LIBRARY OF CONGRESS. ©Ijajt ©qmrtB^ $a— Slielf-.tB.15 UNITED STATES OF AMERICA. '■:■ Is No. 13 IN THE PHYSICIANS' AND STUDENTS' READY- REFERENCE SERIES. A PRACTICAL MANUAL DISEASES OF THE SKIN GEORGE HTROHE, M.D., PROFESSOR OF MATERIA MEDICA, THERAPEUTICS, AND HYGIENE, AND FORMERLY PROFESSOR OF DERMATOLOGY IN THE COLLEGE OF PHYSICIANS AND SURGEONS, BALTIMORE, ETC., ETC. ASSISTED BY J. WILLIAMS LORD, A.B., M.D. LECTURER ON DERMATOLOGY AND BANDAGING IN THE COLLEGE OF PHYSICIANS AND SURGEONS ; ASSISTANT PHYSICIAN TO THE SKIN DEPARTMENT IN THE DISPENSARY OF JOHNS HOPKINS HOSPITAL. PHILADELPHIA AND LONDON ! THE F. A. DAVIS CO., PUBLISHERS, 1892. -\\ <» Entered according to Act of Congress, in the year 1892, by THE F. A. DAVIS COMPANY, In the Office of the Librarian of Congress, at Washington, D. C, U. S. A. Philadelphia, Pa., U. S. A.: The Medical Bulletin Printing House, 1231 Filbert Street. PREFACE. In this book no attempt is made to add one more to the already numerous works for the dermatological specialist. Hence, little space is given to theoretical speculations upon pathology and etiology. It is hoped, however, that the medical student and practitioner will find, in the following pages, some return in practical value for the time spent in their perusal. The author takes occasion to express his obligations for assistance to Dr. J. Williams Lord, his former chief, of clinic and present successor in the Chair of Derma- tology in the College of Physicians and Surgeons. Baltimore, Md., December 15, 1891. (iii) TABLE OF CONTENTS. PAGE Introduction . 1 Anatomy and Physiology of the Perspiratory Glands 3 Disorders of the Sweat Glands 5 Quantitative derangements of the secretion of sweat . 5 Hyperidrosis 5 Anidrosis 8 Qualitative disorders of the sweat secretion 9 Bromidrosis 9 Chrornidrosis . . . 9 Uridrosis 10 Sudamen 10 Prickly heat 10 Anatomy and Physiology of the Sebaceous Glands 15 Diseases of the Sebaceous Glands 16 Functional disorders of the sebaceous glands 16 Seborrhoea 16 Comedo 19 Milium 21 Steatoma . . . *. '" 21 Asteatosis " 22 Structural diseases of the sebaceous glands and peri- follicular tissues 22 Acne 22 Acne rosacea „ 28 Sycosis 30 Eczema . . . . 37 General considerations . „ 37 Acute eczema 40 Chronic eczema 44 Inflammations of the Skin 66 Erythema 66 Urticaria 70 00 vi Table of Contents. PAGE Simple inflammations of the skin 77 Erysipelas 84 Furuncle 86 Anthrax 88 Diffuse phlegmon 89 Malignant pustule 90 Herpes simplex 91 Herpes zoster ..'..' 92 Dermatitis herpetiformis 96 Psoriasis 98 Exfoliative dermatitis 104 Acute exfoliative dermatitis of infants. . . . 104 Bullous exfoliative dermatitis 107 Chronic general exfoliative dermatitis .... 107 Local exfoliative dermatitis 108 Lichen. . . 109 Prurigo Ill Atonic pustular eruptions . Ill Contagious impetigo 113 Pemphigus 114 HEMORRHAGES 119 Symptomatic cutaneous hemorrhages 119 Purpura 119 Scurvy 121 Hypertrophies of the Skin 123 Pigmentary hypertrophies . 123 Freckles ..'.'..' 123 Chloasma 124 Hypertrophies of the epidermal and papillary layers . 127 Epidermal hypertrophy of old age .... . . 127 Epidermal accumulation at the mouths of the hair- follicles . . ^ .129 Epithelial molluscum . 130 Callosities 131 Corns 131 Warts 134 Cutaneous horns 137 Pigmentary nsevus 138 Ichthyosis 141 Hypertrichosis 144 Table of Contents. vii PAGE Hypertrophies of the connective-tissue layers .... 152 Scleroderma 152 Sclerema neonatorum 154 Elephantiasis arabuin 155 Atrophies > 159 Atrophia cutis . . . ' 159 Atrophy of pigment 161 of hair 163 New Formations of the Skin 168 Epithelial new formations 168 Epithelioma 168 Connective-tissue new formations 173 Keloid 173 Fibroma 174 Xanthoma 176 Rhinoscleroma . . 176 Sarcoma . 177 Lepra 178 Scrofuloderma 182 Lupus erythematosus 183 Lupus vulgaris 185 Ainhum 189 Podelcoma 189 Myoma . . . ■ . c 190 Neuroma 191 Perforating ulcer of the foot 191 Vascular new formations 192 Lymphangioma 192 Angioma . 192 Telangiectasis .* 194 Neuroses 196 Hyperesthesia 196 Anaesthesia . . 196 Dermatalgia 196 Pruritus 197 Parasitic Skin Diseases 199 Vegetable parasitic skin diseases . . ; 199 Tinea favosa 200 Tinea trichophytina 201 Tinea versicolor 203 viii Table of Contents. PAGE Animal parasitic skin diseases . 205 Scabies 205 Pediculosis 206 Cutaneous Manifestations of Syphilis ...... 209 General considerations 209 General morphology and classification 210 General diagnostic features , 211 Chronological sequence and course of eruptions • 211 Localization and distribution 213 Color 214 Multiformity of lesions 216 Configuration of eruption 216 Subjective symptoms 217 Racial peculiarities 217 Recapitulation , . 218 The erythematous syphilide 220 The papular syphilide 228 The pustular syphilide 240 Tertiary syphilitic eruptions 246 The tubercular syphilide 248 The nodular syphilide , 252 The ulcerating syphilide 257 The pigmentary s} r philide 262 Syphilitic alopecia 266 diseases of the nails 268 Treatment of the syphilides 268 General treatment 269 Local treatment 284 Formula 290 PRACTICAL MANUAL OF DISEASES OF THE SKIN. INTRODUCTION. A knowledge of the diseases of the skin is of great importance to the practitioner. Although skin dis- eases do not, as a rale, tend to shorten life, the discom- fort or disfigurement they produce are so annoying that persons afflicted with them are more emphatic in their demands for relief than if suffering from maladies of much greater gravity. An eczema of very limited extent, a simple ringworm, or an ordinary eruption of acne, will frequently cause the patient more anxiety than a catarrhal pneumonia with its dangerous sequel, or a reducible hernia with its constant menace of fatal strangulation. The student or young practitioner will find it to his advantage to give some time and attention to the study of this branch of practical medicine. In every com- munity there are sufferers from curable skin diseases who are compelled to bear their afflictions }^ear in and year out because the physicians to whom they have applied for relief failed to recognize the character of the disease, or, recognizing it, failed to apply the appro- priate remedy. Hence, a practical knowledge of the diagnosis and treatment of skin diseases may not seldom (i) 2 Introduction. have a decisive influence upon the 3 r oung practitioner's success in obtaining a practice. It must be confessed, however, that the impression made by most text-books of dermatology is not reas- suring. Complicated classifications or u systems," an awkward nomenclature, great prolixity and a lack of definiteness in the description of typical diseases, and an undue multiplication of morbid processes are the besetting sins of many of our standard works. In the following pages I have tried to give brief and exact descriptions of the various diseases considered, and to indicate the simplest and most direct methods of treatment. The needs of the practitioner have been primarily kept in view. Theoretical questions have been entirely subordinated to plain matters of fact. ANATOMY AND PHYSIOLOGY OF THE PERSPIRATORY GLANDS. The perspiratory glands consist of simple tubules, which at their blind extremities are coiled up into a spherical mass imbedded in the lower portion of the derma, or in the subcutaneous tissue, where they are generally in relation with a mass of fat. The duct, or, rather, that part of the gland not coiled up, passes through the cutis in a straight or slightly wavy line, but becomes spirally twisted on its way through the epidermal layer, ending in a funnel-shaped opening on the surface. The sweat glands are most numerous in the palms, soles, and axillae. They are entirely wanting in the glans penis, prepuce, and the margin of the lips. The average number to the square inch is one thousand, and the total number is estimated at nearly two and a half millions, with a secreting surface of about forty thousand square inches. The total length of tubing, supposing the convoluted ends to be uncoiled, would amount to nearly eighty miles. In the axilla the diameter of the sweat glands is from one-third of a line to a line and a half. (Krause.) The main function of the perspiratory glands is the secretion of sweat. The smaller glands are lined with a nucleated pavement epithelium, while the larger ones have a lining of cylindrical epithelial cells. The convo- luted portion of the gland is surrounded by a net-work of capillaries. They are also richly supplied with nerves. Their secretion contains water, fats, and volatile fatty acids, cholesterin, urea, chlorides, and phosphates. Its (3) 4 Diseases of the Skin. normal reaction is alkaline. Under certain conditions of defective action of the kidneys, the skin may perform the function of these organs vicariously. The suppression of cutaneous perspiration was for- merly looked upon as very serious and generally fol- lowed by fatal results. Experiments made upon small animals (rabbits), by covering the entire surface with an impervious varnish, resulted in the death of the animals. These experiments are not conclusive, however, for it has been found that large dogs and horses thus treated do not die. The fatal result in the smaller animals is explained by the rapid loss of heat from the surface when this is covered with an impervious material. The secretion of sweat varies in different individuals. It is also influenced by differing conditions of environ- ment, such as heat and cold, muscular exertion, dilata- tion of the superficial vessels, increased blood-pressure, abundant or hot drinks, certain medicines, and, above all, the action of certain nerves. Stimulation of the vaso-dilator or paralysis of the vaso-constrictor nerves may produce increased secretion of sweat. Excitation of certain special " sweat nerves," the centres of which are situated in the medulla (Naw- rocki, Ott) and spinal cord (Luchsinger), causes active secretion. It has been found that this secretion may be produced on stimulating the sweat nerves, even after the extremity has been severed from the body. " Sweating may be brought about as a reflex act. Thus, when the central stump of the divided sciatic (in which are contained the sweat fibres) is stimulated, sweating is induced in the other limbs, and the intro- duction of pungent substances into the mouth will fre- quent^ give rise to a copious perspiration over the side of the face." 1 1 Foster : Physiology. Second Am. ed., p. 499. DISORDERS OF THE SWEAT GLANDS. The disorders of the sweat glands are functional; no structural alteration of these glands, independent of any other disease, is known. The sweat may vary in quantity or he altered in quality. The quantitative variations in secretion consist in excessive secretion (hyperidrosis) and deficient secretion panidrosis). I. Quantitative Derangements of the Secretion op Sweat. hyperidrosis — excessive sweating. The quantity of sweat excreted in health varies so widely in different individuals that it is difficult to indi- cate the dividing line between physiological and patho- logical sweating. Hyperidrosis may be general or local. The former is most likelj 7 to be an accompaniment of some diseased state, as phthisis ; or it imvv occur in the course of an acute febrile affection, as pneumonia, typhoid, malarial, or relapsing fevers. In the latter class of diseases the sweating is an indication of defervescence, and requires no treatment. The phthisical sweats frequently demand therapeutic interference on account of their exhausting effects. Among the general hj'peridroses may be mentioned the so-called " sweating sickness " which formerly pre- vailed epidemically in portions of Europe, and which has been observed in France as late as the year 1887. For details in regard to this curious disease the reader is referred to the author's " Text-Book of Hygiene." (5) 6 Diseases of the Skin. General hj-peridrosis is often an accompaniment of corpulence, constituting a very annoying complication of this derangement of nutrition. Local hyperidrosis in the majority of cases affects the palms of the hands, soles of the feet, or the axillae. The foot and axillary sweat has often a very offensive odor. This odor is not present in the freshly-secreted sweat, but is developed in consequence of certain chemical changes in the secretion. Thin belieA^es it to he due to the presence of an organism which he has named bacte- rium fcetidam. Persons so affected are constantly environed by a fetid exhalation, and ma} T be literally said to " stand in bad odor." Local sweating also accompanies many nerve lesions or disturbances. Thus, migraine is often accompanied by excessive perspiration limited to the area of distri- bution of the affected nerve. The general treatment of the excessive sweats of phthisis consists in tonics and astringents. Aromatic sulphuric acid in fifteen drop doses four to six times daily is often of great utility. Atropine in doses of vho ^° ilo g** 1 * 11 (one-third to half a milligramme) can be relied upon with much confidence to check the exces- sive secretion, although a permanent effect cannot be hoped for. In these cases local treatment is usually of little avail. The treatment of the hyperidrosis of obesity is of no avail without such measures as will at the same time result in a diminution of the accumulated fat. 1 In the local hyperidroses the principal reliance must be placed upon local measures. Of course, the condition 1 See "The Guiding Principles in the Treatment of Excessive Corpu- lence," in Phil. Med. Times, vol. xvii, pp. 799, 826. Disorders of the Sweat Glands. 7 of the general health demands attention, and anaemia or digestive derangements require appropriate treatment. Aside from this the constitutional treatment can be summed up under the general head of hygienic measures, — good food, fresh air, exercise, and possibly tonic medicines. For the disagreeable sweating of the palms, a lotion of tannic acid, 2 to 3 grains to the ounce of alcohol (1 to 200), or simply cologne-water or bay -rum (For- mula 1), are very useful. The application of one of these may be followed by a dusting-powder of starch, prepared chalk, or orris-root. Either of these may be combined with oxide of zinc, boracic acid, salicylic acid, or calamine, with good effect (Formulae 2 to 4.) Similar measures will generally be effectual in excessive sweat- ing of the axillary region. For the excessive malodorous sweating of the feet (bromidrosis), many remedies have been recommended. In the milder cases, baths of alum-water, followed by one of the above-mentioned dusting-powders, are some- times effectual. Formula 5 is used with success by the German army-surgeons. For the severer grades of the affection, however, in which the feet are constantly bathed in sweat, the epidermis macerated, and the skin reddened and tender, and at the same time diffusing a most penetrating and offensive odor, there is only one method of treatment known to me which can be relied upon. It was introduced by Hebra, and has, in numerous cases under my care, never failed to cure the disease. The procedure is as follows : — The feet are first washed and thoroughly dried. Each foot is then enveloped in a piece of linen or muslin of proper size (about one foot square) thickly spread with diachylon ointment (Hebra 's ointment, ung. vaselini 8 Diseases of the Skin. plumbicum ; see Formulae 5, 6). Small pieces of linen spread with the ointment are also inserted between the toes. Clean foot-wear is then put on. On the following daj 7 the cloths are taken off, the feet wiped dry with a towel, but not washed. One of tile absorbent powders above mentioned (Formula 4) is thickly dusted on, and the feet again enveloped with the ointment. This pro- cedure is repeated daifv from ten daj^s to two weeks, during which time the feet must not be washed. The ointment is then omitted, but the powder is still used several times a da} 7 . After a few days the epidermis is exfoliated in thick, 3 T ellowish, parchment-like flakes, and new, soft skin appears. Now for the first time the feet may be washed. The new epidermis is of a healthy, pink color, and the secretion normal. The powder should be continued for some time. If the hyperidrosis is not entirely cured, the same course should be repeated ; but this is rarely necessaiy. Thin recommends dusting the shoes and stockings with boracic acid, and wearing a cork sole on the inside of the shoe. He also advises the application of a boracic acid ointment (Formula 7). ANIDROSIS — DEFECTIVE EXCRETION OF SWEAT. This should properly be termed hypohidrosis, as the secretion is rarely entirely suppressed. It accompanies certain grave constitutional or nervous affections, as diabetes, tuberculosis, n^elitis, and poliomyelitis. Locally it also occurs on eczematous, psoriatic and ichthyotic patches. The treatment in each case will be that appropriate -to the underlying general or local condition. The dry- ness of the skin may be relieved by the glycerite of starch (Formula 8). Disorders of the Sweat Glands. 9 II. Qualitative Disorders of the Sweat Secretion. BROMIDROSIS — ODOROUS SWEAT. Certain nervous diseases are accompanied by modi- fications of the odor, with or without increase in the quantity of the perspiration. Hammond has reported several cases of this kind. The odor is not always offensive, but may even be agreeable, as in Hammond's cases, in two of whom it resembled that of violets. In the majority of cases, however, the odor of the sweat in bromidrosis is the reverse of agreeable, and is nearly always due to decomposition of the secretion. The treatment of these cases is that mentioned on page 7. In one of Hammond's cases salicylate of sodium in 5-grain (.3 gramme) doses arrested the hj T peridrosis as well as the emission of the odor. CHROMIDROSIS — COLORED SWEAT. The perspiratory secretion is usually colorless, but sometimes it presents a distinct color. Red, blue, green, yellow, and black sweats have been reported. In many of the reported cases the color was, doubtless, due to some reaction between the sweat and some material adhering to the skin or in the clothing. In others the discoloration was intentionally produced. Colored sweat is also sometimes found in company with uterine or ovarian disorder. In this category probablj 7 belong the cases of bloody sweat, or ephidrosis cruenta, so far as the reports may be considered as trustworthy. So competent an observer as Dr. McCali Anderson has reported an interesting case of this affection, and has quoted a number of others from Erasmus Wilson, T. K. Chambers, Pinel, and other authors. It is noticeable that, in all but one of the cases mentioned, the points of appearance of the bloody fluid were on the front of l* 10 Diseases of the Skin. the body, or on such portions of the surface as could be readily reached with the hands. Duhring states that colored sweat is " not infre- quently connected with uterine disorders," and gives references to a large number of reported cases. In red and yellow sweat E berth and Babes iu have found bac- teria. It is not improbable that colored sweat, unless feigned, is always due to the presence of minute organ- isms. It is known, for example, that the color of blue pus is produced by a bacterium. The treatment might be rationally germicidal. A lotion of mercuric bichloride one grain to the ounce (1 to 500) or Labarraque's solution (liq. sodse chlorinatse) should be effective in case the color is due to micro- organisms. URIDROSIS — URINOUS SWEAT. In cases of kidney disease, in Asiatic cholera, and in experimental observations on the cutaneous perspira- tion, urea and other constituents of the urine have been found in the sweat. As this is merely an incident in some grave underlying disease generally, it does not require any special treatment. SUDAMEN — SWEAT BLISTERS. In cases of typhoid, typhus, and puerperal fevers, rheumatism and pneumonia, there is frequently an eruption of minute whitish, or pearly, non-inflammatory vesicles, coincident with the so-called "critical sweat." The vesicles are due to the excessive secretion, which elevates the epidermis in minute areas. The eruption has no especial significance, and requires no treatment. PRICKLY HEAT. Under ordinary circumstances the average quantity of sweat secreted in twenty-four hours by a healthy Disorders of the Sweat Glands. 11 adult is about twelve ounces. This, however, is ma- terially modified by varying conditions of external tem- perature, character, and amount of food and drink, dress, emotional conditions, or the swallowing of certain medicines. The exact quantity of fluid and other matters discharged daily in the sweat can, therefore, not be definitely stated. Ordinarily this secretion takes place without pro- ducing anj r discomfort; but when it becomes excessive in consequence of the causes mentioned, it often gives rise to a most aggravating and troublesome disease of the skin. The characteristic features of prickly heat are so familiar as to make any extended description unneces- sary. It occurs in the form of small, bright-red pim- ples, rarely larger than a pin-head in size, thickly scattered over the surface of the body, and accompanied by a most distressing sense of tingling, burning, and itching. Often the small red pimples are capped by a minute blister containing a droplet of a colorless or pearly fluid. The eruption m&y appear anywhere upon the skin except the palms of the hands and soles of the feet, where it is rarely or never seen. It is nearly alwaj T s limited to those portions of the body covered by the clothing. In plump, well-fed children, it is also often seen in the folds of the skin at the front of the neck. These little red elevations indicate the mouths of the sweat glands, which are irritated and inflamed in consequence of excessive activity. This is generally due to high temperature, excessive exertion, and unsuit- able clothing. The inordinate use of hot drinks, con- finement in close, ill-ventilated apartments, lack of attention to proper cleanliness of the skin, improper 12 Diseases of the Skin. administration of medicines containing opiates or simi- lar drugs which have an irritating action upon the skin, may give rise to or intensify this disease. Dis- turbances of digestion are also believed to be effective in its causation. The distress caused b} r the eruption leads the sufferer to seek relief by rubbing and scratching the affected surface. The ease obtained in this wa}^ is only tem- porary, however, and in a short time the itching and burning return with greater intensity, the scratching is repeated, and, if no relief is given bj T medical means or a cessation of the cause, an inflammation of the skin proper — an eczema — may be produced, which will often persist a long time and prove very resistant to treatment. I may be permitted to digress here for a moment to call attention to the frequency with which this very obstinate and troublesome disease is the result of neglect of very trivial ailments. An outbreak of prickly heat, or nettle-rash, or a simple chafe, if neglected or im- properly treated, is often followed by an eczema lasting months or years — nay, which not infrequently attends the individual throughout life. Dermatologists see cases almost dail}' in which the ounce of prevention, properly applied, would have far outweighed many pounds of cure. The use of flannel next to the skin, especially during hot weather, is the principal avoidable cause of prickly heat. Flannel clothing ought at no time to be worn directly in contact with the skin. Prickly heat is often greatly intensified hy improper methods of treatment. Hot drinks or other sudorific remedies internally and irritant local applications nearly always make the disease much worse. Disorders of the Sweat Glands. 13 An eruption very similar in appearance to prickly heat sometimes affects children when teething, or when suffering from an attack of acute indigestion or similar complaint. This is a fine nettle-rash. It is not limited to the parts covered by clothing, and not rarely attacks the palms of the hands and soles of the feet. The itch- ing is usually more intense than in prickly heat. The eruption appears and passes away suddenly, and may often be made to disappear by an emetic or brisk purge. It is a popular fallacy that the eruption of prickly heat is salutary, and that no effort should be made to cure it for fear of'" driving it in " and causing some other serious disease. There is no need to fear any ill consequences from a rapid cure of the complaint. The danger is, rather, as already pointed out, that if neglected it will develop into another and much more obstinate disease. Prickty heat need rarely cause much difficulty in treatment. The following measures will usually succeed in promptly relieving the intense irritation and restor- ing the normal condition of the skin : — The dress should be light, all flannels and impervious articles of clothing being removed. Cool baths should be taken often enough to remove the perspiratory secre- tion before it decomposes, and to keep the skin cool. After the bath, the skin should be carefully dried with a soft towel, and the affected surfaces powdered with starch-powder, or a mixture of starch and oxide of zinc (Formula 2), or carbonate of zinc and orris-root (For- mula 3). Lotions containing alcohol, as cologne-water or bay- rum, may also be used when the outbreak is local, following the lotion with one of the powders. Formula No. 4 will often be of good service. All powders used 14 Diseases of the Skin. should be perfectly smooth and contain no gritty par- ticles. Preparations containing sulphur should be avoided, as they are more likely to increase than to alia}' the irritation. If the itching is excessive, lotions containing one to two drachms of bicarbonate of soda to the pint of water (1 to 100) may be applied with a soft sponge and allowed to dry on the skin. Ointments must not be used, as they nearly always aggravate the complaint. If the eruption covers the entire surface, alkaline baths, containing two to four ounces of carbonate of soda to the bath, or bran baths, may be employed, and will rarely fail to give at least temporary relief from the excessive itching. A bran bath is prepared b}Mnclosing from five to six pounds of bran in a thin muslin bag and steeping it in the bath for fifteen to twenty minutes before using the bath. The bag should be occasionally kneaded and squeezed, in order to diffuse the mucilag- inous contents throughout the water. Gelatin and starch baths, containing one to two pounds of gelatin or one pound of starch to the bath, are also often valu- able aids in the treatment. After each bath the skin should be carefully dried without friction and dusted with starch, as above directed. The causes of the disease should be avoided, if possible. ANATOMY AND PHYSIOLOGY OF THE SEBACEOUS GLANDS. The sebaceous glands are tabulated glandular organs found in all parts of the skin except the palms of the hands, soles of the feet, and the dorsal surfaces of the third digital phalanges. Special varieties of these structures are Tyson's glands on the glans penis, the Meibomian glands, and the ceruminous glands of the external meatus. They are nearly always in connection with a hair-follicle. If the hair is thick, as in the scalp or beard, the glands seem to be appendages to the hair- follicle, and discharge their secretion into the follicular canal. On the other hand, the fine hairs seem to be merely appendages to the gland, the duct of the latter opening directly upon the surface, and the hair-shaft passing out through the gland-duct. The glands in the tegument of the glans penis are not connected with hair- follicles. The number of sebaceous glands in the skin of the adult is estimated by Build ey as at least six hundred thousand. Their size varies extremely, measurements having been given at ^q to ^ inch in diameter. The secretion of the sebaceous glands consists of epithelial debris, cholesterin, fat, and fat-ciystals. Its function is probably to keep the skin and hair soft and pliable, and to limit absorption and evaporation. (15) DISEASES OF THE SEBACEOUS GLANDS. The diseases of the sebaceous glands may be divided into functional disorders and structural lesions. The latter frequently arise from the former. I. Functional Disorders of the Sebaceous Glands. SEBORRHEA EXCESS AND ALTERATION OF THE SEBACEOUS SECRETION. Seborrhoea appears under two forms, — Seborrhoea sicca and Seborrhoea oleosa. The former is generally found upon the hairy scalp and the trunk, while the latter is often localized upon the face. Dry seborrhoea of the scalp is frequent in infants, in whom the head is covered with a more or less thick yellowish or brownish crust, under which the skin is dry and of the normal color, or slightly hyperaemie. In the adult, seborrhoea of the scalp usually appears in the form of a furfuraceous desquamation, popularly known as " dandruff." In some cases, however, the scales are massed together in a firm Layer, under which the skin is frequently reddened. When seborrhoea of the scalp lasts for some time it usually causes loss of the hair. It is probable that by far the majority of cases of early baldness are due to neglected or improperly treated seborrhoea ; hence the importance of early atten- tion to this apparently insignificant affection. Upon the chest and back, seborrhoea generally ap- pears in the form of roundish or irregular red patches, (16) Diseases of the Sebaceous Glands. 17 covered by a layer of loose, whitish, greasy scales. Such patches are often found upon the sternal region, and may easily be mistaken for psoriasis. Seborrhea oleosa is almost exclusively limited to the face, especially the nose and cheeks. The skin of these parts is smooth, oil}', and shining. Dust rapidly accumulates on the oily surface, and the affected indi- viduals find it almost impossible to keep clean. The causes of seborrhcea are not well known ; but it is often an accompaniment or a consequence of contin- ued fevers, syphilis, tuberculosis, or general anaemia. In many cases no reason for its existence can be dis- covered. The diagnosis of seborrhcea rarely presents any difficulty. At times, however, it bears such a close resemblance to some other common diseases as to ren- der a careful examination necessary in order to come to a positive decision. The diseases with which seborrhcea is likely to be confounded are eczema, psoriasis, and ringworm. In eczema there is always more redness of the skin and greater itching than in seborrhcea. There is also general^, at some stage of eczema, serous discharge, which is never present in seborrhcea. In psoriasis, the scales are dry, silvery white, and seated upon a bright or deep-red, slightly-elevated base, with a sharplj'-defined margin. In seborrhcea the scales are usually dirt3 T -white, gi'ayi&h^ or yellowish, and greasy to the touch. The border between the affected and normal skin is not well defined. The small patches of seborrhcea upon the chest some- times resemble ringworm. Here the microscope will generally decide the nature of the affection by reveal- ing the spores or mycelium of the fungus of ringworm. A 9 18 Diseases of the Skin. The treatment is principally local. If scales have accumulated to form crusts, these must be softened by some oily application. Sweet-oil and almond-oil are excellent for this purpose. Vaseline and cosmoline are unsuitable, as they *do not saponify in the presence of alkalies (soaps), and hence are difficult to remove, espe- cially from the hairy scalp. Fresh dehydrated lard answers much better. The application of a hot, moist poultice for several hours often promotes the loosening of the scales. After thorough softening of the crust, the scalp or the part affected is washed with soap and w r ater. The best sonp for this purpose is the German soft soap (sapo viridis). This soap has a strong odor of fish-oil, which makes it very disagreeable. The odor can be very well covered, however, by dissolving the soap in alcohol and adding a little oil of lavender or bergamot. This constitutes Hebra's spiritus saponis kalinus. (Formula 9.) About a tablespoon ful of this is poured upon the scalp, and, with the addition of water, smart friction produces a copious lather. The soap is washed out with clean water, and leaves the scalp clean, but usually with a tense sensation, as if the skin was stretched too tightly over the skull. A little oily application, such as vase- line, cold-cream, or almond-oil, will relieve this uncom- fortable feeling. In mild cases the shampooing and inunction of the scalp with a simple unguent will after a time cure the disease ; but in chronic cases something more will be required. Here some of the mercurial preparations, as Formulae 10, 11, 12, or one containing sulphur, as Formulae 13, 14, or tar (Formula 15), will be necessary. I have found carbolic-acid ointment, gr. xv to §j vaseline (1 to 30), to yield most excellent results. The general treatment also demands attention. In Diseases of the Sebaceous Glands. 