meat should be taken but once a day, and in the middle of the day when pos- sible. Breakfast and supper should be very simple, of crackers and milk, bread and milk, or some of the grains well cooked and eaten without sugar. There is a popular idea that oatmeal is injurious. It is best to forbid its use. Fish may be allowed, but not those with dark meat or oily. An occasional egg may be eaten in the morning, but not every day. No pastry, cake, or confectionery should be allowed. Apart from absolute simplicity, the patient's taste may be consulted, care being taken to avoid anything, that he knows will dis- agree with him. It is a good rule to tell the patient that he may eat what he likes, in reason, but not of more than three dishes at a meal. It is unlikely that he will then overeat. Those who eat too little for any reason should be directed to take that little more often dur- ing the day. Butter may be taken freely. Fried and warmed-up meats should be avoided in all cases. Fruits fully ripe or stewed can, as a rule, be liberally partaken of. All alcoholic drinks must be absolutely forbidden. Malt liquors are especially obnoxious to all irritable skins. Tea, coffee, and chocolate are best let alone. Coffee, one small cup, may be allowed for breakfast; or cocoa which is better, if made with a good deal of milk. Milk, if it does not constipate, may be allowed, but not with the regular meals if the patient is on a usual mixed ECZEMA 233 diet. Water should be drunk regularly, and it is not unlikely that much of the benefit derived from visiting foreign spas is due to the regular drinking of water. A good rule is for the patient to drink a glass of water before meals while dressing, a glass of water or other fluid at each meal, a glass of water about two hours after meals and before going to bed. If preferred, bottled table waters may be used. Vichy water may be substi- tuted for plain water once or twice a day. Tobacco is harmful in some cases. In many cases constipation may be the only irregularity detected. It is very important to relieve it by diet and exercise where possible. If we must needs give medicine, the tablet triturates of aloin, belladonna, and nux vomica; the pill of iron and aloes; the extract of cascara sagrada, with or without nux vomica, which may be administered in capsules or as compressed tablets to avoid the disa- greeable taste; Startin's mixture: M. ■Magnesii sulphatis, 5vj-giss 20-30 Ferri sulphatis, 3J 4 Ac. sulphur, dil., 5ij 8 Syr. pruni virgin., 5j 30 Aquae, ad giv ad 120 Sig. — A teaspoonful through a tube, after meals. or any other serviceable remedy may be given. The phosphate of sodium is an excellent laxative for children, a little of it being put into their milk, to which it gives a hardly noticeable taste. Exercise in the open air is as necessary for eczematous patients as for any other class. It should not be taken so as to cause overfatigue. Patients with eczema on the face and hands, or with a tendency thereto, should always protect the skin by a little powder, calamin lotion, or cold cream before going out into the cold, or storm of wind or rain. Though there is no specific for eczema, there are certain drugs that have acted favorably upon the disease in the hands of some observers. Arsenic had best be let alone. It is only of benefit in chronic scaling cases, and in only 234 DISEASES OF THE SKIN a few of them. The wine of antimony, 5 drops (0.33) three times a day, has been found useful. Turpentine, the spirits, is recommended by Crocker in obstinate cases. It is given in an emulsion with mucilage, three times a day, after meals, the dose being 10 minims (0.66) at first, and then if tolerated, increased by 5 minim doses up to 20 to 30 minims (1.33 to 2). While it is being taken not less than a quart of barley-water should be drunk, and the last dose should be taken not later than six o'clock in the evening. In acute eczema, if taken early, sharp catharsis will sometimes tend to lessen the severity of the attack by reducing the congestion of the skin. In chronic eczema, even without evident renal derangement, the acetate or citrate of potash in 15 grain (1) doses will prove useful. The itching may be so severe in some cases that even our local remedies may not allay it, and it may seem necessary to give some medicine to procure sleep. Never use opium. The bromides, chloral, or phenacetin may be given Hyde and Montgomery speak well of calcium chloride in full doses. Bulkley recommends tincture of gelsemium, of which 10 drops (0.66) are to be given, and repeated and increased every half-hour till relief is obtained, or constitu- tional symptoms of languor, tranquillity, dizziness, impair- ment of vision, and drooping of the lids, are produced. Quinin, in \ grain to 15 grain (0.03 to 1) doses, given at bedtime, is commended by some for the same purpose. Rest in bed is desirable in all severe cases of eczema whether they are acute or exacerbations of chronic forms. Local Treatment. — In all cases, whether due to purely local causes or a combination of these and some general cause, local treatment is of the greatest impor- tance. The books teem with prescriptions which have been found efficacious, and some of them contain so many ingredients that it is hard to determine with exactness to what the benefit is due. After all, the matter is very simple and, if the principles are mastered, little diffi- culty will be found in accomplishing the desired end. In acute cases, where we have heat and swelling, employ soothing ECZEMA 235 remedies; in subacute cases, where the swelling has subsided and where the papulation, vesiculation, pustulaiion, or exu- dation are more or less active, use astringent and protective remedies; in chronic cases, where we have thickening with scaling, stimulate; in all cases protect the shin from external irritation. It is better to learn how to use a few remedies and to know what to expect from them, than to try every new method that appears in the medical press. It is a good, broad rule that water should not be used on an eczematous skin, as it removes the newly formed epidermis and exposes the tender skin to the air. In all but chronic cases it should be used sparingly, and only to remove dirt, or crusts, or scales, and the skin should be at once covered with some protecting powder or ointment. If water is used, it should be either rain or boiled water, or water with a little soda, one drachm to the basinful, or with bran in it. Often it is better to clean the skin with an oily lotion or with cold cream than to use water. In acute eczema, lime-water, liquor plumbi subacetatis dil., lead-and-opium wash, or solutions of borax or bicarbonate of soda, 1 or 2 drachms (4 to 8) to the pint (500), may be sopped on three or four times a day, dusted over with corn-starch, compound stearate of zinc, dolomol, bismuth, lycopodium, kaolin, or French chalk, and covered with light, old linen or muslin. Veiel 1 recom- mends menthol 1 and amyli 99 as a dusting powder. All these will allay the itching; but if this is especially severe, the following may be used: ]$ — Camphori, 3ss 2 Zinci oxidi, 3ij 8 Amyli, 5iv ad 16 M. Startin recommends the following: I£ — Zinci oxidi, §ss 16 Pulv. calaminse praep., gr. xxx 5 Glycerini, gj 32 Liq. calcis, 3vij 28 M. 1 Munch, med. Woch., 1909. 236 DISEASES OF THE SKIN As soon as the early and most acute stage is passed — that is, in subacute eczema — a protecting and soothing ointment is to be used, and of these no one is safer than the standard benzoated oxide of zinc ointment, that can be obtained anywhere. If the case be one in which there is much discharge, as in pustular, vesicular, and weeping eczemas, Lassar's 'paste is better than the oxide of zinc ointment, as being a paste it allows the discharge to percolate through it. It is made as follows: 1$ — Zinci oxidi, Amyli, aa 5ij aa 8 Vaselini, gss 16 M. The addition of 10 to 15 grains (0.66 to 1) of salicylic acid to the ounce increases its antipruritic quality, but it is often too stimulating and must be used with caution. See that in it, as in all other ointments, there are no gritty particles left. Dreuw 1 advises the addition of 5 to 10 per cent, of sulphur loti and ichthyol to the ounce (32) of Lassar's paste. All ointments must be smooth, or they do harm rather than good. In using ointments in eczema they should be evenly spread upon cheese-cloth folded four times, or upon old washed muslin, in a layer as thick as the back of a table-knife blade, applied to the affected part and bound down snugly with a bandage. They should be changed twice a day, or more often if the discharge is profuse. Painting a limited moist patch of eczema with a solution of nitrate of silver, 3 to 10 grains (0.2 to 0.66) to the ounce, is often a most prompt method of curing the disease. Ointments are objectionable on account of their greasi- ness, and where possible it is pleasanter to use lotions. Of these, "Calamin Lotion" composed of — 33 M. -Calamin., gr. xx 1 Zinci oxid., 5J 4 Glycerin., 3iv 16 Aquae calcis, 3vj 24 Aqua? rosae, ad §iv ad 120 ECZEMA 237 To this may be added carbolic acid in 1 to 5 per cent, strength to relieve the itching. Peroxide of hydrogen sopped on exerts a beneficial effect on pustulation. In using lotions in cold weather, the patient should be advised to warm them to avoid chilling the skin. The diachylon ointment of Hebra will often prove beneficial, especially after the subsidence of acute symp- toms. It is best used diluted with ungt. aquas rosae in the proportion of 2 parts to 1. Most cases that we are called upon to treat are in or near to the subacute stage, as the acute stage soon passes off. It is always advisable to begin treatment not too boldly. If our protecting and astringent remedies do not cure the case after a fair trial, then we should add stimulants, and of these one of the most reliable is tar, adding it at first in the proportion of about 15 drops (1) of the oil of cade to the ounce (32) of ointment-base, such as oxide of zinc ointment. Ichthyol, thiol, and thigenol may be used in 10 per cent, solution in water during this stage. The last is a good antipruritic, and they all form protective varnishes on the skin. In chronic squamous eczema we need stimulation to whip up the circulation, to produce absorption of the infiltration of the skin, and to promote a return to health. Here tar is one of our most reliable remedies, and it can be used in various strengths and ways. We may use oil of juniper, oleum cadini, the oil of birch, oleum rusci, pix liquida, or coal tar. There is some doubt and diffi- culty about obtaining genuine oleum rusci, which is largely used by tanners in the preparation of Russia leather. The oil of cade is most used. Some prefer this ointment: \ — 01. cadini, Zinci oxidi, aa 3 ss-j aa 2-4 Uguenti. aquse rosae, ad gj ad 32 M. Or the cade may be added to the oxide of zinc ointment in the proportion of 1 drachm (1) to the ounce (32). Or 1$ — Picis liquidse, 5ij 64 Potass, causticse, Sj 32 A quae, ad 5v ad 160 238 DISEASES OF THE SKIN pix liquida may be substituted in about double the strength. Another most excellent way of using tar, and prefer- able to the latter, because not so liable to stain the clothing, is that proposed by Pick, namely, to make a strong tincture of tar, using 40 parts of pix liquida to 20 parts of alcohol; and to paint the part every night with 3 coats of this tincture, letting each coat dry on before another is applied. Then cover with oxide of zinc ointment, the ointment being changed morning and night. Bulkley in some cases recommends tar in what he names liquor picis alkalinus, which is made as follows: M. Dissolve the potash in the water and add slowly to the tar in a mortar with friction. This is to be used diluted twenty or more times with water, and followed by oxide of zinc ointment. In some very chronic, thickened eczemas the tar may be rubbed in pure. If the eczema is very extensive, the tar may be used in olive oil or cotton-seed oil and smeared over the body. In some cases the tar will give rise to systemic poisoning, the urine will become black, and the patient will suffer from headache, oppression, nausea, vomiting and diarrhea, and the pulse will become fre- quent. Of course, under these circumstances the tar must be stopped. Veiel 1 recommends in cases in which tar is not well borne: 1$ — Tumenol, gr. xv-xlv 1-3 Zinci oxidi, Talci, m Glycerin, Aqua? destil., aa p. e. ad S ii j 100 1 Munch, med. Woch., 1909. ECZEMA 239 Brocq, Jambon, and Dind 1 and Chajes 2 recommend coal tar from gas works, both in acute and chronic eczema. The affected parts are to be wiped off with moist com- presses, and the tar applied with a brush. After allowing it to dry for at least twenty minutes, it is to be covered over with talcum powder, or a light gauze bandage. If there are crusts these should be removed with water, the surface painted with a half to 1 per cent, solution of nitrate of silver, and the tar used the next day. If it causes too much dryness, or the parts are delicate, as the scrotum or flexures of joints, the tar should be mixed with equal parts of lard. The applications should be repeated every two to six days, according to the time it takes for the previous application to peel off. Sulphur is, next to tar, one of our best stimulating remedies in squamous eczema. It is not so reliable, as it is more uncertain in its effects. It finds its best use in circumscribed patches, and may be used in vaselin or simple ointment in the strength of 1 to 2 drachms (4 to 8) to the ounce (32). In some skins it produces a good deal of dermatitis. Green soap is often of the greatest service in chronic eczema. It is to be used in the following way: Take green soap; warm water; and oxide of zinc ointment spread on muslin or linen. Dip a piece of flannel in the soap and then in the water, and with it scrub the parts vigorously until all the scales are removed and the skin looks somewhat raw. Now wash off all the soap with plenty of water, dab the part dry with a soft towel, immediately cover with the ointment, and apply a bandage. The soap is to be used once a day and the ointment changed twice a day. Caustic potash, 15 grains to 1 drachm (1 to 4) to the ounce (32); or salicylic acid, 10 to 20 per cent., in other, may be used to reduce very much thickened 1 Annal. de dermat. et de syph., 1909, x, 1, 22, 170. 2 Dermat. Zeit., 1909, xvi, 570. 240 DISEASES OF THE SKIN patches. Nitrate of silver, 10 to 15 grains (0.66 to 1) to the ounce (32), may also be used; or chrysarobin, 10 per cent. Unguent, hydrarg. ammoniat. is of use in chronic eczema of limited area. In chronic, thickened eczema a 40 to 50 per cent, aqueous solution of ichthyol, well rubbed in once a day with a stencil or stiff paint-brush, acts admirably. Both thiol and thigenol are artificial ichthyol, possessing its good qualities without its odor, and may be used in the same way. Resorcin in from 2 to 5 per cent, strength is a good stimulating application. Veiel 1 recommends a 5 per cent, aqueous solution of tannic acid either with or without glycerin. For the reduction of infiltration and removing the scales in a chronic eczema nothing is better for a time than sheet rubber applied to the part and bound down with a roller bandage. The rubber should be removed once a day, sponged off with soda and water, and reapplied. The relief to the itching procured by this means is some- times surprising. As soon as the infiltration is reduced we should resort to our tar remedies for completion of the cure. Many attempts have been made to find a substitute for greasy or oily applications in the treatment of skin dis- eases. Thus we have the plaster mulls of Unna, in which a plaster mass is incorporated with the mulls. Many speak loudly in their praise. Collodion and traumaticin have been used, and answer well, the tar, salicylic acid, or what not, being dissolved or held in suspension. In this way chrysarobin may be used on limited patches of chronic eczema. Gelatin preparations are very valu- able, and applied either to a subacute or chronic patch, especially when there is no moisture, will allay the itch- ing and hasten the cure. Unna's gelatin paste sets at once. It is composed of: 1 Archiv. derm. et. syph., 1911, cvi, 277. ECZEMA 241 I*— Zinci oxidi, 30 Gelatini, 30 Glycerini, 39 Aquee, 10 M. It forms a hard mass that must be melted before it is used. The best way to use it is to put it in a small tin saucepan that fits into another pan that holds water, such as is used for sterilizing milk or cooking oatmeal gruel. This can be heated over a Bunsen burner or spirit lamp. When melted and still warm, it is to be painted over the part under treatment by means of a wide paint brush. Immediately over it is placed a layer of absorbent cotton, and over all a roller bandage. This dressing may be left on for two or three days. The gelatin may be used as an excipient. Gelanthum is an ointment base that does not contain lard or oil, and is a good excipient. Medicated soaps have their advocates. In the treatment of eczema we must not content our- selves by simply giving our patient an ointment, but we must instruct him in the way he should use it. As a rule, and where possible, ointments should not be smeared on the skin, but spread on old linen, muslin, or the like, and bound down with a bandage or with a ring of elastic webbing. In chronic patches it is well to rub in the tar or other ointment. Massage sometimes does good service in reducing infil- tration, the part being stroked upward, in the course of the circulation. Baths are not usually advisable in eczema, and are applicable only to chronic cases. Good results have been reported from some sulphur baths. Residence at the seaside generally proves bad for eczematous patients, but it may be a good thing for some run-down patients, the tonic effect of the sea air out-balancing the evil effects of the dampness. Soda, borax, or bran baths will prove grateful in some cases. Bulkley orders the following: 16 242 DISEASES OF THE SKIN 1$ — Potass, carbonat., giv 130 Sodii carbonat., giij 100 Boracis pulveris, gij 70 Add to thirty-gallon bath with half a pound of starch. M. Crocker recommends counter-irritation over the spine, the nape of the neck for eczema of the upper half of the body, and over the last dorsal and first lumbar vertebra for the lower half. Dry heat, a mustard leaf, or liquor epispasticus may be used. The spinal ice-bag sometimes accomplishes the same result. The x-rays and radium are at times useful in chronic thickened, obstinate patches of eczema. They should be used with caution by experts only, as they are capable of doing much harm. The high-frequency current, D'Arsonval, allays the itching and tends to dissipate the patches. It may be used two or three times a week, the tube being passed over the patch in contact with the skin, or at a little distance from it, according to the amount of stimu- lation desired, and the ordinary applications continued between times. The Kromayer lamp has been used with success. Prognosis. — We can give assurance of curing most cases of eczema as far as the attack with which the patient comes to us is concerned. We can give no positive assur- ance that the disease will not return. The cure of the attack requires patience, careful study of the case, and the intelligent use of remedies. But there are some cases that are exceedingly rebellious. We have to accept the fact that some people are "eczeinatous," and that they cannot be permanently cured unless they are regenerated. We should cure our cases as rapidly as possible, and not take refuge in the excuse of the incompetent man and tell the patient that it is dangerous to cure eczema. We must now consider Regional Eczema. Eczema Ani, as usually met with, is of the squamous, thickened variety with fissuring. It may also be moist. It usually extends up the whole internal fold. It gives rise to great pain in defecation and to much itching at ECZEMA 243 all times. The discharge from this form, as well as from eczema of the genitals, is frequently offensive, owing to the decomposition of the sebaceous secretions. Excessive use of tobacco predisposes to this variety of eczema, probably on account of the nervous irritation inducing itching, for the relief of which the patient scratches and produces the eczema. Other predisposing causes are all those that cause pruritus ani, which see. Treatment. — The first thing is to stop the use of to- bacco, a hard task, as the patient ofttimes is incredulous of its efficacy. Horseback-riding and much walking will sometimes have to be stopped, as they may aggravate the trouble. If hemorrhoids or fissures of the mucous membrane are present, as they quite frequently are, they must be cured in order to obtain a permanent cure of the eczema. The bowels must be kept easy by laxa- tives, so that one soft movement may be had each day. Liver derangements must be corrected to prevent portal congestion, and dieting will be of service. The nates must be separated by folds of lint, and the parts kept scrupulously clean, though water should be used as spar- ingly as possible. Applying 75 to 90 per cent, alcohol both cleanses and disinfects the parts, and allays the itching. It should be used two or three times a day. The itching may be relieved by sopping on hot water, dabbing the part dry, and making the chosen application. In acute and subacute cases the use of alcohol followed by compound stearate of zinc or other dusting powder; or oxide of zinc ointment, will prove curative. In more chronic cases tar or diachylon ointment may be used covered with a dusting powder. Usually the drier the parts can be kept and the less ointment is used the better. Painting a limited surface with salicylic acid, 10 to 15 grains (0.66 to 1) in an ounce (32) of flexible collodion is often followed by the happiest results. Painting with nitrate of silver, 10 to 15 (0.66 to 1) grains to the ounce (32), is sometimes advisable. Here, too, if there is much thickening, wearing rubber cloth for 244 DISEASES OF THE SKIN a few days or using a salicylic acid plaster will greatly hasten the cure. A well-applied T-bandage or bath- ing trunks is the best way of keeping the dressing in place. Thigenol, 50 per cent, solution in water, often acts well. It stops the itching, stimulates the skin, and, as it dries on the skin, does away with the use of ointments. Liquor carbonis detergens, 10 to 20 per cent, strength, sometimes does well. Eczema Aurium.— Eczema may affect both the ear itself and the inside of the auditory canal. When the ear is acutely affected, it is swollen at times so much as to stand out from the head. In acute eczema of the external auditory canal, which is secondary to that of the auricle, the swelling may be so great as to cause dulness if not loss of hearing. Treatment. — Of eczema of the outer part of the ear nothing special need be said excepting that the dressings must be exactly applied to all the little furrows of the ear, and a pledget of lint placed in the furrow behind the ear, thus separating it from the side of the head, so that in sleeping the two surfaces of skin do not come in contact. Painting this part of the ear with a solution of nitrate of silver, 10 grains (0.66) to the ounce (32), will sometimes aid greatly in converting a moist eczema into a squamous one. A cure will be hastened by having the ear covered with a linen bag made in the fashion of an ear-muff. Eczema of the auditory canal is some- times very annoying on account of an accumulation of scales, dulling the hearing. For this condition an oint- ment of tannin, 1 drachm (4) to the ounce (32), or a solution of nitrate of silver, 5 to 20 grains (0.33 to 1.33) to the ounce (32), may be applied throughly by means of absorbent cotton on a probe, the ear being properly lighted by means of a head-mirror, and the operator having the requisite skill. Otherwise the tannic acid ointment, or one of the oxide of zinc, or ammoniate of mercury, or the diachylon ointment may be applied on pledgets of lint rolled up to fit the orifice. It must ECZEMA 245 be remembered that ointments mixed with the exfoliated epidermis of the canal, and forming a paste with it, tend to stop up the canal and produce deafness. Such deaf- ness can be removed by syringing, or mopping with oiled cotton. The insufflation of boric acid will sometimes be better yet. The ear should not be syringed out often, and when it is necessary to do so a solution of borax or baking soda should be used. Eczema Barbae is scarcely ever confined to the bearded portion of the face, but it generally runs over onto the bordering skin, and is often but a part of eczema of the face. It has practically the same symptoms as has eczema capitis. It needs to be diagnosed from ring- worm and sycosis, which see. In treatment, shaving, or cutting the hair close, which is better, should be practised so that remedies may be closely applied. Plucking the hair from the pustules is to be recommended. Its further treatment is the same as that of eczema capitis. It is an obstinate form of eczema, prone to relapse. Eczema Capitis. — The scalp is very commonly the seat of eczema, either by itself or in connection with eczema elsewhere. It has received various names, such as crusta lactea; porrigo; melitagra; scalled head; milk crust; or vesicular or running scall. While any variety of eczema may occur on the scalp, the vesicular is very rarely seen, and the most common is the pustular and the final stage, the squamous. In the acute stage the scalp may be swollen and boggy, and moist, with the hair stuck together. We may find the scalp crusted with a yellowish serous crust, but more commonly there is a greenish or blackish purulent crust, while the scalp is swollen but little. In some cases of pustular eczema there will be discrete, rather large pustules scattered through the hair, besides moist and crusted patches. The hair is always matted together, and the odor from the scalp is unpleasant. If the crusts are removed, they will soon reform. In both the erythematous and the squamous forms the 246 DISEASES OF THE SKIN scalp is red and scaly. There is apt to be more or less thickening of the scalp, and in very severe cases the scalp may be cracked. Not infrequently there will be squamous patches in some places and moist and crusted patches in other places. With eczema of the scalp there is almost always eczema behind the ears. The cervical glands are very often swollen, especially in children, but they need give no anxiety, as they very rarely suppurate. In the chronic form there may be loss of hair, especially in children, when it is sometimes mechanically rubbed off from the occiput. It is never permanently lost. All forms are itchy, the pustular form least so. The patient may complain of a "drawn" feeling of the scalp. As in all inflammatory disease of the scalp, there is over- activity of the sebaceous glands, and the crusts will con- tain a certain amount of fat. In chronic cases there may be, on the other hand, a deficiency of fat. Pediculi are often found on the hair. The disease may affect the whole scalp or only a portion of it, and may run an acute or chronic course. Etiology. — The exciting causes of eczema capitis are all irritants to the scalp. Sometimes it is well-meant, but badly directed efforts at cleanliness, especially in children, who are more often subjects of this form of eczema than are adults. Combing with a fine-toothed comb, too vigorous use of soap and water, the use of a too stiff brush, are some of these. Pediculi are very often the cause — not the pediculi themselves, but the scratching to relieve the itching produced by them. An eczema of the occiput should always suggest their presence, and search then will generally reveal the pediculi, or their nits upon the hair. Sometimes remedies used to kill lice will set up an eczema, such as strong mercurial ointments. Too strong hair lotions and hair dyes not infrequently cause eczema. In most cases eczema of the scalp is but a part of a more or less general eczema and due to the same causes. ECZEMA 247 Diagnosis. — The disease must be differentiated from pityriasis capitis, ringworm, erysipelas, lupus erythemato- sus, a dermatitis, psoriasis, seborrhea, favus, pediculosis, and syphilis. See under these diseases. Treatment. — The treatment of eczema capitis is along the same lines as is that of the disease in general. On the scalp it is always best to use our remedies either in vaselin or oil, as preparations of lard make a disagreeable mess with the hair. Nor should a thick ointment ever be used, excepting perhaps in children before their hair is grown, or on bald heads. If there are crusts on the scalp, they must be removed before any local treatment is used. This may be done best by soaking them with sweet oil containing 1 or 2 per cent, of salicylic acid for twelve or twenty-four hours, and then washing them away with soap and water. Plenty of oil must be used, and it is well to tie the head up in a towel overnight. A woman's or half-grown girl's hair should never be cut in order to treat the scalp. In applying remedies to the scalp, after the acute stage, they should be rubbed in, and not merely smeared over it. In acute eczema equal parts of lime-water and sweet or almond oil, with or without 1 or 2 per cent, of salicylic acid, or carbolic acid, form a good application. Black ivash, or a weak ammoniate of mercury may be used. In subacute and chronic eczema of the scalp, tar, espe- cially the oil of cade, is our most reliable remedy. It must be remembered that it can be used much earlier on the scalp than elsewhere, and most cases will improve under it as soon as the acute stage is passed. It may be begun in the strength of 20 drops (1.33) to the ounce (32) of oil, and increased to 1 or 2 drachms (4 to 8) to the ounce (32). Many people object to the odor of the tar. We can substitute for it: Or, 1$ — Hydrarg. ammon., Vaselini, gr. xx 1 1 33 ad gj ad 32 1 M. R — Ac. salicylici, 01. olivse, gr. xx-xxx 1.33-2 ad 5J ad 32 M. 248 DISEASES OF THE SKIN The oil of cajuput in 5 to 10 per cent, strength may be tried. Neither of these is as good as tar. If the disease is in a chronic condition, shampooing with green soap or its tincture, followed by some oily, not very stimulating application, will prove curative. In this connection it is sometimes best to exhibit the tar in an alcoholic solution. Resorcin in 3 to 10 per cent, strength may be used cautiously in this way. In very obstinate cases precipitated sulphur 10 to 40 grains (0.66 to 2.66) to the ounce (32) of olive oil or albolene at times is excellent. It will do either good or harm. If the scalp is cracked and thickened, great and prompt amelioration will be secured by having the patient wear a close-fitting cap of rubber. Eczema Crurum. — Eczema of the legs acquires its peculiarities from the fact that the circulation of the parts is less active than it is in the upper portions of the body, on account of the action of gravity upon the returning venous blood. Any form of eczema may be present. Varicose veins, either superficial or deep, pre- dispose to it; and an eczema arising from such a cause is spoken of as varicose eczema. It is attended with swelling and often great oedema. It is located principally on the lower part of the leg, and is often complicated by ulceration. Pigmentation of more or less dark-brown color follows or accompanies it, if of any chronicity, and occasionally purpuric spots will be scattered about the chronic patch. As to treatment, nothing special need be said except that it is always advisable to have the legs bandaged snugly from the toes to the knee, and that the best result will be attained when the bandaging is done by the doctor or a trained nurse. Eczema Genitalium often causes a great deal of discom- fort on account of the excessive itching that accompanies it. It affects the scrotum most commonly, which in some cases will be greatly thickened and feel like leather. The skin of the penis also suffers at times as well as the glans. In women, both the lesser and the greater lips of the vulva, as well as the entrance to the vagina, may ECZEMA 249 be affected, and show excoriations and thickening. All forms of eczema may be encountered in the genital region. In chronic eczema of the penis the organ be- comes greatly enlarged both laterally and longitudinally, on account of the thickening of the skin. The disease may be confined to the genitals, or extend to the thighs or the anal region. The presence of diabetes should always be suspected in a case of this kind, and the urine should be examined for sugar. Leucorrhea is a common cause of the disease in women. Treatment. — In the treatment of eczema of the scrotum, apart from that appropriate to general con- ditions and especially to diabetes, it is essential that one should wear a well-fitting suspensory bandage, inside of which the dressing may be placed. The itching may be greatly relieved in all forms by directing the patient to sit over a vessel containing hot water and sop the water up on the parts. The application of 75 to 90 per cent, alcohol will allay the itching, and keep the parts disinfected. It may sting for a few minutes. In sub- acute eczema the skin should be mopped dry, the oxide of zinc ointment, diachylon ointment, or Lassar's paste imme- diately applied, and the suspensory bandage adjusted. Carbolic acid, 1 or 2 drachms (4 to 8) to the ounce (32) of glycerin and water, may also be used, lightly dabbed on, for the purpose of allaying the itching. It should be used twice a day. For chronic, thickened eczema, wearing sheet rubber inside of the suspensory bandage will give positive and immediate relief, and greatly reduce the thickening. After a few days it is well to follow it with a tar or resorcin ointment. The use of the tincture of tar, as spoken of under chronic eczema (page 237), is often most serviceable. In some cases nothing will do so well as the application of the nitrate of silver solution, already given. The spirit of nitrous ether may be used as an excipient of this. Hardaway speaks highly of rubbing the scrotum with a solution of salicylic acid in alcohol, 1 drachm (4) to the ounce (32), and following this with a boric acid or diachylon ointment. 250 DISEASES OF THE SKIN Women should use a T-bandage instead of a suspen- sory. Otherwise the treatment is the same. In them the nitrate of silver treatment at times does remarkably well. Eczema Intertrigo occurs wherever folds of skin come in contact. It usually follows a simple intertrigo, dif- fering from it in having a discharge that stiffens linen, and in its pruritus. In its treatment the parts should be kept separated and as dry as possible by means of a dusting powder, or by placing a piece of old linen or cheese-cloth between the apposed folds of skin. For a dusting powder we may use corn starch either alone or with bismuth or zinc oxide; lycopodium is also an excellent powder; but the best powder of all is the com- pound stearate of zinc. Before any application is made it is best to wipe the skin off with 75 to 90 per cent, alcohol, or, if it smarts too much, a saturated solution of boric acid. As a rule, these cases do best without ointments. This does not apply to eczema intertrigo of the crotch. Here it is well to cover the parts with a greasy application, so as to protect them from the action of the urine. A dilute diachylon ointment often answers admirably. In chronic conditions the same stimulants should be used as in any other chronic eczema. Eczema Labiorum is usually due to nasal catarrh, and can be cured only when the cause is removed. Eczema may occur about the mouth in an orbicular manner. Many people suffer from chapped lips, especially in winter. This is an eczema of the vermilion border. For this little can be done except to caution the patient against moistening the lips. Greasing the lips every night with camphor-ice or the like keeps them in good condition. Glycerin agrees well with some skins, and is harmful to others. The lip may be painted with com- pound tincture of benzoin. Eucerin is a most efficacious application. Eczema Mammarum et Mammillarum. — One of the most annoying accidents to befall a nursing woman is eczema of the nipples. They become excoriated and ECZEMA 251 fissured, the cracks sometimes extending to the base of the nipple. At times a drop of pus can be squeezed from the bottom of the crack. They are exquisitely sensitive, and every time the baby nurses the woman suffers agony. The moisture of the child's mouth and the decomposing milk left on the nipple aggravate the trouble. Mastitis may complicate matters. In the intervals of nursing the nipple scabs over. Either one or both nipples may be affected. The disease may extend onto the breasts, or the breasts may be affected independently of the nipples. Women with pendulous and heavy breasts frequently suffer with a moist eczema in the sulcus beneath them. Apart from this, nothing special need be said about eczema of the breasts. There is one disease of the breasts called Paget's disease of the nipple, which at first very closely resembles eczema. (See Paget's Disease, for diagnosis.) Treatment. — It is often possible to cure eczema of the nipples even while the child nurses. Sometimes it will be necesary to wean the child. Women during the latter months of pregnancy should handle their nipples every day and bathe them with alcohol, to which may be added 20 or 30 grains (1.33 to 2) of borax to the ounce (32) . This will do much to prevent further trouble. The suckling having begun, the nipples should be carefully washed off and dried with a soft handkerchief after each nursing, and dressed with oxide of zinc or diachylon oint- ment should eczema show itself. Of course, the ointment should be removed before the infant is put to the breast, and this should be done with as little water and as much gentleness as possible. If there are cracks, the child should nurse through a rubber nipple, and when it lets go the nipple should be dried and painted with compound tincture of benzoin, or the solution of nitrate of silver already spoken of. It is also advised to touch the cracks with the nitrate of silver stick. This is very painful, and of little use as long as the infiltration of the nipple that causes them continues. The nipples may be washed with a borax solution and covered with an ointment of 252 DISEASES OF THE SKIN boric acid. It is always advisable to use nothing that is poisonous in the dressings. Hardaway recommends the following for eczema under the breasts: I*— Thymol., gr. j 065 Pulv. zinci oleat., gj 32| M. Eczema Manuum. — Eczema of the hands has been called "washerwoman's itch/' "grocer's itch," "brick- layer's itch," and various other itches. It is in many cases a trade eczema, caused by strong alkaline soaps, or contact with sugar, mortar, or other irritant, .such as bichloride solutions, formalin, and the like, and might better be considered as a dermatitis. It may arise independently of any of these trade causes, or it may be part of a general eczema. The acute forms, as they occur upon the back of the hands, do not differ from the same on other parts of the body, and the same may be said of the chronic forms. The palms are seldom prim- arily affected, but secondarily to eczema of the wrists or fingers. The epidermis of the palms, as well as that of the palmar surfaces of the fingers, is thicker than that of the other parts of the body, excepting the soles 'of the feet, and so the vesicles do not rupture readily, but are seen like little, more or less translucent grains under the skin. When they rupture, the skin is left more or less ragged and worm-eaten. The skin over all the joints is liable to crack and form painful fissures. Chronic eczema of the palms prevents free movement of them on account of the thickening and the painful cracking. The skin is reddened and covered with large adherent scales. Itching is intense at times. The whole palm may be affected, or the disease may form limited areas, as upon the centre of the palm, over the thenar eminence, and upon the finger ends. This form of eczema is often difficult of diagnosis from the squamous syphilid. The occurrence of the lesions upon one hand alone should arouse suspicion of syphilis, especially if little or no itching is complained of. ECZEMA 253 Treatment. — Eczema of the palms is one of the most obstinate of eczemas to treat when of chronic form; and requires active stimulation by means of tar; salicylic acid; the soap and salve treatment; rubbing in 5 to 10 per cent, of the oleate of mercury; or painting with caustic potash. Veiel 1 recommends the use of a 1 to 6 per cent, ointment of salicylate of mercury in simple ointment, a bandage being worn at night. After the eczema is cured he advises using twice a day after washing and while the hands are wet, Potassa 30 grains (2), Alcohol, aquse rosse, and glycerin aa p.e. ad § iij (100). The constant wearing of rubber gloves is excellent for the purpose of softening the skin and preparing it for other remedies. It is best to use the canvas-lined gloves, turn them inside out, and wear the rubber next the skin. The hands must be kept out of water. Where this cannot be done, great care must be used in drying them. It is well to have the patient dry on two towels or before the fire, and then either to thrust the hands in a box of corn starch powder or flour, or preferably to apply the proper dressings. * Eczema of the back of the hands is treated the same as an eczema elsewhere. Unna teaches that eczema of the hands and fingers is always secondary to eczema sebor- rhoicum capitis. He recommends in the disease, as it affects cooks, housemaids, and the like, that the hands, on going to bed, should be washed with green soap and water when the eczema is of squamous form, and with a weaker soap when it is moist. Then a paste of Oxide of zinc, 40 parts. Chalk, Lead-water, Linseed oil, aa, 20 parts. or one of Oxide of zinc, Sulphur, Chalk, Linseed oil, Lime-water, aa 20 parts. i Arch. Derm. u. Syph., 1912, cxiii, 1181. 254 DISEASES OF THE SKIN is to be well rubbed in. Before using the paste, when the eczema is moist, the patch should be powdered with flour. The paste is covered with the thinnest rubber tissue, such as is used for bouquet handles. This will stick well. Cotton gloves can be worn at night. In the morning the dressing is not to be removed until the roughest part of the work is done. Then it is to be washed off, and a little of the paste applied until time for the evening dressing. In eczema of the hands of masons, washerwomen, and the like, an endeavor should be made to thicken the corneous layer of the skin by dressing them at night with a paste of Resorcin, Ungt. zinci oxid., aa 10 parts. Terrae silicse, 2 parts. and applying oil or vaselin over it. In the morning the hands are not to be washed, but anointed with some oil. After a time the corneous layer thickens and the old skin falls off. Eczema of the hands due to occupation becomes rapidly well when the patient no longer follows his trade. It is sometimes necessary to seek some other occupation. Hospital nurses are often much troubled in this way, and have to give up nursing. Eczema Narium is often, if not always, associated with a chronic rhinitis. It is very obstinate. Crusts form on the inside of the nose, are picked off, re-form, and after a time ulcers may result from the constant irritation. Sometimes in adults the disease locates itself about the hair follicles, and is very annoying. It is a not uncommon point of departure for recurrent attacks of facial erysipelas. If long continued, it gives rise to a thickening of the upper lip. Furuncles sometimes complicate matters. In the treatment of these cases the first attention must be given to the cure of the rhinitis. Then all crusts ECZEMA 255 must be removed by soaking with oil. For the eczema we may use: 1$ — Glycerol, plumbi subacetat., Ungt. aquae rosae, aa p. e. M. as recommended by Hardaway. Herzog 1 recommends the yellow oxide of mercury ointment, or equal parts of ungt. plumbi and vaselin, spread on lint and accurately applied to the diseased part. Unna rolls his zinc and red precipitate ointment muslin into a pledget and introduces it into the nose. In obstinate cases about the hairs epilation by electrolysis may have to be performed. Eczema palpebrarum is usually of an erythematous character, and occurs as part of the same disease else- where. Eczema of the cilia, also called blepharitis ciliaris, is always pustular. The edges of the lids are swollen, rounded, and more or less thickly strewed with pustules or crusts. The lids stick together on waking in the morning. In the squamous form the edges of the lids are merely red and scaly. It is almost always sym- metrical, occurs usually in strumous subjects, and is due to conjunctivitis. Treatment. — The lids should be anointed before going to sleep, in order to prevent their sticking to- gether. We have always found the following ointment, as given by Prof. D. Webster, of the New York Poly- clinic, most excellent: R; — Ac. salicylici, gr. x Ungt. hydrarg. oxid. rubri, 3j 4 Ungt. aquae rosae, 3vj ad 24 66 M. An ointment composed of R; — Hydrarg. oxid. flav., gr. ij-viij 0113-5 Vaselini, §j ad 32 j M. is recommended by Hardaway. Resorcin, gr. iij in cold cream, oiiss, is editorially commended in the Monatshefte » Arch. f. Kinderheilkunde, 1887, p. 211, 256 DISEASES OF THE SKIN f. prakt. Dermal., 1888, vii., 1057. Whatever is used, we must be sure that any substance entering into it is in an impalpable powder, so as to avoid the possibility of getting anything gritty into the eye. Epilation may be necessary in some cases. Solutions of bichloride of mercury (0.05 to 500) are commended, both for the con- junctivitis and the eczema dependent upon it. In any event, the conjunctivitis must be treated. Eczema Pedum. — Eczema of the soles of the feet, though not so common as that of the palms, presents the same symptoms and calls for the same treatment. The greatest difficulty will be encountered in dressing the toes properly. For this the ointment should be spread upon a long and narrow strip of lint, the centre of the strip placed against the big toe, and the strip wound in and out between the toes. A piece of salve-muslin may be substituted for this with advantage. A piece of rubber sheeting cut to fit the sole and bound down with a bandage takes the place of the rubber glove. Eczema Unguium. -^-Eczema may affect the nail fold alone, and the mail may be scarcely diseased; or the matrix and bed may be diseased, when the nail will lose its luster, and become round, uneven, striated, and atrophied. Only one nail may be diseased, or all of them may be. The nail may be depressed in the centre and turned up at the end, with an accumulation of scales under its free border. Usually eczema of the nails occurs as a part of a general eczema, but it may occur as an independent disease. The fleshy parts about the nails usually present signs of inflammation, and often of an evident eczema. It is best treated by means of cots made of rubber. It must be remembered that an ointment can never be used when rubber is, as the grease rots it. If the time has come for an ointment, linen or leather cots must be substituted for the rubber ones. The ointment to be used will depend upon the condition of the skin about the nails. Strapping the nails with a 10 per cent, salicylic acid plaster is often most satisfactory. ECZEMA INFANTILE 257 Universal Eczema is uncommon, and when it does occur it is usually of the erythematous or squamous variety, with a tendency to cracking in the skin creases of the joints, exudation, scaling, and itching. These symptoms will serve to distinguish it from dermatitis exfoliativa, to which it bears a strong resemblance. Constitutional dis- turbances, such as fever and chills, loss of appetite, and digestive disorders, are not uncommon in these truly pitiable cases. Furunculosis is apt to complicate matters. The patients are slow in recovering, and are apt to be a good deal pulled down by the disease. Treatment.— These patients should be put to bed and the underlying cause searched for, and if possible removed. They are best treated locally by lotions, oils, or vaselin. The ordinary Carron oil, equal parts of linseed oil and lime-water; cotton-seed oil with carbolic acid, 1 part of acid to 60 of oil; or simply smearing the body with vaselin and powdering on corn starch, will each relieve. Salicylic acid in oil, 1 in 30, will also allay the discomfort, but it sometimes causes symptoms of constitutional poisoning, and has to be stopped. Alkaline or bran baths, warm, followed by one of the above, after tapping the skin gently dry, will also relieve, but the bath should not be used more than once a day. Its temperature should be about 90° F. ; it should last ten to fifteen minutes. Bulkley recommends anointing the skin, before drying it, with — R— Acid, carbolic! , gr. xx-5ij 1—6 1 Glycerit. amyli, ad §iv ad 100 1 M. applying it freely. The best way of drying the skin is to envelop the patient in a warm sheet, and pat the skin dry. As the intensity of the eczema lessens, the frequency of the baths must be reduced. The disease will gradually become localized in patches. Eczema Infantile presents certain peculiarities that war- rant its being considered as a special variety of eczema. It is very prone to be of the pustular form, following the 17 258 DISEASES OF THE SKIN rule that in delicate or debilitated subjects an eruption upon the skin is apt to be pustular. While in adults eczema of the face is usually erythematous, in infants it is nearly always pustular. In them it is quite common, if not the rule, to have several regions affected at once, such as the scalp, the face, and the region of the crotch. In them, also, eczema madidans often occurs in these regions. While in adults that form of eczema is most frequently seen upon the legs; in infants it is quite excep- tional there. Eczema of the scalp in infants presents itself as a thick crust formed of purulent matter, epithe- lial debris and sebaceous matter. This is called a milk crust." When the crust is raised the scalp will be found to be thickened, swollen, boggy, and moist, with a puru- lent secretion. The whole scalp may be affected, or only the vertex. With it there will nearly always be a moist surface behind the ears, even though the face may be comparatively or absolutely free. The lymphatic glands will be swollen, but they seldom suppurate. When the face is affected it will sometimes be studded over with holes, superficial ulcerations, which, however, never leave scars. This appearance is seen very rarely in adults. It is often striking to note that the skin about the mouth and nose, and below the eyes, is in perfect health, though pale, while all the rest of the face may be involved in the moist intense inflammation. The creases of the neck, the flexures of the joints, and the region of the genitals usually show an erythem- atous or a moist intertriginous eczema. At times the whole body will be affected with a general, but very rarely with a universal eczema. While the pustular and intertriginous forms of eczema are the most common, we may have all forms present at one time. The papular form is also frequently met with alone. Itching is usually severe, keeping the little patient awake at night, and the tearing made by the nails to relieve the itching gives rise to immense excoriations, especially of the face. Unrelieved, the little patients sometimes become pitiable ECZEMA INFANTILE 259 objects on account of loss of sleep and constant nervous excitement. Etiology. — There are several causes tending to pro- duce eczema in infants. Their skin is vulnerable to all irritants. More than one-third of the cases of eczema occurring before the fifth year of life occur in the first year. Add to the vulnerability of the skin the over- zealous care as to cleanliness commonly bestowed upon it for a few months after birth, and we have a good explanation for its frequence. Bad diet has much to do with its production. The vast majority of the little sufferers are nursed too often if at the breast, "every time they cry" being the rule; or fed too frequently or improperly, " everything that is going" being again the rule. Inattention to the condition of the diapers is another active cause of eczema about the genitals. Teething is, without doubt, an exciting cause, a fresh outbreak of eczema marking the eruption of each tooth. Want of self-control in scratching is an aggravating circumstance. The frequent disturbances of digestion so common at this period of life predispose the infant's skin to eczema with rather more force than do the same troubles in adults. Fat babies are frequent subjects of eczema, especially of the intertriginous variety. Treatment. — The treatment of eczema infantile is along the same lines as that of eczema in adults. Special stress must be laid upon the feeding of infants, and strict rules must be laid down for the parent's guidance. The condition of the breast milk must be inquired into, as it is often of too poor quality to nourish the child. Women will sometimes nurse their children far too long, with the idea of preventing conception. If the child is bottle-fed, the quality of the milk must be investigated, and it, as well as the amount, regulated. It is very necessary to insist upon the. child wearing a mask in eczema of the face and scalp. This may be made of light flannel or muslin, a piece of the stuff being cut somewhat after the shape of the face, 260 DISEASES OF THE SKIN with holes made for the nose, eyes, and mouth. A skull-cap is to be made, on to which the mask may be sewed, or pinned with safety pins. The ointment is to be spread upon lint, cheese cloth, or washed muslin— a strip for the forehead, one for the chin, and one for each cheek. These are to be laid upon the face, and then the mask put over them, fastened to the skull-cap, and tied behind the head by two strings from its lower corners. It is astonishing what relief this affords to the itching, and how much more rapidly the case improves under it. As it is impracticable to use the mask in public practice, Unna's paste made of 1$ — Oxide of zinc, 40 parts. Chalk, Lead-water, Linseed oil, aa 20 parts. M. may be used as a substitute. In making, the first two ingredients are to be mixed together, and then the last two, and then the two parts thus formed. It is to be spread on the part, and cannot be readily rubbed off, though it can be easily removed with a little oil. The itching of the skin can be relieved by appropriate dressings, and it is never necessary to put the child in a home-made strait-jacket, by slipping it into a pillow- case and sewing up the same between the arms and body. This is an extreme measure. In eczema of the crotch great care must be given to changing the napkins as soon as soiled. Fresh, clean ones must be put on, not those that have been dried without being washed. Dr. George H. Fox has called attention to a tight prepuce as a cause of eczema in male children. The urine dribbles away, so that a few drops wet the clean diapers, and thus keep up the trouble. In such cases judicious stretching of the prepuce may obviate the necessity for circumcision. Water must be kept from the skin in all acute cases. Internally, calomel in tablet triturates, T V grain, three times a day for three days, will give good results in many cases, especially in fat babies, even though the ECZEMA MARGINATUM 261 bowels are not constipated. After an interval of three days the calomel is to be given again. Care must be taken not to produce too frequent and loose movements of the bowels. The rhubarb and soda mixture is excel- lent in many cases. Other medication will be necessary according to the nature of the case. Cod-liver oil w r ill often cure a case which has been very obstinate. The local treatment is, according to the rules, already given under Eczema. Eczema Marginatum. — Until 1911 this disease was called tinea cruris and was thought by most authorities to be due to ringworm. By others it was considered as an ordinary eczema occurring in the skin folds, espe- cially about the crotch, which was peculiar in having a sharp margin. Sabouraud in 1907 found that it was caused by a special form of fungus that he called epi- dermophyton inguinale. S. Nicolau 1 has given the best account of the disease. Symptoms. — Its special site is the inguino-cruro- scrotal fold. It begins always at the bottom of the fold from where it spreads upward, and in long standing cases backward into the anal fold, and upwards onto the pubes. It takes the form of red or brownish marginated circles covered with delicate scales, which are sometimes so fine as to be hardly appreciable to the eye. In fully developed cases the patch will end on the inside of the thigh and the scrotum with a sharp festooned margin. In some cases the patch is eczematous in appearance. It occurs in all the skin folds, and at times there will be ring-shaped patches on other parts of the body. One peculiarity of the disease is that it occurs between the toes and fingers, especially the former. In these locations it has been thought to be eczema. It affects principally, according to Sabouraud, 2 the interdigital fold of the fourth and fifth toes. At the bottom of the fold there is a collection of white, cheesy substance which 1 Annal. derm, et syph., 1913, iv, 65. 2 Ibid., 1910, i, 289. 262 DISEASES OF THE SKIN is readily scraped away. Under it the skin is white, shiny, moist, and macerated, and very much thickened, so that it may be scraped off in large patches. About the fold are a few isolated vesicles that dry up and are re- placed by new ones. The plantar surface of the foot is not affected, but the disease may spread on the back Fig. 27 Eczema marginatum. 1 of the foot as a sharply defined dry eczematous patch. The disease itches, and causes pain on walking. The hands are rarely affected and then the appearances are those of eczema or dyshydrosis. The affection of the feet and hands is secondary to the disease in the inguinal 1 Courtesy of Dr. H. Fox. ECZEMATOID DERMATITIS 263 fold with rare exceptions. Untreated the disease may last for years. Etiology. — It occurs more often in males than in females, and though it is doubtless contagious, the source can be traced but rarely. Cases have been reported in husbands and wives and their children. Most patients are between fifteen and forty years of age. A case has been reported in a child, and a few cases in persons' over fifty years old. Most persons are in comfortable circum- stances and cleanly. The epidermophyton inguinale is the cause of the disease. It presents innumerable myce- lial threads about 2/jl in diameter, sometimes running at right angles, and sometimes sinuous. Usually they are in the form of ribbons composed of cells of equal size. These may be of unequal size, ovoid or rounded. They have double contours. Treatment. — An ointment of 1 per cent, chrysarobin, a lotion containing 1 drachm (4) of chrysarobin to 1 ounce (32) of equal parts of chloroform, alcohol, and acetone; or 15 grains (1) of salicylic acid in vaselin 3ij (8) an d cocoanut oil to make § j (32) will cure the disease. When it occurs between the fingers and toes, the macerated skin should be scraped away, and the part treated either with tincture of iodin diluted one-tenth, or a weak solution of nitrate of silver, or a chrysarobin ointment of 1 per cent., which in obstinate cases may be increased to 3 per cent, combined with 3 per cent, of salicylic acid. If the chrysarobin is not well borne a strong mercurial ointment may be used. Eczema Seborrhoicum. — See Dermatitis seborrhoica. Eczematoid Dermatitis.— This name was given by M. F. Engman 1 to. an eczimatoid inflammation of the skin secondary to some injury, such as a scratch, an insect bite, an ulceration, and the like. It begins about the point of injury as an eruption of vesicles or pustules, 1 Amer. Med. : 1902, iv, 769. 264 DISEASES OF THE SKIN and forms a red, scaly, weeping, or crusted lesion. These may coalesce or independently spread to form patches that resemble eczema rubrum. In bad cases the dis- ease spreads rapidly as a freely discharging surface with sharply defined, irregular border. This is undermined with seropurulent discharge, becomes denuded of epi- dermis, and in a few days or weeks more or less large areas are converted into raw surfaces covered with a sticky, purulent discharge which oozes from many points and dries into crusts. The patch may heal to break down again. The disease itches but little. The neighboring lymphatic glands may be enlarged. The disease is inoculable. It may run a chronic course for years. So-called varicose eczema is usually of this type of disease. It is a staphylococcic infection most commonly, though other forms of bacteria are found in some cases. Engman has found that a sulphur paste combined with cleanliness and bandaging is curative. Elephantiasis. — Synonyms: Barbadoes leg; Cochin- China leg; Glandular disease of Barbadoes; Sarcocele of the Egyptians: Tropical big-leg; Bucnemia tropica; Morbus elephas; Pachydermia; Spargosis; Phlegmasia Malabarica; Hernia carnosa; Elephantiasis Indica seu Arabum. A chronic endemic or sporadic disease of the skin, characterized by hyperplasia of the skin and subcutane- ous tissues, due to a stoppage of the lymphatic or venous circulation, especially the former, affecting chiefly the lower extremities, and marked by enormous enlargement of the affected part. Symptoms. — In certain tropical regions, such as India, China, Japan, Egypt, Arabia, the West Indies, and South America, the disease is endemic; but sporadic cases occur in all parts of the world. In the endemic variety there is usually what is called "elephantoid fever," with lumbar pain, nausea, and vomiting, followed by sweating. The ELEPHANTIASIS 265 fever is of high grade, and bears a striking resemblance to malarial pyrexia. In sporadic cases the characteristic fever is wanting, though usually there is some constitu- tional disturbance preceding the local symptoms. In other instances the fever is altogether wanting. Fig. 28 Elephantiasis. (After Taylor.) Locally the affected part at first is attacked apparently by erysipelas, or a deep dermatitis, phlebitis, or lymphan- gitis; it becomes greatly reddened and swollen; and there may or may not be a clear or milky discharge from the skin, and an eruption of vesicles. After a time these symptoms subside, but the part does not return to its normal size, and there is some pitting of the skin on 266 DISEASES OF THE SKIN pressure. After a few weeks or months there is a repe- tition of t,he attack, and the part is left still more enlarged. And so the case progresses with varying periods of qui- escence, and recurrent erysipelatous attacks, each one leaving the part more thickened than before, until it attains enormous proportions. The normal contour of the part is lost; the folds of the skin are obliterated, the surface is smooth and shiny, and the color grows darker, even blackish. Now no impression can be made upon the swelling by pressure of the finger. Ulcerations are apt to occur, and some cases show varicose lymphatics which are tender and painful, and may rupture of them- selves or by accident and discharge a clear or milky chylous, coagulable fluid. The escape of this fluid saps the patient's strength. The parts most frequently affected are the legs, usually one, but may be both; and next to them, the male or female genitals. It occurs also on the arms, face, ears, female breast, and tongue. When the leg is the seat of the disease it becomes so large as to interfere with locomo- tion and compels the sufferer to take to his bed. The surface of the limb may be smooth; or uneven on account of the varicose lymphatics; or warty on account of enlargement of the papilla?. The foot and leg may melt into each other, as it were, all trace of the ankle being- lost. Wherever there are two surfaces in contact there is apt to be a decomposition of the sweat, sebaceous matter, and epithelium, giving rise to a foul odor, like, but worse than, that of an ordinary intertrigo. The lymphatic glands in the groin are enlarged. Eczema may develop with its attendant itching. The appearance of this elephantine leg gave the name to the disease. When the scrotum is the affected part, vomiting often occurs in the febrile attacks, as well as pain in the groins, along the spermatic cord, and in the testicles. Hydrocele may develop, and the abdominal rings, overstretched by the swollen cords, may give opportunity to the formation of hernia upon the subsidence of the acute symptoms. ELEPHANTIASIS 267 The scrotum may become so large as to reach the ground when the patient is standing, and one case has been reported in which it weighed one hundred and ten pounds. One form of the affection is called "lymph scrotum or nevoid elephantiasis," on account of the marked dilata- tion of the lymphatics. There are all degrees of thickening of the skin and subcutaneous tissues, but the recurrent attacks of erysipe- las and the progressive enlargement are characteristic of all. The bones may become enlarged. This is a very rare affection, which is called "acromegaly." In the Lancet of June 11, 1887, several cases are reported, one of which was on exhibition in a travelling show as the "Elephant man." In his case the head attained massive proportions. Etiology. — The disease occurs in both sexes and in all ages, but is most common in men of middle life and in the dark-skinned races. Moncorvo 1 reports a case in an infant four months old, and speaks of a case in one fifteen days old. He believes that it may develop in utero. Floras 2 reports a case beginning at birth and remaining stationary for fifteen years, when it assumed the typical course of the disease. It is particularly prevalent in damp, malarious parts of the seacoast, and the mosquito is supposed to be the carrier of the infection. It is not supposed to be hereditary, though in countries in which it is endemic several members of the same family may be affected by it. Leprosy and elephantiasis have been accidentally associated. Exposure to cold, phlegmasia dolens, cellulitis, ulcers, lupus, repeated attacks of eczema or erysipelas, posture, as the hanging down of a limb on account of rheumatism, pressure upon veins or lym- phatics by tumors, may give rise to the disease. In fact, any disease of the skin that is attended by repeated inflammatory outbreaks favors the occurrence of ele- phantiasis. The filaria sanguinis is said to be the cause 1 Rev. mens, des 'Mai. de l'Enfance, 1886, iv, 101. 2 Arch. f. klin. Chirurgie, 1888, xxxvii, 598. 268 DISEASES OF THE SKIN of the endemic form of the disease. It is not, found in every case, and is rarely encountered in sporadic cases. Pathology. — Anything that will occlude the lym- phatic or venous channels may cause the disease. In endemic cases it is the adult filaria that do this. In sporadic cases the several etiological factors play the same part. However caused, the result is an enormous hypertrophy of the subcutaneous tissue from increase of fibrous tissue in various stages of development. The corium is also increased in thickness, and there is pro- liferation of the epidermis, enlargement of bloodvessels, lymphatics, and nerves. In advanced cases the muscles undergo fibro-fatty changes, and the bones become enlarged (Crocker). Diagnosis. — The recognition of elephantiasis is easy, as its symptoms are pronounced. In some cases of syphilis, however, an elephantiasic thickening of the foot or feet takes place that may be thought to be elephan- tiasis. In it, however, there is an absence of the history of repeated inflammatory attacks, the outline of the thickening is rather well defined, and old cicatrices or ulcers characteristic of syphilis will commonly be found. The condition is one of gummatous infiltration with chronic edema, consequent upon obstruction of the lymphatics. Treatment. — The best thing for a patient with endemic elephantiasis to do is to go to a more health- ful climate. The treatment of the patient during the exacerbations is purely symptomatic, with rest in bed, fomentations, quinin, iron, and the like. Various measures for the cure of the disease have been proposed, but none is perfectly satisfactory. Of course, the scrotal tumor may be cut off. The leg has been amputated at the hip, a dangerous operation. Unfortunately, the other leg has become diseased soon after the one has been cut off. Ligation of the femoral artery has been performed, but the result has not been satisfactory. Compression by means of a rubber bandage, or the ordinary roller band- 1$ — Potass, iodid., gr. xl 2 Potass, chlor., 3j . 4 Sol. hydrarg. perchlor., 5ss 16 Inf. chiretta, ad S viij ad 250 Sig. — gss t. i. d. EMPHYSEMA 269 age, will afford relief. When it is left off for a time enlargement will again take place. It, of course, cannot be used while inflammation is present. Bentley 1 has reported the cure of a case by the inunction of a J dram (2) of mercurial ointment twice daily, and the application of a firm bandage for fourteen days. After that the inunctions were made once a day. Internally he gave iodide of potash alone, or in this formula: M. A. Castellani 2 advises the removal of long elliptical strips of skin, and the hypodermic injection of fibro- lysin 2 c.c. (32 minims) every day or every other day for a month. After a week's pause it is to be given again for thirty or forty injections. A third course is to be given after a week's rest. An india-rubber bandage is to be worn throughout. Galvanism has produced alleviation, if not cure, in some cases. Pusey quotes a case cured by z-rays by Mascat. 3 Hardaway has seen great amelioration in one case by the use of Squire's glycerole of the subacetate of lead. Massage is beneficial. Stretching or excision of a part of the sciatic nerve is spoken of by J. Nevins Hyde as having been followed by amelioration of the condition. Prognosis. — Unless the patient is exhausted by the loss of lymph, the disease may last indefinitely without deterioration of the health. Death may result from pyemia or thrombosis. The patient often dies from some intercurrent affection. Elephantiasis Grecorum. — See Leprosy. Emphysema of the skin is a rare accident. It usually affects the upper chest and neck, and is due to a rupture 1 Lancet, 1878, i, 785. 2 Jour. Cutan. Dis., 1908, xxvi, 225. 3 Lancet, 1898, i, 544. 270 DISEASES OF THE SKIN of the pulmonary alveoli on account of vomiting or paroxysmal coughing, and the air making its way under the skin. The affected part looks swollen, feels cushiony, and gives a delicate crackling sound on palpation. There will be a history of the sudden occurrence of the swell- ing after coughing or vomiting, and probably more or less dyspnea will be experienced. The air slowly escapes and the parts return to their normal condition. Fig. 29 t. * Endothelioma. (Spiegler.) Endothelioma.— Under this title E. Spiegler 1 and others have reported several cases of tumors that occurred in adult life, upon the scalp especially, but also on other Arch. f. Dermat. u. Syph., 1S99, 1, 163. EPIDERMOLYSIS BULLOSA 271 regions. They were present in great numbers and tended constantly to increase in number and in size. They varied in size from a pea to an orange. They projected high above the level of the skin, and were round or flat- tened. They were firm • and elastic, and were either covered with smooth adherent skin or superficially excoriated or ulcerated. The apposed surfaces of neigh- boring tumors were often deprived of epidermis, bled slightly, and secreted a seropurulent, badly smelling fluid, which dried into crusts between the tumors. In one of the cases the disease had lasted forty years, and there was a history of the first tumor having appeared after the healing of a cut of the scalp. Endotheliomas may occur elsewhere than on the scalp. Gottheil 1 re- ported one on the foot. It was a black tumor, irregular in shape, rounded, sharply defined, slightly elevated, and smooth, excepting for two or three small orifices from which blood serum exuded. It was cut out and returned. The diagnosis of these tumors cannot be made with certainty without the aid of the microscope. These tumors originate in the endothelium lining the lymphatics or bloodvessels. Ephelides.— See Lentigo. Epidemic Skin Disease of Savill. — See Dermatitis epidemica. Epidermolysis Bullosa. — Synonyms: Acantholysis bul- losa (Goldscheider and Joseph); Dermatitis bullosa (Valentine) . This is a rare disease, or rather peculiarity of the skin, in which bullae arise upon the slightest pressure. The disease usually first appears in infancy, but may do so later in life, and occurs especially upon the hands and feet, but may occure anywhere on the body, cases having been reported as occurring in the mouth. The tendency to the formation of bulla? lessens toward' middle life. The lesions begin either as red spots, which 1 Jour. Amer. Med. Assoc, 1907, xlvii, 93. 272 DISEASES OF THE SKIN are itchy, or without precedent redness or other subjective symptoms. A bulla begins to form shortly after the exciting pressure, such as from the shoe in walking, or even friction from a suspender, has been received, and keeps on enlarging for two or three days. It then grad- ually decreases, dries into a crust, which falls, leaving healthy skin. If the bulla is broken, it discharges a yellow, slightly sticky fluid, and leaves a suppurating base. It may be hemorrhagic. The disease is heredi- tary in certain families, but it may occur independently of this. It is most pronounced in summer time. In most cases there is hyper idrosis. Pathology. — Elliot, 1 from his microscopical study of the disease, believed it to be "due in a predisposed individual to an excessive response on the part of the bloodvessels to an external irritation, and the consequent pouring out of an enormous amount of serous exudation." He regarded it as an "inflammatory process, originating in the cutis itself, and manifesting itself by the formation of bullae after slight or severe traumatisms." J. Bukov- sky 2 found no change in the unaffected skin, and believed that it is dependent upon some physical defect, such as an inequality of contractility of the skin. Engman and Mook 3 in one case found an absence of elastic tissue in the papular and subpapular parts of the skin, and sparsely distributed and deformed in the deeper parts. On this account the skin vessels lose their tonicity, and slight trauma is followed by an excessive flow of serum into the tissues. Treatment. — No treatment is of avail. Epithelioma. — Synonyms: (Ft.) Epitheliome cancroiide; (Ger.) Epithelialkrebs ; Cancroid, Skin cancer, Epithelial cancer, Noli me tangere, Rodent ulcer. Epithelioma is a chronic, progressive, malignant new 1 Jour. Cutan. and Gen.-Urin. Dis., 1895, xiii, 10. 2 Archiv. Dermat. u. Syph., 1903, lxvii, 163. 3 Jour. Cutan. Dis., 1906, xxiv, 55. EPITHELIOMA 273 growth in the skin or mucous membrane, which is char- acterized by the formation of ulcers with raised, hard, waxy edges, and by a strong tendency to return after apparent removal by knife or caustic. Symptoms. — There are two varieties of epithelioma of the skin. The first is the least malignant, the basal cell variety or the superficial, usually not involving the lymphatic glands, nor producing metastases. The rodent ulcer is the type of this variety. The second variety is the spinocellular variety, which most often occurs at the mucocutaneous junctures, begins commonly as a node, which soon breaks down and ulcerates, involves the lymphatic glands, is prone to metastasize, and is malignant. Epithelioma always begins in a most innocent manner, and may be present for months or years before the patient dreams that he has a serious disease. It may occur upon the skin alone, or upon the mucous membrane alone, or upon both the skin and mucous membrane at their line of juncture. Epitheliomas occurring upon the tongue, larynx, or uterus do not concern us here, as they belong to the domain of surgery. The starting-point of the disease may be a crack or an abraded scaly spot, as on the lip; a small, flat, scaly, sebaceous patch; a white, pearly looking, hard nodule; a senile or other wart or papilloma; a pigmentary mole; a cicatrix; an adenoma; a chronic or lupous ulcer; a psoriatic patch, or some other new growth in the skin. Some of these lesions may have been present for many years, as, for instance, a mole. Some appear but a short time before they frankly declare their nature, such as the waxy nodule. However it may begin, it will be noted that the previously existing lesion more or less rapidly becomes more dense, and after a varying time ulceration occurs, the disease spreads at its edges, and the ulceration grows deeper and deeper, in the infiltrating or spino-cellular form, eating its way through skin, muscles, and bone, or creeping over the surface in the most superficial or basal form. The lymphatic glands 18 274 DISEASES OF THE SKIN may be involved early in the course of the disease in the deep forms, or not for many years in the superficial forms and then commonly the results of secondary infection of the ulceration. Eventually they may be- come swollen, hard, break down, and ulcerate, assuming the appearance of an epitheliomatous ulcer. A typical epitheliomatous ulcer is irregular in shape, with raised, hard, waxy-looking, rounded, or everted edges, over which, quite commonly, course dilated bloodvessels; the floor is uneven, bleeds easily when touched and is cov- ered by a brownish crust or a sanious, purulent secretion. Fig. 30 Epithelioma. (From Prof. G. H. Fox's service at the Vanderbilt Clinic.) Epitheliomas are usually single lesions, but they may be multiple. Sometimes a single epithelioma attains vast dimensions, involving the whole of one side of the face, scalp, and neck in one huge excavated ulcer. Sometimes before the characteristic ulceration develops the new growth may take the form of a single enlarged papilla or a group of them. In some cases it may have a cauli- flower-like appearance, spreading out from a more or less narrow base. Fissures are apt to form between the papillae, and then there is usually an offensive discharge. This is called the papillary form. Subjective symptoms are absent in many cases at first, but in the deep, infiltrating form pain of a lancinating character is present, This often is so severe that the EPITHELIOMA 275 sufferer is robbed of his sleep. In the small and more superficial cancers there commonly is no pain, and the patient experiences only the discomfort incident to the ulceration. If the ulcer extends and goes deep so as to implicate nerves, in nearly all cases lancinating pain is a symptom of the disease. Fig. 31 Epithelioma of the nose. Exuberant growth due to stimulatioi a tar ointment given by a quack. 1 The course of the disease is always chronic. Different cases show different stages of malignancy. Some will prove fatal in four years or less; some will last indefi- nitely. There is no tendency to recovery, though at times a partial attempt at healing will be made. Super- ficial epitheliomas may creep over the skin, healing up in the older parts while spreading outward. While all epitheliomas show a strong tendency to return after 1 Courtesy of Dr. H. Fox. 276 DISEASES OF THE SKIN operation and in the scar left by it, in some cases this tendency is much more marked than in others. While epithelioma may occur upon any part of the body, it is most frequently located upon the lower lip, where it occurs, according to Paget, in 50 per cent, of the cases and is of the spinocellular type. It is very common for it to begin as a crack in the vermilion border, which does not heal but begins to infiltrate later- ally and form a dense well-defined mass with a strong tendency to ulcerate. The neighboring lymphatic glands are involved early in this form. The next most common location is the face. A favorite location upon the face is upon the side of the nose and near the inner canthus of the eye. Here it is very apt to pass over on to the eyelid and destroy it. Not infrequently it begins upon the eyelid itself. The external genital organs of both sexes, and the anal region more rarely, are other common sites. The upper lip is very rarely affected. It is customary to describe a number of forms of epithelioma, but it seems much better, especially for a student, not to encumber his mind with too many names. The superficial, deep-seated or infiltrated, and the papillary forms have already been mentioned. The chimney-sweep's cancer is an epithelioma of the scrotum met with in paraffin- workers and chimney-sweeps. The rodent ulcer used to be described as a special form of disease, and still is so by English surgeons. Clinically, it is supposed to be characterized by occurring on the skin of the upper half of the face, by running a slow and painless course, by not involving the lymphatics, and by lateral rather than perpendicular extension. M. B. Hartzell 1 has described a "morphea-like" epithelioma, of a yellowish-white or pink color, oval shape, and typical wavy border. Etiology. — The cause of epithelioma is undetermined. We know that repeated irritation of a part is often 1 Jour. Amer. Med. Assoc, 1909, liii, 262. EPITHELIOMA 277 followed by its advent. Smoking short clay pipes is not uncommonly followed by epithelioma of the lip; a ragged tooth accounts for many an epithelioma of the tongue; the wearing of spectacles or eye-glasses has in some cases apparently caused the new growth upon the nose; constant picking or inadequate attempts at the removal of warts and scaly spots would seem to account for some epitheliomas of the face; and the scratching to relieve pruritus of the anus may play the same part in producing the disease about the anus. This constant irritation would explain the appearance of epithelioma in paraffin-workers and chimney-sweeps, in chronic ulcers, psoriasis, old cicatrices, and the like. J. N. Hyde 1 sees in the action of the sun's rays a possible cause, and draws attention to the fact that the face and hands are the common sites of the disease. It is to the blue and ultraviolet rays that this action is due. Further, it is more common in men than in women; in farmers than those living in cities; and rare in negroes who are protected by an abundant pigment. Xeroderma pig- mentosum, caused by the action of sunlight, has epithe- lioma as a common sequence. A congenital or acquired phimosis and the repeated inflammation due to decom- posing smegma are forerunners of the disease upon the penis. Age is the most pronounced predisposing cause. The disease is rare under thirty years of age, and increases in frequency beyond that period. One case has been reported by Kaposi in the tenth year of life. Heredity has some influence, though D. Lewis has found that it is not so well marked as it is frequently assumed to be. Males are more often affected than females. It seems to have a predilection for all neoplastic growths. The theory that it is due to a specific parasite, and therefore contagious, thus far has not been demonstrated. Pathology. — Epitheliomas take their origin from the cells of the skin appendages, hair follicles, sweat or 1 Amer. Jour. Med. Sci., 1906. 278 DISEASES OF THE SKIN sebaceous glands, from misplaced enibryological epithe- lium, or, by far most frequently, from the rete Malpighii. Histologically, the tumors are most conveniently con- sidered in two classes which are morphologically quite distinct. The difference between the two depends not so much upon the point of origin of the growth, as upon the tendency of the tumor cells, in the one instance to continue a process of specialization, similar to the normal development of the cells from the stratum mucosum to the stratum corneum, or, in the other, to revert to a more primitive and embryological type. Tumors of the latter class are known as basal-celled epitheliomas. In both forms the essence of the process is a prolifera- tion of epithelial cells of varying size and shape. The resulting cell masses penetrate the corium and often fuse with the formation of alveolar structures, the trabec- ular of which, on section, show dendritic branching. Proliferating epithelial nipples project into connective tissue, which, as far as amount and density are con- cerned, varies greatly, but is always very cellular, rich especially in plasma and giant cells and mononuclear leukocytes. In the first class the epithelial cells have in a measure the life history of normal epithelium, but as they are no longer growing on a free surface, but in enclosed spaces, they become packed in masses, the older cells being forced toward the centres so that at length there are formed concentrically arranged cell masses, which, when cut across present the dense white, lamellated, rounded structures which have been called epithelial pearls. Such pearls are rarely found in other conditions, although they may be present whenever any lesion involves the growth of epithelium into a limited space. In doubtful cases their occurrence with other marks of corniflcation and the presence of intercellular bridges may be of great diagnostic importance. There is variation in the degree and depth to which the corium is invaded. In rodent ulcers the tendency of the growth is to remain near the EPITHELIOMA 279 surface, proliferation and metamorphosis are slow, and necrosis and cicatrization extend pari passu with the lateral growth of the tumor. In larger tumors ulcera- tion takes place at the centre, while the edges become elevated by the papillary hyperplasia, extension of the tumor beneath the skin, and the inflammatory infiltra- tion. Before ulceration the tumor may project above the skin forming a wart-like or papillomatous growth. In the second group the tumor cells resemble those of the rete mucosum, or of certain glands, but in their retro- grade metamorphosis take on the appearance of connec- tive-tissue cells, so that at times the tumor merges into the stroma with no sharp line of demarcation. The proliferating cells may form solid masses of various shapes, and sometimes gland-like or cystic structures. Different forms of degeneration of the stroma contribute along with the metaplasia and appearance of embryonal characteristics, to the formation of a very complex structure. In this class are to be included many tumors which have been described as endothelioma, cylindroma, plexiform sarcoma, and myosarcoma. Diagnosis. — The disease must be differentiated from lupus, syphilis, sarcoma, papilloma, and seborrheal warts. From lupus it differs in an entire absence of brownish lupus tubercles; in beginning late in life, as a rule, while lupus begins in early life; by its compara- tively more rapid course; its lancinating pain; the in- volvement of the lymphatic glands; the deep ulceration; the waxy, raised, hard margin; and the development of the cancerous cachexia. From syphilis it differs in hav- ing a single and not a multiple lesion; in its slower course; in its showing no tendency to recovery; in its not respond- ing to internal treatment; in its painfulness; and in its waxy, raised, hard margin. An initial lesion of syphilis on the lip has not infrequently been taken for an epithe- lioma. In it we have more rapid growth, more induration, an early enlargement of the neighboring lymphatic glands of peculiar hardness, and the appearance of 280 DISEASES OF THE SKIN secondary eruptions on the body, all of which are wanting in an epithelioma. Sarcoma usually occurs earlier in life, tends to more rapid development with metastases in neighboring or distant parts, and either does not ulcerate or ulcerates in a very different way than does epithelioma. From 'papilloma and seborrheal warts there are no positive diagnostic marks of distinction. Either of the two diseases appearing late in life or showing symptoms of activity at that time should arouse our suspicions. Treatment. — Complete and radical destruction of the disease is the only thing to be done in the treatment of epithelioma. As a prophylactic measure, it is well to destroy all suspicious warts appearing after middle life, and to apply appropriate treatment to seborrheal patches occurring at the same period. Superficial caustics should never be used to an epithelioma, as they only encourage its growth. The radical treatment will differ with the point of view, all surgeons inclining to the knife, while dermatologists advocate the curette or powerfully destruc- tive caustics. If the knife is used, it must cut out a wide margin beyond the growth. Extirpation is espe- cially applicable, and the most appropriate treatment for epithelioma of the lip, eyelids, and penis. In the latter the organ must be amputated above the ulcer, if that has attained any size, and the inguinal glands likewise taken out. In all cases in which the lymphatic glands have become involved they should be taken out. Therefore when the lymphatic glands are involved only excision is to be thought of. Curettage and the thorough application of powerful caustics effect a speedy and rapid cure of all forms of the disease. We have found the method advocated by S. Sherwell 1 most excellent. In small lesions it is unneces- sary to use general anesthesia, local anesthesia by cocain or the like being sufficient. In large growths general 1 Jour. Cutan. Dis., 1910, xxviii, 487. EPITHELIOMA 281 anesthesia is necessary. The growth must be energetically scraped away with a curette until all the dead tissue is removed. Then a small curette is to be used, seeking out all small pockets. The bleeding is checked by pres- sure, or by applying a solution of two-thirds of a 10 per cent, solution of cocain and one-third of adrenalin under pressure or by touching with a Paquelin cautery at cherry heat. Then a 60 per cent, solution of acid nitrate of mercury is to be applied with a cotton swab two or three times and allowed to remain on for five to twenty minutes, when it is neutralized with a saturated solution of bicarbonate of soda, and the hole filled up with powdered bicarbonate of soda. The crust is allowed to separate of itself, which it will do in two or three weeks. For a few days there may be considerable inflammatory reaction, that need give no anxiety. Fig. 32 The dermal curette. Epithelioma may also be destroyed by caustics. Arsenic holds the first place among these, Marsden's paste, composed of 1 or 2 parts of arsenous acid and 1 part of gum acacia, by weight, rubbed together and mixed with a 20 to 40 per cent, aqueous solution of cocain into a paste of the consistency of butter just before using, is perhaps the most often used. It is dread- fully painful and often causes great edema. If orthoform is substituted for \ to f of the gum acacia, the paste is hardly at all painful. Before applying an arsenical paste, if ulceration has not taken place, the epithelium should be curetted so as to leave a raw surface. The 282 DISEASES OF THE SKIN paste should be applied to the affected part spread on a piece of linen large enough to overlap the edge of the tumor by half an inch, and left on for twelve to twenty- four hours, according to the patient's endurance and the effect produced. The patient should be seen frequently, and the paste removed as soon as a greenish or blackish eschar is formed. Carbolated vaselin is to be applied after the paste, and kept on continuously until the slough separates, and then simple ointment used. The slough may not fall for weeks, and when it does a clean surface is exposed that soon completely heals. It is to be noted that the use of a strong arsenical paste is much safer than a weak application, as it produces so much inflammation and destruction of tissue that the arsenic is not absorbed. Arsenic is better than some other caustics, as it attacks by preference diseased cells and leaves the sound skin almost unharmed. If the growth has not been destroyed, the process may be repeated. D. Lewis 1 has had good results from using Bougard's paste, as follows: i — Wheat flour, Starch, . aa 60 Arsenic, 1 Cinnabar, Sal. ammoniac, aa 5 Corrosive sublimate, 50 Solution of chloride of zinc at 52°, 245 M The first six ingredients are separately ground to a fine powder and mixed in a mortar. Then the solution of zinc is slowly added while the mass is stirred. It is to be kept covered in an earthen jar. A portion is to be applied accurately to the part and kept on for thirty hours, and followed by a poultice. Cocain, 20 per cent., may be added to decrease the pain. Another method of using arsenic is known as Cerny's. He uses: 1$ — Acid, arsenios. pulv., 1 Alcohol, ethyl, absolut., Aqua? destillat., aa p. e. ad 150 1 Jour. Cutan. and Gen.-Urin. Dis., 1890, viii, 70. EPITHELIOMA 283 The solution is to be shaken up and painted over the denuded surface of the epithelium, and a new coat laid on when the first is dry. It is used daily unless oedema is caused, when a pause is made until this subsides. After a time an eschar forms and falls. The solution is then applied again to the surface, and if only a yellowish crust forms that can be removed without bleeding, a cure has been effected. If a dark adherent crust forms, repeat as before. Healing at last is effected under 10 per cent, boric acid in vaselin. Lactic acid is another powerful caustic, to be applied by mixing it with an equal part of finely powdered silica and spreading it upon gum paper. It is kept on for twelve hours, and renewed twenty-four hours afterward. Hardaway prefers to apply the syrupy acid by means of absorbent cotton for ten or fifteen minutes, and then wash off the excess of acid with water. This is done daily. Caustic potash and chloride of zinc in crayon are recom- mended by A. R. Robinson for epithelioma of the lip and small epitheliomas about the eyelids. The first is a con- venient agent in the form of potassa fusa. It is well to curette away the surface, and then to hold the potash stick against the wound for a few moments until the tis- sues liquefy. The application of dilute acetic acid will check the action of the potash. A raised scar sometimes follows its use. It will flatten in time. The thermo- and galvanocautery and chloride of zinc may be used. X-rays in massive doses, as employed by MacKee (p. ■471), give brilliant results. He advises me that the ordinary basal cell epithelioma will yield, as a rule, to one or two treatments, consisting in quantity of from 6 to 8 Holzknecht units, and in quality of Benoist Xos. 8 to 10. If deep seated or of the squamous cell variety, the same quality should be filtered through 3 mm. of aluminum, and as much as 12 to 18 Holzknecht units given at one time. As no pain or inconvenience is caused by this method, and the results are speedily 284 DISEASES OF THE SKIN obtained, it is to be preferred in the hands of an expert. Repeated exposures to arrays will also cure. A medium hard tube should be used, exposures should be made every other day, the patient should be from four to ten inches distant from the target, and the duration of each sitting should be from three to ten minutes. The surrounding parts should be protected by sheet lead in which a hole is cut a little larger than the size of the cancer. The hard edges should be removed by curettage. It may take six to ten weeks to effect a cure. This is often effected without the production of erythema. Treatment should be suspended when reac- tion appears. It should not be resumed under three weeks. Radium will cure superficial epitheliomas. Prognosis. — The prognosis of epithelioma as to life is good in cases in which only the skin is involved. While, as already said, there are some cases that are rapidly fatal, many do not seem to have any effect on the patient's health for years. The prognosis as to cure is always doubtful. Some cases, whether excised, or destroyed by other means, will return after a time. If they do return, they must be destroyed again. Epithelioma, Multiple Benign Cystic. — Under this title Fordyce 1 places those cases formerly described under the names of hydradenomes eruptifs, syringo-cystadenome, epithelioma adenoides cysticum, and other titles. It is characterized by the eruption of small, pale-yellow, pearly, pinkish, brownish, or reddish-brown tumors from pinhead- to pea-sized, that are located on the face, chest, back, and upper extremities. They are firm to the touch, and painless. Some of the tumors are tense, shiny, freely movable, sometimes with a central depression. Some are translucent, like vesicles; some look more like milia. They slowly increase in number, the individual tumors enlarging to the size of a pea and then remaining stationary. The disease has no 1 Jour. Cutan. and Gen.-Urin. Dis., 1892, x, 459. EQUINIA 285 effect on the general health. In most cases it is hereditary, and begins in early life. The diagnosis from adenoma sebaceum is very difficult, and often cannot be made without the aid of the microscope. Molluscum contagiosum often occurs in childhood and always has a central punctum. Hydrocystoma contains fluid. Microscopic examination shows the tumor to be made up of irregular masses and tracts of epithelial cells, and "cell nests." Colloid degeneration of individual cells is also seen in the cell masses. There are also a down growth and proliferation of the epidermis and external root sheath of the hair follicle. It is supposed that the growths are due to misplaced epithelial cells of indifferent nature (Fordyce). Their treatment is by curetting or electrolysis. Equinia.- — Synonyms: Glanders; Farcy; Malleus; (Fr.) Morve; (Gr.) Rotz. A contagious, specific disease, with general and local symptoms, derived from the horse, ass, or mule. This is a rare disease in the human race, and runs an acute, subacute, or chronic course. It is derived by inocu- lation with the bacillus mallei, and its symptoms show themselves in from three days to six weeks afterward. Its constitutional symptoms are fever, prostration, constipa- tion, and rheumatic pains, with the subsequent develop- ment of a typhoid condition in which the patient dies. The objective symptoms are a profuse purulent or sanious nasal discharge; chancroidal ulceration at the site of entrance of the poison; phlegmonous inflammation of the affected part; adenitis; and a cutaneous efflorescence. The latter is a disseminated eruption of red macules, which develop into yellow papules, upon which variola-like pustules and bullae may form. These may coalesce into superficial ulcerations and gangrenous patches. The skin is swollen and red, and often crusted with the discharge from the pustules. Infiltration of the subcutaneous tissues may occur and deep sloughs may form. There may 286 DISEASES OF THE SKIN be a general adenitis, and the glands may break down and form ulcerating cavities. The whole skin may be involved in these destructive processes. It may run an acute or chronic course. Treatment is usually unavailing in acute cases, and is on general principles. In chronic cases recently cures have been effected by the hypodermic use of mallein, a serum derived from cultures of the bacillus. The initial dose is 1 mg., increasing in the course of a week or so to from 30 mg. to 1 gm. The prognosis is bad. The more acute the symptoms the worse the outlook. Erysipelas. — Synonyms: (Fr.) La rose, Feu sacre; (Ger.) Rothlauf, Rose, Hautrose, Wundrose; (It.) Risipola; St. Anthony's fire, Wildfire, Rose. An inflammatory disease of the skin and the adjacent mucous membranes, attended always with redness and swelling, and often with vesicles, bullae, pustules, diffuse suppuration, and gangrene; and characterized by a ten- dency to spread at the periphery and by fever (Foster). Symptoms. — Though the most modern pathology teaches that erysipelas always originates in or about a lesion of the skin or mucous membrane, and is therefore allied to if not indentical with the same disease as met with in surgical and lying-in wards, so-called surgical erysipelas will not be considered here. The outbreak of the disease, as met with apart from the surgical form, is usually pre- ceded, for a day or so, with malaise, and the attack is often ushered in with a chill, pyrexia, and vomiting. The fever is present throughout the whole course of the dis- ease, excepting in the most mild type, when it may soon subside. The thermometric range is from 101° to 105.5° F. The highest temperatures usually are at night. If there should be a sharp rise of temperature it indicates an exacerbation or invasion of new territory. It is remit- tent in type, irregular in course, and ends by lysis. Some- times the temperature is subnormal. There will be other signs of constitutional disturbance, such as a coated ERYSIPELAS 287 tongue, a quickened pulse, either full, soft, and compres- sible, or, in bad cases, small and weak; headache, drowsi- ness, or, in bad cases, delirium; and sometimes albumin is found in the urine. The most frequent location of the disease, so far as we now are concerned, is the head and face, though it may occur anywhere on the body. The eruption begins usually as a single patch, which is at once rosy red, swollen, sharply defined, irregularly shaped, hot to the touch, and, at first, with a smooth, glazed surface. The redness may be pressed out with the finger, leaving a yellow stain, but promptly returns when the pressure is removed. The patch enlarges, creeping with more or less rapidity over the surface, always preserving its sharp, ofttimes indented border that is raised toward the sound skin; it becomes of a darker hue, sometimes livid; and very commonly, though not uniformly, vesicles or even blebs form on it. These latter may become purulent, and breaking, dis- charge their contents upon the surface, which dry into crusts. As the process extends the central portion becomes flattened and less red. Sometimes new patches may appear, and coalesce with the original patch. Some- times, while spreading peripherally, there may be a recrudescence in the older parts. The area of the disease may be limited or may include the whole body. Very often it seems to be checked by the line of the hair, whether of the beard or scalp. In only a small pro- portion of cases does it invade the hairy parts, involving one-half or the whole of the scalp and extending down upon the neck. Then the patient's appearance is indeed deplorable. His lips are swollen and livid, his eyelids are swollen so that the eyes cannot be opened, and his head seems enormously enlarged. Abscesses may form in the scalp. At times there may be a lighting up of the disease on a distant part of the body, as on the arm with erysipelas of the face. This is known as erysipelas migrans. The lymphatics and the lymphatic glands are involved. The 288 DISEASES OF THE SKIN former often show themselves as red streaks. The glands may suppurate, and gangrene of the skin may declare itself. All grades of inflammation may be reached. Some- times the disease is but slight, sometimes very severe, the constitutional symptoms keeping pace with the severity of the local symptoms. The duration of the disease may be six or seven days, or two or three weeks. The patient is always more or less prostrated by it, though many of the cases we see are ambulant cases. Des- quamation follows on the subsidence of the disease. The subjective symptoms are burning, tingling, itch- ing, and tension. The parts are often tender, and may be spontaneously painful. The disease quite commonly begins about the nose, and may invade the mouth. Occasionally it spreads rapidly over the surface as an advancing, broad, rosy-red, raised line. Sometimes recurrent attacks occur at short inter- vals; generally the disease does not recur. When the scalp is invaded the hair commonly falls during con- valescence. Sometimes some lesion of the skin may be found as the starting-point of the inflammation, or per- haps some lesion of the mucous membrane of the nose, mouth, or ear. In the recurrent attacks the nose is quite commonly the peccant member. But in a very large proportion of cases no lesion at all will be discoverable. When the disease subsides the skin desquamates, and returns at last to the normal condition. Erysipelas occurring upon the trunk or extremities presents pretty much the same symptoms as when occurring upon the face. Etiology. — It is now generally accepted that the disease is infectious, and caused by a specific micro- organism that was described by Fehleisen, 1 which is a streptococcus. Stelwagon states that a special diplo- coccus was found in eight cases in the Philadelphia Hospital. The coccus gains access to the body through 1 Deutsche Zeitschrift f. Chirurgie, 1882, xvi, 391. ERYSIPELAS 289 some lesion of continuity of the skin or mucous mem- brane, however, minute that may be. It therefore some- times follows boils, tubercular ulcers, eczema, and other skin diseases. As in many of the bacterial diseases, so in this one, it is probable that the patient must be in the proper condition of health, or rather ill-health, for the lodgement of the cocci. One attack predisposes to another attack. In frequently recurring cases infection probably takes place through some lesion of the nose or naso- pharynx. It is more frequent in women than in men; in adults than in children; and in winter than in summer. Intemperance, Bright's disease, parturition, and a lowered state of nutrition predispose to it. While the contagious- ness of surgical erysipelas is well known, and commonly observed, it is rare to meet a case of facial erysipelas traceable directly to contagion. The possibility of the occurrence of the disease without infection by the micro- organism is still entertained by some. It has been thought to arise from taking cold or to begin in some circumscribed purulent deposit. There is nothing specific about the pathological anatomy of the disease. Diagnosis. — If the clinical features of the disease are kept in mind, the sharply defined, swollen, red patch advancing with more or less steadiness over the surface, the process being preceded by a chill and accompanied by marked constitutional disturbance, there is little danger of not recognizing it. It may, however, be mis- taken for dermatitis venenata, an acute erythematous eczema, an erythema, or so-called giant urticaria. In dermatitis venenata there is little or no constitutional disturbance, the patches are covered over thickly with large, well-preserved vesicles, and a history of exposure to some source of poisoning is usually easily obtainable. Moreover the disease is commonly upon the face and hands at the same time. In eczema the parts are not so swollen; the margin of the patch fades into the sur- rounding skin, the color is not so brilliant; the surface is 19 290 DISEASES OF THE SKIN rougher and more scaly; there is decided itching and a lack of constitutional disturbance of any magnitude. Erythema lacks the constitutional symptoms of erysipelas ; the redness fades completely away under pressure, without leaving a yellowish stain, and springs back promptly when the pressure is removed; it does not creep over the skin; and it is of short duration. In urticaria there will usually be well-marked wheals or a history of them; great itching; no tenderness; a short course; a history or evidence of digestive disorders, and an absence of marked constitutional disturbance. Treatment. — The great variety of remedies that have been vaunted for the cure of erysipelas evidences the fact that most cases recover of themselves. There are not a few competent observers who are skeptical of the real efficacy of any local treatment. As the disease tends to lower the vitality of the patient we should strive to support his strength by a most nutritious diet, and by alcoholic stimulants in adynamic cases. The internal medication will be symptomatic to a large extent, by means of aconite, quinin, antipyrin, phenacetin, and the like. The tincture of the chloride of iron, in 20 (1.33) to 60 minim (4) doses every two or three hours, is regarded by many as a specific, and should be given in all but the slightest cases. Jaborandi by the mouth, or pilocarpin, J to i of a grain hypodermically, have their advocates, but must not be thought of in debilitated subjects. In severe cases injections of streptococcic vaccines are advisable. Johnson 1 advises giving 10,000,000. This may be repeated on the second day, then every second day, until one week after the temperature has become normal. S. Erdman 2 found vaccines to be of little use, as also Engman has. The local treatment is very important. If there is a wound present, it should, of course, be thoroughly 1 Jour. Amer. Med. Assoc, 1909, lii, 747. 2 Ibid., 1913, lxi. 2048. ERYSIPELAS 291 disinfected on surgical principles. The lead-and-opium wash is an old remedy, and has proved useful in very many cases. It is composed of 1$ — Liq. plumbi subacetat. dil., 5J-ii.J 4-12 Tinct. opii, 5ij-iv 8-16 Aquse, ad Oj ad 500 M. It may be used hot or cold, whichever is most agreeable to the patient. Dry heat will also relieve the discomfort of the patient. Resorcin in watery solution of 2 or 3 per cent, strength seems at times to cut short the disease. White lead paint has done well in some hands. White 1 expects to cure his cases of ordinary facial ery- sipelas by keeping the part constantly covered with cloths saturated with the following: 1$ — Ac. carbolici, 3J 4[ Alcohol., Aqua?, aa Oss aa 2501 M. It may be used every alternate hour. Carbolic acid may also be used in oil, 10 per cent, strength, and rubbed in every hour. Piffard recommends the external use of: J£ — Tinct. belladonna?, 1 part. Glycerini, 1 part. Aquae, 8 parts. M. Ichthyol, in 25 to 50 per cent, aqueous solution, is one of the best applications, the only objections to it being its disagreeable odor and dark-brown color. The parts should be constantly covered with it. Pure alcohol, frequently applied, is an agreeable and efficient remedy, as are cold compresses of a saturated solution of boric acid. The treatment by scarifications about the patch, the incisions being made diagonally, partly in the sound and partly in the diseased skin, and then covered with gauze wet with a solution of bichloride of mercury, 1 to 1000, is known as the Kraske-Riedel method, and should be 1 Trans. Amer. Dermat. Assoc, 1890, p. 42. 292 DISEASES OF THE SKIN always thought of in grave cases. Woelfler 1 recommends compression of the borderline by adhesive-plaster strips, the disease seldom spreading beyond the constricting band. This is especially applicable to erysipelas of the limbs. Painting with nitrate of silver all around the patch has also been done, with the idea of checking its spread. In many cases these procedures are useless. Prognosis. — Many cases of erysipelas recover of them- selves in a few days, while others may run a course of weeks. The prognosis may be said to be good in most cases; but even in those that begin as mild ones we should be on the watch for grave symptoms. When the scalp is affected or the disease spreads upon the trunk the prognosis is more grave than when the face alone is the seat of the disease. When the patient is the subject of chronic alcoholism, or Bright 's disease, or is in the puerperal state, or in either extreme of life, the prognosis is bad. Erysipeloid is a term employed by Rosenbach to desig- nate an erysipelas-like eruption unattended by constitu- tional symptoms. It is also called chronic erysipelas and erythema migrans. It orginates in a wound, is due to infection from some dead, putrefying animal substance, and chiefly affects cooks, butchers, fishmongers, and the like. Gilchrist 2 has seen many cases as the result of crab bites and believes it is caused by some special ferment. It occurs mostly on the fingers, and spreads from the point of inoculation as a dark-red, often livid, sometimes slightly swollen patch with a sharp border. As it travels over the surface the central portion undergoes involution, and thus circles or scalloped patches may be formed. It stops spontaneously after from one to six weeks' duration. There is marked itching or burning during the whole course of the disease. It is distinguished from true erysipelas by the mildness of its symptoms. 1 Wien. klin. Wochenschr., 1889, Nos. 23 and 25. 2 Jour. Cutan. Dis., 1904, xxii, 507. ERYTHEMA 293 A salicylic acid or other antiseptic ointment or a 50 per cent, aqueous solution of ichthyol may be used in treatment. Gilchrist found the most effective treatment is to strap the edge of the swelling with a 25 to 50 per cent, salicylic acid plaster. Erythema. — Synonyms: Dermatitis erythematosa, Ery- sipelas suffusum; (Fr.) Erytheme, Darte erythemoide; (Ger.) Erythem, Hautrothe; Rose rash. Erythema may be passive or active. The former is familiar as lividity of the skin, and the latter as blushing. There are many forms of erythema as a disease, but they may all be classed under one of two main varieties, namely, Erythema hyperemicum and Erythema exuda- tivum. We shall follow Crocker's classification, as it is a practical one. It is a question whether erythema should be regarded as a disease or a symptom. 