Class ZSJuiU Book_^_- GopyrightN COPYRIGHT DEPOSIT. DISEASES OF THE SKIN VAN HARLINGEN TEXT-BOOK OF DISEASES OF THE SKIN BY ARTHUR VAN HARLINGEN, Ph.B. (Yale) M. D. Emeritus Professor of Dermatology in the Philadelphia Polyclinic. Dermatologist to the Children's Hospital. Fellow of the Col- lege of Physicians of Philadelphia. Member of the American Dermatological Association. FOURTH EDITION THOROUGHLY REVISED AND REARRANGED WITH 102 ILLUSTRATIONS. PHILADELPHIA BLAKISTON'S SON & CO, 1012 WALNUT STREET 1907 « UffRARY of CONGRESS Two Cooler Received SEP 28 190? ^ Copynrht Entry Set> 3 \<\*1 CLASS A XXc, No/ tattoo COPY B. Copyright, 1907, By P. BLAKISTON'S SON & CO. Printed by The Maple Press York. Pa. PREFACE TO THE FOURTH EDITION The present differs from previous editions of this work in the arrangement of the description of the various diseases. These, instead of being entered alphabetically, as before, are now- arranged according to the classification generally adopted by American teachers. It is hoped that this will make the book more useful to the student. The text has been almost entirely rewritten to bring it up to the present state of our knowledge; a large number of diseases are described which have not previously been included and a brief account of the pathologic anatomy of the various affections has been inserted. A considerable number of new illustrations have been added. Some of these are from drawings by the author, others are from photographs of cases occurring under his own observation and that of friends. His best thanks are due to Prof. Louis A. Duhring and Prof. Henry W. Stelwagon for advice and assistance in the preparation of the present edition. To Dr. Duhring for the use of several photographs of disease and also of certain drawings of the anatomy of the hair and of parasites made by the author for Duhring's "Treatise on Diseases of the Skin" some years since and published in that work. Dr. Stelwagon has kindly allowed the author to make use of his "Treatise on Diseases of the Skin" and this has been freely drawn upon in the description of some of the rarer diseases VI PREFACE. and in the sections on pathologic anatomy. The same friend has lent several photographs for use in this edition. The scope of this work has not permitted extensive reference to original articles but this has been done to a much greater extent than in previous editions. The author may also here express his indebtedness to the text-book of Hyde and Mont- gomery, and Duhring's "Cutaneous Medicine" and, particu- larly in the anatomical sections, to the admirable "Handbook of the Pathology of the Skin" by Macleod, of London. CONTENTS. PAGE Anatomy and Physiology of the Skin i Symptomatology 22 Classification 30 CLASS I. HYPEREMIAS. Erythema 37 Erythema Hyperaemicum 37 Erythema Intertrigo 38 Erythema Scarlatinoides 40 CLASS II. INFLAMMATIONS. Erythema Multiforme 43 Erythema Nodosum 47 Erythema Induratum 48 Pellagra 50 Urticaria 51 Urticaria Pigmentosa 56 (Edema Angioneuroticum 57 Pityriasis Rosea 59 Dermatitis Exfoliativa 61 Dermatitis Exfoliativa Epidemica 63 Dermatitis Exfoliativa Neonatorum 63 Prurigo 64 Lichen Ruber 65 Lichen Scrofulosus 69 Psoriasis 71 Eczema 83 Eczema Seborrhceicum 141 Herpes 144 Herpes Simplex 144 Herpes Zoster 150 Hydroa Vacciniforme 159 vii Vlll CONTENTS. PAGE Pompholyx 159 Dermatitis Herpetiformis 160 Pemphigus 165 Epidermolysis Bullosa 168 Dermatitis Repens 169 Impetigo Simplex 169 Impetigo Contagiosa 171 Ecthyma 174 Impetigo Herpetiformis 177 Furunculus 177 Carbunculus 181 Plegmona Diffusa 183 Dissection Wounds 184 Equinia 184 Pustula Maligna 185 Erysipelas 186 Erysipeloid 188 Dermatitis Gangrenosa Infantum 189 Multiple Gangrene of the Skin in Adults 189 Diabetic Gangrene 191 Symmetric Gangrene 191 Dermatitis Calorica 192 Dermatitis Congelationis 192 Dermatitis Venenata 195 X-ray Dermatitis 200 Dermatitis Factitia 202 Dermatitis Medicamentosa 205 Varicella 209 Vaccinal Eruptions 211 CLASS III. HEMORRHAGES. Purpura 213 Purpura. Scorbutica 217 CLASS IV. HYPERTROPHIES. Lentigo 218 Chloasma 218 Argyria ' 220 CONTENTS. IX PAGE Tattoo Marks 220 Naevus Pigmentosus 221 Acanthosis Nigricans 224 Clavus 225 Callositas 226 Keratosis Palmaris et Plantaris 227 Keratosis Senilis 228 Keratosis Pilaris 229 Keratosis Follicularis 230 Verruca 231 Cornu Cutaneum 235 Ichthyosis 238 Porokeratosis 244 Angiokeratoma 244 Scleroderma 245 Sclerema Neonatorum 249 (Edema Neonatorum 251 Elephantiasis 251 Dermatolysis '. . 257 CLASS V. ATROPHIES. Atrophia Cutis 259 Atrophia Maculata et Striata 260 Hemiatrophia Facialis 260 Vitiligo 262 Albinismus 263 Ainhum 263 Perforating Ulcer of the Foot 264 CLASS VI. NEW GROWTHS. Cicatrix 265 Keloid 265 Dermatitis Papillaris Capillitii 268 Molluscum Contagiosum 270 Multiple Benign Cystic Epithelioma 272 Adenoma Sebaceum 272 Lymphangioma 273 Xanthoma 275 Xanthoma Diabeticorum 276 X CONTENTS. PAGE Colloid Degeneration of the Skin 277 Naevus Vasculosus 277 Telangiectasis 280 Angioma Serpiginosum 280 Fibroma 281 Neuroma 285 Myoma 286 Rhinoscleroma 286 Tuberculosis Cutis 287 Accidental Inoculations 287 Tuberculosis Verrucosa .......: j . . 288 Tuberculous Ulcers . .... 289 Scrofuloderma . 289 Lupus Vulgaris 292 Lupus Erythematosus 302 Syphilis 307 The Erythematous Syphiloderm .... 308 The Pigmentary Syphiloderm 308 The Papular Syphiloderm 309 The Vesicular Syphiloderm 310 The Pustular Syphiloderm 311 The Tubercular Syphiloderm 313 The Gummatous Syphiloderm 313 The Bullous Syphiloderm 314 Skin Diseases in Hereditary Syphilis 315 Delhi Boil 319 Frambcesia 319 Verruga Peruana 320 Carcinoma Cutis 321 Epithelioma 321 Paget's Disease 329 Xeroderma Pigmentosum 330 Sarcoma Cutis 331 Granuloma Fungoides 331 Lepra 335 CLASS VII. NEUROSES. Pruritus 344 Anaesthesia ' 351 CONTENTS. XI CLASS VIII. DISEASES OF THE APPENDAGES. PAGE i. Diseases of the Nails 353 2. Diseases of the Hair and Hair Follicles Hypertrichosis 360 Atrophia Pilorum Propria 369 Fragilitas Crinium 370 Monilethrix 371 Piedra 372 Trichorrhexis Nodosa 372 Tinea Nodosa 373 Canities 374 Alopecia 376 Alopecia Areata 380 Folliculitis Decalvans 388 Sycosis Vulgaris 388 3. Diseases of the Sebaceous Glands. Seborrhcea 392 Asteatosis 396 Milium 396 Steatoma 397 Comedo 398 Acne 400 Acne Varioliformis 414 Acne Rosacea 415 4. Diseases of the Sweat Glands. Hyperidrosis 422 Anidrosis 426 Bromidrosis 426 Chromidrosis 428 Haematidrosis 429 Uridrosis 431 Phosphoridrosis 43 1 Sudamen 432 Hydrocystoma 432 Granulosis Rubra Nasi 433 Miliaria 433 Hydradenitis Suppurativa 434 Xll CONTENTS. CLASS IX. PARASITIC AFFECTIONS. A. Diseases Due to Vegetable Parasites. page Favus 435 Tinea Trycophytina 437 Ring-worm of the General Surface 440 Ring- worm of the Scalp 441 Ring-worm of the Bearded Region 446 Tinea Imbricata 449 Tinea Versicolor 449 Erythrasma 452 Actinomycosis 452 Mycetoma 454 Blastomycetic Dermatitis 454 B. Diseases Due to Animal Parasites. Pediculosis 455 Pediculosis Capillitii 456 Pediculosis Vestimentorum 458 Pediculosis Pubis 460 Animal Parasites of Minor Importance Attacking the Skin 461 Scabies 463 Animal Parasites of Minor Importance Penetrating the Skin 467 Index 473 DISEASES OF THE SKIN. ANATOMY OF THE SKIN. For the purpose of study the skin may be divided into three parts: the epidermis, the corium and the subcutaneous connec- tive tissue. The latter is, strictly speaking, not a portion of the true skin, but is commonly considered with it for purposes of convenience. THE EPIDERMIS. The epidermis is divided for convenience sake into five layers which are named from within outwards, (i) flie basal layer or stratum germinativum; (2) the prickle cell layer or stratum Mal- pigJiii; (3) the stratum granulosus; (4) the stratum lucidum; and (5) the stratum corneum. These layers may be considered, not so much as special layers, as stages in the gradual evolution of the basal columnar cells, until they become corniried squamae or scales.* The basal and Malpighian layers are next to the corium and dip down between the papillae to form the interpapillary processes; consequently, in vertical sections, the dividing line between epidermis and corium presents a wavy appearance. The Malpighian layer varies in thickness in different localities. It is thickest on the palms and soles and thinnest over the elbows, forehead, and cheeks. The Basal Layer or Stratum Germinativum is the deepest layer of the epidermis and consists of a row or, occasionally, of two rows of regular columnar cells, with oval nuclei, arranged * This description of the minute anatomy of the skin is largely taken from Mac- leod, Handbook 0} the Pathology of the Skin, London, 1903, with occasional references' to Duhring's Cutaneous Medicine, Pt. i, Philadelphia, 1895. 1 DISEASES OF THE SKIN. Fig. i. — Section of skin showing various layers. a, Stratum corneum. b, Stratum lucidum. c. Stratum granulosum. d, Stratum mal- pighii or prickle cell layer, e, Stratum germinativum or basal layer. f, Blood vessels, g, Papillary layer of the corium. h, Reticular layer of the corium. i, Coil or sweat gland. I, Subcutaneous tissue, k, Tactile corpuscle. THE EPIDERMIS. 3 vertically to the wavy line between the epidermis and the corium. The cells of this layer are united together by fine protoplasmic threads which pass from cell to cell across the interepithelial spaces. Towards the corium the protoplasmic fibres are collected into tufts which give a denticulate appearance to the line of demarcation between the two layers. The germinal layer is the one from which the whole of the epidermis is developed. Its cells are constantly dividing by mitosis, and the daughter cells do not divide in the normal state but are simply pushed forward to the surface by new layers of cells forming beneath them and gradually evolving into horn cells. The pigment of the skin is found in the form of numerous brownish pigment- granules scattered around the nuclei of the cells of the basal layer. The Prickle Cell Layer or Stratum Malpighii. Above the basal layer the cells are polygonal in shape and, instead of being arranged in rows, tend rather to be built up in the form of a mosaic. Toward the surface they become more and more flattened. Their nuclei are roundish in shape in the centre of the layer and oval as it merges into the granular layer. These cells are peculiar in that their network of spongioplasm stretches beyond the cells in the form of fine radiating protoplasmic threads which pass across the intercellular spaces to be continuous with the spongioplasm of neighboring cells. The whole of the cells of this layer are, therefore, in organic connection with one another. It was formerly supposed that each of these cells was surrounded by a set of protoplasmic spicules like the projections on a prickly pear and hence the name " prickle cell" layer still given to this layer. Between the prickle cells there are lymph spaces which are bridged over by the protoplasmic fibers.* The Granular Layer or Stratum Granulosum. Towards the surface the prickle cell layer of the epidermis merges into a * Herxheimer has described certain corkscrew-like fibres occurring between the cells of the stratum Malpighi and the basal layer. They run parallel to the long axis of the cell for the most part. Similar fibres are found occasionally between the cells of the granular and horny layers and between the cells of the inner root- sheath of the hair follicle. The exact nature of these, "Herxheimer's spirals," has not been determined, observers differing as to their character and significance. 4 DISEASES OF THE SKIN. layer consisting of two or three rows of flattened cells contain- ing numerous granules which is known as the stratum granu- losum or granular layer. These cells lie more closely together than the prickle cells of the Malpighian layer, their prickles are shrunken, and their nuclei are shriveled and mulberry shaped and appear to have shrunk away from the protoplasm of the cell so as to leave a nuclear space. The granules consist of a substance having relation to the process of cornification and, hence, termed by Unna " keratohyalin." The Stratum Lucidum. Between the granular layer and the stratum corneum there is a thin intermediate layer of cells which is known as the stratum lucidum because, in unstained sections of the skin of certain parts, as the sole of the foot, the layer may be seen as a semi-transparent line across the section, resembling a narrow oily streak across a sheet of paper. The cells of this layer are larger and more irregular in shape than those of the stratum granulosum, their prickles are more shrunken and their nuclei have still further shriveled, and may sometimes be represented only by a mass of debris in the nuclear spaces. The keratohyalin granules have now disappeared and been replaced by a homogeneous oily-looking subsance, known as eleidin, which is present, not only within but between the cells, and which is the chief characteristic of this layer. It is not stained by osmic acid and is, therefore, not fat. The cells of the stratum lucidum, however, stain with osmic acid, showing that they contain fat as well as eleidin. The Stratum Corneum. The stratum corneum is the most superficial layer of the skin. It is the layer which we see and touch, and is the " first line of defense" in resisting external mechanical assaults and the entrance of toxins and micro-organ- isms. This layer varies greatly in thickness in different parts of the skin. On the palms of the hands it averages 4. mm., and on the soles of the feet it may reach 5 to 6 mm., in thickness. It is especially thin upon the face and upon the flexor surface of the extremities. On the flexor surface of the forearm, for ex- ample, it has an average thickness of .02 mm. THE CORIUM. 5 The stratum corneum is composed of epidermal cells which have undergone the process of cornification or keratinization. The individual cells are now known as "horn cells." The most perfect horn cells are situated immediately above the stra- tum lucidum, while towards the surface of the body alterations from drying and pressure produce the flattened degenerate type of horn cell known as the "squame," which is rubbed off con- stantly by the friction to which the skin is subjected. The perfect horn cell is polygonal in shape, faceted on the surface from pressure, and presents a space in the centre from which the nucleus has completely disappeared. The hyaloplasm and eleidin of the cell have given place to a fatty or waxy substance, and the peripheral portion of the spongioplasm has become transformed into a highly resistant substance called keratin. Macleod believes that these horn cells are held together, not by intercellular substance, but by a sort of felting together of the keratinized epithelial fibres. It is this which makes this layer so tough and resistant and which prevents its rupturing in the formation of vesicles and bullae. When the cornification is imperfect and the intercellular bridges do not become trans- formed into keratin, the defective horn cells become separated, air appears between them, and they desquamate in variously sized scales. The existence within the horn cells of the fat or waxy material makes the stratum corneum a waterproof coating to the body, preventing the absorption of water and substances dissolved and suspended in it. THE CORIUM. The corium is the dense fibrous layer of the skin which is situated beneath the epidermis. It supports and protects the hair follicles, glands, nerves, nerve terminations, blood-vessels, lymphatics and fat cells, and it is to this layer that the skin owes its strength and elasticity. The corium is divided into two layers, the superficial or papil- lary layer and the deep or reticular layer. Beneath the reticular 6 DISEASES OF THE SKIN. layer is the subcutaneous tissue, derived, however, from the same embryonic layer as the corium and in the view of many observers a part of the latter. In the papillary layer, the bundles of white fibrous tissue are thin, loosely packed together, and tend to have a vertical direc- tion. In the reticular layer these bundles are more numerous than in the papillary layer; they are also thicker and split and cross each other in various directions, forming a complicated network. In the subcutaneous tissue the bundles unite to form the large trabecular and septa which separate and support the fat lobules. THE PAPILLARY LAYER. The papillary layer is that upon which the epidermis lies and upon which the latter depends for its nutrition. There is no real demarcation between the two layers, but the cells of the basal layer of the epidermis are bathed by the same lymph which circulates in the lymphatic spaces between the fibrous bundles of the papillary body. The papillce are the conical projections of the corium. In some are found the terminal capillary loops, these are called vascular papillce. Others contain certain nerve terminations and are known as sensory papillce. The papillae are usually single, or, more rarely, there may be two or more upon a com- mon base, forming a compound papilla. The papillae are situated on ridges of varying heights. Sometimes there are two rows of papillae on a ridge. These ridges are particularly well marked on the finger-tips where their wavy outlines vary so much in different individuals as to form a well known element in the scientific identification of criminals. THE RETICULAR LAYER. The papillary layer merges into the reticular layer without line of demarcation, the difference in these strata consisting in the arrangement of the connective tissue bundles. The reticular portion is looser in texture, being made up of fasciculi of connec- BLOOD-VESSELS OF THE SKIN. 7 tive tissue which decussate more obliquely and give it a plex- iform arrangement as already mentioned. The thickness of the corium varies greatly in different parts of the body. In the infant it is thin, the subcutaneous tissue being relatively very thick. In the adult it is thickest upon the soles, palms, buttocks and entire back, and thinnest upon the eyelids, prepuce, glans penis, inner surface of the labia majora and some other points. THE SUBCUTANEOUS CONNECTIVE TISSUE. The subcutaneous connective tissue is to be viewed as part of the true skin, the latter merging into it. It is made up of variously sized bundles or fasciculi of connective tissue which cross one another at different angles, thus forming a rhomboidal network. The meshes, though variable in size, are generally larger, the inter fascicular spaces, therefore, being well defined. It possesses a much looser and coarser structure than the corium, and contains in most regions an abundance of fat. In some regions, however, as the eyelid, the latter is wanting. Warren has described columns of this tissue as passing in a nearly vertical direction from the adipose tissue to the bases of, especially, the finer hair follicles. Large blood-vessels pass through the subcutaneous connective tissue, giving off branches to the corium and the structures con- tained within it. Pacinian corpuscles, nerve trunks, lymphatics, sweat glands and the lower part of the hair follicles of deeply seated hairs are all found here. Above, it blends intimately with the corium, while its deeper layers are connected with the superficial fasciae of muscles and the periosteum. The subcutaneous tissue serves as a pad or cushion on the outside of the body and also acts as a temperature regulator of the body, being a poor conductor of heat. BLOOD-VESSELS OF THE SKIN. Both the corium and the subcutaneous tissue are highly vas- cular, having numerous blood-vessels throughout their structure 5 DISEASES OF THE SKIN. in the form of trunks, branches and capillaries. Arterioles for the sweat and sebaceous glands and for the hair papillae also exist. The arteries and veins anastomose in their final ter- mination. Two parallel horizontal plexuses exist, one superficial, in the upper layers of the corium, the other deep, in the subcutaneous tissue. The main vessels of the corium ascend from the sub- cutaneous tissue and give off branches laterally in all directions, richly supplying the glands and hair follicles, as well as the other structures in the corium. In the papillary layer a delicate and highly organized plexus of capillaries exists, affording an abun- dant supply to this region. The papillae receive capillary loops which run through their centre or at their sides parallel to their long axes. L r-> LYMPHATICS. In the subcutaneous tissue the lymphatics are large vessels upon which the rudiments of a muscular apparatus have been observed. In the upper strata of the corium they form a net- work of denser and much smaller vessels. Valves occur in the branches coming up from the deeper network. Unna believes that the greater part of the lymph which circulates through the skin is taken up by the veins which are much larger than the arteries in this locality. The juice spaces are those lymphatic channels which do not possess an obsolutely free outflow into distinct lymphatic vessels lined with endothelium, whether they are deprived of independent walls, as is usually the case, or are provided with them. Lymphatic vessels, on the other hand, may be defined as those canals from which a free outflow into the blood takes place. Juice spaces exist in the epidermis (a tissue destitute of blood-vessels), where they occur embedded in the interspinous passages of the prickle cell layer. The papilke are freely traversed by juice spaces. The excretory ducts of the coil glands, the sebaceous glands, the prickle-cell layer of the hair follicle, and the hair bed have the same inter- NERVES. 9 epithelial juice spaces as the epidermis. The oblique muscles of the skin and the coils of the coil glands float in distended lymph spaces. In the case of the coil glands they supply material for this glandular secretion. The lymph flows to the epidermis mainly from the apices of the papillae, thence spreading in all directions through the epidermis and returning to the corium by the way of the in- terpapillary depressions, through the sweat pores. NERVES. In the skin both medullated and non-medullated nerve fibres are present. The medullated fibres pass into the corium with the blood-vessels from the more superficial of these fibres. Fine non-medullated fibres pass up between the prickle cells of the epidermis and between the cells of the corresponding layer of the hair follicles. A few of the medullated fibres terminate in the special end organs known as the tactile corpuscles, the touch cells of Merkel and the Pacinian bodies of the subcutaneous tis- sue. It is probable that the non-medullated nerves supply the muscular fibres of the arrectores pilorum, the sweat coils and the blood-vessels. The nerves of the skin are numerous in the palms of the hands and the soles of the feet, especially in the tips of the fingers and toes — regions where sensation is particu- larly acute. In addition to sensory nerves the skin is said to possess motor nerves on the smooth muscles of the skin and on all glands which have a muscular layer. Of the vaso-motor nerves of the skin but little is known with any degree of certainty. They are particularly abundant about the arterioles of the skin and exert an influence upon the vascular, muscular, and glandular cutaneous systems, causing increase or diminution of the circulation, as in flushing or blanching of the skin, in contraction of the muscles as in cutis anserina or " goose flesh," or when the hairs "stand on end" and in profuse sweating, local or, more rarely, general. IO DISEASES OF THE SKIN. MUSCLES. The muscles of the skin consist of the arrectores pilorum, the layers of involuntary muscular fibres, and the voluntary mus- cular fibres. The arrectores pilorum, or arrector muscles of the hair, are involuntary muscles. They arise from the fibres of the papillae and are inserted into the fibrous coat of the hair follicle below the sebaceous gland. (See Fig. 2.) They are situated in the oblique angle of the follicle so that on contracting they make the follicle more vertical and so cause the hair to become erect. The condition known as "goose skin" which may result from the action of cold is due to the contraction of these muscles. Muscular layers or membranes are found in the dartos of the scrotum, areolae of the nipples, and in the eyelids. They are stimulated to contract by cold and in contracting they cause a puckering of the skin. Voluntary muscular fibres, or striated muscular fibres, pass from the platysma and from the muscles of expression of the face into the corium, so that when these muscles contract a wrinkling of the skin is produced. PIGMENT. In white races very little pigment is present in the skin, except in the pigmented regions, such as the areolae of the nipples, ax- illae, scrotum and around the anus. The color of the skin depends more on the vascular condition and on the subcutaneous fat. The stratum corneum has a grayish or ground-glass tinge, while the rete is yellowish. In the white races, pigment, except in the hairs, does not appear till after birth, while, in colored races, some pigment is present even considerably earlier. The pigment-granules in white races are situated chiefly in the epithelial cells of the basal layer of the epidermis. In dark races the pigment extends up as far as the transitional layers of the epidermis. ' SEBACEOUS GLANDS. II SEBACEOUS GLANDS. The sebaceous glands are small, sac-like or racemose glands seated in the corium, usually in connection with the hair follicles, (see Fig. 2) but also independently of hairs, in such situations Fig. 2. — Section of hair and hair follicle from Ziemssen. Showing general arrangement of parts. 1. Mucous layer of the epidermis. 2. Basal pigment cells. 3. Papillary layer of the corium. 4. Continuation of basal rete cells. 5. Sebaceous gland. 6. Muscle of the hair. 7. Nerves. 8. Blood corpuscles. 9. Transverse section of blood-vessel. 10. Root of hair. 11. Hair follicle. 12. Papillary vessels. 13. Papilla of hair. 14. Nerves. 15. Medullary substance of hair. A. The hair. B. Stratum corneum of the epidermis, C. Stratum lucidum of the epidermis. D. Stratum granulosum of the epidermis. E. Sebaceous gland. F. Panniculus adiposus. 16. Cortical substance of the hair. 17. Cuticle of hair. 18. Henle's layer of inner root sheath. 19. Huxley's layer of inner root sheath. 20. Outer root sheath. as the free borders of the lips, toward the angles of the mouth, on the labia minora, the areolae of the nipples and the caruncles of the eyes. Accompanying the larger hairs the glands are generally situated on the oblique side of the hair follicle into which they open by 12 DISEASES OF THE SKIN. a short duct. The glands connected with the large hairs, as those of the beard, are relatively small, while those belong- ing to the lanugo hairs are large, as on the nose. The largest sebaceous glands are those about the nose, concha of the ear, scrotum and areola of the nipple. In some cases the gland is made up of a single saccule, in other cases there may be several or even as many as twenty or more. The saccules open into a common duct which pours its contents into the follicle to lubricate the hair. The glands unconnected with the hairs, as those of the nipple, open directly on the surface of the skin. Each saccule or acinus of the sebaceous gland has a connective tissue covering inside, which is a basement layer of flat cells on which are built up layers of cubical cells with round or oval nuclei. Towards the centre these cells have undergone a fatty metamorphosis which results in the exudation of oil globules collecting in the lumen of the duct and forming a whitish mass. When this reaches the hair follicle it becomes mixed with the epithelial debris and partly solidifies to form sebum. Sebum, the product of the sebaceous glands, is an oily, fatty semi-fluid amorphous substance of a yellowish color, and consists of olein, palmitin, stearin, the fatty acids, cholesterin crystals, chlorids and phosphates of the alkaline earths, organic salts, water and occasionally butyric or caproic acid. Mixed up with these are epidermal nuclei, debris of cells and a few horn cells. The Meibomian glands are embedded in the free borders of the eyelids and are the largest sebaceous glands met with. They differ from other sebaceous glands chiefly in their elong- ated form. The Tysonian glands are found upon the glans penis and upon the inner surface of the prepuce. The smegma which forms in this locality and which was formerly supposed to be the secretion of these glands is now believed to be mainly an exfoliation of the horny layer of the epidermis. THE SWEAT GLANDS. The sweat or coil glands are distributed over the skin of the whole body except that of the glans penis, margin of the lips THE SWEAT GLANDS. 1 3 and the nail bed. In the external meatus of the ear they are found as ceruminous glands, on the eyelids they are known as the glands of Moll. The sweat glands are large and small. The large glands are met with in the axillae and groins and around the anus, while the small variety are distributed generally over the skin. In the small glands the diameter of the coils averages 3 mm. to 4 mm.; in the large large glands of the axillae and scrotum it may measure 1 mm. to 3 mm. The glands vary greatly in number in different individuals. They are said to average 2800 per square inch on the palms of the hands, where they are more numerous than elsewhere, except the soles of the feet. Structure. The sweat or coil glands are simple tubular glands composed of a body, consisting of two or more turns of a tube, and forming a coil which is situated either in the reticular layer of the corium or in the subcutaneous tissue; and a duct which traverses the corium in a spiral manner. (See Fig. 1.) The coil or body is a flattened or roundish structure usually composed of several turns of the tube. Near the blunt end it consists of a single layer of cylindrical epithelial cells with oval nuclei. Here and there a connective tissue cell may be found wedged in between two of these cells, thus allowing an inter- change of the gland contents with the lymph of the neighboring tissue spaces. Outside these epithelial cells are involuntary muscle cells, and outside the muscular layer a basement mem- brane has been described. Occasionally brown or yellow pigment-granules may be pres- ent in the epithelial cells of the coil. These are secreted with the sweat and may color it. The excretory duct is made up of two well-defined portions which differ entirely in their structure, namely, (1) the part in the corium, and (2) the channel through the epidermis. The part of the duct which passes through the corium like a corkscrew has a uniform caliber, the epithelium similar to that in the coil and consists of two or three layers of cubical cells 14 DISEASES OF THE SKIN. with a fibrous coating. There is no muscular coat to the duct. A plexus of blood-vessels surrounds the coil and extends up the duct. Small nerve fibres pass to the muscle cells of the coil. On reaching the epidermis the duct proper may be said to end, for it is represented simply by a spiral cleft between the prickle cells of an interpapillary process. Toward the surface this cleft opens out into a funnel-shaped opening, the pore. THE HAIR. Hairs are present on all parts of the human skin except that of the palms of the hands, soles of the feet, red parts of the lips, glans penis, inner surface of the prepuce, inner surface of the labia majora and dorsal aspects of the ungual phalanges of the fingers and toes. The number of hairs to a given area of skin has been variously estimated, averaging, at the vertex of the scalp three hundred to the square centimeter, forty-four on the beard of the chin and eight- een on the back of the hand. Wilson estimated that there were about one hundred and twenty thousand hairs on the whole scalp but the number varies considerably in individuals and according to the color of the hair. The color of the hair is chiefly due to pigment-granules in the cortex, but is also dependent, to some extent, upon the diffuse color of the protoplasm of the hair cells and upon the presence of air between the hair cells. The pigment and diffuse coloring matter diminish with advancing age, and by shrinkage and atrophy of the hair cells and the presence of air between them the white hair of old age is produced. Aside from the scalp the hairs are thickest in the beard and about the genitalia, and thinnest on the trunk and limbs where they form the lanugo. THE HAIR FOLLICLE. The microscopic anatomy of the hair and hair follicle is some- what intricate and its study has been made more so by a com- plicated terminology. Essentially, however, it is as follows: THE HAIR FOLLICLE. 15 The hair follicle is to be regarded as a simple invagination of the skin, enveloped by a condensed layer of connective tissue. Considered from within outwards, the follicle in its upper third has epidermal layers similar to and continuous with those of imp. mm Fig. 3. — Section of normal hair much magnified and showing minute structure. Hair. .4. Cortex. B. Root. C. Cuticle. D. Medulla. Papilla. H. Papilla, showing connective tissue fibres and vascular loops. Hair Follicle. E. External connective tissue layer of the hair follicle. F. Middle fibrous layer of the hair follicle. G. Internal hyaline or vitreous layer of the hair follicle. /. External root sheath. /. Internal root sheath. the epidermis — namely, a horny layer, transitional layers, a prickle cell layer and a basal layer. In the lower two-thirds the horny and transitional layers disappear and only the prickle cell and l6 DISEASES OF THE SKIN. basal layers remain. The epidermic portion of the follicle is enveloped in a dense sheath of connective tissue derived from the corium. The continuation of the prickle cell layer of the epidermis in the hair follicle is generally known as the external root sheath. It consists of polygonal prickle cells with round nuclei which are arranged in several layers but which form only a single layer of cutical cells near the papilla. This layer usually comes out when the hair is epilated and the cells may be seen adhering to it. Between the prickle cell layer and the hair there is a some- what complicated structure known as the internal root sheath. It occupies the lower two-thirds of the follicle. On the inside of the internal root sheath there is a cuticle formed of a single layer of elongated cells with their long axes divided downwards and inwards. These cells fit into the cuticle of the hair, which have an opposite direction. Owing to the close union of the two cuticles, it is almost impossible to epilate a hair without pulling out part of the root sheath. Outside the external root sheath is the connective tissue layer of the hair follicle. It is composed of an external layer of connective tissue cells and fibres, blood vessels and nerves, a middle layer of fibrous bundles arranged circularly, and an internal layer of an apparently homogeneous character known also as the "hyalin" or "vitreous" layer. THE PAPILLA. The papilla of the hair is a differentiated process of the corium, analogous to the papillae of the papillary layer. It is conical in shape, consists of connective tissue fibres and cells supporting a vascular loop and medullated nerves. MINUTE STRUCTURE OF THE HAIR. The hair consists of a shaft or stem which widens out at the lower end of the hair follicle into a bulbous extremity known as the root of the hair. The greater portion of the shaft is formed THE ROOT OF THE HAIR. 1 7 by the cortex, in the centre of which there is a more variable structure known as the medulla. The hair is protected externally by a sheath or cuticle formed of a single layer of cells. The cuticle is made up of quadrilateral flat cells arranged in an imbricated manner, overlapping one another like slates, and have their long axes directed upwards and outwards at an acute angle to the axis of the shaft. The cortex composes more than two-thirds of the shaft when the medulla is present and the whole of it in the absence of the medulla. It consists of bundles of spindle-shaped cells which give it a fibrillated appearance. The cells contain diffuse color- ing matter of a yellowish or reddish tinge. Between them, and, occasionally within them, pigment-granules may be found. The medulla forms the core of the hair and extends to near the tip. By transmitted light the medulla appears as a dark streak in the centre of the shaft from the presence of air in and between the cells. The medulla is made up of rouleaux of plates composed of three or four flattened cells. Medullar only occur in the hairs of the scalp, beard, axillae and pubes. THE ROOT OF THE HAIR. The hair root is the bulbous lower extremity of the shaft It is indented at its upper end by the upgrowing, conical, vascu- lar process of connective tissue known as the papilla. The cells composing the root present, especially near the papilla, almost their original characters and are not differentiated into the appearance they present in the shaft. The cuticle oj the root consists of a single layer of cells, which, near the papilla, are cubical in shape and have their axes directed downwards and outwards. Further along they are directed hor- izontally and finally upwards and outwards. The extension of the cortex in the root is composed of polyg- onal cells with well-marked nuclei, and it is only at the upper limit of the bulb that they assume their fusiform shape and that the fibrous appearance of the cortex becomes evident. These 15 DISEASES OF THE SKIN. cells contain diffuse coloring matter and occasionally pigment- granules. The medulla of the root is formed of cubical non-pigmented cells containing granules of keratohyalin. NAILS. The nails are hard, horny, elastic, translucent structures which are embedded in the corium upon the last phalanges of the fingers and toes. The uncovered part of the nail is called the body, the posterior portion embedded in and concealed by the groove is called the root. Around the lateral and posterior edges of the nail, at the line where the true skin joins the nail, there exists a well-defined groove, the nail groove. That portion of the skin which arises from the groove and which covers in the nail as a fold is known as the nail fold or nail wall. The epon- ychium or nail skin is a thin layer of cuticle which proceeds from the nail fold and, extending forward, covers as a film the beginning of the body of the nail to a variable, but, usually, very short distance. The epidermis beneath the body of the nail is called the hyponychium, that bordering the entire nail the peri- onychium. Upon the outer surface of the nail are more or less marked but minute striae or minute ridges running parallel with the long axis of the nail. The lunula or semi-lunula is the little whitish half-moon-shaped or crescentic spot which exists in front of the nail fold. It is most distinctly defined upon the thumb and is often not defined or wanting upon the toes. The nail is a pecular metamorphosed portion of the epidermis and is made up of two layers in the same manner as is the epi- dermis of the skin, a soft mucous layer and a hard horny layer, the latter composing the nail proper. THE NAIL BED. The nail bed i-s that portion of the corium anterior to the matrix upon which the nail substance rests. It consists of sub- THE MATRIX. 1 9 cutaneous connective tissue, corium and mucous layer of the epidermis. THE MATRIX. The matrix or germ layer of the nail corresponds to the mucous layer of the epidermis. It occupies the posterior portion of the nail bed, lying wholly or partly within the nail fold, and is the exclusive seat of the formation of the nail. The nail grows by the generation of the cells of the mucous layer at the root. The horny cells are pushed forward by the new mucous cells, cornification taking place as in the horny layer of the epidermis of the skin. The nail, when uncut, grows out a certain length and then wears away by natural desquamation of the cells. When carefully tended, as in China and Korea, it may grow to a length of two inches or more. The nails grow more rapidly in summer than in winter and more rapidly in children than in adults. The time required for the growth of the nail from the lunula to the free edge on the fingers is variously given as from 108 to 168 days, varying, probably, according to the condition of the general nutrition, etc., of the individual. Quain gives the growth as one thirty-second inch in a week. PHYSIOLOGY OF THE SKIN. THE SKIN AS A PROTECTIVE ORGAN. The skin is a protective organ in a double sense. It guards the economy from external agents, as heat and cold, chemical and mechanical injury. It serves to enclose and protect the subcutaneous structures and fluids of the body. THE SKIN AS A SENSORY ORGAN. The skin is an organ of common sensation conveying feelings or sensations of various kinds to the nerve centres. Through tactile sensibility, knowledge is obtained of various objects with which we come in contact. The vaso-motor nerves play an impor- tant part in the physiology and pathology of the skin. Pain 20 DISEASES OF THE SKIN. and the temperature sense are also functions of the cutaneous nerves. The skin acts as a regulator of bodily heat and aids in pre- serving a constant temperature of the blood by contraction and exhaustion of peripheral vessels. THE SKIN AS A RESPIRATORY ORGAN. The skin, like the lungs, absorbs oxygen and gives forth car- bonic acid and water. The quantity of oxygen absorbed by the skin, however, is almost infinitesimal. The quantity of carbonic acid exhaled is calculated variously by different authorities from 2.23 grams to 30 grams in 24 hours. Increase in the tem- perature of the surrounding atmosphere, muscular work and other circumstances involving the quantity of blood sent to the skin raise the volume of carbonic acid exhaled. The water exhaled from the skin appears as invisible vapor, "insensible perspiration" or visible vapor "sensible perspira- tion." It may amount to 600 grams in 24 hours, or double that given off by the lungs. Experiments have been made from time to time in coating the cutaneous surface with various impermeable dressings, such as varnish, oil, paint, adhesive plaster, colodion and tar. In man these experiments have not resulted seriously, except when, as in the case of tar, some toxic ingredient of the impermeable covering has been absorbed. THE SKIN AS A SECRETORY ORGAN. The most important function of the skin is that of secretion, which is to be considered under the heads of (1) sweat and (2) sebaceous secretions. Sweat Secretion. The secretion of sweat takes place in the coil of the sudoriparous, sweat or coil gland. The amount of sweat secreted varies in different regions. The palms as a rule give off most, then the soles, face, neck, axillae, genital region, arms and forearms. THE SKIN AS A SECRETORY ORGAN. 21 The sweat is a watery or fatty, colorless, clear fluid, with an alkaline or acid reaction, according to circumstances. It pos- sesses a salty taste and a characteristic odor varying with the individual and the circumstances, and which is due to the presence of volatile fatty acids. In addition to sweat, the coil glands at times secrete oil. Perspiration varies in different persons, the average amount of water poured out is, as was said above, about twice the weight of that secreted by the lungs. The effect of temperature on the secretion is marked. Vascular or muscular activity acting on the blood pressure and the internal use of warm water in quan- tity produce an increase in the secretion. The action of certain drugs on the sweat secretion is marked. Some, as pilocarpin, increase the flow, others, as atropin, diminish it. The relation between the sweat glands and the kidneys is complementary one to the other. Their action in a given case is in inverse ratio. When the skin is active, as in summer, the kidneys separate less water, while, in winter, when the cuta- neous capillaries are chilled, the urinary secretion is increased. Urea is a normal constituent of sweat to the proportion of about o.i per cent., though variations occur. The Sebaceous Secretion. The product secreted by the seba- ceous glands is designated sebaceous matter, or sebum. It is a fatty substance, and in healthy persons, within the glands, is a fluid or semi-fluid substance of variable consistence tending to be- come firmer and of a fatty or cheesy consistence as it reaches the duct. In certain localities where the glands are large, as on the nose and neighborhood, the sebum can sometimes be expressed in firm plugs. Commonly it exists on the skin as a greasy or oily coating. Chemically, sebum consists of fluid olein and solid palmitin, fats, cholesterin soaps, an albuminoid, and the alkaline chlorides and phosphates. Microscopically the sebum shows free fat, fatty cells and cell debris, cholesterin crystals and epidermic scales. The vernix caseosa of the new born and the smegma prceputialis are similar in composition. Cerumen, or ear wax, is 2 2 DISEASES OF THE SKIN. a mixture of the product of the sebaceous and coil glands. The secretion of the Meibomian glands is sebum. ABSORPTION. The whole structure of the skin and its function as a protective organ are directed against the absorption of alien substances. The horny epidermis and the oily covering with which it is endowed by the sebaceous and coil glands serve to resist the pen- etration of substances of any sort. There is, however, a certain faculty of absorption in the uninjured skin, chiefly of volatile and penetrable substances mixed with fatty matters. Ointments containing iodine, belladonna, mercury, etc., when thoroughly rubbed into the skin carry a portion of their ingredients into the economy. Substances of a similar character are also absorbed to a slight extent in the course of prolonged immersion in watery solutions. But when the corneous layers of the skin are removed, as by a blister, absorption takes place with great rapidity. Applications made with the aid of a constant current of galvanic electricity are also absorbed (cataphoresis). SYMPTOMATOLOGY. The symptoms of skin disease are objective and subjective, and they may be limited to the disease itself or involve other parts or even the whole organism. At present we are concerned with the local manifestations of disease which are, generally and in the vast majority of cases, the only symptoms of importance. The general symptoms will be touched upon under the head of the various diseases in which they are manifested. OBJECTIVE SYMPTOMS. These comprise the elementary lesions of the skin and are divided into primary and secondary. A careful study of these lesions and perfect familiarity with their nature is an absolutely PRIMARY LESIONS. 23 essential prerequisite to the study of diseases of the skin. With out a knowledge of the lesions going to make up an eruption the student can neither understand the description of a skin disease, nor convey an intelligent idea of it to another. PRIMARY LESIONS. Macules. Macules, maculae or spots, are variously sized, shaped and colored areas of abnormal skin, usually level and unaccompanied by elevation or depression. Macules may be of any size, from pin-head to palm-size or larger. They may be round, oval or irregular in outline and may be of almost any tint, depending on their origin, but usu- ally red, yellow, or brown. Macules may be due to several different causes: 1. Hyperemia, arterial or venous. The eruption of erythema is an example. The color in these macules can be made to fade by pressure with the finger. 2. Extravasation of blood and blood coloring matter. The eruption here is bright red at first and subsequently changes color like a bruise as absorption occurs. When these macules are in the shape of streaks they are called vibiccs ; when punc- tate petechia; when of larger size ecchymoses. 3. The vessels of the skin may become permanently dilated or new vessels may form. The capillary ncevus is an example of the congenital from. The telangiectasis exemplifies the ac- quired form. 4. Changes in the pigmentation of the skin either from excess or deficiency may occur as macules. In the former case we have as congenital, the mole, as acquired, lentigo or chloasma. Pigmentary macules may also occur as secondary to other in- flammatory changes, as in the stains left by lichen planus and certain syphilodermata. Diffuse pigmentations are not usually called macules but are spoken of simply as discolorations of the skin, as Addison's disease, etc. From loss of pigment arise the white spots known as vitiligo and leukoderma. 24 DISEASES OF THE SKIN. Papules. Papules, or pimples, are circumscribed firm eleva- tions of the skin, varying in size from a pin-head to a split pea, and not visibly containing fluid. They may be round or angular at the base and in elevation convex or lenticular, acutely or bluntly conical or even flat at the top. In color they are some shade of red, white or yellow. They may be situated in the corium, in connection with the sebaceous glands, or about the hair follicles. They are of the following varieties: i. Inflammatory, as in eczema. 2. Com- posed of excessive cornification or accumulation of epidermic cells as in keratosis pilaris. 3. Produced by the accumulation of sebum as in milium or comedo. 4. Produced by hemor- rhage into hair follicles as purpura papulosa. Papules of the inflammatory variety may become transformed into other lesions, as vesicles or pustules, or may break down into ulcers, as in syphilis. They may also take on a scaly charac- ter in the course of their development. Vesicles. Vesicles are circumscribed, rounded or acuminate elevations of the epidermis, varying in size from a pin-point to a split pea, containing a clear or opaque fluid. They may arise directly on the surface as in miliaria; or on the top of an inflammatory base, diffuse or papular, as in eczema. Vesicles may be of different colors according as their contents are pure serum, sero-purulent matter or serum mixed with blood. They may be tense and firm, or flaccid. In some in- stances they are firm, sharply defined, and discrete, as in herpes zoster. In other instances, as in eczema, they tend to run to- gether and rupture readily, discharging their fluid over the surface. In form, vesicles are rounded, circumscribed, and either pos- sess a dome-like roof or are somewhat acuminated. They may have slight depressions on their summits as in varicella. Some- times they are irregular in outline. Anatomically, vesicles are situated between the horny layers, between the horny and mu- cous layers or in the mucous layer, or, in the case of lymph- angiectodes they are in the lymphatics of the corium. They may be single chambered, as in sudamen or multilocular, as in PRIMARY LESIONS. 25 herpes zoster. The points to be observed are their size, color, contents, base, depth, mode of evolution, course, duration, the subjective symptoms, and, if the contents are evacuated, the condition of the skin beneath. Blebs. Blebs, or bullae, are irregularly shaped elevations of the epidermis, varying in size from a split pea to a goose egg, containing a clear or opaque fluid. When recent, they are of a pale yellowish color; when their contents become turbid they are whitish or yellowish; containing blood, they are reddish or brown- ish. Blebs usually have strong walls and are filled out and tense. They do not rupture easily, their contents drying up, but they may be flaccid as in pemphigus foliaceus. Blebs, as a rule, have no areola unless they contain pus, rising abruptly from the healthy skin, but they are usually preceded by a transitory red- ness. There is usually little or no sensation in blebs excepting those of dermatitis herpetiformis or when they are very exten- sive. The points to be observed are their size, shape, contents, duration, and, after rupture, the condition of the exposed surface. Pustules. Pustules are circumscribed, rounded, flat or acum- inated elevations of the epidermis varying in size from a pin- point to a finger-nail, containing pus. Pustules may originate directly or may develop from papules or vesicles. Often tran- sition forms of papulo-vesicles and vesico-pustules may be ob- served. They are usually opaque, yellowish or, when containing blood, brownish. Pustules have, as a rule, a red areola, some- times with induration, as in boils; sometimes they are round and convex, some are umbilicated, as in variola. Some are round and pointed, others, as in ecthyma, flat and irregular. Some pustules arise in the papillary layer of the skin, others in the sebaceous glands, as in acne, around the hair follicles, as in sycosis, or deep in the corium, as in boils. Their course is usually acute and they rupture, the contents drying up int6 a firm crust. If the process is deep enough a scar may be left. Pustules are often painful and tender, sometimes they are attended with burning but seldom with itching. The points to be noted are their size, shape, color, mode of evolution, anatomical position, base, course and sequelae. 26 DISEASES OF THE SKIN. Wheals. Wheals, or pomphi, are rounded, flat, irregular, firm cedematous elevations of an evanescent character. They vary greatly in size from split pea to hand size or larger. In form they are bean shaped, ovalish, or tending to appear in raised lines or stripes. Their color is whitish, rosy or pinkish, often with a pale centre. They form very rapidly, often in a few mom- ents, and after lasting a greater or less time disappear as they came. Usually wheals are the result of angioneurotic irritation, exter- nal or internal, leading to the sudden outpouring of serum from the vessels ; this is followed immediately by a spasmodic contrac- tion of the capillaries. On the spasm ceasing, the released capil- laries take up the fluid again and the wheal subsides. Some- times blood is poured out, as in purpura urticans. Wheals are always attended with severe tingling or itching. The points to be noted are their size, color, mode of evolution, duration, sequelae, and their local or constitutional origin. Tubercles. Tubercles, or nodules, are circumscribed, solid, rounded or acuminate elevations of the skin varying in size from a split pea to a cherry. (It must be remembered that the term "tubercle" refers only to the form of the lesion and does not infer in any instance a re- lationship to pathological tubercle.) In shape tubercles are generally defined semi-globular, con- ical, flat or irregular in outline. They sometimes go on by per- ipheral extension and coalescence to an infiltration in diffuse, slightly elevated masses with sharply defined borders and flat- tish surface. When of inflammatory origin the color is usually red or brownish-red, but in other cases they may be of any color. Tubercles are produced in great part by the cellular neoplas- mata. Syphilis, leprosy, lupus and carcinoma may at times give rise to marked examples of tubercles. They undergo various changes in their evolution, according to their nature and cir- cumstances ; they are either absorbed, or break down and ulcer- ate, and are followed by scars, or they may establish themselves and remain permanent, as in molluscum fibrosum. SECONDARY LESIONS. 27 In examining tubercles their size, shape, color, consistency and course are the points to be specially noticed. Tumors. Tumors are variously sized, shaped and constituted, firm or soft prominences or new growths of all kinds, from a pea and upwards in size, having their seat in the corium or subcu- taneous tissue. They may be of all sizes from a pea to an egg, or larger. They usually assume a rounded or globular form unless compound, in which case the form may be irregular. Tumors may be sessile, almost implanted in the skin, or they may be pedunculated, hanging even by a slender stalk. Their color may be the same as the surrounding skin or, when inflammatory, the color may be reddish of variable shade. The skin covering them may remain intact or may break down and form suppurating, bloody and crusted surfaces. Tumors are occasioned by a great variety of causes, as, for example, altera- tions in the sebaceous glands, various inflammations and new formations in the corium and connective tissue, and new growths of the blood-vessels and lymphatics. They may or may not be painful. SECONDARY LESIONS.* Crusts. Crusts are masses of dried, effete material composed of the products of cutaneous disease, irregularly shaped and sized, and usually yellowish or brownish in color. Several varieties of crusts are observed. Those resulting from an open serous discharging surface are yellowish or brownish- yellow, friable in consistence and, as a rule, without definite out- line or bulk, as in vesicular eczema; those following the break- ing down or drying up of pustules, especially if there be hemor- rhage, are darker, more tenacious and thicker, as in ecthyma. The crusts of syphilis are usually firmer and less friable in structure than those of eczema, and frequently have a heaped up, shell- like appearance; they sometimes have a dark greenish tint, and may be seated upon a superficial or deep ulcer. Sebaceous *See an interesting article by Saboureand on Scales and Crusts, Jour. Cut. Dis., 1903, p. 61. 28 DISEASES OF THE SKIN. crusts, as those of seborrhoea, are yellowish or brownish and have a greasy feel and appearance. The crust of tinea favosa is composed chiefly of epithelial cells, debris and the fungus, the latter generally in profusion, and is of a more or less dingy, sulphur-yellow color and distinctly cup shaped. Scales. Scales are dry laminated masses of epidermis which have separated from the tissues beneath. Scales vary greatly in form, shape and size, according to the disease in which they occur, and their appearance in a given case will often determine the diagnosis. In some diseases scales are proliferated and thrown off in great quantity. In pityria- sis rubra and in active psoriasis handfuls may be gathered daily. Sometimes scales are formed in thick heaps as in psoriasis, some- times in thin branny flakes as in some forms of eczema, some- times in thin micaceous films as in pityriasis rubra. At times the scaly product of skin disease is found composed of a dried serous or puriform matter together with epithelium. Thus a mixture of scales and crusts is often found in eczema and other diseases. Scaling in the form of small or large lamel- lae, constituting sometimes a localized exfoliation of the epidermis designated exfoliative desquamation, is met with in impaired nutrition, as a result of nerve injury or operation. Excoriations. Excoriations are variously sized and shaped areas, characterized by loss of cutaneous tissue, confined usu- ally to the epidermis, generally the result of local injury. They comprise slight wounds, erosions, abrasions of the skin, lacera- tions and scratch marks. Scratching or rubbing on the part of the patient is the cause of the vast majority of excoriations. Excoriations occur most abundantly in eczema, scabies and pediculosis. They also occur in the so-called "neurotic excoria- tions" when they are automatically produced by the patient under the influence of obscure impulses connected with the hysterical state. Also in other conditions where the epidermis is defective. Fissures. Fissures are variously sized and shaped linear cutaneous cracks and wounds, due to disease in the skin or to external agencies, having their seat mainly in the epidermis. SECONDARY LESIONS. 20. They commonly occur in the natural furrows of the skin, as the palms, soles, fingers or toes, but may occur in other regions, as the natural apertures of the body, the nostrils, mouth, anus, etc. They appear as clefts in the skin and are due to a loss of elasticity and resisting power, the effect of disease. They fre- quently occur in eczema and are also met with in ichthyosis, syphilis and psoriasis or as a result of local irritants heat, cold, etc. They appear as clefts, dry or moist linear openings. Ulcers. Ulcers are irregularly sized and shaped losses of sub- stance or excavations of the cutaneous tissues, the result usually of some preceding disease. In some cases the alteration of the tissue is due to a simple inflammatory process, as in simple ulcer of the leg, in others it is due to a specific inflammation, as in lupus vulgaris, carcinoma, syphilis, lepra or other so-called neoplasmata. Ulcers vary as to size and shape. They may be no larger than a pin-head or as large as the hand or larger. Their outline is usually roundish but may be kidney shaped, as in syphilis, or irregular. They may be excavated or shallow, sharply defined, or shelving up irregularly to the surrounding skin. They usually show a purulent discharge. They do not remain con- stant but tend to change their form, either healing or growing larger. Ulcers when healed over leave a cicatrix or scar. Scars. Scars are new formations, consisting mainly of connec- tive tissue, occupying the place of former normal tissue, the result generally of injury or previous disease. Scars are not invariably the result of an injury or previous disease. In morphcea, scleroderma, atrophia cutis and the like, in keloid, lepra, etc., scars develop without previous perceptible disease. As a general thing, however, scars result from ulcers or injuries involving loss of substance. Scars are usually indolent but are sometimes painful. In some diseases, as keloid, they tend to hypertrophy. In hypertrophy of scars immediately following injury or disease, the prognosis is favorable as to the disappear- ance of the hypertrophy. In true keloid, however, spontaneous subsidence is extremely rare. Scars are permanent, continuing to exist through life with little if any alteration. 30 DISEASES OF THE SKIN. CLASSIFICATION. In a text-book, that classification is best which enables the student to grasp the association of diseases so as to conceive of them in their relation to one another. Almost as important as this is the avoidance of any original and individual classification on the part of the author. Much of the "confusion of tongues," which has been attributed to dermatological writers, has arisen from the effort on the part of each writer to put forth such a classification and nomenclature as seemed most perfect, with but little regard to the arrangements of others. American dermatologists, especially of late years, have, how- ever, agreed upon a classification based upon that of Hebra and upon a nomenclature sanctioned by the American Dermatological As- sociation. In this way students all over the country are being taught on the same general scheme, and, awaiting the perfect system which shall be based upon an accurate knowledge of the pathological anatomy of skin diseases and of the processes con- cerned in their evolution, we can do no better, I think, than pursue the plan now so generally adopted. The classification employed in the present volume is as fol- lows: CLASS I. HYPEREMIAS. Erythema hyperaemicum Erythema intertrigo Erythema scarlatinoides CLASS II. INFLAMMATIONS. a. Having erythema as a prominent symptom with exudations of various kinds in addition. Erythema multiforme Erythema nodosum Erythema induratum Pellagra b. Characterized by oedema as a marked symptom. Urticaria Urticaria pigmentosa (Edema angioneuroticum CLASSIFICATION. 3 1 c. Erythemato -squamous. Pityriasis rosea Dermatitis exfoliativa Dermatitis exfoliativa epidemica Dermatitis exfoliativa neonatorum d. Papular. Prurigo Lichen ruber Lichen scrofulosus e. Papulosquamous. Psoriasis f. Multiform (erythematous, papular, vesicular, etc.). Eczema Eczema seborrhceicum g. Vesicular and bullous. Herpes simplex Herpes zoster Hydroa vacciniforme Pompholyx Pemphigus Dermatitis herpetiformis Dermatitis repens h. Vesico -pustular and pustular. Impetigo Impetigo contagiosa Impetigo herpetiformis Ecthyma i. Phlegmonous. Furunculus Carbunculus Phlegmona diffusa j . Erytliemato-oedematous. Erysipelas Erysipeloid k. Pustular, papillomatous, necrotic and gangrenous. Dissection wounds Equinia Malignant pustule Sphaceloderma Dermatitis gangrenosa infantum Multiple gangrene in adults 32 DISEASES OF THE SKIN. Diabetic gangrene Symmetric gangrene 1. Varied — multiform, superficial or deep-seated. Dermatitis calorica Dermatitis traumatica Dermatitis venenata X-ray dermatitis Dermatitis factitia Dermatitis medicamentosa m. Exanthemata* (i) Erythematous maculo-papular Scarlatina Rubeola Rotheln (2) Vesicular Varicella (3) Primarily papular, then vesicular and pustular Variola (4) Erythematous, vesicular, pustular, multi- form, etc. Vaccinal eruptions. CLASS III. HEMORRHAGES. Purpura CLASS IV. HYPERTROPHIES. Lentigo Chloasma Naevus pigmentosus Acanthosis nigricans Clavus Callositas Keratosis palmaris et plantaris Keratosis senilis Keratosis pilaris Keratosis follicularis Verruca Cornu cutaneum Ichthyosis Porokeratosis * Excepting varicella and vaccinal eruptions the exanthemata have not been described in the present work. CLASSIFICATION. 33 Angiokeratoma Scleroderma Sclerema neonatorum (Edema neonatorum Elephantiasis Dermatolysis CLASS V. ATROPHIES. Albinismus Vitiligo Glossy skin Atrophia senilis Striae et maculae atrophicae Diffuse idiopathic atrophy Kraurosis vulvae Ainhum Perforating ulcer of the foot Morvan's disease CLASS VI. NEW GROWTHS. a. Benign. Cicatrix Keloid Dermatitis papillaris capillitii Molluscum contagiosum Multiple benign cystic epithelioma Adenoma sebaceum Lymphangioma circumscriptum Xanthoma Xanthoma diabeticorum Colloid degeneration of the skin Angioma Naevus vascularis Telangiectasis Angioma serpiginosum Fibroma Lipoma Myoma Neuroma Of possible malignancy. Rhinoscleroma Tuberculosis cutis Tuberculosis ulcerosa 34 DISEASES OF THE SKIN Tuberculosis disseminata Tuberculosis verrucosa Scrofuloderma Lupus vulgaris Lupus erythematosus Syphilis Aleppo boil Framboesia Verruga Malignant. Carcinoma Paget's disease Epithelioma Xeroderma pigmentosum Sarcoma Granuloma fungoides Leprosy CLASS VII. NEUROSES. Hyperesthesia Dermatalgia Erythromelalgia Pruritus Anaesthesia CLASS VIII. DISEASES OF THE APPENDAGES. (i) Nails. Onychauxis Atrophia unguium Onychomycosis (2) Hair; hair follicles. Hypertrichosis Atrophia pilorum propria Fragilitas crinium Trichorrhexis nodosa Monilethrix Piedra Tinea nodosa Lepothrix CLASSIFICATION. 35 Canities Alopecia Alopecia areata Folliculitis decalvans Sycosis Conglomerate suppurative folliculitis. (3) Sebaceous glands. Seborrhcea Milium Steatoma Comedo Acne Acne varioliformis Acne rosacea (4) Sweat glands. Anidrosis Hyperidrosis Bromidrosis Chromidrosis Hasmatidrosis Uridrosis Phosphoridrosis Sudamen Hydrocystoma "Miliaria Hydradenitis suppurativa CLASS IX. PARASITIC AFFECTIONS. a. Vegetable. Favus Ring-worm Tinea imbricata Tinea versicolor Erythrasma Pinta disease Myringomycosis Actinomycosis Mycetoma Blastomycetic dermatitis 36 DISEASES OF THE SKIN. b. Animal. Living on or attacking the skin — Pediculosis — capitis, corporis, pubis Cimex lectularius Pulex irritans f Ixodes I Dermanyssus avium Miscellaneous -\ Culicidae I Similidae L Apidae, etc Penetrating the skin (either parasites or larvae) — Scabies Leptus autumnalis Pulex penetrans Dracun cuius Cysticercus cellulosae Demodex folliculorum (Estridae Craw craw Echinococcus, etc. HYPEREMIAS. 37 CLASS I. HYPEREMIAS. The hyperemias properly include only those cutaneous con- ditions characterized by an abnormal flux of blood, unattended by ordinary inflammatory changes. It is difficult to draw the line between hyperaemia and inflammation, for there is often a slight tendency to inflammatory action even in the most typical erythemata. For convenience sake, however, the distinction must be attempted. Hyperaemia is usually active but it may be passive, a stasis or lividity of the surface going on to cyanosis. The active hyperaemias are represented by the non-inflammatory or non-exudative erythemata. ERYTHEMA. Erythema hypercemicum, or erythema simplex is characterized by redness, occurring in the form of variously sized, diffused or circumscribed, non-elevated patches, irrespective of cause. There are two varieties; the idiopathic, under which head are included the erythemata occasioned by heat and cold, continued pressure or rubbing, and the action of irritant or poisonous sub- stances, as mustard, arnica, various dye-stuffs, acids and alkalies; and the symptomatic, due to some general derangement of the economy, as disorders of the stomach and bowels, etc., or con- nected with toxic infection. Such are the roseola of infants and young children and the erythema injectiosum of Esherich and Shaw.* The diagnosis of the idiopathic erythemata is usually made without difficulty. In the symptomatic erythemata consider- able difficulty is sometimes met with, especially when there is any febrile or general disturbance. The symptoms of the various exanthemata, measles, scarlet fever, etc., may be excluded * Shaw. Am. Jour. Med. Sci., Jan., 1905. 38 DISEASES OF THE SKIN. to begin with, but considerable difficulty is often encountered in making an off-hand diagnosis.* Certain general diseases are at times accompanied by hyper- emia of the skin, which shows itself in the form of roundish spots, the size of a pea or finger nail, to which the name roseola has sometimes been given. It denotes simply the form of erythema, and in no way indicates the nature of the disease which has brought it forth. The treatment of erythema simplex must obviously depend upon its cause in any given case. The removal of the obvious cause is alone usually sufficient in idiopathic erythema, but in the symptomatic form of the disease the internal disorder to which the cutaneous manifestation is due must be diligently sought out and treated, with a view to removal. Locally, sooth- ing and astringent lotions may be employed. A much-used lotion in erythema, when the skin is unbroken, is the following: J\. Acidi hydrocyanici, dil., 5ij ( 8. ) Bismuthi subnitrat, 5 i j— iv ( 8-16) Aquae aurantii nor., . . . . . q.s. ad Oss (240. ) Sig. — Outside use. Dilute lead water, or lead water and laudanum, or simple alcohol and water, may be used with satisfaction in most cases. As for powders, though useful, they will be found in practice difficult to keep in contact with the skin. Ointments are very apt to disagree in simple erythema, and should, therefore, as a general thing, be eschewed. ERYTHEMA INTERTRIGO. Erythema intertrigo is characterized by redness, heat and an abraded surface, with maceration of the epidermis. It occurs chiefly in those parts where the natural folds of the skin come in contact with one another, as about the nates, perineum, groins, axillae, and beneath the mammae, and is produced by the fric- tion of two opposing surfaces. It is especially common among *See Wingfield. Erythematous rashes simulating the acute exanthemata. Brooklyn Med. Jour., 1902, p. 349. ERYTHEMA INTERTRIGO. 39 fat persons, women with pendulous mammae, and infants whose skin is tender. The skin feels chafed and becomes hot and sore. Perspiration also, at times, macerates the epidermis, and gives rise to the secretion of an acrid, mucoid fluid. If neglected, a true dermatitis may set in. The affection comes suddenly, and if taken in time may usually be quickly checked, but if not treated it soon becomes very annoying. Occurring between the nates, a common seat of the disease, it may interfere with walking. It is usually harder to cure in infants, where the diaper, saturated with more or less acrid secretions, is constantly in contact with the skin. The disease is one of summer rather than winter, although it may occur at any time of the year, if sufficient cause be present. It is sometimes brought on by wearing rough underclothing. I have known severe erythema intertrigo of the nates and thighs caused by walking about, after sea-bathing, in wet bathing- clothes. The rough surface of the flannel, as it dries, becomes coated with minute acicular crystals of salt, which cut like tiny knives. The patient sometimes supposes himself to have been " poisoned" by a hired bathing dress, when the cause of his erythema is purely mechanical, as just mentioned. The disorder is to be distinguished from eczema, and in the case of infants from the erythema of hereditary syphilis. As erythema intertrigo often runs into eczema, the difference often is only one of degree; eczema is more infiltrated and apt to weep, while characteristic papules or vesicles are seen around the border. Syphilitic erythema is apt to be of a more dusky shade, slightly infiltrated and not entirely disappearing under pressure, but leaving a yellowish color. Moreover, thicker papular or tuber- cular lesions are seen about the anus in many cases and the characteristic nasal-catarrhal troubles are usually present. The treatment of erythema intertrigo is commonly an easy matter. As a rule, very little is required beyond cleanliness and atten- tion. The parts should be washed with cold water alone, or with the sparing addition of a superfatted soap, and dried with a soft rag or 4-0 DISEASES OF THE SKIN. towel. The folds of the skin are to be separated and kept apart by pieces of soft linen, lint, or absorbent cotton. Dusting powders are the most convenient remedies is most mild cases. When there is little discharge, or none, starch or lycopodium may be used. Starch, however, is apt to cake and sour if dusted on a moist surface. The following powders are much less liable to this objection, and may be used alone or in combination: Oleate, stearate, oxide and carbonate of zinc, carbonate and subnitrate of bismuth, magnesia, fullers' earth, kaolin, and talc. When starch is admissible, and there is no break in the skin, the fol- lowing preparation is one of the best: 1$. Pulv. camphorae, 3 j (4 ) Pulv. zinci oxidi, Pulv. amyli, aa . . . . § j (32) M To be made into a perfectly impalpable powder.