19 anaemic or chlorotic individuals, iron in the form of pills of the proto-carbonate (Bland's ferruginous pills, Formula 16), or In combination with arsenic, as recom- mended by the late Sir Erasmus Wilson (Formula 17), is indicated. The tincture of the chloride, especially if made palatable (Formula 18), is also a most active chalybeate. Chronic derangement of the function of digestion is also often present in cases of seborrhoea, and requires appropriate treatment. In acid dyspepsia, I have often obtained excellent results from the administration of lime-water and calumba (Formula 19). Many patients suffering with disorders of the seba- ceous glands are subject to habitual constipation. In these cases, the best drug I have used is cascara sagrada. I generally prescribe the cascara cordial prepared by Parke, Davis & Co., and have always obtained excellent results from its use. Its agreeable taste renders it a very desirable medicine. It is not objected to by the most fastidious patients. The fluid extract not rarely gripes and nauseates. I have never known the cordial to produce these effects. It should be given in tea- spoonful-doses once or twice a day, until one daily evacuation is regularly produced. In dispensary practice I have used with satisfaction for a number of years a combination of sulphate of magnesia and iron (Formula 20). COMEDO. Comedones are small, solid elevations of the skin caused by the retention of the sebum in the gland- ducts. They can be squeezed out of their seat by lateral pressure, and appear as short yellowish or whitish fatt}^ pings, with the outer extremity of a blackish color, known in the vernacular as " black- 20 Diseases of the Skin. heads," or u flesh-worms." They are found in greatest numbers upon the face, chest, and back. They are unaccompanied by inflammation. Xeglect of cleanliness is the most frequent cause of comedones. They nre most frequent in young persons between the ages of twelve and twenty-live. At times no cause can be discovered. The diagnosis can never present any difficulty. The treatment of comedo is simple. The sebum plugs must first be expressed from the gland-ducts. This can readily be accomplished by means of a comedo extractor, or a watch-key. The opening of the key is placed directly over the black extremity of the plug and direct downward pressure made, when the plug is usually easily extruded. Then the skin is washed with soap and water, spirit as saponis kalinus (Formula 9) being an excellent form in which to use the soap. Afterward, a mild, stimulating application should be made to the skin in order to produce contraction of the calibre of the gland-duct and prevent re-accumulation of the secretion in it. For this purpose a mild sulphur or mercurial ointment (Formulae 11, 13) is useful. Van Harlingen recommends a combination of kaolin, glycerin, and vinegar (Formula 21), which I have used with some success. Should the frictions with soap produce irritation and desquamation of the skin, the}' may be inter- mitted for a few da} T s, and a soothing ointment, such as oxide-of-zinc ointment, or cold-cream with starch (For- mula 22), applied in the interval. When the irritation has subsided, the soap-friction must be resumed. If the patient is anaemic or debilitated, the adminis- tration of iron, in the form of acid tincture of the chloride (Formula 18), is indicated. Diseases of the Sebaceous Glands. 21 MILIUM — SMALL RETENTION-CYST OF SEBACEOUS FOLLICLE. This occurs in the form of small, white or pearly, elevated papules, principally situated about the e}'elids. They are very superficial, being merely covered by epi- dermis. They are not likely to be mistaken for any other disease. The best treatment is electrolysis. An electrolytic needle inserted into the growth or passed through its base, and the circuit closed with ^ to 1 milliampere current for a minute, will usually be effectual. After a few days the papule falls off, leaving no scar. The slightly pigmented mark which remains gradually fades out. Simple puncture and expression are also often effectual. STEATOMA — SEBACEOUS CYST ; WEN. Wens are retention-cysts of the sebaceous glands which frequently grow to considerable size. They may occur on any portion of the body where there are seba- ceous glands, but are most frequently found on the scalp, face, neck, and back. The diagnosis between steatoma and lipoma is sometimes difficult. Puncture with an exploring- needle or bistoury and compression will, however, disclose the contents of a steatoma and clear up the diagnosis. The treatment consists in extirpation of the entire gland. Incision and expression of the contents of the sac may succeed, if the interior is thoroughly cauter- ized with lunar caustic. Small cysts may also be destroyed by electroh T sis. Anaesthesia may be produced by injecting a few drops of a 4-percent, solution of 113'drochlorate of cocaine alons; the line of incision. 22 Diseases of the Skin. ASTEATOSTS — DIMINISHED SECRETION OF SEBUM This occurs only in conjunction with other patho- logical conditions ; most markedly with xeroderma. Persons whose hands come in frequent contact with alkalies, alcohol, ether, etc., often suffer from an arti- ficial asteatosis, i.e., the sebaceous matter is properly secreted, but is immediately dissolved in the chemical. The treatment consists in supplying fat to the skin, by means of frictions with lanolin, cold-cream, almond- oil, etc. II. Structural Diseases of the Sebaceous Glands and Perifollicular Tissues. acne. During the period of puberty many of the organs of the body take on a new development. The sebaceous glands of the skin participate in this growth, and, as a consequence, a greater or less degree of functional dis- turbance of these organs is likely to result. The most common form of this functional disturbance consists in an alteration in character and quantity of the sebaceous secretion. The sebum secreted is thicker and is not so readily extruded from the gland-ducts. These latter become filled with little plugs of the secretion, which distend the ducts, and thus produce small papules, with sometimes a slight depression of the summit, which is colored black or brown. This little spot of color is the mouth of the duct filled with the secretion, and the dis- coloration depends upon the deposit of dirt, — dust, carbon, etc., which has adhered to the end of the greasy plug, as has already been described. 1 This is the first stage, in the vast majority of in- 1 See ante, p. 19. Diseases of the Sebaceous Glands. 23 stances, of the disease known as acne. The French writers term it acne sebacee ; while in the English and German literatures it is known as comedo (plural, come- dones). In this stage, acne is a purely functional affec- tion ; if we remove the accumulation of sebum in the glands and gland-ducts and change — by appropriate treatment — the altered character of the secretion, the parts resume their normal condition and the disease is at an end. 1 If, on the other hand, inappropriate or no treatment be adopted, the disease goes on to the next stage, — that of congestive or inflammatory acne. Here, we find, in addition to the merely functional disturbance of the glands, a structural lesion — inflammation, with its consequences, — pus-formation and hyperplasia of connective tissue. The following sketch traces the evolution of an acne papule from its stage of comedo : The walls of the gland-duct and the immediately surrounding connective tissue become compressed, disturbance of the circulation and nutrition within a limited area take place, and in- flammation follows. At this stage the papule is bright- red and painful, usually still showing the black point of the comedo at its summit. The inflammation may now subside and resolution occur, but usually the process goes on to pus-formation. A little drop of pus appears in the centre of the papule, which, if evacuated, is found to surround the plug of inspissated sebum, the original cause of the trouble. If the disease is allowed to go on without appropriate treatment, that form of acne known as the indurated or tubercular acne results. Considerable new formation of connective tissue (inflammatory hyperplasia) takes place, and those unsightly physiognomies so often seen 1 See page 20. 24 Diseases of the Skin. in young men and women between the ages of eighteen and twenty-five result. There are dark-red blotches with firm, brownish nodules, from a split pea to a small bean in size, with angry-looking pustules scattered here and there over the face, the latter being particularly numer- ous on the forehead and cheeks. Causation. — Errors in diet, excessive indulgence in or abstinence from sexual pleasures, masturbation, con- stipation, dyspepsia, eating particular articles of food, such as butter and cheese, have all been accused as causes of common acne. In vary many individuals neither of these conditions, nor even a number of them combined being present, produce the disease ; in others the disease appears in the absence of these various sup- posed causes. Although no single functional disturbance or struc- tural alteration of any internal organ can be held strictly accountable for the causation of acne, the dis- ease cannot be attributed exclusively to external causes. An epigrammatic professor of New England has tersely given the cause of acne in the following propo- sition : " The country girl washes her face with sonp, and does not have acne ; the city girl abstains from the use of soap, and does." Like all epigrams, this is only partly true. In the majority of cases of ordinary acne the abstention from sonp is doubtless the immediate cause of the disease. In other cases, however, this can- not be accused of being the cause. Acne is so frequentty associated with menstruation that every practitioner is familiar with the relationship between this skin disease and the uterine and ovarian functions. The writer thinks he has observed one form of acne which may be classified, and which he has ven- tured to term u menstrual acne." It differs from the Diseases of the Sebaceous Glands. 25 ordinary form of acne in being rarely distinctly pustular, the eruption coming out in the course of a few days preceding or at the beginning of the menstrual period, and frequently disappearing with the menstrual dis- charge, without proceeding to suppuration. Acne vulgaris is usually aggravated during the menstrual period, but the eruption of new lesions does not cease in the interval, and pustulation is often very marked. Some women have an eruption of acne papules during pregnancy, which disappears after the pregnane} 7 termi- nates. The relation between cause and etfect has not been satisfactorily explained. The ingestion of various drugs, as iodide or bromide of potassium, is frequently followed by acne ; the disease disappears on the discon- tinuance of the remedy. Workmen in tar and petroleum or their products not infrequently suffer severely from painful acneiform eruptions. Cleanliness and, if possible, cessation of exposure to the irritant vapors give relief. The only disease liable to be mistaken for acne is the papulo-pustular syphilide. In this, however, the erup- tion of the lesions is usually acute, and it is not likely to be limited to the regions of the bod} 7 usually affected by acne. When the syphilitic nature of the eruption is suspected, an inquiry into the history of the develop- ment of the disease will soon clear up any doubt. Treatment. — Internal medication can usually be dis- pensed witli in the treatment of acne. Where the con- dition of the stomach or bowels seems to demand it, a mild mercurial or saline laxative is probably an aid. In habitual constipation, cascara cordial, as directed on page 19, will often act very happily. Tincture of chloride of iron is always indicated when the congestion 2 B 26 Diseases of the Skin. is considerable, or where there is much pus-formation. In strumous or tubercular individuals codliver-oil is a useful adjunct to other measures. A rigid restriction of diet is not necessary if the digestive function is property performed. The consump- tion of fatty food, if digestible, should be encouraged. Hence, butter, fat meats, or salad-oil should not be pro- hibited. In cases of pustular acne, the administration of calcium sulphide in doses of T V to J grain is highly recommended by some authorities. I have never seen any good result follow its use. The same is true of ergot, which at the present time enjoys- considerable popularity as a remedy in acne. The fluid extract may be given in half-drachm doses twice or three times a day. In some cases acetate of potassium (Formula 23) seems to exert a favorable influence upon the course of the eruption. Arsenic, in doses of T ^ grain (§ milligramme) three times a day, is extremely useful in " menstrual acne." The local treatment of acne is by far the most impor- tant, and in the majority of cases suffices for the cure of the affection. The indications for the treatment are : (1) to remove the accumulation of sebum, (2) to remove the products of inflammation, and (3) to restore the normal func- tional activity of the parts. The first indication is best met by expressing the plugs of sebum daily, by means of a watch-key. Select a key with a smooth, broad base and wide opening, and, placing it directly over the black apex of the papule, press the key down squarely upon the skin. A little pressure will force the plug of sebum out of the gland- duct. This should be done every night. Immediately Diseases of the Sebaceous Glands, 27 after, the face should be washed with warm water and soap, allowing the lather to remain on all night. The spirit us saponis kalinus may be used. In the morning the soap is washed off and the face is dusted with oxide of zinc, calamine, or simple chalk or starch powder. In simple cases, with a moderately thin epidermis, this is all that is necessary, and in three or four weeks the acne is cured. I have also had good results from the use of EichhofT's resorcin soap. In the cases which ma} r , for want of a more definite term, be called " menstrual acne," excellent results can general^ be obtained by the use of a lotion containing sulphuret of potassium and sulphate of zinc (Formula 24). In cases where the epidermis is thick, — a so-called coarse skin, — the treatment should be a little more active. Here a mixture of sulphur and carbonate of potash (Formula 25) should be painted on with a camel's hair brush, after the expression of the sebum plugs, and allowed to remain on all night. It was first recommended by Zeissl,and is certainly a valuable com- bination. In the morning, after washing the face, one of the above mentioned powders, or a little oxide-of- zinc ointment, should be applied. After a few days of this treatment, the skin becomes slightly reddened and scaly, and, in some cases, an un- comfortable sensation of tension or burning occurs. Then the sulphur application should be discontinued for a few days until the irritation has subsided, when the same course should be recommenced. If there are many inflammatory papules or pustules, incision or puncture with a fine, sharp bistoury gives great relief and hastens the involution of the lesions. After the puncture the flow of blood should be pro- 28 Diseases of the Skin. moted by a hot-water douche. A basin is filled with water as hot as can be borne, and a large, soft sponge dipped into it and pressed to the face. This should be continued five minutes or so, and is best done at night before retiring. It is an especially valuable adjuvant to the treatment if the pus-formation is free. In cases of indurated acne, the tubercles should be freely scarified, and, after the bleeding has ceased, mer- curial ointment applied on bits of cloth or leather, and allowed to remain on all night. The tubercles may also be painted with a strong alcoholic solution of car- bolic acid (1 part to 3 or 4 of alcohol) this being re- peated every two or three da3 T s. In rare cases the treatment above recommended is too irritating. A lotion of bicarbonate of soda (3ij to Oj) [1 to 60] will sometimes reduce the hyperemia. The lotion of sulphuret of potassium and sulphate of zinc (Formula 24), diluted with an equal part of water, is also useful in these cases. A lotion of resorcin (2 to 4 per cent.) is often especially beneficial. ACNE ROSACEA. Acne rosacea, or toper's nose, differs in its clinical features, etiology, and its treatment from the condition just described. Its subjects are usually individuals above the age of thirty ; further, individuals who in- dulge to excess in wines or strong liquors — beer-drink- ers more rarely have it. It also sometimes occurs in young people of defective cutaneous circulation, in whom it never gets so marked, however, as in the first class of cases. Acne rosacea begins as a consequence of frequently recurring flushing of the face. The brandy-drinker, speaking generally, has a hyperemia of a portion of the Diseases of the Sebaceous Glands. 29 face every time he takes a drink. The vessels gradually become permanently enlarged, perhaps increased in number, and, in consequence of the local increase in nu- tritive material, some connective-tissue hypertrophy takes place. The increased circulatory activity of the part is accompanied by numerous stases of blood in minute areas, which eventuate in small abscesses, the acne pustules, accompanying the area of vascular injec- tion. In mild degree of acne rosacea, the process stops at the formation of diffused red patches. These cases are often diagnosticated as " chronic erysipelas." Of course, there is no disease properly so called. In cases of a more active type, acne pustules will be found scat- tered over the red base, upon which also may be noticed tortuous, dilated blood-vessels. In the most exa^oer- ated condition, we find the nose much enlarged, lobu- lated, brown or bluish-red in color, and disfiguring the patient very much. In the treatment of acne rosacea, the use of wine or spirits, if this is the cause of the disease, must be forbidden. In those cases where the rosaceous patches are due to deficient nutrition, the patient must be placed under better conditions. Locally, in the patches of dif- fused redness, the application of the alcoholic solution of carbolic acid, above recommended (1 part to 3 or 4 of alcohol), will generalh' give most satisfaction. Where there are tortuous and dilated veins in the skin, they must be slit up with a line knife and a pointed pencil of nitrate of silver drawn through them to cause obliteration of their calibre. Where the connective tissue is much increased, a plastic operation is sometimes necessary to restore a respectable shape to the distorted nose. When pustules are present they should be opened with a bistoury and the pus evacuated. 30 Diseases of the Skin. In mild cases of rosacea-, a wash of corrosive subli- mate, (gr. j to gj) [1 to 500] of diluted alcohol, or of resorcin (2 to 4 per cent.), is sometimes all that is necessary. Occasionally, the redness can be best removed b}' painting the skin with a solution of caustic potassa (3ij to §j) [1 to 4], and immediately washing it off and ap- plying oxide-of-zinc ointment. After a few days the zinc and potassium-sulphuret lotion (Formula 24) may be applied. Dilated vessels may also be obliterated bj' means of electrolysis, using 1 to 2 milliamperes of current and a fine needle. If the operation is properly performed the obliteration is permanent. sycosis. The characteristic features of non-parasitic sycosis are inflammatory papules, pustules, and tubercles, each perforated by a hair and occup3'ing especially the region of the beard, although the eyebrows, scalp, axillae, and pubes may also be seats of the affect ion. The following is the usual history of a case of sy- cosis : A number of painful reddish papules or pustules appear in the beard or moustache, the single lesions being each perforated by a hair. The skin around the papules or pustules is usually reddened and somewhat swollen and infiltrated. In some cases, however, the characteristic lesions remain perfect^ isolated ; no ex- tension lateral^ of the inflammation taking place. The pustules are usually small, flat, or slightly elevated, with scant}' contents which they show little disposition to discharge, unless punctured or broken by pressure or friction. There is often burning and exquisite tenderness to the touch ; rarely severe itching. In Diseases of the Sebaceous Glands. 31 cases of long standing the pus has dried into crusts and scabs, under which the surface is frequently excoriated. At times there are broad, elevated, papillary masses — fungoid excrescences — bearing some resemblance to mu- cons patches. In other cases there are boils and deep abscesses. As the disease progresses, the hair-follicles are de- stroyed, theliairs, at first still firm in their follicles, fall out, and a flat, shiny, reddened, or venated scar results, which often strongly resembles the cicatrix remaining after the involution of lupus. Recovery from the dis- ease rarely takes place without appropriate treatment. The etiology of the disease is not established. Wertheim believes the primary irritation to be due to a disproportion in size between the hair-shaft and the hair-follicle. Hebra and Kaposi attribute it to the after- growth of a new hair at the bottom of the follicle before the mature hair has been shed. The disease is some- times caused by the extension into the hair-follicles of a more superficial dermatitis, such as eczema. At other times it is evidently due to the constant contact with the skin of an acrid discharge; for example, a catarrhal discharge from the nose, which is frequentlv accom- panied by sycosis of tiie upper lip and the parts of the nostril studded with the fine hairs called vibrissa?. When the inflammation is once lighted up it is kept up by the movements to which the hairs are constantly subjected. The form of sycosis under consideration is not con- tagious, is not caused by a parasite, and cannot be conveyed from one individual to another through the utensils or manipulations of the barber. It is not caused by shaving, as the most severe and persistent cases are found in persons who do not shave. It is not 32 Diseases of the Skin. very rare, the lighter forms constituting, perhaps, 4 to 5 per cent, of all forms of skin diseases seen in this part of the country. It is most frequently seen in individuals between twentj'-five and forty years of age. The pathology of sycosis has been shown by Rob- inson to be primarily a peri-foliiculitis, progressively attacking the follicle itself. There is reason to believe, however, that the inflammation may not infrequently begin in the follicle and extend secondarily to the peri- follicular tissues. The diagnosis of non-parasitic sycosis is compara- tive^ easy if the salient features of the disease are borne in mind. Each papule or pustule is perforated by a hair, and the disease is essentially an inflammatory affection of the hair-follicle and the immediately sur- rounding structures. In fact, S} T cosis bears a nearer resemblance to acne than to any other skin disease. In acne the sebaceous glands and structures immediately adjacent are the seat of the morbid process, while in sycosis the hair-follicles and surrounding tissues are the parts affected. From the intimate anatomical rela- tions of the hair-follicles and the sebaceous glands, it is evident that the two diseases must be closely-related morbid processes. From eczema of the bearded portions of the face sycosis is differentiated by the absence of the character- istic features of the former disease. In sjxosis there is usually no itching or discharge of sticky serum, which symptoms especially mark an attack of eczema. In eczema there is likewise more infiltration of the skin, and the inflammation extends beyond the borders of the beard, and may even involve the entire face ; in sj^cosis the inflammation is limited to the parts covered by thick hairs. It should be remembered, however, that Diseases of the Sebaceous Glands. 33 a long-standing eczema of the beard ma}' result in, or, rather, be complicated by sycosis. Even the deep ab- scesses, furuncles, and fungous sores may sometimes be seen in cases of very intense chronic eczema in strumous individuals. From parasitic sycosis the differentiation will be aided by a hisjoiy of the case. The latter disease usu- al ly begins as a ringworm — tinea circinata — and the fungus, which is the cause of the disease, can usually be found without much difficulty in the scales and affected hairs with the aid of a good microscope. In this form of the disease the hairs also fall out much earlier than in the non-parasitic variety. The hairs are also dry, lustreless, broken off, and split at the broken end. When the inflammation extends deeper in the parasitic form, there are usually numerous deep and very painful ab- scesses, which give a knobbed appearance to the lower jaw. On opening these abscesses a mucous or muco- purulent fluid is discharged. The pustular or tubercular syphilide should offer no difficult}' in differentiating it from non-parasitic sycosis. I have, however, seen two cases where the two diseases were present in the same individual, and caused con- siderable hesitation in arriving at a conclusion. In these cases I found the s} T cosis especially obstinate ; both bad a catarrhal discharge from the nose, which kept up the irritation of the upper lip, where the dis- ease was principally localized. In one of the cases the eyebrows were also affected b}' the sycosis. In syphilis the generalization of the eruption and the ten- dency to destructive ulceration of the lesions, when long continued, will enable the diagnosis to be made with little difficulty. The prognosis of sj^cosis is favorable. It demands, 2* 34 Diseases of the Skin. however, more personal attention from the physician in its treatment than almost any other skin disease. A neglect of certain precautions — to be presently pointed out — on the, part of either physician or patient, will result in almost certain failure to cure the disease, and consequent disappointment to the patient and discredit to the doctor. The important points to be insisted upon in the treatment of non-parasitic sycosis are four: shaving of the affected parts, puncturing all abscesses and pustules, the proper application of appropriate ointments, and epilation. I consider it of such importance that the diseased spot should be shaved daily, or every other day, that I decline to begin the treatment of a case unless this advice is followed. There is alwaj^s strenu- ous objection on the part of the patient, who urges vari- ous reasons for not carrying out this procedure. It will be found, however, upon trial, that shaving — if the barber is expert and the edge of the razor keen — is not nearly so painful as the patient anticipates, and the rapid im- provement which follows soon removes all objection to the practice. When there is considerable crusting and scabbing, the accumulated crusts are first softened by the use of sweet-oil, lard, simple ointment, or a poultice, and then shaving commenced. In order to facilitate the removal of the crusts, the beard can first be shorn with scissors. After the face has been shaven, all pustules, tubercles, papules, boils, and abscesses should be opened with a fine, sharp bistoury, and the discharge of their contents and of the blood, which flows prett}* freel}', encouraged hy douches of hot water. This is best done by dipping a large, soft sponge in very hot water and applying it to the diseased surface, continuing this for five or ten minutes. When the bleeding has ceased, Diseases of the Sebaceous Glands. 35 some soothing ointment should be applied on cloths and bound to the parts. Hebra's ointment, or the ointments of ammoniated mercury, calomel (5ss-j to 3J) [1 to 8 or 1 to 16], yellow oxide of mercury (gr. x-xx to §j) [1 to 24 or 1 to 48], or oxide or oleate of zinc will be found to answer the purpose. The irritation soon subsides, and, on daily repetition of this procedure, the face shows marked improvement in a few days. When abscesses and pustules cease to form, I generally direct the 5-per- cent, oleate-of-mercury ointment, and know no other application which g^ves such satisfactory results. An ointment composed of equal parts of Hebra's and mer- curial ointments is also very useful. The diffused red- ness that remains can be made to disappear more rapidly by an occasional superficial scarification, and the appli- cation, twice or three times a week, of a solution of carbolic acid in alcohol (1 to 4 parts). The shaving must be continued for at least a year after the final disappearance of the eruption, for, upon allowing the beard to grow again, the disease is exceedingly liable to return. In many cases of this disease it will be advisable, and will hasten the cure, to pull out the hairs from the inflamed follicles. It will be found that this procedure, if consistently carried out, shortens the duration of the disease very materially. It is, however, not so necessary in the non-parasitic as in the parasitic form, and it is very painful to the patient and trying to the prac- titioner. In those cases where fungous vegetations occur, they may be destroyed by means of caustics or removed by the curette. It is only in very rare cases, however, that such severe measures are required. In most of the 36 Diseases of the Skin. cases coming under the notice of the physician in this country, the aim pie means briefly described will suffice for the cure. In S3^cosis no* internal remedies are requisite, unless there should be disturbance of function of some internal organs, — the digestive apparatus, for example, — when the appropriate remedies demanded by the case should be given. ECZEMA. GENERAL CONSIDERATIONS. Willan and all other English dermatologists, until a very recent period, characterized eczema as a vesicular disease, accompanied hy the discharge of a sticky, albu- minous fluid. Other clinical manifestations of a patho- logical condition, apparently similar to that underlying the vesicular eruption, were classed as separate and distinct diseases. Thus, an itching papular eruption was termed lichen, or prurigo ; a pustular eruption was impetigo ; and an erythematous or a scaly eruption was an intertrigo, psoriasis, or pityriasis. While these names still have a place in dermatological nomenclature, they have at present, in most cases, a different significa- tion to that possessed by them twenty-five }ears ago. Hebra, to whom belongs the credit of freeing derma- tology from the clogs of artificial classifications and a meaningless terminology, recognized the close relation of these various manifestations and gave to eczema a more comprehensive definition than was given to it by the English, French, or early German schools. Accord- ing to this definition, eczema is an acute or chronic non-contagious inflammation of the skin, manifesting itself either in reddened or scaly patches, papules, vesicles, pustules, or fissures, characterized in many cases by the exudation of a colorless, or yellowish, sticky fluid, which dries into amber-colored or brownish crusts, and is accompanied by intense itching. If we accept this definition of eczema, our conception (37) 38 Diseases of the Skin. of the disease becomes at once much more clear and simple. We are led to pay attention to the pathological condition underlying the morbid process, rather than to the manifestations of the disease in any particular case. It is probable that eczema is, in the majority of cases, due to external impressions upon the skin, i.e., it is the effect of some local irritant influence, either chem- ical or dynamic. There can be little doubt, however, that a peculiar predisposition of the skin to take on eczematous inflammation is necessaiy before the influ- ences mentioned will produce an eczema. Thus, in some individuals, the most violent scratching or fric- tion, chemical irritants, or changes of temperature or moisture, will fail to produce an eczema, while in others, any of these influences, even in a mild degree, will pro- duce an outbreak of the disease. It is not necessary to assume, however, that there exists a peculiar d3 T scrasia or diathesis, to which the term eczematous diathesis is applicable. The evidence which we have bearing upon this point seems to the writer to point to the opposite conclusion. Although the writer is firm in the conviction here expressed, that eczema is mostly due to external physi- cal impressions upon the skin, it is not intended thereby to exclude altogether affections of internal organs as predisposing, or even as exciting, causes of outbreaks of the disease. Disorders of the digestive organs, the liver, or kidne} T s, and disturbances of the nervous sys- tem, seem to have an etiological relation to outbreaks of eczema in some cases. Hebra speaks of the frequent coincidence between eczema and menstrual anomalies. These menstrual eczemas, he saj's, are especially localized on the scalp, Eczema 39 face, or lips. In the course of pregnancy, also, eczemas frequently appear, generally in the earlier months, and continue, in spite of all treatment, to the end of gesta- tion. These eczemas are usually localized upon the hands. Some women, who have repeatedly been preg- nant, are able to determine the presence of pregnancy in themselves b} T the outbreak of the eczematous erup- tion on their hands. Th. Yeiel reports an interesting case, in which the eczema appeared in the third month of the patient's third pregnancy, and continued until the termination of the puerperal period, when it disap- peared without treatment. The eruption was limited to the extensor surfaces of the forearms, and recurred at five consecutive subsequent pregnancies. Hebra also refers to the eczema occurring during or after lactation. Sterile women, too, are subject to recurrent eczemas, although these may generally be traced to some definite lesion of the uterus or ovaries. The writer has noticed a form of acute, generalized, eczematous eruption, not described by other writers, which occurs in association with laceration of the cervix uteri. The eruption extends over nearly the entire surface, is finely vesicular, and accompanied by the most intense itching, fever, and subsequent exfo- liation of the epidermis. No treatment addressed to the cutaneous disease seems to be of any avail until the uterine lesion is remedied. Climacteric eczema is referred to b}^ Hebra, and Mr. W. Allan Jamieson, in his recent work, devotes some attention to this form. He says : " Usually the monthly loss has ceased when the eczema appears. This form exhibits a proneness to relapse and to the recurrence of eczema in certain definite regions for many years. More than three-fourths of the cases 40 Diseases of the Skin. occur on the scalp and ears. The extremities also may suffer, but the trunk is scarcely affected in any case. The scaly and weeping varieties predominate, in contrast to the pustular form, .which attacks infants. Itching is well marked. From the commencement to the close there may be no more than a dry, pityriasis eczema, with some loss of hair, liable, however, to be trans- formed into the moist form by external or internal irritants." Eczema is in all cases a curable disease. The pre- disposition of the skin cannot, however, be removed by any means at present known. Eczema is always liable to recur when the irritation is repeated. Hence, while the prognosis as to any individual attack is favorable, a permanent cure cannot be promised in an}^ case. If it be true, as stated above, that eczema is, in by far the larger proportion of cases, due to a merely local impression of greater or less intensity, it follows, as a matter of course, that local measures should suffice for its cure ; and we find this to be generally true. # ACUTE ECZEMA. For purposes of clinical description, eczema is divided into varieties determined by its duration, its localization, and the nature of the primary lesion. Hence, we may speak of acute and chronic, general and local eczema. The varieties depending upon the nature of the pri- mary lesion are the erythematous, papular, vesicular, and pustular. The acute form of these varieties will first be briefly described. Acute erythematous eczema most frequently occurs in consequence of friction of two opposing surfaces of the skin, the action of heat or chemical irritants, or the Eczema. 