1. Due to external causes f E. simplex. E. pernio. < E. intertrigo. E. leve. E. hyperemicum . [E. paratrimma. Erythema ' t E. exudativum 2. Due to internal causes f E. multiforme. ; E. seu Herpes iris. E. nodosum. .E. gangrenosum. f E. fugax. 1 E. urticans. j E. roseola. IE. scarlatiniforme Erythema Hyperemicum. This form of erythema is characterized by simple red- ness without swelling, and usually is not followed by desquamation. This shows that it is due simply to a localized hyperemia without inflammation. It is always of short duration. The redness disappears under pressure, but springs back again as soon as the pressure is removed. It occurs either in circumscribed patches of large or small size, or diffused over large areas. Subjective symptoms are often hardlv noticeable. There mav be some burning 294 DISEASES OF THE SKIN and tenderness, but there is never decided itching. The patient may rub his skin gently, but never scratches violently. In cases due to internal causes there may be slight constitutional symptoms with fever of mild grade, or some digestive disturbance; but these are not properly symptoms of the erythema, but rather of the underlying disease of which the eruption is but an accidental expres- sion. For instance, two people may eat the same thing. In both there may be digestive disturbances. But one will have an erythema and the other will escape. This form of erythema may arise from either external or internal causes. Cases arising from external causes are localized, while those due to internal causes are general. Both are angioneuroses, and predisposed to by an inborn susceptibility — that is, idiosyncrasy of the patient. In the first group we have Erythema simplex, under which are included E. traumaticum and E. caloricum, due to the rubbing of the clothing, the effect of heat or cold, as of the sun or wind, and of various vegetable or chemi- cal irritants. Many of these simple erythemas we have already described under the caption of Dermatitis, which see. They are the simplest reaction of the skin to an irritant. If the irritant is great enough or lasts long enough, a dermatitis is set up. They are usually local- ized, and for treatment require only the removal of the irritating cause, and the application of a simple dusting powder or ointment. The exciting cause continuing, we have inflammation added and a dermatitis produced. Erythema Pernio has been described under Dermatitis Congelationis, which see. Erythema Intertrigo, or simply intertrigo, is an ery- thema occurring between two folds of skin. It is most commonly seen in fat infants in the folds of the skin of the neck and joints. It is also encountered in adults who are corpulent, and is often a very annoying trouble in women, in whom it frequently occurs underneath the hanging breasts. It also occurs between the scrotum and ERYTHEMA 295 inside of the thighs, under the prepuce, in the furrows alongside of the vulva, in the joints, and in all other skin creases. It is then caused by the friction in walking and favored by heat and moisture. It is therefore more common in warm weather. If not at once and properly attended to, the decomposition of the sweat and sebaceous matters will aggravate it; and the irritation being con- tinued, an eczema will develop. It is, in infants, very common about the inside of the thighs, where the wet napkins cause and aggravate it. It is very often accom- panied by a disagreeable, cheesy odor, and, contrary to what obtains in other erythemas, there is moisture upon the skin in some cases. Diagnosis. — The diagnosis from eczema is very often difficult. Indeed, eczema and erythema run into each other so imperceptibly at times that it is difficult to tell where the one leaves off and the other begins. But eczema itches more than erythema, it tends to spread further beyond the affected part, and its exudation is not only sticky, but also stains and stiffens linen. The location in the skin folds should suggest an intertrigo. Happily, the differentiation is a matter of no great importance, as the same treatment is applicable to both. In infantile syphilis we frequently have an eruption upon the buttocks and inside of the thighs that bears a decided resemblance to intertrigo. Here a correct diag- nosis is of great importance. In syphilis the redness commonly extends down the whole inside of the legs to the feet and soles, it is of a darker color, and there will be other symptoms of the disease, such as snuffles, large or small papules to the outside of the red patch, mucous patches, and the like. In infant asylums, where a great number of debilitated as well as syphilitic children are received, opportunities for the differentiation between syphilis and intertrigo frequently occur. Treatment. — The treatment of intertrigo is simple. The opposing surfaces of skin must be separated by pieces of gauze or muslin, the furrows must be kept 296 DISEASES OF THE SKIN perfectly clean, by wiping the surface off with a saturated solution of boric acid, or, in adults where the skin is unbroken, with 90 per cent, alcohol, and dusting powders of starch, talc, lycopodium, and the like, must be freely used. To these powders oxide of zinc, boric acid, or other astringents may be added, the compound stearate of zinc being one of the best applications. Hardaway recommends : I$—-Thymol., gr. j |06 Pulv. zinci oleat., gj 32 J M. As a rule, powders answer better than ointments, though Lassar's paste, as given under Eczema, may be used. Lotions, such as calamin lotion, and a saturated solution of boric acid, are preferable to ointments. The treatment of intertrigo in infants is to be managed in the same way as eczema. (See under Eczema Infantile.) Erythema Leve is an obsolete term, which was employed to indicate the redness seen on edematous limbs. Erythema Paratrimma belongs to the same category, only here it is the redness over bony prominences, as that preceding a bed-sore. We have now to consider the second group of erythema hyperemicum, those erythemas which are due to internal causes. Here might be placed all the exanthematous fevers, as well as the drug eruptions. But the first of these belongs to the domain of general medicine, and the last will be found under Dermatitis Medicamentosa. Erythema Fugax is, as its name indicates, a fugitive erythema — as it were, a prolonged blush. It occurs most often in children with some digestive disturbance, and its chosen location is the face. It lasts for a few moments or hours, and is seldom seen by the physician, although he will be told, not infrequently, by his patients that they are annoyed by a flushing of the face after eating, exposure to cold, or mental emotion. It is to be managed like Urticaria, which see. ERYTHEMA 297 Erythema Urticans is simply the first stage of urticaria. The term should be dropped. Erythema Roseola, or simply roseola. "While children are more subject to this form of erythema than adults, it may occur in the latter. Most commonly it affects the whole body, but it may be localized. As it is due in most, if not all, cases to digestive disorders or other con- stitutional disturbance, it is usually ushered in with a rise of temperature, which may be pretty sharp, 103° or 104° F., furred tongue, restlessness, and the like. Soon the eruption appears, which may be a blotchy redness, or in faintly marked papules, or in rings or gyrate figures. The eruption lasts a few hours only, or, coming and going in different places, it may be prolonged for a few days. Besides digestive disorders, gout, changes of temperature, and the seasons of spring and autumn have been assigned as causes. Diagnosis. — In itself it is a matter of little moment, but as it resembles scarlet fever, rotheln, and measles, its diagnosis is important. It differs from scarlatina in not having such severe constitutional symptoms; in an absence of the strawberry tongue, swollen, reddened fauces, and enlarged glands; in the rash coming out all over the body without following any regular course of development from the neck downward; in the eruption being blotchy or papular, and not a diffused redness. After watching the case for a day the diagnosis will be made evident by the clearing away of the disease wholly or partially. It differs from measles in an entire absence of catarrhal symptoms, and in its eruption not being crescentic, as well as in the irregularity of its course, the mildness of its symptoms, and the brightness of its color. It bears most resemblance to rotheln, and probably the two are often confounded. If there is a clear history of contagion, or more than one member of the family affected at the same time, the diagnosis of rotheln is at once established. Rotheln is more pronounced on the extremities, and the lesions are of a more stable character. 298 DISEASES OF THE SKIN In case of doubt as to the diagnosis of roseola the patient should be regarded as having a contagious disease, isolated, and carefully watched. Treatment. — Little need be done for the patient but to give a laxative, and to relieve symptoms. Erythema Neonatorum makes its appearance in the first few days of life, and is thought to be due to the influence of external and unusual irritants acting upon the tender skin of a newborn child. "The eruption consists of very minute red papules, seated upon a hyperemic base, which can be made to lose their color upon pressure. The lesions are most pronounced upon the back and breast, and fade away in a few days with slight desquamation of the most congested spots. The mucous membranes are unaffected, and there is no evidence of systemic reaction." (Hardaway.) Erythema Scarlatiniforme.- — A scarlatina-like erythema follows the ingestion of a number of drugs, and has been frequently mentioned in the section on Dermatitis Medica- mentosa. The French authors describe a scarlatiniform erythema under the name of erythemes scarlatiniform recidivantes, which, according to Besnier, 1 who has pub- lished an excellent study of the affection, was first described by Fereol in 1876, at the Societe medicale des Hopitaux de Paris. The disease is marked by redness, desquamation, and relapses. Its outbreak may or may not be preceded for one or two days by malaise and slight febrile movement. It begins on the trunk and invades the whole surface in a few hours or in two days. It is a diffused, uniform, intense, scarlatinal or somber-red eruption. There may be slight differences in the shade of color, or the redness may be punctate, or some pinhead- sized vesicles may develop upon it. Sometimes the eruption is limited to a certain portion of the body; sometimes the eruption is general, but not universal, normal islands of skin being found in the general redness. 1 Ann. de derm, et de syph., 1890, i, 1. ERYTHEMA 299 It conies out in patches that run together. There is generally redness of the mucous membrane of the mouth and fauces. There is no thickening of the skin nor infiltration of mucous membranes. The skin burns, and there may be itching. Exfoliation of the skin begins almost as soon as the eruption is out, commencing at the point of invasion. The desquamation is general, and may be furfuraceous, or abundant and in large plaques. Upon the scalp it is furfuraceous. The whole process may take but one or two days, or it may be pro- longed for a month or six weeks. The hair and nails may be shed. The tongue is furred, and may desquamate, but never presents the papilla? of scarlatina. After the beginning of the attack there is usually no fever, and the appetite is preserved. There may be albuminuria during the attack. The relapses, which are apt to occur after intervals of days, months, or years, are less pro- nounced and the patient's health is good in the interim. Etiology. — The cause of the disease is very often obscure. The first attack has been observed to follow exposure to cold, the application of mercurial ointment, or the action of some other irritant. But it is difficult to explain why from such causes relapses should occur. Besnier thinks that in some cases the cause is a poison developed within the individual. In this way he would explain some of the erythemas developing during an acute urethritis, which some observers claim may arise indepen- dently of the taking of copaiba. Scarlatiniform erythemas occur occasionally in septicemic conditions, in typhus fever, in malaria of children, in sewer-gas poisoning, and in various other conditions. Diagnosis. — Brocq considers scarlatiniform erythema as one form of dermatitis exfoliativa, but it is distinguished from it by an absence of evening rise of temperature, by having no permanent effect upon the health, by running a shorter course, and by the skin not being dry, con- tracted, and shrivelled. It differs from scarlatina in the mildness of its constitutional symptoms; by the course 300 DISEASES OF THE SKIN of the eruption; by the absence of tumefaction of the fauces and the strawberry tongue; by the early desquama- tion; by not being contagious; and by its tendency to relapse. If there is any doubt as to the diagnosis, the patient should be isolated. It differs from measles in the absence of catarrhal symptoms and Koplik's spots in the mouth. It differs from erythematous eczema in an entire absence both of thickening and moisture; in being less itchy; and in its rapid course. Treatment. — The treatment is purely symptomatic. Erythema Exudativum. The second variety of erythema differs from erythema hyperemicum in the presence of an exudation into, not on, the skin, so that the patches are raised above the level of the skin, and in never involving the whole surface, but always occurring in circumscribed patches. It is an inflammatory disease. Its several varieties are alike in that the redness disappears under pressure, to return at once when the pressure is removed. It is probable that erythema nodosum is really but a part of erythema multiforme, as the two forms may be present at one time. But it is usually described apart, and although this may not be strictly accurate, it is convenient. Erythema (Exudativum) Multiforme, as its name indicates, is very multiform in its efflorescences. For a day or a few days before they appear there is some constitutional disturbance. This may be nothing more than slight malaise, the patient not feeling as well as usual. From these indefinite symptoms there are all grades, up to fever of 104° F., headache, gastric disturb- ances, and severe muscular and articular pains, like rheumatism. According to Besnier and Doyon, an ery- thema of the pharynx, or a pharyngitis, laryngitis, or bronchitis, often precedes or accompanies the outbreak of the eruption upon the skin. The eruption is most constantly seen upon the backs of the hands and feet, ERYTHEMA 301 and here it commonly begins, though this is denied by Polotebnoff, to whom we are indebted for a most exhaus- tive and able study of erythema. 1 It also appears on the trunk and extremities more or less generally, coming out in crops, and preserving a rough symmetry. Some- times it may remain confined to a single region, as the backs of the hands. Sometimes it occurs on the mucous membranes, as of the mouth and eyes. It is usually most marked and abundant about the joints should they have exhibited rheumatic pains. It is rare not to find lesions upon the backs of the hands. With the appear- ance of the eruption there is a subsidence of the constitu- tional symptoms, though in many cases the patients are more or less definitely ill during the whole course of the disease. The eruption commences as a group of deep-red papules from pinhead- to pea-size, conical or rounded, and this is called erythema papidatum. The eruption may continue as such; or the papules may coalesce and form elevated patches, sharply marked against the sound skin; or they may enlarge to the size of tubercles, thus forming erythema tuberculatum. If they still continue to enlarge, they be- come depressed in the centre and ring-shaped, the peri- phery being deep red, while the centre is purplish. This is called erythema circinatum or annulare. Sometimes it happens that the ring still enlarges by. successive exuda- tions, and then there will be ring within ring, the outer one pink, the next red, the next purplish, thus forming an iris-like play of colors that has been termed erythema or herpes iris. Two rings near each other and enlarging will after a time meet at their peripheries, the points of contact will melt into each other and disappear, and there will form a large patch with a figure-of-eight or scalloped, raised border, and a flattened centre. This is called erythema marginatum. It may travel over a large part of the trunk or the circumference of a limb, 1 Zur Lehre von den Erythemen, Hamburg, 1887. 302 DISEASES OF THE SKIN leaving a fawn-colored pigmentation, which soon fades. Or two rings meet, and each breaks, and only a gyrate line is formed, to which the name of erythema gyratum is applied. Sometimes, though rarely, the exudation is so abundant that the epidermis is raised in the form of vesicles or bulla?. This is erythema vesiculosum seu bul- losum. Hemorrhage may take place into the bulla?. It is uncommon to find all these forms present at the same time, nor must it be understood that one form neces- sarily evolves into the other. The evolution may stop at any stage; most often at the papular stage. Neverthe- less, more than one form is usually seen, so that the term multiform is merited. Crocker says that in children mul- tiformity is less the rule, the constitutional symptoms are more pronounced, and if vesiculation occur the vesicles are more prone to become purulent and leave scars. The duration of the disease is from two to four weeks, but it may be extended by a succession of outbreaks for months or years. Very infrequently a given lesion may persist for weeks. This is erythema perstans. The erup- tion is attended by burning rather than itching, and some- times by a feeling of tension. Slight pigmentation may be left, but it is transitory. Desquamation may follow the eruption, but it is not common. In some patients there is a decided tendency to relapse at irregular inter- vals for years. In Prof. George Henry Fox's service at the Vanderbilt Clinic, I have seen a boy with a relapsing bullous erythema of the face and ears that had appeared at intervals during ten years. The bulla? were of large size, fully distended, and of irregular shape. They left depressed, pigmented cicatrices in some places. Similar cases have been reported by others, as, for instance, by Hardaway , who saw one case with relapses for four years ; and T. C. Fox, who saw two cases with a duration of six- teen years in each case. As complications of erythema multiforme, and espe- cially of erythema nodosum, have been reported endo- and pericarditis, meningitis, pleurisy, pneumonia, and the ERYTHEMA 303 like; but it is better to regard these diseases not as com- plicating the erythema, but as the primary diseases of which the erythema is a phenomenon. Erythema Iris. — This disease was formerly regarded as a herpes, and is described in many text-books as herpes iris. Its other synonyms are hydroa, herpes circinatus, and hydroa resictdeax. It is. only a form of erythema multiforme. It is seen sometimes along with other manifestations of erythema multiforme, or withjierpes, though it usually occurs alone. It is located most often upon the backs of the hands and feet, and upon the arms and legs, but it may occur anywhere upon the skin as well as the mucous membranes. According to Crocker, there are two varieties of the disease, one with a central vesicle or a purplish depression surrounded by one or more whitish rings slightly raised up by effused fluid; the other with a central bulla with one or more rings of more or less discrete vesicles around it. Of these two, the first is the more frequent. The first variety begins as a small erythematous papule upon which a pinhead-sized conical vesicle forms in about twelve hours. The vesicle grows larger and flattens, but preserves a red areola. When about a quarter of an inch in diameter the fluid is absorbed in the centre, leaving a purplish depression; or only a ring of absorption occurs, so that there will remain a vesicle in the centre with a purplish zone about it, then a raised white ring, and around all a narrow pink areola. This play of colors gives the name of iris. The patch may reach the diameter of half an inch, and then undergo involution; or several patches may unite and form patches of one inch or more in diameter, and hemorrhage may take place into the bullae that may form. In the second variety, wmich is the hydroa vesicirfeu.r of Bazin, around a central bulla a ring of split-pea-sized vesicles forms, the vesicles being either discrete or touch- ing. A second or a third ring of vesicles may form out- side of these, the skin between them being a purplish 304 DISEASES OF THE SKIN tint. The bullae and vesicles may leave scars. Crusting also takes place from the breaking or drying of the vesicles. The lesions of both varieties are more or less symmet- rical, though a patch may develop on one side several days before the other. The duration is from three to four weeks or longer. Relapses are common. Burning is usually pronounced, and there may be some itching. From this description it will be seen that the so-called herpes iris is really an erythema. Erythema Nodosum, also called dermatitis contusiforme, and erytheme nouveux (Ft.), is more common than ery- thema iris, but not nearly so common as erythema multi- forme. It is only a variety of erythema multiforme, as it may occur as a part of that disorder. In the vast majority of cases it occurs alone. Its prodromal symp- toms are substantially the same as those of erythema multiforme, but its rheumatic pains are more pronounced and nearly always present. There are also tenderness and pain over the tibia. After a few days of prodromata, round or, more often, oval, bright or rosy-red swellings appear over the tibiae, with their long axis vertical. These are from nut- to egg-size; raised; their borders merge gradually into the surrounding skin; they are painful and often exquisitely tender; firm at first, they may be semi-fluctuating afterward; and their color darkens to a red, then purple, and in undergoing absorption they present the appearance of a black-and-blue spot from a bruise. The color at first disappears under pressure, to spring back when the pressure is removed. The changes of color subsequently seen are due to the gradual ab- sorption of the coloring matters of the blood deposited in the tissues. There are usually not more than a dozen lesions, generally less. They are most frequently located over the tibiae, but may occur as well upon the arms, scapulae, thighs, and mucous membranes. They are roughly symmetrical. The duration of the disease is, like that of other erythemas, two to four weeks. ERYTHEMA 305 Etiology. — The causes of erythema exudativum are not fully determined. It is probably due to some toxic condition of the blood, which may develop in the indi- vidual or be derived from without. It occurs more commonly in women than in men, and in young adults rather than in old people, while erythema nodosum is said to be most frequent in children. It is most frequent in the spring and autumn seasons, in which dampness and cold winds prevail, and sudden changes of temperature are common. The papular erythema is very often seen in recently arrived immigrants. Rheumatism has a well-marked causal relation to erythema nodosum, and, it may be, to the other forms. Syphilis seems to be an etiological factor of some weight in the production of erythema nodosum. Many cases seem to be due to systemic poisoning either by some infectious disease or by auto-infection. Some authorities are of the opinion that such cases should be separated from erythema exudativum, and propose the name of polymorphous erythema. It is seen with cholera, influenza, and the exanthemas; with indigestion, pregnancy, parturition, menstrual disturbances, kidney diseases, and various other internal or systemic disorders. Sometimes the disease seems to be a pure angioneurosis. Cases of erythema multiforme occurring with recurring attacks of gonorrhea have been reported. These appear as reflex angioneuroses without the ingestion of balsamics in the treatment of urethritis. Cases of erythema multi- forme not infrequently follow the ingestion of drugs; at least they are almost identical with it in appearance. Sometimes, according to Polotebnoff, it seems to be an abortive form of prevailing epidemics. Cases certainly should be watched carefully in connection with other symptoms, as they may be but part of the prodromata of some grave disorder. We have seen cases in which a well-marked erythema multiforme preceded for about ten days the outbreak of typhoid fever; the erythema then disappearing and the characteristic typhoid eruption 20 306 DISEASES OF THE SKIN coming in due course. Many of the subjects of erythema are debilitated. Individual predisposition probably plays an important role in the etiology of some cases, espe- cially in the relapsing ones. Pathology. — All forms of the disease show not only hyperemia, but also inflammatory effusion, both of fluid and leukocytes. Upon the amount of this fluid depends the character of the lesion. If small in amount, it will simply push up the epidermis into a papule or tubercle; if of larger amount, we shall have vesicles and bullae. There is also an escape of the coloring matter of the blood in the tissues (Crocker). Microscopically the papillary layer is seen to be the seat of the principal inflammatory changes; oedema, dilatation of the vessels, diapedesis, emigration of white corpuscles, and proliferation of the fixed tissue cells about the vessels. The covering of the bullae and vesicles may consist of the whole epidermis, or of only part of it. In erythema nodosum in addition to these changes, phlebitis of the larger subcutaneous veins has been found, and the frequent presence of white thrombi in the vessels. The epidermis rarely shows pathological changes. Diagnosis. — If the characteristics of erythema multi- forme are borne in mind, little difficulty in diagnosis will arise. These are the sudden occurrence of raised, bright or rosy-red lesions, located by preference upon the back of the hands and feet; the color of which fades away entirely under pressure, to return again when pressure is removed; and on disappearing they leave stains. It most resembles urticaria, but differs from it in having more stable lesions of more varied shape; in absence of wheals; in occurring particularly on the back of the hands and feet; and in burning rather than itching. The papular form differs from 'papular eczema in its chosen locations; in its burning rather than itching; in its papules being larger and never developing vesicles nor forming patches; in an absence of thickening of the skin; in disappearing completely under pressure; in tending to get well without ERYTHEMA 307 treatment; and in leaving stains. The nodes of erythema nodosum differ from syphilitic gummata in occurring suddenly and not gradually. In syphilis the redness does not occur until after the node has existed for some time, and the nodes are not tender nor developed sym- metrically. Moreover, there would be other evidences of syphilis. Treatment. — Villemin 1 maintains that iodide of potas- sium, in doses of at least 30 grains (2) a day, is almost a specific, and will abort relapses. The experience of Besnier and others has not been in accord with that of Villemin. Qyinin, 20 to 30 grains (1.33 to 2) a day, salicy- late of soda in 15 grain (1) doses three or four times a day, and salol sometimes abort or check the disease. Adrenalin, 1 in 1000, has been recommended as a specific. The dose is 10 drops, which may be repeated every three or four hours, watching its effect. As this is a new remedy it must be used with care. Arsenic may be tried in chronic cases. The treatment is mainly symptomatic, and directed to relieving the constipation, regulating the diet, aiding digestion, ameliorating rheumatism, or toning up the system. In obstinate cases the patient had best be kept in bed. Locally any alkaline lotion will afford relief, such as -Pulv. calamin. prsep., gr. xl 2 Zinci oxid., 3ss 2 Liq. calcis, ad §ij ad 64 M. Or, R* — Liquor plumbi subacetatis, ttlxv 1 Aqua?, 5J 32 M. Or, lead-and-opium wash, hamamelis, or other evaporat- ing solutions. Ointments should be avoided, as they do no better than lotions and are disagreeable to use. Sometimes a simple dusting powder will do as well as anything. 1 Gaz. hebdom., May 24, 1886. 308 DISEASES OF THE SKIN In erythema nodosum the patient should be kept in bed. Lotions are often more agreeable to the patient when used warm. Salicylic acid or salicylate of soda by the mouth may afford relief to the sometimes intense pains. Regulation and simplification of the diet, and the administration of diuretics or tonics, according to the nature of the case, will do good in the disease as seen in immigrants. Prognosis. — The disease tends to spontaneous cure. Relapses may occur, though they are by no means. the rule. Exceptionally the disease may run a protracted course, but recovery may be expected. Erythema Elevatum Diutinum. — See Granuloma annulare. Erythema Figuratum Perstans. — According to Wende 1 this is a rare disease that is not a form of erythema multiforme, It begins with scattered, isolated papules, which tend to fade at the centre while extending periph- erally, thus forming circinate erythematous outlines. The outer half of the advancing margin is smooth and slightly raised, the inner margin being scaly, which is a marked feature of the disease. Sometimes it leaves slight scaliness and pigmentation of the surface over which it has past. The larger lesions may be the size of a twenty-five-cent piece, the palm of the hand, or larger. The rings may be of circinate, annular, discrete, confluent, gyrate, or zigzag form. They may increase rapidly or slowly in size. Exacerbations may occur three or four times a year, the eruption, as a rule, not entirely disappearing in the intervals. There may or may not be subjective symptoms. The disease occurs both in children and adults. Other- wise the patients are in seemingly good health. The cause of the disease is not determined. It is probably due to some intestinal intoxication. Treatment is unsatisfactory, as the disease is quite sure to relapse. 1 Jour. Amer. Med. Assoc, 1908, li, 1936. ERYTHEMA INDURATUM SCROFULOSORUM 309 Erythema Induratum Scrofulosorum is a disease first described by Bazin as erytheme indure des scrofuleux. It consists in an eruption of nodular lesions that may remain deep seated for a considerable time, so that they can be made out only by palpation. There may be but one lesion or many. In the majority of cases the disease is bilateral. After a while the overlying skin becomes red, and later violaceous, and the lesions resemble those of erythema nodosum. In size they vary from that of a hazel-nut or larger on the legs, to smaller on the fingers. They are round or ovoid in shape and doughy to the touch. They are usually few in number and discrete, but may be numerous and confluent, and form large brawny infiltrations. They are chronic and indolent in their course, and may undergo involution, or sup- purate or necrose en masse. Polycyclic ulcers may form which heal slowly with scarring, or remain sluggishly open. A dark stain or a scar may be left on the disap- pearance of the lesions. There may or may not be pain or tenderness. They are located most often on the calves of the legs in young people, especially in young women of poor general health and circulation, who stand a great deal and who suffer from chilblains in winter, but may occur in others who present none of these peculiarities. They are prone to relapse at certain seasons. Pathology.— Inflammatory and degenerative changes affect the vessels, and giant cells are present in large numbers. The lesion has been compared in its appear- ance to a necrotic tubercle. No tubercle bacilli have been found in them by investigators excepting Kuz- nitzky, 1 who also obtained positive reactions to tubercle bacilli inoculations, and benefit from their use. Diagnosis. — They differ from erythema nodosum in their more circumscribed form, firmer consistence, darker color, deeper seat, absence of tenderness, tendency 1 Archiv. Dermat. u. Syph., 1910, civ, 227 310 DISEASES OF THE SKIN to ulcerate, and more protracted course. Syphilitic gummata are not bilateral, and usually other symptoms of syphilis can be found. The treatment consists in rest in bed, elevation and compression of the legs, and general tonics. Inocula- tions with Koch's old tuberculin in small doses are often advisable. If there are ulcers they should be treated like any common ulcer. Erythrasma. — A contagious parsitic disease of the skin, occurring especially in the groins and axilla? in the form of sharply defined, brownish-red, desquamating patches, bordered by a fringe of broken and partly detached epidermis (Foster). Symptoms. — The disease begins as little reddish-brown or orange-red points that soon become lentil-sized macules, which coalesce in a patch the size of a silver dollar, or the hand. Several patches join together, so that large sur- faces may be involved. The patches are oval or disk- shaped, or irregular in outline. The color of the patches is orange, red, yellowish, or brownish, or, in the folds of the skin, pale red. Their outline is sometimes marked by a raising of the epidermis. Their surface is dull- looking, and feels less smooth than normal and shows slight furfuraceous desquamation. They are quite tenacious, cannot readily be rubbed off, and show little tendency to spontaneous recovery. There may be slight itching. They are located in the situations where in- tertrigo is liable to occur, such as the axillae, groins, and where the scrotum comes in contact with the thighs. The latter situation is declared by Besnier to be nearly always the original site of the disease. From these favorite locations the disease may spread to the chest, abdomen, or thighs. Besnier 1 met with a case involving the thigh down to the knee. We have seen one case in which nearly all the skin was involved. 1 Jour, de Med. et do Chirurg. prat,, 1883, liv, 351. ERYTHRODERMIA, CONGENITAL ICHTHYOSIFORM 311 Etiology. — The disease occurs most often in men, and never in children. It is rarely seen in this country. It is due to a parasite called the microsporon minutissi- mum, which is described by Balzer 1 as consisting of long, wavy mycelia, that are rarely branched; and of very fine spores. High powers of the microscope are necessary to see them. They are located exclusively in the corneous layer of the skin. He regards them as a common form of parasite that produces the disease in some people only on account of the peculiar fermentation of their skin secretions. Diagnosis. — The disease resembles chromophytosis, eczema marginatum, and chloasma. It differs from chromophytosis in the darkness of its color; in the ab- sence of distinct, rather large scales that can be lifted by the nail; in its location, sparing the trunk, except by extension; and in the character of the microscopic appearances. From eczema marginatum it is distinguished by an absence of all inflammatory symptoms, ring- shaped lesions, and festooned margins, by not being more pronounced at the periphery than at the centre, and by the microscopic appearances. From chloasma it differs in being a parasitic and not a pigmentary disease, in the change it causes in the feel and texture of the skin, and in the effect of treatment. Treatment.- — It is curable by the same means as is chromophytosis, namely, wiping off the skin with pure alcohol followed by a saturated solution of the hypo- sulphite of soda; tincture of iodin; pyrogallol; chry- sarobin; bichloride of mercury; or sulphur. It is more obstinate than is chromophytosis, and quite as prone to relapse unless thoroughly eradicated. Erythrodermia, Congenital Ichthyosiform. — This disease is described by Brocq 2 as a chronic generalized redness of the skin which may be so slight as hardly to attract 1 Ann. de derm, et de syph., 1884, v, 597. 2 Annal. derm, et syph., 1902, iii, 1. 312 DISEASES OF THE SKIN attention, or so intense as to resemble pityriasis rubra or pemphigus foliaceus. There may be a marked hyper- keratosis shown as an exaggeration of the papillae of the neck and folds of the large joints, giving an appear- ance like acanthosis nigricans without the black color. There may be keratosis of the palms and soles; abun- dant pityriasis of the scalp; deformity of the nails, and bullae. The disease is congenital. The etiology is obscure. Diagnosis. — It differs from ichthyosis in its red color, its papular formation, and its involvement of the joints; from pityriasis rubra pilaris by being congenital, involv- ing the whole surface at once, by the different character of its scaling, and by absence of papular formations about hair follicles; from pityriasis rubra by being congenital, by not affecting the general health in spite of its chroni- city, and by the character of its scaling. Treatment is of no avail. Erythromelalgia is a nervous disease characterized by the appearance of a persistent patch of congestion, often on the sole of the foot, attended with swelling, itching, and pain (Foster). Hyperidrosis is often marked. It is a symptom in various grave diseases of the brain and spinal cord. Esthiomene. — This is a disease of the vulvo-anal region that was described by Huguier, 1 and about which there is a good deal of uncertainty. It has been variously considered as a form of lupus, syphilis, elephantiasis, and epithelioma. "It is characterized by a leaden or violaceous hue of the parts, and their simultaneous alteration of shape, induration, thickening, ulceration, destruction, hypertrophy, and infiltration, so that the orifices and canals of the vulvo-anal region may be at the same time ulcerated, enlarged, and constricted, and its grooves and cutaneous and mucous folds exaggerated, thickened, and the seat of more or less extensive and deep 1 Mem. de l'Acad. de Med., 1869, p. 507. FAVUS 313 ulcerations and cicatrices; without pain, without directly threatening life, and for a long time without affecting the constitution." (Foster.) Farcy. — See Equinia. Favus. — Synonyms: Porrigo lupinosa seu favosa seu lavalis seu scutulata; Porrigophyta ; Tinea favosa seu vera seu ficosa seu lupinosa seu maligna; Trichomykosis Fig. 3 3 { ' J . i i* s * \* Favus. (Jackson and McMurtry.) or Dermatomycosis favosa; (Fr.) Teigne faveuse, Teigne du pauvre; (Ger.) Erbgrind: Crusted or honey-comb ringworm, Scall head, True porrigo. A contagious vegetable parasitic disease due to the Achorion Schoenleinii, and characterized by the presence 314 DISEASES OF THE SKIN of discrete or confluent, circular, pale sulphur-yellow cupped crusts, or by asbestos-like masses of grayish friable crusts; by loss of hair producing irregularly shaped, disseminated, red, bald patches; by permanent atrophy of the scalp; and by running a chronic course. Fig. 34 Favus of knee. Symptoms. — Favus affects both the scalp and the non- hairy skin as well as the nails and mucous membrane. We shall first describe it as it affects the scalp. A lesion of continuity, however slight, is probably necessary for contagion to take place. In a case of favus in a newborn child the period of incubation was found to be from six to eight days. It begins either as one or more scaly erythematous spots; or as minute yellowish puncta; or as a group of vesicles smaller than those met with in ringworm. These develop into small sulphur-yellow cupped crusts about the hairs. When the case is seen by the physician the early stage is usually passed, and he will find that the hair is dry and lusterless, and has fallen out FAVUS 315 in places, leaving irregularly shaped bald patches, of all sizes, and of pronounced red color. Upon both the bald patches and the parts still covered with hair the sulphur- yellow cup- or saucer-shaped crusts will be found, with raised or rounded edges, and with one or several hairs growing out of the middle of them. There will be more or less scaling, and, if the disease be of some age, thick mortar-like crusts of grayish color. In some cases when first seen it may be impossible to find the characteristic crusts — scutula as they are called — they being obscured by the mortar-like masses. In some cases the scutula are wanting. If we approach near enough to the patient, we will appreciate a peculiar odor variously described as that of mice, straw, or of a menagerie. The crusts, or scutula, are situated about the hair follicles. They are from pinhead- to split-pea-size, according to age. At first they are covered with a thin layer of epidermis, but later the edges are free. When they are picked off they leave a moist depression which soon fills up, or a pustule, or an atrophied spot. The color is pale or sulphur yellow, or, if of long standing, it may be a dirty or greenish yellow. The crusts are discrete and disseminated or grouped; sometimes they coalesce; they are firm to the touch, and when crushed between the fingers impart a feeling of crumbling like mortar. There is a zone of slight redness about them. Though they may not be seen at the first examination, if the scalp is cleaned off and left to itself they will form in the course of two or three weeks. The baldness is rarely in well-defined patches. The patches may be few in number, or so numerous that the hair occurs only in islands. At first their color is inflammatory red; later they become white and atrophic in appearance. The baldness is permanent. The hair is dry from the first; later it becomes brittle and splits longitudinally; but it is never so easily broken as in ringworm, and can easily be pulled out with its roots. There is itching of the scalp. That is the only subjective symptom. Pustulation does not belong to the 316 DISEASES OF THE SKIN disease, but may be an accidental complication. The cervical glands are often enlarged; but do not break down. Its course is very chronic, and it does not tend to spontaneous recovery as does ringworm at the approach of puberty. Other complications that may arise are pediculosis, eczema, and enlargement of the cervical glands. Occurring upon non-hairy parts favus undergoes mate- rially the same development and forms the characteristic cups. Sometimes it will take the circular form of a ringworm with the formation of vesicles, and resemble Fig. 35 '/ Favus of hand, showing scutula. Side view. it very closely, only that the cups will be sure to develop somewhere. The scutula develop around the lanugo hairs. There may be only one patch of favus or a large part of the body will be covered by the fungous growth in the form of sulphur-yellow cupped crusts and asbestos- like masses. On the non-hairy parts the disease is easier of cure than on the scalp, and is not so apt to leave scars'. In a single case, that of Kaposi, the favic fungus was found implanted upon the mucous membrane of the stomach. The nails may be affected, either in the form of ony- chitis beginning at the side of the nail, hardly distin- FAVUS 317 guishable from the same disease developed from common causes; or in having a scutulum develop in the nail bed and show through the nail. This is rare. The occurrence of favus upon the head will give a clue to the origin of the onychitis. Etiology. — The disease is due to the implantation and growth of the Achorion Schoenleinii primarily in the scalp and secondarily in the hair. It is contagious, either directly from individual to individual, or through wearing the cap or using the hair-brush, and the like, of some fa vie person, but not so much so as is ringworm. It used to be rare in New York City, but on account of its being constantly imported from Europe, where it is very common in certain sections as in Hungary and Poland, the disease is on the increase, and cases occur in native Americans, mostly of foreign parentage. Though children between the ages of six and fifteen years are more commonly affected than are adults, it is by no means uncommon to see it in full activity in people well advanced in life. It has been asserted that the strumous diathesis predisposes to favus, but this is doubtful. Like all other parasites, it requires a certain soil upon which to grow, and does not affect all skins. Neglect of personal hygiene favors its spread. It is a common disease in mice, and may occur in rabbits, dogs, cats, and fowls, and thus be a source of contagion for the human race. Pathology. — The cups are composed almost wholly of the fungus, which consists of flat, narrow, branching and inosculating mycelial threads g-J-Q of an inch in diameter, and of pale-gray color; and of small spores of round, oval, flask, or dumb-bell shape, and of a pale- greenish color (Figs. 36 and 37). The spores gain access to the skin by the orifices of the hair follicles, and, after remaining there undisturbed, begin to grow in the upper part of the hair sac, and between the superficial layers of the epidermis, and subsequently invade the hair, growing in its cortical substance. The cup may be formed 318 DISEASES OF THE SKIN either by the sinking in of the more central portion of the mass, or on account of the central portion being attached Fig. 36 Favus of hand. Front Fig. 37 ^k/T'" ' Achorion Schoenleinii. (After Kaposi.) FAVUS 319 to the hair so firmly that it cannot so readily give way and bow out under the pressure of the growing fungus as do the parts farther away from the hair. The atrophy of the skin is largely due to the pressure of the growing Fig. 38 Achorion Schoenleinii in hair shaft and follicle. (After Kaposi.) fungus, which is powerful enough to destroy the cranial bones of mice; and in part to the inflammation of the skin produced by the presence of the fungus. There are at least four other species of the Achorion which produce favus in animals, and very exceptionally in man. These are achorion galling; oosporia canina of 320 DISEASES OF THE SKIN Sabrazes — Constantin; achorion Quinckeanum of the mouse; and achorion gypseum of Bodin. Diagnosis. — Most cases of favus are easy of diagnosis; the sulphur-yellow cupped crusts; the asbestos-like gray- ish mass; the red, atrophic bald spots, with tufts of dry and more or less kinky hair in them; and the peculiar odor, being so well marked. Ringworm has none of these features. Moreover, it occurs in the form of circular circumscribed, only partially bald patches covered with grayish scales, in moderate amount; has characteristic nibbled-off "stumps" of hair; and under the microscope we find the spores less abundant, smaller, and more uniformly round than in favus. It must .be confessed, however, that without the clinical features of one or the other disease, none but a most expert microscopist could make the diagnosis in a doubtful case by the microscope alone. In eczema baldness is very rare, and we will usually find a characteristic patch of the disease behind the ear; its crusts are greenish and tenacious, not gray and friable; the hair is matted by the sticky exudation; and if discrete impetigo lesions are present, they will contain pus, and not be solid like the favus crust. Leav- ing the scalp alone for a time will decide the matter, as scutula will be sure to form if the disease is favus. Sebor- rheal dermatitis causes a general thinning of the hair; the scalp is not atrophic; there are no scutula, and no achorion in the hair and scalp. Lupus erythematosus resembles favus only in producing atrophic red spots. There will usually be patches of the disease elsewhere, and its whole course is different. Psoriasis does not cause atrophic bald spots, and rarely occurs on the scalp alone. Alopecia areata presents more or less circular bald areas, but these are white, smooth, and of normal texture, and there is no fungous growth in the hair. Alopecia from syphilis in its secondary stage resembles favus more closely than any other disease of the scalp; but it occurs primarily at a later age than does favus, it comes on more suddenly, there is no history of crusts, nor FAVUS 321 cicatricial alteration of the scalp, and there will be other evidences of syphilis on the body, and (especially in women) the broken arch of the eye-brows. Folliculitis decalvans bears a resemblance to favus when the cups and crusts have fallen. In it there are no tufts of dry, wiry hair; the hair comes out less easily when plucked; it is a disease of adults; and no achorion is found in the hairs. It is also a follicular disease, individual inflamed follicles being most always found. Treatment. — In the treatment of the disease we need three weapons — patience, perseverance, and parasiticides. Before using the last we should always epilate, pulling the hair out systematically from day to day, so that eventually all the hair of the scalp is plucked. To do this we may use the epilating forceps (Fig. 39); or Kaposi's Piffard's epilating forceps. method of grasping the hair between the thumb and a spatula or piece of stiff cardboard held firmly in the hand; or, in dispensary practice, we may employ epilating sticks, made, according to Bulkley, of Cerae fiavse, 5ij 8 Laccae in tabulis, 3iv 16 Picis burgundicae, 3x 40 ! Gummi damar., Siss 48 M. These ingredients are to be melted together, and then moulded into sticks a half-inch or more in diameter. They are to be used by melting the end, and when warm applying it to the hair with a sort of boring motion. When cold they are to be suddenly twisted off, when, of course, they will bring many hairs with them. The "calotte," or pitch-cap, used to be employed for this purpose, but was given up because it caused the death of several patients. Kaposi's method is the best of all. If 21 322 DISEASES OF THE SKIN the head is greatly crusted, the crusts may be scraped off with a curette or cleaned off by means of soaking the scalp with oil for a day or two, and then washing with soap and water. For an oil we can use sweet oil, sweet almond oil, or cotton-seed oil, with 3 per cent, of carbolic or salicylic acid. The use of these oils should be continued throughout the whole course of the disease to prevent the spread of the fungus upon the scalp of the patient and of other people. After the first washing we should allow the scalp to go unwashed for twenty-four hours, so as to permit the full action of the parasiticide. After the crusts are removed the diseased hairs should be pulled out. After the cleansing and the epilation the parasiticide must be rubbed and worked into the scalp. Of these there are many from which to choose. An ointment consisting of a drachm (4) of the crystals of iodin in an ounce (32) of goose grease is one of the best. It cannot be used over all if the whole scalp is involved, but in sections. Sulphur ointment is efficacious, if properly and per- sistently used. Other ointments are thymol, naphtol, resorcin, chrysarobin, and pyrogallol in 5 to 10 per cent, strengths, and those of the ammoniate or yellow sulphate of mercury. The ointments are to be firmly rubbed into the scalp every day after washing with soap and water. Or solutions may be employed, as bichloride of mercury; 2 grains to the ounce of ether or alcohol; the oleate of mercury or copper, 10 to 20 per cent.; tar; oil of cade; creosote in ether or alcohol; sulphurous acid in full strength; salicylic acid, 5 per cent, in oil; or tincture of iodin, or resorcin 1 drachm (4) to the ounce (32) of lanolin and oil. Iodin, according to Sabouraud, should be used only once a month; in the meantime the scalp should be washed alternately with alcohol and camphorated alcohol, or with a solution of salol, 1 .5 per cent., and kept constantly anointed with iodin ointment. After a month the epila- tion and the iodin are to be repeated. Hydronaphtol plaster is said to do good service in favus, used according to the method described under Trichophytosis, which FAVUS 323 see. Peroni 1 recommends spraying the head with acetic acid used in an atomizer, after covering any excoriated points with diachylon ointment on a piece of cloth. At first the scalp feels cold. Hyperemia follows which lasts about forty-eight hours and disappears, leaving slight desquamation. When the hyperemia lessens the acid is to be again used. When there are no excoriations the head is to be washed every morning and evening with water and corrosive sublimate soap. Besnier and Doyon 2 recommend as a preparatory treatment for favus that the hair be cut off from and around all the patches, and the whole head covered for two or three hours with equal parts of soft soap and lard. This is to be washed off with warm water, and the head is to be kept covered dining the night with a cap of rubber or other impermeable cloth. The next morning the head is to be washed perfectly clean, bathed with a solution of boric solution (25 to 1000) and covered with borated lint soaked in the following solution: -Sodii salicylate 5uj 12 Sodii bicarbonati, Siiss 10 Aquae, ad Oij ad 1000 M. Over all comes the impermeable cap. After a few days the dermatitis will disappear and the scalp will be clean, and then epilation must be practised, the hairs being pulled not only from the patches, but for about a half- inch about them. Epilation is to be repeated every week until no longer any trace of redness about the hairs exists, and the head is to be kept covered with the impermeable cap. Every evening the whole head is to be rubbed with antiparisitic ointment, such as: 1$ — Bals. Peruv. vel., 01. cadini, 2 to 5 parts. Ac. salicyl., Resorcin., aa 1 to 5 parts. Sulph. prrecip., 5 to 15 parts. Lanolini, Vaselini, Adepis, aa p. e. ad 100 parts. M. 1 Ann. de derm et de syph., 1891, ii, 797. 2 Kaposi: Mai. de la Peau, French ed., Paris, 1891. 324 DISEASES OF THE SKIN Every morning the whole scalp is washed with tar soap, and each favic patch is soaked with the following: i. — Alcoholis (90 per cent.), 100 parts Ac. acetic, (crystals), \ to 1 part. Acid, boric, 2 parts Chloroformi, 5 parts M. Then each patch is to be accurately covered with mer- curial plaster. Epilation is rapidly and painlessly effected by x-rays. It is possible to cure a case by this means, but it is better to use some antiparasitic after the hairs have fallen. The method of using .r-rays is the same as in ringworm, to which the reader is referred. Favus of the non-hairy parts of the body usually yields readily to the removal of the crust and the use of a parasiticide. Favus of the nail may be treated by the constant application of ^a mercurial, resorcin, or hydronaphtol plaster. If the disease is limited to one or two points, they may be cut down upon and the remedy applied directly. Sometimes it may be necessary to remove the whole nail. After a case of favus has been faithfully treated for a number of weeks and looks as if it were well, it should be let alone and watched carefully for a long time. Any red point that appears is evidence that the disease is cropping up again, and should be immediately attacked. Pkognosis. — The prognosis is good, provided the case is faithfully and energetically treated. Relapses will surely occur if any of the fungus remains in the scalp. A cure takes months or years to effect by the older methods, while the use of x-rays greatly expedites the cure. The scars from favus are permanent. Favus of the nail is especially rebellious to treatment, and may cause permanent destruction of the nail. Feigned Eruptions. — See Dermatitis factitia. Fever Sore. — Herpes facialis. FIBROMA 325 Fibroma. — Synonyms: Fibroma molluscum; Mollus- cum fibrosum; Molluscum simplex; Molluscum pendu- lum; Recklinghausen's Disease; Neurofibroma. Fibromata are soft tumors of the skin that are com- posed of a hyperplasia of the connective tissue as well as the subcutaneous tissues, and occur in A'arious shapes, colors, and sizes. The most commonly encountered form of fibroma is Molluscum fibrosum. — This may be of the color of the skin, or pinkish or even brownish or brownish red; most commonly it is of normal skin color. It may be rounded, flattened, sessile, or pedunculated, but always raised above the level of the skin. It may hang down like a polypus. The skin over it feels soft and of normal text me, or it may be thickened or atrophied. Hairs sometimes grow from it. There may be but one or two present, or there may be hundreds of them so that the body is strewed over from head to foot with the variously shaped tumors. The trunk is the most common location for fibromata, but they may occur on all parts and involve even the mucous membranes (Fig. 39). They give rise to no inconvenience except on account of their size, which sometimes may be that of a child's head or larger. Their usual size is from that of a cherry to that of a walnut. Many of them show a slow growth, while many are stationary, and some may undergo involution. Comedones of large size may accidentally form in some fibromata. The larger ones may ulcerate. All of them feel soft, while the larger ones may be elastic to the touch. When they hang down in the form of large skin folds which have undergone hypertrophy, the term fibroma pendulum is applied to them. Dermatolysis (which see) has been considered a form of fibroma. According to some authorities, fibrous moles and soft warts are but forms of fibroma. Scattered among the tumors there may be irregular patches of brown pigment, and more or less freckles, hairy moles, and vascular nevi. The skin may be coarse. 326 DISEASES OF THE SKIN There is another form of fibroma to which the name Achrochordon is applied. They occur as small, soft pedun- culated, vascular, and mole-like lesions upon the face, shoulders, and elsewhere in elderly people whose skin is Fig. 40 Multiple fibromata. 1 degenerated. They often take the form of little hernia- like sacs of skin when their contents have been absorbed. There is also a hard variety of fibromata called des- moids. These occur as round or oval, compact, smooth nodules, from hemp-seed to pea size. 1 From a photograph of a case of Dr. E. T. Tappey, of Detroit. FLESHWORMS 327 Etiology.— Fibromata usually appear in childhood, though they may not do so until later in life. They are sometimes hereditary, and are often seen in several members of the same family. They tend to increase with advancing age— that is, they are not so large or numerous in children as in adults. Children with multiple fibro- mata, Recklinghausen's type, are often stunted both physically and mentally. By some authorities they are regarded as related to neurofibromata. Pathology. — The early tumors and the central por- tion of the older growths, consist of embryonic connec- tive tissue. The density of the tumors increases toward the surface, the larger growths being provided with a firm fibrous sheath. Diagnosis. — Molluscum fibrosum differs from mollus- cum cantagiosum by not having a central depression, and by being of the normal color of the skin. They are also usually far more numerous. From fatty tumors they differ in not being lobulated, and in being pedunculated and less flat. Sebaceous cysts are not so numerous, and their contents can be squeezed out to a large extent, while fibromata are solid. Treatment. — They may be snipped off with scissors or tied off with ligature if pendunculated. If non- pedunculated, they may be destroyed by electrolysis or excised. If of- large size, they may be excised. The galvanocautery may be used to destroy any form. Flea-bites caused by the pulex irritans, occur in the form of small red puncta which may or may not be in the centre of wheals. They sometimes bear a close resem- blance to urticaria that has been scratched. The grouped arrangement of the lesions and the limited areas upon which they occur suggest their origin. A certain amount of protection is afforded by dusting the inside of the clothing with pyrethrum powder. The irritation may be relieved by the use of carbolic acid and alkaline lotions. Fleshworms. — See Comedo. 328 DISEASES OF THE SKIN Fluxus Sebaceus.— See Seborrhea. Folliclis.— Synonyms: Lupus erythemateux dissemine; Folliculites disseminees des parties glabres; Acne vario- liformis of the extremities; Hydrosadenite disseminee suppurative; Necrotising chilblains; Granuloma inno- mine; Toxi-tuberculides papulo necrotiques; Granuloma necrotica. Symptoms. — Considerable doubt exists as to the exact status of the disease. It is probable that it is the same as the small pustular scrofuloderm described by Duhring. The eruption consists in flattened pinhead, rounded papules that develop deep down in the derma. They increase in size to that of a lentil. Their color is dark red or violaceous. They are firm to the touch and sur- rounded by a red areola. Pustules form on top of them, and these dry into crusts which are adherent, and when removed disclose a small but deep ulceration. Pinhead pit-like cicatrices are left which may have pigmented areolae about them for a time. The papules abort some- times and leave no trace on the skin. Their evolution takes four or five weeks, and the lesions come out in crops, so that all varieties are present at the same time. There is no definite grouping nor subjective symptoms excepting, sometimes, tenderness or pruritus. The disease affects all parts of the body, but is most abundant on the limbs, upon which it commences, espe- cially on the hands, feet, elbows, and kness. On the ears and fingers they appear like chilblains. Sometimes the disease is confined to the hands and feet. When the dis- ease spreads it does so by continuity. Its spread may be continuous or interrupted. It comes out sometimes at certain seasons of the year, as spring or autumn. Etiology. — Most cases occur in those who have a poor circulation, as shown by a dusky blueness of the hands and feet, and in children or young people. It is seen with lupus, and in those who present evidence of tuber- culosis or scrofuloderma. It is described by the French as a tuberculide. FOLLICULITIS DECALVANS 329 Pathology. —It is regarded by some as a granuloma. According to Hartzell 1 it begins with inflammatory changes in and around the bloodvessels in the deeper portions of the coriurn, and gradually extends to the surface. There is an abundant round-celled infiltration about the vessels with thickening of their walls and obstruction or obliteration of their lumina, followed by necrosis of the tissue of the corium. Tubercle bacilli have not been found in them. Diagnosis. — Folliclis is allied to acne necrotica. It differs from it mainly in location, the latter preferring the face. It differs from acne in its distribution, slug- gishness, variola-like scars, and absence of comedones. Treatment. — Crocker advises the application of a mercurial plaster before suppuration has occurred. After that has occurred the central core is to be removed and the pit washed out with a 1 in 40 carbolic acid lotion. Everything must be done to improve the general health as in tuberculosis, and to stimulate the local circulation. Whitfield recommends calcium lactate, and nitroglycerin , Folliculitis means an inflammation of the hair follicles. When the hairs involved are those of the beard we have F. barbae, or sycosis (which see). The hair follicles on the extremities, especially of the legs, may become inflamed on account of some irritant applied to the skin. One form of this is tar acne. In workers in oil or paraffin it is no uncommon thing to see each hair on the legs, espe- cially the thighs, standing in the centre of a red papule or pustule. The cure consists in removing the cause, in cleansing the parts, and the application of an alkaline soothing lotion. Folliculitis Decalvans. — Synonyms: Alopecia cicatri- sata (Crocker), or orbicularis (Neumann), or circum- scripta, or atrophicans; pseudo-alopecia atrophicans; pseudo-area ; Ulerythema sycosiforme ; Perifolliculitis i Med. Rec, 1906. lxix, 1012. 330 DISEASES OF THE SKIN cicatrisans; Acne decalvante on pilaire cicatricielle depilante (Besnier); Alopecie innominee (Besnier). These, and still other names have been given to a group of diseases of hairy parts characterized by: (1) A follicular and perifollicular inflammation; (2) a complete destruction of the hair follicles causing absolute bald- ness; (3) the formation of cicatricial tissue; and (4) a tendency of the lesions to agminate or group. It occurs principally in three forms: (1) Alopecia cicatrisata; (2) Depilating folliculitis, and (3) Ulerythema sycosiforme. The last will be described under Sycosis. Alopecia Cicatrisata. — This is the alopecie innominee of Besnier, the pseudopelade of Brocq, and the alopecia orbicularis of Neumann. Symptoms. — The disease begins insidiously without pain or perceptible inflammation. There may be sebor- rhea, pityriasis, or slight pruritus of the scalp. Inspection of the scalp reveals a number of small bald spots, which may be of faint rosy color, but usually are white, smooth, and ivory-like. Any part of the scalp may be affected but the vertex is so most often. The disease may begin at one point, but most often many places are affected, the hair falling from them. There may be only small patches, or large ones with satellites. When there are only small patches, the scalp will appear cribbled with them. They will vary in size from that of a large pin- head to a small or large lentil or a ten-cent-piece. The smaller ones are round or oval, while the larger ones are irregular in shape. In some places two or more larger ones may unite to form still larger, irregular, serpiginous patches. The lesions are often concealed by the long hair. By the coalescence of patches large ones up to the size of the palm of the hand may form, irregular in shape, polycyclic, with notches in the edges showing the remains of primitive patches; or band shape with single hairs or tufts of hair in the cicatricial tissue. Usually there are small and large patches, sharply defined, with an FOLLICULITIS DECALVANS 331 erythematous zone, in which will be hairs showing folliculitis, or some scaling. Fig. 41 Pseudopelade. (Brocq.) Fig. 42 Pseudopelade. (Broeq.) 332 DISEASES OF THE SKIN The diseased scalp is thinned, atrophied, or depressed ordinarily,, but it may be smooth and soft, at times transparent resembling an onion skin. Exceptionally it is lardaceous and succulent. Sensation may be lost in the large patches especially. The hairs at the edge of the patches may be normal, or show some signs of inflammation about them. When the hair falls it has a pulpy, transparent sleeve about its root. All signs of inflammation cease with the falling of the hair. The course of the disease is very slow, excepting at the beginning, when it may be rapid. Its progress is usually marked by periods of quiescence and activity. It takes several years to involve a large part of the scalp and while it never causes complete alopecia, the alopecia is permanent. Etiology. — The disease occurs between the twentieth and fortieth years of life, most frequently in men with dark hair. It is probably parasitic, though no one has isolated a parasite in connection with it. Diagnosis. — The disease is differentiated from alopecia areata by the absence of exclamation-point hairs, and by the presence of many small atrophic patches of permanent baldness. Lupus erythematosus differs from it by being in sharply defined patches either with red closely adherent scales, or else white and depressed with a red border. The patch of lupus is completely bald while in alopecia cicatrisata there are often little tufts of hair in the patches. When favus has its characteristic crusts there is no diffi- culty in diagnosis. In old favus there are tufts of dry curly, wiry hair, which are not seen in pseudopelade. Favus also is a disease of early life, and its hairs are full of spores. Depilatiny folliculitis has inflamed follicles, and pustules about the hair. In cicatricial alopecia from impetigo the areas of baldness are very small and few in number. Depilating Folliculitis. — This is the acne decalvante of Lailler, and the folliculite epilante of Quinquad. FOLLICULITIS DECALVANS 333 Symptoms. — This disease is most common in the scalp but may occur also in the beard, axillae, and on the pubes. It begins as small pustules or papules pierced by hairs. The pustules dry into small crusts. The lesions at first are disseminated and discrete. Neighbor- ing follicles become affected. The hair falls from the pustules and permanent cicatrices are left. In this way Fig. 43 Depilating folliculitis. eventually bald patches are formed. Usually the process has gone on for some time before it is discovered, and then there will be found a number of small patches from one- half inch to an inch or more in diameter, which are pale white, usually glistening, smooth and cicatricial with red points in them. About their edges and among the neigh- boring hairs there are red papules, pustules, and puncti- 334 DISEASES OF THE SKIN form miliary abscesses with hair in their centres. When a hair is plucked from a diseased follicle a red point is left. In this way the disease spreads. There may be tufts of sound hair in among the bald areas. The disease is slowly progressive. Pruritus is often marked. Fig. 44 Depilating folliculitis. Etiology. — Brocq considers the staphylococcus aureus as the direct cause of the disease, and the predisposing factors the same as in sycosis. Diagnosis. — The disease must be diagnosed from alopecia areata, favus, lupus erythematosus, ringworm, and alopecia cicatrisata (which see). Prognosis. — There is no possibility of restoring the hair in either form of the disease. The baldness is per- manent. It is possible to check the advance of the disease in some cases. After a while it may reach a quiescent stage spontaneously. Treatment. — In either form the hair should be plucked from the diseased follicles, and a sulphur or mercury FORDYCE'S DISEASE OF THE LIPS 335 ointment well rubbed into the scalp. We have seen the course of the disease apparently stopped by the daily use of: 1$ — Ac. salicylici, gr. xv 1 Sulphur, colloidal, 3.i 4 Adepis lanse, Adepis anserini, aa p. e. ad 5J 32 01. rosae geran., gtt. viij M. The scalp is to be washed once or twice a week, and the ointment applied after the hair is dry. Folliculitis, Depilating, of the Limbs. — This is a rare affection which is met with chiefly on the anterior and lower parts of the legs and on the thighs. It is symmetrical. It begins as red papules, from millet seed to pea size, pierced by a hair. This is soon sur- mounted by a pustule that dries into a crust. After some weeks the papule becomes absorbed, the hair falls, and a small pigmented cicatrix is left. The hair is per- manently lost, a punctiform cicatrix marking its former site. The disease occurs in patches surrounded by an irregular and ill-defined zone of folliculitis in process of development. It is chronic in its course, occurs usually in middle-aged men, and arises without known cause. Treatment has thus far been without effect. Fordyce's Disease of the Lips. — In 1896 J. A. Fordyce 1 first called attention to this disease, which is probably not very rare, as a number of cases have been reported since then. It affects the mucous membranes of the lips in the form of patches made up of small, irregular, closely aggregated milium-like bodies of light-yellow color, located just beneath the mucous membrane. The same bodies are also scattered disseminately about the patches. Burning and itching, and a feeling of tension as if the lip were swollen, are complained of. Similar lesions occur on the inside of the cheeks along the line of the closed teeth. These are somewhat lighter in color, 1 Jour. Cutan. and Gen.-Urin. Dis., 1896, xiv, 413. 336 DISEASES OF THE SKIN more elevated and papillomatous. The milium-like bodies can be removed readily. They may be found in several members of the same family, and increase with age. They are atrophic sebaceous glands in the mucous membrane. Thus far no effective treatment has been found. Fragilitas Crinium. — See Atrophia pilorum propria. Frambesia. — See Yaws and Dermatitis papillaris capil- litii. Freckles. — See Lentigo. Frost-bite. — See Dermatitis calorica. Fungous Foot of India. — Synonyms: Madura foot; Mycetoma; Podelcoma; Ulcus grave; Tubercular dis- ease of the foot. This is a disease that is endemic in certain parts of India, but has been met with in this country. Though usually affecting the foot and leg, it is seen occasionally on the hands, shoulders, and scrotum. According to Crocker, there are three varieties, the pale, the black, and the red, the latter being very rare. It may begin with slight congestion of the affected part; or as a local induration, either superficial or deeply seated, of some part of the foot, which is firmer, larger, more diffused, and less painful than a boil. When this is opened, it discharges pus at first, later granules like poppy seeds, or mulberry-like masses are mingled with the discharge. Or it may begin as a blackish or bluish mottled discoloration like tattoo puncta. The progress of the disease is slow, but in the course of a few years the foot becomes swollen and distorted, the arch being broken, the toes being over- extended, and the sole convex from behind forward. It becomes dotted over with the raised orifices of sinuses extending deep down into the tissues, and giving vent to the above-described discharge. It is more common in males than in females, and in those who work barefoot, and is rare before puberty. Its origin is obscure, though it is supposed to be due to FURUNCULUS 337 a fungus, perhaps to more than one. It is said by Oppen- heim 1 that the pale variety is caused by an actinomy- cosis, and the black variety by an oidium or mold fungus. Surgical interference combined with the administration of iodide of potassium in large doses is the only hope for a cure. Fig. -45 Mycetoma. Furunculus. — -Synonyms: (Ft.) Furoncle, Clou; (Ger.) Blutschwar; Furuncle or Boil. An acute circumscribed phlegmonous inflammation around a skin gland or hair follicle, characterized by one or more round, more or less acuminated, firm, painful formations, and usually terminating by necrosis and suppuration (Foster). 1 Archiv f. Derm. u. Syph., 1904, lxxi, 209. 22 338 DISEASES OF THE SKIN Symptoms. — This is a common and familiar disease of the skin. Its most frequent locations are the back of the neck, face, forearms, buttocks, and legs, though it may occur anywhere. It begins as a small, round, red, pain- ful spot, which in two or three days enlarges to attain the size of a split pea or silver quarter- or half-dollar. It is now raised above the surface, hard, of a dark-red color at the centre, with the redness fading away into the sound skin, more or less pyramidal in shape, exquisitely tender to the touch, and with a most agonizing throbbing pain. Its centre soon becomes yellow, indicating the point at which suppuration has taken place, and where it will open. From the opening comes the "core," a greenish-gray or whitish pultaceous mass mixed with pus and blood. With the escape of this all the symptoms subside and the cavity fills up by granulation, leaving more or less of a scar. The course of the individual boil is from seven to ten or fifteen days. At times suppuration does not take place, but the mass undergoes resolution. This is the so-called "blind boil." Any boil may leave in the skin a thickened, indurated mass that slowly undergoes absorption. There may be but one boil or there may be dozens of them. They come out in crops of from two to half a dozen at a time. If very numerous, or of large size, they give rise to constitutional disturbance. They may continue to form for weeks, months, or even years, if left untreated. This is what is called furunculosis . Boils are always isolated. They may be confined to one locality or come out in a number of regions at the same time. There may be sympathetic enlargement of the neighboring lymphatic glands. If the disease is extensive, the patient presents a truly pitiable condition. If a boil starts from a sweat gland, it resembles that which originates in a sebaceous gland, except, according to Crocker, it has no mattery head and is somewhat less indurated. This form of boil is called hydradenitis by Verneuil and Bazin. It is of the size of a pea, and is most often met with in the axillae, about the anus and perineum, FURUNCULUS 339 near the nipples, and may form anywhere where there are sweat glands, excepting on the soles of the feet. Boils may occur in the external auditory canal in conjunction with the disease elsewhere. They are exceed- ingly painful and produce deafness. One or both ears may be affected, but usually it is only one ear. They may set up inflammation of the entire canal and tympanum; one case of this sort has ended fatally. If the furuncle is situ- ated in the posterior wall of the canal, or a general in- flammation has been set up, considerable redness and tume- faction over the mastoid region may occur (Dr. A. Rupp 1 ). Etiology. — The cause of furuncles is the entrance into the skin of the staphylococcus pyogenes aureus et albus. Local infection produces crops of boils occurring in one region, and the doctrine of local infection finds further support in the results of treatment by antiseptics. It must be remembered that these micrococci are widely distributed, having been found in dish-water, in the super- ficial layers of decayed vegetable matter, in the swaddling clothes of healthy infants, in the dirt under the finger nails, and in numerous other places. Like other parasites, these require some peculiarity of soil for their growth, or at least an opportunity for gaining entrance to the gland- ular apparatus of the skin. The soil is afforded in lowered vitality of the skin, and thus we find boils in diabetes mellitus, after specific fevers, in anemia, lithemia, uremia, and septicemia; and as a complication of other skin dis- eases, such as eczema, prurigo, lichen tropicus, and scabies. In many, perhaps in most cases, no disorder of the general health can be discovered. The second con- dition is fulfilled by local injury to the skin, such as friction or pressure, or scratching. Boils are contagious, as well as auto-inoculable, and can be produced by inocula- tion of pure cultures of the micrococcus. The popular notion of their origin from too good living or from being run down is only another way of saying that they occur in 1 Personally communicated. 340 DISEASES OF THE SKIN individuals not in perfect health. Boils are said to affect males more often than females, and to occur especially between the twentieth and fortieth years of age. Pathology. — The inflammation begins in the corium and deeper tissues in or about the hair follicles or glands of the skin. "The mechanism of the process is supposed by some to be that the vessels around the gland or follicle become blocked, producing its death, and inflammation is then set up around the necrosed tissue to get rid of it by suppuration." (Crocker.) Diagnosis.— The disease is so common that there is no need for detailing the diagnosis. For the diagnosis from carbuncle, see under that word. Treatment. — In most cases there is no need of inter- nal treatment. If the patient is out of health in any way, we should endeavor to help him back to his normal con- dition. In furunculosis we should always bear in mind the probability of there being diabetes mellitus at the bottom of the mischief, seek for it, and do our best to cure the patient if we find evidence of it. There are many drugs recommended for the treatment of boils, apart from constitutional conditions. Of these, sulphide of calcium is one of the most popular, y 1 -^ of a grain being given every two or three hours, or a J to \ grain three or four times a day. It is of doubtful efficacy. Piffard speaks well of the compound syrup of the hypophos- phites, a dessertspoonful three times a day. Hardy recommends tar-water up to a quart a day. The sulphite or hyposulphite of sodium in 15 to 20 grain (1 to 1.33) doses three times a day is also well spoken of. Yeast is a homely but sometimes efficient remedy, either a J wineglassful being taken night and morning, or a like quantity in divided doses, or one of Fleischmann's yeast cakes being eaten during the day. Le Gendre, 1 believing that boils may arise from the absorption of products of imperfect digestion, advises the disinfection of the intes- tinal tract by the use of the following powder: 1 Union med., 1888, xlv, 98. FURUNCULUS 341 3— £-naphtol, Bismuth, salicylate Magnesia carb., aa gr. ivss 30 M. which is to be given every four hours. The most recent method of internal treatment is by vaccines. Engman says: Bacteriotherapy as frequently fails in the treatment of boils as it succeeds. Autogenous vaccines in such conditions should always be made. The dose varies widely, 50,000,000 should be the initial dose at four days' interval. The daily dose as practised by many ignores the negative phase and is the source of many failures. The stimulation of antibody formation must follow certain fixed chemical and physical laws, few of which are definitely known, but those known must be followed to obtain results. Hot packs and Bier's cups assist the lymph to the part. The local treatment of boils is important and efficient. They should not be poulticed, as, being due to a fungus, the heat and moisture only facilitate the growth of the same and the production of new boils. That new boils are apt to spring up about a poulticed boil is a common experience, and for this reason, if it is deemed advis- able to obtain the relief and comfort that a poultice undoubtedly gives, hot compresses of boric acid should be used. The best treatment for boils is the following: Around the sharpened end of a wooden toothpick is wound a small bit of absorbent cotton. This is dipped in carbolic acid solution, full strength, and bored into the cavity of the boil. The boil should not be squeezed. A 10 per cent, ointment of salicylic acid should be worn constantly over and about the boil. If the boil has not pointed a few drops of a 2 per cent, solution of carbolic acid may be injected into its base. Mercury may be used instead of carbolic acid, the boils being kept covered with emplastrum hydrarg, with a little hole cut in the plaster to correspond to the centre of each boil; or an ointment of the nitrate or red oxide may be used. Painting with iodin is also commended; as well as keeping them 342 DISEASES OF THE SKIN' covered with a saturated solution of boric acid, or an 8 or 10 per cent, plaster or ointment of salicylic acid. Hardaway speaks highly of Unna's carbolic acid and mercury mull plaster. Electrolysis to destroy the follicle is spoken of by the same authority. For some time after the boils are apparently cured it is well to bathe the affected region daily with a saturated solution of boric acid. Furuncles of the Ear.— My friend, Dr. A. Rupp, late aural surgeon to the New York Eye and Ear Infirmary, has kindly advised me on this head as follows: In the treatment of furuncles of the external auditory canal the first requisite is that the physician sees that which he is to treat. If the auditory canal be filled or unclean, it must be syringed out with a 2 to 5 per cent, solution of carbolic acid, followed by a solution of bicarbonate of soda as hot as can be comfortably borne. The canal is to be dried with absorbent cotton, and if the membrana tympani is intact filled with 33 1$ — Hydrarg. bichlor., gr. v Glycerini, Alcoholis, aa 5J aa 32 M. which is to remain in some minutes, and then the excess is allowed to drain off. The canal is lightly closed with borated or salicylated absorbent cotton. Protargol, 5 grains (0.32) to the ounce (32) of water, applied on pledgets of absorbent cotton and left in for an hour or two, gives good results. If the membrana tympani is deficient, the whole canal is to be filled with powdered boric acid and the orifice closed as before. In either cases the cotton is to be changed when soiled. When furuncles are at the inner end of the canal near the membrana tympani, a leech or two in front and a little above the tragus will afford much relief. It is unnecessary to incise the fur- uncles except where pus has formed and has no outlet. Prognosis. — In most cases boils are annoying, but not dangerous. Those about the face give the most trouble. Each boil runs its course in from one to two weeks. GANGOSA 343 How long new boils will continue to form it is impossible to say. If the treatment by carbolic acid is used, the disease is usually soon over. In furunculosis all will depend upon how soon we can get the patient into a better physical condition. Gangosa. — Synonyms: Rhinopharyngitis mutilans. Symptoms. — According to Mink and McLean 1 this disease begins as a tonsillitis or pharyngitis. A yellowish- gray membrane forms. It is elevated, thick, and tena- Fig. 46 Gangosa. cious. In twenty-four hours ulceration takes place. The ulcer is punched out, has undermined edges and a deep uneven floor covered with a yellowish-white, offen- sively smelling discharge, with an inflammatory zone one- quarter of an inch wide about it. It rapidly increases in depth, perforates in seven days, then spreads slowly and steadily, emerges from the nose or oral cavity on to 1 Jour. Cutan. Dis., 1907, xxv, 503. 344 DISEASES OF THE SKIN the face, and after years causes great deformity by converting the skin into a cicatrix. It may last many years with periods of quiescence and activity, without affecting the general health of the patient. Less common is a fulminating form with rapid toxemia and death. Etiology.— The disease occurs in tropical countries, and is especially common in Guam and the Philippines. Most cases occur in the second and third decade of life. It is slightly more common in women. It rarely affects the white race. It is not hereditary. It is due to an undetermined infective agent. Diagnosis. — It differs from leprosy in its sudden onset, absence of bacilli, and by not affecting the health of the patient; and from syphilis by an absence of the history and symptoms of that disease, and by not yielding to its treatment. Treatment. — The authors found the application of tincture of iodin to be the best treatment, combined with antiseptics. Kern 1 has cured cases with mercury, using mixed doses. He found the Wassermann to be positive in many cases. Gangrene of the Skin. — See Dermatitis gangrenosa. German Measles. — See Rubeola. Geromorphisme Cutane is the name chosen by Drs. Souques and Charot 2 to designate an affection that pro- duced changes in the skin of a girl eleven years of age so that she looked like an old woman. The expression of the face suggested that due to facial paralysis. The skin hung in loose folds, and was flabby like the skin sometimes seen in very old people. Apart from loss of natural consistence and elasticity there was no change in the skin. If lifted up, twisted, or folded in any way, it returned very slowly to its normal position; and it was abnormally movable over the subcutaneous tissues, in these things suggesting that form of dermatolysis called 1 U. S. Naval Med. Bui., 1913, p. 188. 2 Nouvelle Iconographie de la Salpetriere. GRANULOMA ANNULARE 345 "elastic skin/' There were no changes in the hair, nails, or teeth. There was no assignable cause for the condition, which was preserved unaltered during an interval of ten years from the first to the last time that the doctor saw the case. Glanders. — See Equinia. Goose Flesh. — See Cutis anserina. Granuloma Annulare. — Synonyms: Ringed eruption; Lichen annularis; Sarcoid tumors; Eruption chronique circinee de la main. Fig. 47 Granuloma annulare. (Little.) Symptoms. — The disease may begin suddenly, or slowly, as a smooth, whitish, bluish or purplish red, translucent nodule, which is made more visible by putting the skin on the stretch. It is deeply seated in the skin and has a firm or doughy feel. More nodules appear, and group themselves in a circle, crescent, or a festooned- shaped lesion. Or the original nodule may spread out into a ring by the disappearance of its centre. The 346 DISEASES OF THE SKIN diameter of the ring is from a half-inch to two inches, and its border is a sixteenth of an inch broad and high. The centre of the ring may be of normal skin color, or pinkish, or show slight atrophy, but no scar is left on healing. Its course is very sluggish. It may last for seven or more years. It shows little tendency to spon- taneous recovery, but does disappear in course of time of itself. There are no subjective symptoms. The most common site of the disease is on the back of the hands, fingers, and wrists. It may occur anywhere on the body, though the scalp and face are rarely affected. There may be only one ring, or several; but the eruption is never profuse. Etiology. — Little is known of its cause. It begins most often in summer, and affects children and young people most usually. The youngest case reported was eighteen months, and the oldest was fifty-two years. It is perhaps predisposed to by a tuberculous family tendency. Pathology. — According to Graham Little 1 the chief changes in the skin are found in the zone where the corium and hypoderm meet. Here there is an accumula- tion of cells forming a microscopic nodule, the central part of which seems to be composed of dilated sweat coils. Similar groups of cells are found about the hair follicles and probably about the bloodvessels. Numerous rows of cells ascend from these to the surface of the skin apparently along the course of the sweat ducts, hair shafts, and bloodvessels. There are also numerous horizontal rows, and a scattered cell infiltration per- meating the connective tissue. The cells are of three kinds: (1) Large mononuclear cells; (2) Spindle-shaped, oblong, or pear-shaped cells, and (3) a few large, faintly stained "epithelioid" cells. Diagnosis.— The disease has such unique features that it is easily recognized. Its slow course, and the 1 British Jour. Dermat., 1908, xx, 213. GRANULOMA PYOGENICUM 347 absence of itching, damage to the skin, and subjective symptoms distinguish it from lichen planus annularis, and syphilis. Treatment. — The local application of resorcin, sali- cylic acid, or ichthyol is efficient. Granuloma Coccioides, also called Coccioidal Dermatitis, is a disease of which cases have been reported almost exclusively from California. It is unsettled whether it is a disease entity or a form of blastomycetic dermatitis. It is a general infection affecting the lungs, viscera, bones, and skin. In some cases the latter escapes entirely. Its cutaneous manifestations are various. There may be tumors, abscesses, or ulcerations. It may resemble blastomycosis, tuberculosis, syphilis, and even glanders. It spreads from the point of infection, if in the skin, by way of the lymphatics. It runs a chronic course and commonly ends fatally. It is caused by infection with a peculiar form of oidium, or mold fungus. Those who regard the disease as distinct from blastomycosis claim that it is a general infection instead of being most often in the skin; that the point of infection is most usually within the body and not in the skin; that its parasite shows no buds but multiplies by endosporulation; and that its cultures are not identical with those of the latter disease. Moreover it does not yield to treatment with iodid of potassium. It is almost uniformally fatal and thus far no treatment for it has been devised. Granuloma Fungoides. — See Mycosis fungoides. Granuloma Pyogenicum. — This is a pea- to nut-sized tumor consisting of granulation tissue. "Proud flesh" is of this nature. It may be sessile or pedunculated. It is seen about wounds, such as that caused by vaccina- tion. It is probable that there is some specific germ to cause the growth of these exuberant granulations. It sometimes takes the form of a raspberry. The application 348 DISEASES OF THE SKIN of nitrate of silver, tincture of iodin, or some antiseptic powder to it will cause it to flatten down speedily. Granulosis Rubra Nasi is a disease of the nose of chil- dren. The cartilaginous part of the nose is more or less red, the redness not being sharply defined. It sometimes spreads to the cheeks and upper lip. Upon the red base are isolated, dark-red papules which may be very small and scarcely elevated, or pinhead size and prominent. They are pointed, non-confluent, and apparently located about the follicle mouths. They pale on pressure. Small vesicles or pustules appear that soon dry up. The nose is generally cold to the touch. There may be telangiec- tases. There is no scaling. Hyperidrosis of the nose or of the whole face is a constant factor. The disease grows better and worse, at times disappearing, but it does not change with the weather. Most of the cases occur in children from seven to sixteen years old who are not robust. Jadassohn's 1 patients were mostly boys. Brandle 2 on the other hand has seen more in girls. It is very persistent, lasting for years, sometimes into adult life, though the disease tends to disappear at the time of puberty. Pathologically, it is a chronic inflammation about the mouth of the sweat ducts. Treatment is unavailing. Brandle advises using arrays. Grocer's Itch is eczema of the hand. Ground Itch, or Uncinarial Dermatitis, is a disease of the feet seen in some tropical countries where the hookworm exists, and is caused by its larva? getting into the skin of the feet. They give rise to an eczematous, very itcjiy eruption of macules which become papular and vesicular, and run together to form patches. Bullae sometimes are seen, and they and the vesicles soon rupture and leave a raw, red, swollen, crusted surface. Untreated lesions may appear elsewhere than on the 1 Archiv Derm. u. Syph., 1901, lviii, 145. 2 Dermat. Zeitschrift, 1911, xviii, 965. . HEMATIDROSIS 349 feet, and ulceration may take place. Soaking the feet in boric acid solution, cleanliness, and the use of remedies such as used in eczema cure the disease. Guinea-worm Disease, Dracontiasis, or Dracunculus, is met with endemically in tropical climates. It is caused by the larvae of the guinea- worm, or filaria medinensis, being swallowed, and developing in the body. It is possible that the worm may gain access through a trau- matism. The female makes its way into the muscles, and within nine or twelve months gives rise to the symp- toms of the disease. The male probably dies and is passed out of the body. The symptoms of the disease are a small tumor under the skin that feels like a coil of soft string; the appearance of a pea to filbert-sized vesicle upon this when the animal is about to escape; tension, pain, and itching; in severe cases inflammation, purulent discharge, hectic fever, and perhaps delirium. The worm is either gradually wholly extruded after the vesicle breaks, or a new tumor forms after a part has escaped, and this after a time breaks and the rest of the worm comes away. There may be only one worm or a legion of them. They are located most often on the foot, but may be found anywhere. Treatment.: — The treatment of the disease is to remove the worm, which is done by winding it carefully around a stick when the head is protruded, giving a turn or two every day until the worm is extracted. Manson advises against this, and speaks of injecting into the tumors a 1 to 1000 solution of bichloride of mercury. This kills the worm, and it can then be removed. Tinc- ture of asafetida in doses of 1 or 2 drams (4 to 8) three times a day kills the worm before extraction. Hematidrosis, or Hemidrosis, is a rare disease of the sweat glands in which, on account of an effusion of blood into the coils and their ducts by diapedesis from the sur- rounding vascular plexus, blood is discharged upon the skin along with the sweat. The subjects are apt to be 350 DISEASES OF THE SKIN hysterical young women, though the affection has been seen in newborn children. It is in some cases vicarious menstruation. The points of election are the face, ear, umbilicus, hands, and feet. Ephidrosis cruenta and bleeding stigmata are other names for the curious malady. The treatment should be directed to the condition of the individual. Hair, Discolorations of. — Hair sometimes falls out to grow in of a different color. The continuous hypodermic administration of pilocarpin has been followed by a change in color of the hair from light to dark. Green hair occurs in workers in copper; blue hair occurs in workers in cobalt and indigo. These colors can be removed by washing. Yellow hair is occasionally seen in icterus. Various chemicals bleach the hair, such as peroxide of hydrogen. Chrysarobin stains it purple; resorcin may stain it green. Bicarbonate of soda changes dark hair to a dirty brown. Hemisporosis, a disease caused by hemispora stellata, is described by de Beurmann and Gougerot. 1 It takes the form of either an edematous, non-fluctuating, livid swelling which develops slowly and runs a chronic course; or of gummatous tumors. Abscesses form, the pus of which contains the parasites. It is cured by the ad- ministration of iodide of potassium. Henoch's Disease. — See Purpura fulminans. Herpes. — An acute inflammatory disease of the skin characterized by an eruption of one or more groups of vesicles upon reddened bases. There are two main varieties of the disease: one occur- ring upon the face, herpes facialis, and one occurring upon the genitals, herpes progenitalis. Symptoms. — Herpes facialis, also called herpes febrilis, herpes labialis, hydroa febrilis, fever blister, or cold sore, 1 Archiv Derm. u. Syph., 1910, ci, 297. HERPES 351 usually occurs upon the lower part of the face, about the mouth (Fig. 48). There is commonly some slight dis- turbance of the general economy, not as part of the dis- ease, but as the cause of it. The patient first notices more or less marked burning, stinging, or itching in the part, and perhaps at the same time erythematous papules may form. After a few hours a number of pinhead- to Fig. 48 JJ' ;: - Herpes febrillis. pea-sized, clear, fully distended vesicles will appear upon an erythematous base. Perhaps the herpetic patch may appear suddenly without antecedent erythema. There is usually not more than one or two patches of small size. There may be a score or more of them, and they may be of large size. The patches are always irregular in shape. There may be but two or three vesicles in a group, or 352 DISEASES OF THE SKIN there may be a dozen of them. They do not tend to break down of themselves, but after a few days dry up into a crust which falls and leaves a red spot that soon disappears. Sometimes the vesicles may coalesce into bullae, the covers of which may fall and a superficial ulceration be left. The duration of the disease is about eight or ten days. The most common location is upon the upper lip, but it may be anywhere upon the face, and not uncommonly the groups develop bilaterally. The mucous membrane of the mouth may also be involved, but here, owing to the heat and moisture, the vesicles are seldom seen, as they break down and leave excoriated points. There is a strong tendency for the disease to recur with the recurrence of the exciting cause. In some cases it recurs at irregular intervals for months and with- out apparent cause. Herpes may occur on any part of the body and pre- sent the same symptoms as when it occurs on the face. Pflugbeil 1 says that a generalized herpetiform exanthem is seen with diphtheria, gonorrhea, malaria, and some septic infections. In the vesicles are found the parasites of the disease in which it occurs. Etiology. — It is still an undetermined question whether herpes facialis is a zoster or not. By most authorities it is considered to be an independent disease; by a few it is thought to be an incomplete zoster. It is known to occur with catarrhal inflammations of mucous membranes, such as a coryza, bronchitis, or pneumonia; with digestive derangement, as gastritis or enteritis; with various febrile diseases such as malaria or scarlatina; and it is very often seen in women as a herald of the menstrual epoch, occurring with great regularity for years. It arises sometimes on account of an injury to the terminal ends of the nerves, and, as such injuries are liable to occur in the tender mucous membrane of the lips, this may be an explanation of its frequency about the mouth. 1 Dermat. Zeit., 1910, xvii, 307. HERPES 353 Infection has been invoked by a few observers as a cause, but this is not proved. It is evidently a neurosis, and in some cases no cause for it can be found excepting nerve disturbance. Sometimes it occurs coincidently with herpes progenitalis or with zoster. Diagnosis. — It must be diagnosed from zoster and from vesicular eczema. From zoster it differs in not occurring in a series of groups scattered along the course of distribution of the trigeminus; and in frequently being bilateral. Generally speaking, there is more marked neuralgia in zoster, though in some cases this is wanting. From eczema it differs in the large size of its vesicles, in their showing no tendency to break down, in being less pruriginous, in running a regular course, and in rapidly recovering by the simple drying up of the vesicles. Treatment. — Left to itself the disease will speedily get well, and really requires no treatment beyond protec- tion with flexible collodion or any indifferent soothing lotion or ointment. We are often asked if we cannot prevent or abort the disease when due to the menstrual flux. Women well know that the application of spirits of camphor will sometimes do this. Hardaway recom- mends rubbing the parts with borax. One of the alco- holic solutions recommended by Leloir for this purpose in herpes progenitalis may be used, namely, either 2 per cent, resorcin; 1 per cent, thymol; 3 per cent, menthol, or 2 per cent, tannin frequently applied. Stelwagon recom- mends painting with the tincture of benzoin, especially when the corner of the mouth is affected. Two or three coats are to be laid on two or three times a day. Herpes Progenitalis. — This has been called herpes pre- putialis, but as it occurs in women as well as men and on other places than the prepuce, the name is obviously incorrect. Symptoms. — The eruption is preceded and accompanied by burning and itching, and the vesicles occur in groups upon an erythematous base. If on the prepuce, that part is sometimes swollen. The vesicles are at first clear 354 DISEASES OF THE SKIN with serous contents, and if on moist locations, as under the prepuce or about the mucous membranes of the female genitals, they soon break down and leave tiny excoriations. There may be but one or several patches of herpes. The disease runs a course of eight or ten days and gets well of itself, unless irritated under the mistaken idea of its being a soft sore, chancroid. According to Bergh, 1 who has made a careful study of the disease in women, the groups usually contain five to eight pinhead- to hemp-seed-sized vesicles, but may have twenty to thirty-five millet- to poppy-seed-sized vesicles. Around each group is a reddish areola. The vesicles are isolated, and seldom confluent. Itching is apt to precede their outbreak. There may also be slight tenderness or swelling of the neighboring glands. In both sexes the patches may be unilateral, bilateral, or median. In men it occurs most frequently on the inner surface of the prepuce, then on its outer surface, the sulcus, glans, sheath of the penis, and rarely in the meatus. In women, Bergh found it most often on the labia majora, then the labia minora, and genito-anal region; seldom on the clitoris or in the vestibule; very rarely on the cervix uteri. The disease has a tendency to relapse, in men with each coitus, in women with each menstrual period. It is common in women to have herpes of the face at the same time, and this has been noted in men. In women, herpes facialis may occur with one menstruation, and herpes progenitalis with another. Etiology. — The cause of the disease is congestion of the genital region. Thus in men it is frequently seen two or three days after each coitus; or accompanying a gonor- rhea or chancroid. A long prepuce seems to predispose to it. In women it comes in 80 per cent, of the cases with menstruation (Bergh), and in them it does not seem to have any marked relation to the sexual act. It is also seen in connection with pregnancy and the puerperal 1 Monatshefte f. prakt. Dermat., 1890, x, 1. HERPES 355 state, as well as in gout, constipation, and digestive disorders. It is a not infrequent disease. Greenough 1 met with it in men in about 17 per cent, of all venereal cases in private practice. In women there are no statistics from private practice, and, indeed, it is in this country but rarely reported. Both Bergh and Unna, however, met with it very frequently in public prostitutes in St. Petersburg and Hamburg. Diagnosis. — The disease of itself is of little moment, but is of great consequence viewed from a diagnostic stand-point on account of its liability to be taken for chancroid or for the initial lesion of syphilis. This can hardly occur if the vesicles are seen, but when they are no longer present some difficulty may arise. From chancroid the superficial character of the lesions and their grouping point to herpes. In case of doubt the use of a simple dusting powder for a day or two will clear up the difficulty because chancroid will continue to enlarge while herpes will become well. Auto-inoculation will afford positive evidence. From the initial lesion of syphilis herpes differs in the absence of all induration of its base and in the inflammatory character of the lesions. By dark-stage illumination the spirochetal are readily demonstrated in chancre. Here again a short wait will clear up the diagnosis. Treatment. — Herpes progenitalis will usually promptly disappear by the use of a dusting powder of bismuth, or oxide of zinc and starch; or by covering it with a piece of lint soaked in an astringent solution, such as a weak lotion of liquor plumbi subacetatis. If suppuration has occurred on account of bad treatment, and the glands are enlarged or tender, the patient had best be put in bed. Circumcision has been recommended to prevent recurrences, but is of doubtful efficacy. It is well to have the patient to wash the parts daily and after coitus. Marriage and fidelity to the wife are good means of curing a relapsing herpes. Astringent washes are useful 1 Arch. Dermat., 1881, vii, 1. 356 DISEASES OF THE SKIN in both sexes. If the "habit" of herpes progenitalis, as it may be termed, has been formed, careful hygienic and general treatment may be necessary for a cure. Stelwagon advises the use of the galvanic current, the positive electrode placed over the lumbar region, and the negative one over the affected part, a current of J to 2 ma. being used. Leloir's directions, as given under Herpes facialis, may be tried for aborting the disease. Herpes Circinatus is either erythema iris or tricho- phytosis corporis. Herpes Circinatus Bullosus was the name given by Wilson to what has since been called herpes gestationis. Herpes Gestationis is regarded as being a dermatitis herpetiformis occurring during and provoked by preg- nancy. It is prone to relapse with each succeeding pregnancy; and slowly subsides after delivery. Apart from its etiological relation, it corresponds closely to dermatitis herpetiformis, which see. Herpes Tonsurans Maculosus. — See Pityriasis rosea. Herpes Zoster. — See Zoster. Herpetide. — This is a class of skin disease which de- pends upon what the French writers call the herpetic diathesis. The affections in this class are marked by long duration, obstinacy to treatment, tendency to relapse, and more or less pain and discomfort. Under it are included eczema, the lichens, psoriasis, and prurigo. Hidrocy stoma. — This disease was formerly regarded as a pompholyx of the face, but Robinson 1 has shown that it is a separate affection. Symptoms. — The eruption occurs upon the face in the form of a large number of discrete, disseminated, tense, clear, watery, boiled-sago-grain-like vesicles. In size they vary from that of a pinhead to that of a pea. In color 1 Jour. Cutan. and Gen.-Urin. Dis., 1893, xi, 203. H1DR0CYSTGMA 357 tliey may be light yellow, of a bluish tint, or white. If pricked, a drop of clear acid fluid escapes. They are obtuse, round, or ovoid. If they are present in great numbers, they may crowd closely together, but do not coalesce. There is no sign of inflammation about them, Fig. 49 Hidrocystoma. and no subjective symptoms arise from them, excepting, at times, a feeling of tension or smarting that is not pro- nounced. After lasting several weeks they dry up and disappear, while new ones appear. The disease is always most pronounced in hot weather, and may disappear entirely in winter. 358 DISEASES OF THE SKIN The eruption is usually seen upon the lower part of the forehead, the orbital region, nose, cheeks, lips, and chin, that is, upon the middle regions of the face. Etiology. — The disease occurs most often in women, and especially in washerwomen. It occurs also in men. It is a disease of adult life, which is favored by warmth and moisture. As it occurs but rarely, and is an acquired disease there must be some yet undiscovered cause for it. Pathology. — The secreting portion of some of the sweat glands has an enlarged lumen from dilatation of the tube and contraction or compression of the epithelial cells against the basement membrane, the lumen being filled with liquid, and a granular material resembling that usually seen in normal glands, but in increased amount. With the exceptions of those thus affected, the excretory apparatus is normal (Robinson). Treatment. — As far as possible the patient must avoid everything that will cause sweating. The individual lesions must be punctured. Dusting powders after wiping the face with pure alcohol are helpful. Hirsuties. — See Hypertrichosis. Hives. — See Urticaria. Hydroa is practically dermatitis herpetiformis. It is an old term recently revived, and is of uncertain sig- nificance. By some it is used to designate eruptions that are midway between erythema multiforme and pem- phigus. Hydroa Estivale.— See Hydroa vacciniforme. Hydroa Vacciniforme. — Hutchinson, under the name of "Recurrent Summer Eruption," Unna, under the name of " Hydroa Puerorum," and Bazin, under the name at the head of this section, and others under the title of Hydroa Estivale, have described a bullous disease that occurs in early childhood and upon exposed parts, espe- cially the nose, cheeks, and ears. It may occur on HYDRO A VACCINIFORME 359 covered parts and later in life. It usually occurs in summer, and then seems to be due to the heat of the sun. It may occur in winter, and be due to the action of high winds. It is a symmetrical disease. There may be some malaise preceding the eruption which begins as erythem- atous spots on which bullse form as such or as the result of the confluence of vesicles, and commonly both vesicles and bullae are present at the same time. The vesicles are prone to become depressed in the centre, dry into crusts, and resemble vaccine scars. When the crusts fall they leave pit-like, red scars, which afterward become white, and are permanent. Sometimes the disease does not go beyond the erythematous stage. Usually there is no itching, but pain or burning. A single attack lasts two or three weeks. The disease recurs from time to time, the relapses at times being so frequent as to render the disease almost continuous; and tends to cease altogether as puberty is reached. The disease is related clinically to both bullous erythema and dermatitis herpetiformis, though it differs from them in leaving scars. Hydroa puerorum of Unna, according to Stelwagon, shows no predilection to exposed parts, is uninfluenced by heat or cold, and does not leave scars. Etiology and Pathology. — Exposure to sun and wind seem to be the exciting cause, especially the former. It affects boys almost exclusively. Scholtz 1 has found albumin in the urine during the attacks which disappears when the eruption does. He finds that the skin of the affected individuals is no more susceptible to the violet, ultraviolet, and blue rays than that of others. He regards it as possible that some kind of systemic intoxication is responsible for the peculiar reaction of the skin. Bowen has shown that it is inflammatory in character. The treatment is not very satisfactory. The exposed parts should be protected as much as possible from the action of the wind and sun by means of veils or a cala- 1 Archiv. Dermat. u. Syph., 1907, lxxxv, 95. 