* The mixture should be kept in a tightly-corked, wide-mouthed bottle. In cases which are obstinate, diluted black wash, applied several times a day, alone or followed by the use of some bland powder, as above, is an efficacious remedy. Dilute alcoholic lotions, composed of alum or sulphate of zinc, a few grains to the ounce, also prove serviceable in stubborn cases. In inter- trigo about the thighs and genitalia there is often an element of hyperidrosis. In these cases tincture of belladonna maybe painted on the parts daily and followed by one of the more astringent powders, as the oxide of zinc. In the case of infants, when the intertrigo is about the anus, and the stools are thin, with an acid smell, the following powder may be given internally: I£. Calcis praecipitat gr. iss (0.096) Bismuthi subnitrat., gr. ij (o. 13 ) Sacch. alb., gr. iij (0.20 ) M. Sig. — One, thrice daily. ERYTHEMA SCARLATINOIDES. Erythema scarlatinoides, or scarlatinijorme " scarlet rash" is the term applied to certain erythemata which are followed *This is commonly known as "McCall Anderson's Powd— ler. ERYTHEMA SCARLATINOIDES. 41 by more or less desquamation. There is an acute and a sub- acute type. In the acute form, fever and slight constitutional disturbance may precede the eruption, or it may appear suddenly without premonitory symptoms. It may appear first at any point, though the face and head are apt to be spared, and it may cover a part or the whole surface. The rash spreads rapidly and in a few hours or days reaches its full development with a punctate macular or diffuse appearance and a color which may be any shade of red, usually scarlet, but sometimes dull and livid. The mucous membrane of the tongue and fauces may be reddened and denuded of epithleium. Desquamation begins three or four days after the onset of the disease. It may be fur- furaceous or the epidermis may come off in sheets, the epidermis of the hand, for instance, being shed complete like a glove. Only in exceptional cases are the nails and hair shed. Complete involution requires from a few days to several weeks. The subacute forms of scarlatiniform erythema show less constitutional disturbance, the rash has a greater tendency to be universal and, together with the desquamation, may per- sist for weeks and months, recurrences being frequent. Some cases are with difficulty distinguished from exfoliative derma- titis, and, in fact, both the acute and subacute types of erythema scarlatinoides at times tend to develop into the more severe affection.* The most common predisposing cause of erythema scarlatin- oides is idiosyncrasy. The exciting cause in most cases is a toxaemia of some kind. Infectious diseases, septicaemic condi- tions, peritonitis, rheumatism, gonorrhoea, abscess, empyema, uraemia, tuberculin or anti-diphtheritic injections, sewer gas pois- oning, certain articles of food and many drugs, may each at times, give rise to the eruption. The diagnosis is at times difficult, especially in the first days of the disease. It is most apt to be mistaken for scarlatina. The constitutional symptoms, however, are not so intense, the *Stelwagon and Hyde and Montgomery refer to reported cases of "skin shed- ding," " deciduous skin," etc., as coming under this head. 42 DISEASES OF THE SKIN. rash appears more rapidly and on any part of the body. It is not so apt to be universal, desquamation begins early and is exten- sive. The fauces, though red, are not swollen. There is absence of the strawberry tongue and all history of contagion. From measles the disease we are discussing differs in not presenting the well known concomitant symptoms and in not beginning on the face. From rotheln by the absence of the characteristic gland- ular enlargements. The treatment of erythema scarlatinoides consists in removing the cause when this can be ascertained. Purgatives, followed by intestinal disinfectants are appropriate in many cases, and careful diet with the addition of tonics and digestive agents may afterwards be employed. Externally, the local applications mentioned under erythema simplex may be directed. While the prognosis is generally favorable, frequent recurrences occur in rare cases and the disease has been known to develop into exfoliative dermatitis (g.v.). ERYTHEMA MULTIFORME. 43 CLASS II. INFLAMMATIONS. ERYTHEMA MULTIFORME. Erythema multiforme is an inflammatory disease character- ized by the occurrence of dusky red macules, papules or tu- bercles occurring discretely or in patches of various size and shape. The name has been given to this form of erythema, on account of the protean character of the lesions, which manifest them- selves as erythematous patches of the most varied shapes and sizes, or as papules, vesico-papules, and tubercles, scattered or in groups. Various names are given, denoting the arrange- ment of the lesions. Thus we have E. annulare, occurring in circular patches. Sometimes the circles are very large, or are broken, and assume gyrate forms; this is E. marginatum. Erythema papulation is the commonest variety. It shows itself in the form of isolated or aggregated flat papules of varied size and shape, bright red, bluish or purplish in color, and which soon fade, seldom lasting longer than a week or ten days. E. tuberculatum is simply an exaggeration of this form, and all of the varieties mentioned are but forms and stages of the same process, and are often met with, two or more occurring together simultaneously on the same individual. The lesions of E. multiforme disappear spontaneously, leaving, perhaps, slight pigmentation and desquamation. Erythema iris, sometimes called "herpes iris" and (one form) "hydroa," is characterized by the appearance of one or more groups of variously sized vesico-papules or vesicles, arranged in the form of concentric rings, attended, as a rule, by the display of various colors. The patches vary in size from that of a small coin to several inches in diameter, and are made up of a number of, usually rather indistinct, vesico-papules or vesicles which 44 DISEASES OF THE SKIN. arrange themselves side by side, so as to form a perfect ring. It is a peculiarity of the disease that new vesicles are constantly forming on the periphery while the centre is healing up. When there are a number of independent patches they sometimes coal- esce, and the interlaced arrangement of the concentric and varie- gated circles present a picture so striking that, once seen, it can never be forgotten. It looks, sometimes, as if the patient had been tattooed in rings of various colors, the prevailing tints being red, yellow, and brown. The backs of the hands and feet, as in the other varieties of E. multiforme, and the arms and legs are Fig. 4. — Erythema multiforme. (Courtesy of Dr. Duhring.) the localities usually attacked, but sometimes the trunk is also involved. The eruption is not usually accompanied by sub- jective sensations of any kind. Erythema multiforme is usually found on the backs of the hands and the fingers, forearms and legs. It may show itself on the face and trunk. Sometimes it attacks the mucous mem- brane of the mouth, anus, etc., and even the conjunctiva. Now and then it is general, involving the whole surface. A marked feature of the disease is the disproportion between its appear- ance and the subjective symptoms' to which it gives rise. Not- ERYTHEMA MULTIFORME. 45 withstanding the angry look which the eruption often assumes, there is very little itching or burning. Sometimes constitutional symptoms, as malaise, headache, rheumatic pains, and gastric derangement, are present in marked cases. The temperature is rarely elevated through considerable febrile disturbance has been noted in a few T cases. The affection is much commoner in the spring and fall, al- though it sometimes occurs at other periods of the year. It is among the eruptions of the skin more frequently met with in this country. The American statistics show 915 cases of ery- thema multiforme among 123,746 cases of skin diseases reported. The etiology of the disease is somewhat varied. In general, the cause may be said to be either nervous, toxic, or infectious. It may occur as the result of moral shock, of menstrual disturb- ance, or irritation of the genito-urinary canal, or in the course of chorea, hysteria, myelitis or other disturbances of the central nervous system. Among toxic influences the ingestion of cer- tain drugs, nephritis or uraemia and, especially, intestinal auto- intoxication may be mentioned. Almost all known infections may be accompanied by attacks of erythema multiforme, as cholera, tuberculosis, syphilis, typhoid, fever septicaemia, etc. Osier has developed the complications of erythema in a series of valuable articles.* Erythema multiforme is a mildly inflammatory affection some- what similar to urticaria. It is, in all probability at first, at least, a toxic angioneurosis. The association with rheumatism has led many to believe that it is due to the same underlying cause. Dilatation of the blood-vessels with cell proliferation around their walls, cell emigration and oedema of the cutis, with some- times extravasation of red blood corpuscles and colored serum characterize the anatomical processes. Erythema multiforme is to be distinguished from urticaria by the absence of burning and itching and the slower and more regular development of the lesions. In urticaria the lesion is a * Am. Jour. Med. ScL, 1895, p. 629. lb., 1904, p. 1, and Brit. Jour. Derm., 1900, p. 227. Chronic Purpuric Erythema, Jour. Cut. Dis., 1903, p. 297. See also Schamberg, An Inquiry into the Nature of the Toxic Erythemata., lb., 1904, p. 461. 46 DISEASES OF THE SKIN. transient wheal and new lesions may often be developed by drawing a hard object across the skin. The individual lesions tend to be evanescent. They are whitish in color with a light rose tint. The color of the erythema multiforme lesions is highly characteristic. They are a raspberry red, sometimes showing a slight bluish-purple reflection. Transition eruptions are not rare and an error in diagnosis is not serious. From papular eczema, erythema multiforme is distinguished by the variety of its lesions, mostly of large size, the absence of burning or itching, the fact that it runs a regular course. In papular eczema the lesions are small, regular in shape and out- line and accompanied by burning and, particularly, by itching with the display of scratch marks, etc. In eczema erythematosum there is less definition of each patch and the redness is commonly diffuse and has not the raspberry tint of erythema multiforme. Rotheln is to be distinguished by its adenopathy, its pharyngeal symptoms and its flattish spots. Other affections with which erythema multiforme is apt to be confounded are, purpura rheumatica, erythema nodosum, der- matitis herpetiformis, lichen planus, and, when bullar, or taking the form of "hydroa," with pemphigus. A reference to the de- scription of these diseases under their respective heads will give the data for distinguishing them from erythema multiforme. Copaibic eruptions sometimes simulate erythema multiforme. In the majority of cases of erythema multiforme no active treatment is called for; salicylate of sodium or strontium, how- ever, has been used with success in some cases. Light diet, the avoidance of stimulating drinks, mild saline laxatives, with the local application of dilute alcohol or of carbolic acid, may be employed, as this: 1$. Acidi carbolici, gr. x ( 0.60) Glycerinae, f3j ( 2. ) Aquae, foj (32. ) M. Dusting powders, as that of camphor, oxide of zinc, and starch, given under erythema intertrigo also prove useful at times. ERYTHEMA NODOSUM. 47 ERYTHEMA NODOSUM. Erythema nodosum is an inflammatory affection, of an acute type, characterized by the formation of rounded or ovalish, vari- ously-shaped, more or less elevated, reddish nodes. The disease is apt to be ushered in by some general disturbance of the system, febrile disturbance, gastric uneasiness, malaise and, not infre- quently, with rheumatic pains and swellings about the joints. The nodes often appear suddenly ; they may come on any part of the body, but are commonly found on the legs and arms. They vary in size from a small nut to an egg, are reddish in color, tend- ing to become bluish or purplish. As they disappear, they under- go various changes of color, like a bruise, and it is often difficult to distinguish the lesions from ordinary contusions, especially when they occur over the shins. When the disease is at its height, the lesions have a tense, shining look, as if they contained fluid, and often an indistinct sense of fluctuation is perceptible. They never suppurate, however. Not unfrequently they are more or less hemorrhagic in character. They vary in number from a few to a dozen or more. They come out, as a rule, in crops. They are painful or tender on pressure, and are usually attended by burning sensations. Sometimes the lymphatic vessels are in- volved. The affection usually terminates in recovery in two to four weeks though the duration varies between wide limits. The constitutional symptoms usually abate in average cases after the first few days. Sometimes, however, the fever continues. Occasionally there is visceral involvement. The disease occurs chiefly among those under the age of thirty. It is more apt to occur among the weak and anaemic. Erythema nodosum is a rather uncommon disease. The nature of the disease is not clear, although the febrile reac- tion and visceral involvement point towards a specific infection. It is closely related to erythema multiforme and, in fact, is believed by many observers to be a manifestation of this disease. I can- not at present share this view. The anatomy of the lesions shows, dilatation of blood-vessels 48 DISEASES OF THE SKIN. and closely crowded cells in the papillary layer and corium and, in some instances, extravasation of blood or transudation of blood coloring matter. The leukocytes are sometimes so massed in the veins that they have the aspect of white thrombi. Phlebitis of the larger subcutaneous veins has been met with. There is marked serous infiltration of the cutaneous and usually subcu- taneous tissues. The epidermis is rarely involved. Erythema nodosum is liable to be confounded with bruises, abscesses, gummata, and the lesions of erythema induratum. The former, however, only occur one, two or three in number as a usual thing, and they may go on to suppuration which never occurs in erythema nodosum. Rheumatism also is a frequent concomitant of the latter disease. The lesions of erythema indura- tum are dark in color from the beginning, slower in their course, soon break down and ulcerate, are unaccompanied by febrile and rheumatic symptoms and usually occur in subjects with tuberculous tendencies. Erythema nodosum usually runs its course in a few weeks and ends favorably. A few fatal cases have been reported, but in these, septic infection, with the skin disease as a symptom or accessory, may be supposed to have existed. The treatment is largely symptomatic and expectant. Rest, preferably in bed, a plain diet with a saline laxative is usually all that is required. Later intestinal antisepsis, quinine and the salicylates may be employed if thought desirable. Locally lead- water and laudanum, followed by 5 to 10 per cent, ichthyol ointment, may be applied as there may be some tenderness and pain in the lesions. Rheumatic pains in the joints require the usual wrapping in cotton, etc. ERYTHEMA INDURATUM. Erythema induratum is a sluggish, chronic, skin affection usually found upon the legs, and characterized by the more or less con- tinuous formation of a succession of nodules which, at first small, enlarge to variable size, become purplish in color and terminate after a long period in necrosis. ERYTHEMA INDURATUM. 49 The lesions usually occur on the sides of the lower calf region, the legs and occasionally the thighs. They are at first invisible, but can be felt on palpation as deep-seated, indurated, pea-sized nodules. In the course of days or weeks they enlarge to the size of a cherry or walnut, the skin over the lesions becoming purple or red and later violaceous. The lesions become softer and gradually disappear by absorption, or they atrophy or undergo necrosis and result in a punched-out, somewhat pleep, sluggish- looking, irregular ulcer. The disease occurs almost exclusively in girls and women between the ages of twelve and thirty, especially those who are obliged to stand much upon their feet. The nature of the affection is obscure, although most observers consider it tu- berculous in origin. Erythema induratum is to be distinguished from syphilitic gum- mata and from erythema nodosum. The syphilitic lesions usually run their course more rapidly, suppurate more freely, and are markedly purulent; in erythema induratum the destruction is rather from necrosis than suppuration. The lesions are more painful and inflammatory in syphilitic gummata, they are fewer in number and do not often occur on both legs. The syphilitic lesions are markedly improved by appropriate treatment, while anti-syphilitic treatment never helps but often aggravates the lesions in erythema induratum. Erythema nodosum is more acute in its course, some lesions remain small and pink, the larger nodes are painful and tender and the lesions never suppurate. Moreover, erythema nodosum usually occurs on the anterior tibial surface of the leg, though it may occur on any part of the body, while erythema indura- tum is confined, for the most part, to the sides and back of the calf. Erythema induratum is an obstinate and persistent disease, but under appropriate treatment the prognosis is favorable. Cod-liver oil, iron, quinine and strychnine with nutritious food are called for. Rest, with the leg in a support, and bandaging SO DISEASES OF THE SKIN. should be employed. Locally antiseptics, as boric acid, europhen, etc., may be applied.* PELLAGRA. Pellagra is an endemic disease of the skin, characterized by the appearance of chronic inflammatory patches of an erythem- atous or erythemato-squamous character, accompanied by burn- ing and itching and frequently leading to debility, digestive dis- turbances and symptoms indicating involvement of the cerebro- spinal system. The disease occurs chiefly in Italy, Roumania and Eastern Europe; it is practically unknown in this country. Sherwell has reported one instance occurring in New York in an Italian sailor. Alcoholic excess, poverty, poor hygienic surroundings, and exposure to the sun are predisposing factors, particularly the latter. It was formerly supposed to be due to the ingestion of spoiled maize, containing the bacterium Maidis, but this view is not now generally held. Post-mortem examinations show pachymeningitis, sclerosis of the brain and cord, anaemic and atrophic conditions of the internal organs, with fatty degenera- tion and pigmentary changes. The diagnosis depends upon the occurrence of the disease in the geographical localities mentioned, while the seat of the lesions on the back of the hands, the lower forearms, face, and often dorsal surface of the feet is characteristic. Dermatitis of a mild type, with occasional vesiculation and bullous lesions, with, later, pigmentation, and accompanied by disturbance of diges- tion, diarrhoea, nervous involvement, melancholy, etc., are also characteristic. In slight attacks the prognosis is favorable; when the symp- toms are severe the outlook is unpromising. The duration, however, of fatal cases is long; fifteen to twenty years in some instances. *See Colcott Fox, Westminster Hosp. Reports, 1888, p. 144; and Brit. Jour. Derm., 1893, pp. 225 and 293; also Ibid, 1896, p. 178; also J. C. White, Jour. Cut. Dis., 1894, p. 471;' Dade, Ibid. 1899, p. 306; Johnson, Ibid, p. 312; and others. The literature is somewhat voluminous. URTICARIA. 51 The treatment consists in placing the patient under the best possible hygienic circumstances, and careful nourishment, with the usual tonics. URTICARIA. Urticaria is an inflammatory disease of the skin, character- ized by the development of wheals of a whitish or reddish color, accompanied by sticking, pricking, tingling sensations. The lesions are apt to come out suddenly and disappear again in a very short time, so that a patient seeking advice is often unable to show a sign of the disease, excepting scratch marks, even at repeated visits to the physician, when he may have been tortured and disfigured by it between times. The wheals are of various sizes, sometimes as small as a split pea, sometimes as large as the palm of the hand. They average finger-nail size. While the smaller lesions are usually round, the larger ones may be very irregular, crescentic, or linear; often they assume a grotesque outline. They may be barely elevated above the skin, or may rise to an eighth of an inch in height. They may be soft or firm to the touch, and whitish or pinkish in color. On the face the urticaria rash may cause great temporary deformity. The lip, or half the lip, for instance, may within a few minutes swell out to a great size, and remain thus for an hour or more. The eruption burns, stings, and tingles, as if the skin had been stung by nettles, hence the popular English name of the disease, ''net- tle rash", while in this country it is popularly called ''hives/' Sometimes these sensations of burning and tingling are merely annoying; at other times they may prove distressing to the last degree. Rubbing and scratching commonly aggravate the dis- ease, bringing out new wheals. The lesions of urticaria frequently change their locality, the eruption appearing now in one part of the body, and again in another. It occurs at all ages and in both sexes. Its duration depends entirely upon the presence or removal of the exciting cause. There are several varieties of urticaria: 1. Urticaria papulosa, described above. One form occurs among children, in 52 DISEASES OF THE SKIN. widely dispersed, pin-head to split-pea-sized, flat, or acuminate papules, which appear suddenly and last for hours or days. It is attended by severe itching.* 2. Urticaria hcemorrhagica, which is, in fact, urticaria occurring in the seat of a purpuric eruption, and is sometimes called "purpura urticans." 3. Urti- caria bullosa, where the wheals are transformed into blebs, which may assume some of the characteristics of pemphigus (see Ery- thema multijorme). 4. Urticaria tuberosa, or "giant urticaria," occurring in the form of large walnut- or even egg-sized, firm, more or less persistent nodes or tumors, resembling somewhat exaggerated tumors of erythema nodosum. Urticaria may be acute or chronic. The acute variety is usually, though not invariably, ushered in by slight febrile symp- toms, languor, headache, depression, gastric disturbance, furred tongue, etc. The rash appears suddenly, and may involve the whole body, or a portion only, accompanied by intense, and al- most intolerable, burning and stinging sensations. In a variable time, from one hour to a day, the symptoms subside and the eruption disappears, without leaving a trace, except in the form of scratch marks. Chronic urticaria may continue for months and years, or, indeed, as long as the cause exists. The individ- ual lesions, which are usually small, come and go as in the acute form; crop after crop may appear, the skin being hardly ever free from them. The patient's general health may appear fair. The causes of urticaria are numerous and of a very diverse character. Certain external irritants and poisons to the skin, as the stinging-nettle, jelly-fish, caterpillars, fleas, bed-bugs, and mosquitoes, are not infrequent causes. Among internal causes, gastric and intestinal derangements are by far the most common. An overloaded stomach, excess in wine, beer, or highly-seasoned food, may occasion an attack, while certain articles of food, * One form of urticaria very commonly met with among children is the affection known as lichen urticatus. It is characterized by the appearance of a pin-head-sized vesicle surrounded by a well-defined erythematous areola. The areola fades away after a day or two and the vesicle runs the usual course of such lesions. The eruption may develop into urticaria or the typical lichen urticatus lesions may be interspersed in the same subject with typical urticaria lesions. URTICARIA. 53 as fish, oysters, clams, crabs, lobsters, pork, especially sausage, oatmeal, mushrooms, raspberries, and strawberries are all apt to bring out the eruption. The opening of a hydatid cyst has been known to give rise to urticaria. Various drugs have the same affect (see Dermatitis medicamentosa) in some individuals. In most cases of urticaria from these causes a certain idiosyncrasy seems to exist. Any irritation of the bowel, as by worms in children, may bring out the eruption. Sudden emotion or mental excitement in certain persons may also produce it. In females menstrual and uterine difficulties may cause urticaria. The disease is intimately connected with the nervous system, and patients who suffer from chronic urticaria are apt to be persons of more or less depraved nervous organization. The pathology of urticaria is similar to that of erythema multi- forme. The disease is an angioneurosis, the lesions being due to vaso-motor disturbance commonly of toxaemic character. In urtic- arial lesions dilatation, following spasm of the vessels results in effusion and, in consequence the overfilled vessels of the central portion are emptied by pressure of the exudation, and the pink or reddish color gives place to central paleness, while the pressed back blood accentuates the bright red tint of the periphery. The anatomy of the wheal shows it to be a firm elevation of a diffused semi-fluid material especially collected in the upper layers of the skin. The epidermis is unaltered but the whole corium is the seat of inflammatory changes. The blood-vessels and lymph- atics are enlarged and the corium swollen with serous exudation. The diagnosis of urticaria does not often present any difficulty, because the lesions are so peculiar in appearance, and because of the peculiar burning and tingling sensations. The small lesions, as found in children, may be mistaken for eczema, but a few scratches with the finger nail on the skin of any part of the body will arouse urticarial red or white bands and streaks, which show an irritable condition of the skin and are very char- acteristic. The treatment of urticaria depends greatly, for its success, upon the discovery and removal of the cause. When this is sus- 54 DISEASES OF THE SKIN. pected to be some gastric disturbance, the precise articles of food of which the patient has been partaking should be inquired into; their quality, as to freshness, etc., should also be a matter of scrutiny. The possibility of the patient having eaten any- ting unusual should also be considered, as well as the previous ingestion of medicine. An emetic may be given in acute cases, if the contents of the stomach have been recently ingested and are suspected of being the cause. The bowels should be freely opened, if required by a saline purgative. The diet should be of the most simple and unstimulating character, and the subse- quent internal treatment should be directed against the digestive difficulty. The treatment in any given case must depend upon the result of a careful investigation into its nature and cause. Among medicines, the laxative mineral waters are often ad- vantageous : Hunyadi Janos, Arpenta — the alkaline waters, as Celestine Vichy or Saratoga Vichy, or sulphur waters, as the Richfield Springs water, with baths taken at the springs, may also at times be used with advantage. Diuretics are often of use. Quinia is often of value, whether malaria be present or not. Antipyrine in 20-grain to 30-grain (1.30-2.) doses at bed- time is sometimes useful. Arsenic is sometimes of service when other remedies fail. Iron also is useful. "Mistura ferri acida" (the formula of which is given under eczema), is a very useful remedy in many cases of urticaria. Bromide of potassium, chloral, and other sedatives may be required to give rest and calm to the nervous system, often injured by long- continued suffering. The preparations of opium should generally be avoided, but codein, gr. J (0.016) four times a day, I have sometimes found to give relief. Belladonna is a valuable remedy. It may be given either in the form of sulphate of atropia in doses of T -^o to -^ grain, (0.00054-0.001 1) morning and evening, or in the following combination : ]$. Ext. belladonnae, gr. fo—fa (o. 001 1-0.0022) Ergotin, Quininae muriatj aa. . .gr. i (0.065) M. Fiat in pil. No. 1. URTICARIA. 5 5 Two of these pills may be given every two hours until relief is obtained or until the dryness of the mouth becomes unsupport- able. Sulphurous acid, in drachm doses, diluted with simple syrup; salicylic acid, in 20-grain doses, thrice daily, and chloride of ammonium, in 10 to 20-grain doses, thrice daily, may at times be found useful. Intestinal antiseptics are very often required, especially in more chronic cases. The following formula may be recom- mended : fy Menthollis, gr. j (0.016) Guaiacol carb., gr. ij (0.13 ) Podophyllin, gr £ (0.008) Hydrarg. chlor. mite gr. £ (0.05 ) M. Fiat in capsulam j. — One of these one to three times a day. External treatment is of importance to calm the burning and tingling pain of the eruption, which is at times almost unendur- able. Alkaline baths, followed by soothing powders, such as are described under the treatment of acute eczema, will be of use. Sponging with vinegar and water, or alcohol, alone or diluted, often gives relief; it should be practiced frequently. One of the most useful applications in my experience is the following: 1$. Menthollis, gr. j ( o 065) Acid carbolic, gr. v ( 0.3 ) Glycerin, f 3 j (4- ) Alcoholis, ad . . .f§j (32. ) M. Chloroform, a drachm (4.) to the ounce (32.) of alcohol, or a drachm (4.) to the ounce (32.) of cold cream, is very good. Dilute ammonia water is useful in some cases. Occasionally a saturated solution of benzoic acid in water is effectual. When one local remedy fails another should be tried. Irritating under- clothing should be avoided, and the patient should sleep in a cool room, with light bed covering. The prognosis in urticaria varies in each case. If the cause 56 DISEASES OF THE SKIN. is a temporary gastric derangement, its removal will soon result in a cure. If, however, the urticaria is chronic and dependent upon some derangement of the nervous, digestive, or generative system of long standing, it is apt to prove very stubborn. URTICARIA PIGMENTOSA. The name urticaria pigmentosa has been given to a chronic inflammatory skin affection beginning in early life with urticaria- like lesions, some of which disappear, to recur from time to time, while others, once formed remain permanently. The disease usually begins in the first months of life, even in some cases a few weeks after birth. Usually wheals, but sometimes blebs, are first noted. The lesions are numerous and are chiefly seated on the trunk, but no region is exempt. Wheals, maculo-papules, papules or nodules, pea to almond size and of a yellowish color, slightly raised and irregularly rounded or oval, first appear. They are disseminated but occasionally appear in lines or with a tendency to an ill-defined crescentic arrangement. The lesions are at first yellowish-brown but later take on a dark brown color. They have a firm feeling under the finger. Manipulation is apt to develop an urticarial wheal. Occasion- ally vesicles or blebs form on the summit of the more typical lesions or around them, and these may have a red areola. The lesions, when they disappear, leave a dark brown stain or in rare cases a cicatrix. Itching, even to a distressing degree, is a characteristic symp- tom, but is not invariably present as in urticaria. The patient rubs but does not often scratch and excoriate the skin. The cause of the disease is obscure. While it usually begins in infancy, cases have been reported when the first symptoms appeared after puberty and even in adult age. Duhring thinks there are two forms of the affection, one being a persistent urtic- aria of a peculiar type, and the other having more the features of a new growth. Urticaria pigmentosa is a comparatively uncommon affection, only about sixty cases have been reported, (EDEMA ANGIONEUROTICUM. 57 but the affection is probably by no means so rare as this would seem to indicate. Examination of sections of the lesions show appearances some- what similar to those found in urticaria, but in addition the papillary layer is filled with "mast cells" arranged in columns, a feature which is characteristic of the process. Sometimes an unusual number of mast cells is found throughout the cutis and extending into the subcutaneous tissue. The epidermis is unchanged, but for an accumulation of pigment in the basal layer of the rete. Urticaria pigmentosa is to be distinguished by the early appear- ance and persistency of the eruption and the yellowish stains which it leaves. Where the activity of the urticarial lesions has subsided those remaining may resemble xanthoma, but rubbing the hand over them will usually develop wheals. The ultimate prognosis of urticaria pigmentosa is favorable, the disease usually disappearing after puberty or after some years. Treatment does not usually affect its prognosis but that employed in urticaria, particularly the local applications, are indicated.* (EDEMA ANGIONEUROTICUM. This affection, originally called "giant urticaria," is charac- terized by one or more acute, circumscribed, cedematous swell- ings, occurring usually in localities, as the eyelid, lobe of the ear, lip, etc., where the tissues are lax. The swelling may appear without any premonitory symptoms or it may be preceded by malaise, and gastro-intestinal disturbances, which symptoms may also accompany the attack. The swell- ing is acute, sometimes developing in a few minutes, and may cause closure of the eyes, immobility of the lips, when these are involved, or some grotesque temporary deformity. The swell- ing may be of the ordinary color of the skin or it may be pink- *For details see Elliott, Jour. Cutan Dis., 1891, p. 296; Stelwagon, Ibid, 1898, P- 576; Gilchrist, Johns Hopkins Hospital Bull., vol. 'vii, 1896, p. 140; Colcott Fox, Brit. Jour. Derm., 1898, p. 411, and for pathologv, Brongersma, Ibid, 1899, p. 179. 58 DISEASES OF THE SKIN. ish or reddish in color. It is harder than ordinary cedema and pits slightly or not at all on pressure. The attack occurs most frequently about the face and head, but the extremities are almost as frequently involved. Cases have been reported of the occurrence of lesions in the larynx, stomach and on the gums and palate. The swelling may last from a few minutes to hours or even several days. Repeated swelling may occur, prolonging the existence of the attack to days or even weeks. One case is on record in which it lasted for a year or more. The affection occasionally recurs. Subjectively, there is a feeling of tension or stiffness in the part involved with itching and burning in some cases. Urticarial efflorescences occasionally occur in connection with the localized cedema. Partial anaesthesia or numbness is also noted at times. Angioneurotic cedema is met with in both sexes and at all ages. It is closely allied to urticaria and probably is produced by the same causes. In some cases there is a family predispo- sition. Articles of food which cause indigestion and the produc- tion of gastric or intestinal toxins favor the occurrence of an outbreak, which is also found to occur in neurotics. Exciting causes are indigestible foods, alcoholic beverages, exposure to cold, malaria, traumatisms, etc. The affection is of angioneurotic origin — a vaso-motor neurosis similar in its pathology to urticaria. The occurrence of suddenly appearing, circumscribed, swellings of hard cedema resembling a sort of magnified urticaria is charac- teristic and it is almost impossible that this affection can be mis- taken for any other skin disease. The affection, except when it occurs in the air passages, is not of any great severity. The individual attacks are to be combated by strict attention to diet, freedom from worry, and the local and general treatment recommended under urticaria.* *See Quincke, Monatshefte j. Prakt. Derm., 1882, p. 129. Osier, Internat. Jour. Med. Sci., 1888, p. 362. Elliott, Jour. Cut. Dis., 1888, p. 19. Hartzell, Univ. Med. Mag., 1890. Wende, Jour. Cut. Dis., 1899, p. 178. PITYRIASIS ROSEA. 59 PITYRIASIS ROSEA. * Pityriasis rosea is a mildly inflammatory disease of the skin, characterized by the appearance of more or less numerous fawn colored or reddish macules or circinate lesions, slightly infil- trated and covered with small fine scales. The eruption is exanthematic in appearance and onset. There is usually an initial lesion, consisting of a ring-formed lesion from one to several inches in diameter, closely resembling ring- worm of the skin. This is ordinarily situated on the trunk, but may occur elsewhere. A week or ten days after the appearance of the initial lesion, a more general eruption breaks out, sometimes accompanied by slight febrile disturbance, urine of high gravity with urates (Gilchrist), and occasionally post-sterno-mastoid and submaxillary glandular enlargement. The fauces may also be slightly reddened. More frequently the generalized eruption appears gradually and quite without general disturbance. It commonly commences upon the flanks or on the abdomen, but may begin on the upper part of the chest, the side of the neck and occasionally on the face or arm. It may spread over the body and limbs, but is usually sparse or absent below the elbows and knees or on the face. The eruption consists of discrete or confluent macular or maculo-papular lesions, from a pin-head to a half-dollar size, slightly or not at all raised. The color of the lesions is rosy or pale red with a more or less tawny or yellowish tint. The sur- face is always dry and slightly scaly, and there is a tendency to heal in the centre, giving a circinate appearance. Once fully de- veloped the eruption may last from two weeks to several months or occasionally much longer. The latter is rare, however. Pityriasis rosea is not a very uncommon disease, occurring about once in five hundred cases of skin disease, according to the American statistics. In itself it is a comparatively trifling affection, but gains im- * The name pityriasis maculata et circinata I prefer, as more descriptive, but pityriasis rosea is the term in most common use. 60 DISEASES OF THE SKIN. portance from the fact that it is very apt to be mistaken for the early macular syphilitic eruption. The latter, however, may usually be distinguished by that tendency to polymorphism which is so characteristic of syphilis. Careful search will almost always show some lesion at one point or another which is characteristic of the syphilitic disease. The glandular involvement is more marked in syphilis. Mucous patches in the mouth are common at this stage of the disease and it is not too late, in many instances, to trace the remains of the chancre. Nevertheless, I have seen some of the most emi- nent dermatologists puzzled over doubtful cases, and time only brings out some characteristic feature. A too hasty decision in favor of syphilitic disease is to be depreciated in doubtful cases.* The circinate lesions somewhat resemble psoriasis, but they are less elevated and less scaly, lacking the hyperemic papillae, and do not occur conspicuously in the psoriasis localities. Ec- zema seborrhoicum, of the variety formerly known as "sebor- rhcea sicca" or "papulosa," is usually confined to the area over the sternum and between the shoulders. The lesions are more oily and thicker and the scales are much thicker and often greasy. The initial lesion of pityriasis rosea is readily mistaken for ring-worm of the body. In some cases only a careful micro- scopic examination will show the presence of fungi in the latter case. I have, moreover, repeatedly seen cases treated for tinea circinata for several weeks until the outbreak of the general eruption determined the true character of the initial lesion. The pathology of pityriasis rosea presents little interest. Unna compares the process to that of flat papular seborrhoic eczema, but with more oedema and spindle cell multiplication and no micrococci or other recognizable microbe in the scales. The prognosis of pityriasis rosea is always favorable, although, in some cases, the eruption seems perfectly rebellious to treat- ment and only gets well in its own good time. The treatment must vary in different cases. Usually the dis- * Renaut (Annates de Derm, et de Syph., 1891, p. 163) reported a case illustrating the simultaneous occurrence of p. rosea and syphilitic roseola with chancre. DERMATITIS EXFOLIATIVA. 6 1 ease tends to get well spontaneously. Crocker has found sal- icin, in fifteen-grain doses three times a day, to hasten involution. He recommends locally a lotion of "liq. carbonis detergens" and liq. plumbi subacetat dil, of each 5ij (8) to aqua rosae 5 vn j (256). This is especially useful where there is itching. I have found the following ointment of service: T^. Hydrarg. oxid. flav., 5ss ( 2.) Petrolati, 5j (32.) M. Another useful ointment is the following: 1$. Acid salicylic, 9i ( 1 20) Sulphur precipitat., 5 j ( 4- ) Petrolati, o j (32. ) M. DERMATITIS EXFOLIATIVA. * Dermal il is exfoliativa is an inflammatory disease of the skin, characterized by redness and exfoliation over a part or the whole surface, arising as such or supervening on other scaly affections, acute or subacute in type and of variable duration. The disease may begin insidiously in one or more limited areas, particularly about the axillae, genito-crural region or other flex- ures, and spread rapidly, or it may involve most or all of the sur- face at once. Occasionally it may be limited, as to the extremites alone. The outbreak is usually preceded by chilliness, malaise, some- times vomiting, and fever which may or may not continue. The skin is at first red with slight infiltration which, later, may become more pronounced. Exfoliation soon begins in the form of thin, variously sized scales or flakes of a dirty gray or brownish tinge ; the underlying skin is smooth, red and shiny and later has a yellowish cast. There is at times considerable burning and itching. After some weeks or months the process begins to abate, the skin loses its inflammatory aspect, is less red, and the exfoliation is less marked and less rapid, and the malady comes to an end. In other cases, after a longer or shorter time a relapse * See Stelwagon, Diseases of the Skin, 4th ed., 1905, p. 185, for fuller description with bibliography. 62 DISEASES OF THE SKIN. occurs, and this may be repeated indefinitely. Occasionally the recovery is permanent. In persistent cases the patient's health is apt to suffer and complications supervene; arthritic troubles, involvement of the mucous surfaces and internal organs, furuncles and abscesses, loss of hair and nails may occur. Some cases of dermatitis exfoliativa envolve from psoriasis or eczema. A great variety exists in the symptoms, for the description of which the student is referred to the numerous monographs and reports of cases. The etiology of dermatitis exfoliativa is obscure. None of the various causes heretofore assigned seem to be satisfactory. The pathology, like the etiology of the disease, is somewhat obscure. In milder cases there is little more than hyperemia while in severe cases considerable inflammatory and atrophic changes occur. In the extreme varieties there is a complete oblit- eration of the papillae with variable atrophy of the interpapillary rete prolongations. The glandular structures disappear in part or wholly and pigment-granule deposit is noted in the lower epiderm. Other and more extensive changes have been noted by observers. The diagnosis of dermatitis exfoliativa may be difficult in the first few days of the outbreak but the nature of the affection becomes manifest after continued observation. From scarlet fever and from erythema scarlatinoides it is differentiated by the (usual) absence of systemic involvement or sore throat. The absence of blebs as a feature is an important point of difference from pemphigus foliaceus. Psoriasis and lichen ruber are rarely if ever universal, the skin is more thickened, and in the former, the scales are more abundant. The beginning papular character of the latter and the presence of typical papules here and there at the borders of areas, even when the disease is extensive, are sufficient to prevent error. In generalized eczema there will almost always be found oozing and discharge somewhere, or at least the history of such. In eczema there is a tendency to thickening of the skin, never to thinning and atrophy. The prognosis of dermatitis exfoliativa varies with the charac- DERMATITIS EXFOLIATIVA. 63 ter of the case. Milder cases will pretty surely recover, though relapses may be feared. In the more severe cases the disease tends slowly but almost inevitably to a fatal termination, through exhaustion and the development of internal complications. The general treatment should be strengthening and sustaining. Among drugs arsenic and sodium salicylate are most generally useful. Otherwise the treatment should be governed by general principles. The local treatment is important. Cooling and soothing ointments, as carbolized petrolatum, cold cream, etc., are of value. Warm baths followed by inunction may also be practiced. DERMATITIS EXFOLIATIVA EPIDEMICA. Epidemic exfoliative dermatitis is a rare affection, most of the cases de- scribed having occurred in certain infirmaries under care of Dr. Savill (Brit. Jour. Dermatol., vol. iv, 1892), and in almshouses, etc. The affection in some of its aspects resembles eczema and in some, ordinary exfoliative dermatitis. The eruption is not preceded by severe signs or symptoms, although vomit- ing and anorexia may occur with diarrhoea and sore throat. The occipital and cervical glands and occasionally the maxillary are enlarged. The upper limbs, face and scalp are usually first attacked. A sensation of itching is ex- perienced and then numerous acuminate red papules appear, irregularly grouped and seated at the follicles. These remain unchanged or coalesce into red patches and the eruption spreads over the body with greater or less rapidity until the entire surface is involved in a deep red infiltration covered with abundant flakey scales. In some cases vesicles form and break, present- ing a raw eczemaform surface. The disease runs its course in six or eight weeks. Relapses are not uncommon. Occurring in almshouse there is five to thirteen per cent of mortality. Death usually occurs from exhaustion with coma, subsultus tendinum, etc. Sometimes pneumonia, gangrene of the feet, etc., occur and albuminuria is not uncommon. The cause of the disease is unknown. DERMATITIS EXFOLIATIVA NEONATORUM. Under this name Ritter (Vierteljahrsschr. j. Derm. u. Syph., Hft., 1, 1879) described an eruption which he observed in the Foundling Asylum at Prague. The affection begins in the first or second week of life, and occa- sionally as late as the fifth, usually in the lower part of the face first, but it may begin anywhere. The lesions are red, scaly patches soon becoming uni- versal with fine branny or lamellar desquamation like exfoliative dermatitis 64 DISEASES OF THE SKIN. of adults. In some cases there are vesicles or flaccid bullae like pemphigus foliaceus and then there are crusts as well as scales, with rhagades about the mouth and anus. There is no fever nor general symptoms. Half of the cases die of marasmus with or without diarrhoea. In favorable cases the disease runs its course in eight or ten days, though relapses may occur. Boils, abscesses and gangrene may occur as sequelae* PRURIGO. Prurigo is a chronic inflammatory disease, characterized by numerous, discrete, rounded, small split-pea-sized, solid, firmly seated, slightly raised, pale red papules, accompanied by general thickening of the skin and intense and constant itching. It is an excessively rare disease in this country. The American statistics show only 34 cases in 123,746 of all varieties of skin disease. It usually begins at an early age, within the first or second year, in the form of an urticaria (see Urticaria pigmen- tosa) and commonly lasts through life. When developed it consists of firm, pin-head to pea-sized elevations under and in the skin, usually discrete, but sometimes grouped. The color of the lesions is pale red, or like the surrounding skin; there are no scales. The disease usually first attacks the extensor surface of the lower extremities, particularly the tibiae. The forearms are next invaded, and then the trunk. The head is rarely attacked ; the palms and soles never. In severe cases buboes may form in the glands of the inguinal regions. The eruption is accompanied by intense itching and conse- quently blood crusts are always present, and in time the hairs are torn and rubbed off, and the skin becomes harsh, thickened, and pigmented. The pathologic changes are similar to those in eczema, they have been carefully studied by Taylor and Van Gieson, (2V. Y. Med. Jour.), vol. liii, 1891, p. 1. The diagnosis of prurigo is not difficult. The disease has a distinct and well-defined history, which prevents it from being *See Patek. Dermatitis Exfoliativa or Ritter's Disease, Jour. Cut. Dis., 1904, p. 269. LICHEN RUBER. 65 mistaken for eczema. Eczema, indeed, often accompanies pru- rigo, being aroused by scratching or the application of reme- dies, but this can be cured by appropriate treatment, while the prurigo goes on, unaffected by treatment. Pruritus is un- accompanied by papules. Pediculosis can be verified by a search for the parasitis and also by noting the localities attacked. (See Pediculosis corporis.) The treatment of prurigo should be first directed to the general condition of the patient. The diet should be generous. Every- thing that will tend to improve the state of the patient's health is to be taken into consideration. Iron, arsenic, quinine, and especially cod-liver oil, may be prescribed. External remedies are particularly useful. Baths of various kinds, and also tar, naphthol, and sulphur applications, are particularly to be men- tioned. The prognosis of prurigo is not very hopeful. It is said to be curable if treatment is commenced in childhood, but scarcely so in the adult. If a case is reported as having been easily cured, it is probably because a mistake lias been made in diagnosis. LICHEN RUBER. Lichen ruber is an inflammatory disease characterized by pin-head to pea-sized flat and angular, or acuminated papules, smooth and shining, or scaly, deep red, discrete or confluent, and running a chronic course attended by more or less itching. There are two varieties as commonly described, lichen ruber acuminatus and lichen ruber planus* Lichen ruber acuminatus (the pityriasis rubra pilaris of some writers) is characterized by the development of hard, dry papules situated at the hair follicles; they may be pale yellow, pink or red, and under a lens show an atrophied hair in the centre, sur- rounded by a sort of horny sheath which penetrates into the follicle. *See R. W. Taylor, "Lichen Ruber as observed in America, and its distinction from Lichen Planus," N. Y. Med. Jour., Jan. 5, 1889, and A. R. Robinson, "The Question of Relationship between Lichen Planus and Lichen Ruber." Jour. Cutan. and Gen-Urinary Dis., Jan., Feb. and March, i88q. 5 66 DISEASES OF THE SKIN. The papules are about pin-head size and are seen most abund- antly on the backs of the hands, on the back of the first and slightly on the second phalanges, wrists, forearms, elbows and knees. They are also found on the trunk. These papules though most characteristic are not usually the first lesions. More fre- quently the first parts attacked are the palms and soles. In extreme cases the eruption is universal and the whole surface is dry and scaly. Anatomically there is increased cornification of the epithelial wall of the orifice of the follicle to which the dermal changes are probably secondary. Unna states that the horny papule may form at a sweat orifice as well as at a hair follicle, or independ- ently of either, and that there is also a general hyperkeratosis of the surface. In the severer forms the other changes are those found in chronic forms of dermatitis, e.g., prurigo. The diagnosis of lichen ruber acuminatus ' is determined in mild cases by the presence of follicular papules, with a horny plug in the orifice of the follicle which can be picked out and produces a cribriform aspect; the dry scaliness of the palms, soles, scalp and face; the absence of any disturbance of the general health — in other words its benign course as compared to most forms of universal dermatitis. In the severe forms the develop- ment is more rapid, with marked constitutional symptoms. The diseases it most resembles are pityriasis rubra or dermatitis exfoliativa and psoriasis. Lichen ruber acuminatus is rare. The treatment is like that employed for the planus form of the disease excepting that arsenic often fails to be of use. Lichen ruber planus is the form most commonly met with. It is characterized by an eruption of papules, varying in size from a pin-head to a split-pea; often they coalesce and form patches. The shape of the papules is peculiar and charactertistic ; they are seldom round, as most papules, but are, instead, quadrangu- lar or polygonal in form. They rise abruptly from the skin to the sixteenth of an inch or less, are flattened on the summit, and show a minute umbilication with whitish puncta. To the touch, LICHEN RUBER. 67 they are firm, smooth, and without scales, excepting in those cases where the disease runs into a papulosquamous stage. They are glazed, and of a peculiar dusky, crimson, or even vio- laceous tint. Usually discrete, the lesions are sometimes aggre- gated, so as to form sheets of raised and infiltrated lesions. The diffuse form of the disease is rarely seen in this country. It is made up of large patches of acuminate lesions. Itching is generally present in both varieties of the disease. It is usually moderate, but may at times be severe. The commonest locality of lichen ruber planus is on the forearms, especially upon the flexor surfaces of the wrists. It occurs also on the palms and soles, on the penis and elsewhere. It is apt to be symmetrical, and the lesions are sometimes arranged in rows. The course of the disease varies; in some cases, under careful treatment, a cure can be effected in a few weeks or months, while other cases run an exceedingly chronic course, even extending to years. Per- sistent, dark brown, or violaceous stains succeed the lesions. The severer forms are said to run a graver course, and to end sometimes in marasmus and death. The cause of lichen ruber is generally to be found in exhaustion, nervous debility and depression, overwork and improper diet, leading to impoverished nutrition. The pathologic anatomy of lichen ruber planus has been studied by Robinson and others. The disease has its seat in the upper part of the corium and usually around a sweat duct. The rete and horny layer are thickened, and the papilla? enlarged, the vessels of the latter showing dilatation. In some recent papules however the corneous layer may be slightly thinned. The central point of the depression usually corresponds to the sweat duct ori- fice. The sweat glands are not affected. In lichen ruber planus the hair follicles have no determining influence on the situation of the papules. Lichen ruber may be mistaken for the papular syphiloderm, which it closely resembles, especially in the coppery or ham color of the lesions. In the variety L. ruber planus, however, the peculiar shape and contour of the lesions, with their smooth, 68 DISEASES OF THE SKIN. umbilicated, or punctate surfaces, will serve to distinguish them.* Eczema papulosum, which often resembles lichen ruber, differs in that the papules are roundish, somewhat acuminate, bright red in color, and intensely itchy. Their evolution also is different. The internal treatment of lichen ruber should be chiefly tonic and supporting. Arsenic is of high value, and is, in fact, almost a specific. The dose, at first two to four minims (0.13-0.26) of Fowler's solution, in a fluidrachm (4.) of wine of iron, should be increased al- most to the limit of tolerance, and persisted in. Arsenic may also be administered hypodermically, using one part of Fowler's solution and five parts of water, beginning with four or five minims (0.26- 0.33) of the mixture. The preparations of iron and cod-liver oil are also useful. Valerian, the bromides, tincture of belladonna, 2 -grain (0.13) pills of carbolic acid, up to eight daily, may relieve the itching. If an urticarial element is present, quinine and ergot may be employed if belladonna fails. Treatment should be instituted early in the course of the disease. Cases of long standing are very stubborn, even to the best directed treatment, which, earlier given, might have proved effectual. Locally, simple ointments, as vaseline or cold cream, may be employed when itching is not present. When the eruption itches, alkaline baths, carbolic acid washes or ointment, dilute hydrocy- anic acid, with water, diluted "liquor picis alkalinus, " made thus: 1$. Potassae caustic, gr. xv ( i.) , Picis liquids, gr. xxx ( 2.) Aquae, f§iv. (128.) M. may be employed. It should be considerably diluted at first. The following ointment is a useful one: 1^. Olei rusci crudi (vel. ol. betulae), 3j (4-) Ung. aquas rosae, § j (32.) Ol. rosae, rt\xv. ( 1.) M. In addition to these, the more stimulating and stronger anti- *Dubreuilh and Le Strat, Ann. de Derm, et de Syph., 1902, p. 209, give the dif- ferential diagnosis between lichen planus and other affections of the palms and soles. LICHEN SCROFULOSUM. 69 pruritic remedies mentioned under the head of eczema may be employed, with the hope of reducing the pruritus and bringing about absorption of the lesions. The following ointment has proved of high value: T\. Hydrarg. bichlor., gr. ij-iv ( 0.13-0.25) Acidi carbolici, gr. x-xx ( 0.65-1.3 ) Ung. zinci oxidi, o j. (32.) M. Hot douches and compresses, once or twice daily, often give relief in severe cases. Occasionally removal from ordinary surroundings, and especially a sojourn at high altitudes, may be required. Chrysarobin, a 10 per cent, solution in chloroform or as an ointment, is sometimes useful in chronic cases. Of late years X-ray treatment has proved valuable. The prognosis of lichen ruber will depend upon the extent of the eruption, its duration, and the patient's general condition. Localized eruptions of L. ruber planus on the wrists and forearms, occurring in persons of average health, do not usually require a very lengthened course of treatment for their cure. When, however, the eruption is extensive and severe, and has lasted a long while, the prognosis is much less favorable. LICHEN SCROFULOSUS. Lichen scrojulosus is an inflammatory disease, occurring chiefly among tuberculous children and young adults, and characterized by the occurrence of small papules of a red color fading into the skin, disposed in groups and circles, and occurring chiefly upon the trunk. The affection is not often met with in this country but is some- what more common in Europe. The papules are from pin-point to pin-head in size, slightly conical, or a bright red, fading later to a pale red or fawn color or even to the color of the normal skin, and tending to be arranged in roundish groups, circles or segments of circles. Sometimes these circles are filled up with other lesions so as to' look like an exaggerated cutis anserina 7° DISEASES OF THE SKIN. Fig. '5. — Psoriasis, showing distribution. PSORIASIS. 71 (Crocker). A minute scale is formed upon each of the other papules which, after lasting a few weeks to months, disappear, leaving small, yellowish, pigmented spots. The eruption is usually limited to the trunk, but in some cases occurring in children the limbs alone may be attacked. Itch- ing is absent or very slight. There are usually some evidences of a tuberculous taint. The disease is kept up by the continuous development of new papules so that if not cured it may run on for years. Occasionally a few acneform lesions occur, and now and then some of the papules have a horny spine projecting from their center. The lichen scrofulosus papule, as was shown by Kaposi many years ago, is formed by a cell infiltration of the papillae around the follicle, and the central scale by a collection of epidermis at its dilated orifice. Whether there is any actual tubercular lesion is a matter of question. Gilchrist* found in one case a granuloma deeply seated, while the folliculitis which produced the clinical symptoms was more superficial. The small size and pale red color of the papules, their peculiar arrangement in groups and circles, their usual limitation to the trunk, the youth of the patient and the absence of itching are the most distinguishing features. The frequent concurrence of tuberculosis in some form is also characteristic. The af- fection is to be distinguished from eczema, certain follicular syphilodermata, punctate psoriasis and true inflammatory lichen pilaris. The prognosis of lichen scrofulosus is favorable. Cod-liver oil internally and externally always removes the eruption. The dose should be small at first and gradually increased. PSORIASIS. Psoriasis. — Psoriasis is a chronic inflammatory disease of the skin, characterized by reddish, slightly elevated, dry, roundish or circular patches, variable as to size and number, covered with * Johns Hopkins Hosp. Rep., 1899, p. 84. 72 DISEASES OF THE SKIN. Fig. 6. — Psoriasis, showing distribution. psoriasis. 73 abundant whitish or grayish mother-of-pearl-colored, imbricated scales. The disease varies greatly in its extent and intensity in different cases, sometimes showing a typical development ; in other cases represented by one or two obscure lesions. It pos- sesses, almost invariably, however, certain characters which serve to identify it. The lesions begin as small, reddish spots, scarcely raised above the level of the skin, which almost immediately become covered with whitish, imbricated scales. They often develop rapidly, reaching the size of coins in a few week-. At Fig. 7. — Psoriasis showing, characteristic appearance and distribution on legs other times the course of the disease is more sluggish. The ex- tent of the eruption varies greatly. A few patches may be all that are present, or the entire surface from head to foot may be involved, with scarcely a clear spot to be found. Commonly, the disease shows itself in the form of variously-sized, scaly patches, scattered over different parts of the body. The patches are characteristic. They are usually rounded, sharply defined from the surrounding skin and consist of a mass of imbricated, 74 DISEASES OF THE SKIN. yellowish- white scales on a red base. When the scales are picked off, a smooth, shiny, reddish surface is shown underneath, on which can be perceived a few pin-point-sized drops of blood. The abundance of the scales is a marked feature in some cases; where they are formed rapidly, that is, in well-developed cases, the patient's bed may be filled in the morning with a handful of scales which have accumulated during the night. When the disease exists about the joints, fissures may show themselves. There is no watery discharge at any period of the disease. Some- times the eruption takes on a highly inflammatory character, with redness, swelling, and severe burning and itching, while Fig. 8. — Psoriasis. Local appearance. (Courtesy of Dr. Knowles.) at other times all these symptoms are much less marked, and, in fact, the patient would hardly be aware of the existence of the disease, except for its appearance. Though the individual patches of psoriasis may be small, and generally are so, yet they sometimes coalesce into hand-sized or larger patches, or may even cover the greater part of a limb. Psoriasis may occur on any part of the body, but is most apt to be seen on the extensor surfaces of the limbs. It is sometimes found on the elbows and knees when it shows itself nowhere else. The back is more commonly attacked than the chest, and the scalp is a frequent seat of the disease. In the latter locality PSORIASIS. /b it sometimes occurs in patches, but more frequently as a diffuse and abundant scaliness. It is apt to extend a little beyond the border of the scalp, especially behind the ears and on the forehead, and this is quite characteristic. Psoriasis does not occur upon the mucous membranes. The so-called "psoriasis of the tongue " is an entirely different condition. In rare cases, as White has pointed out,* psoriasis may degenerate into verruca, keratosis and then into cancer. Cases of cancer occurring after psoriasis have been attributed to the prolonged use of arsenic. Both possibil- ities should be borne in mind. Psoriasis is not contagious. Psoriasis is among the more common diseases of the skin, being met with in this country in the proportion of 3 per cent, of all skin diseases. It is apt to occur in well-nourished, rosy- complexioned, light-haired people, the "picture of health," excepting that they are apt to be a little rheumatic. Now and then, however, it is met with in thin, worn persons, who are in poor health. Psoriasis rarely occurs in children, though Stelwagon has reported a case where it occurred in a child between three and four years of age, and even younger cases have been reported.! It does not often appear to be hereditary, but this tendency is occasionally met with. Some cases of psoriasis are worse in winter, and disappear almost or entirely in summer; others are worse in summer. Diet, I think, has usually little influence in causing the disease, though in some cases it may influence its course quite markedly. J Psoriasis and syphilis are not connected in any way. There is a syphilitic eruption, sometimes called "syphilitic psoriasis," because the lesions resemble those of psoriasis. This most un- happy term has caused much confusion of mind, but it must be remembered that the cause, course, and treatment of syphilis differ in toto from those of psoriasis. (See Sy philoderma papillosum.) The pathogenesis and the proper interpretation of the his- topathological changes in psoriasis are unsettled problems. * J. C. White, Am. Jour. Med. Sri., Jan., 1885. tSee Crocker, Diseases of the Skin, 3d Ed., Phil., 1905, p. 365. I Vaccination sometimes brings out an eruption of psoriasis, cf. Aronheim, Mon- atslicjte /. Prakt. Dermatol., 1900, v. 30, p. 545. 6 DISEASES OF THE SKIN. Some cases suggest a trophoneurotic or vaso-motor origin, others appear to be toxic and dependent on systemic conditions. A theory of parasitic origin has been maintained by some distin- guished observers.* Microscopically the lesions, in the corium, especially in the papillary and subpapillary portions, show evidence of subacute or chronic inflammation. There are vascular dilatation, moder- ate oedema and infiltration of polymorphoneuclear and round cells especially around the vessels. The papillae are elongated. The rete shows marked hyperplasia, especially of the interpap- illary processes. There is intercellular oedema, the transitional layers are partially or totally absent and the process of cornifi- cation is incomplete, the outer cells retaining their nuclei. The diagnosis of psoriasis is easy when the affection is well- developed and presents its typical appearance. The form and aspect of the lesions, and the history of the case, will usually serve to determine its nature. Scanty and ill-developed eruptions of psoriasis are, however, at times, distinguished only with diffi- culty. Nevertheless, it is an important matter to accurately determine the nature of the disease, for its treatment is widely different from that of the affections with which it is liable to be confounded; its prognosis also is different, and in addition two of the other affections are contagious. Two or three small patches of psoriasis occurring alone, upon the arms or legs, may be mistaken for eczema. Itching, however, is always present in eczema, and, therefore, itching is one sign that an eruption in question is not of this nature, though not a sure one, since psoriasis also sometimes itches. In the majority of cases of eczema, there will be a history of moisture at some time. Psoriasis is always dry and scaly; never moist. The scales of psoriasis are more abundant, larger, and whiter than those of eczema. The patches of psoriasis are usually bold and well-defined in outline, while those of eczema fade into the surrounding skin. *See Hyde and Montgomery. Diseases of the. Skin, Phil., 1904, for discussion and bibliography. psoriasis. 77 Syphilis, in the form of the papulo-squamous syphiloderm, is very apt to be mistaken for psoriasis, and vice versa. Psoria- sis, however, is more apt to be symmetrical in its distribution. It inclines to involve a large portion of the surface at once, or to be found in regions remotely separated, which the squamous syphilitic eruption rarely does. In psoriasis the lesions seem to be on the surface, so to speak. They are very scaly, but without much infiltration. The syphiloderm, on the other hand, is deeply indurated, and is only scantily covered with scales. In psoriasis the knees and elbows are apt to be involved. In syph- ilis these are not often attacked. Occurring on the palms or soles, the disease is apt not to be psoriasis, which is very rare in this locality. The color, though often deceptive, sometimes aids in diagnosis. It is usually much lighter in psoriasis, while in syphilis it is apt to be a dusky, ham color. The age of the patient and the duration of the disease may give a clue to the diagnosis. Psoriasis generally first shows itself before the age of twenty; this form of syphilis later. The history of psoriasis is that of a chronic disease, lasting for years continuously, or in an inter- mittent manner. Syphilis rarely retains one form for any length of time. Other points in the history; infection, the occurrence of other lesions, etc., may come into use. Itching is rare in syph- ilis, rather common in psoriasis. Finally, the "touchstone of treatment" may be resorted to in very obscure cases. Tinea circinata and psoriasis are sometimes mistaken for one another, but the patches of tricophytosis are less inflammatory, red and infiltrated, and are much more superficial. The scales in tricophytosis are larger and lighter, and the patches show no attempt at symmetry. The microscope shows the existence of a fungus in the scales of tricophytosis circinata, which is absent in psoriasis, and a history of contagion may often be obtained in the former disease which is absent in the latter. Psoriasis may occasionally be mistaken for eczema seborrhce- icum, as this disease occurs on the chest and back. It may also be confounded with severe forms of lupus. A comparison of the description just given of psoriasis with that of the two for- 7© DISEASES OF THE SKIN. mer diseases will show in what points the difference lies. Pso- riasis may likewise be mistaken for lichen ruber or lupus ery- thematosis. (See under diagnosis of these affections.