41 influence of moisture. Hence it is oftenest seen in the perineum and on the inner surfaces of the thighs in children and adults, and, in fact, wherever the surfaces of the skin are habitually in contact, especially if the effect of the friction is heightened by heat and decom- posing secretions. This condition, known in the ver- nacular as " chafe," is often the source of great annoyance to both physician and patient, from its obstinacy, Acute papular eczema is most frequently found on the forearms, hands, and feet, and is often due to the influence of high temperature of the air (as in aggra- vated cases of u prickly heat"), 1 or to persistent scratching. The writer has seen it not infrequently follow an outbreak of the small, papular urticaria, so often localized upon the back of the hand and fingers. The severe itching accompanying the urticaria causes the part to be rubbed and scratched until the temporary disturbance of nutrition has become prolonged, and what was at first simply an evanescent affection has become one of more permanence. Papular eczema frequently runs into a stage of fur- ther development of the lesion, and becomes vesicular. In other cases the vesicular form is the one first devel- oped. This is the old typical form of eczema, — closely aggregated, fragile vesicles, which, bursting, exude a stick} r fluid that stiffens but does not stain linen. It is frequently seen upon the face, ears, and genital organs. There is often much serous infiltration of the skin, giving the part the appearance of erysipelas. There is, however, no pain or febrile disturbance, so marked in the latter disease. In er} T sipelas the skin is dark-red and shiny, while in eczema the color is much less deep. 1 See page 9. 42 Diseases of the Skin. In eczema there is also burning, and, in most cases, intense itching. Pustular eczema is most frequently seen as it affects the hairy scalp in children or the hairy regions of the face in adults. The pustular character is very frequently the expression of a depravement of the system. Perhaps, in most cases of vesicular eczema, the vesicular character of the disease has disappeared when the physician is called. The vesicles have burst, and their contents have either dried into 3 T ellowish-brown crusts, or a red, weeping surface is exposed. This is the eczema rubrum of authors, and should be consid- ered as a secondary form of the disease. When it occurs in parts where the skin is subject to much movement, as the flexures of joints, etc., fissures result, extending into the cutis, which are very painful some- times. This is what is termed in the books eczema rim o sum. In a small proportion of cases, eczema in all or a number of its various forms will be found attacking the entire bod3' or its larger surface. In such cases the vesicular and pustular forms will be found on the face, head, limbs, and genitals ; the erythemato-squamous form will be found on the trunk ; the flexures of the joints will be occupied by the fissured and weeping- forms; while the papular variety will be almost exclu- sive^ localized upon the forearms and legs. Acute eczema may be limited to certain portions of the body, or may extend over the entire surface. There are certain sites of predilection where it is often local- ized. These are the face, the genital organs, and the extremities. Acute eczema oftener presents the vesicular char- Eczema. 43 acter than do the chronic cases of the disease. It begins suddenly by an outbreak of small vesicles, aggre- gated in heaps, the eruption usually having arrived at its height in the course of fort} r -eight hours. In the most favorable cases, the involution of the process now begins, the contents of the vesicles are absorbed, and the dried epidermis cast off in whitish scales. In other cases the vesicles rupture and the contents dry upon the surface in gum-like crusts, which drop off in a few days, leaving a slightly reddened but otherwise normal surface. The eruption of the vesicles is accompanied by red- ness and tumefaction of the skin, and subjective sensa- tions of burning, tension, and, later, by itching. If the surface involved is extensive, the constitutional symp- toms of fever may also be present. This favorable termination of the affection is, how- ever, exceptional. In the majority of cases relapses occur, or the action of local irritants prolongs the mor- bid process, and the disease, while undergoing certain clinical modifications, persists and eventuates in chronic eczema. Acute general eczema, in which the disease attacks almost the entire surface of the body; is rather rare. In such cases the various primary manifestations will usually be present upon different parts of the surface, as above mentioned. In acute eczema of the face there is usually great oedema of the skin, especially about the eyelids, which are sometimes swollen to such an extent as to prevent opening the eyes. The redness is also marked, and sometimes suggests the appearance of erysipelas, but the tense, shiny skin of the latter is not present in eczema. The surface is usually uneven, owing to the 44 Diseases of the Skin. presence of papules and vesicles. Upon the ear the vesicles are usually present in very great number. The genital organs are affected with acute eczema in the male oftener than in the female. When the penis is attacked the swelling is enormous, and as it occurs very rapidly the patient is often greatly alarmed. The organ is thickly studded with innumerable little vesicles. In the course of a few days the swelling usually diminishes and the organ returns to its normal size. There is rarely any exudation upon the skin of the penis. In eczema of the scrotum the swelling is also very great, and the vesicles soon burst and exude a large quantity of the characteristic sticky fluid of eczema. The decomposition of this exudation gives rise to an ex- ceedingly disagreeable odor unless the most scrupulous cleanliness is observed. Upon the hands and feet acute eczema appears in the form of numerous tense vesicles, varying in size from a hemp-seed to a small pea. At first there is a " furry " sensation, succeeded by itching. When there is much swelling the mobility of the fingers and toes is lessened, and in some cases entirely abolished, on account of the pain and tension. The vesicles in eczema of the hands and feet are frequently very tense and resistant. They do not burst readil} 7 . Sometimes several run together to form a good-sized bleb. The itching is usually intense, and is often relieved only b}^ fierce scratching. CHRONIC ECZEMA. In chronic eczema the typical characters presented by the acute are very often absent. The persistence of • the morbid process gives opportunity for the production of various pathological conditions, such as excoriation, Eczema. 45 scaling, crusting, and scabbing. The infiltration of the skin increases, the normal pliability of the integument becomes lost, and, on pinching up a fold, it resembles leather of various thicknesses, rather than living skin. In most cases there is considerable discharge and violent itching. When the disease continues a long time the skin becomes pigmented, especially in lines marking out the erasions produced by the finger-nails in scratching. Very often the lesions due to scratching extend down into the papillary layer, as shown by the dried blood- crusts which are found upon the eczematous patch. Although chronic as well as acute eczema may affect the whole surface of the body or only a limited area, it is most frequently observed in certain localities, in each of which it presents clinical peculiarities requiring separate description. In describing these various forms of the disease the practical needs of the physician and student will be kept in view. Only those features will be noted which are necessary to arrive at an accurate diagnosis. According to its localization, chronic eczema may be divided into — 1. Eczema of the scalp. 2. Eczema of the face. 3. Eczema of the trunk. 4. Eczema of the genitals and anus. 5. Eczema of the flexor surfaces of joints. 6. Eczema of the hands and feet. 7. Eczema of the legs. Eczema of the scalp is most frequent in children, in whom it is usually present in the pustular form. It may also appear as the erythematous or squamous, the latter being the variety most frequently seen in adults. ■46 Diseases of the Skin. It may occur in patches or uniformly distributed over the entire scalp. The crusts are usually thick, and yellowish, greenish, or brownish. They are formed of scales, pus, and the secretion of sebaceous glands. If strict attention is not paid to cleanliness, the material of which the crusts are composed undergoes decompo- sition and exhales a very disagreeable odor. The hairs are frequently matted together in the scabbing process, and the whole scalp may be covered by a large, firm crust, under which there are sometimes large collections of pus. When eczema of the scalp is neglected, espe- cially in children, the head will frequently be found in- fested with lice. On the other hand, the irritation caused \>y the presence of lice is not rarely the starting- point for an eczema. Eczema of the scalp sometimes extends beyond the hairy part of the head and invades the forehead, ears, and back of the neck, in form of a red band, covered by whitish, unctuous scales. The haij sometimes falls out, but permanent bald- ness from eczema is extremely rare. Enlargement of the post-auricular and post-cervical glands is nearly always present in eczema of the scalp, especially in children. The table on the opposite page is a modification of one given by McCall Anderson, and presents the most prominent differentiating points between eczema of the scalp, pustular syphilide, psoriasis, ringworm, and sebor- rhoea. With its aid, and remembering other essential features of the disease, no difficulty ought to occur in making a diagnosis. Eczema of the face is either limited in extent, or the entire face may be attacked by the morbid process. The affection ma}^ also be confined to the. hairy portions of Eczema. 47 a p-ts c 1? 5. Bore raduall ito heal o o — cd £. S3 gp 5 2 r* OS on 20 O P 2? fsrp ^ K K* ~"p C c 00 ' P P p $a 00 P? ? CD » & ,+ 9 8 P* 8 S d ►p *\? »g 3 CD OS X 2 2 Sg 8 5*8. 1 § P >* I I Pi P OD S CD P OR} ^W p, O O p Bo 5* p- tPCD p p CD 2 P^. c-t- p CD P^ o CO o cd p* CD vO ? P 3 b ! £>S CEP ^2*3 p £* p 01 cd S- "•. • 8«< » £1 . 00 c o % £> w~ p CD O P>2 ? P ^ P^ <1 ^ p CD - *■" P; a 2 OQ ^ s? £P q g^ < p » 2 CD CD cc^ co P ■ p. cr*p CD r ^ . P^ CD ^ c+- p — cp^g p P ~ 2 • CD P P ►p £L O P CD CD ^ P 2 I c o p e-f P o" p 5*2 -i 5 t O CO 1— ' 3^» - SP CO a -; p ^?Ep CD n ?M ?H . p 6 o S t! O * P* 5 1 ? CD 0^ Qj cd"^ CD p p CJ p' 5" 0*3 ^- p p ■P - CD T3 c c§ 2. g- p E, x. £. 3 o a p h CD h- CT 00 Co CD ^T 1 CD co p-P CD P ^ CO Pj CD P^ S P CD O ^ CO "* OCT? ^ £ p P^ Hj ED ^a p g 2 CO >.* Q0 ft a o P P W 48 Diseases of the Skin. the face, i.e., the beard, eyebrows, eyelids, and internal surface of the nostril. Eczema of the beard is a pus- tular inflammation around the hair-follicles, accompanied by burning, itching, sero-purulent discharge, and crusting. If the inflammation extends deepty into the hair- follicles, a condition similar to that known as sycosis is established. In the latter the inflammation is limited to the hair-follicles and the peri-follicular tissues, while in eczema the inflammatory process may extend beyond the surface covered with hair. In eczema of the eyebrows, the ciliary borders of the eyelids and the internal surface of the nostrils, the condition is principally a folliculitis. Little flat pustules occur, perforated in the centre by a hair. The hairs are not loose in the follicles, however, as in parasitic dis- eases, but are firmly attached, and cannot be removed without causing pain. Unna has described a form of eczema under the name of seborrhoeal eczema, which usuallj T begins on the scalp, and may extend in patches over the entire body. It is scaly, has well-defined borders, and usually itches but slightly. Upon the non-hairy parts of the face eczema usually appears in the form of the erythematous, pustular, or scaly varieties. The erythematous or erythemato- squamous general^ appears upon the forehead, sides of the nose or chin, and is general^ accompanied by intense itching. The eczematous action upon the lips, the angle between the nostrils and cheeks, the eyelids, and the post-auricular angle is generally manifested by the Dresence of one or more fissures, which render move- ments of these parts painful, and from which the ec- Eczema. 49 zematous fluid often exudes in considerable quantity. The post-auricular eczema is often very persistent. The same may be said of fissured eczema of the lips, which, when long continued, may cause considerable infiltration and hypertrophy of the labial margin. It is also often very painful; every time the mouth is opened some of the fissures are stretched or torn, and, in consequence, laughing, talking, eating, or any movement of the mouth causes much pain. In children eczema of the face is frequent, and, when extensive, has given rise to the popular name u milk-crust." The scabs in this condition are formed by the drying of the exudate mingled with sebaceous secretion. The only diseases likely to be mistaken for eczema of the face are ringworm and erythematous lupus. In the former the patches are always circular or with gyrate outlines, with a somewhat pale, scaly centre, and papu- lar or vesicular border. In erythematous lupus the color of the patch is dark-red or brownish, the scales are greasy and adherent, and, when detached, fine pro- longations are observed on their under surface. Eczema of the trunk may occur in scaly patches from the size of a small coin to that of a hand. The patches are usually dry and scaly. When chronic there is often much infiltration. The itching is usually not very severe. The disease is often localized about the nipples of nursing-women, constituting the troublesome affection known as "sore nippies." The nipple is red, swollen, with deep, very painful clefts (fissures) running around its base. The act of nursing causes the mother exces- sive pain. The disease is very obstinate on account of the difficulty of giving the parts complete rest. 3 C 50 Diseases of the Skin. Several } r ears since, Sir James Paget described a form of eczema of the nipple which is liable to run into cancer of the breast. Microscopic examinations by Thin and Wile have shown that the disease is epi- theliomatous at a very early stage, if not from the beginning. But the fact remains that, in an individual predisposed to cancer, any persistent irritation may determine the point where the disease will localize itself. In the opinion of the writer, cancer of the breast, or of any other part, may result as the direct consequence of the irritation of a prolonged eczema. It is especially advisable, therefore, that mammary eczemas should not be neglected, but should be cured as quickly as possible. Sir James Paget gives the following lucid account of this disease as observed by him in fifteen cases : — " The patients were all women, varying in age from forty to sixty or more years, having in common nothing remarkable but their disease. In all of them the dis- ease began as an eruption on the nipple and areola. In the majority it had the appearance of a florid, intensely red, raw surface, very finely granular, as if nearly the whole thickness of the epidermis was removed — like the surface of very acute diffuse eczema, or like that of an acute balanitis. From such a surface, on the whole or greater part of the nipple and areola, there was always copious, clear, yellowish, viscid exudation. The sensations were commonly tickling, itching, and burn- ing, but the malady was never attended by disturbance of the general health. " I am not aware that in any of the cases which I have seen the eruption was different from what may be described as long-persistent eczema, or psoriasis, or by some other name, in treatises on diseases of the skin; and I believe that such cases sometimes occur on the Eczema. 51 breast, and, after many months' duration, are cured, or pass by, and are not followed by any other disease. But it has happened that, in every case which I have been able to watch, cancer of the mammary gland has followed within, at the most, two years, and usually within one year. The eruption has resisted all treat- ment, both local and general, that has been used, and has continued even after the affected part of the skin has been involved in the cancerous disease. u In practice the question must be sometimes raised whether a part through whose disease or degeneracy can- cer is very likely r to be induced should not be removed. In the member of a family in which cancer has frequently occurred, and who is at or beyond middle age, the risk is certainly very great that such an eruption on the areola, as I have described, will be followed within a year or two by cancer of the breast. Should not, then, the whole diseased portion of the skin be destroyed or re- moved as soon as it appears incurable b}^ milder means ? " Prof. McCall Anderson gives a table of diagnostic points between Paget's disease and eczema of the nipple, which may aid in the differentiation : — Paget's Disease. 1. Occurs in women over forty years of age. 2. Surface affected, in typical cases, of brilliant-red color, raw and granular-looking after re- moval of crusts. 3. When grasped between the thumb and forefinger, superficial induration often felt, "as if a penny were laid on a soft elastic surface and grasped through a piece of cloth." Eczema of the Mamma. 1. Generally in women before the age of forty ; especially dur- ing lactation. 2. Surface not so red and raw- looking, and not granular, but often punctated. 3. Infiltrated, but no indu- ration. 52 Diseases of the Skin. 4. Edge not abrupt. Never elevated. 5. Obstinate sometimes, but yields to treatment appropriate to eczema. 4. Edge of eruption abrupt and sharply cut, and often elevated. 5. Very obstinate ; and only yields to extirpation or other treatment applicable to epitheli- oma generally. Around the navel, especially in children, eczema is not infrequent. A circumscribed area of the skin be- comes swollen and inflamed, and presents a weeping surface. The itching is usually veiy troublesome. The decomposing secretion often keeps up the irritation for a long time. Eczema of the genital region presents differences as it appears in the two sexes. Occurring upon the male organs, chronic, like acute, eczema does not always affect both penis and scrotum at the same time. Upon the penis the inflammation will generally be noticed to occupy the summits of the transverse folds of integu- ment when the organ is in the flaccid condition. To make this plain it is only necessary to seize the prepuce and draw it forward, when the folds will be smoothed out and the ridges will be seen as red lines running transversely to the organ. Along the inferior surface of the penis the skin will be more or less uniformly reddened and discharging. The mucous surfaces of the prepuce and glands are not attacked by the eczematous inflammation. Eczema of the scrotum presents itself as a red, dis- charging, raw-looking surface, from which the epidermis seems to have been stripped off. The discharge is sticky, and has an extremely unpleasant odor. Some- times the ridges of the corrugated scrotal skin are alone affected, and when this is put upon the stretch red lines are seen running across the diseased surface in various directions. In rare instances, where the disease has Eczema. 53 lasted a long while, the skin becomes greatly thickened and infiltrated, producing an appearance resembling elephantiasis. In such cases the penis is often almost or entirely hidden by the hypertrophied scrotum, which rises up and surrounds it. The itching is usually very intense, especially at night. In the female, eczema of the genitals is usualty local- ized upon the greater labia, and may spread thence to the thighs or abdomen. The mucous membrane cover- ing the lesser labia may also become inflamed. There is great swelling, puffin ess of the labia, and increased secretion from the mucous membrane, very much re- sembling, at times, an attack of gonorrhoea. The itching is very annoying. A frequent cause of eczema of the genitals is diabetes ; and it will alwa}^s be well to exam- ine the urine for sugar in cases of intractable eczema of these parts, in both sexes. Eczema of the perineum and anus is also very trou- blesome. The itching is usually intense, and the affec- tion very resistant to treatment. Fissures frequently exist, radiating outward from the anal margin, and cause intense pain at every faecal evacuation. The fis- sures discharge an abundant quantity of serum, which rapidly undergoes decomposition and increases the irri- tation of the parts. Eczema of the flexor surfaces of the joints is one of the most painful of this class of affections. The skin is greatly infiltrated, and deep fissures, extending down into the corium, run transversely across the patch, giving great pain at every movement of the joint. The eczema, when attacking the joints, is nearly always S3 7 mmetrical. Not infrequently the pain, on motion, is so great that the patient refrains from moving the joint at all, keeping it immovable in the position where it is 54 Diseases of the Skin, most favorable, and often presenting the symptoms of ankylosis. The disease, when it attacks these localities, cannot be mistaken for any other affection. Eczema of the hands and feet most frequently pre- sents the vesicular form, the vesicles preserving their walls for a considerable period. When it is chronic, the fissured condition just described is often found at the flexures of the joints. Sometimes the pain from these is so great that motion of the fingers and toes becomes practically impossible; at other times the epidermis of the palms and soles becomes greatly thickened. I have seen the epidermis, in cases of eczema of the soles of the feet, fully half an inch in thickness. Eczema of the legs is one of the most frequent local varieties of eczema. It occurs very often in connection with varicose ulcers of the lower extremities. It may appear as red, shiny patches, over which the skin is thickened and tense, or as a red, weeping surface, cov- ered with scales and crusts. The itching is usually very intense. An artificial dermatitis, which may run into eczema, is not infrequently induced in this localit} T by scratching, in patients infested with lice. In some cases of very persistent eczema of the legs the skin becomes very much thickened, hard, and even warty, and the condition known as elephantiasis is pro- duced. DIAGNOSIS. The attempt has been made to give a sufficiently exact description of the various manifestations of ec- zematous inflammation of the skin, to render any detailed remarks on its differential diagnosis unnecessary. In discussing the local varieties of the disease the cliao;- nostic features have also been pointed out. It may still be advisable, however, to recapitulate the salient symp- Eczema. 55 toms of eczema, and contrast them with the diseases most likely to create doubt as to the diagnosis. It will be remembered that, in eczema, the primary lesions are erythema, papules, vesicles, and pustules, and that usually there will also be one or more of the secondaiy lesions, or lesion relics : excoriations, scales, crusts, scabs, or fissures. As diagnostic features, must be mentioned the discharge — " weeping " — from the affected surface, and the itching, which is nearly always a symptom of the disease. It is also well to bear in mind that eczema produces no ulceration, and leaves, after disappearing, no scars. The various forms of herpes present some resem- blance to, and ma} T be mistaken for, eczema. But in herpes there is no itching. If any subjective symptom is present at all, it is either burning or pain. In herpes the vesicles are large, aggregated in groups, and not disposed to break and form crusts. In shingles the distribution and arrangement of the vesicular groups are so peculiar that no doubt can arise. That form of herpes commonly termed " fever-blis- ters" is so familiar to every one that it is not likely to be confounded with eczema. Sometimes, however, it becomes irritated, and runs into a true eczema. Another disease which sometimes presents a great similarity to eczema is the itch. In this, as in eczema, the lesions are multiform, — papules, vesicles, pustules, and excoriations being present. In itch, however, the lesions are usually separated and scattered over the entire body, except the head and face, which are gener- ally exempt. In eczema, on the other hand, the tendency is to remain localized in patches. In itch, the parasitic animal — the itch-mite — which is the cause of the disease, can also usually be discovered. 56 Diseases of the Skin, Psoriasis sometimes causes considerable difficulty in diagnosis ; but if it is remembered that in this disease the affected surface is always dry, that the scales are silvery white and seated upon a sharply-defined red base, which readily bleeds when the scales are scraped off, that it is usually localized upon the extensor sur- faces, and that the itching is less intense than in eczema, the differentiation can usually be made. In lichen, the distinctly papular, dry, umbilicated lesions, with the characteristic localization and aggre- gation, will enable one to arrive at a diagnosis. TREATMENT. The treatment of eczema is naturally divisible into internal and external. Assuming that the physician is imbued with the general therapeutic principle that all disturbances of function of internal organs should be corrected, if possible, before or coincidently with begin- ning the treatment of the skin disease, I will proceed to the consideration of the internal remedies appro- priate in the treatment of eczema. The first of these in importance and usefulness is arsenic. This remedy should not be given in acute cases, however ; but in chronic papular or scaly eczema it often acts with almost specific power. The form in which arsenic is given is of some im- portance. Fowler's solution (liquor potassii arsenitis) often produces nausea, on account- of its taste. This tendency is easily overcome by giving the medicine in a tablespoonful of sherry wine. The proper dose of Fowler's solution, to begin with, is 3 to 5 drops three times a day. It should always be taken with or imme- diately after meals. The dose should be very gradually increased until the limit of physiological tolerance is Eczema. 57 established. It is my practice to add one drop to the daily dose every third day until slight puffiness of the e} T elids or redness of the conjunctivae conies on. The dose should then be slightly diminished, and its effects on the disease noticed. It will generally be found that in scaly diseases improvement has begun even before the limit of tolerance has been reached. The medicine can be continued indefinitely without bad effects. No danger need be apprehended of " cumulative doses," arsenic being rapidly eliminated from the system. Pearson's solution (liquor sodii arseniatis) is also used sometimes, but has no advantage, so far as I know, over the preparation above mentioned. It may be given in doses of ten drops, gradually increasing until the desired effect is produced. Be Valangin's solution (liquor arsenici chloridi) is one of the best of this class of preparations. It may be made extemporaneously by dissolving one grain of arsenious acid in one fluidounce of w T ater, and adding half an ounce of dilute hydrochloric acid. This may be given in fifteen-drop doses in sweetened water after each meal. The dose can be increased by adding one drop to each dose every other day. The acid acts as a digestive tonic, which is often indicated in diseases benefited by arsenic. Arsenic may also be administered in the form of pills. The pilulse Asiatics^ have long been esteemed as an efficient preparation in psoriasis. They consist of arsenious acid and black pepper. Formula 27, sug- gested by Duhring, ma} T be used. The remedy next in value and importance to arsenic is iron. It is often of use in the acute form of the disease, the best preparation in these cases being the tincture of the chloride. In pustular eczemas, 3* 58 Diseases of the Skin. syrup of the iodide is often of great value. Of the most unqualified value is codliver-oil. In so-called " strumous " children, where there is much formation of pus on the eczematous patch, the lymphatic glands enlarged, the skin dry and harsh, codliver-oil may be prescribed with the confident expectation of great improvement in the patient's condition. Eczema has often seemed to me to be connected with the excessive consumption of tea, especially if too little nutritious food was taken. In such cases milk should be substituted for the tea, and endeavors made to induce the patient to increase the quantity of beef, eggs, and similar articles of food. Fresh air and exercise are important adjuvants to any plan of treat- ment. In many cases of eczema a sharp purge is often of value as initiatory to the treatment. A full dose of sul- phate of magnesia or calomel will often be useful. In other cases, the daily administration of a small dose (5j) [4.] of sulphate of magnesia, either combined with sulphate of iron (gr. ij) [.12] or quinine (gr. i to ij) [.06 to .12], will aid the cure. I often prescribe a com- bination of sulphate of magnesia and tincture of chlo- ride of iron (Formula 28). Calomel in i to \ gr. [.01 to .03] doses three times a daj T for 3 to 4 days is often of value. I very often prescribe the smaller dose in acute eczemas of children. An excellent tonic prescription is one containing iron and phosphoric acid (Formula 29). Acetate of potassium combined with fluid extract of taraxacum, according to Formula 30, will often greatly aid local measures in cases of acute eczema. Local Treatment. — Of far more importance than the internal medication is the local or topical treatment of Eczema. 59 eczema. The " management," as Dr. Bulkley happily styles it, of a case of acute eczema will often draw upon all the resources of the physician's art. It is not only requisite that he shall know what remedies to use, but he must know how to apply them and what effects to expect. It is often of more importance to know what not to do than to have a large formulary at com- mand and use it with indiscretion. In acute eczema, whether general or localized, almost any application ma}^ act as an irritant. The applica- tion of simple water may often act injuriously. Sooth- ing measures must be exclusively emplo3 T ed. Among these the use of dusting-powders may be first men- tioned. Combinations of oxide of zinc, starch, precipi- tated chalk, lycopodium, or some similar article will be useful. If the itching is very severe, black-wash, bicar- bonate of sodium (gr. v~x to %)) [1 to 30-50], carbolic acid (gr. i-iij to §j) [1 to 200], or simply lime-water will give great relief. A lotion containing atropine (gr. j to 3j) [1 to 500] will promptly relieve the itching, but is too dangerous for use, except over small surfaces. Starch or bran-baths occasionally give great comfort, but it is better to defer their use in acute general eczema until the intensity of the inflammation has somewhat subsided. After the bath the eczematous surfaces should be dusted with one of the powders above men- tioned, or some bland, fatty preparation (vaseline, sweet almond-oil, lanolin) may be applied. Under this treat- ment, with careful attention to the general condition of the patient, the disease usually quickly disappears. In other cases, however, the morbid process persists, and the disease becomes chronic. Here the treatment must be different. If the infiltration is not very great, some fatt} T application will be most useful. 