360 DISEASES OF THE SKIN min lotion. If bullae form, they must be treated as in pemphigus. Hyperesthesia. — This is that condition of the skin in which pain is experienced on the slightest contact even of a current of air, in this differing from dermatalgia, in which the pain is spontaneous. When the sense of pain is exaggerated while the sense of touch is lessened, it is called Hyperalgesia. The hypersensitiveness may be for cold only, or for heat only, which is not so common. It is a neurotic disease, and is met with most commonly as a symptom of other diseases, such as non-tubercular leprosy, hydrophobia, and hysteria. Idiopathic cases are met with, though rarely. The hyperesthesia may be general or localized, unilateral or symmetrical. The treatment is in most cases that of the disease of which it is but a symptom, and belongs rather to the domain of the neurologist than to that of the derma- tologist. Hyperidrosis. — Synonyms: Ephidrosis; Idrosis; Suda- toria; Polyhidrosis; Excessive sweating. A functional disorder of the sweat glands characterized by an excessive flow of sweat. Symptoms. — Hyperidrosis may be general or localized: unilateral or symmetrical; in large or small amount. The cases of general sweating occur most often symptomatic- ally in the course of general diseases, such as phthisis, malaria, and rheumatism, and do not concern us now. Some cases occur idiopathically. Such patients are usually fat. The hyperidrosis may be constant or at intervals, being excited by the slightest irritation of the nervous system, or by muscular exertion. The outburst of the sweat is generally preceded by a prickling sensa- tion. It is often accompanied by prickly heat (lichen tropicus) . We are called upon as dermatologists to treat localized sweating more often than the just-described variety, and such cases occur most commonly upon the palms and HYPERIDROSIS 361 soles, in the axillae, about the genitals, and on the face and scalp. The excessive flow of sweat may be constant; but it is usually paroxysmal, and often under the influ- ence of the emotions. It is usually more pronounced in warm than in cold weather. Fat people are more prone to it than are those who are thin: anemic and delicate people rather than .the robust. The affected part may be warm or cold; if the first, it is apt to be somewhat hyperemic. Occurring in places that are warm and covered, such as the feet, bromidrosis is a common accompaniment. The disease may last for years. Sweating palms usually feel cold and clammy. Some- times the amount of sweating is only enough to keep them more or less constantly moist; sometimes it is so abundant that the sweat drops from the hands and fingers, or even fills up the hollow of the upturned palm and runs over the edge. It spoils gloves, and interferes with many forms of work. Sweating soles are soon followed by tender feet, the epidermis becoming sodden, macerated, and removed. It interferes with walking. The edge of the foot just about the soles appears as a white or gray line or seam of sodden epidermis with a pinkish seam above it. The sodden appearance is also well-marked between the toes. Sweating in the axillae spoils the clothing, and is only rendered worse by the rubber dress-shields so commonly worn by Avomen. Eczema accompanies it not infrequently. In its paroxysmal form it is frequently encountered in patients stripped for examination in public. This form has been aptly named by the French the "military sweat," as it is seen so often in examining recruits for the army. Sweating about the genitals is often accompanied by intertrigo, which may also occur on other parts subject to hyperidrosis where folds of skin are in contact. Sweating of the face is most commonly encountered upon the forehead, nose, and eyelids, beads of sweat standing out upon them or running off in little rivulets. It is here that hemidrosis is most common. 362 DISEASES OF THE SKIN Upon the scalp it has been observed that its occurrence is frequently followed by loss of hair. Unilateral sweating is occasionally met with. It may affect half of the forehead, face, or whole body. Upon the forehead and face this form of sweating may occur as an accompaniment of migraine and be limited to the painful region; it is in paraplegia that one-half of the body alone is affected. Kaposi 1 has reported one case of hyperidrosis affecting only the upper half of the body. Etiology. — The disease is probably due to a disturb- ance in the sphere of the sympathetic system. The slightest excitement, as that from drinking a cup of tea, or some passing emotion, may cause it in those predis- posed to it. It has followed lesions of the cerebrospinal nerves. It occurs in all classes and conditions of men, and in all ages and both sexes. Stel wagon has found local hyperidrosis most frequently between the ages of twenty and forty years. In some cases it is hereditary. Ill health seems to be the cause in many cases; it may be anemia; chlorosis; lithemia; hysteria; neuras- thenia; or general debility. Flat-foot is found in con- nection with some cases affecting the feet. In any case it is purely a functional disease of the sweat glands, they being structurally unchanged. The diagnosis is so evident that we need not stop to differentiate it systematically. Treatment. — The condition of the patient's health is to be carefully investigated, and tonics, mineral acids, nux vomica, or other medicine ordered according to the nature of the case. If there is no indication for this plan, or it does not succeed, recourse may be had to belladonna or atropin to the point of producing their full physiological effect; or pilocarpin, yo grain, three times a day; or agaricin in doses of ■§■ grain; or ergot \ a drachm of the fluidextract three times a day. Crocker has found 1 Arch. f. Dermat. u. Syph., 1899, xlix, 321. HYPERIDROSIS 363 a full teaspoonful of precipitated sulphur in milk twice a day the best remedy. If it loosens the bowels too much, he prescribes it as follows: 1$ — Pulv. cretae co., 5"j 12 Pulv. cinnam. co., ad 3ij 8 Sulph. prsecip., 5i ad 32 Sig. — A teaspoonful twice a day. M. The local treatment of sweating hands and armpits in many cases is as unsatisfactory as the constitutional treat- ment. There have been many plans proposed. Local faradization is one agent. Very hot water may be sponged on for a few minutes; belladonna ointment or liniment may be rubbed in; or we may use some astringent applica- tion, as of subnitrate of bismuth, tannin, alum, sulphate of zinc, borax, and the like, in alcohol, ointment, or powder. As a rule, ointments cannot be used on the hands and face. The most reliable lotion is probably a saturated solution of boric acid, or a 3 per cent, solution of salicylic acid. Kaposi speaks highly of the good effect of bathing the parts with a 5 per cent, solution of naphtol in alcohol, and keeping them powdered with 1 part of naphtol to ^fay of starch. PifTard recommends freshly prepared silicic hydrate, 1 part, in cold cream, 9 parts. Sulphate of qidnin, 5 per cent, in alcohol, may be tried. For sweating of the feet permanganate of potash in 1 per cent, strength may be used. Unna recommends ichthyol in 2.5 per cent, ointment, and the use of ichthyol soap. Formalin in 3 per cent, solution painted on three times a day has its advocates. P. Richter 1 advises sprinkling tartaric acid between the toes and in the stockings for sweating of the feet; and painting with a 10 per cent, solution of chromic acid every five days for sweating of the hands. Stelwagon recommends a 10 to 20 per cent. tannic acid ointment, or diachylon ointment spread on cloths and applied snugly to the feet after washing them with soap and water. At the end of twelve hours the 1 Allg. Med. Centr. Zeit., 1897, lxvi, 927. 364 DISEASES OF THE SKIN dressings are to be changed without washing, and so continued for ten to fourteen days. The skin usually exfoliates at the end of that time, and then the feet are to be washed and dressed with a dusting powder. For other methods see under Bromidrosis. The x-ray has proved useful in all forms of localized sweating, and may be used in obstinate cases. Pusey advises their use one to three times a week until the sweating is checked, care being taken to avoid producing erythema. If the trouble recurs this treatment is to be repeated. The prognosis is doubtful, many cases proving very rebellious to treatment. Hypertrichosis. — Synonyms: Hirsuties; Trichauxis; Polytrichia; Dasyma; Trichosis hirsuties; (Fr.) Poils accidentels; Superfluous hair. Symptoms. — Hypertrichosis is a growth of hair that is either abnormal in amount or occurs in places where, normally, only lanugo hairs are present. It may be general or partial, congenital or acquired. The general form is also congenital, but it is never universal, as no hair grows upon the palms and soles, the backs of the last phalanges of the fingers and toes, the inside of the labia majora, the prepuce, and glans penis. Subjects of this malady are usually born covered more or less thickly with hair, which may be light or dark in color. This continues growing longer, coarser, and darker until it reaches its full development. As a rule, the long hair covering the body is fine, resembling more the hair of the head than that of the beard, as is also the case with the hair on the face of these people. With this excessive growth of hair there is usually combined a deficiency of teeth, especially marked in the upper jaw. Subjects of this malady are called homines pilosi, and are met with in all quarters of the world. Of partial congenital hypertrichosis we have an immense number of examples. This condition is apt to be of the nature of nevus. The distinction between a localized HYPERTRICHOSIS 365 hypertrichosis and a nevus is made mostly upon the color of the underlying skin. In the former case the skin is perfectty normal, while in the latter it is pigmented and may be otherwise altered. These localized and partial cases of hypertrichosis are most frequently met with in the sacral or lumbar region, and not infrequently are associated with spina bifida. Partial acquired hypertrichosis is more common than is the congenital variety, and takes the form either of an excessive growth of hair in regions where it is usually found, or of the development of hair in regions usually hairless or provided only with downy or lanugo hair, or of the development of pubertal hair at an early age. The following cases are instances of excessive growth and precocious development. Chowne 1 speaks of a boy, eight years of age, who had the whiskers of a man. Beigel 2 has seen a six-year-old girl with pudenda like a twenty- year old woman, both in shape and hair. A case of excessive growth was met with by Leonard 3 in a man whose beard measured seven feet six and a half inches in length. Other instances of excessive length of beard are found in medical literature. 4 Many men have an excess of hair upon the chest and shoulders. Hair is generally better developed upon the forearm than upon the upper arm, and upon the legs than upon the thighs. As men grow old they are apt to have long hairs grow from the nose, nostrils, and the ears. These are instances of the growth of strong hair where normally only lanugo hairs are present. The growth of the beard in women is the form of hypertrichosis which concerns us most, as it is the defor- mity which we will be called upon to cure. As women grow old, especially after they have passed through the menopause, a slight moustache or a few straggling dark hairs on other parts of the face often appear. These 1 Lancet, 1852, i, 421. 2 Virchow's Archiv, 1868, xliv, 418. 3 The Hair, its Diseases and Treatment, Detroit, 1881. 4 Jackson and McMnrtry, Diseases of the Hair and Scalp, Phila., 1912. 366 DISEASES OF THE SKIN growths seldom annoy them much, as they are accepted as evidences of advancing years. The case is very differ- ent when a young woman is afflicted with a beard, and most of the patients who apply for relief from their facial hair are between twenty and thirty-five years old. In Fig. 50 J ■, \ 1« .y 4 11 !■" '.■ .,/ ,m Hirsuties. 1 them the hair generally begins to grow so as to be notice- able at about the eighteenth year of age. To get rid of the trouble the tweezers are first resorted to; then depil- atories are tried; sometimes burning is attempted, and as a final refuge a razor is used. All the time the hair By the courtesy of Dr. S. Dana Hubbard. // YPERTRICHOSIS 367 grows coarser and more abundant. Some of these women shun company, keep themselves shut up all day, their health deteriorates, and, constantly brooding over their misfortune, they are prone to become hypochondriacal and melancholic. The amount of hair present in these cases varies. Perhaps the commonest growth is the moustache alone. In most of our cases the hair has grown thickest and coarsest under the chin and upon the front of the throat. It is rare, even in the best developed cases, to have much hair under the lower lip. Sometimes the growth is as complete, as heavy, and as coarse as is met with in men. The skin in many cases is coarse, muddy, greasy, and studded with acne. From time to time cases of transitory hypertrichosis have been reported. This has been noticed during the treatment of a fractured limb, the hair being much more prominent upon the part that has been kept quiet and warm. In some of these cases the increase is probably more apparent than real, the hair not having been rubbed off by friction. Likewise, after injury to nerves the hair sometimes becomes hypertrophied, only to fall out after recovery. Continued irritation of a part, as by blisters, may stimulate hair growth which may or may not be transitory. The most interesting of this group of cases is that comprising those of hirsuties occurring during pregnancy and disappearing after some months. Wilson reported a case of delayed appearance of menstruation in which hair grew upon the face. After the menstrual func- tion was established the hair ceased to grow and gradually disappeared. We have had a case in a woman with amenorrhea, in which the hair disappeared from the face on the return of menstruation. Etiology. — The cause of hypertrichosis is very obscure in some of its forms, while in other varieties we can more readily discover it. In general congenital hirsuties heredity plays an important part. But hereditary tendencies will not explain the first appearance of these congenital cases. Virchow endeavored to account for them upon oG8 DISEASES OF THE SKIN the theory of nervous influence, founded upon the fact that in the Kostroma people — a markedly hairy father and son — the lack of development of the teeth and jaws was in the same zone as the overdevelopment of the hair on the forehead, nose, cheek, and ears; these regions all being supplied by branches of the trigeminus or fifth cranial nerve. Unna's theory of congenital hypertrichosis is that it is due to a persistence of the fetal or primitive hair; the change of type between the primitive and permanent hair not taking place. The cause of acquired hirsuties is, in some cases, not far to seek. Heat and moisture will apparently increase the growth of hair, just as they favor the growth of vegetable life. Thus the hair has grown luxuriantly under the stimulation of poultices, and on the limbs when confined in a fracture box. To these factors must be added an increase of the flow of blood to the part. Increase of the flow of blood will stimulate hair growth independently of heat and moisture. At least Prentiss' case of hair growing more luxuriantly and coarser under the use of pilocarpin, which causes hyperemia of the skin, would seem to indicate this. Hypertrichosis fol- lowing injury to nerves is probably dependent upon vaso- motor disturbances. The growth of hair upon exposed parts, as upon the arms and chest of laboring men, sailors, and the like, is due to the local irritation of the sun and wind. Now we come to the more obscure cause of facial hirsu- ties in women. To account for this, numerous hypotheses have been formed. Probably the one most generally accepted is that it is in some way connected with de- rangement of the uterus and appendages. Because in some bearded women there has been some evident derangement of the sexual organs, it has been affirmed that some similar derangement is present in all. This is on a par with the too loosely accepted idea that the too free use of alcohol is the only cause of rosacea. In the cases I have met with, the majority were as free from H YPERTRICHOSIS 369 uterine trouble as the rest of their sex. While it is true that some of these women are of masculine build, and have a masculine voice, most of them do not exhibit these characteristics. In some cases, however, there does seem to be some relation between the reproductive organs and the growth of the beard. Heredity is well marked in the majority of cases. It is improbable that attempts at destroying the fine hair cause the develop- ment of the coarse hair. It is more likely that they only strengthen its growth. Women are prone to trace the appearance of hair on the face to the use of vaselin, cold cream, and the like. There is no scientific foundation for this. An interesting study of the relation between hirsuties in women and insanity was made by Hamilton. 1 He regards hair growth on the face in women as the in- evitable result of the overactive and continuous exercise of the uterine and ovarian functions. He believes it to be of neuropathic origin, connected with disorders of the fifth cranial nerve; and that when it occurs upon the face of an insane person it is indicative of an unfavorable form of insanity, especially if the subject has not reached mid- dle life. E. Dupre and Duflos 2 found among 1000 sane women 230 with fine hair on the face, 40 with a medium growth, and 10 with a heavy growth. Among 1000 insane women they found 441 with a slight or medium growth of hair and 56 with a heavy growth. They also found evidences of neuropathic tendencies and mental derangements in the antecedents of many non-insane women with hirsuties. We may sum up the evidence on the etiology of facial hirsuties in this way: While at times there appears to be a relation between the uterine, or, more properly, the menstrual function, and the growth of hair on the face, shown by a decrease or deficiency of the first, and an increase of the second, still in the majority of cases no 1 Med. Rec, 1881, xix, 281. 2 Annal derm, et syph., 1902, 111 ct seq. 24 370 DISEASES OF THE SKIN such relation is discoverable, and it must be viewed as a deformity, or a freak of Nature, or as a matter of inheri- tance. Treatment. — For general hypertrichosis we can prac- tically do nothing. This, not because we cannot destroy hair so that it will not grow again, but because of the great amount of time it would take to destroy it. The only form of hirsuties which urgently calls for relief is that occurring upon the face of women. In 1875 Dr. Michel, of St. Louis, devised the method of removing the hairs in trichiasis by means of electrolysis, which was taken up by Dr. Hardaway, of the same city, for the removal of superfluous hair. The question is often asked, "Is the removal, by this method, per- manent?" This question may be answered, "It is, without a shadow of a doubt." The object being to destroy the papilla, and that being very small and often placed at an unexpected angle to the surface of the skin, it is not possible always to accomplish this at the first attempt; but with patience and the necessary skill it will finally be permanently destroyed. At times, after the dark, coarse hairs have been removed, there will be found a number of finer and lighter hairs. This appear- ance is due partly to the uncovering of these hairs, and partly to lanugo hairs becoming stronger by natural development. In most cases, with proper care and the use of a fine needle, the amount of scarring will be very slight, amounting to nothing more than fine punctate cicatricial spots. In some peculiarly irritable skins it is very difficult to prevent the formation of plainly visible scars. The upper lip is also prone to scarring. If the proper conditions are not observed, the operator must expect to produce a good deal of disfigurement. The amount of pain experienced by the patient will vary greatly. Certain parts of the face are far more sensitive than others. On the whole, the pain does not amount to much. After a time the skin seems to become tolerant of the action of the current and the patient no H YPER T RICH OS IS 371 longer complains. Hyperpigmentation may be produced by the operation. This is a very rare complication, and is mentioned only by way of warning. The instruments needed for the operation are a good twenty-cell zinc-carbon (galvanic) battery, or a rheo- stat connected with the street current, a sponge elec- trode, a proper needle-holder, a fine needle, a pair of epilating forceps, and, if the operator's eyes are not good, a lens of low power. Any sponge electrode will answer. There are various patterns of needle-holders, any one of which may be used. It should be long enough to be held with ease, and not too long to be readily manipulated. The most essential instrument is the needle. Hardaway recommends a needle made of iridium and platinum. He claims that it will follow the direction of the hair follicle, and more surely hit the papilla than a steel needle. We have had most satisfactory results with a jeweler's instrument called a " steel broach." These come in many grades; those known as Nos. 5 and 7 are serviceable ones. A lens is generally not needed. Dr. Piffard invented a needle-holder with lens attachment, which he has found useful. If one's eyesight is not good, he had best wear spectacles furnished with large magni- fying lenses. A galvanometer is not essential, but very desirable. A good light is necessary for the operation, and a cloudy day is a bad one for working. An operating-, reclining-, or dentist's chair, especially the last, is a com- fort, and the patient should be so placed that the part to be operated on is on a level with the operator's eye. The operation is done in the following manner: The patient, being in position, is to be given the sponge electrode attached to the positive pole of the bat- tery, and told to hold it in one hand. The hair to be extracted is then seized with the forceps, and put slightly on the stretch in the direction in which it nat- urally grows. The needle, attached to the negative pole, is then inserted parallel with the hair and into the 372 DISEASES OF THE SKIN follicle. One soon learns to know whether the follicle is entered or not by the sense of touch. When the follicle is entered the needle glides along smoothly; when it is not entered a sense of resistance is communi- cated to the fingers as the skin is punctured. The depth to which the needle is to be thrust will vary with the case. Roughly speaking, it is from T V to T \ of an inch. The needle being inserted, the patient is told to place the palm of the disengaged hand over the sponge electrode. In a few moments there will be frothing about the needle, and in from half a minute to a minute or more the hair will come away upon the very slightest traction. The hand is to be removed from the sponge before the needle is withdrawn from the follicle. The hair must not be pulled on with any force, for the ease with which it leaves the follicle is evidence of the com- pleteness of the operation. The hairs must not be ex- tracted in close proximity, because the inflammatory action thus set up will lead to more or less deep ulceration and subsequent prominent scars. It is best to extract only the coarser hair, and to leave the lanugo hairs alone. The strength of the current to be used will depend upon the quality of the patient's skin and the recentness of the filling of the battery. Six cells are the fewest I have used, and fifteen the greatest number — more exactly, a current strength of 1 to 2 ma. Immediately after operating, the part worked on should be bathed with pure alcohol. The patient should be directed to bathe the face in hoi water and to anoint it with cold cream several times during the day following the operation. T. Bloebaum 1 advocates the use of galvanocaustic needles as superior to electrolysis for the destruction of hair. A platino-iridium needle is used by him, which is thrust while glowing 2 or 3 times into the follicle, and thus he destroys one hundred hairs in fifteen minutes. 1 Deutsche med. Zeit., 1897, xviii, 609. H YPER TRW HOSTS 373 He claims for his method not only greater celerity, but also less scarring and pain. The microbrenner of Unna has its advocates. Kromayer 1 recommends the use of specially constructed cylindrical knives from 0.1 to 2 mm. diameter, which are driven into the skin to the depth of 1| mm., and at once withdrawn. The hair comes away with the knife, or can be readily plucked out. He claims that his method does not leave scars. Of late, the x-rays have been used to destro3 T hair, and apparently successfully. The operation has to be often repeated, sometimes as many as 40 to 100 times. Short and mild exposures should be given, so as not to cause more than a passing erythema. They should be stopped as soon as the hair falls or an erythema occurs. After waiting six weeks a second, shorter, course of exposures should be made. There is always danger of dreadful scarring, and the production of lasting pigmentation and wrinkling of the skin with many telangiectases from their use, but improvement in technique is constantly lessening these dangers. In from one-third to one-half of the cases a successful result has been had. It is to be recommended only in very bad cases, where the patient prefers the wrinkled skin to the hair. The hair may be temporarily removed by pulling or shaving, or the use of depilatories. Of the latter, sulphide of barium 2 drachms (8), oxide of zinc and starch, each 3 drachms (12), maybe used. The powder is to be mixed with water to the consistence of a paste, which is spread on the part for ten to fifteen minutes or until a certain amount of warmth is felt. It is then to be washed off and a soothing ointment applied. Any of these proced- ures makes the hair grow coarser. Sabouraud 2 says that if an ointment composed of: I^ — Thalii acetat., gr. v Zinci oxidi, £T. xxxvij 2 Vaselin., 3v 20 Lanolin., Aquae rosae, aa 3iss 5 M. Deutsch. med. Woch., 1905, xxxi, 179. 2 La Clinique, 1912, p. 102. 374 DISEASES OF THE SKIN is applied every night to lanugo hairs it will destroy them in eighteen months. Peroxide of hydrogen may be advised to bleach dark hair and thus render it less con- spicuous. Fig. 51 Hyponomoderma. (After Van Harlingen.) Hyponomoderma, or creeping eruption, is a disease of the skin due to its invasion by the larva migrans of gastro- philus. In this country it is very rare, but in Russia and Arabia it is said to be common. It is recognized as an irregular, tortuous, narrow, raised red line from one- sixth to one-eighth of an inch wide, the advancing end of which is club-shaped. It will be noted that the line extends over the surface of the skin at the rate of about ICHTHYOSIS 375 one inch a day. The beginning of the track fades after a few days. There is no definite course of the disease. Crocker records a case which had continued extending for two and a quarter years. There may be some pruritus, especially when it occurs on the palms and soles, and the skin may be scratched. Any part of the body may be affected. Women are said to be more often affected than men in Russia. The larva is scarcely 1 mm. long, broadest in the middle, and bifurcated posteriorly. It is marked by numerous black plates, and has hook-like spines ar- ranged in nine rings about the body. About the mouth are a number of large and small prickles placed thickly in rows, from which protrude two small mouth-hooks. They live normally in the horse's stomach. It is prob- ably the eggs that are deposited on the skin of humans (Boas 1 ). The treatment is by excision of the dark end of the track. Stelwagon cured one case by cataphoresis with a solution of 2 grains to the ounce of bichloride of mer- cury to an inch and a half area about the advancing end, and nitric acid to the suspected site of the parasite. Hut chins 2 cured his case by injecting twoi or three drops of chloroform for one-quarter of an inch in the line of advancement, and covering it with zinc oxide plaster. Ichthyosis. — Synonyms: Xeroderma; Xeroderma ich- thyoides; Ichthyosis vera seu congenita; Sauriasis; (Fr.) Ichthyose; (Ger.) Fischschuppenausschlag; Fish- skin disease. Ichthyosis is a congenital, general or partial, chronic disease of the skin, characterized by dryness, harshness, and scaling of the skin, and sometimes by the develop- ment of warty looking growths. Symptoms. — Though the disease is congenital, it usually does not show itself until after the second month, and 1 Monatshefte f. prakt. Dermat., 1907, xliv, 505. 2 Jour. Cutan. Dis., 1909, xvi, 521. 376 DISEASES OF THE SKIN sometimes not until the second year. There are four varieties of the disease, namely, xeroderma, ichthyosis simplex, ichthyosis hystrix, and ichthyosis congenita. Xeroderma is the mildest grade of the disease. The skin is dry, harsh, slightly scaly, grayish or dirty-look- ing, and its natural lines are more pronounced than usual. Upon the extensor surfaces of the limbs it is particularly marked, and here too it is accompanied by keratosis pilaris. It is most annoying to young women who want to wear short-sleeved dresses. It is doubtless far more common than statistics show, as it very often is slight in amount. Ichthyosis Simplex. — This is a more severe grade of the disease in which the skin is dry, harsh, and scaly, and divided off into small diamond-shaped or polygonal figures (Fig. 52). While the whole cutaneous surface may be involved, the disease is usually most pronounced upon the extensor surfaces of the legs and arms. The face, scalp, palms, and soles are often spared. The skin about the extensor surfaces of the elbows and knees is generally thrown into well-marked folds, while the flexor surfaces of the same joints are unaffected, the skin in these situations being soft and natural. While upon the extremities the disease is well developed, upon the trunk it may assume more of the xerodermatous form. When the face and scalp are affected they are simply very scaly, while on the palms and soles we have accentuation of the normal lines. In a typical case the skin, especially of the extremities, will be grayish, greenish, or blackish green in color, dry, and the little polygonal plates will be attached at their centres and turned up slightly at their edges, so that they appear depressed in the centres. The amount of loose scaling is sometimes abundant, but usually moderate in amount. The hair, if the scalp is involved, is dry. The nails are often pitted. Ectropion may result in those rare cases in which the disease affects the face severely. Itching is often complained of, and eczema may complicate matters. There are a marked ICHTHYOSIS 377 absence of perspiration and lessened sebaceous secretion; and the patients are sensitive to cold,. The disease is usually worse in cold weather. Ichthyosis. 1 Ichthyosis hystrix is a very rare form of ichthyosis, and occurs in the form of patches of warty, dark-green, papillary projections markedly raised above the skin, or of small papillary growths with horny caps. The skin feels rough and harsh. It may cover wide areas of the body, but does not involve the whole surface. The same name has been applied to an entirely different disease that is described under Papilloma lineare, to which the reader is referred. 1 Courtesy of Dr. Fox. 378 DISEASES OF THE SKIN Ichthyosis congenita is the most rare form of the dis- ease. It is also called Keratoma follicularis, Keratosis diffusa seu epidermica seii intra-uterina, and the " Har- lequin fetus." It is considered by some to be a general seborrhea. It is present at birth, the skin being covered with fatty epidermic plates cracked in all directions and arranged transversely to the axis of the body. The fissures may extend into the corium. The eyes are held partly open, or there may be ectropion; the lips cannot be moved; and the feet are contracted and deformed. The color is yellowish white or grayish. The scrotum and penis may not be involved. The infants are either born dead or survive birth but a short time, though S. Sherwell has reported one case that was living at five months of age. There are also cases of ichthyosis intra-uterina in which, after the removal of the vernix caseosa, the skin looks red, glazed, and dry, and soon assumes the characteristics of ichthyosis simplex. With the exception of ichthyosis congenita, the dis- ease does not show itself until some months after birth, but by the second year it has made its appearance. As a rule, it increases in severity as the patient grows older, until adult age, when it usually remains stationary or perhaps improves a little. It is a chronic disease and shows no tendency to get well. It does not seem to affect the patient's health, and it should be regarded rather as a deformity than a disease. Occasionally mental weakness and other congenital defects have been noticed. Etiology. — We know of no cause for the disease beyond heredity, which may be direct, skip a generation, or be through a lateral branch. Many cases occur without manifest heredity. It has been ascribed to consanguinity of the parents. It attacks both sexes about equally. It shows a tendency to occur only in one sex in certain families, while in other families both sexes are equally affected. It is a congenital defect in the development of ICHTHYOSIS 379 the skin with a disturbance of the functions of the perspiratory and sebaceous glands. There are said to be cases of the disease that are not hereditary, but due to well-marked nerve disturbances, greatly reduced nutrition, and the drinking of ava, a fermented liquor in use in the Hawaiian Islands. Pathology. — The epidermis undergoes a peculiar cornification. Horny cells are formed directly from the rete without the intervention of a granular layer. The horny cells are homogeneous and apparently without nuclei. The thickness of the epidermis is due in part to the fact that the corneous cells are not shed as rapidly as in normal conditions. The sweat and sebaceous glands are constantly atrophied, or the latter may be entirely wanting. The panniculus adiposa is deficient, the elastic tissue unaltered, and the erectores pilorum hypertrophied. Diagnosis. — The disease is so unique that if its char- acteristics are remembered there can be no difficulty in diagnosis. There is no other disease commencing in infancy that at all corresponds to ichthyosis simplex. Xeroderma may resemble a mild grade of squamous eczema, but has not its history. Sometimes we meet with a dry skin that is not ichthyosis, but is only a passing state and has not existed from infancy. Ichthy- osis congenita differs from seborrhea in its crust not being removable by soaking in oil and by proving fatal. Treatment. — The treatment is largely palliative. The free use of Russian baths or of prolonged warm baths, simple or with soda, and washing with soap, followed by inunctions of vaselin, lanolin, or oil, such as cocoa-butter, will keep the skin supple. Unna 1 reports several cures from the use of Eucerin after bathing with salicylic acid soap. Kaposi recommends a 5 per cent. naphtol ointment, or a 2 per cent, solution in spirit us saponis, viridis, or cod-liver oil, in conjunction with naphtol soap. Andeer 2 recommends a 3 to 20 per cent. 1 Monatshefte f. prakt. Dermat., 1909, xlviii, 261. 2 Ibid., 1884, iii, 365. 380 DISEASES OF THE SKIN ointment of resorcin well rubbed in, and covered with a bandage, and claims a cure in eight days. The daily application of a lotion composed of \ an ounce (16) to 1 ounce (32) of glycerin in a pint (500) of rose-water or of lime-water is one of the simplest and best methods of treatment. Whatever is used must be persisted in. M. Bockhart 1 reports one apparent cure by giving a daily morning bath with soap and water, followed by an inunction of a 5 per cent, sulphur ointment. The oint- ment was used also at noon and at night. Internally, cod- liver oil was given. Twice a year for six weeks salt baths were substituted for the soap-and-water baths. After three years of continuous treatment a pause was had and there was no return for three months. After nine years' treatment, with pauses in between, the patient was well, and remained so up to the time of writing, after six years. Besnier recommends, as adjuvants to the local treat- ment, regular gymnastic exercise and the internal admin- istration of cod-liver oil. Thyroid extract has been used with benefit in some cases. It should never be used unless the patient can be watched by the physician, as it is a dangerous remedy. The administration of jabo- randi by the mouth or pilocarpin hypodermically will soften the skin, but in a deformity of the skin that cannot be removed its use is inadvisable. Axmann 2 reports a cure by the use of the Schott Uviol lamp. After nine sittings of ten minutes each the skin was smooth. After a pause of four weeks, nine more sittings were given. After thirty-five sittings with from eight to fourteen day pauses, the disease was cured. D. H. Stewart 3 effected a .permanent cure of one case by irrigation of the colon with 5 gallons of water at a temperature of 120° F., containing 4 tablespoonsful of table salt to the gallon. This was given one day, and on the next a pill of calomel and hyoscyamus was ad- 1 Monatshefte f. prakt. Dermat., 1901, xxxiii, 616. 2 Dermat. Zeitschrift, 1907, xiv, 109. 3 Jour. Cutan. Dis., 1905, xxiii, 52. IMPETIGO SIMPLEX 381 ministered. This alternating treatment was continued for four weeks, when the skin became smooth, and so con- tinued for more than two years. Pkognosis. — The prognosis is good as to life, bad as to cure. Thus far it has proved practically incurable. All one can hope to accomplish is to render the patient com- fortable and fit to mingle with his kind by repeated courses of treatment. Ichthyosis congenita is fatal in a few days, if the child is not born dead, as is usually the case. Impetigo Simplex. — Our own writers largely follow Duhring in their description of this disease, and as soon as they vary from his description, it seems to us that, instead of simple impetigo, they describe the contagious form. . According to Duhring, the appearance of the dis- ease may or may not be preceded by loss of appetite, constipation, or malaise. The eruption consists of one to a dozen or more pustules that are pustules from the beginning. They are split pea to finger nail in size, rounded, and raised above the surface of the skin. They have thick walls, a more or less marked areola, little surrounding infiltration, and no central depression. Their color is yellowish or whitish. They manifest no disposition to rupture, are discrete and disseminated, and do not incline to coalesce. While they may occur anywhere, they are seated by preference on the face, hands, feet, and lower extremities. Itching and burning are absent, as a rule. The course of the disease is acute, its duration being several weeks. The pustules gradually undergo absorption and dry into a crust, or they may be ruptured by external injury. The crust when it falls leaves a reddish base without pigmentation or scar. The disease is not contagious, and occurs mostly in children. Such is the disease as described by Duhring. It will be seen by reading the section on impetigo contagiosa that it bears a strong resemblance to that disease. He 382 DISEASES OF THE SKIN differentiates it from impetigo contagiosa on account of its being pustular and not vesicopustular from the start, its deeper seat, and its being raised and not umbili- cated. Impetigo of Bockhardt. — The best description of this form of impetigo is by Sabouraud. 1 He described it as occurring primarily on hairy regions, usually the scalp, as an eruption of pustules pierced by hairs. They are confluent or disseminated. They are yellowish green, rounded, umbilicated or accuminated, and vary from millet to pea size. There is an areola about the young pustules which diminishes with their age. They are not readily broken. They reach full development in three to five days, the crust falling in a week. A folliculitis is often left, or a furuncle or abscess follows. There is sometimes a dermatitis of the scalp of severe grade, and the glands of the neck are often swollen. Suc- cessive crops of pustules are frequent, thus prolonging the course of the disease. The disease may spread from the scalp to the face, neck, back, thighs, and buttocks. It is due to infection with the staphylococcus aureus, and is regarded by Sabouraud as being distinct from impetigo contagiosa, though often complicated by it. His view is not accepted by all. Crocker regarded it as simply a form of contagious impetigo. Impetigo Contagiosa. — Synonyms: Porrigo contagiosa; Impetigo parasitica seu streptogenes. An acute inflammatory, contagious disease, occurring especially on the face, hands, and exposed parts, and char- acterized by the appearance of vesicopustules and bullae. Symptoms. — By Tilbury Fox, who first described the disease, and others who followed him, its onset is said to be marked by slight febrile disturbances. These are very slight, and we have not satisfied ourselves as to their occurrence in the many cases that we have seen, except incidentally as part of some digestive disorder that may 1 Ann. de derm, et de syph., 1900, i,62 and 427. IMPETIGO CONTAGIOSA 383 be present. The eruption consists of flat vesicopustules that come out in crops. They are of various sizes, from a pea to a finger-nail. They are at first surrounded in well-marked cases with a red halo, which soon fades. They tend to increase slowly in size, and sometimes assume an annular shape. They are not fully distended, but flaccid, and not infrequently upon the hands, espe- Impetigo contagiosa. 1 cially in children, they bear a strong resemblance to a burn of the second degree. If the covers of the vesicles or small bullae are not disturbed, their contents in a few days will dry up, and the vesicopustule will change into a straw-yellow granular crust, which is placed super- ficially upon the skin with its edge somewhat detached, 1 G. H. Fox: The Skin Diseases of Children, New York, 1897. 384 DISEASES OF THE SKIN and, it may be, turned up — in fact, it looks "stuck on." When the crust is removed or falls of itself, there is exposed an erythematous spot, which in a short time will disappear and leave no trace of its existence. If the vesicles are torn by scratching, or if by any other means their covers are removed, we shall find very superficial losses of substance — a moist surface covered with a Fig. 54 Impetigo contagiosa circinate form. 1 slight purulent secretion, or crusted lesions. Even this disappears and leaves no trace, passing through the erythematous stage in its course to recovery. Such are the appearances presented in the majority of cases. In adults the lesions sometimes assume a circinate form, but the ordinary impetigo lesions are also present. Besides this usual and typical form we meet with 1 Courtesy of Dr. H. Fox. IMPETIGO CONTAGIOSA 385 another and rarer variety, in which, instead of vesico- pustules, there are large bullae. These may be several inches in their long diameter, are of irregular oval shape, not fully distended with fluid, and sometimes show a slight depression in their centres. Their contents are at first serous, but soon become seropurulent. They seem to be longer preserved than the vesicles, but otherwise run the same course. At first they have a slight zone of redness about them, but this soon disappears. They either are formed by two or more vesicopustules running together, or spring up of themselves. They may attain their full size at once, or enlarge slowly. Rarely do they exist alone; generally the typical vesicopustules will be found in their neighborhood or elsewhere on the body. It is the bullous form that is liable to be mis- taken for pemphigus, and has been called contagious pemphigus. Impetigo contagiosa is located principally upon the face, most often on the chin, and on the hands; it may also occur upon the scalp, legs, and trunk, especially in infants. D. W. Montgomery 1 has met with it on the mucous mem- brane of the mouth, nostrils, and conjunctiva. According to our experience, the bullous form is most often seen upon the trunk. The lesions of both varieties are discrete ; exceptionally two or more may run together. They are superficial, and rarely very numerous. The bullous lesions are generally widely separated from one another. The disease does not run any definite course, and may last weeks or months; a slight amount of itching is sometimes present. Etiology. — It is, as its name indicates, very conta- gious, and often occurs in epidemics. It is readily in- oculable both on the subject of the disease and on others. Not infrequently we see a mother or other attendant of a child with the characteristic lesions of impetigo contagiosa upon the arms, derived from carrying the child suffering with the same disorder. Barber shops 1 Jour. Cutan. Dis., 1910, xxviii, 345. 25 38G DISEASES OF THE SKIN are a prolific source of contagion. The contagious ele- ment is a streoptococcus primarily, though staphylococci are found also in older lesions. We know that all pus is under certain circumstances inoculable, and hence it has been maintained that there is no such disease, properly speaking, as contagious impetigo. But when we succeed in inoculating from an ordinary pustule, we produce an ordinary pustule, not the characteristic vesicopustule of impetigo contagiosa. It has been stated by some authorities that the disease is due to an inflammation set up by lice on the head of the particular case or can be traced back to some other case of pediculosis. In some cases pediculosis capitis may be present, because both diseases occur with special frequence in children of the poor. In our experience, in most cases no such relationship can be traced. Cases of contagious impetigo sometimes follow vaccination, and thus has been sug- gested the possible connection between impetigo and vaccinia. It is more frequent in the warm months than in the cold. Children furnish the vast majority of the cases. Pathology. — The pustule is roofed in by the horny layer, and its floor is the rete. The upper part of the corium displays a mild acute inflammatory reaction, with the usual features. By most observers the disease is thought to be due to staphylococcus aureus. Kauff- mann 1 thinks he has found a staphylococcus that differs from the ordinary staphylococcus pyogenes in its cultures, in its less resistance to destructive agencies, in its inocula- tions producing vesicles and not pustules, and in being less virulent. Sabouraud 2 and others believe it to be due to streptococcic infection; while still others have found now the one and now the other form of coccus in the disease. It is evident we need still more light on this subject. Diagnosis. — Impetigo contagiosa is diagnosed by the presence of discrete, partially distended vesicopustules, 1 Dermat. Zeitschrift, 1899, vi, 792. 2 Ann. de derm, et de syph., 1900, i, 62. IMPETIGO CONTAGIOSA 387 which are located upon the exposed parts — head, face, and hands — in most cases; they are sometimes grouped; they run an acute course, and dry up into straw-yellow "stuck-on" crusts. It is sometimes preceded by slight constitutional disturbances, and accompanied by a slight amount of itching. It must be differentiated from simple impetigo, pustular eczema, varicella, scabies, pemphigus, and possibly ecthyma. The lesions of simple impetigo are pustules from the start, while those of impetigo contagiosa are first vesicles and then vesicopustules. The pustules of impetigo are prominently raised, and run no definite course. The vesicopustules of impetigo contagiosa are flattened, and run a rather definite course. The crusts of impetigo are generally greenish, while those of the contagious form are yellowish. Impetigo is not so readily inoculable as is impetigo contagiosa, and is much more widely dissemi- nated, as a rule. Simple impetigo is a deeper process than the contagious form. Pustular eczema is itchy; its pustules tend to break down quickly, run together, and form large patches, which soon become covered with a greenish or blackish crust. These phenomena are entirely foreign to impetigo conta- giosa. Eczema does not present vesicopustules nor bullae, as a rule. Varicella is an acute contagious disease, with constitutional symptoms in most cases. Its vesicles are smaller than those of impetigo contagiosa, and they run a definite course peculiar to themselves. They are widely distributed over the whole surface, usually appear first on the trunk, sometimes occur on the fauces, and not infrequently leave pitted scars. Contagious impetigo is in most cases limited to the exposed parts, it never occurs upon the fauces, and its lesions leave no trace. The crusts of varicella are small, while those of contagious impetigo are large. The diagnosis from scabies offers little difficulty. When we bear in mind that scabies is very itchy, that it occurs usually as a copious eruption upon the hands, wrists, and 388 DISEASES OF THE SKIN forearms, about the umbilicus, on the nipples of females and the genitals of males; that scratched papules and pustular lesions are more characteristic of it than vesi- cles, and that it presents the pathognomonic furrows, we should not confound it with impetigo contagiosa, which has none of these symptoms. Further, impetigo will, in almost all cases, occur upon the face at the same time as upon the hands, and that location is very rarely attacked by the itch mite. The diagnosis from pemphigus is by no means always easy. The occurrence of the bullous form of contagious impetigo is so rare that it is no wonder it is mistaken for pemphigus. Indeed, it is probable that not a few of the cases reported as acute pemphigus in children, which pos- sessed apparant contagious qualities, were instances of this bullous form of impetigo. The diagnosis between the two diseases can scarcely be made with certainty by the appearance of the bullae alone; we must also take into consideration the general course of the disease. The differential diagnosis may be given as follows : Pemphigus. Impetigo Contagiosa. (Bullous form.) 1. Occurs chiefly in adults. 1. Occurs chiefly in children. 2. No source of contagion can be 2. A source of contagion can usu- found. ally be found. 3. No particular sites of prefer- 3. Met with most often upon the ence; if anything, it is most trunk; sometimes it may oc- frequent on the extremities. cur on the face, hands, or ex- tremities. 4. Chronic in its course; marked 4. Acute in its course, rarely last- by frequent relapses; may re- ing more than a few weeks, turn from year to year. 5. Bullae are fully distended with 5. Bullae not fully distended, but a clear fluid, so that their flaccid, and contain seropuru- covers appear tense. They of- lent fluid. They may have a ten spring up out of the sound well-marked red halo while skin without areola. slowly attaining their full size. Characteristic vesicopustules are generally present else- where at the same time. 6. Lesions often occur in great 6. Lesions few in number, do not numbers, so as to cover the involve the whole body, and whole body, and at times are itch but little, if at all. pruriginous. 7. Disease obstinate to treatment, 7. Disease yields readily to treat- and prognosis usually grave. ment; prognosis uniformly good. IMPETIGO HERPETIFORMIS 389 Ecthyma is probably only a form of impetigo conta- giosa that occurs in broken-down subjects. It affects by preference the lower extremities, is seen most often in adults, and its lesions are deep pustules which are highly inflammatory and painful. Treatment. — -The treatment of the usual form is to direct the affected parts to be scrubbed with warm water and soap to remove the crusts, and covered with a 5 per cent, carbolized vaselin, or with oxide of zinc oint- ment with carbolic acid in the same strength, or with the ointment of the ammoniate of mercury diluted one-half. The last is the best. If there is a good deal of crusting, the crusts may readily be removed by soaking them with oil or warm water, after which the applications mentioned may be made. Salicylic acid may be used in ointment in 3 to 5 per cent, strength. When there is an eczema complicating matters Lassar's paste with salicylic acid answers all indications. In the bullous form it is well to prick the bullae at their most dependent part, and let the fluid escape, after which the lesions may be treated as just indicated. Prognosis. — The prognosis of impetigo contagiosa is always good; so readily is it cured that the patients seldom present themselves a third time for advice. Impetigo Herpetiformis. — This disease was first de- scribed by Hebra 1 in 1872. In this country it is exceedingly rare, only a few cases having been reported. It is from Kaposi 2 that the account here given is taken. The disease begins with an eruption of pustules in the genitocrural region, about the umbilicus, on the breasts, and in the axillse; later upon various other locations. The pustules are crowded together, grouped, pinhead size, with at first opaque and later greenish-yellow con- tents. They dry into a dirty-brown crust, while immedi- 1 Wien. med. Wochenschr., 1872, No. 48. 2 Pathologie und Therapie der Hautkrankheiten. 390 DISEASES OF THE SKIN atley around them new pustules appear in double or threefold circles, by the drying of which the crust is enlarged. The disease spreads by the growth of the individual groups and by the coalescence of neighboring ones. Underneath the crusts the skin appears red and covered with new epidermis; or deprived of epidermis, moist, infiltrated and smooth; or papillary, but never ulcerated. Within three or four months the whole cutaneous surface is involved, swollen, hot, covered with crusts, showing torn and excoriated places, with here and there circles of pustules. The mucous membrane of the tongue may show circumscribed gray patches. There is a continuous remittent fever, and each outbreak of pustules is marked by chills, high fever, and dry tongue. Nearly all cases prove fatal. The disease has affected almost exclusively pregnant women, few men having been reported with the malady. Delivery has not stopped the course of the disease. It is probably of septic origin. Diagnosis. — The disease is stated by Kaposi to differ from dermatitis herpetiformis in being only pustular; in its peculiar location and manner of spreading; in the absence of itching; in the severe constitutional symptoms; and in its lethal ending. Treatment. — No treatment has proved successful. We can only do our best to nourish the patient; and by means of baths, dusting powders, or alkaline lotions, render her as comfortable as possible. Intertrigo. — See Erythema intertrigo. Iodic Acne. — See Dermatitis medicamentosa. Itch. — See Scabies. Keloid. — Synonyms: Kelis; (Fr.) Cancer tubereux, Cheloide; (Ger.) Knollenkrebs. A connective-tissue new growth in the skin, occurring most commonly upon the chest; characterized by hard- ness, by a pinkish color, and by sending off prolongations in all directions (Fig. 55). KELOID 391 Symptoms. — It is usual to divide keloids into two varieties, one of which is called the true or spontaneous keloid, and the other the false or secondary keloid the result of injuries. Of late the opinion is gaining ground that no such distinction can be made, and that even the true keloid results from some slight injury. As most commonly met with, it consists of a single, firm, hard, Fig. 55 Keloid. pinkish, freely movable, oval or elongated, elevated tumor upon the upper half of the sternum, from which claw-like processes are given off in all directions. While there may be but one tumor, the lesions may be multiple, there being either one large and several small ones upon the chest, or many scattered over the body. They begin as 1 From G. H. Fox's Photographs of Skin Diseases. 392 DISEASES OF THE SKIN small pinkish elevations and gradually enlarge until they attain a certain size, when they may remain stationary or else slowly grow. They assume all sorts of shapes and sizes. Sometimes they have an even surface, sometimes they are nodular. They may be quite small, or they may be so large as to run nearly half-way across the chest. Then the appearance is as if the skin were drawn up into the tumor. The epidermis is smooth over them, and the pink color is due to dilated bloodvessels. Sometimes the color is white. Though they are rarely met with on the face of the white races, they are very common upon the face of the negro. They are often attended by a good deal of pain, or pruritus, or pricking sensations. Beside this form of keloid, that may or may not be spontaneous, we have the evident scar keloids that occur over the site of an injury to the skin. These have fol- lowed syphilids that have destroyed the skin, variola pustules, psoriasis, a blister, or acne. 1 They may be limited to the site of the previous lesion or spread beyond it. This form of keloid is very often seen on the face of the male negro who shaves, the cheeks and chin being studded over with small, hard, white elevations. The hypertrophied scar resembles keloid, but never spreads beyond the limits of the injury, has no claw-like pro- cesses, is not so pinkish nor so permanent. Keloids very rarely ulcerate or change into malignant growths. But it is not uncommon for epithelioma to develop on hypertrophic scars. Etiology. — We know scarcely anything as to the cause of keloid, and can only beg the question by saying that it is a predisposition on the part of the skin. It is probable that some minute injury precedes the tumor. The negro race is peculiarly prone to the disease. Sex is without influence, and it may occur at any age, though rare before puberty and in old age. Histologically the structure of the keloid is similar to that of the cicatrix — 1 Purdon: Jour. Cutan. and Ven. Dis., 1882-83, i, 203. KELOID 393 that is, it is a dense fibrous connective-tissue growth which has its seat in the true skin. Treatment. — As a rule, it is safest to leave the growths alone. Cutting them out is often disappointing in its results, as they are apt to return. Multiple scari- fications followed by the application of acetic acid have been successful. Leloir and Vidal 1 recommended follow- ing multiple scarifications with a boric-acid dressing. The next day mercurial plaster is to be applied, and changed every morning and evening. Perseverance in this method, they say, may result in a cure. Compres- sion by means of an elastic bandage or by mercurial plaster sometimes reduces the prominence of the tumors. Hardaway has succeeded in removing one keloid and two hypertrophied scars by means of electrolysis, and Brocq has commended the method. A stout needle must be used and multiple punctures made in all directions, and in the tissues for a space beyond the tumor. Galvanism is said to reduce hypertrophied scars. Balzer and Mous- seaux 2 recommend the use of a 20 per cent, solution of creosote in oil. A cubic centimeter of the solution is to be injected into many points until the tumor pales. This is followed by inflammation, swelling, and sloughing off of a portion of the keloid, and rather deep ulceration. After a few days the ulcerations are healed and the injec- tions are repeated. Andeer 3 recommends resorcin and a bandage. S. Tousey 4 advocates the use of thiosinamin, and reports some favorable cases. It may be used either hypodermically once a day or every other day, 12 to 15 minims of a 10 per cent, solution in equal parts of pure glycerin and sterilized water; or by mouth, 3 grains (0.2) being given during the day. We have tried this treat- ment in a number of cases without benefit. L nna recom- mends thiosinamin plasters. The use of x-rays has been followed by the disappearance of a number of keloids. 1 Ann. de derm, et de syph., 1890, i, 193. 2 Ibid., 1898, ix, 1147. 3 Centralbl. f. med. Wissenschaft, 1888, xxvi, 785. 4 New York Med. Jour., 1897, lxvi, 624. 394 DISEASES OF THE SKIN Pusey advises daily exposures, on every second or third day, gradually carried to the point of producing an ery- thema unless the growth subsides. It takes from one to six months to remove them. The massive dose might be used. Ravaut 1 reports good results from the use of hot air produced by the Gaiffe apparatus. Fibrolysin is also advised. Hypodermic injections of morphin, or the application of belladonna ointment, may be necessary to relieve pain. Prognosis. — It is possible for hypertrophied scars to undergo spontaneous involution. This is especially the case in the scar keloid following syphilis. Usually this cannot be expected in true keloid. Keloid of Addison.— See Morphea. Keloid of Alibert. — See Keloid. Keratodermia Excentrica. — See Porokeratosis. Keratodermia Gonorrhoica. — In some cases of gonorrhea, especially those with severe articular and general manifes- tations, there occurs upon the hands and feet, rarely on the trunk, an eruption of keratotic growths. On the feet there is a thickening of the corneous layer of the soles, especially along the border. The dorsal surface of the toes may be affected. Irregular horny masses with uneven surfaces form. The skin is brownish yellow, upon which are brown or purplish-brown nodules y 3 0- to 2 cm. in diameter. With the cure of the gonorrhea the masses scale off and disappear. Keratolysis Exfoliativa is the name applied by A. Sangster 2 to a case of congenital exfoliation of the skin which resembled ichthyosis, excepting that its scaling was more papery, like that seen in dermatitis exfoliativa. Keratosis Follicularis. — Synonyms: Ichthyosis sebacea cornea (Wilson) ; Ichthyosis follicularis (Lesser) ; Darier's 1 Annal. derm, et syph., 1910, i, 145. 2 British Jour. Dermat., 1895, vii, 37. KERATOSIS FOLLICULAR! S 395 disease; Psorospermosis; Psorospermose folliculaire vegetante; Acne sebacee cornee. Symptoms. — This disease affects nearly the whole cutaneous surface, though in White's 1 case the .palms and soles were free. It frequently is first seen on the face. The eruption begins as pinhead-sized papules, which are firm and of the color of the skin, looking like keratosis pilaris. As they increase in size they become hyperemic; still growing, they become hemispherical or flattened, with smooth or polished, dense adherent coverings of nail-like consistence, and varying in color from dull red to purplish, dusky-red, brown, and brown- ish-black. Some of them are excoriated by scratching and bear hemorrhagic crusts. These lesions are discrete and the skin about them normal. They are located in the hair follicles. In places the lesions run together and form elevated areas with uneven surfaces, covered by thick yellowish or brownish, flattened horny concretions; or there may be brownish or blackish plates. The patches feel rough and somewhat greasy. Here and there, especially in the inguinal, genital or anal region, will be found papillomatous excrescences; or enormously dilated follicular openings filled with comedo-like, firm, slightly projecting concretions forming hemispherical elevations, which when expressed are found to be hard and perfectly dry, leaving the follicle mouth patulous. It spreads gradually and in course of years it may become generalized. The nails become coarse, slightly thick- ened, and ragged at their free edges. Boeck 2 says that they are often the seat of a marked hyperkeratosis with- out a trace of the disease itself anywhere in their neigh- borhood. The hard palate in White's case showed some follicular elevations. Pruritus is marked in some cases. A fetid odor is given off from the patient. Upon the scalp the disease may appear for a long time as a pityriasis steatodes, but later the same elevations 1 Jour. Cutan. and Gen.-Urin. Dis., 1889, vii, 201. 2 Arch. f. Dermat. u. Syph., 1891, xxiii, 857. 396 DISEASES OF THE SKIN about the hairs can be made out as are seen upon the general integument. Upon the back of the hands and fingers the eruption presents the appearance of simple papillary growths, little pale-white, slightly raised, con- fluent and adherent masses. This is one .of the char- acteristic lesions of the disease. Upon the palms and soles, instead of elevations, we find punctate depressions, and perhaps a hyperkeratosis. Hyperidrosis is often marked. In the axillae, on account of maceration by sweat, the masses are not so hard and horny, and the scales can be rubbed off, when a moist, red, warty surface is exposed. The course of the disease is a progressive one by the springing up of new lesions. It develops symmetrically. It seems to have no damaging effect on the health. It affects especially the scalp, axillae, inguinal region, abdo- men below the umbilicus, back of the hands and feet, and the wrists. Etiology.— We know nothing positive about the eti- ology of this rare affection. White met with it in a father and daughter, and Pohlmann 1 reports five cases occur- ring in three generations of one family. This suggests heredity as a cause. The disease may begin at any age, cases having been reported as commencing in the first weeks of life, in the sixth, sixteenth, twenty-second, twenty-seventh, and thirty-sixth years, though most cases occur before the twenty-fifth year. Males are more often affected than females. Pathology. — J. T. Bowen, who made a careful ex- amination of White's first case, says that "the disease is a keratosis of the epithelial lining of the mouths of the follicles, which, by extension downward, gradually pro- duces pouch-like depressions in the corium. The capacity for corneous metamorphosis is so great that the central portion becomes a firm horn, which by production of horny matter from below is gradually pushed out above 1 Archiv. Dermat. u. Syph, 1909, xcvii, 195. KERATOSIS FOLLICULARIS CONTAGIOSA 397 the surface of the skin. There was no proof that the sebaceous glands were affected by the horny change." The keratosis may occur outside of the mouths of the follicles. Diagnosis. — The disease differs from pityriasis rubra pilaris in lacking the constant and early involvement of the palms and soles ; in the absence of the isolated papules pierced by hairs on the dorsum of the fingers; and the extensive, diffused, scaly dermatitis of the face, neck, and other parts; and in having horny plugs. It differs from acanthosis nigricans in not affecting the mucous mem- branes ; not having warty, deeply pigmented growths, and not being associated with visceral disease. Treatment. — The proper treatment is yet undeter- mined. It might be well to try the methods found useful in ichthyosis. X-rays have benefited some cases. Prognosis. — It is always a very obstinate disease and prone to relapses. The general health is not affected as a rule. Epitheliomas have developed in exceptional cases. Keratosis Follicularis Contagiosa. — This is a rare disease that was first described by Brooke. 1 It is akin to keratosis follicularis, and some cases described as acne sebacee cornee. According to Brooke's description the first change in the skin is a thickening of the corneous layer so that there is an accentuation of the little rhomboid spaces of the skin. Minute black specks appear in them, some of which develop into pap- ules from the top of which spines protrude. The spines are long and thin like bristles; others are short and thick like comedones. When extracted pit-like depressions are left. These give the skin a rough, nutmeg-grater feel. Some of the larger papules become inflamed and resemble acne pustules, while others assume a warty appearance. The lesions may aggregate into patches which are rough to the feel, the skin about them having 1 Internat. Atlas of Skin Diseases, 1892, part vii, plate xxii. 398 DISEASES OF THE SKIN a dirty yellowish-brown color. The disease is symmetrical and is found chiefly on the nape of the neck, the shoulders, and extensor aspects of the limbs. It may be found anywhere on the body. Etiology and Pathology. — It occurs most often in children and is contagious, spreading through a family. It is a hyperkeratosis affecting chiefly the follicles, and extending to the other epithelial layers. Treatment. — Softening of the skin by an ointment containing an alkali such as carbonate of soda, or potash will remove the lesions. Relapses may occur. Keratosis Palmaris et Plantaris. — Synonyms: Keratoma palmare et plantare hereditarium ; Ichthyosis palmaris et plantaris; Tylosis palmse et plantse. This is a form of congenital or acquired callositas. It is characterized by the appearance upon the palms and soles of masses of thickened skin of leathery consistence and yel- low or brown color. They come without apparent cause, and usually show a symmetrical arrangement. The palms or the soles alone may be affected, but it is always both palms or both soles that are affected. There is sometimes a zone of redness about the thickened plates. Sometimes the whole palm or sole is covered, sometimes the horny masses occur in islands. The plates may be shed period- ically, only to reform. The surface of the plates may be smooth or uneven. Exceptionally the disease spreads on to the dorsal surface. Hyperidrosis is frequently marked. The nails at times show hypertrophic changes. Pain may be complained of when the hands or feet are used. If the feet are affected, the pain may be so great as to prevent walking. Etiology. — The disease is hereditary in many in- stances, and congenital, and like ichthyosis tends to affect only one sex in the family. We do not know its cause, and we class it as a trophoneurosis. It some- times has been noted to follow the prolonged ingestion of arsenic. Its pathology is the same as that of callositas. KERATOSIS PILARIS 399 Treatment. — Little benefit is to be expected from internal treatment. Brocq advises large doses of arsenic; Brooke has found ichthyol, 3 drops t. i. d. of use; and Klotz gave pilocarpin in one case with benefit. The plates may be removed by salicylic acid plaster or oint- ment, 10 to 20 per cent, strength. The same end is reached by poultices, the wearing of rubber sheeting, and the application of various plasters. A permanent cure can hardly be expected. In some cases z-rays have removed the thickening. Keratosis Pilaris. — Synonyms: Lichen pilaris; Pity- riasis pilaris; Ichthyosis seu hyperkeratosis follicularis; Cacotrophia folliculorum; (Fr.) Xerodermic pilaire, Ich- thyose anserine des scrofuleux. Symptoms. — As its name indicates, this is a disorder of cornification. It is characterized by a heaping up of the corneous cells about the mouths of the hair follicles in the form of small conical, whitish or grayish elevations. Between them the texture of the skin is normal; its color may be unchanged or rosy, or of a grayish or brownish shade. It occurs chiefly upon the extensor surfaces of the limbs, especially upon the upper arm and thigh, but may occur anywhere. The appearance of the affected part resembles cutis anserina, being dotted over with pin- head- to small-pea-sized papules, each one of which is either pierced by a hair or has a black dot at its summit indicating the mouth of the hair follicle. The papules are often scaly. The hair is either normal, broken off, or only to be found by opening the papule, when it will be seen curled up inside of it. The skin feels dry and harsh. There may be slight pruritus. Pityriasis capitis may be present at the same time. As the disease is attended by but slight, if any, subjective symptoms it is often overlooked. It is a chronic affection in most cases, though it often is much less pronounced in warm weather when sweating is increased. Brocq describes a keratosis pilaris of the face begin- 400 DISEASES OF THE SKIN ning as minute scaly papules about the hairs, which crowd together to form patches and give a rosy red tint to the skin. After a time the disease seems to destroy the follicle, and we find depressed scars arranged in rows or scattered about on the red patch. This bears some resemblance to lupus erythematosus, and is the ulery- thema ophryogenes of Taenzer. Besnier describes a somewhat similar condition as occurring upon the extremities. Etiology. — The disease is sometimes congenital and often forms a part of ichthyosis. It is most common in women, and those who do not bathe frequently, or in whom there is a dry or a peculiarly coarse quality of skin. Pathology. — According to S. C. Boeck 1 the lesions are due to a markedly increased growth of corneous cells within the hair follicles and in that part of the sweat duct that lies within the epidermis, with the development of horny plugs in the mouths of the hair follicles and sweat pores, forming papules. Diagnosis. — It differs from cutis anserina in being a permanent condition; from the miliary papular syphilid in being whitish, grayish, or blackish, and not dark-red or raw-ham color, and in being removable by soap and water. Lichen scrofulosorum occurs in strumous subjects and in well-marked circular or crescentic patches, which is foreign to keratosis. Papular eczema differs in being very itchy, and in having red inflammatory lesions. Ichthyosis is a general affection of congenital origin, has peculiar markings of the skin, and is not limited to the hair follicles. Lichen pilaris (Crocker) has red patches at the beginning, spiny plugs, and occurs in patches. Treatment. — The vigorous use of green soap and water in an alkaline bath, followed by oil or vaselin, will remove the evidences of the disease. Vapor or Russian baths may be used for the same purpose. Hyde 1 Dermat. Wochenschrift, 1912, Iv, 1459. KERATOSIS SENILIS 401 prefers general cool baths containing J of a pound of common salt to each gallon of water, after taking which the skin is to be rubbed with a coarse towel or flesh- brush. As the affection is allied to ichthyosis, it may be treated on the same plan. Keratosis Senilis. — This malady may occur as a slight thickening of the corneous layer of the skin in the form of thin, dirty or brownish-gray plates, bean size or larger, which are adherent to the skin, but at first can be readily rubbed off, leaving a moist or oily surface. They soon re-form, and in course of time, if frequently removed, it may be noticed that the base shows small bleeding points, later a superficially ulcerated surface, and still later all the signs of an epithelioma. Or it may take the form of warty outgrowths, of dirty brown or black color, which are hard, and when picked off crumble in the fingers. These also in course of time, if frequently removed, may undergo epitheliomatous changes. Both forms may be more or less greasy in character. Their first stage may be a lentil-sized or larger pigmentary patch. They are most often located on the face or the backs of the hands, locations most exposed to the action of sunlight. If irritated by attempts at picking them off they may be converted into epitheliomas. Etiology. — Senility of the skin is the cause of the disease. While they occur most often after sixty years of age, they may occur at a much earlier age, at any time after middle life. It is probable that lack of care of the skin, and exposure to the sunlight are active causes in their production. It is said that they are seen in farmers and out-door workers in the country more commonly than in city dwellers. Treatment. — When small and when they are com- paratively young they may be removed by the use of an ointment containing 1 to 5 per cent, of salicylic acid, to which may be added precipitated sulphur in like amount. If they are hard they had best be let alone, or treated as if they were epitheliomas by currettage and caustics, or 26 402 DISEASES OF THE SKIN arrays. It must be borne in mind that the senile skin bears the rays badly, and they must be used with caution. Freezing by carbon dioxide snow removes them perfectly with scarcely perceptible scar. Keratosis Spinulosa. — See Lichen pilaris of Crocker. Kerion.- — Synonyms: Trichomykosis capillitii; Tinea kerion; Kerion Celsi. Symptoms. — This is a more or less chronic inflamma- tion of the scalp or beard that most often is a form of ringworm, but may be produced quite independently of that disease. It is most commonly seen on the scalp. The affected part becomes red, edematous, swollen, and boggy, and may assume a purplish color. Its surface is glazed, uneven, and studded with a number of yellowish suppurating points, or with foramina out of which oozes a sticky, viscid, gelatinous, transparent fluid. Sometimes suppuration may occur attended by a seropurulent discharge. The swelling is round or oval in shape, and varies in size; it may be but one or two inches in diam- eter, or as large as a turkey's egg. The pustules form about the hair in the early stage; later the hairs fall and the discharge takes place from the openings of the hair follicles. If the tumor is opened, a thick, viscid material escapes. If the disease occurs with ringworm, the hair will be broken off. Permanent baldness may result if the inflammation is intense. There are more or less pain and tenderness, and at times itching and burning. The posterior cervical glands may be enlarged. Etiology. — The disease is comparatively rare. It occurs chiefly in children of poor constitution. It is most commonly due to the trichophyton fungus passing- deep down into the hair follicles. In most cases the fungus is of animal origin. It ma}' be caused by the application of irritants to the scalp, or follow eczema, favus, or folliculitis of that part. Diagnosis. — Kerion must be diagnosed from an abscess, a papilloma, a gumma, and a sebaceous cyst. KOILONYCHIA 403 An abscess is not preceded by ringworm, has no history of an irritant applied to the scalp, and may arise without any antecedent disease of the scalp; it is more painful; it is often accompanied by a sensation of throbbing, by chilliness, fever, and general malaise; when fully formed there is fluctuation, and when opened it gives exit to pus. These symptoms are not met with in kerion. A papilloma is non-inflammatory, firm to the touch, and is unaccom- panied by a discharge. A gumma is usually accompanied by other signs of syphilis, and tends to break down and ulcerate. A sebaceous cyst is slow in its growth, the skin over it is normal, there is no discharge, and when opened it gives vent to a cheesy mass. A fatty tumor is a chronic, elastic, freely movable swelling, with normal skin over it. Treatment. — In treating a case, epilation should be performed in order to save the hair and give exit to the discharge. If some irritant application is the cause, that should be discontinued, and hot-water dressings with boric acid, antiseptic solutions, or mild emollient applica- tions employed. If the cause is ringworm, the remedies proper for that disease should at once be used. What they are will be found under Trichophytosis capitis. Prognosis. — The disease is curable, though sometimes with difficulty. Many cases get well of themselves. It may cause permanent baldness. Koilonychia, or Spoon Nails, is a condition of the nail in which it becomes more or less concave from side to side, sometimes anteroposteriorly. The nail is thin and easily bent, its surface is furrowed, and its free border irregularly notched. Its color is whitish, its edge being dirty gray. It begins on one finger and gradually affects all the nails. It is often associated with leukonychia. The nails are easily broken. There is often a subungual keratosis at the free borders of the nails. It is a chronic disease, and may be hereditary; or acquired, as from having the hands much in water. 404 DISEASES OF THE SKIN Kraurosis Vulvae is the name proposed by Breisky 1 for a form of atrophy of the skin of the external genitals of women, which may occur at any age. The disease has its seat in the vestibule, the labia minora with the frenulum and preputium clitoridis, the inner surfaces of the labia majora up to the posterior commissure, and the contiguous skin of the perineum. It gives rise to the appearance of a defect in the development of the normal folds of the vulva. At times the labia minora and the preputium clitoridis are apparently wanting. The affected skin is white and dry, the epidermis is often thickened, and tel- angiectasic vessels are visible. Stenosis of the vulvar entrance may result, and thus obstruction be offered both to coitus and parturition. The cause is obscure; possibly a long-continued blennorrhea, or a congenital defect, or a process analogous to leukoplakia buccalis. Thibierge 2 teaches that it is a disease that develops in those whose ovarian activity has ceased either on account of the menopause or removal of ovaries. Treatment is of no effect. 3 Lentigo. — Synonyms: Ephelides; (Ger.) Sommerspros- sen, Linsenflecke; Freckles. Freckles are properly a species of chloasma. They occur as light to dark-brown or even black macules, and are usually located upon exposed parts, especially the face and back of the hands, but they may occur anywhere. In size they vary from that of a pinhead to that of a split pea. They give rise to no subjective symptoms. They usually do not appear before the eighth year of life, but congenital cases have been reported. The latter should rather be classed among the pigmentary nevi. A division is sometimes made between those that are permanent and occur upon unexposed places and those which occur in summer to disappear in winter. To the former the name lentigo is given, and to the latter ephelides. As old age 1 Zeitschrift f. Heilkunde, 1885. 2 Annal. Derniat. et Syph., 1908, xix, 1. 3 Janovsky, Monatshefte f. prakt. Dermat., 1888, vii. 951. LENTIGO 405 is approached freckles no longer form, and the old ones are apt to disappear. Lentigo maligna is a form of lentigo that comes in old age in the form of dark-brown, small, irregular spots of pigment that occur on the eyelids, and even the conjunc- tiva, and coalesce into patches which later may change into an epithelioma. Etiology. — The cause of freckles is probably an inborn peculiarity of the skin. It has been advanced as a theory of their production that they are due to the chemi- cal action of the sun's rays upon the blood. Blondes are more prone to them than are brunettes. Many people never freckle. Symptomatically they occur as part of atrophoderma pigmentosum. Pathology. — Freckles are but circumscribed deposits of pigment. Cohn 1 has endeavored to show that len- tigines differ from ephelides in being discrete, slightly elevated, and having their pigment in all the layers of the epidermis, as well as in the cutis, and in being associated with changes in the bloodvessels of the cutis; while ephelides are crowded together, their pigment is only in the basal layer of the epidermis, and there are no changes in the bloodvessels. Treatment. — The treatment of freckles is the same as that of chloasma. The only prevention is to protect the skin from the action of the sunlight by wearing veils or by the use of some lotion containing a pigment, such as calamin lotion, or a brown grease paint. Hardaway recommends for their removal the following: R — Hydrarg. ammon., Bismuthi subnitrat., aa, 3J aa 4 Ungt. aq. rosse, ad gj ad 32 M. He speaks highly also of electrolysis for the removal of very black freckles. Bulkley recommends the fol- lowing : , — Hydrarg. bichlor., gr. vj 4 Acid, acetic, dil., 5ij 8 Ac. boric, gr. xl 2 5 Aquae rosae, ad 3iv ad 128 M Monatshefte f. prakt. Dermat., 1891, xii, 119. 406 DISEASES OF THE SKIN This is to be used night and morning, at first gently, but afterward to be well rubbed in. The skin may be caused to exfoliate superficially by dabbing on the skin two or three times a day an aqueous solution of bichloride of mercury, J to 4 grains to the ounce. As soon as scaling begins the lotion should be discontinued. Stelwagon prefers : 1$ — Hydrarg. bichlor., gr. iv-viij 0.26-0 [52 Tinct. benzoin., 3 i J & Zinc, sulphat., gr. xx-xl 1.33-2 65 Alcohol, Aquae, aa p. e. ad Siv 128 M. used in the same way. Peroxide of hydrogen bleaches them. They may also be touched with dilute acetic or lactic acid, trichloracetic acid, or with pure carbolic acid. There is hardly any use in endeavoring to cure freckles occurring from the action of the sun, as they depart of themselves. Lepothrix. — Synonyms: Trichomycosis palmellina sen nodosa; Nodositas pilorum microphytica. Symptoms. — Various colored nodes surrounding the hair are found in subjects who sweat profusely. These are met with most frequently in the axillae, then upon the chest, pubes, and inside of the thighs. They are grayish, yellow, yellowish red, or brown. When the hair is dry they are hard. They may be located anywhere on the hair but do not invade the follicle. In slight grades the hair is thickened, sometimes to twice its normal size by a sticky mass that surrounds it, or is deposited on it in knobs. It may be normal in length, or shortened and end in a knob. From freshly plucked hair the mass may be shaved off with ease, but when the hair is dry it is apt to be injured by removing the deposit. Both the cleanly and the uncleanly show these nodes, blondes being affected more than brunettes. In this country the disease is not often seen. Etiology. — The cause of the disease is the lodgement on the hair of a species of schizomycetes forming zooglea LEPRA 407 masses. They may be simply deposited on the hair, or attached to a scale at its angle of attachment. In growing the parasite may penetrate to the cortex of the hair and split it into fasciculi. It is predisposed to by excessive sweating. Bacterium prodigiosus is the cause of red sweat. Treatment. — A cure is readily effected by washing the part with soap and water, and bathing with bi- chloride of mercury solution 1 in 1000 or a saturated solution of boric acid. The latter is best for blonde patients as their skin is apt to be easly irritated. Lepra. — Synonyms: Elephantiasis Grecorum; Leonti- asis; Satyriasis; Lepra Arabum; (Fr.) La Lepre; (Ger.) Der Aussatz; (Norweg.) Spedalskhed; Leprosy. A chronic, endemic, constitutional disease due to infection by a specific bacillus ; characterized by anesthe- sia, erythematous patches, tubercles, ulcerations, atro- phies, and deformities according to the structures most, affected; and ending in death. Symptoms. — It is usual to describe three forms of leprosy — the tubercular, the maculo-anesthetic, and the mixed. This is convenient for clinical purposes, though not absolutely correct, as even in the nearly pure tubercular form there is more or less anesthesia. All forms exist in all endemic regions, but now one and now another form predominates. The tubercular form is the one most common in cold countries, the anesthetic in hot countries. Morrow, 1 however, found that in the Hawaiian Islands the tubercular form constituted one- half of the cases, while the anesthetic form formed but one-third of them. The incubation stage is undetermined. It may be several months or many years. During this stage there are no special symptoms. Tubercular Leprosy. — Sometimes this form appears sud- denly without prodromata, but usually for days, weeks, or 1 New York Med. Jour., 1889, 1, 85. 40S DISEASES OF THE SKIN months, before the disease frankly declares itself the patient[is out of health. He feels indefinitely ill, depressed, and listless; he has dyspepsia and diarrhea; he is weak, Fig. 56 Tubercular and anesthetic leprosy. 1 chilly, and suffers from profuse sweating. There may be nosebleed. Frequently the first, and generally unrecog- 1 From a photograph kindly loaned me by Dr. P. A. Morrow, of New York. LEPRA 409 nized symptoms of the disease are a husky voice, and a nasal discharge, showing an early implication of the mucous membranes. Then a remittent fever of malarial type appears. This fever may occur without the other prodromas, and may recur with each new outbreak of tubercles. It ranges from 99° to 106° F. It may last from several days to several weeks. After a time an erythematous eruption appears upon the face, ears, the forearms, and thighs. It consists of purplish or mahogany-red, slightly raised, hyperesthetic, smooth, shiny patches, of one or several inches in diameter, usually of oval form. The eruption may fade entirely away, to appear again with a fresh outbreak of fever. After some three to six months of the exanthem the tubercles appear, either upon the sites of the previous lesions, or quite independently of them. They begin as pinhead-sized pink papules that enlarge to split-pea- or even to hen's-egg-sized, yellowish-brown tubercles. If a number of these run together, large infiltrated patches are formed of irregular shape and nodular surface. Infiltrations may also arise by an increased deposit of leprous material in the macules, for the macules them- selves are formed of leprous material, and are not simply erythematous lesions. Sometimes the infiltrated patches that arise from the macules may assume ring shapes, by clearing up in their centres. The tubercles are completely anesthetic. They may come anywhere, but are most commonly seen in the eye-brows, lobes of the ears, the face generally, and upon the extremities. They are rare on the glans penis, palms, and soles. The scalp is said never to be affected. The mucous mem- branes of the mouth, nose, larynx, trachea, uterus, and vagina are also involved, as may be the conjunctivae. The tubercles may undergo spontaneous involution in one place, while fresh outbreaks of them occur in other places. Or they may soften and break down and form leprous ulcers, which are indolent, sharply defined, and glazed over with a mucous discharge of a peculiar 410 DISEASES OF THE SKIN odor. These may attain enormous dimensions, becoming serpiginous and phagedenic. When these ulcers go deep, as they may do on the lower extremities especially, there may take place spontaneous amputation of the fingers, toes, or whole members. This is one form of mutilating leprosy, which is most frequently encountered in the anesthetic form of the disease. Or the tubercles may, on disappearing, leave atrophic spots. Their develop- ment and involution are always slow. The appearance of a well-developed case is striking. The face is deformed by the tubercles, and assumes the "leonine" expression on account of the thickening of the eye-brows causing them to protrude, so that the eyes are sunken and have a stern expression. The hair is wanting in the eye-brows. The immense lobes of the ears hang down. The lips protrude and are often everted. Tubercles stud the face. The forearms are enlarged and knobby. The hands are deformed. There is very com- monly a discharge from the nose, a disagreeable odor from the mouth, and the sense of smell is lost. The eye-sight is often lost; the voice is cracked and croaking. The lymphatic glands are often swollen. Happily, both in men and women sterility is the rule. There are com- monly atrophy of the testicles and loss of sexual power in men. The disease is steadily progressive, and death occurs in eight years on an average, though the disease may last for many years. Crocker says 40 per cent, die of the disease itself, 40 per cent, die from renal or lung complications, and the rest from diarrhea, anemia, or general marasmus. Maculo-anesthetic leprosy announces its onset not by febrile symptoms, but by shooting, lancinating pains in the chief nerve trunks, as the ulnar, median, peroneal, and saphenous. There are also pain and tenderness in various places, and a state of general hyperesthesia. Itching is regarded by Morrow as being one of the most common and characteristic prodromas of this form of leprosy. There may also be symptoms of general malaise LEPRA 411 and digestive disturbances. A frequent early symptom is a vesicular or bullous eruption upon the fingers and toes, with at first serous, then purulent contents. These may burst and leave a white, shining, anesthetic spot, or an ulceration that heals with an anesthetic cicatrix. Numbness soon follows the hyperesthetic state. The Fig. 57 Macular leprosy patient cannot grasp things firmly, and the consequent unskilfulness of his action may be the first thing to attract his attention. This shows muscular weakness as well as numbness. After some months of these prodromal symptoms an eruption of macules similar to those of the tubercular 412 DISEASES OF THE SKIN variety appears upon the extremities, face and back. They are isolated, of oval shape, hardly raised above the surface, and of a pale-yellow to reddish-brown color. They may be quite small or of large size. These often enlarge peripherally and clear up or become atrophic in the centre, forming rings. The macules become intensely red, and enlarge during the outbreaks of leprous fever, which occurs as in the tubercular form. Sometimes, instead of being oval, they will take the form of wide streaks or of gyrate figures. They are often hyperesthetic when newly formed, but always perfectly anesthetic when they have become atrophic, and even before that in cases that have lasted some little time. The large nerve trunks, as that of the ulnar, are at first hyper- esthetic, but later are anesthetic and can be felt like a whip-cord and rolled about under the finger without giving rise to pain. Anesthetic areas w'ill be found independently of the macules and in old cases a rather general anesthesia develops, so that the patient may burn himself without noticing it. The anesthetic areas are subject to change from time to time. Solitary bullae appear from time to time, as well as urticaria-like lesions. Marked atrophy of the muscles of the hands and feet occurs, and paralysis of the extensor muscles of the second and third phalangeal joints. Wasted interossei muscles and permanent flexion of the last phalanges of the fingers give as characteristic an expression to the hand in this form of leprosy as the tubercles do to the face in the tubercular form. After some ten years or so, during which the greater part of the cutaneous surfaces may have become studded over with white, wrinkled, hairless, atrophic spots, the permanent stage is reached. During these years pain- less amputation of many of the joints may have occurred by a process of dry gangrene (Lepra mutilans). Erysipelas may occur. The nails and hair are shed. Sleeplessness may prove a distressing symptom. Loss of sexual power and sterility are manifest late in the LEPRA 413 disease. There is a marked anesthesia of the soft palate, uvula, and pharynx. This form lasts much longer than the tubercular form, fifteen years being an average duration. Sometimes a fair degree of health is preserved for a much greater length of time. In most all cases more or less hebetude of mind is marked, be- coming more pronounced with the duration of the disease. The mixed form is a combination of the symptoms of the two former varieties, and perhaps is the one most commonly met with in this country. Indeed, it is the rule that all tubercular cases present certain symptoms of the anesthetic form, and vice versa, the variety being named from the prevailing lesion. Etiology. — Up to within a few years various agencies were regarded as causes of leprosy, such as residence by the seashore, eating of putrid fish, heredity; but in the light of our present knowledge there is but one cause, and that is contagion. The contagiousness of the disease is a strong plea for the segregation of the lepers within our own country. Leprosy is seen in both sexes, though the male sex is more often affected. It is rare in children, and is never seen in infants; a strong argument against heredity. Its incubation stage is very long, reaching over a period of years. It occurs in all countries and climates, but is endemic in certain regions. It seems that a damp, cold climate, or a hot, moist climate favors the disease. Spor- adic cases have been reported, but careful investigation would doubtless show that they had been exposed to contagion. Vaccination has been a carrier of contagion. It may gain entrance to the system, as through an abrasion of the skin, but its most common route is prob- ably through the nose and mouth. Pathology. — The bacillus lepra? is the cause of leprosy. This has been found in the skin, mucous membranes, the tubercles, the infiltrations, the lymphatic glands, nerves, spleen, liver, walls of the bloodvessels, hair follicles, and sebaceous glands. It was discovered bv 414 DISEASES OF THE SKIN Hansen in 1874, and pure cultures of it made in 1909 by Clegg and Duval. "This bacillus occurs as straight or very slightly curved rods, 5-0V0 °f an mcn m length, which may have knob-shaped expansions at their ends or in their length, due to the presence of two or five spores." (Crocker.) After gaining entrance to the tissue the bacilli lie in the lymph spaces and produce an infiltra- tion of round and spindle-shaped connective-tissue cells, lymphocytes, mast cells, and occasionally polynuclear leukocytes. As they multiply they form colonies united by zooglea, and plasma cells appear around the capillaries. A certain number become intracellular, and large char- acteristic cells containing vacuoles, nuclei and bacilli single or in clumps may be noted. These are lepra cells. The bacilli spread by the lymphatic and blood streams. The lepra nodule resembles, but is less vascular than ordinary granulation, tissue. The epidermis is not involved. Just below the epidermis are seen the largest tumor cells. The youngest and smallest cells are at the base of the nodule. In the upper layers are found the so-called "globi," accumulations of degenerated cells, sharply circumscribed, and densely packed with bacilli. Diagnosis. — In a fully developed case little difficulty in diagnosis can arise. Sometimes lepra will need to be differentiated from erythema multiforme; syphilis; lupus; morphea; vitiligo, and syringomyelia. The presence of anesthesia, the occurrence of lepra fever, and the enlarge- ment of the ulnar nerves in any doubtful case will establish the diagnosis of leprosy. Besides these, erythema runs a more acute course; syphilis of the tubercular form presents redder tubercles, which ulcerate more rapidly, are grouped, and a history of syphilis is usually attainable; the lupus tubercles are small, of apple-jelly color, soft, do not produce thickening of the eye-brows and nodular lobula- tion of the ears, and group themselves in patches in which cicatricial tissue will be found; morphea has a lardaceous appearance with a violaceous border; vitiligo patches are more lead-white and sharply defined, while LEPRA 415 the skin is unaltered in texture and normal in sensation. Syringomyelia lacks the nerve enlargements, the lepra fever, and the multilations of leprosy. Treatment. — The best chance for recovery from leprosy is removal to a region where the disease is not endemic. This, with attention to hygiene, and a general tonic treatment, will do a great deal toward a cure. Qiiinin may be given during the febrile attacks. Of internal remedies, chaulmoogra oil holds the first rank, with an initial dose of 3 minims three times a day, and then gradually increased to as high a dose as the patient will stand. Nausea, vomiting, and diarrhea show when this is reached. It may be given in capsules. As this oil may cause fatty degeneration of the liver and kidneys if given over too long a period, it is well to interrupt its administration from time to time. Gynocardic acid has sometimes been substituted for it in doses of f grain (0.033) to 2 grains (0.2) t. i. d., the magnesium or sodium compound being used. G. H. Fox 1 has cured one patient by giving nux vomica or strychnin up to full constitutional effects, and then administering chaulmoogra oil continu- ously. Gurjun oil is also highly commended in an emul- sion of 1 part of the oil and 3 parts of lime-water, of which the dose is J ounce (16) morning and night. Unna claims to have cured one case with sulpho- ichthyolate of sodium from 6 (0.36) to 45 (3) grains a day, but others who have tried it have not had the same suc- cess. Salicylate of soda, 30 grains (2) every four hours until 2 drachms (8) are taken; salol in full doses; thymol, 45 (3) to 60 (4) grains a day; carbolic acid up to 15 grains (1) a day, are advocated by Lutz, Besnier, and others. H. R. Crocker 2 has had good results in one case by weekly and then semi-weekly hypodermic injec- tions of J of a grain of bichloride of mercury in 20 minims of oil. These were given for three months and then 1 Post-Graduate, 1885-6, i, 143. 2 Lancet, 1896, ii, 364. 416 DISEASES OF THE SKIN intermitted for three months. Dyer 1 and Woolson 2 report good results from the use of antivenene. Externally the chaulmoogra or gurjun oil may be rubbed in daily, an emulsion of it being made with 1 to 3 parts of lime-water or olive oil. Mastin, a product of the cultivation of lepra bacilli on milk, is said to be useful in early cases. A solution of one part in 100 parts of hot sterilized olive oil is used, 0.5 c.c. is injected once a week, and later 1 c.c. The ulcers are to be treated upon the usual surgical principles. Unna 3 recommends rubbing into all the lesions, but those on the hands and face the following: I^ — Chrysarobin., Ichthyol., aa 3iss Ac. salicyl., gr. xl Ungt. simpl., ad §iv 2 '5 ad 128 I M. On the face and hands he substitutes pyrogallol for the chrysarobin. To counteract the bad effects of the drugs he administers 30 drops (2) of dilute hydrochloric acid during the day. For women and children he substitutes resorcin for the chrysarobin. To old nodes, after pro- tecting the surrounding skin, he applies during five to seven days a plaster mull containing 20 to 40 parts of salicylic acid and 40 parts of creosote. The so-called Bhau Daji treatment 4 is said to have pro- duced remarkable effects in from six to eight weeks after it was begun. It consists in the use of the oil of hydno- carpus inebrians, of which fromTfUO (0.66) togss (0.16) is taken in the morning in boiled milk. The patient is also anointed with the oil. Two hours afterward the oil is washed off in a warm bath. He is anointed again on going to bed. He is not allowed to eat pork, beef, or fish, nor to drink alcoholics, tea, or coffee. He is fed on milk, fruit, vegetables, butter, eggs, mutton, and fowls. Roake 5 1 New Orleans Med. and Surg. Jour., Oct., 1897. 2 Phila. Med. Jour., Dec. 23, 1899. 8 Jour. Cutan. and Gen.-Urin. Dis., 1896, xiv., 413. * British Jour. Dermat., 1893, v, 203. 5 Ibid. LEUKOPLAKIA 417 advocates excision of the tubercles, followed by the application of pure carbolic acid. The thermo- and electro- cautery may be used to the same end. X-rays seem to exert a curative effect on the lesions. Segregation is the only preventive measure. Prognosis. — The prognosis is bad, as the disease steadily progresses to a fatal termination unless the patient can be removed from the endemic region. If he can be removed, there is a chance of staying the disease. In some instances the disease, even when the patient does not change his residence, pauses in its course for a long time; but eventually it will again become active. Leukopathia Unguium or Leukonychia. — This affection consists in the appearance of white spots in the nail, which originate in the lunula, and gradually approach the free end of the nail as it grows forward. Sometimes these take the form of stripes or lines. Rarely the whole nail is affected. The nail substance is otherwise unaltered. The spots are thought to be due to air spaces in the nail sub- stance. M. L. Heidingsfeld 1 believes that they are due to a disturbance in the growth, development, or keratini- zation of the matrix cells in their change to nail struc- ture. Why these occur we do not know. Possibly there may be a process of fatty degeneration of the nerve cells and subsequent absorption of the fat (Taylor) . Or they may be caused by pressing back the nail fold in over- zealous manicuring. They are common in the young, and coincident with white spots in the teeth (Hutchin- son). They very often are noticed after fevers or other lowered conditions of health. Nothing can be done for this deformity except caring for the general health of the patient and stopping any bad habit. Arsenic might be tried. Leukoplakia. — This is an affection of the mucous mem- brane of the tongue, lips, inside of the cheeks, glans 1 Jour. Cutan. and Gen.-Urin. Dis., 1900, xv, 490. 27 418 DISEASES OF THE SKIN penis and vulva, that has been described under the names psoriasis buccalis, ichthyosis linguae, leukokeratosis buc- calis, tylosis linguae, and smoker's patches. It occurs in the form of ivory-white or bluish-white, glistening, irregularly shaped patches upon the mucous membranes, that may be a little elevated. To the touch and tongue they feel rough. They may give rise to no discomfort, or they may interfere with chewing and speaking. They may be fissured or papillomatous. There is sometimes salivation. On the penis the disease appears as a circular band like infiltration with whitening and thickening of the mucous membrane. There is always danger of the development of carcinoma from them. They are caused by smoking, or occur in syphilis, psoriasis, lithemia, stomachic or intestinal catarrh, diabetes, and disturbed nervous influences. Rubbing of the tongue against the sharp edge of a decayed tooth sometimes seems to cause them. It is thought by some that syphilis is at the bottom of all of them, it affecting the tissues in such a way that the various irritants incite the disease. But cases occur in non-syphilitic subjects. Sometimes they arise without assignable cause. Diagnosis. — Leukoplakia differs from the mucous patch in its more chronic course and slight tendency to ulceration. Lichen planus, when occurring in the mouth, resembles the disease very strongly, but takes the form of rings, festoons, and disks, and the typical lichen papules can be found on the skin. Treatment. — It is very essential that tobacco be given up if the patient has been in the habit of using it. It is also necessary to address remedies to the cure or relief of any lithemic or digestive disorder; and to have the teeth put and kept in good order. The frequent use of normal salt solution as a mouth wash is advisable combined with the application of balsam of Peru daily or every other day. An antisyphilitic treatment may be tried. The hypodermic administration of mercury is far better that the administration of the LEUKEMIA CUTIS 419 same drug by the mouth. Sometimes a patch may be removed by the daily application of pure lactic acid; or | per cent, solution of bichloride of mercury; or 10 to 30 per cent, solution of salicylic acid; or 20 per cent, of chromic acid; or 2 to 10 per cent, of bichromate of potash; or by galvano- or actual cautery. S. Sherwell has had good success with the acid nitrate of mercury in 10 to 50 per cent, strength, according to the intensity of the process. Great care must be had in its use, the surround- ing parts being protected by means of absorbent cotton, and an alkali held ready to neutralize any of the acid that has gone beyond the intended part, as well as to apply to the cauterized surface after a few moments. It is a very painful procedure. Hyde advocated the use of the dental burr after the injection of cocain. The use of the high-frequency spark is advocated by Con- stantin. 1 A 20 per cent, solution of cocain should be kept in contact with the place for two or three minutes. Healing is said to take place in two weeks. Prognosis. — It is a very obstinate disease. Patches not infrequently take on a cancerous change. Leukemia Cutis. — Leukemia is a disease characterized by a persistent increase of white-blood corpuscles associ- ated with changes in the lymphatic glands, bone marrow, and spleen. In this condition the skin is involved at times. The majority of cases occur in young people. The skin manifestations vary. In some cases there are eczematous patches, with much thickening of the skin, upon which tumors may or may not form. The patches do not yield readily to treatment directed to the cure of eczema, and the itching is intense. In other cases there is an eruption of tumors that are flat, slightly raised, yellowish or brownish red, from the size of a millet seed to that of a cherry. There may be only a few of them or there may be very many, and crowded together on a thickened skin so as to give the patch a 1 Annal. derm, et syph., 1911, ii, 91. 420 DISEASES OF THE SKIN tabulated appearance. Some of them may have a central depression. They seldom ulcerate. In any case there is a general enlargement of the lymphatic glands. In the tumor form the disease resembles granuloma fun- goides, but the tumors do not tend to ulcerate, the general enlargement of the lymphatic glands is pronounced, and the blood count is decisive. Eczema is more tractable to treatment, and is unattended by general lymphatic enlargement. The treatment is that of the underlying disease. Lichenification. — This is the neurodermite of the French. Symptoms. — The disease begins as an intermittent itching of the skin of a limited area; or more rarely as a chronic pruritus with paroxysmal crises. The itching is always intense. On account of the scratching to relieve the itching, changes take place in the skin by degrees. It becomes slightly reddened and assumes the appearance of shagreen leather, with here and there flattened, shiny papules somewhat like those of lichen planus. Gradually it takes on a brownish-red or pigmented color, becomes greatly thickened, infiltrated, and marked by ridges that cross each other at right angles. The patches so formed vary in size and shape. While commonly oval they may be triangular, semi-circular, or of other shape, such as band or linear. A fully developed patch has about it a zone of light brown or brownish-red color, which is slightly thickened, shades off into the surrounding skin, and has on it a lot of hypertrophied papilla? in rows that cross each other. The zone is wanting at times. Inside of this zone, or alone if it is wanting, the skin is greatly thickened, brownish or pigmented, marked by ridges that cross each other at right angles, and, usually scaly. The disease is essentially chronic, lasting, with intermissions, for years. If recovery occurs, the skin resumes its normal appearance. It is met with most often on the back of the neck, the upper and inner surface of the thighs, the loins, between the buttocks, LICHENIFICA TION 421 the lower external part of the leg, the scrotum, labia rnajora, popliteal and axillary spaces, palms and soles. Cases of "chronic itching papular eruption of the axilW reported by G. H. Fox and others probably are of this class. Fig. 58 Lichenification as seen in axilla. (M. Hassen.) 1 Etiology. — The disease may be secondary to any itching skin disease, as eczema or psoriasis. It often develops of itself. It is more frequent in women than in men, and occurs almost always in neurotic subjects. The real cause is yet to be found. 1 Jour. Araer. Med. Assoc, 1911, lvi, 194. 422 DISEASES OF THE SKIN Diagnosis. — Chronic squamous eczema bears a strong resemblance to licheniflcation. The quadrillage of the skin, the chronic course of the disease often extending over years without change, and the absence of patches of acute or subacute eczema elsewhere, should differ- entiate licheniflcation. Treatment. — Attention should be given to the general condition of the patient, such drugs as phenacetin, aspirin, bromids, and perhaps arsenic being given. Locally the high-frequency current, .T-rays, or other form of electricity may relieve itching. Ointments and lotions containing tar, carbolic acid, ichthyol, resorcin, or other antipruritics should be used. Lichen Nitidus. — This is a rare disease of the skin judging by the small number of cases reported. As it gives rise to no inconvenience in most cases, it may be more common than is supposed. One of the best descriptions we have seen is by Arndt, 1 from which what follows is largely taken. Symptoms.: — The disease consists in an eruption of pinhead-sized, sharply rounded or polygonal, hemi- spherical or fiat papules, of the color of the surrounding skin, or pale red or yellowish brown. Most of them have a small depression in the centre. They are but slightly raised, and of nearly uniform size. They show no tendency to group, but sometimes occur in lines or aggregated patches in which the individual lesions do not coalesce. They may last for years, and then disappear without leaving a trace on the skin. Their site of predilection is the penis; less often they occur on the abdomen, especially about the umbilicus, and the flexor surface of the elbows and wrists. At times the eruption is widespread, when it is symmetrical. The palms, soles, and face are usually free. There are no subjective symptoms. All cases but one have been in males. 