*) The constitutional treatment of psoriasis, should be based on a careful study of the history and habits of the patient. Attention should be given to the patient's general health and his condition, whether stout and well-nourished, or thin and delicate. Regard must be had also to any functional derangement. The history of the eruption itself must also be inquired into, as to its acuteness or chronicity, as to local and constitutional treatment which may have been previously em- ployed, together with the effects of the same. In addition, inquiry should be made regarding the influence of the seasons, and whether the eruption is apt to disappear for a time and to break out again. Fortified with this knowledge, the medical treatment can be entered into intelligently. In the large majority of cases arsenic is preeminently the remedy. But, while arsenic is as near a specific as, in the nature of things, it is possible for any medicine to be, yet it must be employed judiciously if its good effects are to be obtained, or even if we do not wish to do harm. Arsenic should not, as a rule, be given where there is much gastric irri- tation, and it is hardly necessary to say that it should not be con- tinued, should it disagree even slightly. The patient should be warned of its possible effects, and should be under the constant guard of the physician; on the first symptom of indigestion, pain in the stomach or bowels, or diarrhoea, the dose should be lessened or the use of the medicine suspended. Large or almost toxic doses do not hasten the cure of psoriasis; they sometimes even retard it by upsetting the stomach. Sometimes only a minute dose, as half a minim of Fowler's solution, is borne at first, when, later, tolerance is gained and a full dose can be given. Some patients need and will bear large doses of arsenic, but this idiosyncrasy must be learned by careful, tentative * Cf. Diagnosis of psoriasis plantaris. Darier and others, Annates de Derm, et ■de Syph., 1896, p. 607. psoriasis. 79 increase of the dose, beginning always with a moderate one. Arsenic should not usually be given in acute and inflammatory forms of psoriasis. Arsenic acts slowly. When, in a case of psoriasis, it is going to do good, improvement generally begins to be shown after two or three weeks, but to get the full benefit of the drug it must be given for several months, and its admin- istration should be continued for several months after the erup- tion has disappeared. Liquor potassii arsenitis, or Fowler's solution, is the best form in which to administer arsenic. It should never be administered in drops, as mistakes are likely to occur. It may be given in water alone, or in a bitter infusion or tincture, or with wine of iron: 1$. Liq. potas. arsenit., oij ( 8.) Yini ferri, ad t'oiv. (128.) M. Sir.. — A teaspoon ful in water, after meals. The dose here is four minims — a fair average dose for an adult. The amount may be gradually increased, say every three days, until an effect upon the eruption becomes percep- tible, or until the limit of tolerance is reached. Sometimes it is desirable to give arsenic in pill form : ly. Pulv. acidi arseniosi, gr. ij ( .13) Pulv. piperis nigrse, Pulv. glvcyrrhiz^ rad., aa 3ij. (2.60) M. Fiat pil. No. xl. Sic. — One after meals. Or occasionally powders may be preferred: 1^. Pulv. acidi arseniosi, gr. ij ( .13) Pulv. sacch. lactis, gr. cl. (9.75) M. Fiat chart. No. xl. Sig. — One immediately after meals. In some stubborn cases arsenic may be given hypodermically. I usually use a sterilized Fowler's solution. When this gives rise to too much pain a 1 per cent, solution of arsenic chlorid in Schleich's solution may be employed. Strict antiseptic pre- 80 DISEASES OF THE SKIN. cautions should be taken. The gluteal region is the best locality for puncture. The dose at first should be small, i minim of Fowler's solution or T ^j grain (0.00065) arsenic chlorid daily, once or twice a week gradually increased. In unskilful hands abscesses may be produced. Some cases of psoriasis require tonics. Tincture of the chloride of iron is the best medicine to use in those meagre, worn-looking persons, as nursing mothers, when the attack has come on during lactation. Next to iron in value is cod-liver oil, and these remedies occasionally succeed when arsenic fails. In acute inflammatory cases diuretics are occasionally of service. Acetate of potassium, in half -drachm (2.) doses, may be given three or four times a day, in a wineglass of water. The alkaline mineral waters are also of service. Iodide of potassium has been highly lauded. I have tried it repeatedly without gaining any benefit whatever; nor have I succeeded with salicin though this remedy has proved useful in some hands. On the other hand carbolic acid in 1 grain (0.065) dose increased has proved success- ful insome cases when arsenic has failed. Other drugs have been administered in psoriasis, but I think that those just mentioned will be found sufficient. The local treatment of psoriasis is of more or less importance, according to the nature of the case. When the lesions are nu- merous, small, and widely disseminated, and there are no disagreea- ble subjective symptoms, local treatment is inconvenient and need not be employed. When, however, there are a few large patches, or when the eruption is situated on some conspicuous part of the person, or gives rise to annoying burning or itching, local treatment is required and will be found advantageous. If there are scales, these should be first removed by rubbing with sapo- viridis and hot water, or by the use of a hot- water bath. If the patches are few in number, large and very scaly, the following solution, well rubbed in, will remove the scales readily, and give an opportunity for making healing applications: Py. Acidi salicylici, 5 j ( 4-) Alcoholis, • fo-iv. (120.) M. PSORIASIS. 8l Or, 1$. Acid, salicylic, 3iv ( 5.32) Ol. ricini oiv. (128. ) These are especially useful on the scalp, when, after the scales have been cleansed off by this means or by means of "spiritus saponis kalinus" (two parts of sapo-viridis dissolved in one part of hot alcohol and filtered), used as a shampoo, an oil composed of one drachm of oil of cade to the ounce of oil of almonds or of alcohol may be well rubbed in by the aid of a soft brush. On the edge of the scalp and about the face the best ointment is that of ammoniated mercury, twenty to forty grains (1.30 to 2.60) to the ounce. When it is desirable to get rid of the scales and patches in the most rapid manner possible, chrysarobin (chrysophanic acid) is the best application. An ointment of half a drachm to a drachm (2.-4.) to the ounce (32.) is very efficient , and will remove a patch in a few days, leaving a white spot of skin surrounded by a purplish areola in its place. But there are strong objections to the use of chrysarobin. It discolors everything with which it comes in contact, dyes the hair orange-yellow, and ruins the clothes. It cannot be used on the scalp, nor about the eyes and cheeks, because it induces a pseudo-ervsipelatous dermatitis there, and it cannot be trusted in the hands of most patients, because, unless used cautiously, it may inflame the skin wherever used. G. H. Fox has suggested the following solution, which is quite effectual and saves the smearing which renders the chrysa- robin ointments so annoying and disagreeable: 1$. Chrysarobin, 5j ( 4-) ^Etheris et alcoholis, aa q. s. Collodii, 5 j. (32. ) M. Rub up the chrysarobin with a little alcohol and ether, and add the collodion. It forms a sort of emulsion, which should be shaken before using. By the aid of a camel's-hair pencil in the cork, this may be painted over the affected patches after removal of the scales. When it dries, it will not come off on the clothes, a great advantage. 6 82 DISEASES OF THE SKIN. Next to chrysarobin in activity comes pyrogallic acid. This may be used in ointment— a drachm to the ounce (4. to 32.). It is not so effectual, but is much more cleanly, although it leaves a blackish stain. I think it the best local application for psoriasis. The only caution to be observed is, not to rub it over a large area, say a quarter of the surface of the person, at any one time, for fear of absorption. The following combination may be used after the scales have been removed by a bath: Ify. Acid, pyrogallic, gr. xij ( 0.72) Acid, salicylic, gr. viij ( 0.48) Collodii flexile, f 5 j. (32. ) M. The ingredients may be dissolved in some appropriate men- struum or suspended in the collodion. A brush should be inserted in the cork for convenience in painting on. The applic- ation should extend a little beyond the patch. Preparations of tar have been used from time immemorial in the treatment of psoriasis, but I think the remedies above mentioned are better, and they are certainly much more agree- able. When there is a good deal of itching, however, tar may be used, either as an ointment, of one to two drachms (4. to 8). to the ounce (32.), or in the following formula: 1$. Saponis viridis, Picis liquidae, Alcoholis, aa, 5iv. (16.) M. This is to be rubbed firmly into the patches, previously denuded of scales, twice daily. Hebra's modification of Wilkinson's ointment : 1$. Flor. sulphuris, Ol. cadini, aa oiv (16. ) Sap. viridis, Adipis, aa oj (32. ) Creta prep., 3ii ( 8. ) is useful. ECZEMA. 83 In very severe and extensive, or in universal psoriasis, baths with inunctions of bland oils and fats are better than any of the applications mentioned. Tar may be used in these cases, with caution. The prognosis of psoriasis, so far as the individual attack is concerned, is, in medium and mild cases, usually favorable. But the disease is prone to relapse, and the physician should warn his patient that, while the attack can be cured, the affection is liable to return, and that no treatment, however well directed, will surely prevent the disease from coming back. Severe cases, especially when the entire surface is covered with the disease, are often rebellious to all treatment. ECZEMA. Eczema is an inflammatory, acute or chronic disease of the skin, characterized at its commencement by erythema, papules, vesicles or pustules, or a combination of these lerions, accom- panied by more or less infiltration and itching, terminating either in discharge, with the formation of crusts, or in desquamation.* Eczema is one of the commoner forms of skin disease met with in this country, occurring in the proportion of about 27 per cent, of all cutaneous affections. It is eminently a protean disease. At one time it begins as an erythema; later this may become moist and secreting, and finally terminate in a thickened, dry, and desquamative surface. At another time the affection may begin in the form of vesicles or pustules, with swelling and heat. These soon burst, and a red weeping surface results, which is soon coated with bulky crusts from the drying of the liquid, gummy discharge. The character *This definition of eczema is a good working one and is sufficiently character- istic to designate the affection from a clinical standpoint. It would take pages to present an adequate picture of the protean character of the disease. This is given so far as possible in the description of the various forms of the affection in the fol- lowing pages. Under the pathology of the disease will be found some mention of the various theories of its origin. In the present unsettled condition of our views as to the nature of eczema nothing very definite can be asserted. (Cf. The Passing of Eczema, by J. Nevins Hyde, Jour. Cut. Dis., 1904, p. 30.) 84 DISEASES OF THE SKIN. of the patch may then suddenly change, and instead of a weep- ing surface there may exist a dry, scaly, infiltrated, fissured patch of skin, which continues until the disease is removed. Or, again, papules may first appear; these may remain as such through- out their course, or may pass into other lesions, or they may be associated sooner or later with vesicles. There is no other disease of the skin in which the lesions undergo such sudden and manifold changes, and every variety may manifest itself in turn upon the same individual. More or less itching is almost always present in eczema. It may vary in degree from the merest titillation to unendurable torture. Sometimes burning takes the place of itching; at other times they occur together. Eczema may be acute, running its course in a few weeks and then permanently disappearing, or it may be chronic and con- tinuous, or recurring through years. It may occur in small patches, single or multiple, or more rarely covering extensive surfaces. Unless very extensive it is not ushered in by consti- tutional symptoms. The varieties of eczema are named according to the lesions which the disease assumes at its beginning. These are as fol- lows: Eczema Erythematosum. This form shows itself in typical cases, first as an undefined erythematous state of the skin, occur- ring in small or large patches without discharge or moisture. Commonly the patch, which is sometimes slightly infiltrated, is covered with fine, thin scales of epidermis, and now and then the surface is slightly excoriated. The skin may be bright or dark red or even violaceous. It often has a yellowish tinge. It is occasionally mottled. The process may affect a small surface or a large one; it is often better one day and worse the next, or it may even go away entirely only to return a little later. It is apt to be chronic, and the relapses are annoying and discourag- ing, especially in winter time. Exposure to external heat or cold, a heavy meal or indulgence in alcoholic drink, is apt to be followed by an exacerbation of the disease. Burning and itch- ECZEMA. 85 ing, alone or together, are prominent symptoms. Eczema ery- thematosum may run its course as such, or may develop into eczema squamosum. Vesicles or pustules are rarely seen. Eczema erythematosum is most apt to occur upon the face and genitals. Eczema Vesiculosum. Vesicular eczema commonly begins by a feeling of heat and irritation in the part, which shows a diffused or punctate redness, with itching and burning, and small vesicles soon show themselves, either alone or grouped, or sometimes running together. They are soon rilled with a yel- lowish, gummy fluid, and then they ordinarily break or form a crust. Sometimes, however, the vesicles simply dry up with- out breaking. In more marked cases new crops of vesicles con- tinue to come out, and when a considerable surface is covered, the quantity of fluid poured out is quite large, and the under- clothing or dressings are saturated. When the secretion dries, it is very sticky and tenacious, and this is characteristic of this form of eczema. Typical eczema, as described, is not so com- mon as the more complex varieties where the lesions are multi- form, papules, papulo-vesicles, vesicles, pustules, and other lesions being found in conjunction. The two chief characteristics of this form of eczema, wherever found, are the itching and the gummy secretion, leaving a yellow stain upon the linen. Pa- tients are almost always struck by this feature. Vesicular eczema may occur in very small patches, or in quite extensive areas. As it shows itself in children over the face and scalp, it forms the eruption popularly known as milk crust, scalled head, tooth rash, or moist tetter. Eczema Pustidosum (Eczema Impetiginosum). Pustular eczema is very much the same in its original appearance as vesicular eczema, only that the lesions assume the form of pustules rather than of vesicles. There is usually less heat and itching. A strict line cannot be drawn between the two forms, for they are apt to run into each other, and may coexist on the same sub- ject and in the same patch. The scalp and face are favorite seats of pustular eczema, and it is apt to occur in children who 86 DISEASES OF THE SKIN. Fig. 9. — Eczema pustulosum. (Courtesy of Dr. Duhring.) ECZEMA. 87 are badly nourished or who are being brought up by hand. It also occurs in ill-fed and scrofulous adults. The same causes which would bring on vesicular eczema in a tolerably healthy individual will arouse the pustular form in a poorly-nourished person. For this reason pustular eczema always calls for tonic and supporting treatment. Eczema Papillosum. Papular eczema appears in the form of small, round or acuminated papules, varying in size from a small to a large pin's head. In color the lesions are bright or dusky red, sometimes violaceous. They may be discrete, or may run together, forming large patches, and these are often infiltrated. Now and then they become abraded and moist, forming eczema rubrum. Papular eczema is apt to occur on the arms, trunk, and thighs, especially the flexor surfaces. It may involve a very small surface, or it may cover a large area of the body, and it is apt to be the most stubborn, troublesome, and annoying of all the forms of eczema. Itching is the most promi- nent and troublesome symptom; at times this is agonizing. Patients tear and gash themselves in their efforts to gain relief and I have seen chronic cases where the nails have been worn to the quick and the ends of the fingers polished by the almost ceaseless efforts of the patient to assuage the torment, if only for a moment. Eczema Rubrum. This must be regarded rather as a secon- dary condition resulting from previous morbid action, than a dis- tinct variety. It is a variety only in a clinical sense. It may result from eczema erythematosum, vesiculosum, pustulosum, or papulosum. In eczema rubrum the surface of the skin is inflamed and infiltrated, red, moist, and weeping; occasionally it is more or less covered with yellowish or brownish crusts, often completely overspreading the part. Unless artificially detached, these crusts may sometimes continue to adhere, the process of exudation meanwhile going on underneath. Under these circumstances the appearance of a rough, dirty, yellowish or brownish scale is observed, instead of the shining, red, ooz- ing surface. Eczema rubrum may occur upon any part of the DISEASES OF THE SKIN, Fig. io. — Eczema rubrum. (Courtesy of Dr. Duhring.) ECZEMA. 89 body, although it is most commonly found upon the legs or the flexures of the joints, particularly the former. The swollen, infiltrated, violaceous, red leg of eczema rubrum, with its vari- cose veins, its glazed and shining or raw surface oozing serum at a thousand pin-head orifices, with furious itching and burning, is a characteristic spectacle not to be forgotten when once seen. Eczema Squamosum. Scaly eczema is an important clinical variety of the disease. Like E. rubrum, it follows and results from the erythematous, vesicular, pustular, or papular forms of the disease. It 'is particularly apt to succeed erythematous eczema. When typical, it shows itself in the form of variously sized and shaped reddish patches, which are dry and more or less scaly. The skin is always more or less infiltrated or thickened. Squamous eczema may be only an ephemeral stage in the evo- lution of the disease. More commonly, however, the term is applied to denote a chronic condition, which may last for a long time. Other lesions are encountered in eczema which are worthy of mention. These are rhagades or fissures, occurring when the diseased and infiltrated skin becomes cracked by flexure, as about the joints or at the margins of the lips or anus. Chapped hands, for example, are typical instances of fissured eczema. Sometimes eczema may assume a warty condition, and at other times hard, sclerosed patches may form. In addition to the clinical varieties of eczema above described, the disease may fitly be divided into varieties, according as it assumes the acute or chronic form. The division, which is a distinct one, refers not so much to the actual duration of the disease as to the pathologic changes which occur during its course. When the general inflammatory symptoms are high and the secondary changes insignificant, the disease may be said to be acute. Wlien, however, the process has settled into a definite course, the same lesions continually repeating them- selves, accompanied by secondary changes, the disease is to be considered chronic. 90 DISEASES OF THE SKIN. Eczema is by far the commonest of all skin diseases. It at- tacks persons in all grades of society, and occurs at all ages and in both sexes. In some cases the tendency to it appears to be, in a certain sense, hereditary. It occurs commonly in the children of persons of light complexion, with fair to reddish hair, with a tendency to tuberculous affections. Some persons are so prone to eczema that the slightest provocation will bring on the eruption, and an attack of dyspepsia, which in another person would have no effect on the skin, or contact with an irrit- ant which in most persons would only cause a transient dermat- itis, is, in such individuals, a sufficient cause to produce an eczematous eruption. Dyspepsia and constipation are among the commonest predisposing causes of eczema. In certain individ- uals the presence of an excess of uric acid and urates in the sys- tem is sufficient to produce and keep up eczema. The occur- rence of gout and rheumatism in connection with eczema has often been alluded to by writers. I am inclined to think, how- ever, that gout is among the rarer exciting causes. Improper food, as to quantity and quality, acts as an exciting cause. It is, however, among infants and young children that this cause of eczema most frequently comes into play. Pregnancy and lactation, debility, nervous exhaustion, excessive mental or bodily work, dentition, vaccination, internal irritation, as of ascarides or taenia in the bowels, may also determine the eruption of eczema. Eczema in most of its forms cannot, strictly speaking, be called contagious. When a purulent discharge exists, however? the disease may be self-inoculated or transmitted. It cannot be acquired from being in contact with or handling the discharge.* Among the local causes of eczema, which are numerous and important, and which give rise to the condition known as "arti- ficial eczema," are certain cutaneous irritants, as croton oil, mercurial ointment, tincture of arnica, tincture of cantharides, mustard, antimonial ointment, sulphur, and turpentine. Here *In the light of our present knowledge this statement is perhaps too positive. Auto-inoculation as in eczema intertrigo may sometimes occur. ECZEMA. 91 also may be mentioned the rhus venenata and toxicodendron, the poison oak and ivy. All these irritants, and especially the latter, usually at first provoke dermatitis (see Dermatitis venenata), yet in certain individuals and under certain circumstances this may pass on to true eczema. Heat and cold, excessive per- spiration, especially about the genitalia, and other places where the skin inclines to form folds, may favor the occurrence of the the affection, which under the latter circumstance is known as ezcema intertrigo. Eczema is of much commoner occurrence in the winter than in the summer. The atmosphere of January and February, and particularly in this latitude the cold bleak weather of March, seems to favor the occurrence of the disease. Many cases of eczema get well in summer only to recur again in winter. On the other hand, however, cases are occasionally encountered where the attack only occurs in summer time, relapsing thus year after year. Water, as in water dressings or in fomentations, or in the inordinate use of bathing, may be a cause of eczema. The custom of very frequent bathing, especially when soap is used, is often harmful to the skin to a considerable degree. Alkalies, acids, strong and harsh soaps, may give rise to chapping and fissuring of the skin and to eczema. Finally, among the local causes of eczema may be mentioned the irritation caused by the presence of lice and itch mites, together with the scratching to which they give rise.* The diagnosis of eczema is of great importance, especially as the disease shows itself in such protean forms. There are, however, certain features of eczema, one or more of which are present in every case of the affection, and these may serve to aid in the diagnosis. Inflammation of the skin exists in a greater or less degree in all cases of eczema. It is indicated by a certain thick- ening of the skin, which may usually be seen by the eye, and in most places detected by rolling a small pinched-up portion of *It must be kept in mind that the first result of such local irritation is, as has been said, properly speaking, a dermatitis and that this only goes on to an eczema in persons predisposed to this affection. 92 DISEASES OF THE SKIN. the skin between the finger and thumb. Swelling and oedema exist in all acute eczemas, and often in chronic cases. The patch is red and congested. In most cases of eczema there has been more or less fluid exudation or moisture, at one stage or another, in the history of the disease. This is termed "weeping, " "discharging," or "running." The fluid may be clear, limpid, and yellowish, or turbid and puriform, or it may contain blood. This discharge is a most characteristic feature of eczema, and is not present in any other disease. The crusts formed by the dry- ing up of the discharge are characteristic. When this has been copious the crusts form rapidly, and in quantity so as sometimes to cover and mask the skin. They are yellowish, brownish, or greenish in color, and when removed show a moist surface be- neath, but no ulceration. Among the most important diagnostic symptoms of eczema is the subjective one of itching. It is often intense, being more marked than in other diseases. It is rarely altogether absent, though it may vary much in degree. Burn- ing is also a not infrequent subjective symptom, being more apt to be present in erythematous eczema, and often giving way to itching as the disease progresses. The itching of eczema often gives rise to an irresistible inclination to scratch, as was noted in speaking of the papular variety of the affection. The diseases with which eczema is most likely to be confounded are the following: Erysipelas sometimes resembles eczema erythematosum, espe- cially as it occurs upon the face. It is, however, acute ; it begins at a given point and creeps slowly from place to place. The inflam- mation is a deep one; the surface is smooth, shining, tense, and more or less dusky red, while deep infiltration, oedema, heat, and swelling exist underneath. Erysipelas is also accompanied by considerable fever and constitutional disturbance. There is no discharge from erysipelas save that from bursting bullae, which sometimes form during the latter stages of the disease. Urticaria, particularly that variety accompanied by the forma- tion of small, papular lesions, is occasionally mistaken for eczema papulosum. The irritable condition of the skin, the history of ECZEMA. 93 itching and burning occurring before the appearance of the lesions, all characterize urticaria in contradistinction from eczema. If, when the edge of the finger-nail, a pin, or other sharp object be drawn along the skin, a raised white welt, rapidly changing to red, is observed, urticaria is usually present. Herpes zoster sometimes resembles eczema vesiculosum, but is distinguished from it by the arrangement of the vesicles, the more regular grouping of the lesions of zoster along the line of some well-known nerve trunk, and the ordinary occurrence of neuralgia in connection with the zoster eruption. Psoriasis is often confounded with eczema, the diseases, when occurring in limited patches or upon the scalp, being sometimes almost indistinguishable. Old, infiltrated, inflammatory patches are especially difficult to make out, but in psoriasis the edges usually terminate abruptly, while in eczema they are more apt to fade into the surrounding skin. The scales on eczema patches are thin and scanty; on the patches of psoriasis they are comparatively more abundant, larger, silvery, and imbricated. In eczema there is usually some history of moisture or weeping, in one stage of the disease or another; in psoriasis the process is always dry. The distribution of the disease, and the occur- rence of patches on other parts of the body, may aid in the diag- nosis. In doubtful cases, where only a few scattered lesions are presented for examination, the whole surface should be diligently searched over, for a single lesion in some part of the body may, by its typical aspect, betray the nature of the disease where the majority of the lesions are quite doubtful in appear- ance. Lichen ruber planus may be confounded with eczema, but the peculiar square shape of the lesions in lichen ruber planus, together with their dusky, violaceous hue, and the fact that they usually run a quiet, chronic course, without change, and leave a deep stain behind, all serve to distinguish this affection from eczema. Dermatitis exfoliativa is a very rare disease, It presents symptoms which resemble closely those of generalized erythematous and 94 DISEASES OF THE SKIN. squamous eczema. It may be distinguished, however, by its uni- versal redness ; the abundance of large, thin, papery, whitish, epider- mic scales, which continually reproduce themselves; slight itching; burning heat; and, lastly, by the absence of marked infiltration and thickening of the skin, a symptom common in eczema. It undergoes but slight changes throughout its course. Tinea circinata is sometimes mistaken for eczema, but the course of the two diseases is quite different, and the microscope will almost invariably settle the question of diagnosis by showing the presence or absence of the characteristic fungus of tinea. Tinea tonsurans, in its milder and more chronic stages, may readily be mistaken for eczema; the diagnostic points will ap- pear in the description given of that affection. Sycosis, both of the hyphogenous and coccogenous varieties, sometimes resembles eczema of the beard. The former, how- ever, is scantily crusted, and when the crusts are removed, instead of the smooth, soft surface of eczema, a rough, dusky- red, mammillated surface is revealed. The loose hairs are also loaded with the characteristic microscopic fungus about their roots. Coccogenous sycosis is essentially an inflammation of the hair follicles, and while eczema is superficial, sycosis usually spares the surface and attacks the hair follicles only. Favus sometimes resembles eczema; but the peculiar canary- yellow color of the favus crusts and their mouse-like odor is almost unmistakable, and the microscope will quickly settle the question of diagnosis, for the peculiar fungus of favus is very abundant in the lesions of this disease. Scabies is very likely to be confounded with eczema, and the diagnosis is often difficult. This can easily be understood when it is considered that the eruption of scabies is, in fact, largely an eczemaform dermatitis. Eczema, however, does not show the marked preference for certain localities as the hands and fingers, buttocks, axillae, abdomen, mammae, nipples, and penis, which scabies displays. But, chiefly, the presence or absence of the peculiar burrow of the itch insect will decide almost infal- libly between the two affections. ECZEMA. 95 Syphilis. Ezcema of the scalp is at times liable to be mis- taken for syphilis. There is a form of pustular eczema, char- acterized by the presence of a few scattered lesions of the scalp, without a sign of disease elsewhere, which it is sometimes diffi- cult to differentiate from the pustular syphiloderm of the scalp. The occurrence or absence of a history of syphilis, or of concom- itant syphilitic lesions in other parts of the body, and the success or failure of a treatment other than anti-syphilitic, will demon- strate whether one or the other affection is present. Occasion- ally fissures with abundant purulent secretion occur on the scalp in the course of syphilis, and this form of the eruption may closely resemble confluent pustular eczema. The disgusting odor which ordinarily accompanies the discharge from this form of syphilitic disease will usually, however, serve to distinguish it. The treatment of eczema must be both general and local. Constitutional remedies judiciously employed are almost always needful, and prove of decided benefit in the majority of cases. In some cases, as where the eruption is local and due to some external irritant or where it is exceedingly limited in extent, no internal measures are called for. The subject of diet must be carefully attended to; all articles which are difficult of diges- tion must be avoided, and especially salt or pickled meats, pastry, cabbage, cheese, and beer, or wine. The bowels should be care- fully regulated; dyspepsia is often the sole exciting cause of eczema and the physician, who desires to treat this affection in any of its forms with success, should be prepared to deal with dyspep- sia in the majority of cases. The condition of the kidneys should be looked into. Diuretics are frequently of value. Sa- line laxatives are frequently called for in the treatment of eczema, and mong these the following tonic aperient, to which the name of "Mistura ferri acida" has been given, is one of the best: 1$. Magnesii sulphatis, o I ( 32. ) Fcrri sulphatis, 3j ( 1.3) Sodii chloridi, 5j ( 4- ) Acidi sulphurici dil.. f 5j ( 4- ) Infus. quassia?, ad f§iv. (128. ) M. Sig. — A tablespoonful in a tumbler of water, before breakfast. 96 DISEASES OF THE SKIN. Another formula which may be prepared extemporaneously is the following: 1$. Magnesii sulphat., § j (32. ) Ferri sulphat., gr. viij ( 0.52) Sodii chloridi, 5j ( 4. ) Acid sulphuric dil., 5j ( 4- ) Ext. quassiae fid., 5 j ( 4. ) Alcoholis, 3iv ( 5.20) Aquae, ad fgiv. (128. ) M. It is important that the full quantity of water should be taken, as the volume of fluid seems to influence the action of the medic- ine. Sometimes hot water is less unpalatable with this mix- ture than lukewarm or cold water. In some cases, especially in winter time, the proportion of magnesium sulphate must be increased. The laxative mineral spring waters, as the Hathorn and Geyser springs of Saratoga, or the Hunyadi Janos (or Arpenta), German mineral waters, are beneficial in many cases. I like the Hunyadi Janos best for most cases, and I sometimes prescribe it after a short course of the Mistura ferri acida, as its use can be kept up indefinitely without an increase of dose. In infantile eczema, where constipation exists, the simple unspiced syrup of rhubarb, in repeated small doses, alone or with magnesia, is often found desirable. A very good powder is the following: R. Hydrarg. chlor. mite, gr. vi-xij (04-0.8) Pulv. rhei, gr. xviij (1.2 ) Magnesias calcinat., 5ss. (2. ) M. In Chart. No. vj div. Sig. — One, at night. To make these more acceptable they may be given as com- pressed tablets or in capsules. This is for an infant six months to a year old, of average strength. In weakly infants the dose of calomel and rhubarb should be slightly reduced. The powder should be continued until its effect is seen. Purgation, however, should not be induced. A somewhat similar prescription, without the mercu- rial, and in a fluid form, is the following: ECZEMA. 97 1$. Pulv. rhei, Sodii bicarb., aa 5j-iij ( 4.-12.) Aquae men th. pip., foiv. (128. ) M. Sig. — A teaspoonful, after meals. This dose is given thrice daily. Elliott uses the following for young babies: I}. Hydrarg. chlor. mite, gr. T fo (0.0065) Ol. ricini, Mist, cretae, Aquae, aa rr|xv. (1.) M. This dose is given thrice daily. In adults, especially when the eczema is acute, and occurs in a robust individual, the laxative treatment is best introduced by a brisk mercurial purgative. Especially is this the case when the patient is suffering from constipation when first seen. Here the bowels are to be thoroughly unloaded, to begin with, and then we may enter upon the more direct treatment of the dis- ease. It is wonderful to see what a good effect two or three compound cathartic pills, or six grains (0.39) of blue mass, given the evening before the administration of Mistura ferri acida, will have on the patient's comfort, external and internal. Afterward let the case be treated internally, on general medical principles, and let cathartics and laxatives be given or withheld, as the patient's condition suggests. In old persons, particularly when the patient has been a high liver or is rheumatic, or in those unusual cases where a gouty element may exist, diuretics and alkalies are indicated. In such conditions the following prescription was recommended by the late Tilbury Fox: 1$. Magnesii sulphat, 5iv ( 16. ) Magnesii carbonat., 5j ( 4. ) Tinct. colchici., rrjxxxvj ( 2. ) Ol. menth. pip., rqij ( 0.13) Aquae, fovij. (224. ) M. Sig. — Two tablespoonfuls in a wineglass of water, every three or four hours. 7 98 DISEASES OF THE SKIN. The following formula, suggested by Hardaway, has been found useful : ~fy. Ol. morrhuae, fgiv (128.) Pancreatin saccharat., 3j ( 4-) Pulv. acaciae, q. s. Glyceriti hypophosphiti, Syr. calcis lactophosphatis, Aquae, aa f§iv (128.) Ol. gaultheriae, gtt. xxx. ( 2.) M. Ft. Emulsio. Sig. — Tablespoonful three times a day, after meals. The acetate and carbonate of potassium in full doses, and also the alkaline mineral waters, may be employed. In persons of debilitated constitution or in scrofulous persons, particularly in the badly-nourished children of tuberculous parents, cod- liver oil is demanded, and iron in various forms is to be recom- mended in some cases. The following prescription is one which I often employ with satisfaction: B. Tinct. ferri chlor., Acidi phosphorici dil., aa f§ j ( 32.) Syrupi limonis, ad foiv. (128.) M. Sig. — A teaspoonful in a wineglass of water, after meals. Syrup of the iodide of iron and wine of iron are also eligible preparations, particularly for children. Quinine and strychnia are sometimes called for by the general condition of the patient. Arsenic is useful in a limited class of cases, more especially in anemic cases where it acts as a tonic simply and not in any way as a specific. In former times the use of arsenic in eczema of all grades and varieties was much abused, and even now it too often forms a part of that routine treatment which is the refuge of ignorance. Frequently, so far from doing good, it does harm by upsetting the stomach, and its effect seems to be particularly pernicious in some acute and inflammatory forms of the disease. Tar has been used in some chronic cases internally, with benefit. Sulphur-spring waters are also used occasionally. ECZEMA. 99 Regarding the local treatment of eczema, ordinary water may be employed for washing purposes, in most cases; when the skin is delicate and sensitive, distilled water or water made milky by the addition of some bran or starch. It is generally better to use water which has recently been boiled when this is practicable. A very good method of softening the water, par- ticularly where it is to be applied to the face, is to take a hand- ful of bran, sew it up in a small linen bag, and squeeze the bag, like a sponge, through a basin of water until the water is quite milky. This gives a soft and agreeable quality to the water when it is applied to the skin. The water may be used cold or warm, as best suits the feelings or fancy of the patient; but the most important point is not to use too much of it or too often. The best rule for the use of water in eczema is to use it as sparingly as possible. The only two indications for its employment are, either the removal of crusts or the cleansing from absolute and unendurable assoilment; water sometimes seems to act upon the eczematous skin almost like poison. White castile soap is ordin- arily the only soap necessary to cleanse the skin of crusts and scales, but the superfatted soaps now put extensively upon the market are preferable in acutely inflammatory conditions. Occasionally the stronger potash soaps, mus tbe brought into use. Sometimes the "spiritus saponis kalinus" the formula of which is given below may be used instead of the solid soaps. Whatever soap is employed, it should always subsequently be completely washed off the skin, unless a distinctly macerating or caustic effect is desired, or, occasionally, when the medicinal effect of some contained ingredient is desired. The local treatment of eczema is of great importance; many cases can be cured by outward applications alone, and there are very few where these can be dispensed with entirely. Before instituting local treatment, the part affected should be examined, with the view of determining whether the disease is acute or chronic, and what the characteristic lesions, the amount of heat, redness, swelling, etc.; and also the condition of the epidermis, whether intact or torn and abraded. It is IOO DISEASES OF THE SKIN. most important, also, to take into consideration the area involved, whether this be great or small, for not only must we be on our guard not to use irritant remedies, but it must be remembered also that some applications are poisonous by absorption, when applied over large raw surfaces. In most cases of eczema there are certain secondary products, crusts, scales, and extraneous matter, which must be removed before the local remedies can be advantageously applied. Some- times it is difficult to get patients to remove these extraneous matters; a feeble attempt is made, giving rise, perhaps, to pain or slight bleeding, and the statement is offered that the "scab" cannot be gotten off. The mass of rancid grease, decomposing pus, serum, and sebaceous matters, mingled with epithelial debris, make a very poor covering, however, for an abrasion or ulcer which is to be healed, or to which local treatment is to be applied successfully. The physician should give the most pre- cise directions as to the method of removing the crusts or, better, should, when practicable, remove them himself. Soap and water alone will not do this. Poultices made with hot almond oil and rendered aseptic, or at least sprinkled with boric acid, applied to the crusts after these have been themselves thoroughly saturated with the oil, will often suffice. At other times, compresses wrung out of hot water and covered with oiled silk will do better, occasionally solution of hydrogen peroxide may be employed. Frequently a strong solution of carbonate of sodium, also applied on compresses, will soften crusts more rapidly than anything else. Sapo viridis spread on lint, like ointment, laid on the skin and covered with waxed paper or oiled silk, will soften the most stubborn crusts. Crusts in the scalp sometimes cling stubbornly, on account of the numerous hairs running through them. By lifting the edge gradually and cutting away the hairs from underneath, the crust can be lifted expeditiously and with- out pain. I dwell on this little point because I have so often seen well-directed treatment fail of its intention, because the way had not been prepared for the local remedies. Two general principles may be mentioned with regard to the ECZEMA. IOI local treatment of eczema. These are, first, that in the acute form the treatment can scarcely be too soothing; secondly, that in the chronic form the treatment can hardly be too stimulating. Of course, these general principles must be modified somewhat, according to individual circumstances, especially with regard to the latter. Acute Eczema. When a remedy is to be applied for the first time to a case of acute eczema, it is usually better to use it over a limited area until its effect is perceived, for it must be borne in mind that a remedy which has been of service in one case will not necessarily suit another, even when the general features of the disease are the same. If one remedy does not suit, another must be tried, for it is often difficult to decide beforehand what application will be most useful. The indication is to give ease to the patient, and medicaments must be changed, if necessary, until this end is attained. Starch powder is best for large surfaces at first; the parts may then be covered with muslin or soft linen. Lycopodium, sub- nitrate of bismuth, dermatol, talc, or similar indifferent or anti- septic powders, alone or associated, may be employed on isolated patches. The starch poultice is one of the most important moist applic- ations. Potato starch is preferable. It should be mixed with 5 to 10 parts of boric acid per iooo, and then placed in a flat bag, dipped in boiling water, and allowed to cool before applying. In some cases the starch may be applied as a paste, and then covered with very fine soft linen and- carefully fastened in place with bandages. No form of treatment gives more relief in acute eczema than this if carefully applied and changed every three or, at most, six hours. In less severe cases, or in later stages of the disease, these moist applications may be made by covering the affected part with two or three turns of soft linen or muslin, impregnated with decoction of bran or starch water, and covered with thin, impermeable cloths. The linen dressings should be made aseptic before each application; care should be taken to 102 DISEASES OF THE SKIN. avoid creases and folds. If the patient is cold or afraid of be- ing cold, cotton or flannel may be applied over all. In severe cases impermeable cloths may be applied directly to the skin, but these should be of the finest tissue, and not of thick rubber cloth which is sometimes employed to the injury of the patient. All these modes of treatment represent in reality the con- tinuous bath; their action, in certain cases, is most favorable, both in giving relief to the patient and in curing the disease. Careful attention to detail is, however, absolutely necessary. In some severe cases of acute eczema benefit is obtained from oleaginous preparations. These should be made with sterilized oil, alone or with the addition of a small quantity of laudanum, bi-carbonate of sodium, boric acid, etc. The method of applic- ation is similar to that described above, and is to be employed with the same precautions. In acute vesicular or erythematous eczema water used in ablution is, as a rule, injurious, and irritates the skin. It should never be employed, except in cases of extreme necessity, for the absolute requirements of cleanliness. In the place of washing, the affected part may be powdered, from time to time, with a dusting powder, such as the following, known as "McCall An- derson's powder:" 1$. Pulvis camphorae, 5ss (2.) Pulvis zinci oxidi, oiss ( 6.) Pulvis amyli, 5vj- (24.) M. The following plan of treating acute vesicular eczema is that of Dr. James C. White, of Boston, which I have used in hundreds of cases with great satisfaction. I consider it one of the best forms of treatment for the majority of cases in the early acute stages of eczema. The affected part is to be bathed with lotto nigra ("black wash"). This is used either in full strength, or else diluted with an equal part of lime-water, and sopped on the surface by means of a rag or mop, or applied by means of cloths saturated with the wash and allowed to remain on the surface. As a sub- stitute for the ordinary wash, the following, nearly the same in ECZEMA. 103 character, may be used, especially on the face, as it clings better to the skin: fy. Hydrarg. chlor. mite, 5ss ( 2.) Mucilago tragacanthae, 5j ( 32.) Liquoris calcis, ad 5 x jj- (384.) M. 1$. Hydrarg. chlor. mite, oss ( 2.) Liq. calcis, f§xjj. (360.) M. After the wash has been applied for some minutes, oxide of zinc ointment, or in winter the following: 1$. Pulv. zinci oxidi, gr. lxxx ( 5.20) Ung. aquae rosae, Petrolati, aa oiv. (16. ) M. is applied gently with the finger, before the surface has had time to dry; and this treatment is repeated at intervals of a few hours. Sometimes ''Lassar's paste" may be substituted for this. It is composed as follows : 1$. Zinci oxide. Amyli aa oii ( S.) Petrolati oiv (16.) As a rule the itching and burning is relieved at once, and occa- sionally the disease is arrested in its course. Sometimes the black wash may be applied every half hour or hour, the ointment being laid on at longer intervals. When there is a good deal of inflammatory action, and when the skin is thickened and more or less doughy and cedematous, bread poultices, made of bread crumb mixed with ice-cold lead- water may be employed. The sedative effect of this application is extremely soothing and grateful. The following lotion is highly recommended in some cases: 1$. Pulv. zinc. carb. pnecip., §i (32 Pulv. zinci oxidi, oss ( 16 Glycerini, 5ij ( 8 Aquae, fgvj. (192 .) M. It should be applied frequently, by means of a bit of rag or a rag mop, the sediment being allowed to remain on the surface. 104 DISEASES OF THE SKIN. Another very good remedy, in my experience, and one par- ticularly adapted to the treatment of eczema covering a consider- able surface, is the following: 1$. Ext. grindeliae robustae, fid.,. . f§ss ad f5ij (16.-64.) Aquae, Oj. ( 512.) M. This is preferably applied on cloths, which are permitted to remain in contact with the surface until nearly or quite dry, before removal. A lotion of sulphate of zinc, fifteen to thirty grains (1-2) to the pint (512.) of water, acts admirably in some cases, especially in eczema about the hands. When itching is a severe and prominent symptom, applications of hot water, or of cloths wrung out of the same and applied in quick succession, as hot as may be borne, to the affected side, often allay this exasperating symptom when all else has failed. Carbolic acid, which is one of the most efficient anti-pruritics, can rarely be employed in the acute stages of eczema, but now and then, when burning is less prominent as a symptom, and when itching is most tormenting, it is of use. It may be combined with black wash, as thus: ly. Acidi carbolici, 5ij— iv (8. -16.) Glycerins, foj ( 32 ) Lotio nigrae, Oj. (512. ) M. The erythematous form of eczema, when the skin is yet unbroken, and when there is at the same time more or less inflammatory infiltration, is that in which carbolic acid is likely to agree. It must be applied with caution, however, in the acute stage of eczema, until it is found to agree with the individual case under treatment. While, as a general thing, ointments are not found to agree in acute eczema, yet in a certain number of cases these prepara- tions appear to suit better than lotions. The oxide of zinc oint- ment, the hard-ridden and universal remedy for skin diseases, here finds its legitimate sphere. Bulkley recommends that in- stead of being made with lard it should be made with cold cream, and should contain sixty instead of eighty grains of the oxide of ECZEMA. I05 zinc to the ounce. Both of these changes are, improvements. The oxide of zinc ointment, as dispensed, is too thick and almost tough, especially for winter use in this climate. So, for conveni- ence sake, it may be presoribed mixed with an equal weight of vaseline or cosmoline. It should not be benzoated, or if benzoin is used it should be used in small quantity. The unguentum aquae rosae is a much better base for all or almost all oint- ments than lard or vaseline. The lard is apt to turn rancid, wiiile the vaseline is too thin for ordinary use, although preferable, on this account, for use in the hairy parts. Oleate of zinc enters into the composition of a number of ointments which are of value in the treatment of acute eczema. It is made as follows: Take one part of oxide of zinc and eight parts of oleic acid; stir together; allow to stand two hours; heat until dissolved. On cooling, a yellowish- white, hard mass results, which may be variously made into ointments. The fol- lowing is one formula : II. Zinci oleat., Olei olivse, aa 5iv. (16.) M. Or it may be made up with cold cream: lk. Zinci oleat., Ung. aqiue rosae, aa oiv (16.) Olei amygdala?, q. s. M. Oleate of bismuth acts in very much the same manner. The following formula, brought into notice by Dr. McCaU Anderson, is an elegant preparation when prepared with due pharmaceu- tical skill : "McCall Anderson's Ointment." ]$. Bismuthi oxidi, 5 j Acidi oleici, 5 j Cerae albae, oiij Yaselini, 5ix 01. rosas, rr^ij. * Rub up the oxide of bismuth with the oleic acid, and let it stand for two hours; then place in a water-bath until the bismuth oxide is dissolved; add the vaseline and wax, and stir till cold. ( 4. ) (32. ) (12. ) (36. ) ( . [2) M.* 106 DISEASES OF THE SKIN. Subnitrate of bismuth is a very agreeable and slightly astrin- gent as well as sedative remedy, when used in the form of oint- ment. The following — 1$. Pulv. bismuth subnitrat., 3ss-3 j (2.-4.) Ung. aquae rosae, §j. ( 32.) M. is an excellent application in acute eczema of the scalp, par- ticularly in children. Diachylon ointment, made according to the formula of Hebra, with due care, and by a skilled pharmaceutist, is most grateful and soothing to the inflamed skin. It is composed as follows: 1$. Olei olivae opt., f §xv ( 480.) Pulv. Kthargyri, Siij— ovj ( 120.) Aquse, q. s. Coque. Fiat unguent.* Diachylon ointment is usually more effective when spread upon cloths than when rubbed in with the finger and, in fact, the same may be said of all ointments applied with a view to their soothing effect. The patient should be directed to cut out bits of linen cloth to fit the part to be covered, and then to spread the soft ointment upon these as thick as butter upon bread. When applied, they should be covered with oiled silk or waxed paper, for cleanliness sake. Among other soothing dressings may be mentioned finally, cold cream of cucumber ointment, glycerole of starch, almond and *The following directions are taken from Duhring: "The oil is to be mixed with a pint of water and heated, by means of a steam bath, to boiling, the finely- powdered litharge being sifted in and stirred continually; the boiling is to be kept up until the minute particles of litharge have entirely disappeared. During the cooking process a few more ounces of water are to be added, from time to time, so that, when completed, water still remains in the vessel. The mixture is to be stirred until cool. The ointment is difficult to prepare and requires skill- ful manipulation. When properly made it should be of a light yellowish-gray color, and of the consistency of butter. To ensure a good article it is essential that the very best olive oil and the finest litharge be employed." The physician should examine each lot as made up, when this is possible, and he should in all cases decline to employ any ointment which has been on hand over a week. Although one of the most perfectly soothing and sedative of all ointments, unguentum diachylon is probably more apt to be ill-made or decom- posed when dispensed, than any other. ECZEMA. 107 olive oils, and dilute glycerine. The olive oil must be pure and of good quality; the cotton seed oil often supplied in its place is irritating. While glycerine in full strength disagrees with many skins, yet, where diluted with one to three parts of water, it will usually be found to agree. In papular eczema, the eruption being more discrete and scattered, the applications to be made must differ somewhat in form from those employed in vesicular eczema. Lotions are usually preferable, and, in many cases, where the individual lesions are widely separated, these alone are admissible. Then, too, the inflammation is of a different character, and pursues, as a rule, a more chronic course. Soothing applications, there- fore, do not often come into use, and we are more apt to have recourse to stimulant remedies, as the so-called anti-pruritics, and chiefly tar and its derivatives. Carbolic acid is the most important and generally useful of these remedies, and the one most apt to do good in papular eczema. A further account of the treatment to be employed in acute eczema will be found under the head of the treatment of eczema attacking particular regions of the body. Chronic Eczema. In some cases the treatment employed in the acute stage of eczema may also be made use of in the chronic condition of the affection; more frequently, however, other and more stimulating remedies will be found more serviceable. Carbolic acid may be employed, either in the form of a lotion, or as an ointment, of the strength of five to twenty grains (0.32-1.30) to the ounce (32.) of oxide of zinc ointment, benzoated lard or vase- line. It may be relied upon as an anti-pruritic remedy when all others fail, and is a most valuable application in chronic eczema. Tar and its preparations come largely into use in the treatment of chronic eczema. The tarry preparations must be handled with care, however, for, if used injudiciously, or in too great strength, they are apt to inflame the skin and retard the process of cure. They are most apt to be useful when the disease has completely reached the chronic stage, and when there is more or less infiltra- tion. In using tar in the form of ointment, which is ordinarily Io8 DISEASES OF THE SKIN. the most convenient form of employing this remedy, its strength should at first rarely exceed one to two drachms (4.-8.) to the ounce (32.). It can be increased later, if the skin requires and will bear in- creased stimulation. The two forms of tar commonly employed are the pix liquida of the Pharmacopoeia and the oleum cadini. Their effect upon the skin is apparently identical. A very convenient formula is the following: 1$. Ol. cadini, ' 5ss ( 2.) Ung. aquae rosae, 5 j. (32.) M. On the scalp, fluid or semi-fluid preparations are usually more convenient than ointments ; the following formula is recom- mended by Duhring: 1$. Picis liquidae, 5 j (4-) Glycerinae, f 3 j ( 4-) Alcoholis, f3vj (24.) Ol. amygdalae amaras, ln \ xv ( O M. The oil of cade mixed with three or four parts of alcohol or of oil of almonds, may be used as an application in some forms of eczema of the scalp. These preparations are not to be smeared on the surface, or applied on cloths, as the soothing remedies. Much of their efhcacy depends upon their proper and thorough application; they must be worked into the skin, in order to pro- duce their full effect; patients and attendants should be especially instructed on this point. In thick old patches of chronic disease, the following preparation may be thoroughly rubbed in by means of a little mop of cotton fastened to the end of a stick : 1$. Picis liquidae, Saponis viridis, Alcoholis, aa 3ij. (8.) M. This preparation is known under the name of "tinctura saponis cum pice." To produce a stronger impression, caustic potash may be used instead of the soap, in the proportion of five to fifteen grains to each ounce of the mixture. The following ECZEMA. I09 preparation, known as ''liquor picis alkalinus, " was introduced to the notice of the profession by Dr. Bulkley: 1$. Picis liquidae, 5ij (8.) Potassae causticae, 5 j (4-) Aquae, f 5v. (20.) M. The potash is to be dissolved in the water, and gradually added to the tar, while rubbing in a mortar. Of course, this preparation is much too strong to be used undiluted, excepting in the rarest cases. As a lotion, it may be diluted with from eight or more parts of water at first, down to two parts after a little trial; care should be taken not to make the lotion too strong at first. The liquor picis alkalinus may also be combined with ointment, from one to two drachms to the ounce. In some cases of chronic eczema with much thickening Hebra's modi- fication of Wilkinson's ointment may be used: 1$. Flor. sulphuris, Ol. cadini, aa oiv (16.) Sap. viridis, Adipis aa 5 i (32.) Crctae preparat., oiiss. (10.) M. Soaps play an important part in the treatment of chronic eczema. Strong alkaline soaps are used in eczema for their remedial effect, being particularly employed when some in- filtration is to be removed, or when a stubborn and rebellious local patch of disease requires strong stimulation. Of these, the most generally useful is that known as "Hebra's soap," "green soap," or, as it has been called in other parts of this work, "sapo viridis," a strongly alkaline potash soap. It may be employed alone or in the form of an alcoholic solution, known as "spiritus saponis kalinus:" 1$. Saponis viridis, oij (64.) Alcoholis, f5j. (32.) M. Dissolve with the aid of heat, and filter. It may be scented with lavender or other perfume if desired. IIO DISEASES OF THE SKIN. This wash is very useful also for cleansing patches of eczema when covered with accumulated crusts and scales. Under ordinary circumstances, and unless left in contact with the skin with a particular object in view, these stronger soaps, should be washed off at once, and some oleaginous or fatty sub- stance applied. Much mischief is sometimes done by allowing caustic soaps to remain in contact with the skin. Sapo viridis is particularly useful in extensive infiltrated eczema rubrum of the leg and other parts. It should be well rubbed into the affected patches, by means of a flannel rag, until con- siderable smarting, abundant serous discharge, and, perhaps, slight bleeding are induced. The soap is then to be completely washed off with pure hot water, the patch of disease lightly dried with a soft cloth, and some soothing ointment, applied, spread upon strips of cloth. This process is repeated once, or sometimes twice, daily, and when it can be properly carried out is a rapid and efficient method of dealing with this form of eczema. In old, infiltrated patches of eczema, and in eczema of the palms partic- ularly, solutions of caustic potash, ten to forty grains (0.60-240.), or even a drachm (4.), to the ounce (32.), may be employed to advant- age. The stronger of these must be used by the physician himself, and should not be entrusted to the patient or to his attendants. The application should be made with a little mop tied to a stick, or occasionally with a bit of wood. The parts should be immedi- ately bathed with cold water, or covered with cold-water compresses, and after a short time a soothing ointment may be applied. This procedure reduces infiltration and stops itching very effectually. Pushed too far, there is danger of causing local sloughing, with subsequent scars. It should not be used more than once or twice a week under ordinary circumstances. Other remedies for the chronic forms and stages of eczema may be mentioned, as follows: Mercurial preparations are particularly valuable, especially when the disease is confined to a small area. When covering a considerable surface, mer- curials should be used with care, or not at all, both on account of the possibility of overstimulation and for fear of absorption ECZEMA. Ill with resultant salivation. Calomel is the most generally useful of mercurial preparations; it may be employed according to the following formula : J$. Hydrarg. chloridi miti, gr. x-xxx (0.65-2.) Ung. zinci oxidi, Petrolati, aa §ss. ( 16. ) M. The red oxide of mercury in ointment of the strength of five to thirty grains to the ounce, is also often very useful. Some- what milder is the ointment of ammoniated mercury, which may be employed in somewhat less proportionate strength to advant- age in the pustular eczemas of children. Sulphur is also a highly useful application in some forms of eczema, particularly when there is a moist surface, or when its 4 1 cornif ying " influence is required to regenerate the horny epithelium of the skin. It may be used in the form of ointment of the strength of one to two drachms to the ounce of cold cream, in chronic eczema rubrum, occurring in patches; also, occasionally, in chronic pustular ec- zema, particularly about the hands. It should usually be used in a mild strength at first, and after a few days' use should gen- erally be substituted, for a time at least, by some other prepara- tion. A combination of tar and sulphur ointments sometimes acts happily in old chronic eczemas with much itching and infil- tration. Boric and salicylic acids have been highly recommended by authors of repute during the past few years. "Lassar's paste," given above, is a very excellent preparation for use in hot weather. In winter it is a little stiff, and I think the proportion of starch might conveniently be reduced for cold weather. Some dermatologists employ gelatines in these forms of eczema. Two common formulae are as follows : Pick's gelatine: — 1$. Gelatin., §iss ( 48.) P. zinci oxidi, oj ( 32.) Glyceringe, §ij-3viss ( 90.) Aquae, oiij-ovj. (120.) Gradually heat the ingredients as above until thoroughly incorporated. 112 DISEASES OF THE SKIN. Jameson's gelatine: — Gelatin., giss ( 48.) P. zinci oxidi, 5j ( 32.) Adipis, 5j ( 32.) Glycerinse, Sviss. (208.) These are heated together over a water-bath, and two per cent, salicylic acid added. The gelatines are melted at a low temperature and applied with a brush. They have the advantage of neatness and occlu- sion, and save the use of bandages. They are somewhat incon- venient in application, though they may be of advantage in hos- pital and dispensary practice. Another formula frequently employed is "Ihle's ointment:" 1$. Resorcin, gr. x (0.6) Lanolin, Vaselin, Pulv. zinci oxidi, Pulv. amyli, aa 3ij- ( 8.) M. Some years ago Mr. Squire, of London, brought forward the preparation known as glycerole of the subacetate of lead as a remedy in chronic eczema. His formula is as follows : Acetate of lead, 5 parts; litharge, 3 \ parts; glycerine, 20 parts, by weight. Mix and expose to a temperature of 350 F., and filter through a hot water funnel. The clear viscid fluid resultant contains 129 grains of the subacetate of lead to the ounce (5.26 gm. to 30 gm.). This is used as a stock, from which the preparations employed are made by dilution with simple glycerine. This preparation may be used in the treatment of chronic eczema rubrum of the leg, particularly when the disease is extensive, of a dusky red hue, accompanied by weeping, oedema, and a varicose condition of the veins. Also in eczema of the palms and soles. In eczema of the leg the glycerole stock may be used diluted with three parts of pure glycerine. Strips of linen soaked in this preparation are applied to the affected limb and covered with wax paper and a bandage, the dressing being changed once or sometimes twice daily. This method of treatment may be employed to advantage in many cases when the treatment by ECZEMA. 113 means of sapo viridis and unguentum diachyli cannot be carried out. In eczema of the palms and soles the following ointment gives good results: 1$. Glycerol, plumbi subacetatis, f 5ss (2.) Glycerinae f 5iss (6.) Ung. aquae rosae, 3j (4.) Cerae albae, q. s. M. This is to be made into a tolerably firm ointment, and applied to the affected parts. It is better to precede its use with the application of solutions of caustic potash, and it should be spread thickly upon narrow strips of linen, and placed in close apposi- tion to the affected parts, being covered with wax paper to pre- vent soiling. For obstinate, circumscribed patches of eczema, blistering with cantharidal collodion will sometimes be found beneficial.* With the same object, strong solutions of carbolic acid in alcohol, tincture of iodine, and solutions of nitrate of silver, or even the solid stick, may be employed. Vulcanized india rubber has been used extensively in the treatment of eczema, and may be employed with advantage, both as a protective against atmospheric influences, as a preparative for other applications, and as a direct therapeutic agent. Rubber cloth in sheets, rubber masks and finger-stalls, are also often employed in the various forms of eczema with advantage. In severe or ex- treme cases of eczema, furuncles often occur as a sequel, due to the implantation of the staphylococcus pyogenes by scratching and rubbing at a time when the system is impaired. To prevent the occurrence of these furuncles, some parasiticide, as thymol, carbolic acid, resorcin, or sulphur, should be added to whatever ointment is employed toward the end of the treatment. Unna thinks that the addition of one or two parts of corrosive sublimate per thousand of oxide of zinc ointment is the surest preventive of post-eczematous furunculosis. * Of the late Rontgen ray or X-ray has been used to advantage in the treatment of chronic and rebellious patches of eczema. So far as I have had experience with this plan of treatment I have found it of value when all other means have failed. (See Pusey and Caldwell, "The Practical Application of the Rontgen Rays, etc.," Phila., 1905.) 8 114 DISEASES OF THE SKIN. Having now spoken of the acute and chronic forms of eczema in general, it will be advantageous to next consider this disease as it is met with in different localities. Universal eczema is very rare; when it does occur it is usu- ally erythematous or squamous. Its history in these cases will serve to bring out one or another of the points mentioned in discussing the general diagnosis of the disease, and so lead to its identification. Eczema oj the Scalp. This is usually erythmatous, vesicular, or pustular. The first variety rapidly runs into the squamous, the scalp being more or less covered with red, scaly patches, which are very itchy. The pustular variety is common among children. The pustules commonly come out in great numbers about the hair follicles. They soon rupture, and the liquid, oozing over the skin, forms yellowish-green crusts, sometimes amounting to thick masses. The hair becomes matted and caked; the scalp, if not cleansed, gives out a very offensive odor; and the disease, unless checked by proper treatment, may. last from a few weeks even to years. The itching is usually not so decided in this as in other forms of eczema. Sympathetic enlarge- ment of the lympathic glands about the back of the neck and behind the ear is common and, in the case of children, often gives rise- to great anxiety on the part of parents. The glands never suppurate, and the patient's friends may be assured, with confidence, that, as the irritation and inflammation about the scalp subside, the glandular engorgement will spontaneously disappear. Small abscesses often complicate eczema of the scalp in unhealthy children. Pediculi also are very frequently present, and the scalp should be examined for the insects or their nits in all cases of supposed pustular eczema, because, in reality, the affection may be a dermatitis superinduced by the irritation of the pediculus capitis. A patch of pustular eczema occurring in the occipital region, especially in neglected and ill-nourished children, almost invariably points to the presence of pediculi as a cause. When present, they should at once be removed by the means described under Pediculosis capitis. ECZEMA. 115 Eczema of the scalp may be confounded with psoriasis, sebor- rhcea, favus, syphilis, and tinea tonsurans. From psoriasis of the head eczema may be distinguished by the symptoms men- tioned in the general diagnosis of the disease. Seborrhceic eczema sometimes resembles ordinary eczema capitis very closely, but the pearly color of the scales and the not unfrequent combination of more or less seborrhcea with the eczema, making the scales greasy, as also its diffusion, and the history of the case, are important elements in distinguishing the two forms of the disease.* Other points have been touched upon above. Pustular eczema alone is likely to be mistaken for favus, but the mustard or canary color of the favus crusts, their commonly cup-shaped outline, and the dry, pulverulent consistence of the masses of fungus, together with the microscopic appearance, will be sufficient to distinguish it from eczema. As before mentioned, certain syphilitic diseases of the scalp may be mistaken for eczema. The history of the case, with the characteristic symptoms above given, are ordinarily sufficiently distinctive. Erythematous or squamous eczema may sometimes be mistaken for tinea ton- surans. The patches of eczema, however, are not attended with loss of hair. In ring-worm of the scalp the hairs are broken off uniformly about an eighth or a quarter of an inch beyond the scalp. The hair has a nibbled appearance. The patches in ring- worm are apt to be roundish in outline. In eczema they are irregular. The color of the scalp is of a leaden hue, while in eczema it is reddish, and has more the appearance of inflam- mation. The itching in eczema is marked. In tinea tonsurans it is slight. A history of contagion is frequently found in con- nection with tinea tonsurans. The treatment of eczema capitis will, of course, depend upon the variety and stage of the affection in each case. In pustular eczema the crusts must first be removed by means of hot water and soap, preceded, if necessary, by thorough saturation with olive or almond oil, to soften and loosen the crusts. Some- times the scalp must be well saturated with oil and covered with * See Eczema seborrhceicum. Il6 DISEASES OF THE SKIN. a cap over night; and perhaps the process must be repeated; at all events, the crusts must be removed before any applications are made. Occasionally the oil alone appears to exert a cura- tive influence, but usually more decided treatment is required. The hair in children, boys, and men may be cut short, especially when lice are present. In women this sacrifice is not necessary, and should not be permitted. Now and then, however, we meet cases where women are suffering with severe and neglected eczema due to pediculosis of long standing, and where the hairs are so matted and glued together that we are obliged to have recourse to the scissors. As to medicinal applications: in inflammatory cases, black wash or one of the carbolic acid lotions may be applied with a sponge or cloth for ten or fifteen minutes at a time, morning and evening, and these may be followed each time by an oily prepara- tion. If ointments can be used, the following are of value: 1$. Bismuthi subnitrat., oj (4-) Petrol ati, o j. (32.) M. Or this: 1$. Hydrarg. ammoniat., gr. x-xx (0.6.