60 Diseases of the Skin. The most valuable will be Hebra's ointment (For- mulae 6, 7), Lassar's paste (Formula 3), oxide-of-zinc ointment, vaseline with or without i to 1 drachm of calomel to the ounce (1 to 4-8). If the infiltration is considerable, these simple applications will not suffice. Remedies must be used which will hasten the exfoliation of the thickened epidermis and promote the absorption of the infiltration in the true skin. These remedies are: mercurial ointment, calomel, ammoniated mercury, subnitrate of bismuth, tar, car- bolic acid, and sometimes chiysarobin or pvrogallic ^ acid. These may be used either in the form of Ointment or lotion, the former in most cases giving the best results. Methods of use are quite as important as a thor- ough knowledge of the medicament to be emplo3 T ed. Hence, it will be advisable to take up the treatment of the various local forms of eczema seriatim. In most cases of eczema, but especially in eczema of the scalp, the first point to be attended to is the re- moval of the crusts. This is accomplished by covering the effected surface thickly with fresh lard, olive-oil or almond-oil, and putting on a flannel cap. After ten to twelve hours this application is to be repeated, if neces- sary, and when the crusts and scabs have been loosened the} T are washed off with warm water and soap. Castile soap answers best for this purpose. The soap must then be thoroughly washed out with clean water and the scalp dried with a soft towel. The diseased surface is now ready for the application of an ointment. One of the best is the white precipitate ointment of various strengths (9j-5U to §j) [1 to 4-20], depending upon the amount of infiltration present. The red and yellow oxides of mercury (gr. iii-x to §j) [1 to 50-150] or calo- Eczema. 61 mel (5ss-j to 5j) [1 to 4-8] may also be used. Tar may often be used with great advantage in eczema of the scalp. Its offensiveness can usually be modified by combining it with cold-cream, using the birch-tree tar by preference. Formula 32 is a useful combination. Sulphur alone or combined with salicylic acid is also of value in some cases of seal}' eczema of the scalp, and in seborrheal eczema. Resorcin in 2- to 4-per-cent. ointment often acts very happily. When eczema of the scalp is due to the presence of lice, or if these parasites are present, the part affected should be first saturated with petroleum, which promptly kills the lice, as well as their ova, or " nits," as they are called. It is unnecessary to cut the hair short in treat- ing eczema of the scalp. Eczema of the hairy parts of the face is often very persistent. The first indication, after removal of the crusts, is daily shaving, after which an ointment of yellow oxide of mercury, or of white precipitate, or one composed of equal parts of mercurial ointment and simple cerate, kept constantly applied, will bring about a cure. If these are too irritant, Hebra's oxide-of-zinc or oleate-of-zinc ointments may be tried. I have had excellent success with the last named. The face is sometimes the seat of an erythematous or erythemato-squamous eczema which itches intensely, and is often very difficult to cure. A lotion containing oxide of zinc frequently gives the best results. Formula 33 is a good combination. This is a much more agreeable application than an ointment, and often gives excellent results. An ointment containing yellow oxide of mercury and starch (Formula 34) is also very useful. The hair-bulbs of the eyelashes and of the hairs on 62 Diseases of the Skin. the mucous surface of the nostrils — the vibrissae — are sometimes the seat of a very persistent eczematous in- flammation. In these cases codliver-oil is generally indicated. Locally, epilation, followed by the application of } r ellow oxide-of-mercury ointment (gr. x to gj) [1 to 50], or painting the diseased parts with a strong solution of nitrate of silver (5*-ij to §j) [1 to 4-8] will often promote the cure. Dilute citrine ointment ( 3 i— U to §j) [1 to 4-8] is also a good application. Fissured eczema of the lips is a very trouble- some affection* It is usually very persistent. When it lasts a long time the lips sometimes become thickened and ectropic. Solution of nitrate of silver (5j to §j) [1 to 8] or caustic potassa (3ss to §j) [1 to 15] followed by a stiff cerate, " lip salve," containing 1 drachm of calomel to the ounce [1 to 8] will in most cases produce a prompt cure. Chronic eczema of the palms of the hands and soles of the feet generally yields promptly to appropriate treatment. If the epidermis is very much thickened it may be first softened by soaking in hot water rendered alkaline with carbonate of soda, or friction with Hebra's soap-tincture (Formula ID), and then ail ointment made of equal parts of mercurial and Hebra's ointments con- tinuous^ applied. The cure is sometimes very rapid, the infiltration and fissured condition of the skin disap- pearing as if by magic. Other local measures will rarel} T be needed. Eczema of the dorsal and lateral surfaces of the fingers is, however, very troublesome. It often attacks laundresses, cooks, seamstresses, and grocers, the nature of whose occupations prevents the continuous applica- tion of a remedy. The itching is usually intense.. It often requires applications of solution of caustic potassa Eczema. 63 (3j to 5j) [1 to 8], followed Ivy Hebra's ointment, or ammoniated mercury ointment. India-rubber gloves or " finger-stalls " are often of great service in the treatment of these chronic eczemas of the hand and fingers. They act by confining the moisture, and thus macerating and softening the dis- eased epidermis. Eczema of the joints is a very painful affection. The diseased skin is divided into little squares or lozenge- shaped spaces by fissures of greater or less depth, running in various directions. Every motion of the joint causes intense pain. It is often found in the popliteal region, and from its painfulness may interfere with locomotion. Hebra's ointment alone, or combined, when there is much infiltration, with equal parts of mercurial oint- ment, will generally cause the disease to yield. Appli- cations of the nitrate-of-silver or canstic-potassa solu- tions are sometimes necessaiy, however. Eczema of the legs is often dependent upon a varicose condition of the veins of the part. In these cases proper support must be given to the dilated vessels before much good can be accomplished by applications directly addressed to the disease. If the case is very chronic and there is much infiltration of the skin, painting with the potassa solution (3ss-j to |j) [1 to 8-15] or fric- tion with Hebra's tincture of soap, or Bulkle} 7 's liquor picis alkalinus (Formula 35) should be used. This should precede the application of Hebra's oint- ment, carbolic-acid ointment, or ointment of ammoniated mercury, carbonate of lead, oleate of zinc, or oxide of zinc. The ointment must be kept on by a well-applied flannel roller-bandage (made of " Domette " flannel). After the cure is complete, an elastic stocking should be worn to give the superficial veins proper support. 64 Diseases of the Skin. In eczema of the legs, the rubber bandage is often applied, but, unless there is considerable infiltration of the skin, it may do more mischief than good. The cases in which the rubber bandage is applicable must be carefully selected. Chronic eczema of the scrotum often tests severely the endurance of the patient and the therapeutic re- sources of the practitioner. In some cases the eruption will rapidly disappear under a simple calomel ointment. In others, a tar ointment or a dilute solution of liquor picis alkalinus will have the desired effect. These are the cases which John Hunter must have had in mind when he said that skin diseases may be divided into three classes': those that sulphur will cure, those that mercury will cure, and those the devil himself cannot cure. The experience of most practitioners will prob- ably place chronic eczema of the scrotum in the last- mentioned class. Unless there is considerable infiltration of the skin, only mild applications, such as oxide of zinc, oxide of mere my, or Hebra's ointments, should be used. The itching yields better if a little tar or carbolic acid is added to the ointment. In some cases, where there is little thickening and redness, and only slight scaling, a weak sulphur and salicylic-acid ointment will prove suc- cessful. In obstinate cases the possibility of diabetes should be borne in mind and the urine carefully ex- amined for the presence of sugar. A variefcj 7 of eczema which attacks the scrotum, perineum, and insides of the thighs, with a moist or scaly surface and a well-defined border, is not rarely seen. This is really a parasitic affection, and requires parasiticide treatment. This disease is often very obstinate, and many reme- Eczema. 65 dies may be used in turn with little or no good effect. The application of strong sulphurous acid once a day, as recommended by Bulkley, or of a solution of bichlo- ride of mercury in tincture of myrrh, as recently advised by R. W. Taylor, will generally give good results. I have used, instead of the tincture of myrrh, the com- pound tincture of benzoin (Formula 36), which is, I think, better than the former. Eczema of the nipple often yields quickly to an ap- plication of simple cerate containing one drachm of calo- mel to the ounce [4„to 30.]. In more obstinate cases the nipple may be painted with a pigment composed of one drachm [4.] of oil of cade to one ounce [30.] of collodion or liquor gutta-percha. This is also a useful application in fissured eczemas of the lips. Salol dissolved in ether and collodion (Formula 3T) is also recommended in eczema and fissure of the nipple. • C 2 INFLAMMATIONS OF THE SKIN The class of inflammations of the skin includes a number of affections which cannot be strictly termed inflammatory, but which are so near, and sometimes even overlap the border-line, that they cannot well be excluded. These affections are the erythemas, urticaria, and some of the drug eruptions. The exanthemata are not skin diseases proper, but specific fevers with local cutaneous manifestations. They rarely come under the notice of the dermatologist, except in cases of doubtful diagnosis, and the cutaneous lesion scarcely ever calls for local treatment. They will not receive notice in this work, therefore, be\ond point- ing out the differential diagnosis where necessary. In classifying the erythemata and urticaria with the inflammatory diseases, I am in accord with the expressed judgment of the representative body of American der- matologists. ERYTHEMA. Erythema is a redness of the skin due to excess of blood in the part. It may be transitory or lasting. The hyperemia ma} 7 be active or passive. In the former the skin is usually bright red in color, and the temper- ature slightly elevated. Sometimes there is also slight swelling, indicating exudation of serum, and, perhaps, cell-proliferation ; in other words, inflammation. In passive hyperemia the color is of a deeper red, brown- ish or bluish, and there is no local elevation of temper- ature. There ma} 7 at times be slight haemorrhages into the dermal tissues. (66) Inflammations of the Skin. 67 The erythemas are clinically divided into the con- gestive and exudative. In the former the redness is due merely to a temporary accumulation of blood in the part. Jn the other forms the redness is more perma- nent and accompanied by exudation and local altera- tions of nutrition. These are the exudative erythemas, and constitute the transition forms to the inflammations proper. Congestive erythemas may either be idiopathic or symptomatic. The idiopathic forms are all produced either by traumatism, heat, or irritants acting on the skin. Thus, we have a redness of the skin from con- tinned pressure upon any part, as, for example, under belts, girdles, garters, or upon the tubera ischii after sitting for a length of time. A semicircle of redness is frequently seen upon the forehead from a tight hat-band. Moderate chafing also exhibits an example of traumatic erythema; when it becomes more severe, it is apt to run into eczema. Light degrees of sunburn give examples of the erythema produced by heat. A class of remedies termed rubefacients in works upon therapeutics give rise to the erythema from irri- tants. The ingestion of certain drugs also frequently causes an erythematous eruption. A more important group of hyperemias (congestive erythema) is that of the symptomatic. It is a common observation that many febrile, and also non-febrile, dis- eases are accompanied at times by circumscribed red- ness of the skin. Typhus and t3 r phoid fever, rheumatism, small-pox, and vaccinia may be accompanied by an eruption of rose-colored spots. The} r are important in a diagnostic point of view. In many of the diseases of children, especially disorders of the digestive organs, fugitive 68 Diseases of the Skin. hyperemias may be observed. At times they may bear considerable resemblance to an eruption of measles or scarlatina. In small-pox epidemics a peculiar hj^peraemia is sometimes observed, occurring contemporaneously with the primary fever, i.e., two or three days before the appearance of the eruption. This is, consequently, of considerable importance as a diagnostic point. An eiythematous efflorescence appears upon the abdomen and upper part of the thighs, having the form, when the thighs are adducted, of a truncated pja-amid with the base upward ; the hyperemia is bounded by an im- aginary transverse line at the height of the umbilicus and another about two inches above the knees, and con- necting the extremities of these lines by two others, running parallel with the loins. The operation of vaccination — or, more properly, the vaccine disease — is sometimes accompanied by an eruption of rose-colored spots, — the so-called roseola vaccina ; it is of no importance, and requires no treat- ment. Exceptionally, however, it runs into a derma- titis (erysipelas), and may then become a serious complication. The treatment of simple erythema is merely symptom- atic. An evaporating and cooling lotion, as cologne- water, or a lotion of bicarbonate of sodium, half an ounce to the pint of cool water (1 to 32) will be all that is required. When the hyperemia approaches the in- flammatory stage, as in erythema intertrigo (chafing), the following measures will give satisfactory results : The parts should be kept clean and as dry as practi- cable. Portions of the skin ordinarily in contact and rubbing against each other, as in the perineal region, between the buttocks, in the axillae, under pendulous Inflammations of the Skin. 69 mamniffi, etc., should be kept separated by pledgets of lint, dusted with oxide of zinc or precipitated chalk. Where the redness is intense, and there is much heat or tingling, black-wash, applied on soft cloths and fre- quently renewed, is an admirable application. Formula 38 will often prove useful. All the exudative erythemas may conveniently be grouped together under the collective title erythema multiforme. The sub-varieties are the papular, bullous, and nodose forms. A large number of intermediate forms have been described, but they are so manifestly merely stages of the affection that they will not be de- scribed as separate diseases. Erythema multiforme is characterized by its location, which is almost always on the backs of the hands and feet, extending in some cases up the arms and legs, and even in rare instances invading the entire bod} r . The latter is especially liable to occur in the course of rheumatism, diphtheria, and other febrile diseases. The papular form of erythema multiforme is the most frequent. The papules are small, dark red, sometimes shading into brown, and flattened. In a few days, usu- ally, the reddish color gives place to varying shades of brownish, greenish, bluish, even black, these depending upon the exit of the coloring matter of the blood during the height of the process. The eruption is frequently the source of much alarm, but in itself has no signifi- cance. The papules are usually interspersed with ery- thematous spots, rings, gyrating lines (where two or more rings have run into each other), tubercles, and sometimes vesicles or large blebs. These sometimes simulate an eruption of pemphigus (q. v.). The nodose form of erythema multiforme consists of circumscribed swellings of various sizes, from a bean 70 Diseases of the Skin. to a lien's egg, or larger, mostly situated upon the ante- rior surface of the leg, but also upon the face and other portions of the body. They are at first red in color, but afterward become bluish, greenish, or purplish, resembling very closely a bruise. They are painful and sore to the touch. They never suppurate. Sometimes the swellings closely simulate syphilitic gummata. but they never break down, as these latter formations do. The treatment is simple. Pain or burning may be relieved by a cooling lotion. In the generalized forms of erythema multiforme the patient should always be carefully examined in order to determine whether the eruption is symptomatic of grave internal diseases. It has been observed in connection with rheumatism, with cardiac complications, pneumonia, diphtheria, and Brigkt's disease. URTICARIA. Nettle-rash is an acute eruption accompanied by tingling, burning, and itching. The typical form of this eruption is a broad, flat, slightly elevated papule, with a bright-red border and a whitish or lighter red centre. This lesion is termed a wheal, and is the characteristic feature of the affection. The wheal is, however, not the only form in which the eruption of urticaria manifests itself, as the efflorescence may be composed in great part, or entirely, of small papules, linear elevations, or considerable tuberosities. from the size of a hazel-nut to a lien's egg. The size of the lesions clearly depends simply upon the amount of exudation and. perhaps, upon a greater or less predisposition in the skin to irritative action of this character. The eruption generally begins with great suddenness, is sometimes accompanied with febrile symptoms, and frequently disappears as suddenly as it Infla m malions of th e Skin. 7 1 came. Itching and burning are characteristic S3^mptoms of the eruption. Sometimes the top of one or more of the wheals is occupied by a vesicle. This simply de- pends upon the increased effusion of serum, and, beyond slightly changing the appearance of the eruption, has no significance. In rare cases, especially in delicate, irritable skins, pigmented spots, yellowish, greenish, or brownish in color, ma} T remain for some time to mark the sites of the eruption. Anatomically, the wheal consists of an exudation of serum into the Malpighian layer of the epidermis and the upper layers of the corium, with a limited annular hyperemia due to a dilatation of the smaller vessels in the marginal zone of the wheal. The causes of urticaria are both external and in- ternal. In addition to the irritating influence of plants of the nettle family, and which has given to the affec- tion one of its popular names, nettle-rash, the external, direct, or traumatic causes of urticaria are : the bites of the various insects, — lice, mosquitoes, fleas, bed-bugs, — contact with larvae of various species of lepidoptera, and in some cases scratching or friction of the skin. It is, however, only in persons with a peculiar irrita- ble condition of the skin that urticaria of any great extent follows these influences. In such cases a single flea-bite may give rise to the most intense pruritus and general urticaria. In children it is frequently caused by the irritation of the bites of lice or bed-bugs. In these instances, remedies which do not comprise removal of the cause have no effect on the duration of the affection. The most frequent causes of urticaria are internal or indirect, the eruption on the skin being probably a reflex effect of an irritation of some internal organ. In by 72 Diseases of the Skin. far the majority of instances it is due to irritation of the stomach or other portion of the intestinal canal. The ingestion of certain articles of food, especially shell-fish, pork, cheese, strawberries, and raspberries, or the administration of various medicinal agents, especially terebinthinate remedies, produce in certain predisposed individuals an abundant outbreak of urticaria. The eruption is frequently accompanied by symptoms of decided gastro-intestinal irritation, as vomiting and purging, sometimes choleriform in character. Not in- frequently catarrhal jaundice is present in these cases, and seems to intensify the pruritus, probably by a direct irritation of the cutaneous nerves, due to the circulation of biliary matter in the blood. Very often the urticaria can be ascribed only to a peculiar id ios}^^!^^ with reference to the articles of food causing the eruption, while at other times d}'Spep- sia, or, rather, gastric irritability, seems to be present. In these cases the individual is compelled to limit him- self to a very short diet-list, any deviation from which is sure to brino- on an attack of acute indigestion and urticaria. This latter is especially liable to be the case in the frequently-recurring, almost chronic urticaria, so often seen in young children. In persons suffering from the gastric irritability here referred to an eruption of little, pinkish, intensely itch- ing papules frequently occurs, accompanying attacks of acute indigestion. This papular eruption is primarily nothing more than an urticaria, but in consequence of the continual scratching which it induces eczema results secondarily. The primary eruption is frequentty not recognized, and hence the eczema is too often believed to be caused by the gastric derangement, leading to its irrational treatment. Inflammations of the Skin. 73 If, in consequence of the administration of an alkali, or a small dose of calomel, the urticaria ceases, its cause being removed, the eczema generally gets well without further treatment, unless it has become chronic, when proper local measures should be instituted. A number of functional or organic disorders of the female sexual apparatus are sometimes complicated by chronic urticaria, but as these troubles are usually accompanied by gastric derangement, the latter may, in most of the cases, be the exciting cause of the eruption. Mr. Lawson Tait has recently reported a number of cases in which urticaria came on after abdominal sec- tion. Hebra first called attention to the frequent asso- ciation of urticaria with uterine disorders. Scanzoni has likewise pointed out this coincidence. In malarial regions intermittent urticaria, with or without febrile symptoms, is sometimes seen. Emo- tional disturbances, such as fright, anger, or great sorrow, appear not infrequently to stand in a causative relation to urticaria. Moreover, many well-defined ner- vous disorders are complicated with the same affection. It must also be confessed that cases occur for which no cause can be discovered. The prognosis, so far as life is concerned, is favor- able. If the cause of the disease can be discovered and removed, it usually requires no further treatment. Yevy often, however, it becomes chronic and persistent, either from non-recognition of the cause or because the latter cannot be removed. The diagnosis is easy. Remembering the charac- teristic lesion of urticaria, and the subjective sensations of itching or burning always present, no mistake is liable to occur in differentiating this from other cutane- 4 D 74 Diseases of the Skin. ous diseases. To discover the cause is, however, as has been before pointed out, often most difficult and unsat- isfactory. The pathology of urticaria is one of those unsettled problems which abound not only in dermatolog3 T , but also in other special fields of medicine. Chemical exam- inations of the urine have shown that there is frequently a deficient elimination of urea and uric acid in cases of urticaria. It has been supposed by some that the reten- tion of these excretoiy matters in the blood produces an irritating effect upon the peripheral nerves in the skin, and so gives rise to the development of the char- acteristic eruption. It has also been supposed that a similar irritation may be produced in consequence of the resorption of some products of decomposition in the alimentary canal. While both these theories ma}^ be to a certain very limited degree true, they explain but few of the cases. The nature of urticaria has long been held to be neuropathic, but only the most recent discoveries in the ph} T siology of the nervous system have furnished some sound and reasonable basis upon which to build a safe and satisfactory theory. Without going into the history of the researches upon the vaso-motor nerves, it will suffice to say that it is now pretty generally admitted that there are two sorts of vaso-motor nerves, antagonistic to each other in their effects upon the vessels, — the vaso-constrictors and vaso-dilators ; that these nerves originate in ganglia situated in the spinal cord and medulla oblongata, and that the\ r leave the cord by the posterior nerve-roots. This important disco very contradicts Bell's law, that onl}^ afferent nerves are contained in the posterior nerve-roots, and demonstrates that these roots also con- Inflammations of the Skin. 75 tain efferent nerves. Whether the vaso-motor nerves are really sensitive nerve-fibres, or whether these bun- dles contain an independent set of vasal nerves, is not yet known. „ It has been further demonstrated that a reflex eon- traction or dilatation of the small blood-vessels is possible, and, furthermore, that certain systems of ves- sels act in a manner antagonistic to each other. This antagonism has been particularly studied in relation to the vessels of the skin and of the abdominal viscera. It has been found, namely, that when the constrictors control the abdominal vessels, the dilators act upon the vessels of the skin. 1 The latter is not to be ascribed to a passive dilatation in consequence of the increased blood-pressure, a complementary dilatation, so to speak, but active and due to a stimulant effect, possibly reflex, upon the vaso-dilators of the skin. The circumstance pointed out by Strieker, and be- fore referred to, that irritation of sensitive nerve-fibres causes dilatation of vessels, seems to point to a solution, namel} 7 , that certain sensitive nerve-fibres possess, in addition, the function of vaso-motors. The action of the vaso-dilators cannot always be due to reflex impres- sions, because the effect is produced upon a very limited section of the skin, and in other cases is produced at the site of the irritation. Examples of this are seen in the circumscribed production of urticaria in consequence of contact with nettles, bites of insects, etc. ; but I can- not doubt that general urticaria, the accompaniment of gastric irritability, is due to a reflected impression upon the vaso-motor centres themselves. 1 Strieker (Allg. Pathologie, p. 216) says: "There is reason to believe that in the nervous centres the constrictors for the vessels of the abdom- inal viscera and the dilators for those of the skin are more easily excited than their antagonists." *T6 Diseases of the Skin. Treatment. — Notwithstanding the frequency of urti- caria, the therapeutics of the affection are in a very unsatisfactory state. When the eruption is the result of irritating ingesta in the stomach or intestinal canal, an emetic or brisk purge will in most cases promptly relieve the affection. As an emetic, I decidedly prefer the sulphate of zinc (20 grains [1.3] in water), or fluid extract of ipecac given in a little syrup. Except in young children, however, such acute cases do not very often come into the hands of the practitioner, and almost never into those of the specialist. When, however, the disease has become chronic, or is very frequently recurring, it gives a great deal of annoyance both to the patient and physician. The cause must be sought out and removed, if possible. It is frequently necessary to go over the patient's func- tions, one by one, to rigidly revise the diet-list, regulate the bowels, stimulate the action of the liver, if this seems necessary. The urine should be examined, and any abnormality of this secretion corrected, if possible. The saline laxatives and diuretics will find frequent application in these conditions. In cases where the eruption shows a regular periodicity in its recurrence, full doses of quinine sometimes have a prompt effect, and, if it fails, arsenic may be tried and sometimes found successful. Recently, several of the later remedies have been tried and reported favorably. Thus 20-grain doses [1.3] of salicylate of sodium three times a day have been followed by prompt cure in a number of cases of more or less persistent urticaria. My own experience with this remedy is favorable. Schwimmer reports suc- cess in similar cases with ^-grain [.001] doses of atro- pine sulphate. Still more recently, Pick has reported Inflammations of the Skin. 77 brilliant results with pilocarpine. The eruption disap- pears as soon as the . effect of the remedy upon the sweat glands becomes apparent. It may be used hypo- dermatically in doses of | grain [.01], or half-drachm [2.] doses of fluid extract of jaborandi may be given. It promises to be worthy of trial. Some years ago I treated, experimentally, several troublesome chronic cases with drop doses of balsam of copaiba, which I had seen recommended in some journal. My success with this remedjr was not uniform, however, and I should be disposed to give the jaborandi or salicylate of sodium the preference. The local treatment is sometimes a matter of importance. Any spirituous lotion, sol. car- bolic acid 1 to 2 per cent., or black-wash may be used. I have found the least disagreeable antipruritic lotion to be one consisting of 1 drachm of benzoic acid to a pint of water [1 to 130]. SIMPLE INFLAMMATIONS OF THE SKIN. The inflammatory diseases included under this title are divided into such as are due to the influence of mechanical violence (dermatitis traumatical), from chemical irritants (dermatitis venenata), from extremes of temperature (dermatitis calorica), from the inges- tion of certain drugs (dermatitis medicamentosa) , and those due to some profound neurotic or vascular dis- turbance (dermatitis gangrenosa). Traumatic dermatitis is due to local mechanical injury. It includes inflammations from excoriations, bites and stings of insects, bruises, lacerated wounds, or prolonged pressure on a part. The treatment consists primarily in removal of the cause, if still acting, and the application of such meas- ures as will reduce the inflammation. Cold water, astrin- 78 Diseases of the Skin. gent lotions, and, if the deeper structures have been exposed, antiseptic dressings may be used. Dermatitis from chemical irritants locally applied is not infrequent. Cantharides, croton-oil, tartar emetic, mercurial compounds, turpentine, arnica, mustard, petroleum, poison-ivy, poison-sumach, strong acids and alkalies, acrid secretions or discharges from wounds or ulcers may all cause dermatitis of varying degrees of intensity. All the different lesions characteristic of inflammation of the skin may be present. The dermatitis from poison-vine or poison-sumach is relatively frequent in the spring and autumn. Contact with these plants produces an intense inflammation characterized by redness, great swelling, burning, and itching. There is usually an abundant eruption of vesi- cles, which break and pour out a profuse, sticky, serous secretion. The hands, face, and genital organs are most frequently affected. The diagnosis is usually easv, eiysipelas and acute eczema being the only diseases that can be mistaken for it. In the former there is absence of itching and vesiculation, and the fever is usually high. In acute eczema the outbreak is usually rarely so violent, except in young children, in whom the action of the poison can generally be excluded. Eczema also has usually a different localization from the poison-vine eruption, being rarely limited to the same portions of the surface as the latter. There is a popular tradition that when an individual once suffers from a poison-vine eruption it will return annually for seven years, without renewed exposure. This is an error. Most people w T ho suffer from the eruption every 3^ear contract the same after being again exposed to the cause. Inflammations of the Skin. 79 The treatment must be directed to subduing the inflammation and relieving the subjective symptoms. In the poison-vine eruption, lotions of sulphate of zinc (3ss to water Oj) [1 to 250], or of bicarbonate of soda (3j to Oj) [1 to 16], or black wash generally give prompt relief The first named is said by Hardaway to be almost a specific. Van Harlingen recommends fluid ex- tract of grindelia robusta (5U to water §j) [1 to 4], Tincture of lobelia with an alkali (Formula 39) is also highly recommended. All of these lotions are to be applied to the affected surface on cloths kept constantly wet with the prepara- tion. Diving-powders, such as prepared chalk, starch, or orris-root, may also be sometimes used to advantage. The inflammation due to arnica or any of the other articles mentioned above generally jields quickly to mild astringent lotions or ointments (oxide-of-zinc oint- ment, Hebra's ointment) or dusting-powders of starch containing camphor, oxide of zinc, or calamine. Dermatitis from extremes of temperature includes both inflammations from excessive heat (burns) and from extreme cold (frost-bite). Burins are usually divided, according to the intensity of the acting cause, into three degrees. In the first there is redness, some pain and swelling. In the second degree vesicles or blebs form upon the inflamed skin, accompanied usually try severe pain. In the third degree, necrosis of tissue to a varying depth occurs. If the burn is very severe or of great extent, there is usually great depression of sj^stem and the patient may die of shock. In other severe cases the patient survives the shock, but succumbs to exhaustion, septic absorption, embolism, or pneumonia. The prognosis in all severe grades of burns is grave. 