1 Dermat. Zeit., 1909, xvi, 551. LICHEN OBTUSUS CORNEOUS 423 Etiology and Pathology. — Nothing is known of the cause of the eruption. It is thought by some to be a tuberculide as the tissues have a tubercular makeup with epithelioid and giant cells. Diagnosis. — It differs from lichen planus in not itching, in its papules not enlarging, nor forming rings, and in the absence of the purple color. Flat warts are readily removed by the curette. Lichen scrofulosorum differs from it in being follicular and scaly. Treatment thus far has been unavailing. Lichen Obtusus Corneous. — C. J. White 1 following Brocq, who first described the disease, gives the symptoms of this rare malady as follows: The eruption consists in the appearance on the skin of a number of globular lesions, from 3 to 10 mm. in diam- eter, which are found most often on the upper and lower extremities, especially on the extensor surfaces. They begin as roundish, hemispherical papules, pinkish white in color, which slowly enlarge, and assume a brownish or rather deep cafe-au-lait tint. They are covered by a complete layer of fine, dry, grayish, very adherent scales, which become stratified, and later have a cornified appear- ance. The lesions are discrete and few, and develop with extreme slowness. The disease is very itchy, the patient scratching for relief until the horny tips of the papules are torn off. The lesions may present crater-form depressions, sometimes filled with' blood crusts. Some of the papules have horny plugs in them. Most all the cases have occurred in women. In White's case, the blood was found to coagulate in two minutes and fifty seconds, the normal time being one minute and forty-five seconds. The calcium contents was 1 to 600, the normal being 1 to 1500. White regards the disease as the same as that described by Hardaway as " Multiple tumors of the skin accom- 1 Jour. Cutan. Dis., 1907, xxv, 385. 424 DISEASES OF THE SKIN panied by intense pruritus": and by Schamberg and Hirschberg as "Multiple tumors of the skin in negroes associated with itching." It is probable that the "Noduli Cutanei" of Arning and Lewandowsky 1 belong to this class of lesions, as well as the "Porrigo Nodularis" of Hyde. Brocq was uncertain whether it was a form of lichen planus or a pure neurodermatitis, but was inclined to the later view. White's case improved under lactic acid internally, and chrysarobin externally. Lichen Pilaris. — This term is usually used as a synonym of keratosis pilaris. But Crocker describes it as a separate disease, the lichen spinulosus of Devergie. Symptoms. — It develops acutely or subacutely in crops. It consists in an eruption of pinhead-sized, red, conical papules, in the centre of which is a horny spine pro- jecting about j-q of a inch. These spines can be picked out, and leave a depression in the papule. After a time the redness subsides and the papule becomes the color of the skin. The papules are crowded together in patches, which are round, or large and irregular in outline. They occur in few or many regions and are symmetrically dis- tributed. The face, upper parts of chest, hands, and feet are usually exempt. They give a nutmeg-grater sensation to the hand when passed over the patches. There is little or no itching. Etiology. — Children are the chief subjects of the disease, boys more often than girls. Diagnosis. — It differs from keratosis pilaris in its spines, its inflammatory redness, acuteness of outbreak, and its patchy 'character. Lichen ruber acuminatus is marked on the backs of the hands, which are spared in lichen pilaris, and is scaly and lacks the spines. Treatment. — Alkaline baths and linimentum saponis well rubbed in will cure the disease. If there is much inflammation, it is best to use an oil instead of the soap liniment. 1 Archiv Derm. u. Syph., 1911, ex, 3. LICHEN PLANUS 425 Lichen Planus. — A chronic disease of the skin charac- terized by an eruption of smooth, waxy, angular, umbili- cated, red papules, that tend to form scaly, lilac-colored, elevated, and infiltrated patches especially upon the flexor surfaces of the wrists and the inside of the knees. While the testimony from skilled observers is over- whelming that lichen planus papules may occur with lichen ruber, and while some cases of lichen ruber have developed after and together with lichen planus, still we see so many cases of the latter occurring by itself that Fig. 59 Lichen planus. (Fox. 1 ) it merits a special description. In this country and in England lichen planus is far more frequent than is lichen ruber, and is regarded as a separate disease. Symptoms. — The disease begins as an eruption of small purplish- or crimson-red, angular, flat, slightly raised papules, varying in size from yg- to J of an inch in dia- meter. The surface of the papules is smooth and shiny, " waxy-looking," and they have a small depression in the centre. When fully developed the papules may have 1 G. H. Fox: The Skin Diseases of Children, New York, 1897. 426 DISEASES OF THE SKIN on them delicate gray striations, which are characteristic of the disease. The papules may remain discrete, and be disseminated over a larger or smaller area; or they may arrange themselves in rows, or form rings, or aggregate themselves into patches, the single papules disappearing. The single papules are not scaly, the patches are slightly so. The patches may be small, and if so there is apt to be a well-marked depression in their centre, and their shape is round or oval. The larger patches have no Fig. 60 Lichen planus. (Fox.) definite shape nor depression, but are well defined and elevated. Characteristic single papules will be found scattered about in the neighborhood of the patches. The color of the patches is characteristic, and may be defined as lilac. It is an important aid in diagnosis. The disease is very pruritic, and excoriations are often seen. Both the papules and patches on disappearing leave behind pigmented, slightly atrophic spots, which after a time, fade away. It is still a moot-point as to whether the individual papule enlarges peripherally or LICHEN PLANUS 427 not. Like those of psoriasis, the papules of lichen planus may appear upon scratched surfaces. The disease is most often met with upon the anterior surface of the wrists and forearms, and upon the inside of the knees, the former being the favorite location. But it may occur anywhere, other favorite locations being the flanks, lower part of the abdomen, and of the legs, and it may involve a large part of the body, though it rarely becomes general. The glans penis is at times affected, sometimes before the disease is seen elsewhere. If the prepuce is long the papules will be white like on the mucous membrane of the lips. If the glans is uncovered, the color of the papules will be the same as on the skin. The eruption has also been seen on the vulva. On the palms and soles there may be red, slightly hyperkeratotic, papular elevations that become confluent, and form irreg- ular patches that may involve the whole palmar surface of the hands and fingers. The edge of the patches is sharply defined by a slightly raised border with, at times, a red zone on the outside. The palms feel like parch- ment and are of a brown color. When the nails are affected, they have on them either prominent elevations, like papules, forming vertical lines, or raised lines that run parallel to each other. The nails are rough, and at the free border of some nails there are corneous pads of brown color. The mucous membranes of the lips and mouth are affected, and the disease then appears as white spots difficult if not impossible of diagnosis without the occurrence of the typical eruption on the integument. The involvement of the mucous membranes is rarely reported. It is probably more common than is supposed, because the mouth is seldom inspected, as the lesions give rise to no discomfort. As a rule, there is more or less symmetry shown in the disposition of the efflorescences; and pruritus, which usually is marked. The general health is often unaffected, but, on the other hand, many of the subjects of the disease are not in perfect condition when the disease begins, and not a few others become 428 DISEASES OF THE SKIN greatly broken down on account of the loss of sleep, and continual discomfort caused by the pruritus. The course of the disease is chronic, and new outbreaks are liable to occur. Fig. 61 $ Lichen ruber moniliformis. (After Taylor.) Kaposi 1 has described a unique form of this disease under the name of lichen ruber moniliformis, in which the typical lesions became tranformed into keloidal nodes arranged in lines (Fig. 61). The nodes were in some places as large as cherries with their bases confluent and their upper parts separated by furrows. Unna 2 described 1 Vierteljahr. f. Dermat. u. Syph., 1886, xiii, 571. 2 St. Petersburg, med. Wochenschr., 1884, i, 447. LICHEN PLANUS 429 under the name of lichen obtusus, a form of the disease in which the papules are midway between the acuminate and the plane. They are large and waxy, discrete, often convex, frequently bluish white, not scaly, and but slightly itchy. A lichen verrucosus and a lichen hyper- trophicus have also been described. These are seen most often on the lower parts of the legs and do not look at all like the usual eruption. They are elevated, warty, firm, violaceous, in irregularly shaped patches of various sizes. The gray striations are usually well marked on them. This form is specially obstinate to treatment. Hallopeau and others have reported cases in which angular flat papules of white color occur, under the name of lichen planus atrophicus seu sclerosus seu morpheicus. It is met with on the upper part of the chest and arms. White papules are seen in colored races. Lichen planus striatus occurs as a long band, usually upon the inside of the thigh, sometimes extending the entire length of the limb. Pemphigoid eruptions occasionally occur as part of the disease. Crocker, who at one time described an infantile form of the disease in which the papules come out acutely in groups, acuminate at first, but soon becoming flat, angular, and red, changing to purple, now regards it as merely a miliaria rubra. Etiology. — We know no more about the causes of lichen planus that we do about those of lichen ruber. A neurotic element is marked in many of the cases, and cases have been reported in which the papules were dis- tributed along the course of a nerve. 1 Nervous exhaus- tion, rheumatic sweating, and checking perspiration are given as causes. Its subjects are mostly adults, many of them otherwise in good health. Many are careworn or worried. It does occur in children. It is probable that a toxemia of some sort, probably derived from the intestinal tract, is the foundation of the disease. It is 1 Mackenzie: British Med. Jour., 1884, ii, 1077. 430 DISEASES OF THE SKIN more frequent in women than in men in this country and in England, though in Austria the reverse obtains. Pathology. — According to Fordyce 1 the disease begins by a dilatation of the bloodvessels and lymph spaces of the papillae of the skin, causing , a proliferation of the connective-tissue cells, the papillae becoming swollen and reddened. At the same time or soon after there is a round-celled infiltration in the subpapillary layer. The lymph spaces are enormously dilated, the tissues become edematous, an intra- and inter-cellular edema making its appearance in the epidermis. Later the rete pegs and the middle layer of the rete flatten, the cells assume more of a spindle shape, and the granular and horny layers hypertrophy. This increases especially in the lower part of the central part of the papule, where it sinks in at the expense of the rete and forms a small horny plug, producing the umbilication. Subepidermic vesicles fre- quently form, probably due to a serous exudation on account of a lowering of the resistance of the epidermis. The appendages of the skin are unaltered. The gray striae are due to the thickening of the granular layer. Diagnosis. — An eruption of flat, shiny, angular, umbilicated papules of a lilac color showing grayish striations situated on the anterior surfaces of the wrists can be nothing but lichen planus. The same character- istics are diagnostic anywhere on the body, and sufficient to distinguish the disease from eczema and psoriasis. Moreover, eczema will show a tendency to moisture, or the papules will undergo change; and psoriasis will be almost sure to have characteristic patches upon the elbows and knees, covered with more abundant white and ofttimes thick scales. Syphilis sometimes bears a strong resemblance to lichen planus, but itching is less marked, its eruption is more polymorphous, and its color is more that of raw ham. Treatment. — In the treatment of lichen planus, nerve tonics or sedatives and attention to the general health 1 Jour. Cutan. Dis., 1910, xxviii, 57. LICHEN PLANUS 431 as well as to the hygiene both- of the body and mind, are our most reliable agents. Arsenic is useful in some cases. Polland 1 advises salvarsan intravenously injected. Morris speaks highly of biniodide of mercury in the initial dose of yV °f a grain, which is to be gradually increased. The protiodide of mercury, i to i of a grain three times a day, is useful in many cases. Antipyrin, phenacetin, and the spinal douche render good service. Alkaline diuretics sometimes do well, such as the acetate of potash. Boeck and R. W. Taylor speak well of 15-grain (1) doses of chlorate of potash fifteen minutes after eating, followed in a quarter of an hour by 20 drops (1 .33) of dilute nitric acid in a wineglassful of water. Crocker speaks highly of salicin, 15 to 20 grains (1 to 1.33) three times a day, and of quinin. Salicylate of soda or salol often acts well. In obstinate cases change of scene in travel often cures when other measures fail. Locally, stimulants, such as tar, pyrogallol, and chrys- arobin, will prove serviceable. Stelwagon says that liquor carbonis detergens is the most efficient application. It is to be used at first diluted with 10 to 15 parts of water. If well borne the strength should be increased until it is used pure. It is to be dabbed on twice or more often daily. It may be used as an ointment of 10 to 15 per cent, strength. Unnas ointment, as given under lichen ruber acuminatus, is widely used. Touch- ing the papules with pure carbolic acid may be tried. In acute cases alkalin lotions such as calamin lotion with carbolic acid will allay irritation. Thymol and naphtol may be tried as in lichen acuminatus. In chronic cases Hardaway recommends: -Saponis olivse praep., 5iv 120 Olei rusci, Glycerini, aa gj aa 32 01. rosmarini, 3iss 6 Alcoholis, ad gviij ad 250 M. well rubbed in w T ith a piece of flannel. The patches are sometimes favorably affected by mercurial plaster. 1 Dermat. Zeit., 1913, xx, 778. 432 DISEASES OF THE SKIN Some cases in which the skin is very irritable are best treated by means of prolonged simple or medicated emollient baths, followed by some ointment such as vaselin or eucerin. In the hypertrophic form salicylic acid plaster is useful. The patches may be curetted out. The x-rays also remove them. Pusey advises that they be used on alternate days, or less frequently, care being taken to avoid dermatitis. In generalized cases they relieve the pruritus, as also does the high- frequency current. Prognosis. — The prognosis is generally favorable, though the disease is often very obstinate. Relapses are not infrequent. Lichen Planus Sclerosus et Atrophicus of Hallopeau. 1 Symptoms. — -The sites of predilection of this disease are the upper part of the trunk, about the breasts, over the clavicles extending over the shoulders and down over the upper part of the back, the neck, axillse, and forearms; also at times on the abdomen, thighs, vulva, buccal mucous membrane, vaginal mucous membrane, and, in one case, on the temple. The eruption consists in irregular, often polygonal, flat-topped, white papules. Some of the papules may be conical. The color is ivory or mother-of-pearl, sometimes with a yellowish tinge. The papules are firm to the touch and when in groups they may be wrinkled on top. Occasionally a rosy or slightly pigmented zone surrounds them. They may be grouped or discrete. If grouped in patches, one or more black or dark horny plugs, or minute pits will be seen on the shiny surface. The patches may be several centimeters in diameter, or linear. They are persistent, but after a time undergo involution, and leave smooth, white, atrophic areas. Usually there is moderate itching. Diagnosis.- — It differs from lichen planus in having white instead of red papules, and in being less pruritic. It 1 O. S. Ormsby: Jour. Amer. Med. Assoc, 1910, c, 901. LICHEN SCROFULOSORUM 433 differs from circumscribed scleroderma in having papules, and horny plugs or pits. Treatment is along the same lines as lichen planus. Lichen Ruber Acuminatus. — The general voice of au- thority declares that this disease is the same as pityriasis rubra pilaris, and to the latter the reader is referred. Lichen Scrofulosorum or Scrofulosus. — A disease of the skin occurring in strumous subjects, consisting in an erup- tion of small pale papules that tend to group in round or half-moon-shaped figures upon the abdomen, sides of the chest, and flanks. It is one of the so-called tubercu- lides. Symptoms. — It occurs in the form of pinpoint- to pinhead-sized, grouped, conical papules, which may be of the color of the skin, or pale red or fawn colored. These papules occur around the hair follicles and form small round groups, or circles or segments of circles, upon the abdomen, sides of the chest, flanks, and neck in adults; and upon the extremities in children. They are somewhat scaly, but give rise to no inconvenience, so that they are often overlooked. In some cases the pap- ules are so numerous that the groups lose their distinctive shape, and large surfaces are covered, giving the skin a dirty-brown color. Many disseminated and discrete pap- ules are scattered over the body outside of the patches. Acne pustules may form; and a brown pigmentation of the face has been observed in some cases. The papules finally undergo absorption, desquamate, and leave transi- tory yellowish pigmentation. The disease runs a chronic slow course. Eczema may complicate matters. Kera- tosis pilaris is frequently well marked upon the limbs. Etiology. — The great majority of the subjects of this disease present evidences of tuberculosis and many, if not most, react to the tuberculin tests. A few are robust. The disease is most common in childhood, and is very uncommon after the twenty-fifth year of life. It is thought by many authorities to be a tubercular disease, 28 434 DISEASES OF THE SKIN due to the toxins of tuberculosis. Tubercle bacilli are not found in the papules. Pathology.— The papule is composed of lymphoid, epithelioid, and giant cells, infiltrating the papillae about the follicular opening, or the tissue about the vessels, hair follicles, and sebaceous glands. Semiglobular masses in the horny layer of the epidermis, and around the hair follicles, have been described. 1 Diagnosis. — The disease must be differentiated from papular eczema, the papular syphilid, lichen ruber, a punctate psoriasis, and keratosis pilaris. Eczema differs from it in greater itching, in the brightness and rapid development of the papules, and in its tendency to vesic- ulation or moisture. The papular syphilid is of darker red color, much larger, and more polymorphous; the patient's age is usually greater, and the history and course of the eruption will soon decide the diagnosis. Lichen ruber has darker papules, which do not group in circles and segments of circles; they itch, and tend to involve the whole surface. The patients are more often adults, and there is a profound constitutional disturbance. Pso- riasis itches, is abundantly scaly, and its papules soon enlarge and form characteristic patches. Keratosis pilaris affects the extensor surfaces of the limbs by pre- ference, each papule is plainly about a hair, and the papules do not group. A curled-up hair will often be found in the centre of the papule. The absence of spines in the papules distinguishes it from Crocker's lichen pilaris. Treatment. — The persistent use of cod-liver oil both internally and externally will cure the disease. The syrup of the iodide of iron or the iodide of starch may be given with the oil. Good hygiene and food are valuable adjuncts. For the cod-liver oil, which is disagreeable for external use, other oil, such as cocoa-butter, may be used ; or vaselin with or without oil of cade. Crocker 1 Gilchrist: Johns Hopkins Hosp. Bull., 1S89, page 84. LUPUS ERYTHEMATOSUS . 435 recommends the addition of liq. plumb, subacetatis, Tflxv, (1) or thymol, 5 grains (0.33) to the ounce (32) of vaselin. The disease tends to get well of itself. Lichen Simplex. — See Papular eczema. Lichen Tropicus. — See Miliaria. Lipoma is a fatty tumor. Lues. — See Syphilis. Lupus Erythematosus. — Synonyms: Seborrhea conges- tiva; Lupus superficial ; Lupus sebaceous; Lupus ery- thematodes; Scrofulide erythemateuse or Ery theme centrifuge (Fr.); Dermatitis glandularis erythematosa (Morison) ; Ulerythema centrifigum (Unna) . This is a chronic disease of the skin, occurring in vari- ously sized, slightly elevated, scaly, red patches which show a strong tendency to the production of atrophic scars. Symptoms. — There are two varieties commonly de- scribed, namely, the circumscribed or discoid, and the diffuse, or disseminated, or aggregated. To these some of the English writers add a third, the telangiectic. The circumscribed or discoid form is the one most often met with. It occurs generally on the face, especially upon the sides of the nose and cheeks, the scalp, and the ears; more rarely upon the hands and feet; and still more rarely on other parts of the body. It begins by the appearance of several isolated or grouped red spots slightly elevated, of pinhead to split-pea size, with a thin adherent scale upon them. Some of these spots may be depressed in the centre. When the scale is removed there will be found upon its under side a delicate projection formed by a plug of sebaceous matter that dipped down into the mouth of the sebaceous gland. The mouth of the gland will be found patulous. These spots increase in size by peripheral extension to form disk-shaped figures of varying size; neighboring ones will coalesce, and thus patches will be formed, also covered with the fine grayish or white adherent scales. Now when the scale is raised 436 DISEASES OF THE SKIN a number of the characteristic prolongations will be found on its lower side. The margins of the patches are slightly raised, but the middle parts undergo in- volution, are lower than the margins, and after a time Fig. 62 9*mm' :: ] •<."■■' if ~'- : - : ' , ■-: dfcV " ►\ Lupus erythematosus. 1 are apt to become cicatricial, the skin being atrophied. The scar-tissue thus formed is thin, delicate, and white, never puckered or deforming. The color of the patches is red, but of a peculiar hue By courtesy of Dr. S. Dana Hubbard. LUPUS ERYTHEMATOSUS 437 that is characteristic, and perhaps can be best defined as violaceous. There is never any moisture connected with the disease. Burning or itching may or may not be pres- sent. The patches are of indefinite duration — months or years. At times they disappear of themselves, and do not leave scars, but the rule is that scars are left. The extent of the disease varies greatly, as well as the shape of the patches. The greater part of the face may be involved, or there may be only a single patch. Usually the eruption is symmetrical. A characteristic location for the disease is upon the back and sides of the nose and the contiguous parts of the cheeks, forming what has been fancifully called a butterfly, the ridge of the nose representing its body, and the cheeks its wings. Sometimes gyrate figures are formed. If the lobes of the ears are affec- ted they may at first resemble erythema pernio, but later become shrunken. When the fingers and toes are affected they present the appearance of chilblains, a per- sistent erythema; but when involution takes place there is left an atrophic condition. It may also appear on the hands and feet in the same way that it does on the face. The mucous membranes and the vermilion border of the lips may be affected, presenting patches with punctate excoriations of red color, or spotted with grayish masses of exudation and superficial cicatrices. The lips sometimes appear as if painted with collodion that is peeling off. Occurring upon the scalp it leads to per- manent loss of hair from well-defined patches, and the same may be said of it as it occurs on other hairy parts. The affected areas are not only bald, but converted into thin cicatricial tissue, at first red, later white. The disease may become stationary after a time. Relapses are liable to occur. The general health is unaffected. The diffuse or disseminate form is a more acute process, and exceedingly rare in this country. The disease usually begins on the face, and the limbs are involved before the trunk. It may follow the ordinary form of the disease, or appear suddenly, or slowly develop. The patches are 438 DISEASES OF THE SKIN from pinhead to finger-nail size, slightly elevated, reddish brown, hyperemic, and hard; they pale under pressure, and are attended with heat and burning. In this stage they resemble erythema exudativum or the papular stage of eczema. There may be from twenty to a hundred or more of them crowded together upon the face and scat- tered over the body. Many of them may disappear in a few days without leaving any trace, while others will remain and become characteristic patches of lupus erythe- matosus with depressed cicatrices. The individual lesions do not increase in size, and the patches are formed by aggregations of single lesions. The eruption may be accompanied by a high degree of inflammation, exuda- tion, and crusting, or even by bullse. There may be deep, painful subcutaneous tumors in the joints, and glands at first, over which characteristic patches will form. In some acute cases the development of the patches is accompanied by fever, osteocopic pains and nocturnal headaches, and in some cases the patient will pass into a typhoid condition and die of some lung complication. Or there may be a persistent inflammation of the face, erysipelas per starts, which may lead through a typhoid state to death. There may be also swelling of the parotid glands and of various lymphatic glands. In some cases the disease bears a close resemblance to chilblain. The telangiectic form occurs, according to Crocker, as a persistent circumscribed redness, which close inspection shows to be due to dilated vessels. It is commonly located symmetrically upon the cheeks. Upon pinching up the skin it will be found to be markedly thickened. Some few comedones may be present. There is no desquamation. It runs a chronic course. Crocker also describes a nodular form in which round or oval, convex, distinctly raised nodules appear, which are brownish-red in color. They vary in size from a hemp-seed to a small bean. They occur upon the face most often, but may occur elsewhere. They may undergo involution. LUPUS ERYTHEMATOSUS 439 Etiology. — About two-thirds of the cases occur in women. It seldom occurs before puberty, and most of the cases are under thirty years of age, though Kaposi has seen a case in a child of three years. Beyond these facts we know but little of its etiology. The French regard it as a scrofulous affection which, in the light of modern pathology, is regarded as tuberclar. While nothing suggesting its relation to a tuberculous process has ever been found in the skin, still, as not a few patients show other symptoms of a general tuberculosis, such as swollen or broken-down glands in the neck or cicatrices from the same, or give a history of tuberculosis in other members of their family, there is a growing opinion that the disease is a species of tuberculosis of the skin due to the toxins of that disease. The disseminated form is more often related to tuberculosis than is the discoid form. Crocker suggests a feeble circulation and prolonged expo- sure to great cold or heat as possible causes. It has been seen to follow upon frost-bite and sunburn. It would also seem that those who are subjects of seborrhea are predisposed to the disease. Pathology. — In spite of much careful study the exact pathology of the disease is still undetermined. J. A. Fordyce and 0. H. Holder 1 believe that the process is due to embolism of the small arteries, arising either on account of an alteration in the blood due to a toxin, or to some change in the walls of the vessels, or to a thrombus brought from some distant part. In the majority of cases the earliest manifestations of the disease are capillary obstruction and then an infiltration of round cells in the middle of the lower zone of the corium, the sebaceous glands and hair follicles being secondarily involved. The cicatricial scarring is the result of atrophic processes. Robinson 2 regards the disease as a local infectious pro- cess, a granuloma, inflammatory in character. This view is held also by Schoonheid. 3 1 Med. Rec, 1900, lviii, 41. 2 Trans. Amer. Dermat. Assoc, 1898, p. 70. 3 Arch. f. Dermat. u. Syph., 1900, liv, 163. 440 DISEASES OF THE SKIN Diagnosis. — The disease must be differentiated from lupus vulgaris, eczema, rosacea, psoriasis, and syphilis, A typical case occurring upon the face in the form of red patches, with fine cicatrices in the centre, and covered with a delicate white or grayish adherent scale, from the under side of which are a number of projections, offers no difficulty in diagnosis. Lupus vulgaris differs from lupus erythematosus in occurring before puberty, in showing no disposition to symmetry, in the presence of apple-jelly tubercles, in being a deep-seated disease, and in leading to far more disfiguring cicatrices. Eczema never leaves scars, is prone to exudation, itches, its scales do not show prolongations from the under side, and its patches undergo more rapid and varied changes. Psoriasis will be pretty sure to show characteristic patches covered with thick scales, and never causes scarring or leads to permanent loss of hair. Rosacea is largely composed of dilated bloodvessels, occupies the middle third of the face, often presents superficial pustules, does not leave scars, and is subject to frequent exacerbations. In syphilis a history of other lesions will be obtainable, there will be more evident infiltration, and the course of the lesions will be more rapid. The disseminate form of the disease is very difficult of diagnosis at first, but as soon as characteristic patches form the difficulty is removed. When lupus erythematosus occurs upon the scalp it causes a bald spot that may be mistaken for alopecia areata, but differs from it in its irregular shape, in the signs of inflammation in it, and in the cicatricial condi- tion of the scalp it leaves. Folliculitis decahans often shows inflamed follicles about the bald patch, lacks the comedones often seen in lupus erythematosus, frequently has tufts of hair in the patches, and has an irregular indented edge. A microscopic examination of the hairs from about a patch will decide as between lupus erythematosis and favus or ringworm. Treatment. — Little beyond the care of the general condition of the patient upon general principles can be LUPUS ERYTHEMATOSUS 441 done for lupus erythematosus in the way of internal medication. McCall Anderson advocated the use of iodide of starch, made by triturating 24 grains of iodin with a little water, and gradually adding 1 ounce of starch, rubbing them well together until the mass becomes deep blue in color. Of this a heaped teaspoonful, increased gradually, may be given three times a day in water or gruel. Iodide of potassium, is also commended, as are 'phos- phorus and salicylate of soda. Crocker speaks well of salicin in 15-grain (1) doses three times a day, increased to 20 (1 .33) or 30 (2) grains. It is especially useful in acute cases. Whitehouse 1 has had good results from iodoform, 1 grain, t.i.d., after meals. Quinin given in increasing doses seems to exert an influence on the disease when the patient can tolerate large doses. Hallander commends it in com- bination with painting the patch with tincture of iodin after washing it with absolute alcohol followed by ether. His dose is 7J grains (0.5) of quinin from two to eight times a day, the number of doses being gradually increased. When the patch begins to fade the number of doses is to be gradually reduced. Few can carry such amounts. If cinchonism develops the drug is to be stopped until it subsides, and then begun again. Local Treatment. — Sometimes in the early stages alkaline washes, such as lotions of zinc or lead, may be used. Or one composed of i — Zinci sulphat., Potassii sulphurat., aa 5 J aa 4 Alcohol, 5iij 12 Aquae rosse, ad § iv ad 128 M. as in acne and rosacea. Green soap or prepared olive soap, or its tincture, may be used in more chronic cases. This is often serviceable for the disease as it attacks the eyelids. The affected parts are to be well rubbed with it, using a piece of flannel. The process is to be repeated every few days. If the reaction is too great, a little oil 1 New York Med. Jour., 1899, lxix, 159. 442 DISEASES OF THE SKIN or a glycerin lotion may be applied. Crocker advocates the addition of 1 or 2 drams (4 to 8) of the oil of cade to the ounce (32) of the tincture of green soap. Carbolic acid, pure, applied to the patches, as first advised by G. H. Fox, often acts admirably. It turns them white at first. Caution is necessary at first, only a small patch being painted with it. If used on a large patch it may cause the patient to faint. The application is to be repeated as soon as the crust falls. Fowler's solution 3 j (4) in distilled water g j (32) and spirits of chloroform 2 drops, applied externally in the morning and evening, is sometimes efficacious. Resorcin, 50 per cent, aqueous solution, applied once or twice a day until decided reaction takes place, and then cold cream or calamin lotion used until the reaction subsides, is a good plan of treatment. The resorcin solution must be repeated when the reaction has subsided. Pyrogallol, 10 per cent, in ointment, sometimes does well. N. Walker thinks that oxidized pyrogallol, 1 to 2 per cent, in acetone collodion, is the best means we have; while others consider a combination of 10 per cent, pyrogallol with 40 per cent, of salicylic acid in collodion is better than anything else. Trichloracetic acid, in full strength so as to whiten the skin; oil of cade; solution of naphtol, 1 per cent.; tincture of iodin or iodide of glycerin; caustic potash, 1 part to 6 or 12 of water, have their advocates. Hydronaphtol plaster, resorcin plaster of 10 to 20 per cent, strength, and mercurial plaster are often excellent when persisted in. Sulphur or ichthyol in ointment or paste does well in some cases. Thilanin sometimes does well. H. Hebra has introduced the method of sopping the patches every fifteen minutes with pure alcohol containing 4 per cent, of menthol. Liquid air, or the snow from carbon dioxide, acts like caustics in these cases and sometimes gives most brilliant results. The part is frozen with it for from sixty to ninety seconds. This is one of the best methods of treat- ment. Both the Finsen light, the Kromayer lamp, and x-rays have cured many cases. The first gives the best LUPUS ERYTHEMATOSUS 443 results — though they are attained slowly — and do not make the disease worse. It is not so useful in the chronic, thickened, deep-seated patches, as in the more superficial form. In some cases x-rays aggravate the disease. The high-frequency current, applied by means of vacuum glass tubes or a carbon point from three to ten minutes, has cured some superficial cases. The tube should be held a short distance from the skin so as to cause a bombard- ment of it by the sparks, and the strength of the current used should be such as to be short of causing severe pain. Stelwagon advises using it for from three to ten minutes, and repeating in from five to ten days. All cases should be carefully watched that the reaction from our remedies does not go too far. If the remedy produces too much reaction, it must be stopped, a mild zinc lotion applied until the irritation subsides, and then the remedy is to be used again. If these superficial caustics do not cure, resort may be had to linear scarifications, making a series of cross- hatchings, taking care not to go very deep. The bleeding is to be checked by pressure and the application of car- bolic acid, 2 drachms (8) to the ounce (32). Limited sur- faces must be taken at a time. Electrolysis by means of multiple punctures will sometimes give brilliant results. Sometimes running the needle across the patch, making a number of parallel insertions, will have a good effect. Evasion with a curette, galvano- or Paquelin cautery and strong escharotics, such as the acid nitrate of mercury, may have to be used in very obstinate cases, but not till all other means are exhausted, as they are apt to leave deep scars. Prognosis. — The prognosis should be guarded, as the disease is a most obstinate one, and prone to relapses. Though it may persist for many years there is a tendency to recovery as the disease is seldom seen in old people. A cure may, however, be affected by patient perseverance. It is wise always to tell our patients that scars are liable to be left, not only by the treatment employed, but by the 444 DISEASES OF THE SKIN disease itself. An accidental attack of facial erysipelas cured one case under my observation. Epithelioma may develop on the cicatrix of a patch. The discoid form has little effect upon the health of the patient, but the dis- seminated variety not infrequently ends fatally. Lupus Pernio. — This disease affects the uncovered parts, hands, face, and especially the ears, nose, and upper lip. It is ill-defined, and extends over large surfaces. It is marked by cyanosis, telangiectasis, infiltration of the skin, diffuse tumefaction, Assuring of the skin, and superficial vesiculation. Slight ulcerations form that become cov- ered with crusts and last a long time. The old patches are studded with irregular cicatrices. It is a chronic dis- ease with no subjective symptoms. It occurs in lymphatic subjects. Its exact place has not been determined, some authorities regarding it as a form of lupus ery- thematosus, others as belonging to lupus vulgaris, while still others regard it as a chronic, infective granuloma. Lupus Vulgaris. — Synonyms: Noli me tangere; Herpes esthiomenes; (Fr.) Dartre rongeante, Scrofulide tuber- culeuse, Esthiomene; (Ger.) Fressende Flechte. This is a chronic neoplastic disease of the skin due to its invasion by the tubercle bacillus, and characterized by one or more brownish-red papules, tubercles, or infiltrated patches, that tend either to absorption or ulceration, and always leave scars. Symptoms. — Lupus vulgaris usually begins in child- hood and upon the face; the cheek and nose being the parts most usually affected. The initial lesion is a dark- red or brown pinpoint- to pinhead-sized papule, which may be on a level with the skin, depressed below, or raised above it. It is a tubercle in an anatomical sense. When it is punctured by a blunt instrument it is felt to be soft, readily being entered. There may be but a single lesion, but usually there are a few of them either grouped or scattered. After a time slightly scaly patches will form by the coalescence of the lesions which have enlarged into LUPUS VULGARIS 445 brownish-red, semi-translucent, smooth, shiny tubercles, or by the development of new lesions between the old ones. The shape of the patches is irregular. Rarely are they ring-shaped. The size of the patches varies greatly, but they are always elevated above the surface of the skin, of a dark-red color, and studded with the little brownish-red papules, so-called tubercles. The appearance of these tubercles has been likened by Hutchinson to that of apple- jelly. About the patch there may spring up new tuber- cles in the sound skin. There may be but one patch, or the whole face may be more or less covered with a num- Fig. 63 A case of lupus vulgaris. 1 ber of them. Symmetry is not a feature of the disease, often only one side of the face being affected. Sometimes two or more patches will coalesce at their borders, their centres will fade out, or rather become atrophic, and a gyrate patch will form, creeping over the skin with a well-marked, elevated, dark-red border. The centre of all the patches is lower than the border, and eventually is atrophic. The course of the disease is slow and chronic, and the fate of the patches varies greatly. For months or years they may remain absolutely quiet, and then Courtesy of Dr. H. Fox. 446 DISEASES OF THE SKIN show signs of activity by new lesions appearing about the edges of the patches or in the scar tissue. This recrudescence in the scar is a characteristic of the dis- ease. The patches may entirely disappear, leaving a fine smooth cicatrix; this is rare without treatment. Or they may break down and form ulcers, which are irregularly rounded, shallow, with easily bleeding floors, and a moderate amount of purulent secretion that dries into a crust. This is the so-called lupus exulcerans, and is not very frequent in this country according to my experience. Sometimes upon this ulcerated surface papillary or warty growths will spring up, the so-called lupus papillomatosus or verrucosus. Sometimes the infiltration of the patch is unusually great, and then we have lupus hypertrophicus. Most commonly we have a non-ulcerated, exceedingly chronic infiltrated patch with areas of cicatricial tissue scattered through it. When the disease attacks the end of the nose, the whole of the soft parts is involved, and it will cause it to shrink up and convert it into cicatricial tissue. When the ear is diseased, it also shrinks up so as to be half the size it was originally. These changes are due either to ulceration or to the gradual absorption of the lupus tubercles. While the face is the site of predilection of lupus, it may also occur upon any part of the skin of the body, as well as upon the mucous membranes. In this latter situation it is most often secondary to the disease else- where; still it is often primary. Thus Bender 1 found that 30 T 3 o- per cent, of all his lupus cases began in the nasal mucous membrane. Pontoppidan also found the origin of the disease to be the nasal mucous membrane in many cases. In the nose it frequently leads to per- foration of the septum, and sometimes causes great deformity of the nose, but it does not attack the bones. All other mucous membranes may be attacked, the rectum and vagina being least often affected. Upon 1 Vierteljahr. f. Derm. u. Syph., 1888, xv, 891. LUPUS VULGARIS 447 mucous membranes we do not see the same tubercles as on the skin, but papillary excrescences which form patches. They may be absorbed or ulcerate. The conjunctivae may be involved primarily or secondarily. Epithelial cancer has developed in very rare instances upon the lupoid tissue itself, more commonly upon the scar tissue left by the lupus. Whenever it develops as a sequela of lupus its course is more rapid and its prognosis far more grave than is usually the case. Erysipelas is a not infrequent complication of lupus, and is sometimes curative in its action. Lupus of the extremities is often followed by permanent deformities and disabilities, and sometimes by tubercular lymphangitis. Implications of the lymphatic glands is exceptional in lupus, and then only in advanced cases. Under the names of lupus follicularis disseminatus and lupus miliaris have been described unusual cases of tuber- culosis of the skin that are seen mostly in young people in a rather acute form, reaching their full development in a few weeks or months. It affects especially the forehead and cheeks, upper extremities, and back. The eruption consists in large and small nodules infiltrating the whole thickness of the skin. On a number of them are seen miliary brownish nodules partly in groups, partly dis- seminated. These nodules also sometimes occur in the skin apart from the tumors. The lesions are isolated as a rule, but may become confluent in patches. It is thought that they are due to emboli coming from some internal tubercular deposit. Etiology. — Lupus has long been regarded as a mani- festation of scrofula. It is now demonstrated that it is a tubercular disease. It should be placed under the title of Tuberculosis cutis, but usage makes it advisable to con- sider it by itself. Many patients with lupus are plainly tubercular; many, 55 T 9 ^ per cent, of Sach's 1 cases, are either tuberculous themselves or have a decided history 1 Vierteljahr. f. Derm. u. Syph., 1888, xiii, 241. 448 DISEASES OF THE SKIN of the occurrence of tuberculosis in their family. The tubercular history is far less pronounced in this country than it is in Europe. It is no uncommon thing for several members of the same family to have lupus. It is probable that we could find a close connection between lupus and infection with the tuberculous virus in all cases, were it practicable to do so. It has been noted frequently to follow piercing of the ears, and circumcision accord- ing to the Jewish rites, and, at times, vaccination. It frequently follows measles. Exceptionally the infection of the skin may take place by way of the lymphatics or bloodvessels from a tubercular focus more or less distant. Another evidence of its tubercular origin is found in the nearly uniform reaction of lupus to tuberculin. It is much more frequent in females than in males, about 62 per cent, being in females according to Block's and Sach's statistics. It begins in more than half the cases before the fifteenth year. It may begin as early as the second year. It is almost always a disease of youth. Pathology. — The pathology of lupus has been studied by many competent investigators. "It is a neoplasm of the granuloma class, and consists of a small-celled infiltra- tion which begins in the deep part of the corium, and from thence gradually invades all the other skin structures," says Crocker. Giant cells are more numerous than usu- ally observed in tuberculous tissue, and there is greater formation of vascular connective tissue. In the older nodules the tubercular elements necrose and may be absorbed and replaced by connective tissue, or break through the thinned epidermis with consequent ulceration and secondary septic infection. The tubercle bacillus is found in the tissues, though sparsely. Inoculations of animals have not always been successful, but in a goodly number of cases the inoculations have been followed by general tuberculosis, so as to warrant our belief in the tubercular nature of the disease. It has been suggested that as the bacilli are present in but a small number the irri- tation of the tissues is due to the toxins produced by them. LUPUS VULGARIS 449 Diagnosis. — Lupus is most commonly confounded with a tubercular or gummous syphilid. It may have to be differentiated from a scrofuloderm originating in a caseous gland, from an epithelioma, lupus erythematosus, and possibly lepra. From syphilis it is diagnosed by the presence of the characteristic apple-jelly tubercles; by its slow course; by its history; by the absence of all other signs of syphilis; by its little tendency to ulceration; by the superficial character of its ulcers and their slight crusting; and by its sparing the bones. If there is still any doubt, appeal may be made to the effect of treatment by means of the iodide of potassium and mercury, which will have no effect upon the lupus. As the scrofuloderm is another manifestation of the tubercular diathesis and amenable to the same treatment as that of lupus, its differentiation is not so important. It, however, will begin about a caseous and broken-down lymphatic gland or gumma, will probably have sinuses, and no character- istic tubercles. An epithelioma begins usually after the thirty-fifth year; has no tubercles; and forms a deep ulcer with raised, hard, waxy edges crossed with dilated bloodvessels. " The diagnosis from lupus erythematosus is given in the preceding section. Leprosy presents large tubercles which are anesthetic, and this at once decides in its favor. In any doubtful case a von Pirquet test should be made. Treatment. — As lupus is a tubercular disease, and sometimes is followed by tuberculosis of the lungs, care must be given to the general health of the patient, and he must be placed in the best possible hygienic surroundings. His diet should be nutritious, and cod-liver oil, iodin, the hypophosphites, and iron should be given. While these measures may not remove the lesions they place the patient in a better condition to resist the spread of the disease. The thyroid extract has been used with some benefit. Buch 1 reports the cure of a case, of fourteen 1 Practitioner, 1901, xiv, 140. 29 450 DISEASES OF THE SKIN years' standing, by the administration of urea. He began by giving 20 grains (1.33) three times a day and increased the dose gradually to 1 drachm (4) . Tuberculin injections, using the new tuberculin (T. R.) according to the new method of using small doses of 1 to 2 milligrams and increasing the dose by 2 milligrams, have done well in some cases. The injections should be followed by slight reaction and an increase to 1° F. in temperature. The injections may be repeated every two days. Bernhardt 1 recommends as especially useful in the ulcerating forms combining salvarsan with tuberculin. He gives 0.3 of salvarsan, and four days afterward 1 milligram of tuber- culin, the latter being repeated in three and then in five days, and the salvarsan in sixteen days. Fig. 64 Scarifying knife. But local treatment is of the greatest importance, and the disease must be gotten rid of root and branch. If a single diseased cell remains, the disease is sure to return. To effect its destruction surgical procedures had best be resorted to. The whole patch or patches may be scraped out with the dermal curette, and this followed by a 25 or 30 per cent, pyrogallol ointment for a week or ten days, and that in turn by mercurial plaster for another equal term. The pyrogallol will cause free sup- puration and destroy the cells left behind by the curette. A second or third course may be necessary. Piffard advised to touch the base left after curetting with the galvanocautery at a red heat. The wound is then to be packed with absorbent cotton. After about ten to fourteen days the crust and cotton will fall off and leave a soft, smooth, pliable cicatrix. Multiple scarifications 1 Archv. Derm. u. Syph., 1913, cxiv, 401. LUPUS VULGARIS 451 have proved of service. They may be made with a many-bladed instrument constructed for the purpose, or with a scalpel, or a knife shaped like a butcher's cleaver (Fig. 64). They must go deep enough to penetrate all the softened tissue, but not to wound the sound parts. The resistance offered by the healthy tissue will be suffi- cient guide for this. The scarifications should be so made as to divide the tissues into little squares, thus: They may be repeated in five or six days, and need no after-treatment. This is Vidal's method. The individual tubercles may be bored out with Morris' double-screw instrument, or with dental burrs and hooks dipped in pure carbolic acid, as proposed by Dr. George H. Fox. This is an excellent method. The galvano- or Paquelin cautery may be employed to destroy the patch. This will require the administration of an anesthetic, while the former procedures do not require it, or at most any- thing more than local anesthesia by means of cocain. Multiple punctures by means of the galvano- or thermo- cautery at somber red heat at 1 mm. distance for small patches and linear scarifications with cautery knife for large ones, followed by emplast. de Vigo, and repeated once a week, is Besnier's method. Electrolysis in mul- tiple punctures or by passing the needle through the patch or by means of a flat metallic button, is a useful mode of treatment. The current must measure 3 to 5 ma., and it must be continued for five minutes, when the button is used. Lang 1 advocates excision of the patches when not too large, followed by grafting. This method is to be preferred in small patches, and cures may be expected in more than half the cases. These surgical procedures have largely superseded the 1 Dermat. Zeitschrift, 1900, vii, 805. 452 DISEASES OF THE SKIN use of caustics, though the latter are valuable and may be used when the patient fears an operation. Arsenic may be employed in the form of a paste, such as Hebra's modification of Cosme's paste: 1$ — Ac. arsenos, gr. x j 65 Hydrarg. sulphuret, rubri, 5j 4 Ungt. aq. rosse, ad §j 311 M. which is to be spread on lint or linen, applied evenly, and bound down firmly. It is to be left on for twenty- four hours, then removed and re-applied till ulceration is set up. It is painful. Vienna paste, equal parts of caustic potash and unslaked lime; or a chloride of zinc paste may be used, such as 1 part of zinc to three parts of starch. Both are painful. Many think highly of boring into the patch with the solid nitrate of silver stick. Salicylic acid, 20 to 25 per cent., in plaster or plaster- muslin, changed once or twice a day is good. It is well to combine creosote with the salicylic acid, .2 parts to 1, to allay the pain caused by the acid. The local appli- cation of bichloride of mercury in solution gr. j (0.06) to 5j (32) to ulcerated forms, and in ointment to non- ulcerated forms, is commended by White and others. Unna 1 recommends painting with pure carbolic acid for from two or four days. He also has had good results with a salve-muslin containing 1 per cent, of bichloride of mercury, 20 per cent, of carbolic acid, and 30 per cent, of oxide of zinc. He 2 has also recommended the following procedure : Little sticks of hard wood are sharp- ened and then soaked for several days in a solution of 1$ — Hydrarg. bichlor., gr. xv 1 Ac. salicylici, 5iiss 10 ! Athens sulph., 3vj 24 01. olivjfi, ad giij ad lOO! M. A stick is forced into each tubercle, cut off close to the skin, and covered with gutta-percha or carbolized mer- 1 Monatshefte f. prakt. Dermat., 1891, xii, 341. 2 Ibid., 1895, xxi, 281. LUPUS VULGARIS 453 curial plaster. After two days the plaster is removed, leaving a surface covered with a thin layer of pus. The holes made by the sticks have become enlarged and the sticks lie loose in them. The sticks are removed, the sur- face aseptically cleansed, the holes filled with a powder of -Hydrarg. bichlor., gr. iss 1 Magnes. carbonat., 3iiss 10 Ac. salicylici, 3i gr. xv 5 Cocain. muriat., gr. viiss 015 M. which is blown on with a powder-blower and worked in by the fingers or with a wooden spatula. The patch is again covered with the plaster for twenty-four hours, when the procedure is repeated for another day. The subsequent treatment is by pyrogallol. C. Boeck's 1 treatment has been endorsed by others. He used a paste of 1$ — Pyrogallol, Resorcin, Ac. salicylic, aa 5j gr. xlv 7 Gelanthi., Pulv. talci, aa 5j gr- xv 5 M. spread thickly upon the part with a wooden spatula and covered with a thin layer of absorbent cotton, which is allowed to remain for a week. If there is any ulceration it is best to paint it with a 5 per cent, solution of novo- cain, or 1 per cent, nitrate of silver and cover with a layer of anesthesin. The dressing is to be repeated until its action seems to have gone deeply enough. In lupus of the nasal opening he recommends a 10 to 15 per cent, ointment of pyrogallol, while for lesions of the mouth and pharynx painting the parts six to eight times daily with M. -Resorcin, Talcum, aa. 3v 20 Mucilage of gum acacia, 3iiss 10 Bals. Peruv., 5j gr- xv 5 is best. 1 Monatshefte f. prakt. Dermat., 1909, xxviii, 439. 454 DISEASES OF THE SKIN S. Reines 1 endorses Ehrmann's method, which is to cover the part with a 33 J. per cent, resorcin paste spread on linen and bound' down. This is to be removed in twelve hours, and leaves the skin a grayish-white color. This gray pellicle is to be curetted off, and the paste re-applied, and the treatment so continued for five or six days. For the next two or three days a boric acid oint- ment is to be used. Return is to be had to the resorcin and the method followed out till cured. Large patches must be treated in small sections at a time. After the first four or five days the .T-rays may be used. A. W. Williams 2 reports the cure of one case and great im- provement in others by painting the part with a 5 per cent, watery solution of eosin until the skin is stained a distinct pink color, followed by exposure of the part to the direct sunlight for one or two hours daily. The most recent treatments of lupus are by the Ront- gen rays, phototherapy, the high-frequency current, and radium. The first two methods require expensive apparatus, and radium is very costly. In using pho- totherapy or F insert's method each sitting lasts one hour. The treatment must be repeated daily. It does not act well in ulcerative cases and in old cases which have been operated on and have a great deal of scar tissue. In suitable cases the cosmetic effects are very good. Good results have been obtained by the Kro- mayer lamp, the lamp armed with the blue glass window being pressed against the skin and exposures of one-half to one hour being given. The results from x-rays are more rapidly obtained, and are equally as good. According to MacKee only the ulcerative and hypertrophic types yield well to the rays. One or two treatments should be given of 4 to 6 Holznecht units and 8 to 10 Benoist. Radium is still on trial and reports from observers vary as to results obtained. The high-frequency current with an Oudin resonator and a carbon or platinum point may be i Berlin klin. Woch., 1905, xliii, 1161. 2 British Jour. Dermat., 1907, xix, 43. LYMPH ANGIOMA CIRCUMSCRIPTUM l.V> used to destroy individual tubercles in patches of small size. Pkognosis. — The prognosis should always be guarded. Relapses after any plan are too often seen. A scar must result both from the disease and its treatment. The pos- sibility of the development of a general tuberculosis must also be borne in mind, although many patients preserve throughout the course of the disease a robust state of health. Lymphangiectasis.— Varices of the dermal lymphatics may be superficial or deep; and affect their trunk, meshes, or lacunas, though most commonly all parts are diseased. When they are superficial they form ampul- lary swellings at the surface of the skin which may be isolated or agglomerated. In size they vary from that of a millet-seed to that of a pea or larger. In color they vary with that of the skin. They break more or less easily and discharge lymphatic fluid. If deep, they can be more readily felt than seen, or form upon the surface of the skin isolated or associated raised cords which run a more or less tortuous course. After a time these also break and discharge lymph. Hallopeau and Goupil 1 describe under this title a dis- ease that they believe to be of tubercular origin, and that appears about a bony prominence of the extremities as a diffuse tumefaction or a cushion-like elevation resembling varicose vein tumors. They eventually open and dis- charge pure lymph or lymph mixed with pus. Fresh tumors arise in the course of the lymphatics in an ascend- ing series; also gummy nodes. The affected limb is swollen, indurated, and of more or less somber red. The prognosis is grave, and the proper treatment undetermined. Lymphangioma Circumscriptum. — Synonyms: Lymph- angiectasis, Lymphangiectodes, Lupus Lymphaticus, and Lymphorrhagica Pachydermia, is a rare disease. It con- 1 Ann. de derm, et de syph., 1890, i, 957. 456 DISEASES OF THE SKIN sists, according to Crocker, of a number of minute, deep-seated, shiny, translucent vesicles, closely crowded together in irregularly outlined groups of from one-third to one-quarter of an inch in size. These groups are arranged irregularly with healthy skin between them, or a few scattered vesicles in the otherwise healthy skin. They are usually confined to a single small area. The vesicles are deep-seated with thick walls, some of them almost warty-looking. They are pinpoint to Fig. 65 Lymphangioma. (Epstein. 1 ) hemp-seed size, colorless or straw-colored, or pinkish, and contain a clear fluid. Some have vascular strise or tufts over them, others red clots, others contain extra- vasated blood. They run a chronic, non-inflammatory course, spreading slowly at the periphery, and tending to relapse if removed. Most of the few cases reported have occurred in males and begun in early childhood. The disease is of lymphatic origin, and the main feature is the dilated lymphatic vessels. 1 By permission from Jour. Cutan. and Gen.-Urin. Dis., 1892, x, 214. MILIARIA 457 The treatment consists in destruction by caustics, excision, or electrolysis; but relapses are liable to occur. Lymphangioma Tuberosum Multiplex. — This is a still more rare disease than lymphangioma circumscriptum, and consisted, in Kaposi's case, in the appearance all over the trunk and neck of hundreds of lentil-sized, rounded, brownish-red, smooth, glistening, disseminated, flat or elevated tubercles. They were firm and elastic, slightly painful, and upon some of them were dilated bloodvessels. One or two other cases of the same kind have been reported by others. The disease generally begins in childhood or early youth. By some this disease is regarded as a form of benign cystic epithelioma. Lymphosarcoma. — See Sarcoma. Maculae et Striae Atrophicae. — See Atrophoderma stria- tum et maculatum. Maculae Ceruleae. — See Pediculosis vestimentorum. Malignant Papillary Dermatitis. — See Paget's disease. Mask. — See Chloasma. Medicinal Eruptions. — See Dermatitis medicamentosa. Measles. — See Morbilli. Melung. — According to H. Ziemann, 1 this is a dis- ease that effects negroes on the West African coast. It begins between the tenth and fifteenth year of age, develops symmetrically, and affects only the hands and feet, stopping at the wrists or ankles. It takes the form of more or less round, oval, or irregular macules, which are reddish-white with a tinge of yellow. When the disease is fully developed the hands and feet have an extra- ordinary marbled or piebald appearance. It seems to be hereditary, and to affect more boys than girls. It is probably a form of vitiligo. Miliaria. — Synonyms: Sudamina; Lichen tropicus : Stro- phulus; (Ger.) Frieselausschlag; Schewissflechte ; Prickly heat. 1 Archiv. f. Dermat. und Syph., 1905, lxxiv, 163. 458 DISEASES OF THE SKIN This is a disease of the sweat glands due to excessive sweating, which may or may not be inflammatory, and is characterized by an eruption of discrete papules, vesicles, or pustules. Several varieties are described, but it is enough to distinguish two forms, namely, sudamina and lichen tropicus. Symptoms. — Sudamina, also called miliaria crystallina, is the form that is met with during the course of febrile diseases, especially when the fever ends by crisis, and occurs as an eruption of an immense number of small, closely crowded, but discrete, bright, pearly vesicles entirely without inflammation or subjective symptoms. They are most abundant on the trunk, especially upon its anterior plane, but may occur anywhere. After lasting a few hours or days they are absorbed and dis- appear by drying up, possibly with some scaling, or they may rupture and dry up. Lichen tropicus is very commonly seen in this country during warm weather. It may consist in an eruption of pinpoint, bright-red papules (miliaria papulosa); or of very small vesicles upon an inflamed skin (miliaria rubra) ; or the eruption may be a composite one of papules inter- spersed with vesicles and pustules. Whichever form it may assume, the lesions are present in great number, and closely crowded together, though not aggregated. It may involve the whole surface of the body, but is most com- mon on covered parts, and especially upon the trunk. The eruption is apt to become better or worse according to the changes in the temperature of the atmosphere. The disease may last in this way throughout the warm weather. It is no uncommon thing for furuncles to form, and even cutaneous abscesses. Itching, pricking, and burning are always annoying accompaniments. If the skin is much scratched, eczema may complicate the disease. The old nurse's "red gum," the strophulus of older writers, is a miliaria. Kaposi regarded the disease as an eczema. Etiology. — The cause of sudamina is retained sweat, owing, probably, to epithelial scales clogging up the sweat MILIARY FEVER 459 pores when sweating is stopped on account of the fever. When the fever passes and the sweat glands resume their function the rush of sweat to the surface raises up the epithelium over the pores into little vesicles. They soon give way and the trouble is over. Lichen tropicus is due to congestion about the sweat pores and irritation of the skin when profuse sweating is induced by too warm cloth- ing and hot weather. It is also suggested that checking a profuse sweat may cause it. It is seen most commonly in babies and fat people. It is noticeable in New York that the children who live near the river front and are a good deal in the salt water escape the disease, while it is very common in the rest of the tenement-house population. Diagnosis. — Sudamina differs from vesicular eczema in its sudden occurrence during a febrile process; in being non-inflammatory; in its vesicles not breaking down readily and in not itching. Lichen tropicus differs from eczema in the minuteness of its papules; its sudden appearance; not forming patches which are moist; having a high atmospheric temperature as an evident etiological factor, and the tingling rather than the itching of the eruption. Treatment. — Sudamina needs no treatment, as with the subsidence of the fever it gets well of itself. Lichen tropicus requires attention to the diet, cutting off the meat in children and lessening its amount in adults. Cooling drinks and the administration of gentle saline laxatives are also advisable. Locally, bathing in salt water or alkaline lotions, and subsequently powdering of the skin, conjoined with wearing light clothing, and not using too warm bed covers, will relieve and ofttimes cure the trouble. Miliary Fever, or the sweating sickness, is an epidemic disease accompanied by profuse sweating and miliaria. The epidemics have occurred most often in France. It has not been observed for many years. It is described 460 DISEASES OF THE SKIN as having prodromas of fever, nervousness, muscular cramps, constipation, cough, and nose-bleed. The eruption appears first on the face, from which it spreads over the trunk and extremities. It may be papular, vesicular, erythematous, or purpuric in character. After the erup- tion is over the skin may desquamate. Death results in from 12 to 33 per cent, of the cases. Milium. — Synonyms: Grutum; Strophulus albidus; Acne albida; Tuberculum sebaceum. Symptoms. — These are small pinhead- to split-pea- sized, firm, whitish or yellowish, slightly elevated papules that occur usually upon the face. They are spherical in shape, and slowly increase in size up to a certain point, when they remain stationary. When incised and pressed upon laterally a small, white, round, oval, or lobulated mass emerges. They give rise to no subjective symptom. While their most common site is the face below the eyes, they may occur anywhere on the face; and also upon the border of the lips, the penis, and scrotum. In this latter situation they are more decidedly yellow in color, flat, and often attain the size of a small bean. Along the corona glandis they are sometimes very thickly strewed. On the genitals of women their most frequent site is the labia minora. There may be but one or two, or a score of them. Occurring in the eye-lids they are called chalazion. When they undergo calcareous degeneration (an infre- quent occurrence) they form cutaneous calculi. Come- dones are often present at the same time with milia. Any part of the body may be affected. Etiology. — Milia occur chiefly in infants and young adults, and sometimes follow other diseases of the skin, such as pemphigus, erysipelas, or those in which destruc- tive processes have taken place and cicatrices formed. They are often congenital. Pathology. — They are supposed to be due to retained secretion on account of the upper layers of the stratum corneum growing over the openings of the sebaceous MOLLUSCUM CONTAGIOSUM 461 glands, or to a non-development of the glands. Robinson thinks that some of them are due to "miscarried embry- onic epithelium from a hair follicle or from the rete," while those "following pemphigus, erysipelas, syphilis, and lupus consist of fatty epithelium and cholesterin, the epithelium being often arranged in concentric layers around a central flat nucleus. " Diagnosis. — They must be differentiated from xan- thoma. The latter are more of a lemon-yellow or buff color, and cannot be squeezed out when incised. Mollus- cum is sometimes mistaken for milium, but it is more prominent and hemispherical, and has a central punctum, out of which its contents can be squeezed without punc- turing its top. Treatment. — The treatment consists in pricking the top of the papule and pressing out its contents. To make sure of the destruction of the growth a drop of carbolic acid or iodin may be introduced into the cavity remain- ing. Hardaway advocates electrolysis as being the speediest and best treatment. If operative procedures are inadmissible, the skin may be caused to exfoliate by the use of green soap, salicylic acid, or resorcin ointment, when the milia will be destroyed. Prognosis. — Milia may disappear spontaneously from the skin of infants, but in older children and adults they remain unaltered indefinitely. Mole. — See Nevus. Molluscum Contagiosum. — Synonyms: Molluscum epi- theliale seu sebaceum seu sessile seu verrucosum; Epi- thelioma contagiosum; (Fr.) Acne varioliforme, Ecder- moptosis. Symptoms. — This is a contagious disease of the skin that occurs in most cases upon the face and in chil- dren, and is characterized by the appearance of one or more rounded pearly white or pinkish discrete tumors, varying in size from that of a pinhead to that of a large pea (Fig. 66). These tumors are waxy or opaque, and 462 DISEASES OF THE SKIN on top are slightly flattened, and show an umbilication or small depression, out of which the soft cheesy contents of the tumors can be squeezed. They are at first very small, but gradually grow until they attain a certain size, when they may remain unchanged for an indefinite period; or they may become inflamed, break down of themselves, discharge their contents, and disappear either without leaving any trace or with a very slight Fig. 66 Molluscum contagiosum. 1 scar. Not infrequently scores of these tumors are found on the same subject. They are commonly sessile, but may become more or less pedunculated. The genitalia, breast, and scalp are affected next to the face in point of frequency, while the tumors may occur anywhere but on the palms and soles. They have an incubation period of several weeks or months. 1 By the courtesy of Dr. S. D. Hubbard. MOLLUSC UM CONTAGIOSUM 463 Etiology. — Children are far more often affected than adults. If adults are affected, it will usually be found that they are in attendance upon children who have molluscum. The bad hygienic conditions under which poor people live seem to predispose to the affection, as it is rare to meet with it among the well-to-do. There is little doubt that the disease is contagious. Though inoculation experiments have failed in most instances, Fig. 67 Molluscum contagiosum. 1 still there have been a few cases in which they were successful. In the spring of 1891 a child with molluscum contagiosum came into my service in Randall's Island Hospital, and within a few weeks, no attempt being made to destroy the tumors, there were six cases in the wards. Pathology. — The true pathological anatomy of these growths has not been settled, but the old idea that they spring from the sebaceous glands is no longer entertained. The rete seems to be the starting-point of the disease. 1 By the courtesy of Dr. J. A. Fordyce. 464 DISEASES OF THE SKIN One of the most characteristic features of the disease is the so-called " molluscum corpuscle," which is but a changed epithelial cell (Fig. 67). These appear, under the microscope, as large, ovoid, lustrous bodies, without nuclei, some being either wholly or partly contained in an epidermic envelope, . and some being entirely un- covered. Several parasites have been declared to be the cause of the disease by different investigators. Charles J. White and W. H. Eobey, 1 after careful investigation, state that the disease is not parasitic, and that the mol- luscum bodies are an extraordinary metamorphosis of the rete cells into keratin. Diagnosis. — The appearance of this disease is so characteristic as to be diagnostic. It is most apt to be confused with milium; but if it is remembered that a milium has no central depression, while a molluscum has, the confusion will exist no longer. If the lesions are taken for the vesicopustules of variola, a hardly probable occurrence, pricking their tops will at once show that they are not pustules, and if they are watched for a day or so it will be found that they remain unchanged. Warts do not have the pearly appearance of molluscum and their central punctum. Treatment. — The speediest way of getting rid of the tumors is to scrape them off with a curette. To insure their not returning it is advisable to touch the base of each tumor with a drop of carbolic or stronger acid. Or it is sufficient to make a small slit in the top of the tumor with a scalpel, squeeze out the contents, and touch the base with carbolic acid. If operative measures are refused strong boric acid lotions, or salicylic acid 3 per cent, in sulphur ointment may be used. Molluscum Fibrosum seu Pendulum. — See Fibroma. Morbilli.— Synonyms: Rubeola; (Ger.) Masern; Measles. This is one of the contagious exanthemas. Its stage of incubation is from eight to twenty-one days, usually 1 Jour. Med. Research, 1902, vii, 255. M0RB1LLI 465 from ten to twelve days. It is characterized by prodro- mas of marked catarrhal symptoms, such as conjuncti- vitis, coryza, and bronchial inflammation, more or less fever, and constitutional disturbance; and then, on about the third day, an eruption of small red, flat papules or macules that rapidly enlarge, and unite with others to form mulberry-colored little patches often of a crescentic shape, with areas of sound skin between. H. Koplik 1 calls attention to the fact that one or two days before the eruption appears on the skin there will be found on the buccal mucous membrane and on the inside of the lips small, irregular, bright-red spots with a minute bluish speck in the centre. The eruption begins on the face and neck, spreads downward, and covers the whole body in about a day and a half. The fever begins to decrease on the second day of the eruption. The rash begins to disappear by the third or fourth day, and is gone by the ninth day. Furfuraceous desquamation follows the subsidence of the exanthem. Sometimes it is so slight as to be hardly noticeable, and it is never so marked as in scarlatina. In atypical cases there may be scarcely any disturbance of the health, and the eruption may be so slight as to be hardly noticeable; or the onset may be marked by high temperature; or the eruption may be excessive or hemor- rhagic. The last is the most dangerous form. Diagnosis. — The only dermatoses with which measles is apt to be confounded are an erythema, rotheln, or German measles, variola, and the macular syphilide. But the catarrhal symptoms; the regular progression of the eruption from above downward ; and the crescentic, patchy arrangement and dark color of the lesions are sufficient to differentiate it. In erythema we may have some constitu- tional disturbance, but it is of short duration; the erup- tion is more pronounced on the trunk and extremities, and shows no order of progression; the color of the erup- 1 Arch. Pediat., Dec, 189fi. 30 466 DISEASES OF THE SKIN tion is a brighter red; there is an absence of crescentic arrangement; and very often an accompanying urethritis will suggest the ingestion of some of the balsams as a cause of the trouble. In rotheln there is not so much constitutional disturbance, less catarrhal complications, and a pronounced swelling of the glands of the neck. The eruption is usually a remarkably fine papular one, not so patchy as in measles and of shorter duration. Variola in its early stage is sometimes difficult to diag- nose from measles. Backache is usually a marked symp- tom in variola; its papules are smaller, harder, and more shot-like, and lack the crescentic arrangement of measles. The subsequent course of the disease is, of course, very different from that of measles. The erythematous syphilid affects the sides of the chest and the abdomen more than the face; the rash lasts for weeks after any possible fever has passed; its lesions have no definite arrangement and come out in successive crops, so that at the same time there will be present lesions of different age, and staining of the skin from those that have gone. Treatment is purely symptomatic. Morphea. — See Scleroderma. Morvan's Disease is a disease of the spinal cord which causes profound cutaneous lesions, such as ulceration, bullae, and fissures of the palmar side of the hands and fingers, and paronychia and necrosis of several phalanges. It is allied to, if not identical with, syringomyelia, wmich see. Moth Patch. — See Chloasma. Mother's Mark. — See Nevus. Multiple Fungoid Papillomatous Tumors. — See Mycosis fungoides. Myasis Externa Dermatosa is a dermatitis due to the penetration of the skin by certain kinds of flies, which lay their eggs under the skin. These subsequently hatch out and give rise to the dermatitis. MYCOSIS FUNGOIDES Mycetoma. — See Fungous foot of India. 467 Mycosis Fungoides. — Synonyms: Inflammatory fungoid neoplasm; Multiple fungoid papillomatous tumors; Fibroma fungoides; Lymphadenie cutanee; Granuloma fungoides; Eczema hypertrophicum seu tuberosum; Ulcer- Fig. 68 Mycosis fungoides. ative scrofuloderm; Lymphodermia perniciosa; Sar- comatosis generalis; Multiple sarcoma cutis; Fungoid dermatitis; Beerschwamahnliche multiple Papillargesch- wiilste der Haut. 1 Courtesy of Dr. H. Fox. 468 DISEASES OF THE SKIN A chronic progressive disease of the skin, characterized by the appearance with or without an antecedent erythe- matous or eczematous stage, of fungating tumors that tend to break down and ulcerate. It leads, through marasmus, to death. Symptoms. — The many names that have been applied to this rare disease testify to the uncertainty of our knowl- edge of its proper place in the .classification of skin dis- eases. It assumes so many forms that it is impossible in our limited space to give a complete picture of the disease. In some cases the first thing noticed is what appears to be a simple eczema, erythema, urticaria, or psoriasis in variously sized patches, tending to be round or circinate in form, and accompanied by marked pruritus. One characteristic of one variety of prodromal erythema is that the macules arrange themselves in circles in the centre of which is a single macule like a bull's eye. These lesions occur anywhere, and constitute the first or premy- cosic stage of the disease. They may disappear for a time, to reappear in the same places or elsewhere. Ex- ceptionally this stage is wanting. After some months, or two or three years or more, the patches become raised, glistening, and infiltrated, more deeply red, and pea-sized papules form. These disappear, and new ones form. This is the second stage, and may last months or years. Then the characteristic tumors form either by the papules enlarging and coalescing, or as tumors at once rising out of the sound skin, without an antecedent erythematous stage. The tumors are oval, hemispherical, annular or irregular in shape, sharply defined, sometimes slightly pedunculated. They are of whitish, bright-red, bluish- red, or dark-red color. They are sometimes hard and elastic, sometimes soft and succulent. The epidermis over them is tense, thin, and glistening. They may be absorbed and disappear, new ones appearing; or they may become necrotic and ulcerate. In size they vary from that of a pea to that of the fist. At first they occur only on the trunk and may limit themselves to a single MYCOSIS FUNGOIDES 469 region; later, they come anywhere, and involve even the mucous membrane of the mouth. When ulcers form from breaking down of the tumors they are horse- shoe-shaped or crescent ic with round, broad edge. The itching and pain continue well into the tumor stage, when they may lessen. The lymphatic glands enlarge painlessly. The hair falls from over the tumors. The general health of the patient is undisturbed for a long time, but at last a general marasmus sets in and the patient dies, usually from an uncontrollable diarrhea or some lung complication. There has been but one case of recovery reported. Etiology. — The majority of the cases have been in men over forty years old. The disease is held not to be contagious by some, while others hold the opposite opinion. Blanc 1 found in one case that there w T as a marked reduction in the white-blood corpuscles, their proportion to the red being 1 to 130, instead of 1 to 350 or 500. Various microorganisms have been found in connection with the disease, but no one has been settled on as the cause. This is about all that is known of the etiology of the disease. Pathology. — The earliest histological changes are edema and dilatation of the bloodvessels and the lymph capillaries, often accompanied by some slight endothelial proliferation. Soon the corium is marked by an infiltra- tion which may be diffuse or circumscribed in irregular patches, spreading outward from the vessels. In the centre of an infiltrated region the cells are densely packed and the structure bears a strong resemblance to an invad- ing small round-celled sarcoma, but at the edges the true infiltrating granulomatous nature of the growth is always evident, and the multiform character of the infiltrating cells can more easily be made out. There are many small round cells, and fewer plasma, mast, multinuclear and 1 Jour. Cutan. and Gen.-Urin. Dis., 1888, vi, 256. 470 DISEASES OF THE SKIN giant cells, all of great diversity in size, shape and stain- ing qualities. Mitoses and cell fragments are numerous and indicate cell proliferation and degeneration. Usually there is also some diapedesis of red-blood corpuscles. At first the epidermis may be unaffected, but more often it shows various changes such as edema, acanthosis and parakeratosis. The rete may hypertrophy, mitotic figures appear, and the interpapillary processes become long and thick. But as the granulomatous tissue gradually increases in amount, causing the growth to project above the surrounding surface, the epidermis begins to show the effects of stretching and impaired nutrition, the rete thins out until it may consist of only a single layer of cells, and finally ulcerates. In the last stages there is extensive crenation or frag- mentary degeneration of the granulomatous cells accom- panied by a basophilic disintegration of the fine col- lagenous and elastic tissue net-work which supports the growth. While much study has been given to the pathology of the affection there is no agreement among pathologists as to its essential nature. By many it is supposed to belong to the class of infecting granuloma. Diagnosis. — The diagnosis of the disease in its early erythematous stage is very difficult, and probably cannot be made with certainty. There is something peculiar in the sharply circumscribed outline, the chronicity, circinate form, and capriciousness of the patches and the intense pruritus. Psoriasis affects other localities at first, its patches are not so infiltrated, and it is more scaly. Eczema is a moist disease at some time and more multiform in character. When the tumors develop, and the capricious manner of their coming and going is observed, the diag- nosis is more evident. Treatment. — Kobner reports the cure of a case by means of hypodermic injections of arsenic. Crocker speaks encouragingly of salicin in all stages before ulcera- tion takes place. A general tonic treatment is always MYOMA 471 indicated. Locally, pyrogallol; ichthyol; mercurial oint- ment; injections of carbolic acid; resorcin, and camphor- ated naphtol have been used, and may be tried. The itching is most rebellious to treatment and demands the use of antipruritics. The tumors, when not in great num- bers, may be cut out, though the operation is of doubtful utility. The ulcerations that result from breaking down of the tumors must be treated on surgical principles. In x-rays we have a means of curing the intense itching and causing a complete disappearance of all the lesions. MacKee advises that each tumor be given a dose of H. 2 to 4; and B. 8 to 10. Too many tumors should not be treated at one sitting for fear of systemic poisoning. Though at first relief from the itching is obtained and the tumors disappear, later the itching and the tumors may return and be uninfluenced by the rays. Nevertheless, it is the only treatment that has availed at all, and should be tried. Prognosis. — Death is the outcome of the disease, and it may occur in from a few months to fifteen years, the average time being from two to four years. Myoma. — Like most of the tumors, so this one concerns the surgeon more than the dermatologist. Two main varie- ties are described, namely, simple myoma or leiomyoma, and dartoic. Myomata may be single or multiple. They are composed of muscular fibers, and vary in size from that of a split pea to that of an orange. They are painful on pressure, and sometimes spontaneously. They are pink or red in color, or of that of the sound skin; disseminated or aggregated into patches, though still retaining their individuality. The epidermis over them is unchanged. The single tumors may be sessile or pedunculated, and may attain the size of an orange. They may occur anywhere, but principally on the arms. The dartoic variety has its seat most often on the female breasts, and on the genitalia of both sexes, and is usually a single tumor. Simple myomas are more commonly multiple, 472 DISEASES OF THE SKIN and occur upon the upper extremities, though they may occur anywhere on the body. Most of the cases are in middle-aged or elderly men. They may be congenital. If they contain a good deal of fibrous tissue, they are called fibromyoma; if they contain large bloodvessels, they form angiomyoma; or, if the lymphatics are involved, we have lymphangiomyoma. The diagnosis is often difficult without the aid of the microscope. Excision is the only thing that can be done for them. Myxedema. — This is a constitutional disease with cutaneous symptoms. The skin becomes waxy pale, yellowish, shining in some places, dull and earthy- looking in others; it is dry, scaly, exfoliating on the extremities, sometimes ulcerated, and verrucose on the lower limbs. The fingers and toes are sometimes livid. There are partial or general alopecia, and deformity and fragility of the nails. There is a general edematous swelling of the whole integument as well as of the mucous membranes, and this edema does not pit on pressure. The swelling is most marked on the face. The skin about the eyes becomes puffed up so as almost to close the eyes. Cushions of fat fill the supraclavicular spaces. There is atrophy of the thyroid gland. The patient's intellectual faculties become dulled, the speech is slow, and the gait unsteady. • The disease affects women far more often than men, and involves all parts of the body. There are enfeeble- ment of mind, and a great impairment of the senses of touch, taste, and smell; a torpidity of movement and of the digestive function. It ends fatally either by maras- mus or by complications on the side of the internal organs. The diagnosis in the early stage is difficult; when fully developed it could hardly be taken for anything else. The cause of the disease is unknown. Treatment. — All the symptoms are removed by the use of thyroid extract or powder, improvement being rapid. When the treatment is stopped the patients after NEVUS PIGMENTOSUS 473 a time lapse into their former state, so that the adminis- tration of the thyroid has to be more or less continuous. Nettlerash. — See Urticaria. Neuralgia Cutis. — See Dermatalgia. Neuroma Cutis is an exceedingly rare disease, of which but a few cases have been reported. Neuromata are small, flat, pinkish or pale-red, firm tumors firmly im- bedded in the skin. They are painful spontaneously and on pressure. The pain may be paroxysmal in character. They are relievable by cutting out part of the nerve with which they are connected. Nevus. — A nevus, strictly speaking, is a congenital mark or growth in the skin, which may be either pigmen- tary or vascular. The name is occasionally applied to acquired new growths similar to the congenital ones. Nevus Anemicus. — This is a congenital defect in the skin which appears as one or more pale unelevated areas. When the skin is rubbed they remain pale while the sur- rounding skin is reddened. They are due to a deficiency of the blood supply to the areas. Nevus Pigmentosus. — Synonyms: Nevus spilus; Nevus pilosus; Nevus verrucosus; Nevus lipomatodes (Ger.); Fleckenmal, Pigmental, Linsenmal, Pigmentary mole; Mother's mark. A congenital, circumscribed hyperpigmentation of the skin, often accompanied by a growth of coarse hair and hypertrophy of the connective and fatty tissues. Symptoms. — These growths are closely allied to lentigo and chloasma, as an hypertrophy of pigment is a promi- nent feature of them. When they consist of pigment only, and are not raised above the surface of the skin, they are called nevus spilus. When besides the pigment there is an hypertrophy of the connective tissue, and they are raised and uneven, the name nevus verrucosus is applied to them; or nevus lipomatodes if they are soft 474 DISEASES OF THE SKIN and contain fatty tissue; if hair grows from either form, then we speak of nevus pilosus. In color they vary from a light to dark brown or black. According to Dubreuilh and Petges 1 they may be of blue color, flat or raised, sharply limited, lentil size, and look like an India ink mark. Other forms of pigmentary nevi are often present. In size they vary from that of a split pea to that of an area large enough to cover the whole back. Most corn- Nevus lipomatodes. monly they are of small size. They may be located anywhere, though most often on the face, neck, and back. There may be but one or two or hundreds of them. They may have no special distribution, or they may occur in streaks or bands. They may be unilateral or bilateral, and sometimes symmetrical. If hair is in them, it is coarser, stiffer, and generally darker than that of the head. Sometimes large, hairy moles bear a 1 Annal. derm, et syph., 1911, xi, 552. NEVUS PIGMENTOSUM 475 strong resemblance to the fur of animals. They grow in proportion to the growth of the individual, and cease growing when he has attained his growth. They are usually congenital, but may be acquired, and are liable to undergo malignant change in advanced life. They give rise to no subjective symptoms. They are permanent growths. They rarely disappear of themselves. Fig. 70 Nevus pilosus. 1 Etiology. — They are congenital growths, as a rule. The small pigmentary nevi so often seen on the trunk in adults, sometimes spoken of as permanent freckles, often are acquired. To account for the appearance of these malformations we have only the theory of nerve influence, and that is by no means satisfactory. Their name of "mother's mark" shows that the popular super- stition agrees with the scientific theory. We can simply regard them as anomalies.' 1 By courtesy of Dr. S. Dana Hubbard. 476 DISEASES OF THE SKIN Diagnosis. — Moles differ from lentigo in being con- genital and permanent, and in an hypertrophy of connec- tive tissue and a growth of hair being connected with them. The difference between hairy moles and hyper- trichosis is in the substratum; in the latter the underlying skin is otherwise normal. Moreover, moles occur in definite patches. Treatment. — We can destroy these growths and leave behind but little scar. If there is but a single pigmen- tary mole, it may be cut out. In this case it will leave a linear scar. It is generally better to destroy the growth by touching it over carefully with nitric or trichloracetic acid. This is done by stippling, as it were, making a row of dots in this fashion — At the time of the next visit a row of dots should be made in between the former ones, and so the stippling is to be continued until in course of time the nevus is de- stroyed. If done with care and slowly, the result is very good. Fuming nitric acid is best. Electrolysis by multiple punctures, or by transfixing the mole and making tracks in various directions, is a sure and speedy way. They may be destroyed by sparking with the high-frequency current. J. Brault 1 recommends tattooing them with a solution of 30 parts of chloride of zinc and 40 parts of sterilized water. The eschar falls in five to ten days. It may be necessary to repeat the process. Hairy moles are best destroyed by electrolysis, as in superfluous hair, only here a coarser needle may be used, as we are not so particular about a little scarring. In extensive hairy moles Rbntgen rays may be used to cause a fall of the hair, when we can work better with acids upon the pigmentation. Radium will remove all forms of nevus. Freezing by liquid air, or the snow made by 1 Ann. de derm, et de syph., 1895, vi, 33. NEVUS VASCULARIS 477 carbon dioxide, is a speedy and reliable method. If done with care the scar is good. It is the method of choice. The warty growths may be removed by a curette. Nevus Unius Lateris. — See Papilloma lineare. Nevus Vascularis. — Synonyms: Xevus vasculosus seu sanguineus; Angioma; (Ger.) Feuermal, Gefassmal; (Fr.) Tache de feu, Tache vasculaire; Port-wine mark, Birth- mark, Claret stain. Symptoms. — These are composed mainly of vascular tissue, and are congenital or appear during the first month of life. They are usually single, but may be multiple. They vary greatly in size, shape, and color, but all possess one feature in common — they pale under pressure. They may be pinhead-sized spots, not raised above the surface of the skin; or they may form large, erectile, elevated, pulsat- ing tumors; or they may spread out so as to involve a large area. They may be pink, bright red, dark red, or even purple in color. When on the face they become more pronounced on crying, coughing, and the like. They may disappear spontaneously; increase in size during a few months or years; or, most commonly, remain unchanged. According to their size they have received various names. The small, flat, or scarcely raised nevus composed of capillaries is called nevus simplex, or capil- lary nevus. This is the form very often seen in children, on the lips, or nape of the neck. It is not infrequent for it to disappear of itself after a while, leaving either no trace or a delicate atrophic scar. When it is so large as to form a patch as big as the hand or larger, it is called nevus flammeus, or port-wine marl;. The surface of this form is often uneven and studded with small erectile vascular tumors, or, may be, pigmentary moles. It often becomes dark purple after exposure to cold. The large erectile pulsating tumors are called nevus tuberosus, angi- oma cavernosum, venous nevus. They differ very much from the other forms in appearance and formation. Their surface is uneven and lobulated. This form is 478 DISEASES OF THE SKIN apt to increase in size, and may attain enormous dimen- sions. Blue nevi, or benign melanoma, are steel-blue macules 3 to 4 mm. long, and 2 to 3 mm. wide, round or oval, looking like powder grains. At times some slight thickening of the skin may be felt. They are located on the extremities or face, and usually there is but one. Nevi may occur anywhere on the body, but are most frequent on the head and face. They may also occur upon the mucous membranes primarily or secondarily. The back, nates, pudenda, and lower limbs are said by Crocker to be the most common sites of the cavernous form. All forms of nevi may be hardly perceptible at birth, but become gradually more evident afterward. Etiology and Pathology. — Vascular nevi are prob- ably always congenital malformations, though their appearance upon the skin may be retarded for some time. Their frequent occurrence on the nape of the neck suggests local injury either during gestation or par- turition. The simple capillary nevi, which include the port-wine marks, are simply an increase in number and size of the capillaries. In the venous nevi we have also a new growth of connective tissue forming a mesh-work, and they are supplied directly by an artery without the interposition of capillaries. Women are more prone to nevi than are men. Diagnosis. — There can be no difficulty in diagnosis, excepting that a nevus may be taken for a telangiectasis. This error would be of little consequence, since the latter is simply an acquired nevus, and differs chiefly in having a central red point from which the dilated capillaries radiate. Treatment. — Electrolysis may be used for the de- struction of these growths. The current strength should be from 2 to 3 milliamperes. The best way to use it in capillary nevi and port-wine marks is by making multi- ple punctures in parallel rows, perpendicularly to the skin and down through its entire thickness. To expedite NEVUS VASCULARIS 479 matters, one may use either a circle of needles set in a handle, or a row of three needles. The negative pole is to be connected with the needle-holder, and the operation is to be conducted in the same way as in removing superfluous hair. By this method it is possible to destroy small nevi entirely, and to diminish very much the unsightly appearance of large port- wine marks. As electrolysis necessarily destroys the skin, a scar will be left. But this is less conspicuous than the nevus, and if the operation is carefully done the scar is soft, smooth, and pliable. There is also much less danger of a de- forming scar from the use of a single needle than from a group of them. Therefore, this method is preferable, though more tedious. The punctures must not be made close together; at least a sixteenth of an inch should be left between them. After the nevus has been carefully gone over, it should be left alone for a couple of weeks or more for the full effect of the operation to be seen. It can be done over again, and another interval of time allowed, and so on until the growth is destroyed as much as possible. Besides electrolysis we may use multiple scarifications obliquely to the skin, or high-frequency cauterization. Or we may use the ethylate of sodium freshly prepared and applied to the absolutely dry skin, using a brush or glass rod. To avoid scarring, only a small part of the nevus must be attacked at a time. A crust will form, which must be left to come away of itself. Fuming nitric acid, or the acid nitrate of mercury or trichlor- acetic acid, may be stippled over the growth, care being had that the little dots are made in rows with spaces between equal to the size of the dots. At the next sitting the dots should be made between the first ones. In this manner the stippling is carried out until the nevus is destroyed. Or vaccination may be performed over it; or multiple punctures may be made by means of a steel needle dipped in nitric or carbolic acid. Marshall Hall advocates breaking up the nevus by introducing a cata- 480 DISEASES OF THE SKIN ract needle close to the edge of the growth, pushing it across to the opposite side, then nearly withdrawing it, and again pushing it in at a little distance from the first puncture. These nevi have been cured by x-rays, radium, and the Kromayer lamp. Most excellent results may be obtained by the use of liquid air or car- bonic dioxid snow. In some cases the scars left are hardly perceptible. It is not successful in port- wine marks. These are almost impossible to remove. We have found cauterization with the high-frequency current, using a carbon or metallic point, a good means. For cavernous nevus we may use electrolysis also, but here we pass the needle obliquely into the skin in the hope of striking the deep vessels. It is well, sometimes, to pass the needle from the edge deep under the nevus and clear through to the other side, let the current pass for half a minute, partially withdraw the needle, and again push it in another direction, so as to avoid scarring as much as possible. Some prefer introducing two needles, connected each with one pole of the battery, in opposite directions. A platinum or gold needle must be used with the positive pole. A current strength up to 5 milliam- peres is often necessary to destroy these growths. Exci- sion may be performed, but sometimes this gives rise to alarming hemorrhage. Multiple punctures with a steel shoemaker's awl, heated to a red heat and allowed to cool to a black heat, or the point of a Paquelin or galvano- cautery heated to a dull red, are other good methods of treatment. It has been proposed to use a metallic plate perforated with a number of holes with which to exercise strong pressure upon the nevus while the galvanocautery is introduced through the holes. Injections of carbolic acid, perchloride of iron, alcohol, and the like are some- times effectual but always dangerous methods. Wyeth uses injections of water at a temperature of 180° to 200° F., injecting 10 to 60 drops and repeating the injec- tions every three or four days. There is some danger of embolism from this method. Setons are not used as NON-ER Y THE MA TO US NOD ULES 481 much as formerly. Compression by an elastic bandage is at times curative when the nevi are located over bony prominences. As many capillary nevi in children disappear in time it is advisable not to interfere with them at once, con- tenting ourselves with painting them with collodion and waiting until the child is old enough to desire their removal. Unna thinks that the addition of 10 per cent, of ichthyol to the collodion increases its efficacy. Of course, if they are very unsightly we cannot wait, nor should we temporize with cavernous nevi. In children one works more comfortably by using an anesthetic, but it is not absolutely necessary. Keloidal scars may be an unfortunate result of treatment in some cases. Prognosis. — The prognosis should be guarded, and the cases carefully watched. All nevi may increase in size, though very many remain stationary. There is always danger from hemorrhage in angiomas. Many of them disappear spontaneously, probably by plugging of the supplying bloodvessel. Scarring, more or less evident, must be expected from our efforts to destroy the growths. Nevus Verrucosus. — See Papilloma lineare. Nodules, Non-erythematous of Arthritics. — Brocq applies this name to cutaneous and subcutaneous tumors that he has met with in connection with the gouty diathesis They are of two varieties. The first one he calls ephemeral cutaneous nodules. They occur upon the fore- head and form ill-defined elevations of the skin, of small- pea to hazel-nut size, and entirely painless. They are movable with the skin, though sometimes they are adher- ent. They appear first during the night and disappear within twenty-four hours. The second variety is the subcutaneous rheumatismal nodule. It forms a small tumor resembling a gumma. The skin slides freely over it in most cases. The color of the skin is unchanged. It is firm and elastic to the 31 482 DISEASES OF THE SKIN touch. Generally such tumors are painful on pressure, at times spontaneously. In size they vary from that of a pea to that of an almond, and they are sharply defined. They may remain for days or weeks, when they disap- pear, leaving no trace. They often come in successive outbreaks. Their seat of predilection is about the joints, and upon the fibrous tissues that cover the superficial bones. They are generally discrete, and frequently very numerous. Their appearance often coincides with symp- toms of pericarditis or pleurisy. Their treatment is that appropriate to the rheumatism that seems to be their cause, especially iodin and the iodids. Nodulus Laqueatus is that condition of the hair in which it seems to tie itself into knots. The hair is usually dry and curly. It is probably caused by handling of the hair, and does not occur spontaneously. (Edema Cutis, Acute Circumscribed. — This disease is also called angioneurotic oedema, acute idiopathic oedema, peri- odic or giant swelling. It is a question whether this is a form of urticaria or not. It is certainly allied to it in the suddenness of its onset; in the attending erythema and digestive or other constitutional disturbances; and in the character of its lesions. It differs from urticaria in being recurrent in the same locations; in the shading off of the swellings into the surrounding skin; and at times in being unattended by itching. It is prone to occur upon the face, and there often closes one or both eyes in an enor- mous swelling; or the lips so that the mouth cannot be opened. In some cases a history may be obtained of the occurrence of the same disease in other members of the family. It usually begins in early adult life and tends to recur. It may occur on the mucous membranes, causing suffocative attacks if the larynx is involved, and acute digestive disturbances if the stomach is affected. It occurs in various parts of the body as swellings which may be the color of the normal skin, pinkish, or dull red, that appear suddenly and disappear in a few hours, or persist for OIDIOMYCOSIS 483 several days. While these do not itch, the patient com- plains of burning, tension, and throbbing. In the pres- ent state of our knowledge it is probably well to regard it as urticaria edematosa. The treatment is the same as in urticaria. (See Urticaria.) (Edema Neonatorum. — This disease was formerly con- founded with sclerema, but is now separated from it. Symptoms. — It is a rare disease, that begins upon the legs within the first three days of life. The oedema spreads upward along the thighs, shows itself upon the hands, then upon the genitals and back. It may begin on the back or face, or the hands may be affected at the same time with the legs. It is hard and pits only on deep pressure. The skin is of a violaceous red or more or less intense yellow, and feels cold. The infant is coma- tose; its pulse is feeble; its breathing labored; and its cry sharp. A high temperature may exceptionally be present. Death usually results on account of some pul- monary affection or from collapse. Exceptionally, re- covery takes place. Etiology. — The disease occurs in feeble, ill-nourished children, in those prematurely delivered or exposed to poor hygienic surroundings. Diagnosis. — It differs from sclerema in being more limited to certain localities; in the skin being more livid from the first, and not so hard; in affecting the depen- dent parts; and in lacking the stiffness of the joints. (Crocker.) Treatment. — Though the prognosis is exceedingly bad, an attempt should be made to nourish the child as well as possible by artificial feeding; it should be wrapped in flannel and kept warm; and the limbs should be rubbed with warm oil, or camphorated alcohol, in such a way that the blood is forced toward the heart. Oidiomycosis is due to the infection of the skin with the oidium cutaneum. It is marked by the eruption of ulcerating gummatous nodes, and resembles bias- 484 DISEASES OF THE SKIN tomycosis, syphilis, and sporotrichosis. The diagnosis is made by cultivating the fungus. Onychauxis, Onychogryphosis. — These are both hyper- trophies of the nail, either in length, breadth, or thick- ness; or in all at the same time. When the growth is markedly forward and the nail is much thickened, it is called onychogryphosis. The nail in these instances gen- erally turns to one side after reaching a certain length, sometimes so much so that a big-toe nail may lie over the second and third toes. If the hypertrophy is lateral, we are apt to have onychia — ingrowing toe nail. The hyper- trophied nail is rugous, but highly polished, brown, and there is often an accumulation of scales under it, which at times gives rise to a bad odor from decomposition. The toe nails are those most often hypertrophied, but the finger nails may be so affected. Etiology. — Badly fitting boots and neglect of proper care of the nails are causes of onychauxis and onycho- gryphosis. They often arise without discoverable cause. They may be due to a congenital predisposition. They very often occur as part of some chronic skin or constitu- tional disease, such as eczema, psoriasis, leprosy, syphilis, and ichthyosis. The thickening may be due to disease of the matrix or to a thickening of the horny layer only. Treatment. — The hypertrophied nail may be removed by mechanical means, such as by a file, saw, or knife. The continued use of salicylic acid sometimes will cause the thickened mass to fall off. The oleates of tin and lead; the continuous wearing of rubber cots; and liquor potassse, are also efficacious in softening the thickened mass of the nail. The action of all these agents is as- sisted by daily removing the softened layers by mechani- cal means. When the hypertrophy is but a part of some other disease it will be benefited by the same means as will benefit the cause from which it arises. If it is due to an inflammatory disease of the nail bed or matrix, that must receive attention. (See Onychia and Paronychia.) After the nail deformity has been overcome it may return. ONYCHIA 485 Onychia or Onychitis. — By this is meant acute inflamma- tion of the matrix of the nail bed. The end of the finger or toe, especially about the matrix and nail fold, is red- dened and swollen, and there is more or less throbbing pain. If unchecked the nail is lifted from its bed, more or less pus escapes from underneath it, and it is eventually shed. The inflammation often spreads to the adjacent parts of the finger, and then we have that condition com- monly called whitlow. When the nail falls a spongy nail bed is left, often with exuberant granulations. Under proper treatment a good nail may be reproduced, though in many cases either a very much deformed one will result or one that differs somewhat in appearance from the other nails. In some cases, instead of this phlegmonous form, we have a dry inflammation that is known as onychia sicca Here the nail is discolored, its edge thickened and brittle, its surface rough and more or less pitted. Eventually the nail is shed. This condition is met with most often in syphilis. A chronic onychia is occasionally seen, and is one of the causes of onychauxis. Etiology. — Onychia is due to traumatism or to some other disease of the skin, such as syphilis, eczema, psoria- sis, parasitic diseases, dermatitis exfoliativa, rheumatism, and the strumous state. Treatment. — The treatment of onychia varies with the stage of the disease and with the cause. Occurring as part of some general disease of the skin, the treatment appropriate to the general disease will be beneficial to the onychia. Arising as an independent disease, or resulting from traumatism, the application of a 10 to 20 per cent, resorcin ointment or plaster, or a 5 to 10 per cent, salicylic acid ointment, or painting with tincture of iodin, will often abort the disease in an early stage. The liquor alumeni acetatis kept constantly applied is an excellent application. Ichthyol, 25 to' 50 per cent., in ointment form, is also useful. Stelwagon advises soaking the nail in a warm solution of bicarbonate of soda, 4 (0.26) to 5 (0.33) grains to the ounce (32), if the nail is hard 486 DISEASES OF THE SKIN and inelastic; also painting it with a 2 to 5 per cent, solution of nitrate of silver in sweet spirits of nitre. If the disease has gone on to suppuration, surgical pro- cedures will have to be resorted to, such as splitting of the nail or its removal as a whole, and subsequent dress- ing with iodoform, aristol, or a bichloride solution. Onychomycosis. — This term means the invasion of the nail by a fungus, such as the trichophyton or achorion. For further information see Trichophytosis and Favus. Oriental Sore. — See Aleppo boil. Osteosis Cutis. — A case of osteosis of the skin of the foot was reported by Sherwell 1 in 1892. It involved the plantar surface of the left foot about the heel and on the fourth toe. The patches were of cartilaginous hardness, with horny surfaces studded with nodosities. The patches were fairly movable over the underlying parts. They were painful when stepped on. The patient was a girl, six years old. The patches were excised, but formed again within six months. A histological examination by Cole- man 2 showed that they contained cancellous bone. Paget's Disease of the Nipple.