-1.2) Petrolati, oj- (32.) M. The following is somewhat more stimulating. It appears to have a drying effect when there is discharge: 1$. Hydrarg. chlor. mite, gr. xx-xl (1.2-2.4 ) Petrolati, oj- (32.) M. A small portion only should be applied at once, but this should be rubbed in thoroughly. When a stimulant effect is desired, an ointment of the red oxide of mercury, ten to twenty grains (.60-1.20) to the ounce (32.), may be employed. The am- moniated mercury ointment is particularly useful in cases where the eczema is due to the presence of lice. When still stronger stimulation is required, especially when exudation has ceased, and the scalp is red and scaly, one of the following ointments may be employed : 1$. Ung. hydrarg. nitrat., OJ-iv (4.-16.) Petrolati, 3iv. 16. M. ECZEMA. 117 Or, 1$. Picis liquidae, 5 j ( 4-) Petrolati, oj. (32.) M. As these cannot be applied when the hair is long, a fluid prep- aration must then be employed: 1^. Ol. cadini, f 3ss ad f oj (2.-4.) Ol. amygdalae, ad foj. ( 32.) M. Alcohol may be substituted for the oil when the hair is quite thick. In some cases, when there is scaly eczema of the scalp with some tendency to greasiness, and the occurrence of sebor- rhcea, the following ointment acts happily: 1$. Acidi tannici, 5j (4-) Petrolati, 5 j- (32.) M. When the hair is long, glycerine and alcohol in equal pro- portions may be substituted for the petrolatum. Eczema oj the Face. This form of eczema is more apt to be met with in children (see Eczema infantile), but is also found in adults, on the cheeks and elsewhere. The form of eczema found in adults is usually the erythematous, on the cheeks, nose, forehead, and sometimes extending around to the ears and down the neck. The skin becomes bright or dusky red, with intense burning and some itching. It becomes thickened, infiltrated, and stiff, with some scaliness. This form of eczema is more apt to occur in winter and among persons exposed to cold and wind. In addition to such general means of treatment as are called for by the patient's condition, active local measures should be used. Lead-water lotions are valuable in the acute stage, and also black wash. Black wash should be sopped on the skin, or laid on by means of rags saturated with it, and re- newed hourly. This may be followed by an ointment, especially if the patient must move about and cannot keep the wash in contact. Oxide of zinc ointment with equal part of vaseline may be employed, or "Lassar's paste" in some cases. In order to protect the skin from cold air, which is very in- Il8 DISEASES OF THE SKIN. jurious when the skin is in this condition, the following paste may be applied: 1$. Tragacanth. Glycerinae, aa oiv (16.) Sodii biborat., oss ( 2.) Aquas destillat., q. s. M. With these materials, a thin, adherent, quickly drying paste may be made, with which the skin of the face may be painted just before going out of doors. This is almost or quite invisible, and yet acts as a perfect protective. On coming in doors it may be washed off readily with a little warm water, and then the lotions and ointments may be applied. This is worth remembering, because not every one can stay at home, day after day, and keep applications constantly to his face, and it is well to be prepared with some such alternative, which if it does little good yet pre- vents much harm to the skin. As soon as possible the soothing applications should be changed for lotions and ointments containing tar and carbolic acid. The carbolic acid wash may be tried even when the eruption is at its height, being more apt to be useful if itching, rather than burn- ing, should be the prominent symptom. The following formula is a good one: 1$. Acid carbolic, 5iij ( 12.) Glycerinae, oj ( 32.) Lotio nigra, Oj. (512.) M. Water may be substituted for the lotio nigra. The proportion of carbolic acid may be increased or dimin- ished as the case requires. There is a proprietary solution of coal tar which is known as " liquor carbonis detergens, " and which is miscible with water, which is an excellent lotion for use in this form of eczema; it should be employed in the proportion of one part to eight of water or stronger. It is closely imitated in the following formula by Duhring: 1$. Picis mineralis, 5ij ( 8.) Alcoholis, fgij. ( 64.) ECZEMA. 119 Strain, and add Liq. ammoniae fort., rqviij ( 0.5) Glycerinae, f5vj ( 24. ) Aquae destillatae, ad f5xij (384. ) M. The following combinations may be suggested: 1$. Liq. carbonis detergens, f 5ij ( 8.) Liq. plumbi sub. acetat. dil foij ( 8.) Aquae rosae, ad Oss. (256.) Or, 1^. Liq. carbonis detergens, foij ( 8.) Pulv. zinci carb. praecip., qv ( 20.) Pulv. zinci oxidi, oiv ( 16.) Glycerinae, f 5j ( 4-) Aquae rosae, ad Oss (256.) When ointments are borne, the following is useful in very many cases: 1$. Picis liquidae, oss— oij (2.-8.) Ung. aquae rosae, oj. ( 32.) M. Now and then fissures and cracks form in the infiltrated skin, especially about the alae nasi. The following pigment is very efficient in healing these, and may often be used as a protective over other parts of the face, where there is no objection to the discoloration: I}. Ol. cadini, 5j (4.) Liq. gutta perchae, seu collodii, o j. (32.) M, Let a brush be put in the cork, and let the patient paint the skin over several times a day. This pigment has the advantage over ointments that it cannot be rubbed off. Another excellent ointment in erythematous eczema of the face is this: 1$. Ung. hydrarg. nitrat., Olei cadini, aa oj ( 4-) Pulv. zinci oxid 3ss ( 2.) Ung. aquae rosae, ad oj (32.) Ol. rosae, q. s. M. Eczema oj the lips is ordinarily accompanied by swelling, redness, heat, infiltration, slight scaliness, and fissures. The 120 DISEASES OF THE SKIN. muco-cutaneous surface of the skin outside may be attacked, and the symptoms and treatment differ according to the seat of the eczema. Eczema of the lips is to be distinguished from herpes and syphilis. Herpes runs a distinct, short course, and is composed of discrete, well-marked vesicles or groups of vesic- les. Eczema is more obstinate, and covers a larger surface. Syphilis occurring about the mouth usually either assumes the form of circumscribed, more or less irregular erosions on the inside of the lip, or else is seen localized in the angles of the mouth, forming a more or less deep fissure and secreting a puri- form fluid. Eczema of the lips, especially when occurring on the muco-cutaneous surface, is difficult and painful to treat. Solution of caustic potash, twenty grains (1.20) to the ounce (32), is of use when there is infiltration. The muco-cutaneous surface should be carefully dried before it is applied, and after- wards, to prevent running. Ordinarily, milder preparations are best. The following is a useful combination: 1^. Acidi phosphorici, dil., Glycerinae, Syrupi, aa f§ss. (16.) M. Sig. — Apply to parts three times daily. The same formula, with the addition of enough water to make six ounces (192.), may be given internally in teaspoonful doses thrice daily. When a dry, wrinkled, scaly condition exists, G. H. Fox suggests the use of an ointment containing five grains (0.3) of thymol to the ounce (32) of cold cream. When the outer edge of the lip is affected, the following oint- ment is useful: 1$. Zinci oxidi, Mellitis, aa 3ij (2.66) Olei amygdalae, ovj (24. ) Cerae flavae, 3ij. (8. ) M. In winter a condition analogous to eczema produces annoying fissures of the lip, which may be treated by moistening the fissure and applying a pointed stick of nitrate of silver. After- ward the compound tincture of benzoin may be painted on as a ECZEMA. 12 T protective. Another procedure in chronic cases is to forcibly tear open the crack a short distance and then rub in, by means of a bit of cotton on a stick, a minute quantity of strong red oxide of mercury ointment, forty to sixty grains (2.66~4)to the drachm (4). There is a form of eczema occurring on the upper lip, about the opening of the nostril. This has been considered under eczema of the nares. Eczema 0} the eyelids often occurs in scrofulous and badly- nourished children, and less frequently among adults also. The follicles of the eyelashes are involved, small pustules forming, which dry into crusts, gluing the edges of the lids together. These are usually more or less red and swollen. Conjunctivitis may or may not be present. The treatment varies, according to the severity of the case. Mild cases require no more than the application of a weak nitrate of mercury ointment, made of the officinal ointment diluted with three to six parts of cold cream, or an ointment of ten grains (0.65) of red oxide of mercury to the ounce (32.) of cold cream. In severe cases the eyelashes should be extracted, the edges of the lids carefully dried and then touched with a camel's-hair pencil moistened with a drop of a 2 per cent, solution of caustic potassa. This application is to be wiped away immediately and the effect neutralized by the applic- ation of cold water. The operation may be repeated every day until the infiltration, exudation, and itching subside; after which one of the stimulating ointments just mentioned may be used to complete the cure ; or a small portion of the following ointment, may be applied on the inside of the lower lid with a spatula and gently worked over the insides of the closed lids with the aid of the linger: 1$. Hydrarg. oxid. flaw, gr. j (0.06) Petrolat, oj. (4- ) M. Eczema of the nares deserves special mention. Hardaway points out that we have two distinct clinical and pathological conditions in many cases, eczema and inflammation of the fol- licles of the vibrissas, which latter is in effect a folliculitis barbae, 122 DISEASES OF THE SKIN. or coccogenic sycosis, and to which the name Eczema sycosi- forme is sometimes given. When simple eczema of the nares exists, a similar inflammation is not unfrequently present in the upper portion of the nasal passages, and this complicates the condition, which is apt to be stubborn to treatment. The mucous membrane of the nasal passages is, in its upper portion, so far as the unaided vision can reach, dry, red, and glazed. Near the nasal orifice excoriations and even shallow ulcers are sometimes met with, and the passages are apt to be clogged up with dried crusts. Children, particularly ill-nourished infants, are most commonly the subjects of this form of eczema, which is to be carefully distinguished from syphilitic nasal disease, both by the history of the patient, the absence of concomitant syphilitic eruptions, or other symptoms, and the fact that the disease is always more superficial in eczema, erosions, if present, being shallow and secreting serum and mucus rather than pus. The local treatment of this form of eczema consists in first softening any crusts which may obstruct the nostrils by painting with a soft, camel's-hair brush, or dropping into the nostril warmed olive or almond oil. When the crusts are thoroughly softened, they can easily be removed, but no force must be used. The orifices are then gently anointed with some soothing or slightly stimulant and astringent ointment, as the McCall An- derson ointment. When the vibrissas are affected, a sort of furuncle may arise just within the nares, accompanied by intense pain and tension, and usually resulting in resolution without suppuration. The parts being rigid, there is no room for extension of the inflam- matory process. The outside integument of the nose often be- comes red and subsequently desquamates. The disease process may run its course in a few days, or, by the extension of the inflammation to new follicles, may drag on over several months. In chronic cases one is sometimes con- sulted rather for the redness of the nose than for the actual dis- ease. The affection appears to attack persons who have become ECZEMA. 123 worn out by fatigue, mental strain, or worry. Although not strictly speaking an eczema in this form, yet it is so closely con- nected with the eczematous inflammation as to deserve mention here. Any discharge from the nostrils must be treated as an indispensable preliminary to the cure of the skin affection. Hardaway recommends cod-liver oil emulsion internally, preceded, in some cases, by the sulphide of calcium, in one- tenth grain doses every three hours. Locally he advises one part of glycerine to two parts of Squires' glycerole of the sub- acetate of lead applied freely, by means of a camel's-hair pencil to the inside and outside of the nose. Ichthyol applied pure to the pustule or pustules often gives relief. Fomentations of water as hot as can be borne may be applied several times daily, and the hairs should be plucked from the inflamed follicles. When the disease spreads down on the upper lip, the sulphur and tragacanth lotion (see Acne) is usually the best treatment. Local depletion may be required. Later, Hardaway suggests the ointment of the glycerole of lead. In severe, long-continued cases, where relapses are common, the hair papillae may be de- stroyed by electrolysis. Eczema 0) the beard is sometimes excessively stubborn and annoying. Pustules, usually seated about the hairs, form with great rapidity and persistence, and are followed by yellowish or greenish crusts, often matting the hairs together. Usually the affection is confined to a limited locality, as the corner of the upper lip, near the commissure, or just at the beginning of the nostrils; but occasionally the whole beard may be involved, and the disease may extend to other parts of the face. In this respect the affection differs from sycosis (see Sycosis coccogenica), which is always limited to the hair follicles. The latter is also a deep process involving the follicles themselves, while eczema barbae is essentially superficial, occupying the surface of the skin alone, and taking in the hair follicles only incidentally. Papules and tubercles, not uncommon in sycosis, are absent in eczema barbae. The two affections do, however, often resemble one another very closely. 124 DISEASES OF THE SKIN. Ringworm of the beard (see tinea Sycosis) is sometimes mis- taken for eczema barbae; it is important to distinguish between the two diseases. Crusts are generally abundant in eczema; in this form of sycosis they are generally (though not always) scanty. When the crusts are removed, the eczematous surface is smooth, while in tinea sycosis it is rough, uneven, tubercular, and lumpy — a very important point. The hairs in eczema are usually firm in their follicles, and the attempt to remove them causes pain, even when there is a good deal of suppuration about the root. In tinea sycosis, on the other hand, the hairs come away without the least pain or difficulty; they are often crooked, but are usually quite smooth and dry, while the hairs of eczema are surrounded by the glutinous root sheath. Above all, the hairs in tinea sycosis almost invariably contain the»characteristic fungus; besides which, the source of contagion in this highly contagious disease can frequently be traced out. Finally, patches of char- acteristic ring- worm not unfrequently can be seen on the neigh- boring skin. The treatment of eczema of the beard should be prompt and energetic. The crusts must first be removed with oil or poultices, followed by soap and warm water, and then the beard must be carefully shaved. This is a painful operation when first performed, and patients often rebel against it. It is well to be firm, however, and it is sometimes unsafe to take the responsibility of a case unless the patient complies with these directions. After the first time, shaving is much less painful, and patients do not object. Ointments and other applications cannot be brought into intimate contact with the surface when there are hairs growing upon it. In the acute stage, the treatment by sapo viridis and unguentum diachyli, as described under the general treatment of eczema, is best. Later, a weak sulphur ointment, of half a drachm (2.) to the ounce (32.), or the sulphur and tragacanth lotion (see Acne), may be employed. Eczema of the ears may occur in any form, and may involve either the outside or the meatus. In the acute forms and stages the ears are red and swollen, and they burn and itch severely. ECZEMA. 125 The disease, when it involves the meatus, may cause temporary deafness from occlusion by large and abundant epidermic flakes and scales. Ointments, as a rule, are most useful in eczema of the ears, though in the acute vesicular form, black wash, or some other lotion, may first be employed, as in the general treat- ment of acute eczema. When there is a deep crack behind the ear, of long standing, sapo viridis may be briskly rubbed in, followed by an ointment containing tar or calomel, a drachm to the ounce. This is a good combination: J$. Picis liquidae, 5 j (4-) Ung. zinci oxidi. 5 j- (3 2 -) M. Calomel may be added to this formula. When the meatus is involved, if ointments, etc., are used, the opening may become gradually clogged with debris, and deafness, often quite alarming to the patient, may result. In these cases the meatus is to be carefully syringed out with warm water, containing a little borax, sodium carbonate, or common salt, in order to remove all the wax, epithelium, grease, etc. Oil of sweet almonds may be dropped into the meatus first, to soften the mass. Care must be taken in these manipulations, and especially in making applications, not to injure the membrana tympani. The crusts being removed, and the meatus gently dried, the affected parts may be touched with a solution of nitrate of silver, two to three grains (0.13-0.2) to the ounce (32), and dry charpie applied, or if there is much oozing, cold cream in small quantity. If the skin is infiltrated, a solution of caustic potash, ten grains (0.65) to the ounce (32), may be applied by means of a camel's-hair pencil, carefully stripped before introduction, so as not to leave a drop which may run down to the tympanic membrane. These applications may be made every day or two, and as the acute symptoms pass off, an ointment of tannic acid, one drachm (4) to the ounce (32), may be substituted for the cold cream. In the intervals of this treatment, which must be carried out by the physician, the pa- tient may syringe the meatus out once or twice daily with the following solution: 126 DISEASES OF THE SKIN. 1$. Acid, carbolic, cryst., Zinci sulphat., aa gr. xij ( 0.8) Glycerinae, f oiij (12. ) Aqua? rosae, ad f 5 xij (48. ) M. Eczema occurring about the ears, and particularly in the meatus, is apt to be stubborn. Eczema of the genitals is one of the most painful and distress- ing forms of the disease. In the male, the penis or the scrotum alone may be involved, or both together. The latter is more commonly the seat of the disease, and the tissues of the skin here become greatly thickened, swollen, and infiltrated. Moist- ure, crusts, and painful fissures along the folds of the skin are often present. Itching is a severe and prominent symptom, and the disease is apt to be very chronic. In the female the labia and even the vagina may be invaded. The affection here is even more distressing than in the male. Itching is violent and causes extreme misery. The diagnosis is not difficult. Pruritus alone is apt to be mistaken for eczema of the genitals, and here the absence of visible primary lesions will decide the character of the case. The itching comes first in pruritus, and then the skin is torn and bleeding, from the scratching. Sometimes eczema of the genitals yields quickly to treatment; this is when it is recent and superficial; chronic eczema with thickening and infiltration is often obstinate to an extreme degree.* In the acute and superficial form, simple or medicated warm baths are often grateful and give much relief. The following is a fair sample of the method of making up these baths: 1^. Potassii carbonat., §iv (128.) Sodii carbonat., oij (64.) Pulv. boracis, oij ( 64.) M. Dissolve in a quart or so of water; add four to six ounces of dry starch, placed beneath the water in the hand, which is then opened and beaten through. Six to eight ounces of glycerine may then be added if thought desirable, and the whole mixed * Diabetes should be suspected in severe cases of eczema of the genitals, and the urine should be examined. ECZEMA. 127 in with about thirty gallons (60 liters) of hot water in a long bath tub. The patient remains in the bath for fifteen to twenty minutes. On coming out the parts are to be carefully dried without rubbing, and then at once thickly dusted with powdered subnitrate of bismuth, or wrapped up in an ointment composed of one part of cod-liver oil to two parts of suet. When baths cannot be taken, or even when these are employed, it will often be found advantageous to use between times lotions of lead- water or black wash, or the fluid extract of grindelia robusta,t two drachms (8.) in a pint (512.) of water. If the patient is obliged to go about his work or business, it will be well, if he be a man, that the part be wrapped or supported in fine linen wrappings to protect it. One of the various dusting powders, as nitrate of bismuth lycopodium, magnesia, etc., may be dusted on, or if powders are found too drying, a little vaseline may be smeared over the surface. In both men and women it is important to keep adja- cent parts separate from one another, as the heat and moisture engendered infallibly make the disease worse. Where there is infiltration the treatment must be different. Whatever applications are made, however, will do more good if the parts are first bathed with water as hot as can be borne. The sapo viridis and unguent um diachylon treatment, described above, under the head of general treatment, is a most excellent method for use in chronic and indurated eczema of the genitals when it can be had. When there is considerable itching car- bolic acid wash — acid carbolic, 5 n j ( I2 > glycerine, §j (32.) ; aqua?, Oj (512) — is of advantage. It is particularly useful in eczema of the female genitals, and its application, which may be prac- ticed at intervals of a few hours, should be preceded, when pos- sible, by bathing with hot water. In eczema of the scrotum, when there is much itching, the following application may be employed : 1$. Argenti nitrat., gr. x-xxx ( 0.65-2.) Spiritus ceth. nit., f o j- (32.) M. This is to be painted on the parts, and will serve to protect them; if found too stiff, some ointment may be applied as soon 128 DISEASES OF THE SKIN. as the pigment is dry. Stimulating ointments, mercurial, tarry, etc., as given above, may be employed from time to time, as required, and one thing should be tried after another until relief is gained; for in this form of eczema, more than in any other, perhaps, the treatment must, of necessity, be largely empirical and tentative. Eczema oj the anus is not very common — pruritus of this region being usually mistaken for this disease — but when it occurs, may cause much infiltration and fissuring, with not unfrequently involvement of the neighboring parts. It is very apt to result from a neglected pruritus of this part. (See Pru- ritus ani.) It usually assumes the erythematous form, and when fissure results great pain is experienced on defecation. On account of this, constipation from over-retention of the faeces is commonly present, with the effect of heightening the discom- fort and pain caused by the passage of the stools. Itching and burning sensations, worse at night on going to bed, and in severe cases pain on defecation — these are the chief symptoms of eczema ani. The treatment is, in general, the same as that of infiltrated eczema in other localities. The parts should first be washed with ichthyol soap or with a mild sublimate soap. The following ointment may then be applied: 1$. Acid boric, oj (4-) Cocaine hydrochlorate, 3j (4-) Lanolin, oj- (32.) M. Tar ointments in various proportions are very useful. The following formula gives the tar in the least offensive form possible, first applying a five per cent, solution of cocaine hydrochlorate to prevent undue pain: 1$. Picis liquidae, oj (4-) Medullas bovis, 5 vj (24.) Cerae albas, oj (4-) Ol. rosas rr\y. ( 0.3) M. Almond oil containing twenty per cent, carbolic acid forms a cleanly and not disagreeable application. It may be rubbed ECZEMA. 129 n with the fingers every night on retiring. Even when the mucocutaneous surface is abraded and fissured, this oil gives relief, while many applications pain severely. When there are deep fissures, these should be split open and touched with the nitrate of silver stick, the tar ointment being subsequently applied. The parts should be kept scrupulously clean, and the patient should be exhorted not to scrape and dig at the skin, but to fly to his ointment or oil when the attack comes on, and es- pecially to keep these close at hand when undressing for the night. If there is any tendency to congestion and moisture about the nates and perineum, these should be powdered with starch or astringent powders. Laxatives, by permitting the passage of the faeces in a softened condition, and also possibly by relieving the circulation in the hemorrhoidal veins, may often be of service. The astringent injection mentioned under pruritus ani is often of great service. Eczema intertrigo resembles erythema intertrigo (see Ery- thema intertrigo), but shows the characteristics of eczema. The parts should be dusted frequently with astringent powders, kept from rubbing, if possible, by the interposition of lint or cloth, and rest, when possible, should be enjoined. Sometimes astringent lotions are useful. Eczema oj the breasts may occur about the nipple or on the lower edge of the breasts. The former variety is often brought about or kept up by nursing. The diagnosis, especially from syphilis and from Paget's disease which is very important, is to be made by ex- clusion. Eczema occurring in this locality shows the infiltration, redness, exudation, burning, itching, etc., characteristic of the affec- tion. The sapo viridis and unguentum diachylon treatment, or that by solutions of caustic potash, is the best when there is much infiltration. The treatment in every case should be decided and vigorous. When fissures of the nipple occur in nursing women, leaden shields may be used and the cracks in the nipple moistened, touched with nitrate of silver stick (an excessively painful operation for the moment, but the pain of which can be reduced by previously touching the cracks with a twenty per 9 130 DISEASES OF THE SKIN. cent, solution of cocain hydrochlorate), and painting with com pound tincture of benzoin. By this means cracks in the nipple can often be healed up while the child is nursing. When eczema occurs about the lower edge of the breast it generally takes on the form of eczema rubrum or eczema intertrigo, and is in part due to a pendulous condition of the mammae. The usual treat- ment of lotions, as black wash, astringent powders, and the in- terposition of lint or absorbent cotton will work a cure. Eczema oj the umbilicus is usually moist and fissured. A disagreeable odor generally accompanies the affection in this locality, and there are scales and crusts. The disease is apt to be mistaken for syphilis if it occurs only in this locality, but in syphilis ulceration usually takes place, and the smell is more than disagreeable; it is positively offensive. The little pit should be kept thoroughly clean, and the diseased part should be painted every day or so with a solution of nitrate of silver, four to ten grains (0.24-0.65) to one ounce (32.), and then the sides kept apart by dry cotton. Eczema of the leg is a very common form of the disease, especially among old people. The erythematous and vesicular varieties are commonest at the beginning, but these soon change to eczema rubrum or weeping eczema. The affection occurs in one or more patches of various size, the whole leg being not unfrequently involved. When it comes under notice it has gener- ally lasted some time ; the skin of the leg is smooth, shiny, dusky red or violaceous and unbroken; or it may be moist and weeping, or covered in part or wholly with scales and crusts. There is always a good deal of thickening and infiltration, with burning and itching to an extreme degree. Varicose veins often accom- pany this form of eczema, and varicose ulcers are not uncommon. Eczema rubrum sometimes occurs in elephantiasis of the legs; here it is secondary to the other affection. The diagnosis of eczema of the leg is not difficult. Ulcers, when present, are to be distinguished from syphilitic ulcers. The treatment of eczema of the leg must vary with the nature of the case. In moist, weep- ing eczema the sapo viridis and unguentum diachylon treat- ECZEMA. 131 ment is the best when it can be carried out. Next to this is the treatment by means of glycerole of the subacetate of lead. Both forms of treatment have already been described. A paste sug- gested by Unna is often useful. It is composed as follows : 1$. Kaolin., Ol. lini. (seu glvcerinae), aa ovj (24.) Pulv. zinci oxidi, Liq. plumbi subacetat., aa oss. (16.) M. This forms a thick, creamy liquid, which dries with tolerable rapidity on exposure to the air. It is best preserved in a bottle with a large brush in the cork. This prevents evaporation and permits the ready application of the remedy. A thin coating is painted on the skin and allowed to dry, which usually occurs in a few moments, or if it does not dry quickly enough a little powdered kaolin or starch may be dusted over the surface by means of a wisp of cotton. A bandage is then applied firmly from the toe to the knee, and the dressing allowed to remain in place for twenty-four hours. At the end of that time, the band- age being removed, the dried paste can be readily detached. When it sticks closely to the skin it is better not to tear it off, but to paint over the whole limb. This process is repeated daily, the area covered diminishing with the healing up of the disease, until, finally, pigmentation occurs. Ravogli uses, first, a liniment of two-per-cent. ichthyol in a mixture of glycerine, almond oil, rose water, and lime-water, applied on patent lint and covered with a layer of cotton. Subsequently he uses oxide of zinc ointment or diachylon ointment, containing six- per-cent. ichthyol. An excellent treatment for chronic eczema rubrum of the leg, complicated, as this so often is, by ulcers, is the following: After cleansing the ulcer from all debris, secretion, etc., it is covered with powdered iodoform, aristol or europhen thickly dusted on. The whole area of eczema around the ulcer and extending to the entire limb if required, is then painted with the following: 132 DISEASES OF THE SKIN. 1^. Acid, salicylic, Acid, carbolic, aa 3ij ( 8.) Zinci oxid., giv (128.) Mucilag. tragacanth, Glycerin, aa Sxiiiss ( 54.) Aquse destillat., §iv. (128.) The proportion of oxide of zinc may be varied slightly so as to obtain the consistency of thick cream. After the diseased skin has been well coated with this paint, a double-ended roller bandage is to be applied. The bandage is to be thoroughly soaked in water and applied while still wet by its middle across the foot just below the instep, the ends being crossed and recrossed at every turn with a half twist. If care- fully applied, this bandage may remain in place for several days, or even a week, without arousing any discomfort. It is, there- fore, particularly suitable for dispensary patients, and those whose circumstances forbid a frequent visit to the physician. Occasionally massage may be employed to stimulate the cir- culation in the diseased limb and to hasten the absorption of the products of inflammation. Before using this procedure, the surface should be disinfected by washing with some parasiticide soap, followed by a wash of i to iooo corrosive sublimate or a saturated solution of boric acid in distilled water. When enlarged or varicose veins occur in connection with eczema of the leg, particular pains must be taken to support the vessels and to give tone to the circulation. The patient should sit or lie with the limb in an elevated position, and should never permit it to hang down. Walking exercise may some- times be taken in moderation with benefit, if the limb has been supported by an elastic stocking, or by one of Martin's rubber bandages. Bandages of one kind or another should always be employed in eczema of the leg, both to support the dressing prop- erly, and, as has been said, to give tone to the vessels. Too much stress cannot be laid on the importance of attending to the con- dition of the circulation in eczema of the leg. The rubber bandage is particularly useful in a limited number of cases, especially when there are ulcers present. It should be applied ECZEMA. 133 directly to the limb, care being taken to exercise firm and even, but not too severe pressure. At night the bandage should be removed and cleansed and placed in carbolized water, from which it can be removed in the morning and dried previous to re-application. The leg should be dusted with starch and boric acid; or it may be bathed with hot water containing a little carbolic acid, if there is much itching, and then is to be dusted with boric acid and wrapped up loosely in a muslin bandage, or cloth, for the night. The rubber bandage must be used with caution, and the leg frequently examined by the physician. If applied carelessly it may do harm by cutting into the skin or by macerating it. Eczema of the hands may attack cither the back or the palm. The appearance and course of the disease is so different, how- ever, in one case or the other, that they must be considered separately. Eczema vesiculosum is the variety most common on the backs of the hands, and on the backs and sides of the fingers. Sometimes the pustular variety is found, and occa- sionally fissured eczema about the knuckles and pulps of the fingers. The vesicular form of eczema is not unlike that found in other localities, excepting that large blebs occasionally form. It may be acute or chronic, and in some cases the nails are also involved in the disease. It is apt to occur as the result of exposure to acids, alkalies, brick-dust, etc. The diagnosis between eczema and scabies of the backs and sides of the fingers and hands is sometimes difficult. In scabies the peculiar burrow of the itch insect, a short, irregularly curved, beaded, black line, a quarter of an inch in length, is often present, and the vesicles are few in number and scattered. In eczema, on the other hand, the vesicles are numerous and closely grouped. In scabies the vesicles are firm, and usually remain unruptured until they are opened by mechanical means. In eczema the vesicles usually rupture spontaneously, at an early period. The vesicles of scabies commonly exhibit through their summits a fine, dark, irregular line, made up of points, being the original burrow in the epidermis which has been raised by the formation 134 DISEASES OF THE SKIN. of the vesicle. This is, of course, wanting in eczema. The occurrence of scabies elsewhere over the body will also assist in the diagnosis. Vesicular eczema of the backs of the hands may also be confounded with the rare disease known as dysidrosis or pompholyx. (See Pompholyx.) Eczema of the backs of the hands, and particularly eczema of the fingers, is apt to be very intractable, sometimes recurring every year or oftener, at regular intervals. In the acuter forms of vesicular eczema of the backs of the hands, lotions, as black wash, and particularly a lotion of two to four grains (0.13-0.26) of the sulphate of zinc to the ounce (32.) of water, are useful in the more chronic form of the disease. Stimulating ointments commonly answer the best purpose in the chronic form. When the case is chronic and not very extensive, the vesicles may be ruptured by an application of solution of caustic potash, twenty to forty grains (1.30-2.60) to the ounce (32.), ap- plied with a pointed stick, or brushed quickly over the surface and washed off. The application is to be followed by a soothing oint- ment. India rubber finger-stalls are sometimes employed with success. Fissures in the ends of the fingers should be painted with liquor gutta perchae repeatedly for several days, and then allowed to remain untouched until the shell which forms peels off. Then a weak solution of caustic potassh may be used. The fingers being soaked for a few minutes and then dried, after which the solution of gutta percha is again to be applied. Eczema of the backs of the feet differs in no essential from eczema of the backs of the hands. It is less frequent, however, and when it occurs is apt to be less extensive and less rebellious to treatment. Eczema of the palms and soles presents some peculiar features. Owing to the thickness of the epidermis in these localities, the appearance of the affection is somewhat marked. Infiltration, thickening, more or less callosity, dryness, and fissuring mark the disease. It is very chronic and intractable. Sometimes deep and painful fissures occur, and when these are found upon the feet locomotion is rendered almost or quite impossible. The diagnosis of eczema of the palms and soles is often difficult. It is apt to be confounded with psoriasis and syphilis. ECZEMA. 135 From psoriasis, eczema differs in showing, at times, moist and bloody fissures, while those of psoriasis are usually dry, and show little disposition to bleed. The patches of eczema are usually larger than those of psoriasis, and their edges pass gradually into the healthy skin. The patches of psoriasis are smaller, darker, covered with more abundant and paler or white scales. But the best point in diagnosis is the appearance of the disease on other parts of the body. When the palms and soles alone are affected, it is sometimes hardly possible to distinguish eczema from psoriasis. The latter, however, is exceedingly rare, so that the chances are one hundred to one in favor of any given case turning out to be eczema. The diagnosis between eczema and syphilis of the palms and soles is not usually so difficult, although sometimes, when the affection is not found elsewhere, one may be puzzled to come to a decision. The infiltration of syphilis is of a firmer nature than that of eczema; it also extends more deeply into the skin. The patches are smaller and more cir- cumscribed, and sharply defined upon the edge, and they have a tendency to spread upon the periphery and to assume the circinate form. Eczema is usually much more uniformly diffused; it is apt to be of a light color, while syphilis is darker, and some- times ham-colored. It is also apt at times to itch, while syphilis does not itch. The history, and especially the occurrence of concomitant lesions elsewhere, will often aid the diagnosis. The treatment of eczema upon the palms and soles must be of the most active and vigorous character, if relief is to be expected. The first point is to get rid of the thick epidermis. This may be accomplished by covering the palm with rags, spread with sapo viridis or wet with a five- to ten-grain solution of caustic potassh, and covered with rubber cloth. These are to be kept on day and night, until the epidermis is softened, macerated, and reduced to something like its normal thickness. Then stimulating oint- ments, containing mercury and tar, may be employed. When the physician himself can conduct the treatment of the case, the following plan may be employed: Let the affected palm or sole be soaked for some minutes in water as hot as may conven- 136 DISEASES OF THE SKIN. iently be borne; and then, after the superfluous moisture has been hastily removed, let a twenty to forty per cent, solution of caustic potash be firmly rubbed into the affected skin at all points, by means of a small mop, made of cotton tied to a short stick. If this produces an uncomfortable heat, the surface may be washed with pure, cool water; otherwise, the following ointment is to be applied directly: 1$. Hydrarg. ammoniat., 3j ( 1.33) Adipis, 3ss ( 2. ) Sevi benzoinati, 5ij-9j ( 9-33) Ol. amygdalae dulcis, up: ( 0.65) Ung. petrolii, ad 3vj. (24. ) M. It should be spread over the surface, and also laid thickly upon rags and applied; waxed paper being wrapped about each finger and placed over the palm, both for cleanliness' sake and to aid the effect of the ointment. This is to be repeated daily until cracks heal up, the skin becomes thin and supple, and begins to assume a healthier appearance. Then the potash applications are suspended, and a weak tar ointment — a drachm to the ounce — is rubbed in daily, to complete the cure. Though the treatment just described is more particularly applicable to the palms, yet it may also be employed upon the soles. However, a better treatment for that form of eczema affecting the thicker skin of the soles is the glycerole of lead treatment, described above. The salicylated rubber plasters may be used with very good effect. These are applied in the form of strips, and moulded so as to fit the skin closely, without folds or wrinkles. They may remain on for twenty-four hours to several days, but must be removed when they become loose, or, in any case, after some days. The softened epidermis may then be scraped away, and one of the applications above mentioned may be made. The plaster should then be again applied until the thickened, horny epidermis is removed to a great extent, after which an ointment may be applied. The treatment of this form of eczema requires even more ECZEMA. 137 patience than that of the other forms. Perseverance, however, will finally be crowned by success, unless the patient's general condition should be seriously at fault.* Eczema, when it occurs upon the nails, shows them deprived of polish, rough, uneven, and often punctate or honeycombed. The nail becomes depressed, particularly about the root, at which point its proper nutrition is arrested. It may gradually recover its normal condition, or it may be cast off and replaced by a new nail. With regard to treatment, tar ointment, one drachm (4.) to the ounce (32.), applied about the root, with the internal administration of arsenic, promise the best results. When there is much tenderness, unguentum diachylon may be used at night, and an ointment of a drachm (4.) of salicylic acid to the ounce (32.) of benzoated lard, or a salicylic rubber plaster, may be applied in the day time. It should be remembered that any blows or pressure applied to the end of the nail acts as an irritant, and consequently some kind of splint should be used to protect the nail. The rubber plaster will serve the purpose if properly applied, and the nail should be cut short. Eczema of the back of the fingers is fre- quently accompanied by disease of one or more nails, which passes away with the eczema or soon after. Eczema in Infants. — Infants are liable to eczema from the first weeks of extra-uterine life, the chief differences between the disease as shown in these cases and as it manifests itself in later life being, on the one hand, the restricted causes which may give rise to the disease, and on the other hand, the different appearance of the eruption, dependent upon the peculiar structure of the skin in early life. Eczema in infants and in young children is due either to digestive disturbances, to teething, or to that inherited weakness of constitution and poor nutrition generally attributed to the scrofulous habit. Bottle- fed infants are most apt to suffer from ind'gestion, and these are also most liable to the eruption of eczema. While too much * Of late I have used the X-ray with excellent effect, alone or in connection with the older forms of treatment. For the technique see Allen or Pusey and Caldwell's Treatises on Radiotherapy. 138 DISEASES OF THE SKIN. stress must not be laid upon the irritation of teething as g.ving rise to eczematous eruptions, yet when the tendency to eczema exists, each tooth, as it comes out, will often be accompanied by an eczematous rash, which fades away as the tooth develops. It will be found, on observation, that the children of parents who suffer from a tendency to phthisis, or who present the symp- toms commonly associated with the idea of scrofula, are most apt to be attacked with eczema, even when fed on the breast and presenting no signs of indigestion. When, as among the lower classes, improper nourishment and bad hygienic surroundings are added, the disease sometimes takes on a quite severe form. In children who suffer from repeated attacks of eczema, last- ing after the period of teething, and without either disturbed digestion or the scrofulous taint to account for the persistence of the disease, the skin will often be found to present that dryness and rough, scaly appearance usually associated with ichthyosis, and the ichthyotic condition will grow more marked as the child grows older. Moreover, asthma is a not unfrequent complication or accom- paniment of the chronic eczema of childhood, and I have seen several cases where eczema, ichthyosis, and asthma occurred in the same individual. The diagnosis of infantile eczema is usually not difficult. About the buttocks, genitalia, and folds of the neck it com- monly occurs in the form of E. erythematosum or E. intertrigo. In the former locality it may be mistaken for syphilis, but the absence of deep infiltration, and, above all, the absence of characteristic syphilitic lesions, whether of the palms and soles or of the body generally, will usually assist the diagnosis. The vesicular and pustular form is that commonly met with upon the cheeks, behind the ears, and about the head generally. It some- times runs on to E. rubrum, with very abundant discharge of serum. Occasionally shallow ulcers with crusts form, and in this variety it is at times difficult to say whether we have eczema or syphilis. Especially is this the case when the child is poorly nourished and emaciated. But in syphilis we are apt to have ECZEMA. I39 ''snuffles," cracks in the commissure of the lips, and lesions about the anus; also, some of the lesions are apt to be infiltrated, and to show deeper ulceration. Eczema tends to itch to a marked degree, and this alone will commonly distinguish it. Papular eczema is more apt to occur in older children; it may very readily be mistaken for scabies, but the points given under that head (see Scabies) will serve to distinguish between the two affections. The treatment of eczema in infants must depend, to some extent, upon the cause. When indigestion seems to be at the bottom of it, the food must be changed and regulated. The physician, who desires to treat such cases of infantile eczema as come under his care with satisfaction and success, must study, in each case, to obtain suitable food, and see that it is properly administered. Constipation in infants is a frequent cause of eczema, and should be combated. If habitual, the food should be changed with the view of improving this condition, while for occasional use the following powder may be administered: 1$. Hydrarg. chlor. mitis, gr. xij fo.S) Pulv. rhei. gr. xviij (1.2) Magnesiae calcinat 5ss. (2. ) M. Div. in chart No. vj. SlG. — One every morning. This is the dose for an infant of eight to ten months; the quantity, of course, should be regulated according to the general condition of the child, as well as its age. It should not be given for more than a few days successively, and purging should be avoided. I find this a very useful powder in eczema of an acute or semi-acute character in constipated infants. If there is vomiting and dyspepsia, then lactopeptine, or pepsin and bis- muth, may be administered. When general debility exists, particularly when there is a scrofulous taint, syrup of the iodide of iron, in doses of five to ten drops, even in infants of a year old, may be administered. Sometimes, also, cod-liver oil, internally or by inunction, may be employed. The external treatment of eczema in infants will depend upon 140 DISEASES OF THE SKIN. the form of the disease present. When this is erythematous, and situated about the buttocks, genitalia, and folds of the neck, astringent dusting powders, as kaolin, oxide of zinc, and sub- nitrate of bismuth, may be employed; while parts that are in apposition should be separated by a thin wisp of absorbent cotton. Starch powders often do more harm than good in these cases, because they soon get moist, caked, sour, and irritating; but by the addition of boric acid this may be obviated. Black wash and dilute lead-water may be used in some cases. Oint- ments are generally not well borne in this form of eczema. In vesicular and vesiculo-pustular eczema, and especially in eczema rubrum about the face and head, ointments are more useful. Scales and crusts should be cleaned away as much as possible, and then the milder and astringent ointments may be used first, and later those of a more stimulating character. Powdered boric acid may be applied when there is moisture, and an ointment of boric acid, a drachm to the ounce of petrolatum, may be applied. The following are convenient formulae: — 1^. Pulvis zinci carbonat., 5j (4-) Ung. cucumis, 5 j- (32.) M. 1^. Bismuthi subnitrat., 3j (4-) Ung. aquse rosae, 3 j. ( 32.) M. In the more chronic forms of eczema rubrum of the face and scalp, more stimulating ointments are well borne, as this: 1$. Picis liquidae, 3ss ( 2.) Pulv. zinci oxidi, 5ss ( 2.) Ung. aquse rosae, oj- (32.) M. Another excellent ointment for use in the more chronic forms of eczema in children is the following: 1^. Sulphuris praecipitat., Picis liquidae aa 5ss-j (2.-4.) Ung. zinci oxidi, oj- ( 32.) M. Instead of anointing with ointments, the cheeks and scalp, or other affected parts, may be painted with the following pig- ment, which is very effectual, and cannot be rubbed off like the ointments: ECZEMA SEBORRHCEICUM. 1 4 1 1$. Ol. cadini, 3 j (4-) Collodii, 5j. (32.) M. Put a camel's-hair brush in the cork. The prognosis of infantile eczema is almost always favorable, and every effort should be made to cure the disease. The opin- ion formerly held by some that it is dangerous to cure infantile eczema has no basis in observed facts. ECZEMA SEBORRHCEICUM. Eczema seborrhceicum was the name first given by Unna to a group of diseases formerly included under the name pity- riasis capitis, seborrhea capitis, seborrhea corporis, seborrJiwa sicca, etc., together with certain anomalous forms of eczema which had formerly been grouped under that head. In its typical forms eczema seborrhceicum almost invariably begins on the scalp and often remains limited to this region, though frequently it extends to the ears, temples, forehead, neck, and adjacent parts. On the scalp the disease may show itself in the form of greasy scales or crusts or in a rather dry and branny exfoliation. As it reaches the edge of the scalp and extends beyond it, it shows a sharply defined red border. Xext to the scalp the thorax is most frequently affected. Here the affection shows itself in yellowish or fawn-colored, greasy, scaly patches and circles confined for the most part to the sternal region though occasionally spreading beyond it. The inter- scapular region is also a favorite locality. In these localities the disease may remain located for months or years or in some cases an extension may take place to other parts of the body especially where the sebaceous and perspiratory glands are largest and most active as in the axillae and groins. In most cases the disease runs its course unchanged but occa- sionally a transformation to the ordinary forms of moist eczema may occur in which the characters, both clinical and histological, of the original eczema seborrhceicum are lost. In other cases, especially in children, eczema seborrhceicum may show many 142 DISEASES OF THE SKIN. of the features of psoriasis and may indeed appear to develop into the latter. Such cases, if really seborrhceic in character, will usually improve under local applications containing sulphur, while if essentially psoriasic, the internal administration of ar- senic will usually do good. The latter has no effect in seborrhceic eczema. The etiology of eczema seborrhceicum remains for the most part in doubt. Some observers have considered it of a parasitic nature but such a variety of organisms have been found in con- nection with the disease that it is difficult to assign an exclu- sively causative role to any particular one.* Locally, heat, moist- ure, friction and other forms of irritation may act as predisposing causes. The use of flannel next the skin in workers and those who perspire freely is a cause of the disease, whence the name " flannel- rash" applied to some of its forms. The pathology of eczema seborrhceicum is somewhat the same at that of ordinary eczema. Even in the mildest grades of the affection as in "pityriasis capitis" Elliott found slight inflammatory infiltration around the capillary vessels, etc., while in the severer grades the inflammatory infiltration extended to the subpapillary plexus, and in higher grades to the entire cutis which was then somewhat cedematous. The sebaceous glands were normal, the coil glands in many instances were di- lated and- contained cast-off epithelial cells mixed with a granu- lar debris. From other forms of dermatitis and from simple eczema, eczema seborrhceicum may be distinguished by its origin in the scalp, its oily secretion and crusts, the yellowish color and sharp outline of its lesions, its tendency to spread peripherally in cir- cinate outlines, and by its lack of marked subjective sensations. In some forms of the disease the diagnosis from psoriasis is difficult, but the location of the lesions on the flexor rather than on the extensor surfaces, the oily character of the scales and crusts, the yellowish color, the greasy and scaly center of * See Elliott, Morrow's System, iii, for a full account of eczema seborrhceicum. Also N. Y. Med. Jour., 1895, lxii, p. 528. ECZEMA SEBORRHCEICUM. 143 circinate lesions undergoing involution and the general course of the eruption will usually suffice to distinguish the disease. Pityriasis rosea may present appearances identical with those of eczema seborrhceicum of the trunk and extremities. The lesions in the former disease, however, do not appear on the scalp, usually have ill-defined frayed-out borders, and the enlarg- ing rings present a dry, fawn-colored center which is free from greasy scales. The affection, moreover, runs an acute course, rarely lasting more than six or eight weeks as a general thing (Hyde and Montgomery). The treatment of eczema seborrhceicum is largely local. Internal remedies seem to have little effect. On the scalp the crusts and scales should be washed off with a medicated soap as the empyroform soap or a tar soap. The following ointment should then be rubbed well into the scalp, being par- ticularly useful where there is any moisture: 1$. Pulv. zinci oxidii, oiss (6.) Sulphur, praecipitat, 5j (4-) Terrae siliciae, 5ss { 2. ) Adipis benzoinat, oj- (32.) An excellent ointment to use on the scalp where the hair is not too thick or on the bearded face, sternum, etc., is the follow- ing: 1$. Sulphur, praecipitat., Sulphur, sublimat., aa gr. xv ( 1.) Hydrarg. ammoniat., gr. xxx ( 2.) Petrolati flavae, 5ss. (16.) M. Elliott suggests resorcin, 3 to 20 per cent., in alcohol and water; Hyde and Montgomery the following: 1$. Sulphur, praecipitat., 9j _ 5ij ( 133 to 8.) Balsam Peru, rr^io ( 0.66) Petrolati, jj (32. ) M. Sometimes in obstinate cases short, mild exposures to the X-ray mav be of service. 144 DISEASES OF THE SKIN. HERPES. Herpes is a skin affection, characterized by the appearance of one or many discrete, transparent vesicles, varying from the size of a pin-head to that of a small pea, commonly occurring in groups or clusters and seated on an inflamed base. The eruption is apt to occur along the line of distribution of nerves. The lesions run a pretty uniform course, lasting from eight to ten or fourteen days. The clear serous contents of the vesicles first become clouded and then gradually dry up, with the formation of yellowish crusts which fall off, leaving transitory spots of pigmentation. The appearance of the eruption is usu- ally preceded or accompanied, or both, by more or less burning, and, in the case of herpes zoster, by pain, either localized in the eruption or distributed along the line of the nerve supply. There are three forms of herpes: H. simplex, H. pro geni- talis, and H. zoster. The affection known as "herpes iris" on account of its herpetiform lesions, is a variety of erythema multiforme, under which head it will be found described. The three forms of herpes are so different in their location and course that they are usually described as entirely separate and distinct diseases. H. zoster, for instance, rarely recurs in the same individual. H. simplex may recur at any time, and in some cases does recur periodically, while H. progenitalis recurs inveterately in some cases. There is, however, some link of union between the affections, in addition to their close adherence to the herpetic type of lesion, and to their occurrence along the distribution of nerves. This is shown by the fact, occasionally observed, of the simultaneous occurrence of the different forms of herpes. HERPES SIMPLEX. This form of herpes was formerly known as H. labialis or facialis, but this designation is too narrow, as the eruption may be, and frequently is, met with in other parts of the face — the cheeks, alae nasi, eyelids, and ears being occasionally attacked, HERPES SIMPLEX. 145 and is also, though rarely, met with on the body or limbs. Oc- curring about the lips and nose, the eruption is popularly termed "fever blister" or "cold sore." There is a form of herpetic erup- tion about the tonsils and adjacent parts, accompanied by high fever, and occasionally appearing epidemic in character, which closely resembles the so-called "follicular tonsillitis," but may readily be distinguished by the strictly herpetic character of the lesions.* When the lips are attacked by herpes simplex, one only is usually affected, the lesions commonly occurring at the bound- ary between the skin and the mucous membrane. The lower lip is most frequently attacked. The lesions here not infrequently coalesce and form a bleb. The contents of the vesicles dry up within from three to six days, and form brownish or yellow- ish crusts which loosen and fall off spontaneously. When the crusts are prematurely detached the cure is delayed. Herpes of the lips is a frequent concomitant of various gen- eral disturbances. Slight ailments of the digestive organs, affections of the chest, as pneumonia or pleurisy, malarial fevers, etc., are often accompanied by an outbreak of herpes of the lips. Some women have an eruption of herpes on the lips before, during, or after each menstrual period. f Eruptions of herpes of the lip are observed repeatedly following the use of a dental instrument in filling the teeth. Herpes may occur upon the mucous membrane of the tongue and of the oral cavity generally. The lesions here lose their vesicular character, because the epidermic cover is macerated away almost as quickly as it forms, and a shallow ulcer, the well-known "canker" of the mouth, results. Herpes of the nostril and alae nasi is a frequent result of a cold in the head. It presents no peculiarities other than those mentioned in speaking of herpes of the lips. Herpes simplex is almost unquestionably a neurosis of the skin. * For an excellent description of the various forms of herpes of the pharynx see Lermoyez and Barozzi, Annates de Derm, et de Syph., 1897, p. 791. fSee Bergh, Herpes Menstrualis, M onatshejt. /. Prakt. Dermatol., vol. x, 1890, p. 1. 146 DISEASES OF THE SKIN. Although in no case has any anatomical change in the nerve trunks, in the ganglia, or in the nerve centers, been found, as in H. zoster, to account for its occurrence, yet the facts that it is found in the areas of distribution of certain cutaneous nerves, that it resembles so closely H. zoster, and that it seems sometimes to occur as the result of reflex impressions, all point to a nervous origin. The diagnosis of herpes simplex is rarely difficult. The peculiar discrete character of the eruption, the well-filled vesicles, each on a more or less inflamed base, sometimes coalescing in the later stages, but always showing the character of distinctness, the fact that the group of lesions is sharply defined, and also that the lesions tend to dry up in their entirety rather than to run together, point toward the disease in question. Moreover, the fact that herpes runs a regular and strictly limited course is highly characteristic. Herpes upon the line of junction between the skin and mucous membrane, and upon the mucous surface of the lips, especially when it occurs near the commissure, may sometimes be mis- taken for the initial lesion of syphilis or for mucous patches. From the initial lesion of syphilis, herpes is distinguished by its more superficial character and the absence of infiltration, as well as by the absence of glandular involvement, the submental and other neighboring glands being invariably involved in con- nection with the syphilitic lesion. Mucous patches in the oral cavity are sometimes mistaken for herpes, but the mucous patch is almost always much larger and more superficial, with a squarish outline and a flat gray floor, with usually a narrow red border. The herpetic ulcer is small, circular, or "polycyclic" in outline, with sharply-defined edges. Herpes upon the skin of the face may be mistaken for herpes zoster and for eczema, and, possibly, in rare cases, for dermatitis venenata. From H. zoster it is distinguished by the absence of neuralgia and the more diffuse outline of the grouped lesions. Moreover, herpes zoster never, in my experience, HERPES SIMPLEX. 147 attacks the opening of the nostrils or the muco-cutaneous junc- ture of the lips. H. simplex facialis likewise runs a more rapid course than H. zoster. Eczema vesiculosm of the face is always marked by the fact that the commingled lesions run together, and are never made up of discrete vesicles. There is also an absence of the red base observed in the lesions of H. facialis, and in eczema some characteristic lesions are almost always found in places rarely or never attacked by herpes. Finally, the course of an eczema is not a brief and limited one like that of herpes, but tends rather to an irregular and often chronic prolongation. Dermatitis venenata shows lesions often resembling those of herpes, but the distribution is almost invariably different, and the tendency to spread and to appear in other localities is quite marked. There is, furthermore, in dermatitis venenata, almost always a history of exposure to the emanations of the poison vine. The treatment of herpes simplex is very simple, being confined to the local use of soothing and emollient applications. In herpes of the lip a little cold cream, or diluted oxide of zinc ointment, is usually all that is required. Sometimes the oleate of bismuth ointment (see McCall Anderson ointment, under Eczema), with the addition of europhen or some other antisep- tic, is useful. Care must be taken not to detach the crusts prematurely, as this lengthens the duration of the affection. In cases of extensive herpes of the face, like the one described above, a soothing application, as a poultice of bread crumb and dilute lead-water, sprinkled with powdered boric acid, mil give relief, a mild ointment being substituted for this when the crusts begin to form. The prognosis is very favorable in all cases of herpes simplex, the affection running a definite course. Its duration, however, cannot be shortened, and all the popular remedies for cutting short an attack of herpes of the lip must fail ex- cept in cases in which the lesions themselves are abortive and ephemeral. I48 DISEASES OF THE SKIN. HERPES PROGENITALIS. Herpes progenitalis is found on both males and females. The vesicles are usually four to six in number, varying in size from that of a pin's head to that of a split pea. They occur usu- ally close together and are apt to coalesce. The whole area covered by the group of lesions is rarely greater than that of a ten-cent piece, or, at most, a quarter-dollar. The parts usually affected are, in the male, the preputial sulcus, the lining of the prepuce, the glans, the margin of the prepuce, and, more rarely, the shaft of the penis. Now and then herpes of the mucous membrane of the urethra is met with, when a discharge, liable to be considered gonorrhoea!, accompanies it. This condition may account for some of the cases of "clap" occurring in males who have never indulged in sexual connection. Occasionally severe neuralgic symptoms accompany the out- break of genital herpes in the male, having often no relation in intensity to the severity of the skin eruption. A single vesicle may be present in connection with excruciating neuralgic pains, not confined to the penis only but radiating to the perineum, buttock, thigh, and leg. Unfortunately this distressing variety of herpes genitalis is apt to be recurrent. In women, herpes progenitalis is uncommon, excepting among prostitutes. The lesions are found upon the labia minora, prepuce of the clitoris, labia majora, clitoris, introitus vaginae, and, more rarely, on other neighboring parts. The attention of the patient is called to the eruption by a slight itching and burning sensation; a small, red patch is observed, on which a crop of vesicles, at first clear, but soon becoming purulent, is seen. . If situated on the mucous membrane the vesicle soon breaks down, so that the lesion which is, in fact, first noticed is a superficial erosion. Unless irritated, the lesions tend to heal within a week or two. The tendency to relapse is very marked. In the female it may recur with each catamenial period, while in the male each coitus may be followed by an outbreak. Venereal diseases of a non- syphilitic character, as gonorrhoea and balanitis, seem to predis- HERPES PROGENITALIS. 1 49 pose to the occurrence of the affection. It is much more common in the male, during the period of youth and early manhood, but in the female may occur up to middle age. Herpes progenitalis is apt to be mistaken for chancroid. In the earlier stages, sub- sequent to the opening of the herpetic vesicle, indeed, the individ- ual lesions are almost identical in appearance in both diseases.* The number and distribution of the lesions is a great help. The lesions of chancroid are not so numerous as those of herpes, and are not grouped together in the way the latter are. When multiple, the lesions of chancroid are the result of auto-inocula- tion, and are, therefore, of different ages. Time, also, shows the difference. After a few days the herpetic sore begins to get better, while the chancroid is getting worse. The syphilitic initial lesion need not often be confounded with the herpetic vesicle. It does not begin as a vesicle; it is seldom multiple; it is indurated at some time in its course; is accompanied by indurated glands, and does not appear as a sore until some days after the exposure.! In the female the later syphilitic lesions may sometimes be mistaken for herpes, and vice versa. The same principles of diagnosis which come into use in distinguishing herpes from the other affections above mentioned, will, however, be found of service in such cases, and in any case careful observation of the lesions for several days will much assist the conclusion. Eczema of the genitalia may resem- ble herpes, but the itching and generally severe and more exten- sive character of the eczematous disease "serve to distinguish it. Herpes progenitalis usually requires very little treatment. Sometimes, however, various remedies are required. The best remedy for ordinary use is dilute lead-water, applied on a soft * Not infrequently, the chancroidal virus is inoculated upon the herpes lesion and occasionally a genuine herpes progenitalis may be seen displaying its char- acteristic features, these changing afterward to those of chancroid and later as- suming the appearance of the initial lesion of syphilis, and followed by the generalized lesions of that disease. I have watched this curious procession at times and have been obliged to revise my diagnosis once and again with the changing appearance of the lesions as their evolution proceeded. t In herpes pressure between the thumb and finger will cause a drop of serum to exude, while in chancre this usually does not occur, or can only be brought about with difficulty. i5° DISEASES OF THE SKIN. piece of linen or a wisp of absorbent cotton. Black wash is a good dressing in many cases; or finely-powdered nitrate of bis- muth may be used. Sometimes more stimulating applications are required. Powdered calomel, sprinkled on the erosions morning and night, or equal parts of calomel and oxide of zinc may be used. When the disease is prone to recur, astringent washes may be employed as a prophylactic. Circumcision is sometimes useful in inveterate cases occurring in the male, but even this has been known to fail. HERPES ZOSTER. Herpes zoster is an acute, inflammatory disease characterized by the appearance of groups of vesicles, situated upon inflamed bases, of unilateral distribution and corresponding in a general or particular way to the distribution of certain nerves. The eruption is generally preceded and accompanied by neuralgic pain. This is often disproportionate to the amount Fig. 12. — Herpes Zoster Facialis. {After Barensprung.) Fig. 13. — Herpes Zoster Labialis. of the eruption. Old persons are apt to suffer more severely from neuralgia than the young, in fact children are often quite free from pain. The eruption makes its appearance in the form usually of an inflamed condition of the skin, attended with HERPES ZOSTER. mi heat and burning sensations, and groups of discrete pin-head to split-pea sized vesicles, situated on a bright-red surface, appear over the region. The vesicles are often crowded together so as to coalesce, forming irregular patches. New vesicles continue to appear until the fourth, or as late as the eighth day, when the eruption is at its height; it remains in this way a few davs, and then begins to decrease, the vesicles shriveling, and by the tenth day or so drying up, leaving brown crusts, which drop off. is / tl. Fig. 14. — Herpes Zoster Occipito- collaris. Fig. 15. — Herpes Zoster Cervico- suc-clavicularis. The vesicles do not burst, as do those of -eczema. Ten days to three weeks is the average duration of an attack. The eruption does not always run a typical course. Only a few vesicles may appear, or they may abort before fully develop- ing. On the other hand, they may suppurate and leave scars, though the disease commonly leaves no trace. The neuralgia varies from a very slight tingling to the most excruciating pain. Herpes zoster may attack any part of the body or even 152 DISEASES OF THE SKIN. the mucous membranes.* It is commonly found upon the trunk and head; less frequently upon the limbs. It fol- lows very closely the course of the nerves and Cantrell has pointed out that the earliest appearance of the eruption is at the point most remote from the affected nerve center. The eruption is named according to the region upon which it occurs, as H. zoster capitis, H. zoster brachialis, H. zoster facialis, etc. On the head it most frequently occurs in the course of the supra- orbital nerve, and it may affect the eye, giving rise to severe pain. On the head, both sides are sometimes affected; elsewhere the affection is almost always unilateral. The chest is the commonest seat for the occurrence of the eruption; and the names formerly given to the disease, "zona," "cingulum" — a girdle, indicate this. Cantrell, combining my statistics with those of Duhring and Stelwagon (Phila. Med. Jour., March 26, 1898) found 193 cases of herpes zoster reported in a total of 19,492 cases of skin disease. The af- fection, according to Cantrell's analysis of these cases, occurs most frequently in the months of August, October and Novem- ber. The minimum number were encoun- January, February and March. Half the cases occurred between thirty years. Half the cases also were of thoracic zoster. The was a little more frequent upon the left than upon the right side. Fig. 16.— Herpes Zoster Cervico brachialis. tered in ten and eruption Involving the intercostal nerves, the neuralgia often causes the affection to be taken for pleurisy, until the eruption makes its appearance. Dr. R. G. Curtin, of Philadelphia, pointed out to me, some years ago, that in all probability some cases of pleurisy are in See Fournier, Zona des Muqueuses, Jour, des Mai. Cut. et Syph., August, 1 891. HERPES ZOSTER, 153 reality cases of herpes zoster. He has since written upon this subject.