80 Diseases of the Skin. The treatment of burns of the first degree consists simply in relieving the pain. For this purpose nothing is superior to a lotion of bicarbonate of soda, applied on soft cloths which are kept constantly saturated. The same application is useful in burns of the second degree. The blisters should be punctured, and the de- nuded epidermis protected by absorbent cotton or lint. Dusting-powders of starch, carbolized oil, or a paste of carbolic acid, vaseline, and prepared chalk will be of value. In the profound burns of the third degree, the re- moval of the necrotic masses should be promoted by poultices or warm-water dressings rendered aseptic with carbolic acid, or solution of sodium hypochlorite. The denuded surfaces should then be dusted with iodoform or dressed with boracic or carbolic-acid ointment. Care should be taken to prevent the formation of contractile or hypertrophic scars. Frost-bite. — Like burns, frost-bites also manifest themselves in different degrees. The first degree, or erythematous frost-bite, is popularly known as chilblain. The parts most frequently attacked by chilblains are the toes and fingers. The nose and ears are also sometimes affected. The affected spots are bluish-red, slightly swollen, sometimes painful, but most frequently annoy by their persistent burning and itching. They often return in successive winters. Sometimes the epidermis is destroyed by rubbing or scratching and a superficial, painful ulcer remains. In the second stage of frost-bite, blebs with serous or bloody contents form, under which a deep ulcer is often found. The healing of this generally takes place very slowly. In the third stage, deep sloughs take place, which Inflammations of the Skin. 81 usually require amputation of the affected extremity. If the necrotic masses are not removed by the surgeon, septic absorption is liable to occur, and the patient dies of septicaemia or p} T 8emia. The treatment of acute frost-bite — that is, during the action of the cold — usually consists in rubbing the frozen part with snow or coldw T ater until the circulation is re-established. In the author's opinion, however, it would be more appropriate to immerse the frozen part in hot water in order to restore promptly the circulation of blood. Afterward, astringent lotions of acetate of lead, sulphate of zinc, or alum may be used. In chilblains, collodion painted on the spot is fre- quently of service. A dilute solution of nitric acid (§ij to Oj) [1 to 8] is also recommended. A camphor- ated paste (Formula 40) may also be used. A mixture of equal parts of ichtliyol and oil of tur- pentine, painted on with a camel's hair brush, is highly recommended by a recent German writer. In the second stage the sloughing bases of the blebs should be touched with a strong solution of nitrate of silver (5j to §j) [1 to 8] and afterward dusted with iodoform or powdered boracic acid. In the third stage, if amputation is not required, or is impracticable, the surface after removal of the slough must be dressed on antiseptic principles. Dermatitis from the ingestion of certain drugs is rather more frequent than is generally supposed. A considerable number of medicines in daily use produce in some persons inflammatory eruptions which are often puzzling to the physician as well as annoying to the patient. With regard to most of these drugs, only a compara- tively small proportion of individuals who take them 4* 82 Diseases of the Skin. are attacked. The reason for the susceptibility on the one hand and the immunity on the other is not known. The following is a brief abstract of the cutaneous manifestations which have been noted after the adminis- tration of the drugs mentioned : — Erythematous eruptions have been noticed after taking belladonna, hyoscyamus, stramonium, nitrite of amyl, chloroform, arsenic, quinine, opium, turpentine, cubebs, copaiba, antipyrin, and benzoate of sodium. Urticaria has been observed after taking copaiba, quinine, opium, chloral hydrate, carbolic acid, arsenic, bromide of potassium, salicylic acid, and antipyrin. The urticarial and erythematous eruptions are fre- quently combined in the same case. Polymorphous erythema has occurred after arsenic, quinine, digitalis, copaiba, and bromide of potassium. Vesicular and bullous eruptions sometimes follow the administration of arsenic (herpes zoster), cannabis Indica, iodide and bromide of potassium, quinine, sali- cylate of sodium, phosphoric acid. Pustular and phlegmonous eruptions (pustules, boils, abscesses, diffuse phlegmons, erysipelatous inflamma- tion) have been observed after taking iodide and bromide of potassium, arsenic, quinine, hyosc} 7 amus, opium, chloral hydrate, digitalis, iodide of mercury, calomel, and pilocarpine. Purpura has been noted after iodide of potassium, salicylic acid, quinine, chloral hydrate, and camphor. The diagnosis of drug eruptions may cause some difficulty. The eruption from quinine sometimes pre- sents a very marked resemblance to scarlet fever, at others to acute general eczema, and at still others to erysipelas. The first and last can generally be excluded by the absence of other symptoms, such as the high Inflammations of the Skin. 83 temperature, pro.dromic fever, and sore throat in scarlet fever, and the burning pain and fever in erysipelas. The searlatiuiform quinine eruption sometimes begins with a decided chill, followed by high temperature and other symptoms of intense fever. The desquamation may present all the features usually considered characteristic of scarlet fever. The treatment of the drug-eruptions consists in stop- ping the administration of the drugs causing them and meeting special indications as they arise. Gangrenous dermatitis is a rare affection in which gangrenous patches appear upon different parts of the body, usually symmetrically. The patches are most frequent upon the fingers, but may occur on any part of the body. In a case observed by the author the affection w T as limited to the hands. The disease has been described under various names, such as local asph} T xia of tissues, symmetrical gangrene, and Ray- naud's disease. The causes are unknown. Most of the cases heretofore reported were in females, and some authorities believe that the sloughs were artificially produced. It is a well-known fact that sloughing patches have frequently been produced by the appli- cation of caustics for the purpose of malingering. In some diseases of the central nervous system acute bed-sores occur. They are probably results of vaso-motor disturbances. In cases where injury to the main nerve-trunk of a limb has occurred, gangrenous patches are sometimes observed in the area of distribu- tion of the injured nerve. Gangrenous dermatitis, lim- ited to the point of inoculation, is not rarety observed after vaccination, especially w 7 ith animal virus. Electricity and stimulant applications are indicated, but little good can be promised from these measures. 84 Diseases of the Skin. ERYSIPELAS. It is probable that erysipelas is in all cases due to the inoculation of a specific virus. There is not suf- ficient evidence that it can develop out of a simple inflammation without the presence of its specific cause. In nearly every case a careful search will discover some pre-existing lesion where the inoculation may have taken place. The face, scalp, and extremities are the most frequent seats of ei*3 T sipelas. In young infants a veiy fatal form is also liable to begin in the umbilicus. The symptoms of erysipelas are : high fever, — the temperature frequently reaching 104° to 105° F. (40° to 40.5° C), — headache, coated tongue, nausea and vomiting, and in severe cases, or in nervous individuals, mental disturbance (delirium). The skin becomes painful, red, swollen, and shiny. If the case is mild these symptoms disappear in a day or two, and the normal condition of the skin and the general system is re-established. In severer cases the fever continues, the inflammatory area extends progres- sively, the skin becomes boggy, and vesicles or blebs ap- pear upon the inflamed patch. The latter may burst and thick crusts form by the drying of the effused fluid. Local patches of gangrene may occur. In the face, the deformity produced by the swelling is often very great. The effusion into the loose connective tissue of the eye- lids is often so extensive as to completely close the e}^es. The ears become thickened, tense, shin} r , and stand out prominently from the sides of the head. All of the affected skin is exquisitely sensitive, and the lightest touch or movement causes complaints of pain. The fever and gastric disturbances continue until the violence of the disease has reached its acme, after which the Inflammations of the Skin. 85 symptoms progressively decrease. Unless sloughing occurs, the integrity of the skin is restored. At times, however, limited areas of solid oedema remain, espe- cially about the lips, eyelids, and lower extremities. In some cases a predisposition to a return of the disease remains, and the patients are compelled to pass through an attack three, six, or even twelve times a year. Eventually, in many of these latter cases, a condition simulating elephantiasis arabum remains. Recent researches (Koch, Fehleisen, Orth) indicate that the disease is due to a micrococcus, which has been isolated by Fehleisen. Pure cultures of this organism injected into healthy individuals have produced the disease. The prognosis of erysipelas depends greatly upon the vital resistance of the patient. Persons of good habits, temperate, not run down by overwork or fore- going disease, and living amidst hygienic surroundings, are very likely to recover, even from severe cases. On the other hand, persons of depressed vitality, or of dissipated habits, especially those addicted to alcoholic excesses, frequently succumb to the disease. The eiy- sipelas of the newborn is also almost always fatal. Erysipelas occurring as a complication of vaccinia is often of grave significance, because it is mostl}- an indi- cation of a debilitated constitution in the vaccinee. The treatment of erysipelas by the internal adminis- tration of tincture of chloride of iron is so often fol- lowed by marked decrease of the inflammation that I cannot doubt the good effects of this remedy. It is my practice to give it in half-drachm [2.] doses, well diluted, every two or three hours. Irritability of the stomach sometimes interferes with this treatment for a time, but if the administration of the medicine is persisted in, 86 Diseases of the Skin. and especially if a little dilute phosphoric acid and syrup of lemon are added, the stomach soon becomes tolerant of it, and it is retained. It is often useful to combine quinine with the iron. Locally, a simple cold- or hot-water dressing will relieve the heat and burning pain. Lotions of bicarbon- ate of soda, of acetate of lead and opium, or of carbolic acid are also widely used. The parenchymatous injection of a 2- to 3-per-cent. solution of carbolic acid into the periphery of the in- flamed area, as at first recommended by Hiiter, is highly thought of by some. Painting the inflamed patch with tincture of iodine is also believed to limit the spread of the inflammation. Collodion, either alone or holding in solution iodoform, has been used with success in the same manner. Recently the local application of white- lead paint has been highly recommended b}' Dr. Lewis, of New York. FURUNCLE. A boil is an acute, circumscribed inflammation of the skin, frequently extending into the subcutaneous tissue. It usually begins as a small induration, gradu- ally elevating the skin into a conical prominence, tender to the touch, and accompanied b} r severe throbbing pain. The apex of the cone is the site of a small, yel- lowish pustule, and when this is punctured a few drops of pus escape. In some cases this terminates the morbid process, and the induration gradually disappears. These are called " blind boils." In the majority of cases, however, the inflammatory area extends to the size of a hazel-nut, or even an English walnut. In the course of a week the swelling becomes boggy in the centre, the summit breaks down, and a yellowish plug of dead con- nective tissue, covered with pus, is discharged. When Inflammations of the Skin. 87 all the necrosed tissue has been thrown off the cavity fills up by granulation, and a small, irregular scar re- mains to mark the site of the boil. The causes of boils are, in the majority of cases, external irritants. Thus, they frequently occur at the back of the neck, where the}^ are often due to friction of a stiff, jagged collar. About the wrists they are often caused by a frayed shirt-cuff. Between the but- tocks, or about the genitals, they are often due to acrid discharges or other irritants. They are not rarely ac- companiments of pruritic skin diseases, and are then caused by the irritation of scratching. Boils are often an external evidence of diabetes, and when, in any case, large numbers of boils occur scattered over the surface, it is well to bear this con- nection in mind. It is a common saying that boils never come singly, but always in crops. This is in large measure due to im- proper treatment. The continued application of poul- tices, or irritant salves and plasters, is often responsible for the persistence of furuncular eruptions. The diagnosis presents no difficulties. The treatment of boils consists in free incision, fol- lowed by warm dressing or a poultice, and the internal administration of large doses (n^xx to xxx) [1.3 to 2.] of tincture of chloride of iron. Quinine may often be added with advantage. A brisk purge may be given at the beginning of the treatment if indicated, but the persistent administration of laxatives, such as sul- phur, cream of tartar, and similar medicines, is to be deprecated. I have never seen any good effects from the use of sulphide of calcium or arsenic in boils, but often the reverse. 88 Diseases of the Skin. The incision of the boil should be made as soon as the diagnosis is certain. It relieves the congestion and throbbing pain, frees the way for the exit of the slough and pus, and leaves a fine, linear mark, instead of the irregular scar which nearly always remains if the boil has been allowed to break. The poulticing or hot-water dressing should be con- tinued only long enough to permit the engorged vessels in the areola of the slough to become depleted. Five or six hours is usually long enough. Afterward, the incision should be covered with a piece of lint smeared with carbolic-acid ointment. ANTHRAX. Carbuncle may be described as a diffused boil with multiple openings. In all essential particulars it is identical with the affection last described. The ear- buncular swelling is broader, not so elevated as, and more firmly indurated than, that of a boil. Its surface is irregularly flattened. The necrotic masses are dis- charged through a number of openings, which have caused the top of a carbuncle to be compared to a sieve. There is usuall} 7 severe pain, considerable fever, and often great depression of the system. The causes are the same as those of furuncle. The treatment differs in no respect from that of boils, except that it should perhaps be more energetic. In car- buncle of the lip, in which the prognosis is usually con- sidered so very grave, early incision and the free adminis- tration of iron and quinine are imperative. To delay incising the swelling until pus is discovered b} r fluctuar tion, is merely tampering with the life of the patient. The dressing after. incision should be actively antiseptic, in order to prevent septic absorption. Lotions of carbolic Inflammations of the Skin, 89 acid (5 per cent.) or of mercuric bichloride (1 to 2000) should be kept constantly applied. In addition to the administration of iron and quinine for their "specific" effect, the patient should have a liberal allowance of good food and alcoholic stimulants. This is especially important in patients of advanced age, who so often succumb to this disease. DIFFUSE PHLEGMON. Diffuse phlegmonous inflammation of the skin, also termed phlegmonous erysipelas, is properly a celluli- tis. It is most frequently observed in the forearm and the neck. The morbid process consists in a necro- sis of connective tissue, accompanied or followed by lymphangitis and dermatitis. The origin of the affec- tion is probably always septic. The disease begins with a chill, followed by fever. The patient sometimes has recurret attacks of chilliness, or regular periodic rigors. The affected locality be- comes painful, hard, and swollen. In a few days the in- duration gives place to a boggy fluctuation. In some cases resolution may take place even at this time, but generally the connective tissue breaks down and is con- verted into an ichorous pus, in which numerous frag- ments of broken-down connective tissue are found. If the affected surface is extensive the strength of the patient rapidly becomes exhausted, or symptoms of septic absorption come on. When the neck is the part involved, there is deep destruction of tissue, and the pus frequently gravitates into the mediastinum. In fatal cases, nephritis is an almost invariable com- plication. The treatment must be conducted on surgical prin- ciples. Deep and extensive incisions, to afford free D 3 90 Diseases of the Skin. exit to the necrosed tissue, and antiseptic dressings constitute the local measures. Internally, iron, quinine, and alcoholic stimulants are indicated in all cases. MALIGNANT PUSTULE. This is a localized gangrene due to the inoculation of the virus of splenic fever (bacillus anthracis). It usually appears on the hand, but sometimes also on the face. It begins as a red papule or tubercle, accompa- nied by itching or burning. A hemorrhagic vesicle soon appears on the apex. The base becomes infiltrated to the size of a dollar or larger. This often undergoes necrosis, and, if the patient escapes general infection, leaves a scar after healing. Lymphangitis, axillary abscess, and extensive slough- ing of the tissues of the arm, chest, or neck are frequent complications, and often carry off the patient. The dis- ease occurs especially in persons handling the hides of animals that have died from splenic fever. It is rarely observed in this country . Absorption of septic matters sometimes occurs, during dissection or post-mortem examination, either through an accidental wound or through a slight abra- sion. A localized inflammation results, which may eventuate in a lymphangitis and general septic infec- tion. Oftener, however, a hemorrhagic vesicle or a painful tubercle appears, to which Wilks has applied the term u verruca necrogenica." The treatment consists in cauterizing the point of inoculation, and dressing the resulting sore with iodo- form. It is probable that the ill effects of septic inoculation can be prevented by the free use of a disinfectant solu- tion of mercuric bichloride (1 to 1000). Inflammations of the Skin. 91 HERPES SIMPLEX. Simple herpes is usually divided into two varieties, which differ in their localization, as well as, probably, in causation. They are herpes of the face and herpes of the external genital organs. Herpes of the face occurs most frequently on the lips, at the angles of the mouth, and upon the nose. The eruption generally appears in the course of inflammatory or febrile diseases ; hence, called " fever- blisters." It has no prognostic significance. The eruption occurs in groups of pearly vesicles, which either dry up, leaving a thin, brownish scale to fall off, terminating the morbid process ; or the vesicles are ruptured and a superficial painful erosion remains, which, if seated at the labial angle, may remain for a long time and cause considerable discomfort. At every movement of the mouth — in laughing, talking, or eat- ing — the sore spot is disturbed, pain is caused, and healing is delayed. An eruption of herpetic vesicles also occurs some- times, on the mucous .surface of the mouth, and may cause much annoyance. The treatment is simple. The constant application of a mild calomel ointment,, or, if the site of the erup- tion is moist, dry calomel dusted on, are all the therapeutic measures necessary. The disease tends to spontaneous recovery, and will always get well if not irritated or injured. Herpes of the external genitals is rather a frequent affection. It occurs in both sexes, but is most frequent in males. It appears in little clusters of clear vesicles, situated either upon the cutaneous or mucous surface of the prepuce, or upon the glans. The tops of the vesicles soon become macerated and rubbed off, and 92 Diseases of the Skin. leave small superficial erosions, which sometimes are quite painful. The affection is frequently, recurrent, breaking out in some individuals after every sexual intercourse ; in others, it only appears after intercourse with certain women, indicating that something irritant in the vaginal secretions causes the eruption. In other cases again, no connection can be traced between the outbreak and a foregoing irritation. When the affection occurs on the glans or mucous surface of the prepuce, or on the mucous surface of the labia, the diagnosis between herpes and the initial lesion of syphilis is often difficult, and sometimes impossible. In these cases a delay of a few days will usually clear up the diagnosis. The irrational treatment with strong caustics, to which every lesion on the genitals is sub- jected by so many physicians, is often the cause of uncertainty in making a diagnosis. The treatment consists in the application of pow- dered calomel, oxide of zinc, or boracic acid. The vesicles should be protected from rupture by a pledget of lint or absorbent cotton. Where the tops of the vesicles have been rubbed off, and the eroded base exposed, iodoform dusted on produces rapid healing of the sores. Sometimes the tendenc} T to recurrence of the affection can be diminished by the regular use of astrin- gent lotions containing tannic acid, alum, or sulphate of zinc. Cleanliness, of course, is all-important. In cases of redundant prepuce, circumcision will exert a favorable influence upon the relapsing tendency. HERPES ZOSTER. Herpes zoster, or " shingles," 1 consists in an eruption of groups of large vesicles upon an inflamed patch of 1 A corruption of the Latin Cingulum, a girdle ; so called because in the typical form of the disease it surrounds the body, partly, like a girdle. Inflammations of the Skin. 93 skin, generally limited to one side of the body, follow- ing the distribution of the peripheral terminations of the sensory branches of nerves, usually preceded by slight febrile symptoms, and more or less severe neural- gic pain. It usually begins as follows : After a few days of slight febrile disturbance and neuralgia, sometimes very intense, an eruption of small, erythematous spots is noticed, in the centre of which there develop small papules. In a da} r or two the papules have changed into vesicles, which are often umbilicated like small-pox vesicles; the contents of the vesicles either dry into thin crusts or change into pustules, which sometimes leave slight scars, resembling somewhat the pits in small-pox. In from two to four weeks the crusts have fallen off, leaving the skin in its normal condition, or else the scars just referred to may remain to mark the site of the eruption. The pain is usually most severe and per- sistent in old persons. In children it is sometimes entirely absent, merely a slight soreness being felt. Shingles is a self-limited disease, and occurs, as a rule, but once in a life-time. The severe neuralgia may last weeks, months, or even years after the disappearance of the disease. The cause of shingles is still a matter of discussion. The regularity of distribution of the eruption and the pain first led von Barensprnng to attribute it to nerve- lesions. Rare opportunities for post-mortem exam- inations in cases of shingles revealed l^persemia, or nflamination of the corresponding cutaneous nerves in continuit3 r , or some structural alteration in the ganglia. The cause of the disease in the nerves, in some cases, is traumatism : thus, zoster sometimes occurs in conse- quence of injuries to the cutaneous nerves or ganglia; 94 Diseases of the Skin. but, in the majority of cases, the neuropathy has been looked upon as spontaneous. Contrary to most dermatologists, the writer believes that shingles should be classed with the acute infectious diseases. Points in favor of this view are : — 1. The strictly self-limited character of the disease, and its tendenc}^ to spontaneous recovery after a slightly varying duration. 2. The constant occurrence of more or less well- marked prodromic s3*mptoms. 3. The character which it possesses, with the other specific diseases, of occurring but once (generalfv) in a life-time. 4. The uselessness of attempts to " cut short " the disease b}~ therapeutic measures. 5. The well-attested quasi epidemic character of its prevalence at times. Erb, Landouzy, Gerne, and Kaposi have recently adopted this view, which was first distinctly proposed by myself, in a paper published in the Archives of Dermatology for. July, 1877. No other theory so readily accounts for the pathogen}^ of herpes zoster. Herpes zoster is localized according to the distribu- tion of the cutaneous nerves ; thus, in the face, it gener- ally follows the distribution of the fifth or seventh, which latter receives sensory branches from the fifth. When it occurs in the course of the ophthalmic branch of the fifth, there are usually intense pain and inflam- mation of the eye, which may lead to disorganization of that organ. Zoster may be conveniently subdivided into facial, where the distribution is as just described ; occipital, following the ramifications of the third cervical, which gives off the occipitalis minor, auricularis magnus, and Inflammations of the Skin, 95 subcutaneous colli. Among the other local forms, the cei'vico-subclavicular follows the distribution of branches of the fourth cervical, supplying the clavicular and subclavicular regions, shoulder, and upper part of the back. Cervico-brachial follows the distribution of branches of the four lower cervical and two upper dorsal nerves, and occupies the neck, shoulder, or upper extremity. Dor so-pectoral follows the distribution of the third, fourth, fifth, sixth, and seventh dorsal (intercostal) nerves. Before it breaks out, the malady termed inter- costal neuralgia frequently exists for some da}^s. It is the most frequent variety of zoster, and from it and the following division the name zoster, a belt, 1 is derived. Dor so-abdominal zoster follows the distribution of the eighth to twelfth dorsal and first lumbar nerves, extending in a beautiful zone of vesicles from the spine to the linea alba. Lumbo-inguinal follows the distribution of the first and second lumbar nerves and anastomosing branches, being most frequently confined to the inguinal region. Lumbo-femoral follows the distribution of the second, third, and fourth lumbar nerves, occupying buttock, hip, thigh, or leg. Sacro-ischiatic and genital occurs upon the penis, scrotum, or, in the female, the vulva and the perineum. The prognosis in herpes zoster, so far as the eruption is concerned, is favorable. The neuralgia accompanying it is, however, frequently very persistent. The treatment is extremely simple : protecting the vesicles from rupture by covering them with cotton- batting ; dusting with a powder of starch or chalk con- taining morphine or camphor, to relieve pain. For the 1 See note, p. 92. 96 Diseases of the Skin. same purpose, hypodermatic injections of morphine or atropine in the track of the nerve. Large doses of quinine have been recommended. Recently, phosphide of zinc, T 2 2 to | grain [.005 to .01] three times a day, has been used, internally, in the form of a pill, and, it is asserted, with success in relieving the pain. For the neuralgia, which is sometimes so persistent after the eruption has disappeared, arsenic, belladonna, or, locally, electricity may be used. In patients with broken-down health, the measures appropriate in such cases — good food, fresh air, exercise, iron and quinine — should be directed. The regular and proper use of the constant current promises most success in relieving the pain. DERMATITIS HERPETIFORMIS. This is a rare disease which has been described by several authors, but most thoroughly studied by Duhring, from whose writings on the subject the following ac- count is condensed. The disease may appear in various types, — erythematous, papular, vesicular, bullous, pus- tular, or a combination of all of these. In severe cases prodromata are usually present for several days preceding the cutaneous outbreak, consist- ing of malaise, constipation, febrile disturbance, chilli- ness, heat, or alternate hot and cold sensations. Itch- ing is also generally present for several days before any sign of efflorescence. Even in mild cases slight sys- temic disorder may precede or exist with the outbreak. This latter may be gradual or sudden in its advent and development. Not infrequently it is sudden, one or another manifestation breaking out over the greater part of the general surface diffusely or in patches in the course of a few days, accompanied by severe itching or burning. Inflammations of the Skin. 97 A single variety, as, for example, the erythematous or the vesicular, may appear, or several forms of lesions ma} r exist simultaneously, constituting what may very properly be designated the multiform variety. The tendency is, in almost every instance, to multiformity. There is, moreover, in almost every case a distinct dis- position for one variety, sooner or later, to pass into some other variety ; thus, for the vesicular or pustular to become bullous, or vice versa. This change of type may take place during the course of one attack or on the occasion of a relapse ; or, as is often the case, it may not show itself until months or 3 r ears afterward. Not only multiformity of lesion, but irregularity in the order of development, is the rule, whether during an attack or later in the course of the disease. Itching, burning, or pricking sensations almost alwa}'S exist. When the eruption is profuse they are intense, and cause the greatest suffering;. As in the case of eczema, before and with each outbreak, they become most violent, abating in a measure only with the laceration or rupture of the lesions. The disease is rare, but is of more frequent occur- rence than formerly supposed. The natural history of the disease is interesting. The process is in almost all instances chronic, and is characterized by more or less distinctly-marked exacerbations or relapses, occurring at intervals of weeks or months. This disposition to appear in successive crops, sometimes slight, at other times severe, is peculiar. Relapses are the rule, the dis- ease in most cases extending over years, pursuing an obstinate, em'phatically chronic course. All regions are liable to invasion, including both flexor and extensor surfaces, the face and scalp, elbows and knees, and palms and soles. Excoriations and pigmentation, diffuse and 5 E 98 Diseases of the Skin. in localized areas, are in old cases always at hand in a marked degree. The pigmentation is usually of a mottled, dirty, yellowish or brownish hue, and is persistent. The treatment is symptomatic. The itching gen- erally requires measures for its relief. Locally, the preparations of sulphur and tar may be used with good effect. Internally, arsenic in small doses, combined with iron and quinine, sometimes seems to be useful. PSORIASIS. Psoriasis is a chronic disease of the skin, character- ized by the excessive formation of pearly-white scales seated upon a reddened, somewhat elevated base. On detaching the scales with the finger-nail, the denuded spot bleeds slightly. The disease begins with punctiform, reddish spots, the tops of which become covered in a day or two with minute collections of white scales. These efflorescences are alwaj'S multiple. They increase peripherally, and soon attain the size of a split pea, or lentil, when they look very much as if drops of mortar had been spat- tered upon the skin. The peripheral increase continues, so that the individual lesions become disks of the size of various coins. The individual patches may now run together, forming irregular-figured patches of various sizes. The development of new points of efflorescence continues, so that in a case of some duration all the different-sized lesions may be present. When involution of the patches occitrs, the scales disappear from the centre, leaving a slightly elevated, more or less red or grayish, pigmented spot, while the scale-covered border may continue extending periph- Inflammations of the Skin. 99 erally. The pigmentation finally disappears, leaving no scar to mark the site of the eruption. The only subjective symptom attending an outbreak of psoriasis is itching, which is seldom very intense. In rare cases it is, however, exceptionally severe. It is most marked in the beginning of the disease. The anatomical changes consist principally of an enormous hyperplasia of the Malpighian layer of the epidermis, with secondary hyperemia and exudation in the corium, especially the papillary layer. The epithe- lial hypertrophy may extend downward, invading the cutis, and in very exceptional instances (White) lead to cancerous degeneration of the affected skin. The eruption is usually symmetrical, and no portion of the skin is exempt ; but it is especially localized on the extensor surfaces of the limbs and trunk, over the sacrum, and upon the haiiy scalp. The palms of the hands and soles of the feet are only very rarely affected. In nearly all cases the elbows and knees are the seats of large, thick patches. Upon the scalp the accumulation of scales is often enormous, a thick crust being formed, which covers the entire head. There is usually a hypersemic band ex- tending crown-like around the head, be}^ond the hairy border. When it affects the ears it may produce func- tional deafness, by causing an accumulation of scales in the auditory meatus. The nails are sometimes attacked, becoming dry, brittle, roughened, and lustreless. Bearing the principal features of psoriasis in mind, the diagnosis in most cases should not be difficult. In some instances, however, no little difficulty arises in differentiating it from diseases presenting like ap- pearances. 