— Synonyms: Mammillaris maligna ; Malignant papillary dermatitis ; Epitheliomatose eczematoide de la mamella (Besnier). Symptoms.— This is a rare disease of the skin that is named after Paget, who first described it in 1874. 3 It usually occurs in women over forty years of age, and at first has the appearance of an eczema madidans — that is, it presents "a florid, intensely red, raw surface, very finely granular, as if the whole thickness of the epidermis had been removed. From such a surface, on the whole or greater part of the nipple and areola, there is always a copious, clear, yellowish, viscid exudation." Besnier believes that its primary stage is a keratosis, which, under 1 Jour. Cutan. and Gen.-Urin. Dis., 1892, x, 119. 2 Ibid., 1894, xii, 185. 3 St. Bartholomew's Hospital Reports, vol. x, p. 83. PAGET S DISEASE OF THE NIPPLE 487 any irritation, assumes an eczematous appearance. The edge of the patch is sharply defined and slightly raised. Sometimes, instead of the raw surface, we have crusting, or even scaling. Telangiectases may be seen here and there. After months or years marked induration is mani- fest, pinching up the patch imparting the sensation, as described by Mr. Morris, of "a penny felt through a cloth." Burning or itching is complained of, which makes the disease the more nearly resemble an eczema. But it does not yield to the ordinary treatment of eczema, and its border gradually extends. The female breast, usually the right one, 1 is the most often affected, and there it always begins at the nipple, spreading thence over the areola and skin. After a few months, or perhaps not for twenty years, signs of scirrhous cancer appear. The nipple becomes more and more retracted and ulcerated. Shooting pains are complained of. Hard nodules develop in the raw surface or deep down in the skin. The mam- mary gland itself may become affected. The disease in most cases is unilateral. The cancerous cachexia develops later with ganglionic enlargements. The disease has been reported as occurring on the scrotum, the male nipple, glans penis, vulva, axilla, umbilical region, and buttocks, but these are exceptional sites. Pathology. — It is still an open question whether the disease is malignant from the start, or, beginning as a simple inflammation, becomes malignant, just as we find epithelioma of the tongue developing upon a leukoplakia. Later investigations seem to indicate that the process is epitheliomatous from the beginning. J. A. Fordyce's 2 researches show the disease to be an "inflammation of the papillary region of the derma leading to oedema and vacuolation of the constituent cells of the epidermis, followed by their complete destruction in some places and abnormal proliferation in others." He holds that the disease spreads down the lactiferous ducts from the skin. 1 Wickham: Maladie de Paget, Paris, 1890. 2 New York Med. Jour., 1897, lxvi, 445. 488 DISEASES OF THE SKIN O. H. Schultze 1 believes that the disease is not an epi- thelioma either as to the skin or the tumor in the breast. The latter he finds to be an adeno-carcinoma, but he offers no theory to account for the connection between malignant papillary dermatitis and the duct carcinoma. The changes in the lactiferous ducts are secondary. Diagnosis. — Though very important, it is exceedingly difficult at first to differentiate positively a case of Paget's disease from an eczema. Eczema of the nipple is very common during the child-bearing period, while Paget's disease occurs most commonly after the climacteric. In eczema we do not have, as a rule, the raw granulating surface of Paget's disease, while we do have more varia- tion in the course of the disease, exacerbations, and seasons of apparent quiescence. In eczema the patch is not so sharply defined, and its border is not raised ; about it there are apt to be outlying pustules or vesicles, and there is not the papyrus-like induration. When the nipple be- comes retracted and ulcerations take place, together with shooting pains and enlarged lymphatics, the diagnosis is easy. Treatment.— At the beginning, and while the diag- nosis is still doubtful, the usual remedies for eczema should be tried. If these fail, as they will if the disease is not eczema, or if the right diagnosis is arrived at, powerful caustics must be used if the disease is still superficial. We may use, as recommended by Darier, a solution of chloride of zinc, 1 in 3, to produce an exfoliation of the diseased epidermis, and follow it with a mercurial plaster, alternating with iodoform or aristol. Or a chloride of zinc paste may be kept on, spread thickly on lint, for four to six hours, and the slough poulticed off or allowed to separate under wet boric lint, or under oiled silk, as recom- mended by Crocker. Fuchsine in ointment, 1 grain (0.06) increased to 5 grains (0.33) to the ounce (32), cured one case in Elliot's hands. !Jour. Cutan. Dis., 1903, xxi, 201. PAPILLOMA 489 The paste used in the Middlesex Hospital in these cases is made as follows: 1$ — Zinci chlorid., 5iv 16 Liq. opii sed., 5iv 16 Amyli, oiss 6 Aquse, Si 32 S. — Ft. pasta. M. When there is ulceration, but not much induration, the surface should be thoroughly curetted and dressed anti- septically. When nodules have- formed and there is marked induration under an ulcerated surface, the whole diseased surface must be freely excised or the breast removed entire. In fact, it seems best to amputate the breast as soon as the diagnosis is made, when the patient is past the child-bearing period. If an operation or the use of caustics is inadvisable for any reason, relief to the pain and discomfort may be had by dressing w T ith a fuchsine solution, 1 per cent, strength. X-rays used as in epithelioma have cured some cases, and are always indicated in inoperable cases or those refusing operation. Panaris Nerveux of Quinquaud belongs to that group of obscure diseases in which stand Mor van's disease and syringomyelia. It is characterized by swelling of the extremities, slight redness, and attacks of intense pain, terminating in eight to fifteen days by fissure of the finger-end and fall of the nail. Sometimes the skin of the finger-end becomes sclerosed and atrophied. Brocq advises in its treatment the constant applica- tion of chloroform liniment, and of irritant lotions or frictions or the galvanic current to the cervical region and along the course of the nerves supplying the parts. Inter- nally, he advises the valerianate of ammonia or of quinin. Papilloma.— By this term is meant a papillary out- growth from the skin. Such are common warts, ver- rucous eczema, papillary excrescences following ulcera- tion, Kaposi's dermatitis papillaris capillitii, ichthyosis hystrix, nevus unius later is, and the like. The term is, therefore, of uncertain significance. Some authors have 490 DISEASES OF THE SKIN described papillomata apart from the above-designated diseases, and Hardaway reports at length a case of gen- eral idiopathic papilloma in a seven-months-old child. Mental defects have been noted in some of these cases. A mucopurulent secretion often is present, welling up between the papillae. The condition is a rare one. Under the name of papilloma area elevatum Beigel has described one of these rare cases. Fig. 71 Papilloma lineare. (Fox. 1 ) Papilloma Lineare. — Called also papilloma neuroticum, ichthyosis hystrix, nerve nevus, nevus unius lateris. This G. H. Fox, The Skin Diseases of Children, New York, 1897. PARAKERATOSIS VARIEGATA 491 disease is commonly described under ichthyosis. As it has no symptom in common with that disease, it is best to regard it as a separate disease. It occurs in the form of warty, papillary growths that may be isolated though grouped, and of pinhead size; or they may be massed together into elevated, dark-green plates traversed by deep lines; or arranged in long parallel rows. These growths may occur on only one side, and in a single region; or on both sides of the body and in several regions. They sometimes seem to follow the course of nerves in their distribution. Pruritus is sometimes complained of. While often congenital, they sometimes do not develop until a number of years after birth, and all tend to increase until early adult life. Their cause is undetermined, various theories being advanced to account for them. Their arrangement in lines is probably due to their occurring along Voight's cleavage lines of the skin. The peculiar arrangement of the lesions distin- guishes the disease from ordinary warts. The treatment consists in scraping away the growths with a curette; or picking up the skin into a fold and snipping off the top of the ridge with scissors ; or applying a 10 to 20 per cent, ointment or plaster of salicylic acid. Parakeratosis Scutularis. 1 — Under this name has been described a disease that occurred on the scalp of a man forty-one years old. The whole scalp, with the exception of a strip at the periphery, was covered by a thick, greasy crust that enveloped the hair in bundles. Some single hairs had on them cuffs of yellowish-white, waxy, horny substance, one inch or more long, that were in connection with the crusts on the scalp. The growth of the hair was not much interfered with. At the edge of the scalp was a hairless, red, dry, and rough strip. Parakeratosis Variegata. — Synonyms: Dermatitis psori- asiformis nodularis; Dermatitis variegata; Erythro- 1 Internat. Atlas of Rare Skin Diseases, No. 3. 492 DISEASES OF THE SKIN dermie pityriasique en plaques; Lichen variegatus; Psoriasiform and lichenoid exanthem. Symptoms. — This disease was first described by Unna. 1 It occurs as a generalized eruption, the face and head being often spared, in the form of macules which are oval or round and arranged so as to include healthy areas of skin in the groups, giving the skin a reticulated appear- ance. They vary in size from millet-seed to that of a child's palm. The patches are smooth or covered with fine, delicate scales. Scattered among them at times are flat, pinhead-sized papules w T ith a small scaly centre, which soon subside into macules. The general color of the eruption is pale lilac, but it may be red, disappearing under pressure, or brownish in tint. The patches fade in warm weather, but reappear in cold weather. The disease is chronic, lasting in spite of treatment for years. There is, as a rule, no subjective symptom. There may be some itching. Diagnosis. — It differs from psoriasis in lacking the characteristic scaling of that disease and in the very super- ficial character of the patches. It differs from lichen planus in its color, in not especially involving the sites of lichen, in the absence of itching, and the character of its scales. Treatment is unavailing. The remedies used in psoriasis may be tried, and the x-rays. Parasitic Diseases. — The diseases of the skin caused by parasites may be divided into two classes: (1) Those due to vegetable parasites. (2) Those due to animal parasites. Group I comprises favus, ringworm, chromophytosis, erythrasma, blastomycosis, granuloma coccidioides, pinta. These will be found described under their proper headings. In 1899 E. Lusk 2 reported a case whose symptoms re- sembled those of scabies, but it was due to mucor corym- bifer that was found escaping from the vesicles. 1 Monatshefte f. prakt. Dermat., 1890, x, 404. 2 Med. Rec, 1899, lvi, 204. PARASITIC DISEASES 493 Group II comprises a large variety of parasites. Scabies and pediculosis, due respectively to the acarus and pedic- ulus, are described at length in this book. The brown tail moth is referred to under dermatitis and the grain mite under acarodermatitis. Besides these we have — The leptus autumnalis, harvest bug, or mower's mite, that bores its head into the skin, causes great itching, and induces violent scratching and consequent excoriations. The demodex folliculorum is described in relation with the comedo. The pulex penetrans, chigoe, or jigger, that resembles a flea, but penetrates under the skin with its head, sets up inflammation and, perhaps ulceration and gangrene, and has to be dug out of the skin with a blunt needle. The pulex irritans, or common flea, whose bite causes an urticarial eruption in susceptible individuals. It is distinguished from that disease by having a hemorrhagic spot in the centre of the lesions and in their grouping. Powdering the underclothing with insect powder is a pro- tection against fleas. Stelwagon recommends the wear- ing of a piece of camphor in a small bag under the clothes for the same purpose. The cimex lectularius, or common bed-bug, attacks the skin for its food, punctures it, and at the same time injects an irritating fluid to increase the hyperemia and the food supply. A wheal, or raised red spot with a central puncture, follows the bite, and a purpuric spot results. The irritation is relieved by any of the means serviceable- in urticaria. Gnats and mosquitoes and their effects are all too familiar to require extended notice. Ixodes, or wood-ticks, the filaria sanguinis and filar ia medinensis, the tenia solium, and the echinococcus , all find lodgement at times in the human skin. These parasites do not exhaust the list, but are the principal ones. Dermatobia Noxialis. — This parasite 1 is very prevalent in South America, and is the larva of diptera. It con- 1 E. Costa: Jour. Cutan. Dis., 1910, xxvii, 24. 494 DISEASES OF THE SKIN sists of 11 segments, and measures 7 mm. in width and 14 mm. in length. It is round; whitish on the back, and yellowish-brown on the sides and abdomen. It has tentacles on its head, and two strong hooks turned back- ward. The same kind of hooks are on all the segments. It causes round, soft, elastic, adherent tumors of the color of the skin, which may be as large as a mandarin or smaller. They present a small opening from which a frothy, whitish serum may be squeezed. From these tumors the worm can be extracted, after which the tumors heal. The application of a 4 per cent, solution of carbolic acid will kill the parasites and cure the disease. Sarcopsylla Penetrans. 1 — This is an African parasite that lives in the soil and penetrates the human skin. It is a whitish, globular worm. It causes a swelling of the skin, the surface of which looks as if it were covered with barnacles. Pain and intolerable itching afflict the sufferer. After a while the tumor ulcerates and the worm is expelled, leaving a wound with a gangrenous margin. The feet are most frequently affected, but the disease also occurs on any part of the body surface. To cure the trouble, the worm is to be extracted ; mercurial ointment forced into the multiple punctures of the skin; and the swellings covered with camphorated alcohol. Paronychia. — This affection is popularly known as a whitlow, run-around, or ingrowing toe nail. Ingrowing toe nail results from the nail shoving or being shoved into the soft parts, either on account of disease of the nail itself, or of ill-fitting shoes, or of injury. The big-toe nail at its inner or outer edge, is the most common site of the disease, though any toe may be affected. The finger nail may suffer, the inflammation being set up by some injury or infection. The furrow, fold, and bed of the nail all become inflamed, ulcerated, and exquisitely tender and painful, the pain being of a throbbing char- acter, with the discharge of more or less pus. It is said 1 E. Costa: Jour. Cutan. Dis., 1910, xxvii, 24. PEDICULOSIS 495 to be more common in young people than in old, and far more frequent in men than in women. Paronychia of either the ulcerative or non-uleerative form is frequently met with in syphilis. Treatment. — Severe cases of paronychia most often find their way to the surgeon's hands. In syphilitic paronychia general antisyphilitic treatment is required. In the non-ulcerative form mercurial ointment, diluted with one or two parts of diachylon ointment, may be used, or the mercurial plaster. The liquor alumeni acetatis kept constantly applied is an excellent remedy. In the ulcerative form the parts should be cauterized with nitric acid or a strong solution of acid nitrate of mercury, followed by water dressings. Afterward the part may be dressed with iodoform or aristol. Band- aging, strapping, with mercurial plaster, and the use of rubber cots are also useful methods of treatment. In ingrowing toe nail a wedge-shaped piece should be cut out of the middle of the free edge of the nail and the nail should be filed down the middle, or, if that does not relieve the pressure, it may have to be removed in part or entire. The insertion of borated lint between the nail and the nail fold, or using boric acid in powder first and some threads of lint or a little absorbent cotton to separate the parts, and strapping the toe with adhesive plaster, will also answer well. If ulceration has taken place, the ulcer- ated surface should be dressed with iodoform or aristol. If the ulceration be covered with exuberant granulations, they should be touched with the nitrate of silver stick. As a preventive of the trouble, wearing well-fitting shoes and keeping the nails clean and cut down the middle are the best means at our command. Pediculosis. — Synonyms: Phthiriasis; Morbus pedicu- laris; Pedicularia; Lousiness. Symptoms. — There are three varieties of lice that infest the human species, namely, the pediculus capitis, pediculus vestimentorum, and pediculus pubis. Though 496 DISEASES' OF THE SKIN they all belong to one family, they differ among them- selves, and have distinct regions which they invade. The pediculus capitis infests the head only, and of that the occipital region and the parts over the ears are the common seats of invasion. From these it generally spreads to the parietal region, which is one of the best places in which to seek for nits, and, maybe, all over the scalp. Nits of all species of lice are small pear-shaped light yellow or light brown, hard, shiny bodies fastened on one side of the hair, from which they are removed with difficulty. There are but one or many nits on a hair. The lice cause irritation of the scalp both by their movements and by the insertion of their haustellum into follicles of the skin for feeding purposes. Lice have no mandibles. There is no such thing as a louse-bite. They simply suck their nutriment by inserting their haustellum into the follicles of the skin. The victim scratches to relieve the itching and irritation, and this gives rise to a dermatitis of eczematous character with the production of large pustules. A fully developed and characteristic case shows the hair in the occipital region matted together with a sticky secretion and, it may be, blood crusts, more or less eczematous lesions and large crusted pustules scattered over the whole scalp, enlarged lymphatic glands in the neck, and perhaps a few small pustules on the neck and face. When a patient presents himself with a pustular eruption on the back of the neck, or with a number of large, crusted pustules scattered over the scalp, pediculosis capitis should always be suspected, and search made for the pediculi or their nits upon the occipital and parietal regions. Very often no pediculi can be found; but if the disease is pediculosis, the nits will be discovered in the localities mentioned. The pediculus vestimentorum, or body-louse, inhabits the seams of the clothing, where it lays its eggs, and which it leaves only for the purpose of feeding upon the skin. It inserts its haustellum into the follicles of the skin, and thus produces a small hemorrhagic spot, even with the PEDICULOSIS 497 surface of the skin, which is a pathognomonic lesion of the disease. This feeding gives rise to itching, and the victim scratches to relieve it, thus producing a second symptom, excoriations. These have one peculiarity, which is, that they are very apt to take the form of long, parallel scratch marks, because the patient digs into his skin with all four nails at once. Moreover, as the lice live by prefer- ence in the shirt-band at the back of the neck, these long scratch marks are most often seen over the shoulders. Whenever they are seen we should suspect lice. Excori- ations are also seen on the inner or outer side of the limbs in locations corresponding to the seams of the clothing and about the waist corresponding to the location of the waist- band. In certain individuals, besides excoriations and hemorrhagic specks, Ave will find ecthymatous pustules, ulcerations, and, in very old cases, a great deal of pigmen- tation, so that the skin appears as if affected with a general chloasma. Any of these symptoms — hemorrhagic specks, excoriations, and itching, which is incessant in pronounced cases — should lead us to suspect lice, and a careful search of the seams of the clothing will reveal them, unless the patient has changed everything before coming to us. It must be remembered that the lice dwell both in linen and woollen clothing, and in bad cases, in the bedding also. W. A. Jamieson 1 has found in many cases that the lanugo hairs, especially on the back and shoulders, have nits on them, and believes that this fact accounts for the relapses often seen in the disease. The pediculas pubis, crab-louse or morpion, has a far wider feeding range than the other varieties. Though its favorite habitat is the pubic region, it may be met with upon the hair of the abdomen, chest, axillae, beard, eye- brows, and eye-lashes. Itching, excoriations, eczematous lesions, and nits on the hair are the symptoms it gives rise to, though the disturbance is not so great as that caused by the other forms of lice. The nits are rounder than 1 British Jour. Dermat., 1S99, xi, 103. 32 498 DISEASES OF THE SKIN those of the head-louse and darker in color, sometimes looking like small concretions on the hair. It is the least common variety. It requires careful search and a sharp eye to discover the vermin at times, as they are almost transparent, and usually are attached to the hairs head downward, and close to the skin. Cobbold taught that the pediculus that inhabits the eye-lashes was a dis- tinct species, the pediculus palpebrarum; but by most authorities the distinction is not made. In some cases, instead of red punctate marks, we find dull or slaty-gray, or pale-blue, lentil- to split-pea-sized macules scattered over the pubes, abdomen, extensor surface of the arms, axillae, and inside of the thighs. These are known as maculae cerulece, or taches ombrees. They do not disap- pear on pressure. They last for a few days, and then disappear of themselves. To give rise to these spots there must be a predisposition on the part of the skin. Most of the few reported cases have been in debilitated sub- jects. According to Duguet, 1 the macules are produced by the emptying of the contents of the salivary glands of the louse beneath the human epidermis. Etiology. — These different varieties of pediculosis are due to different varieties of lice. The head-louse (Fig. 72) is about 2 mm. long and 1 mm. broad, with a triangular head and broad thorax and short legs. The body-louse (Fig. 73) is larger than the head-louse, being 2 or 3 mm. long, with a more oval head and longer legs with more developed claws. The pubic louse is broader and flatter than either of the others, with rounder head, longer, stronger, and more claw-like legs, resembling somewhat a crab (Fig. 74). The color of the lice is gray or white. They propagate with great rapidity, the young hatching out in six or seven days, and being capable within eighteen days of propagating their species. It has been calculated that two female lice might become the grandmothers of 10,000 lice in eight weeks' time. The pediculus capitis 1 Gaz. des Hop., 1880, liii, 362. PEDICULOSIS 499 deposits its eggs close to the scalp and secretes a glue-like substance that sticks the ovum to the hair. There may be but a single ovum on a hair, or many of them. The distance of the nit from the scalp shows the length of time that the disease has existed. As it takes the hair about a month to attain the length of three-fourths of an inch, if we find the nit that distance from the scalp we know that it was deposited at least one month before. The severity of the symptoms to which the lice give rise will vary with the individual, some people being far Fig. 72 Fig. 73 Pediculus capitis (male). (After Kuchenmeister.) Pediculus vestimentorum. (After Kuchenmeister.) more susceptible than others. Infection takes place from other people or from infested body or bed-clothing. Women and children are the most frequent victims of pediculosis capitis; adults, and especially elderly people, of pediculosis vestimentorum. Pediculosis pubis is most frequently contracted during sexual intercourse, and is, therefore, most common in young adults. Dirt and uncleanness favor all forms, though even the most cleanly may at times harbor vermin. M. Oppenheim 1 has found a green coloring matter in the cells of the 1 Archiv f. Derm. u. Syph., 1901, lvii, 235. 500 DISEASES OF THE SKIN corpus adiposum of the pubic louse, and when these pigment-bearing lice are more abundant than the non- pigment-bearing ones, the more blue spots or maculae cerulese there are. He thinks that the blue color is due to the action of a salivary ferment upon the human blood. Diagnosis. — Pediculosis capitis needs to be diag- nosed from eczema. The characteristic location of its lesions upon the occipital region and nape of the neck, with its scattered and discrete large pustules over more or less of the scalp, should always suggest pediculosis; Fig, 74 Pediculus pubis. (After Schmarda.) then if the lice or their ova are found by searching the hair, the diagnosis is established. Nits here, as elsewhere, are differentiated from epidermic scales by being located upon the side of the hair, while the scale has a hair passing through its centre (Fig. 74) . The nit, too, is of a yellowish color, somewhat pear-shaped, with its larger rounded end upward; and it adheres closely to the hair, so as not to be readily removed. It is not always easy to distinguish pediculosis vestimentorum from pruritus cutaneus, especially if at the time the patient presents himself he has clean clothes on throughout. Both may occur in elderly people, and both may last a long time PEDICULOSIS 501 ^;> t: ::'.- with no other lesion than scratch marks. In pruritus we may find evidences of atrophic skin changes; the itching is often paroxysmal, and made worse by the patient becoming overheated. If we find the parallel scratch marks over the Fig. 75 shoulders and the hemorrhagic specks, we can make a positive diagnosis of pediculosis. From urti- caria pediculosis vestimentorum dif- fers in having hemorrhagic specks and in the parallel scratch marks. Urticaria may complicate a pedicu- losis. Scabies differs from pediculo- sis in appearing by preference upon the anterior face of the wrists, upon the breasts in females, upon the penis of males, and about the umbilicus of both sexes. Its lesions are not long, parallel scratch marks, but small scratched papules. If the lice of their ova can be found in any case, the diagnosis of pediculosis is made easy. Dermatitis herpetiformis differs from pediculosis in wanting the parallel scratch marks and in the markedly grouped character of its lesions. There will often be found groups of vesicles scattered about the skin. There can be no difficulty in diagnosing pediculosis pubis. Any itching about the pubic region should lead to an investigation, which, if carefully made, will reveal the pediculi or their nits. Treatment. — The most ready means of curing the disease when in the hairy regions is to shave the hair off and make some emollient application to the scalp to cure the eczema. But this is not advisable, excepting in Ova of head louse at- tached to hair. (After Kaposi.) 502 DISEASES OF THE SKIN children and in men in hospitals, and is not necessary. The most speedy and practicable method in public practice is to soak the hair of the head or pubic region with raw petroleum or kerosene, with an equal amount of sweet oil. This may be done night and morning for two days, and the parts then washed with soap and water. This will effectually kill all the lice, and probably destroy the life of the ova. The latter must be removed for fear that they are not dead, and for this purpose we may use a fine-toothed comb to the hair or pull the hair through a cloth saturated with vinegar or dilute acetic acid, which will soften the glue-like substance of the nits. No attention is to be paid to the dermatitis until after the cause of it is removed, when it will rapidly get well under any simple treatment. In private practice an infusion or tincture of delphinium staphisagria (lark- spur seeds), or a 10 per cent, solution of carbolic acid, or a J to 1 per cent, solution of bichloride of mercury, may be substituted for the petroleum. The bichloride should not be used if there is much dermatitis. The ointment of the ammoniate of mercury is efficient, but, as a rule, an ointment should not be used on hairy parts. Blue ointment is a well-known remedy for pediculosis pubis, but it is apt to set up a dermatitis that is undesir- able, and should not be prescribed. Sabouraud advises the use of equal parts of compound spirits of ether and xylol applied on absorbent cotton. He says it kills the lice and the nits instantaneously so that they may be easily removed with a comb. For pediculosis vestimentorum there is no use in mak- ing any application to the skin. The woollen clothes should be baked in a hot oven, and the underclothing and sheets should be well boiled. If this cannot be done, or new clothes obtained, powdered sulphur or delphinium may be powdered in all the seams of the clothing, and a 5 per cent, ointment of carbolic acid applied to the body. Jamieson recommends smearing the whole body in all cases with vaselin, and then giving a warm carbolic acid bath. PELLAGRA 503 Pellagra. — Synonyms: Risipola lombarda; Mai de la rosa; Mai roxo; Lombardian leprosy. Symptoms. — It has prodromal symptoms of progressive weakness, serous diarrhea, lassitude, giddiness, headache, and burning sensations in the back, limbs, hands, and feet. These make their appearance in the spring, and, shortly after, an erythema affects the back of the hands down to the articulation of the first and second phalanges, the back of the wrists and forearms up to the elbow, the back of the feet, if the person goes barefoot, the front of the neck and chest to the lower edge of the first piece of the sternum, and, in women and children, the forehead, nose, and cheeks — that is, all those regions exposed to the sun. The palms may be affected. The color is bright, dark or livid red, and is not a simple erythema, as the color cannot be made to disappear completely under pressure. In negroes the skin looks as if soot had been sprinkled on it. The skin is often so swollen as to prevent all work. Bullae may form upon the affected parts and be followed by erosions. In a few weeks desquamation begins, but the skin continues discolored and thickened up to July or August, when a gradual decline of all the symptoms takes place. The gums are usually swollen, and the tongue red. There may be salivation. During the winter the patient may appear quite well, but a relapse is pretty sure to occur during the next spring, and to recur each succeeding spring with ever-increasing severity of all the symptoms, and spread of the eruption; the patient emaciates, loses strength, develops grave cerebrospinal neuroses, becomes insane, such as dementia or delirium, and after months or years sinks into a typhoid state, and dies. The skin becomes atrophied, smooth, shining, cracked, or it may be thickened. There is a loss of cutaneous sensibility, and the erythematous redness gradually extends over the whole surface of the body. The average duration of the disease is five years, but death may occur in a few weeks in acute cases, or not until twenty years in the chronic form. 504 DISEASES OF THE SKIN Etiology. — The disease is endemic in northern and central Italy, especially in Lombardy, Venetia, and iEmilia; in the southwestern part of France, and in the northern part of Spain. It may occur anywhere, and is growing more and more prevalent in this country, especi- ally in the Southern States. Women are most subjected to it, children least so. It seems to be a disease fostered by poverty, want, an insufficient diet and bad hygiene. An almost exclusive diet of decomposed or fermented corn, or, possibly, other grains used to be considered as the exclusive cause of the disease, but this is now ques- tioned, as it occurs in people living in bad hygienic con- ditions though not living on corn. J. D. Long 1 thinks it may be due to an ameba. Sambone, of Italy, lays it to the Buffalo gnat; Roberts 2 is inclined to agree with Sambon. Siler, Garrison, and MacNeal 3 think that the stable fly is the carrier of the contagion. They found the disease to be more prevalent in towns than in the country, and in women confined to the house rather than in men working in the fields. We still do not know the cause of the disease. It is neither contagious nor hereditary. Pathology. — The liver, kidneys, spleen, and myo- cardium show fatty degeneration; ulcers are often found in the intestines, and degenerative changes in the brain and spinal cord. Diagnosis.- — A suspicion of a case being one of pellagra should be aroused whenever an erythema upon the exposed parts is met with in a person coming from the regions in which the disease is known to be endemic, especially if it is combined with diarrhea and more or less lassitude and hebetude. Treatment. — The treatment of the disease is mainly hygienic and symptomatic. Crocker has faith in the efficacy of arsenic for adults, and frictions with chloride i Jour. Amer. Med. Assoc, 1910, lv, 734. 2 Ibid., 1911, lvi, 1713. 3 Ibid., 1914, lxii, 8. PEMPHIGUS 505 of sodium solution in children. J. D. Long 1 recommends enemas of bisulphate of quinin in normal salt solution; a diet of milk, toast, rice, and starchy food; pancreatin or bicarbonate of soda in capsules coated with phenyl salicylate; mercurial inunctions; potassium iodid; daily purgation with salts; and rest in bed. H. P. Cole and G. J. Winthrop 2 have cured a number of cases by trans- fusion of blood from one who has recovered from the disease, or who has lived on the same food and in the same environment; about 20 c.c. being used. Pemphigus. — Synonyms: Pompholyx; (Ger.) Blasen- ausschlag. A chronic disease of the skin characterized by the eruption of successive crops of bullae upon the apparently sound skin and with either transient or no antecedent erythema. At one time every bullous eruption was a pemphigus, but with more careful observation and study a number of bullous eruptions have been established as distinct diseases. Many cases now included under dermatitis herpetiformis used to be regarded as pemphigus. It is probable that this process of elimination will continue. In the meantime a considerable degree of uncertainty pervades our knowledge of the disease, both as to its symptomatology and etiology, and we can only await further developments. While in this attitude we must have some sort of a chart to guide us, and it has been our object to draw the lines of pemphigus with as great sharpness as possible. Pemphigus Vulgaris, the form most commonly en- countered, may begin with an outbreak of bullae, or there may be more or less constitutional disturbance before their appearance. The latter condition is more often seen in debilitated subjects, children, and old people, and consists in chilliness, nausea, and perhaps a rise of two or three degrees of temperature. These con- 1 Jour. Amer. Med. Assoc, 1910, Iv, 754. 2 Ibid., 1910, liv, 1534. 506 DISEASES OF THE SKIN stitutional disturbances may recur before the appearance of each crop of bullae. The characteristic eruption is an outbreak of two or more up to a hundred or more pin- head-sized vesicles that in a few hours develop into tense, oval, hemispherical, prominently raised, fully distended bullae with translucent contents. The size of the bullae varies; it may be but one-eighth of an inch in diameter, or by the coalescence of several neighboring bullae, large, irregular ones of two or three inches in diameter may be formed. One distinguishing feature of these bullae is that they have no areola, but spring up at once from the seemingly healthy skin. Their contents soon become turbid, or perhaps purulent, and then a slight inflam- matory halo may form. Hemorrhage into the bullae rarely occurs, when it does it is pemphigus hemorrhagica. The bullae do not tend to rupture spontaneously, but to dry up, and leave the dried cover as a crust. If they are ruptured accidentally, an excoriated place is left that heals more or less readily, according to the general condition of the patient. Some pigmentation may be left for a time to mark the site of each bulla. The eruption may take place anywhere, but affects particularly the lower part of the face, the trunk, and limbs. The region of the crotch is a favorite site. It is usually bilateral, and may be roughly symmetrical. Bullae may occur, in grave cases, in the mouth and throat. The life of the individual bulla is two to eight days; but while One crop is disappearing a new one occurs, and the duration of the disease may thus be measured by weeks or months. Sometimes there is an interval of weeks or months between the outbreaks. In favorable cases a few crops appear, and that is all, the patient making a good and complete recovery. In less favorable cases, or when the eruption is very extensive, frequent relapses and many excoriations take place, the patient's strength becomes exhausted by the constant drain upon his system and loss of rest on account of the discomfort of his condition, and he. may die in a typhoid state, or of PEMPHIGUS 507 some intercurrent affection. A number of cases of death from the disease within two or three weeks have been reported, and to these the name of acute pemphigus is given. A few authorities have reported acute bullous eruptions running their course in three to six weeks and ending in recovery as acute pemphigus. Many of these cases were probably cases of bullous erythema, as in them a preceding erythema is noted in the reports of the cases. Most cases run a chronic course, extending over months or years. In rare instances a diphtheritic membrane may form at the site of the bulla; or, instead of healing taking place, a gangrenous process may be set up, with considerable destruction of tissue; or hemorrhage may take place in some of the bullae. All the mucous membranes may be affected by pemphi- gus, and the excoriations that thus form in the mouth add greatly to the discomfort of the patient. The conjunctiva is not spared, and if attacked serious deformity results. Neumann has described as pemphigus vegetans a bullous eruption in which healing does not take place, but the base becomes covered with sprouting granulations and assumes an uneven surface marked by furrows and secret- ing a thin fluid. The raw patches thus formed spread slowly at their circumference, and neighboring ones coalesce. In women the first lesions are usually seen about the vulva, and from there the disease spreads over the genito-anal region. In all cases the regions affected are the axillae, the root of the neck, the hands and feet, crotch, elbows, and scalp. It never becomes universal. Pigmentation often follows the drying up of a bulla. The disease proves progressive; marasmus, and, finally, death closes the scene. Most of the cases are in syphilitics. Cases of pemphigus neonatorum have been reported from time to time, and epidemics of it have been de- scribed. These are so evidently septic in origin that they hardly admit of being classified under the heading of 508 DISEASES OF THE SKIN pemphigus. Careful reading of not a few outbreaks of contagious pemphigus reported in the German journals will convince one who is acquainted with the bullous form of contagious impetigo that a mistake in diagnosis had been made by the reporter. Still, until further evidence is forthcoming, it is probably advisable to allow that both of these varieties of the disease do exist. Pem- phigus pruriginosus is another variety made by writers. It fits in quite well under Duhring's dermatitis herpeti- formis. Pemphigus Foliaceus differs considerably from pem- phigus vulgaris. Behrend 1 teaches that the difference between the two forms is simply a matter of coherence between the epidermis and corium, this being so slight in pemphigus foliaceus that we have a flaccid bulla instead of the tense, fully distended one of pemphigus vulgaris. Pemphigus foliaceus is the most rare variety of the disease, Crocker giving its occurrence as one in five thousand cases. It may present its peculiar features from the start, or begin as an ordinary pemphigus, or as a super- ficial cutaneous oedema, or as dermatitis herpetiformis. Its characteristic lesions are flaccid bullae, with opaque contents, that soon rupture and leave raw, moist surfaces with an edge of ragged epithelium. The fluid of the bullae changes its position with the position of the patient, always seeking the most dependent part, and soon becomes purulent. After the disease has existed some time the patient emits a sickening odor on account of the large amount of raw surfaces of the ruptured bullae that are bathed with sero-pus. Affecting at first only a limited space, by degrees the disease spreads so that the whole body-surface becomes red and weeping, looking like eczema rubrum, with crusts and areas of ragged epithe- lium. The palms and soles are often spared on account of the thickness of their epidermal coverings. When the 1 Vierteljahr. f. Dermat. u. Syph., 1879, vi, 191. PEMPHIGUS 509 skin is thus generally involved, it is difficult to establish the fact of the occurrence of new bullse. The mucous membranes of the mouth and pharynx are affected in like manner, becoming converted into raw patches. The hair falls out; the nails become thinner, brittle, atrophied, and, it may be, drop off; and ectropion is apt to result from the contraction of the skin about the eyes. The condition of the patient is most deplorable in these extensive cases: his skin is stiff and sore, and perhaps smarts; and after months or years he succumbs to the drain on his system, sinks into a typhoid state, and dies. During the early part of the disease there may be no constitutional disturbance. But eventually death is quite sure to result, if not from the disease, from some inter- current affection against which the patient is unable to offer any resistance. Etiology. — We know very little about the causes of pemphigus. The trophoneurotic theory of the disease offers us a cloak for our ignorance, and perhaps is, after all, the true one. Experiments have demonstrated that bullae can be made to form by operations on the spinal cord, and observation has shown that bullse do form in certain spinal diseases. Both sexes are subject to the disease. Children are more often affected than adults. The septic origin of certain bullous eruptions has already been spoken of under the heading of pemphigus neona- torum, and a number of cases of acute pemphigus occur- ring in butchers and in those engaged in handling meats have been reported by G. Pernet and W. Bullock. 1 All these ended fatally in a few days. Johnston believes that the disease is caused by a toxin developed in the internal economy of the individual and finds eosinophilia present in marked degree. Bullous eruptions are heredi- tary in some families, and in some subjects follow slight injuries to the skin. This is named Epidermolysis bul- losa, which see. Chilling of the body seems to have been 1 British Jour. Dermat., 1896, viii, 157. 510 DISEASES OF THE SKIN the exciting causes of some cases. Most subjects of the disease are debilitated. Some have advanced the theory that an excess of ammonia in the blood or defective kidney-elimination is the cause of the disease. Attacks of the disease have been observed to occur with each new pregnancy in some women. Pathology. — "Most authors regard the actual for- mation of the bulla as due to an inflammation of the papil- lary layer, with outpouring of fluid from the vessels; but Auspitz calls it an akantholysis, or loosening of the prickle-cell layer, by the sudden escape of fluid from the vessels destroying the young prickle cells and lifting up the epidermis as a whole. Any inflammatory phenomena, he thinks, are secondary." (Crocker.) G. Grinew 1 has found in pemphigus foliaceus that the red-blood corpuscles are decreased, while the white are slightly increased. The size of the blood cells is decreased so that the blood is watery. Hemoglobin is decreased as is the specific gravity of the blood. The number of lymphocytes is lessened, while the leukocytes and eosinophile cells are increased. Microorganisms have been found in the fluid both of the bullae of chronic and acute pemphigus, and a peculiar diplococcus has been demonstrated by several observers in apparent causal relation to the disease. Diagnosis. — If we regard the pathognomonic symp- toms of pemphigus vulgaris as fully distended bullae springing up out of the sound skin without any antece- dent erythema and without inflammatory halo, and occur- ring in crops so as to run a chronic course, then little difficulty will arise in diagnosis. A bullous erythema has bullae arising upon an erythematous base or with erythe- matous lesions elsewhere, and runs a comparatively acute course. Dermatitis herpetiformis differs from pemphigus in the grouping and multiformity of its lesions, and the great amount of itching that attends it. No matter how long it has lasted, it is seldom accompanied by the con- i Dermat. Zeit., 1904, xi, PEMPHIGUS 511 stitutional disturbances that are met with in pemphigus chronicus. In bullous urticaria the bulla rises upon a wheal. The bullous syphiloderm occurs usually on the palms and soles in infants a few days old, the bullae become purulent and form thick crusts, and there are present other signs of syphilis. The bullous form of impetigo contagiosa will be quite sure to present the char- acteristic impetigo pustules upon the hands or face, and search will probably discover some child with impetigo with whom the patient has come in contact. Varicella bullosa occurs epidemically, and runs a short course. Pemphigus foliaceus when in its early stage, and affect- ing but a small area, is readily diagnosed by the occur- rence of its flabby bullse, arising without antecedent injury. After it has lasted long enough to involve a large area it is with difficulty differentiated from eczema rubrum and dermatitis exfoliativa. In fact, without the history of the case it is sometimes almost impossible to make the diagnosis. It may be differentiated from eczema rubrum by its crusts being composed less of dried exudation than of epithelium, by the slight amount of exudation, by the ragged look of some part of the disease, and by careful watching for and finding the large flaccid bullse which will be sure to appear if the case is one of pemphigus. Moreover, in universal eczema rubrum the itching is more pronounced. Dermatitis exfoliativa differs from pemphigus in the absence of moisture and of bullae, and in the thinness of the exfoliated epidermis. Lichen ruber acuminatus is perfectly dry and presents characteristic papules. Treatment. — The drug upon which most reliance is placed in the treatment of this disease is arsenic. We may use Fowler's solution; or arsenous acid in pill-form, as the tablet triturate with piperina, or the Asiatic pill. Whatever form is given, it is advisable to begin with small doses and gradually increase them until the limit of tolerance is reached or the disease is controlled. Unfor- tunately it often disappoints us in its effects. Crocker 512 DISEASES OF THE SKIN regards salicin as almost as valuable as arsenic, given in doses of 15 grains (1) three times a day and increased to double that amount. Quinin is also valuable either given by the mouth in increasing doses up to 30 grains (2) during the day, or hypodermically. Attention to diet and hygiene, and the general condition of the patient, with the judicious use of tonics, such as iron, strychnin, and cod-liver oil, will often do as much, if not more, than arsenic to cure the patient. Locally, dusting powders of oxide of zinc, starch, lycopodium, or bismuth in varying combinations; lotions of lime-water, borax, zinc, liquor plumbi subacetatis, and the like, prove helpful in allaying irritation and discom- fort. Lassar's paste is also a good application. Unna 1 recommends equal parts of linseed oil, lime-water, oxide of zinc, and chalk, both to dry up the bullae and prevent their return. Linimentum calcis with 1 minim of creo- sote to the ounce is recommended by Hardaway. The continuous warm bath has afforded great relief in the Vienna hospitals. The bullae may be opened if they are troublesome. Alkaline and antiseptic mouth- washes will afford relief where the mucous membranes are affected. Prognosis. — The chances of recovery are uncertain. While many cases of pemphigus vulgaris recover, relapses are the rule, and if the patient is not strong, or the dis- ease has lasted a long time, a guarded prognosis should be made. Hemorrhagic, diphtheritic, or f ungating bullae are of bad augury. Pemphigus vegetans, pemphigus foliaceus, and pemphigus acutus arising from infection are almost invariably fatal. Perforating Ulcer of the Foot is an accident liable to occur in those in whom the nerve supply of the foot is deficient, as in locomotor ataxia, syphilis, leprosy, and peripheral neuritis. The most common location for the ulcer is at the metatarsophalangeal articulation of the great or little toe, or the cushion of the great toe. It may be 1 Monatshefte f. prakt. Dermat., 1888, vii, 108. PERIFOLLICULITIS SUPPURATIVA 513 only on one foot, or both feet may be affected. The process is slow, beginning as a proliferation of the epi- dermis like a corn, under which suppuration takes place, and an ulcer is left. This goes deeper into the tissues, until a sinus forms that reaches to the bone. The edges of the ulcer are hard. The external opening is often smaller than the sinus below. Usually there is little pain, though there may be hyperesthesia of the sur- rounding parts, and attacks of inflammation at times. This painlessness distinguishes it from a suppurating corn. The palms may be affected in the same way as the soles. The disease is very intractable, and must be managed on surgical principles, amputation of the whole or part of the foot being required in some cases. Death may result from the disease. Under the name of Hand-and-foot Disease, Hyde reported 1 three cases of ulcerations of the hands and feet that he regarded as due to trophoneurotic disturbances. In these cases, with or without functional disturbances, such as hyperidrosis and coldness of the hands and feet, bromidrosis, local anesthesia, vertigo, faintness, and rheumatic pains, there were found various grades of dystrophia unguium, from roughness to onychogry- phosis, tender and painful or insensitive maculations of the hands and feet, or both; different dermatoses, such as erythema, eczema, ichthyosis, local alopecia hypertrichosis, symmetrical tylosis, with or without spontaneous exfoliation or recurrence. After a time ulcerations formed on the hands or feet, or on both hands and feet. Perifolliculitis Suppurativa Conglomerata. — Under this title Leloir 2 has described and figured a rare disease of the skin which especially affects the back of the hands. Symptoms. — It seems to commence as a diffused red patch upon which develop small pustules, which itch slightly; or as small, red, more or less conglomerate, 1 Philadelphia Med. News, 1887, li, 416. 2 Ann. de derm, et de syph., 1884, v, 437. 33 514 DISEASES OF THE SKIN slightly itching elevations that form patches. The patches, however formed, are sharply defined, raised from 2 to 5 mm., round or oval, flattened, and of red, vinous, viola- ceous, or blue color. They vary in size from that of a ten-cent piece to that of a silver dollar, and are often crusted. When the crust is removed, the exposed surface is smooth or mammillated, but never papillomatous; and riddled with a number of pinpoint to pinhead- sized openings, corresponding to glandular orifices, many of which are closed with a plug of greenish, dried pus. Beside these openings there are a number of green- ish points that are ready to become such whenever the epidermis over them is removed. At a more advanced stage the openings form small pinhead-sized ulcers. By compression of the patch these openings give vent either to a drop of pus or serous fluid, or little, elongated, vermicelli-like whitish masses. In still more advanced cases the patches become more elevated, fluctuation manifests itself, and sero-pus may be expressed. The patches are usually single, but may be multiple. The back of the hand and wrist are the usual locations of the disease; but it may occur upon the dorsum of the foot or the outer side of the thigh, or be disseminated, but chiefly located on the extremities. The course of the disease is acute. It is fully developed in eight days; it then continues a week or two and disappears in about twelve days more. If badly treated, it may last longer, and be followed by a papillary condition. It is unattended by subjective symptoms, except slight itching. It leaves either no trace of itself, or a delicate superficial cicatrix that disappears, or a slight staining that soon fades. The hair is unaffected, though the disease may involve its follicles. Pathology. — The disease is a purulent inflammation of the skin follicles, especially of the lanugo hairs, and the pilo-sebaceous follicles of regions deficient in true hairs. It is possibly microbic in origin. Crocker regarded it as a form of ringworm. PERNIO 515 Diagnosis. — The disease is diagnosed from trichophy- tosis by its more rapid course, and recovery under sim- ple treatment; by the hair being unaffected; and by the absence of the trichophyton in the hair. Anthrax differs from it in the more pronounced character of its local and general reaction, its central core, and inflammatory indu- ration. Tuberculosis verrucosa cutis is much slower in its evolution, is serpiginous, and does not yield to simple treatment. Eczema differs from it in not having such sharply marked borders; in wanting the characteristic openings and livid tint; and in having more pronounced itching, a mucous, sticky discharge, and a comparatively long duration. Treatment. — The treatment is simple and consists in squeezing out the pus once a day, bathing the part for half an hour in warm carbolized water on a solution of boric acid, and covering with an antiseptic dressing. If papillae have formed, they should be scraped off, and the surface touched with nitrate of silver. In some obsti- nate cases it may be necessary to scrape out the whole patch. Perleche. — According to Brocq, this is a disease occur- ring in infants and affecting the commissures of the lips. Their epithelium is pale, macerated, desquamating, while the skin underneath is red and slightly inflamed. Some- times fissures will form that are painful, and may bleed when the patient opens his mouth wide. The inflam- mation may spread to the neighboring regions. It runs a course of two or three weeks, but is subject to relapse. It is contagious, and is due to a streptococcus. It bears a close resemblance to the fissures of the lip met with in syphilis, but is marked by an absence of all other symptoms of syphilis. The treatment consists in touching the diseased parts with sulphate of copper or alum, or an antiseptic solution, and in carefully looking after the nursing-bottles. Pernio. — See Dermatitis calorica. 516 DISEASES OF THE SKIN Phagmesis. — A rare condition in which it is said that feathers instead of hair adorn the body. Phtheiriasis. — See Pediculosis. Piedra. — Synonyms: Tinea nodosa; Trichomycosis nodosa. Symptoms. — There are two varieties of this disease, Piedra and Piedra nostras. Piedra occurs in Cauca, one of the United States of Colombia, and was first described in 1874 by Dr. N. Osorio, of the University of Bogota, but may occur else- where. It consists in the occurrence along the shaft of the hair of from one to ten small dark-colored nodes which are very hard and gritty, and rattle like stones when the hair is combed or shaken. The stony hardness of the nodes gave the disease its name "Piedra," which is the Spanish for "stone." These nodes are always placed at irregular intervals along the hair-shaft, begin- ning at about half an inch from the point of exit of the hair, the root being unaffected. The disease occurs most commonly in women, men being rarely affected, and it is the head-hair alone which exhibits these nodes. The disease is non-contagious, and is met with only in warm valleys. Piedra nostras consists in the presence of hard, smooth, poppy-seed-like nodes and elongated sheaths of brown color upon the hair of the beard and moustache. They are from 2 to 12 mm. long, and about twice the thickness of the hair upon which they are attached. The hairs are unaltered. Etiology. — Dr. Osorio thought that the nodes in Piedra were produced by an agglomeration of epithelium in certain parts of the hair. Mr. Morris 1 believes it is due to the use of a peculiar mucilaginous linseed-like oil, which is used particularly by the native women to keep their hair smooth and shiny. Another theory is that it is due to the use of water of certain stagnant 1 Lancet, 1879, v 407. PINTA 517 rivers which is very mucilaginous. Heat seems essential for its production, as the employment of either of these fluids will not cause the disease in cold climates. Microscopic examination of the affected hair shows that the nodes consist of a honeycombed mass of pig- mented spore-like bodies, the whole mass arising from one cell which sends out spore-like columns radially in all directions. As soon as the cells have reached a certain size they seem to alter their shape, become darker in color, and form a psuedo-epidermis. It is, therefore, a fungous growth. The nodes were found to be very hard to cut, and when considerable force w T as used they broke. The cause of Piedra nostras is a fungus growth. Diagnosis. — Piedra differs from trichorrhexis nodosa, in the stony hardness of the nodes, in its occurring prin- cipally upon the head-hair, in its probable etiology, and in the microscopical appearances it presents. Piedra nostras differs from Piedra by its nodes being larger, and by occurring on the hair of the beard. Treatment. — -By the use of hot water the nodes can be entirely removed. Pimples. — See Acne. Pinta. — Synonyms: Mai de los pintos; Tinna; Caraate or cute; Quirica; Spotted sickness. This disease occurs in the Philippines, southern Mexico, Panama, and South America. Symptoms. — According to Crocker, from whose work this account is drawn, it consists of scaly spots varying in color, shape, number, and size. They show themselves first on the uncovered parts, but may affect any and all of the cutaneous surface. The disease spreads by the periph- eral extension of old patches and the formation of new ones. The patches are round or irregular in shape, sharply or ill-defined, and of black, gray, blue, red, or dull-white color. The red and white patches are deeper- seated than the others, being located in the rete and corium. The patches may be of uniform color, or of 518 DISEASES OF THE SKIN different tint, but do not change their color after they have once formed. They are scaly and usually feel rough and dry. The hair grows gray and falls. There is some itching, and a bad odor emanates from the patient. The course of the disease is chronic and shows no tendency to recovery. Etiology.— The disease is contagious, and its spread is favored by dirt and neglect. It is most common in the poor natives of Indian stock. It is of fungous origin, and, in fact, seems to be allied to chromophytosis. Treatment. — The treatment is the same as for chro- mophytosis and ringworm. Pityriasis Alba Atrophicans. — This disease begins in early life as a partly lamellar, partly branny desquama- tion of the skin without redness or any other form of efflorescence. The skin may be affected wholly or in part. After lasting ten to fifteen years it is followed by secondary atrophy of the skin, which becomes thinner, and softer. The subcutaneous fat is lost and the veins show through. Pityriasis Capitis. — There are two forms of this disease, pityriasis simplex and pityriasis steatoides. Scaling of the scalp is physiological if of so moderate a degree as to be unnoticeable. If of more intense degree it constitutes a disease. Pityriasis Simplex Capitis. — Synonyms: Dandruff; Seborrhea sicca (Hebra). Symptoms. — The hair is usually dry and lusterless, with white or gray scales scattered through it, giving it a powdery appearance. The amount of scaling may be so great that the collar of the coat or dress is covered with them. This is what is called dandruff. The scalp is covered with the scales, beneath which it is dull white in color. There may be areas of the scalp of normal appearance. The scalp itches, and may show signs of having been scratched. PITYRIASIS STEATOIDES 519 Etiology. — While the disease may occur in children, most cases begin at or about the age of puberty. It is more frequent in men than in women. All things that lower the nutrition of the subject tends to aggravate the disease. It is probably due to the infection of the scalp by the spores of Malassez, which are the same as the bottle bacillus of Unna. Diagnosis. — It differs from ring worm in not causing thinning of the hair, in the absence of stumps, and the spores and mycelia of that disease. Chronic squamous eczema is more pruritic, often extends beyond the hair line, and shows evidence of inflammation. In psoriasis the patches are more sharply defined, of red color, more thickly covered with heaped-up scales, and typical patches of the disease will be found elsewhere on the body. Pityriasis Steatoides. — Synonyms: Seborrhea sicca; Eczema seborrhoicum. Symptoms. — The scalp is covered with scales of a yellow or amber color, often heaped up into crusts. They are distinctly greasy to the feel. They adhere more or less closely to the scalp. ' They are often very abundant. The scalp may be of normal color, or slightly rosy with a glistening surface. The whole scalp is usually affected, and exceptionally the disease may go over beyond the border of the hair. The scalp itches. After a time the hair begins to fall. The process is often associated with seborrhea and pityriasis simplex. The disease not infrequently passes over into a seborrheal dermatitis or an eczema may develop. Etiology. — This form of pityriasis is due to infection of the scalp with Sabouraud's polymorphous coccus with gray culture. It is usually secondary to pityriasis simplex, and seems to be the result of a double infection with the spores of Malassez and the just mentioned coccus. Both sexes are affected. It begins most often between the twentieth and thirtieth year of age. It is rather more 520 DISEASES OF THE SKIN frequent among the poorer classes. The barber shop, is a very common spreader of contagion. Dia gnosis. — In seborrhea we have the so-called fila- ments, and the presence of the microbacillus. In sebor- rheal dermatitis there is redness and swelling of the scalp, and a tendency of the disease to involve many different parts of the body. In eczema the signs of inflammation are marked, a sticky exudation is often in evidence, the disease is more patchy, and the itching more marked. In psoriasis the scales are not greasy, the patches are sharply defined, and characteristic lesions of the disease are found scattered over the body. Treatment. — The treatment of both forms of pity- riasis is practically the same. The most efficient remedies are antiparasitics, such as sulphur, mercury, resorcin, and tar. When the scalp is dry and scaly it is best to exhibit our remedy in the form of an ointment. If the scales are greasy and the hair oily, then alcoholic com- pounds are better. In many cases it is best to use a lotion for a few days until the scalp becomes drier, and then an ointment. It must be kept in mind that a sulphur preparation is not to be used alternately with one con- taining mercury, as a black sulphide may form which is annoying to the patient. While any application is being made to the scalp, the latter should be washed at least every two weeks. The formula that are useful in pity- riasis are given in the section on alopecia pityroides, to which the reader is referred. Prognosis. — Both forms of pityriasis are chronic. Complete recovery in which no relapses occur are rare. The simple form is said not to be followed by loss of hair, but as in most cases it develops into the steatoid form, which always causes baldness, alopecia may be stated to be the end result of the disease unless it is kept in check. By continued judicious care of the scalp the hair may be indefinitely preserved. Pityriasis Lichenoides Chronica. — See Parakeratosis varie- gata. PITYRIASIS ROSEA 521 Pityriasis Maculata et Circinata. — See Pityriasis rosea. Pityriasis Pilaris. — See Keratosis pilaris. Pityriasis Rosea. — Synonyms: Pityriasis maculata et circinata; Herpes tonsurans maculosus (Hebra); Roseola pityriasiaca (Barduzzi); Pityriasis circine et margine (Vidal); Pityriasis rosee (Gibert); Erytheme papuleux desquamatif. An acute disease of the skin characterized by an eruption of rosy-red macules that enlarge into dry, scaly, oval or annular patches with rosy-red peripheries and chamois-yellow, wrinkled centres; it runs a definite course and terminates in recovery. Symptoms. — The outbreak of the disease may be pre- ceded by slight constitutional disturbances, such as malaise, loss of appetite, and headache, with a slight rise of temperature just before the outbreak of the eruption. Crocker says that there is often enlargement of the post-sternomastoid and submaxillary glands, and maybe other glands. The eruption itself most often begins without prodromas upon the upper part of the chest, a little above the breasts, or, according to Brocq, 1 at the level of the waist-band, anteriorly and a little to one side, where he locates what he calls the "primitive patch." The primary lesions are miliary or small papules of pale-red color, surrounded by an erythematous zone. These soon enlarge into rosy-red, slightly raised macules, and slowly increase peripherally into oval or rounded patches with well-defined borders raised somewhat higher than the centres. When the patches have attained a diameter of half an inch or more the centres begin to clear up by becoming of a yellow, old-parchment color, scaly and shiny, while the border is pale red. Later the centre may disappear and rings only remain; or if two or more patches meet at their borders, irregular gyrate figures may be formed. All the lesions do not attain the same degree of development, and in well- 1 Ann. de derm, et de syph., 1887, viii, 615. 522 DISEASES OF THE SKIN developed cases lesions in all stages will be found. The lesions are slightly scaly from the commencement and the furfuraceous desquamation continues until the faint mark left by the lesion disappears. Itching, usually slight in amount, and only when the person is warm, is the only subjective symptom. Sometimes it is severe. The eruption is most marked upon the neck, infra- and supraclavicular regions, sides of the chest, and shoulders; it may be marked also on the abdomen and buttocks. The whole body may be involved, but the hands and feet are usually spared, and it is uncommon on the face. After some three to six weeks the disease tends to spon- taneous recovery, although it may last for months. Fig. 76 Pityriasis rosea. By the courtesy of Dr. S. I. Rainforth. Etiology. — We know nothing about the cause of the disease. It affects all ages and both sexes. Crocker finds that one-third of the cases are in children. Most of the cases we have seen have been in young adults. This difference may be accounted for by the fact that he has a large children's dispensary service. Some cases seem to be due to overheating of the skin by wearing PITYRIASIS ROSEA 523 too heavy underclothing. Hyde and Montgomery teach that it occurs most often in blond subjects who have been enfeebled by great physical fatigue or overstudy in school. The disease seems to occur epidemically in some instances, and cases are apt to present themselves in groups. Contagion has not been established. Bazin regards it as arthritic. It may be parasitic, but as yet the parasite awaits demonstration. Vidal 1 describes a parasite that he names the microsporon anomen, as found in pityriasis circine et margine, which is the same disease. Hebra regarded it as a manifestation of tricho- phytosis, and some authorities still think that some cases are diffused ringworm. There is a strong probability that it is due to a toxin developing in the intestinal tract. Pathology. — The process is a mild inflammation in the upper cutis, more marked toward the periphery of the lesions. In the more pronounced cases minute vesicles, visible only microscopically, are found beneath the corneous layer. Diagnosis. — Pityriasis rosea must be differentiated from the early circinate, scaling, macular syphiloderm; annular psoriasis ; seborrheal dermatitis ; and disseminated trichophytosis. The one most distinguishing feature of pityriasis rosea is the wrinkled old-parchment yellow of the centre of the ring. This is absent from the lesions of all the other diseases with which it is likely to be confounded. The syphilid is of a less bright-red color, and there surely will be some other evidence of syphilis to guide us. Psoriasis is far more scaly; the scales are of a white color; the tips of the elbows and the anterior face of the knees will be especially affected; and typical psoriatic patches will be found somewhere. Seborrheal dermatitis occurs upon the middle sternal and inter- scapular regions particularly; the patches have a greasy feel; the scales are thicker than in pityriasis rosea; the papular lesions are more raised and evidently in relation 1 Ann. do derm, et de syph., 1882, iii, 22. 524 DISEASES OF THE SKIN to a follicle of the skin ; and the lesions show little tendency to spontaneous involution. Cases occur in which it is very difficult to make the diagnosis between this and pityriasis rosea. In trichophytosis the fungus is readily found under the microscope, which is a decisive test. Apart from that, ringworm does not spread so rapidly nor involve such wide areas. Measles differs from it by having catarrhal and constitutional symptoms, and by the absence of the rings with old parchment-like centres. Treatment. — Pityriasis rosea is a self-limited dis- ease, and recovery is sure to take place in a short space of time, usually from three to six weeks. Though treat- ment seems not to have any marked effect on the dis- ease, we may use lotions of salicylic acid, 10 to 20 grains (0.66 to 1.33) to the ounce (32), or of boric acid; or con- tent ourselves by allaying the itching with lotions of carbolic acid 10 (0.66) grains to the ounce (32), calamin, oxide of zinc, and the like. Tepid alkaline or bran baths may be used, followed by a dusting powder. Crocker has faith in salicin in the dosage of 15 grains (1) three times a day. Pityriasis Rubra. — See Dermatitis exfoliativa. Pityriasis Rubra Pilaris. — This name was first given by French writers to a disease that had been known for a long time as lichen ruber, and was first described by Hebra. It has driven the earlier name out of the field, unjustly as we think. Symptoms. — A typical case has three principal ele- ments: (1) Asperities of the follicular orifices; (2) Desqua- mation; (3) Roughness of the skin with exaggeration of its folds. The disease generally begins suddenly, without prodroma, but there may be some malaise nervousness, insomnia, hyperesthesia of the finger ends, formication, and the like. These prodromas are of short duration, and rarely cause the patient to go to bed. The uncovered parts are usually first affected with the eruption, but it may appear primarily upon the trunk PITYRIASIS RUBRA PILARIS 525 or extremities. The initial lesion may be a simple exfolia- tion; an erythema; a scaling erythema; a fine but scanty furfuraceous desquamation; a shiny redness with pityriasis; desquamation of nail bed, or fragility of nail. However beginning, the more pronounced form appears in a certain number of days or weeks, and may develop or abort at any point, or be limited to any region, or involve the whole body. When fully developed, a patch or the whole skin, as the case may be, presents the following character- istics: It is covered with elevations that are generally conical, but may present great diversity of shape. They may be discrete or coalesce. They may be so small as to be seen only by the aid of a microscope, or elevated many millimeters above the surface, with corresponding diam- eter. They are scaly, and vary in color from a silver white or gray to a bright or opaque red, red brown, or rosy yellow. Their summits may be flat, uneven, cone-shaped, or truncated, giving issue to a hair broken off at a little distance above the surface of the skin, and, it may be, sheathed by a corneous or sebaceo-squamous case. Instead of a hair protruding, it may form only a small comedo-like spot at the centre of the summit, or it may be wanting, or it may seem to exist alone, giving to the region the appearance of a badly shaven beard. Sometimes the cone presents a crater, at the bottom of which is a black point, a punctured scaly plate, or a psoriatic point. Patches are formed by the coalescence of the papules. They are fairly well defined, of all shapes, scaly, grayish in color, rough to the touch, and bear a resemblance to chagreen leather. Scattered about the usual papules will be found. The patches are very capricious, coming and going. The skin is scaly, dry, hard, rough like a file, and presents a "goose-skin" appearance. The scales may be scraped off without any loss of blood. The disease is generally symmetrical, but the lesions may be disseminated without order, or in irregular lines, groups, or islands, or may unite in tessellated areas. 526 DISEASES OF THE SKIN The cone-like elevations do not occur on the scalp, and are rare on the soles and palms. In these locations the disease takes the form of abundant desquamation upon a reddened base. When the face is attacked the skin is dry, red, scaly, and thickened. All other regions may be affected, the cones forming about the follicles of the skin, especially about the hair follicles. The back of the phalanges of the fingers are nearly always affected, appearing rough, uneven, and covered with patches of characteristic papules. This appearance of the back of the phalanges is one diagnostic mark of the disease. A favorite site is the upper part of the inter natal furrow. In very severe cases nearly all the surface is involved. Some variations from the type are encountered in different regions, but characteristic types will be found somewhere on the body. The hair may fall, and the nails may be deformed, opaque, and raised by an accumulation of scales under them. The general condition is unaltered, and little, if any, discomfort is experienced. The duration of the disease is indefinite. It may disappear entirely or completely. Relapses are the rule. Second and subsequent attacks may be shorter than the first. Etiology. — The etiology of the disease is obscure. It is rarely met with. It occurs at all ages, and in both sexes, but most often in infancy or youth, and in males. Many causes have been assigned to it, such as cold, excesses, rheumatism; but none of these can be definitely said to be the cause. Pathology. — The essential change is a hyperkeratosis in the epithelial lining of the orifice of the hair follicle. All the layers of the epidermis are much thickened. Secondary inflammation occurs in the upper part of the derma. Diagnosis. — The disease is to be diagnosed from ichthyosis in not being congenital; in attacking by pre- ference the joints, scalp, face, and neck; and in its spon- taneous recovery for a time. From dermatitis exfoliativa PLICA POLONICA 527 by its benign course; its location about the follicular openings; and by the thick scaling of the palms and soles. Lichen planus presents angular, flat, umbilicated papules of peculiar violaceous color, is very pruritic, and usually spares the face and backs of the phalanges of the hands. Psoriasis at times bears a strong resemblance to pity- riasis rubra pilaris, but it seeks the elbows and knees particularly; its scales are larger; and it is not a follicular disease, never presenting comedo-like plugs, broken-off hairs, or little elevations. Tkeatment. — No satisfactory treatment has been found. Arsenic may be given. The general health of the patient must be cared for. Locally the remedies applicable to psoriasis or to ichthyosis can be used with advantage. Like in that disease, an attack may be over- come, but no assurance can be given against a relapse. Thus far no fatal case has been reported, though Hebra's cases of lichen ruber were commonly fatal. Pityriasis Simplex. — See Pityriasis capitis. Pityriasis Tabescentium is that condition occurring in marasmic individuals where there is scaling of the whole skin especially marked on the extensor surfaces of the extremities and trunk. Pityriasis Versicolor. — See Chromophytosis. Plica Polonica. — Synonyms: Trichosis plica; Trichoma; (Pol.) Koltun; (Ger.) Weichselzopf; (Fr.) Plique polo- naise; Polish ringworm. Symptoms. — This is rather a condition than a disease, in which the hairs of the head and other parts become matted together into variously shaped masses, on which rest all sorts of extraneous matters deposited from the air; and in which are harbored vast hordes of pediculi. Sometimes these matted tresses are near the scalp, and sometimes far away. Not infrequently an oozing eczema of the scalp will be found. The masses will assume all sorts of shapes, to which various names have been applied . 528 DISEASES OF THE SKIN An offensive odor often emanates from the scalp. Occur- ring among ignorant people, as is usually the case, these Fig. 7 r , ifli HP 1 •V - mwa m 1 Neuropathic plica. (Stelwagon.) plicas are regarded with superstition. The patient and friends refuse to have them cut off lest some dire disease befalhthe bearer. POMPHOLYX 529 Under the name of Plica Neuropathica a few cases of matting of the hair into masses like those in plica polonica have been reported as occurring in cleanly individuals. Etiology. — The cause of the condition is want of cleanliness combined with an oozing dermatitis of the scalp due to pediculi or any other cause. Plica neuro- pathica seems to be due to a peculiarity of the hair causing it to felt. Treatment. — The treatment consists in the liberal use of soap and water, and curing the dermatitis. If allowed, the most effective way of beginning treatment is to cut off the hair. The patient must be instructed in hygiene of the scalp. Pompholyx. — Synonyms: Dysidrosis; Cheiro-pompholyx. Symptoms. — The first thing that the patient notices is a burning and itching of the palms or soles, and sides of the fingers or toes In a few hours small, clear, sago-grain- like vesicles, sometimes grouped, and with an erythema- tous zone about them, appear in these locations. They are often very numerous, and some of them run together to form small and large bullae. Their contents are at first clear and neutral; later they become turbid and have an alkaline reaction. These \ T esicles do not tend to spon- taneous rupture. In a few days they dry up, their covers fall, and large and small, dry, red surfaces are left to mark their locations. If the lesions have been very numerous, the whole of the old skin may be shed. In slight cases the palms or soles will be dotted over with irregularly shaped red spots with ragged edges. As a rule, the backs of the hands and feet are unaffected, though the rule has many exceptions. It is usually symmetrical or bilateral. Abortive attacks are quite common in which the disease is limited to two or three lesions on the side of one or more fingers. The sub- jective symptom is burning, though itching may occur. The patients are seldom in perfect health, and are usually nervously depressed. Hyperidrosis of the affected parts 34 530 DISEASES OF THE SKIN commonly accompanies or precedes the outbreak, and sometimes a lichen tropicus will be found on the trunk. The duration of the attack varies from a few days to three or four weeks, and relapses in the same or follow- ing years are common. Most all cases are seen in the summer. It is usually symmetrical, though one side may be affected before the other. Some systematic writers regard the disease as an eczema. Etiology. — Over the causes of the disease there has been and still is active discussion. It seems to be in some way connected with the sweat glands, but whether it is a simple impediment to the escape of the sweat or an inflammatory disease is not determined. Some able pathologists ally the disease to herpes, and deny any connection with the sweat glands. Occurrence of the disease in hot weather points to the sweat apparatus being at fault. There is probably a vasomotor neurosis at the bottom of the trouble. It affects all ages and both sexes, though most common in young adult women, and in those who are of nervous temperament or the subjects of worry and over-fatigue. It is said that organic or functional heart disease is the cause of some cases. Unna states that he has found constantly a bacillus in sections of the vesicles. Pathology. — Robinson, who has carefully studied this disease, regards it as a neurosis allied to herpes and pemphigus. He thinks it has nothing to do with the sweat glands, but that it is inflammatory. The contents of the vesicles, he shows, is not sweat, but serum; and the reaction of the fluid is alkaline or neutral in its early stages, never acid. It also contains a large amount of albumin and some fibrin. It comes from the papillary bloodvessels, and passing between the rete cells collects in different situations in the stratum mucosum. Diagnosis. — Pompholyx must be differentiated from eczema, scabies, pemphigus, and erythema bullosum. It differs from eczema in its vesicles not tending to break down of themselves; in not presenting a moist surface POROKERA TO SIS 531 after the vesicle tops fall ; and in running a more definite course. The sago-grain-like appearance of the vesicles is not peculiar to it, as it is frequently seen in eczema of the hands, and is due to the thickness of the epithelium, preventing the ready escape of the fluid. Scabies may bear a close resemblance to pompholyx but can be readily differentiated by finding the burrows, and noting the location of the eruption upon the anterior surface of the wrists, the breasts in women, the genitals in males, and about the umbilicus in both sexes. Pemphigus of the hands and feet is exceedingly rare in adults, and pom- pholyx has never been reported in infants. Moreover, pemphigus lacks the vesicular lesions of the sides of the fingers. Erythema bullosum is always on the back of the hands and wrists, and is not itchy, though it may burn. Treatment. — A simple astringent ointment, as of oxide of zinc, or diachylon; or an ointment of the oleate of zinc or lead; or an alkaline lotion, will allay the irritation and hasten the disappearance of the disease. Lassar's paste with 10 to 20 grains (0.66-1.33) of salicylic acid to the ounce (32) is a good application. It hastens the exfoliation of the old skin. When that has taken place it may be continued, without the salicylic acid, to pro- mote healing. General hygiene should be enforced; and tonics of iron, arsenic, or whatever seems indicated by the condition of the patient, given. Porrigo Contagiosa. — See Impetigo contagiosa. Porokeratosis. — Synonyms: Hyperkeratosis atrophica seu excentrica, Keratodermia eccentrica. Under this name Mibelli, 1 and later Respighi, 2 have described a disease of the skin that occurs in the form of raised or sunken yellowish-gray to brown patches of vari- ous sizes and irregular shape, with a continuous thin, 1 Monatshefte f. prakt. Dermat., 1893, xvii, 417, also Annal. derm, et syph., 1905, vi, 503. 2 Monatshefte f. prakt. Dermat., 1894, xviii, 70. 532 DISEASES OF THE SKIN horny, linearform tortuous ridge about them. The patch may begin as a very small, horny, dry, hard and acu- minate elevation which seems to well up from the orifice of a cutaneous gland. Around this the collarette forms. The patches may be small or one or more inches in diam- eter. The skin inside of the border may be normal, Fig. 78 Porokeratosis. (Respighi.) rugous, smooth, scaly, or atrophic; while around the patches it may be normal, hyperemic, or pigmented. The amount of atrophy varies being most on the face and over bony prominences. The disease occurs on the dorsal and palmar surface of the hands and feet, the extensor surface of the forearm and leg, and exceptionally on their POSTMORTEM WARTS 533 flexor surface. On the palms and soles and sides of fingers it takes the form of corns. It may also occur on the face, neck, and scalp, and the mucous membrane of the mouth. In the mouth the lesions vary in size from small pinhead to large lentil. They are sharply limited, with a linear, white, opaque border enclosing an opaline area that may be raised or flattened, convex or concave, or atrophic. There are no subjective symptoms. Some of the lesions may disappear spontaneously, and neighboring lesions may melt into each other. Generally the disease spreads slowly so as to occupy large areas. Respighi describes five distinct forms: (1) Miliary and submiliary papules; (2) Hemp-seed- to lentil-sized papules; (3) Guttate to nummular papules; (4) Ring and circinate disks, which is the most common form. Their edges are raised, regular, toothed, or zig-zag, and may be composed of papules arranged in chains. The disks may be round, oval or elliptic; (5) Ball-shaped lesions 3 to 4 mm. high. All forms begin as papules. The disease is bilateral and tends to symmetry. The nails may be affected, becoming cloudy, striped longitudinally, rough, thickened, raised from their bed, brittle, and they may be shed. There are no subjective symptoms. The skin may be abnormally dry. The disease usually begins in early life, but may begin at any age. It is hereditary in some families. Most of the cases are in males. Many members of the same family may be affected. It is a very rare disease without known cause. It consists in a hyperkeratosis of the sweat-gland orifices and destruction of the glands. The sebaceous glands and hair follicles may be involved in the process. It is thought by Mibelli to be a species of papilloma lineare. It is an eminently chronic affection. The treatment consists in destruction by electrolysis or in excision. Port-wine Mark. — See Nevus. Postmortem Warts. — See Tuberculosis verrucosa cutis. 534 DISEASES OF THE SKIN Prairie Itch. — This disease has been found to be in most cases a combination of pruritus hiemalis and scabies. It is not a disease sui generis. Prickly Heat. — See Miliaria. Prurigo. — Synonyms: Strophulus prurigineux; Scrofu- lide boutonneuse benigne; (Ger.) Juckblattern. A chronic disease of the skin characterized by begin- ning in infancy as an urticaria, and changing into a recurring eruption of pale, hard, exceedingly itchy, dis- crete papules, located especially upon the extensor surfaces of the extremities. It increases in severity from above downward, and is accompanied by enlargement of the inguinal glands. There are two types of this disease, namely, prurigo mitis and prurigo ferox. These blend into each other. While the malady is more commonly reported from Vienna than elsewhere, it occurs in many countries. It is rare in this country, and most of the cases met with are of the mild type. Symptoms. — The disease begins in infancy, quite com- monly toward the end of the first year, as an outbreak of urticarial wheals of various sizes and shapes. It may begin in childhood. The urticarial eruption persists, but after a time a preponderance of small wheals will be remarked, and a preference for the trunk and the extensor surfaces of the limbs. During the second or third year the urticarial element is lost and the characteristic papular eruption gradually preponderates, and at last takes its place. The papules are pinhead to hemp-seed in size, flat, firm, of the color of the skin, or of a bright-red, rosy, or yellowish-white color, and in many cases so little raised as to be felt rather than seen. When the skin is irritated the papules may assume the character of small wheals. The efflorescences are located principally upon the extensor surfaces of the limbs, and more sparsely on the trunk, while the scalp, the flexures of the large joints, the palms, soles, and genitals are free. The flexure PRURIGO 535 surfaces of the extremities may be affected. The papules are not grouped. Pruritus is intense, so that excoriations and torn pap- ules are present over all the affected parts. The patients have a pale, weary expression of countenance, and evi- dently are in poor condition. The skin is often dry and it may be scaly. When the lesions are but few in number and scattered about upon the extremities we have prurigo mitis. When a great number of papules are present, and the disease is widespread, we have prurigo ferox. Now we have the typical form of the disease such as is shown in the Vienna skin clinics. We note that the skin feels rough; that it is strewed over with a great number of small papules which have the color of the skin or are pale red; defaced with scratch-marks; eczematous in places; darkly pigmented, it may be brown, from the constant irritation of scratch- ing, and that the color of the general integument is in strong contrast with the pale color of the face; that the skin is thickened in some places, while the flexures of the joints are free from change and as soft as normal; that these changes in the skin are progressively worse from above downward, so that the legs from the knees down are most markedly involved ; and that the inguinal glands are enlarged so as to form buboes. Ecthymatous lesions may arise. The intensity of the itching may be so great as to prevent sleep, and even in some cases to drive the patient insane. The duration of the disease is indefinite; it may last a lifetime, but often tends to disappear with advancing years. The type of the disease remains the same through- out — that is, prurigo mitis does not change to prurigo ferox. Etiology. — Prurigo affects both sexes, though it is more prevalent in the male sex. It is far more common among the poor, especially Europeans, and those who are uncleanly. It is not very common in this country, especially in the ferox type. It is not uncommon to find 536 DISEASES OF THE SKIN several members of the same family with the disease. A phthisical family history has been affirmed to be an etiological factor by some authorities. Some cases are better in winter and some in summer. It is a disease of infancy continuing through life. It seems to be related to urticaria. A neurosis probably is the under- lying cause of the disease. Pathology. — The prurigo nodule is caused by an interstitial edema of the rete, with the eventual formation of vesicles. The papilla? are likewise edematous, and show perivascular infiltration. The early lesions much resemble urticarial papules. Diagnosis. — The diagnosis is made by the occurrence of pale papules upon the extensor aspects of the limbs; by the increasing severity of the symptoms from above downward; by the enlargement of the inguinal glands, by the peculiar look and complexion of the patient, and by the continuance of the disease from early infancy. It is differentiated from eczema by the sparing of the flexures of the joints; by the presence of the characteristic pap- ules, and by its greater obstinancy to treatment. From papular urticaria it can be distinguished only by its general course. In fact, a doubtful case must be carefully studied over a considerable length of time before a posi- tive diagnosis can be made. Scabies and pediculosis can be readily separated by the occurrence of the lesions on the palms, between the fingers, and on the genitals in the one; and the parallel scratch marks over the shoulders in the other. Ichthyosis spares the flexures as does prurigo, but it is marked by polygonal scales, not papules; and is free from the great number of excoriations found in prurigo; it is, moreover, a disease that affects the whole body-surface more generally. Treatment. — The disease is exceedingly obstinate to treatment. The patient must be put in as good physical condition as possible by means of hygiene, cod-liver oil, iron, and a good diet. Tincture of cannabis indica is commended by Crocker for relief of the itching, in doses PRURIGO 537 of 5 minims (0.308) increased to 30 minims (1.84) to a ten- year-old child, given three times a day directly after meals, and intermitted for two weeks after every six weeks. These seem to me to be large doses. Simon 1 and others recommended pilocarpin hypodermically, 15 minims (1 ) of a 2 per cent, solution once a day, for adults, or a corre- sponding quantity of jaborandi by the mouth. After the dose the patient is to be put in bed and covered with woollen blankets, where he is allowed to sweat for two or three hours. Carbolic acid, 5 to 10 (0.33-0.66) grains a day in pill, and the bromide of potassium have their advocates. Antipyrin and phenacetin exert a controlling influence over pruritus, and they are among the most valuable internal remedies in prurigo. The latter, though not so active as the former, should be tried first in full doses, as it is much safer. Thyroid extract has been recommended. External treatment is very important. Naphtol is most highly commended, a 2 to 5 per cent, solution, according to age, being rubbed in every night, and a bath of naphthol-sulphur soap being taken every second night. In older children and adults the soap treatment of Hebra, as described in the section on Eczema, is useful. Sulphur ointment used as in scabies after a daily bath; tar used as in psoriasis; a 5 or 10 per cent, lotion of carbolic or salicylic acid, or the same combined with vaselin; a 5 per cent, boric acid ointment, all have their advocates and all may be tried in obstinate cases. Baths followed by inunctions of cod-liver oil, simple oil, tar oil, or lard, are often useful; as well as baths of alum, soda, and corrosive sublimate. Jacquet and Tenneson report great amelioration from wrapping the affected parts in some protective dressing, such as rubber sheeting or absorbent cotton. The spinal douche might do good in some cases. Treatment should be continued for weeks or months after apparent cure of the disease. 1 Berlin, klin. Wochenschr., 1879, xvi, 721. 538 DISEASES OF THE SKIN The prognosis as to cure is bad, excepting in recent and not severe cases. These may be cured. As a rule, all we can do is to mitigate the patient's discomfort. Relapses are the rule. A few young patients become well as they reach full maturity. Pruritus Cutaneous. — Symptoms. — By pruritus cutaneus we mean a functional neurosis of the skin whose only essential symptom is itching. This induces scratching, and scratch-marks are always to be found as a secondary symptom. These usually are in the form of scratched papules. If the itching is great and continuous, we will have other secondary effects, such as thickening and pigmentation of the skin, and eczema of various degrees. The itching varies greatly in degree, from simply an occasional slight attack to such an intensity as to render the patient's life unendurable and tempt to suicide. The pruritus is commonly paroxysmal, but in some cases the pauses between the paroxysms are so short that the itch- ing is practically continuous. It is almost always worse at night, and robs the sufferer of sleep. Changes of temperature aggravate the itching, as a rule. Very com- monly warmth makes matters worse, and the sufferer will begin to scratch and keep on scratching while in the neighborhood of a fire or in bed warmly covered. He cannot resist the impulse to scratch, and so in bad cases he shuns society and becomes morbid. Under the general title of pruritus are often placed various paresthesias, such as formication, tingling, and burning. The pruritus may be general or local. Thus we have pruritus universalis, a term that can seldom be applied with strict accuracy, as pruritus is rarely universal. In these cases the itching is now in one place and now in another. Bulkley, 1 by a series of observa- tions on himself, strove to establish some law of reflex excitation, in which he was so far successful as to find 1 Jour. Cutan. and Gen.-Urin. Dis., 1887, v, 459. PRURITUS CUTANEOUS 539 that if he scratched one spot that itched, he relieved the sensation there, only to have it break out elsewhere. This general pruritus is most often encountered in pruri- tus senilis, or the itching of the skin of old people, and in pruritus hiemalis and pruritus estivalis, which are induced respectively by the cold of winter or the heat of summer. These very often manifest themselves on the thighs and legs only. Bath pruritus is that form of itching which comes on after taking a bath, and lasts a variable time. Stelwagon has found that if the clothes are put on at once, the itching lasts for a shorter time than if the patient goes to bed. Of local pruritus we have many instances. Thus we have pruritus ani, which afflicts both sexes, though more often men than women, and in which the itching extends to the mucous membrane of the anus. The parts are often sodden looking and emit a disagreeable odor. This same extension is also seen in pruritus vufoce. This localized itching, with the corresponding pruritus scroti in men, often occurs in connection with pruritus ani. In all these three the parts almost always become thick- ened and eczematous from the constant rubbing and scratching to which they are subjected, and nympho- mania is sometimes a consequence of the itching vulva. The scalp, face, especially about the nose and mouth; the palms and soles, and between the fingers and toes, are frequent sites of itching. More rarely local areas any- where w T ill be affected with recurring attacks of itching. Etiology. — That the pruritus is due to a functional disturbance of the sensory nerves there is no doubt. Ac- cording to Bronson 1 it is due to a disturbance of the sense of contact. Those with naturally dry skin are more apt to suffer than those whose skin is moist. For success in treatment and accuracy in prognosis it is necessary for us to endeavor to determine the cause of such disturb- ance. The contact of wool irritates some skins. Hepatic 1 Med. News, April 18, 1903. 540 DISEASES OF THE SKIN derangements cause a certain proportion of cases. The intense itching of the skin in jaundice is evidence of this. Digestive disorders and constipation; excretory dis- orders, as of the kidneys and skin; albuminuria; lithemia; and diabetes, all have influence in causing pruritus. Depressed mental states, and the disorders of the nervous system induced by the abuse of tobacco, tea, alcohol, opium, and the like, produce pruritus. In tabes, pruritus often alternates with gastric crises. Pruritus is not infrequently met with during the menopause. Reflex influences from the sexual sphere and the power of imagination are responsible for some cases. In illus- tration of the latter, everyone knows how many people will begin to scratch when the subject of lice is mentioned; and how that long after the acarus is killed in scabies the patient will continue to complain of itching, and will not be assured that he is cured of his disease. In pruritus senilis the skin will be found to be atro- phied and the fatty tissue underlying it absorbed, in not a few cases. Pruritus ani is often due to hemorrhoids or fissures of the mucous membrane; or to ascarides; or to the excessive use of tobacco, as well as to the causes enumerated above. Stricture of the urethra has been found to be the cause of both it and pruritus scroti. Pruritus vulvae is very often due to leucorrhea, preg- nancy or tumors of the uterus or ovaries, or occurs during the menopause. In this form diabetes is quite commonly the cause. Pruritus hiemalis begins at any time from October to January, and continues until the spring is well advanced. The effect of cold upon the skin seems to check the secretory functions. Bulkley has found pruritus to be more common in men than women, fifty of his eighty cases being men. In some families an itching skin seems to be hereditary. Diagnosis. — If we bear in mind that pruritus has no lesion of its own; and if, whenever a patient complains of itching of the skin, we institute a search for the pedic- ulus, or the itch-mite, or their lesions; or the wheal, or PRURITUS CUTANEOUS 541 at least a history of it; and find none, then Ave have by elimination gone far toward establishing a diagnosis of pruritus. Sometimes it is difficult to determine whether an eczema is secondary to the scratching for the relief of itching, or the itching is a part of the eczema. Only an attempt at curing the eczema and long observation of the case will enable us to make a true diagnosis. Many errors in diagnosis will be avoided by close study, as true pruri- tus is not so common as other itching diseases. Treatment. — To find and remove the cause is the first essential in treating a case. How difficult this task may be will be seen by a study of its etiology. Nevertheless, the patient must be considered, and every organ interro- gated, and every deranged function regulated as far as possible. Tea, coffee, alcohol, and tobacco should be interdicted; a dietary carefully laid down; and the rules of hygiene, such as those relating to exercise, bathing, and clothing, enforced. To relieve the itching as such we may give the tincture of cannabis indica, 10 minims (0.616) three times a day, in water after meals and gradu- ally increase the dose up to 20 (1.23) or 30 minims (1.84); or the tincture of gelsemium in 10-minim (0.616) doses every half -hour till 1 dram (3.7) is taken or toxic effects produced; hypodermic injections of pilocarpin y ¥ to -§- of a grain; quinin, 10 (0.66) to 15 grains (1) at bedtime; carbolic acid, 1 to 2 minims three times a day and increased; wine of antimony, 5 to 7 drops after meals; salicylate of soda, 15 grains (1), or antipyrin or phenacetin in full doses. Besnier recommends valerian, or valerianate of ammo- nium. But the relief so obtained is transitory, and we should not rest content until we have found out, and where possible removed, the internal underlying cause. Opium should never be given, as it causes pruritus. Linser 1 had marked success from using serum injections, giving 10 to 20 c.c. daily for five successive days. He directs that 50 c.c. of blood be drawn in a sterile centrif- 1 Dermat. Woch., 1912, liv, 365. 542 DISEASES OF THE SKIN ugal glass. This is defibr mated by shaking for five minutes with glass pearls. It is then put in the electric centrifugal machine. The serum is used after allowing it to stand for half an hour. The external treatment is of great service in alleviating the itching, even if it does not cure the disease. For this purpose general baths with soda (§ viij to x to 30 gallons), or nitric or hydrochloric acid (gj to 30 gallons), may be used. After the bath the body is to be dried by wrapping in a warmed sheet and patting the skin dry; then the skin should be smeared with vaselin and powdered with corn-starch from a flour-dredger. For local pruritus we may use lotions, of which one of the most efficient is: 1$ — Acid, carbol., 5j-ij 4-8 1 Liq. potassae, 3j 4 01. lini, ad 5j 32 | M. Sig. — Shake before using (Bronson) . The patient should be cautioned to tap the itching point gently with this, and not rub it in. So used, it will cause no damage and may stop the itching for hours. Carbolic acid may be used as a spray in the strength of J an ounce (16) to the pint (500) of water with 1 ounce (32) of glycerin. To this 5 to 20 minims of oil of peppermint may be added (Hardaway). Stelwagon recommends for general use: 1$ — Ac. Carbolici, Glycerini, Alcohol, Aquae, 3j-iij 4-12 5ij 8 Sj 32 aa, ad Oj 500 M. Alkaline lotions, as bicarbonate of soda, 5j (4) to the cupful of water; or acid lotions, such as vinegar dabbed on the itching spot, will often relieve. Liquor carbonis deter gens 5j to §iv (4 to 120) or fy— Thymol, Liq. pqtassse, Glycerin, Aquae, 3ij 8 3J 4 3iij 12 Sviij 250 M. Liquor picis alkalinus, 3j to 5iv (4 to 120); or yerchloride of mercury, gr. J to 3 to gj of water, or resorcin, 3 to 10 PRURITUS CUTANEOUS 543 grains (0.2 to 0.65) to the ounce (32). All these are well attested as useful. Peroxide of hydrogen is highly com- mended by Bronson. It may be used as a toilet wash two or three times a day. For pruritus ani, scroti, et vulvae sitting over a basin or pail of very hot water and sopping it up on the parts followed by patting the skin dry and using a starch powder, will often give the patient a quiet night. Con- stipation, if present, must be relieved. If an eczema is present, that must first be cured. Cocain lotions, as one of 20 per cent, of cocain and 5 per cent, of glycerin; or menthol 3 to 10 per cent, in oil of sweet almonds, or of glycerin and water; and carbolic acid lotions are also useful, as well as the ointment of the ammoniate or nitrate of mercury. Schafer 1 says that bromotan, 10 per cent, in equal parts of lanolin and vaselin applied on a bandage two or three times a day cures quickly. Cocain had best be left alone, as there is always danger of form- ing the cocain-habit from the use of this seductive drug. Bulkley's antipruritic powder, of 1 dram (4) each of camphor and chloral rubbed together till liquefied, and added to 1 ounce (32) of starch powder, will sometimes prove very effective. The parts may be painted with nitrate of silver, gr. 15 (1) in spts. setheris nitrosi § j, (32) or with 15 per cent, solution of caustic potash. A saturated solution of boric acid is also good. When the parts are excoriated neither menthol, peppermint, nor the chloral- camphor powder can be used. Guaiacol 5 or 10 per cent, with starch powder, is one of the newer remedies. Sup- positories containing belladonna, cocain, or creosote may give relief in these cases. Of course, hemorrhoids, fissures, or other rectal diseases must be cured if found. The high frequency current, the x-rays or the Kromayer lamp may be used with great benefit. W. M. Banks 2 recom- mends in pruritus ani the use of the large bulbous-headed point of the Paquelin cautery, so as to frizzle the skin 1 Frauenartz, 1906, xxi, 2. 2 British Med. Jour., 1900, i, 561. 544 DISEASES OF THE SKIN for an inch and a half about the anal orifice. If there are rugous folds a smaller cautery should be used. In pruritus hiemalis it is sometimes necessary for the patient to wear linen underclothing next the skin; and over it the woollens usually worn. Other patients find more relief from wearing silk underclothing. Anti- pruritic lotions should be prescribed and a dusting powder so freely used that the meshes of the underclothing are filled with it. The treatment indicated above for pru- ritus is applicable here also. In some cases the only relief is found in removal to a warmer climate. In pru- ritus senilis great relief is often obtained by simply keeping the parts well greased with eucerin or cocoa butter. In some obstinate cases of general pruritus great ame- lioration may be obtained by the actual or Paquelin cautery applied lightly along the spine. The same means has sometimes been successful in localized pruritus, as of the vulva or scrotum, but now the parts themselves are touched with the cautery. Spinal douches are highly thought of by some French authorities. In these chronic cases it must be remembered that a cure can be effected with difficulty as long as the patient is exposed to the wear and tear of his life. Many nervous patients are well when travelling or living out-doors. Prognosis. — The prognosis is doubtful. Some cases are very obstinate, and some are incurable. Happily, thorough study of the case will be rewarded in most instances by a cure. Pseudo-erysipelas. — By this term is meant cellulitis or diffused phlegmon. Pseudoleukemia Cutis is a very rare disease. It is a form of Hodgkin's disease. A case is reported by Joseph 1 as occurring in a man in previous good health. It com- menced as a number of small glandular swellings in the neck. Shortly after their appearance severe general 1 Deutsche med. Wochenschr., 1889, p. 946. PSORIASIS 545 pruritus began to aft'ect the patient. Then the inguinal and axillary glands became greatly enlarged, and a general eruption of hemp-seed-sized papules occurred. These were more easily felt than seen, and were of a pale-red color. The epidermis over them was unchanged. Wheals also appeared that changed into papules. The skin between the papules was dark-colored, thickened, and dry. The case ran a chronic course, marked by relapses. Psoriasis. — Synonyms: Lepra Grecorum ; Lepra alphos; Alphos; Psora; (Ger.) Schuppenflechte. A disease of the skin characterized by an eruption of round or ova l, bright-red patches covered with more o± less thick, sil very- white T adherent sca les; by occurring especially upon the extensor surf aces oftKe elbows, knees , and extremities, and upon the^ calp; by running a chroj iic course marked by remissions and relapses; and by being more or less pruritic. This is one of the more common skin diseases forming in this country about 3 per cent, of all cases. Symptoms. — Its features of variously sized, sharply defined red papules or patches covered with more or less abundant silvery-white scales that occur especially upon the extensor surfaces of the elbows and knees, are so pronounced that the disease once seen is readily recog- nized even by the tyro. The primary lesion of psoriasis is always a pinkish or bright-red, pinhead-sized papule covered with a dry sil very- white or grayish scale. It is rare to meet with a case in which these small lesions are seen alone, and when it is, it is called psoriasis punctata. Careful search of any but an inveterate case will be rewarded by finding these lesions somewhere on the body. They soon begin to enlarge by peripheral extension into larger patches, which have received various names, although preserving the same, essential characteristics. When they attain the diameter of about one-quarter of an inch, and bear a 85 546 DISEASES OF THE SKIN rather thick scale, they look like drops of mortar, and the case is then spoken of as psoriasis guttata. When the lesions form coin-sized patches we speak of psoriasis nummularis. A single patch may grow to be two inches in diameter, or even larger, and preserve its circular Fig. 79 Psoriasis. (From Prof. G. H. Fox's service in the Vanderbilt Clinic.) shape. But the large patches are usually formed by the coalescence of several smaller patches, and may attain to a size sufficient to cover the greater part of a limb or even the trunk. Its circular outline is now lost, and the patch has a more or less scalloped, indented border bearing so strong a resemblance to the maps drawn by PSORIASIS 547 children that Piffard suggested the term psoriasis geo- graphica for it; but the more usual name is psoriasis diffusa. After a patch has reached a certain size it may clear up in the centre and form a ring, and in this way we have psoriasis circinata. Several of these rings may Fig. 80. Psoriasis. (From Prof. G. H. Fox's service in the Vanderbilt Clinic.) meet at their circumference, when the points of contact will disappear and gyrate figures will be formed. When the eruption is so general as to involve the whole or greater part of the body, we speak of it as psoriasis universalis. Not infrequently these cases bear a striking resemblance to dermatitis exfoliativa. 