* When zoster occurs on the limbs the flexor surface is com- monly attacked. It rarely appears below the knees. The Fio. 17. — Herpes Zoster Brachialis. course of herpes zoster is acute, and, though somewhat variable as to duration, it tends to recovery. It rarely occurs twice in the same person. Now and then, however, cases are met with where it recurs year after year, perhaps six to nine times. f Fig. 18. — Herpes Zoster Dorso-abdominalis. The disease is usually a descending acute neuritis provoked by various causes. The process usually has its beginning in * Is Herpes Zoster a Cause of Pleurisy and Peritonitis? Sanitarian, Dec, 1890. See also Am. Jour. Med. Sci., 1902, exxiii, p. 264. tSee Elliott, Relapsing Herpes Zoster, Jour. Cut. Dis., 1888, p. 324, and Grindon, Recurrent Zoster, lb., 1895, pp. 191 and 252. In the latter paper which includes an analysis of 61 cases the author shows that most of such cases can not be regarded as true herpes zoster. i54 DISEASES OF THE SKIN. the ganglionic system — in the cervical or spinal ganglia. The eruption does not always follow the distribution of a nerve nor even that of interbranching nerves and sometimes it slightly Fig. 19. — Herpes Zoster Sacro-ischiadicus. (a) Genitalis in female. overlaps the median line, due to the interlocking of some fibres at their origin. In most cases of herpes zoster the ganglia show softening, Fig. 20. — Herpes Zoster-ischiadicus. (b) Genitalis in male. enlargement and inflammation, and the nerves are inflamed and thickened. In traumatic and probably other cases (if these HERPES ZOSTER. J 55 can indeed truly be included under herpes zoster) the peripheral nerves alone may be affected. Zoster-like eruptions are not necessarily herpes zoster.* This as I have long maintained! is probably an infectious disease Fig. 21. — Herpes Zoster Lumbo- femoralis. Fig. 22. — Herpes Zoster Lumbo- femoralis. from the fact that it rarely occurs more than once in a lifetime, is usually associated with adenopathy, systemic disturbance, etc. J "A large list of agencies are named as effective in the production of the zoster eruption. Among them are certain poisons (carbon dioxide, bella- donna and atropine), pyaemia, carcinoma, fever, measles, pulmonary inflam- *See Head and Campbell, The Pathology of Herpes Zoster and its Bearing on Sensory Localizations. Brain, 1900, p. 7,2,5. t See my article, Recent Views of the Origin and Nature of Herpes Zoster. Am. Jour. Med. Sci., Jan., 1902. % Cf . Hay, Jour. Cutan. Dis., 1898, xvi, p. 1. Also Walthers' cases of three young students successively occupying the same room and being each succes- sively attacked by herpes zoster. Allg. Med. Central Zeitg., April 24, 1878. 156 DISEASES OF THE SKIN. mations (including phthisis), septicaemia, hemorrhages, traumatism and malaria. It has also followed vaccination, the passage of electrical currents, the extraction of teeth, an accidental prick by a thorn, the tapping of hy- datids, and gun-shot wounds of the body. Inasmuch as no one of these causes can be cited as certainly effective in all cases, it can merely be said that any influence sufficient to induce inflammation of a sensory nerve or its ganglion may be followed by the objective signs of the disease." (Hyde and Montgomery.)* Fig. 23. — Herpes Zoster Cruralis Fig. 24. — Herpes Zoster Cruralis. The cutaneous lesions originate in the deeper portions of the rete. The exudate from the hyperaemic corium, especially its papillary layer, presses upward into the rete, the epithelia of which are thus separated and vertically elongated, the lacunae between them being distended with serum and a few round cells. At the base or sides of the vesicles, either lying free within * For a discussion as to the influence of arsenic in producing Zosteriform lesions see Neilsen Monatshefte f. Prakt Dermatologie, vol. xi, 1890, p. 302. Also Rasch Annates de Derm, et de Syph., 1893, p. 150. HERPES ZOSTER. 157 them or in the oedematous neighborhood of them, peculiar* swollen round cells may be observed. These were at one time taken for protozoa but their true nature has been demonstrated by Unna,* Gilchrist and others. They are known as "balloon cells." The diagnosis of well-developed typical herpes zoster presents no difficulty. The neuralgic pain, the appearance of the vesicles in distinct groups, upon a highly inflammatory base, and the tendency to preserve their form intact, are characteristic. In eczema, which it most resembles, the lesions tend to exude moisture, dry up, and crust, while in herpes zoster there is no discharge. Eczema itches, H. zoster burns. From simple herpes, H. zoster is distinguished by the presence of pain, by its non-recurrence, its unilateral character, and by its rare occur- rence upon the favorite seats of H. simplex, the lips, alae of the nose, and genitalia. The treatment of herpes zoster is largely palliative. The disease runs a naturally favorable course, tending to recovery, and the symptoms of neuralgia and burning in the seat of erup- tion alone require treatment. No remedy for internal use is known to have the power of aborting or shortening the attack. For the neuralgia, phosphide of zinc, in doses of one-third of a grain (.02) may be given at the commencement of an attack, and repeated every three hours. It may be combined with one- third (.02) of a grain of extract of mix vomica. If this fails, in severe neuralgic cases morphia may be given at night hypo- dermically. Of late antipyrine and phenacetine in 10 grain (.6) doses have been employed with marked success. Electricity, in the form of the constant galvanic current, often gives relief. A continuous galvanic current of between two and three mili- amperes may be applied over the root of the nerve two or three times daily for ten minutes at a sitting. This application also relieves the after pains of herpes zoster, when these supervene on the eruptive stage. The vesicles should be carefully pre- * Brain, 1903, xxiii, p. 362. Sec also Pollitzer H. Zoster of the hair follicle. Jour. Cut. Dis., 1903, p. 73 and Hartzell, lb., 1894, p. 369. 158 DISEASES OF THE SKIN. served from rupture. Powders may be used in most cases with advantage. The following is a convenient powder : J^,. Pulv. amyli, Pulv. zinci oxidi, aa Bss (16. ) Pulv. morphias sulphat, gr. ij. ( 0.12) M. It is a good plan to sew a soft flannel bandage around the affected part, if the locality will admit, after the application of this powder, to be removed only when required. This will prevent the rubbing of the clothing, which is very irritating. Among lotions, lead-water, lead-water and laudanum, fluid ex- tract of grindelia robusta, half an ounce (16.) to the pint (512.) of water, or the following zinc lotion : 1$. Zinci ca.rbonat. praecip., Pulv. zinci oxidi, Pulv. amyli, Glycerinae, aa. 3iv ( 16.) Aquae, Oss. (256.) M. Ointments containing fifteen to twenty grains (1.-1.30) of extract of opium or extract of belladonna to the ounce (32.), may be ap- plied, spread upon cloths, or rubbed in with the finger, when the eruption occurs on the scalp. Among pigments, the essential oil of peppermint, painted over the course of the affected nerve, and over the vesicles, if unbroken, is said to be a very good ap- plication. Billstein recommends salol, gr. xx (1.33), to ether, gj (32.), applied locally. Durant observed good results from the use of a solution of adrenalin chloride (1-10,000) in the conjunc- tivitis accompanying an attack of herpes zoster, involving the upper part of the face and forehead on the left side. A solution of the same drug (1-1000) in normal sodium chloride solution with \ per cent, chloretone applied, by means of a brush, over the entire region of the eruption 2 or 3 times a day, absolutely controlled the pain. The prognosis of herpes zoster is almost always favorable, the eruption running its course in a few weeks, in almost all cases. Neuralgia is apt to persist, in some cases with abnormal sensations, but these in time disappear. In old patients the per- HYDROA VACCINIFORME. 1 59 sistent neuralgia is a very trying symptom. H. zoster of the orbital region, however, sometimes endangers the eye, and may be followed by deep scars over the scalp with neuralgia and anomalous sensations in the skin. Xow and then, herpes zoster is a symptom of some form of septicaemia, etc., and is of grave import. HYDROA VACCINIFORME. Hydroa vacciniforme is a recurrent, usually vesicular, scarring, summer eruption, beginning in early life almost always in males, and as a rule disappearing in adult age. The eruption is chiefly or entirely confined to the uncovered regions. It begins as a small red spot or papule on the top of which a pin-head sized vesicle or bulla develops. This goes on to umbilication with a reddish or brownish crust while the vesicle is spreading on the periphery which gives it a resemblance to a vaccine lesion. Sometimes several lesions coalesce, forming a large bleb. The crusts fall off after a time leaving a pitted and permanent scar. The disease progresses by successive outbreaks and may last for three or four weeks or recur after exposure to sun and wind. As manhood approaches the tend- ency to the disease diminishes and it finally disappears, in rare cases leaving considerable scarring. POMPHOLYX. This affection originally called by Tilbury Fox ''Dysidrosis" is a vesicular and bullous inflammatory disease of the skin confined to the hands and feet. The disease is far more common on the hands than on the feet, it occurs chiefly in the summer. The eruption commences with burning and tingling, with the development of deeply imbedded vesicles, singly or in groups, along the sides of the fingers and on the palms, but no part is exempt, in bad cases. The appear- ance of the vesicles has been compared to that of boiled sago grains imbedded in the skin. The vesicles never rupture spon- l6o DISEASES OF THE SKIN. taneously. In ten days or a fortnight the contents are absorbed, and the detached epidermis is exfoliated. The disease is most common in young women of a nervous temperament and is apt to occur in those broken down from worry and ill-health. The disease is supposed to be connected with the sweat follicles. It is apt to recur. The treatment should be tonic and supporting. Locally, soothing ointments with, in some cases, painting with i per cent, nitrate of silver solution. DERMATITIS HERPETIFORMIS. (DUHRING'S DISEASE.) Dermatitis herpetiformis may be defined as a chronic multi- form skin affection, characterized by successive outbreaks in which the eruption may be at one time herpetiform and vesicular, at another pustular, while in other instances, or at other periods in the history of a given case, wheal-like lesions or bullae may predominate. The lesions tend to assume a circinate arrange- ment, and severe and intolerable itching, with more or less constitutional disturbance, is a common accompaniment. In severe cases prodromal symptoms are usually present for several days preceding the cutaneous outbreak; they consist of malaise, constipation, febrile disturbance, chilliness, heat, or alternate hot and cold sensations. Itching is also generally present for several days before any sign of efflorescence shows itself. Even in mild cases slight systemic 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. A single variety, as, for example, the erythematous or the vesicular, may appear, or several forms of lesion may exist simultaneously, constituting what may very properly be desig- nated the multiple variety. The tendency is, in almost every instance, to multiformity. There is, moreover, in many cases a distinct disposition for one variety, sooner or later, to pass DERMATITIS HERPETIFORMIS. 161 into some other variety; thus, for the vesicular or pustular to become bullous, and vice versa. This change of type may take place during the course of an attack, or on the occasion of a relapse, or, as is often the case, it may not show itself until months or years afterward. Not only multiformity of lesion, but Fig. 25. — Dermatitis Herpetiforms. Herpetiform variety. (Courtesy of Dr. Duhring.) irregularity in the course of development is, it may be repeated, the rule. Itching, burning, or pricking sensations almost always exist. When the eruption is profuse they are intense and cause the greatest suffering. They become more violent before and with each outbreak, abating in a measure only with the laceration 162 DISEASES OF THE SKIN. or rupture of the lesions. The disease is rare, but of more frequent occurrence than was formerly supposed to be the case. It occurs in both sexes and at all ages but usually in adults. The disease process is in almost all instances chronic, and is characterized by more or less distinctly marked exacerba- tions or relapses, occurring at intervals of weeks or months. The disposition of the eruption to appear in successive crops, some- times slight, at other times severe, is peculiar. Relapses are Fig. 26. — Dermatitis Herpetiformis. Bullar variety. the rule, the disease in most cases extending over years, pursuing an obstinate, emphatically 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 in localized areas, are in old cases always at hand in a marked degree. The pig- mentation is usually of a mottled, dirty yellowish, or brownish hue, and is persistent. DERMATITIS HERPETIFORMIS. 1 63 Dermatitis herpetiformis is apt to occur in individuals of neurasthenic type or in those in whom the nervous system has been subjected to unusual strain. Mental crisis, nervous shock, fright, anger, menstrual irregularities, pregnancy, the puerperal state, septicaemia, physical fatigue, exposure to cold, and defec- tive renal secretion have all been cited as causes of the malady (Hyde and Montgomery). Examination of the lesions in dermatitis herpetiformis shows acute inflammation in the upper part of the corium, dilatation of the vessels, marked oedema with infiltration of the lymph spaces and some plasma cells. The vesicles are filled with a coarse network of fibrin containing polymorphonuclear, with some mononuclear and eosinophile cells, red blood and epi- thelial cells and coagulated albumin. The deeper portion of the corium is unchanged for the most part. Eosinophilia is present but its exact significance has not been established. The diagnosis is -at times difficult, the affection being liable to be mistaken for impetigo herpetiformis, pemphigus, herpes, erythema multiforme, and eczema. The diagnosis in typical cases is made readily; in others, the distinction between dermatitis herpetiformis, impetigo herpeti- formis and certain forms of pemphigus is very difficult. It is possible that between the three there may be transitional forms scarcely to be assigned to one category or the other. The same is true of certain exceptional varieties of erythema multiforme (Hyde and Montgomery). As regards treatment, all authorities agree that this is unsatis- factory. So indeed is the treatment in all bullous diseases of the skin, but in many instances a careful study of the case will lead to an intelligent effort to raise the general nutrition to a higher level and to direct the purely medicinal treatment to the par- ticular needs of the case. Change of air and scene, a stay at the sea- shore or at the mountains or at some mineral springs, when such a procedure is available, should be the preliminary to other treatment. The usual tonics, cod-liver oil, phosphorus, iron, arsenic, strychnia and quinine may also be used. Electricity 164 DISEASES OF THE SKIN. has sometimes been found of value. Among specific drugs, arsenic in doses as large as can be borne alone or combined with strychnia should be administered. Mackenzie recommends 10 to 20 minims (0.5 5-1. 12) of the tincture of cannabis indica three times a day with 20 grains (1.30) of antipyrine at night. Crocker recommends salicine in 20 grain (1.30) doses three times a day, increased rapidly up to 25 or 30 grains (1. 65-1. 95). Hyde and Montgomery recommend mild laxatives and the free drink- ing of water between meals with the occasional administration of small doses of a mercurous laxative. Locally, washes are often more grateful to the skin than oint- ments and are required to sooth the severe itching and irrit- ation of the skin. The following is a convenient formula: 1$. Acid, carbolic, 5iij ( 12.) Glycerinae, f o j ( 32.) Aquae, ad Oj. (512.) M. Elliott suggests ichthyol in a lotion of 25 to 50 grains to the ounce of water, or, better, in the following combination: Ty. Ammon. ichthyol., gr. xxx-oj ( 2.-4.) Olei amygdalae dulcis, Aqua calcis. aa. f5ss. (16. ) M. This is to be rubbed in several times daily, and allowed to remain on the surface; or patent lint, saturated in it, is to be bandaged on the affected parts. Frequent starch baths, to which bicarbonate of sodium may be added, in the proportion of four ounces (128) to the ordinary full bath, sometimes proves useful. Stelwagon recommends "Liquor carbonis detergens" in strength varying from 1 part to 10 of water up to full strength. When soothing ointments are required the McCall Anderson's ointment, (see Eczema) may be used, or weak sulphur ointments. Duhring, however, uses strong sulphur applications.* From the number of remedies recommended it may be seen * Duhring, The Treatment of Dermatitis Herpetiformis. Am. Jour. Med. Sci., Feb., 1801. PEMPHIGUS. 165 that no treatment has as yet proved entirely satisfactory. We can but employ one after another until relief is gained. The prognosis in dermatitis herpetiformis should be guarded. Some cases appear to get well, it may be after months or years, but others persist. Relapses are not uncommon. PEMPHIGUS. A great many different diseases have been included under the name pem- phigus, and some recent writers have seemed almost inclined to abandon the title entirely as describing an entity. However, it may be convenient for the present to continue to group certain affections having the occurrence of blebs as their chief characteristic under this head. Any one meeting an anomalous case of a bullous character varying from the form which I have intended to depict may perhaps find it described in literature under some of the following heads: Pemphigus pruriginosus, pem- phigus neuriticus, pemphigus hystericus, pompholyx (of Willan and other writers), hydroa herpetiforme, hydroa bulleux, pemphigus diutinus, pemphi- gus circinatus, pemphigus haemorrhagicus, pemphigus gangrenosus, etc. Duhring, in his work, describes the relationship between some of these and what he describes as true pemphigus. Pemphigus is an acute or chronic inflammatory disease, characterized by the formation of a succession of irregularly- shaped blebs, varying in size from that of a pea to an egg. There are two varieties, P. vulgaris and P. joliaceus. In pemphi- gus vulgaris the disease may attack any part of the body, but is common upon the limbs. It may also attack the mucous mem- brane of the mouth and vagina. The lesions are blebs, from beginning to end, forming slowly, or sometimes rapidly in the course of a day. They may be few in number or quite numerous and often vary greatly in size in the same case. They are tensely stretched, like bladders of liquid, and rise directly from the level of the skin, which is not usually reddened, and never elevated. No case should be called pemphigus the bleb of which begins in the form of macules, or large papules. They are clear at first, with serous contents, but later are opaque, contain- ing a certain portion of pus. They do not rupture spontaneously, but gradually dry up, each bleb lasting one to three or six days. 100 DISEASES OF THE SKIN. The lesions are apt to come in crops; they do not burn or itch to any marked degree. In adults there is little or no disturbance of the general system. In children the disease is apt to be accom- panied by feverishness. In pemphigus foliaceus the blebs are flaccid and only partly filled with fluid, which seems rather to undermine the epidermis than to lift it into blebs. The lesions often coalesce, involving a large part of the surface; fresh lesions are continually forming; the fluid dries into thin, whitish flakes, which are cast off, leav- Fig. 27. — Pemphigus. ing an excoriated, red surface, and presenting the appearance of a superficial scald. The disease may last for years and the patient finally succumb to exhaustion. Pemphigus vegetans is the name given to an extremely rare affection hav- ing the character of a bullous erythema and a pemphigus together, with the additional formation of vegetating fungoid papillary growths, closely resem- bling condylomata. In fact, the earlier cases observed by Hebra and Kaposi were erroneously regarded as syphilitic. True pemphigus is a rare disease in this country; only 291 cases are reported in the 204,866 cases of skin disease of the American statistics. It is more common in children than in adults. Poor food and bad hygiene, pregnancy and menstrual PEMPHIGUS. 167 disorders, mental depression, general debility and prostration, are among the causes. The disease is not contagious. The diagnosis of pemphigus is usually not difficult. The presence of blebs does not necessarily indicate pemphigus, as these are developed in other diseases and by artificial means. So-called "pemphigoid" eruptions, obscure in origin and nature, are sometimes met with, but their course is not that of pem- phigus, properly so called. Pemphigus is not, under any cir- cumstances, to be confounded with the bullous syphiloderm, formerly called "pemphigus syphiliticus." The latter is a puru- lent bleb, drying up into a thick crust, with a deep ulcer under- neath. Erythema multiforme, in the bullous form, and impetigo contagiosa, are occasionally mistaken for pemphigus. A refer- ence to these diseases under their respective titles as well as the others above enumerated will show their characteristic points. The internal treatment of pemphigus is important. The general history and circumstances of the case must be looked into, and any defects of constitution or circumstance remedied. Among drugs, arsenic is most potent. Fowler's solution, in doses of four minims (.22), thrice daily at first, rising gradually to the limit of tolerance, may be given. Wine of iron is the best excipient for Fowler's solution in these cases. Arsenic produces its effects slowly, and it should be persisted in for months, if necessary. Even then, a cure, or even amelioration, mav fail in so chronic and inveterate a disease. Quinine is of value, and in some cases linseed meal, in ounce doses, with milk, has proved valuable. Cod-liver oil and stimulants may be required at times. The patients should be allowed to rest, and should be free from worry and anxiety, so far as this is practicable. Local treatment is also important. The blebs should be punc- tured and evacuated as soon as they have formed. Soothing and astringent lotions, and especially in my experience a tem- porary wet dressing of solution of mercury bichloride 1-4000 to 1-2000 is very useful. Powders of oxide of zinc with the addition of iodoform or europhen may be employed. Baths containing bran, starch, or gelatine may be used in some cases. 1 68 DISEASES OF THE SKIN. The continuous bath, in which the patient lives, eats, and sleeps for months, has been employed in severe cases. Occasionally, water does not agree, and in these cases mild ointments, as that of oxide of zinc, or diachylon, or one of the pastes mentioned under eczema, may be prescribed, always with the addition of some antiseptic. Pemphigus runs an extremely uncertain course. Relapses frequently occur. When the blebs are numerous, flaccid, imper- fectly formed, and inclined to rupture, and when they are rapidly and frequently formed, the prognosis is unfavorable. Repeated febrile attacks also indicate an unfavorable tendency. On the whole, then, we may say that the prognosis of pemphigus must be very guarded, as even when beginning as a slight attack, an unfavorable turn may be taken and the case end fatally.* EPIDERMOLYSIS BULLOSA. Epidermolysis bullosa is an affection or condition of the skin in which there is a strong tendency to the rapid formation of bullae whenever the integument may be slightly bruised or rubbed. In the majority of cases the disease has existed from infancy or early childhood and there is a clear history of heredity. The general health of the patient may be excellent and the skin may remain sound so long as it is subjected to no irritation, but very slight causes as the pressure of a shoe in walking, grasping a hammer, etc., may be sufficient to cause the appearance of bullae lasting some days, often painful and disappearing without leaving a scar. Exceptionally hemorrhagic bullae form followed by scarring (Bowen's case). Histological examination throws little or no light on the nature of the disease. * The following references to American literature will be of service to anyone who may wish to push the investigation of this subject further than the limits of the present volume will permit: Duhring, Cutaneous Medicine, Pt. II, p. 449; Pemphigus Neonatorum, Killiam, Am. Jour. Obstetrics, 1889, p. 1039; Ravogli, Cin. Lancet-Clinic, 1889; Corlett, Indiana Med. Jour., Nov., 1893, p. 158; Pem- phigus Foliaceus, Sherwell, Arch. Dermatol., Jan., 1877, and Jour. Cut. andGen.- Urin. Dis., 1889, p. 453: Hardaway, Jour. Cut. and Gen.-Urin. Dis., 1890, p. 22; Graham, Canadian Med. Jour. Sci., June, 1879; Klotz, Am. Jour. Med. Sci., Dec, 1891; Pemphigus Vegetans, Hyde, Jour. Cut. and Gen.-Urin. Dis., 1891, p. 412. DERMATITIS REPENS. 1 69 Treatment is only palliative. No means have been ascertained whereby a recurrence of the blebs can be prevented.* DERMATITIS REPENS. Dermatitis repens is an inflammatory disease of the skin occur- ring usually upon the hands and characterized by the formation of vesicles or bullae extending on the periphery. The affection was supposed by Crocker, who first described it, to originate in a traumatism. This is not necessarily the case, however. The affection begins on the palmar surface of a finger or the palm of the hand in the form of a raised bleb under thick and soggy epidermis. This quickly spreads upon the per- iphery and after awhile the epidermis separates and opens in the center to pull off, leaving a raw, red surface which quickly be- comes a dry, red one. Meanwhile the edge of the lesion, push- ing on always in a centrifugal manner, is raised into a linear bullae containing a small amount of sero-pus. The finger, palm, entire tand, wrist and even forearm may be involved, the lesion skinning off the member like a glove. t The disease is probably an infective dermatitis. The treat- ment is purely local. IMPETIGO SIMPLEX. J Impetigo simplex is an inflammatory, pustular disease, char- acterized by one or more pin-head, pea- or finger-nail sized, dis- crete or confluent, circular or irregularly-shaped pustules, usually running an acute course, unattended as a rule by marked itching or burning. Impetigo simplex is the simplest form of impetigo, but is not * See Elliott, Jour. Cutau. Dis., 1895, xiii, p. 10; lb., 1899, xvii, p. 539; New York Med. Jour., April 21, 1900. Also Bowen, Jour. Cutan. Dis., 1898, xvi, p. 253, and Wende, lb., 1902, xx, p. 537, lb., 1904, xxii. p. 14. t For an excellent picture see Stowers, B. Jour. Derm., 1896, viii, p. 1. X Some writers consider this form of impetigo as a variety of impetigo con- tagiosa, and include it under this head. They describe in addition what is called the impetigo of Bockhart, as being the true typical impetigo. Others, and my- self among them, consider Bockhart's impetigo as a folliculitis, and divide the true impetigos as in the text above. I70 DISEASES OF THE SKIN. at the present time by any means as common as impetigo con- tagiosa. When typical it shows itself in the form of lesions which are from the beginning pustules, firm, hard, raised and surrounded by a slight areola. The elevation is marked and the lesions may at times appear semi-globular. There is no central point, depression or umbilication. The pustules are grayish-white or yellowish in color. When mature the areola subsides, leaving the crusts rising direct from the skin. The pustules are discrete and, even when grouped together, do not show any tendency to coalesce. In number they vary from two or three to a dozen or more. They may occur upon any part of the body but are most common on the face, hands, fingers, feet, toes and lower extremities, and, sometimes upon the palms and soles. They are not as a rule attended by itch- ing or burning. They run an acute course, usually lasting a week or ten days. The crusts desiccate and drop off leaving reddish bases without pigmentation or scar. The affection is confined for the most part to children. It is, according to Duhring, from whom this description is taken, one of the rarer pustular manifestations. The chief interest in the diagnosis of impetigo simplex is its differentiation from impetigo contagiosa. The two affections resemble one another pretty closely but there are important clinical differences. The initial lesion in impetigo contagiosa is generally a vesico-pustule; in simple impetigo it is always a pustule. The lesion of impetigo contagiosa is remarkably super- ficial; that of impetigo simplex has a deeper seat and thicker walls. The pustule of impetigo contagiosa tends to flatten, and is often marked by umbilication; that of impetigo is raised and without central depression. From pustular eczema, impetigo simplex may be distinguished by the size and peculiar conformation of the pustules, these being large and prominent while those of eczema are small and not raised. In impetigo simplex the pustules are discrete while in eczema they tend to run together and form pustular patches. In impetigo there is little infiltration whereas, in eczema, infil- IMPETIGO CONTAGIOSA. 171 tration is -a pathognomonic feature. In impetigo there is gener- ally no itching while in eczema the itching is marked. Impetigo simplex somewhat resembles ecthyma, but in the latter the pustules are flat, and are surrounded by extensive inflam- matory, hard bases. In impetigo they are elevated and generally have only a slight areola. In ecthyma the crusts are brownish or blackish in color, large, flat, and seated upon an excoriated or even ulcerated surface. Impetigo simplex occurs in the healthy and strong; ecthyma in the debilitated and cachectic. The treatment of impetigo is both prophylactic and curative. Being due to the implanation and growth of the Staphylococcus pyogenes every effort should be made to prevent the affection spreading and to destroy the parasite. Poultices rendered anti- septic by the addition of boric acid should be employed to remove the crusts, the entire surface of the body should be frequently cleansed with warm water and corrosive sublimate soap, and compresses wet with a saturated solution of boric acid or a solu- tion of bichloride of mercury 1-2000 should be applied to the lesions. If ulcers form beneath the crusts, these should be thoroughly cleansed by means of peroxide of hydrogen and dusted with europhen or aristol, and if an ointment is called for, one containing one of these substances or a strong boric acid ointment may be employed. Internal treatment is not usually required. IMPETIGO CONTAGIOSA. Impetigo contagiosa is an acute, inflammatory, contagious dis- ease, characterized by the formation of one or more superficial, discrete, roundish or ovalish, vesico-pustules or blebs, the size of a split pea or finger-nail, which pass into crusts. The erup- tion is commoner among infants and young children. Isolated, flat, or slightly raised vesicles are first seen, small in size at the beginning, but rapidly spreading on the periphery until they become like little blebs, with a thin, withered-looking, collapsed wall. The lesions are few in number. Usually they are dis- 172 DISEASES OF THE SKIN. crete, but sometimes two or more coalesce. They are most commonly found about the mouth, on the chin and nose, and on the hands. Crusts form in a few days, usually yellowish or straw-colored, and, as they dry, loosen at the edges, so as occasion- ally to look as if they had been stuck on the skin. The surface Fig. -Impetigo Contagiosa. beneath is moist and excoriated. The mucous membranes of the mouth and conjunctiva are occasionally invaded. The disease may extend from place to place by auto-inoculation. It runs its course in about ten days, tending to a spontaneous recovery. Sometimes, however, it runs an anomalous course. IMPETIGO CONTAGIOSA. 1 73 The eruption here may consist of a few, even one or two, lesions only, about the nose and mouth with possibly one or two upon the fingers. In other cases it may be diffused over body and limbs resembling varicella or pemphigus. Occasionally circinate lesions are seen. Sometimes, instead of showing vesicles and blebs, small pustules appear from the first. The disease, although commoner amongst children, may occur in adults. Sometimes a group of cases of impetigo contagiosa of the beard region will occur among men who have been shaved by the same barber. Such cases, however, may commonly be traced to a child as the origin. Impetigo contagiosa is contagious and auto-inoculable. It is observed commonly in the lower ranks of life, although it may occur among the more refined. It is most common between the ages of two and ten. It is common among boys at school and foot- ball players. The disease is sometimes confounded with varicella by careless observers.* Impetigo contagiosa is due to a streptococcus. So soon as the vesicles are developed the Staphylococcus pyogenes aureus, which multiplies much more rapidly than the streptococcus, escapes and new foci of infection may occur which are caused by the invasion of the staphylococcus alone or chiefly. These sec- ondary lesions may take on the appearance of ordinary impetigo. The lesion is formed between the rete and the horny layer, this latter being the roof wall. There is a surrounding mild inflam mation. The underlying upper part of the corium displays acute inflammatory action with the usual features, The central portion of the lesion shows a large number of the staphylococcus pyogenes aureus, often streptococci as well as other cocci. Impetigo contagiosa is to be distinguished from pustular eczema, ecthyma, varicella and pemphigus. Eczema is distinguished by its greater variety of lesions, by the greater amount of infiltra- *See Stelwagon, Impetigo Contagiosa, its Individuality and Nature, Pliila., Med. News, Aug. 29, 1883; also Corlett, Cleveland Jour. 'Med., vol. iii, 1898, p. 513; Allen (General, bullous), Trans. Am. Derm. Assn., 1896; Elliott, Jour. Cut. Dis., 1894, p. 194; Engman, " Impetigo contagiosa and its bacteriology," lb., 1901, p. 180, (with review and bacteriology). 174 DISEASES OF THE SKIN tion,the itching, etc. From ecthyma the present disease is distin- guished by the occurrence of the inflammatory base and areola. Ecthyma is also more common on the legs. It also occurs chiefly among adults and in persons of depraved life and impaired vitality. The lesions of varicella are uniform and smaller, rarely larger than split peas, and more or less disseminated, with no tendency to grouping and with insignificant crusting. Although impetigo tends to rapid recovery its course is some- times prolonged by re-infections and, occasionally, by the con- current appearance of pediculosis capitis. The treatment of impetigo contagiosa is simple. Cleanli- ness is the basis. One of the medicated soaps, as EichofPs, or some other bichloride of mercury soap may be used to cleanse the surface, after which an ointment of ammoniated mercury, from 10 to 20 grains (0.65 to 1.35) to the ounce (32.) of cold cream should be gently rubbed in. ECTHYMA. Ecthyma is characterized by one or more pea or finger-nail sized, generally discrete, flat pustules situated upon an inflam- matory base, followed by yellowish or brownish crusts and pig- mentation, usually occurring in subjects in depraved health. The pustule of ecthyma appears a few hours after inoculation in the form of a red point. At the end of the second day a minute papule or pustule appears in the center of the red lesion. By the end of the third day the lesion has become acuminated in the center, and by the fourth day the ecthymatous pustule is fully developed in the form of a yellowish-white pustule the size of a large pin-head or small pea, surrounded by a red areola, at the edge of which the derma is somewhat infiltrated. By the fifth to the eighth day the pustule has increased considerably n size and has become flattened. By the ninth to the eleventh day a central crust has formed, around which is a whitish circle formed by the epidermis, which has been elevated by pus. Beyond this is the red areola. ECTHYMA. n At this point the lesion may cease to extend and may begin to heal, disappearing by the end of the fifteenth to the twentieth day, and leaving behind only a superficial, more or less pigmented cicatrix of a reddish-brown color, which tends gradually to disappear. Sometimes ulceration takes place under the crust. Occasionally the lesion of ecthyma extends more and more until it reaches an extraordinary size; the crust becomes thick, and gangrene may supervene. In broken-down subjects the affec- tion may become grave. Such forms of ecthyma are not infre- quently observed in our almshouses and prisons. Ecthyma is inoculable and auto-inoculable. Ecthyma usually attacks the lower limbs, although the shoulders and other parts may be attacked. It sometimes gives rise to lymphangitis and phlebitis. The subjective symptoms consist of slight itching or burning. Occasionally general symptoms of feverishness, etc., are observed. The cause of ecthyma is found in the introduction of pyogenic cocci, particularly streptococci into the skin. Filth and neglect arc the most common aggravations. In infants improper or in- sufficient diet and gastro-intestinal troubles and scrofula are predominant causes. The pustule of ecthyma differs from the pustule of eczema or the pustule of impetigo in the severity of the exudative process by which it is produced and in its limitation to the exact seat of external irritation. The process always begins as an inflamma- tion in the lower epidermal layers, fibrinous centrally and cedematous peripherally and which invades the dorma superfi- cially or deeply; minute intercellular cavities form, which melt together and filled with a fibrinous and purulent fluid. The fluid cavity involves the upper corium and exceptionally the entire corium. The pus usually contains staphylococci and streptococci. By the extension of the process to the corium there is an actual loss of tissue resulting in a cicatrix. Ecthyma is apt to be confounded with other pustular affec- tions, as pustular eczema, impetigo, dermatitis herpetiformis in some of its phases, and with the large pustular syphiloderm. 176 DISEASES OF THE SKIN. A careful examination of the locality and character of the pustu- lation and the general condition of the patient will make the diagnosis easy. Syphiloderma pustulo-ulcerosum or "rupia" sometimes closely resembles ecthyma. The syphilitic eruption, however, is more deeply ulcerated, has a larger and more infiltrated base and is surmounted by a more abundant and raised crust. The general treatment of ecthyma consists in improving the health of the patient by proper hygiene and diet, and by the employment of tonics. The internal treatment should include rest, fresh air, bathing, cleanliness, with such nourishing food as milk, eggs, strong soups, etc. In a few cases the administration of alcohol and malt liquors is desirable, but in the majority of cases these should not be prescribed. In old persons tonics and remedies which will stimulate the action of the kidneys may be employed. The following formula, analogous to the well- known Basham's mixture, is useful: 1^. Liq. ammoniae acetat., fjiiss ( 48. ) Acid acetic, dil., 9iv ( 5.20) Tinct. ferri chlor.. f3ij ( 8. ) Curacoae, f oiij (96. ) Aquae, Oss. (256. ) M. SlG. — A tablespoonful in water three times a day between meals. In younger persons we may prescribe a brisk purge with blue pill and colocynth, followed by an aperient tonic, as the "Mist, ferri acid." (See under Eczema). In broken-down cases pure tonics, as quinine, iron, etc., may follow these or be used in connection with them. The external treatment of ecthyma is essentially antiseptic and parasiticide. Since ecthyma is probably due to infection, the first thing to do is to suppress this factor, and next to prevent the propagation of the disease by scratching and auto-inoculation. The crusts, if numerous, are to be removed by a bath, preferably containing the sulphuret of potassium or by enveloping the parts in a rubber cloth or by the use of starch poultices con- taining boric acid (see Eczema). The parts are then disinfected by sublimate soap, or by means of carbolized lotions or a 1 to IMPETIGO HERPETIFORMIS. 1 77 iooo solution of bichloride of mercury. The lesions are sub- sequently dressed with ointments containing iodoform, europhen or other antiseptics. IMPETIGO HERPETIFORMIS. Impetigo her pet i form is is a rare affection of the skin occur- ring in pregnant females, characterized at first by the appearance of superficial, miliary pustules, the contents at first opaque and later yellowish-green in color. Successive pustules form during the course of the disease, having a marked tendency to form groups. The lesions are surrounded by a red areola, and rest upon an inflamed base. A dirty, brown crust finally forms upon the center of the fully developed pustule, while a single, double, or even triple ring of new lesions appear, surrounding the original one, which follow the same course. The lesions originally appear at isolated points, especially the fold of the groin, the umbilicus, the breasts, and axillae, but gradually spread and coalesce until large areas become affected. When the crusts become detached and fall off, the underlying skin is found red and covered with fresh epidermis, or moist, weeping, infiltrated, and covered with numerous papules. Sometimes the mucous membranes are involved, there are symptoms of fever and general disturbance, with a fatal result in most cases, either in the course of the first attack, or in a second one occurring during a subsequent pregnancy. The affection is an infection and probably septicemic in char- acter. Most cases reported have been observed in Vienna. Heitzmann, how- ever. Archives of Dermatology, 1878, p. 37, and Fordyce. Jour. Cutan. Dis., 1897, p. 495, have reported cases occurring in this country. FURUNCULUS. Furuncle, commonly known as "boil," is a deep-seated, in- flammatory disease, characterized by one or more variously-sized, circumscribed, more or less acuminated, firm, painful formations, usually terminating in central suppuration. 178 DISEASES OF THE SKIN. Boils may occur singly, or in numbers. When they occur in successive crops the condition is known as furunculosis. The lesion, at first a small, ill-defined, reddish spot, situated in the true skin, and tender and painful from the first, soon becomes larger, slightly elevated, and shows a tendency to suppurate about its center. It arrives at maturity in a week or ten days, and is then a slightly-raised, rounded, or pointed formation, with a suppurating center, called the core. At times no center of suppuration forms; it is then called a "blind boil." The size of a boil may vary from that of a split pea to a large coin. Its color is dusky red; it usually gives rise to a dull, throb- bing pain, increasing in intensity until suppuration takes place, and then subsiding. Though the boil may attack any part of the body, its favorite seats are the face, ears, back of the neck, shoulders, axillae, but- tocks, perineum, scrotum, labia, and legs. Sometimes it is ac- companied by some general constitutional disturbance. Neigh- boring glands may be sympathetically enlarged. Boils sometimes occur as complications or sequelae of other diseases, e. g., eczema. An acute attack of eczema often winds up with a crop of boils. Sometimes the boil tends to return again and again in about the same spot. The remote causes giving rise to boils are various and some- times obscure. Often they are the result of a low and depraved condition of the system. General debility, overwork of a mental sort, excessive bodily fatigue, nervous depression, improper food, and irregularity of the functions of the body are among the common causes of boils. They are sometimes encountered, however, in persons apparently enjoying perfect health, and given to active and varied out-door exercise and amusement. The boils to which the hydropathist points with pride, as evidence that the peccant humors are being "driven out," are in reality the evil result of erroneous hygiene and regimen. Boils not unfrequently occur in the course of other diseases, as diabetes, chlorosis, fevers, uraemia, and septic pyaemia. Occasionally certain atmospheric conditions, prevailing chiefly in the spring FURUNCULUS. 179 and autumn, seem influential in determining the occurrence of boils, which at times appear to prevail as a sort of epidemic. Boils have their immediate origin in the invasion of the sebace- ous gland, hair follicle, or, possibly in some cases, a sweat gland by the staphylococcus pyogenes aureus. The core or central slough of a boil is composed of pus and the glandular and perifollicular tissue in which it had its origin. The intense zone of inflam- matory deposit around the center, by shutting off the vascular supply, results, along with the liquefying action of the cocci and leukocytes, in the breaking down of the central portion and the production of the core mass. Most boils begin as an impetigo lesion or sycosiform pustule, the cocci penetrating and spread- ing from this point. The diagnosis of furuncle is generally easy, the affection being familiar to every one. From anthrax, or carbuncle, it differs in only having one point of suppuration — the core — while the former has several or many such centers. The furuncle also is inclined to be rounded or acuminate; carbuncle is flat. Furun- cle is small; carbuncle varies in size, from half an inch to three or four or more inches in diameter; furuncle is tender to the touch; carbuncle, though spontaneously painful, is not tender. Boils generally occur in numbers; carbuncle is commonly single. Now and then certain pustular syphilodermata resemble boils, but their indolence, painlessness, and darker, duskier color, together with the chronic, slow course which they run when unaffected by treatment, will rarely give rise to difficulty in the diagnosis. The successful treatment of boils is, at times, by no means easy. Each case demands careful study, with the view, if possible, of ascertaining the cause at work, and obviating this, if it can be done. The various functions of the body are to be carefully regulated. The diet should be of good quality and varied. Wine and malt liquors may be prescribed in rare cases, and when the patient is not accustomed to their use. The regimen should be moderate and conducive to the general im- provement of the system. Fresh air and out-door exercise are l8o DISEASES OF THE SKIN. to be urged in most cases. Tonics are very often called for. Quinine in considerable doses, as much as fifteen grains (i) per diem, and iron, alone or with strychina, may be given. Cod-liver oil is also suitable in some cases. The "Mistura ferri acid.," often prescribed in eczema, is useful at times. Arsenic, alone or in combination with iron, is sometimes of value. The hypophosphites are also frequently prescribed to advantage. Fresh brewers' yeast in tablespoonful doses three times daily is an old remedy recently revived. Such are the remedies most usually relied upon in the treatment of furuncu- losis. No one can be recommended as a specific; what will do good in one case may fail in another. Locally, one method of aborting the forming boil may be recommended; it is, when a hair is growing out of the center of the boil to pull it out. This will sometimes check the further development of the boil. A fine-pointed stick dipped in ichthyol should be thrust into the follicle immediately after depilation. The application of cold, in the form of powdered ice poultices, is recommended by Hebra. The use of caustics, as a red-hot needle, nitrate of silver, or a mixture of equal parts carbolic acid and glycerine, nitric acid, acid nitrate of mercury (or a pointed stick of caustic potash), may be used to the apex of the forming boil. Salicylic acid- may be applied in the form of a plaster: 1$. Acid salicylic, 3ij (8.) Emplast. saponat., §ij (64.) Emplast. diachyli, 5j- (32.) M. This is to be applied spread upon a cloth as an ordinary plaster. When the boil begins to discharge, a hole is cut in the plaster, to permit the escape of the products of suppuration. A ten per cent, salicylic acid ointment well rubbed into the skin may be employed instead. Ichthyol may be employed, rubbed into the skin in full strength. When suppuration is once established the boil should be opened and thoroughly scraped out with a sharp spoon. To prevent the transmission of infection the parts about the boil should be CARBUNCULUS. l8l shaved when there is hair and the skin kept clean by frequent washing with the tincture of green soap or by the use of some antiseptic soap. Peroxide of hydrogen forms one of the best applications to fol- low incision and scraping. It is said that under this application the pain ceases, and the separation of the core takes place pain- lessly. Incisions should not be employed at any stage unless absolutely required, and then only with antiseptic precautions and subsequent antiseptic dressings. An incision sometimes carries the virus to new points. The prognosis of furuncle is generally favorable. Occurring in broken down persons in great and increasing numbers a very great deterioration of the health ensues. In young infants espec- ially where there is a tuberculous infection the prognosis of mul- tiple furunuculosis is grave. CARBUNCULUS. Carbuncle is a hard, more or less circumscribed, dark red, painful, deep-seated inflammation of the skin and subcutaneous connective tissue, variable as to size, terminating in a slough. Carbuncle is usually accompanied by a good deal of constitu- tional disturbance. It is ushered in by a chill followed by fever. The skin over the affected part becomes hot and painful, and a firm, fiat, more or less sharply circumscribed inflammation, of a somewhat dusky red hue, forms, which is deeply seated in the tissues. It is painful, with commonly more or less of a burning sensation. The symptoms become gradually more marked during ten days to two weeks, when the tissues begin to break down and soften, and the skin becomes gangrenous. Perfora- tions appear at various points, either filled with tough, yellow, fibrous cores, or hollow; and from these issues a yellow, sanious fluid. The surface soon assumes a cribriform or sieve-like appearance, which is very characteristic. Unless the carbuncle is small the whole skin covering it usually sloughs sooner or later, leaving a large open ulcer, healing slowly. The duration of carbuncle is usually from four to six weeks, 102 DISEASES OF THE SKIN. though its course depends somewhat on the age and strength of the patient. It is usually single, and its favorite seats are on the back of the neck, shoulders, back and buttocks. The hairy scalp, the front of the abdomen, and the lips are all looked upon as situations of especial danger. Carbuncle attacking the upper lip is believed to be an especially fatal variety. It is apt to be found in young persons, runs an acute and rapid progress and is apt to lead to a fatal result from pyaemia. This form of disease is by some believed to be a variety of malignant pustule. Against this view it may be stated that pain and the presence of pus in considerable quantities are characteristic of this form of disease, while both of these are, to a great extent, absent in malignant pustule. (Cameron.) In elderly persons carbuncle is a serious disease, and when extensive is apt to terminate fatally. Boils often appear about the borders of carbuncle. The affection some- times occurs in connection with diabetes and Bright's disease. The cause of carbuncle is the invasion of the part by the same staphylococcus which gives rise to furuncles. The disease is not, however, a group of boils, but a much more deeply-seated and serious affection. The inflammation starts simultaneously from numerous points, from the hair follicles, sebaceous and possibly from the sweat glands; the inflammatory centers break down, and the pus finds its way to the surface; finally, the process ends in gangrene of a part or of the whole area. The pyogenic micro-organisms are present in abundance in the tissues. The inflammation may also, in some cases, start deeply down from some point or points in the subcutaneous tissue. It is probable that the intense inflammation shuts off the vascular circulation and thus produces necrosis of the tissues. Carbuncle is distinguished from furuncle by its size, flatness, multiple points of suppuration, and extensive slough. From erysipelas, which it sometimes resembles in its early stages, its circumscribed outline will soon distinguish it. The general treatment of carbuncle should be strongly sup- porting. Nourishing food must be freely given, and in some PHLEGMONA DIFFUSA. 1 83 cases stimulants, although sparingly and with caution. The best opinion is opposed to the excessive and indiscriminate use of stimulants formerly customary. Tincture of iron and quinine are the best medicines. The latter should be given in sixteen to twenty-five grain doses once daily. Anodynes should be given freely when required to procure rest at night. Fresh air and exercise, when these can be taken, are important factors. When the carbuncle is tense and hard, antiseptic poultices, prefer- ably made with a 1-2000 solution of corrosive sublimate, and deep, cruciform incisions for relief followed by scraping may be resorted to when required, and when practiced with the addition of thorough antisepsis and the application of strong parasiticide remedies is perhaps the best procedure. The parts should be kept clean, washed frequently with a weak carbolic solution, and the slough removed as rapidly as possible, so as to leave a minimal amount of diseased tissue in contact with the springing granulations. At the earliest possible moment after suppuration has commenced the carbuncle should be freely opened and the dead tissue scraped out thoroughly, and afterwards the cavity packed with an antiseptic, as iodoform. Antisepsis lies at the foundation of all modern local treatment of carbuncle. The first thing to do is to get at the noxious germs and destroy them, remembering always not to use such vigorous treatment as will further inflame the tissues. To the antiseptic treatment should be added such soothing remedies as are admissible. Sometimes the thermo-cautery is used to remove portions of the diseased tissues. When the ulcer begins to granulate it must be encouraged to heal. The prognosis should be extremely guarded. Death may occur from exhaustion, pyaemia, collapse, or, when the scalp is affected, by inflammation and effusion within the cranium. PHLEGMONA DIFFUSA. Phlegmona diffusa or phlegmonous cellulitis is a more or less extensive in- flammation of the cutaneous or subcutaneous tissues which is similar to or closely allied to cellulitis and to erysipelas. 184 DISEASES OF THE SKIN. After malaise and rigors a febrile action ensues with sharp or dull pain at the site of the disease. The first appearance is of a hard lumpiness or infil- tration, somewhat deeply seated and attended by swelling and cedema, which may involve a considerable area. In the course of five or ten days some soft- ening occurs with tendency to discharge or retrogression and disappearance of the swelling. Sometimes a necrosis takes place or burrowing of pus under the tissues. The disease is probably due to infection by the erysipelas coccus and pyo- genic staphylococcus. The disease may be mild or severe and rapidly fatal. The treatment is that of erysipelas with local surgical measures as required. DISSECTION WOUNDS. These may be due to irritative secretions from dead bodies, pus cocci, or tubercle bacilli. The infections from the latter will be found described under tubercle of the skin. Post-mortem pustule begins by an abrasion of the skin rarely noticed and quickly followed by the appearance of a small, red, itchy spot, which rapidly develops into a vesico -pustule or pustule, having a dull, red inflammatory base. The pustule dries or breaks, then fills up again, etc. If removed a small ulcer appears beneath. The lesion is more or less painful, surrounded by swelling and lymphatic involvement — septic infection sometimes occurs. Post-mortem pustule occurs in the dissection room or, rarely, among butchers. The essential (bacterial) cause is not known. Treatment consists in opening the pustule, removing the crust, cleansing with hydrogen dioxide, and the use of wet, antiseptic, corrosive sublimate dress- ings. Or an antiseptic powder as iodoform or europhen may be used. EQUINIA. Equinia, glanders or farcy, is an inoculable, acute or chronic disease of ma- lignant type, derived from the horse, mule or ass, and characterized by grave constitutional symptoms, inflammations of the nasal and respiratory passages, and a vesico -pustular, papulo -pustular or deap-seated tubercular or nodular ulcerative eruption. The disease may gain access to the body through some break in the skin or of the mucous membrane of the eye, mouth, etc. After a time malaise, fever, etc., set in and a phlegmonous inflammation or pustule may show itself at the site of inoculation, which later breaks down into an unhealthy ulcer tending to spread. Inoculation of the eye or nose may lead to destructive ulceration of the part. Other pustules may arise, deep-seated nodules, the so-called farcy buds, may appear and the lymph glands and channels may be- come thickened. The mucous membrane of the nose is peculiarly apt to be involved with ulceration and profuse thick mucoid discharge. In acute cases PUSTULA MALIGNA. 1 85 the febrile symptoms continue. Occasionally sepsis may supervene with fatal issue. The disease is rare in this country. It is usually contracted from horses and occurs among those who care for those animals. It may be transmitted from man to man. Equinia is caused by the presence of the glanders bacillus {Bacillus mallei), found in all lesions, the blood and other fluids and tissues. The lesions are made up of round -celled granulation tissue which breaks down easily. The diagnosis is made from the presence of nasal discharge, cutaneous and mucous membrane lesions occurring in combination. Microscopic examina- tion for the characteristic bacillus should be made in doubtful cases. The treatment is empirical; the prognosis in most cases unfavorable. PUSTULA MALIGNA. Malignant pustule, or anthrax, is a furuncle- or carbuncle-like gangrenous lesion resulting from inoculation with the bacillus anthracis, and usually ac- companied with constitutional symptoms of more or less gravity. The disease in man is of rare occurrence and results from inoculation from some animal, usually one of the horned domestic animals. About twelve hours to three days after the introduction of the virus a flea-bite -like macule is observed at the affected point, usually the back of the hand, cheek, or some other exposed part. In twelve to fifteen hours this is succeeded by an inflam- matory and pruritic papule, which is transformed rapidly into a flaccid ves- icle filled with bloody serum and surmounting a firm, indurated base; or a larger blood-filled bleb develops reposing upon a somewhat painful, engorged, and often densely indurated base, involving extensively the subcutaneous tissue. One or more lesions may follow in the surrounding integument, coal- escence of which lesions produces a large, angry, cedematous, and often gan- grenous ulcer with a reddish areola. The area involved may be from coin to palm size. The lymphatic vessels and ganglia become inflamed and often suppurate and metastatic abscesses may ensue. High fever, septic absorption and death follows in severe cases. The disease is induced by the inoculation of the Bacillus anthracis, the same poison which causes the splenic fever, Texas fever or charbon in cattle. The germs are found everywhere in the blood and tissues. The diagnosis of malignant pustule is made from the characteristic lesions of a central eschar, with. areola or crown of vesicles and indurated base, es- pecially occurring in one liable to contact with animals. Poisoned wounds, facial chancre and the pustular eruptions caused by contact with the dead bodies of men and animals are to be excluded. The disease is a serious one, but with early diagnosis and prompt treat- 1 86 DISEASES OF THE SKIN. ment the danger is lessened. Excision of the entire area is to be promptly practiced under strict antiseptic precautions to prevent reinfection. Subse- quently the ordinary treatment of open wounds. Sodium sulphite or hypo- sulphite with quinine should be given internally, with alcohol, carbonate of ammonium, etc., if required. ERYSIPELAS. Erysipelas is a specific inflammation of the skin and subcu- taneous tissue, most commonly of the face, characterized by shining redness, swelling, oedema, heat, and a tendency, in some cases, to vesicular and bleb-formation, and accompanied by more or less febrile disturbance. The outbreak, in average cases, is preceded by a period of malaise, chilliness, nausea lasting a few hours to several days, and rapidly followed by .the appearance of the cutaneous eruption. This appears at a place where there has been a break in the con- tinuity of the skin in the form of an area of disease, from a dime to a silver dollar size, elevated, swollen, red and shining, with a glazed appearance. There is a feeling of burning, often some tenderness, and sometimes more or less itching. The border is sharply defined, elevated, and bright-red, it spreads gradually or rapidly by peripheral extension, and in some cases there may arise new points of infection near by, spread and merge into each other. In the course of several days to a week the disease has usually reached its acme, and may then cover a great part of the face or the entire region. In most cases the skin is dark red, swollen, tense, and shining, but sometimes there are vesicles or pustules or exceptionally the part may be partially undermined with serous effusion. Sloughing may ensue in rare instances. When the erysipelas involves a limb streaks of red along the lines of the lymphatics may be noticed. The constitutional symptoms vary and the temperature may be elevated from one or two to several degrees above the normal. After remaining a few days stationary the process begins to subside, the swelling abates, the color changes to brownish-red, yellowish and whitish shades and at the end of ten days to a few weeks the disease is well. Desquamation to a greater or less extent follows. ERYSIPELAS. 1 87 Considerable variation from the type occurs in some cases. Thus the disease may light up in one place while healing in another, or it may wander from place to place over the surface. Erysipelas is both contagious and infectious. The essential cause is believed to be the streptococcus of Fehleisen and possibly other organisms. The disease finds entry by a prick or abrasion sometimes so minute as to escape detection. A not unfrequent point of infection, says Stelwagon, from whom this description of the disease is taken, is a sycosiform inflammation just inside the nostril. As predisposing causes may be mentioned, a poor condition of .the health, debility, alcoholism, in fact anything which de- presses or weakens the vital forces and lessens the resisting power of the organism. The specific germ is the sole pathogenetic factor in the disease. One attack does not protect against a subsequent one, in fact it makes such an attack more likely, probably because some of the germs remain latent in the skin. Erysipelas is an infectious dermatitis. The corium is invaded in severe cases by the strep- tococci and this invasion may extend down into the subcutaneous tissue. In rare instances streptococci have been observed in various organs. The diagnosis of erysipelas is usually not difficult. The char- acter of the onset, the shining redness, the swelling, the sharply defined elevated border, and the accompanying constitutional disturbance are all pathognomonic. Phlegmona diffusa, the ery- themata, acute eczema and dermatitis are most apt to be mis- taken for erysipelas and vice versa. Some form of ivy poison- ing and iodoform dermatitis also resemble erysipelas. Erysipelas is not often a fatal disease. Occurring in debilitated persons, however, or after an operation the prognosis is more grave. The constitutional treatment of erysipelas should be of a tonic, stimulating character with nourishing food, chiefly milk, in severe cases. Tincture of iron in doses of 15 to 40 minims (1-2.65), quinine, 2-3 grains (0.13-0.2), with moderate doses of strychnia IOO DISEASES OF THE SKIN. are called for. Locally ichthyol in lotions of 10 to 20 per cent, in water or ointment forms the best application. Antiseptics as carbolic acid, boric acid, resorcin, etc., in solutions of various strength from one per cent, upward may also be used. Painting with strong nitrate of silver solution or tincture of iodine in a band just beyond the spreading border of the disease sometimes arrests its progress. ERYSIPELOID. Erysipeloid is a rare skin affection somewhat resembling erysipelas but lacking the more striking local appearances and the constitutional symptoms which characterize the latter. The affection is observed in those who handle putrid meats or fish, such as butchers, fish-dealers, poultry-dealers, etc., or from crab-bites (Gilchrist). The disease starts from some fissure or abrasion in the skin. It consists at first of a dull red or purp- lish spot or zone, scarcely elevated, which tends to spread; as it spreads the first part involved usually clears up. If infection takes place at several points, a ring-like or festooned appearance may result. The advancing border of the erythema is sharply defined against the surrounding skin, and is commonly purplish or even livid in color. There may be some swelling or puffiness. Itching and burning are sometimes marked. Its progress is slow and sometimes only a small area as a single finger may be in- volved. Subsiding, the color changes to a yellowish and finally disappears. There is no scaliness. The disease is said to be due to an organism found in dead or decomposing animal matter and probably of the family of cladothrix. Gilchrist, however, believes it due to a ferment. The affection is to be distinguished from erysipelas and ring- worm. The treatment is the same as that of erysipelas. Ichthyol probably forms the best local application.* * Morrant Baker first described the disease under the name ''Erythema Ser- pens," St. Bartholomew' s Hosp. Reports, ix, 1873, p. 198. In this country Elliott, Jour. Cutan. Dis., 1888, p. 12, and Gilchrist, New York Med. Rec, 1896, vol. xlix, p. 783, and Jour. Cutan. Dis., 1904, p. 507, have given the best account of the affection. DERMATITIS GANGRENOSA INFANTUM. 1 89 DERMATITIS GANGRENOSA INFANTUM.* Dermatitis gangrenosa infantum, erythema gangrenosum or varicella gangrenosa is a gangrenous affection observed in infants and children, arising spontaneously or following other vesicular or pustular eruptions, more especially varicella and vaccinia. The eruption often follows varicella. The vesicles instead of drying up in the usual manner become crusted centrally, often with a pustular border and surrounded by a red areola. Ulcer- ation begins beneath the crust and results in an eschar. Contig- uous lesions may become confluent and form an irregular ulcer of some size and depth. Cicatrices, of course, result. The disease has been known to follow vaccinia, taking its starting point in the neighborhood of the vaccine vesicle. Cases arising spon- taneously generally show first upon the buttocks as small pap- ulopustules. Cases vary in gravity, some being slight, others of ominous severity with fever vomiting, etc. The disease is rare and chiefly met with in debilitated infants. The treatment is tonic with antiseptic dressings. MULTIPLE GANGRENE OF THE SKIN IN ADULTS. Under this head are included cases variously described as spontaneous gangrene of the skin, disseminated gangrene, hysteric gangrene and gangrenous zoster. Some cases of apparently spontaneous gangrene, occurring in hysterical girls and others, are undoubtedly factitious in origin. Others, and such are many of the cases reported as hysterical gangrene, are produced in part by unconscious movements of the patient and in part are apparently the result of angioneu- rotic spasm. Still other cases as those following burns and injuries seem to be trophoneurotic in character. The typical lesion of hysterical gangrene is an oblong ery- thematous patch looking like an urticarial lesion or as if result - * See Hutchinson on Gangrenous Eruptions in Connection wilh Vaccination and Chicken-pox, Lond. Med. Chir.Soc. Trans., 1882, p. 1. Elliott, Dermatitis Gan- grenosa Infantum, A T . Y. Med. Rec, May 16, 1891. 190 DISEASES OF THE SKIN. ing from rubbing the skin. The epidermis soon loosens from the patch, a superficial slough forms, dries, and is cast off as a crust. There is no ulceration. Fig. 29. — Multiple Gangrene of the Skin (Neurotic Excoriations or Hysterical Gangrene. (After Doutrelpont.) Multiple gangrene not hysterical in origin follows fevers as typhoid, malaria, scarlet fever and measles.* * For a fuller description of this form of gangrene see Stelwagon and Hyde and Montgomery. Cf. also Hartzel, Trans. Coll. Phys. Phila., 1898, p. 1; also C. J. White, Recurrent Hysterical Dermatitis, Jour. Cut. Dis., 1903, p. 415. For a discussion of hysterical gangrene see the author's papers, "The Hysterical Neuroses of the Skin." Am. Jour. Med. Set., 1897, cxiv, p. 64, and Jour. Cutan. Dis., xxi, p. 403. The picture given in the text is from Doutrelpont "neber ein Fall von acute multiple Hautgangrene," Arch. / Derm, v Syph., vol. xiii, 1880 p. 179. DIABETIC GANGRENE. 191 DIABETIC GANGRENE. Gangrene occurring in connection with diabetes may show itself spontaneously without previous injury to the affected skin, or it may arise at the seat of a slight injury or at the seat of the skin affections common in such subjects. In cases arising spon- taneously there may be loss of sensation, neuralgic pain, cold- ness, or intermittent flushing or Avidity. Blebs and vesicles may then ensue, the parts becoming dark colored and death of the part ensuing. In diabetic gangrene following traumatism the disease may spread and involve deeper tissues. Parts exposed to knocks and injuries, as the legs and hands, especially the former, are liable to be attacked. The patches in diabetic gangrene are rounded, irregular, or even serpiginous. Constitutional disturbance and subsequently septic symptoms sometimes occur. Diabetic gangrene is very rare. It is a serious symptom and renders the prognosis of the disease much less favorable.* SYMMETRIC GANGRENE. Symmetric gangrene is an affection, usually of the extremities, of probably trophic nature, characterized by local ishaemia and asphyxia which may terminate in gangrene of the skin and underlying tissue. | The extremities, such as fingers, toes, ears and nose are usually affected. It is generally symmetric. The first symptoms are coldness and paleness of the parts, with pain and numbness. Later the parts become dark red, livid and bluish and some- times swollen, with, not unfrequently, tenderness and shooting pains. The process may retrocede at this point to recur later * See Kaposi, " Hautkrankheiten der Diabeten," Wien. Med. Wochens., 1884, Xos. 1, 2, 3 and 4. C. W. Allen, Med. News, Oct. 24, 1896. Morrow, "The Cutaneous Manifestations to Diabetes," Med. Record, April 11, 1896. t The affection was first carefully described by Reynaud in 1862 and hence is usually known bv his name. 192 DISEASES OF THE SKIN. or sometimes it does not go beyond this stage. Finally, however, in marked cases it goes on to dry gangrene or if the fingers or toes are affected the extremities become withered. In other cases more extensive gangrene occurs and the affected parts separate as a slough. The affection has been ascribed to various agencies; cold, exposure, general disturbance of nutrition, a sequence or asso- ciated condition of severe systemic fever or disease, nephritic disorders and various neuroses. It is a vaso-motor nutritive disturbance. There is first a contraction of the arterioles and capillaries, followed by dilatation and paralysis of the vessels. The prognosis varies with the severity of the case. Numerous cases of vaso-motor disturbance stopping just short of the pro- duction of gangrene are met with, and not unfrequently such cases go just over the boundary. But severe and extensive cases of symmetrical gangrene are apt to eventuate fatally. The treatment must vary with the underlying cause. In mild cases where actual gangrene has not yet occurred I have found nitroglycerine of value. Amyl nitrite may also be used. The galvanic current, frictions with cold and stimulating applic- ations may also be employed. DERMATITIS CALORICA. Dermatitis calorica includes dermatitis resulting from both heat and cold. As the former of these varieties under the title "Burns" is fully described in all text-books of surgery, I shall omit its description here and proceed to the consideration of: DERMATITIS CONGELATIONIS. The inflammations of the skin produced by cold resemble, in many respects, those produced by heat, only, unlike burns, their course is slow. In addition, a certain morbid predisposi- tion on the part of the patient is a necessary condition of their occurrence. The occurrence of chilblains does not necessarily depend on the influence of extreme cold; indeed, the affection DERMATITIS CONGELATIONIS. 