100 Diseases of the Skin. Sebarrhcea of the scalp often presents a condition very similar, at first glance, to psoriasis. In the former, however, the scales are greasy and dirty-look- ing, and there is often falling out of the hair. The abrupt-curved border is also wanting in seborrhcea, in which the redness is generally less marked, and shades off insensibly into the normal skin. Scaly eczema may sometimes resemble psoriasis so nearly as to make an exact diagnosis impracticable for some time. By carefully watching the progress of the disease, however, the differentiation can usually be made. In eczema there will often be moist patches interspersed among the scaly spots, and there will be yellowish crusts and scabs in addition to the scaliness. In psoriasis, exudation of fluid upon the surface and crusts are absent. The well-defined outline is also want- ing in eczema. The squamous syphilids may sometimes be mistaken for psoriasis. The eruption in syphilis is generally more copiously distributed on the flexor than on the extensor surfaces, and is especially liable to occur in the palms of the hands. On scraping off the scales in the syphilitic eruption there is no bleeding. The red color in psoriasis is due to hyperemia of the cutis, and disappears under pressure. In syphilis it is due to an infiltration, is not so bright-colored, and does not dis- appear under the finger. In scaly syphilis there are nearly always scaly patches in the palms of the hands. In psoriasis the palms are very rarely affected. Ringworm of the scalp sometimes resembles patches of psoriasis very closely. In ringworm, however, the hairs are nearly always affected, being dry and broken. The bright-red base of the psoriasis lesions is also want- ing in ringworm. Inflammations of the Skin, 101 The prognosis is favorable so far as any individual attack is concerned. But in psoriasis there is always a peculiar predisposition of the skin, which we cannot, with our present knowledge, eradicate. Hence, it is the rule for psoriasis to recur at a variable interval. For this reason we can never promise any patient a cure in the strict sense of the term. The treatment of psoriasis must be both constitu- tional and local. Among the internal remedies the first place belongs to arsenic. For details of administration of this remedy, see section on treatment of eczema, pages 56 and 57. From considerable personal experience I am firmly convinced of the great value of arsenic when properly administered. Its unquestionable specific action in modifying the epithelial tissues renders it an especially appropriate remedy in psoriasis, and, in fact, all chronic seal}' skin diseases. In some cases of psoriasis it will pro- duce a complete disappearance of the eruption without any local measures whatever. It must be confessed, however, that local treatment alone is competent in man} 7 cases to remove the lesions, especially if the out- break is not very extensive. I believe I have seen good effects follow the admin- istration of alkaline diuretics, either as the only internal treatment or as a precedent to a course of arsenic. The preparation preferred is the acetate of potassium, which I usually order in combination with fluid extract of taraxacum, as in Formula 41. Carbolic acid, 4 to 5 grains (.25 to .30), three times a day, made into pills, with powdered licorice, has been recommended, but the benefit derived from it is very slight. The local measures of treatment may be divided 102 Diseases of the Skin. into the preparatory and curative. To the former belong water (baths, lotions) and soap, while in the latter category are included tar, sulphur, naphthol, mer- curial preparations, chrysarobin, pyrogallic and salicylic acids. Baths and lotions, either of pure water or rendered alkaline with carbonate of soda, are useful in removing the accumulated scales or patches of psoriasis. Their employment should be combined with soap and friction, in order to free the surface of scales and allow the remedial application to be made directly to the dis- eased skin. The frictions with soap and water should always precede the application of whatever medicament is used. Tar has always enjoyed a high reputation as an external remedy in psoriasis. It is employed either pure or in ointment, or alcoholic solution. Dr. Bulkley has introduced an alkaline solution of tar, which is soluble in water, and which is frequently of great value in the treatment of psoriasis. It is pre- pared according to Formula 42. This may be applied to indurated patches in full strength, as above, or diluted with an equal part of water. It should always be followed by some sooth- ing ointment, such as oxide of zinc or calomel ointment. As a substitute for tar, naphthol has been used by Kaposi and others. It may be employed in oint- ment (5ss-j to §j) [1^8 to 1-16] or in alcoholic solution (3j to §j) [1 to 8], Its advantages over tar are that it has no decided odor, and does not discolor the skin or clothing. At the same time it appears to be much less efficient than tar. Sulphur is a remedy of value in psoriasis. It is sometimes, employed, with good effect, in the form of Inflammations of the Skin. 103 the solution of sulphuret of lime, known as Vleminckx's solution (Formula 43). The patches are rubbed with this until slight bleed- ing results, when the solution is washed off with water and a soothing ointment applied for several days, until the irritation has subsided. If the infiltration has not disappeared, the same procedure may be repeated. This method of treatment, although very effectual, is painful, and should not be applied over large surfaces at a time. It is only required in old cases, where the infiltration is deep and extensive. One of the most efficient applications is chrysarobin. It may be ordered in ointment (9j-3j to 3j) [1-24 to 1-8], or, better, in collodion or solution of gutta-percha in chloroform, which is painted on the patches daily, or every other da}\ The strength of this paint may be varied from 5 to 20 per cent. It has the advantage over ointments of being dry, cleanly, and immovable. A caution must be added against using a strong application of chrysarobin about the head and face. It stains the skin and hair of a reddish brown, and not infrequently causes an erysipelatoid inflammation in the vicinity of its application. It also indelibly stains linen. Pyrogallic acid, applied in the same manner as chrysarobin, is also often effectual in psoriasis. It stains the skin brown or black, and, if applied over a large surface at a time, m&y cause symptoms of poison- ing (strangury, dark-colored urine, etc.). Salic3 T lic acid in solution in collodion (10 to 20 per cent.) is useful at times, especially in mild cases. For psoriasis about the face and scalp I have always used, with good effect, the ointment of ammoniated mercury (5ij to §j) [1 to 4]. In the milder degrees of 104 Diseases of the Skin. psoriasis it nearly always produces a rapid disappear- ance of the lesions. It should not be applied over too large a surface of the skin at a time, as it may be absorbed and cause symptoms of mercurial poisoning. The treatment of psoriasis is often unsatisfactory, and when, after long and earnest endeavor, the patient has been freed from his disease, a renewed outbreak of the eruption usually appears in the course of a few months, or a 3 r ear or two. A permanent cure can never be safely promised. EXFOLIATIVE DERMATITIS. I venture to class under this title several affections differing in their clinical features, but having as a com- mon symptom superficial inflammation of the skin, with furfuraceous or laminar desquamation of the epidermis. Exfoliative dermatitis ma}' be acute or chronic, general or local. I. ACUTE EXFOLIATIVE DERMATITIS OF INFANTS. In text-books on skin diseases may be found accounts of a fatal affection, which is described under the name of "Acute Pemphigus." The disease attacks young children only, runs a rapid course, and is, in the ma- jority of cases, terminated by death. Hebra and most dermatologists of his school emphatically deny the occurrence of pemphigus in an acute or epidemic form. A r on Hitter has described the disease under the title at the head of this article. He observed two hundred and ninety-seven cases in the course of ten years. The mortality was about 50 per cent. The children attacked were nearly all between two and five weeks old. There is usually a prodromal stage, manifested by abnormal dryness of the integument with desquamation of the epidermis, in the form of fine, Inflammations of the Skin. 105 branny scales. The skin of the lower part of the face, especially about the angles of the month, becomes red and slightly tumid. The margin of the redness, which rapidly spreads, is indistinct, not being sharply defined against the healthy skin. At the same time, the skin at the angles of the month becomes fissured and covered with scabs. The mucous membrane lining the pharynx and buccal cavity is reddened, and the palatal arch is the seat" of superficial erosions, covered by a grayish- white exudation. The appetite and digestion of the infant remain unimpaired, and there is no increase of temperature. The redness and thickening of the skin extend over the entire bod}". The face becomes covered by yellowish, translucent scabs upon a reddened base, intersected in various directions by fissures. The skin becomes wrinkled, and the upper layer separates from the cutis. The epidermis ina} r be detached in large flakes or is cast off spontaneously. This process, continuing until the entire surface is denuded of epidermis, presents an appearance similar to that following an extensive scald- ing. In favorable cases the dark, raw-flesh color of the cutis soon gives way to a lighter red, and in some cases the normal color of the skin is restored in twenty-four to thirt} T -six hours. In unfavorable cases, on the other hand, the color is a dirty, brownish red, and the cutis becomes dry and parchment-like. In those cases which terminate in recovery the normal condition is entirely re-established in a week or ten da}^s, the skin for a few days being covered by a fine, branny desquamation. As sequelae of the disease, eczemas of considerable extent, or pea-sized and larger, superficial boils and ab- scesses, sometimes in large numbers, occur and delay complete recovery. At other times extensive phlegmon- 5* 106 Diseases of the Skin. ous infiltrations occupy considerable tracts of skin, and may result in gangrenous destruction of tissue and death. In the latter conditions, pneumonia and col- liquative diarrhoea not rarely precede the fatal termina- tion. Relapses are infrequent. When they occur, the disease is of a milder t}< pe than originally. The disease seems to be a manifestation of septi- cemic infection, principally localized upon the external integument. The diagnosis is easy, no other disease being liable to be mistaken for it. In erysipelas, which sometimes affects infants in a similar manner, there is always con- siderable elevation of temperature ; this symptom is absent in exfoliative dermatitis. In pemphigus there are blebs surrounded by a reddish border, separated from adjoining blebs by healthy integument. In ex- foliative dermatitis the redness and thickening are progressive and occupy finally the entire surface. The post-mortem appearances present nothing char- acteristic. The etiology is unknown. The disease is not contagious. There are no known means of prevention. The treatment is purely symptomatic. Sufficient nourishment of the infant at the breast is of the first importance. Pure air, the room not kept too warm. Locally, cool baths, drying the skin with fine, soft cloths, and carefully avoiding friction will meet the in- dications in most cases. Ragged and loose patches of epidermis should be clipped off with the scissors, and all denuded and fissured surfaces dusted with finety-pow- dered calomel. The crusts which accumulate at the angles of the mouth and render nursing difficult and painful, are best gotten rid of by soaking them with oil of sweet almonds and carefully removing the loose Inflammations of the Skin. 101 ones by means of a dressing-forceps. Baths of oak- bark (80 to 100 grammes to 1 litre of water), one-half of this decoction to be added to each bath, are sometimes useful. In uncomplicated cases no internal medication is necessaiy. All complications, of course, should receive appropriate treatment. II. BULLOUS EXFOLIATIVE DERMATITIS. In another form of exfoliative dermatitis, the epider- mis is slightly raised over greater or less areas by collec- tions of serous or sero-purulent fluid. This finally dries up, or escapes through ruptures in the epidermis, and the latter is detached in papery flakes. The surface of the skin under the exfoliating epidermis resembles that already described (p. 106). This form of the disease is generally described in dermatological works as pemphi- gus foliaceus. It is sometimes acute, but more fre- quently chronic. It is usually a disease of early life, although occasionally observed in adults. The prognosis in this disease is usually grave. The strength gradually gives wajr, and the patient dies under all the manifestations of exhaustion. The treatment must be guided by the condition of the patient. The exposed skin must be protected by some bland, fatty application. A paste of finely-powdered starch and vaseline, equal parts, may be freely applied. Internally, roborant remedies — iron and codliver-oil — will be indicated. Arsenic in small doses may be tried. Inunctions of codliver-oil will be useful. III. CHRONIC GENERAL EXFOLIATIVE DERMATITIS. This is a rare disease, first accurately defined by Hebra, who named it pityriasis rubra. There is deep- red discoloration of the skin, little infiltration, no ex- udation on the surface, and absence of papules, vesicles, 108 Diseases of the Skin. or fissures. The epidermis is constantly exfoliated from the entire surface, in large, papery scales. The subject- ive symptoms are slight, the itching being usually very moderate. In course of time (months or years) the skin becomes dry, harsh, loses its elasticity and pli- ability, the hairs fall out, and the nails become cracked and deformed. The patients generally die of progressive exhaustion or succumb to some intercurrent disease. The administration of quinine sometimes causes an acute, general, scaly eruption, resembling somewhat exfoliative dermatitis. The prognosis is grave. Few patients recover from the disease. The diagnosis from general eczema is not difficult. In eczema there are always moist patches ; there is usuallj r infiltration, and the entire surface of the skin is rarely attacked. In general exfoliative dermatitis, there is sometimes not the smallest patch of healthy skin remaining. No other disease is likely to be mistaken for it. No treatment has hitherto been found of any value. Inunctions of almond and raw linseed- or codliver-oil promise best results. Internally, iron and good food are indicated to counteract the tendency to exhaustion. IV. LOCAL EXFOLIATIVE DERMATITIS. This disease has been described as a pityriasis (fur- furaceous desquamation), occurring in small, round spots and larger ci re in ate patches. The color of the lesions is a pinkish or rose tint, and the spots are cov- ered with fine, white scales. There is sometimes slight itching, but no other subjective symptoms. The patches are not infiltrated. The chest and neck appear to be the sites of predilection, but in one case observed by the Inflammations of the Skin. 109 writer the face was especially affected. According to Duhriiig, the disease usually lasts from four to six weeks. The general appearance and course of the affec- tion recalls the vegetable parasitic skin diseases, but no characteristic fungus has yet been discovered. The treatment consists in the application of mild ointments, such as calomel (5ss to §j) [1 to 16], or yel- low oxide of mercury (gr. x to lj) [1 to 50], or salicylic acid fgr. v to §j) [1 to 100]. Internally, no treatment is required. LICHEN. Lichen occurs in the form of flat or acuminated, red papules, seated upon normally colored skin. The erup- tion may be discrete or aggregated. Two varieties are described : the plane {lichen planus) and the acuminated {lichen ruber acuminatus). The disease is rare, — about one case being observed in five hundred cases of skin diseases of all kinds. The plane variety appears as crimson, flattened, or even slightly umbilicated papules, angular in outline, usually discrete, though sometimes aggregated in disk- shaped groups. The localities in which it is oftenest found are the flexor surfaces of the forearm, the calves of the legs, the thighs, the penis, and scattered about the trunk. The acuminate variety consists of pin-head- sized, conical, firm papules, capped with a hard, dry mass of epidermic scales, which convey a rough sensa- tion to the hands when passed over the affected surface. In the most aggravated form these papules become closely crowded together, until they present an almost uniform red sheet of eruption. This is, however, ex- ceedingly rare in this country. Dr. R. W. Taylor has shown that the two forms here described are essentially different diseases. 110 Diseases of the Skin. . When the eruption disappears, either spontaneously or as the result of treatment, a dark, slaty pigmentation remains for some time. There are, generally, no marked subjective S3'mp^ toms. Itching is sometimes present, however, and may be a prominent sjnnptom. The disease differs from papular eczema in always preserving the papular form, which is the only lesion present. In eczema there are nearly always some of the other manifestations of the disease. The itching is usually less intense in lichen. The dark, slaty pigmentation is also characteristic. In psoriasis the pigmentation is usually less persistent. The flattened or umbilicated summits of the plane va- riety are so characteristic that little difficulty can arise in the diagnosis. In the milder cases the prognosis is fa Adorable. In those cases, however, where a large surface is covered by the eruption, the patients frequently die from marasmus. In the treatment arsenic claims the first place. It should be given until the full pli3 T siological effects are manifested, when the disease will usually be found to yield. Tonic medicines will also be needed in many cases. The itching, when present, can often be alla3 r ed by alkaline baths or lotions containing carbolic acid. In the more localized forms of the eruption amnion iated mercury ointment is sometimes of benefit. Scrofulous lichen is described b} T German authors, but has not been observed in the United States. The papules are small, pale-red or yellowish, sometimes scaly, and do not itch. The internal and external use of codliver-oil never fails in curing the disease. Inflammations of the Skin. Ill PRURIGO. Prurigo is an exceedingly rare disease in this country. The proportion of prurigo to all cases of skin disease reported to the American Dermatological Association is about one in ten thousand. The disease appears as a papular eruption, generally beginning in childhood, attacking by preference the extensor surfaces of the limbs, and never the face or palms of the hands. The flexor surfaces of the joints also generally remain free from the eruption. The itching is intense. In no other disease does this symptom approach in severity the itching of prurigo. The disease is differentiated from lichen by the iso- lated character of the lesions, and from eczema by the absence of exudation upon the surface (unless an arti- ficial eczema has been produced by the scratching) and the persistence of the papules throughout the duration of the disease. The summits of the papules are often covered by small brown crusts, the result of excoria- tions produced by the finger-nails in scratching. The prognosis is gloomy. A permanent cure is not to be hoped for, and even temporary relief is difficult to secure. The treatment must be palliative. Ointments con- taining tar and sulphur may be used with good effect. Latterly, ointments or lotions of naphthol (5 to 10 per cent.) have been found to give relief. Happily, few practitioners in the United States are liable to be called upon to treat this terrible disease. ATONIC PUSTULAR ERUPTIONS. Pustular eruptions will usually be found in individu- als who are anremie, or in otherwise vitiated health. 112 Diseases of the Skin. Excluding pustular eczema, syphilis, or pyaemia, a cer- tain number of cases of pustular eruptions will be met with which cannot be definitely ranged under one head- ing. In most text-books they are described under the titles " impetigo " and " ecthyma," but many modern dermatologists discard these terms altogether. These eruptions are usually due to local irritations in debili- tated subjects. The pustules are from a pin-head to a pea, or even a large bean, in size, flat, or slightly convex, with inflamed borders. When they are ruptured they leave shallow ulcers, with a grayish, unhealthy- looking base. The pustules may be disseminated over the entire bod}', but are in most cases localized. In adults they are most frequently found upon the legs. I have noticed them especially in sailors and other persons similarly exposed, and who were, in addi- tion, overworked and underfed. In many of the cases which have come under my notice, a slight sponginess of the gums, suggesting a scorbutic tend- ency, has been observed. In badly-nourished chil- dren the pustules are not seldom seen upon the face and hands. The treatment of these atonic pustular eruptions and their sequelae, the superficial ulcers, is simple and promptly effectual. Cleanliness, dry clothing, dry and comfortable bed, fresh air, good and sufficient food and rest will often produce a cure without any medicine. Tonic medication will, however, be advisable generally. As a medicine, tincture of chloride of iron, in doses of 20 to 30 minims three or four times a day, will fulfill all the indications. Locally, carbolic-acid ointment, or the ointment of **xide or oleate of zinc, or carbonate of lead will pro- mote healing of the slight ulcerations. Inflammations of the Skin, 113 CONTAGIOUS IMPETIGO. This disease was first described by the late Dr. Til- bury Fox, in 1862. It generally appears in the form of vesico-pustules or blebs, varying in size from a pea to a Lima bean. The blebs rise abruptly from a non-inflam- matory base, and usually appear as if only partly filled with fluid. The fluid, which is at first clear, rapidly becomes changed into a thin, milky pus. This is soon absorbed, or dries with the roof of the bleb into a thin, brownish crust, with turned-up border, lightly adherent at the centre, looking as it' "stuck on," as Fox ex- pressed it. The eruption usually first appears upon the face or hands, and, being auto-inoculable, may be transferred to other portions of the body. It is very contagious, and usually affects all the children of the same family. It rarely attacks adults, but may be inoculated upon them, as I have shown experimentally. When the scabs fall off a brownish surface remains, which gradually fades away. The disease runs its course in from two to four weeks. The lesions are usually discrete, but sometimes a number of the blebs run together, forming a larger patch, which may resemble eczema ; the latter disease may also be produced by scratching or improper treatment. In uncomplicated cases the diagnosis is usually easy. Contagious impetigo is sometimes mistaken for pemphi- gus ; but the peculiar character of the crusts in the former* and the chronic nature of the latter disease will suffice to distinguish the two affections. The disease is spread by contact. It is believed by some to be caused by a parasitic growth. Fox seems to have regarded it as an infectious disease. Its cause is unknown. E 9 114 Diseases of the Skin, The treatment consists in cleanliness, removal of the crusts, and dressing the surface with oxide of zinc or a weak ammoniated mercury ointment (gr. v to §j) [1 to 100]. If the child is badly nourished, tincture of chlo- ride of iron and codliver-oil will be useful. Patients with contagious impetigo should be isolated, to prevent spreading of the disease. PEMPHIGUS. Pemphigus is a chronic disease of the skin, charac- terized by the outbreak of blebs, varying in size from a small bean to a hen's egg, or larger, generally appearing in crops, and accompanied by more or less febrile disturbance. This definition sufficiently characterizes pemphigus, and marks it as a disease standing by itself. It is not merely an eruption of blebs, but successive crops of these blebs appear. The blebs of pemphigus rise abruptly from the sound skin, have no inflammatory areola, and are, in most cases, tensely filled with a clear, yellowish — sometimes purulent — fluid, or at times con- tain blood. In a few days the fluid is re-absorbed ; the roof of the bleb, with some of its contents, dries into a thin scale, which, when removed, leaves a reddened, but otherwise apparently healthy, base. If, by means of the prick of a needle, or otherwise, the contents of the bleb are discharged, the latter collapses and dries up, as in the last instance. Unless irritated by mechanical means or stimulating applications, pemphigus blebs rarety con- tain pus, and no ulceration takes place at their base; hence uncomplicated pemphigus leaves no scars. The blebs consist of single cavities, not subdivided into com- partments, as are the pustules and bullae of small-pox in their earlier stages. Inflammations of the Skin. 115 Diagnosis. — The disease probably most frequently mistaken for pemphigus is contagious impetigo. There can be little doubt that many cases of " acute pemphi- gus " in which the patients recover, or epidemics of pemphigus, are really cases of contagious impetigo. 1 The resemblance is sometimes very close, and only a careful investigation will disclose the true nature of the disease in many instances. If the characteristic marks of the two diseases are remembered, however, no mistakes should occur. In a number of cases of e^sipelas, frost-bite, burns, scalds, and the application of cantharides or mezereon, bullae appear on the affected part. Here pemphigus can always be excluded by the presence of the uniformly reddened or inflamed base upon which the blebs appear. In the later stages of acquired S3^philis, a bullous eruption sometimes appears, which is termed, b} r some authors, " syphilitic pemphigus." The name is mislead- ing, as the eruption of bullae is the sole point of resem- blance. The bullous syphiloderm, as this affection is more properly termed, is differentiated from pemphigus b}^ an inflammatory areola surrounding the base of the bleb, which becomes purulent, the contents drying into a greenish-brown scab seated upon an ulcerated base, constituting what is called rupia. The bullous syphilo- derm is more frequent in children as a manifestation of inherited syphilis. The early stage of true lepros}^ is frequently accom- panied by an eruption of bullae. In this disease, how- ever, some lrypersesthesia, followed by anaesthesia of the spots occupied by the blebs, generally precedes the erup- 1 The grave variety of so-called "acute pemphigus" has been de- scribed under the title, "Acute Exfoliative Dermatitis of Infants." See p. 104. 116 Diseases of the Skin, tions. Other concomitant symptoms of grave involve- ment of the constitution will also be present, and enable the physician to exclude pemphigus. Small-pox may cause a difficult}^ in diagnosis, — a dif- ficulty which is, perhaps, more serious than that pre- sented by most other diseases, on account of the results which may ensue if a case of the former should fail to be recognized. In small-pox, however, the blebs always contain pus or blood; are not simple cavities, but sub- divided into compartments ; are seated upon an inflamed base, and followed by ulceration and loss of substance. The prodromic symptoms of small-pox can also usually be verified in the latter disease; these do not occur in pemphigus. In rare cases of exudative erythema, large blebs sometimes occur as one of the multiform manifestations of this disease. The accompanying papules and the generally-present patches of diffused red or brownish discoloration will serve to distinguish the affection. The so-called herpes iris, which has doubtless sometimes been mistaken for pemphigus, is now generally regarded as merel}^ one of the forms of exudative er\ T thema. In some rare cases of urticaria, the summit of the wheal is occupied by a bleb, which im'vy simulate the bullous eruption of pemphigus. The presence of other wheals, the urticarial irritability of the skin, and the in- tense itching in nettle-rash will serve to distinguish it from pemphigus. Dermatitis herpetiformis may- cause some doubt in diagnosis, but in this disease the lesions tend to multi- formity, while in pemphigus only blebs are observed. Charcot has pointed out that a bullous eruption sometimes occurs in consequence of nerve-lesions. These eruptions may appear consecutively, simulating Inflammations of the Skin. lit the recurrent eruptions in pemphigus. Scars remain in these cases, however, to mark the seat of the blebs, which is an exceedingly rare result in pemphigus. In the latter disease, also, the eruption would not be so strictly limited to the area supplied by an injured nerve. Scabies is occasionally accompanied by large bullae. The presence of papules, pustules, furrows, and excoria- tions, accompanied by severe itching, and the acarus, discoverable with a lens, would exclude pemphigus. An important, possibly frequent, and certainly rarely- recognized cause of bullous eruptions is the ingestion of certain medicines. Arsenic, potassium bromide and iodide, quinine, copaiba, and phosphoric acid have been followed by bullous eruptions more or less resembling pemphigus. It should, in all cases of doubt, be ascer- tained whether such medicines have been taken, before deciding upon the diagnosis. It needs to be added that the practitioner must be constantly on his guard against being victimized by feigned bullous eruptions, i.e., eruptions of blebs caused by the designed application of chemical or dynamical irritants to portions of the skin with intent to deceive. Hysterical women are, of course, the most frequent offenders in this respect; but it must not be forgotten that men sometimes malinger by feigning various for- midable skin eruptions. The methods by which bulhe are produced artificially consist in the application of hot iron, sinapisms, cantharides, strong acids or alkalies, and, perhaps, in some instances, prolonged pressure. The possibility of this occurring must be constantly borne in mind in order to avoid being discomfited by a malicious or dishonest patient. The causes of pemphigus are unknown. The prognosis is generally favorable. While relapses 118 Diseases of the Skin. are exceedingly liable to occur, individual attacks can usually be controlled by proper treatment. When the eruption is very extensive, however, the patient may succumb to the disease. Treatment. — Arsenic appears to be almost a specific in pemphigus. The medicine must be given in full closes and freely pushed. Fowler's solution may be given, in 8- to 10-drop doses, three or four times a day. It should be given in sherry wine, as it is better borne by the stomach than when diluted with water. Quinine is also useful. Good food and proper li3 r gienic surround- ings are important adjuvants to the treatment. Locally, much may be done to increase the comfort of the patient. The blebs should be punctured and the affected parts may be bathed with a lotion of carbolic acid (gr. x to §j) [1 to 50] or black-wash. Various dusting-powders may also be used. When itching is severe, Bulkley's liquor picis alkalinus diluted with 6 to 10 parts of water will often give relief. Bran or gelatin baths are sometimes useful. In some cases, ointments, such as Hebra's or oxide- of-zinc ointment or Lassar's paste, applied on cloths, give more relief than baths or lotions. Exfoliative pemphigus has been described on page 107, under the title " Bullous Exfoliative Dermatitis." HEMORRHAGES. Cutaneous haemorrhages are either traumatic or S3 r mptomatic. The former are such as result from mechanical injuries, or the bites or stings of insects. Flea-bites sometimes cause minute extravasations of blood in the cutis, which are of importance merely on account of the liability of mistaking them for other and perhaps graver troubles. The hemorrhagic spots are surrounded by an erythematous areola, and are generally attended by considerable itching. SYMPTOMATIC CUTANEOUS HAEMORRHAGES. I. PURPURA. Three varieties of purpura are usually described, viz., the simple, rheumatic, and hemorrhagic. The first and third probably differ merely in degree, while rheu- matic purpura seems to be an outward expression of the blood change produced by the rheumatic diathesis. The cutaneous manifestations differ very slightly. Simple purpura generally appears without constitu- tional disturbance. The eruption consists of " small, distinct, purple specks or patches," varying from a pin- head to a split pea in size. They may be disseminated over the surface, but are usually most numerous upon the lower extremities. There are no subjective symp- toms, unless the eruption is accompanied by nettle-rash, as sometimes happens. The prognosis is quite favorable. No treatment is necessary unless the general condition of the patient demands it. (119) 120 Diseases of the Skin. Rheumatic purpura occurs in small spots, usually localized about the knees and ankles, although it may be generally disseminated. It is accompanied b} T fever and rheumatic pains in the joints. The prognosis is really dependent upon the con- stitutional condition (rheumatism). Cases have ended fatally. The treatment is that of articular rheumatism. Sali- cylic acid, alkalies, or oil of wintergreen may be given in appropriate doses. No local treatment is necessary. Hsemorrhagic Purpura. — Hemorrhagic spots and patches of various sizes, varying from a pin-head to a small coin, appear upon the skin and visible mucous membranes. There may be bleeding from the nose and conjunctivae, spitting or vomiting of blood, and bloody discharges from rectum and bladder. Lassitude, loss of appetite, and digestive derangements usually precede the eruption for several days or weeks. The haemor- rhages from the mucous membranes may be profuse and cause grave depression of the vital powers. The causes of the disease are not known. In not a few cases it has seemed to be connected with the admin- istration of quinine. Iodide of potassium may also produce a purpuric eruption, as described in a previous chapter. The author has seen a purpuric eruption as one of the symptoms of poisoning by camphor. The prognosis is usually favorable. If uncomplicated with any acute, infectious^disease, or hereditary syphilis, hsemorrhagic purpura rarely ends in death. Treatment. — Ergot, aromatic sulphuric acid, and tincture of chloride of iron are the remedies usually depended upon in this disease. Quinine, alcoholic stimulants, good food, especially fats, and hygienic sur- roundings are important adjuncts in the treatment. For Haemorrhages. 