548 DISEASES OF THE SKIN Every case of psoriasis does not exhibit all these varie- ties, because the disease may stop at any period of its evolution. But in any case there is apt to be a number of variously sized lesions. Whatever the size of the patch may be, it will always be observed that the redness extends but little beyond the scales. The amount of the scaling will vary. Sometimes the scaling will be but slight; sometimes it will be so abundant that it will heap up into such crust-like masses as to suggest the adjective rupioide. The scales are constantly being shed, and as constantly renewed. They may be readily scraped off with the nail; and if this is carefully done, a delicate glistening membrane will be exposed, under which will appear dot-like red points. That is, we have removed the epidermis and exposed the mucous layer of the skin, the red points being the tops of the slings of bloodvessels of the papillae. This is thought by some to be character- istic of psoriasis, but with care it may be produced in other diseases. The color of the scales is silvery white or grayish. Darker scales are due either to the deposition of dust or the admixture of blood. The color of the patch will vary from a pinkish red to a dark red, the darker color being seen upon the legs, where the color of all lesions is darker on account of the partial stasis in the return flow of blood. The disease is always a dry one, there being absolutely no discharge feature in its course. The patches are sharply defined, but so little raised that they can be nearly all scratched away. While psoriasis may occur anywhere on the body, and, as we have seen, may become universal, its most fre- quent locations are the extensor surfaces of the limbs, elbows, and knees, or rather the face of the tibia just below the knee, and the scalp. It may occur upon the first two locations alone. When it occurs upon the scalp careful examination will generally show some lesion elsewhere on the body, and we will usually find a little patch in front of the ears, and very often there PSORIASIS 549 will be a red scaly line on the forehead just in front of the hair-line, a feature that is as striking and as char- acteristic of psoriasis as the corona veneris is of syphilis. The hair does not fall, as a rule. In some cases, how- ever, we may have transient or permanent alopecia. The whole scalp may be covered with a continuous patch, or distinct scaly patches may form as on the body. In any event the border of the patch will be sharply defined. It is very rare to find psoriasis on the mucous membrane of the mouth. M. Oppenheim 1 has seen one case developing there in connection with marked psoriasis of the rest of the body. It appeared in the form of bluish-white, sharply defined, oval, raised patches of various sizes. The palms and soles are very rarely the seat of the dis- ease, and then only as part of general psoriasis. It is true that a few cases have been reported in which it has been said to have been located upon one hand alone, and this by competent observers; but all the probabilities are in favor of such cases having been either syphilis, which is most likely, or squamous eczema. The disease is bilateral, and sometimes may show a decided tendency to symmetry. In old, inveterate cases there may be considerable thick- ening of the skin, a feature that is usually wanting, and fissures may form about the joints that may be painful and bleed. This may also occur on the scrotum, or on the trunk where the skin is in folds. The nails are affected in some cases, becoming opaque, lusterless, furrowed transversely, discolored, and some- times cracked; while they are raised from their beds by the accumulation of scales underneath them. All the nails are rarely diseased at the same time; usually it is but one or two nails on each hand or foot. Sometimes the disease is limited to a strip along the side of one nail. There is no constitutional disturbance in this disease, 1 Monatshefte f. prakt. Dermat., 1903, xxxvii, 489. 550 DISEASES OF THE SKIN the patients usually being in as good health as the majority of people. Sometimes they have pains in the joints Fig. 81 Fig. 82 Psoriasis of the hands. (By the courtesy of Dr. S. I. Rainforth.) that are regarded as rheumatic by some, and as neurotic by others. Itching is very often an annoying symptom. Sometimes it is entirely wanting. PSORIASIS 551 The course of the disease is variable. Although it is always chronic, it presents at times acute symptoms. Relapses are the rule, to which there are few exceptions. In some cases the skin will be entirely free from all trace of the disease for months or years. In most cases this freedom is only partial; even though the patient thinks he is clean, some little spot will be discoverable. The dura- tion of each patch is also variable. It may disappear in a few weeks or remain for months. Most cases are better Fig. 83 Psoriasis of the sole. (By the courtesy of Dr. S. Dana Hubbard.) in summer, to become worse in winter. When the patches disappear, they do so completely, though a slight amount of scaling may be present for a short time. Lederman 1 has seen leucoderma follow the disappearance of the lesions. In a few very rare cases a chronic psoriatic patch has become papillomatous and then epitheliomatous. Etiology. — Various theories have been advanced in the etiology of psoriasis, and some facts have been estab- lished by our study. We know that the disease is heredi- 1 Archiv f. Dermat. u. syph., 1907, lxxxiv, 359. 552 DISEASES OF THE SKIN tary in a number of cases. Greenough 1 found the pro- portion as high as one-third. It may occur at any age. Kaposi has reported a case at eight months of age, and Riehl 2 one at thirty-eight days. Whitfield has had one case three weeks old. It usually is a disease of early adult life, making its first appearance before the thirtieth year. A primary attack is rare after the fiftieth year. It affects both sexes and all conditions of life. These things we know. While the majority of patients seem to be in the best of health, some are rheumatic or gouty. In some cases there will be an unusual amount of indican in the urine. A lowered condition of the general health seems, in some cases, to favor an outbreak either of a primary attack or of a relapse. Thus, it is no uncommon thing to see the disease in women growing worse during pregnancy or lactation. Malassimilation or digestive disorders also seem to aggra- vate or provoke the disease, Hardaway even affirming that he has known the inordinate eating of oatmeal to cause the disease, while Gowers 8 reports cases produced by the ingestion of borax as a medicine. Hyde is inclined to believe that as the disease occurs most upon covered parts, deprivation of the skin from contact with the sun's rays, may be one cause of it. Polotebnoff 4 has written an elaborate thesis to show that the disease is a vasomotor neurosis, affirming that in a majority of cases there will be found evidences of either trophic or vasomotor disturb- ances, or a history of more or less profound nervous troubles either in the patient or his family. A number of cases following fright or nerve-shock have been re- ported. In the Vierteljahr. f. Derm. u. Syph., for 1878, Lang brought out his parasitic theory, and in No. 208 of Volkmann's Sammlung klin. Vortrdge the thesis is further elaborated, the fungus being represented by illustrations. 1 Boston Med. and Surg. Jour., 1885, cxiii, 163. 2 Monatshefte f. prakt. Dermat., 1895, xxi, 283. 3 Lancet, October 24, 1884. 4 Monatshefte f. prakt. Dermat., 1891, Erganzungsheft, No. 1. PSORIASIS 553 lie has found some support from other observers, but the parasite he described has not been accepted as the cause of the disease. Destot produced the disease in a man by inserting a piece of psoriatic skin into a freshly scarified place. This was followed by an eruption of psoriasis which ran the usual course with four relapses in two years. 1 Crocker accepts the parasitic theory, and accounts for the wide distribution of the disease by assuming that the parasite gains entrance into the blood from the point of inoculation, and through the circulation affects the general skin. It is a well-known fact that an injury to the skin of a psoriatic, such as a pin-scratch, will determine the loca- tion of a patch of psoriasis. Pathology. — Pathologists by no means agree in their teachings as to the histology of psoriasis. By some it is regarded as inflammatory, while others believe it to be a keratolysis, or an anomaly of cornification in which an imperfect corneous layer is formed. Some teach that the process begins in the rete, and the changes in the corium are secondary; while others hold the reverse view. Lang names his parasite epidermidopliyton, and describes it as composed of mycelia and spores, either disseminated or in groups, which are so delicate as to be seen only with very high powers. Histologically there appears to be a hyperplasis of the rete, except directly over the papillae, which latter are enlarged and more vascular than normal. The epi- dermis seems composed of only two layers, the thickened rete, and the parakeratotic corneous layer, the lamellated loosely coherent strata of which still retain their nuclei. There are serous cellular infiltrations in the upper corium, especially about the hair follicles, sebaceous glands, and enlarged bloodvessels. Diagnosis. — A typical case of psoriasis presenting round or oval, variously sized, pinkish-red, dry patches 1 Hallopeau: Ann. de derm, et syph., 1901, ii, 337. 554 DISEASES OF THE SKIN covered with thick silvery-white scales, scattered more or less generally over the body, but showing a marked preference for the extensor surfaces of the extremities, and especially of the elbows and knees, is readily recog- nized. In some less typical cases it needs to be differ- entiated from syphilis, eczema, dermatitis exfoliativa, lichen ruber, and lichen planus, seborrheal dermatitis, and possibly from lupus erythematosus. From the papulosquamous syphilide of the secondary stage of the disease it differs by showing preference for the extensor surfaces of the limbs and the posterior surface of the trunk, though there are many exceptions to this rule. The syphilide is not so scaly; its red is darker, more raw-ham colored; the lesions are more infiltrated, giving a more shotty feeling to the ringer; they do not itch; they run a more acute course, and are of more uniform size, never exhibiting the patchy character of psoriasis. It is usually easy to establish the presence of other mani- festations of syphilis, such as sore throat, pains in the bones, fall of the hair, and perhaps the remains of the initial lesion. The later scaly syphilide is never general; is unsymmetrical, usually consisting of one or two groups of lesions that show no tendency to affect the elbows and knees. The lesions are more raised and prone to leave scars. There will also be the history of past syphilides to guide us, and an absence of those relapses so common and characteristic of psoriasis. The Wasserman test if positive will decide in favor of syphilis. Eczema squamosum is far more pruritic than psoriasis usually is; the patch is more infiltrated; the scaling is less, the scales being thinner; exudation can be readily induced; and a history of moisture at some time will be found. The patch of eczema is generally less sharply defined, and is more apt to shade off into the surrounding skin. If the scales of a psoriatic patch are removed, a delicate membrane is left showing red dots — the tops of the bloodvessel slings in the papillae; if the same thing is done in eczema a discharging surface will be left. PSORIASIS 555 It is quite impossible to differentiate a true case of der- matitis exfoliativa at first sight from one of general pso- riasis. If it does arise from psoriasis, there will be a history of its gradual spread from typical lesions, quite different from what obtains in true dermatitis exfoliativa, which is more rapid in its evolution. Psoriasis is rarely so absolutely universal as is dermatitis exfoliativa. Watching the case for a time will establish the diagnosis. If psoriasis is the malady, it will declare itself after a time by the diffused redness clearing up and typical psoriatic patches showing themselves. Lichen ruber presents small, pointed papules upon the trunk at first, and not the large scaling papules upon the extensor surfaces of the limbs as in psoriasis. When the disease becomes general we will have the history of those lesions, and the skin will be more thickened and rugose. Lichen planus occurs by preference on the flexor rather then the extensor aspects of the limbs, and in the form of flat, shining, angular, smooth papules, rather than of round, freely scaly ones. The color of its patches is violaceous and not bright red. If it becomes universal, it does so evidently by the springing up of new small lesions between the old ones, and not by the peripheral growth and coalescence of those already existing. The thickening of the skin is also much greater than in psoriasis. In the diagnosis from seborrheal dermatitis Unna lays great stress upon four points: (1) Seborrheal dermatitis spreads from above downward, mostly in the middle line of the body, and its lesions are quite stationary in char- acter; while psoriasis begins on the elbows and knees, and more speedily affects the whole body. (2) There is always a history of a seborrheal affection of the scalp in seborrheal dermatitis. (3) The scales of seborrheal dermatitis are fatty and crumbling, and the patches are yellowish; in psoriasis the scales are white and friable, not greasy, and the patches are bright red. (4) The proneness of the patches of seborrheal dermatitis to form 556 DISEASES OF THE SKIN bow-shaped figures, or rings more or less broken. Psori- asis may be circinate, but the margins of the figures are not so narrow and not follicular as they may be in seborrheal dermatitis. Treatment. — Though external treatment alone will often remove the evidences of psoriasis from the skin, producing a cure of the disease — if that may be said of a disease that is almost sure to relapse — we generally can procure more prompt results by a combination of internal and external remedies. The first inquiry in all cases should be made as to the general condition of the patient, and we should endeavor to establish in him as perfect a state of health as is possible. A restricted diet certainly does have a good deal of influence in causing an amelio- ration of the disease, and most authorities forbid the use of red meats. No hard-and-fast lines can be set in this respect. In the service of Prof. George Henry Fox, who is a strong advocate of dieting in skin diseases, we have seen some patients improve under a strictly vegetable diet, and others do equally well on a dietary composed largely of milk and animal food. A stout, evidently overfed, plethoric patient will be benefited by abstaining form all, or nearly all, meat. In this class of patients it is a good plan to insist upon a milk diet for a few days. An ane- mic, underfed patient will, on the other hand, improve under a more liberal dietary. Alcoholics, and especially malt liquors, should be interdicted in all cases, as well as rich gravies and highly spiced foods. Besides these general measures we have a number of drugs that have gained a more or less well-earned reputa- tion as remedies for psoriasis, though it must be con- fessed that they are more or less empirical remedies. Arsenic would be named, without doubt, by most gen- eral practitioners as the remedy for psoriasis. It does do good in this disease, but at the same time it is not to be considered as a true specific. In acute cases it aggravates the disease and should never be given. In chronic cases that have proved very stubborn it may be tried, and some- PSORIASIS 557 times it will produce a speedy cure. When the disease begins to disappear, it will hasten its disappearance. The vast majority of cases will do quite as well without it. It may be given in the form of Fowler's solution with or without the wine of iron, and administered in water three times a day after meals. The initial dose for an adult should be about 3 drops, and the amount should be grad- ually increased until the limit of toleration is reached. Crocker thinks that the efficiency of this form of arsenic is enhanced by the addition of \ a dram (2) of the tincture of lupulus to each dose. The Asiatic pill is the favorite mode of using arsenic in Vienna. It is composed, accord- ing to Kaposi, of — — Pulv. ac. arsenosi, gr. xj 75 Pulv. piperis nigrae, 3iss 6 Gummi acaciae, gr. xxij 1 50 Pulv. althse. rad., gr. xxx 2 Aqua?, q. s., q- s. M Div. in pil. No. c . One pill is given after meals, and the dose is increased gradually every four of five days until 10 or 12 are taken each day, unless some constitutional disturbance is caused. The method of increase is by first giving 1 pill after each meal; then 2 pills after breakfast, and 1 after the other two meals; and then 2 after breakfast, 2 after the midday meal, and 1 in the evening, and so on. Or, we may make use of the tablet triturates of arsenous acid with piperina, giving those containing -$-$ of a grain of the arsenic in the same manner as with Asiatic pills. Any other preparation of arsenic may be used. Hypodermic injections of arsenic or the cacodylate of sodium have been employed with success, but it would be hard to induce an American patient to endure this method. Stel- wagon reports occasional success from using in this way sterilized Fowler's solution with f grain of carbolic acid to 5 minims of Fowler's solution. He begins with 3 minims of the mixture diluted with 4 or 5 parts of water, once a day. The administration of the drug must be persisted in for a long time, and it may prove curative 558 DISEASES OF THE SKIN by itself. It is best not to continue its use for more than three or four months, as it is apt to produce permanent and general pigmentation of the skin and keratosis. Alkalies that act as diuretics are often very helpful, quite apart from any indication for their use on account of gout or rheumatism. A beginning psoriasis, or even a case of some duration, will be favorably influenced by the administration of the acetate or citrate of potassium in 15-grain (1) doses before meals, well diluted, and followed by drinking J a glass of water. The undoubted efficacy of large doses of the iodide of potassium, as recommended by Haslund, 1 may depend, in part at least, upon its diuretic action. He gives the salt in increasing doses, so that as much as 600 grains have been administered to one patient during the day. When assistant phy- sician to the New York Skin and Cancer Hospital, in Dr. G. H. Fox's division, I tried Haslund's plan in several cases. They certainly were greatly benefited. The objections to this method are the expense of the drug and the danger of the sudden production of poisoning, shown by palpitation of the heart, severe headache, and faintness, necessitating either the keeping of the patient in a hospital or under the constant attendance of a physician. Turpentine oil is highly commended by Crocker as follows: It may be given in capsule, or, preferably, as an emulsion rubbed up with mucilage of acacia. The initial dose is 10 minims three times a day after meals. It may be increased by 5 or 10 minims at a dose until the patient, if tolerant of it, is taking 30 minims three times a day. Barley-water must be freely drunk during the day to prevent any bad effect on the kidneys, and the last dose of the turpentine should be taken not later than six or seven o'clock in the evening. Dyspepsia and irritability of the urinary organs contraindicate its use. The same authority advocates the use of salicylate of soda in 15- 1 Vierteljahr, f. Derm. u. Syph., 1887, xiv, 677. PSORIASIS 559 grain (1) doses three times a day after meals, or salicin in dosage of 15 grains (1) three times a day, increased to 20 grains (1.33). Dilute lactic acid, 10 (0.66) to 30 (2) drops well diluted may be given before meals. The Bulgarian lactic acid cultures or tablets may be used, and seem to have some virtue. The wine of antimony in 5 to 10 minim (0.33 to 0.66) doses is recommended by Sir Malcolm Morris as efficacious in acute cases. Hyde speaks well of the protiodide of mercury, -J- grain three times a day. Chrysarobin by the mouth, { of a grain in sugar of milk three times a day, and increased to 1 or 2 grains at a dose, acts well in some cases, but is very apt to cause so much nausea and vomiting as to compel its discontinuance. Carbolic acid in drop doses t.i.d. after meals, gradually increased, certainly is helpful in some cases. It may be exhibited in glycerin and peppermint water and is well borne. It may be given up to 20 grains (1.33) a day. It cannot be given to those who have any renal disease. PolotebnofT, believing the disease to be a neurosis, advocates the use of bromide of potassium and of ergot. As most patients are worse in winter than they are in summer, when the skin is more moist from active perspiration, a residence in a mild climate might well be commended to a chronic psoriatic. External treatment. — Before making any application to the psoriatic skin the scales must be removed by bathing with soap and water, or by warm alkaline baths. Some- times bathing followed by inunctions of the skin with simple oil, or vaselin, combined with attention to diet, will produce a cure. These measures should be tried first in all beginning cases. In some cases there will be well- marked eczematous conditions. Then we must use remedies applicable to that disease. Generally we must resort to more stimulating remedies. The most useful and most promptly curative external remedy is chrysarobin (chrysophanic acid). The objections to it are its tendency 500 DISEASES OF THE SKIN to produce an acute dermatitis and its permanent staining of everything with which it comes in contact. These unpleasant effects may be in part overcome by combining the drug with flexible collodion or traumaticin, but only in part. The dermatitis is always most marked upon those parts in which there is laxity of the skin, and if it is used on the face it is prone to produce great swelling about the eyes. Care must be taken not to get it in the eyes, as it causes violent conjunctivitis. These effects should make us very cautious about using it on the scalp, and prevent its use on the face. The most active form in which to use the drug is in an ointment, as of lard, lanolin, or vaselin. Gelanthum and plasment are excipients that have the merit of not being greasy, and of being readily and entirely removed by means of water. Flexible collodion and traumaticin (liquid gutta-percha) are good excipients. The drug may be rubbed up with water into a paste and applied to the spots and then covered with a piece of oxide of zinc plaster. This is a neat way of using it where there are but few patches. The strength of chrysarobin should not exceed 1 dram (4) to the ounce (32), as a rule; though in exceptional cases it may be used in greater strength. Its activity is increased by the addition of salicylic acid (3 per cent.), and then it is best to use it in a lower percentage, even 5 per cent, being active enough. An alkaline bath before using the chrysarobin increases its potency. If we use an ointment, it should be thoroughly rubbed in once a day after the scales are removed. If the vehicle is gelanthum, plasment, collodion, or gutta-percha solution, the spots should be painted over as often as the film left by the application falls. The patient should always be warned against getting the drug in the eyes. A favorite formula of Dr. George H. Fox is the following: 1$ — Chrysarobin, Ol. cadini, aa 2 parts. Ac. carbolici, 1 part. Ac. oleic, 50 parts. M. PSORIASIS 561 The combination recommended by Dreuw has shown itself in my hands the best way of using this drug. I use a modification of his formula as follows : 1$ — Ac. salicylici, 3iiss 10 Chrysarobin, Ol. rusci, aa 5v 20 Adepis lanaB, Adepis anserini, aa 3vj gr. xv 25 M. The chrysarobin reaction is usually mild. If the chrysarobin produces too great a reaction, it must be stopped, and the skin treated with vaselin and starch powder, or an alkaline wash; or a smaller dosage may be tried, even as small as two or three grains to the ounce. The action of the drug upon the skin is peculiar. It stains the skin about the patches a mahogany red, while the patches become smooth and white. It discolors the nails and the hair, but after a time the staining disappears. Not so the staining of the clothing, which is permanent. It is said that it can be somewhat less- ened by soaking the clothes in plain water before using soap in washing. Before chrysarobin was discovered much reliance was placed on the ointment of the ammoniate of mercury. It is still a reliable remedy, but it cannot be used over the whole body in a general psoriasis' on account of the danger of absorption of mercury. It is the pleasantest and promptest application to the scalp and face, and can be used there while chrysarobin is used on the rest of the bodv. An ointment of i\- Hydrarg. amnion., gr. xx 1 Hydrarg. chlor. mitis, gr. xl 2 Petrolati, ad 3j ad 32 33 66 M. is sometimes better than that of the ammoniate by itself. Other mercurial ointments, such as that of the yellow oxide, and a dilute ointment of the nitrate, may be used. Lang has found the bichloride of mercury in collodion in 1 to J per cent, strength a good application. It would probably be an unsafe one in a case of any extent. 36 562 DISEASES OF THE SKIN Tar is another old and reliable remedy, still much used in France. It may be employed in an ointment, or oil, or dissolved in alcohol. The oil of cade, oil of birch, or pure tar may be used in the strength of \ dram (2) to 4 drams (16) to the ounce (32). In Paris the following is sometimes used: 1$ — Glycerol, amyli, 01. cadini, aa 500 parts. Sapo. viridis, 5 " M. This is to be rubbed in at night; the patient is to sleep in a flannel gown, and wash the ointment off in the morning. Kaposi recommended the following: 1$ — 01. rusci, 50 parts. iEtheris sulphuris, Alcoholis, aa 75 " Filtra et adde 01. lavandulae, 2 " M. Balzer 1 reports cures in a month or six weeks by giving 20 to 30 baths containing \ — 01. cadini, 3xiiss 50 Yolk of egg, No. i No 1 Ext. quillayse Ad., 5iiss 10 Aquae, ad 5 viij 250 M. The patient is to remain in the bath for about one hour. If a slight erythema is caused the baths may be omitted on two days of the week. The body may be anointed with vaselin at night. Tar in any form is a dirty application, and is prone to produce inflammation of the skin, as well as toxic symp- toms. Anthrasol, which is a colorless tar, should be used on exposed parts. Pyrogallol (pyrogallic acid) is efficacious, but can be used only in cases in which the eruption is not extensive, on account of its poisonous action when absorbed. It may be used in the strength of about 10 per cent, in 1 Bui. Soc. franc, do derm, et syph., 1912, 70. PSORIASIS 563 ointment. It stains the skin, but causes less inflamma- tory reaction than chrysarobin does. Thymol was introduced by Crocker. It may be used as an ointment or lotion in the strength of 15 grains (1) to 3 drams (12) to the ounce (32). As it is colorless and of pleasant odor it is suitable for use on the face. The same authority advocates the use of turpentine locally. He uses the oleum pini sylvestris with sufficient oil of lavender or essence of lemon to mask its odor. If used undiluted, the skin must be smeared with vaselin to prevent its cracking. It is better to use it diluted with olive oil, 5j (4) of oil of turpentine to gvij (220) of olive oil, the proportion of the oil of turpentine being increased as the skin becomes accustomed to it. The addition of oil of cade or oleum rusci to the mixture increases its efficacy. Salicylic acid, 5 to 20 per cent, strength, will remove the scales, and in some cases will prove curative. It is often a good plan to add it in 3 to 5 per cent, strength to our other ointments. The soap treatment, as described under chronic eczema, is of great value in some chronic circumscribed cases. Sulphur ointment, oleate of copper "rufigallic" acid, 10 per cent, in ointment, and resorcin, have all done well in some cases. Anthrarobin, and aristol have not proved themselves as active as some of the older remedies. Gallacetophenone in 5 to 10 per cent, strength as an ointment or dissolved in collodion may be tried, but is not as good as chrysarobin. Some patients have found benefit from the use of natural mineral waters at spas. It is possible that much of the benefit so obtained is from the prolonged and regulated bathing. Wearing rubber clothing next the skin, or with a fine piece of muslin between the rubber and the skin to avoid the production of eczema by the rubber, will soften and remove the scales, and hasten the disappearance of the patches. The x-rays are useful to remove chronic obstinate patches. Caution must be used in their use. The lesions disappear 564 DISEASES OF THE SKIN in from three to six weeks. The Kromayer lamp is useful especially in obstinate patches. Hyde and Mont- gomery recommend sun-baths daily or several times a week, and Stelwagon speaks well of exposure of the skin to the arc light. In psoriasis of the nails a 2 or 3 per cent, ointment of salicylic acid, pushed beneath the nail as far as possible, is a reliable remedy. The nails may be scraped thin and the finger ends wrapped up in the same ointment. Prognosis. — A cure of psoriasis may be promised with a fair degree of certainty so far as the removal of the eruption then out is concerned; but no promise can be made that the disease will not relapse. In this respect psoriasis resembles rheumatism and gout. While most relapses are readily removed in the course of a few weeks, in some cases one or more patches will be remarkably obstinate. Psorospermosis Follicuiaris Cutis. — See Keratosis follic- ularis. Pterygium is simply an overgrowth of the normal nail- fold at the proximal end of the nail, so that it covers to a greater or less extent the lunula. It may be cut off. Purpura. — Synonyms: Hemorrhea petechialis; (Ger.) Blutfleckenkrankheit. Symptoms. — By this term is meant a hemorrhage into the skin which is not caused by direct traumatism. It is always readily recognized by the red, purple, or blue- black color of its lesions, which cannot be made to dis- appear by pressure. The hemorrhage may take place into any part of the skin; into the subcutaneous tissues; or into any of the glandular apparatus of the skin. It occurs with suddenness, and produces variously sized lesions to which certain names have been applied. When they are small, from pin-point size to perhaps half an inch in diameter, they are called petechia. When occur- ring in the form of more or less long streaks they are PURPURA 565 called vibices. Large bruise-like lesions with more or less swelling are ecchymoses. Blood tumors of all sizes are ecchymomas or hematomas. The color of all purpuric lesions depends upon their age. When first formed they are bright red, claret, or purple. Before disappearing they pass through various shades of color such as are seen after an ordinary bruise, becoming blue black, green- ish black, or brownish. These changes are due to the gradual absorption of the effused blood and the hematin deposited from the blood globules. There is no definite time for complete absorption to take place, but eventually no trace is left of the previous hemorrhage. If the extravasation of blood takes place into the hair follicles, we will have papules formed. If between the layers of the epidermis, hemorrhagic bullae may result. Hemorrhage into sweat glands will give rise to hemati- drosis. As complications of other dermatoses hemor- rhage may occur, as in urticaria, pemphigus, and eruptive fevers, but these should not be elevated into special varieties of purpura. There are five varieties of purpura, namely, purpura simplex, purpura senilis, purpura hemorrhagica, purpura rheumatica, and Henoch's purpura. It is convenient for us to preserve these varieties for a time, though the results of the latest studies seem to indicate that the third variety is but a more developed form of the first, cases of simple purpura having been seen to run into the hemorrhagic form. By Crocker and others the third variety is regarded as a form of erythema exudati- vum. It, too, has been seen to run into the hemorrhagic form. Purpura Simplex is the most common variety, and usually takes the form of petechia?, the lesions being round or oval, or irregular in shape, or even circinate. Duhring describes a case of the circinate form, as does Stel wagon. 1 The lesions appear suddenly, generally with- 1 Jour. Cutan. and Gen.-Urin. Dis., 1887, v, 369. 566 DISEASES OF THE SKIN out antecedent symptoms, and often at night. Like other varieties of purpura, the lower extremities are the most common seat of the eruption, especially their flexor aspects, but any part of the skin may be attacked, as also the mucous membranes. Crocker affirms that in children the lesions appear first upon the neck and upper part of the back. The lesions appear in crops, and most often are symmetrical. There may be but a single outbreak, and the whole disease may be at an end in a week or two, or it may be prolonged for many weeks by a succession of outbreaks. There is usually no constitutional dis- turbance, or a slight rise of temperature and malaise, and the only things the patient complains of are the spots, and perhaps some itching. Valvular heart lesions are not infrequent. Recovery is the rule. Purpura senilis is a form of purpura which occurs usually in persons over sixty years old who have senile skins. It occurs in red or telangiectatic hemorrhagic patches on the extensor aspects of the forearms, hands, legs, and feet; most often on the first two. It occurs spontaneously and is unattended by subjective symptoms. The lesions may be single or multiple but always isolated and ungrouped. They begin as macules which coalesce to form the patches. These are bean sized, round or oval, irregular, more or less sharply defined. In eight to ten days they begin to fade, and disappear in the course of a few months (Pasini). 1 Purpura Hemorrhagica. — This form is also called morbus maculosus Werlhoffii, and land scurvy. It usually begins without prodromas, and is heralded by pro- nounced malaise, rise of temperature, headache, and perhaps convulsions. It differs from the previous variety in the more extensive hemorrhages that take place, ecchymoses forming rather than petechias, and in free bleeding from all the mucous membranes — nose, mouth, stomach, urethra, rectum, vagina. These 1 Monatsheftc f. prakt. Dermat., 1906, xliii, 451. PURPURA 567 are so copious and uncontrollable at times that the patient will literally bleed to death in a few hours. Sud- den death may also be caused by hemorrhage into the meninges and brain. An excellent study of this purpura fulminans has been made by Lockwood. 1 In his case there was a rise of temperature to 106.2° F. just before death, and the patient died in about sixty hours from the onset of the disease. Happily all cases of hemorrhagic purpura are not fatal. In them the bleeding is mod- erate in amount, and the patient is gradually restored to health. Relapses may occur. Purpura Rheumatica. — This is also called peliosis rheu- matica. It resembles purpura simplex in every way, excepting that the outbreak of the eruption is preceded or followed by pain in the joints accompanied by swelling, the malaise is more marked, and there is often rise of tem- perature. The eruption is frequently most abundant about the joints. The acute symptoms subside in two or three days, but relapses are frequent. True rheumatism may be present at the same time. Valvular heart lesions have been reported to occur after this variety of purpura, even without rheumatism. Rarely this variety may pass over into the hemorrhagic form. Henoch's Purpura, according to Osier, "is seen chiefly in children, and is characterized by relapses or recur- rences, often extending over several years; by cutaneous lesions, which are those of erythema multiforme rather than simple purpura; by gastro-intestinal crises — -pain, vomiting, and diarrhea; by joint pains or swelling, often trifling; and by hemorrhages from the mucous mem- branes. Any one or two of the above symptoms, may be absent; the intestinal crisis with enlargement of the spleen may be present and recur for months before the true nature of the trouble becomes manifest. The prognosis is, as a rule, good." Balzer and Galup 2 describe an annular purpura which 1 Med. Rec, 1891, xxxix, 155. 2 Bui. de la Soc. franc, d. derm, et syph., 190X, xix, 17. 568 DISEASES OF THE SKIN begins as punctiform spots, or lentil sized, or linear. These slowly enlarge centrifugally into annular figures. On disappearing they leave slightly atrophic colorless spots. They occur symmetrically on the limbs, and sometimes secondarily on the trunk. Etiology. — Purpura may occur at any period of life, in both sexes, and in the most varying conditions of health. There is no doubt that it occurs as a symptom in different diseases and cachexias; after the ingestion of certain drugs, and under other circumstances too numerous to catalogue here. To permit the escape of blood one or both of two things have occurred, namely, a change of the blood itself that allows of its passing through the walls of the vessels, or a change in the vessel walls themselves that permits the blood to pass through them. Purpura has been noted after the loosening of some artificial support to a part of the body, such as a tight bandage worn for a long time. It occurs not infrequently in old age. In both these conditions it is due to a weakening of the tone of the vessel. In the former case matters right themselves in a few days — a happy conclusion that cannot be anticipated in the latter case. Weakness of vascular walls may also be the cause of those somewhat rare cases of purpura without cachexia seen in infants. Other cases of purpura are due to small thrombi lodging in the smaller vessels. Some cases seem to be due to vasomotor or trophic nerve action causing either sudden alterations in the calibre of the vessels or degenerations in their walls. Recurring purpura has been noted about the point of greatest pain in neuralgia. The microbian and infectious origin of purpura has its advocates. Some authorities believe that purpura occur- ring in an infectious disease is due to microorganisms. Letzerich 1 published a brochure on this subject in 1889, in which he described the "bacillus purpuras hsemor- rhagicse Letzerich" as the cause of the disease. This 1 Monatshefte f. prakt. Dermat., 1889, ix, 312. PURPURA 569 has sharp angles and edges, is readily cultivable, and pure cultures injected into rabbits give rise to hemor- rhages either spontaneously or on slight trauma. His findings have been confirmed by others. There is a growing belief in the theory of auto-intoxication as a cause of some of the cases. Pathology. — It is in the corium that the hemorrhages chiefly occur, but the subcutaneous tissues are sometimes implicated. Examination of the blood shows irregular changes in the number of blood cells and in their form, as well as in the quantity of fibrin. Diagnosis. — The diagnosis of purpura is easily made. No other disease produces bright-red, slightly elevated lesions, the color of w T hich cannot be made to disappear under pressure. From flea-bites it is distinguished by the absence of a central punctum in the lesions. Purpura hemorrhagica bears a close resemblance to scurvy, but in the latter a dietary deficient in vegetables is a marked etiological factor ; there are also greater prostration, swell- ing of the gums, loosening of the teeth, and brawny swelling of the limbs. It is possible that further inves- tigations of scurvy may show that it is but a form of purpura hemorrhagica that has been modified by diet. Treatment. — In simple purpura there is not much to be done except to put the patient in as good a hygienic condition as possible, give proper attention to any cach- exia, administer ergot and iron, and relieve symptoms. In peliosis rheumatica and purpura hemorrhagica the patient should be kept absolutely quiet in bed, his diet should be of the most nutritious and easily assimilable kind, and ergot and iron administered. Calcium chlorid, 15 to 30 (1 to 2) grains t. i. d. has been advised by Wright to increase the coagulability of the blood. It must be dis- continued after a few days. Of course, if there is hemor- rhage from the nose, vagina, or other mucous cavity, an effort must be made to stop the flow by means of a tampon, ice, hot water, or any method that experience has proved useful. Erogtin may be employed hypoder- 570 DISEASES OF THE SKIN inically; and turpentine; dilute sulphuric acid; nitrate of silver in pill-form, \ to J of a grain three times a day; and other astringents have been found useful. Letzerich recommends for the local treatment of bleeding from the 1$ — Tinct. ratanhiae, 10 parts. Tinct. iodini, 5 " M. of which 10 drops are to be taken in a wineglassful of water. For this purpose other astringents, as tannin, alum, and the like, may be used. Adrenalin should be tried in purpura hemorrhagica. Prognosis. — From the beginning of a case it is not possible to say how it will turn out, purpura simplex sometimes changing to the hemorrhagic form. We should, therefore, be very guarded in our prognosis. Most cases met with terminate favorably. Some apparently des- perate cases recover. Pustula Maligna. — Synonyms: Anthrax; Malignant pustule; (Fr.) Charbon; (Ger.) Milzbrand. . This is a disease of cattle, sheep, and horses, in which it is called splenic fever, and is due to local inoculation with the bacillus anthrax, often through the agency of flies. If the bacillus gains access to the internal organism, it produces a rapidly fatal general disease with no skin lesion. In the human, the exposed parts — face, hands, and neck — are the most frequent sites of the disease. In a day or two after inoculation the patient notices a burn- ing or itching of the affected part and the formation of a livid-red papule upon which a bulla or pustule soon forms. This ruptures, the red spot changes into a black gangren- ous eschar, the parts around it become indurated, edema- tous, of dusky-red hue, and studded with small vesicles or pustules. There are marked involvement of the lymph- atics and enlargement of the neighboring glands, that may suppurate. In favorable cases the slough separates and healing by granulation takes place. In fatal cases the gangrenous process extends rapidly, symptoms of RHINOSCLEROMA 571 septic infection declare themselves, and the patient succumbs to the disease in from two to eight days. In all cases there is more or less constitutional disturbance. Diagnosis. — The diagnosis of malignant pustule is made mainly by the rapidity with which the disease develops; the presence of the gangrenous patch with the hard indurated tissues about it; and the severity of the constitutional symptoms. The finding of the bacillus will verify the diagnosis. Treatment. — The total excision of the diseased patch by means of a free incision is the most radical and effect- ual treatment for the disease. The injection of tincture of iodin, or of a 5 per cent, solution of carbolic acid under the eschar is a good method .of treatment. The hypo- sulphite or sulphite of soda, and large doses of quinin, are worthy of trial. Quinquaud's Disease. — See Folliculitis decalvans. Raynaud's Disease. — See Dermatitis gangrenosa. Recklinghausen's Disease. — See Fibroma. Red Gum. — "An obsolete term for various transitory eruptions in teething children" (Foster). Commonly this is miliaria rubra. Rhinophyma is the term used to designate that form of hypertrophic rosacea in which pendulous tumors develop on the nose. These may attain to so great a size that they hang down over the mouth. See under Rosacea. Rhinoscleroma. — Synonyms: (Fr.) Rhinosclerome; Peri- sarcoma. Symptoms. — This is an exceedingly rare disease that was first described by Hebra and Kaposi. It affects almost exclusively the nose and its mucous membrane, and assumes the form of flat or slightly raised, sharply defined, isolated or confluent, very hard, lobulated, elastic plates, tumors, or nodes which are painful on pressure. These lesions are located in the skin or mucous mem- brane of the septum of the nose, or in the aire nasi 572 DISEASES OF THE SKIN and the neighboring parts of the upper lip. They can be raised from the underlying parts, but the skin is so infil- trated that it can move only with the growths. The color of the skin may be normal, or bright or dark- brownish red. It may look like a keloid or hypertro- phied scar. The contiguous skin shows no abnormalities whatsoever. The epidermis over the growths often shows rhagades, from which exudes a viscid secretion which dries into yellowish adherent crusts. Fig. 84 Rhinoscleroma. The disease begins as a thickening and hardening of the septum of one or both alse without inflammatory reaction or pain. Slowly the nose becomes deformed, broad, and flat, and at last by progressive thickening of both septum and alee the nostrils become occluded. The process may involve the lips so that the opening of the mouth becomes greatly lessened, and may affect the gums. More frequently it proceeds backward along the nostrils on to the velum palati. The growth shows little ten- dency to ulceration or retrograde metamorphosis. At the RHINOSCLEROMA 573 most superficial parts excoriations occur. Late in the disease the teeth may loosen and fall out, and the gums may atrophy. The disease begins in some cases in the pharyngeal vault. The epiglottis and larynx may be involved in the process, and aphonia, and suffocative or epileptiform attacks may occur. There is no constitu- tional disturbance, and the only subjective symptoms are those of discomfort on account of the interference with respiration. The disease is steadily progressive, shows no tendency to recovery, and recurs rapidly when the diseased parts are cut away. Etiology and Pathology. — It occurs in all social grades, and affects both sexes with about equal frequency. It usually begins between the fifteenth and fortieth years. It is most frequent in warm climates, and is specially prevalent in Austria and Russia. A bacillus has been found in the tissues by Frisch that is regarded as the cause of the disease. It is described as short, thick, ovoid, capsulated, in free groups and in cells. It is named bacillus rhinoscleromatis. The disease is a granuloma, the corium and papillary layers being densely infiltrated with small cells. In places there is very dense fibrous tissues. There is hardly any change in the epidermis. Diagnosis. — -The location upon the nose and upper lip alone, the ivory hardness of the growths, and their pro- gressive course without tendency to ulceration or soften- ing, will establish the diagnosis as against syphilis, epithe- lioma, and sarcoma. Keloid rarely occurs upon the nose, and never runs the characteristic course of rhinoscleroma. Treatment. — Treatment is very unsatisfactory. The growths may be excised or curetted away, but neither process will assure against a relapse. The nostrils may be kept open by means of sponge-tents, and the like. Besnier 1 recommends boring into the tissues with points of chloride of zinc for the purpose of giving passage to air. Pyrogallic acid, 10 per cent, in vaselin, and salicylic 1 Ann. de derm, et de syph., 1891, ii, 603. 574 DISEASES OF THE SKIN acid, 1 per cent, solution injected into the tumor, have been recommended as of value. Lustgarten treated one case with excellent result by the x-rays. Prognosis. — The prognosis is bad. The disease is progressive, and threatens life by suffocation on account of involving the larynx. Rhus-poisoning. — See Dermatitis venenata. Ringworm. — See Trichophytosis. Ritter's Disease. — See Dermatitis exfoliativa neonato- rum. Rodent Ulcer. — See Epithelioma. Rosacea. — Synonyms: Acne rosacea; Gutta rosacea seu rosea; Acne erythematosa; (Fr.) Acne rosee, Couperose, Rosacee; Rosee; (Ger.) Kupferrose, Kupferfinne, Kup- frigegesicht. A chronic disease of the skin, limited in most cases to the middle third of the face from above downward, and characterized by a diffused or patchy redness made up of dilated capillaries. This disease is very commonly called acne rosacea, but inasmuch as the papules that often occur with the disease are not true pustules it is best to drop the "acne" from its title. Symptoms. — Rosacea is one of the more common skin diseases and is peculiar in affecting, with few exceptions, only the middle third of the long diameter of the face — the forehead, nose, and adjacent portions of the cheeks, and the chin. The nose may be affected alone, and in many cases the forehead escapes entirely. The disease has three forms or stages. The first consists in a simple redness of the affected skin with more or less well-marked dilatation of the capillaries. In the second stage there is an added element of superficial papules and pustules, and perhaps nodules. In the third stage there is marked hypertrophy of the skin. The process may stop at any stage. A seborrhea may complicate the disease, Unna even claim- ROSACEA 575 ing that his seborrheal eczema is the first stage of all cases of rosacea. The first stage varies in degree. At first there may be faint flushing of the skin, as after the ingestion of hot Fig. 85 Rhinophyma. (Courtesy of Dr. H. Fox.) fluids, exposure to cold, and the like. This being re- peated, permanent dilatation of the capillaries takes place. The dilated capillaries are not evident all over the patch. The greater part of the patch may present an even red- ness. The border of the patch is ill defined, and no 576 DISEASES OF THE SKIN matter how fiery red the color may be the skin feels cool to the touch. This is because the congestion is passive on account of a sluggish circulation. In some cases, how- ever, there may be but little general redness, only a number of dilated capillaries. These telangiectases are best seen on the nose. In some cases there may develop a congestive seborrhea or even an erythematous eczema which, yielding to appropriate remedies, leaves behind an undoubted rosacea. The second stage may develop from the first after the latter has lasted a considerable length of time, or be almost coincident with it. The number of papules and pustules may be considerable, and the tubercles large. If so, the amount of redness will be great. The peculiar feature of the pustules is their superficiality. They are usually quite small, say of pinhead size, and when pricked give exit to but a small drop of thin pus. The tubercles are enlarged or clogged sebaceous glands, but all these lesions are but secondary to the chronic hyperemia, and not primary, as in acne. There may also be comedones and true acne scattered over the face. While the majority of cases never go beyond the second stage, in some cases the continued and excessive hyper- emia leads to an increase of connective tissue, and the nose, tip and sides, becomes converted into a lobulated mass of tissue, sometimes so great as to form pendulous tumors hanging down over the mouth. This last con- dition is known as rhinophyma. The whole nose is of deep-red or purple color, and studded over with crater-like openings, leading down into the thickened mass. At times ulceration occurs in these crypts and causes additional annoyance and deformity from destruction of tissue. While in the vast majority of cases the middle third of the face alone is affected, in some cases the whole face becomes red, and the redness may extend down upon the neck. Rosacea is seen at times on the scalp of bald- headed persons just above the forehead. Etiology. — The cause of the disease is probably a vasomotor reflex neurosis. Schwimmer regards it as a ROSACEA 577 trophoneurosis; Unna, as a seborrheal dermatitis. It occurs in adult life, most frequently after the twenty-fifth or thirtieth year, though it may occur even at puberty. There is no connection between it and acne. While many patients will tell you that they had "pimples" when young, as many will inform you that they have always had a good complexion until the rosacea began. Women are more frequently affected than men. Digestive disturb- ances are a very common cause of the disease, and the trouble may be located either in the stomach, intestines, or accessory digestive organs. Drinking of alcoholics will undoubtedly cause it, on account of producing both gastric catarrh and reflex dilatation of the facial vessels. The inordinate use of strong tea acts in the same way, and probably gives rise to as many cases as does alcohol. Exposure to the weather or to extremes of temperature will cause rosacea without digestive disturbances, but when combined with the latter leads on to the most bril- liant examples of it. Constipation, menstrual derange- ments, anemia, chlorosis, gout, lithemia, the menopause, each one has been noted in connection with rosacea. The use of cosmetics has been followed by it. Various mor- bid conditions of the mucous membrane of the nose have been found in connection with it. Tight lacing is frequently followed by rosacea. Pathology. — In the first stage there is dilatation of the bloodvessels in the cutis. In the second stage this is more pronounced, and the corium is slightly thickened and edematous in places. In the third stage there is in addition enormous hyperplasia of the connective-tissue elements of the cutis, and the sebaceous glands are enlarged (Elliot). Diagnosis. — When we meet with a case of redness of the skin, with or without papules, pustules, or tubercles, that is limited to the middle third of the vertical diameter of the face, it is probably one of rosacea. It differs from acne in its limited area, the superficial character of the pustules, the absence of comedones, and the capillary dila- tation. Lupus erythematosus may occur in the same loca- 37 578 DISEASES OF THE SKIN tion, but in it we do not find the dilated capillaries; but we do find thickening of the skin, adherent scales with prolongations from their under side, a sharply defined, slightly raised border to the patches, and, if the disease has lasted any time, more or less delicate cicatricial tissue. In its early stage the diagnosis is not always easy. Lupus vulgaris should not confuse us, as in rosacea there is an entire absence of the characteristic apple-jelly-like tuber- cles of lupus. The tubercular syphilid may resemble rosacea in its second or third stage, but soon it undergoes softening and ulceration — processes that do not occur in rosacea. Moreover, it is not symmetrical, but occurs in the form of groups of tubercles, presents no telangi- ectases, and evidences of other syphilides are usually to be found. Erythematous eczema burns and itches, the skin is somewhat swollen and scaly, and feels harsh and leathery. Sometimes an eczematous condition complicates a rosacea, and the latter declares itself only when the former is cured. Treatment. — In order to treat rosacea successfully we must first endeavor to remove the cause. We must inquire as to the patient's general condition. Then we must address ourselves to the regulation of any deranged function. We must stop the use of alcoholics in any form, and the ingestion of all hot fluids, such as tea, coffee, and soup. All these tend to produce dilatation of the bloodvessels of the face and to keep up those conditions we wish to remove. The patient's diet should be care- fully regulated, so as to make digestion as easy as pos- sible. The drinking of a half pint of hot water before meals is to be advised. Medicinally, tincture of nux vomica, the mineral acids, or alkalies are to be adminis- tered q. r. n. Nux vomica has often seemed to render good service, even without there being marked digestive disturbance. Salol is a good remedy in many cases of intestinal fermentation. Ergot or ergotin proves useful in some cases, either with or without uterine disturbances. Ichthyol is commended by Unna. The ammonia sulphate is the preparation he advises, and it is best given in ROSACEA 579 capsules to cover the taste. The dose is 3 drops two or three times a day. Ichthalbin, 15 grains (1) t. i. d., has been substituted for ichthyol, and some good results from its use have been reported. Whitfield advises the administration of 1 to 2 grains of menthol after meals, or half a teaspoonful of syrup of codeia in a wineglass full of water before meals. The local treatment is important in hastening a cure, but is not of itself curative in well-marked cases of reflex rosacea. The patient must be instructed to protect the skin from the action of wind and weather, by either applying some ointment, such as cold cream, or a lotion, such as the calamin lotion, or a powder, such as corn- starch, before venturing out of doors. The face should be bathed with hot water every night before going to bed, the water being as hot as the skin can stand without burn- ing, and it should be sopped on for about ten minutes, fresh supplies of hot water being added from time to time so as to maintain a uniform temperature. This is benefi- cial because the primary dilatation of the vessels caused by it is followed by contraction. After the bathing the following lotion may be applied: -Zinc, sulphat., Potass, sulphuret., aa 5j aa 4 Aquae rosas, ad giv ad 120 M It is, perhaps, as good as any application we can make. Van Harlingen gives another good one as follows: -Sulphur, praecipitat., 5J 4 Pulv. camphorae, gr. v 38 Pulv. tragacanth., gr. x 66 Aquae rosae, Liq. calcis, aa 5J 32 M. Resorcin 5 or 10 per cent, in water or dilute alcohol may be advised. If any one of these lotions is used several times a day it may cause the skin to peel off after a few T days. If so, it is to be stopped and a cooling lotion or ointment used until the peeling stops, when the lotion may be used again. It is desirable in obstinate cases to cause the skin to peel off. 580 DISEASES OF THE SKIN Instead of lotions, sulphur ointment (5 j to § j) (or 4 to 32) or the white precipitate ointment may be used, or simply powdered sulphur. In obstinate cases Vleminckx's solu- tion may be used. It is composed as follows: 1$ — Calcis, 3iv 16 Sulphur, sublimat., 5j 32 Aquae destillat., gx 320 M. Boil together with constant stirring, until the mixture measures 6 fluid ounces (186), then filter. This is to be diluted four or five times at first, and used at night only, followed by cold cream in the morning. The dilution is to be lessened by degrees. Ichthyol, in 5 to 50 per cent, strength in aqueous solution, has been highly extolled by Unna and others. W. J. Munro 1 recommends painting the nose, after bathing with hot water, with a solution of adrenalin, made by dissolving one of Borroughs & Welcome's tablets in 1 dram (4) of water with a little camphor. This first causes redness, followed in five minutes by paleness. During the day the lotio alba is to be used; and from 2 to 6 of the tablets of adrenalin are to be taken by the mouth, stopping them if vertigo or nausea is caused. G. W. Wende 2 reports a cure by using galvanism, placing the anode over the abdomen and the cathode on the face. If the case is highly inflammatory when first seen, our first attempts should be in the direction of reducing the inflammation by means of soothing ointments. After a few days we can begin the treatment of the rosacea. Surgical procedures are necessary to hasten the removal of pustules, and to destroy dilated vessels and hypertro- phic tissue. Pustules are quickest removed by the curette, or acne lancet as in acne. Dilated vessels are best destroyed by electrolysis with the electric needle attached to the negative pole, introducing it perpendicu- larly into the vessel at one or more points or longi- 1 Austral. Med. Gaz., 1900, xix, 496. 2 Buffalo Med. Jour., 1898-9, xxxviii, 254. ROSACEA 581 tudinally in its course, and letting it remain for a few seconds until the vessel appears as a white line. The method of using electrolysis is more fully described under hypertrichosis. It is often necessary to repeat the operation several times before the vessel is destroyed. The operation is prone to leave punctate scars. The thermocautery may also be used in the same way. Mul- tiple scarification is most useful in reducing red patches. It may be done by means of a scalpel, making parallel lines near together and through the skin, and then a second series over these; or a multiple scarifying-knife, as sold in the shops, may be used for the purpose. H. Fournier 1 advises the use of a flat needle rounded at its end and bevelled on its under side. The vessels are to be cut obliquely to their long axis, while the skin is put on the stretch. After scarifying, bleeding should be encouraged for a few moments by the application of warm water. Then the surface should be swabbed over with a solution of carbolic acid, 2 drams (8) to the ounce (32) of glycerin and water. This will check the bleeding and constringe the vessels. No after-treatment is needed, as a rule. If reaction tends to go too far, a soothing oint- ment may be applied. The operation should be repeated once every week or two. Multiple punctures may be made with the acne lancet, the subsequent treatment being the same as after multiple scarifications. It is astonish- ing to see how rapidly the redness will be reduced in many cases, and this without deformity being caused. Multiple scarifications may be employed for the reduc- tion of tuberculated masses — rhinophyma — but a plastic operation is the most satisfactory method of treatment. Both the high frequency current by sparking and the Rontgen rays have been used with benefit. The latter clear up the acne element and reduce the connective-tissue overgrowth, but will not remove the dilated vessels. Prognosis. — In cases of rosacea arising from exposure to weather in drivers and sailors, and in those following similar pursuits, we cannot expect to effect a cure, as the 1 Jour. mal. cut., etc., 1895, vii, 257. 582 DISEASES OF THE SKIN patients cannot do the one thing necessary — give up their occupations. In most all other cases we can promise great amelioration of the annoying redness, and in many we can effect a cure ; but we had best not attempt to treat a patient who will not follow our directions as to diet and hygiene. Rotheln, Rubella, or German measles, is a mild con- tagious disease that resembles measles, but differs from it in the mildness of all its symptoms, in the lighter color and smaller size of its lesions and in the absence of the crescentic arrangement of them. It is seen mostly in children. Its period of incubation is from one to three weeks. Its period of invasion is from a few hours to a day or so, and marked by slight malaise and fever, sometimes so slight as to be overlooked. The eruption is not so blotchy as measles, the lesions being pale red, macular or maculo-papular, varying in size from a pin- head to a lentil, and the catarrhal symptoms are absent or but slight. Swelling of the glands of the neck is a symptom that may or may not be present, but when present is characteristic. The lesions may take the form of small papules, and assume rather a brownish than a red color. There may be very few of them. The eruption is often itchy, and the lesions may occur on the mucous membranes. The duration of the disease is but a few days, and the health of the patient may be undisturbed. Desquamation may occur. It differs from scarlatina in the mildness of all its symptoms, and in the absence of the diffuse scarlet eruption of the latter disease. The absence of catarrhal symptoms, and mildness of the general symptoms taken in connection with the enlarge- ment of the cervical glands distinguish it from measles. The treatment is purely symptomatic. St. Anthony's Fire.— See Erysipelas. Salt-rheum. — See Eczema. Sarcoid. — According to J. Darier 1 this name was first proposed by Kaposi who included under it granuloma 1 Monatshefte f . prakt. Dermat., 1910, 1, 419. SARCOID 583 fungoides, lymphodermia perniciosa, and sarcoma. As described in the literature the disease presents in lour types, namely: (1) Boeck's Multiple Benign Sarcoid. (2) Darier's Subcutaneous Sarcoid. (3) The Nodular Sarcoid of the Extremities. (4) The Spiegler-Fendt Type. I. Boeck's Multiple Benign Sarcoid, or Miliary Sar- coid.— Of this there are three forms. (1) The tubercular form, which occurs in bean- to nut-size, round, oval, or irregular shaped nodules, of which there may be few or many. (2) The papular form, which occurs in hemp- to bean-size papules, of which there may be hundreds or thousands. (3) The infiltrated form, which occurs in patches which are ill defined, hard, and slightly or not at all raised. The disease may begin suddenly as a diffused, slightly pruritic, edematous redness of the skin, which disappears in a few days, and leaves one or more hard lesions of the skin. Or a papule forms deep down in the skin, which grows slowly, and raises up the skin into a firm papule or nodule. These may last months or years. At first they are red; later they become reddish, violet, or yellow- ish, and at last brownish. Under the diaskop they are less pronounced than those of lupus, and often appear as if composed of small hemp-seed-sized bodies of yellowish or gray color. When they undergo retrogression they sink in the middle, are covered with a net work of tel- angiectases, and surrounded by a yellow, often scaly border. After they disappear there remains a small pig- mented spot, or one that is atrophic with telangiectases. They never soften or ulcerate. The lymphatic glands may or may not be swollen. There are no subjective symptoms. There may be but a single tumor. Relapses are frequent. The most usual sites of the disease are the face, back, shoulders, and extensor aspect of the arms. They may occur on the scalp, buttocks, or legs. The palms and soles are spared. They are moderately symmetric in distribution. They may begin about scars. Women are more often affected than men, and most of the patients are tuber- culous. Cases have been noted between the thirteenth 584 DISEASES OF THE SKIN • and forty-fifth year of age. Histologically the tumors seem to be a chronic, infective granuloma. They must be differentiated from sarcoma, leukemia cutis, syphilis, leprosy, and. tuberculosis. Lupus miliaris has transparent papules with cheesy centres, is inoculable in animals, and reacts to tuberculin, while those of sarcoid do not. Lupus erythematosus tuberosus is differentiated by biopsy. Lupus pernio is a seasonal disease, its lesions are softer and of different color, and neither clinically nor microscopically sharply defined. The best treatment consists in arsenic, or in calomel injections. II. The Subcutaneous Sarcoid of Darier. — This is a com- paratively rare disease. It consists in a subcutaneous, painless, creeping, new formation inclined to unlimited growth, to generalization, and to softening or ulceration, without effect on the general health. The disease begins gradually. The lesions are nodes, which are sometimes isolated, round or oval, hazel-nut to walnut size; sometimes they join together to form stripes that follow the course of bloodvessels, or uneven patches 15 to 20 cm. long, that lose themselves in the surrounding skin. The number of nodes vary. They are hard and painless, and either movable on the underlying parts, or attached to the skin. Their color is reddish, lilac, or slate. The disease occurs specially in the region of the ribs, on the shoulders, back, sides, or haunches, and is symmetrical. It is seen only in adults, and is a tuberculid, reacting to tuberculin. The disease is located in the subcutaneous tissue and sends projections into the cutis. It consists of epithelioid and connective-tissue cells, and lymphocytes intermixed with typical or half-developed giant cells. About the new formations lie defined cell heaps of the same kind of cells. The fatty tissue is atrophied and sclerosed. This form of sarcoid differs from the first type in the appearance, size, subcutaneous location, and typography of its lesions. III. The Nodular Sarcoid of the Extremities. — This form is probably the same as erythema induratum. The SARCOMA 585 eruption consists in circumscribed thickenings and harden- ings of the cutis and subcutaneous tissues, which are painless, and seldom soften or ulcerate. They appear in crops, beginning as pea- to hazel-nut-sized subcutaneous tumors, either movable or adherent to the skin. After a time they become violet, lilac, red, or slate color. They run together and form patches which may be depressed in the centre. They may last months or years, but ultimately disappear and leave no trace in the skin. They are more common than the other types of sarcoid, and are located on the extensor aspects of the arms and legs. They occur both in the young and old, but espe- cially in females. It is difficult to diagnose them from tuberculous gummas excepting that the latter are more virulent and richer in tubercle bacilli. IV. The Spiegler-Fendt Type. — In this form the erup- tion consists in red or lilac, flat, or prominent nodes which are located deep in the skin and may unite to form large patches. They occur principally on the trunk, are more or less attached to the skin, painless, and may or may not ulcerate. They run a rapid or slow course and may be fatal. It is not a tuberculid and is cured by arsenic. Sarcoma.— We are here interested in sarcoma of the skin alone. Sarcomas may be primary in the skin, but most often they are secondary. They form variously sized tumors, but tend to run a malignant course, multiplying more or less rapidly, breaking down, affecting internal organs by metatasis, and killing the patient in a few months or years. There are three types of sarcoma, namely, the round-cell sarcoma, the small-cell sarcoma, and the melano- or pigment sarcoma. Sarcomas may be divided into two varieties — the pigmented and the non- pigmented. Very commonly sarcomas are of mixed type. Primary melanotic sarcoma or melanoma originates frequently from an irritated nevus or other pigmented lesion, but may occur independently. Regions rich in chromatophores show a proneness to the disease, such as the anal and genital. At first it is always single and 586 DISEASES OF THE SKIN small. It tends to enlarge and attain the size of a nut. In shape it is oval or spherical. It is nearly always sessile. Its color is dark blue or black. It is very hard to the touch. It may remain stationary for a long time, but eventually new tumors will appear, either about the original one or at distant points by way of the lymphatics. Some of the original tumors will disappear, while new ones appear; some will break down and form irregular ulcers whose floors are black and uneven, and secrete a thick, melanotic liquid, or a little pus, or almost solid black matter. The neighboring lymphatic glands become enlarged, and may break down and discharge the same inky black fluid. A large lobulated mass may be formed by the coalescence of a number of smaller lesions. The viscera become involved, and death soon occurs. There may be melanemia and melanuria. A rare form of melanotic sarcoma is described by Hutch- inson as melanotic whitlow, which at first is a chronic onychitis, the border of which looks like a lunar-caustic stain. It very gradually develops into a fungating tumor, slightly pigmented. The nail is shed, and generalization occurs (Crocker.) Non-pig wiented primary sarcoma may be generalized or localized. The generalized form begins usually upon the extremities, and causes upon the hands and feet a peculiar hard edema, accompanied by tension of the skin, and perhaps itching or pricking. It may begin as brownish- red, livid, purple, or blue patches, upon which pinhead- sized nodules appear, which gradually enlarge. In some cases little, infiltrated, isolated, blue or reddish-brown nodes will form. Sometimes the first appearance will be a diffused cyanotic patch, which later will become a bossy elevated patch. When the disease is fully developed the hands and feet are thick, deformed, infiltrated, as firm as cartilage, brown or blue with a red tint. The skin is glossy, scaly, uneven. The nodes may be raised, pedunculated, or ulcerated. Similar lesions are found upon the rest of the body, though rarely on the trunk. They may remain stationary, disappear, fall off, multiply, SARCOMA 587 ulcerate, or, finally, involve the mucous membranes and cause death. The localized form develops ordinarily from an irritated nevus, and is most often encountered on the extremities. It forms a hard, wrinkled tumor, which may ulcerate. Its color is usually that of the normal skin, though it maybe red. It may grow to be the size of an orange or take on a mush- FlG Multiple idiopathic hemorrhagic sarcoma. room-like form. It may not generalize for a long time, or it may do so spontaneously or after an attempt at removal. To this class of tumors Hutchinson's recurrent fibroid of the skin belongs. As described by him, "it begins usually on the lower extremities, grows slowly at first, but recurs rapidly and persistently after removal, however wide the incision, and ultimately generalizes, fungates, forms blood cysts, and destroys the patient." 588 DISEASES OF THE SKIN Sarcomas are very vascular, and are subject to profuse hemorrhage when injured or when they ulcerate. Under the name of idiopathic multiple hemorrhagic sar- coma a disease was first described by Kaposi. It occurs in adults, and begins as an edema of the hands, feet, and face, with more or less pruritus. Later dark-blue or purplish spots appear deep in the skin, which after a time form raised nodules, which may be sessile or pedunculated, but are always dark blue or purple. They vary in size up to a cherry or larger, or may be isolated or grouped. They are tender, and the patient may experience more or less pain. The extremities or face become elephantiasic in appearance, and covered with scales, and more or less rugous. The tumors may remain for a long time or dis- appear, or, rarely, ulcerate. The color of the tumors is due to vascular development. The disease is chronic in its course, and may last for fifteen or twenty years without affecting the patient's health, or the patient may die after a few years by extension of the disease and the involvement of the mucous membranes and internal organs. The disease may extend up the limbs to the trunk. Recovery may take place. Etiology. — We know very little in regard to the etiology of sarcoma. It occurs at all ages, some of the most malignant cases being seen in childhood. Brocq says that the localized non-pigmented sarcoma is most frequent in robust men of forty to sixty years. Piffard gives the ages at which they are most prone to occur as before the fifteenth and after the forty-fifth years. The Kaposi type is most often seen in men. The Jewish race is especially prone to it. It occurs in Russia and Italy more frequently than elsewhere, and in those who are much exposed to vicissitudes of wind and weather and live in bad hygienic surroundings. It is possible that all types may be due to infection, but the etiology of the disease is obscure. Pathology. — Sarcomas of the skin are histologically identical with sarcomas of deeper parts. They are connective-tissue tumors in which the cellular elements SARCOMA 589 greatly predominate in bulk over the intercellular sub- stance. In this respect the tumors are comparable to embryonic connective tissue. The structure and form of the cells vary in different sarcomas, and the inter- cellular substance may be very scanty and of delicate structure in one tumor, and in another approach in quality and appearance the frame work of normally developed connective tissue. It is from these variations in the cells and intercellular substance that the tumors are numerously classified as simple sarcomas including the spindle and small and large round-celled sarcoma, and the lympho- and fibrosarcomas; organized sarcomas including the alveolar sarcomas or endotheliomas, and the angiosarcomas; and lastly those sarcomas character- ized by secondary changes in the cells or ground substance, among which the form of greatest dermatological import- ance is the melanosarcoma. In any of these the usual various retrogressive changes may occur, such as fatty, colloid, or hemorrhagic degeneration, caseation, necrosis, ulceration, etc. Melanotic sarcomas are vascular small or large round- celled, or more often spindle-celled tumors, with sometimes a giant cell here and there, and characterized by the pres- ence of abundant intra- and intercellular, granular and diffuse pigmentation. It has been recently demonstrated that many malignant pigmented tumors, arising from pig- mented moles and nevi, and formerly classed as melanotic sarcomas, are in reality carcinomas. In idiopathic multiple hemorrhagic sarcoma the cells are round or fusiform, and there is a rich network of vascular sinuses and thin-walled bloodvessels. Hemor- rhagic areas are scattered throughout the growth, and deposits of pigment derived from the extravasated blood. All the pigmentation is due entirely to the capillary hemorrhages. Involution, when it occurs, is through destruction and resorption of the tumor cells and pigment, with concomitant connective-tissue organization. Diagnosis. — The diagnosis of sarcoma is generally easy, but at times it is difficult. The pigmented forms 590 DISEASES OF THE SKIN are usually readily recognizable by their color and fre- quently by their origin in a pigmented nevus. The non- pigmented single sarcomas may be distinguished from epithelioma by its feel, which, though firm, lacks the hard- ness that is characteristic of cancer. Fibromas are not so firm as are sarcomas, are more commonly pedunculated, and show no tendency to degenerative changes. Mycosis fungo'ides has a primary eczematous stage; its tumors are of a brighter red, and they come and go, and undergo various changes much more rapidly than do sarcomas, and pruritus is pronounced. Treatment. — Excision of a single non-pigmented sar- coma is often curative. In multiple sarcoma, and in the melanotic variety, operative interference is usually not only not curative, but has often seemed to hasten generalization. Kobner and others have used hypodermic injections of arsenic with brilliant results in some cases. Kobner used Fowler's solution of half strength, and injected 2| to 4 drops of it once a day. After three months the dose was increased to 7 J and then to 9 drops. Others have tried arsenic without effecting a cure. Still it is worthy of trial, as it may cure the disease if it is well borne by the patient. Inoculation by the toxin of the streptococcus has cured some cases, but its use is not with- out danger to the life of the patient. The x-rays will cause the disappearance of the tumors in some cases, but they are prone to relapse. Wallhauser 1 has reported the disappearance of the tumors in multiple hemor- rhagic sarcoma after four to six months' use of com- presses of bichloride of mercury, 1 to 2000, and after a while 1 to 500. Prognosis. — This is always grave. The course of the disease is nearly always from bad to worse, though the fatal result may not be reached for many years. Especially is this the case in multiple hemorrhagic sarcoma. Mela- notic sarcoma is more rapidly fatal than is the ordinary form. i Jour. Amcr. Med. Assoc, 1909, liii, 1608. SCABIES 59 1 Scabies. — Synonyms: The Itch; (Fr.) Gale; (Gr.) Kratze. A contagious disease of the skin due to its invasion by the acarus scabiei, and characterized by excessive itching, worse at night, and by excoriated lesions, pustules, and cuniculi upon the anterior face of the wrists, between the fingers, on the breasts of females, the penis of males, and about the umbilicus of both sexes. Symptoms. — The popular name of scabies, which is the Itch, gives us at once one of the marked features of the disease. Itching is always present in it. While it may be somewhat in abeyance during the day, it is hardly ever absent, and at night in bed it is so bad, in susceptible individuals, that sleep is well-nigh impossible. The itching gives rise to scratching, and the scratching to the secondary symptoms of the disease — scratched papules and eczematous patches. The first thing that the patient notices is that his skin itches. To relieve this he scratches, and sooner or later, according to the resistance of his skin, he produces pin- head-sized excoriations. Later, the irritation continuing, eczematous patches may result. When he presents himself to the physician, the latter will find on examina- tion excoriations due to scratching, and he will notice that the lesions are located principally between the fingers, on the anterior surface of the wrists and somewhat on the forearms, about the axillae, upon the breasts about the nipples in women, upon the male genital organs, about the umbilicus and lower part of the ab- domen, and often upon the buttocks of both sexes, and, in children especially, upon the anterior surfaces of the ankles and between the toes. In adults, these latter situations are not so frequently affected. Closer examination may be rewarded by the discovery of the pathognomonic sign of scabies, namely, the cuniculus, or burrow, which is usually found most readily on the inner border of the hand, on the inside of the fingers, and on the penis. It forms a delicate, slightly raised, whitish or grayish, wavy, often bowed line, from one- eighth to one-half an inch in length, and having a white 592 DISEASES OF THE SKIN speck at one end which marks the place where the itch- mite is. These are not always to be found; indeed, in most cases they are difficult to find, because they are broken up either by the occupation of the individual, by the use of soap and water, or by scratching. In people with delicate skin the burrowing of the itch- mite will set up an inflammatory process, and papules, vesicles, and pustules will form, quite independently of the scratching. While the regions mentioned are the ones always affected in well-marked cases, variations in the extent of the disease are observable. In some cases the hands are free, and but few lesions are present anywhere. Here, if it is a male, the crucial test will be the examination of the privates, where a scratch mark or a burrow will be found almost without fail. In other cases hardly any part of the body will be free from excoriations, pustules, or eczematous patches, excepting the face, which is affected only exceptionally, and then nearly always in children. In these bad cases furuncles and large ecthy- matous pustules join themselves to the already multi- form eruption of scabies. Urticaria is also present in some cases, its wheals being interspersed among the other lesions. Should some intercurrent fever arise, the symptoms of scabies will subside, to reappear when the fever is past. The so-called Norwegian itch is only a very much aggravated form of the disease, on account of the want of personal cleanliness of the people. The face in this form may be affected, the nails split and shed, and the palms and soles covered with thick crusts. Etiology. — Scabies is due to the irritation set up by the acarus scabiei and by the scratching employed to relieve the same. The vesicles, papules, or pustules about the burrows are due directly to the acarus; it may be on account of some irritating substance secreted by it. The disease is contagious, but requires prolonged contact, as by holding the hand or sleeping with an infected person. It is very rare for it to be communicated to a physician in examining a patient. SCABIES 593 According to Greenough, 1 it is most prevalent between the ages of five and thirty, and comparatively rare after the fiftieth year. This, he thinks, is due to the fact that in advanced life the epidermis becomes harder and dryer, and forms a less suitable habitat for the acarus. A few years ago the disease was not common in this country, Fig. 87 Acarus scabiei. Back. but now it is an every-day occurrence to meet with new cases in our dispensaries, and not an infrequent one to meet with it in private practice. Pathology. — The acarus scabiei is very small, being barely visible to the naked eye, the female being but one- sixtieth to one-eightieth of an inch long, and the male still smaller. Its width is about two-thirds of its length. It has eight legs: — four on each side of its head, to which 1 Boston Med. and Surg. Jour., Sept. 23, 1886. 38 594 DISEASES OF THE SKIN suckers are attached, and four posteriorly, to all of which, in the female, bristles are attached; while in the male the inner ones are wanting in bristles, but provided with suckers for attaching himself to the female in copulation. On the back are a number of short bristles. A glance at Figs. 86 and 87 will describe the animal better than words. Fig. 88 Acarus scabiei. Under surface. The impregnated female acarus having landed on the skin, soon stirs about, and having found a suitable place, it rests on its hind feet, takes an oblique position, pierces the skin, and bores a hole into which it forces itself. It lodges in the deeper layers of the epidermis, above, and sometimes in the mucous layer. It bores a burrow equidistant between the surface of the epidermis and the level of the papillae of the corium. Being prevented by the bristles on her back from moving backward, she SCABIES 595 moves forward, and lays her eggs. Her duration of life is from six weeks to two months, and during this time she lays some fifty eggs. These hatch out, reach the surface of the skin, the females meet the male, become impregnated, Fig. 89 Burrow of scabies with acarus. (After Kaposi.) bore in their turn into the skin, and so keep up the process. As the thinnest parts of the skin are most easily punctured, it is in these parts that we find the lesions most commonly. The scratching often extends far beyond the sites of the 596 DISEASES OF THE SKIN burrows. Fournier found that an acarus dies in seven days when immersed in cold water, in ten days when in warm water, in two to four days in a solution of green soap. He denies the commonly accepted view that the acarus is a night-prowler, though he allows that it is most active at night. Diagnosis. — The presence of pustules and scratch marks between the fingers, on the anterior face of the wrists, about the umbilicus, on the breasts in women or the genitals in men, is enough to make the diagnosis of scabies. If a cuniculus can be found, it will be corroborative evidence. Eczema is more patchy and is not so markedly limited to the characteristic locations of scabies. Pedicu- losis vestimentorum presents long, parallel scratch marks instead of the small excoriations of scabies, and their char- acteristic locations are over the shoulders, about the girdle, and along the outer and inner side of the limbs where the seams of the clothing come. The itching of scabies is worse at night, while that of pediculosis is most marked in the daytime. Urticaria is a general disease characterized by wheals, and shows no tendency to localize itself in certain regions. Should urticaria com- plicate scabies, the wheals will be disseminated while the lesions of scabies will be most marked in their character- istic locations. Treatment. — If the disease is recognized, there is no difficulty in curing it, though there are various methods employed. Perhaps the oldest and one of the most reli- able, though not the most rapid "cure," is to have the patient take a warm bath with soap and water, scrubbing himself thoroughly so as to remove as much of the old epidermis as possible. Then he should dry the skin with vigorous friction, and rub into every diseased spot ordinary sulphur ointment. When this is done he should smear the rest of the skin with the ointment, put on the same clothes, and go about his business. The rubbings with the ointment are to be repeated morning and night for three days, the patient wearing the same underclothing SCABIES 597 by day, and bed- and night-clothing by night. At the end of three days another bath is to be taken, the clothing changed, and the patient should then present himself for examination. If fresh lesions are found, a second course should be taken, which most always will be sufficient. An artificial eczema is apt to be set up by the sulphur, and as eczema itself itches we must not take the con- tinuance of pruritus beyond the second course as evidence of the scabies not being cured. It is better to stop the sulphur for a few days, and put the patient upon a mild, protective dressing to his skin, such as vaselin and corn starch. If the itching grows worse instead of better, a third course of rubbing must be gone through with. In- stead of plain sulphur ointment we can add balsam of Peru, about half a dram to the ounce, or use the modi- fied Wilkinson's ointment, as follows : ; — Sulph. sublimat., 01. cadini, aa 5iv aa 16 Cretse praeparat., 3nss 10 Sapo viridis, Adipis, aa Si aa 32 M. S. Sherwell, 1 instead of using sulphur in ointment form, has the patient rub into the skin the dry sulphur powder and throw in between the sheets of the bed, a \ teaspoonful of the same. We have tried this plan in private practice with perfect success. The treatment in the St. Louis Hospital of Paris is a heroic one, but is said to cure in one hour and a half. According to Fournier, the patient is scrubbed violently for half an hour with green soap; then for another half hour the scrubbing is continued while he is in a bath; then he is rubbed with Helnierich's ointment : I^ — Potass, carbonat., §ss 16 Sulphur, sublimat., gj 32 Adipis, 5x 320 M. Now he puts on his clothes without removing the salve, and is discharged cured. 1 New York Med. Jour., 1893, i, 432. 598 DISEASES OF THE SKIN (3-naphtol in 5 to 10 per cent, strength in ointment or oil, is a good remedy, free from the sulphur smell, and not so irritating. Kaposi recommends it in the following form: 1$ — /S-naphtol, 15 parts. Sapo. viridis, 50 " Cretse alb. pulv., 10 " Adipis, 100 " M. and Crocker says: "I can speak of it in the highest praise." It is well fitted for private practice. McCall Anderson extols styrax liquida with a double amount of lard. As the itch is very prevalent in Scotland, the doctor should know of what he speaks. Too free use of this remedy may cause a nephritis, so patients using it must be watched. Epicarin, 10 per cent, in ointment, is a recent remedy well spoken of. I have found it quite as irritating as is sulphur. For infants and young children, balsam of Peru is the pleasantest application we can make, it being rubbed in morning and night, either pure or diluted with sweet oil; or a mitigated form of sulphur ointment may be used. It is possible to cause constitutional symptoms by using the balsam of Peru, but this is rare. In all cases the clothing and bedding must be disin- fected — washable things by boiling, and woollen clothing by baking or by ironing with a very hot iron. All affected members of the family must be treated at the same time. An irritable condition of the cutaneous nerves sometimes lasts long after the scabies is cured and must not be mistaken for a still active itch. Prognosis. — The prognosis is always good, provided the applications are made thoroughly enough. Scarlatina. — Scarlet fever is an acute contagious erup- tive disease with an incubation period of one day to two or three weeks, with an average of eight days. It is a disease of children in the vast majority of cases, though adults are not exempt. It is characterized by a rapid rise of temperature at the beginning, which may reach SCLEREMA NEONATORUM 599 102° to 104° F., redness of the fauces, a strawberry tongue, and the appearance of a fine punctate scarlet rash, which, first appearing on the neck, chest, and flexures of the joints, rapidly spreads over the whole body. The redness may be even over all, so as to give a boiled-lobster appearance to the skin; or the red points may be distinct, although close together. The redness usually disappears on pressure. Vesicles may appear. A great deal of constitutional disturbance and prostration with more or less soreness of the throat usually attend the eruption, but convalescence is well established in the second week in the uncomplicated cases. Abundant desquamation follows the subsidence of the eruption, which continues for days or weeks. Complications are frequent such as otitis media, rheu- matoid pains, abscesses of the neck, heart disease, and albuminuria. Diagnosis. — There is often a striking resemblance be- tween scarlatina and erythema scarlatiniforme, and some other erythemas. (See Erythema.) Measles has more pro- nounced catarrhal symptoms, its eruption is macular, not punctiform, and crescentic. Treatment is symptomatic, and addressed to any complicating disease. Sclerema Neonatorum. — Synonyms: Scleroderma neona- torum; Induratio telse cellulosse; (Fr.) Algidite progres- sive, L'endurcissement athrepsique; (Ger.) Das Sklerem der Neugeborenen. This happily rare disease was first differentiated from oedema neonatorum, according to Crocker, by Parrot, in* 1877. It may be primary, but most often it is secondary to some exhausting disease, such as pneumonia or intes- tinal catarrh. It may be present at birth, and rarely occurs after the first ten days of life. It is characterized by hardness of the skin, which generally at first is cir- cumscribed and affects the legs. It may be diffused from the first, or it soon becomes so and extends to the lumbar 600 DISEASES OF THE SKIN regions, back, chest, and so all over the body, becoming universal by the fourth day. It may begin on the face, and it may stop before becoming universal. It may be but slightly developed on the chest. At first the skin is pale and waxy; later, it becomes livid and cold, and the child looks as if frozen. The skin becomes attached to the underlying parts, smooth, tense, and does not pit on pressure. Movement is impossible for the child, and the body may be raised without bending a joint. When the face is affected it is impossible for the child to nurse. Its respirations are greatly reduced in number, its pulse falls to sixty per minute, its temperature is below normal, its breath is cool, and it dies within a week. The primary congenital cases are either stillborn or die in one or two days. Localized cases sometimes recover, the hardness of the skin disappearing. Etiology. — The cause of the disease is obscure. It is seen almost exclusively in foundling asylums and among the very poor. It is,- therefore, a disease of depressed vitality. Langer 1 regards it as the result of solidification of the fat, which in infants contains 31 per cent, of palmi- tin and stearin, that of adults containing 10 per cent. The fat in infants, he says, is nearly all concentrated in the subcutaneous tissues, where it is five times as thick relatively as it is in adults. Naturally, an infant's tem- perature is higher than an adult's. If it is lowered by any depressing cause, the fat may solidify. Solidifica- tion may take place also under the action of cold, or by oxidation, as in fevers, withdrawing some of the constit- uents of the fat. Parrot regards the disease as one of desiccation from the drain of a diarrhea, or the like. Diagnosis. — Sclerema neonatorum is differentiated from oedema neonatorum by being more general in its dis- tribution, by the skin being harder and more tense, and not pitting on pressure, and by the rigidity of the joints. Scleroderma occurs at a later age than does sclerema, and 1 Wien. mod. Presse, 1881, xxii, 1375. SCLERODERMA 601 the skin lacks the coldness of the latter. There are no other diseases with which sclerema can be confounded. Treatment. — The course of the disease is almost in- evitably toward a fatal termination, and little more can be done than to keep the little body as warm as possible, to rub in oil, and to administer concentrated nourishment and stimulants. Money 1 reported a case in 1889 that was cured in six weeks by mercurial inunctions. There was no history of syphilis in the case. Scleroderma. — Synonyms: Sclerema seu Sclerom adul- torum; Scleriasis; Dermato-sclerosis; Chorionitis; Scler- ostenosis; (Fr.) Sclereme des adultes, Sclerodermic; (Ger.) Haustsclereme; Hide-bound disease. A subacute or chronic disease, characterized by hard- ness and rigidity of the skin. Symptoms. — The name of this disease indicates the most peculiar feature of it — that is, hardness of the skin. It may come on without apparent cause, the patient first noticing the stiffness of the skin; or it may follow expos- ure to dampness and cold, and be preceded by pains of rheumatic nature. It may begin in any part of the skin, but has a preference for the upper half of the body. It is usually symmetrical, though it may be more pronounced on one side than on the other. Having begun, it spreads, it may be very slowly, or it may be so rapidly as soon to involve large areas of the body. It often runs a capricious course, growing better and worse, and leaving sound areas in the midst of the diseased parts. There may be one patch or a number of patches, and the patches assume many shapes, though most commonly they are elongated, running lengthwise of the limb. There are two varieties of the disease: 1. The infiltrat- ing form. In this there is a good deal of infiltration of the skin, which is hard, cannot be pinched up, does not pit on pressure, and is attached to the deeper structures. The appearance given to the affected part is cadaveric. 1 Lancet, 1889, i, 526. 602 DISEASES OF THE SKIN In some cases there may be hard oedema. The affected part is usually on the level of the surrounding parts, though it may be slightly raised. The infiltration merges gradually into the neighboring parts, its border being ill defined and more readily felt than seen. The natural folds of the skin are obliterated, erythema may be present at first, and telangiectases are frequently observed upon the surface. Not infrequently the patch has a lilac border. The color of the skin is paler than that of the normal integument, and in some places it may be that of ivory. Some scaling may be present, or pigmentation of a mot- tled or diffused character may give the patch a fawn or black color. Owing to the stiffness of the skin the move- ment of the joints is interfered with, a state of pseudo- ankylosis being established. If the face is affected, it loses its expression, and the features become immobile. The eyelids may escape for some time; but if the disease passes on to the atrophic stage, soon to be mentioned, the eyes become wide open and cannot be closed. If the chest is much affected, respiration is interfered with. The temperature of the skin is usually lowered one or two degrees. It may be normal, or somewhat elevated. Senisibility may be increased, normal, or decreased. Pruritus is at times annoying. The secretions of the skin are lessened with the increase of the disease. The disease may invade all the mucous membranes. When it affects the tongue chewing, swallowing, or speaking may be interfered with. 2. The atrophic form may succeed the infiltrating form after months or years. Crocker thinks that it is prob- able that atrophy follows the edematous infiltration only. When atrophy begins it is progressive, and the skin be- comes dry, wrinkled, parchment-like. It is most often the upper part of the body that is affected — the face and arms. Continuous contraction of the skin produces an atrophy of the muscles under it, so that finally nothing remains of the original structures but the skin and bones, and the joints are ankylosed. The face being affected, Morphea. From Tenneson's Precis Iconographiques des Maladies de la Peau. MORPHEA 603 we will find a corpse-like expression, wide-open eyes with ulcerated corneas, shrunken gums with loosened and fall- ing teeth. The limbs being affected, slight injuries will produce ulcerations over bony prominences, and the limbs will be semiflexed. The sclerodactylia of Ball is scleroderma of the atrophic variety, affecting the hand and causing marked atrophy, loosening the joints, and distorting the hands, "so that the third and fourth fingers are curled up into the hand, the first and second are bent at the first phalangeal joint, while the thumb phalanges are overdistended" (Crocker). The general health remains unaffected in both forms, often for years; but should the disease be very pro- nounced, at last a marasmic condition develops and death occurs. Apart from the pruritus and feeling of stiffness, we may have no subjective sensation, excepting that pain on pressure is exquisite. At times burning is complained of. The disease, when of the infiltrated variety, tends to a slow and interrupted course toward recovery. In the atrophic variety recovery may take place. Of course, the atrophied skin will never regain its natural texture, but the disease may cease to spread and increase. At best its subject is but a sorry specimen. Children may have scleroderma, the youngest reported case being thirteen months. In them the disease is said to run a more rapid course, both in development and recovery, than it does in the adult. Vidal 1 describes a form of scleroderma following a lesion of the skin, such as an eczema, which gives rise to a lymphangitis, and is usually met with on the leg. Morphea, Keloid of Addison, is the circumscribed form of scleroderma. It occurs either as circumscribed, variously sized, oval or irregularly shaped patches, or in the form of bands, the former being the more common. It begins as a congested, red, rosy, or lilac macule, which enlarges, pales in the centre, becomes hardened, and 1 Gaz. des. Hop., 1878, li, 939. 604 DISEASES OF THE SKIN assumes the form of a characteristic patch of the disease. This patch looks like a piece of old ivory or of lard set in the skin, being of a yellowish-white color. The color may be pinkish, yellow, brown, or even black. The skin over the patch is usually smooth and easily pinched up. It may be wrinkled, or eroded in the centre. It may be level with the surface of the skin, or raised above it, or sunken below it. Around it is a lilac border due to dilated vessels. When the patch is pinched between the fingers it feels firm, like leather. There may be but a single patch or a number of patches. As a rule the disease is unilateral. After a varying length of time it may disappear spontaneously, although it may remain for a number of years. There are usually no subjective symptoms, and the disease remains unchanged until it disappears. In some cases it enlarges by new patches developing at the periphery of the old one and uniting with it. Exceptionally there may be some itching or pain, and ulceration may occur. Sensation is generally preserved. The band form is usually single, and may form a depressed sulcus or a raised ridge, looking much like a cicatrix. In addition to the bands there may be atrophic spots. The most common locations of morphea are anywhere on the trunk, but specially on the breasts; on the head and face in the parts supplied by the fifth nerve; and on the limbs. It is not infrequently associated with other nervous phenomena, and may occur along the course of a nerve, like zoster. Nettleship 1 has reported a case in the region of the first and second divisions of the fifth nerve with paralysis of the intra-ocular branches of the third nerve, which in time had associated with it hemi- atrophy of the whole of the left side of the head. There is no disturbance of the general health. The secretion of sweat over the patches may be normal, lessened, or absent. When the disease disappears it may leave no 1 Trans. Clin. Soc. Lond., 1882-3, xvi, 199. MORPHEA 605 trace of itself; or it may be followed by pigmentation, or even permanent atrophy, not only of the skin, but also of the muscles. A form of leprosy has been wrongly named morphea. Etiology. — Women are far more often the victims of scleroderma than are men — three to one. It is most common in young and middle-aged adults. Apart from this, we are in uncertainty as to the true cause, though rheumatism, gout, exposure to cold and heat, bad hygiene and poor food, changes in the thyroid, and neurotic influences have each been found in apparent causative relation to the disease. At the foundation of the trouble there is supposed to be some defect in the nervous system, not improbably in the vasomotor centres. "Most of the symptoms are referable to obstruction, on the one hand, to the arterial blood supply, and on the other, to the venous and lymph flow" (Crocker). Pathology. — There is atrophy of the fat in the derma and subcutaneous tissue, with condensation and increase of the connective tissue. The bloodvessel walls are thickened, and their lumina narrowed by the pressure of surrounding masses of cells of unknown origin. These cells are plentiful also in the neighborhood of the glands, which, in the later stages may be atrophied. The pa- pillae are hypertrophied only in those cases which show a papillomatous tendency. Diagnosis. — There is no other disease of the skin with which diffused scleroderma could well be confounded, excepting sclerma or oedema neonatorum, or cancer en cuirasse. The age at which the first two occur — namely, the first few days of life — would throw them out. Can- cer en cuirasse is more rapidly fatal in its course, is at first or soon marked by subcutaneous nodules that tend to break down and ulcerate, and is accompanied by lancinating pain. Keloid differs from morphea in having claw-like pro- cesses, in being more vascular and harder, and in want- ing the old-ivory color and lilac border. Leprosy has 606 DISEASES OF THE SKIN anesthetic patches, which morphea has not. Vitiligo is a pigment change only, and has no other symptoms. Treatment. — It is doubtful if treatment is ever directly of avail. At best it is unsatisfactory. A gen- eral symptomatic treatment with tonics, good diet, and maintenance of the body heat is indicated. Stelwagon recommends the administration of arsenic, sodium sali- cylate, and cod-liver oil. Thyroid extract should be tried. Galvanism, inunctions of the skin with oil, and massage may be tried. West 1 has reported amelioration in one case by the external use of chaulmoogra and olive oils. Stelwagon has had good results in morphea from oil of turpentine 1 to 2 parts in 6 of oil of sweet almonds, or with 1 part of beta-naphtol, 2 parts oil of sweet almonds, and 10 parts of lanolin. Hyde has obtained benefit by the use of common salt, either moistening it with warm water until it is partially dissolved, and then rubbing it briskly over the entire surface of the body excepting the face, and then washing it off with water of decreasing temperature until cold water is used; or a warm tub or sponge bath is taken containing J of a pound of salt to the gallon. Mercurial or thiosinamin plaster may be tried. We have seen one case improved by inunc- tions of vaselin containing 10 per cent, of salicylic acid. Electrolysis has proved helpful in small patches of mor- phea. The high-frequency current is sometimes useful. Prognosis. — While recovery may take place, it is uncertain as to its occurrence. Death may result in the diffused form. In children the prognosis is more favorable. Scrofuloderma. — Modern pathology has led, or is lead- ing us to use the term tubercular as synonymous with scrofula, and a number of dermatoses that were for many years regarded as scrofulodermas have been proven to be due to the bacillus tuberculosis. The most brilliant example of this is lupus vulgaris. Many of the scrofulides of the French have been shown by more careful obser- i Trans. Path. Soc. London, 1883, xvi, 252. SCROFULODERMA 607 ration to belong to various other well-recognized forms of skin disease. The marks of a scrofulous affection are, according to Bazin: (1) the involvement of the deeper layers of the skin; (2) the sharply circumscribed character of the lesions; (3) the absence of pain; (4) hypertrophy followed by atrophy of the affected parts ; (5) the reddish, violaceous, or livid color of the lesions; and (6) indelible cicatrices left by the same. In the present condition of our knowledge of the sub- ject, and in a book of this sort, it is impossible to do more than to place here a few affections of the skin that do not fit in under other well-established diseases, while premis- ing our remarks by saying that they are either really instances of cutaneous tuberculosis or due to its toxins or will eventually be taken out of their present position as scrofulodermas. In all of them we have, at the same time, that general make-up of the individual that long has been recognized as scrofulous. The patients are mostly young subjects, flabby of flesh, with pasty or doughy com- plexions or transparent skins, thick upper lips, perhaps with clubbed fingers, a marked tendency to chronic catarrhal inflammations of all the mucous membranes, chains of enlarged glands in the neck, and perhaps with some old or present bone lesions. They are usually dull and apathetic, but may be unusually intellectual, and are prone to die with tubercular lung diseases. The most common scrofuloderm is that resulting from a suppurating caseous gland, usually of the neck — the scrofulous tuberculous ulcer. The gland, before it breaks down, implicates the skin over it, and it becomes of violaceous or livid color, attached to the underlying parts. By and by the skin gives way at one or several points; the sanious, unhealthy pus escapes through the openings; these enlarge, coalesce with others, and so form the characteristic ulcer. This has undermined edges; is of irregular shape; its base is covered with flabby granulations; it discharges a thin, sanious pus; shows little tendency to crusting; is almost painless, and heals 608 DISEASES OF THE SKIN very slowly, leaving a puckered, disfiguring scar that is often bridled, with bands of connective tissue running across the site of the ulcer, under which a wooden tooth- pick, or the like, can be passed. Only one gland may be affected, or there may be a number of them that enlarge and break down. This same form of ulcer may originate from what is called a scrofulous gumma, a subcutaneous nodule independent of the glands, that slowly enlarges to a soft tumor, breaks down, and ulcerates. These tumors frequently occur on the limbs, and the bones may be involved in the destructive processes set up. While this is the most common scrofuloderm, we occa- sionally meet with two forms described by Duhring — the large and the small pustular scrofuloderm. The former has "large, rounded, ovalish, or irregularly shaped, yellow- ish, flat pustules, with a deep-red or violaceous areola/' This begins to crust in the centre, and the crust is usually flat and scanty, brownish and adherent. Underneath it is an ulcer with the characters and course of those just described. There may be one, two, or more lesions. The small pustular scrofuloderm " consists in the forma- tion of pinhead- and small split-pea-sized, disseminated, yellowish, flat pustules, with usually a raised, violaceous areola." These crust over with depressed yellowish or gray adherent crusts, which when removed, or when they fall off, leave depressed, punched-out scars resem- bling variola. Their course is very chronic and painless. They occur upon the face and extremities of strumous individuals. This form is probably the same as folliclis of Barthelemy. Etiology. — The causes of these scrofulodermas are those of the strumous state plus infection by the tubercle bacillus, and need not be gone into here. They are most commonly met with in early life. Diagnosis. — The scrofulous ulcer differs from that of lupus vulgaris in an entire absence of the characteristic lupous tubercles, and in its history of beginning in a caseous gland. Moreover, in lupus we do not have, as a SEBORRHEA 609 rule, the pronounced strumous condition that we have in the scrofuloderm. The pustular scrofuloderms sometimes resemble syphilis, but there is an absence of other signs of syphilis, and the presence of the strumous state. More- over, the pustular syphilide is generally far more dissemi- nated than is the scrofuloderm; its course is far more acute; it yields more readily to treatment, and leaves a smoother, less disfiguring scar. • Treatment. — The treatment of the ulcers, as well as the softening glands, is upon surgical principles. The regulation of the diet and hygiene of the patient, and the administration of cod-liver oil, iron, the compound syrup of the hypophosphites, or other tonic, is the most essential part of the medicinal treatment. Tuberculin injections should be tried. Locally, to the pustular scrofuloderms we may apply iodoform ointment, aristol, or other anti- septic powder, or mercurial ointments or lotions. Crocker speaks well of chaulmoogra oil emulsion in the dose of 10 to 30 minims, combined with its external use as an ointment in the strength of 1 part to 3. Seborrhea. — Synonyms: Stearrhea, Steatorrhea, Sebor- rhagia, Fluxus sebaceus, Acne sebacea, Pityriasis, Ich- thyosis sebacea, Tinea amiantacea seu asbestina, Lichen circinatus; (Fr.) Acne sebacee. Acne fluente; (Ger.) Schmeerfluss; Gneis; (Ital.) Seborrea. A functional disorder of the sebaceous glands, in which there is a hypersecretion of sebaceous matter, which may be of too fluid or too solid consistence, ' and forms either an oily coating or greasy crusts on the skin. Symptoms. — Normally the sebaceous glands secrete only sufficient oil to keep the skin soft and supple. This normal oil is not visible to the naked eye. Under certain imperfectly understood conditions the glands secrete a too fluid and abundant oil that is readily seen as an oleagi- nous coating of the skin. This form of seborrhea is called seborrhea oleosa, and by many authorities is now declared to be the only form of seborrhea. By others, it is thought 39 610 DISEASES OF THE SKIN that under certain other equally imperfectly understood conditions the secretion of these glands is not only too abundant, but also too consistent. Then the sebaceous matter cakes upon the skin in the form of more or less thick plates or masses, and to this condition the name of seborrhea sicca is given. The latter form is regarded by those who believe that there is but one form of seborrhea as pityriasis steatodes. In deference to the older teach- ings, both forms will be described. The most common locations of seborrhea are, naturally, those regions where the sebaceous glands are the largest or most numerous, namely, the scalp, the chest, the interscapular region, and the face. Seborrhea oleosa, while it may occupy any or all of these regions, is usually submitted to us for treatment when it occurs upon the face and scalp. Upon the face it is seen most often on the nose, where it forms a greasy coating. At times this is so slight as to be felt rather than seen, imparting a slippery sensation to the finger. At other times it is so abundant that it can be seen at a distance as drops or beads of oil, and when it is removed with a cloth or blotting-paper it leaves an oily stain upon it. When it is wiped off it at once reforms. As the greasy patch catches the dust, the face is apt to look dirty. At times the skin of the nose may be hyperemic. The fore- head is, likewise, a not uncommon site for this form of seborrhea. Upon the nose it may occur as the only dis- ease of the skin. Upon the forehead and nose it is not an unusual accompaniment of acne. Acne and comedones may complicate the disease in any location. The scalp may be affected primarily or secondarily to the forehead. It and the hair appear oily or greasy, the degree varying a good deal. Inspection of the scalp shows marked dilatation of the pilosebaceous glands. If it is pinched up between the fingers a number of minute, white, vermicelli-like masses will protrude from the follicles. These are the seborrhoic filaments of the French writers, and are regarded by them as pathognomonic SEBORRHEA 611 of the disease. They may be waxy in consistence (sebor- rhea sicca), or as soft as butter. The whole scalp is involved. Scaling is absent as a rule. It is apt to cause alopecia. Seborrhea sicca occurs with much greater frequency than does the oily form of the disease. We are called upon to remove it from all the regions already mentioned as the locations for the manifestations of seborrhea. It most usually appears in the form of yellowish or grayish fatty plates or masses, which when taken and rubbed be- tween the fingers impart a greasy feel. Upon the scalp it constitutes one form of dandruff. Here it may be gen- eral, involving the whole scalp; or it may locate itself in certain places in a more pronounced way than in others; or it may take the form of rings. It not infrequently occurs as a band on the forehead following the edge of the hair. The hair is dry, and after a time, the sebor- rhea continuing, it begins to fall, and at last baldness is established. In this form of seborrhea the hairy regions are espe- cially affected, and we find it in the eyebrows, bearded portions of the face, and the hairy portions of the chest. The axillae and pubes are rarely affected. In all these places it presents similar appearances — yellowish or gray- ish fatty plates. Upon the chest it is not uncommon to see the fatty matter in little heaps, piled up, as it were, about the mouths of the hair follicles. Close observation will show that the follicle mouths are wider open than they should be. As in the oily form, the skin feels greasy, and acne and comedones may be present. The inter- scapular region is frequently affected, and both here and on the chest the disease often takes the form of round or irregularly shaped patches which look as if they were covered with a brownish-yellow varnish. This is the seborrhea corporis of Duhring and the lichen circinatus of the older English authors. Aside from the appearance of the fatty crusts and a slight amount of itching when the patient is warm, this 612 DISEASES OF THE SKIN form gives rise to no symptoms. When the crusts are removed the underlying skin is of normal appearance, It may be slightly paler than it should be, but it is never moist. If the patient happens to be bald, he does not find the yellowish fatty crusts upon his bald head desir- able. But the most serious aspect of the case is that if the disease is not cured it is very sure to cause the hair to fall, especially if the patient is at all predisposed to baldness. Besides the regions already mentioned as the usual locations of seborrhea, we meet with the disease also upon the ears (in the tragus and behind the ears) and in the anal fold The scalp is, however, by far the most frequent location of the disease, and here it may exist alone for years. Whenever it exists elsewhere it is sure to be found at the same time upon the head. In infants the disease is very common, taking the form of thick crusts upon the scalp that are often of a dirty- gray color. These give the careful mother a good deal of annoyance, she being in great dread lest some one should think that she is not careful to keep the precious baby clean. This form of the disease is usually the remains of the vernix caseosa. Etiology.