1 93 is said to be commoner in warm than in cold countries, and may occur at a temperature not below 32 F. Anaemic and chlorotic persons are more apt to be the subjects of the affection. The erythematous form of chilblain shows itself in the form of circumscribed patches, of a livid, red color and somewhat tubercular character, the color disappearing under pressure of the ringer. The lesions itch and burn painfully. They occur most commonly upon the ringers and toes, but may appear also on the ears, nose, or other parts of the face, or, indeed, on any part of the body which is exposed to cold. Their course is essentially chronic; usually they do not change in appearance but sometimes become hard and infiltrated, while at other times, under the influence of pressure or rubbing, as of the shoe, or of scratching, a bleb or pustule forms. The pain is then considerably increased, especially when the bulla or pustule bursts and leaves an ulcer. These changes, however, frequently lead to the cure of the affection, which might otherwise have lingered on in- definitely. The bullous form of chilblain is formed under the influence of a more intense degree of cold, and is characterized by the formation of watery or sero-sanguinolent blebs, the size of hazel- nuts or goose-eggs. If they are not punctured they undergo no change for some time, but at last break, after having effected considerable destruction of tissue, the bones even of the feet and hands being in extreme cases occasionally laid bare and exfoliating. The escharotic chilblain is a still more extreme degree of the same process, sloughs forming, which may be cast off without further effect, or which may poison the blood with fatal result.* Lupus erythematosus may sometimes be mistaken for chil- blain, and, in fact, occasionally follows it. For the diagnosis reference may be made to the general features described under its former head. The treatment of chilblain is, first of all, in the way of pre- * Chilblain has been supposed to bear some relation to tuberculosis, and is undoubtedly related to Reynaud's disease and to the "glossy skin" of Weir Mitchell and other writers. 13 194 DISEASES OF THE SKIN. vention. A sufferer from this disease must not expect to be cured while continuing to expose himself to the influences which produced it. Warm and sufficient clothing, protection of the hands and feet, and in cases where the general system is below par, such medication and hygiene as will improve this condition ; such are the points to which attention must first be paid. In mild acute chilblain, rest, in the horizontal position, frictions with cold water or snow, and astringent sedative lotions, as lead- water, lotion of grindelia robusta (see Dermatitis venenata), or opiate washes, may be prescribed. In the more chronic forms of erythematous chilblain stimulant applications are called for. When unbroken the lesions may be painted with tincture of iodine, or, better, with oil of peppermint, pure or mixed with one to six parts of glycerine. The following pigment is con- venient of application: ty. Tinct. iodini, 9j ( 1.33) Athens, f3iiss (10. ) Collodii, foj- (32. ) M. SiG. — Apply with a camel's-hair brush. When the lesions are broken, or in any case, the following forms an excellent application: 1$. Terebinth Venetian, 3iij (12.) Ol. ricini, f 3iss ( 6.) Collodii, ad oj (32.) M. SiG. — Apply with a brush as often as required to shield the chilblain from the air. The following ointment may also be employed: J$. Plumbi acetat., ohss (10.) Ol. rapi (Colza), fg j (32.) Vitel. ovi., j (3.) Cerae flavse, 3iss. • ( 6.) M. Lassar recommends: 1^. Acid, carbolic, gr. xvss ( 1.08) Ung. diachyli, Lanolini, aa 3v (20. ) Ol. amygdalae, 3iiss (10. ) Ol. lavandulae, gtt. xx. ( 1.33) M. DERMATITIS VENENATA. 195 Liniment of aconite may be used, but with caution. Carbolized cosmoline sometimes relieves the burning and itching. The severer forms of dermatitis from cold belong rather to the province of the surgeon than the physician. When opera- tive interference is not demanded, they are to be treated in a similar manner to burns of the like gravity. DERMATITIS VENENATA.* Dermatitis venenata includes the various eruptions produced by the local effect of toxic agents. Chief among these is the inflammation caused by contact with poisonous plants, of which the poison ivy and the poison oak are best known. The effect of the rhus vine and oak varies greatly with the individual. Some persons are so susceptible that they cannot pass to the windward of the vines, or be exposed to the smoke from their burning, without suffering severely, while others can handle them with impunity. The severity of the eruption may also vary from the production of a few vesicles to a very severe eruption, and even death is said to have been caused in several reported cases. As regards the symptoms of this form of dermatitis, there is, first, a period of incubation, varying from a few hours to several days. In children fretfulness and slight fever may precede the outbreak of the eruption. The first local symptoms are burning, heat, and itching, usually observed on the face and hands, as these are the most exposed parts. The surface becomes reddened, with occasional livid spots, and the cellular tissue in the vicinity becomes cedematous. About this time the char- acteristic vesicles begin to appear, usually first of all between the fingers. The next locality involved, in males especially, is usually the genitals. From here the eruption may spread to other parts of the body. * For detailed information consult the monograph on Dermatitis Venenata by Dr. James C. White, Boston, 1887, and "Dermatitis Venenata," a supplemental list by the same author, Jour. Cutan. Dis., 1903, p. 441. Also Morrow's work on Drug Eruptions, New York, 1887. 196 DISEASES OF THE SKIN. When the eruption is at its height, the surfaces involved are of a lurid red color, more or less cedematous, occupied by patches of papules and vesicles, the latter often confluent, with fre- quent excoriations exuding a clear yellow fluid, which gums on linen, and dries into a soft crust. The eyes are often closed from swelling of the eyelids, while the nose, lips, and ears are swelled, and drip with serum. The genitals are often enormously tumefied, and in the most aggravated cases there may be such excessive general oedema that the patient may be rendered actually helpless. In the more marked cases there is sometimes a slight febrile reaction, with coated tongue and constipated bowels. General symptoms are absent, however, in mild cases. The subjective sensations are usually itching and burning in the affected parts. In severer cases this may be intensified to a burning, stinging heat, and the torture may be so great as to deprive the patient of sleep and require the administration of narcotics. The eruption remains at its height for several days, but by the end of a week the acute symptoms have usually sub- sided, though a few stray lesions sometimes continue to appear. The diagnosis of rhus poisoning is usually made without difficulty, because a history of exposure to the poison vine or oak may almost always be obtained. In addition, the localities attacked are characteristic. The vesicles are usually first found between the fingers, where the skin is thin, then on the dorsal surface of the fingers and hands, and last on the thickened skin of the palms. The eruption is more scattered than that of eczema, with which affection it is most liable to be confounded, and the vesicles are usually developed as such, springing often directly from the skin without going through the preliminary stage of papules, as is usually observed in eczema. Dermatitis venenata is not, strictly speaking, contagious. In recent cases the poison can be conveyed from one person to another, or from one part to another, by simple contact of the surface. Thus, the penis may be handled, in micturition, immediately after handling the poison vine, and thus this locality is very apt to be attacked. DERMATITIS VENENATA. 1 97 Eczema is very apt to occur as an immediate sequel to dermat- itis venenata, but the latter disease does not predispose to erup- tions of any kind as a remote result of its influence upon the system. White thinks that there is no evidence of a continuance or re- newal of the operation of the poison after its primary impression on the skin has exhausted itself, and therefore the accounts which we have of yearly recurring attacks of dermatitis venenata indicate renewed exposure, and not spontaneous periodical exacerbation of poisonous influence. A multitude of remedies have been, and constantly continue to be, suggested for the relief of rhus poisoning, some of which are effectual, while others have appeared to prove successful merely because the affection, running a spontaneous course toward recovery, has gotten well while they have been in use. In my experience the use of black wash, in the form of cloths kept wet with the wash and in constant contact with the skin, is one of the most useful remedies. White recommends the following : 1$. Pulv. zinci ox., 3iv ( 16.) Acid, carbolic, 5j ( 4-) Aquae calcis, Oj. (512.) M. This, after being shaken, is sopped over the affected parts freely and repeatedly through the day and by night as well, so often as the patient is waked by the intense itching and burning which characterize the inflammation in its early stages. It may be applied over the whole surface of the body and for any length of time -with safety, and is generally well borne at any stage of the disease. Decoction of white oak bark is also useful. The following, recommended by Hardaway, of St. Louis, has done good service: ly. Zinci sulphat., 5ss ( 2.) Aquae, Oj. (512.) M. Sig. — Apply on cloths every hour through the day, and several times during the night. 190 DISEASES OF THE SKIN. A remedy which is often used with great satisfaction is the fluid extract of grindelia robusta : 1$. Ext. grindeliae robustae, fluid., foij-iv (816.) Aquse, Oj. (512.) M. This is to be applied to the affected parts on cloths, which are to be thoroughly wet with the solution and then allowed to dry almost completely upon the skin, removing them when nearly dry and renewing the application, but not keeping the cloths constantly sopping wet, as with other sedative and astringent lotions. Astringent powders may also, at times, find appropriate place, as on the face, when the patient is obliged to go about, and can- not keep wet cloths, etc., applied. The following may be men- tioned : I£. Pulvis zinci carb. praecip., Amyli oryzae, aa oj. (32.) M. Or this: 1^. Magnesii carbonatis levis, Pulveris lycopodii, aa oss. (16.) M. At times none of these applications seems effectual, when the employment of some simple domestic remedy, as a solution of washing soda in water, gives relief. I am inclined to think that failure more frequently results from inadequate or improper application of remedies than of the want of virtue in the latter. Most patients presenting themselves with rhus poisoning are children, on whom it is difficult to apply any remedy effectually. The parts affected are often difficult to cover, and constant movements cause the best placed bandages to be quickly mis- placed. If it were possible to place some fixed adhesive dressing, this would be of advantage, but where there is much secretion such applications will not remain long in contact with the skin. A solution of tar, or oil of cade in collodion, or gutta percha one drachm to the ounce, may be used on parts where the itching is severe, and where the skin has not yet been broken. The advantage of this is that small scattered patches can be covered without the necessity of extensive dressings. DERMATITIS VENENATA. 1 99 White recommends a solution of gelatine in glycerine and water : 1$. Gelatin, oiv ( 16.) Glycerin, . . f 5 j ( 32.) Aquae destillat., ad f§iv. (128.) M. This may be used when the skin is broken, and, by the addi- tion of a drachm (4.) of boric acid, may be made antiseptic at the same time. When washes have been used in the daytime, they may be replaced by ointments at night. These should usually have vaseline as a base. The following may be suggested: 1$. Acid, tannic, gr. xv ( i.) Petrolat., oj. (32.) M. Or salicylic acid may be employed in the same proportion as the tannic acid. When there is much itching carbolic acid may be used in the ointment : T$. Acid, carbolic, gr. x-xx ( .6-1.2) Hydrarg. chlor. mite, gr. x ( .6) Pulv. amyli, 5j ( 4- ) Petrolat., oj. (32. ) M. The calomel should be used with caution, or omitted when the surface to be covered is considerable. Where constipation exists, it is well to give a purgative at the beginning of the treatment. No other internal treatment is required. The prognosis of this form of dermatitis is, of course, favorable, although the occurrence of successive crops of eruption may delay the cure for some weeks. (Various other plants are mentioned by Dr. J. C. White, in his very complete monograph on "Dermatitis Venenata," as known or believed to exercise an irritant and poisonous action on the skin. Among these, which are very numerous, the best known are the following: Cashew nut, Indian turnip, skunk cabbage, 200 DISEASES OF THE SKIN. the upas of Java, cultivated at times in our gardens ; bitter orange, catalpa, arnica montana (not the American arnicas), flea-bane, burdock, euphorbia, manchineel of Florida, mucuna pruriens or cowhage, flax?, bayberry (employed in making cheap "Bay rum"), poke, smartweed, wood anemone, clematis, larkspur, buttercup, ipecac, cinchona and quinine, Balm oj Gilead, mezereon, thapsia, nettle, hyacynth bulbs, etc. Of inorganic substances which may give rise to dermatitis are paraffin, petroleum, common or sea salt, bichromate of potas- sium and aniline dyes. In addition, a number of drugs may produce the same condition. Some, if not all, of these will be found mentioned under Dermatitis medicamentosa. Of the animal kingdom, mention may be made of the lower forms of marine life — hydroa, medusa; , polyps, etc. — of which the best known are the Portuguese Man-of-war, the jelly fishes generally and sea urchins. The commoner animal parasites will be found mentioned under their various names, or that of the diseases they produce, as bed-bug, scabies, pediculosis, etc. Reference may be made to the monographs of White, Piffard, and Morrow for fuller details. (Advantage is sometimes taken by malingerers and hysterical persons of the known action of the agents mentioned above to produce artificial eruptions.) X-RAY DERMATITIS. The Rontgen ray, at present used extensively in the treat- ment of various diseases of the skin, may itself, if incautiously used, produce a dermatitis at times extremely intractable to treatment. The first signs of cutaneous disturbance sometimes do not present themselves for several days or longer after exposure. The milder forms occur as a peculiar reddish flush or erythema resembling sunburn and which, in the course of several days to a few weeks, gradually disappears. In other cases, freckles, telangiectases, growth of downy hairs in smooth places, or temporary falling of the hair where this naturally grows may X-RAY DERMATITIS. 201 occur. Sometimes the erythema is rapidly succeeded by a super- ficial, ill-defined vesiculation and with or without a trifling swell- ing or pufhness; such cases often give rise to a good deal of pain. Sometimes exfoliation follows the erythema. In those whose hands are constantly exposed to the ray, as with physicians making constant use of it professionally, a persistent redness with scali- ness ensues. Sometimes this may become permanent or lead to atrophic changes. In a few cases keratoses have resulted, fol- lowed by carcinoma. Such cases are rare and may for the most part be referred back to the early employment of the X-ray by inexperienced operators. However, the possibility of atrophic and other changes occurring must be kept in mind and due caution should be employed in the treatment of benign skin diseases. In a very few instances the destructive effect of the ray has gone so far as to give rise to sloughing with the production of excessively painful ulcers of a more or less permanent character. The etiology and pathology of X-ray dermatitis are at present in doubt. Most observers consider the changes as trophoneu- rotic in character. Macleod* concludes that the X-rays in small doses have a stimulating effect on the elements of the healthy skin. Large doses are capable of devitalizing the tissue ele- ments, interfering with the process of reproduction and causing their degeneration. The more highly differentiated structures, such as the hair follicles, glands, nails and blood-vessels, are more readily and severely affected by the rays than the less differentiated epidermal cells or the fibrous stroma of the corium. Pathologically altered cells, whether of epiblastic or mesoblastic origin, are far less resistant to the rays than healthy cells, and are devitalized by small doses of the rays. This destructive ac- tion on diseased elements may be taking place while the healthy elements in the neighborhood, instead of having their vital- ity inhibited, may be stimulated to a process of repair. The action of the rays is cumulative and when the cellular degenera- tion reaches a certain degree the toxic products of the breaking- * Brit. Jour. Derm., 1903, p. 365, quoted by Stelwagon. 202 DISEASES OF THE SKIN. down cells are capable of setting up an inflammatory reaction, which is a secondary phenomenon. This inflammatory reaction is peculiar in that it occurs in a tissue, the vitality of whose various elements has already been impaired by the action of the rays, and in that it is associated with greater destructive changes than those produced by the actinic rays and is apt to lead to ulcera- tion and necrosis, and is liable to be followed by an imperfect process of repair. The treatment of X-ray burns is largely preventive. The dangers of too long and too frequent exposure, too close proximity and a high current intensity are so far as possible to be avoided. In the treatment of limited areas the interposition of sheets of lead with windows of requisite size to permit the exact area de- sired only to be exposed will be found useful. In operating upon the face I use a wire mask covered with a number of sheets of tin-foil with an opening the size of the lesion to be operated upon. The milder forms of X-ray dermatitis require the same soothing applications as are employed in the treatment of acute eczema and simple dermatitis. When stubborn ulceration takes place curettage with subsequent skin-grafting appears to be the only recourse. The prognosis of the milder forms of X-ray dermatitis and even where slight ulceration has taken place is favorable eventually. In the more severe ulcerations the prospect is unfavorable. Fortunately such cases are extremely rare and when the manage- ment of the ray is in skilled and judicious hands should scarcely ever occur. DERMATITIS FACTITIA. Feigned diseases of the skin include those various forms of dis- ease which are artificially produced with the intention to deceive. Such affections are usually seen in beggars, criminals, soldiers, sailors, and others who may have an object in deceit, or they may be self-produced in hysterical or insane persons. In the latter case the occurrence of hysterical neuroses must be taken into DERMATITIS FACTITIA. 203 account for it is often difficult to distinguish a pure neurosis from a partly artificial or a wholly artificial eruption. Among the skin affections which have been imitated are javus, alopecia areata, tinea tonsurans, scabies, bromidrosis, hcematidrosis, chromidrosis, urticaria, ulcers, erysipelas, various forms of derm- atitis, etc.* Of these the various forms of dermatitis are the most interesting because they occur among hysterical persons and often without any explicable motive. Indeed, cases are on record where a true hysterical dermatoneurosis has occurred at one time while later a factitious imitative eruption of the same character has been observed.! Mechanical irritation may be employed, with the result of giving rise to eruptions resembling one of the usual forms of dermatitis. Sangster described the case of a young girl, where the diagnosis was made first as "abortive herpes," and later as "neurotic excoriation," where painful erythematous patches were succeeded by exudation on the surface of serum and sero- pus, each patch terminating in desquamation, and running its course in ten to fourteen days. There was no vesiculation or loss of substance. The longest interval during which the patient had been free from the lesions was three months. The case came under observation at intervals for three years, but finally Sangster was able to satisfy himself that the lesions were pro- duced purposely by forcibly tearing with the nails. Stelwagon has described the case of a girl of nineteen, pale, nervous, and suffering from hysterical aphonia, who applied for relief for an eruption which had persisted almost uninterruptedly for three months, and which consisted in groups of two or more parallel, elongated, crusted lesions, situated on the flexor and extensor surfaces of the forearms and on the tibial surfaces of the legs, with eczemaform patches in the flexure of one elbow and on one instep. The crusts resembled those of impetigo contagiosa. The patient, who had been for some time unsuccess- fully treated, was finally suspected of simulation, and on being *See Laugier, Die. de Med. et de Chir. Practiques, Art. Maladies Simulees. |See the case of Louise Lateau under Hcematidrosis. 204 DISEASES OF THE SKIN. closely questioned, confessed having produced the lesions by constant rubbing with the finger ends. The sensation thus given was an agreeable one, and it was this, she asserted, and not the desire to gain sympathy, which was her object. Bazin reported a case in which a young girl succeeded in producing an eruption of bullae by introducing cantharides powder under the epidermis. Pierrepont (Sajous' Annual, vol. iv, 1889, p. 62) gives a similar case caused by fly blisters. A case was reported by the late Dr. Fagge, of London, in which a young girl caused an eruption of bullae resembling those of pemphigus by the application of nitric acid to the skin. Feigned diseases of the skin are often very difficult of diagnosis. On the one hand, care must be taken not to mistake professional eruptions, as bakers', bricklayers', sugar-boilers', bartenders' dermatitis, or the eruptions produced by the ingestion of drugs (see Dermatitis medicamentosa) or of certain edibles, for facti- tious eruptions; and, on the other hand, it must be remembered that various skin diseases may be closely simulated by artificial means, and that such deception may be kept up for months. In the case of soldiers and prisoners, where fraud may be sus- pected, such measures as bandaging, surveillance, etc., may be practiced; but among hysterical females of the better classes the difficulties of diagnosis are heightened by the fact that factitious eruptions may be caused by a sort of automatic mental impulse, and without any perceptible object. Two points must be remembered in such cases. First, the disease is almost always anomalous in the time, place, or manner of its appearance and in the course it runs. Second, it almost always shows some sign of having been artificially produced, and is almost invariably in a position easily and conveniently access- ible to manipulation. Thus the face, forearms, chest, and mam- mary region, and after these the lower limbs, are most apt to be the seat of the eruption. If, in addition, any motive for malin- gering, or for exciting interest and sympathy, can suggest itself, the case should be carefully looked into from this point of view. The lesions and their neighborhood should be examined, DERMATITIS MEDICAMENTOSA. 205 with a view to detecting any trace of the use of mechanical irritants, or of such domestic articles as are apt to be used; mus- tard, vinegar, cantharides, nitric acid, etc., have all been employed. The examination should always be so made as to avoid suspicion of its object, and if the physician comes to a positive conclu- sion that the eruption, in any given case, has been artificially produced, let him not think of proclaiming his conclusion, which will probably only lead to the suspicion, on the part of friends and relatives, that he does not know his business. Better to treat such cases with placebos, and have them recover spon- taneously, without forcing the patient to admit a deception, or pitting one's reputation for sagacity against the patient's veracity. Of course, I have chiefly in mind the case of hysterical women feigning skin diseases. DERMATITIS MEDICAMENTOSA. Drug eruptions are those produced by the ingestion of sub- stances ordinarily used as medicines. These must be taken up into the system to produce the effects here understood. The direct irritative effects caused by the application of drugs to the surface are described under the head of Dermatitis venenata. Some drugs, as iodine and its salts, will produce eruptions in almost any individual if taken in considerable quantity or for a sufficient length of time; others, as quinine, only produce an effect in persons having a peculiar idiosyncrasy toward the drug. The following drugs have been known to produce erup- tions upon the skin as a result of their ingestion: Arsenic, antipyrine, anacardium, anitmony tartrate, belladonna and atro- pia, bitter almonds, bromine, borax, benzoic acid, boric acid, can- nabis indica, chloral, copaiba, cubebs, digitalis, duboisia, hyo- scyamus, iodine, iodoform, mercury, opium, pilocarpine, phos- phoric acid, quinine, salicylic acid, santonine, tar and its deriv- atives and congeners, turpentine, carbolic acid, creasote, rosin, and petroleum* *A large number of other drugs ai*e enumerated by writers on the subject. See Morrow on Drug Eruptions, also Hyde and Montgomery, and Stelwagon. 206 DISEASES OF THE SKIN. The eruptions produced by these drugs are generally limited to a few pretty well-defined groups, and bear a family resem- blance to one another. Erythematous, scarlatiniform, and urticarial rashes are usually met with. Less frequently, pustu- lar, bullar, purpuric, or nodular eruptions are encountered. There is nothing about the appearance of these eruptions which is so characteristic that the drug causing it can be pointed out in any given case. We are able, however, in most instances, to designate an eruption as due to the effect of some drug, because, while resembling closely some other eruption in its lesions, the drug eruption is always different in some well-defined symptom. It may be excessively profuse, or it may be accompanied or unaccompanied by fever, contrary to the usual rule, or the lesions may occur in some unusual place and run a peculiar course. The eruptions due to iodine and bromine differ so much from the other drug eruptions that they are best considered at length. There is an erythematous eruption due to bromine, which may occur in any part of the body, but is usually confined to the lower extremities; it is diffuse, and at times painful. A maculo- papular eruption has been described as occurring on the face and neck, the skin having a congested violaceous hue, with a copious eruption of maculo-papules and pustules, with enlarge- ment of the sebaceous ducts and the formation of sebaceous crusts. The skin is flushed, but does not itch. As there is some fever and constitutional disturbance, this eruption may be mistaken for the erythematous syphiloderm, but the sebaceous character of the lesions is characteristic. Wigglesworth has described a bullous eruption due to bromine, and characterized by lesions which were somewhat acuminated and varied in size from that of a split pea to the end of the finger. In some instances the bullae ruptured, leaving sometimes a simple fringe of torn epidermis, and sometimes an ulcerated surface. Some of the bullae appeared to contain blood. The pustular eruptions due to bromine are better known than any of the other varieties. In their simplest form, resem- DERMATITIS MEDICAMENTOSA. 207 bling acne, they occur sooner or later in almost all persons sub- jected to a course of the bromides. Occasionally a furunculoid or anthracoid eruption is observed. Here the smaller lesions are pea-sized, prominent, convex, vesico-pustules, seated on a hard, slightly elevated base, and surrounded by a vividly red areola. The larger lesions are flattened elevations, covered by a moist, flaccid cuticle, or thick, light brown crust, and surrounded by a dark red areola. The crust or cuticle being removed, the sur- face beneath presents numerous pin-head-sized, yellowish-red protuberances. The secretion is found to be chiefly sebaceous in character. These confluent lesions may be from one-fourth of an inch to several inches in diameter. The peculiarity which chiefly distinguishes this form of bromide eruption from acne is that it may occur in any locality, often being found where acne never occurs, and neglecting entirely the favorite localities of that disease. A bromine eruption is occasionally met with which resembles the eruption of erythema nodosum. In the diagnosis of bromine eruptions the dusky rose or viola- ceous color of the lesions must be taken into account, and also the distribution of the lesions, the fcetor of the breath, and the presence of bromine in the urine must be considered. Of course, the history is of importance. With regard to the amount of the drug necessary to produce these skin eruptions, it can only be said that it varies greatly. While usually it is requisite that bromine or its compounds should be taken in considerable doses, and for some length of time, yet cases are on record in which very small doses have quickly brought out a characteristic eruption. Like the eruptions due to bromine, those due to iodine have, some of them, at least, been familiar for a long time. The eruptions from iodine may be erythematous, papular, vesicular, bulbar, pustular, or hemorrhagic. The erythematous form shows itself in large disseminated patches in various parts of the body, sometimes forming a sort of iodic roseola. The forearms are usually attacked. If the use of the iodide is persisted in, the 208 DISEASES OF THE SKIN. eruption may pass on to the papular form. The papular erup- tion is characterized by heat of the skin, with reddish patches, on which are situated numerous large papules elevated very slightly above the surrounding skin, sometimes disseminated over the surface generally. This form of eruption is not unlike urticaria, but has a brighter and less circumscribed coloration. It is rare. Vesicular eruptions resembling eczema are said to have been caused by the ingestion of iodine or its compounds, and several observers have reported a peculiar bullous eruption situated usually upon the head, neck, or upon the upper extrem- ities; less frequently upon the lower extremities and trunk. The lesions begin as pin-point-sized vesicles, or as shot-like papules, at the apices of which vesiculation subsequently occurs. The lesions are pale, yellowish-white and glistening. If the iodine be persisted in, and especially if given in large doses, the bullae change to red and purple, and become filled with sero-pus and even ichor. In a few instances blood has been found in the bullae at an early stage. The pustular eruption due to the ingestion of iodine or its compounds is in almost every respect analogous to that pro- duced by the bromides, only that the confluent form is ex- tremely rare. It is peculiar in its subjective symptoms, itching at first, and later giving rise to severe throbbing pain. This symptom, together with the violaceous color of the lesions, and their cheesy, non-purulent contents, serves to distinguish the iodine eruption from syphilis or any other disease with which it is liable to be confounded. A purpuric eruption due to the ingestion of iodine or its com- pounds is now and then met with. It may be brought on even by minute doses of the drug, the case of an infant having been re- ported where a fatal result was caused by a single dose of two and a half grains. Usually, however, the eruption is not severe, and is found upon the legs. Now and then other hemorrhages may be caused simultaneously. It is usually produced at an early date from the first exhibition of the drug, but its appearance is occasionally delayed until the drug has been administered for VARICELLA. 200, some time. The purpuric eruption ceases when the iodine is stopped, but may be reproduced by even minute doses.* Both the iodine and bromine eruptions may often be pre- vented by the simultaneous administration of arsenic. As much as ten minims of Fowler's solution may be given in each dose when this is borne by the patient. Paget recommends the administration of aromatic spirits of ammonia with the same view. The other drug eruptions, aside from those due to bromine and iodine, may be classed together, on the ground that they are almost always of an exanthematous character, resembling scarlatina, measles, roseola, urticaria, etc., and that idiosyncrasy bears a much more important part in their production than in the case of the drug eruptions described above. As regards the manner of the production of drug eruptions, this question has not as yet been settled. Three theories have been advanced: (i) That of skin elimination, the drug acting as an irritant as it passes through the cutaneous tissues or glands. (2) Increased skin elimination due to defective condition of the ordinary eliminative organs, more particularly the kidneys. (3) The neurotic theory, the action being either purely reflex, anal- ogous to urticaria ab ingestis, or due to the influence of the drug upon the vaso-motor centers or on the peripheral nerves. VARICELLA.f Varicella, or chicken-pox, is a contagious, febrile, systemic affection of benign type, occurring chiefly in children, and characterized by an eruption of discrete, scattered, superficially seated, thin-walled, usually small-pin-head to pea-sized vesicles. The disease has an incubative period of ten to fourteen days, * Among recent contributions on the subject, see Lorta Wright Myers, " A Rare Bromide Eruption." Jour. Cutan. Dis., 1904. p. 231; Pollitzer "Iodoform Erup- tion from Mesotan." lb., '03, p. 466; also D. W. Montgomery, "A Tuberous Iodid of Potassium Eruption Simulating Histologically an Epithelioma. ''lb., 1904, p. 65. t The other exanthemata, scarlatina, rubeola, rotheln and variola are so ex- tensively described in the text-books of general medicine that it has not been thought advisable to include them here. 14 2IO DISEASES OF THE SKIN. after which occur malaise, chilliness and languor. The patients, usually children, then suffer from a fever of 99°-ioo° F., lasting from a few hours to two or three days, after which defervescence is commonly complete. With the onset of the fever,, or in many cases, without any fever, the rash appears at first upon the head and trunk and later in other localities in successive crops, assuming at first the form of rosy macules or slightly elevated lesions, lacking the characteristic shot-like feeling of the variolous papule. The vesicle rapidly forms on this macular base, pin-head to pea- sized, rounded or oval, rising well from the surface with limpid contents. When fully developed, the underlying papule or macule usually fades, leaving the clear vesicle standing directly out from the skin without any areola. The eruption varies greatly in extent in different cases. It may be quite abundant or, in some cases, scanty, and even occasionally one or two lesions are all which are to be discerned. The individual lesions reach full development in several hours to one or two days, by which time desiccation has already set in, drying to thin film-like crusts. The lesions leave no scar as a general thing, but sometimes, whether as a result of purulent infection or otherwise, deeper action takes place and a small pit results. The process is, as a rule, ended and the crusts fallen off in from seven to twelve days after the inception of the disease. Varicella is contagious and by some believed also to be inocul- able. A second attack in the same individual is extremely rare. The attack, it need hardly be said, does not protect against small- pox. It is a disease of children, most cases occurring between the ages of one and five, rarely it has been observed in adults. The diagnosis of varicella is to be made from the lightness or absence of systemic disturbance, the scattered distribution of the eruption, usually upon the trunk and also upon the scalp, the superficial nature of the lesion, its thin, easily ruptured wall and the irregular crop-like appearance of the eruption. The disease is to be carefully differentiated from small-pox. Very VACCINAL ERUPTIONS. 211 unfortunate results occasionally result from mistaking one af- fection for the other.* The prognosis of varicella is favorable in all cases. Treat- ment should be largely expectant. VACCINAL ERUPTIONS, t The vaccinal eruptions may be divided into two classes: (i) Eruptions due to pure vaccine inoculation, and (2) eruptions due to mixed inoculations. The following table shows the various eruptions displayed. (Frank.) f Local (1) Due to vaccine virus \ I Systemic (2) Due to mixed inocula- tion introduced at time of vaccination or subse- quently. I Local ^ Systemic f Local erythema J Dermatitis I Local vaccinia I Adenitis f More or less generalized ery- thema (erythema vaccinium, roseola vaccinia) i Urticaria Erythema multiforme Vaccinia (generalized vaccinia) Purpura. I Impetigo contagiosa Furunculosis Cellulitis Erysipelas Gangrene Tuberculosis cutis Gangrene Pyaemia Syphilis Leprosy Tuberculosis *See Morrow "On the Diagnosis of Small-pox," Jour. Cutan. Dis., 1886, p. 72, and for the sad result of mistaken diagnosis, Dyer on the "Differential Diag- nosis of Varicella and Variola," New Orleans Med. and Surg. Jour., Jan., 1896. fSee Malcom Morris, B. Med. Jour., Nov. 29, 1890; Frank, Jour. Cutan. Dis., 1895, P- J 42; Dyer, New Orleans M. and S. Jour., Feb., 1896; Stelwagon, /. Am. M. A., Nov. 22, 1902, and Corlett, Jour. Cutan. Dis., 1904, p. 495. 212 DISEASES OF THE SKIN. (3) Sequelae of vaccination Eczema Urticaria Pemphigus I Psoriasis I Furunculosis. The vaccinal eruption most frequently seen is the erythema, which in ordinary cases surrounds the point of vaccination like an areola, sometimes spreading from this point and at other times showing itself in scattered patches over various parts of the surface. Next to this in frequency are the urticarial and erythema-multiforme-iike eruptions. A regional, vaccinia-like eruption sometimes met with may be impetigo contagiosa. Adenitis is often present. There appear to be two periods for the occurrence of vaccinal eruptions, the first three days or after the ninth day. Eczema and psoriasis sometimes start from vaccination in persons prone to these diseases. In other instances vaccination seems to have a beneficial effect on previously existing eruptions. Serious diseases as syphilis, leprosy, tuberculosis, have been inoculated in vaccination, but such cases are extremely rare and in the present state of our knowledge need never occur. Ordinary vaccinal eruptions cannot always be prevented and the physician should never be blamed for such untoward occur- rences if ordinary precautions have been taken. Strict antiseptic and protective treatment should be carried out immediately after the vesicles have developed and the cases should be seen from time to time by the vaccinator until the wounds have healed. PURPURA. 213 CLASS III. HEMORRHAGES, PURPURA. Purpura is an affection of the skin, characterized by the appearance of hemorrhagic spots of various sizes, and accom- panied or not by similar hemorrhages in the mucous membranes and viscera. It may be idiopathic or symptomatic. The idio- pathic form commonly presents itself in two varieties, P. simplex and P. hemorrhagica. Purpura simplex is characterized by the appearance, in successive crops, of numerous petechial spots in the skin and visible mucous surfaces. These are usually attended with little or no constitutional disturbance, although malaise, loss of appetite, etc., may precede the outbreak of the eruption by some days. The spots come out suddenly; often in the night, and the patient finds his skin, usually the legs and about the knees, strewn with sharply-defined, pin-head to pea-sized hemorrhagic lesions. The color of the eruption, at first bright red, soon becomes purplish, and the lesions may be single and scattered, or here and there mingled in irregular patches. The only subjective symptom observed is slight itching on the appearance of the lesions; often even this is absent. Occasionally wheals, like those of urticaria, occur with the hemorrhages, and then there may be much itching. Blebs have been noticed in this form of purpura. Purpura simplex is more apt to be observed in the old than in the young. An attack may last from a fortnight to several months, the cutaneous lesions coming out in crops. The causes are often obscure; it occurs in the well-nourished as well as the debilitated. Malarial influences also have an effect in causing the disease. The lesions of purpura simplex are so peculiar, being small hemorrhages under the skin which do not disappear on pressure, that there is usually no difficulty in making a diagnosis. The 214 DISEASES OF THE SKIN. lesions may, however, be confounded with flea-bites. The puncture made by the insect in the center of each hemorrhagic point will, however, settle the diagnosis. There is one form of purpura simplex which is known as purpura rheumatica, where the prodromal symptoms are more severe, and where severe rheumatic pains are felt, especially in the joints of the lower limbs. When the eruption comes out the rheumatic symptoms abate; relapses here are common; the disease may last for months, and sometimes takes on the appearance of erythema multiforme. Under the name peliosis rheumatica or Schonlein's disease, a rare affection beginning, sometimes with severe sore throat and displaying symptoms of purpura, rheumatism and erythema conjoined, has been described. Henoch's purpura, chiefly observed among children, seems in some cases to be a combination of purpura and angioneurotic oedema. It is apt to be accompanied by gastro-intestinal crises — pain, vomiting and diarrhoea, joint pains or swelling, and hemor- rhages in the mucous membranes. Recurrences are common. Acute hemorrhagic nephritis may occur in severe cases (Osier). The second variety of idiopathic purpura, P. hemorrhagica, also known as morbus maculosus Werlhofii, is a much more severe disease. It begins by marked prodromal symptoms, as debility, loss of appetite, languor, headache, and a feeling of general dis- tress. The spots of eruption appear suddenly, first upon the limbs, and then spreading to other parts of the body, occurring usually in great numbers and often coalescing to form hand-sized patches. Hemorrhages from the mouth, gums, nose, stomach, bowels, and bladder, and even into the brain, may occur simul- taneously and the disease may have a fatal termination. The disease may occur at all ages, and among the strong and well- nourished, as well as among the weak and ill-fed. The symptomatic forms of purpura are those in which the hemorrhage into the skin is a comparatively insignificant symptom of a more important disease. The specific fevers, various forms of anaemia, leucocythemia and scurvy form one group of these. Another is formed of cases where the extrav- PURPURA. 215 asation of blood into the skin is caused by the ingestion of drugs. A third group includes cases occurring from mechanical causes, as feeble circulation, varicose veins, thrombosis, etc. A fourth group includes all those cases in which the nervous system is primarily at fault, as tabetic purpura, purpura in connection with diseases of the central nervous system and neuralgia, etc. The etiology of purpura is still somewhat obscure. No one cause can be set down as essential in all cases. In addition to the ingestion of certain medicines, notably iodine and its com- pounds, salicylic acid and chloral, such influences as malaria, scorbutus, anaemia, etc., may give rise to the eruption.* Levy thinks the purpura in these cases is microbic in origin — one variety may be toxic and one septicaemic. In the first variety, toxins are formed by the microbes confined to certain organs (for example, the intestinal tract after eating spoiled meat) which act on the vaso-motor nerves through tbe blood by which a dilatation and finally a rupture of the capillaries of the skin are produced and followed by the characteristic appearance of macules. In the septic form the microbes are directly carried beneath the skin into the blood current and become the cause of microbic emboli. The effect may be increased if the microbes situated under the skin should, by chance, produce toxins which might act on the vaso-motor nerves. Some purpuras of toxic origin may arise from intestinal auto-intoxication. In grave types of purpura there is usually great diminution in the red blood corpuscles. In a case reported by Cureton, three days before death these numbered 1,680,000, rapidly going down to 310,000. Anatomically the effusion has its seat in the corium, especially the papillae and sometimes in the subcutaneous tissue as well; the involved blood-vessels are usually dilated and filled with red blood corpuscles. The diagnosis of purpura presents, as a rule, no difficulty. Few *See Shattuck "Lymphatic leukemia, with Purpura" (case), Jour. Cut. Dis., 1904, p. 118; also Engman " Malaria Purpura," lb., 1903, p. 489. 2l6 DISEASES OF THE SKIN. or no other diseases excepting scurvy are attended by effusions of blood under the skin. In scurvy the disease occurs in persons deprived of vegetable food and fruits and is generally preceded or accompanied by softening and sponginess of the gums, bleed- ing of the latter and loosening of the teeth* The hemorrhagic lesions are also usually limited to the legs and ankles with a tendency to swelling of the parts. Flea-bites have been mistaken for purpura but the evidence of a central puncture and their scanty number should distinguish these lesions from those of purpura. The prognosis of purpura must always be expressed with a certain caution. Cases beginning mildly sometimes later become quite serious. Most mild cases, however, terminate favorably after an indefinite time, varying from a few weeks to several months. In hemorrhagic purpura the prognosis is grave. In the treatment of purpura, attention must first be paid to the removal of the cause, if this can be ascertained. Nutritious diet, and above all, if the hemorrhage be extensive, perfect rest in the horizontal position, are important. In purpura simplex, ergot, iron and quinine, the mineral acids, together with frictions and cold baths, are beneficial. Purpura hemor- rhagica calls for prompt and decided treatment. In addition to perfect rest and diet in ordinary cases, tincture of the chloride of iron in doses of twenty to thirty drops, alone or with ergot and digitalis, may be given. Turpentine and acetate of lead, with opium, may be administered in some cases. Nitrate of silver in J grain (0.0108) doses two or three times a day has been used with success. Calcium chloride in 15-30 grain (1-2) doses three times a day has also been recommended. It should only be used a few days as it in time deminishes the coagulability of the blood. Oil of erigeron, in five or ten-drop doses, on sugar, every two or four hours, is highly recommended. In severe cases ergotine may be given hypodermically, one grain (0.065) every four hours. Electricity has succeeded when other remedies have failed. Finney recommends ergot and belladonna at first, and bark, ammonia, and the mineral acids later. PURPURA SCORBUTICA. 21 7 PURPURA SCORBUTICA. Purpura scorbutica or scurvy is closely allied in its skin manifestations to typical purpura. Scurvy, however, is due to long-continued deprivation of proper food, especially fruits and vegetables, with the accompaniment of other bad hygienic conditions. It usually occurs among sailors but may also occur on land and especially among improperly or insufficiently fed infants. The symptoms are general emaciation and loss of strength, swelling of one or more joints, and a more or less swollen, spongy and even gangrenous condition of the gums. Concomitantly, dark purplish, hemorrhagic patches appear upon the lower portion of the legs, sometimes small hemorrhages oc- cur, but in any case the color is more dusky than the petechia and ecchy- moses of ordinary purpura. Ulceration takes place in some cases both in the skin and the gums. Hemorrhages from the mucous surface, fcetor of the mouth, exhaustion and death may supervene in severe cases. The treatment of purpura scorbutica consists in the removal of the patient from the bad hygienic conditions which have caused the disease, and placing him under the most favorable conditions possible. Lemon or lime-juice and abundance of fresh vegetables should be supplied. In some cases the usual tonics, iron, quinine and strychnine are required. Locally the gums and mouth should frequently be washed out with diluted tincture of myrrh " eau de Botot " or other astringent mouth washes. In some cases the limbs may be bandaged but local treatment is not often necessary. Closely connected with purpura is the hemorrhagic condition, known as "bloody sweat," or " haematidrosis," which consists in the appearance at the outlets of the excretory ducts of the sweat glands of a reddish fluid contain- ing blood. It is usually in small quantity and localized, and is a cutaneous hemorrhage, taking place about the sweat glands, and emptying itself through the sweat ducts. It is a very rare disease. (See Hcematidrosis.) 2l8 DISEASES OF THE SKIN. CLASS IV. HYPERTROPHIES. LENTIGO. Lentigo, or freckles, are yellowish, brown or blackish pigmen- tary, circumscribed cutaneous macules, varying in size from a pin-head to that of a pea or larger, and appearing for the most part on exposed regions, as the face and backs of the hands. Exceptionally freckles may occur on the back, thighs, buttocks, etc. They are usually met with in the young and are more apt to occur in the summer months and after exposure to the sun. They do not give rise to any subjective symptoms. Occasionally lentigo is an early symptom of the exceedingly rare disease of the skin, xeroderma pigmentosum. In old persons freckles appear on the backs of the hands and to a less degree on the face as the precursors of senile warts. Freckles consist of a circumscribed amount of pigment in the rete mucosum — merely, in fact, a localized increase in the normal pigment, differing from chloasma only in the size and shape of the pigmentations. The treatment of lentigo is unsatisfactory. The pigment spots may be removed but if at all numerous they tend to return almost immediately. A lotion of bichloride of mercury of one to four grains to the ounce of alcohol and water will often cause peeling of the epidermis which will bring off the pigment with it. Peroxide of hydrogen will also clear off superficial freckles. Other preparations may be found in the larger works on diseases of the skin. CHLOASMA. Chloasma is a pigmentary hypertrophy of the skin, character- ized by the appearance of variously sized and shaped yellowish, CHLOASMA 219 brownish, or blackish patches, or as more or less diffused dis- coloration. The eruption begins slowly and insidiously and may not attract attention until a considerable area is involved. The only symptom is the deposit of pigment. There is no elevation, the surface of the skin remains smooth, except in a few cases where the sebaceous glands seem to be involved, and there are no subjective symptoms. The face is the part most frequently attacked, although it may be found on the trunk or limbs. Idiopathic chloasma includes all those cases in which the pig- mentary increase is due to external agents, as the sun's rays, blisters, etc. Symptomatic chloasma includes those forms which occur as a consequence of organic or systemic disease, as in Graves' disease, Addison's disease, tuberculosis, syphilis, etc. The most important variety of this form is chloasma uterinum, due to disturbances, functional or organic, of the utero-ovarian system. Here the pigmentation is almost always on the face, sometimes forming a sort of mask. It may be quite extensive over body and limbs, especially when due to pregnancy. The causes of chloasma have been partly mentioned in de- scribing the varieties. Most cases coming under observation are utero-ovarian in origin. Anaemia, chlorosis, chronic indiges- tion, neurasthenia, nervous shocks, etc., may also be mentioned as causative. Pathologically, chloasma is merely an increase in the phys- iological pigment function. It is apparently under the influence of the nervous system and in some cases the supra-renal glands seem to play a part. Anatomically, increased deposit of pigment is observed having its seat partly or wholly in the mucous layer of the epidermis. Chloasma is to be distinguished from tinea versicolor, vitiligo, and chromidrosis. In tinea versicolor the eruption is rarely met with upon the face and rarely occurs off the trunk and upper arms. It is scaly and a microscopic examination of the scales shows the fungus. In vitiligo the patches are dead white and it is only the surrounding skin which is darker than normal. In 220 DISEASES OF THE SKIN. chromidrosis the fact that the glands are chiefly involved is ascertained by the secretion which covers the darkened skin. The treatment of chloasma requires a careful study of the case from every point of view. The condition of the general health, the digestion, the utero-ovarian functions should all be examined into. If anaemia or chlorosis are present these must be combated. Locally the treatment is somewhat simi- lar to that of lentigo, but rather more severe as the pigment tends to go deeper. Exfoliation of the skin is the result to be aimed at and this should be accomplished as thoroughly as the patient and circumstances will permit. Too strong exfoliatives as blis- tering, etc., must not be resorted to as deeper pigmentation may follow. The following preparation has been recommended: 1$. Hydrarg. chlor corrosiv., gr. iij-xij (0.2-0.8); acid acetic dil, ~>ij (8.); sodii biborati, gr. xl (2.65); aq. rosae q.s. ad f§iv (128). Other preparations will be found in the text-books but in practice they mil be found either inefficient or uncontrolable. It must be admitted that as a general thing the treatment of chloasma is very unsatisfactory. ARGYRIA. Argyria is a form of discoloration of the skin, resulting from the prolonged administration of some salt of silver, usually the nitrate. The dose necessary to produce the effect is uncertain. As little as 280 grains (16.) taken over a con- siderable period has been reported as causing the discoloration. The earliest sign is a dark blue line along the edges of the gums. The color of the skin resulting is of a bluish-gray or slate color. It is general over the surface but most pronounced over the parts exposed to the light, as the face and hands. The hair and nails are also discolored, the hair having a faint reddish tinge. The pigment is found in the form of reduced silver, chiefly in the upper- most papillary layers of the corium. It is also observed in the membrana propria of the sweat glands. A deposit is also found in the internal organs with the exception of the nervous system. When once established the discoloration is permanent. Yandell had two patients in whom the discoloration disappeared under the use of iodide of po- tassium. In other cases, however, this has failed. TATTOO MARKS. Tatooing, or the mechanical introduction of pigments under the skin, is a well-known process. The pigments employed are carbon, cinnabar, carmine N^VUS PIGMENTOSUS. 221 and indigo. The substances once introduced it is usually not long before the subject is anxious to get rid of them again. Most methods employed involve the production of a reactive and destructive inflammation which results in the formation of a crust which may be cast off, taking the pigment with it. Brault's method consists of cleansing thoroughly the surface and tattooing in a solution of 30 parts of zinc chloride in 40 parts of water; mild inflamma- tory reaction ensues, a crust forms and, after some days, falls off leaving a scar. Repetition is sometimes necessary. Variot's plan is, first to put on the mark a concentrated solution of tannin, which is then tattooed in, making punctures close together; he then rubs a stick of silver nitrate firmly over the surface, allows it to remain for several minutes and then wipes it off. A crust forms as before. The cicatrix is said to be scarcely visible. Ohmann-Dumesnil, Nelson and Skillern have successfully used glycerole of papoid, spreading it upon the surface and driving it in with a bunch of needles. Caroid has recently been employed with greater success. Small spots may be removed by means of the electrolytic needle or the cu- taneous punch. Gun-powder stains are practically the same as tattoo marks, and are to be removed in the same way. N^VUS PIGMENTOSUS. Ncbvus pigmentosus, or mole, is a circumscribed increase in the pigment of the skin, usually associated with hypertrophy of one or all the cutaneous structures, especially of the connective tissue and hair. There are several varieties of pigmentary naevus, named usu- ally from the predominant characteristics, naevus spilus, naevus pilosus, naevus verrucosis and naevus lipomatodes. Ncbvus spilus is the ordinary mole. The usual seats of these growths are upon the face, the neck, the chest, the back of the hand, and the shoulders. Moles vary in color from the natural shade of the skin to dark brown or black. They are usually very small, from pin-head to small-pea size, but they may at times cover considerable areas of the surface. They may be quite smooth or covered with fine or coarse hair. Hairs are more apt to be met with in hypertrophic pigmentary naevi. Sometimes pigmentary naevi approach the color of vascular naevi on account of the numerous enlarged blood-vessels which they 222 DISEASES OF THE SKIN. contain. The boundary line between the two is not accurately defined. Moles are extremely common. There is scarcely any one who has not one or more in some part of the person. It is only when they occupy a conspicuous position, however, that the physician is called upon to treat moles, unless in cases where they are of such size or so inconveniently placed that their re- moval is desirable for convenience sake. Moles are more frequently found on the insane and in per- sons who suffer from some hereditary taint. Fig. 30. — Nasvus Pigmentosus or Hypertrophicus. The larger pigmentary nasvi present very often curious shapes and sizes (naevus spilus, hypertrophic variety). Ncbvus pilosus is the hairy mole which, in addition to the com- mon, smooth mole just described, presents an abnormal growth of hair light or dark and usually coarse in structure. Ordinarily these are small but they may cover a considerable portion of the body. Occasionally they assume the curious configuration of a pair of hairy swimming drawers as in the illustration. NMVUS PIGMENTOSUS. 22' Ncbvus verrucosus is the warty, pigmented naevus with a soft or hard, mamillated, rough surface, showing increase of all of the skin tissues, with often marked hypertrophy of the papillae giving rise to a furrowed, uneven surface. Ncbvus lipomatodes is the type in which there is an excessive fat and connective tissue hypertrophy with smooth or hairy surface and sometimes resembling mollus- cum. Occasionallv pigmentary naevi are ar- ranged in narrow bands, limited to one side of the body, forming the type known as linear ncevus, naevus unius lateris, etc.* Moles are seen in both sexes and are usu- ally congenital, though small ones may ap- pear at any time of life. Pathologically the ordinary pigmented naevus is similar to a freckle except that it is larger with often a slight connective tissue hypertrophy. In the other varieties there may be hypertrophy of all parts of the cutaneous structures. Pigmentary naevi sometimes form the place of origin of malignant growths, much less frequently than warts, however. The smaller moles may be destroyed by applications of nitric acid or caustic potash, the latter to be used with great caution, if the solid stick is employed, because of its tendency to spread in the surrounding tissues. The electro-cautery may also be employed. A scar may be expected in all but the most superficial pigmentary naevi after any operation. When there are hairs implanted in the naevus, electrolysis *See D. W. Montgomery, "The Cause of the Streaks in Naevus Linearis," Jour. Cutan. Dis., 1889, p. 132. Also Hyde, Rare Forms of Congenital . . . Naevus, etc., Chicago Jour, and Med. Exam., 1877, vol. xxxv, p. 377. Fig. 31. — Naevus Pilosus. (After Schii'immer.) The figures k n represent small, hairy moles, grep- resents a more angiomat- ous condition. 224 DISEASES OF THE SKIN. applied to these is the preferable method; while the hairs are being destroyed the mole is likewise being removed, and often may be nearly or entirely obliterated by this procedure. In larger naevi operation with the knife may be required. Fig. 32. — Naevus Lipomatodes. ACANTHOSIS NIGRICANS. Acanthosis nigricans is a rare disease of the skin, characterized by general pigmentation of a yellowish or brownish color, together with the formation of verrucous elevations at various points. The disease develops slowly or rapidly, the discoloration showing itself chiefly about the flexures and other sites of the papillomatous growths. The verrucous growths are most numerous and highly developed in the axillary, genito-crural, anal and abdominal regions, being at times developed to a highly hypertrophic, warty mass fissured deeply in the natural lines of the CLAVUS. 225 skin. Keratosis of the palms and soles is usual. Occasionally the mucous membranes are affected. Dystrophy of the hair and nails is frequent. The disease tends to a fatal termination in some months or years by cancerous affection of some internal organ. The majority of the cases observed have been under twenty years of age . In one case supra-renal extract has seemed to do good. Otherwise, treat- ment has only proved palliative and the prognosis is unfavorable. CLAVUS. Clavus, or corn, is a small, circumscribed, conic, deep-seated, horny formation usually seated about the toes, with the small end of the growth pressing down upon the corium. A corn resembles a callosity in consisting of thickened, horny epithelium, but differs in being smaller and circumscribed, averaging a pea in size and being provided with a central prolong- ation or horny peg, known as the core. Two varieties of clavus are recognized, the hard corn, occur- ring on the dorsal surface of the toes or other external parts subjected to pressure and rubbing, and the soft corn, occurring between the toes and which is depressed in the center, of a gray- ish color and more or less macerated on the surface from heat and moisture. Occasionally suppurative action takes place be- neath the corn and when neglected or badly treated it may become the starting point of eryispelas or other infection. Although corns usually occur from pressure and friction, simi- lar growths have been observed when this cause could not have obtained. The corium beneath the down-pressing apex or core is thinned and the papillae are usually atrophied though they may be hypertrophied around the margin. Structurally the growth is made up of closely packed epidermic cells arranged in concentric layers. The treatment of corns consists in the first place in re- moval of the cause. The shoes must be made to fit properly or the corn, even if completely removed, will return. In addition felt corn plasters may be temporarily employed. The corn should be soaked in hot water and scraped with a 15 226 DISEASES OF THE SKIN. moderately sharp knife previously sterilized by alcohol or passing through a flame. Corns are sometimes pared with a razor, an extremely hazardous procedure and which is sometimes fatal. A good chiropodist working with aseptic instruments should always be employed if more than a slight scraping is required. After the external epidermic overgrowth is some- what removed the following paint is often employed: 1$. Acid silicylic, gr. xxx (2.); ext. cannabis indicae, gr. x (0.65); collodii, flexilis, aa fgj (4.) M. This is to be painted on the corn night and morning for several days, at the end of which time the parts are soaked in hot water and the horny mass or part of it will, as a rule, come readily away with a little rubbing or scraping. Personally I prefer to use the ten per cent, or forty per cent, salicylic " paraplastes " of Unna which can be procured through German importers. These are rubber plas- ters impregnated with the medicament and which have a wonder- fully softening effect when kept in contact with the corn for a day or two. Care should be taken to cut the plaster small enough not to extend beyond the boundary of the corn as its effect on the thin epidermis is very strong. In soft corns the important point is to separate the toes by cotton or wool so as to prevent maceration. The corn itself may then be touched with a nitrate of silver stick or a drop of tincture of iodine or nitric acid may be carefully applied. The latter is best but should only be employed in skilful hands, the surrounding skin being so thin and tender that any overflow may cause violent inflammatory reaction. When the soft corn is exceedingly sensitive dilute lead-water may be applied. CALLOSITAS. Callositas, sometimes called tylosis, is a hard, horny, thickened epidermic patch, due to hyperplasia of the stratum corneum and occurring for the most part on the hands and feet. Callosities consist of small or large patches of excessive epi- dermic accumulation, usually seen on parts subject to pressure KERATOSIS PALMARIS ET PLANT ARIS. 227 or friction but which are also sometimes caused by chemical irritants. The palms soles, fingers, and toes are favorite loca- tions, but they may occur at any point where the skin has to protect itself from external violence by throwing out excessive horny epidermis. Sometimes callosities occur as the result of the prolonged administration of arsenic. They are not to be con- founded with the patches of keratosis palmaris et plantaris (g. v.). Anatomically, the growths consist in the thickened upper epidermic layers. The deeper strata of the skin remain as a rule unaffected. The treatment consists in the removal of the cause, in soften- ing of the skin in hot water, scraping and the application of sali- cylic acid plasters or " paraplastes " as described under clavus. KERATOSIS PALMARIS ET PLANTARIS. Keratosis palmaris et plantaris, sometimes called tylosis or ichthyosis of the palms and soles, is an hypertrophy of the corn- eous layer of these parts, usually of a more or less horny and plate- like character. The disease is usually congenital. In severe cases the whole palmar and plantar regions are the seat of a thickened, usually smooth, hardened, and sometimes seemingly translucent, yel- lowish, brownish-yellow, or yellowish-gray, calloused epidermic plate. The disease is usually limited strictly to the palm and sole but may sometimes extend a little beyond and occasionally involves the knuckles. The nails are slightly tilted upwards and thickened by underlying thickened epidermis. At the edge of the thickening there is usually a pinkish or reddish areola or zone. In some instances there is associated hyperidro- sis of the parts, in which the epidermic mass is still tough but sodden and not horny. There may be a generalized ichthyosis. Cases of keratosis of varying character differing from the type above described have been reported by several authors. The disease is almost always congenital, though acquired cases have been described, and it is not unfrequently hereditary 228 DISEASES OF THE SKIN. in a few cases for two or more generations. Pathologically the disease is closely allied to callositas, the constant factor being the thickening and hardening of the skin. The only disease for which keratosis palmaris et plantaris is likely to be mistaken is the condition produced by arsenic and, therefore, the history of any given case is important. Treatment cannot, of course, remove the disease, but it may ameliorate the symptoms. Local measures alone are of value and, of the applications, those containing salicylic acid are most active. A strong plaster, ten per cent, to twenty per cent, alone or with soap plaster may be used, the skin being previously softened by prolonged baths and soakings in strong soapsuds. Occasionally ten per cent, to thirty per cent, caustic potash so- lutions may be used cautiously. The Rontgen rays have some- times been employed with benefit. KERATOSIS SENILIS. Keratosis senilis is the term applied to the somewhat hard, generally small, thickened epidermic patches found on the skin in old age. The term is also applied to the sebaceous warts found under the same circumstances. The skin in old age shows, on the one hand, a tendency to atrophy and, on the other, to the development of hypertrophic epidermic and pigmentary growths including the so-called sebor- rheic warts. These are greasy or crusted patches usually pea to bean size or larger which when scraped reveal a slightly raw or bleeding surface. The scaliness increases in thickness and sometimes in area, and from such a crust or degenerative sebor- rheic patch an epithelioma occasionally results. In different lesions the seborrhceic or the warty element may predominate. The usual site of these formations is the face but they may occur upon any part of the body. The back is often the seat of great numbers of lesions. They usually begin to show them- selves between the ages of fifty and sixty but may occur earlier. If attended to in time the prognosis of keratosis senilis is favor- KERATOSIS PILARIS. 229 able but their chief significance is the possibility or probability of development into epithelioma. In their earliest appearance frequent and vigorous washing with some good toilet soap, as with sapo viridis or one of the medicated soaps of Eichoff or Stiefel, will encourage the normal exfoliation of epidermis and prevent, to some extent, the abnor- mal epithelial formation. When fully developed, however, the best plan of treatment is destruction by a caustic of mild, medium or intense strength. Glacial acetic acid, trichloracetic acid or strong solutions of bichloride of mercury will remove threatening pigmentary spots or commencing keratoses. When fully developed seborrhceic warts exist, fuming nitric acid may be employed with due care, or in the more hypertrophic condi- tions and where the warty character is more highly developed it may be necessary to use solutions of caustic potash or even the solid stick. When numerous keratoses are spread over a wide surface, as the back, excellent results maybe obtaned with theRont- gen ray. KERATOSIS PILARIS. Keratosis pilaris is a hypertrophic affection characterized by the formation of pin-head-sized or slightly larger conic epider- mic elevations seated about the apertures of the hair follicles. In its mildest form this affection is seen on the backs of the arms and on the thighs, in the form of numerous minute, dry, horny growths, of the color of the surrounding skin, looking like "goose flesh." The hairs growing from these elevations are usually atrophied or curled up in their follicles. In the more marked forms of the disease a well-marked, hard, pin-head- sized papule is observed, which may be of various shades of red or brown. Sometimes the lesions become hypertrophied to the size of acne papules. The color usually disappears more or less upon pressure. In these forms of keratosis pilaris the hair disappears entirely or is broken off short at the surface. Keratosis pilaris is usually unaccompanied by any sensation, but at times there is considerable pruritus. 