121 the haemorrhages from the mucous membranes, cold or astringent applications or tampons ma}' be required. To promote the absorption of the effused blood in the lower extremities, properly applied bandages are often useful. Woodbury has found fluid extract of hamamelis (5ss-j) [2. to 4.] of benefit. The bleeding from the gums can be controlled, in a measure, by the local appli- cation of a 4-per-cent. solution of hydrochlorate of cocaine. The latter remedy was first used in this con- dition by Waugh. Poulet advises nitrate of silver in the form of pills, \ grain (.008) three times a day. II. SCURVY. Although scurvy is principally a disease of the general system, it has such marked cutaneous manifes- tations as to demand a brief reference here, especially with regard to its diagnosis from the affections just described. The symptoms of scurvy are lassitude, listlessness, pains in the limbs, depression of spirits ; the skin becomes pale and sallow. Petechial spots appear, generally first on the lower extremities. These may coalesce and form large, irregular patches. There is a puffy condition of the face, especially marked around the eyes. The scleral conjunctiva sometimes becomes of a deep red color, but this condition is not accompa- nied by pain or purulent discharge. The gums become spongy and swollen, sometimes to such an extent as to project completely beyond the teeth. They bleed upon the slightest touch. This condition of the gums is, however, not an invariable accompaniment of scurvy, as it is held to be by so many authorities. There is often great shortness of breath. The skin and deeper tissues are infiltrated with blood, and tumors and bruise- 6 F 122 Diseases of the Skin. like swellings are frequently produced by the slightest injuries. The skin is liable to break down upon very slight pressure, and result in fungoid ulcers, which are often very destructive. The diagnosis from hemorrhagic purpura is not dif- ficult if the S3 T mptoms of the two diseases be borne in mind. The pallor, listlessness, short-windedness, spongy condition of the gums, and bloating of the face are absent in purpura. The treatment of scurvy consists in suppling an abundance of fresh meat and fresh vegetables, and placing the patient in a dry, well-lighted apartment. Fresh lemon-juice is highly useful in the treatment of the disease, as well as in its prevention. As a preventive of scurvy at sea, two ounces of lemon- or lime-juice per week should be allowed to each person. When scurvy appears, the supply should be unrestricted. Locally, cocaine may be applied for the bleeding from the gums, as practiced by Waugh and Woodbury in purpura hemorrhagica. HYPERTROPHIES OF THE SKIN. The lrypertrophies of the skin may be limited to either of the histological strata of this organ, or may involve more than one. Hypertrophies of the epidermal layer, including pigmentary, epithelial, and papillary hypertropy, with their combinations, will be first con- sidered, and will be followed by the hyperplastic altera- tions of the vascular and connective tissues. I. Pigmentary Hypertrophies. FRECKLES. The sun's rays, acting as a stimulant through the peripheral-nerve terminations, sometimes cause an over- production of pigment in the skin, which is collected in small, roundish masses, causing yellowish or brownish spots. These spots are called freckles, and they are more frequent in persons of blonde complexion. They are especially distributed on those portions of the skin covered by clothing, and are more noticeable in summer. The Germans call them Sommerfiecke (summer spots). The discoloration is due, as above stated, to an increase in quantity of the normal pigment of the skin. The peculiar arrangement of the coloring matter is, doubtless, due to some action of the peripheral nervous system which is not clearly understood. Freckles are generally believed to disappear entirely during the winter season. Hebra has shown, however, that this is not the case, but that they grow so faint, in the absence of strong sunlight, that they are no longer noticeable. (123) 124 Diseases of the Skin. These little pigmentary blemishes can hardly be looked upon as a disease, but, from a cosmetic point of view, the}' are undesirable possessions. Hence, many persons, especially of the gentler sex, are anxious to get rid of them, and frequently apply to the physician for treatment. Inasmuch as the overproduction of pigment cannot be checked by any means at our command, a radical cure cannot be promised. The affection is, how- ever, amenable to palliative treatment. A number of applications may be used, which will cause a temporary disappearance of the spots. Salicylic acid is one of the most effectual of these remedies. It is used in alcoholic solution or in ointment (Formulae 43, 44). During the day a lotion of corrosive sublimate (gr. j to §j) [1 to 500] may be applied two or three times. These applications will soon produce a slight scaling and roughness of the skin, which is easily subdued by grycerite of starch. Should the skin become red and irritated, the applications must be intermitted until the irritation subsides. Should a stronger application be needed, Formula 45, recommended by McCall Anderson, may be tried. This will generally be found too irritant, however, for a skin that freckles. Glycerin lotion or glycerite of starch should be used during the day. In slight cases a lotion of borax and chlorate of potash (Formula 46) answers the purpose very well. CHLOASMA. This is a very frequent affection, occurring upon the face, especially in women suffering from disorders of the generative apparatus. It is rare in men. The common name for it is " moth-patches." The affection consists of yellowish-brown or brownish patches on Hypertrophies of the Skin. 125 various parts of the face. The forehead, chin, temples, and lower portions of the cheeks are principally affected. There is neither desquamation nor infiltration, and no subjective symptoms of any kind are present. The causes are obscure. It is known that the dis- coloration appears frequently during pregnancy, to disappear after parturition. It is also a frequent ac- companiment of uterine and ovarian disorders, and often disappears when these troubles are cured. The relation of cause and effect is, however, not known. Chloasma resembles very closely tinea versicolor, a discoloration of the skin due to a vegetable parasite. The latter, however, in nearly all cases occurs upon the chest, abdomen, arms, and neck, namely, upon those portions of the body covered by clothing. It is very rarely seen upon the face or hands. Chloasma, on the other hand, is almost entirely limited to the face. Tinea versicolor is slightly scaly and sometimes itches. Neither of these features is present in chloasma. Finally, the latter disease occurs nearly altogether in females after the age of puberty, and generally in those who suffer from some derangement of the generative organs. Tinea versicolor is often er seen in males. The treatment of chloasma consists in removing the uterine or ovarian disease, if any can be found, upon which the pigmentation depends, and in promoting the casting off of the superficial epidermal layer, so as to bring a less pigmented stratum to the surface. For this purpose, the applications recommended above, for freckles, will be found useful. The ointment or lotion of salicylic acid, or a lotion of corrosive sublimate, 2 to 3 grains to the ounce, may be used. Soft soap, spread upon strips of muslin like an ointment and allowed to remain upon the pigmented skin for several hours, will 126 Diseases of the Skin. produce a maceration and desquamation of the epider- mis, which often leaves the skin of a normal color after the redness has disappeared. The discoloration will, however, return, unless the use of one of the ointments or lotions mentioned is continued. The application which will give the most satisfactory results is an ointment of subnitrate of bismuth and white precipitate (Formula 47). This is applied to the discolorations at bed-time, and removed in the morning with Hebra's spiritus saponis kalinus. This ointment I have used in a large number of cases with uniform success. Sometimes it is a little too active, and produces irritation of the skin. Its use must then be intermitted for a few days, or the oint- ment made weaker. Some skins can stand a much stronger application, however, and I have used as much as two drachms of each of the active ingredients to the ounce of vaseline. The effect becomes manifest in a few days after beginning the use of the preparation. There is slight scaling and roughness of the skin, showing that a fur- furaceous desquamation of the epidermis is going on. In the course of ten to fifteen days the skin has become much paler, and, if the application be continued, the normal tint of the skin can be regained. This can, how- ever, only be maintained by the continued use of the ointment, unless the disease of the internal organs, upon which the discoloration depends, has been removed. The pigmentation of the skin from sunburn usually soon disappears after the cause has ceased acting. The bleaching can be somewhat hastened by a lotion of cor- rosive sublimate in emulsion of almonds (gr. j to §ij) [1 to 1000]. Hypertrophies of the Skin. 127 Permanent discolorations of the skin are sometimes produced by a mustard poultice or blister. Hence, care should be taken to avoid making these applications to the face, or upper part of the chest in women, as they may prove the source of an annoying or humiliating disfigurement in the latter. I have seen a number of cases in which the chest had become pigmented from mustard poultices, thus interfering with the wearing of dresses cut decollete. To many women this is not alto- gether a trifling matter. In these discolorations the use of the salic} T lic-acid lotion, already mentioned, will prove useful. The prog- nosis must not be too sanguine, however, as the pig- mentation is liable to return. In certain chronic cachectic conditions, as cancer, tuberculosis, malaria, and Addison's disease, there is often a local or general pigmentation of the skin. As a matter of course, in these cases, there can be no ques- tion of treatment of the discoloration. Scratching, friction, pressure, or constant irritation of the skin may be followed by localized pigmentations. Scars, especially those resulting from syphilitic infiltra- tions, also often leave dark spots and markings. They usually disappear without special treatment. II. Hypertrophies of the Epidermal and Papillary Layers. EPIDERxMAL hypertrophy of old age — keratosis senilis. In many elderly white persons, of both sexes, small patches of thickened epithelium xire found, variously scattered upon the face, trunk, and extremities. These plaques are usually in the shape of roundish, or irreg- ular, slightly elevated, brownish or blackish collections. Sometimes they are dry and hard, or cornified, but 128 Diseases of the Skin. oftener the patch is greasy to the touch, friable, and easily scraped off with the finger-nail, leaving a moist and- reddened or slightly bleeding base. When these epithelial patches are scraped or rubbed off, they rapidly re-form, causing the individuals so affected much annoyance, and often uneasiness, by their persistence. Physicians generally regard this as a trifling ail- ment, and pay no attention to it; but careful observa- tion will show that, not rarely, the constant epithelial hyperplasia results in an at}j ( 4. ). Tr. capsici, . . . . 3j ( 4. ). Vaselini, gij (60. ). 01. bergamii, .... gtt. iv ( 0.2). M. ft. ungt. 292 Formulae. 14— R Sulplmris praecip., . . . 3j ( 4 ). Ungt. aquae rosae, . . . §ij (60.). M. ft. ungt. 15 — R Sulphuris praecip., . . . £j ( 4. ). Acidi salicylici, . . . gr. xx ( 1.3). Vaselini, gij (60. ). M. ft. ungt. 16— B 01. nisei crudi, . . . 5j (4.). Ungt. aquae rosae, . . . gij (60.). M. ft. ungt. 17— R Ferri sulpli., Potassii carb., . . . . aa 3j (4.). M. ft. pil. no. xl. S. : One or two three times a day. An excellent ferruginous tonic. 18 — R Liq. potassii arsenitis, Syrupi simplicis, . . aa 3ij ( 8.). Vini ferri, . . . . giss (45.). Aquae, §ij (60.). M. S. : Teaspoonful immediately before or after each meal. (Each teaspoonful contains nearly 4 minims of Fowler's solution.) \&— R Tr. ferri chlor., . . . gss (15.). Acidi phosph. dil., . . . 3ij ( 8.). Syrupi limonis, . q. s. ft. giij (90.). M. S. : Teaspoonful in water after each meal. 20— R Tr. calumbae, Aquae calcis, . . aa %iv (120.). M. S. : Tablespoonful at meal-time. 21— R Magnesii sulph., . . . gj (30.). Tr. ferri chlor., . . . 3j ( 4.). Aquae, . . . q. s. ft. giv (120.). M. S. : Tablespoonful to be taken in a tumblerful of water before breakfast. Formulae. 293 22— R Aceti, 3ij. ( 8.). Glycerini, .... 3iij (12.). Kaolini, 3iv (16.). M. ft. pasta. 23— R Pulv. amyli, . . . . Sij ( 8.). Ungt. aqua? rosse, . . . gj (30.). M. ft. ungt. 24 — R Potassii acetat., Ext. taraxaci fl., . . aa §j (30.). Aquae, . . . q. s. ft. giij (90.). M. S. : Teaspoonful in a tumblerful of water three times a day, after meals. 25 — R Potass sulphureti, Zinei sulpliatis, . . aa £ss (2.). Glycerini, . . . .. . 3j ( 4.). Aquae rosae, . q. s. ft. giij (90.). M. S. : Apply two or three times daily. 26 — R Sulplmris praecip., Potassii carb., Sp. vini rectif., Glycerini, . . aa 3j (4.). M. ft. pasta. S. : To be applied at night in indurated acne. 27 — R Acidi arseniosi, . . . gr. ij ( .13). Pulv. piperis nigr. , Pulv. glycyrrhizse, . . aa gr. xxxij (2. ). M. ft. pil. no. xxxij. S. : One three times a day. 28— R Magnesii sulph., . . . gj (30.). Tr. ferri chlor., . . . 3iss ( 6.). Aqua?, . . q. s. ft. giv (120.). M. S. : Tablespoonful in a gobletful of water every morning. 294 Formulae. 29— R Tr. ferri chlor., . . . 3iij (12.). Acidi pliospli. dil., . . - 3ij ( 8.). Syrupi liinonis, . q. s. ft. Jjij (60.). M. S. : Teaspoonful in water after each meal. 30 — R Potassii acetat., Ext. taraxaci fl., . aa gj (30.). Aquae, . . . q. s. ft. §iij (90.). M. S. : Teaspoonful in a tumblerful of water three times a day, after meals. lassar's paste. 31 — R Acidi salicylici, . . e gr. x ( .65). Pulv. amyli, Zinci oxidi, . . . aa gij ( 8. ). Vaselini, gss (16. ). M. ft. ungt. 32— R 01. rusci, 3ss ( 2.). Ungt. aq. rosae, . . gj (30.). M. ft. ungt. 33— R Pulv. zinci oxidi, . . . 3ij ( 8.). Mucil. acaciae, . . . • 3j ( 4.)' Emuls. amygdal., . . . §ij ( 60.). Aquae rosae, . q. s. ft. giv (120.). M. S. : Apply every three or four hours. 34 — R Hydrarg. oxidi flav., . . gr. x ( .65). Pulv. amyli, Vaselini, . . . aa gj (30. ). M. ft. ungt. LIQUOR PICIS ALKALINUS. 35— R Picis liquidae, . gj (30.). Potassae causticae, . . . gss (15.). Aquae, . . . . giiss (75.). M. S. : Dissolve the potash in the water and add slowly to the tar, in a mortar, with friction. To be used diluted with 1, 2, 4, or 8 parts of water. Formulae. 295 36— B Hydrarg. bichlor., . . gr. iv ( .25). Tine, benzoini co., . . . §j (30. ). M. S. : Apply ^with a camel's hair pencil. 37— B SaloL, ^Ether., .... aa 3ss (2.). Collodii flex., . ad 3ij (8.). M. Paint on chapped nipples. 38 — B Pulv. zinci oxidi, gss (16.). Pulv. caniphorae, . 3iss ( 6.). Pulv. amyli, . Si (32.). M. S. : Dusting-powder. 39— B Tr. lobeliae, gij (60.). Sodii bicarb., . 3j ( 4.). Aquae, .... §ij (60.). 40 — B Pulv. camphorae, # ■gr. x ( .6). Cretae preparatae, . SJ (30. ). 01. lini, .... . ftl (60. ). Bals. Peruv., . . gtt. XX ( 1. ). M. ft. pasta. 41 — B Potassii acetatis, . . . gj (30.). Ext. fl. taraxaci, . . . §ij (60.). M. S. : Teaspoonful three times a day in a tumblerful of water. 42— B Calcis vivae, . . . . gss ( 16.). Sulphuris sublim., . . . §j ( 30.). Aquae, gx (300.). Boil the mixture until it measures four fluidounces (120.), and filter. 43 — B Acidi salicylici, . . . 3ss ( 2.). Spiriti myrciae, . . . gij (64.). S. : Apply night and morning with a soft rag or sponge. . m ( 8.) ■ 3j ( 4.) • Sss ( 16.) • 3iij ( 12.) - In (190.) 296 Formulae. 44 — R Acidi salicylici, . . . 3ss ( 2.). Hydrarg. ammoniati, . . 3j ( 4.). Ungt. aquae rosae, . . . ^j (32.). M. ft. ungt. S. : Apply at night. 45 — R Saponis viridis, . . . gij (64. ). Sp. vini rectificati, . . . gj (32. ). Hydrarg. bichloridi, . . gr. vj ( .4). 01. lavandulas, . . . gtt. x ( .6). M. Solve et filtra. S. : Apply at night, and wash it off in the morning. 46 — R Sodii boratis, . Potassii chlorat., Glycerini, Sp. vini rectif., Aquas rosae, . . q. s. ft, M. S. : Apply with a soft sponge several times a day. 47 — R Bismuthi subnitrat., Hydrarg. ammoniat., . aa £j ( 4.). Vaselini, !§j (32.). M. ft. ungt. 48 — R Aeidi salicylici, . . gr. x-xxx ( .7-2.). Sulplmris praecip., Pulv. amyli, Ungt. aquas rosae, M. ft. ungt. 49 — R Acidi salicylici, ... gss ( 2. ). Ext. cannabis Indicae, . . gr. v ( .3). Collodii, . . . . . gij (64. ). M. S. : Put a small camel's hair pencil in the cork. 50 — R Hydrarg. bichloridi, . . gr. xv ( 1.). Collodii flexilis, . . . §j (32.). M. S. : Paint on the warts once a day until they drop off. 3ss ( 2- ) §ss (16. ) a (32. ) Formulae. 297 51 — R Adipis benzoati, Glycerini, Petrolati, .... M. S. : Apply after bathing. 52 — R Potassii bicarb., Glycerini, Ungt. bisrnuthi oleatis, . Si ( 4.). m*i ( b.). gss (16.). Siij ( 12.). giss ( 48.). giv (128.).— M. DEPILATORIES. 53 — B Barii sulphidi, Zinci oxidi, Coccionellae, 5iss ( 6. ). 3vj (24. ). gr.j( .065).— M. 3ss ( 2.). Jss (16.). 3« ( 3.). 54 — B Arsenici sulphidi flavse, Calcis vivse, Farinae tritici, . Mix with water to form a paste, and apply with a wooden spatula. In three or four minutes the paste is scraped off, the part washed with hot water, and a dusting-powder of starch or oxide of zinc applied. 55 — R Calcii hydrosulphureti, . . 3ij (8. ). Glyceriti amyli, Pulv. amyli, . . aa 3j (4. ). 01. neroli, .... gtt. j ( .065).— M. This is applied in a thick layer, and washed off in ten to fifteen minutes with warm water. Afterward a dusting-pow- der should be applied. 5Q — R Sodii boratis, . . £iiss ( 10.). Glycerini, Tr. benzoini, . aa 3j ( 4.). Aquae cologniensis opt., . . £ 8 s ( 16.). Aquae aurantii flor., q. i 3. ft. gvj (192.). 57— B Tinct. capsici, .... gss ( 16.). Glycerini, . 3ij ( 8.). Sp. myrciae, . . q. s. ft. gviij (256.). M. S. : To be well rubbed into the scalp nightly. 13* 298 Formulae. 58 — R Resorcini puri, Sp. myrciae, 59 — R Sulphuris praecip., Sp. myrciae, 60 — R Sulphuris praecip., Ungt. aquae rosae, M. ft. ungt. 61 — R Resorcini puri, . Ungt. aquae rosae, M. ft. ungt. 62— R Acidi salicyli, . Sulphuris praecip., Ungt. aquae rosae, M. ft. ungt. 63 — R Acidi carbolici, . Aquae, 64 — R Acidi salicylici, Acidi borici, Glycerini, Sp. vini rectif., Aquae, * 65 — R Acidi carbolici, . Lanolini, . M. ft. ungt. 66— R Thymolis, . Ungt. aquae rosae, M. ft. ungt. CAMPHOR 67 — R Campliorae, Chlorali hydrat , M. ft. solutio. 68— R Cocaini, . . . Lanolini, . M. ft. ungt. 3ss-j ( 2.-4.). gviij (256. ).~M. 3ss ( 2.). gviij (256.).-M. 3ss ( 2.). 3J (32.)- gr. vx-xx ( 1.-1.3). Ij (32. )• gr. x( .7). 3ss ( 2. ). Ij (32. )• 3i-iij (4.-12.). Oj (500. ).— M. 3ij 3j ( 8.) ( 8.) 4.). aa gj ( 30.). ad gviij (250.).— M. . HIM -7). • H (32.). • gr.x( .7). • Jj (32. ). CHLOKAL. . aa 3ij (8.). . gr. x ( .7). • Ei (32. ). INDEX. Acne, 22 causation of, 24 treatment of, 25 Acne rosacea?, 28 treatment of, 29 Ainhum, 189 Aix-la-Chapelle, 279 Alopecia, 163 areata, 165 Anaesthesia, 196 Angioma, 192 pigmentosum, 140 treatment of, 193 Angiomyoma, 190 Anidrosis, 8 Anthrax, 88 Area eel si, 165 Arsenic in eczema, 56 Asteatosis, 22 Atrophia cutis, 140 Atrophies, 159 Atrophy, cutaneous, 160 of pigment, 161 of the hair, 163 of the skin, 159 unilateral, of the face, 160 Bacterium foetidum, 6 Baldness, 163 cause of, 163 treatment of, 166 Balzer on hypodermatic use of mer- cury, 277 Body-louse, 207 Brassavola on syphilitic alopecia, 266 Bromidrosis, 7, 9 Bullous exfoliative dermatitis, 107 Bumstead and Taylor on mercurial inunction, 274 Burns, 79 Callosities, 131 Cancer of skin, 168 Chloasma, 124 Chromidrosis, 9 Chyluria, 158 Colored sweat, 9 Comedo, 18 Condylomata lata, 236 Conical papular syphilide, 229, 230 diagnosis of, 230 Connective-tissue new formations, 173 Contagious impetigo, 113 Corn-cures, 134 Corns, 131 diagnosis of, 132 treatment of, 133 Crab-louse, 208 Crural eczema, 54 Dandruff, 164 Dermatalgia, 196 Dermatitis calorica, 79 exfoliativa, 104 exfoliative, of infants, 104 gangrenosa, 83 herpetiformis, 96 medicamentosa, 81 traumatica, 77 venenata, 78 Disse and TaguchPs microbe of syphilis, 254 Drug eruptions, 81 Du Castel on hypodermatic use of mercury, 277 Dupuytren's pills, 271 Duration of treatment in syphilis, 282 Eczema, 37 acute, 40 chronic, 44 diagnosis of, 54 general considerations, 37 local treatment of, 58 localization of, 45 treatment of, 56 varieties of, 40 of anus, 53 of face, 46 of joints, 53 of legs, 54 (299) 300 Index. Eczema of nipple, 50 of perineum, 53 of scalp, 45 of the genitals, 52 of the hands and feet, 54 of the trunk, 49 Ecthyma, 112 Electrolysis in hypertrichosis, 147 in keloid, 174 Elephantiasis arabum,155 graecorum, 178 Elephant's leg, 155 Epidermal hypertrophies, 127 Epithelial molluscum, 130 new formations, 168 Epithelioma, 168 diagnosis of, 172 Erysipelas, 84 causation of, 85 treatment of, 85 Erythema, 66 congestive, 67 exudative, 67 intertrigo, 68 multiforme, 69 symptomatic, 67 syphilitica, 220 treatment of, 68 Erythematous syphilide, 220 diagnosis of, 224 minute anatomy of, 228 prognosis of, 228 Exfoliative dermatitis, 104 Favus, 200 Feigwarzen, 236 Fibroma, 174 Fibromyoma, 190 Filaria sanguinis hominis, 157 Fish-skin disease, 141 Flat papular syphilide, 231 Flesh-worms, 19 Fournier on the pigmentary syphi- lide, 263 Freckles, 123 Frost-bite, 80 Furuncle, 86 Gangrenous dermatitis, 83 General exfoliative dermatitis, 107 Gibert's syrup, 273 Gonorrhoeal erythema, 226 Giintz on potassium bichromate in syphilis, 281 Gummous syphilide, 252 Gummy tumor, 252 Hair, hypertrophy of, 144 Head-louse, 207 Hebra on hypodermatic use of mercury, 275 Hemorrhages of the skin, 118 Herpes facialis, 91 of the genitals, 91 praeputialis, 91 simplex, 91 zoster, 92 causation of, 93 distribution of, 94 treatment of, 95 Herpetiform syphilide, 241 Hide-bound skin, 152 Hilton on location of varicose ulcers, 261 Hirsuties, 144 Horns, cutaneous, 137 Hot springs of Arkansas, 279 Hygienic treatment in syphilis, 281 Hyperesthesia, 196 Hyperidrosis, 5 treatment of, 6 Hypertrichosis, 144 causes of, 145 treatment of, 147 Hypertrophies of the skin, 123 Hypodermatic use of mercury, 275 Ichthyosis, 141 treatment of, 143 Impetigo, 112 contagiosa, 113 Impetiginous syphilide, 241 Indurative oedema of infants, 154 Inflammations of the skin, 66 Inunction-cure for syphilis, 274 Itch-mite, 205 Kaposi on histology of the gummy nodule, 254 Keloid, 173 Keratosis pilaris, 129 senilis, 127 Kerion, 202 Keyes on "tonic treatment" of syphilis, 228 Large papular syphilide, 231 pustular syphilide, 243 diagnosis of, 243 Lenticular pustular syphilide, 243 syphilide, 231 Lepra, 178 syphilitica, 232 Index. 301 Leprosy, 178 anaesthetic, 180 causes of, 181 diagnosis of, 181 treatment of, 181 tubercular, 179 Leucoderma, 161 Lewin on hypodermatic use of mer- cury, 275 Lichen, 109 planus, 109 ruber, 109 scrofulosus, 110 syphiliticus, 229 Lipoma, 175 Local exfoliative dermatitis, 108 treatment of syphilides, 284 Lupus erythematosus, 183 diagnosis of, 185 treatment of, 185 vulgaris, 185 diagnosis of, 187 treatment of, 188 Lustgarten's syphilis microbe, 254 Lymphangioma, 192 Lymphangio-myoma, 190 Lymph-scrotum, 158 Macula syphilitica, 220 Macular syphilide, 220, 262 McDade's formula, 280 Madura foot, 190 Malignant pustule, 90 Mandelbaum on hypodermatic use of mercury, 277 Maunder on diagnosis of ulcerating syphilide," 261 Massa on syphilitic alopecia, 266 Mercurial baths in syphilis, 278 fumigations in syphilis, 277 Mercury in syphilis, 269 Microsporon furfur, 203 Miliary syphilide, 229, 241 Milium, 21 Moist papular syphilide, 236 diagnosis of, 239 Molluscum epitheliale, 130 Morphoea, 153 Moth-patches, 124 Mucous patches, localization of, 238 of the skin, 236 Myoma, 190 Nsevus, neurotic, 139 pigmentary, 138 Nrevus pilosus, 138 Neuroma, 191 Neuroses, 196 New formations, 168 Nodular syphilide, 252 differential diagnosis of, 254 minute anatomy of, 253 prognosis of, 257 Odorous sweat, 9 Paget's disease, 50 Papular syphilide, 228 minute anatomy of, 239 prognosis of, 240 Papulo-granular syphilide, 229 -squamous syphilide, 232 Parasites, animal, 205 vegetable, 199 Parasitic skin diseases, 199 Pediculosis, 206 Pedi cuius capitis, 207 corporis, 207 pubis, 208 Pemphigus, 114 acute, 104 diagnosis of, 115 foliaceous, 107 treatment of, 118 Perforating ulcer of the foot, 191 treatment of, 191 Perspiration, chemistry of, 3 secretion of, 4 Perspiratory glands, anatomy and physiology of, 3 Phlegmon, 89 Pigmentary hypertrophies, 123 syphilide, 262 diagnosis of, 264 prognosis of, 265 Pillon on the pigmentary syphilide, 263 Pityriasis rubra, 107 versicolor, 202 Plaques muqueuses, 236 Podelcoma, 189 Porcupine disease, 142 Post-infective stage of syphilis, 247 Potassium bichromate in syphilis, 281 J Prickly heat, 10 Prurigo, 111 Pruritus, 197 Psoriasis, 98 diagnosis of, 99 treatment of, 101 302 Index. Purpura, 119 hemorrhagica, 120 rheuinatica, 120 simplex, 120 Pustula foeda ani, 236 Pustular syphilide, 240 in negroes, 244 prognosis of, 245 Pustule ortiee, 220 Rhinoscleroma, 176 Ringworm, 200 diagnosis of, 202 treatment of, 203 Rosacea, 194 Roseola urticata, 222 syphilitica, 220 Rupia, 243 Salivation in syphilis, 284 Sarcoma, 177 Scabies, 205 diagnosis of, 206 treatment of, 206 Scaly papular syphilide, 232 diagnosis of, 234 Scarenzio on hypodermatic use of mercury, 275 Schleimpapeln, 236 Sclerema neonatorum, 154 Scleroderma, 152 Scrofuloderma, 182 Scurvy, 121 Sebaceous cyst, 21 glands, an atom v and physiology of, 15 Seborrhoea, 16 diagnosis of, 17 oleosa, 17 sicca, 16 treatment of, 18 Shingles, 92 Shoemaker on hypodermatic use of mercury, 276 Sigmund on inunction cure, 274 Sims on McDade's formula in syphi- lis, 280 Skin cancer, 168 Small papular syphilide, 229, 241 diagnosis of, 242 Spiritus saponis kalinus, 18 Squamous syphilide, 232 Steatoma, 21 Striae atrophica, 159 Sudamen, 10 Sweat, secretion of, 4 Sweat, chemistry of, 3 derangements of secretion of, 5 glands, anatomy and physiology of, 3 number of, 3 Sweat-blisters, 10 Sweating sickness, 5 Sycosis, 30 causation of, 31 diagnosis of, 32 parasitica, 202 treatment of, 34 Syphilide merisee, 231 Syphilides, chronological sequence of, 211 classification of, 210 color of, 214 configuration of, 216 diagnostic features of, 211 general morphology of, 210 general treatment of, 269 localization and distribution of, 213 multiformity of, 21 6 precoces, 212 racial peculiarities of, 217 subjective symptoms of, 217 tardives, 112 Syphiloderma pigmentosum, 262 Syphilis cutanea maculosa, 220 in the negro, 217 of the skin, 209 Syphilitic acne, 241 alopecia, 266 diagnosis of, 267 disease of the nails, 268 ecthyma, 243 eczema, 224 gumma, 252 impetigo, 241 lupus, 248 psoriasis, 232 Syphiloma, 252 Syrupus trifolii comp., 280 Taches syphilitiques, 262 Telangiectasis, 194 Tertiary syphilitic eruptions, 246 Tinea circinata, 201 favosa, 200 sycosis, 202 tonsurans, 202 trichophytina, 201 versicolor, 203 treatment of, 204 Treatment of the syphilides, 268 Index. 303 Tubercular syphilide, 248 diagnosis of, 250 prognosis of, 251 Ulcerating syphilide, 257 diagnosis of, 259 prognosis of, 262 Ungiarola, 268 Uridrosis, 10 Urinous sweat, 10 Urticaria, 70 causation of, 71 diagnosis of, 73 pathology of, 74 treatment of, 76 Van Swieten's liquor, 271 Variolaform syphilide, 243 Vascular new formations, 192 Virchow on histology of syphilitic infiltrations, 253 Vitiligo, 161 Warts, 134 electrolysis in, 136 Wen, 21 Xanthoma, 176 Xeroderma of Hebra, 140 simplex, 142 Zeissl on treatment of moist pap- ules, 286 Zittmann's decoction, 281 Zoster, 92 CATALOGUE OF THE PUBLICATIONS OF F\ A.. 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Price, in United States and Canada, post-paid, $1.00, net ; Great Britain, 5s. 6d. ; France, 6 fr. 20. CATHELL— Book on the Physician Himself, and Things that Concern His Reputation and Success. By D. W. Cathell, M.D., Baltimore, Md. Being the Ninth Edition (enlarged and thoroughly revised) of "The Physician Him- F. A. Davis, Philadelphia, Pa. self, and What He Should Add to His Scientific Acquirements in Order to Secure Success. " In one handsome Octavo volume of 298 pages, bound in Extra Cloth. Price, in United States and Canada, post-paid, $2. 00, net ; Great Britain, lis. 6d. ; France, 12 ir. 40. This remarkable book has passed through eight (8) editions in less than five years, has met with the unanimous and hearty approval of the profession, and is practically indispensable to every young graduate who aims at success in his chosen profession. It has just undergone a thorough revision by the author, who has added much new matter, covering many points and elucidating many excellent ideas not included in former editions. CLEVENGER — Spinal Concussion. Surgically Consid- ered as a Cause of Spinal Injury, and Neurologi- cally Restricted to a Certain Symptom Group, for which is Suggested the Designation "Erichsens Disease," as One Form of the Traumatic Neuroses. By S. V. Clevenger, M.D., Consulting Physician, Reese and Alexian Hospitals; Late Pathologist, County Insane Asylum, Chicago; Member of numerous American Scientific and Medical Societies; Col- laborator American Naturalist, Alienist, and Neurologist, Journal of Neurology and Psychiatry, Journal of Nervous and Mental Diseases; Author of " Comparative Physiology and Psychology," etc. For more than twenty years this subject has occasioned bitter con- tention in law courts between physicians as well as attorneys, and in that time no work has appeared that reviewed the entire field judicially until Dr. Clevengers book was written. It is the outcome of five years' special study and experience in legal circles, clinics, hospital and private practice, in addition to twenty years' labor as a scientific student, writer, and teacher. Every Physician and Laioyer should own this work. In one handsome Royal Octavo volume of nearly 400 pages, with 30 Wood-Engravings. 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A Practical Investigation of the Clini- cal and Therapeutic Value of the Gases in Medical and Surgical Practice, with Especial Reference to the Value and Availability of Oxygen, Nitrogen, Hydrogen, and Nitrogen Monoxide. By J. N. Demarquay, Surgeon to the Municipal Hospital, Paris, and of the Council of State ; Member of the Imperial Society of Sur- gery; Correspondent of the Academies of Belgium, Turin, Munich, etc. ; Officer of the Legion of Honor ; Chevalier of the Orders of Isa- bella-the-Catholic and of the Conception, of Portugal, etc. Translated, with notes, additions, and omissions, by Samuel S. Wallian, A.M., M.D., Member of the American Medical Association ; Ex-President of the Medical Association of Northern New York ; Member of the New York County Medical Society, etc. In one handsome Octavo volume of 316 pages, printed on fine paper, in the Best Style of the Printer's Art, and Illustrated with 21 Wood-Cuts. 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Price, in United States and Canada, post-paid, $1.75, net ; Great Britain, 10s. ; France, 13 fr. 20* F. A. Davis, Philadelphia, Pa. EISENBERG — Bacteriological Diagnosis. Tabular Aids for Use in Practical Work. By James Eisexberg, Ph.D., M.D., Vienna. Translated and augmented, with the permission of the author, from the latest German Edition, by Norval H. Pierce, M.D., Surgeon to the Out-Door Department of Michael Reese Hospital ; Assistant to Surgical Clinic, College of Physicians and Surgeons, Chicago, 111. In one Octavo volume, handsomely bound in Cloth. In Press. GOODELL — Lessons in Gynaecology. By William Goodell, A.M., M.D., etc., Professor of Clinical Gynaecology in the University of Pennsylvania. With 112 illustra- tions. Third Edition, thoroughly revised and greatly enlarged. One volume, large Octavo, 578 pages. Price, in United States and Canada, Cloth, S5.00 ; Full Sheep, S6.00. Discount, 20 per cent., making- it, net, Cloth, §4.00; Sheep, §4.80. Postage, 27 cents extra. 