— The usual etiological factors of seborrhea, as given in the text-books, are debility, chlorosis, constipation, and a number of other things, indicating that the condition of the patient is below par. It is quite common to see seborrhea appear on the scalp after some constitutional illness. The disease affects all classes and conditions of men, all ages, but with the greatest frequency between the ages of fifteen and thirty, and both sexes. There is no doubt that heredity is the cause of many cases of seborrhea, as very often the greasy skin can be traced back through many generations. There are many things that seem to indicate a conta- gious element in the etiology of seborrhea sicca. Cases have been reported in which a husband or wife has contracted dandruff after marriage, he or she having SEBORRHEA 613 been, before, free from the same. The experiments of Lassar and Bishop point in the same direction. They took the scales from the head of a student who was losing his hair, and, having made a pomade of them with vaselin, rubbed the same into the back of a guinea-pig, and the pig became bald. Up to a few years ago we accepted without question the theory that seborrhea is a functional disease of the sebaceous glands. This is now doubted by some authorities. Unna teaches that the process is inflammatory from the start, and that the oil that fills the epithelial scales comes not from the sebaceous glands, but from the sweat glands. What we have called sebor- rhea sicca he would have us call, for the present at least, seborrheal eczema. (See Dermatitis seborrhoica.) He regards it also as parasitic. In support of his thesis he presents us with microscopic studies and certain argu- ments. His work has been reviewed by other competent pathologists, and his observations have been substanti- ated by other findings. His proposition that the sebaceous glands are not responsible for seborrhea has not been accepted generally. What is called seborrhea oleosa, Unna believes to be nothing more than hyperidrosis, to which he gives the name of hyperidrosis oleosa. This view he must take of necessity, on account of his theory of the office of the sweat glands. It is affirmed that seborrhea is due to a microorganism. Sabouraud gives strong evidence that it is due to a microbacillus that is identical with the acne bacillus of Unna. Diagnosis. — There is no difficulty in the diagnosis of seborrhea oleosa, as there is no other disease which gives the oily, greasy appearance to the skin. The diagnosis of seborrhea sicca is usually easy. It is to be recognized by the presence of fatty grayish or yellowish plates or crusts, seated either upon a normal or slightly reddened skin. These crusts or plates differ from those met with in eczema in being more readily removed, and imparting to the finger a greasy feel. Moreover, the 614 DISEASES OF THE SKIN crusts of eczema are of a more solid consistence, being formed by the dry ng of an almost mucilaginous dis- charge upon the skin. When eczema occurs upon the head the exudation glues the hairs together. In sebor- rhea the hairs are not glued together, but are dry and powdery. In eczema there is more or less itching at all times, while in seborrhea the itching comes on most gener- ally when the head is hot, as from artificial lights, sweat- ing, and the like. In eczema there is moisture or a strong tendency thereto. In seborrhea moisture is never seen. Seborrheal dermatitis always presents redness of the skin, and at times passes over into an eczematous condition. Psoriasis is another disease with which seborrhea sicca is apt to be confounded, as it, too, occurs in the form of scales and crusts upon the scalp. If a case presents itself with these conditions upon the head alone, we probably have to do with a case of seborrhea, as psoriasis rarely exists upon that region alone. Seborrhea usually occurs diffusely, while psoriasis occurs in the form of circumscribed patches. The crusts of seborrhea are yellowish or grayish, while those of psoriasis are of a silvery hue. In some cases, however, seborrhea will occur in circumscribed patches, and the crusts of psoriasis may be of a grayish hue. When seborrhea sicca occurs upon the chest and back in the form of rings with scaly centres, we have before us a more difficult problem in diagnosis. Now we must decide whether we have to do with a seborrhea, a ring- worm, or a pityriasis rosea. The resemblance to ring- worm is often very striking, but ringworm does not, as a rule, occur in so diffuse a manner. If, at the same time with the lesion on the chest, we find other lesions on the back between the shoulder-blades, we may be quite sure that the case is one of seborrhea. Happily in any doubt- ful case of ringworm, we will surely find the trichophyton. Upon examining the scalp, if the disease be seborrhea, we will surely find plain evidence of it there. There should be no difficulty in recognizing the presence of a SEBORRHEA 615 ringworm on the scalp. In the differential diagnosis from pityriasis rosea we are deprived of the kindly aid of the microscope. Here, too, the occurrence of seborrhea on the scalp will aid us in our decision. Moreover, pityriasis rosea is generally more diffused over the trunk than is seborrhea, and occurs also on the arms and abdomen. By close inspection we may trace the development of the disease from its beginning as a small red spot through its successive growth into the typical oval to annular patch with its withered parchment or chamois-leather-like look- ing centre. It is scaly, never crusted. In some cases, however, the diagnosis will remain somewhat doubtful. Treatment. — Any deterioration in the patient's gen- eral condition must be combated by appropriate means. Sabouraud advises the administration of arsenic and phosphoric acid. It is possible that reduction in the use of fat-producing food may be useful in the oily form. In the local treatment of the dry form ointments do best, while in the oily forms lotions are preferable. One of the best drugs in the less oily form is sulphur. After the removal of the crusts by washing with soap and water, the sulphur is to be applied in the strength of a dram of the precipitated sulphur to an ounce of rose ointment It should be well rubbed into the scalp, and the appli- cation repeated every night for one week. It must be remembered that the remedy is to be applied to the scalp and not to the hair, and that it is necessary to use only a very little of the ointment. After one week's use of the sulphur the head is to be washed with soap and water, and the salve, immediately reapplied. During the second week it will be sufficient to make the applica- tion every other night. Thus the treatment is to be con- tinued, the number of applications being reduced until they are made but once a week. By this time the disease will usually be cured. The patient is to be cautioned that relapses are likely to occur, and therefore it will be best for him to keep a supply of his salve on hand, so as to attack the trouble as soon as it shows itself. 616 DISEASES OF THE SKIN The ointment recommended by Dr. E. B. Bronson is a very elegant as well as efficient substitute for the sulphur. It is: 1$ — Hydrarg. ammon., gr. xx-xl 1.33-2.66; Hydrarg. chlor. mitis, gr. xl-lxxx 2.66-5.33J Vaselini, ad §j ad 32 M. This is to be used in the same manner as the sulphur ointment. While one or the other of these will bring the case to a happy issue, it is well to have a variety of means at command. H. R. Crocker 1 commends: -Ac. acetici, 5ss-j 15-30 Resorcin., _ 3i 4 Aq. cologniensis 5ij 60 Glycerini, 3j 4 Aqua? rosse, ad 5 vii j ad 240 M. Some other remedies are salicylic acid in castor oil, 3 per cent, strength; resorcin in oil, diluted alcohol, or vaselin in 3 to 10 per cent, strength; or a solution of hydrate of chloral, a dram to the ounce. A favorite formula is : , 06 1$ — Hydrarg. bichlor., gr. j Resorcin. seu, 3J 4 Euresol, 01. ricini, gtt. XV 1 Alcohol, ad giv ad 120 M. This will cause an exfoliation of the scalp in some cases, but this does no harm. Resorcin should never be pre- scribed for those whose hair is white, gray, or blond, as it stains the hair a greenish shade. For a soap, both for cleansing and stimulation, the tincture of green soap or tar soap may be used. If the scalp is peculiarly irritable, then it is best to use a milder soap, such as glycerin soap. The treatment of seborrhea of the body and face is upon the same lines as that of the scalp, only on the body we can use an ointment instead of an oil. 1 Clin. Jour., London, 1897, x, 81. Sporotrichosis. (Arndt.) SPOROTRICHOSIS HYPODERMICA 617 For the seborrhea of infants usually all that is re- quired is to keep the scalp well oiled with olive oil. If this does not cure, then a mild sulphur ointment with vaselin may be used. For seborrhea oleosa of the face, dabbing ether on the part will most promptly remove the greasy look. Washing with soap and water will act as a stimulant. Powdering with sulphur and starch; or using a 3 per cent, solution of resorcin in alcohol and water, will tend to cure, but the disease is seldom eradicated, and is always more difficult to treat than the dry form. Prognosis. — Seborrhea oleosa is often recovered from when the patient is in good general condition. Sebor- rhea sicca is usually readily relieved, but is very sure to return, so that the patient must keep by him for further use any remedy he has found efficacious. Seborrhea Congestiva. — See Lupus erythematosus. Shingles. — See Zoster. Siderosis. — A defacement of the skin due to the en- trance into it of small particles of iron or steel, producing blue-black marks. It is seen in iron-workers. Spider Cancer. — See Telangiectasis. Sporotrichosis Hypodermica. — According to De Beuer- mann and Gougerot 1 this disease is due to the invasion of the skin by several kinds of Sporotrichium, a vege- table fungus. Symptoms. — The invasion takes place insidiously. Once the disease begins it is progressive. It usually causes no disturbance of the general health, but in some acutely developing cases there may be fever, loss of flesh, and other constitutional symptoms. It occurs in three forms. 1st Form. Three or four weeks after invasion there is an eruption of subcutaneous nodules over the whole 1 Annal. derm, et syph., 1906, vii, 837. 618 DISEASES OF THE SKIN body. Each nodule attains its full maturity and be- comes an abscess in from four to six weeks. They begin as small, subcutaneous, hard, elastic, movable, painless nodules, 5 to 6 mm. in diameter, which are but slightly elevated. The skin at this stage is unchanged. They slowly enlarge to the diameter of 20 or 30 mm., become more elevated, and the skin over them becomes rosy, violaceous, or brown in color. In about four weeks' time softening of the nodes occurs. The nodes go on to form abscesses which do not tend to open of themselves. The contents of these abscesses is viscous or gummous, at first translucent though streaked with pus. Later it is purulent, opaque, and thick, and cultures show sporotrichium Beuermann. If an abscess is opened, the incision remains open, and a little thick serum wells out which may or may not be purulent. The incision gapes and transforms itself into a round ulcer, secreting a sero-pus, which forms a thick crust. Untreated the disease continues to spread in the same manner. 2d Form. This is like the first, but its abscesses are larger, they heal easily, contain gray-whitish pus, and in their cultures is found another species of sporotrichium called S. Dori. This is a fungus midway between a streptothrix and a trichophyton. 3d Form. In this, in from one to three months after a traumatism, a small cold abscess develops at the point of inoculation which leaves a persistent ulceration last- ing many months. Some days or weeks after the initial lesion a hard nodule appears above it in the course of the lymphatic trunk, and so the disease spreads up the limb. The nodes undergo softening and ulcerate spon- taneously. The lymphatic trunks between the nodules can be felt like whip cords, but the skin is sound and the health unaffected. This form is due to the S. Schenkii, which differs from the other two. Cases of mixed types are occasionally encountered. Etiology. — The disease is caused by the invasion of the skin by the sporotrichium, of which there are several SPOROTRICHOSIS HYPODERMICA 619 varieties. The organism consists of branching, septate, coarse mycelia, from which ovoid bodies develop by budding. Infection takes place usually from decaying vegetable matter, and the disease is met with principally in farmers. Fig. 90 The organism from Case 1, a branching, septate coarse mycelium, from which ovoid bodies (spores) develop by budding, either from lateral or terminal filaments, or from the sides of the threads. (Sutton: Jour. Amer. Med. Assoc, 1911, lvi, 1309. Diagnosis. — Syphilis is diagnosed from sporotrichosis by having fewer gummatous lesions which undergo a slower evolution, and form smaller abscesses. They open of themselves, and the ulcers that form have more in- filtrated dark red borders, their floor is more uneven, and their crusts are green. Their cultures do not show sporo- trichia. Mercury cures them, and has no influence on sporotrichosis. Blastomycosis affects the health more profoundly, its evolution when acute, is attended by fever, its abscesses are painful, and it has other skin 620 DISEASES OF THE SKIN lesions. The organism found in the cultures is not the same. Treatment. — All forms yield readily to iodide of potassium, 30 to 60 grains a day. The gummas should be opened, and the ulcerations treated with compresses of a solution of iodine 1, potassium iodide 10, water 500. Sweating, Excessive.— See Hyperidrosis. Sycosis. — Synonyms: Sycosis non parasitica; Sycosis menti; Sycosis barbae; Mentagra; Acne mentagra; Fol- liculitis barbae; Folliculitis pilorum; Herpes pustulosus mentagra; Lichen menti; Acne sycosis; (Fr.) Sycosis non parasitaire; Dartre pustuleuse mentagre; Adeno- trichie; (Ger.) Bartfinne, Bartflechte; Fikosis; (Eng.) Barber's itch. An acute or chronic follicular and perifollicular inflam- mation of the long hairs, chiefly affecting the bearded portions of the face; characterized by an eruption of papules, pustules, and nodules perforated by hairs; by the formation of infiltrated patches; and by a greater or lesser amount of crusting. Sometimes the disease is so intense that abscesses form. Symptoms. — The disease begins by the formation of a number of red inflammatory papules and nodules which are more or less conical, usually raised above the surface of the skin, and always perforated by hairs. Their appearance is preceded and accompanied by disagreeable local sensations, such as pricking, burning, and smarting, and at times by a feeling of tension in the part on account of swelling of the skin. In acute cases there is con- siderable redness of the skin between the papules, and the inflammation may be so intense as to give rise to enlargement of the neighboring lymphatic glands. The papules and nodules vary in size from that of a millet- seed to that of a pea, and are isolated or grouped, not every hair follicle in a diseased part being affected by the perifollicular inflammation. Only in very severe SYCOSIS 621 outbreaks or in acute exacerbations do the papules and nodules tend to run together and form infiltrated patches. The papules and nodules soon change into pustules, which are likewise always pierced by hairs. These Fig. 91 Sycosis vulgaris of moderate development. (Stelwagon.) pustules, conical in shape, and perforated by hairs, are pathognomonic of the disease. In old cases they are met with in the infiltrated patches arising apparently without the preceding appearance of papules and nod- ules. The pustules show no tendency to rupture, but the 622 DISEASES OF THE SKIN pus accumulates below, swells up alongside of the hair, appears upon the surface of the skin, and dries into thin crusts. The amount of crusting is never very great, far less than in eczema of the beard, mainly limited to the affected follicles, and is most appreciable when the beard is growing. If the inflammation is very intense, we may meet with small cutaneous abscesses here and there instead of pustules. According to A. R. Robinson, the amount of pus-production varies with the individual attacked, being more rapid and abundant in the robust than in the scrofulous; in acute than in chronic cases. The hairs, if of any length, are early affected in appear- ance, becoming lustreless. They are at first firmly seated in their follicles, and when pulled upon give rise to pain, and if extracted their root sheaths will appear as clear glassy cylinders. Later, as pus forms more abundantly in the perifollicular tissues, and the follicles themselves are involved in the process, the hair becomes loosened and easily extracted, when its root sheath will be found swollen with pus. If the pus production is exces- sive, the hairs will fall of themselves or upon the slightest traction. When this occurs the hair papillae may be so damaged that no new hairs will form. In chronic cases the beard is markedly thinned, though permanent loss of hair is the exception. The disease may attack any part of the bearded face, and may be met with in other hairy regions, as the neck, the eyebrows, scalp, axilla, and pubes. Occurring else- where than on the face the disease is called folliculitis, and not sycosis. But the beard is by far most often the site of the disease, the other situations being affected in the order in which they are named. Occurring in the beard, it may be limited to a single region and show no tendency to spread. Thus it is met with very frequently upon the upper lip alone, or at times upon the cheeks alone. When it affects the upper lip alone it is always preceded by nasal catarrh, and takes the form of a SYCOSIS 623 diffused dermatitis with much thickening of the lip and some crusting. It may attack the whole bearded face in an acute outbreak, or it may involve it by extension from a limited area during a number of successive outbreaks. Very often it spares the chin. In chronic cases it is usually symmetrical. The course of the disease is chronic and made up of a number of acute exacerbations. If left to itself, it may produce a good deal of deformity, the lesions breaking down, ulcerating, and leaving cicatricial tissue and more or less baldness, though this is excep- tional. To this the name of ulerythema sycosiforme has been given. A typical case of sycosis presents the following appear- ance: upon a single region, two or more regions, or upon the whole bearded portion of the face there will appear a number of isolated or grouped papules, nodules, and pustules pierced by hairs. The skin about the lesions is reddened and swollen, it may be indurated, and there is a slight amount of crusting. There is no tendency for the disease to spread to non-hairy parts, but very commonly the eyebrows will be similary affected, and a blepharitis will be present. When the case is watched for a time marked exacerbations will arise often without apparent cause, last for a few days, and then the disease will sink into a subacute condition only to light up again. When the disease affects the vibrissas of the nose, by extension from the upper lip, the Schneiderian membrane becomes swollen and exquisitely sensitive. The patient does not complain of itching, but of pain and discomfort. The disease tends to run a chronic course, lasting for years. Etiology. — The disease is undoubtedly microbic due to the invasion of the hair follicles by staphylococcus albus et aureus. In the great majority of cases it is the latter. It is not very common, perhaps one case in three or four hundred. It is doubtless contagious in some cases, and frequently transferred by the agency of the barber shop. It is seen in men almost exclusively, as we might 624 DISEASES OF THE SKIN expect, as it is the beard that is most often affected and attacks them most frequently between the ages of twenty-five and fifty. It affects all classes and condi- tions. Most of its subjects are in poor general con- dition. Eczema is often a forerunner of sycosis, the one process passing over into the other. A nasal catarrh is the cause of the majority of cases occurring on the upper lip. Shaving with a dull razor against a stiff beard is said to be sometimes an exciting cause, though those who do not shave are by no means exempt from the disease. The barber shop is a prolific source of contagion. An irritant applied to the skin may excite it, such as exposure to intense heat, the dust of a workshop, cosmetics, poultic- ing and the like. Exposure to inclement weather is regarded by Wilson as the principal cause. Given a hyperemic or irritable condition of the skin of the face, arising from any internal or external cause, the hairs, especially if they are coarse, may excite the disease, acting as irritants when touched or moved. Hebra thinks that some cases may be due to an abnor- mality in the growth of new hairs. Wertheim ascribed the inflammation to irritation of the hair follicle by hairs, whose diameter was, relatively, too large for their follicles. Pathology. — The disease is primarily a perifollicu- litis, the hair follicles being affected secondarily, and after them the sebaceous glands. The hair papillae, as a rule, are not destroyed. Tommasoli has described a special organism as its cause, which he named bacillus sycosiferus fetidus, and has produced the disease in rabbits by inoculating them with pure cultures of his bacillus. Diagnosis. — The distinguishing characteristic of sycosis is the presence of pustules pierced by hairs. It may be diagnosed from trichophytosis barbae, eczema barbae, the small pustular syphiloderm, acne, and lupus. The differential diagnosis of sycosis from trichophytosis barbce is as follows: SYCOSIS .25 Trichophytosis Barbae. Begins as a small scaly spot, a su- perficial ringworm, and gradu- ally involves the deeper parts of the hair. Has its favorite seat upon the chin and the submaxillary region; rarely attacks the upper lip. The eruption consists of nodules which tend to group and are studded with a number of hairs. The internodular portions of the skin often remain unaffected. Is a deep inflammatory process so soon as the hairs become af- fected. Hair is diseased primarily, and is twisted, split and broken. May readily be removed by slight traction and without pain. Its root is often dry. Subjective symptoms slight, may be only slight pruritus. Patches of ringworm often present on other parts of the body, and sometimes the disease extends upon the neck or face. Hairs and scales loaded with the trichophyton fungus. Is a progressive disease, and when cured not liable to relapse. Sycosis. Begins suddenly with an outbreak of papules which soon become pustules, each of which at the start involves a hair. Its favorite seat is the upper lip, and sometimes it alone is in- volved. Involves the hairy por- tions of the face more generally, and is often symmetrical. The eruption consists of papules and pustules, each of which is pierced by a single hair, and they show no disposition to group. The intervening skin is generally reddened, and may be diffusely infiltrated; and ab- scesses may form. Is a more superficial inflamma- tion. Hair diseased secondarily, and comes away at first with diffi- culty, causing much pain. Later is easily removed and its root is swollen with pus. Subjective symptoms of pricking, burning, and tension of the part. These are often intense and at- tended by swelling of the face. Limited in most cases to hairy parts of face. No tendency to extend on non-hairy parts of face or neck. The ordinary pus cocci only are found. The course of the disease made up of a number of acute outbreaks. Liable to relapse. The differential diagnosis from eczema of the beard cannot be made with so much certainty, and often we must remain for a while in doubt as to the true nature of the case. At times sycosis is left by a preceding eczema, and we may meet with a case in the transition stage when a sure diagnosis would, manifestly, be impossible. A typical case of pustular eczema is attended by a far greater amount of crusting than is sycosis, and the crust is of a more greenish or blackish color. Upon removing the crust in eczema a moist and oozing surface will be exposed, while in sycosis we will do no more than remove the "tops from a number of pustules. In eczema the pus- 40 626 DISEASES OF THE SKIN tules break down more readily than in sycosis, and they are not so accurately located about the hairs. In eczema the whole surface of the skin is involved, and the process tends to extend upon non-hairy parts of the face. While exceptionally eczema is confined to the hairy portion of the face, this is always so in sycosis. Eczema itches, sycosis does not. The duration of the disease will at times help us to a diagnosis, sycosis being far more chronic than is eczema. In syphilis, when the beard is involved, we will find pustules upon other portions of the body, and the history will help us to a correct conclusion. Further, the pustules or papules of syphilis are grouped in circles and segments of circles, are of a peculiar color, and their development is painless and comparatively slow. Acne is scattered about the whole face, and is usually met with in young persons. Comedones are present, and the pap- ules, pustules, or tubercles have no definite relation to the hair. The course and history of lupus are so different from those of sycosis that it is hardly possible for them to be confused. In lupus vulgaris we have the charac- teristic brown tubercles, which do not contain pus, are not confined to the hairy portions of the face, generally begin in early life, and tend to ulcerate or to be absorbed and leave behind cicatrices. Treatment. — The treatment of sycosis is both general and local. While many cases will yield to local treatment alone, there are quite as many, if not more, which require general treatment. The surroundings of the patient must be inquired into, and his mode of life, and we should endeavor to put him in as good a hygienic condition as possible. He should be advised against exposing himself to dust and wind, and then only with his face powdered or protected with ointmnet, and even against smoking, especially in a wind where the smoke blows against the face. The proper regulation of the diet is important. Many cases will improve if we stop their tea, coffee, hot drinks of all sorts, ale, beer, and spirits. If the digestive process seems at all embarrassed, it is well to put the SYCOSIS 627 patient on a light diet for morning and evening, and direct him to take his principal meal at noon, eating meat only at that time. Anything that is known to him to be indigestible must, of course, be prohibited. In a word, the diet and hygiene of the patient should be regulated. What medicines we should administer will depend upon the stage of the disease. In the acute stage, when there are much swelling and inflammation, a good dose of blue pill, calomel, or some other active cathartic is to be ordered, to be followed by an alkaline diuretic. Small doses of calomel, T V of a grain, three times a day, for two or three days at a time, are useful in reliev- ing the congestion of the skin. In chronic cases iron, cod-liver oil, and other tonics are indicated if there is a state of debility. Arsenic is advised in very obstinate cases. If indigestion is present, we must address our remedies to its relief before we give arsenic or other remedy for the disease proper, and then we will probably have no need of so-called specifics. The local treatment must vary with the condition found, whether it be acute or subacute, and is more important than the general treatment. When the disease attacks the upper lip the nose must be examined for evidences of catarrh, and that condition treated if found. In the management of an acute case of sycosis soothing remedies are needed. Hot water should be sopped upon the part for some five or ten minutes once or twice a day, and this should be followed, if the beard is growing, by the use of a simple oil, such as olive oil or sweet almond oil; or if the face is shaved, the zinc oxide ointment or cold cream may be used; or better still, Lassar's paste, as follows : 1$ — Amyli, i Zinc oxidi, aa 3ij aa 8| Vaselini, ad §j ad 32 1 M. Powdering the part with corn starch, or bismuth and talc, after smearing on a little vaselin, will at times give ease and comfort. 628 DISEASES OF THE SKIN In the early stage, if the inflammatory symptoms are not very intense, a mild white precipitate ointment will sometimes check the disease. Duhring recommends bath- ing the face with "black wash," followed by zinc oxide ointment with a dram (4) of alcohol or a half dram (2) of camphor to the ounce (32), spread on cloths and bound on; and speaks well of oxide of zinc ointment with 15 to 30 (1 to 2) grains of calomel to the ounce. When the disease has reached the pustular stage, and there is more or less crusting, the crusts are to be removed by the free use of olive oil, or oil of sweet almonds with 2 per cent, of salicylic acid, letting it soak in thoroughly over night and washing the part with soap and warm water the next morning. If the crusts are thick, it is a good plan to tie up the bearded face in a towel after anointing it with oil. After the crusts are gotten rid of, the hairs should be pulled out of the pustules and epila- tion continued until pustules cease to form. The patient must be made to understand that epilation is necessary both for the cure of the affection and the salvation of the hair. After epilating, the oxide of zinc ointment, Lassar's paste, or diachylon ointment is to be used. Shaving is recommended, but it seems to me better to content our- selves with cutting the hair short. Shaving is prone to irritate the skin, and certainly would favor the dissemina- tion of the pus organisms. Sulphur in the form of an ointment, \ drachm to 1 drachm (2 to 4) to the ounce (32), or in powder, is a valuable remedy, though some- times it is too irritating. Instead of an ointment we may use oxide of zinc, 1 drachm (4) to the ounce (32) of linseed or other oil. Shoemaker advises the application of equal parts of oleate of mercury and olive oil. In subacute and chronic cases a more active treatment is necessary. Here our aim is not so much to allay inflammation as to stimulate the skin. To this end we may use the soap and sake treatment of Hebra, which renders such good service in chronic cases of eczema. SYCOSIS 629 In some cases better results will be attained by the use of diachylon ointment, or Lassar's paste with 10 or 15 grains (0.66 to 1) of salicylic acid to the ounce (32). In very obstinate cases in which there is much thickening of the skin green soap may be kept applied to the part like an ointment. When sufficient inflammatory reaction is produced emollient measures, as in the acute stage, should be used. Our success in treating these cases will vary with the thoroughness with which the dressings are applied. All ointments must be spread on cloths, not on the skin, and the dressings must be kept continuously in close contact with the affected part. Sometimes a sulphur ointment, J drachm to 2 drachms (2 to 8) to the ounce (32); an oint- ment of iodide of sulphur; the ointment of the ammoniate (gr. xv-xxx ad §j) or the nitrate (3;HJ ad 5j)> or the red oxide (gr. v-xv ad §j) of mercury will prove useful. Robinson recommends the following ointment. 1$ — Ungt. diachyli (Hebra), Ungt. zinc oxidi., Ungt. hydrarg. ammon., Bismuth, subnitrat., giss aa 48 3hj 12 3iss 6 M. He has found cod-liver oil the best local application in strumous subjects. Behrend has obtained good results by scraping the affected parts with the dermal curette and dressing with a simple ointment or oil. All abscesses must be opened. In some cases the following ointment has given me satisfaction after other combinations have failed: — Ac. salicylic, gr. x ! 66 Sulph. colloidal, 5j 4 Eucerin, 3vj 24 i Adipis anserini, ad gj 32 01. rosse geran., gtt. XV 1 M Solutions of the bichloride of mercury, 1 to 1000; or of resorcin in alcohol 5 per cent, strength, after shaving, may be used. Tumenol in 10 per cent, ointment at times is excellent. -/S-naphtol, gr. xv Spts. sapo. viridis, 5vj Alcoholis, 5iss Bals. Peruv., 3ss Sulph. loti, 3iiss 630 DISEASES OF THE SKIN Kaposi recommends the following: ai 45 2 10 M. The ammonio-sulphate of ichthyol and other drugs used by cataphoresis are commended. Boric acid does good in some cases. To assure against a relapse it is necessary to continue making applica- tions to the skin for four or five months after apparent recovery. The x-rays have a brilliant curative effect in sycosis. MacKee advises giving a massive dose of H. 4 and B. 8 to 10. It is well to use some one of the antiparasitic lotions or ointments while using radiotherapy. The use of staphylococcic vaccines has its advocates. According to Engman, the results usually obtained from the treat- ment of this disease by stock or autogenous vaccines are not satisfactory unless hot packs are used, for obvious reasons. The disease is purely follicular with the guard- ing wall of the follicle to protect the cocci from influx of fresh lymph. Hot packs under an impervious cover applied three or four times a day change conditions materially. The dose varies as in furunculosis. Prognosis. — This is one of the most obstinate of diseases. Left to itself, when once under headway it shows no tendency to get well, and has been known to last twenty or thirty years. Even under the most judi- cious treatment it is an obstinate disease, taking weeks or months before a cure is effected. Relapses are exceed- ingly liable to occur, and these sometimes show a dispo- sition to recur at certain seasons. Unless the hair is carefully plucked from the inflamed follicles permanent baldness may be caused. But the disease is not danger- ous to life, and it is curable. Syphilis. — Synonyms: Malum venereum; Lues; Morbus Gallicus, seu Italicus, sen Hispanicus, sen Neapolitanus, SYPHILIS 631 'Seu Indicus; (Fr.) Verole, or Grosse verole; (Ger.) Lust- seuche; (Eng.) Bad disorder, Pox. Large books have been written upon this disease. Here we can give only a brief outline of it, and that as it affects the skin alone. For a further account the reader should consult the larger special treatises. Symptoms. — Syphilis may be acquired or hereditary. It is acquired by local infection, the first manifestation of which is the appearance of the initial lesion, commonly called the chancre or hard sore. In probably 90 per cent, of the cases this initial lesion is located on the genitals, and in the vast majority of these its site in males is the glans and prepuce. But the initial lesion may be found on any part of the body, and within the mucous cavities. According to a table of 198 extragenital lesions compiled by Pospelow, 1 the female breasts were affected in 69 cases; the lips in 49 cases; the throat in 46 cases; and then in very much less frequency the gums, tongue, chin, eyelids, nose, trunk, anus, arms, and legs. Some obscure cases of syphilis are due to the initial lesion being in the urethra or upon the cervix uteri or deep in the throat, and thus escaping detection. The initial lesion appears within two to six weeks after inoculation with the syphilitic poison; usually the inter- val is less than four weeks; exceptionally it may be ten weeks. This is the period of incubation. Opinions are divided as to whether the initial lesion is a purely local- ized lesion or the expression of a general constitutional infection that first declares itself at the point of inocula- tion. The initial lesion may assume the form of a scaly patch, a dry or moist papule, a superficial erosion, or a circumscribed ulcer with perpendicular edge. Induration of the base is a characteristic of all forms of initial lesion ; it is sharply defined and imparts to the fingers a distinct resistance that may be as firm as cartilage. Commonly it is parchment-like. To detect it, the lesion must be 1 Arch. f. Dermat. u. Syph., 1889, xxi, .59. 632 DISEASES OF THE SKIN gently pinched between the thumb and finger. It is present coincidently with the appearance of the initial lesion or within a few days afterward. It remains for a long time after the disappearance of the lesion — for two or three months or longer. The secretion from the initial lesion, when present, is thin and chiefly serous. The duration of the lesion is variable; it may disappear before the outbreak of cutaneous symptoms, but very often remains for some time after this event. Unless there has been ulceration, no cicatrix will be left. It may leave a staining of the skin or an induration. It is usually a solitary lesion, though it may be multiple. Taylor 1 says it is not uncommon to see from three to thirteen chancres which appear successively either due to auto-infection, or infection from two individuals. En- largement of the nearest lymphatic glands accompanies the initial lesion. If on the external genitals, it will be those of one or both groins. They become hard and are painless and freely movable. Suppuration is rare, and probably the result of mixed infection. A pleiad of glands, three arranged in a triangle, is quite character- istic of syphilitic infection. In women initial lesions are often so small and last so short a time that they are not noticed. In them induration is often not noticeable, and the diagnosis is much more difficult than in men. They are found on the external genitals, within the vagina, and on the cervix uteri. The initial lesion may at first assume the character of the soft sore. This is the result of mixed infection with both the virus of syphilis and of the local venereal ulcer. The ulcer will after a while become indurated and as- sume its proper characteristics. It is in these cases that a suppurating adenitis may develop. Modifications from location of the initial lesion must also be noted. (1) Of the urethra: A chancre may be at the meatus, in the fossa navicularis, or deeper parts. At the meatus 1 Jour. Cutan. Dis., 1906, xxiv, 401. SYPHILIS 633 it attracts attention by causing a slight impediment to urination. The lips are found glued together by a scanty viscid secretion. The normal opening of the urethra becomes lessened by the induration, which usually involves the entire circumference of the meatus. If located deeper down, it may give rise not only to inter- ference with urination, but also to some pain, and later to a mucopurulent or purulent discharge like that of gonorrhea, because it causes a urethritis. It may be felt as a hard, tender, circumscribed nodule, and be seen, with the endoscope, as a grayish-red erosion of the urethral wall. It may give rise to symptoms of stricture. (2) Of the anus: A chancre may be without the anus, at its margin, or within the anal ring, and usually presents a thickened, fissured, ulcerated surface. It is of a pale- rose tint, and decidedly indurated. (3) Of the fingers: 1 An initial lesion may be seated at any part of the phal- anges, but most often at the sides or base of the nail, or at its free margin. It begins as a papule, pustule, ex- coriation, or fissure, and attracts attention as an obstinate hang-nail or fissure; or as an irregular, deep-red, some- what elevated mass that is ulcerated and covered with a scanty serous secretion. The finger is apt to be swollen at its end. The epitrochlear and axillary-ganglia are enlarged, and there may be moderate lymphangitis. (4) Of the lips: This chancre is usually covered with a greenish-brown crust, which, when removed, leaves either an erosion of little, if any, hardness, or an ulceration of cartilaginous consistence. It may begin as a fissure or painful excoriation. The lips may be greatly swollen. Either the upper or lower one may be affected; usually only one. The submaxillary glands on the side of the lesion are commonly first affected. (5) Of the tongue: Here we meet with a hard, circumscribed, flat, slightly elevated, dull-red, smooth, pea-sized nodule; or a round, sharply defined, fleshy red, raised, hard ulcer. The 1 An admirable study of these lesions by Dr. R. W. Taylor will be found in the Medical Record, 1891, xxxix, 69. 634 DISEASES OF THE SKIN cervical and submaxillary glands are enlarged. (6) Of the throat: The patient first notices difficulty or pain in swallowing, the latter in the region of the tonsils. Then the submaxillary and cervical glands become swollen. Examination shows an intense, limited or diffused, gen- eral or unilateral, brown or dark redness of the pharynx. The tonsils are enlarged, hard, and red, and may be eroded, and perhaps covered with an ash-colored deposit —a false membrane. Or we may find an irregular, hard ulcer with gnawed-out edges, and, it may be, crater- shaped floor covered with dirty brown or grayish deposit. One or both tonsils may be affected. (7) Of the nipple: Chancres of the nipple are usually multiple, and may Fig. 92 Chancre of the lips. (By the courtesy of Dr. S. D. Hubbard.) take the form of an erosion, a scaly patch, or an indur- ated fissure. The size varies from that of a lentil up even to three inches in diameter. They are sometimes linear, sometimes sickle-shaped along one side of the nipple, and sometimes completely encircle the nipple. The nipple is red or dark, enlarged, hardened, and at times flattened. Mastitis may complicate matters. The axillary glands are enlarged, as are often those along the upper edge of the pectoralis major. On healing the initial lesion leaves a flattening of the nipple, and per- haps a leaning of it to one side, characteristics that should put us on our guard in the examination of wet-nurses. About six weeks after the appearance of the initial SYPHILIS 635 lesion (it may be as early as the twenty-fifth day, or as late as the one hundred and sixtieth), we have the stage of eruption of the so-called secondary syphilides. Usually just before the outbreak of the eruption, or shortly after it, examination will show a general enlargement of the lymphatic glands, especially the epitrochlear and postcervical. At the time of the eruption, or shortly before, the patient may experience certain constitutional disturbances, such as severe headache, malaise, pains in the joints, and a rise of temperature of moderate extent. In very many cases these disturbances either do not exist, or are of so slight severity as not to attract the patient's notice. In some cases a more or less profound anemia will manifest itself, or the patient will fall into a markedly cachectic condition. Either of these may last far into the secondary period of the disease. Weakly individuals are more prone to these severe constitutional derangements than are the robust, and Fournier teaches that they are most apt to appear in women. The eruptions of syphilis are, for convenience, divided into two groups named, respectively, secondary syphilides and tertiary syphilides; or the early and late lesions. No hard-and-fast lines can be drawn, as sometimes those lesions usually seen late in the disease manifest themselves early in its course. The secondary syphilides are those that develop during the first two years after infection. They are marked by a more or less general and symmet- rical dissemination over the whole cutaneous surface; by polymorphism; by running a rather definite course; by implicating the more superficial parts of the skin and mucous membranes; and by leaving little, if any, trace of themselves. In these respects they differ from the lesions of late syphilis, which are grouped and limited to certain regions, are not polymorphic, show less tendency to run a definite course, involve the deeper structures, and are prone to leave permanent scars. The eruptions of secondary syphilis are the erythema- tous, the papular, and the pustular syphilide. The first 636 DISEASES OF THE SKIN eruption of the secondary stage is usually an erythema- tous one, the macular syphilide, or the syphilitic roseola. Unlike other syphilides, which are all largely composed of new cell-growth, this may be a hyperemia without cell- infiltration. It may be a general eruption, though usually most marked upon the sides of the trunk and flexor aspect of the limbs. The macules are about the size of a ten-cent piece, or smaller, of a faint rose-red color, circular in form, and little if at all raised above the skin. At times we meet with annular lesions from dis- appearance of the centre of the macule. This is especially seen in the colored race. The lesions excepting in relaps- ing eruptions, are distinct from each other. They become more evident on exposure to cold, it being no uncommon thing to see them appear upon the patient's body while he is before us stripped for examination. After being out for a time their color becomes purplish red, changing to a tawny or yellowish red, and later to a brownish yellow. In their early stage they can be made to dis- appear on pressure. They either disappear and leave no trace or some pigmentation, or they develop into papules. The evolution of this eruption usually requires a week or ten days; sometimes it may be much less. The duration of the eruption is from one to three months if not removed by treatment. Relapses occasionally occur, and these may be met with as late as the end of the first year. Then it is usually limited to certain regions. It gives rise to no inconvenience, and is often overlooked by the patient except when it appears on the face or hands. At this time there are apt to be an ery- thematous condition of the pharynx, some sore throat, a rheumatoid affection of the joints, falling of the hair, perhaps an iritis, and mucous patches in the mouth, upon the vulva, in the groin, upon the scrotum and under surface of the penis, and about the anus. While the diagnosis is easy, if we have seen the patient from the time of the initial lesion, in some cases we must differentiate between it and mottling of the skin; an SYPHILIS 637 exanthem; a medicinal eruption, chromophytosis ; and, if we have annular macules, trichophytosis corporis. From mottling of the skin it is diagnosed by the fact that in syphilis we have macules of a reddish tint interspersed with skin of normal hue, while in mottling we have light macules with dull purplish-red interspaces. From an exanthematous fever it is diagnosed by the absence of catarrhal or gastric symptoms and marked pyrexia, and by the sluggish character of its lesions. From a medicinal eruption it is diagnosed by an absence of gastric disturbance, and by its lesions lacking the urticarial or edematous character. From chromophytosis it differs in having a red rather than a cafe-au-lait color, by not being scaly nor capable of removal by scraping, by its more extensive distribution, and by the absence of the microsporon furfur from the scales when they are examined under the microscope. From trichophytosis it differs in the greater extent of its distribution, and in the absence of the trichophyton fungus from scales scraped from the skin. From pityriasis rosea the differentiation is some- times difficult when the syphilitic macules have assumed a ring-form. As a rule, there is no difficulty, as a pity- riasis rosea will be scaly, and will present not only rings, but macules of all sizes, while the syphilitic macules are not scaly and are of more uniform size. The papular syphilide, while usually following the erythematous syphilide, may be the first eruption of the disease. Indeed, a great many cases begin as a maculo- papular eruption. The papules may develop from macules or may appear as papules. Very commonly both macules and papules will be present at the same time. If it fol- lows the macular form, it is apt to appear while the latter is fading. The eruption consists of a greater or less number of firm, rounded, fleshy, red elevations of the skin, varying in size from that of a pinhead to one inch in diameter. After continuing unchanged for a certain time they undergo absorption; the oldest or central part of the 638 DISEASES OF THE SKIN papule disappears first, sinks in a little, and becomes scaly. It is then that slight pruritus may be complained of. They are scattered over the whole cutaneous surface, and often appear in well marked groups with somewhat of a crescentic arrangement. They are prone to relapses, and sometimes are seen as a relapsing eruption in the tertiary stage of the disease, when they do not occur as a general eruption, but in groups upon one or more regions of the body. According to their size, they have received the names of the lenticular and miliary papular syphilide, the former being the larger and most common eruption. The lenticular papular syphilide is a hemispherical or flattened, firm, fleshy, lentil- to split-pea-sized promi- nence with a smooth and glossy surface. Not infrequently the superficial layer of epidermis over it is wanting from the central portion and slightly detached around the base, forming a fringe called the collarette of Biett. This is regarded as a diagnostic symptom. The color of the pap- ule is at first light red; later it assumes a raw-ham color that is best seen on the legs. From the knee down it may have a purplish or hemorrhagic appearance. Such papules are usually present in great number and scattered over the whole body. On the face they are apt to locate along the hair-line on the forehead, forming the corona veneris. On the scalp they are not very numerous, and are apt to become papulopustules and crust; or they itch slightly and are scratched. The palms and soles are usually well covered in any general outbreak of them. Here they appear as reddish spots under the thick epi- dermis, and a little later than on the rest of the body on account of the thickness of the epidermis retarding their outbreak. Desquamation is often seen over the papules on the palms and soles. Sometimes the eruption is very slight in extent, only a few scattered papules being found. This syphilide develops slowly, runs a course of one or two months, and disappears, leaving pigmentation or slightly depressed spots neither of which is permanent. In undergoing resolution the papules may become scaly SYPHILIS 039 and form a papulosquamous syphilide, or pustules may form on them during their course, and we then have the papulopustular syphilide. While the form of the lenticular syphilide just described is the typical one, we see at times larger papules, from three-eighths to half an inch in diameter, forming the discoid or large, flat, papular syphilide. This rarely, if ever, is a general eruption, but is limited to certain regions. It may occur alone or with the lenticular Fig. 93 Papular syphilide of palms. (By the courtesy of Dr. S. D. Hubbard.) syphilide. It usually follows the latter or appears when it is fading. It frequently comes as a relapsing syphilide, and often appears late in the second year. It has a flattened surface and a circular outline. The lesions often coalesce and form patches which frequently become scaly and resemble psoriasis. The scaling is never very great; the scales are thin and adherent, and do not cover the whole patch. They frequently occur upon the flexor aspect of the extremities and in the bends of the joints. 640 DISEASES OF THE SKIN Instead of forming patches by coalescence, the individual papule may enlarge at the circumference and become depressed at the centre and form circinate lesions, whose surface may become moist. Fig. 94 Annular syphilide. (Courtesy of Dr. H. Fox.) The moist papule or mucous patch is a modified form of the lenticular papule, and is simply a papule subjected to heat and moisture. It is found where two folds of skin rub together, as in the penoscrotal fold, between the scrotum and inside of the thigh, around the anus and vulva, and upon mucous membranes. It is of circular shape and has a flattened surface which is sometimes depressed in the centre. Newly formed ones have a bright-red or raw appearance, but they soon become SYPHILIS 641 covered with a dirty whitish coating made up of thickened and softened epidermis. About the anus and vulva they form large flattened tubercules called condylomata lata (Fig. 95). They give forth a most offensive odor when not kept clean. When in the mouth they form "opaline patches/' looking as if the mucous membrane had been penciled with nitrate of silver. They are usually not elevated. If at the angle of the mouth, they are generally fissured. The mucous patch is one of the most conta- gious of syphilitic lesions, the evidence of infection being an initial lesion of syphilis, and not a mucous patch. It is also at times, especially when it comes late in the dis- ease, most obstinate to treatment, and inclined to relapse during many years. Fig. 95 Condyloma lata. (After Taylor.) The miliary papular syphilide is much rarer than the other form of papular syphilide; in fact it is one of the least common of the syphilides. The eruption consists of numerous pinhead- or slightly larger-sized conical papules of a purplish-red hue, either disseminated over the whole body or aggregated in groups forming circles or segments of circles. They are developed about the hair follicles and have depressed centres. Many of them may be surmounted by a small vesicle or vesicopustule. 41 642 DISEASES OF THE SKIN This constitutes what has been named the vesicular syphilide. Sometimes the lesions when closely pressed into patches may be scaly. It may be an early lesion or a relapsing later one. In the latter case the eruption is not abundant, but in groups. The color is brownish-red, and pigmentation and permanent pitting are left by the lesions, if they have lasted any time. They rarely change into condylomata. Their evolution is rapid, being fully developed within two weeks. Pea-sized conical papules sometimes are seen among the miliary ones. When the papules form groups, bearing a fancied resemblance to a bunch of grapes they are spoken of as corymbiform. The diagnosis of the papular forms of syphilis is gen- erally easy because other symptoms of the disease will be sure to be present and to establish the diagnosis. It is possible that error may arise in distinguishing the patches of scaling papules from psoriasis, but here the location of the patches upon the flexor surfaces of the extremities, and over the bends of the elbows; the scaling not being commensurate with the patch, but having a dull red, sharply defined border about it; and the well-marked infiltration of the patches, are all features that would throw out the diagnosis of psoriasis. The miliary papular syphilide may be confounded with lichen planus or keratosis pilaris, but the absence of itching is always in favor of a syphilide; and the conical or rounded shape of its papules is in strong contrast with the flat, angular, and umbilicated papule of lichen planus. The syphilide is also a much more widely disseminated eruption than is lichen planus or keratosis pilaris likely to be, and is never seen confined to the anterior face of the wrists as is lichen planus. The pustular syphilide is the last eruption belonging to the secondary stage that remains to be described. It is always evidence of a poor condition of the health of the patient who bears it. It may be the first eruption of SYPHILIS 643 syphilis, or follow the erythematous or papular form, or occur later. It may develop from a macular or papular syphilide, or occur with either of them. It may occur as a relapsing eruption late in the tertiary period. It is held by some authorities that it is always the product of infection of a syphilide by pus organisms. The appear- ance of this form of syphilide is not infrequently accom- panied by fever. It may assume varying forms and sizes, to which in the faulty nomenclature of the older writers have been given the names of non-specific lesions, greatly to the confusion of the student. The lenticular pustular syphilide (variola form) occurs as a disseminated eruption of small hemispherical, pea- sized pustules, having a hard, papular base and more or less of an inflamed areola. It may develop by the soft- ening of a papule or be a papulopustule from the start. In the latter case its eruption will be marked by fever, which is apt to recur with each succeeding outbreak. The eruption may be general or upon certain regions. The lesions are discrete, and do not form marked groups, although in the pustular eruptions, as in others, it is easy for one who looks for them to find groupings in circles and segments of circles. A few days after they appear they begin to dessicate, and the larger ones may umbili- cate. At this stage they become crusted with a dirty yellow, brownish, or greenish-brown crust. This falls soon and leaves a transient pitting and pigmentation. Relapses may occur. The miliary pustular syphilide (acne-form). The erup- tion consists of millet-seed- to pinhead-sized acuminate pustules developing generally from papules and occurring in small groups of about the size of a quarter- or half- dollar. It may occur as a general eruption, but is apt to be more marked and lasting on the extremities than on the trunk. The lesions, especially when occurring upon the flexor aspect of the joints, are liable to coalesce. They are developed in and around the hair follicles, and may be perforated by hairs. They are topped with small 644 DISEASES OF THE SKIN crusts. The eruption lasts two or three months by the outbreak of new lesions, unless controlled by treatment. It leaves pigmentation and pitting that may remain for several months. While these are the two chief varieties of the early pustular syphilide, there is another variety that is called the impetigo-form syphilide, which occurs most commonly in the middle or latter part of the first year of syphilis. It may occur as late as in the third year. In it the pus- tules are small and flat, and by confluence an impetiginous crust is produced. They may form patches with crusting only at the border. This form is met with usually on the face, arms, and thighs. A few superficial ecthymatous lesions may develop, but ecthymatous lesions are usually late manifestations. The diagnosis of the pustular syphilide is usually easy from the presence of other symptoms of the disease. The lenticular form may be mistaken for variola or varioloid. It differs from these in the infiltrated bases of the pustules, in being composed of lesions of varying size and age, in not occurring in the mouth, and in not running a definite rapid course. The miliary form might be mistaken for acne, but it is never confined to the face, chest, and back as is acne, nor does it present comedones, and so great multiformity of lesions. Tertiary Syphilides. — The erythematous, papular, and pustular syphilides are those eruptions that occur in the early months of syphilis and during the first year. As we have seen, thay may also constitute relapsing eruptions later in the disease. Modifications of them may occur late in the secondary period or even in the tertiary period. Besides these, we have a second group of syphilides that occurs any time after the first year, and sometimes as late as twenty or more years after the initial lesion, when the patient may have lost all remembrance of it. To these eruptions the name of tertiary or late syphilides is given. Their peculiarities have been indicated in a general way SYPHILIS 645 when writing of the early syphilides. They are the tubercular, or nodular, the squamous, the pustulo- crustaceous, the gummatous, and the ulcerative syphilides. Exceptionally these eruptions may occur before the second year, when they are to be regarded as precocious lesions. The tubercular or nodular syphilide occurs in the latter part of the second year of syphilis, or later. Exception- ally it may occur during the first year as a so-called precocious syphilide. As a rule, the early syphilides cease appearing after six or seven months, and then after a varying interval of rest the late lesions appear. These may never come at all, usually as the result of judicious treatment, or it may be because of the vigorous resistance of the constitution of the individual. Nodular lesions occur in the form of clustered nodules in the deeper part of the corium. At first they are of faint-red color; gradually they become a dull red, and later still darker. In size they vary from that of a split pea to that of a hazelnut, and constitute firm, elastic, fleshy protuberances. They are round, smooth, and somewhat glossy, or flat, rugous, and withered. They are frequently scaly. Most often they are arranged in circles or segments of circles; or they may be in the form of rings from the first, or in consequence of the disappearance of the central members of the group (Fig. 96). There may be but a single group; or numerous groups may be scattered over the body in asymmetrical manner. A very frequent location for them is the pos- terior portion of the neck or on the face. The later in the course of the disease they occur, the more they are apt to form but a single group. If uninfluenced by treatment, nodules may continue to form for years, the old ones disappearing and new ones coming. They disappear either by absorption, or by softening or break- ing down and forming a sharply-cut ulcer with perpen- dicular edges and yellow sloughing base. A number of the lesions breaking down at once and coalescing, a large 646 DISEASES OF THE SKIN ulcer with scalloped border, indicating its composition from single lesions, and with more or less thick greenish Fig. 96 Nodular syphilide. (Courtesy of Dr. H. Fox.) crust, will form. In either case they leave depressed, smooth cicatrices, at first pigmented, but later white. SYPHILIS 64; They give rise to no subjective disturbances. Rarely do they form a general eruption. The diagnosis of this form of syphilide is usually read- ily arrived at by finding other symptoms of syphilis. Oc- casionally it may be confounded with lupus vulgaris and Annulat nodular syphilide. (After Taylor.) leprosy. From lupus it is differentiated by the compara- tive rapidity of its course, lupus being a disease of exceed- ing slowness of development; by its occurrence in mature years, lupus being a disease of youth; by its sharp-cut round ulcers; by its thick greenish crusts, and by the smoothness of its cicatrices, those of lupus being puckered 648 DISEASES OF THE SKIN and deforming. Syphilis at times bears a striking re- semblance to leprosy when its tubercles are located in the Fig. 98 Nodular syphilide. (By the courtesy of Dr. S. D. Hubbard.) Fig. 99 Nodular syphilide. (Courtesy offDr. H. Fox.) eyebrows, face, and ears, but the absence of anesthesia is a positive diagnostic sign against leprosy. Moreover, other SYPHILIS 649 symptoms of leprosy, such as swelling of the ulnar nerves and peculiar brown patches, will be absent. The squamous syphilide is not usually described, as it is a modified form of either the papular or the tubercular lesion. In using the term here, I follow Dr. George H. Fox, and like him adopt it purely on clinical grounds. Fig. 100 The circinate squamous syphilide. (By the courtesy of Dr. S. D. Hubbard.) He applies the term to scaly patches of circular or irreg- ular form that occur after the first year of syphilis. These patches are covered with t^in horny scales seated upon an infiltrated base. We may have one of two forms : the discoid or the circinate. The discoid form is almost peculiar to the palms and soles and neighboring parts, and constitutes the only apparent lesion. The round patch of varying size, but with a sharply defined 650 DISEASES OF THE SKIN reddish seam beyond the scaling, and an infiltrated base tends to become serpiginous, creeping over a considerable portion of the skin. Sometimes while it advances at one border it heals at the other; at other times it clears up in the centre, leaving an elevated, scaling marginal ring. The ring may be broken and leave a curved line, and if two or more of these lines meet, we have a gyrate figure. Usually but one palm or sole is involved. The skin is apt to crack in the natural creases, and then the patient will suffer some pain and discomfort. It is always an obstinate lesion to cure, persisting sometimes for months or years. The circinate form differs from the one just described in being annular from the first, and in occur- ring not only on the palms and soles, but elsewhere on the body. It is often seen on the face, about the mouth and chin, and seems to be specially apt to affect the negro race. A seborrhea sicca frequently complicates it. Unna teaches that the lesion is a combination of sebor- rhea and syphilis. The diagnosis of this form of syphilide from a squam- ous eczema of the palm is often one of great difficulty Ths fact that only one palm is affected is always sug- gestive of syphilis. Moreover, in syphilis there is more infiltration and much less itching. Indeed, the latter may be entirely absent. In syphilis the lesion is often crescentic, with sound skin between the horns of the crescent. This is never seen in eczema. Psoriasis of the palm is in most cases not to be thought of as a stum- bling-block in diagnosis, as it is exceedingly rare for psoriasis to affect the palms, and then only as a part of a general outbreak of the disease. Some writers use the term syphilitic psoriasis for the scaly palmar syphilide, but it is a most faulty method of nomenclature. The pustulocrustaceous syphilide is characterized by large and usually deep-seated pustules or ulcers, covered by prominent and peculiar crusts. It is the ecthyma- form of R. W. Taylor and other authorities. It occurs as a late and localized form of the disease; never as a SYPHILIS 651 general eruption. It may occur as a precocious syphilide. It is seen in debilitated subjects, and is of gradual de- velopment, without febrile symptoms as in the pustular syphilide. It has preference for the scalp, face, and extremities. It assumes three forms, the ecthymatous, rupial, and pemphigoid. The ecthymatous form begins as an eruption of one or more round, flat pustules of a diameter of one-quarter to one-half inch. They may become as large as a silver half-dollar. They have a well-marked inflammatory areola and a swollen and indurated base. The pus soon dries and forms a flat, greenish or brownish-black crust, whose centre is sometimes depressed. At first the crust fully covers the pustule, but later, either through drying or on account of an increase in the size of the pustule, a raw rim is left around it. When it is now removed it exposes a typical punched-out ulcer with its base covered with sanious pus, which rapidly dries into a new crust. Under proper treatment the pustule heals, and when the crust falls there will be left a healed or nearly healed ulcer. A permanent cicatrix is left when healing is com- pleted, which is smooth and white eventually. This syphilide is seen most often on the legs and arms. If the course of the disease is not checked, the crust is cast off by increased suppuration, and the ulcerative syphilide is before us. The second variety of the pustulocrustaceous syphilide is that which is commonly known as rupia. It differs from the preceding variety in being more superficial at the beginning, and in forming a conical, laminated crust somewhat resembling an oyster shell. It begins either as a superficial pustule or as a small flattened bulla with no inflammatory induration. Upon the primary lesion a greenish crust develops, under which ulceration, with suppuration, occurs. The margin of the ulceration extends a little beyond the original crust. A new crust forms upon it, raising up the original one, and this pro- cess being repeated, at last a laminated crust is formed. 652 DISEASES OF THE SKIN When the ulceration extends more rapidly in one direc- tion than another it follows that the crust will be higher at one end that at the other. Crusts may form a half- inch or more in height, and one or two inches in diameter. If the lesions are numerous, they are usually small; if few, large. When these thick conical crusts are re- moved, the ulcer is exposed and is less deep than in the ecthymatous form. On healing, a permanent, smooth, white cicatrix is left at last. The third variety of the pustulocrustaceous syphilide is the pemphigoid or bullous form. It is a very rare lesion in acquired syphilis, though quite common in hered- itary disease. It consists in an eruption of superficial, purulent, flattened bullae from 1 to 5 cm. in diameter, which tend to dry into thick crusts. They are surrounded by a dull red areola, and are soon covered by dark green- ish-black adherent crusts. If the patient be in fair health, the ulceration under the crusts will not be deep. If the patient be a broken-down subject, the ulceration may be very deep. It will leave either a pigmented atrophic spot or a pronounced scar, according to the depth of the ulceration. The diagnosis of the pustulocrustaceous syphilide is usually easy if the disease is known to the observer, as no non-specific disease resembles it closely. The so-called ecthyma cachecticum is more inflammatory than is the ecthymatous syphilide, and more superficial. The bullous syphilide often bears a striking resemblance to pemphigus, and can be diagnosed only by a study of all the features of the case. The gummous syphilide is perhaps one of the most char- acteristic of the late lesions of syphilis. It consists in a deposit of gummy material in the skin. The distinction between some tubercular lesions and a gumma is often very indistinct, and made principally by the size. The gumma begins in the subcutaneous tissue and involves the skin secondarily. It may take the form of a single tumor, a group of nodules, or a diffused infiltrated patch. It is SYPHILIS 653 Fig. 101 nearly always a late lesion, and while it may undergo absorption it possesses a strong tendency to break down and ulcerate (Fig. 101). The single tumor begins as a small, pea-sized nodule, seated in the subcutaneous tissues so deeply as to be appreciated only by the touch. It grows slowly; in the course of weeks or months it may attain the size of a nut and push up the skin over it into an evident tumor, which is movable, firm, elastic, painless, and rolls under the finger. Increasing in size, it involves the skin, which then becomes of a dull reddish color. When the skin becomes involved the tumor is no longer movable, and soon fluctuation may be felt that would lead the inexperienced to open it as an abscess. If he did so, it would be a mistake. He would find only a little pus, a gummy substance, and some blood. Left to itself, the tumor may be absorbed, or it may break down and ulcerate, leav- ing a characteristic deep and round ulcer. The scalp and forehead are the chosen sites for this syphilide, though it may occur anywhere. It some- times attains a large size — as large as a hen's egg. When this lesion occurs as a precocious syphilide it is usually of small size and multiple. When gummas occur in the form of grouped nodules, the skin between them is apt to become infiltrated with a gummatous deposit, and the patch will present the dull brownish-red color of the late syphilides. The individual members of the group run a course similar to that of the isolated gumma, but do not attain its size. When they Gummas. (After Jullien.) 054 DISEASES OF THE SKIN break down they form a large irregular ulcer. This variety of the gumma is frequently met with upon the scalp, the nose, the outer aspects of the extremities about the joints, and around the lower portion of the leg and ankle. Diffuse gummatous infiltrations of the skin probably precede all serpiginous ulcerations. Apart from this it is rarely seen, and almost always ends in ulceration. Other gummatous deposits are known as syphilitic dactylitis, admirably described by R. W. Taylor, and syphilitic bursitis, carefully studied by E. L. Keyes. One being a bony and the other a synovial disease, they do not here concern us. The diagnosis of the gumma must be made with care. It may simulate other forms of tumors. It is not as hard as the sarcoma, nor as compressible as the lipoma, and it invades the skin. An abscess is usually attended by pain and signs of inflammation, and runs a more acute course than does the gumma. The ulcerative syphilide, according to Dr. George H. Fox, merits being described by itself, though in itself only a sequence of a tubercular, pustulocrustaceous, or gummatous syphilide, because in the majority of cases of syphilitic ulcers met with it is hard or impossible for us to say what the preceding lesion has been. For con- venience, he describes the superficial, the serpiginous, and the deep or perforating forms of syphilitic ulceration. The superficial syphilitic ulcer is circular, with sharply cut edges and dirty yellowish purulent base. It most often follows a pustular or pustulocrustaceous lesion, and may appear comparatively early in the disease, especially in debilitated subjects. It is usually of the size of a quarter- or half-dollar, and frequently coalesces with other ulcers to form ulcerative patches with scalloped margins. The face and legs are its most common sites. The serpiginous ulcer is so called because it tends to creep over the surface, healing by a cicatrix as it passes along. It may develop from a single circular ulcer healing SYPHILIS 655 in the middle or at one side, and leaving a crescentic or "horseshoe" ulcer at the other side, with a sharp convex margin, beyond which is a narrow zone of infil- tration upon which the ulceration constantly encroaches, while healing at its concave border. Or a group of crusted pustules or softening tubercles form a number of small round ulcers, of which the outer ones usually make a curving line. While those in the centre and at one side tend to heal, new lesions develop at the periphery of the opposite side, which ulcerate and perhaps coalesce, and so the disease creeps on. This form is often observed upon the back and on the extremities; it is not par- ticularly painful, and the patient's health may not be impaired. The deep ulcerations of syphilis result, for the most part, from the breaking down of gummatous deposits. The small ones are crater-like in shape. Often the opening of the softened tumor is smaller than the softened mass, and it is not infrequent to find the cavities of adjacent tumors running together subcutaneously. Ulcerative syphilides sometimes are covered with exu- berant granulations. The diagnosis of syphilitic ulcers from non-specific ulcers is most important from a therapeutic stand-point. A chronic ulcer, if it is not syphilitic, is probably either traumatic, tubercular, or cancerous. The traumatic ulcer is acute and highly inflammatory; of irregular shape; has a history of traumatism, and heals rapidly, except- ing in very broken-down subjects, under simple dress- ings. The tubercular ulcer, if from broken-down caseous glands, has a history of the previous glandular affection; is irregular in shape; often presents a number of sinuses and ridges of inflamed tissues, and runs a sluggish course. If it is a lupous ulcer, there will be found somewhere in the neighborhood the characteristic apple-jelly-like tubercles; there will be a history of commencing in early life; the edges of the ulcer will be shelving or undermined, and there will usually be more or less 656 DISEASES OF THE SKIN deforming cicatrices present. A cancerous ulcer, usually an epithelioma, will have a history of beginning in a pimple, wart, mole, or such like; will be irregular in shape with an uneven floor; will be apt to be attended by lancinating pain; will usually be a single lesion, located on the face, and will have a raised, waxy, rolled-out border, over which delicate bloodvessels will be seen to course. The diagnosis of ulcers of the leg lies between one of syphilis and of varicose dermatitis. If the ulcer is irreg- ular in shape with shelving edges, rather superficial, sur- rounded by a brawny, infiltrated, brownish or dark-red tissue with more or less scaling, and there are varicose veins above it, we have to do with the so-called varicose ulcer. This is in sharp contrast with the round or scal- loped bordered, deep, punched-out ulcer with perpen- dicular edges and greenish base, around which there is but a small zone of redness. The diagnosis of syphilis is strengthened when we find a number of ulcers, or the cicatrices of old ulcers. As a rule the syphilitic ulcer is located on the posterior surface of the upper half of the leg, while the varicose ulcer is on the anterior surface of the lower third of the leg. The diagnosis from a traumatic ulcer has already been given. Over the pigmentary syphilide there has been no little discussion. By this term is not meant pigmentation fol- lowing a syphilide, which is sufficiently common, and due to a staining of the skin with hematin, but a true pig- mentation without antecedent lesion, which is sometimes seen on the sides of the neck, especially in women. It is composed of irregularly round or oval spots, one-eighth of an inch to one inch in diameter, with ill-defined mar- gins, and cafe-au-lait color, which does not fade on pres- sure. The color may be very faint. The lesions may be discrete or confluent. When they are very numerous they have been compared by Fournier to a "network of lace with large meshes," and to it has been given the name of collarette of Venus. This is one of the rarer manifestations of syphilis. SYPHILIS 657 Alopecia due to syphilis has already been described under the heading of Alopecia Syphilitica, which see. Syphilitic affections of the nails may be due to lesions of the nail-bed or matrix or both; or of lesions about the nail. In the first variety the nails are damaged in their nutrition, becoming brittle, furrowed, discolored, and broken; or they may become detached from the bed and fall. They may become thickened, but less commonly. In the second variety we have a paronychia, the nail furrow becoming swollen or perhaps ulcerated. General Diagnosis of Syphilis. — In any case of doubt in diagnosis of an eruption we have three methods of investigation to which to appeal. (1) The finding of the treponema pallidum: This is done by placing a drop of serum taken from any lesion on a slide, and examining with the dark stage apparatus of a microscope. They may also be seen without the dark stage by mixing the serum with an equal amount of ink, and adding im- mersion oil when dry. The latter is not as reliable as the former. (2) Making a Wassermann test : If the case is one of syphilis the reaction will be positive in about 90 per cent, of the cases. It usually does not appear until in the fifth or sixth week of the disease. A positive reaction indicates syphilis. A negative one is not absolute proof of the case not being syphilis. But if several tests are made at short intervals and they remain negative the case is almost surely not one of syphilis. The test is useful in all stages of the disease, and in latent syphilis. The taking of mercury may interfere with the positive reaction for a time, and when it is stopped for a time it may appear again. (3) The luetin test of Noguchi: This is a suspension of treponema pallida that has been grown in pure culture and then destroyed by beat. It is made by injecting into one arm T V c.c. of luetin and, at the same time into the other arm, an equal amount of the culture medium without the organisms. In a certain proportion of cases of syphilis the site of the first injection shows a reaction after a few hours in 42 658 DISEASES OF THE SKIN the form of an inflammatory nodule with or without a halo. It is at its height on the second or third day. It is not so reliable as the Wassermann test. One marked feature of the cutaneous lesions of syphilis is that they do not itch. Itching does occasionally occur with the scaling papular and crusted syphilides, when it is due to the irritation of the nerve ends by the crust or scale, and in some cases the patient will complain of an itching of the skin which is quite independent of syphilis, but in themselves they do not itch. The early eruptions of syphilis are general and exhibit a marked polymorphism, many different lesions being often present at the same time; as, for instance, macules, papules, and pustules. The late eruptions exhibit a strong tendency to grouping of the lesions in circles and segments of circles, and one characteristic of the circles is that they are seldom complete, but broken somewhere in their outline. The color of the lesions is peculiar, and perhaps may be best described as that of raw ham, though the classic term is "copper." This color is by no means always present. It is not seen in the early bloom of the early lesions, but is pretty sure to be found in those that have existed for some time, and in the late lesions. The color of a lesion on the legs, it must be remembered, must not be regarded for purposes of diagnosis; it is upon the arms, face, trunk, and thighs that we must look for the characteristic color. Painlessness is often a suggestive symptom pointing toward syphilis when we have to decide as to the nature of an ulceration. It is well not to lay too much stress upon the history of the case in making up our mind as to a late syphilide, because with the best intentions the patient may forget having had an insignificant initial lesion some twenty, or perhaps thirty, years before. Etiology. — Schaudinn, Hoffman, and many others have found spirocheta, or trepenoma pallida in syphilitic lesions. SYPHILIS 059 They are the only cause of the disease. The spirocheta pallida is a very slender thread closely wound in a cork screw shape, 7 to 21 microns long, with 8 to 20 spirals, and actively motile by rotation on its long axis in either direction without changing its position, or moving from place to place. Its ends are sharp. It has been found in the fluid expressed from syphilitic lesions, primary and secondary, both superficial and deep, congenital and acquired, and in smaller number in gummas. The chancre, mucous patch, and condyloma are specially rich in them. It also is found in the internal organs and the spinal fluid. It is always of pale color. Fig. 102 Treponema pallidum. (Courtesy of Dr. Noguchi.) The disease occurs in all ages, even before birth. It may be acquired directly or secondarily. That it is not more often acquired from drinking glasses and the like is because its organism dies soon after exposure to the air. It is inoculable in apes. Pathology. — With the exception of the roseola whose pathology is that of any toxic erythema, all the various syphilitic lesions are histopathologically similar. The papule may be taken as the type of syphilitic cutaneous lesion, from which the other forms differ only in extent, severity, and secondary accidents. The papule is composed of a dense granulomatous 660 DISEASES OF THE SKIN infiltration of the papillary layer of the corium, with small round cells, among which plasma cells are abundant and mast cells present in considerable number. The infiltration first follows the course of the bloodvessels, and appears to be secondary to an endarteritis and endo- phlebitis, though the latter is not so conspicuous as the arterial changes. New capillaries invade the infiltration and a moderate diapedesis from these gives to the gross lesion its characteristic raw ham color. The collagenous connective tissue bundles are increased in size and num- ber, and enclose in places groups of plasma cells which occasionally take on the form of giant cells. The infil- tration undergoes a fatty degeneration, or a coagulation necrosis due to the obliterating endarteritis, with subse- quent absorption or ulceration. There is never any attempt at organization into connective tissue. The overlying epithelium is affected only secondarily. m Hereditary Syphilis. — This differs from the acquired form in having no initial lesion, the disease being ac- quired in utero from either one or both parents. We cannot enter upon a discussion of the many connecting theories as to whether or not the child is diseased on account of springing from a diseased ovum, or sperma- tozoa; or the possibility of the disease, acquired by the mother after her pregnancy, reaching the fetus through the placental circulation; or like interesting questions over which the battle rages. For us now it suffices to make the bald statement that the disease may be acquired from one or both parents. It is most sure to be acquired from the motner, and it may be inherited by the fetus from a mother infected some months after conception. It is possible for a woman to show no signs herself of syphilis, and yet to give birth to a syphilitic child. It is exceedingly rare for the apparently healthy mother of a child hereditarily syphilitic to be infected by it. But a Wassermann test will show she is syphilitic though she may present no clinical evidence of the disease. As a SYPHILIS 661 result of syphilitic infection in utero, the child may be born prematurely, and dead; it may be born at term, dead, and showing specific lesions; or it may be born alive with, some syphilitic eruption; or, as is commonly the case, the eruption may not appear before the second or third week. Miller, 1 from a study of 1000 cases of congenital syphilis in a foundling hospital in Moscow, found that the first appearance of the disease was in the first month of life in 64 per cent, of the cases; and in the second month in 22 per cent. In congenital syphilis there is a marked absence of that sequence of events more or less observed in acquired syphilis, but the diag- nosis is usually quite as easy. The earliest eruption to appear, as to point of time, is, according to Miller, the bullous syphilide, which he met with in 25 per cent, of the cases. One of the earliest and most characteristic symptoms of hereditary syphilis is "snuffles," due to an ozena, which gives the child great discomfort by inter- fering with breathing and nursing. The erythematous syphilide is, according to Taylor the most frequent and earliest eruption; according to Miller, it occurs in 45 per cent, of the cases. It begins on the lower part of the abdomen as minute round or oval spots, that disappear under pressure at first. It invades the whole body within a week, when the lesions will no longer fade under pressure, but assume the characteristic syphilitic color. One form of the erythematous syphilide in children is seen upon the inside of the thighs, about the anus, and on the buttocks, and may extend down to the feet. It is patchy in character, the patches being either of small size, or large by the coalescence of several smaller ones. It differs from intertrigo in its patchy character, in its darker color, and in its wider distribu- tion. The papular syphilide and its modified forms of the mucous patch and condylomata lata are common congeni- 1 Jahrb. der Kinkerheilkunde, 1888, xxvii, Heft 4. 662 DISEASES OF THE SKIN tal lesions. The lenticular syphilide, large and small, is met with far more frequently than the miliary papular syphilide. It is usually a symmetrical and general erup- tion. It may be smooth or scaly, and always has the raw ham color. Mucous patches are very often at the junction of the mucous membrane and the skin, as on the lips or anal orifice. The movements of the parts will give rise to painful fissures — rhagades — which constitute a sign of hereditary syphilis as characteristic as the " snuffles." These rhagades Miller met with in 70 per cent, of his cases. Mucous patches also occur in the cavity of the mouth. Condylomata lata occur where two skin surfaces rub together, and especially where there is more or less moisture, as about the anus and genitals, in the groins and axilla?, and between the fingers and toes. Their color is usually grayish pink to dark brown; their size varies greatly, and their surface is flat, or fissured and ulcerated, and exudes an offensive secretion. They are characteristically located when at the angles of the mouth, in combination with mucous patches in the mouth with rhagades between. The pustular syphilide may be general, but is usually most pronounced on the thighs, buttocks, and face. It shows a tendency to group about the mouth. It is usually indicative of profound syphilization. The pustules may leave scars. Ecthymatous pustules may develop, but usually not till late in the disease. The vesicular syphilide is a rare form of early con- genital syphilis of severe type. It is never general, but appears as groups of closely packed together vesicles upon the chin, about the mouth, or on the nates, forearms, hypogastrium, or thighs. They are seated upon infil- trated, brownish-red bases. The larger vesicles may be seated upon papules. This eruption is apt to be asso- ciated with a pustular or bullous syphilide. The bullous syphilide, unlike what obtains in adults, is comparatively common in congenital infantile syphilis. Miller found it in 25 per cent, of his cases. It frequently SYPHILIS 663 exists at birth or as the earliest syphilide, and is indicative of a severe form. It is most commonly seen on the palms and soles, which are often covered with the lesions, while few, if any, are on the trunk. The face is a favorite location for the eruption. The bullae are either tense or flaccid, and at first have seropurulent contents that soon become purulent. They are seated upon a raw ham colored infiltrated base. Hemorrhage into them not infrequently occurs. When they rupture or dry up they exhibit an unhealthy-looking ulceration that soon becomes covered with a greenish crust. Some of them may dry up with little, if any, ulceration. It rarely relapses. It differs from pemphigus in occurring upon the palms and soles, while sparing the trunk, and in the profound cachexia and the presence of other signs of syphilis. The tubercular syphilide is not common, and is always a late lesion. While it may be seen as early as the sixth month, it is more apt to occur much later as a relapsing syphilide. In appearance and course it resembles the same lesion of acquired syphilis. The gummatous syphilide is also a late manifestation of the disease, and is sometimes met with in early adult life as a lesion of congenital syphilis. Kaposi regards as a special and characteristic symptom of hereditary syphilis a diffused infiltration of the palms and soles, the skin of which is uniformly brownish red, dry, shiny, and fissured. Besides the skin-lesions the infant bears certain unmis- takable signs of syphilis. It has a marked pallor, and, no matter how blooming it may appear at first, it soon Hutchinson's teeth. 664 DISEASES OF THE SKIN loses flesh and assumes "an old man" countenance. It has a characteristic, hoarse, toneless cry, which once heard will be remembered. Its hair is scanty, its nose is apt to be flattened, and altogether it is a most woeful- looking object. The skin eruptions usually occur within the first six months of life, and if the child can be brought / through that period it may suffer no more. Nevertheless congenital syphilis, like the acquired disease, may be latent for years, to crop out once more. The victims of congenital syphilis, sometimes show the notched or peg-shaped teeth, regarded by Hutchinson as a certain sign of the disease (Fig. 103). This appearance is pre- sented by the second set of teeth only, and is not abso- Fig. 104 Dactylitis. (After Bergh.) lutely diagnostic, as the same has been met with in scrofula. The two middle upper incisors are those which are depended on for diagnosis. "They are small, often converging, sometimes diverging. The cutting-edge of the teeth is sometimes narrowed, rounded off. They are stunted and badly developed, often marked with seams in front, and of a dirty brownish color, but their chief peculiarity is found in their edges, which, being thin when cut, break off centrally, leaving a broad, shallow, vertical notch on the lower border of the tooth" (Keyes). The syphilitic child is subject to diseases of the bones, one of the most characteristic of which is dactylitis. Another characteristic is the prominent bosses on the SYPHILIS 665 forehead. Space will not permit of a detailed description of the bone and other lesions apart from those of the skin. Treatment. — The treatment of syphilis is by the use of both constitutional and local remedies, and by a con- stant and long-continued watchfulness on the part of the physician over the patient's hygiene and general well- being. One chief obstacle to the successful treatment of a case is the patient's lack of faith in his physician. Most patients, just as soon as the eruption for which they sought advice fades away, will cease coming to the physician, and will pay little heed to his warning, that unless they keep themselves under medical supervision for three or four years they will be liable to serious trouble later on. Nevertheless, our first duty is to so instruct them. Then, before putting the patient upon a regular course of treat- ment, we should give him careful directions as to his exercise, liberal diet, and bathing, and should stop his alcohol, insist upon his taking plenty of sleep, and giving up the use of tobacco. This last is not only to put him in better condition, but also to prevent mucous patches in the mouth. It must never be forgotten that there is no use in giving medicine to a dead man, and that while a patient is taking antisyphilitic treatment every means should be taken to keep him in the best possible physical condition. Very often a patient who is not making satisfactory progress will immediately improve when he is given a change of air and general tonics. The patient should be cautioned against drinking out of public drinking-cups, and apprised of the danger of infecting others by means of table utensils, pipes and the like. Now he is ready for his course of treatment. Constitutional Treatment. — Treatment should be begun as soon as we are sure that the patient has syphilis. As the treponema pallida is usually readily found in the initial lesion and is positive proof of syphilitic infection, treatment should be begun as soon as it is found with- out waiting for the appearance of a secondary eruption as used to be advised. 666 DISEASES OF THE SKIN We will consider first the treatment of early syphilis and the use of mercury. This drug, regarded by the majority of physicians as the sheet-anchor in the treat- ment of syphilis, is administered, for its constitutional effect, by the mouth, by inunction, by fumigation and by hypodermic injection. Of these different methods, the most frequently em- ployed is the first — that is, by the mouth. This is the most convenient and the most unreliable method, and should not be used if it is possible to give the drug by inunctions or intramuscularly. The salt of mercury most frequently used is the protiodide, otherwise called the green iodide. This may be exhibited either in pill, tablet triturate, or granule, the tablet triturate being the preferable form. The objection raised by many authori- ties to the use of the protiodide, namely, its irritant effect on the intestinal tract, is its shining virtue, because instead of giving warning of intoxication by causing salivation, it does so by causing colicky pains and diar- rhea. The dose to begin with should be from \ to J of a grain three times a day after meals, and the number of pills increased by one every third or fourth day until there is a little " colicky diarrhea." The dosage should be then continued at the same number of pills, until the symptoms are controlled. Then we can reduce it to half the number. It may be necessary, to give a little opium at the same time with the mercury, in order to control the diarrhea if it is deemed advisable to con- tinue the drug at the point of full tolerance, and this not only with the protiodide, but with other salts. Practically the daily dose of the protiodide may be put at 4 or 5 of the \ grain tablets, and 3 or 4 of the \ grain ones, and opium is rarely called for. Many prefer to use metallic mercury in the form of hydrargyrum cum creta, or calomel in the dose of 1 or 2 grains two or three times a day after meals, increased every three or four days sufficiently to influence the erup- tion. Salivation is, in the general run of cases, to be SYPHILIS 667 avoided. Some authorities prefer to combine a tonic with the mercury. Taylor gives the following : .45-.58 39 M. Ft. -Hydrarg. protiodid., Ferri et quininse citrate., Ext. hyoscyami, pil. No. xxx. gr. vij-ix 3iss gr. vj Ft. -Hydrarg. tannici, Quin. sulphat., Ext. hyoscyami, pil. No. xxx. gr. xv-xxx 3J gr. vj 1-2 4 39 M. In severe cases in which it is necessary to get the patient rapidly under the influence of mercury, calomel in Yj- grain doses in the form of tablet triturates may be given every hour until the gums become tender. Then the calomel should be stopped and the treatment continued with small doses of the protiodide. Besides these preparations of mercury we may use the bichloride in doses of ■$% to j-% of a grain in solution. It is usually given in compound syrup of sarsaparilla or some bitter infusion. The most common mode of administer- ing it is in combination with the iodide of potassium, the so-called mixed treatment, the formula for which will be given later when speaking of the treatment of late syphilis. The best opinion is in favor of reserving the use of iodine until the early stage is passed. The tan- nate of mercury is well spoken of in the dose of half a grain. Space will not allow of mentioning the other salts of mercury that have been recommended. The proper quantity for administration having been learned by experiment, the drug should be administered continuously for from four to six months. Where practicable the use of mercury by inunction is the speediest and best way of getting the patient under the influence of the drug. It may be used from the first or at any time during the course of the disease. Its great advantages are the promptness with which it acts and the sparing of the stomach and intestinal tract. Its great disadvantages are that it is a dirty method, impracticable with most patients, as it attracts notice from friends 668 DISEASES OF THE SKIN and attendants; and the difficulty encountered in getting the patient to carry out the treatment with thoroughness. It is admirable for hospital treatment. The patient is to be told to rub into his skin, once a day, a piece of ungt. hydrarg. cinereum, or an ointment made with lanolin as a base, of the size of a hazel-nut — from \ drachm to 1 drachm (2-4). He is to divide the mass into two equal parts, and work it into his skin with the heel of his hand for about fifteen minutes while he sits before a fire or in a warm room. Before beginning the inunctions he is to take a warm bath, and to bathe the parts about to be rubbed with alcohol so as to open the pores of the skin and to remove any sebaceous matter. The first day he is to rub the ointment into the bends of both elbows; the second day, over the sides of the chest; the third day, over the abdo- men; the fourth day, on the inside of the thighs; and the fifth day, behind the knees — that is, he is to choose the parts least covered with hair; and to change the sites of the inunctions, so as to avoid setting up a mercurial dermatitis. On the sixth day he is to take another bath, and on the seventh day to resume the inunctions. The treatment is to be pursued until active symptoms of the disease are overcome, when all treatment may be sus- pended. A thorough course of from eighty to a hundred inunctions is said to be often followed by a permanent cure. If the inunctions are to be made by an attendant, he should wear a stout rubber or leather glove. As a substitute for inunctions, E. Welander 1 proposes spreading about 1| drachms (6) of mercurial ointment on the inside of a small pillow-case ticking, and having the patient wear this, properly fastened, next the skin over the anterior plane of the body, day and night. Kro- mayer 2 advises the use of a mask made of a light wire frame covered with several layers of muslin impregnated with a thin layer of mercurial ointment. It is made to fit over the nose and chin and worn at night, bandages 1 Arch, f . Dermat. u. Syph., 1897, xl, 257. 2 Monatshft. f. prakt. Dermat., 1908, xlvi, 475. SYPHILIS 669 being used to hold it in place. After five nights' use the mask is to be reversed and used for B.ve nights more. At first it may cause disturbed sleep, and dizziness in the morning. He has found it more active than inunctions but not so active as injections. Mercuriol may be sub- stituted for the usual mercurial ointment. These plans of treatment are good only in slight cases. Fumigation is a method which is not used as much now as formerly. It requires the use of a special apparatus and a great amount of time and trouble. It is said to be a very efficient method, especially useful in bad cases and where prompt results must be attained. From \ to 1 drachm (2-4) of calomel, metallic mercury, or other salt of mer- cury, is vaporized by means of the special apparatus, the naked patient sitting over it enclosed in a cabinet or blankets, out of which only his head protrudes. Each bath lasts ten minutes, and it is repeated every second day. The intramuscular injection method of administering mercury, was first advocated by Scarenzio in 1854. It is quite as efficient as inunctions, perhaps a little more so. It is cleaner than the latter. The injections are usually made deep down in the gluteal region, behind and above the great trochanter. Its disadvantages are that the injections are usually painful; sometimes are followed by emboli and abscesses, and require daily or frequent visits to the physician's office. They are useful where we wish to have a very prompt effect from the mercury, as in a malignant precocious case of syphilis; or where the stomach must be spared; or where the disease has not yielded to the ordinary plans of treatment. Great care must be given to the sterilization of the needle and of the skin. A great number of salts of mercury and combinations have been introduced, each one of which has been found by its producer the best and most reliable. An admirable study of them will be found in Hare's Sys- tem of Therapeutics, vol. ii, by Prof. R. W. Taylor. Here we can indicate, and briefly, but a few. Taylor gives one of corrosive sublimate, gr. xl (2.33); glycerin, 5j (4); dis- 670 DISEASES OF THE SKIN tilled water, 3hj (12), of which 12 drops are used at each injection. The albuminate of mercury, dose 15 minims: the formamide (Liebreich), dose \ to a whole Pravaz syringeful of a 1 per cent, solution: calomel, 1 part, to liquid vaselin, 12 parts, dose \ Pravaz syringeful once a week; "gray oil," composed of 20 parts of pure mercury, 40 of liquid vaselin, and 5 of ethereal tincture of benzoin, dose J of a syringeful every ninth day; 1 the salicylate, 22J (1.5) grains in lanolin 15 grains (1) and benzoinal ad §ss (16). Dose | to 1 syringeful. And many others. As a rule the soluble salts solutions are injected once every day or so, and the insoluble ones once a week. A final judgment as to the comparative merits of the many salts cannot yet be given. Dr. John A. Fordyce has kindly advised me in regard to the use of salvarsan as follows: The arsenical preparation, salvarsan, is the most efficient drug at present in use to combat the syphilitic infection. Given in the primary stage the disease may be aborted, the Wassermann reaction remaining persistently negative, and no further clinical symptoms manifesting themselves. When the secondary contagious lesions are present it has a much more rapid effect than any other drug in limiting the time during which the patient is a menace to his surroundings. In the later period of the infection when combined with mercury it has a much more marked influence over the Wassermann reaction than mercury alone. In malignant syphilis there is no remedy known which has such a marvelous influence on the symptoms. In cases which are resistant to mercury or where mercury has been administered for a long period of years with repeated relapses and with persistence of a positive Wassermann reaction salvarsan is the drug above all others to control the manifestations. Salvarsan is a light yellow powder put up in her- metically sealed ampoules in doses varying from 0.1 gm. 1 Leloir and Tavernier: Giorn. Ital. d. Mai. Ven. e del Pelle, 1889, xxiv, 247. SYPHILIS 671 to 1 gm. Its active principle is arsenic of which nearly 3 grains by weight or the equivalent is nearly 4 grains of arsenous acid occurs in a dose of 0.6 gm. While its preparation and administration to the initiated are simple, in the hands of the inexperienced undesirable results may follow, and it is therefore incumbent upon everyone attempting to treat syphilis to familiarize him- self with the proper technique. In the preparation of the drug for injecting the follow- ing precautions are to be accentuated: (1) The water em- ployed for its solution should be distilled on the day of use, as old distilled water contains organisms or their products which give rise to reactions. (2) The saline solution should also be made from freshly distilled water and the salt should be chemically pure. (3) The sodium hydroxide solution should be fresh and free from pre- cipitate. (4) All the apparatus used in connection with the preparation and administration should be sterile. (5) Each ampoule before opening should be tested for cracks, by placing in alcohol, and if any are present or the tube has been opened for some time it should be discarded, as salvarsan oxidizes on exposure and becomes toxic. Xeosaharsan, a later preparation than salvarsan, is a slightly darker powder and one-half heavier, 0.9 gm. of the former being equal to 0.6 gm. of the latter. It is a neutral, extremely soluble salt, its chief advantage being simplicity of preparation. As it oxidizes very rapidly, forming a poisonous compound, in making the solution shaking is to be avoided and it must be used immediately For intravenous use it is diluted in sterile distilled water at room temperature in the proportion of 0.9 gm. to 100 c.c. It is not as safe as salvarsan. Methods of Administration. — The intravenous mode of administration by the gravity method is the one of choice. If, however, the proper technique cannot be carried out it is advisable to give the drug intramuscularly. For intravenous use the amount of fluid employed in 672 DISEASES OF THE SKIN the case of salvarsan is in the proportion of 0.1 gm. to 30 c.c. The procedure is as follows: Pour into a glass stoppered graduated cylinder 60 c.c. of hot freshly distilled water. Drop the contents of a 0.6 gm. ampoule on the water and shake vigorously until every particle is in solution. Next add drop by drop a 15 per cent, caustic soda solution until the resulting precipitate is again redissolved. To this end 15 to 19 drops are required. The solution must be perfectly clear, but over-alkaliniza- tion should be avoided as thrombosis of the vein is apt to occur. The dilution is then made to 180 c.c. with 0.5 per cent, saline solution. For intramuscular injections an oily suspension may be made of salvarsan or neosalvarsan in sterile glycerin, liquid paraffin or iodiopin. The powder is placed in a sterile mortar and rubbed with 1 c.c. of the vehicle, more being gradually added until the suspension reaches, a volume of 2 to 4 c.c. Salvarsan may also be given in alkaline solution, but this is usually very painful. The powder is dissolved in 10 c.c. of hot distilled water and enough caustic soda solution added to give a clear solution. It is then diluted to 20 c.c, 10 c.c. being injected into each buttock. Preparation of the Patient. — The patient should have a physical examination to determine the condition of his heart and kidneys. If there are no contraindications he should take a laxative the night before and abstain from all food for at least three hours before its adminis- tration. For the intravenous injection he should lie on his back. A tourniquet is placed about the upper arm to distend the veins in the cubital space and one of these is usually chosen. If it cannot be seen it can often be felt under the finger and failing this, in the case of fat people, or women with small veins, one may be selected in the wrist or back of the hand or even the ankle or foot. It is never necessary to cut down on a vein as search will always disclose one somewhere on the upper or lower extremities accessible to an operator with SYPHILIS 673 technical ability. The skin is sterilized, and as soon as the needle is in the vein and the blood flows back the tourni- quet is released, the clamp on the tubing is loosened, and the fluid allowed to run in slowly. When the desired amount has been given the needle is quickly removed and a small dressing applied. If the needle fails to pene- trate into the lumen of the vein, when first inserted the fluid infiltrates the surrounding tissues causing severe pain. It should then be quickly withdrawn and the fluid expressed through the puncture. The patient should be on a very light diet and rest in bed until the follow- ing day. This should be insisted upon as unpleasant symptoms like headache, nausea, or gastro-intestinal disturbances may intervene if these directions are not carried out. For the intramuscular injection the patient lies on his abdomen. The skin on the buttocks is disinfected and the injection given deep into the gluteal muscles. The areas are well massaged. Dosage. — In order to avoid the toxic effect of salvarsan it is advisable to give small initial doses until the toler- ance of the patient is determined and then the dose may be gradually increased. The average dose for an adult man is from 0.3 gm. to 0.45 gm. and for women from 0.25 to 0.35. The advantage of these medium sized doses is that they can be repeated at shorter intervals and kept up for a longer time than when the maximum dose is given. In early syphilis a few doses of mercury intra- muscularly should precede the systematic use of salvarsan. The best results are obtained by giving it in series of from four to six intravenous injections at intervals of about ten days combining it with intramuscular injections of mercury, continuing with eight or ten of the latter after the salvarsan series. At the end of this course of treatment a month's interval should elapse and the series of salvarsan and mercury injections repeated. Two or more such courses may be necessary in order to influence the Wassermann reaction in early syphilis. 