230 DISEASES OF THE SKIN. The affection is more common in early adult life. It is most usually observed during the winter months and in those having naturally a dry skin. It is often observed in connection with ichthyosis. Anatomically the disease consists of a hyperkeratinization of the upper part of the pilo-sebaceous follicular outlet, and the papular elevation results from the formation of this super- abundant or accumulated horny mass which projects beyond the orifice. In some cases slight inflammatory appearances coexist. The affection is to be distinguished from the miliary papular syphiloderm and from lichen scrofulosus. The dull ham- brownish red papules of syphilis have a more general distribution, are more infiltrated and firmer to the touch and tend to distribu- tion in groups. Other symptoms of syphilis are also apt to be present. In lichen scrofulosus — a rare disease — the eruption is usually limited and occurs in distinct, more or less rounded groups or patches, and most commonly upon the trunk, especially the abdomen. The extensor surfaces of the limbs are rarely involved. " Goose flesh" which this disease resembles ai first glance is a transitory condition. The treatment is largely local. Warm baths with the use of toilet soap or sapo viridis are to be followed by inunctions with a mild salicylic ointment (2 per cent, to 6 per cent.). Soda bicar- bonate or borax baths are also useful. KERATOSIS FOLLICULARIS.* Keratosis jollicidaris, called also ichthyosis follicularis, Darier's disease, psorospermosis, acne sebacee cornee and by various other names, is a rare affection characterized by the appearance of small, horny elevations, at first not unlike the lesions of keratosis pilaris, but later consisting of greasy-look- ing papules or dry, firm, brownish papular elevations semi-globular in shape and small to large pin-head size, disseminated over the involved area. In the center of the large lesions is usually a firm, hard or fatty-looking mass or plug. The disease is usually most abundant about the face, scalp and chest, loins, genito-crural regions and the extremities. It may in time be- * Bowen, Jour. Cutan. Dis., 1896, p. 209, gives a complete account of this disease. VERRUCA. 231 come generalized. On the scalp there is usually a thick seborrhceic crust but no loss of hair. When grown larger and confluent the surface may pre- sent a nutmeg grater or papillomatous appearance. There may be consid- erable itching. The disease centers about the hair follicles and is in fact a keratosis of the mouths of the pilo-sebaceous ducts. The psorosperm as a cause is no longer considered. The disease is persistent and usually slowly progressive. It does not af- fect the health. Though incurable it may be ameliorated by frequent bath- ing and the application of softening ointments, as those containing salicylic acid, sulphur and resorcin. Keratosis jollicularis contagiosa is a rare affection, usually occurring among children, characterized by a slight thickening of the horny layer with an ac- centuation of the cutaneous furrows and a yellowish to yellowish -black dis- coloration. Later black points developing into papular elevations containing projecting horny processes are observed. The regions affected are usually the neck, trunk, extensor aspects of the extremities, and less commonly the face and flexor surfaces. The affection is said to respond readily to soften- ing and alkaline applications.* VERRUCA. Verruca, or wart, is a small, circumscribed, epidermal and papil- lary growth which may be soft or hard, and rounded, flat, acumin- ated or filiform. For convenience' of description warts may be divided into several clinical varieties. Verruca vulgaris, the common wart, occurs chiefly upon the hands, it is large pin-head to pea-sized or larger, round and with a broad base. It is generally hard, somewhat elevated, flattened and circumscribed. As a rule it is of slow and gradual growth. The surface is at first smooth but later becomes rugous. The color is at first that of the natural skin, later it may become yellowish, brownish or even black. Usually there are one or several present but at times they are very numerous. They occur chiefly among the young. Sometimes a single lesion, the "mother wart," appears followed later by several others. While this form of wart is more common upon the hands it * Brooks, International Atlas, 1892, part vii, plate xxii. 232 DISEASES OF THE SKIN. may occur on the forehead and elsewhere. Occurring on the sole it has received the name verruca plantaris and is occasionally mistaken for corns. It may give rise in this locality to con- siderable pain and inconvenience. Now and then this form of wart is found upon the vermilion of the lips. Verruca plana occurs in older persons in the form of pea to finger-nail sized, flat growths, very slightly elevated, occurring about the face, forehead, shoulders, etc. They are usually of a dark color and become in time papillomatous on the surface and covered with a sebaceous crust which is shed or rubbed off from, time to time {verruca sebacea). They sometimes resemble moles and with the various degenerative epithelial and pig- mentary changes of the skin are characteristie of old age. Verruca plana juvenilis are peculiar lichen-planus-like warts with roundish, square or polygonal base, flat, smooth and usually situated upon the face, where they may be few or many in number. Occasionally there is a slight central depression. They are normal skin color, grayish or brownish. The chin, the lower part of the cheeks and the forehead toward the temporal region are the favorite seats. They are slow and insidious in their coming and may last for years. Verruca digitata is the name given to a form of wart where the lesion is cleft or like fingers. The base is solid and often somewhat constricted. These warts are horny toward the ends of the digitations but soft at the base. They bleed more readily than the flat warts. They are pea-size or occasionally larger, and are most prone to occur upon the scalp. A variety of these are the filiform warts, verruca filiformis, growing from the skin like a single short thread. These are most apt to occur about the neck. Verruca acuminata, condyloma acuminata, venereal wart, cauliflower excrescence, is a variety of wart usually occurring on the mucous and muco-cutaneous surfaces of the genital and anal regions. They may occur also in the mouth and tongue and even in moist folds of the skin as the axillae and groins. The growths are pointed or flattened, single or numerous. They VERRUCA. 233 usually show a pinkish or reddish color. They sometimes re- semble a cock's comb. In extreme cases, especially about the female genitals, these warts grow luxuriantly, forming cauliflower- like masses. When seated in a moist region they are apt to secrete a yellowish, puriform fluid, decomposing readily and giving rise to a peculiarly offensive odor. They are apt to be found about and within the genitals of prostitutes suffering from gonorrhoea. In the male they occur about the sulcus of the glans penis. They tend to increase and extend. Warts are usually considered contagious. The verruca acuminata are unquestionably so and are also auto-inoculable. Inoculation experiments in ordinary warts seem to indicate a period of incubation extending over one to several months. The initial factor in the production of a wart is a break or fissure of some sort, probably permitting a microbic invasion which causes irritation, and, following this, hypertrophy of the epidermis and papillae with some increased connective tissue and capillary overgrowth. Verruca acuminata is largely made up of con- nective tissue elements with marked papillary hypertrophy, excessive development of the rete and an abundant vascular supply. The horny layer is often almost or completely wanting. Warts are not often confounded with other affections but the juvenile variety is to be distinguished from lichen planus which it sometimes resembles. The latter, however, rarely occurs on the face, the lesions are apt to be squarish in shape and have a slight depression in the center and often a fine glistening scale. Warts on the sole resemble callosities but on cutting or shaving them down the wart-like structure can be perceived. Warts about the tips of the fingers are to be distinguished from verruca necrogenica or dissection tubercle. I have seen in one case a wart-like lesion on the tip of the forefinger turn out to be the initial lesion of syphilis. As the microbic element is at the bottom of the verrucous growth, antiseptic and parasiticide applications are likely to be of service. The affected localities should be frequently washed with a 234 DISEASES OF THE SKIN. bichloride of mercury soap, and when the warts are numerous and closely placed together, a solution of the bichloride (1-2000) may be applied from time to time to advantage. This treat- ment should precede and accompany the use of other remedies. Small digitate and filiform warts may be clipped off with curved scissors, the base being touched with nitrate of silver stick. The dermal curette or scraping spoon may be employed in the flat ones. The ligature, escraseur, or galvano-caustic wire may be employed in the larger, peduncula:e variety. Con- dylomata about the female genitals and anus and elsewhere are best treated by washing the parts with dilute liquor sodae chlorin- atae, and afterward dusting the surface with powdered calomel, resorcin, or a powder composed of equal parts of burnt alum and savin. Perhaps the best treatment of condylomata consists in frequent bathing with bichloride of mercury solution (1-2000) and dust- ing the parts with a powder composed as follows: J^. Pulv. sabinae, Pulv. acidi salicylici, aa oiv. (16.) M. Glacial acetic, nitric, chromic, or carbolic acids may also be used. The larger condylomata may be attacked by the electric cautery. Common warts may be cauterized by one of the acids mentioned, or by means of caustic potash, in stick or solution. These more severe measures should not, however, be resorted to unless the milder applications fail. The following prescrip- tion answers in many cases: 1$. Ext. cannabis indicae, gr. x ( 0.65) Acid salicylici, 3ss ( 2. ) Collodii, Bj. (32. ) M. Apply daily, for three or four days, and then scrape the wart, and, if neces- sary, apply again. Other collodions which may be used are these : ly. Acidi salicylici, gr. v-xxx ( 0.30-2.) Alcoholis, f 5ss ( 2. ) ^theris, ' f 5ij (8. ) Collodii flexili, ad £5iv. (16. ) M. CORNU CUTANEUM. 235 Or: ly. Acidi salicylici, Acidi lactic ; aa 5ss (2. ) Collodii flexili, f 3iv. (16. ) M. Another useful preparation is the following: 1$. Acidi salicylic, 3ss ( 2. ) Emplast. hydrarg., Ung. hydrarg., aa oiv. (16. ) M. Fiat, emplastrum. This is kept constantly in contact with the wart for about a week. The epidermis becomes macerated and can be sepa- rated from the cutis while the warts crumble away. The salicylic rubber plaster of Johnson and Johnson is also an excellent application. It softens the wart, which can" then be scraped off. The following is an excellent, although very energetic, applic- ation. It should be employed with caution, care being taken that the effect does not extend too far: 1$. Hydrarg. bichlor., gr. iv-viij ( 0.24.-48) Collodii flexili, l&v. (16. ) M. Now and then warts resist all treatment, or spring up as fast as removed. In such cases arsenic may be given with some hope of preventing the recurrence of the growths. It should be admin- istered in the form of Fowler's solution in the dose of two to four minims thrice daily. Magnesium sulphate in doses of from 10 to 20 grains (0.65-1.30) morning and evening may also be employed. The tincture of thuja occidentalis in doses of 20 drops to 2 drachms (1.33 to 8.) three times a day may be employed. Occasionally the presence of warts seems due to some nervous or constitutional influence, and they stubbornly resist all treatment. CORNU CUTANEUM. Horns in the human being are of the same nature as those of animals although they grow from the skin, whereas the horns 236 DISEASES OF THE SKIN. of animals are always implanted in bone. They are usually single, although at times multiple, in one or two cases recorded Fig. 33. — Cornu Cutaneum. Multiple. (After Bat ge.) they have been numerous. They are solid, laminated or fibril- lated, hard and dry, grayish, yellowish, brown or black in color, CORNU CUTANEUM. 237 generally twisted or bent, except when quite small. Horns usually vary from 2 mm. to 6 mm. in diameter and 5 mm. to 2 cm. in length, but some have been reported of considerable size, up to 5 cm. in circumference in one case and in another 4 cm. in length. Their growth is usually slow but variable and they Fig. 34 — Cornu Cutaneum. (After Pancoast.) Photographic Rev. Med. and Surg., 1870-71, vol. i. may either drop off or be knocked off, exposing a red, raw sur- face from which another is liable to be produced. Horns are apt to occur in old age; they are rare before forty but have been seen in infancy. The majority start from seba- ceous cysts or from sebaceous warts, or, it is said, from scars or occasionally from epitheliomata. They are essentially hyper- trophic horny warts. They arise from the deeper layers of the 238 DISEASES OF THE SKIN. stratum mucosum. The papillae are hypertrophied and the growth is situated on the papillae, groups of which extending into the horny mass have been observed. The horny formation itself consists of agglutinated epidermic cells forming small col- umns or rods. The treatment of horns is simple. The growth is to be soft- ened by poultices or wet dressings and twisted off and the base thoroughly burned out with caustic as epithelioma is apt to de- velop sooner or later. Larger horns must be cut out completely. ICHTHYOSIS. Ichthyosis is a congenital, chronic, hypertrophic disease, usu- ally occupying the whole surface, characterized by dryness, harsh- ness, or scaliness of the skin and a variable amount of papil- lary, growth. Two varieties are generally described, I. simplex and I. hystrix. Ichthyosis simplex may be so mild in form as to amount to little more than a certain dryness and roughness of the skin. It may, on the other hand, be quite severe. As ordinarily met with, ichthyosis simplex consists of an altered state of the skin, characterized by a harsh, dry condition of the whole surface, accompanied by the production of scales, sometimes fine and branny, at other times coarser, and shaped after the lines and furrows of the skn. The latter, from their resem- blance to fish scales, have given occasion to the name of the disease, "ichthyosis," or the " fish-skin" disease. The amount of scales depends upon the age of the patient, the severity of the disease, and the efficiency of any treatment which may have been employed. The scales, if not removed by frequent bathing, tend to accumulate. They are usually whitish, grayish, or yellowish in color, with sometimes a glistening look. Occasionally the general color of the eruption is of a more or less yellowish or dark olive green. Even when the disease is not severe, it gives the surface an unwashed look. The localities in which ichthyosis is developed to the most marked degree are the lower extremities, from the hips to the ICHTHYOSIS. 239 ankles, and the arnib and forearms. The skin of the backs of the hands and the face often has a peculiar, smooth, drawn, parchment-like appearance, which is very characteristic. Sen- Fig. 35. — Ichthyosis. (After a model by Baretta.) sible perspiration is, in most cases, absent, excepting in the face, axillae, palms, and soles. There is sometimes marked hyperidro- sis in the two last. The disease is worse in winter than in sum- 240 DISEASES OF THE SKIN. mer; in mild cases it is apt to almost disappear during the latter season. The course of the disease is essentially chronic. Begin- ning to show itself distinctly during early childhood, it grows more and more marked with each year of the patient's life. It sometimes appears to be hereditary, but no distinct and invari- able hereditary influence seems to prevail in all cases. Ichthyo- tic parents usually beget healthy children. The patient him- self generally enjoys fair or good health. The disease occurs in all races, both sexes, and in every grade of society. The pathological changes observed in ichthyosis were originally considered seated essentially in the epidermis, but now they are thought to originate in the connective tissue chiefly of the corium. The epidermis is thicker than normal with increased formation of epithelial scales and a heightened tendency to cornification, the process of exfoliation being slowed. Degenerative changes are also observed in the coil and sebaceous glands. The diagnosis of ichthyosis is usually not difficult. The his- tory alone differs from that of all other skin diseases, its chronic- ity offering a marked contrast to the rapidly developing char- acter of the acute inflammatory disorders. Internal treatment is ineffectual, or nearly so, in many cases of ichthyosis, so far as the complete cure of the disease is con- cerned, but much can be done to ameliorate the patient's condition, and toward preventing entire atrophy of the cutaneous glands. Arsenic and cod-liver oil should be administered separately or together. A pill, containing -%-$ grain (0.002) of arsenic, three times a day, may be given with propriety to adults, but the dose must be proportioned to the idiosyncrasy of the patient. It should be continued in courses of several months with intervals. Cod- liver oil may be given pure and alone, in the form of emulsion or in capsules. There may be cases in which jaborandi or pilo- carpine may be employed for short periods, but this drug is so apt to disagree that it should rarely be employed.* As regards the external treatment, this should be active and * See excellent article on treatment, by Unna, Monatshefte, /. Prakt. Dermatol., 1883, p. 196. ICHTHYOSIS. 241 continuous. The skin is to be kept moist and supple by the fre- quent administration of warm baths with alkalies or soap. Vapor baths are also useful. Inunctions of some emollient material should always be practiced after the bath. In well- marked and severe cases the soap treatment will be found valua- ble to remove some of the dry and horny epidermis and prepare the way for the application of emollients. A sufficient quantity of sapo viridis is to be rubbed into the skin twice daily for four to six days, during which period the patient is to refrain from bathing. A bath is first to be taken four or five days after the last rubbing, when, in fact, the epidermis has begun to peel off; afterward, inunction with a simple ointment is to be practiced, in order to prevent Assuring of the new skin. For this purpose, oil of sweet almonds, glycerine, pure or diluted, with one to seven parts of water, or one of the following ointments may be used : J^. Adipis benzoat, giv (128.) petrolati, 5j ( 32.) Glycerinae, 5 j- ( 4-) M. Sulphur has been very highly extolled as a remedy in ichthy- osis. It has been employed in the form of ointment in the strength of half a drachm to a drachm to the ounce, and more recently by impregnating the underclothing with sulphur, hang- ing it in a box, and vaporizing flowers of sulphur on a hot — not too hot— plate. The clothing should be reimpregnated every five or six days. The following ointment is recommended by Brocq: I}. Acid, salicylici, 9ij-iv ( 2.6 to 5.32 ) Sulphur praecipitat., 5iij (12.) Glycerinae, Lanolini, aa oij- (64.) M. Another formula recommended by Brocq is this: 1^. Acid, salicylic, Acid, tartaric, Resorcini, aa 5 j (4.) Sulphur, praecipitat., oijss (10.) Adipis, oj (32.) Lanolini, §iij. (96.) M. 16 242 DISEASES OF THE SKIN. These ointments should be well rubbed in every evening and removed with soap in the morning. Ichthyol ointment may be useful in some cases, as follows: 1$. Ichthyolis, oij-iv ( 8. to 16.) Acidi salicylici, 5j ( 4-) Sulphuris praecip., 5ij ( 8.) Adipis, §iv. (128.) M. To be applied at night and washed off next morning with ichthyol soap. The prognosis of ichthyosis is entirely unfavorable as regards v . . permanent cure, but alleviation of the . N symptoms may be brought about very jS satisfactorily. The affection should really be regarded as a deformity ~idM& rather than a disease, though it pre- disposes strongly to the occurrence of l£jr* eczema, particularly of the hands. ,J Ichthyosis Fcetalis. Infants affected >J>* ''y this peculiar condition sh^w at ^f% birth a thick, hard, resistant epi- dermis, without elasticity. The skin is covered with dried sebum; it has a dirty yellow color, is hard, rigid, and deeply fissured at all points, owing to the effect of the infant's growth dur- ing foetal life upon its inextensible j0 integument. ■:f The mouth is widely opened; the ^■f infant can neither close it, nor can it jr take the breast. All the lines of the .. ^ face are obliterated; every movement Fig. 36. — Ichthyosis rcetahs.* J is made with difficulty. Even if the patient is born alive, it soon succumbs to inanition or to the exhaustion due to the splitting and suppuration of the numer- ous fissures. The etiology of the affection is not known. * I have unfortunately lost the reference to this case and therefore can not give due credit which I extremely regret. A. V. H. ICHTHYOSIS. 243 Ichthyosis hystrix is characterized by the formation of irreg- ularly shaped and sized, ill-defined, rough, harsh, yellowish, brownish, or greenish patches, made up of enormously hyper- trophied, more or less horny papillae. Unlike the ordinary form of ichthyosis, this is apt to be localized, and rarely covers the surface to any extent. It is sometimes distributed in the line of the nerves. Sometimes the papillae are so hypertrophied as to stand out like porcupine quills — hence the name " hystrix." In ichthyosis hystrix, in addition to the changes noted in ichthyosis simplex, the direct transition from rete cells into horny cells, without intermediate change has been noted. The anatomical conditions resemble those observed in old warts, enormously elongated papillae, above which the horny layer is piled up in thick, stratified coats. There is a moderate cell infiltration of the papillae with dilated vessels. The treatment of ichthyosis hystrix is essentially that of any warty or horny, non-malignant growth. The patch, if not too large, may be poulticed until softened, and then attacked by caustic potassa or glacial acetic or chromic acid, or it may be re- moved by the knife. In one case considerable improvement was gained by painting the surface, twice daily, with the following: 1$. Acidi salicylici .... oss ( 2. ) Ext. cannabis ind., gr. x ( 0.65) Collodii, gj. (32. ) M. The salicylic rubber plasters made by Johnson and Johnson and the "paraplastes" of salicylic acid made after Unna's form- ula in Germany prove useful in these cases. Another preparation which, it is said, has been used with good effect is the fluid extract of thuja occidentalis, painted on in the same way. The prognosis of ichthyosis simplex and hystrix is unfavorable. A few cases have been cured it is said, but the utmost we can expect is amelioration of the various inconveniences caused by the disease. 244 DISEASES OF THE SKIN. POROKERATOSIS. Porokeratosis is a rare variety of hyperkeratosis described by Mibelli, Wende.f Gilchrist J and others. The disease is slow and insidious, beginning as a trifling, superficial but slightly elevated, warty looking formation, or as thin callous spots which slowly enlarge, throwing out a sort of dyke or rimmed edge and leaving an atrophic, slightly callous center. The border shows occasional minute, wart-like or papillary concretions. It is often wavy or almost poly cyclic in outline. The enclosed atrophic area is dirty grayish - white, sometimes brownish or pinkish, while the raised border is brownish- gray, darker and well defined. The favorite seats of the eruption are the dorsal aspects of the hands and feet, but it may occur elsewhere The rings are one to several inches in diameter or smaller. The eruption has been thought parasitic and inoculable, but no positive proof has been adduced. The process is a hyperkeratosis affecting the lower horny and upper rete layers. The sweat glands are plugged with horny epithelium, and the hair follicles are involved. In the central area the papillary layer of the derma is almost obliterated. The treatment is not satisfactory. The electric needle has been used in some cases with success. ANGIOKERATOMA.? Angiokeratoma is an affection, usually of the extremities, occurring for the most part in those subject to chilblains, and characterized by the appear- ance of telangiectases which subsequently develop into warty elevations. The telangiectases usually follow chilblains, appearing as pin-point to pin- head sized lesions, discrete or crowded together. They are pinkish in color, later becoming darker or changing to purplish or reddish -brown. The backs of the fingers or the dorsal surface of the toes, especially towards the basal portions, are the favorite sites, although they may be found elsewhere. After a while slight elevation is noted and the surface may become rough, irregular and horny, presenting when the lesions are closely bunched the ap- pearance of warts, with telangiectases on them. The disease is apt to appear or to take on fresh action in cold weather. There are no subjective symp- toms. *Monatsh. j Prakt. Derm., Nov. 1893; International Atlas of Rare Skin Diseases Vol. iv., 1893., pi. xxvii; also Monatsh. f Prakt. Derm., 1895, vol. xx., p. 309. "\Jous. Cut. Dis., 1898, p. 505. %Bull., Johns Hopkins Hosp., 1897, p. 107 and Jour. Cut. Dis., 1899, p. 149. §See Cottle, St. George Hosp. Rep., 1877-8., vol. ix. p. 758, with colored illus- tration., Pringle, B. Jour. Derm., 1891, pp.- 237, 282 and 309.; Zeisler. Jour. Am. Derm. Ass., 1893 (abstract of paper); and Fordyce, Jour. Cut. Dis., 1896, p. 83, Plates, etc. SCLERODERMA. 245 Anatomically the change is primarily a vascular one followed by keratosis as a secondary phenomenon. The disease is persistent with no tendency to involution. Electrolysis of each lesion has proved the best treatment. SCLERODERMA.* Scleroderma is a chronic disease characterized by a circum- scribed, localized, or general and more or less diffuse hardening of the integument, which is usually rigid, stiffened, indurated, or hide bound to a greater or less extent. Two varieties are usually described, the diffused and circum- scribed. Scleroderma diffusa is the affection described first under the name of scleremie des adultes, by Alibert, in 1817. The induration, which is so marked a symptom of the disease is variously described in different cases, and writers seem to vie with one another in their attempts to express vividly the peculiar sensations offered to the sight and touch. In some cases the skin is described as being of stony or board- like hardness, or feeling like that of a frozen corpse, without the sensation of cold. In other cases it is compared to brawn or leather. Adherence of the skin to subjacent tissue is not uncom- mon — "hide bound," or "perfectly immovable," are the expres- sions used. In a case coming under my own personal observa- tion, the skin over the forearms was so bound down that the limbs seemed as if carved out of wood. The underlying muscles, particularly those of the limbs, are generally more or less wasted. One of the most distinctive characteristics of this variety of scleroderma is symmetry and diffusion as distinguished from localization. Commencing, as in most of the cases reported, on the back of the neck, the disease spreads equally on either side of the median line; or, when it begins in the limbs, both are usually attacked at once. * For recent views and history see Colcott Fox, B. Jour. Dermatol., 1892, p. 101; Lewin and Heller, Die Sclerodermic, Berlin, 1895, and Raymond, Clinique des Maladies de la Systeme Nerveux, 3me serie, p. 683, for the neurological point of view. Also Dercum, Jour. Nervous and Mental Dis., July, 1896. 246 DISEASES OF THE SKIN. The surface covered is almost invariably large; those cases reported in which the disease seems to tend toward localization, are usually to be regarded as, in all probability, belonging to the other variety of the disease. A marked characteristic of this variety of scleroderma is that no distinct boundary exists to the affected areas; they seem to melt imperceptibly into the surrounding skin. The color of the affected skin varies much in different cases. In many cases pigmentation exists to various degrees, while in other cases the skin either retains its normal tint, or becomes pale-yellowish or waxy in color. A curious fact is that the pig- mentation seems much deeper in the immediate neighborhood of the sebaceous follicles. In a certain number of cases, it is said that spots or patches of pigmentation at various points pre- cede and presage the induration of the skin in these localities. This, however, is more likely to occur in the circumscribed and localized form of scleroderma. Neither fever nor local inflammatory reaction of any kind ushers in, accompanies, or follows the appearance of the disease in any typical case. (Edema is rarely, if ever, observed in diffuse scleroderma. Occasionally swelling of the hands or feet has been observed, as a result of mechanical interference with the circulation. The rapidity with which the disease attacks and spreads over the skin varies in different cases. In some, large areas of skin become indurated in a very short time; in others, the onset is slow and insidious. In no case is there any marked elevation of the indurated skin above the level of the surrounding and unaffected parts, though tubercular elevations have occasionally been observed. Where the tightened skin plays over prominent bony parts, as the knuckles, a tendency to ulceration is often observed. Cutaneous sensibility in most cases remains unaltered. The appendages to the skin, the glands and hair, are rarely affected. Scleroderma diffusa runs a very chronic course; many cases may be under observation for years, with little or no change SCLERODERMA. 247 apparent, and this under the persistent employment of decided and varied treatment. The existence of scleroderma does not necessarily exclude that of other skin diseases; acne, comedo, and eczema have been observed simultaneously, and in the same localities. No previous ailment seems to exercise a predis- posing influence, unless it be rheumatism. The immediate cause in many cases has been exposure to dampness and cold. The pathological anatomy of scleroderma diffusa is simply that of a hyperplasia of the fibrous element of the papillary layer and corium, with decrease of subcutaneous fat and increase in pigment deposit. Scleroderma diffusa is not in itself a fatal affection. In the few cases in which death has occurred while the patient has been under observation, it has usually occurred from some intercurrent disease, totally unconnected with the scleroderma. It is true that, in one case recorded, death was hastened by the extremely inflexible condition of the facial integument, which interfered greatly with deglutition, while in some others respiration was much impeded through immobility of the thoracic walls. Scleroderma localis, (morphosa, keloid oj Addison) appears in typical cases, in the form of one or more patches, from one- half to two inches in diameter, coming gradually without sub- jective symptoms so that they may not attract attention until fully developed. Each patch is of irregular roundish, oval, or elongated shape, of a dead white or old ivory-white color, bor- dered with a narrow violet, lilac, or pink zone made up of minute blood-vessels. The patches are level with the skin, generally unilateral and often distinctly arranged in the course of a nerve area like herpes zoster. They may appear anywhere but are most usually seen on the breasts, head, and face, particularly in the line of the supra-orbital nerve, and most of all on the limbs, especially the lower limbs. As a rule, the skin over the patch feels like parchment and may be pinched up, but sometimes it is like a plate let into the skin. As the disease progresses the spots may sink below the level of the skin. The diseased area, when once developed, may remain stationary a long period and 248 DISEASES OF THE SKIN. then gradually fade and the skin become normal. In other cases new patches may continue to form. The duration of the disease may be from one to ten years. Another form of localized scleroderma is the band form. Usually this consists of a single elongated, cicatricial looking patch, adherent to the subjacent tissues and forming a sulcus or raised into an irregular keloidal ridge. When slight, between the brows, as I have seen in two instances, a half to one inch shallow furrow extended up the center of the forehead into the hairy scalp. Ulceration sometimes occurs in morphcea and in other cases bullae are seen. Scleroderma localis is more common in females than males. People of neurotic temperament are more apt to have the disease and it is said to be the result, at times, of worry. Local irrita- tion also may be a predisposing cause. In the majority of cases no adequate cause can be assigned. Facial hemiatrophy is probably closely connected with this form of the disease. Scleroderma is supposed by some to be a neurosis, trophoneu- rosis or angioneurosis, by others the vascular system is said to be at fault, while still others attribute it to changes in the connec- tive tissue, especially its intercellular substance. The anatomical changes are chiefly in the corium and sub- cutaneous tissues. There is a marked increase in the connective tissue element with thickening and condensation. The fat atrophies and gives place to connective tissue. The vessels are diminished in caliber. The glandular structures are unchanged except in the later stages when they are atrophied. The his- tological changes in localized scleroderma vary little, it is said, from those of the diffused type in its early stage. The only form of scleroderma which is liable to be confounded with any other disease is the morphcea patch of the early localized form which resembles the white anaesthetic spots of leprosy, but differs in being normal in sensation, and vitiligo from which it differs in being something more than a mere transfer or absence of pigment. SCLEREMA NEONATORUM. 249 The prognosis of scleroderma, except in the extreme forms of the diffuse variety, is favorable as regards its influence upon health and life. As a general thing, however, the affection tends to persist indefinitely. A few cases of both varieties are re- ported to have recovered. The treatment of scleroderma is very unsatisfactory for the most part ; change to a dry pleasant climate, avoidance of exposure to cold and dampness and all kinds of tonic and invigorating treatment are, of course, to be prescribed when possible. Mas- sage and the application of suitable stimulant applications are also in order. When drugs must be depended upon, arsenic, iron, quinine, strychnia and cod-liver oil may be employed. Some have gotten benefit from thyroid extract but the fact must be mitted that the disease usually takes its own course. In the cases which have come under my notice I have never seen any effect whatever produced by any remedy. I have seen some cases spontaneously improve with the lapse of time. SCLEREMA NEONATORUM. This rare affection is in no way connected with scleroderma, although- the latter was at one time called "sclerema of adults." It usually shows itself in the first days of extra-uterine life, having in all probability begun in foetal life. The first marked symptoms are commonly observed from the third to the sixth day after birth, when the lower extremities are seen to show considerable areas of shining, tense, white skin, sometimes tinged with red, or of a dirty-brown or yellowish color. The tissues are cedematous, pitting on pressure with the finger, while the skin is so much thickened that it cannot be pinched into folds between the thumb and finger. Begin- ning in the calf, the disease soon extends to the thighs, spreads over the abdomen, up the trunk, involves the head and upper extremities, and, in fine, after a brief period (three hours to three days) invades the entire body. Of course, we can know nothing of the subjective symptoms, but the rapid fall in body 250 DISEASES OF THE SKIN. temperature, the frigidity of the affected parts, and the general depression of functional activity, point to a serious general condition. The infant's bodily movements are imperfect and restrained; it lies numb and stiff, usually with closed eyes and wrapped in lethargic slumber; it declines food, partly on account of mental hebetude and partly because of the difficulty of making ' the movements of the mouth necessary to nursing. The heart is weak, and the pulse is rapid and sometimes almost imperceptible. The respirations are irregular and shallow, with occasional rales. The patient occasionally utters a complaining w T hine. The urine and stools are diminished in quantity. The symptoms mentioned usually increase in severity with continually falling bodily temperature and increasing weakness, until death ends the scene at the end of from four to ten days. Sclerema neonatorum is almost invariably fatal, though recovery has been noted in a few cases where the disease was not extensive. The cause of the disease seems to lie in an extensive implication of the blood-vessels. Atelectasis of the lungj, con- genital disease of the heart, or other constitutional anomalies, have been brought forward as explanatory of the origin of the disease. Surroundings and pre-natal conditions of an unfavor- able hygienic character — want, privation, etc. — appear to have some influence in the causation of the disease. Anatomical examination show T s deep involvement of all strata of the cutaneous envelope. The widespread infiltration of the subcutaneous tissues allows the easy separation of these layers from the deeper layers of muscles and the fasciae. On section, a yellowish- white, serous fluid, mostly composed of oil globules, exudes. Of the internal organs, the lungs and kidneys are usually hyperaemic, while the brain and the serous membranes are usually cedematous. The brief duration of the affection, however, usually allows only the earlier stages of these changes to be observed. The treatment of sclerema neonatorum is of a roborant and restorative nature, and should be undertaken at the earliest CEDEMA NEONATORUM. 25 1 possible moment. Rubbing with hot blankets, etc., and the internal administration of restoratives may be employed. (EDEMA NEONATORUM. (Edema of new-born infants was formerly confounded with sclerema, but Parrot has shown that the affections are distinct. The disease is generally observed at or within a day or two of birth, and not unfrequently in infants born before term. The oedema is usually observed upon the calves, posterior portion of the thighs, the hands, and the genital organs. The affected parts are pale and pit upon pressure. Usually this is the extent of the disease, but at times it is more severe, the skin becomes livid, and a firm, hard oedema may invade the entire body and limbs. Respiration becomes difficult and the patient succumbs with suffocation and coma, or with some pulmonary complication. In lighter cases, tending to a favorable termination, the oedema gradually disappears and recovery takes place after some days. The therapeutic indications are: i. To render the action of the heart more vigorous. Hygiene, good food, a small quantity of some stimulant, particularly wine, may be employed. 2. To favor the dispersion of the effused fluid by re-estabhshing the functions of the skin. Friction, massage with warm flannel or the warm hand, aided by warm oil, spirits of camphor, etc. Friction and malaxation in the direction of the venous current is advisable. The vapor of benzoin is sometimes employed. 3. Warmth. The infant should be placed in a "couveuse" or "incubator," or given hot baths, wrapped in hot flannels, etc. ELEPHANTIASIS. Under the name of elephantiasis arabum, or pachy derma, a morbid condition of the skin is designated, which is characterized by hypertrophy of the derma and of the subcutaneous cellular 252 DISEASES OF THE SKIN. tissue limited to certain regions of the body, and the result of re- peated attacks of inflammation of the capillaries and lymphatics. Elephantiasis occurs under two different forms: (i) the elephantiasis of tropical countries, which is due to the presence in the economy of the filaria sanguinis hominis, and (2) the elephantiasis occur- ring in temperate climates and resulting from various morbid conditions, most of which are unknown or but little under- stood. The affection usually begins by an at- tack like erysipelas, with lymphangitis, pain, and fever, followed by slight en- largement of the part. Similar attacks subsequently occur from time to time, the limb or region involved being slightly increased in size upon each occasion. At the end of a year or more, after a num- ber of these attacks have taken place, the part is usually found to have increased considerably in size, to be chronically swollen, cedematous, and hard. In the limbs, the leg particularly, not only will the entire member be found enlarged, but the skin itself decidedly hypertrophied, as shown by the prominent papillae, fissures, and more or less discoloration and pigmentation. A verrucous condition of the surface is also very common as shown in the illustrations. The process usually goes on until very considerable deformity results. The appear- ance of the disease varies in one part or another of the body. The commonest seat of disease is in the leg, one limb alone being generally attacked. The genitalia are next in point of frequency attacked. Other regions are more rarely assailed. The amount of pain attending the disease varies; it is sometimes severe during the inflammatory attacks, while at other times and in other cases no pain is felt. The increased weight of the part, as in the case of the scrotum or leg, may interfere with locomotion. * Jas. R. Wood's case, Photog. Review of Med. and Surg., vol. ii, p. 37. Fig. 37. — Elephantiasis.' ELEPHANTIASIS. 253 Elephantiasis is found in all parts of the world, but is far commoner in tropical regions, where it seems to be endemic. Lymph scrotum is a form of elephantiasis closely allied to chyluria. Elephantiasis telangiectodes, also known as "Xaevoid elephan- tiasis," is a hypertrophic development said to have a con- genital origin and to be due to overnutrition resulting from the underlying increase of the vascular supply. Acromegaly is a hypertrophic condition allied in its external, clinical appearances to elephantiasis. It will be found more fully described in works on nervous diseases, as the nerve symp- toms predominate. Manson has shown that the mosquito is a probable factor in the causation of some cases of elephantiasis, particularly in trop- ical countries. Poor food, unhygienic living and similar con- dition are contributing factors. Elephantiasis sometimes oc- curs in connection with leprosy but there is no relation between the two diseases. It is not contagious nor hereditary. When occur- ring in several members in one family this is rather because the patients have been surrounded by the same conditions. The pathological changes in elephantiasis are the result of lymphatic obstruction and this, in the case of the tropic forms, is the result of the invasion of the filaria, while the non-parasitic cases such as originate in our country are the result of repeated attacks of streptogenous inflammation. The seat of the disease change is for the most part in the subcutaneous tissue, and the bulk of the enlargement is made up of hypertrophic connective tissue. In the verrucous cases there is also papillary hypertrophy. After prolonged dura- tion of the disease the underlying muscles may undergo atrophy and fatty degeneration and the bones may show uniform or irregular enlargement. The treatment of elephantiasis may be medicinal or surgical. During an inflammatory attack, rest, with local sedatives, are called for. Boric acid in saturated solution, or ichthyol may be applied; in fact, the treatment appropriate to erysipelas 254 DISEASES OF THE SKIN. is also proper in this stage of the disease. After the pain and heat have subsided, the part attacked is to be encased in a closely- fitting bandage, alone or in connection with other remedies. Methodical compression, is a very important and, up to a certain point, the most advantageous treatment which can be applied. Fig. 38. — Elephantiasis wilh warty growths. (Courtesy of Dr. Roland G. Curtin.) At first the bandage should be applied so as to produce a gentle but firm and even pressure, the amount of pressure being grad- ually increased from day to day. Thus the oedema is gradually reduced, a certain amount of absorption follows, and the venous and lymphatic systems regain tone. Strips of adhesive or India- ELEPHANTIASIS. 255 rubber plaster may be used in some cases. Later, Martin's rubber bandage may be applied, the limb being first covered with a thin layer of cotton batting. Esmarch's bandage has been used, but I can see very little advantage in its employment, and the loss of tone caused by the sudden emptying of the swollen vessels makes it unlikely that a healing contraction will take place. More probably the flaccid vessels would rapidly enlarge again when the pressure was removed. Some such treatment as this, with rest, is the most appropriate, and should be perse- vered in as long as it seems to do good. The rest should include repose in a horizontal position, and should, if possible, be continu- ous. If the leg is the part attacked, it may be bound to a wire anterior splint, such as is used in the treatment of fractures, and then, if this is suspended on a frame over the bed, considerable freedom of movement for sitting up, using the bed-pan, changing the sheets, etc., can be attained without disturbing the dressing. When eczema, with or without ulceration, is present, some approved local remedies may be used simultaneously with the bandaging, etc. One of the best forms of dressing for an eczem- atous elephantiasis is that of salicylic paste with the double muslin bandage, applied wet, as described under eczema rub- rum of the leg. There comes a time, however, when this form of compression ceases to be of benefit, and then the question arises, what further can be done to bring. the parts to' a normal condition? When the affection is of long standing and a considerable degree of fibrous hypertrophy is present, it must be confessed that the chance of entire restoration is poor. We know of no medica- ment or application which will cause the absorption of fibrous tissue on such a large scale. When, however, the effusion is slight, or at least when the solid deposit in the tissues is recent, massage will often do much toward causing its absorption. This plan of treatment also has the advantage that it may be employed upon the face, the genitals, etc., where the bandaging processes above described would not be available. There is no question but that the means of treatment at our disposal 256 DISEASES OF THE SKIN. in elephantiasis of these parts are scanty enough in any case. Electricity, in the form of galvanism, has been employed by Mann in one case successfully. A zinc-carbon battery of sixteen cells was used, and the negative pole, a metal plate, was placed on the sole of the foot, while a moistened sponge, attached to the positive pole, was brushed across the surface of the limb.* Internally, quinine may be given during the febrile exacerbations, with a view of abating the fever. Iodide of potassium has also been recommended. Sulphide of calcium has recently been employed in lymph scrotum with marked success. It is supposed to kill the filariae which may be present in the blood or lymph channels, and in any case is well worth a trial. The dose is three to six grains (0.20-0.40) daily, in divided doses. Change of climate is sometimes of great importance. In cases where the disease has been contracted in a tropical climate, if the person seeks a more temperate region before the hypertrophic condition is far advanced, the attacks of fever often cease, and much may be hoped regarding recovery. On the other hand, if he remains in a tropical climate, repeated exacerbations of fever occur, each followed by a progressive advance in the hypertrophic process, and recovery is almost impossible. Ligation of the femoral artery has been practiced in a number of cases of elephan- tiasis of the leg. When the scrotum is attacked, an operation with the knife is the best treatment. The prognosis of elephantiasis, once fully developed, is unfavor- able as regards entire cure. Much may be done, however, in the earlier stages of the disease to arrest its progress. Great deformity attends the disease. Elephantiasis scarcely ever term- inates fatally, though it is said a fatal result may follow an in- flammatory attack in rare cases. * Helf rich {Deutsche Med. Zeitung, November 7, 1887), recommends in severe uncomplicated cases the excision of strips of skin after elastic compression, and followed by elevation of the limb and massage. The excision must go through as much skin as can be pinched up into a fold. With antiseptic precautions the wound heals by first intention. The after-treatment consists in development of the muscles by electricity and massage by tapotement. Massage by stroking is to be avoided as tending to develop the subcutaneous tissues. Bandaging should be continuous. DERMATOLYSIS. DERMATOLYSIS. 257 Dertnatolysis is a rare anomaly of the skin, consisting in a more or less circumscribed hypertrophy of the cutaneous and subcutaneous structures, characterized by softness and looseness of the skin, and a tendency to hang in folds. It is a rare and Fig. 39. — Dermatolysis. {After Marcacci.)* very striking affection, and may occur over various parts of the body, sometimes developing to an enormous size. The " elastic skin" men who exhibit themselves in various parts of the country, Annates de Derm, et de Syph, 1880, p. 132. 17 ^ DISEASES OF THE SKIN. present a striking instance of an anomaly closely allied to dermat- olysis. Here, however, a remarkable looseness and elasticity of the connective tissue is the chief characteristic. The affection Fig. 40. — Dermatolysis. (After Marcacci.) is closely allied to elephantiasis. Microscopic examination of such cases shows the derma to be transformed into a myxomatous mass deprived of the fibrous fasciae which in the normal skin limit the excessive elongation of the elastic fibres. The treat- ment of the circumscribed form of the disease is removal by the knife, or galvano-cautery when this is practicable. ATROPHIA CUTIS. 2 59 CLASS V. ATROPHIES. ATROPHIA CUTIS. There are several forms of cutaneous atrophy, some of which seem to occur " idiopathically " and without obvious cause, while others are the result of some general disorder or of some injury to the nerves. In the "glossy skin" of writers upon nervous diseases, the extremities, especially the fingers, become pinkish or reddish, smooth, shining, and glossy, as though varnished. The lesions resemble chilblains in appearance. The affection is Fig. 41. — Atrophy of Skin (" Geromorphism Cutanee")-* accompanied by burning pain, and follows intractable neuralgia, wounds, and other lesions of the nerve trunks. General idiopathic atrophy of the skin is a very rare condi- tion, in which the skin becomes dark and discolored in patches, and swollen, then contracts, becomes of an olive color, and seems * Cas d'une atropine idiopathique de la Peau. Derm, et de Syph., 1886, p. 505. A. Pospelow. Annates de 260 DISEASES OF THE SKIN. too small for the body. The sensibility of the skin is deadened and the movements of the body are effected with difficulty. Under the name Geromorphism cutanee Charcot describes a form of congenital atrophy of the skin producing a curious senile aspect. Millard reports a case where transverse striae were disposed symmetrically on the anterior and external sur- face of the thighs a little below the trochanters subsequent to a severe attack of typhoid fever. The patient showed an abnormal rapidity of growth in height during this period. Atrophia Maculosa et Striata. Another form of atrophy of the skin is that known as "atrophic lines and spots." This form of atrophy may also be "idiopathic" or symptomatic. In the first case it comes without apparent cause, the patient's attention often being attracted to the lesions only by accident, and after they have existed for some time. The lines {stria atrophica) are usually half a centimeter to a centimeter in diameter, and three to ten centimeters in length; the spots {macula atrophica) are roundish or ovalish, and from a pin-head to a pea- or finger- nail size. Both lesions present a smooth, glistening, s^ar-like appearance, are perceptibly thinned to the touch, slightly de- pressed or grooved, and show a peculiar mother-of-pearl lustre. The lines are usually found in numbers running parallel to one another, and in an oblique direction. The spots are generally isolated. They may occur on any part of the body, but are usually found on the buttocks, hips, and on the thighs, upon both extensor and flexor surfaces. They run a slow course, and give rise to no inconvenience. Their origin is obscure; they are sometimes found in connection with morphcea. Symptomatic lines and spots of an atrophic character are those formed by stretching of the connective tissue bundles, as seen on the skin of the abdomen in pregnancy, etc. Occa- sionally this form of atrophy may follow severe diseases, as typhoid fever. Hemiatrophia Facialis. Unilateral facial atrophy is a trophic disease of the skin marked by a gradual withering of the tissues, affecting one side of the face and involving at first the cutaneous ATROPHIA CUTIS. 261 and subcutaneous tissues, and later the deeper tissues and bones. The affection begins as a circumscribed whitish, yellow- ish, or brownish discoloration of the skin, accompanied by rapid thinning. The discolored patch then sinks in, as a result of the atrophy of the subcutaneous tissues, and finally the thinned parchment-like skin lies directly upon the bone, without, how- ever, becoming adherent to it. The various appendages of the skin take part in the affection. The hairs turn white and sometimes fall out, the sebaceous secretion is perceptibly dimin- ished, while the secretion of sweat is at times increased. The appearances described are commonly at first and most markedly manifested in the sub-orbital or the lower maxillary region, but the chin, forehead, or temple may show the trophic depression. The disease may begin at various points simul- taneously. In addition to involvement of the external tissues atrophy of the tongue and soft palate may occur. Hemiatrophia facialis runs a rapid progress at first, and later remains at a standstill for long periods, to take up fresh activity some time afterward. Hereditary influence has not been proved. Women are more frequently attacked than men. The affection shows itselfbefore the thirtieth year, and usually between the tenth and fifteenth year. Of two cases, which have come under my observation, one was a boy, the other a young man of twenty, who, however, had had the affection some years. The causes of the disease are not accurately known, and there is much diversity of opinion on the subject. By some the disease is considered to be due to some injury or disease of the lymphatics, by others due to some direct influence exerted on the trophic fibres of the trifacial or other nerves. Another theory is that the per- ipheral nerves are at fault, while some French writers conceive, the disease to depend upon a primary atrophy of the fatty layers beneath the skin. Facial hemiatrophy has in several cases been observed to follow measles or scarlatina. One case is on record where the disease was bilateral, and another where the shoulder and wrist were involved as well as the face. 262 DISEASES OF THE SKIN. Hemiatrophia facialis may be mistaken for vitiligo or alopecia areata, but close examination will show an actual loss of sub- stance which will distinguish it from these milder affections. A diagnosis having been made, the affection, for practical purposes, passes out of the hands of the dermatologist. Elec- tricity forms the most hopeful plan of treatment, but the pros- pect of restoration to health is highly unfavorable. VITILIGO. Vitiligo is an affliction of the skin characterized by the dis- appearance or transfer of pigment in the affected areas, and by an accumulation of pigment in the immediately surrounding portions of skin. It shows itself in the form of one or more, usually sharply defined, rounded, ovalish or irregular-shaped, variously-sized and distributed, smooth, whitish spots, around the borders of which the surrounding skin shows an increase of pigment. The number of spots is usually not numerous, although larger areas or even the entire surface may be involved in rare cases; they are smooth and on a level with the surrounding skin, and save for the discoloration cannot be distinguished from it. The texture of the affected skin is, indeed, normal, except that the amount of pigment has diminished, a diminution which extends to the hairs growing on it, which usually turn white. The disease is popularly known as "piebald skin," and when occurring in the negro, has sometimes given rise to the notion that the skin was turning white, like that of a Caucasian. In many cases when vitiligo affects the scalp or other hairy parts, the hairs over the affected area turn white, and occasionally fall out. The disease is striking and disfiguring. Vitiligo sometimes disappears spontaneously after years, but treatment has little effect. The occurrence of vitiligo seems to depend in some way upon faulty innervation. Leloir has observed parenchymatous neuritis in the nerve fibrils distributed to the affected patches. Clinically, vitiligo is often found in connection with nervous disorders, peripheral and central. It is said occasionally to be the precursor of tabes. Arsenic is the only remedy which, ALBINISMUS. 263 in my experience, has had a good effect, when used for months. Electricity, hydrotherapy, and all means of improving the general nutrition should be resorted to. Feulard reports the cure in a young girl of vitiligo, accom- panied with alopecia areata (between which and vitiligo there seems at times to be some connection), by applications of acetic acid, followed by tincture of cantharides and the occasional use of solutions of bichloride of mercury, say four grains to the ounce of alcohol and water. The disease is sometimes mistaken for morphcea, macular leprosy, and chloasma. A reference to the description of these diseases will show wherein they differ. ALBINISMUS. The condition known as albinism, consists in a congenital absence of the normal pigment. It may be partial or general. In the latter case the sub- jects are known as albinos. Here the skin is of a milky-white or pinkish color, the hair white, yellowish-white or red, and even the iris and choroid of the eye are more or less deprived of pigment. It is said that in the negro the eyes are not affected, and cases are on record where the color of the affected patches has returned. This affection is to be carefully distinguished from vitiligo (q. v.). AINHUM. Ainhum is a disease peculiar to the African race, who first gave it this name, which signifies " to saw," and is characterized by a slow, progressive, fatty degeneration, generally with increase in volume of the toes, especially the smallest, resulting from a linear strangulation. The af- fection begins by a not quite semi-circular furrow in the digito -plantar fold, occupying the internal and inferior portion of the root of the small toe, with- out anv marked inflammation, pain or ulceration which may attract the attention of the individual affected. Gradually the furrow becomes deeper, and sometimes slightly ulcerated, and extends itself to the upper (dorsal) and external surface of the toe, thus forming, at last, a circular groove; while the anterior part of the toe — that is, that which is in front of the groove — becomes swollen to twice or three times its natural size and loses its shape, becoming oval or almost globular. The epidermis becomes rough; the nail is said not to become particularly changed, but it is turned outward by the rotation of the toe on its axis, which always takes place when the pedicle by which the toe remains attached to the foot becomes very thin, and the anterior part of the toe interferes with progression. Spontaneous ampu- 264 DISEASES OF THE SKIN. tation sometimes takes place. The affected parts preserve their normal sensibility. The progress of the affection is very slow, the time elapsing between the formation of the original furrow and the more or less perfect completion of spontaneous amputation having been, in some instances, ten years or more. When the little toe of one foot has been affected some time, that of the other foot becomes usually likewise diseased. After both the small toes are re- moved, neither any other toe, nor any of the fingers, nor any other part of the body becomes affected. (In rare cases the little fingers have been found affected.) Brazil, the West Indies, and the West Coast of Africa are the commonest localities of the disease, but within the last few years cases have been re- ported from the southern United States. In the early stages free transverse incision of the constricting band may arrest the disease. The only treatment, after strangulation has been effected, is the early removal of the useless and cumbersome member. PERFORATING ULCER OF THE FOOT. Perforating ulcer of the foot is a tropho-neurotic atrophy of the skin, affecting usually the sole, although the palm may be affected, and which, beginning as a callous formation, develops into an indolent and usually pain- less sinus leading down through the deeper tissues to the bone. The- most elaborate study of the disease has been made by Savory and Butlin.* It begins with the formation of a localized callosity or epidermal thickening, sometimes essentially the nature of a corn, most usually situated over the articulation of the metatarsal bone with the phalanx of the first or last toe, the regions which are subject to more or less pressure. Suppura- tion and necrosis take place beneath the callosity which is thrown off, dis- playing a small, deep, perforating ulcer or sinus, the opening of which is surrounded by granulations. Walking is usually painful. In typical cases other tropho-neurotic changes are observed. There are probably ulcers from pressure which are mistaken for true perforating ulcer. The disease usually occurs in connection with tabes and other nervous disorders. Treatment of true perforating ulcer is unsatisfactory. Even amputation has been followed by the development of an ulcer in the stump. Fortunately the pseudo-tropho-neurotic perforating ulcer is that most frequently met. Here the horny callosity is to be soaked in hot water or covered with a salicylic acid plaster until it softens and then pared off with a knife or dug away with a sharp spoon. The ulcer is then to be stimulated by the ap- plication of nitrate of silver and dressed with aristoi or europhen. The prognosis in pseudo-neurotic perforating ulcer is good. * London Medico-Chir. Soc. Transactions, vol. lxii, 1879, p. 373, with plates, etc.; also, Gasquel, These de Paris, July 1890. KELOID. 265 CLASS VI. NEW GROWTHS. Cicatrix, or ordinary scar may be included under new growths. There are two varieties, the elevated or hypertrophic and the depressed scar, the scar formation developing only sufficiently to skin over or cover the preceding depressed wound or ulcer. The scar, even when hypertrophic, shows no tendency to invade the surrounding healthy tissue as does keloid. To form a scar the damage to the skin must involve the corium; destruction which extends only to the corium, although removing the whole epidermis, includ- ing the rete, does not leave a scar, being replaced. The scar is composed of interlacing bundles of connective tissue with ab- sence of glandular structures, lymphatics, hair follicles, hairs and furrows. Xerves are rarely present. Scars tend to grow less with time, although in the case of children they grow with the general growth. The treatment of scars is generally surgical. Multiple scarifying, ''cross hatching," is sometimes of use. Acne and small- pox scars are said to have been improved in appearance by the use of the X-ray. KELOID. Keloid is a fibro-cellular new growth of the corium, character- ized by one or more irregularly-shaped, variously-sized, elevated, smooth, firm, somewhat elastic, pale red, cicatriciform lesions. The disease usually begins as a small, pea-sized nodule, increases slowly in size, and commonly assumes an ovalish, elongated, or crab-claw-shaped form, or may occur in streaks or lines. The lesion varies greatly in shape, and may be quite small or as large as the palm. The outline is well defined, and the surface contour rounded and highest in the center. Taken between the fingers it has a firm, dense, slightly elastic feel. Its surface is smooth, shining, and generally devoid of hair, and its color reddish or pinkish. The lesion is usually single, though several may exist simultaneously. It is more common over the sternum, but it is also met with on the mammae, neck, ears, arms, and elsewhere. It is sometimes painful, especially on 266 DISEASES OF THE SKIN. pressure, and occasionally, but rarely, it itches. Now and then acute inflammatory symptoms may arise in a keloidal tumor, giv- ing it a malignant appearance. These usually disappear in turn spontaneously. The course of the disease may be rapid or slow; having attained a certain growth it is apt to be stationary, and may remain a lifetime, though in most cases it ultimately disappears. Keloid may originate spontaneously or in cicatrices. The two varieties run into each other. Cicatricial keloid often orig- inates in the most insignificant scars. Bites of leeches, erosions, or pin-scratches are enough in individuals predisposed to the disease. Lehonneur {These de Paris, 1856) saw a case where the pressure of a shirt button was sufficient to give rise to keloid. Besnier has seen multiple keloid follow non-parasitic sycosis, and I have observed the same in several cases. Acne, es- pecially of the variety known as acne indurata, of the back and chest, is often followed by keloid. Psoriasis may be followed by keloid (Purdon). Keloid of the lobe of the ear, following the piercing for ear-rings or the wearing of ear-rings, is not uncommon. Burns by fire, or chemicals, particularly the latter, cuts, flogging, tattooing, and wounds of all kinds are not unfre- quently followed by this growth. Keloid is also met with in syphilitic individuals.* The occurrence of spontaneous keloid, at first admitted, was for some years doubted by many dermatological au- thorities. At present, however, its existence has been proved beyond a doubt by the observations of De Amicis (Cong, de Dermatol., 1889), Ory (Bull, de la Soc. Anat., 1875), Schwim- mer (Ziernsserts Hand-book), Bouzon (These de Paris, 1893). Most cases reported were of multiple tumors, from a dozen or so in number up to 318 in the case reported by De Amicis. In the case, both of spontaneous and cicatricial keloid, some constitutional peculiarity seems to be present. Most writers consider heredity to play a part in the production of this growth but facts in support of this view are wanting, excepting in the *R. W. Taylor {Jour. Cut. and Ven. Dis., 1883, p. 308) says that keloid oc- curs in one-half of one per cent, in his experience of syphilitic practice. KELOID. 267 cases reported by Hebra. "Scrofula" has also been invoked, but without much evidence to support the view of its diathetic effect. It is otherwise with syphilis. Bouzon finds that an analysis of 75 reported cases of keloid gave 16 or 20 per cent, when the patients were syphilitic, a great increase in the propor- tion over Taylor's statistics, but both writers consider syphilis to be a marked predisposing cause. The negro race is pecul- iarly susceptible to keloid. Under the microscope the lesions of keloid are seen to be made up of a dense, fibrous mass of tissue, whitish in color and composed of compact bundles of connective tissue, having their seat in the corium, and arranged in a meshwork. In the newer lesions fusiform cells and blood-vessels are found in this mesh- work and extending beyond the macroscopic limits of the growth. The newer keloid lesions look a little like sarcoma under the microscope; the older ones like fibroma. The symptoms of keloid are so striking that no difficulty need be experienced in making a diagnosis. It is most liable to be mistaken for simple cicatrix, from which it may be dis- tinguished by its color, outline, elevation, and consistence, and, frequently, by the presence of pain. Acne keloid (Dermatitis Papillaris Capillitii), however, is very liable to be mistaken for ordinary keloid. A careful study should be made of all cases of keloidal acne occurring on the nape of the neck or about the scalp. The treatment of keloid is rarely satisfactory. When operated upon by the knife or caustic it is apt to return, and frequently in an aggravated form. Caustic potash is the best caustic to use, but the growth should be touched with great caution while it is still making progress, or disappointment may be the result. Two forms of treatment have recently been recom- mended as successful. One of these consists of repeated scari- fications, such as are described under lupus vulgaris. These must be perserved in, as at first the keloid surely returns. After a while, however, it is said to disappear. Parasiticide remedies should be applied simultaneously. Hardaway has used multi- 268 DISEASES OF THE SKIN. pie puncture with the electrolytic needle with success. Marie avoids scarification, and uses hypodermic injections of creasote dissolved in oil (20 per cent.). The operation is followed by pain for some hours and causes suppuration, which results in destruction of the growth without relapse. Hypodermic injec- tions of morphia are occasionally required to allay the pain. Chloroform and anodyne liniments may also be prescribed for the same purpose, and I have used the fluid extract of hama- melis with benefit. Wilson recommends painting the group with a solution containing one drachm of iodide of potassium, an ounce of soft soap, and an equal quantity of alcohol, followed by the application of lead plaster spread on a piece of soft leather, the dressing being kept on a week and then replaced by another. The prognosis of keloid is not very favorable. The utmost that can be said in any given case is that it may disappear either spontaneously or under the use of supposed remedies after a time. Perhaps scarification and electrolysis may be more suc- cessful than the other forms of treatment. Its course is usually progressive, with occasional temporary arrest of development. Very often, however, the lesions remain stationary for years. DERMATITIS PAPILLARIS CAPILLITII. This affection, which partakes of the nature of sycosis, acne, and keloid, at once, is usually found upon the back of the neck just below the hairy scalp. The initial lesion is a follicular and perifollicular inflammation simulating ordinary acne. It is accompanied, however, from the beginning by a deep infiltra- tion of the derma, which can be perceived by pinching the skin between the fingers. The hair follicles involved are usually completely destroyed; some, however, persist and often appear in the form of a bunch of two, three, or more hairs springing from a common opening in the center or edge of a keloidal tubercle, and resembling a sort of brush. These hairs are thick and twisted, being evidently altered from their normal condition. Around each pustule of DERMATITIS PAPILLARIS CAPILLITII. 