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Introductory. II. The Infant. III. Childhood. IV. Adolescence of the Male. V. Adolescence of the Female. VI. Marriage: The Husband. VII. The Wife. VIII. Hus- band and Wife. IX. To the Unfortunate. X. Origin of the Sex. In one neat 16mo volume, bound in Extra Cloth. Price, in United States and Canada, post-paid, SI. 00 ; Great Britain, 6s. 6d. ; France, 6 fr. 20. HARE — Epilepsy : its Pathology and Treatment. Being an Essay to which was Awarded a Prize of Four Thousand Francs by the Academie Royal de Mede- cine de Belgiaue, December 31, 1889. By Ho bart Amort Hare, M.D. (University of Pennsylva- nia), B.Sc, Clinical Professor of the Diseases of Children, and Demonstrator of Therapeutics in the University of Pennsylvania; Catalogue of Medical Publications. Laureate of the Royal Academy of Medicine in Belgium, of the Medical Society of London, etc. 12mo. 228 pages. Neatly bound in Dark-blue Cloth. No. 7 in the Physicians' and Students' Ready -Refer- ence Series. 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Designed by Johx M. Keating, M.D. This record-book is small, neat, and complete, and embraces all the principal points that are required by the different companies. It is made in two sizes, viz. : No. 1, covering one hundred (100) examinations, and No. 2. covering two hundred (200) examinations. The size of the book is 7 x 3% inches, and can be conveniently carried in the pocket. Prices, post-paid : No. 1, for 100 Examinations, bonnd in Cloth, United States and Canada, 50 Cents, net ; (ireat Britain, 3s. 6d. ; France, 3 fr. 60. Xo. 2, for 200 Ex- aminations, hound in Full Leather, with Side-Flap, United States and Canada, .^1.00, net; Great Britain, 6s. 6d.; France, 6 fr 20. m KEATING AND EDWARDS -Diseases of the Heart and Circulation in Infancy and Adolescence. With an Appendix entitled u Clinical Studies on the Pulse in Childhood.'' 1 By Johx M. Keatixo. 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Rohe, M.D., Professor of Obstetrics and Hygiene, College of Physicians and Surgeons, Balti- more ; Visiting Physician to Bay View and City Hospitals ; Director of the Maryland Maternite ; Associate Editor "Annual of the Uni- versal Medical Sciences," etc. Profusely Illustrated by Wood-Engrav- ings and Original Diagrams, and published in one handsome Royal Octavo volume of 383 pages, bound in Extra Cloth. Price, in United States and Canada, post-paid, §§2.00, net; Great Britain, lis. 6d. ; France, 12 fr. 40. The constantly increasing demand for this work attests its thorough reliability and its popularity with the profession, and points to the fact that it is already the standard work on this very important sub- ject. The part on Physical Electricity, written by Dr. Liebig, one of the recognized authorities on the science in the United States, treats fully such topics of interest as Storage Batteries, Dynamos, the Elec- tric Light, and the Principles and Practice of Electrical Measurement in their Relations to Medical Practice. Professor Rohe, who writes on Electro-Therapeutics, discusses at length the recent developments of Electricity in the treatment of stricture, enlarged prostate, uterine fibroids, pelvic cellulitis, and other diseases of the male and female gen i to-urinary organs, etc., etc. MANTON— Childbed ; its Management; Diseases and their Treatment. By Walter P. Manton, M.D., Visiting Physician to the De- troit Woman's Hospital; Consulting Gynaecologist to the Eastern Michigan Asylum; President of the Detroit Gynaecological Society; Fellow of the American Society of Obstetricians and Gynaecologists, and of the British Gynaecological Society ; Member of Michigan State Medical Society, etc. In one neat 12mo volume. N~o. in the Phy- sicians' and Students' Ready-Reference Series. In Preparation. MASSEY — Electricity in the Diseases of Women. With Special Reference to the Application of Strong Currents. By G. Betton Massey, M.D., Physician to the Gynaecological Department of the Howard Hospital; Late Electro-Therapeutist to the Philadelphia Orthopaedic Hospital and Infirmary for Nervous Diseases; Member of the American Neurological Association, of the Philadel- phia Neurological Society, of the Franklin Institute, etc. Second Edition. Revised and enlarged. With New and Original Wood- Engravings. Handsomely bound in Dark-Blue Cloth. 240 pages. 12mo. No. 5 in the Physicians' and Students' Ready-Reference Series. Price, in United States and Canada, post-paid, §§1.50, net; Great Britain, 8s. 6d. ; France, 9 fr. 35. F. A. Davis, Philadelphia, Pa. "A new edition of this practical manual attests the utility of its exist- ence and the recognition of its merit. The directions are simple, easy to fol- low and to put into practice, the ground is well covered, and nothing is assumed, the entire book being the record of ex- perience." — Journal of Nervous and Mental Diseases. "It is only a few months since we noticed the first edition of this little book ; and it is only necessary to add now that we consider it the best treatise on this subject we have seen, and that the improvements introduced into this edition make it more valuable still." — Boston Medical and Surgical fourn. "The style is clear, but condensed. Useless details are omitted, the reports of cases being pruned of all irrelevant material. The book is an exceedingly valuable one, and represents an amount of study and experience which is only appreciated after a careful reading." — Medical Record. MEARS— Practical Surgery. By J. Ewing Mears, M.D., Lecturer on Practical Surgery and Demonstrator of Surgery in Jefferson Medical College ; Professor of Anatomy and Clinical Surgery in the Pennsylvania College of Dental Surgery, etc. Third Edition. Revised and Enlarged. In Prep- aration. Medical Bulletin Visiting List, or Physicians' Call Record. Arranged upon an Original and Con- venient Monthly and Weekly Plan for the Daily Recording of Professional Visits. This is, beyond question, the best and most convenient time- and labor- saving physicians' pocket record-book ever published. Phy- sicians of many years 7 standing and with large practices pronounce this the best list they have ever seen. It is handsomely bound in fine, strong leather, with flap, including a pocket for loose memoranda, etc., and is furnished with a Dixon lead-pencil of excellent quality and finish. It is compact and convenient for carrying in the pocket. Size, 4 x 6X inches. In three styles. Send for Descriptive Circular. Net Price, post-paid; No. 1, Regular Size, for 70 patients daily each month for one year, United States and Canada, $1.25; France, 7 fr. 75. No. 2, Large Size, for 105 patients daily each month for one year, United States and Canada, $1.50; France, 9 fr. 35. No. 3, in which "The Blanks for Recording Visits in" are in six (6) removable sections, United States and Canada, $1.75 ; France, 13 fr. 30. Special Edition for Great Britain only, 4s. 6d. MICHENER — Hand-Book of Eclampsia; or, Notes and Gases of Puerperal Convulsions. By E. Michener, M.D. ; J. H. Stubbs, M.D. ; R. B. Ewing, M.D.; B. Thompson, M.D.; S. Stebbins, M.D. 16mo. Cloth. Price, 60 cents, net ; Great Britain, 4s. 6d. ; France, 4 fr. SO. 10 Catalogue of Medical Publications. NISSEN — A IVSanua! of Instruction fop Giving Swedish Movement and Massage Treatment. By Prof. Hartvig Nissen, Director of the Swedish Health In- stitute, Washington, D.C. ; late Instructor in Physical Culture and Gymnastics at the Johns Hopkins University, Baltimore, Md, ; Author of "Health by Exercise without Apparatus/' Illustrated with 29 Original Wood-Engravings. In one 12mo volume of 128 pages. Neatly bound in Cloth. Price, in United States and Canada, post-paid, §1.00, net ; Great Britain, 6s. ; France, 6 fr. 20. Physicians' All-Requisite Time- and Labor- Saving Account- Book. Being a Ledger and Account-Book for Physicians 1 Use, Meeting all the Requirements of the Law and Courts. Designed by William A. Seibert, M.D., of Easton, Pa. There is no exaggeration in stating that this Account-Book and Ledger re- duces the labor of keeping your accounts more than one-half, and at the same time secures the greatest degree of accuracy. To all physicians desiring a quick, accurate, and comprehensive method of keeping their accounts, we can safely say that no book as suitable as this one has ever been devised. Prices, Shipping Expenses Prepaid : No. 1, 300 Pages, for 900 Accounts per Year, Size 10 x 12, Bound in %-Russia, liaised Back-Bands, Cloth Sides, in United States, $5.00 ; Canada (duty paid), 85.50, net; Great Britain, 28s.; France, 30 fr. 30. No. 2, 600 Pages, for 1800 Accounts per Year, Size 10 x 12, Bound in %-Russia, Raised Back- Bands, Cloth Sides, in United States, $8.00 ; Canada (duty paid), 88.80; net ; Great Britain, 42s. ; France, 49 fr. 40. A circular showing the plan of the book will be sent free to any address on application. Physicians' Interpreter: In Four Languages (English, French, German, and Italian). Specially arranged for diagnosis by M. von V. The object of this little work is to meet a need often keenly felt by the busy physician, namely, the need of some quick and reliable method of communicat- ing intelligibly with patients of those nationalities and languages un- familiar to the practitioner. The plan of the book is a systematic arrangement of questions upon the various branches of Practical Medicine, and each question is so worded that the only answer re- quired of the patient is merely Yes or No. The questions are all numbered, and a complete Index renders them always available for quick reference. The book is written by one who is well versed in English, French, German, and Italian, being an excellent teacher in those languages, and who has also had considerable hospital experience. Bound in full Russia Leather, for carrying in the pocket. Size, 5 x 2% inches. 206 pages. Price, in United States and Canada, post-paid, $1,00, net; Great Britain, 6s. ; France, 6 fr. 20. F A. Davis, Philadelphia, Pa. 11 PRICE AND EAGLETON— Three Charts of the Nervo- Vascular System. Part I. — The Nerves. Part II. — The Arteries. Part III. — The Veins. A New edition. Revised and Perfected. Arranged by W. Henry Price, M.D., and S. Potts Eagletox, M.D. Endorsed by leading Anatomists. "The Xervo- Vascular System of Charts" far excels every other system in their completeness, compactness, and accuracy. Clearly and beautifully printed upon extra-durable paper. Each chart measures 19 x 24 inches. Price, in the United States and Canada, post-paid, 50 cents, net, Complete ; Great Britain, 3s. 6d. ; France, 3 fr. 60. PURDY— Diabetes: its Cause, Symptoms, and Treat- ment. By Chas. W. Purdy, M.D. (Queen's University), Honorary Fellow of the Royal College of Physicians and Surgeons of Kingston ; Member of the College of Physicians and Surgeons of Ontario : Author of " Bright's Disease and Allied Affections of the Kidneys : " Member of the Association of American Physicians ; Member of the American Medical Association ; Member of the Chicago Academy of Sciences, etc., etc. With Clinical Illustrations. In one neat 12mo volume. Handsomely bound in Dark-Blue Cloth. iVo. 8 in the Physicians' and Students 1 Beady-Reference series. Price, United States and Canada, SI. 25, net ; Great Britain, 6s. 6d. ; France, 7 fr. 75 ; post-paid. REMONDINO— Circumcision: its History, Modes of Operation, etc. From the Earliest Times to the Present ; with a History of Eunuchism, Hermaphro- dism, etc., as Observed Among All Paces and Nations ; also a Description of the Different Operative Methods of Modem Surgery Practiced upon the Prepuce. By P. C. Remoxdixo, M.D. (Jefferson) ; Member of the Ameri- can Medical Association; Member of the American Public Health Association; Member of the State Medical Society of California, and of the Southern California Medical Society. Ix Press. Nearly Ready. No. 11 in the Physicians' and Students' Ready-Reference Series. ROHE — Text-Book of Hygiene. A Comprehensive Treatise on the Principles and Practice of Pre- ventive Medicine from an American Stand-point. By George H. Rohe, M.D., Professor of Obstetrics and Hygiene in the College of Physicians and Surgeons, Baltimore ; Member of the American Public Health Association, etc. 12 Catalogue of Medical Publications. Second Edition, thoroughly revised and largely rewritten, with many illustrations and valuable tables. In one handsome Royal Octavo volume of over 400 pages, bound in Extra Cloth. Price, United States, post-paid, $2.50, net ; Canada (duty paid) 852.75, net ; Great Britain, 14s. ; France, 16 fr. 20. Every Sanitarian should have Roh6's " Text-Book of Hygiene " as a work of reference. Of this new (second) edition, one of the best qualified judges, namely, Albert L. Gihon, M.D., Medical Director of TJ. S. Navy, in charge of U. S. Naval Hospital, Brooklyn, N. Y., and ex-President of the American Public Health Association, writes : "It is the most admirable, concise remme of the facts of Hygiene with which I am acquainted. Professor Rohe's attractive style makes the book so readable that no better presentation of the important place of Preventive Medicine, among their studies, can be desired for the younger members, especially, of our profession." SAJOUS— Hay Fever and its Successful Treatment by Superficial Organic Alteration of the Nasal Mucous Membrane. By Charles E. Sajous, M.D., formerly Lecturer on Bhinology and Laryngology in Jefferson Medical College ; Vice-President of the American Laryngological Association ; Officer of the Academy of France and of Public Instruction of Venezuela ; Corresponding Member of the Royal Society of Belgium, of the Medical Society of Warsaw (Poland), and of the Society of Efygiene of France ; Member of the American Philosophical Society, etc., etc. With 13 Engravings on Wood. 12mo. Bound in Cloth. Beveled edges. Price, in United States and Canada, $1.00, net; Great Britain, 6s. ; France, 6 fr. 20. SANNE— Diphtheria, Croup: Tracheotomy and Intuba- tion. From the French of A. Sanne. Translated and enlarged by Henry Z. Gill, M.D., LL.D. Diphtheria having become such a prevalent, wide-spread, and fatal disease, no general practitioner can afford to be without this work. It will aid in preventive measures, stimulate promptness in the application of and efficiency in treatment, and moderate the extravagant views which have been entertained re- garding certain specifics in the disease diphtheria. A full Index accompanies the enlarged volume, also a list of authors, making, altogether, a very handsome Illustrated volume of over 680 pages. Price, United States, post-paid, Cloth, $4.00 , Leather, $5.00. Canada (duty paid), Cloth, $4.40 ; Leather, $5.50, net. Great Britain, Cloth, 22s. 6d. ; Leather, 28s. France, Cloth, 24 fr. 60 ; Leather, 30 fr. 30. F. A. Dan's, Philadelphia, Pa. 13 SENN— Principles of Surgery. By N. Senx, M.D., Ph.D., Professor of Principles of Surgery and Surgical Pathology in Rush Medical College, Chicago. 111.; Professor of Surgery in the Chicago Polyclinic; Attending Surgeon to the Mil- waukee Hospital ; Consulting Surgeon to the Milwaukee County Hos- pital and to the Milwaukee County Insane Asylum. In one handsome Royal Octavo volume, with 109 fine Wood-En- gravings and 624 pages. Price, in United States, Cloth, §4.50 ; Sheep or Half-Russia, So. 50, net. Canada (duty paid), Cloth, §§5.00 ; Sheep or Half-Russia, S6.10, net; Great Britain, Cloth, 24s. 6d. ; Sheep or Half-Russia, 30s. France, Cloth, 27 fir. 20; Sheep or Half-Russia, 33 fr. 10. This work, by one of America's greatest surgeons, is thoroughly complete ; its clearness and brevity of statement are among its con- spicuous merits. The author's long, able, and conscientious researches in every direction in this important field are a guarantee of unusual trustworthiness, that every branch of the subject is treated authorita- tively and in such a manner as to bring the greatest gain in knowledge to the Practitioner and Student. Physicians and Surgeons alike should not deprive themselves of this very important work. A critical examination of the Wood- Engravings (109 in number) wiU reveal the fact that they are thoroughly accurate and produced by the best artistic ability. Stephen Smith, M.D., Professor of Clinical Surgery in Medical Department of University of the City of New York, writes: "I have examined the work with great satisfaction, and regard it as a most valuable addition to American Surgical literature. There, has long been great need of a work on the prin- ciples of Surgery which would fully illustrate the present advanced state of knowledge of the various subjects em- braced in this volume. The work seems to me to meet this want admirably." u The achievements of Modern Sur- gery are akin to the marvelous, and Dr Senn has set forth the principles of the science with a completeness that seems to leave nothing further to be said until new discoveries are made. The work is systematic and compact, without a fact omitted or a sentence too much, and it not only makes instructive but fascinating reading. A conspicuous merit of Senn's work is his method, his persistent and tireless search through original investigations for additions to knowledge, and the practical character of his discoveries. This combination of the discoverer and the practical man gives a special value to all his work, and is one of the secrets of his fame. No physician, in any line of practice, can afford to be without Senn's ' Prin- ciples of Surgery.' " — The Review of Insanity and Nervous Diseases. SHOEMAKER— Heredity, Health, and Personal Beauty. Tartu ding the Selection of the Best Cosmetics for the Skin, Hair, Nails, and All Parts Relating to the Body. By John V. Shoemaker, A.M., M.D., Professor of Materia Medica. Pharmacology, Therapeutics, and Clinical Medicine, and Clinical Professor of Diseases of the Skin in the Medico-Chirurgical College of Philadelphia; Physician to the Medico-Chirurgical Hos- pital, etc.. etc. This is just the book to place on the waiting-room table of every 'physician, and a work that will prove useful in the hands of your patients. 14 Catalogue of Medical Publications. The health of the skin and hair, and how to promote them, are discussed ; the treatment of the nails ; the subjects of ventilation, food, clothing, warmth, bathing; the circulation of the blood, diges- tion, ventilation; in fact, all that in daily life conduces to the well- being of the body and refinement is duly enlarged upon. To these stores of popular information is added a list of the best medicated soaps and toilet soaps, and a whole chapter of the work is devoted to household remedies. The work is largely suggestive, and gives wise and timely advice as to when a physician should be consulted. Complete in one handsome Royal Octavo volume of 425 pages, beautifully and clearly printed, and bound in Extra Cloth, Beveled Edges, with side and back gilt stamps and Half-Morocco Gilt Top. Price, in United States, post-paid, Cloth, S3. 50 ; Half- Morocco, S3. 50 net. Canada (duty paid), Cloth, S3. 75; Half-Morocco, $3.90, net. Great Britain, Cloth, 14s.; Half-Morocco, 19s. 6d. France, Cloth, 15 fr. ; Half- Morocco, 22 fr. SHOEMAKER— Materia Medica and Therapeutics. With Especial Reference to the Clinical Application of Drugs. Being the second and last volume of a treatise on Materia Medica, Pharmacology, and Therapeutics, and an independent volume upon drugs. By John V. Shoemaker, A.M., M.D., Professor of Materia Medica, Pharmacology, Therapeutics, and Clinical Medicine, and Clinical Professor of Diseases of the Skin in the Medico Chirurgical College of Philadelphia ; Physician to the Medico-Chirurgical Hos- pital, etc. ,etc. This is the long-looked-for second volume of Shoemaker's Materia Medica, Pharmacology, and Therapeutics. It is wholly taken up with the consideration of drugs, each remedy being studied from three points of view, viz. : the Preparations, or Materia Medica; the Physiology and Toxicolog} r , or Pharmacology ; and, lastly , its Therapy. Dr. Shoemaker has finalty brought the work to completion, and now this second volume is ready for delivery. It is thoroughly abreast of the progress of Therapeutic Science, and is really an indispensable book to every student and practitioner of medicine. Royal Octavo, about 675 pages. Thoroughly and carefully indexed. Price, in United States, post-paid, Cloth, $3.50; Sheep, $4.50, net. Canada (duty paid), Cloth, $4.00; Sheep, $5.00, net. Great Britain, Cloth, 20s. ; Sheep, 26s. France, Cloth, 22 fr. 40 ; Sheep, 28 fr. 60. The first volume of this work is devoted to Pharmacy, General Pharmacology, and Therapeutics, and remedial agents not properly classed with drugs. Koyal Octavo, 353 pages. Price of Volume I, post-paid, in United States, Cloth, $2.50, 'net; Sheep, $3.25, net. Canada, duty paid, Cloth, $2.75, net ; Sheep, $3.60, net. Great Britain, Cloth, 14s., Sheep, 18s. France, Cloth, 16 fr. 20; Sheep, 20 fr. 20. The volumes are sold separately. F. A. Davis, Philadelphia, Pa. 15 SHOEMAKER— Ointments and Oleates, Especially in Diseases of the Skin. By John V. Sfoemaker, A.M., M.D., Professor of Materia Medica, Pharmacology, Therapeutics, and Clinical Medicine, and Clinical Professor of Diseases of the Skin in the Medico-Chirurgical College of Philadelphia, etc., etc. Second Edition, revised and en- larged. 298 pages. 12mo. Neatly bound in Dark-Blue Cloth. No. 6 in the Pliyzicians' and Students' Beady -Reference Series. Price, in United States and Canada, post-paid, SS1.50, net ; Great Britain, 8s. 6d. ; France, 9 fr. 35. The author concisely concludes his preface as follows: " The reader may thus obtain a conspectus of the whole subject of inunction as it exists to-day in the civilized world. In all cases the mode of preparation is given, and the therapeutical application described seriatim, in so far as may be done without needless repetition." It is invaluable as a ready reference when ointments or oleates are to be used, and is serviceable to both druggist and physician. — Canada Medical Rec- ord. To the physician who feels uncertain as to the best form in which to prescribe medicines by way of the skin the book will prove valuable, owing to the many prescriptions and formulae which dot its pages, while the copious index at the back materially aids in making the book a useful one. — Medical News. SMITH — The Physiology of the Domestic Animals. A Text-Book for Veterinary and Medical Students and Practitioners. By Robert Meade Smith, A.M., M.D., Professor of Comparative Physiology in University of Pennsylvania ; Fellow of the College of Physicians and Academy of the Natural Sciences, Philadelphia ; of the American Physiological Society ; of the American Society of Natural- ists ; Associe Etranger de la Societe Francaised'Hygiene, etc. In one handsome Royal Octavo volume of over 950 pages. Profusely illus- trated with more than 400 fine Wood-Engravings and many Colored Plates. Price, in United States, Cloth, So. 00; Sheep, S8.00, net. Canada (duty paid), Cloth, ^5.50; Sheep, S6.60, net. Great Britain, Cloth, 28s.; Sheep, 32s. France, Cloth, 30 fr. 30 ; Sheep, 36 fr. 20. This new and important work is the most thoroughly complete in the English language on the subject. In it the physiology of the domestic animals is treated in a most comprehensive manner, especial prominence being given to the subject of foods and fodders, and the character of the diet for the herbivora under different conditions, with a full consideration of their digestive peculiarities. Without being overburdened with details, it forms a complete text-book of physiology, adapted to the use of students and practitioners of both veterinary and human medicine. This work has already been adopted as the Text- Book on Physiology in the Veterinary Colleges of the United States, Great Britain, and Canada. 16 Catalogue of Medical Publications. SOZINSKEY — Medical Symbolism. Historical Studies in the Arts of Healing and Hygiene. By Thomas S. Sozinskey, M.D., Ph.D., Author of " The Culture of Beauty," "The Care and Culture of Children," etc. 12mo. Nearly 200 pages. Neatly bound in Dark-Blue Cloth. Appro- priately illustrated with upward of thirty (30) new Wood-Engravings. Ao. 9 in the Physicians' and Students 7 Ready-Reference Series. Price, in United States and Canada, post-paid, $1.00, net; Great Britain, 6s. ; France, 6 fr. 30. STEWART— Obstetric Synopsis. By John S. Stew^art, M.D., Demonstrator of Obstetrics and Chief Assistant in the Gynaecological Clinic of the Medico- Chirurgical College of Philadelphia; with an introductory note by William S. Stewart, A.M., M.D., Professor of Obstetrics and Gynaecology in the Medico-Chirurgical College of Philadelphia. 42 Illustrations. 202 pages. 12mo. Handsomely bound in Dark-Blue Cloth. A r o. 1 in the Physicians' and Students' Ready-Reference Series. Price, in United States and Canada, post-paid, &1.00 net ; Great Britain, 6s. 6d. ; France, 6 fr. 20. ULTZMANN — The Neuroses of the Genito-Urinary Sys- tem in the Male. With Sterility and Impotence. By Dr. R. Ultzmann, Professor of Genito-Urinary Diseases in the University of Vienna. Translated, with the author's permission, by Gardner W. Allen, M.D., Surgeon in the Genito-Urinary De- partment, Boston Dispensary. Illustrated. 12mo. Handsomely bound in Dark-Blue Cloth. JS r o. 4 in ^ ie Physicians' and Students' Ready- Reference Series. Price, in United States and Canada, post-paid, $1.00, net; Great Britain, 6s. ; France, 6 fr. 20. Synopsis of Contents. — First Part — I. Chemical Changes in the Urine in Cases of Neuroses. II. Neuroses of the Urinary and of the Sexual Organs, classified as: (1) Sensory Neuroses; (2) Motor Neu- roses; (3) Secretory Neuroses. Second Part — Sterility and Impotence. The treatment in all cases is described clearly and minutely, WHEELER — Abstracts of Pharmacology. By H. A. Wheeler, M.D. (Begistered Pharmacist, No. 3468, Iowa). Prepared for the use of Physicians and Pharmacists, and especially for the use of Students of Medicine and Pharmacy, who are preparing for Examination in Colleges and before State Boards of Examiners. This book does not contain questions and answers, but solid pages of abstract information. It will be an almost indispensable companion to the practicing Pharmacist and a very useful reference-book to the F. A. Davis, Philadelphia, Pa. 17 Physician. It contains a brief but thorough explanation of all terms and processes used in practical pharmacy, an abstract of all that is essential to be known of each officinal drug, its preparations and therapeutic action, with doses; in Chemistry and Botany, much that is useful to the Physician and Pharmacist ; a general working formula for each class and an abstract formula for each officinal preparation, and many of the more popular unofficinal ones, together with their doses; also many symbolic formulas; a list of abbreviations used in prescription writing ; rules governing incompatibilities ; a list of Solvents ; tests for the more common drugs ; the habitat and best time for gathering plants to secure their medical properties. The book contains 180 pages, hy 2 x 8 inches, closely printed and on the best paper, nicely and durably bound, containing a greater amount of information on the above topics than any other work for the money. Price, in United States and Canada, post-paid, $1.50, net; Great Britain, 8s. 6d. ; France, 9 fr. 35. WITHERSTIIME— International Pocket Medical Formu- lary. Arranged Therapeutically. By C. Sumner Witherstine, M.S., M.D., Associate Editor of the "Annual of the Universal Medical Sciences ; " Visiting Physician of the Home for the Aged, Germantown, Philadelphia ; late House- Surgeon to Charity Hospital, New York. Including more than 1800 formulae from several hundred well-known authorities . With an Appendix containing a Posological Table, the newer remedies included; Important Incom- patibles; Tables on Dentition and the Pulse; Table of Drops in a Fluidrachm and Doses of Laudanum graduated for age ; Formulae and Doses of Hypodermatic Medication, including the newer remedies; Uses of the Hypodermatic Syringe; Formulae and Doses for Inhalations, Nasal Douches, Gargles, and Eye-washes; Formulae for Suppositories; Useof the Thermometer in Disease ; Poisons, Antidotes, and Treatment; Direc- tions for Post- Mortem and Medico-Legal Examinations; Treatment of Asphyxia, Sun-stroke, etc. ; Anti-emetic Remedies and Disinfectants; Obstetrical Table; Directions for Ligation of Arteries; Urinary Analy- sis; Table of Eruptive Fevers; Motor Points for Electrical Treatment, etc. This work, the best and most complete of its kind, contains about 275 printed pages, besides extra blank leaves. Elegantly printed, with red lines, edges, and borders; with illustrations. Bound in leather, with Side-Flap. Price, in United States and Canada, post-paid, $83.00, net ; Great Britain, lis. 6d. ; France, 13 fr. 40. YOUNG— Synopsis of Human Anatomy. Being a Com- plete Compend of Anatomy, including the Anatomy of the Viscera, and Numerous Tables. By James K. Young, M.D., Instructor in Orthopaedic Surgery and Assistant Demonstrator of Surgery, University of Pennsylvania; Catalogue of Medical Publications. Attending Orthopaedic Surgeon, Out-Patient Department, University Hospital, etc. Illustrated with 76 Wood-Engravings. 390 pages. 12mo. No. 3 in the Physicians' and Students' Ready-Reference Series. Price, in United States and Canada, post-paid, 581.40, net ; Great Britain, 8s. 6d. ; France, 9 fr. 25. While the author has prepared this work especially for students, sufficient descriptive matter has been added to render it extremely valuable to the busy practitioner, particularly the sections on the Viscera, Special Senses, and Surgical Anatomy. The work includes a complete account of Osteology, Articulations and Ligaments, Muscles, Fascias, Vascular and Nervous Systems, Alimentary, Vocal, and Respiratory and Genito-Urinary Apparatus, the Organs of Special Sense, and Surgical Anatomy. In addition to a most carefully and accurately prepared text, wherever possible, the value of the work has been enhanced b}^ tables to facilitate and minimize the labor of students in acquiring a thorough knowledge of this important subject. The section on the teeth has also been especially prepared to meet the requirements of students of dentistry. In its preparation, Gray's "Anatomy" (last edition), edited by Keen, being the anatomical work most used, has been taken as the standard. The following Publications sold only by Subscription, or Sent Direct on Receipt of Price, Shipping Expenses Prepaid. Annual of the Universal Medical Sciences. A Yearly Report of the Process of the General Sanitary Sciences Throughout the World. Edited by Charles E. Sajous, M.D., formerly Lecturer on Laryn- gology and Rhinology in Jefferson Medical College, Philadelphia, etc., and Seventy Associate Editors, assisted by over Two hundred Corre- sponding Editors and Collaborators. In Five Royal Octavo Volumes of about 500 pages each, bound in Cloth and Half-Russia, Magnificently Illustrated with Chromo-Lithographs, Engravings, Maps, Charts, and Diagrams. Being intended to enable any physician to possess, at a moderate cost, a complete Contemporaiw History of Universal Medi- cine, edited by many of America's ablest teachers, and superior in every detail of print, paper, binding, etc., a befitting continuation of such great works as " Pepper's System of Medicine," " Ashhurst's In- ternational Encyclopaedia of Surgery," "Buck's Reference Hand- Book of the Medical Sciences." F. A. Davis, Philadelphia, Pa. 19 SUBSCRIPTION PRICE Per Year (Including the "SATEL- LITE" for one year) : in United States, Cloth, 5 Vols., Royal Octavo, $ 15.00, Half-Russia, 5 Vols., Royal Oc- tavo, $20.00. Canada (duty paid), Cloth, $16.50; Half- Russia, $22.00. Great Britain, Cloth, <£4 7s ; Half-Rus- sia, £5 15s. France, Cloth, 93 fr. 95 ; Half-Russia, 124 fr. 35. The Satellite of the "Annual of the Universal Medical Sciences." A Monthly Review of the most important articles upon the practical branches of Medicine appearing in the medical press at large, edited by the Chief Editor of the Annual and an able staff. Published in connection with the Annual, and for its Subscribers Only. Lectures on Nervous Diseases. From the Stand-point of Cerebral and Sp>inal Localization, and the Later Methods Employed in the Diagnosis and Treatment of these Affections. By Ambrose L. Rannet, A.M., M.D., Professor of the Anatomy and Physiology of the Nervous System in the New York Post-Graduate Medical School and Hospital ; Professor of Nervous and Mental Diseases in the Medical Department of the University of Vermont, etc. ; Author of " The Applied Anatomy of the Nervous System," " Prac- tical Medical Anatomy," etc. , etc. Profusely Illustrated with Original Diagrams and Sketches in Color by the author, carefully selected Wood-Engravings, and Reproduced Photographs of Typical Cases. One handsome Royal Octavo volume of 780 pages. Price, in United States, Cloth, $5.50; Sheep, $6.50 ; Half- Russia, $7.00. Canada (duty paid), Cloth, $6.05 ; Sheep, $7.15; Half-Russia, $7.70. Great Britain, Cloth, 32s,; Sheep, 37s. 6d.; Half-Russia, 4 0s. France, Cloth, 34 fr. 70 ; Sheep, 40 fr. 45 ; Half-Russia, 43 fr. 30. Lectures on the Diseases of the Nose and Throat. De- livered at the Jefferson Medical College, Philadel- phia. By Charles E. 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