43 674 DISEASES OF THE SKIN In late syphilis and in hereditary forms of the disease even several series may fail to change the reaction. Suggested by the success of salvarsan many other arsenical preparations have been brought out, but none has shown itself the equal of salvarsan. Of these contra- leusin, a combination of salicylic acid, sozojodal, quinin, and bichloride of mercury, has met with some favor. The dose is 1.5 cc, which is given with a glass syringe. The injections are given intramuscularly in the buttocks. It is repeated in five days. After four injections are given, a pause of from one to four months is made, and then the series repeated. Late Syphilis. — The treatment of the later manifesta- tion of syphilis is the same as the earlier ones — by the use of salvarsan and mercury. The former will cause a prompt disappearance of the ulcerative and other lesions of the skin and tongue. If for any reason salvarsan cannot be used then the so-called mixed treatment will be most appropriate to the case. As usually administered it is made up according to one of the following formulas: T$— Hydrarg. bichlor. vel, 06-12 Hydrarg. biniodidi, aa, gr. j-ij Potass, iodidi, 3J~iJ 4-8 Inf. gentian, co. vel, Syr. sarsaparillae co., aa ad §iv ad 120 M. Dose: A teaspoonful three times a day after meals. Or, 1$ — Hydrarg. biniodidi, gr. ss-ij 03-1 Ammon. iodidi, 3ss 2 Potass, iodidi, 3ij-5j 8-32 Syr. aurant. cort., Biss 45 Tr. aurant. cort., 5i 4 Aqua?, p. s. ad 5"j ad 100 M Dose: A teaspoonful in water three times a day. (Key< ss.) If any deep lesions threatening destruction of tissue appear early in a case of precocious or malignant syphilis ; or if the disease attacks the nervous system, the larynx, pharynx, or eye — in fact, at any time when there is need of prompt effects and for any reason salvarsan cannot be used, we must administer the iodides. If the patient has had no mercury for some time, it is best to give SYPHILIS 675 it to him now either by the mouth, injections, or inunc- tions, while the iodide is administered separately but at the same time. The iodide of potassium is most generally used, and next to it the iodide of sodium. There is no set dose for the iodide. It is best given in a dose of 5 grains (0.33) in solution in water, three times a day, before meals, diluted in milk, or Vichy, or soda water; or some three hours after meals. Delavan 1 has found that the iodide can be given most satisfactorily by putting 5 drops of a saturated solution in the bottom of a small tumbler, with 15 drops of essence of pepsin, and pouring upon it 2 ounces (64) of warm milk. This is to be set away in a cool place, and will form a rennet custard, which can be easily swallowed. This is a good method when we wish to give nourishment with the medicine or when the throat is sore. The mixture can be given a pleasant taste by adding a teaspoonful of sherry wine. The dose of the iodide should be increased by 1 or 2 drops each day — that is, 6 drops t. i. d.; then 7 drops t. i. d., and so on, until the nose runs and the eyes water, or some symptom of iodism develops. The most con- venient method of administration is to have a solution made containing 1 grain of the iodide to each drop of the solution, so that every drop represents a grain. Most patients bear iodine well, but in some even drop doses produce iodism. Iodic acne is very often induced, but should not cause us to stop using the drug. It is advis- able to suspend the administration of the iodides from time to time, and to give mercury, which, after all, must be depended on for curing syphilis. Now and again we will meet with cases that do not improve under either mercury or iodine, but relapse and relapse, or remain stationary. Such cases should be sent out of town, ordered change of air for a time, and put on a purely tonic course of treatment. Very often when the patient returns home he can take his medication 1 Med. Rec, 1891, xl, 651. 676 DISEASES OF THE SKIN easily, and the previously obstinate lesions will yield readily. This is but what we said at first: the patient's general condition must all the time be carefully watched over. Salivation is an unpleasant accident that may occur under the use of either mercury or iodine. At one time it was quite common — indeed, mercury was purposely pushed so far as "to touch the gums," and, of course, this was often overdone. Its symptoms are tenderness of the teeth, so that pain is felt when the jaws are snapped to- gether; the gums are swollen; there is a metallic taste in the mouth; a fetid odor of the breath; increased flow of saliva by day and night; all the mucous membranes of the mouth are swollen, so much so as to interfere with mastication and deglutition, and in very bad cases there may be ulceration, loosening and fall of the teeth, and caries of the bones. Prevention is always better than cure, and to this end we should see that our patient's teeth are in good order before beginning treatment, and direct him to wash his mouth frequently with chlorate of potash solution, 10 or 15 grains to the ounce, or one of alum, and to keep his teeth clean. The patient should be seen frequently at first, so as to stop the mercury before salivation attains any serious degree. Salivation having begun, the mer- cury must be stopped, and the potash solution in same strength may be continued, and 1 or 2 drachms (4 to 8) of it swallowed during the day. The compressed tablets are useful. Dilute Labarraque's solution, or solutions of permanganate of potash or other astringent, may be used for a gargle and mouth-wash. A laxative should be admin- istered, the patient kept warm in bed, and, if necessary, an anodyne given. Until Wassermann gave us his serum reaction test it used to be a question how long treatment should be continued. Now we know that the disease is not cured as long as the test remains positive. Treatment must be continued until a negative reaction is obtained, and SYPHILIS 677 after that the patient's blood must be tested for two or three years at least. If the test is still negative at the end of that time the disease may be considered cured. Local Treatment.— While internal treatment by salvarsan and mercury is quite competent to remove the syphilides, their disappearance can be materially hastened by local treatment by means of mercurial applications. Ointments of metallic mercury, of the ammoniate, the red oxide, and the oleate, with solutions of the bichlorides, are the preparations most generally employed. Many attempts have been made to abort syphilis by excision of the initial lesion, or its destruction by means of caustics. These have been failures in most instances. This is not to be wondered at in the light of R. W. Taylor's studies, 1 which show that "in the very first days of syphilitic infection the poison is deeply rooted beneath the initial lesion, and extends far beyond it, infecting all the parts beyond even to the root of the penis." The initial lesion should be dressed with iodoform or calomel, or kept covered with dry lint powdered with either of these. It may be said that in all the early and generalized syphilides local treatment needs practically to be applied only to lesions on exposed parts — that is, face, neck, hands, and wrists. The erythematous syphilide is usually so ephemeral that no local treatment is necessary. Mer- curial baths may, however, be used for general outbreaks of syphilis. If the erythematous lesions persist upon the exposed parts, their departure can be hastened by the use of the ointment of the ammoniate of mercury rubbed in morning and night. The same ointment may be applied to the papular syphilide. A still more prompt effect can be produced, if the patient can be seen often enough, by the physician touching each lesion with a solution of the bichloride of mercury in alcohol 3 to 5 grains (0.18 to 0.33) 1 Med. Rec, 1881, xl, 1. 678 DISEASES OF THE SKIN to the ounce (32), according to the size of the lesions and the profuseness of the eruption. Of course, if the eruption is very profuse, this plan cannot be followed. It is most applicable to a sparse and relapsing eruption. The mucous patch should be touched with the nitrate of silver stick or with an aqueous solution of chromic acid, 10 grains (0.66) to the ounce (32). Condylomata are best treated with dusting powders, preferably calomel, freely applied and covered with absorbent cotton. The squamous syphilide of the palms and soles is often obstinate, but will usually yield to the persistent use of mercurial ointment. Sometimes it will be necessary to soften the part by having the patient wear sheet rubber next the skin for several days, and then use the ointment. If the parts are covered with a very much thickened epidermis, we may have to remove this by using salicylic acid, as in chronic squamous eczema. Mercurial plaster worn continuously is efficient. The tubercular syphilide occurring discretely can be touched with the bichloride solution already mentioned. When in groups it is best treated by means of mercurial plaster. The gumma may be covered with mercurial plaster or ointment. It should not be incised unless it shows unmis- takable evidences of containing pus. Ulcers following whatever lesion may be covered with mercurial plaster or ointment, or dressed with iodoform or aristol. If they become sluggish, they may require stimulation, just as a simple ulcer does. To this end we may touch them with balsam of Peru, or add the same to our mercurial ointment. Some ulcers will do best under the treatment applicable to a simple ulcer, while the iodide of potassium is pushed. Treatment of Congenital Infantile Syphilis.— The most popular method is to spread upon pieces of flannel a mass of mercurial ointment of about the size of the end of the finger, and tie a piece of this one day over each elbow-joint; another day over each groin; another, SYPHILIS 679 under each knee; and another, over the abdomen, allow- ing the movements of the child to work the ointment into the skin. Or hydrarg. cum creta, 1 grain three times a day, may be given by the mouth. Monti 1 recommends the following: I 1 I 2 3| M. 1$ — Calomel, pur., gr. iss Ferri lactatis, gr. iij Sacch. alb., gr. xlv Ft. in pulv. No. x. Sig. 1 to 4 powders daily. The greatest attention must be given to the hygiene of the child and to its diet. Cod-liver oil should be given along with the mercurial. The nose must be kept clear, and if this is not practicalbe the child must be fed with a spoon. After the disappearance of symptoms tonics should be given, one of the best being the syrup of the iodide of iron. In all other respects the treatment of infantile syphilis is the same as that of the acquired form. Kaposi commends the tannate of mercury for children; dose, \ to f of a grain three times a day. Prognosis. — The prognosis of syphilis as seen at the present time and in this country may be said to be good. Many cases go no further than a general erythematous or papular eruption, even when untreated. In one of robust health the disease is usually readily manageable. In debilitated subjects it sometimes proves intractable. The worst feature of the disease is the great uncertainty of its course, no one being able to promise confidently, no matter with what treatment, that relapses and late visceral syphilis will not occur. Since the introduction of the combined salvarsan and mercury treatment the number of reinfections has greatly increased. This shows that the disease is curable. The continuance of the negative Wassermann tests also attests its cure. The prognosis of congenital syphilis is not as good as is that of the disease as it affects adults. Many, perhaps most, of the cases seen in public institutions die. In pri- 1 Arch. f. Kinderheilku de, 1885, vi., 1. 680 DISEASES OF THE SKIN vate practice more can be done, and we should always count upon the remarkable reparative powers of childhood in making our prognosis. A great deal will depend upon the inborn vigor of the child. Syringomyelia, or Morvan's Disease, is a disease of the spinal cord, the consideration of which belongs rather to the neurologist than the dermatologist. It interests us because various cutaneous lesions occur during its course, such as glossy skin, hyperkeratosis, hyperidrosis, and paronychia with necrosis of the phalanges; and because in some phases it resembles certain stages of leprosy. Tattoo.- — These well-known stainings of the skin by means of India-ink, vermilion, charcoal, and gunpowder, although at first objects of pride to the boy or girl, later are apt to become objects of aversion. They are very difficult to remove, especially if they are at all extensive. Fig. 105 r by means of cloths wrung out of hot water, frequently renewed and covered with oiled silk. One of the oldest and best treatments for ulcers is to touch them daily with balsam of Peru and cover them with oxide of zinc ointment, or. better, with Lassar"s paste. Dry dressings for the ulcer are preferable to ' applications, and for this we may use iodoform, iodol, aristol, subnitrate or subiodide of bismuth, or 712 DISEASES OF THE SKIN dermatol, or any of the antiseptic or stimulating pow- ders. If there is an eczema or dermatitis about the ulcer, it is requisite to cover the powder and the whole patch with some mild or stimulating ointment according to the state of the skin. In this case the ulcer must be dressed once or twice a day. If there is not much derma- titis, we can dispense with the ointment, and dress the leg antiseptically and leave it for several days. Applications of nitrate of silver may be used to stimulate an atonic ulcer or to smooth down exuberant granulations. Strap- ping with adhesive plaster is another excellent means of treating ulcers upon not very much inflamed bases. Skin grafting, according to Thiersch's method, is the most prompt and sometimes the only way to cause large ulcers to heal. For further surgical treatment of ulcers text-books on surgery must be consulted. Ulcer, Tropical Phagedenic. — This is an ulcer secondary to a lesion of the skin that occurs in the tropics, and is marked by rapid extension and gangrenous destruction of tissues. It may be mild or malignant in its course. The latter eats deeply, involving even the bones. It is probable that closer study would show that all such ulcers should be placed under the diseases of which they form a part, such as yaws, syphilis, etc. Ulerythema. — This is a name proposed by Unna for those diseases in which there is a more or less persistent erythema upon which follows cicatrization by a process of absorption of inflammatory infiltration, and without ulceration. Under this heading comes lupus erythe- matosus. Ulerythema sycosiforme is a very severe form of sycosis in which little vesicopustules occur at the mouths of the hair follicles forming crusted patches. When the acuteness of the disease is passed the patches are left red and scaly, the skin is cicatricial and the hair permanently destroyed. There may be one or many patches, and the disease may invade the temporal regions of the scalp. ULERYTHEMA 713 Ulerythema ophyrogenes according to Taenzer 1 begins in infancy and lasts through life. It affects the eye- brows as a hyperkeratosis and redness of the outer end. There is a more or less complete stopping up of the hair follicles. In the mild form the process may extend to Fig. Ill Lupoid sycosis. (Rainforth.) the ears and down the neck and arms. In the severe form the whole of the eyebrows is affected, as well as the upper lip, and scalp. It causes destruction of the skin, and on the scalp it may completely destroy the hair. 1 Monatshft. f. prt. Dcrmat., 1889, viii, 187. 714 DISEASES OF THE SKIN The disease is indolent in its course, and intractable to treatment. It bears a resemblance to "folliculitis decalvans." Ulerythema acneiforme is the name given by Unna 1 to a purely local, probably parasitic, disease of the skin which is limited to the neighborhood of individual hair follicles. It begins as an inflammatory erythema, which, after persisting for some time, leads either to the forma- tion of a well marked cornification of the cuticle and comedones, or to cicatricial atrophy. It differs from acne in beginning on the middle of the cheek and margin of the auricle; in extending to the hairy scalp; in being primarily an inflammatory ery- thema; in an absence of suppuration, and in atrophy occurring without suppuration. It differs from acne necrotica in complete absence of necrosis, suppuration, and ulceration; in prominence of comedones, and in having no resemblance to variola in its scar. Uncinarial Dermatitis, or ground itch, is due to the invasion of the skin by nectator Americanus or hook worm which lives in the mud in some tropical countries. It attacks those who go bare footed. It causes itching, followed by redness and swelling, papules, and vesicles. In bad cases pustulation may take place, and extensive ulceration leaving scars. In mild cases the dermatitis subsides in one or two weeks. Systemic infection may take place marked by prostration, pains in the epigas- trium, shortness of breath, palpitation, and fever. It may cause death with symptoms of profound anemia. The treatment of the dermatitis is by alsolute cleanliness, and soaking the feet in a saturated solution of boric acid, or a weak solution of bichloride of mercury. Uridrosis or Sudor Urinosis. — By this is meant the excretion by the sweat pores of sweat loaded with the constituents of the urine, specially urea. The sweat then 1 Internat. Atlas of Rare Skin Diseases, No. 1. URTICARIA 715 often has a urinary odor, and deposits crystals of urates upon the skin. It is usually met with in severe renal disease where there is suppression of urine. Urticaria. — Synonyms: Cnidosis; (Fr.) Urticaire; (Ger. Nesselsucht, Nesselausschlag, Porcellanfriesel; (Eng.) Net- tlerash, Hives. An acute or chronic disease of the skin characterized by the appearance of wheals. It may run an acute or chronic course. Symptoms. — The vast majority of cases run an acute course. The characteristic feature of the disease is the appearance of wheals — that is, firm, flat, circumscribed elevations of the skin which are at first pink, and then white. They may remain pink. They may be round, oval, annular, or elongated, and are always surrounded by a red areola. They vary in size, sometimes being no larger than the head of a pin, papular urticaria, and some- times of the diameter of an inch. They show no tendency to group, but are irregularly disseminated over the whole body. Though they are not symmetrical in dis- tribution, both sides of the body are affected at the same time, and they show some preference for the extensor surfaces of the arms and legs. They itch, burn, and tingle, and are always scratched. They are ephemeral, each lesion lasting but a short time — from a few minutes to a day. Exceptionally some wheals will last several days. New lesions crop out as old lesions fade, and thus the eruption is continued. The mucous membranes are often affected at the same time with the skin; and if the pharynx is attacked there may be suffocative symptoms. The duration of the disease as commonly met with is but a few days, and not infrequently the wheals may be entirely absent during the day, to break out again at night. Very often when the patient is seen by the phy- sician, he can find nothing but scratched papules. But the patient will tell him that when he is undressing, or is warm in bed, the itching becomes unbearable, and lumps 716 DISEASES OF THE SKIN looking like mosquito-bites break out upon him. The skin of a patient with urticaria is very irritable, so that a sharp tap upon it or drawing the nail across it will produce a wheal. The outbreak of the disease may be sudden without constitutional disturbance, or there may be some burning and tingling of the skin before its appearance. Or there may be some febrile movement, and some evident dis- turbance of the digestion, such as vomiting or dyspeptic symptoms. When the disease is cured the lesions dis- appear without desquamation, and leave no trace. Such is the acute form. Chronic urticaria differs from the acute form mainly in its duration. Instead of recovery taking place in a few days or weeks, its course is one of months and years. Sometimes the outbreaks of the eruption show marked periodicity, occurring at stated intervals after pauses of complete immunity. The eruption is generally not so extensive in the chronic as in the acute form. If the itching has been very severe and the scratching propor- tionally excessive, the skin may become pigmented, as in other chronic pruritic diseases. The wheals assume different appearances in different cases, and different adjectives are used to express the varying pictures. It is not necessary to burden the mind with these, though they are convenient for descrip- tive purposes. Thus we have urticaria tuberosa seu gigans, where the lesions are unusually large; urticaria bullosa, where the wheals are surmounted by bullae; urticaria hemorrhagica, where hemorrhage into the wheals occurs; urticaria wdematosa, probably the same as acute circumscribed oedema or acute angioneurotic oedema, where the wheal occurs in locations in which the subcutaneous tissues are lax, as about the eye, nearly closing it, or on the tongue, causing it to swell enorm- ously and threaten suffocation; urticaria papulosa, or lichen urticatus, where the wheals are small, a form com- mon about the buttocks of children. URTICARIA 717 Urticaria factitia is the name used to express the fact that, on account of the irritability of the skin, a wheal may readily be excited by local irritation. Urticaria yerstans simply refers to the persistent character of the single lesion. Urticaria maculosa is the name proposed by Fournier for that form in which the wheal remains red. Etiology. — The causes of the disease are more numer- ous than the forms it may assume. Most of the acute and many of the chronic cases are dependent upon irri- tating ingesta, such as shell-fish, strawberries, cheese, pickles, mushrooms, pork, sausages, even mutton in some, and almost anything in other people, it being largely a matter of idiosyncrasy; medicinal substances, such as quinin, cubebs, copaiba, salicylic acid, opium, and other drugs. The rupture of hydatid cysts has been followed by urticaria. Dyspepsia in its various forms, and con- stipation, are common factors, especially in chronic urti- caria, as are intestinal worms in children. So also at times may be disorders of the liver, uterus, and ovaries. Some very severe cases occur during pregnancy. Some cases seem to be purely emotional in origin. Gout, rheu- matism, malaria, and functional or organic diseases of the nervous system will be found at the bottom of many cases of chronic urticaria. Wright holds that diminu- tion in the lime salts in the blood that interferes with its coagubility is the cause. Not only do we have internal causes producing the disease, but also external causes, such as contact with the jelly-fish; crawling of caterpillars over the skin; the action of cold, or sudden changes of temperature; the galvanic current and bites of insects. Urticaria is a common accompaniment of scabies and pediculosis. Pathology. — Urticaria is due to a vasomotor dis- turbance. At first there occurs a spasmodic contraction of the vessels of a circumscribed area of the skin, which is followed by paralytic dilatation of the vessels and retardation of the circulation. Serous exudation ensues, 718 DISEASES OF THE SKIN forming the wheal, which at first is pink, and then be- comes white, on account of the pressure of the fluid forc- ing out the blood from the central parts of the wheal. When the paresis ceases, the serous exudation is ab- sorbed and the part returns to its normal condition. T. C. Gilchrist, 1 Torok, and others do not believe in the vasomotor theory of the disease, but think that it is an inflammation of the skin, due to the escape of some toxin from the blood into the derma. J. Baum 2 has pro- duced wheals experimentally in frogs. He found that the capillaries dilate and fill with blood, the arteries dilate slightly and the veins more. The circulation gradually becomes slower, until stasis occurs at the periphery of the wheal. In ten to twenty minutes the wheal appears on account of oedema of the part. Diagnosis. — The occurrence of wheals is pathogno- monic of urticaria, as they occur in no other disease. When they are present there is no difficulty in diagnosis. When they are not present and we find only scratch marks we have to decide whether we have to do with urticaria or eczema, scabies, pediculosis, or dermatitis herpetiformis. Eczema differs from urticaria in the tendency its lesions have to run together and form patches. It never could be so generally distributed without presenting some characteristic patches. Scabies shows scratch-marks on the hands and feet, between the fingers and toes, in the axillae, about the umbilicus, and on the breasts of the female and the penis of the male. The cuniculi may be found in most cases. Pediculosis shows long parallel scratch marks over the back, between the shoulders, along the outside and inside of the limbs where the seams of the clothing come, and about the waist. Dermatitis herpetiformis presents grouped lesions, which usually are vesicles, but may be papules. Ery- thema of papular or tubercular variety may resemble 1 Jour. Amer. Med. Assoc, 1896, xxvii, 1222. 2 Berlin, klin. Woch., 1905, xlii, 9. URTICARIA 719 urticaria, but it is a markedly symmetrical disease, and burns rather than itches. Treatment. — In acute urticaria the administration of a prompt cathartic or saline laxative will usually cure the disease if due to some irritating ingesta. Emetics may be useful, if we see the case before stomachic diges- tion is ended, but in most cases we are called in when it is too late for them to be of service. Saline laxatives, mineral acids, the rhubarb and soda mixture, salol, resorcin, creosote or other intestinal disinfectants are of service in the more chronic cases. Of course, if the eruption is due to the ingestion of drugs, they must be stopped. In chronic cases, besides medicinal treatment we must regulate the diet, studying each case by itself. It is often well to put the patient on a strictly milk diet for a few days, and then add other articles with care. Alco- holics in all forms, and especially beer or other malt liquors, should be prohibited. If the gouty or rheumatic diathesis is at the foundation of the trouble, it must be combated. If the outbreak shows marked periodicity, sulphate of quinin may do good. Salicylate of soda salicin, and salol and alkaline diuretics and laxatives sometimes do good service even when there is no evident rheumatic tendency. In fact, we must endeavor in every way to get our patient into a normal state of health. Ravitch 1 regards thyroid extract as a specific. Whitfield advises giving calcium lactate. The most difficult class of cases are those in which a neurosis alone seems to be the cause. Then belladonna, atropia, arsenic, the bromides, antipyrin, phenacetin, and galvanism may be tried. Pilocarpin, wine of antimony, colchicum, ergot, are also commended. It may be necessary to procure sleep in some cases by giving bromides, sulphonal, and the like. Opium is to be avoided. In very obstinate cases the patient should be sent away from home and . relieved from all business cares. 1 Jour. Cutan. Dis., 1907, xxv. 512. 720 DISEASES OF THE SKIN In the urticaria of pregnancy Linser 1 has had remark- able results from the injection of serum taken from another pregnant woman. The directions for giving the serum will be found in the section on pruritus cutaneous. Local Treatment is of great service in allaying the itching, but it will not cure the disease. The parts may be sponged with alkaline lotions, such as a teaspoonful of baking-soda to a hand-basinful of water. Sometimes more relief is obtained by an acid solution, such as vinegar pure or with water. Carbolic acid in vaselin, or alcohol and water, is sometimes very efficacious. In vaselin, 10 per cent, strength is sufficient; in lotion form we may use, to the adult skin, 1 to 2 (4 to 8) drachms to the ounce (32) directing the patient to dab and not rub it on the skin. Hardaway prefers using the acid in a spray, 2 to 4 (8 to 16) drachms to the pint (500), with 1 ounce (32) of glycerin. To each atomizerful 10 drops of oil of pepper- mint may be added to increase its antipruritic qualities. Menthol, 1 to 10 per cent, in alcohol or almond oil, is said to be efficacious. Crocker speaks highly of liquor carbonis deter gens, 3j togiv (4 to 120); terbene, oivtogiv (16-120); and equal parts of sanitas and water. Salicylic acid, 20 grains (1.33) to the ounce (32) of castor oil, is good, but disagreeable. Camphor and chloral hydrate, each from J to 1 drachm (2 to 4), rubbed together and added to 1 ounce (32) of starch or ungt. simplex, is another good antipruritic. Chloroform dabbed or sprayed on renders prompt relief. Baths are sometimes of use. Having the patient take a warm bath containing either 2 to 6 pounds of bran, or a J to J a pound of bicarbonate of soda, or an ounce of nitromuriatic acid, just before going to bed; then drying the skin by wrapping in a warm sheet and patting the skin dry; then smearing the skin with a film of vaselin and dredging over this corn starch powder, will often give him a good night's rest. Prognosis. — The vast majority of cases of urticaria recover in a few hours or days. The chronic cases often i Dermat. Woch., 1912, liv, 365. URTICARIA PIGMENTOSA 721 are most obstinate, but unless some severe nerve lesion is at the bottom of the case, they can be cured by patient and perservering effort. When occurring in the course of pregnancy, premature delivery may have to be induced to relieve the woman of her suffering. Urticaria Pigmentosa. — Synonym: Xanthelasmoidea. U. perstans pigmentosa. This is not an ordinary urticaria, that, on account of its chronic course and the scratching to which it has been subjected, leaves more or less pigmentation of the skin. Such a condition of things is not infrequently seen. Urticaria pigmentosa begins within the first six months of life by an eruption of wheals or tubercles, which at first are about the size of a split-pea, and of a brownish or yellowish-red color, with a pink areola. Later they may increase in size, or several may coalesce to form a large one, and assume a yellow or buff color. These wheals appear in crops, and run a very chronic course, each one persisting for weeks or months. Then they shrink, become softened, and disappear, leaving brownish pigmentation. As the course is chronic, we will find on the patient wheals or tubercles of red or yellow color, of various sizes, some hard and tense, some soft and wrinkled, and brown stains of the skin. Ordinary urticarial evanes- cent wheals will sometimes be found, and rubbing of the apparently stationary tubercles will cause some of them to enlarge. The wheals are most often located on the trunk and neck; then on the limbs, face, and head; but they may appear on any part of the body surface as well as on the mucous membranes of the mouth and pharynx. Itching is usually present, but may be absent. After a number of years the wheals will no longer come out, and recovery is generally complete at about the age of puberty, though the disease may last much longer than that. Morrow 1 has reported one case of over twenty years' 1 Jour. Cut an. and Gen.-Urin. Dis., 1895. viii, 445. 46 722 DISEASES OF THE SKIN duration. The majority of the cases, according to Crocker, occur in boys. We know no cause for the disease. Histologically, the characteristic feature, beside the oedema and deposit of pigment in the epidermis, is the cellular infiltration of the upper derma composed chiefly of mast cells. In this disease, even in the healthy skin, the number of mast cells is remarkably increased. Thus far treatment has been in vain. It is esentially the same as in chronic urticaria. One case was cured by Torok and Schein 1 by the x-rays, used to the pro- duction of a dermatitis. Vaccinal Eruptions. — The eruptions that accompany or follow vaccination may be local, starting from the point of inoculation; or general, and due to the absorption of the virus, which in some subjects acts as do medicinal sub- stances in other people. The majority of them are due not to any bad quality of the virus, but either to some accidental infection or to idiosyncrasy. Sometimes an ulcer will form at the site of the vaccination; or starting from this point we may have a dermatitis, cellulitis, lymphangitis, erysipelas, abscess, or furuncle. At times exuberant granulations, or what is called an infective granuloma, may develop upon the seat of the vaccination. An outbreak of impetigo contagiosa may originate from inoculation, the pus of the sore becoming transferred to other parts by the finger nails; or an eczema or psoriasis may be set up by the irritation of the sore, just as they may follow other affections of the skin. General eruptions usually appear, according to Harda- way, after the ninth or tenth day of vaccinia, and assume an erythematous, papular, or papulovesicular character. The roseola vaccina of Hebra is an erythematous eruption of macular character, commencing usually upon the arms, and sometimes spreading over the whole body. It is accompanied in some cases with slight rise of tem- perature for a few hours. It disappears and leaves no trace. i Wien. med. Woch., 1902, liii, 847. ■ Ev * - -' * ■* ^ *i %'fi : a in 2. ° 3 PQ VARIOLA 723 We may also encounter erythema multiforme and urti- caria complicating vaccination. It is possible that a bul- lous eruption may occur, but this is very rare. Syphilis also may be inoculated in arm-to-arm vaccination. Gan- grene may occur in the sore and other accidents. All of these are rare. Varicella, or Chicken-pox, is an eruptive fever of mild grade, with an incubative period of two weeks. It is characterized by an outbreak of a greater or less number of transient red papules and clear vesicles, of pinhead to pea size, and varying shape, that come out in crops. Later they may become pustules. A long vesicle is very char- acteristic of this eruption, as is the location of the vesicle or pustule to one side of the areola. The eruption is usually scanty. Umbilication occurs in some of the vesi- cles. The vesicle can be easily ruptured. There is usually only slight constitutional disturbance. The mucous mem- branes may be involved. In the early stages there is possibility of taking the disease for variola. It is differen- tiated from it by the mildness of its symptoms, the finding of lesions in all stages, the ease with which the vesicles may be ruptured, the infrequence of umbilication and the rapid course it runs. Treatment is purely expectant. Variola, or Smallpox, is an acute contagious fever with an incubative period of about two weeks. It is charac- terized by very severe prodromal symptoms, such as a chill with fever, of 103°, vomiting, headache, and intense pain in the back and legs, and the appearance, usually on the third day, of an eruption of minute red spots that in twenty-four hours change into small, round, hard, shotty papules. The eruption is first seen on the face about the forehead and mouth and on the neck and wrists. In about three days vesicles form upon the papules, and attain their full development by about their fifth day. They then are umbilicated, are located upon a hard base, and have a well-marked areola. Now they change into pustules, and a well-marked secondary 724 DISEASES OF THE SKIN fever attends the change. After about four or five days the pustules dry up into crusts, and afterward these fall, leaving pitted cicatrices in many places. In regular cases it takes three or four weeks for complete shedding of the crusts, making the entire duration of the disease from five to six weeks. Severe types of the disease are known as confluent and hemorrhagic variola, and are marked by more severe symptoms and complications. The mucous membranes are commonly involved. In varioloid, modified smallpox, the constitutional symptoms as well as the eruption are of much milder grade. Diagnosis. — Variola bears a resemblance to the pus- tular syphilide; for the differential diagnosis, see the " pustular syphilide. " Acne and pustular eczema both have lesions resembling those of variola, but are limited to certain regions, and are not general eruptions. Vari- cella and papular erythema have been mistaken for variola. In its earlier stages the diagnosis of variola is very difficult. In pronounced cases, on the other hand, the diagnosis is easy. For the diagnosis from varicella see varicella. Veld Sore. — According to Crocker, this is a disease met with in South Africa. The sores occur most often on the hands and forearms, feet, and legs. They begin as itch- ing pinhead papules, vesicles, or pustules, which rapidly increase in size. They rupture readily and form painful dirty-looking sores, covered with a crust exuding pus and serum. There is often a lymphangitis and enlargement of the lymph glands. Sometimes it may take the form of a huge flat pustule covering the whole of the back of the hand. Cultures show a coccus resembling staphylo- coccus aureus. It may be only a form of tropical im- petigo contagiosa or ecthyma. Horseflies are accused as being the distributing agent. The treatment is by means of antiseptic dressings. Verruca. — Synonyms: (Ft.) Verrue; (Ger.) Warze; Wart. VERRUCA 725 These exceedingly common papillary outgrowths assume various appearances, to which descriptive names have been given. Thus we have verruca vulgaris, or the wart so often seen on the hands of children and young people. These vary in size from that of a hemp-seed to that of a Verruca vulgaris. (By the courtesy of T Dr. S. Dana Hubbard.) split-pea, or larger where two or more become aggregated. They are sessile, hard, conical, with flattened tops. They may be smooth, or uneven, showing their papillary for- mation. They may be of the color of the skin, or some shade of yellow, brown, black, or green. There may be 726 DISEASES OF THE SKIN a number of them, and they may be isolated or aggre- gated. They may occur elsewhere than on the hands. One variety occurs on the soles of the feet. They look like callosities. They are often painful. When the hard calloused skin is shaved off the warty character of the growth is disclosed. Verruca digitata is a wart in which the papilla? are separated distinctly from each other. These occur in groups, and are often seen on the scalp. Verruca filiformis is a wart in which the papillse are not only distinct, but fine, almost thread-like. Each papil- lary outgrowth stands by itself. These are soft to the touch, and occur on the face, eyelids, and neck. Ver- ruca plana is a flat wart, but slightly elevated, and vary- ing in size from that of a pinhead to a half -inch in dia- meter. These sometimes occur in large numbers. In young people they occur upon the face and backs of the hands, and may or may not be pigmented. In old people they occur on the trunk and arms and are pigmented, and are called verruca senilis or seborrheal warts. Ver- ruca acuminata, also called condyloma acuminata, vegeta- tion dermique, spitzen warzen, and venereal or moist wart, is met with in the anal and genital regions of both sexes, as also in the axillse, under the hanging breasts, in the umbilicus, and between the toes. These are vascular, sessile or pedunculated, and composed of a great number of closely aggregated projections of various shapes. On exposed situations they are dry and of the color of the skin; while in locations that are moist — that is, between the skin-folds — they are covered with a whitish puriform secretion, and, unless kept very clean, they emit an offen- sive odor. They sometimes attain to an immense size. Etiology. — We do not know the cause of warts. They are contagious, or auto-inoculable at least, and par- asites have been isolated and declared to be the morbific agents. They have been produced by inoculation. Minute particles of glass or iron have been found in some warts suggesting that they may be caused by traumatism or local irritation. They occur more fre- VERRUCA 727 quently in the young than in the old, and may be con- genital. Venereal warts are traceable to irritating dis- charges, but not by any means always to a gonorrhea. They are undoubtedly contagious. Pathology. — Warts concern the rete mostly, being markedly downward and upward growths of its cells. The papillae beneath the wart are flattened. The corneous layer of the skin is hypertrophied, but less compact than normal. Verrucse acuminata? differ from other warts in the absence of any anomalies of keratinization, and in the excessive development of the rete, marked papillary enlargement and abundant vascular supply. Treatment. — The treatment of most all warts is prompt and efficient by means of the curette, scraping them off while the skin is slightly stretched. If there is any doubt about their returning, their bases may be touched with iodine or nitric acid. Generally simple scraping is sufficient. The wart often is thus turned out of the skin entire, like a pea from a pod. No scar is left, because the corium is not wounded. Electrolysis may be used. The digitate and filiform warts may be snipped off with the scissors. If operative interference is refused, the warts may be removed by painting with tincture of iodine; or a saturated solution of salicylic acid in collodion ; or a 20 per cent, solution of resorcin; tincture of thuja; or nitric or trichloracetic acid. G. W. Fitz 1 says that paint- ing them daily with a 10 per cent, solution of chrysarobin in traumaticin, after rubbing them down with fine sand- paper, will remove them in a week or so. In the country children's warts are removable in some cases by the appli- cation of the juice of the common milk-weed. Chromic acid is a powerful caustic. Caustic potash is not a safe agent to use, unless care is had to limit its action by a ring of wax about the wart. The galvanocautery may also be employed, as well as x-rays and carbonic dioxid snow. Sparking with the high-frequency current is also a good method of treatment. 1 Boston Med. and Surg. Jour., 1899, cxl, No. 26. 728 DISEASES OF THE SKIN Venereal warts may be removed by keeping them clean and dry, and painting them with liq. plumbi subacetatis, or a solution of the per chloride or persulphate of iron; or dusting them with salicylic acid and starch, or with boric acid. It is said that warts may be removed by internal treat- ment. Sulphate of magnesia, 2 to 3 (0.12 to 0.18) grains to a child and J a drachm (2) to an adult, three times a day, is one remedy. Besnier has tried this method in a number of cases with absolute unsuccess. Tincture of thuja occidentalis is said to be efficacious. Crocker thinks he has seen cures effected with full doses of nitromuriatic acid, while others advocate arsenic. J. B. Cooper 1 claims to cure warts in from four to six weeks by giving a wine glass of lime water in a little milk after the noon day meal. C. Watson 2 has cured a case of multiple warts by giving a J ounce of castor oil twice during the first week, and once a week afterward. We have tried this without success. Warts very often disappear of themselves and no one has ever seen them fall. Verrue. — See Verruca. Verruga Peruana. — This disease is said to occur in the narrow, hot valleys of Peru. It begins as a fever resem- bling malaria, accompanied by anemia, pains in the joints, neuralgia, and swelling of the liver and spleen. The patient may die in this stage. If he survives, the warts follow the fever. They may appear suddenly without the prodromal fever. They may be miliary in size, and rosy and translucent; or larger, forming dull, horny papules; or nodular in size, when they may be complicated with fur- uncles. They may come out in groups and run together. They are scattered over the body. They may undergo spontaneous involution. When in groups, they may break down and ulcerate. A special bacillus is supposed 1 Brit. Med. Jour., 1905, ii, 441. 2 Brit, Jour. Dermat., 1903, xv, 178. VITILIGO 729 to be the cause of the disease. They are to be scraped off with a curette, and the patient is to be removed from the endemic area and given large doses of the chloride of iron, and of quinine. Fig. 113 Leukoderma. (By the courtesy of Dr. S. Dana Hubbard. J Vitiligo. — Synonyms: Leucoderma; Leucasmus; Leu- copathia; Achroma; Piebald skin. An acquired loss of pigment of the skin characterized by the formation of symmetrical white patches with con- vex borders surrounded by an area of hyperpigmentation. Symptoms. — This is an acquired anomaly of pigmen- tation, the opposite to chloasma. It is akin to albinismus, only that the latter is a congenital condition. It consists in the disappearance of the pigment of the skin in circum- scribed round or oval patches so that white areas are 730 DISEASES OF THE SKIN Fig. 114 formed. At the same time there is an accumulation of pigment around the areas, so that there is at once a process of apigmentation and of hyper- pigmentation. The size of the patches varies greatly. They may be no larger than a ten-cent piece or of immense size. The disease most commonly begins upon the neck, face, or backs of the hands, but may begin any- where. It is chronic. It may progress so as eventually to in- volve nearly the whole body; or it may become stationary; or, in rare cases, the skin may be- come pigmented again. It is a symmetrical disease in nearly all cases. The general health is un- affected, and there is no change in the sensibility of the patches. In some cases the white parts are unusually sensitive to ex- posure to the sun. When the scalp or hairy regions are affected the hair turns white. The disease is most evident in the summer on account of the increased pigmen- tation that normally occurs in the sound skin at this season. Etiology. — The cause of the disease is obscure. All we can now say is that it is probably a disturbance of innervation. It is uncommon for it to occur before the tenth year of life, though it may do so. Adults are most frequently affected. Both sexes are subject to it. It seems in some cases to be hereditary. It is assumed Leucoderma. (After Hyde.) WASH LEATHER SKIN 731 that it is a neurosis. It is more common in the warm than in the cold countries, and is particularly common in negroes. Exposure to the sun and cold seems to be an excitant in some cases. It has followed typhoid fever, scarlatina, and malarial fever. Wood 1 says that when mulattoes contract syphilis they become several shades lighter all over the body. Symptomatically it is seen with morphea, Addison's disease, and alopecia areata. There is also a syphilitic vitiligo. Diagnosis. — There is little difficulty in diagnosis, as there is no other disease in which the only symptom is a loss of pigment with a surrounding pigmentation. In morphea the patch may be raised, and the skin is changed in texture, and there is apt to be a little lilac ring about it. In chloasma the patch itself is dark with a convex border, while in vitiligo the border of the pigmentation is con- cave. The concave border of the pigmentation will also distinguish the disease from chromophytosis, which is also scaly. The normal sensation of the patches dis- tinguishes them from leprosy, in which the patches are anesthetic. Treatment. — Unfortunately there is hardly anything that can be done in the way of treatment. Galvanism or faradism may be tried, and nerve tonics given. Thyroid extract, or adrenalin may be tried. We must content ourselves with making the patches less evident by remov- ing the pigment from about them by the means given under Chloasma. Or we can stain the patches so that they shall be less white, as by the use of walnut juice. Besnier and Doyon believe that they have cured cases in young subjects by the prolonged use of bromide of potassium internally, and saline or bromo-iodide baths externally, with or without injections of pilocarpin. Wart. — See Verruca. Washleather Skin is that condition of the skin in which certain metals, specially silver, mark it with a black line. 1 Jour. Cutan. and Ven. Dis., 1883, i, 274. 732 DISEASES OF THE SKIN It occurs, as a rule, in patients suffering from diseases which directly or indirectly affect either the trophic or the sensory nerves, such as renal disease, tuberculosis, erysipelas, and hemiplegia. It sometimes precedes the occurrence of bed-sores. Xanthelasma. — See Xanthoma. Xanthoma. — Synonyms: Xanthelasma; Vitiligoidea ; Molluscum cholesterique ; Fibroma lipomatodes. A peculiar disease of the skin characterized by the appearance of discrete patches, or tubercles, of chamois or lemon-yellow color. Symptoms. — Xanthoma may assume one of two forms: Xanthoma planum or Xanthoma tuberosum sen tubercu- latum. In the former we meet with flat, chamois leather- like, or lemon-yellow plates that are either slightly raised above the level of the skin or not at all raised. Excep- tionally they may be dark yellow, whitish or creamy, or deep brown. They vary in size from an eighth of an inch to an inch in their long diameter, feel soft and smooth to the touch, and when pinched between the fingers no infil- tration of the skin is perceptible. They are irregular in shape, tending to form elongated figures. When in patches, they feel almost velvety, and when examined with a lens they often are seen to consist of an aggregation of small granules, many of which have a central pinkish punctum. They are slow in growth, and when they have attained a certain size may remain stationary. The favorite site of xanthoma planum is in the upper eyelid, where they are not infrequently seen. There they commence at the inner canthus, most often of the left eye, and spread in a semicircle about the eye, while shortly afterward a similar growth begins on the right upper eyelid. They may be found also on the lower lid. Next in point of frequency to the eyelids, they occur upon the flexures of the joints and upon mucous membranes. Xanthoma tuberosum exhibits lesions of the same color as does the plane variety, or they may be reddish yellow, XANTHOMA 733 but they are raised above the skin, and may attain to a large size. They are soft, smooth, round or oval, with telangiectases over them when small. When large, they are firmer and more irregular in shape, being made up by aggregation of a number of smaller tubercles. Xanthoma multiplex is the name applied to cases in which both varie- ties are present. In all forms, unless there is jaundice, the skin between and about the lesions is normal in color. Most cases give rise to no subjective symptoms, but there may be some itching or burning. If the disease occur upon the palms or knees, it may cause discomfort or even pain on kneeling or handling objects. Xanthoma tuberosum is most frequently seen upon the knees, elbows, knuckles, and other points of pressure, the trunk being not so much affected. Symmetry is generally observed. Xanthoma multiplex is often very widely distributed. Sometmes the lesions run in streaks, or, as in Hardaway's case, 1 are arranged like a zoster. Under the name of Pseudoxanthom elastique E. Bodin 2 has described an eruption of pinhead-sized, oval or round, pale yellow lesions that occurred in symmetrical patches, about which were scattered single lesions. The surface of the patches was smooth or slightly granular. They occurred on the lower part of the abdomen, clavicular region, anterior wall of axillae, inside of arm, forearm, and thighs. The skin in xanthoma is not alone affected. Xantho- matous bodies are found in the liver, mucous membranes, and tendons. Jaundice is not infrequently met with. The disease is progressive for a time, and then may remain stationary for years, or may undergo spontaneous resolution. Etiology. — Xanthoma occurs much more frequently in adults than in children, and that form that occurs in the eyelids is much more common in women than in men. Several cases may be seen in the same family, and the 1 St. Louis Courier of Med., October, 1884. 2 Ann. de derm, et de syph., 1900, i, 1073. 734 DISEASES OF THE SKIN disease is sometimes hereditary. But we really do not know as yet what is the cause of the disease, though vari- ous theories have been advanced. Crocker states that four-fifths of the cases of xanthoma multiplex occurring after puberty are associated with chronic jaundice. Hepatic diseases; diabetes; diathetic conditions of various kinds; migraine; embryonic cells left in the skin — each have been found in connection with one or many cases. Hardaway may not be wrong in his idea that it is a dia- thetic disease, and that when it occurs with jaundice it is because the same tubercles have been deposited in the liver as in the skin, and the jaundice is secondary to them. Pathology. — It is a connective-tissue new growth containing an abundance of fat. Between the connec- tive-tissue bundles the so-called "xanthoma cells" are found. According to Politzer 1 these are not cells but fragmented and degenerated remains of muscle fibres with proliferated sarcolemma nuclei. Crocker does not accept this, but states that he considers "inflammation as the primary feature, and the xanthoma cells and con- nective-tissue growth secondary, and the whole process of toxemic origin." The color of the lesions is due to fat-globules (Heitzmann). Diagnosis. — The diagnosis of this unique disease is made by the occurrence of chamois-leather-colored soft plates or tubercles, such as occur in no other disease. Milium may bear some slight resemblance to xanthoma, but it is hard and firm, not soft and velvety, and white, not yelloAv. It is easily squeezed out after a prick through the skin over it, an impossibility in xanthoma. Treatment. — The patches may be excised. They may be destroyed by electrolysis. As in the operation for removal of superfluous hair, the fine steel broach attached to the negative pole of the galvanic battery is used, and it is passed under the growth from side to side. A series 1 Jour. Cutan. Dis., 1910, xxviii, 633. XANTHOMA DIABETICORUM 735 of tracks under the growth and parallel to each other are made, the current always being completed after the needle is in position and broken before the needle is removed. A current of 2 or 3 ma. should be used. Besnier 1 reports good results from the administration of phos- phorus in cod-liver oil, giving 1 mg. per day, and increasing the dose each day by a J of a mg. until 3 mg. are taken. After fifteen days this is stopped and turpentine is given. Stern 2 tried this plan without success, but succeeded in removing patches of the disease from the eyelids by the use of a 10 per cent, solution of corrosive sublimate in collodion. Shepherd, of Montreal, saw one case recover after an operation for biliary calculi; and McGuire removed one with monochlor acetic acid. Stelwagon commends trichloracetic acid, at first diluted, applied cautiously to a small part at a time, the reaction being controlled by vaselin or cold cream. Fuming nitric acid applied carefully by means of a small cotton swab in a series of dots will destroy them. Salicylic acid in collodion, 10 or 15 per cent., may be used. Pkognosis. — The growths when fully formed remain stationary, showing no tendency to change in any way, Exceptionally they may disappear of themselves. Treat- ment is most often disappointing, as when apparently removed they tend to return. Xanthoma Diabeticorum. — Besides the xanthoma just described, there is another form which is regarded as a distinct affection, and called Xanthoma diabeticorum. Symptoms. — It consists in the eruption of round, firm, dull red papules, on top of many of which is a yellow or yellowish-white head, and over many there are dilated vessels. Some papules may be pierced by hairs. They may be discrete or grouped or in lines. They may itch or pain, and are located especially on the buttocks, elbows, and knees, but may occur anywhere. The eruption 1 Jour, de Med. et de Chir., April, 1866. 2 Berlin, klin. Woehenschr., 1889, xxx, 393. 736 . DISEASES OF THE SKIN appears suddenly, and after months or years may dis- appear quickly. Relapses may occur. Etiology.— As the name indicates, in most cases dia- betes is found, but it occurs without it at times. Pathology. — The disease process appears to be of the same nature as ordinary nodular xanthoma, but with more inflammatory phenomena and less connective-tissue growth (Crocker). Diagnosis. — It differs from ordinary xanthoma in its more sudden development; in disappearing sooner or later, perhaps to recur; in the hardness of its lesions, which are never macular; in the frequent absence of a yellow color; in the presence of a certain amount of inflamma- tion; in the absence of jaundice and presence of diabetes mellitus; in its more pruriginous character; in avoiding the eyelids; and in having its lesions about the mouths of the hair follicles. In fact, it resembles ordinary xan- thoma mostly in its location upon the elbows, knees, and other points of pressure, and in the general configuration of the lesions. Treatment should be directed to the diabetes, which is at the foundation of the disease, and to the allaying of the itching. Yaws. 1 — Synonyms: Framboesia tropica; Pian; Bouba; Parangi; Verruga; Granuloma seu Polypapilloma tropi- cum. This is a disease that occurs only in tropical countries. The stage of incubation lasts from two to eight weeks up to three or four months, and is without special symptoms. At the end of this stage the initial lesion appears. It is a pinhead-sized papule that becomes pustular, and then changes into an ulcer with perpendicular edges. The occurrence of the initial lesion is often unobserved, and some authorities deny its existence. The stage of inva- sion, with more or less well-marked fever and rheumatic pain, which abate before the eruption appears, lasts one 1 This account is condensed from Crocker. YAWS 737 or two weeks. The eruption is preceded by enlargement and tenderness of the lymphatic glands, and consists of pinhead- to lentil-sized, slightly elevated papules on a broad base. The papules enlarge; the epidermis splits and curls off from their centres, and exposes a yellowish point which develops into a flat, moist, red or pink tumor, looking not unlike a raspberry. These tumors range in size from that of a split pea to that of a nut, are round or oval, discrete or coalesced into large irregular masses. The surface of the tumor is covered with a thin, yellowish, foul-smelling discharge, that dries into a crust, which may ultimately assume a rupia form. In the mouth and in moist situations no crusts form, and the tumor will resemble a mucous patch. They reach their full develop- ment in from two to four weeks, remain stationary for months, and then dry up and fall off, leaving a stain on the skin, that eventually disappears. They may break down and ulcerate, involving both the adjacent soft parts and the bones. The tumors are not tender. The disease tends to recovery, but is subject to relapses. It is contagious, and one attack is protective to a certain extent. Death occurs in bad cases. It is supposed to be due to a specific micrococcus. Castellani 1 has found a special form of spirochete in the tumor which he named spirochete pertenuis, which is inoculable in monkeys. The Wassermann test is positive. It is probable that the disease is a form of syphilis. Diagnosis. — The diagnosis is from syphilis. It differs from it in attacking children specially, in having no initial lesion, in its lesions not showing polymorphism, in absence of lymphatic nodes, and in being itchy. More- over, the disease does not protect against syphilis. Treatment. — The treatment is the same as in syphilis — that is, by mercury and iodide of potassium, and care of the patient's general condition as to hygiene and sur- roundings. A number of cases have been cured by 1 Jour. Cutan. Dis., 1908, xxvi, 151. 47 738 DISEASES OF THE SKIN injections of salvarsan. Locally, disinfectant and mer- curial applications should be used. Zoster. — Synonyms: Zona; Herpes zoster; Ignis sacer; (Ger.) Feuergiirtel, Gtirtelkrankheit; Shingles. An acute disease of the skin characterized by an uni- lateral eruption of groups of vesicles upon reddened bases scattered along the course of certain nerves. Symptoms. — Zoster, like psoriasis, presents such marked lesions that once seen it is readily recognized when seen again. It occurs in the form of groups of vesicles seated upon red bases, and arranged along the course of nerves upon which there are ganglia. The vesicles are at first filled with serum that afterwards may become cloudy. They do not tend to break down of themselves, but are frequently ruptured by accident. The size of the groups varies greatly. There may be but a few vesicles or a large number of them closely crowded together. Sometimes a group is no larger than a three-cent piece, and sometimes it is several inches in its longest diameter. Sometimes the vesicles may run together and form blebs. The shape of the groups is always irregular. There may be but two or three groups or a score of them. In nearly all cases the disease is unilateral, though it is not uncommon for one or two groups to be found close to the middle line, on the side opposite to the site of the disease. Cases of double zoster are very rare, usually with an interval of some days between the appearance of the lesions on the two sides, and practically never on the same plane. All the groups do not come out at once, but, as it were, by a series of outbreaks, the earliest ones to appear usually being those nearest the point of exit of the nerve. The eruption is usually at its height in a week, the vesicles drying up, forming a crust and falling off, leaving a red mark that soon fades. The whole duration of the disease is from ten days to three of four weeks. In many, if not most, cases the patient experiences ZOSTER 739 neuralgic pain in the nerve along whose course the erup- tion is about to appear. This is sometimes wanting, and generally lessens or disappears when the eruption appears. Sometimes the pain is severe during the duration of the eruption, and after it is gone. Tender points may often be found over the points of exit of the nerves, like those found in neuralgia. In some patients there will be fever before the outbreak of the vesicles or the successive appearance of new groups. The vesicular stage is preceded by an erythematopapular stage. Very rarely some of the groups may abort at this stage. Exceptionally, zoster may occur on both sides of the body. In nearly all cases the disease does not recur. Exceptionally a patient may have several attacks of the disease. Most cases of zoster occur upon the trunk, and, it is said, especially on the right side. It also occurs upon the face, on branches of the fifth nerve, when it may involve the eye and produce blindness by destructive ulceration of the cornea. The neck may be affected, and with it the arm. The leg, too, may suffer. Generally the eruption does not reach further down than the elbow and knee, though it may occupy the forearm and hand, leg and foot. In rare instances the tongue and pharynx may be affected. Various names are used to designate the location of the eruption, such as zoster frontalis, ophthalmicus, cervicalis, intercostalis, genitocruralis, and the like. In rare cases hemorrhage may occur into the vesicles, or they may be purulent from the start, or they may ulcerate, or become gangrenous. The neuralgia may continue in old or debilitated subjects in so severe a manner as to threaten the exhaustion of the patient from pain and loss of sleep. Or pruritus, hyperesthesia, or anesthesia may be left for some time after the disappear- ance of the eruption. Or paralysis of motion may follow the attack, as well as atrophy of muscles. Scars will follow the disease if ulceration has occurred. Etiology. — Zoster occurs more often in children than in adults. Sex seems to have little influence. It follows 740 DISEASES OF THE SKIN upon^ injuries to nerves in some cases, and has been associated with caries of the ribs. It has been known to occur while the patient was taking arsenic. It occurs frequently in the damp, cold weather of the spring and autumn, so much so as to give rise to epidemics. Indeed, some regard the disease as infectious on account of the epidemic character it sometimes has. Some cases seem to arise from peripheral irritation of cutaneous nerves. A descending peripheral neuritis of the spinal ganglion is regarded by Crocker as the condition most frequently associated with the disease. He also regards the disease as of toxic origin. In a great number of cases disease of Fig. 115 Zoster of arm. the ganglia upon the posterior roots of the spinal nerves has been found postmortem. When the fifth nerve is affected, it is the Gasserian ganglion that is diseased. Zoster may arise from injury, as a wound of a nerve- trunk, and then we may have an ascending zoster, the first group being nearest the point of injury. Pathology. — The zoster vesicle begins in the lower rete layer; the epithelial cells enlarge, assume vari- ous shapes, probably from pressure, and finally liquefy. Even in the formed vesicle some of the distended cells may be seen adherent to the floor. The roof is formed by the corneous layer. Besides serum and the debris ZOSTER 741 of epithelial cells, the vesicles may contain few or many pus cells, and even in the hemorrhagic form, some red- blood corpuscles. There are secondary inflammatory changes in the rete and in the derma. J. F. Schamberg 1 says that on the posterior roots of the spinal nerves are found: (1) Acute inflammation with exudation of small, red, deeply staining cells. (2) Extravasation of blood. (3) Destruction of ganglion cells and fibres, and (4) Inflammation of the sheath of the ganglion. Diagnosis. — Zoster in most cases is readily recogniz- able. It differs from eczema in having larger vesicles that do not tend to rupture; in its patchy character, the patches being located along certain nerve-trunks; in the neuralgia that accompanies it, and in the definite course that it runs. Herpes facialis or progenitalis sometimes resembles zoster quite closely, but in them there will often be a history of previous attacks; they will not occur so markedly as groups of vesicles upon one side alone, and they will not be preceded by the same amount of neuralgia. By some authorities herpes and zoster are considered to be the same disease. Treatment. — The most important part of the treat- ment of zoster is to prevent the breaking of the vesicles and the possible ulceration that would follow and leave scars. To this end we should avoid ointments and use dusting powders, such as oxide of zinc, bismuth, starch, guaiacol, 5 per cent, with starch powder, or, what is better, we should paint the vesicles with flexible collodion with or without morphin, which sometimes seems to abort the formation of vesicles. The application of a 30 to 50 per cent, aqueous solution of ichthyol is one of the best methods of treatment. It relieves the pain and protects the groups from rubbing by the clothing. It is also advisable to cover the eruption with a soft linen bandage to prevent rubbing. If the vesicles have become 1 Jour. Amer. Med. Assoc, 1907, xlviii, 746. 742 DISEASES OF THE SKIN broken and ulceration has ensued, then we have to treat the ulcers on surgical principles. To relieve the pain of zoster the galvanic current gives good results, one sponge electrode being placed over the spine, and a steel roller electrode attached to the other pole and passed around the groups for ten or fifteen minutes once or twice a day. A current-strength of 2 or 3 ma. may be used, and, if it can be done, the last application should be made just before going to bed. Other means are hypodermics of morphin; blistering or dry cups over the root of the nerve; guaiacol as mentioned above, and the use of the menthol cone, or oil of peppermint. Phosphide of zinc, -J of a grain every three hours, is thought by some to relieve the pain and limit the eruption. For the persistent neuralgia that at times follows these cases, arsenic, or strychnin, iron, quinine, cod-liver oil, and a good, nutritious diet are necessary. Opium or other analgesic may have to be given to allay pain and procure sleep. Prognosis. — Most cases of zoster run a favorable course and get well of themselves. It is only in old or debilitated people that we need fear any serious results. There is always the possibility of the occurrence of ulcera- tion and gangrene, though it is not to be expected in the vast majority of cases. The popular opinion that if zoster occurs on both sides at once and forms a girdle the patient will die, has no foundation in fact, as such an occurrence is unknown. APPENDIX. The following formulae are given as guides in the preparation of prescriptions for the treatment of skin diseases. Many, if not all of them, have been well tried and their value proved. A. BATHS. Simple Water Baths: Cold 40°-65°F. Cool 65°- 75° F. Tepid 85°-95°F. Warm 95°-100° F. Hot 100°-110°F. Wet Pack. Wrap patient in a wet sheet and roll up in a blanket. After twenty to thirty minutes remove the pack, rub dry, and anoint with oil or ointment. Useful to remove the scales in psoriasis and to diminish hyperemia. Medicated Baths. To an ordinary bathtubful, say thirty gallons of water, add for Bran bath . . 2 to 6 pounds bran. Potato-starch bath 1 pound starch. Gelatin bath . . 1 to 3 pounds gelatin. Linseed " 1 pound linseed. Marshmallow bath 4 pounds marshmallow. Size bath . . . 2 to 4 pounds size. These baths are useful in erythematous, itchy, and scaly diseases. In using bran it should be tied up in cheese-cloth bags before being put in the water. For an alkaline bath add to bath, Bicarbonate of soda . . 2 to 10 ounces, or Carbonate of potassium . 2 to 6 " or Borax 3 " These baths are useful in eczema, psoriasis, urticaria, prurigo, and pruritic diseases. For an acid bath add to bath, Nitric acid 1 ounce, or Muriatic acid . , . . 1 " Or may use of each § " Of use in chronic pruritic disease. 744 APPENDIX Iodine Bath: Iodine crystals \ to 1 drachm. Iodide of potassium, vel . . \ ounce. Liquor potassae 1 to 2 ounces. Glycerin 2 ounces. Add to 30 gallons of water. Useful in scrofulous and squamous diseases. Bromin Bath: Bromin 20 drops. Iodide of potassium . . . . . 2 ounces. Add to 30 gallons of water. Same indications as iodine bath. Sulphuret of potassium . . . 2 to 4 ounces. Add to 30 gallons of water. Used in scabies, chronic eczema, lichen, and psoriasis. Startin's Compound Sulphur Bath: Precipitated sulphur 2 ounces. Hyposulphite of soda 1 ounce. Water 1 pint. Add to 30 gallons of water. Same indications as the sulphuret of potassium bath. Mericurial Bath: Bichloride of mercury .... 3 drachms. Hydrochloric acid 1 drachm. Water 1 pint. Add to 30 gallons of water. Used in pityriasis rubra and the syphilides. B. FOR INTERNAL USE. 1. Turpentine Emulsion: 1^ — 01. terebinthinse, 1T|,x-xxx; 0.66-2 01. limonis, mij; 12 Mucilag. acacise, 5ss; 16 Aquse destil., _ gss; 16 M. Sig. — A teaspoonful three times a day immediately after meals. One quart of barley-water to be drunk during twenty- four hours. (Crocker.) Used in psoriasis, eczema, and hyperemias. 2. Mixed Treatment: a.T$ — Hydrarg. bichlor., . gr. j-iij; 06-.2 Potass, iodid., 5iv-viij; 16-32 Tinct. cinchon. co., giiiss; 112 Aquse destil., ad giv; 120 M. Sig. — One drachm in water t. i. d. one hour after meals. (Taylor.) Used in syphilis. s APPENDIX 745 b. 1$ — Hydrarg. biniod., gr. ss-ij; Ammon. iodid., 5ss; 2 Potass, iodid., 5ii~5j; 8-32 Syr. aiirant. cort., §iss; 48 Tinct. aiirant. cort., 5J5 4 Aquae destil , ad § iij ', ad 100 Sig. — One-half ounce t. i. d. after meals. (Keyes.) Used in 1 03-. 13 M. c. 1$ — Hydrarg. bichlor. vel, Hydrarg. biniod., gr. j-ij; Potass, iodid., 5j _ ijj Inf. gent. co. vel, Syr. sarsaparillse co., ad giv; Sig. — One drachm t. i. d. after meals. Used in syphilis. 4-8 ad 120 06-.13 M. 3. I$— Pil. hydrarg., gr. xl; 2 66 Ferri sulphat. exsic, gr. xx; 1 33 Ext. opii, gr. v; 33 M. Div. in pil. No. xl. Sig— One t. i. d. (Taylor.) Used in syphilis. Sulphate of quinine may be substituted for the iron. 4. 1$ — Hydrarg. chlor. mitis, gr. iss; Ferri lactatis, gr. iij ; Sacch. alb., gr. xv; Ft. in pulv. No. x. Sig. — One to four daily. (Monti.) Used in infantile syphilis. M. 5. 1^—01. gurjun., §j; Liquor calcis, 5 iij; Sig. — One-half ounce twice a day. Used in leprosy. 321 100 M. 6. 1$ — Tine, cannabis indicae, Tltx-xxx; 0.66-2 Pulv. tragacanth. co., gr. x; Aquae destil., ad Sj; ad 32 Used in pruritus and prurigo. (Bulkley.) (50 M. Startin's Mixture : 1$ — Magnesii sulphat., Ferri sulphat., Acid, sulphur, dil., Syr. pruni Virgin., Aquae destil., Sig. — One drachm t. i. laxative and tonic. ad 3vj-xij; 24-48 3j; 4 5ij; 8 5j; 32 5iv; ad 120 M. *ter meals, through a tub e. As a 746 APPENDIX 8. Asiatic Pills: 1$ — Acid, arsenosi, gr. xj; 75 Pulv. pip. nigrae, 3iss; 6 Gummi acaciae, gr. xxij; 1 05 Pulv. althae rad., gr. xxx; 2 Aquae destil., q. s.; q. s. M. Div. in pil. No. c. Sig. — One to three pills a day after meals, and increase to tol- erance. Used in psoriasis. C. FOR EXTERNAL USE. a. Caustics. 1. Cosine's Paste: ]$ — Acid, arsenosi, gr. x; 66 Hydrarg. sulphuret. rub, 3ss; 2 Ungt. rosae vel, Sacch. alb., gss; 16 To destroy epithelioma or other new growths. 2 Marsden's Paste: 1$ — Pulv. acid, arsenosi, 5j~ij; 4-8 Pulv. gummi acaciae, Orthoform, aa 3ss-j; 2-4 Mix with a forty per cent, solution of cocaine to form a paste just before using, and apply to not more than one square inch at a time. Same indications as Cosme's Paste. 3. Bougard's Paste: 1^— Wheat flour, Starch, aa 60 parts. Arsenic, 1 part. Cinnabar, Sal ammoniac, aa 5 parts. Corrosive sublimate, \ part. Sol. chlor. of zinc @ 52°, 245 parts. M. Grind first six ingredients to a fine powder, then mix them in a mortar. Add solution of zinc chloride slowly stirring. Keep in earthen jar. May add cocaine up to 20 per cent, to allay pain. Sig. — Apply accurately to part; keep on for thirty hours; follow with poultice. Same indications as Cosme's Paste. 4. Salicylic Acid (Crocker) : ^— Glycerini, §j; 321 Acid, salicyl., q. s.; q.s. | M. Make of consistency of thick cream. To lessen painfulness of application may add Ac. carbolici vel, Creosoti, 3j; 4| M. Used to destroy warts, lupus, and epidermic thickenings. APPENDIX 747 5. Vienna Paste: 1$ — Calcis, Potassae, aa p. Make into a paste with alcohol just before using. Used in lupus and scrofulides. aa 4 1 q. s. aa 16 1 61 321 M, M. 6. Canquoin's Paste: 1$ — Zinci chlor., aa 5j; Ammon. chlor., Pulv. amyli, 5iss; Aquae destil., q. s.; Make into a paste at time of using. Used to destroy lupus, epithelioma, and the like. 7. Middlesex Hospital Paste: 1$ — Zinci chlor., Liq. opii sed., aa 5iv; Amyli, 5iss; Aquae destil., §j; Same indications as Canquoin's paste. 8. Depilatory Paste: 1$ — Barii sulphid., 5ij; 81 Zinci oxidi, Amyli, aa* 5iij; 12 j M. Make into a paste with water and apply a thin coating for ten to fifteen minutes, then clean off and apply a bland ointment M. b. Lotions. 1. Belladonna Lotion: ty — Tinct. belladon., Glycerini, aa 1 part. Aquae destil., 8 parts. For erysipelas. (Piffard.) 2. Lotio Plumbi et Opii: 1$ — Liq. plumbi subacetat. dil., aa 5j; Tinct. opii, ad Oj; For erysipelas and inflammatory conditions. 3. Carbolic Acid Lotion: 1$ — Acid, carbol., 3j; Alcoholis, Aquae destil., aa Oss; For erysipelas. (White.) 4. Bismuth Lotion: 1$ — Bismuth, subnitrat., gr. viiss; Zinci oxidi. 3ss; Glycerini, TUxv; Hydrarg. bichlor., gr. a; Aquae rosae, 5j; M. aa 321 ad 500 M. aa 2401 M. For rosacea and hyper emic conditions. 016 M. 18 APPENDIX 5. Lotto Alba: 1$ — Potassae sulphurat Zinci sulphat., Aquae rosae, For acne and rosacea. > aa ad 5j; Siv; aa ad 4 128 6. Kummerf eld's Lotion: fy — Spts. camphorae, Spts. lavandulae., aa 3ss; aa 2 Sulph. precip., Aq. cologniensis, Aqu83 destil., For acne. gr. xv. 5j; Sij; 1 4 64 7. Sulphur Lotion: 1$, — Sulphuris loti, Alcoholis, Etheris, Glycerini, Potass, carb., Aq. rosae, Used in acne. aa Sij; Bvij; aa ad 8 250 M. M. M. 8. Vleminckx's Solution: 1$ — Calcis vivae, 3iv; 16 Sulphur, sublimat., §j; 32 Aq. destil., gx; 320 M. Boil together with constant stirring until the mixture measures six fluid ounces (190), then filter. Useful in scabies, psoriasis, and acne. 9. Calamin Liniment: 1$ — Pulv. calamin., gr. xl; 2 Zinci oxidi, 3ss; 2 Linimenti calcis, 5 j ; 32 For erythema, eczema, and hyper emic conditions. 6G M. 10. Calamin Lotion: 1$ — Pulv. calamin., gr. xx ; Zinci oxidi, 5i; Glycerini, 5j; Aq. calcis, 3yj; Aq. rosae, ad §iv; For erythema and eczema. 1 4 4 24 128 32 M. 11. Liquor Picis Alkalinus: . 1$ — Picis liquidae, § ij ; 64 Potass, causticae, 5j; 32 Aquae destil., 3v; 20 M. Dissolve the potassa in the water and add slowly the tar in a mortar with friction. For chronic eczema, or, diluted ten to twenty times, for acute eczema. APPENDIX 2. Piffard's Substitute for Tar 1$ — Ac. salicyl., gr. x-xxx; 0.66-2 01. lavandulse, 3iiss; 10 01. citronellse, 3ss; 2 01. pini sylvestris, 5ij; 60 01. ricini, §iss; 45 For eczema capitis. 749 13. Tinct. Saponis Co. of Hebra: Of, — 01. cadini, Sapo. viridis, Alcoholis, aa § j ', Filtra et adde Spts. lavandulse, 5ij; Stimulant in chronic eczema. 14. Carron Oil: 1$ — Aq. calcis, 01. olivse vel, 01. lini, For burns. 15. Fox's C. C. C. Mixture: 1$ — Chrysarobin., 01. cadini, Acid, carbolici, Acid, oleici, For psoriasis. 16. Kaposi's Tar Lotion: 1^—01. rusci, Etheris sulphuris, Alcoholis, Filtra et adde 01. lavandulse, Used in psoriasis. 17. 1$ — Amyli glycerolis, 01. cadini, Sapo viridis, For psoriasis. External use. 18. Hardaivay's Lotion for Licftcn Planus: aa 32 2 1 50 parts part, parts 50 parts 75 a 2 a 5 parts -Sapo. olivse prep., oiv; 01. rusci, Glycerini, aa Sj; 01. rosmarini, 5iss; Alcoholis, ad § viij ; ad 128 32 6 250 M. M, Equal parts. M, M. M. M. M. 19. Lotio Ac. Boracis: 3^— Ac. boracis, 5iv vel q. s.; 1601 Etheris sulph. methyl., §v; 160 1 Spts. vini rect., ad gxx; ad 640 1 M. For ringworm, after washing with hot water and soap, and drying. (A. Smith.) 30 APPENDIX 0. I$— Naphtoli, Spts. sapo. viridis Alcoholis, gr. xv ; 5vj; giss; Bals. peruv., Sulph. loti, For sycosis. (Kaposi.) gtt. XXX Siiss; M. 21.1$ — Sodii hypophosphitis, Sj; Glycerini, gss; Aquae destil . , 5 vii j ; For dermatitis venenata. (Morrow.) 32 16 256 M. 22. I$— Zinci oxidi, Magnesii carbonat., aa 5j; Aristol, 5 ij 5 Aquae rosae, ad §iv; Sig. — For dermatitis venenata. 23. 1^— Zinci oxidi, Ac. carbol., Aquae calcis, For dermatitis venenata. 3iv; 5j; ad Oj; (White.) 24. Thymol Lotion: fy— Thymol., Liq. potassae, aa 5j; Glycerini, 5 ss ; Aq. sambuci, gviij; For pityriasis capitis. Also for prurit amount of thymol. 25. 1$ — Pilocarpin. muriat, Aquae rosae, Alcohol @ 75°, gr. vij 5ij; 5vj; ad 4 8 120 161 4| ad 500| M. Sig. 26. I$- Etheris, Spt. lavandulae, aa 5vj — Hair lotion (Sabourand.) 4 16 256 60 180 24 M. -Hydrarg. bichlor., Resorein vel, gr. iv ; Euresol pro capillis, 3 ij ', 8 Spts. formicari, 5j; 32 01. ricini, 3j~hj 4-12 Alcohol© 70°, ad gviij; 250 Sig.— Hair lotion. (White.) c. Ointments. 1. Bassorin Paste: 1$ — Bassorin, 48 parts. Dextrin, 25 " Glycerin, 10 " Water, ad 100 " 24 M. APPENDIX 751 2. Gelatin Paste (Unna) : 1$ — Zinci oxidi, 30 parts. Gelatini, 30 " Glycerini, 39 " Aquae destil., 10 " M. Heat in water bath before using. As a protective dressing and excipient. 3. 1$ — Hydrarg. protiodod., gr. v-xv; 0.33-1 Hydrarg. ammon., gr. x-xxx; 0.66-2 Ungt. simplicis, 5j; 32 M. Used in acne. (Duhring.) 4. 1^ — Ungt. lanae, 3 iiss ; 10 Ac. acetici, 3ij gr. xlv; 11 Adepis benzoat., 5 iiss ; 10 Sulph. precip., gr. xlv; 3 M. Used in acne. (Unna.) 5. Naphtol Ointment: 1$ — /3-naphtol., 10 parts. Sulph. precip., 50 " Vaselini, Sapo. viridis, aa 25 " M. Used in acne. (Lassar.) 6. Lassar' s Paste: 1$ — Zinci oxidi, Amyli, aa 5ij; aa 8 Vaselini, 5iv; ad 32 M. Used in eczema. 7. 1$ — Zinci oxidi, 40 parts. Creta preparat., Liquor plumbi, aa 20 " 01. lini, Mix the first two together, and the last two together, and add one part to the other. Use as a protective in eczema . (Unna.) 8. fy—0\. cadini, Zinci oxidi, aa 5ss-j; aa 2-4 Ungt. aquae rosae, Sj; 32 M. For chronic eczema. 9. Sulphur Cream: fy — Cerae albae, 5iijss 14 01. petrolati, 5 iiss; 80 Aquae rosae, Sj-5ij; 40 Sodae biborat., gr. xvnj; 1 18 Sulphur precipitat., 5 hiss; 14 Used in seborrheal dermatitis and pityriasis capitis. 752 APPENDIX 10. 1$ — Hydrarg. ammon., gr. xx-xl; 5-10 Hydrarg. chlor. mitis, gr. xl-lxxx; 10-20 Vaselini, ad %'y, 'ad 100 Used in 'pityriasis capitis. (Bronson.) M. 11. Bismuth Ointment: 1$ — Bismuthi subnit., Kaolini, aa, 5iss; Vaselini, ad giss; For chloasma. (Unna.) 12. Chrysarobin Ointment: T$ — Chrysarobin, gr. 1; Ac. salicylici, gr. x; Plasment. vel Adipis, ad Si; Used in psoriasis and ringworm. 13. 1$ — Chrysarobin, Ichthyol., aa gr. Ixxv; Ac. salicyl., gr. xxx ; Ungt. simpl., ad Biij; Used in leprosy. (Unna.) 14. 1$ — Hydrarg. amnion., Bismuthi subnit., aa 5jj' Ungt. aq. rosae, ad §j; Used in lentigo. (Hardaway.) 15. 1$ — Ac. salicylici, gr. x; Ungt. hydrarg. ox. rub., §j; Ungt. aquae rosae, 3vj; For blepharitis. (Webster.) 16. 1$ — Hydrarg. sulph. rubri, gr. xv: Sulph. sublimat., 5vj; Adipis, ad § iij ; 01. bergamot., q. s.; Used in sycosis. (Behrend.) 17. B,— Ungt. diachyli (Hebra), Ungt. zinci oxidi, aa Siss; Ungt. hydrarg. ammon., 5 iij 5 Bismuthi subnitrat., 5iss; For sycosis. (Robinson.) 18. B,— 01. fagi, Flor. sulph., aa 5iiss; Pulv. cretae alb., 5 '■, Adipis, Sapo. viridis, aa 5v; For sycosis. (H. Hebra.) aa 6 ad 48 3 ad 32 aa 5 2 ad 126 aa 4 ad 32 1 24 ad 100 q. s. aa 48 12 6 M. M. M. M. 66 M. M. M. aa 10 4 aa 20 M. APPENDIX 19. Naphtol Ointment: J$ — /3-naphtol, 3uj gr. xl; 15 Creta preparat., 3hss; 10 Sapo. viridis, 5iss. 50 Adipis, ad 5iij; ad 100 Used in scabies. (Kaposi.) 20. I$— Sulphur., Si; 32 Potass, carb., 3ij; 8 Adip. benzoat., 5v; 160 01. chamomilis, 5ss; 2 Used in scabies. (Wilson.) 21. Helmerich's Ointment: fy — Sulphur., 5ij; 32 Potass, carb., Si; 16 Adipis, Svuj; 256 Used in scabies. 22. Wilkinson' s Ointment (Hebra): 1$ — Sulphuris, 01. cadini, aa gss; aa 16 Sapo. viridis, Adipis, aa 5i; aa 32 Creta preparat., 3iiss; 10 Used in scabies. 23. 1$ — Ac. salicylici, 2-3 parts. Sulphur, precip., 10-15 " Lanolini, 70 " Vaselini, 18 " For chromophytosis. (Brocq.) 24. 1$ — Hydrarg. bichlor. gr. j-v; 0.6-0.3 Ac. carbol., gr. xx ; 1.3 Ungt. zinci oxidi, ad Si; ad 32 Used in lichen ruber. (Unna. ) 25. 1$ — Ac. salicylic, gr. x; Colloidal sulphur, 3j; 4 Eucerin, 5vj; 24 Adipis anserini, 3j; 4 01. rosse geran, gtt. xv ; 1 Used in sycosis. d Miscellaneous. 1. Anti-pruritic Powder: fy — Camphori, 3ss; 2 Zinci oxidi, 3ij; 8 Amyli, 3iv; 16 53 M. M. M. M. M. 66 M. M. (Bulkley.) 48 754 APPENDIX 2. Corn Remedy: 1% — Ac. salicylici, Ex. cannabis indicse, Alcoholis, Etheris, Collodion flex., gr. xv ; 1 gr. viij; mxv; 1 lUxl; 2 mlxxv; M. Apply with brush three times a day for a week. Soak feet and pick out corn. (Vigier.) Emulating stick: I$— Cera flavse, 5iij; 12 Laccse in tabulis, 5iv; 16 Picis Burgundicse, 5x; 40 Gummi damar, 5iss; 48 Make in sticks one-half to one inch in diameter and two inches long. (Bulkley.) 4. Glycerin Jelly: 1$ — Gelatini, gr. xxv ; Glycerin, Aquse destil., gr. ccxxv; 3iv; 5. Glycerole of Subacetale of Lead: I$— Plumbi acetat., gr. cxx; 8 Plumbi oxidi, gr. lxxxiv; 6 Glycerini, 5j; 32 M. Digest the lead in the glycerin heated to 300° F. in an oil bath for half an hour, constantly stirring. Filter in a chamber heated to 300° F. INDEX. Abscess, 59 ' Acanthosis nigricans, 60 Acantholysis, 60 bullosa, 271 Acarodermatitis urticariodes, 61 Acarus scabiei, 593 Achorion Schoenleinii, 317 Achroma, 729 Acne, diagnosis, 69 etiology, 65 pathology, 68 prognosis, 79 symptoms, 62 treatment, 71 agminata, 81 albida, 460 artificialis, 79 atrophica, 80 bromic, 193 cachecticorum, 80 decalvant, 330 erythematosa, 574 follicularis, 154 frontalis, 81 indurata, 64 iodic, 194 keloid, 197 keratosa, 80 lupoid, 81 mentagra, 620 necrotica, 81, 84 necroticans et exulcerans nasi, 83 papulosa, 62 pilaris, 81, 330 punctata, 63, 154 pustulosa, 63 rodens, 81 Acne rosacea, 574 scrofulosorum, 83 sebacea, 609 simplex, 62 sycosis, 620 tar, 79 telangiectodes, 81 urticata, 83 varioliformis, 81, 328, 461 vulgaris, 62 Acne arthritique, 81 fluente, 609 keloidique, 197 miliare scrofuleuse, 81 punctuee, 154 sebacee cornee, 395 ulcereuse, 81 Acnitis, 81 Acrochordon, 326 Acrodermatitis chronica atrophi- cans, 84, 123 perstans, 84 Acrodynia, 85 Acromegalia, 267 Acromegaly, 85 Actinomycosis, 85 Actinotherapy, 41 Adenocarcinoma, 86 Adenoma sebaceum, 87 sudoriferum, 87 Adenotrichie, 620 Ainhum, 87 Albinism, 88 Aleppo boil, 88 bouton, 88 m evil, 88 Algidite progressive, 599 Alopecia adnata, 89 areata, diagnosis, 106 etiology, 103 756 INDEX Alopecia areata, pathology, 105 prognosis, 109 symptoms, 100 treatment, 106 atrophica, 329 cicatrisata, 330 circumscripta, 100, 329 follicularis, 100 orbicularis, 329 pityrodes, 95 prematura idiopathica, 91 symptomatica, 94 seborrhoica, 95 senilis, 90 syphilitica, 98 Alopecies cicatricielles innomi- nees, 330 Alphos, 545 Analgesia, 110 Anesthesia, 110 Angiokeratoma, 110 Angioma, 477 infective, 112 pigmentosum et atrophicum, 120 serpiginosum, 112 Angiomyoma, 472 Anhidrosis, 114 Anidrosis, 114 Anonychia, 114 Anthrax, 134, 570 Aplasia pilorum intermittens, 119 Area celsi, 100 occidentalis diffluens, 100 serpens, 100 tyria, 100 Argyria, 114 Arrectores pilorum, 27 Asiatic pill, 745 Asteatosis, 114 Atheroma, 160 Atrophia cutis, 120 maculosa cutis, 123 pilorum propria, 115 unguium, 119 Atrophoderma, 120 albidum, 123 idiopathica diffusa, 123 pigmentosum, 120 senilis, 124 striatum et maculatum, 125 Aussatz, der, 407 B Bacillus acnes, 66 leprae, 413 mallei, 285 prodigiosus, 145 Bacteriotherapy, 50 Bacterium prodigiosus, 407 Bad disorder, 631 Baelz's disease, 126 Baldness, 89 circumscribed, 100 congenital, 89 premature, 91 senile, 90 Barbadoes leg, 264 Barber's itch, 620, 691 Bartfinne, 620 parasitische, 691 Bartflechte, 620 Baths, 743 Bed-bug bites, 493 Beigel's disease, 126 Birthmark, 477 Blackheads, 154 Blasenausschlag, 505 Blastomycetic dermatitis, 163 Bleb, 33 Bloodvessels, 21 Blutfleckenkrankheit, 564 Blutschwar, 337 Boil, 337 Botryomycosis hominis, 127 Bouba, 736 Bougard's paste, 282, 746 Bouton, 62 Brandschwar, 134 Bromidrosis, 128 Bronson's ointment, 205 Bucnemia tropica, 264 Bulla, 33 Bulpiss, 129 Bunion, 130 Burning, 39 Cacotrophia folliculorum, 399 Calamin lotion, 748 Calculi, cutaneous, 460 Callositas, 130 INDEX 757 Callosity. 130 Callus, 130 Calvities, 89 Cancer, chimney-sweep's, 276 en-cuirasse, 138 epithelial, 272 skin, 272 spider, 681 tubereux, 390 Cancroid, 272 Canities, 131 Canquoin's paste, 746 Caraate, 517 Carbon dioxide, 48 Carbuncle, 134 Carcinoma, 137 lenticulare, 138 melanodes, 138 tuberosum, 138 Carron oil, 749 Cataphoresis, 50 Causalgia, 162 Chalazion, 460 Chalazodermia, 213 Chaleur du foie, 140 Chancre, 631 Chap, 139 Charbon, 570 Cheilitis exfoliativa, 139 glandularis aposthematosa, 139 Cheiro-pompholyx, 529 Cheloide, 390^ Chicken-pox, 723 Chigoe, 493 Chilblain, 168 necrotising, 328 Chloasma, diagnosis, 142, 146 etiology, 142 prognosis, 143 symptoms, 140 treatment, 142 uterinum, 141 Chorionitis, 601 Chromidrosis, 143 Chromophytosis, 146 Cicatrix, 36 Cimex lectularius, 493 Claret stain, 477 Classification, 52 Clastothrix, 116 Clavus, 151 Clavus syphiliticus, 153 Clou, 337 Cnidosis, 715 Cochin-China leg, 264 Cold sore, 350 Colloid degeneration, 153 milium, 153 Columnae adiposae, 21 Comedo, 154 Condyloma acuminata, 726 lata, 641 Congelation, 48 Connective tissue, subcutaneous, 21 Cor, 151 Corium, 20 Corn, 151 Corne de la peau, 158 Cornu cutaneum, 158 humanum, 158 Corpuscles of Krause, 23 of Meissner, 22 Pacinian, 23 tactile, 22 Cosme's paste, 746 Couperose, 574 Crab louse, 497 Craw-craw, 159 J Crust, 34 Crusta lactea, 245 Cute, 517 Cuticle, 17 Cutis anserina, 159 laxa, 213 pendula, 213 verticis gyrata, 159 Cyanopathie cutanee, 144 Cyst, dermoid, 159 sebaceus, 160 Cystecercus cellulosse cutis, 161 Dactylitis, 664 Dandruff, 518 Darier's disease, 394 Dartre erythemoide, 293 humide, 218 pustuleuse mentagre, 620 rongeante, 444 vive, 218 758 INDEX Dasyma, 364 Defluvium capillorum, 99 Demodex folliculorum, 156 Depilatory paste, 747 Dermatalgia, 161 Dermatitis ambustionis, 166 blastomycotica, 163 bullosa, 271 calorica, 166 coccidioides, 347 congelationis, 168 contusiforme, 304 eczematoid, 263 epidemica, 174 erythematosa, 293 exfoliativa, diagnosis, 172 etiology, 171 neonatorum, 175 pathology, 172 prognosis, 174 symptoms, 170, 171 treatment, 173 factitia, 176 fungoid, 467 gangrenosa, 178 infantum, 179 glandularis erythematosa, 435 herpetiformis, diagnosis, 185 etiology, 184 pathology, 185 prognosis, 187 symptoms, 181 treatment, 187 malignant papillary, 486 medicamentosa, 188 multiforme, 180 papillaris capillitii, 197 papillomatosa capillitii, 197 psoriasiformis, 491 nodularis, 491 repens, 198 seborrhoica, diagnosis, 203 etiology, 202 pathology, 203 prognosis, 206 symptoms, 200 treatment, 204 traumatica, 206 uncinarial, 348, 714 variegata, 491 vegetans, 207 Dermatitis venenata, diagnosis, 210 pathology, 210 symptoms, 208 treatment, 210 verrucosa, 213 z-ray, 199 Dermatobia noxialis, 493 Dermatolysis, 213 Dermatomycosis favosa, 313 furfuracea, 146 microsporina, 146 tonsurans, 687 Dermatosclerosis, 601 Dermatosis Kaposi, 120 Desmoides, 326 Dhobie itch, 214 Diabetic eruptions, 214 Diagnosis, general, 29 color in, 38 configuration in, 38 history in, 39 location in, 36 microscope in, 40 Diaskop, 41 Diphtheria of skin, 215 Distichiasis, 215 Dracontiasis, 349 Dracunculus, 349 Duhring's disease, 181 Durillon, 130 Dysidrosis, 529 ECDERMOPTOSIS, 461 Ecphyma globulus, 216 Ethyl chloride, 48 Ecthyma, 216 infantile gangreneux, 179 terebrant de l'enfance, 179 Eczema, diagnosis, 227 etiology, 224 pathology, 226 prognosis, 242 symptoms, 219 treatment, 231 ani, 242 aurium, 244 barbae, 245 capitis, 245 INDEX 759 Eczema crurum, 248 exfoliativum, 169 foliaceum, 169 genitalium, 248 hypertrophicum, 467 infantile, 257 intertrigo, 250 labiorum, 250 madidans, 222 mammarum, 250 mammillarum, 250 manuum, 252 marginatum, 261, 686 narium, 254 orbicular, 224 palpebrarum, 255 pedum, 256 rimosum, 220 rubrum, 222 seborrhoicum, 200, 519 tuberosum, 467 unguium, 256 universale, 251 varicosum, 224, 248 verrucosum, 224 Eczematoid dermatitis, 263 Eiterpusteln, 216 Elastic skin, 213 Elephantiasis, diagnosis, 268 etiology, 267 pathology, 268 prognosis, 269 symptoms, 264 treatment, 268 Arabum, 264 Grecorum, 407 Indica, 264 Emphysema of skin, 269 Endothelioma, 270 Endurcisement athrepsique, 599 Ephelides, 404 Ephidrosis, 360 cruenta, 350 tincta, 143 Epidermis, 17 Epidermodophyton, 553 inguinale, 261 Epidermolysis bullosa, 271 Epithelialkrebs, 272 Epithelioma, diagnosis, 279 etiology, 276 pathology, 277 Epithelioma, prognosis, 284 symptoms, 273 treatment, 280 adenoides cysticum, 284 contagiosum, 461 multiple benign cystic, 284 Epitheliomatose eczematoide de la mamella, 486 pigmentaire, 120 Equinia, 285 Erbgrind, 313 Eruption, creeping, 374 feigned, 176 recurrent summer, 358 ringed, 345 Erysipelas, diagnosis, 289 etiology, 288 prognosis, 292 symptoms, 286 treatment, 290 chronic, 292 suffusum, 293 Erysipeloid, 292 Erythema, 285 annulare, 301 bullosum, 302 caloricum, 294 circinatum, 301 elevatum diutinum, 308 epidemicum, 85 exudativum, 300 figuratum perstans, 308 fugax, 296 gyratum, 302 hyperemicum, 293 induratum scrofulosorum, 309 intertrigo, 294 iris, 303 laeve, 296 marginatum, 301 migrans, 292 multiforme, diagnosis, 306 etiology, 305 pathology, 306 prognosis, 308 symptoms, 300 treatment, 307 neonatorum, 298 nodosum, 304 paratrimma, 296 pernio, 168, 294 760 INDEX Erythema perstans, 302 roseola, 297 scarlatiniforme, 298 simplex, 294 tuberculatum, 301 traumaticum, 294 urticans, 297 Erytheme centrifuge, 435 noueux, 304 papuleux desquamatif, 521 Erythrasma, 310 Erythrodermia, congenital ich- thyosiforme, 311 Erythrodermie exfoliante, 169 pityriasique en plaques, 492 Erythromelalgia, 312 Esthiomene, 312, 444, Examination of patient, 40 Exanthem, psoriasiform and lichenoid, 492 Excoriation, 35 Farcy, 285 Favus, diagnosis, 320 etiology, 317 pathology, 317 prognosis, 324 symptoms, 314 % treatment, 321 Feigned eruptions, 176 Feu sacre, 286 Feuergiirtel, 738 Feuermal, 472 Fever-blister, 350 Fibroid, recurrent, 586 Fibroma, 325 fungoides, 467 lipomatodes, 732 molluscum, 325 pendulum, 325 Fibromvoma, 472 Fikosis,~ 620 Finnen, 62 Finsen light; 42 Fischschuppenausschlag, 375 Fish-skin disease, 375 Fissure, 35 Flea bites, 327, 493 Flechte, fressende, 444 Flechte, kleien, 146 nassende, 218 scheerende, 685, 687 Fleckenmal, 473 Fleshworms, 154 Fluxus sebaceus, 609 Folliclis, 328, 608 Folliculitis, 329 desseminees des parties glab- res, 328 Folliculitis barbae, 620 decalvans, 329 depilating, 333 of limbs, 335 pilorum, 620 Foot, tubercular disease of, 336 Fordyce's disease of lips, 335 Fragilitas crinium, 115 Frambcesia, 197, 736 Freckles, 404 Friesselauschlag, 457 Frost-bite, 168 Fungous foot of India, 336 Furuncle, 337 Furunculi atonici, 216 Furunculus, 337 Gale, 590 Gangosa, 343 Gangrene, multiple cachectic, 179 symmetrical, 178 Gefassmal, 477 Gelatin paste, 750 Gerromorphism cutanee, 344 Glandular disease of Barbadoes, 264 Glands, sebaceous, 25 sweat, 26 Glanders, 285 Glossy skin, 123 Gnat bites, 493 Gneis, 609 Goose-flesh, 159 Grain itch, 61 Granuloma annulare, 345 coccidioidal, 347 fungoides, 467 INDEX '61 Granuloma innominee, 328 necrotica, 328 pyogenicum, 347 tricfiophyticum, 689 tropicum, 736 Granulosis rubra nasi, 348 Gra}mess, 131 Ground itch, 348 Grubs, 154 Grutum, 460 Guinea-worm disease, 349 Gum, red, 571 Gumma, scrofulous, 607 syphilitic, 652 Giirtelkrankheit, 738 Gutta rosacea, 574 rosea, 574 Hair, anatomy of, 23 beaded, 119 blanching of, 131 discolorations of, 350 nodose, 119 ringed, 132 superfluous, 364 Hand-and-foot disease, 513 Harlequin fetus, 378 Harvest bug, 493 Hauthorn, 158 Hautnervenschmerz, 161 Hautrose, 286 Hautrothe, 293 Hautschmerz, 161 Hautsclereme, 601 Hautwiirmer, 154 Heat eruption, 218 Helmerich's ointment, 752 Hematidrosis, 349 Hemiatrophia facialis progres- siva, 124 Hemidrosis, 349 Hemorrhea petechialis, 564 Hemisporosis, 350 Henoch's purpura, 567 Hernia carnosa, 264 Herpes circinatus, 180, 303, 685, 687 esthiomenes, 444 facialis, 350 Herpes febrilis, 350 gestationis, 180, 356 iris, 303 labialis, 350 phlyctenodes, 180 preputialis, 353 progenitalis, 353 pustulosus mentagra, 620 squamosus, 687 tonsurans, 687 barbae, 691 maculosus, 521 zoster, 738 Herpetide, 356 exfoliative, 169 Hide-bound disease, 601 Hidrocystoma, 356 High-frequency current, 47 Hirsuties, 364 Hitzblatterchen, 218 Hives, 715 Homines pilosi, 364 Horn, cutaneous, 158 Hiihnerauge, 151 Hutchinson's teeth, 663 Hyalom der Haut, 153 Hydradenitis destruens suppura- tiva, 81 Hydradenomas eruptifs, 284 Hydroa, 180, 303 bulleux, 183 estivale, 358 febrilis, 350 herpetiforme, 182 puerorum, 358 vacciniforme, 358 vesiculeux, 303 Hydrosadenite disseminee sup- purativa, 328 Hyperalgesia, 360 Hyperesthesia, 360 Hyperidrosis, 360 oleosa, 613 Hyperkeratosis atrophica, 531 excentrica, 531 follicularis, 399 linguae, 127 Hypertrichosis, etiology, 367 symptoms, 364 treatment, 370 Hyponomoderma, 374 762 INDEX Ichthyose anserine des scrofu- leux, 399 Ichthyosis, diagnosis, 379 etiology, 378 pathology, 379 prognosis, 381 symptoms, 375 treatment, 379 congenita, 375 follicularis, 394, 399 hystrix, 377, 490 intra-uterina, 378 linguae, 418 palmaris et plantaris, 398 sebacea, 609 cornea, 394 vera, 375 Idrosis, 360 Ignus sacer, 738 Impetigo, Bockhardt's, 382 contagiosa, diagnosis, 386 etiology, 385 pathology, 386 prognosis, 389 symptoms, 382 treatment, 389 herpetiformis, 389 parasitica, 382 simplex, 381 streptogenes, 382 Induratio telae cellulosae, 599 Initial lesion, 631 Intertrigo, 294 Iodic acne, 194 Itch, 590 barber's, 620, 691 bricklayer's, 252 Dhobie, 214 grain, 61 grocer's, 252 prairie, 534 washerwoman's, 252 Lxodes, 493 . Jigger, 493 Juckblattern, 534 Kahlheit, 89 kreisfleckige, 100 Kelis, 390 Keloid, 390 Addison's, 603 Alibert's, 394 Keratodermia gonorrhoica, 394 eccentrica, 531 Keratolysis exfoliativa, 394 neonatorum, 175 Keratoma, 130 follicularis, 378 palmare et plantare, 398 Kerratosis diffusa, 378 epidermica, 378 follicularis, 394 contagiosa, 397 intra-uterina, 378 palmaris et plantaris, 398 pilaris, 399 senilis, 401 Kerion, 402 Celsi, 402 Knollenkrebs, 390 Koilonychia, 403 Koltun, 527 Kratze, 590 Kraurosis vulvae, 404 Kummerfeld's lotion, 747 Kupferflnne, 574 Kupferrose, 574 Kupfrige gesicht, 574 Lamp, iron electrode, 42 Kromayer, 43 mercury, 42 uviol, 43 Larva migrans, 374 Lassar's paste, 751 Leberflecken, 140 Leichdorn, 151 Leiomyoma, 471 Lentigo, 404 maligna, 120, 405 Leontiasis, 407 Lepothrix, 406 Lepra, diagnosis, 414 INDEX 763 Lepra, etiology, 413 pathology, 413 prognosis, 417 symptoms, 407 treatment, 415 alphos, 545 Arabum, 407 Grecorum, 407, 545 Leprosy, 407 Lombardian, 503 Leptus autumn alis, 493 Leucasmus, 729 Leucoderma, 729 Leucokeratosis buccalis, 418 Leuconychia, 417 Leucopathia, 729 unguium, 417 Leucoplakia, 417 Leukemia cutis, 419 Lichen annularis, 345 circinatus, 611 hypertrophicus, 429 menti, 620 nitidus, 422 obtusus, 423, 429 corneous, 423 pilaris, 399, 424 planus, diagnosis, 430 etiology, 429 pathology, 430 prognosis, 432 symptoms, 425 treatment, 430 sclerosus et atrophicus, 432 ruber acuminatus, 433, 524 moniliformis, 428 planus, 425 scrofulosorum, 433 scrofulosus, 433 simplex, 221 spinulosus, 424 tropicus, 457 urticatus, 715 variegatus, 492 verrucosus, 429 Lichenification, 420 Lineae albicantes, 126 Lines, symptomatic, 125 Linsennecke, 404 Linsenmal, 473 Liodermia essentialis c. melanosi et telangiectasia, 120 Lipoma, 435 Liquid air, 49 Liquor picis alkalinus, 748 Liver spot, 140 Lotio alba, 747 plumbi et opii, 747 Lousiness, 495 Lues, 630 Lupus ervthemateux disseminee, 328 erythematodes, 435 erythematosus, diagnosis, 440 etiology, 439 pathology, 439 prognosis, 443 symptoms, 435 treatment, 440 exulcerans, 446 follicularis disseminatus, 447 hypertrophicus, 446 lymphaticus, 455 miliaris, 447 pernio, 444 papillomatosus, 446 sclereux, 707 sebaceus, 435 superficialis, 435 verrucosus, 446, 707 vulgaris, diagnosis, 449 etiology, 447 pathology, 448 prognosis, 455 symptoms, 444 treatment, 449 Lustseuche, 631 Lymphadenie cutanee, 467 Lymphangiectasis, 455 Lymphangietodes, 455 Lymphangioma, 455 tuberosum multiplex, 457 Lymphangioma, 472 Lymphatics, 21 L3'inphodermia perniciosa, 467 Lymphorrhagica pachydermia, 455 M Macule cerulese, 498 Macule, the, 29 764 INDEX Macule, symptomatic, 125 Madura-foot, 336 Mai de la rosa, 503 de los pintos, 517 roxo, 503 Malingering, 176 Malleus, 285 Malum venereum, 630 Mamillaris maligna, 486 Marsden's paste, 746 Masern, 464 Mask, 140 Massage, 50 Measles, 464 German, 581 Melanhidrosis, 144 Melanoderma, 140 Melanosarcoma, 585 Melanosis lenticularis, progres- siva, 120 Melasma, 140 Melitagra, 245 Melung, 457 Mentagra, 620 Merkel's touch cells, 23 Microsporon anomeon, 523 Audouini, 695 furfur, 148 minutissimum, 311 tropicum, 149 Middlesex Hospital paste, 747 Miliaria, 457 crystallina, 458 Miliary fever, 459 Milium, 460 Milk crust, 245, 258 Milzbrand, 570 Mitesser, 154 Mixed treatment, 744 Mole, pigmentary, 473 Molluscum cholesterique, 732 contagiosum, 461 epitheliale, 461 fibrosum, 325 pendulum, 325 sebaceum, 461 sessile, 461 simplex, 325 . verrucosum, 461 Monilethrix, 119 Morbilli, 464 Morbus elephas, 264 Morbus Gallicus, 630 Hispanicus, 630 Indicus, 631 Italicus, 630 maculosus Werlhoffii, 566 Neapolitanus, 630 pedicularis, 495 Morphea, 603 Morpion, 492 Morvan's disease, 466, 680 Morve, 285 Mosquitoe-bites, 493 Moth-patch, 140 Mother's mark, 473 Mower's mite, 493 Mucous layer, 19 patch, 640 Myasis externa dermatosa, 466 Mycetoma, 336 Mycosis frambcesiodes, 197 fungoides, diagnosis, 470 etiology, 469 pathology, 469 prognosis, 471 symptoms, 468 treatment, 470 microsporina, 146 Myoma, 471 Myxadenitis labialis, 140 Myxedema, 472 N Nails, anatomy of, 24 atrophy of, 119 ingrowing, 494 Nectator Americanus, 714 Neoplasm, inflammatory fungoid, 467 Neuralgia of skin, 161 Neurofibroma, 325 Neuroma cutis, 473 Nerves, 22 Nesselausschlag, 715 Nesselsuch, 715 Nettlerash, 715 Nevus anemicus, 473 araneus, 681 flammeus, 477 lipomatodes, 473 lupus, 112 IXDEX 765 Nevus, nerve, -190 pigmentosum, 473 pilosus, 477 sanguineus, 477 simplex, 477 spilus, 473 tuberosus, 477 unius lateris, 490 vascularis, 477 vasculosis, 477 venous, 477 verrucosus, 473 Xodule, 31 Xodules, ephemeral cutaneous, 481 ervthematous of arthritis, 481 rheumatismal, 481 subcutaneous rheumatic, 481 Xodulus laqueatus, 482 Xoli me tangere, 272, 444 Nomenclature, 53 (Edema, acute idiopathic, 482 angioneurotic, 482 cutis, acute circumscribed, 482 neonatorum, 483 Oidiomycosis, 483 Onychauxis, 484 Onychia, 485 Onychitis, 485 Onychogryphosis, 484 Onychomycosis, 486, 691 Ophiosis, 100 Oriental sore, 88 Osmidrosis, 128 Osteosis cutis, 486 Pachydermatocele, 213 Pachydermia, 264 Paget 's disease, 486 Pain, 40 Panaris nerveux, 489 Panne hepatique, 140 Panniculus adiposus, 21 Papillargeschwiilste, Beer- schwamahnliche, 467 Papilloma, 489 area elevatum, 490 lineare, 490 neuroticum, 490 : Papule, 30 i Parakeratosis scutularis, 491 variegata, 491 Parangi, 736 Parasitic diseases, 492 Paronychia, 494 Pedicularia, 495 Pediculosis, diagnosis, 500 - etiology, 498 symptoms, 495 treatment, 501 Pelade, 100 Peliosis rheumatica, 567 Pellagra, 503 Pemphigus, diagnosis, 510 etiology, 509 pathology, 510 prognosis, 512 symptoms, 505 treatment, 511 acutus contagiosus, 508 a petit es bulles, 180 circinatus, 180 foliaceous, 508 grangenosus, 179 neonatorum, 507 pruriginosus, 180, 508 vegetans, 507 Perifolliculitis cicatrisans, 330 suppurativa, 513 Perisarcoma, 571 Perleche, 515 Pernio, 168 Phagmesis, 516 Phlegmasia Malabarica, 264 Phthiriasis, 495 Phylzaci agria, 216 Phvto-alopecia, 100 Pian, 736 ruboide, 197 Piebald-skin, 729 Piedra, 516 Pigmentflecken, 140 Pigmentmal, 473 Pimple, 62 Pint a, 517 766 INDEX Pityriasis, 609 alba atrophicans, 518 capitis, 518 lichenoides chronica, 520 maculata et circinata, 521 nigricans, 143 parasitaire, 146 pilaris, 399 rosea, diagnosis, 523 etiology, 522 pathology, 523 symptoms, 521 treatment, 524 rubra, 169 pilaris, diagnosis, 526 etiology, 526 pathology, 526 symptoms, 524 treatment, 527 simplex, 518 steatodes, 518 tabescentium, 527 versicolor, 146 Plica neuropathica, 529 polonica, 527 Podelcoma, 336 Poils accidentels, 364 Poison ivy eruption, 208 Poliosis, 130 Poliothrix, 130 Polyidrosis, 360 Polypapilloma tropicum, 736 Polytrichia, 364 Pompholyx, 505, 529 Porcellanfriessel, 715 Porokeratosis, 531 Porrigo, 245 contagiosa, 382 decalvans, 100 favosa, 313 furfurans, 687 lavalis, 313 lupenosa, 313 nodularis, 424 scutulata, 313 true, 313 Porrigophyta, 313 Port-wine mark, 477 Pox, 631 Prairie itch, 534 Prickly heat, 457 Proud flesh, 127, 347 Prurigo, 534 Pruritus, 39 cutaneous, diagnosis, 540 etiology, 539 prognosis, 544 symptoms, 538 treatment, 541 Pseudo-alopecia area, 329 atrophicans, 329 Pseudo-erysipelas, 544 Pseudo-leucemia cutis, 544 lupus, 163 Psora, 545 Psoriasis, buccalis, 418 diagnosis, 553 etiology, 551 pathology, 553 prognosis, 564 symptoms, 545 treatment, 556 Psorospermosis, 395 Pterygium, 564 Pulex irritans, 493 penetrans, 493 Purpura, diagnosis, 569 etiology, 568 pathology, 569 prognosis, 570 symptoms, 564 treatment, 569 Pustula maligna, 570 Pustule, 33 Pyodermatitis vegetans, 207 Q Quinquaud's disease, 332 Quirica, 517 Radiotherapy, 43 Radium, 47 Ray fungus, 85 Raynaud's disease, 178 Recklinghausen's disease, 325 Red gum, 458 Rete malpighii, 19 Rheumatism of skin, 61 Rhigolene, 48 INDEX 767 Rhinophyma, 571, 575 Rhinoscleroma, 571 Rhus poisoning, 208 Ringskurv, 687 Ringworm, 685, 687, 691 crusted, 313 honeycomb, 313 Polish, 527 Tokelan, 682 Risipola, 286 lombarda, 503 Ritter's disease, 175 Rodent ulcer, 276 Rogna grossa, 216 Rosacea, diagnosis, 577 etiology, 576 pathology, 577 prognosis, 581 symptoms, 574 treatment, 578 Rose, la, 286 rash, 293 Roseola, 297 pityriaca, 521 Rotheln, 582 Rothlauf, 286 Rotz, 285 RubeUa, 581 Rubeola, 464 Run-around, 494 Rupia, 651 escharotica, 179 S St. Anthony's fire, 286 Salt rheum, 218 Salsfluss, 218 Sarcocele of Egyptians, 264 Sarcoid, 345, 582 Sarcoma cutis, multiple, 467 diagnosis, 589 etiology, 588 pathology, 588 prognosis, 590 symptoms, 585 treatment, 590 Sarcomatosis generalis, 467 Sarcopsylla penetrans, 494 Satyriasis, 407 Sauriasis, 375 Savill's disease, 174 Scabies, diagnosis, 596 etiology, 592 pathology, 593 prognosis, 598 symptoms, 591 treatment, 596 Scald, 218 Scale, 34 Scall, 218, 245 head, 245, 313 Scar, hypertrophied, 392 keloidal, 392 Scarf skin, 17 Scarlatina, 598 Scarlet fever, 598 Schmeerfluss, 609 Schuppenflechte, 545 Schweissflecht, 457 Scissura pilorum, 115 Sclerem der Neugeboren, 599 j Sclerema adultorum, 6011 neonatorum, 599 Scleriasis, 601 Sclerodactylie, 603 Scleroderma, 601 neonatorum, 599 Scleroma adultorum, 601 Sclerostenosis, 601 Scrofulide boutonneuse, 534 erythemateuse, 435 tuberculeuse, 444 Scrofuloderma, 606 ulcerative, 467 verrucosum, 707 Scurvy, land, 566 Sebaceous glands, 25 Seborrhagia, 609 Seborrhea, 609 congestiva, 435 corporis, 201, 611 nigricans, 143 oleosa, 609, 610 sicca, 518, 519, 611 Shingles, 738 Siderosis, 617 Skin > anatomy of, 17 bloodvessels of, 21 cancer, 137, 272 elastic, 213 glossy, 124 lesions of, 29 768 INDEX Skin, loose, 213 lymphatics of, 21 muscles of, 27 nerves of, 22 neuralgia of, 161 physiology of, 27 rheumatism of, 161 Smallpox, 723 Soap, superoxide of soda, 753 Sommersprossen, 404 Spargosis, 264 Spedalskhed, 407 Sphaceloderma, 177 Spider cancer, 681 Spilosis poliosis, 131 Spiradenoma, 87 Spirocheta pallida, 658 Spoon nails, 403 Sporotrichosis hypodermica, 617 Spotted sickness, 517 Startin's mixture, 745 Stearrhea, 609 nigricans, 143 Steatoma, 160 Steatorrhea, 609 Stigmata, bleeding, 350 Stone-pock, 62 Stratum corneum, 19 granulosum, 19 mucosum, 19 Streaks, idiopathic, 125 Streptococcus of Fehleisen, 288 Strophulus, 457 albidus, 460 prurigineux, 534 Sudamina, 457 Sudatoria, 360 Sudor urinosis, 714 Sulphur cream, 206 Summer eruption, 358 Sunburn, 167 Sweat, blue, 144 glands, 26 green, 145 yellow, 145 red, 145 Sweating, excessive, 360 sickness, 459 Swelling, giant, 482 periodic, 482 Svcosis, diagnosis, 624 etiology, 623 Sycosis, pathology, 624 prognosis, 630 symptoms, 620 treatment, 626 barbae, 620 capillitii, 197 frambesia, 197 menti, 620 non-parasitica, 620 parasitica, 691 Syphilis, diagnosis of erythema- tous, 636 general, 657 gummatous, 654 papular, 642 pustular, 644 pustulocrustaceous, 652 squamous, 650 tubercular, 647 ulcerative, 655 etiology, 658 hereditary, 660 pathology, 659 prognosis, 679 secondary, 635 symptoms, 635 tertiary, 644 treatment, 665 Syringocystadenome, 284 Syringomyelia, 680 Tache de feu, 477 hepatique, 140 ombree, 498 vasculaire, 477 Tanne, 154 Tattoo, 680 Teigne du pauvre, 313 faveuse, 313 pelade, 100 tondante, 687 tonsurans, 687 Telangiectasis, 681 Tetter, 218 Therapeutic notes, 41 Tinctura saponis viridis, 750 Tinea albigena, 686 amiantacea, 609 INDEX 769 Tinea asbestina, 609 barbae, 691 circinata, 685 decalvans, 100 favosa, 313 ficosa, 313 imbricata, 682 kerion, 402 lupinosa, 313 maligna, 313 nodosa, 516, 684 sycosis, 691 tondens, 687 tonsurans, 687 vera, 313 versicolor, 146 Tinna, 517 Tongue, black, 127 hairy, 127 Toxituberculides papulo necro- tiques, 328 Trepenoma pallida, 658 Trichauxis, 364 Trichiasis, 684 Trichoclasia, 116 Trichoma, 527 Trichomycosis capillitii, 402 favosa, 313 nodosa, 406, 516 palmellina, 406 Trichonosis cana, 131 discolor, 131 poliosis, 131 Trichophytosis, etiology, 693 pathology, 694 prognosis, 704 svmptoms, 685 treatment, 696 barbae, diagnosis, 691 symptoms, 691 capitis, diagnosis, 690 symptoms, 687 corporis, diagnosis, 687 symptoms, 685 unguium, diagnosis, 693 symptoms, 693 Trichoptylose, 116 Trichorrhexis nodosa, 116 Trichosis hirsuties, 364 plica, 527 Tropical big leg, 264 Trypanosomiasis, 705 49 Tubercle, the, 31 anatomical, 707 Tuberculosis cutis, 706 orificialis, 706 miliary, 706 ulcerosa, 706 verrucosa cutis, 707 Tuberculum sebaceum, 460 Tumor, the, 34 itching, 424 multiple fungoid, 467 Tyloma, 130 Tylosis, 130 linguae, 418 palmse et plantae, 398 Ulcer, the, 35, 710 tropical phagedenic, 712 Ulcus grave, 336 perforans, 512 rodens, 276 Ulerythema, 435, 712 acneiforme, 714 centrifigum, 435 ophyroginis, 713 sycosiforme, 329, 623, 702 Uncinarial dermatitis, 714 Uridrosis, 714 Urticaria, diagnosis, 718 etiology, 717 pathology, 717 prognosis, 720 symptoms, 715 treatment, 719 pigmentosa, 721 Vaccine therapy, 50 Vaccinia, 722 Vagabond's disease, 496 Varicella, 723 gangrenosa, 179 Variola, 723 Varioloid, 724 Veld sore, 724 Verole, 631 Verruca, 724 770 INDEX Verruca necrogenica, 707 Verrue, 724 telangiectasique, 110 Verruga, 736 peruana, 728 Vesicle, the, 32 Vienna paste, 746 Vitiligo, 729 capitis, 100 Vitiligoidea, 732 Vleminckx's' solution, 748 W Wart, 724 postmortem, 707 telangiectatic, 110 Warze, 724 Washleather-skin, 731 Weichselzopf, 527 Wen, 160 Wheal, the, 31 Whitlow, 485, 494 melanotic, 586 Wildfire, 286 Wilkinson's ointment, 752 Wood-tick, 493 Wundrose, 286 X-ray, 43 dermatitis, 199 Xanthelasma, 732 Xanthelasmoidea, 721 Xanthoma, 732 diabeticorum, 735 Xeroderma, 375 ichthyodes, 375 pigmentosum, 120 Xerodermic pilaire, 399 Xerosis, 114 Yaws, 736 Zona, 738 Zoster, diagnosis, 741 etiology, 739 pathology, 740 prognosis, 742 symptoms, 738 treatment, 741