269 acne a keloidal growth forms, constituting in time a nodulated hard tumor over the entire area implicated. The nodules vary in shape and elevation, but are mostly somewhat conical and about the size of a large indurated acne tubercle. In the white races the color of the lesions is a bright red or rose color, sometimes showing fine branching capillaries like those observed in keloid. About the border of the affected region small acne- form pustules or rather folliculitis pustules are seen, which are traversed by hairs. The lesions have a tendency to group and form by confluence large indurated masses, which resemble and, in fact, are often taken for keloidal tumors. The seat of the affection is almost invariably upon the back of the neck, just below the edge of the scalp, where it occupies a broad transverse band about where the collar rubs. It may occur, however, elsewhere. Acne pustules are usually found at the same time scattered about, especially in the region of the moustache and beard. Lebou has shown that Dermatitis papillaris capillitii is a perifolliculitis of the hair follicles in which the embryonal tissue surrounding the follicles, instead of tending to suppuration, goes on to the formation of sclerous tissue. The disease is extremely rebellious to treatment, and the prog- nosis, when the process is fully developed, is unfavorable. All sources of irritation should be avoided; a large soft collar should be worn, or, better, no collar. In the early stages of the disease the acneform pustules should be destroyed as soon as they form. They should be opened and tincture of iodine or solutions of bichloride of mercury or ichthyol should be applied to the cavity. External treatment over the whole surface, including the sur- rounding skin, should be continuously employed. Salicylic acid rubber plaster on the lesions, with frequent and thorough applic- ations of bichloride soap or sapo viridis, should be followed by ap- plications of a parasiticidal character, as ichthyol, a saturated solution of boric acid in alcohol, etc. Occasional poulticing with starch poultices sprinkeld with boric acid will aid the treatment. The thermo-cautery may also be used with good effect. 270 DISEASES OF THE SKIN. The knife, which is very frequently called into play in the removal of the tumors, is not effective unless immediately fol- lowed by cauterization. There is no doubt that the affection is infectious and due to the invasion of some parasite not yet described. It spreads by auto-inoculation, which is favored by the use of the knife in operation. MOLLUSCUM CONTAGIOSUM. Molluscum contagiosum is a disease of the skin, characterized by the appearance of rounded, semi-globular or wart-like pap- ules or tubercles, of a whitish or pinkish color, varying in size from a pin-head to a pea. The lesion frequently looks like a drop of wax upon the skin, or like a pearl-button, flattened on top and with a darkish point in the center, representing the aper- ture of a follicle. They usually occur on the face, especially the eyelids, cheeks, and chin. They are also met with on the neck, breast, and genitalia. They increase in size slowly or rapidly, and are usually without sign of inflammation, though inflammation may exist at times. They eventually terminate by disintegration and sloughing of the mass. They give rise to no pain, itching, or other inconvenience. The affection is un- questionably contagious. Molluscum contagisum is not a disease of the sebaceous glands as formerly supposed. It is a hyperplasia of the rete or a benign epithelioma. Opinions differ as to whether it takes its start from the epithelial lining of the hair follicle or in the rete layer proper. Although the disease is probably parasitic, the psoro- sperm bodies found by some observers do not seem to be the true parasites. Molluscum contagiosum is liable to be confounded with molluscum fibrosum, but the two may be distinguished by their anatomical characters. In M. contagiosum the opening of the follicle can often be seen as a blackish point at the apex of the tumor. The lesions are superficial and rise above the skin. They are mostly confined to the face. The tumors of M. fibro- MOLLUSCUM CONTAGIOSUM. 271 sum do not show the black follicular opening. They are also found in great numbers all over the body, and are not confined to one or two localities. From warts, which they sometimes resemble, the tumors of M. contagiosum must be distinguished by a careful comparison of structure. Local treatment is alone required. Applications of ointment Fig. 42. — Molluscum contagiosum. of white precipitate, or sulphur ointment, well rubbed in, will sometimes suffice to remove the tumors. If this fails they may be opened with a small knife, the contents squeezed out and the bottom of the cavity cauterized with nitrate of silver. They may also be burned out with mild caustics, but severe measures 272 DISEASES OF THE SKIN. should never be used, because the disease is slight and tends to get well spontaneously. Electrolysis has been recommended by Rohe and Hardaway. MULTIPLE BENIGN CYSTIC EPITHELIOMA. This affection, known also as epithelioma adenoides cysti- cum and hydradenome eruptij, besides various other designa- tions, is characterized by small tubercular or nodular lesions of a pinkish, pearly or pale yellowish color; and usually seated about the face, upper part of the trunk anteriorly and posteriorly, and less frequently on the arms. The lesions begin as black dots or minute flat skin-colored papules. They vary from pin-head to pea-size, projecting above the surface, and have a shining semi-translucent appearance. They are usually rounded, conical, or in the larger lesions flat, with a slight central depression. At times minute capillaries can be seen in the surrounding skin. They usually remain stationary but occasionally may show de- generation and ulceration with rolled edge like an epithchoma. The disease begins in early adult life. It is an epithelial growth, the epithelial cells occurring in masses with occasional cysts. In some cases it resembles epithelioma in structure. The lesions are to be distinguished from those of molluscum contagiosum, hydrocystoma, and colloid miliun. The treatment should be removal by the knife or caustic as in epithelioma. ADENOMA SEBACEUM. This affection is characterized by the appearance of small tumors which are congenital or appear soon after birth. These are pin-head to split-pea sized, rounded, convex, either normal skin color or waxy, brownish or reddish. The surface may be smooth or rough and is covered with fine blood-vessels. The tumors are more or less grouped or bunched at either side of the nose or they may be scattered over the whole face or even appear LYMPHANGIOMA. 273 upon the scalp. The skin is apt to be coarse grained with large gland openings. The disease is a hyperplasia of the sebaceous and probably also of the sweat glands. In rare cases involution has been noted but the affection when once established usually persists. The tumors may be removed by the curette, the knife, or electrolysis. Adenoma of the Sweat Glands. Most cases described under this head are in reality multiple benign cystic epithelioma, but it would appear that a few genuine cases have been reported. They are among the rarities.* LYMPHANGIOMA. New growths of the lymphatics of the skin have been described in isolated cases by numerous authors, the appearances being so different in the various cases that it has been very difficult to assemble any considerable number into a single type. Wegner,t however, divides the various forms of the disease into (a.) lymph- angioma simplex, (b) lymphangioma cystoides and (c) lymphan- gioma cavernosum or circumscriptum, {Morris). Lymphangioma simplex consists both of dilatation and of new growths, it presents the appearance of isolated or grouped, circumscribed swellings, compressible and somewhat elastic, variously-sized and with somewhat dilated lymphatic channels leading into them. The genitalia, lips and mouth are the most frequent localities. The surface is covered with transparent vesicles in greater or less number which, if ruptured, give exit to fluid (milky ?) exudation sometimes lasting a long time. Such lymphangiomata when situated on the lips forms one variety of macrocheilia and on the tongue macro glossia. Cystic lymphangioma is usually congenital in origin, consist- * See references in Stelwagon under this head. tWegner, Archiv. j. Klin. Chirurg., 1877, vol. xx, p. 641. See also Pospelow, Arcliiv. f. Derm, u Syph, 1879, p. 521, and Noyes and Torok, Brit. Jour. Dermatol., 1890, p. 359 and 1891, p. 8. Numerous other references are given by Stelwagon, Dis. Skin, 4th Ed., p. 627, et seq. 18 2 74 DISEASES OF THE SKIN. ing of large multilocular cysts, most commonly seen on the upper part of the neck, in which regions they are often known as hygro- mata colli. In this locality they may be very deeply prolonged. These tumors belong rather to the domain of surgery. Lymphangioma cavernosum or circumscriptum is a limited regional or patch eruption connected with the lymphatics, characterized by pin-head to small pea-sized, usually somewhat deep-seated, often red-dotted, closely crowded vesicles. The eruption, which is rare like the other forms of lymphan- gioma, consists in groups of variously-sized, thick-walled frog- spawn-like, grayish, pinkish or reddish vesicles, the grouped aggregation being one to three inches in diameter; warty growths and telangiectases are also seen. The eruption usually is found on the shoulders, neck and scapular region. Though some of the vesicles disappear, the tendency is to grow or in cases to appear to shift from one spot to another. The disease is usually congenital, though it has been known to develop from the border of a scar. Authorities differ as to the histology of the disease, but it is usually supposed to be a dilatation and new growth of the lymphatic capillaries with, in some cases enlargement of neigh- boring blood-vessels forming a lymphangiectasis and telangiec- tasis combined, from which the tumors develop. Lymphangioma tuberosum multiplex is a somewhat similar condition, cases of which have been described by Pospelow, Roberts, and myself. The affection is of very rare occurrence, and is characterized by the appearance of numbers of tumors scattered, or in groups, over the general surface of the trunk. The lesions vary from small split-pea to hazel-nut size, of a reddish- brown or bluish-white color, smooth, rising from the surface, and rounding into it. On pressure over the larger lesions, the finger sinks deeply into the tissues, as into a bladder filled with fluid. They are accompanied, in some cases at least, by numer- ous lesions of fibroma molluscum. Microscopic examinations show the tumors to be composed of connective tissue, traversed by numerous lymphatic dilatations. XANTHOMA. 275 XANTHOMA. Xanthoma is a slightly elevated, flattened or somewhat rounded, soft, neoplastic growth of a yellowish color, usually seated as one, several or more lesions about the eyelids and occasionally of more or less general distribution. Two varieties are described, xanthoma planum, in which the lesions are flat, and xanthoma tuberculatum or tuberosum, when they are nodular. The plane variety is usually found upon the eyelids in the form of one or several roundish or square, smooth, opaque, yellowish patches looking often like a piece of dull chamois skin let into the skin. Occasionally they may be darker and even brown in color. They may be symmetrical or confined to the upper or lower lid of one side, sometimes they are fused into an orbicular patch covering the entire lids and extending slightly beyond. They give rise to no sensation whatever. This form of xanthoma develops very slowly and once fully formed shows no tendency to heal although cases are on record where the lesions have spon- tanously disappeared.* Xanthoma tuberculatum or tuberosum, sometimes called xanthoma multiplex, may be found on any part of the body except the eyelids. The most common localities are the hands, elbows, knees, buttocks and feet. The lesions are rounded and from pea-size to considerably larger, even to egg size. They occur singly or grouped. In children the affection often occurs in numerous and disseminated lesions. Excepting as regards outline and grouping they are essentially the same as the lesions of xanthoma planum or "palpebrarum" as it used to be called. Xanthoma may occur on the mucous membranes, the cornea of the eye and possibly elsewhere. Jaundice is said to be a not infrequent precursor or accom- paniment of xanthoma multiplex. Pathologically xanthoma is a benign, connective tissue new growth development with concomitant or subsequent partial fatty degeneration. The chief changes are in the corium the epi- *C. F. Legg, Path. Soc, London Lancet, vol. 2. 1879, p. 617. 276 DISEASES OF THE SKIN. dermis being slightly if at all affected. Large cells filled with fat granules and closely aggregated fat-drops, having a defined membrane and large, sometimes several or more nuclei are found lying between the bundles of connective tissue, consti- tuting the so-called " xanthoma cells." Xanthoma does not tend to spontaneous cure. The lesions may be removed by incision, the curette and when small by caustics or electrolysis. The X-rays have been used in some cases to advantage.* XANTHOMA DIABETICORUM. Xanthoma diabeticorum is a rare affection observed in dia- betic individuals, consisting of scattered, sometimes grouped and aggregated, somewhat inflammatory, papular or nodular elevations, with, usually, in most lesions, the basal portion red- dish and the apex of a yellowish or yellowish-white color, and generally accompanied by slight subjective sensations of itch- ing or pricking. The eruption may come on gradually or it may be abundant from the start. The lesions are somewhat firm or hard, pin- head to small pea-sized, rounded or conic, rather sharply defined papules, usually discrete, though sometimes aggregated or in patches. The lesions are usually of a dull reddish color at first and later show more or less of a yellow tinge resembling xan- thoma planum. Though occurring anywhere on the body the favorite seat of the eruption is on the buttocks, forearms, elbows, knees and back. There is almost always sugar in the urine in typical cases and the amount of the eruption is said to vary with the degree of the diabetes. In all the cases I have seen, immediate relief or entire disappearance of the eruption followed the successful treatment of the diabetes. Microscopically the lesions resemble those of the other forms *See Schwimmer, Ziemssen's Hand-book of Diseases of the Skin, p. 577; also, Pollitzer, New York Med. Jour., 1899, vol. ii., p. 73. A histological Study. N^VUS VASCULOSUS. 277 of xanthoma excepting that the inflammatory element is more marked and the connective tissue growth less pronounced. The treatment is that of diabetes. Locally carbolic and other anti-pruritic washes may be employed. COLLOID DEGENERATION OF THE SKIN. {Colloid Milium.) This extremely rare affection is characterized by the appearance in the skin of numerous small tumors — rounded, flat, or raised — the size of a pin's head to a split pea, of a pale or lemon color, bright, shining, and translucent. They look like vesicles, but when pricked are found to be firm, or to exude a little blood and transparent gelatinous fluid. The favorite sites are the forehead, about the orbits, the nose and the cheeks. The lesions have also been observed on the cornea and the septum nasi. The process is a colloid degeneration of the connective tissue of the corium. The treatment is re- moval by scraping with the sharp spoon, when this is practicable. NjEVUS VASCULOSUS. Naevus vasculosus {angioma, mother's mark, port-wine mark, birth mark, etc.) is a congenital new growth and hypertrophy of the vascular tissues of the corium and subcutaneous tissues. Blood vascular growths occur in three forms, ncevus vasculosus, telangiectasis, and angioma cavernosum. Ncevus vasculosus includes those vascular anomalies of the skin which are either visible at birth or very soon after. It occurs in the form of one, or sometimes several, spots, from the size of a small pin-head to that of the palm of the hand, or larger tracts. While these are usually level with the skin, the smaller ones are occasionally found raised like small red tumors. The color of the lesions varies greatly. Usually it is a bright red, but at times it has a deep port-wine tint. In some cases the color is like a stain or an erythematous blush. At other times tortuous blood-vessels may be seen coursing over the surface. Pressure by the finger causes a momentary pallor. The epider- mis over the lesions remains unchanged. On superficial inspec- tion the lesions seem sharply defined, but on closer examination 278 DISEASES OF THE SKIN. the edge of the vascular area is seen to fade gradually into the surrounding skin. Naevus vasculosus has little tendency to grow when once developed. Occasionally, especially in the case of infants, phagedena or gangrene will suddenly occur in these patches without appreciable cause (probably in consequence of the occur- rence of thrombus), and the entire growth will slough away, leaving a scar exactly delineating the area of the former naevus. As regards the cause of naevus, the explanation given by Virchow, namely, superfluous vascular formations in those por- tions of the embryo at which junction of the various parts takes place, seems most plausible. A small quantity of matter left over, squeezed out between the joints as it were, like superflu- ous building material, forms these naevi and the similar growths of lymphatics, hair, pigment, etc. Naevus vasculosus simplex is most frequently met with about the head, and next to this upon the trunk, and then the extrem- ities. Among 333 cases observed by Weinlechner, 243 were found upon the head. Of these 200 were in the face, of which 54 were frontal, 35 palpebral, 32 nasal, 30 labial, and 26 buccal. Of 20 cases of naevus of the face which I have seen, 12 were in females and 8 were in males. As regards position, 14 were on the right side, 4 on the left side, and 2 appeared to be symmetrical. The treatment of vascular naevus, aside from the radical surgical measure of bodily removal by the knife or ligature, has one principal underlying it, namely, that of obliterating the blood-vessels by pressure, inducing coagulation, or by exciting enough inflammatory action in the growth to obliterate the caliber of the vessels composing it. This may be accomplished in any one of a number of ways. Minute naevi no larger than the head of a pin may be destroyed by puncture with a red-hot needle, or with a needle charged with nitric or glacial acetic acid, or by electrolysis, with the aid of one or more needles connected with the positive pole of a four- to ten-cell combination of a constant current battery. When the growth is a little larger, from the size of a split pea to that of a ten-cent piece, it may be treated N^VUS VASCULOSUS. 279 by caustic applications. Of these, sodium ethylate is one of the most efficient. It rarely causes severe pain, and may be applied on the end of a glass rod. Other caustics are nitric acid and glacial acetic acid, which are available in the larger as in the smaller-sized naevi. Solution of caustic potash is also occasionally used, although this is a remedy of dubious value, since, to get it strong enough for a proper effect on the tissues, we must make it so powerful as to run the risk of too rapid action and consequent hemorrhage. Injections of tincture of the chloride of iron, with tincture of cantharides, carbolic acid, and the like, into the substance of the growth, have been recom- mended, but these methods are not without danger, when the growth has not been first isolated, and fatal cases of embolism have been reported as following the use of the iron solution. Vaccination has long been practiced in suitable cases. The virus must be pricked in with needles at a suitable number of contiguous points simultaneously. Linear scarification, as used in telangiectasis and rosacea, may occasionally be employed. The galvano-cautery and Paquelin's cautery have also been used. Recently the X-ray has been employed and I have found it of great value in extensive superficial cases. The prognosis of naevus vascularis is usually favorable. The growth gives rise to little or no sensation, rarely increases in size, except sometimes at the second dentition, and sometimes decreases or disappears spontaneously, especially at puberty. Occasionally, however, the smaller and prominent growths under- go malignant change, and this, as well as their unsightly appear- ance, should be considered by the physician who may be called upon for an opinion as to the advisability of treatment. Angioma cavernosum consists of a dense framework of new- formed connective tissue enclosing loculi or chambers of varying capacity, containing blood, and not only communicating with each other, but with the larger vessels in the vicinity. They are said to be rarely congenital, but are acquired soon after birth. Sometimes they originate from a naevus or superficial telangiectasis. Often when fully formed they are distinctly 280 DISEASES OF THE SKIN. encapsulated. The baggy purplish masses or tumors, filled with contorted, vein-like channels, sometimes met with on the faces of adults, are cavernous angiomata. They belong rather to the field of the surgeon than to that of the dermatologist. TELANGIECTASIS. Telangiectases are new growths consisting of blood-vessels, and in this respect are similar to naevi. They differ form the latter, however, in being acquired, and not congenital. They are commonly first observed in adult life and occasionally multiply with advancing years. They occur in localized and in diffuse forms. The diffuse form is excessively rare. I have observed one case. The localized forms of telangiectasis are characterized by the occurrence of minute, flat or slightly elevated, pin-head to pea-sized maculae; diffuse patches; linear ramifications of individ- ual vessels or contorted congeries of a plexus of the latter, usually pinkish or violaceous in color. The lesions are non-inflammatory and painless, and occur single or in small numbers, chiefly upon the face, but also upon the neck, back of the hands, etc. They may occur in the neighborhood of various skin diseases, partic- ularly in leprosy, keloid, lupus, scleroderma, etc., cicatrices, and sometimes upon the surface of tumors. In angiokeratoma angioma pigmentosum et atrophicum, rosacea, etc., they form the chief element. The treatment is the same as that of naevus vasculosus. ANGIOMA SERPIGINOSUM. This is an exceedingly rare disease beginning in early life, insidious and slow, and characterized by the appearance of minute, firmly-seated, pin- point to pin-head sized, elevated, bright red to dull red, or purplish points or papules. The lesions increase in size and then involution begins in the center, while the lesion extends in the periphery so that an annular circulate, or serpiginous configuration is assumed. Infective satellites form beyond the periphery and go through the same evolution. The center is not cica- tricial but only slightly discolored. The process seems to be of an angiosar- comatous character. It is to be distinguished from lupus vulgaris, q. v. FIBROMA. 28] FIBROMA. Fibroma, also called moJhiscum fibrosum, is a chronic hyper- trophic affection of the skin, characterized according to the variety of the affection by a single or a few pendulous tumors, Fig. 43. — Fibroma, diffuse form. (After Recklinghausen.) or by numerous sessile or pendulous growths of the cuta- neous connective tissue. Though it is possible that these two varieties may run into each other, the generalized variety very 252 DISEASES OF THE SKIN. often showing one or several tumors of large size, and the cir- cumscribed tumor being occasionally accompanied by a num- ber of small lesions, yet it will be convenient to consider them separately. The generalized form of the disease is characterized by the presence of cutaneous tumors, from a dozen or more to thousands in number, sessile or prominent, roundish in outline, soft, indo- lent, and generally of small size, though occasional exceptions occur. The lesions are found on all parts of the surface, even upon the palms or soles, but are usually most numerous upon the head and trunk, where they are sometimes so closely set as to be confluent. They occur somewhat less frequently upon the limbs, diminishing as the extremities are approached. The skin covering the genitals is occasionally, though rarely, affected, In some cases, where a post-mortem examination has been made, some of the internal organs have been found to display these tumors, and in several cases they have been observed in numbers upon the nerves. The lesions vary in size from that of a pin-head to a hazd-nut, and are found occasionally as large as a hen's egg, but rarely larger. The smaller ones may be felt in the skin but rarely rise above the surface, while the larger ones are more prominent and tend to become pedunculated and pendulous. The seat of the lesions is in the derma, and they move with it. Their color is that of the normal skin or slightly pinkish; occasionally they are covered with a fine vascular network, giving a violaceous tint. On some lesions, especially those upon the back, the ori- fice of a dilated sebaceous duct can be seen, from which a plug of sebum (comedo) may be squeezed. The sebaceous glands, however, are in no way essentially connected with the growth; nor are the hairs, but the latter occasionally fall out, probably from pressure. The tumors are of various consistency, but they are always more or less soft and flaccid, excepting in the case of the larger ones, which are occasionally distended and firm, with a smooth, glistening surface as if the tumor were cedematous. Alongside FIBROMA. 283 of such tumors may be seen others which have a flaccid, empty feeling, like a scrotum without its testicles or a raisin deprived of its seeds. A curious point is that, although the tumor can be rolled between the fingers, firm pressure reveals a firmer central core of tissue vaguely defined to the touch. Fig. 44. — Fibroma. Generalized fibroma is an indolent disease, and patients rarely come under the notice of the physician excepting for some inter- current affection. While the tumors usually seem perfectly stationary, yet now and then a case is observed in which one or several of the lesions seem to increase in size and may become 284 DISEASES OF THE SKIN. enormous. The period at which this change takes place varies in different cases. It may occur at puberty, or in the female during gestation if the tumor be seated upon the labia. The growth thus distinguished becomes pendulous, while preserving its rounded form, or takes the form of a dewlap, approaching to the kindred formation known as dermatolysis, pachydermatocele, cutis pendula, etc. (See Dermatolysis.) Circumscribed fibroma commonly occurs in the form of one, two, or rarely three tumors (which in the latter case are situated alongside of one another) of variable, but always considerable size, which is the greater according to the size of the tumor. The size in some cases reported has been enormous. In one case an enor- mous fold of skin sprang from the ear, which was greatly elongated, and from the back of the head, covering the neck, chest, and abdomen, fell in voluminous folds like a mass of intestine. The patient when seated was obliged to carry the mass in her lap. The localities from which these single tumors spring are the temple, upper eyelid, the nucha, behind the ear and at the level of the last cervical vertebra, the chest below the breast to the hip, and, chiefly, the labia majora. In one case the growth sprang from the sole of the foot. The skin covering these lesions is normal or slightly pigmented, smooth, or rough and rugous. In consistence they are like a mammary gland to the touch. Circumscribed fibroma is indolent and only calls for re- lief when the tumor is so large as to inconvenience the pa- tient, when an operation may be required. Degenerative changes of an inflammatory or malignant character sometimes occur in the tumors of fibroma molluscum, particularly of the circumscribed variety. The etiology of fibroma is obscure. Hebra has asserted that the disease occurs in persons of stunted mental and physical growth, and this is the experience of many writers, which has also been mine in the cases I have observed. It is more common among women than among men. Fibroma is a rare disease; only 86 cases were reported in the 112,775 cases of the American statistics. NEUROMA. 285 It is a curious fact, and one worthy of note, that in all cases of fibroma which have been examined post-mortem, new growths similar to those on the skin have been found upon the main trunks of the nerves. It has been suggested that fibromata of the skin are originally neuro-fibromata, the nerves being at first present and then disappearing as the tumor grows and the connective tissue becomes prominent. The diagnosis of fibroma rarely presents any difficulty. The number and distribution of the lesions, the unchanged character of the skin covering the tumors, the variety in size and shape of the latter, and the pendulous character of the larger tumors, are all highly characteristic. From molluscum contagiosum the tumors are to be distinguished, by not having any depression or aperture upon their summits. In rare cases where this exists a comedo can be squeezed out of the opening. They are, more- over, situated in the skin, which is normal over them, whereas the lesions of M. contagiosum are nearer the surface of the skin, which is tightly stretched over them. The tumors of fibroma are distinguished from those of lipoma by the fact that the latter are soft and lobulated in structure. The diagnosis between fibroma and other hypertrophic growths of the skin is rendered difficult because our ideas regarding the line to be drawn between fibroma and such affections as dermatolysis, pachydermatocele, and elephantiasis, are indistinct. The prognosis of fibroma is favorable excepting for possibil- ity of malignant degeneration, which, though extremely unusual must be considered. The treatment is limited to the removal of unsightly or dis- comforting tumors by the knife or the galvano-cautery. NEUROMA. Neuroma is a rare affection, characterized by the presence of variously- sized and shaped nerve growths, having their seat primarily in the true skin. The lesions are visible to the eye as split-pea-sized tubercles, scattered, or aggregated in large numbers over the affected locality. The lesions are of a rose or pink color, smooth and firm, and the intervening skin normal. Pain, of a paroxysmal character, and extremely severe, is the chief symp- 286 DISEASES OF THE SKIN. toms. Movement of the affected part, a draught of cold air, or even mental worry and excitement are often sufficient to cause pain and even agony. A microscopic examination of the tumors in the few cases observed has shown them to be composed of medullated nerve fibres and connective tissue in varying proportions, and in one case of smooth muscular fibres also. They were, in fact, actually fibromata, at least in the case of the older lesions. (See Fibroma.) The affection must be distinguished from painful subcutaneous tubercle, a not uncommon affection. Here the lesion is usually single, and is not sit- uated in the skin, but in the subcutaneous tissue. The only treatment of neuroma cutis is the excision of a portion of the nerve trunk leading to the affected area. This has given entire relief in one case, while in another case the same operation failed entirely. MYOMA. Myomata, or dermatomyomata, are small tumors occurring either single or multiple. One variety, the more common, is solitary or grouped in a single locality. The lesions are cherry to apple sized, and may be sessile or pedunculated. Their usual seat is upon the breasts and genitalia in both men and women. They are contractile, vascular, of slow growth, and usually indolent, although at times they are found to cause much pain. The tumors are usu- ally composed of smooth muscular fibres, but may contain considerable fibrous tissue, in which case they are known as fibromyomata. Sometimes the vascular element predominates, and at other times the lymphatic, so that, at times, the exact character of a given tumor may be very doubtful. Simple or generalized myomata constitute an exceedingly rare affection. They are characterized by minute tumors the size of a lentil, more or less, of slow development, roundish or oval, of a pale rose or a deep red color, according to their size, and disseminated here and there over the trunk or limbs. Their peculiarity is that they are tender and painful, often to a high degree, the pain often occurring in paroxysms of extreme intensity. They are composed of unstriated muscular tissue, The treatment is ablation by knife, caustic, or electrolysis. RHINOSCLEROMA. Rhinoscleroma is a chronic neoplastic affection, starting in the mucosa of the nose, particularly of the alae and septum, and extending gradually to the cartilages and skin of the nose and surrounding parts. In a few cases the posterior part of the soft palate and neighboring organs, as the larynx and trachea, are the starting point. As the growth enlarges, the shape of TUBERCULOSIS CUTIS. 287 the nose is gradually altered, becoming broader and flatter, and the organ feels hard and rigid to the touch like ivory. The lumen of the nose becomes occluded, the surrounding parts partake of the growth and become quite disfigured. The color is normal or reddish, smooth and is traversed by small blood-vessels. The direct cause of the disease is supposed to be the bacillus rhinoscler- omatis. Histologically the process is considered of a granulomatous charac- ter. Rhinoscleroma is highly rare in this country and thus far has only been met with among foreigners. Removal by the kaife is perhaps the best treatment, but the tumors are apt to recur. It does not threaten life at any stage. TUBERCULOSIS CUTIS. Tuberculosis of the skin includes all those affections which are caused by the tubercle bacillus. Considerable confusion at present exists regarding the exact relationship obtaining between some of these diseases, but the attempt will be made to include the most important ones recognized by authoritative writers. We may arrange the tuberculodermata under the fol- lowing heads: (i) Accidental inoculations, (2) tuberculous ulcers, (3) scrofuloderma, (4) lupus vulgaris. ACCIDENTAL INOCULATIONS. Under the head of accidental inoculated tuberculosis are in- cluded the various forms of anatomical, or dissection tubercle, or wart. The anatomical tubercle is usually inoculated in dis- sections or in operations on tuberculosis patients. The hand is the common seat of such inoculation and particularly the thumb and forefinger, a circumstance which is explained by the frequent contact with various objects which may bear the con- tagion. Cases have been observed in which tuberculosis of this variety has been inoculated upon the forearm by contact with a tuberculous patient. Other cases where the face or other parts have been wounded by utensils belonging to tuberculosis patients have been reported. 265 DISEASES OF THE SKIN. Anatomical tubercle usually shows itself first by the appear- ance of a small red papule, in the center of which is seen a white point which softens and ulcerates, exuding a thin sero-pus. It then becomes covered with a yellow crust; not infrequently a series of similar papules form around the qriginal one, ordin- arily coalescing with it to constitute a larger lesion. Occasionally a lesion is accompanied on its appearance by a more intense inflammatory action resembling an abscess or felon, and results in an ulcer covered with a grayish crust. When completely developed the anatomical tubercle is made up of a warty infiltration of the skin of a livid red color, the sur- face of which is covered with hard, horny masses divided in numerous segments; the shape of the lesion is irregular, the development extremely slow, and the lesions may grow to the size of a quarter of a dollar by coalescence of similar elements. At this period the anatomical tubercle seems to remain for some time in statu quo; occasionally, however, new lesions appear in the neighborhood. Microscopic examination shows very much the same appearance as that presented in some forms of lupus. Under the name of tuberculosis verrucosa, is described a form of tuberculosis cutis, which is somewhat similar to the anatom- ical tubercle. According to the authors who have described this form of tuberculosis cutis, however, this form of tuberculosis does not necessarily occur in connection with inoculation from without. It may be observed in persons who are already suffer- ing with the symptoms of general tuberculosis. It is much more active in its nature, tending to spread more rapidly, and is often accompanied by secondary infection, as shown by lymphangitis and adenitis, and subsequently visceral tuberculosis. The diagnosis of these forms of tuberculosis of the skin is sometimes difficult, but the peripheral hyperaemic border, the miliary ulcer- ation around the lesion or at the bottom of the fissure, and the tendency to cicatrization in the center in older cases are quite characteristic. The diseases with which tuberculosis verru- cosum is most likely to be confounded are the ordinary wart, TUBERCULOUS ULCERS. 2SO. simple papilloma, benign vegetations, papillary epithelioma, pap- illomatous naevus, some forms of lichen planus and of syphilo- derma. Some years ago I met with a case where the initial lesion of syphilis produced accidentally by an operating knife resembled very closely the anatomical tubercle. This lesion occurred on the tip of the index finger of the right hand. I was at first convinced that it was an ordinary wart and treated it as such. Somewhat later I came to the conclusion that it was an anatomical tubercle, but was extremely surprised when my pa- tient appeared with enlargement of the axillary glands and generalized erythematous eruption unquestionably syphilitic in character. Perhaps the diagnostic mark in this case should have been the locality, as tubercle is much more apt to occur on the back of the finger around the nail. TUBERCULOUS ULCERS. The tuberculous ulcer is usually found seated upon the muco- cutaneous surfaces of the buccal and anal regions but may occasionally be found elsewhere. It is generally single but occasionally several ulcers have been observed in the same neighborhood or separated in various regions of the body. The ulcer rarely exceeds one to two centimeters in diameter, it is usually circular or oval and occasionally polycyclic in outline resembling in this respect the lesions of herpes. The edges are sharply defined, looking as if punched out or even slightly undermined. The ulcer secretes a small quantity of sero-puru- lent fluid and is rarely covered by a crust ; it is granular, mammil- lated and covered with small reddish points intermingled with reddish-gray projections. The tuberculous ulcer is usually painless. SCROFULODERMA. That form of tuberculosis of the skin to which the term " scrof- uloderma" has been most generally applied is the tuberculous gumma of the skin. This sometimes begins in one or more 19 290 DISEASES OF THE SKIN. of the superficial lympathic glands, especially under the jaw, about the neck and clavicular region. The glands become enlarged and the process extends to the skin overlying them, which becomes red and infiltrated. Finally, a cold abscess forms, and is discharged through the skin, and an ulcer of slow progress, with undermined violaceous border results. At other times the process begins in the external skin where it is known as the "scrofulous gumma" on account of its re- semblance to syphilitic gumma. The most superficial of these gummata begin as a small infiltration or node in the skin, of a livid red color. Increasing in size, slowly at first, and later more rapidly, the lesion sometimes extends in one or more di- rections, involving the entire skin and softening at one or more points to form small ulcers, with burrowing sinuses extending from one to another. The discharge from these ulcers is usu- ally sero-purulent or sanious, and occasionally bloody, and the skin may be undermined by numerous communicating galleries. Occasionally the disease takes on a diffuse, infiltrating form, spreading in an irregular patch over the skin, involving its entire surface and giving rise to serpiginous, shallow ulcers. The scrofulous ulcer never shows any disposition to heal. It may look as if it were on the very verge of cicatrization, but it does not actually scar over, or, if it does, a week or two later the cicatrix opens in one place while forming in another. In addition to the localities above mentioned, this form of scrofuloderma may occur over the cap of the shoulder, in the groin, and elsewhere. It is generally accompanied by other signs of the scrofulous condition, by old scars, etc. In children this form of tuberculous disease often shows itself in the form of funmculoid lesions which break down rapidly, form abscesses and when numerous may lead to a fatal result. Another form of disease which was first described by Duhring under the name of the small pustular scrofuloderm shows itself in the form of small, hard, scattered, flat papules, with a raised violaceous area. The lesions may occur upon any part of the body, but are usually met with upon the forearms, legs, and SCROFULODERMA. 29 1 face. At first, they look like the small pustular syphiloderm, but crust over after some weeks and the crust, dropping off later, leaves a depressed pit-like cavity of a size to admit the head of a pin. Finally the lesion disappears, leaving a punched-out scar like that of small-pox. The course of the disease is extremely slow. New lesions form while the old ones are cicatrizing and while the affection does not give rise to any pain or other annoy- ing sensation, it is very rebellious to treatment. A type described by Duhring as the large, flat, pustular scrof- uloderm appears in the form of one or more pin-head to small split-pea sized indurations which soon become pustular and enlarge peripherally, forming a fairly large, flat, often irregularly- shaped, yellowish or brownish-yellow, flat, thin, crusted pustule, with an areola of a dull red or violaceous color. The crusting is slow, beginning in the center, and quite scanty, unlike the large, flat, pustular, syphiloderm where the crust is thick and extends over the whole lesion with an abundant secretion of pus underneath. When the crust of the scrofuloderm is removed a superficial, irregular, edged, granular looking scrofulous ulcer, with uneven base covered with thin purulent secretion, is seen. The ulcers may heal in the center and spread peripherally. Their course is slow. They leave a soft superficial scar. Treatment of Tuberculosis of the Skin. The important point in the treatment of tuberculosis of the skin is to destroy the center of the disease, which may, if left alone, infect the entire system. Where the lesions are superficial, easily gotten at, and in a position where caustics or other destructive agents can be used, the suppression of the lesion is not difficult, but occasionally the superficial skin lesions are accompanied by inter- nal foci of disease which cannot be reached by any caustic or other local measures. The internal treatment of tuberculosis of the skin is sometimes neglected. I think that we cannot go wrong in administering cod-liver oil in considerable doses, either pure or made up as the pharmacists supply this remedy in the present day. The French writers suggest six to eight table- spoonfuls in 24 hours. This is a much larger dose than most 292 DISEASES OF THE SKIN. of our patients in this country are able to bear, but my impres- sion is that the larger the quantity of the oil which can be taken and digested the more benefit may be expected. Where cod- liver oil is not easily digested I have sometimes found very good benefit from the aid of bread and butter. It should be urged upon patients as a medical prescription. When taken in very large quantities the system is supplied with very digestible, fatty matter, and I have sometimes observed most excellent effects from this remedy. After all, it is only a question of some easily diges- tible fat to be introduced into the economy. In addition to cod-liver oil the syrup of the iodide of iron in very considerable doses is often found useful. I, myself, have observed some cases of lupus improve very much under iodide of potassium. Of course, the general hygienic treatment of tuberculosis now so well known should be employed and it must be remembered that cases of tuberculosis of the skin are apt to develop tuber- cle in other organs so that general prophylaxis is practiced. LUPUS VULGARIS. Lupus Vulgaris. Lupus vulgaris is a very chronic, new cell growth, depending upon infection with the bacillus tuberculosis, characterized by variously-sized and shaped, reddish or brown- ish patches, consisting of papules, tubercles, or flat infiltrations, usually terminating in ulceration and cicatrices. The disease varies in appearance in different cases, and also according to the locality attacked and the stage of its develop- ment. It usually begins by the formation of small, yellowish- red or brown points under the skin, which increase in size, coal- esce, and form irregularly-shaped, roundish or serpiginous, ill-defined patches of various size. The points referred to enlarge until they form papules, and finally tubercles. It is at this stage that the disease usually comes under notice. The lesions are of all sizes, from pin's head to split pea, are brownish- or yellowish- red in color, and are covered with a thin layer of imper- fectly-formed epidermis. They are firm or soft, and are pain- less. At this stage of development the disease may retrograde LUPUS VULGARIS. 293 and terminate in absorption of the lesions, leaving a thin, des- quamative, cicatricial tissue, or it may go on to ulceration and complete destruction of the infiltrated skin, resulting in much disfigurement. In its earlier stages lupus vulgaris is rarely attended by any subjective symptoms, but later there is some- times pain. The commonest seat of the disease is about the Fig. 45. — Lupus vulgaris. face, especially the nose, cheeks, and ears. It frequently attacks the extremities, especially the fingers, where it may result in serious deformity. The limbs and trunk may also be involved. Lupus vulgaris is a destructive disease, often resulting in seri- ous disfigurement. It spares none of the external tissues, and may invade the mouth, cartilages of the nose, ear, larynx, and even the eve. 294 DISEASES OF THE SKIN. The disease usually originates in childhood. It is never congenital. It is rarely, if ever, hereditary. It is much com- moner on the continent of Europe than in Great Britain, and is rare among natives of the United States. The diagnosis of lupus vulgaris from syphilis, the disease with which it is most likely to be confounded, is chiefly to be made by the history of the case in question. In addition, the ulcers of lupus are comparatively superficial; those of syphilis ordinar- ily deep, and often having an excavated appearance. The ulcer of lupus is commonly less extensive than that of syphilis. In lupus there arc, as a rule, a number of points of ulceration which tend to become confluent ; whereas, the ulcers of syphilis usually remain distinct. The border of the syphilitic ulcer is sharply defined; that of lupus is not apt to be so. The secretion of the syphilitic ulcer is apt to be copious and offensive ; that of lupus is scanty and inodorous. The crusts of lupus are thin and brownish; those of syphilis are bulky and frequently have a greenish tinge. Lupus is slow in its course; syphilis is rapid. A syphilitic ulcer may form in five or six weeks, while it may take as many years for the lupus disease to give rise to so much destruction. The scar of lupus is distorted, hard, shrunken, and yellowish. That of syphilis is whitish, smooth, thin, often surprisingly small, considering the destructive process which has gone before. A history of other syphilitic symptoms is some- times, though by no means always, to be obtained in syphilitic ulcer, and too much stress must not be laid on the absence of this. Lupus may be confounded with epithelioma. Though the diseases may occur together, yet such occurrence is rare. The localization of epithelioma, with its usually painful character, and the circumscribed induration of the lesion, will usually serve for the diagnosis. The ulceration of epithelioma generally starts from one point and spreads peripherally, while the ulcer- ation of lupus usually begins at many points within the patch. Epithelioma very seldom occurs in the young; lupus begins in childhood. LUPUS VULGARIS. 295 Lupus vulgaris is to be distinguished from L. erythematosus by the occurrence of ulceration, which never takes place in the latter. The patches in L. erythematosus are superficial, uni- formly reddish in color, and are at times covered with adherent, grayish scales. They are, moreover, circumscribed, and are without papules or tubercles. The sebaceous glands and fol- licles are generally markedly involved in L. erythematosus; in L. vulgar's they remain unaffected. Acne rosacea at times bears some resemblance to lupus vul- garis, but may readily be distinguished by its dilated vessels, color, the presence of acne pustules, its history, and its course. The treatment of lupus vulgaris is chiefly local, though con- stitutional remedies are also to be employed. It appears to be somewhat more amenable to internal treatment in this country than abroad. It is, however, one of the most obstinate of all cutaneous diseases. Hygienic treatment is of great import- ance. Cod-liver oil is the most efficient internal remedy, and, next to this, iodide of potassium. It may be given with the oil, as may also iodine and phosphorus. Internal 'remedies should usually be well tried before external applications are made, as they alone sometimes suffice to obtain a cure. The external remedies used in the treatment of lupus vulgaris are of a me- chanical nature, or comprise various caustics. They should be selected with a view to the extent, locality, and character of the lesions in any given case. In the earlier stages stimula- ting applications may be employed, with a view to bring about absorption. Equal parts of tincture of iodine and glycerine, painted over the part, mercurial plaster, tar, and ointment of the red iodide of mercury may be used for this purpose. I must confess, however, that in my hands these milder remedies have usually failed of success, and I have always, sooner or later, had recourse to more severe measures before a cure could be obtained. Of true caustics, potash, nitrate of silver, arsenic, carbolic acid, acetate of zinc, chloride of zinc, and pyrogallic acid may be mentioned. The first and last of these I believe to be most efficient. 296 DISEASES OF THE SKIN. Caustic potassa should be used when thorough and extensive destruction of tissue is desired. A stick of the caustic should be wrapped in a bit of rag, with only the point protruding, and this should be bored into all the disease-foci, which will be found to break down easily. It should be remembered that the effect of this caustic goes somewhat beyond the point touched. Dilute acetic acid or vinegar should always be kept at hand to limit and check the spread of the caustic and to neutralize it. The pain is severe for the moment, but ceases on the applica- tion of the acetic acid or vinegar. Nitrate of silver is efficient in some cases, and is said not to leave scars. Papules and tubercles may be destroyed by boring into them with the solid stick, while patches are most successfully treated by the saturated solution repeatedly applied with the charpie brush.. Nitrate of silver is one of the best caustics to use in operations on lupus about the face, but it does not penetrate deeply. The following formula of Unna's is also recommended: 1$. Hydrarg. bichlor., gr. iij (0.2) Acid, carbolic, gr. xij (o 8) Alcoholis, f 5j. (4- ) M. A small, sharpened stick is dipped into this solution, and bored into each little lupus deposit. The pain is brief. Pyrogallic acid, in the form of ointment, one drachm (4.) to the ounce (32.), applied thickly spread upon cloths, and renewed twice daily, is painless and efficient in many cases. It selects the diseased tissue and acts but little, or not at all, on the healthy. Chloride of zinc is used according to the following formula: 1^. Zinci chloridi, Antimonii terchloridi, aa, 3ij l (8-) Acidi hydrochlorici, q. s. M.. Enough acid is added to dissolve the chloride of zinc, and the mixture rubbed up in a mortar with enough powdered liquor- ice to make a paste. This is spread upon a cloth and applied while moist. It is a powerful caustic, very painful, and eats through healthy and diseased tissue alike. I have never found occasion to use it. LUPUS VULGARIS. 297 Ethylate of sodium is an excellent application, and being less painful than some other caustics, may be preferred in small operations not demanding an anaesthetic. It should be applied on a glass rod, the parts dried so far as possible, and no water should be allowed to touch the parts while the ethylate of sodium is being applied. Fig. 46. — Dermal curettes. Erasion, or scraping by means of the curette or scraping spoon, is useful in many cases, and is a plan of treatment I can highly recommend from experience. The instruments are cup-shaped, of steel, with sharp edges, and fastened by a short shank to a convenient handle. In size, they vary from a split pea to half the size of a teaspoon. The part to be operated upon is first frozen by means of a hand-ball atomizer, charged with ether or rhigolene, or by the application of a gauze bag filled with powdered ice and salt, and the diseased tissue is scraped or dug out. If any of the diseased tissue is left, a recurrence of the lupus must be looked for; the operation, there- fore, must be thorough. Small nodules remain- ing may be removed by the use of the dental burs Fig. 47.— Dental and excavator here pictured, as suggested by Dr. George H. Fox, of New York. Scraping may often be appropri- ately supplemented by the application of caustics, as pyrogallic acid, caustic potassa, or even the actual or galvano-cautery. One of the best forms of treatment is by linear scarification. Squire has devised a multiple-bladed knife, by which this operation, over large surfaces, is much facilitated. 298 DISEASES OF THE SKIN. The scarifier pictured below is one which I have devised, em- ploying the principle suggested by Squire, with an arrangement of the blades suggested by Pick. In my instrument, five blades, shaped like those commonly employed for gum lancets, are ar- ranged parallel to one another, the central one being fixed in a small ivory handle, and the others being removable so as to fa- cilitate their cleansing. The handle of the instrument is to be GEHRIG & SON =^» Fig. 48. — Multiple scarifier. Van Harlingen's modification. held like a pen, and a series of parallel cuts are to be made, going as deeply as is considered necessary. Cross cuts are then made, and the cross hatching is continued until in severe cases, the whole surface is hashed up. After excision or scarification a caustic should be applied, with antiseptic dressing to follow. The operation may have to be repeated, but in the end a clean, healthy scar is the result. Besnier considers that lupus vulgaris is often transmitted by Fig. 49. — Holder for galvano-cautery knives. About half-size. the "bloody operations," as they are called, such as excision, scarification with knives, erasion with curettes, etc. He, there- fore, recommends the employment of the electro-cautery.* Besnier employs a number of electro- cautery knives of various shapes, with the view to reach all the various sized and shaped deposits of lupous tissue in the skin. Many of these I habitually employ. My favorite knives are the flat-bladed knife and the point. * The healing power may be derived from a Fleming cautery battery (see Fig. 51) or from a storage battery like that used in the portable X-ray apparatus. LUPUS VULGARIS. 299 When only a small space is to be covered, most patients can endure the pain, which is but momentary. When a considerable area is to be operated upon, however, ether must be admin- istered. The knives are to be heated to a dull cherry- red, and as most operations are about the face, some care must be exercised to avoid ignition of the ether when this anaesthetic is employed, and even more when rhigolene spray is used. Of late years the Finsen and the Rontgen or X-ray treatments Fig. 50. — Besnier's galvano-cautery knives. have superseded other forms of local treatment in hospitals and large cities where these methods can be employed. As regards the Finsen method this depends upon the bactericidal effects of concentrated chemical rays, using the arc light and controlling or preventing the action of the heat rays. The technique of this method is so complicated and its use so restricted that it seems unnecessary to describe it at length in this work and reference may be made to special papers on the subject.* * See in particular Malcom Morris and Dore, The Light Treatment in Lupus and other Diseases of the Skin, Practitioner, April, 1903. 3°° DISEASES OF THE SKIN. The use of the X-ray in the treatment of lupus vulgaris is now an accepted procedure and being much more readily obtain- able in this country than the Finsen light may be resorted to in certain cases, especially where the disease is extensive, to great advantage. It does not always agree with the skin and in a certain number of cases excites violent inflammation without ameliorating the disease, but where it agrees the effect of the X-ray is peculiarly rapid and satisfactory. Sometimes a small dose is sufficient but usually X-ray dermatitis to the second degree, vesi- culation or serous exuda- tion must be produced be- fore an impression is made upon the disease. Caution, however, should be em- ployed in this as in the milder skin diseases in order that an excessive ef- fect may not be produced. Stelwagon suggests that "the first exposure should be given with a tube of low or medium vacuum at ten inches, distance for five minutes, duration and at intervals of three or four days. After a period of ten days to two weeks, if no susceptibility has been shown, the distance can be gradually reduced to three or four inches and the time lengthened to ten or fifteen minutes and the exposures made at more frequent intervals." "In those instances where moderate reaction has been purposely provoked and kept up, after a few weeks, treatment should be discontinued until this subsides, and in some cases improvement sets in and continues. The method Fig. 51. — Cautery battery. LUPUS VULGARIS. 3OI should again be resumed as soon as improvement begins to flag."* The prognosis of lupus vulgaris will depend upon the form of the disease, its duration, the age of the patient, and the extent of surface involved. The disease, in any case, is very stubburn, Fig. 52. — Portable X-ray aparatus as made by Queen & Co., Phila. and runs a chronic course. If it be confined to one patch or region, a more favorable termination can be looked for. The disease usually results in marked scarring and deformity. The pathology of cutaneous tuberculosis is a complicated and as yet not very clearly understood subject. So far as the anatomy of the lesions is con- * The X-ray apparatus given in Fig. 52 shows the minimum required in the phys- ician's office or by the patient's bedside. This can be added to as the taste or requirements of the operator may demand to an indefinite extent. As regards technique reference may be made to the works of Pusey and Caldwell and of Allen on Radiotherapy. 302 DISEASES OF THE SKIN. cerned this has been thoroughly worked out. (See Bowen, The Pathology of Cutaneous Tuberculosis, Boston Med. and Surg. Jour., Nov. 12, 1891, p. 516.) But theories as to the introduction of the bacillus and the possibility of morbid action from toxins have not been uniform nor conclusive. Stel- wagon and Hyde and Montgomery may be consulted in their more elaborate treatises by those desirous of knowing the prevalent speculations on this subject. LUPUS ERYTHEMATOSUS. Lupus erythematosus is a chronic, mildly or moderately inflammatory, small-celled superficial new growth formation, characterized by one, several, or more, circumscribed, variously- sized, usually oval or rounded, discrete or confluent, pinkish to dark red patches, covered slightly and more or less irregularly with adherent grayish or yellowish scales, and seated most commonly upon the face, less frequently upon the scalp also, and exceptionally upon other parts. The disease usually begins in the form of one or more round- ish, pin-head to small pea-sized, erythematous patches, which enlarge upon their periphery, and often coalesce to form larger, irregularly-shaped patches. After a time the patches increase in thickness and show more infiltration, and when fully developed there may be a number of patches, varying in size fram a split pea to a silver dollar, or the palm of the hand, having usually a distinct and clear-cut marginal outline. In color they are reddish or violaceous, and are sometimes covered with fine or coarse, grayish or yellowish, remarkably adherent scales, at times scanty, at other times forming sebaceous-looking crusts, like those found in eczema seborrhceicum of the face. In localities where the sebaceous glands are large, as upon the nose and adjacent parts, the crusts are firmly attached to the open- ings of the sebaceous glands, which are often plugged up with sebum or denuded and patulous. In other cases, the eruption does not seem to involve the sebaceous glands in particular, but seems purely erythema-like in form and appearance. The patch spreads on its margin, which is usually higher than the center, the latter being commonly paler, and often LUPUS ERYTHEMATOSUS. 303 showing atrophic depression. After a variable time the patch attains a certain size, and may remain stationary. There is never any moisture or discharge in connection with the disease. Sometimes it seems to spread by the occurrence from time to time of erysipelas-like attacks, after the cessation of which the area of permanent disease will be seen to have increased and new circles to have formed. Lupus erythematosus is usually found upon the face, one or both cheeks, below the eyes, and the bridge of the nose, being the commonest seat of the affection. Often both of these localities are attacked by the disease, which forms the rude figure of a butterfly with outstretched wings. The muco-cutaneous and mucous surface of the lips, the ears, scalp, back, chest and other parts of the body may be attacked. Lupus erythematosus is remarkable for its chronicity and may persist through life. It tends to increase, from time to time, by repeated attacks. Ultim- ately, the process is apt to end in the formation of a superficial cicatricial tissue. The subjective symptoms vary in different cases, depending somewhat upon the activity of the disease. At times there is much burning and itching, while in other cases there may be no subjective symptoms. Females are more liable to it than males, and light- than dark- haired persons, and it occurs notably on those who are subject to disorders of the sebaceous glands, sometimes, indeed, appear- ing to originate in a patch of localized seborrhcea. The views of various observers regarding the etiology and pathology of L. erythematosus vary considerably. There is little doubt in my mind that the disease is in some way related to tuberculosis although the tubercle bacillus is not found in the lesions. Robinson * concludes that L. erythematosus is a chronic in- flammatory disease of the cutis with special histological char- acters, as shown in the changes in the blood-vessels — new blood- vessels in the affected area, lymph-vessels and lymph-channels, *Trans. Am. Derm. Assn. 1808. 304 DISEASES OF THE SKIN. and the new formation of an adenoid tissue — reticular tissue — the presence of mononuclear and absence of polyneuclear cells in the cell infiltration ; and these changes must depend upon the presence of a poison generated in loco. In other words lupus erythematosus is a local infective process — a granuloma. When fully developed, the typical patch of lupus erythem- atosus offers such a striking picture, with its reddish or viola- ceous color, its sharply circumscribed outline, its infiltrated surface, occasionally studded with plugged-up or gaping seba- ceous openings and covered with adherent sebaceous scales, and its place of election, the nose and cheeks, that it can scarcely be mistaken for any other disease. It is to be distinguished from lupus vulgaris by the absence of papules, tubercles, and ul- ceration. The sebaceous glands are not affected in lupus vul- garis. Lupus erythematosus rarely begins before puberty; lupus vulgaris usually begins in childhood. Lupus vulgaris is a deep- seated disease, and is attended, sooner or later, with ulceration and disfiguring cicatrices; lupus erythematosus is comparatively superficial. Psoriasis sometimes resembles lupus erythematosus very closely, but may be distinguished by its course and by the various symptoms peculiar to it. Syphilis sometimes resembles lupus erythematosus superficially, but its history is very different. The results of treatment in lupus erythematosus are extremely varied. In one case the therapeutic measures employed will prove rapidly and easily successful, while in another apparently equally light case every known method of treatment may be exhausted without producing more than a temporary effect on the course of the disease. Besnier says that nothing is more deceptive than the therapeutics of lupus erythematosus, even allowing for recent incontestable advances. Spontaneous cures, speedy success with the most simple and the most diverse methods, frequent relapses, often failure, even when recourse is had to the most active measures — this is what the practitioner has to expect in the treatment of lupus erythematosus. Internal remedies are called for in some cases. They are to be selected to meet the especial indications which may be manifested. LUPUS ERYTHEMATOSUS. 305 Iodine, arsenic, iodide of potassium, and cod-liver oil may, one or another, often be employed with advantage. Hygienic measures, chiefly nourishing diet, fresh air, and sea bathing, are important. The external treatment is that which will usually be found most available and of the greatest value. In the milder forms of the disease it is to be remembered that patches often disappear without leaving a scar. Care must be taken, therefore, not to make matters worse than they would naturally turn out. No strong caustics are to be used in such cases. Stimulating ap- plications may be first tried. The following mild stimulant is useful when the patches are more erythema-like in appearance, recent, spreading, and superficial, with little infiltration and no involvement of the sebaceous glands: 1$. Zinci sulphat., Potassii sulphuret., aa oj ( 4-) Aquae. §iv. (128.) M. If this is too strong, it may be diluted, but if it agrees, the first two ingredients may gradually be increased in quantity to four drachms (16). A 10 per cent, to 20 per cent, salicylic acid rubber plaster may be employed at times to advantage. Sapo viridis is also a good stimulant application, relieving the disease by itself alone when used in mild cases. It may be applied spread upon cloth in the form of a plaster, or rubbed in with water. Dissolved in one-half its weight of alcohol, it forms the "spiritus saponis kalinus," of even more value as an outward application. The patches are to be well scrubbed with the spirit, until any scales that may be present are removed, when it may be washed off with water and some mild ointment applied. Mercurial ointment is useful in some cases, prepared as a plaster, and applied continuously. Sulphur may sometimes prove serviceable applied in the form of an ointment, a drachm (4.) or more to the ounce (32.). Pyrogallic acid has been used with success in the form of an ointment, a scruple to a drachm '1.34-4.) to the ounce (32.), or in collodion. This, it must be 20 306 DISEASES OF THE SKIN. remembered, is a semi-caustic, and its effects must be watched. Stronger and even caustic applications are demanded in some cases, but they should never be used until the weaker ones have been tried. A solution of caustic potash, one part to three or six of water, is one of the best of these. It may be applied by means of a charpie brush upon a stick. Fuming nitric acid may also be used; it is less painful than the potash. As a general thing the milder applications are best. The galvano-cautery has sometimes been used with suc- cess, as also has the curette or scraping spoon, but in cases demanding, from their extent and infiltration, such strong measures, the practice of linear scarification is better than any of the caustics or other strong remedies just mentioned. This may be carried out by using a fine scalpel or tenotome, or the multiple scarifier (see under L. vulgaris), holding it in the hand like a pen, and making a series of parallel incisions about one-sixteenth of an inch apart, and extending entirely through the skin. Having covered the patch to be operated upon with a series of incisions running in one direction, a fre^h series, perpendicular to the first, should follow, and even a third series may be practiced, until the diseased skin is fairly hashed up by the knife. Excepting in persons of particularly tough fibre, it will be necessary to freeze the skin, with a little bag of ice and salt, or by means of ether or rhigolene spray, before operating. Bleeding may be checked by the application of absorbent cotton with pressure. Successive patches of a square inch, more or less, may be operated on daily, until the entire surface has been covered. The wounds should be dressed with some antiseptic preparation, as europhen or aristol. When the wounds are healed, which will be very soon, the operation can be repeated on any patches that may have escaped. Scarification thus accom- plished leaves little scar, and gives more satisfactory results than any other treatment of the kind. I have recently used the X-ray with considerable success, and can recommend this form of treatment in suitable cases. It is not adapted to recent patches or where the erythematous element SYPHILIS. 3°7 is prominent, but where the disease is more chronic, especially when the glandular involvement is marked, it offers an excellent method of treatment. SYPHILIS. The syphilitic eruptions of the skin are characterized by certain features in common. These are: i. Polymorphism. Fig. 53. — Syphiloderma erythematosum. {Courtesy of Dr. Stelwagon.) 2. Peculiar color. 3. Rounded form. 4. Apyretic, indolent, non-itchy character. 5. Curability by mercury. They will be conveniently considered under the following heads: I. Erythematous. II. Pigmentary. III. Papular. IV. 308 DISEASES OF THE SKIN. Vesicular. V. Pustular. VI. Tubercular. VII. Gummatous. VIII. Bullous. The erythematous or macular syphiloderm is the earliest and one of the commonest manifestations of syphilis, but occur- ring, as it often does, upon the covered parts of the body, and giving rise to no subjective symptoms, it often passes unnoticed. It comes out from the sixth to the eighth week after the appear- ance of the chancre, but when mercury has been given from the first its advent may be very much delayed. It presents itself in the form of diffuse macules of various sizes, and of a pale rose, later a brownish or yellowish tint. It is usually seen on the sides of the body and on the abdomen, chest, and back, also on the flexor surfaces of the limbs, rarely upon the face and hands. The diagnosis of the erythematous syphiloderm is usually not difficult. It is commonly accompanied by some of the other symptoms of syphilitic infection, general malaise, nocturnal headache, wandering pains in the limbs, sore throat, etc.; while not infrequently traces of the chancre, and the engorgement of the inguinal, sub-occipital, and other glands, can be made out. The erythematous syphiloderm runs a slow course, and is often accompanied, toward the last, by papular and other lesions, showing the polymorphous nature of the disease. The pigmentary syphiloderm {leukoderma syphilitica) is a rare manifestation. According to Taylor, three forms are encount- ered: (i) Spots or variously-sized brownish patches. (2) More or less diffused brownish discoloration which subsequently becomes the seat of small, spotty leukodermic changes, which increase in size, and the general appearance of which is reti- form. (3) An abnormal or uneven distribution of pigment, the surface having a dappled or marbled appearance. The pigmentary syphiloderm is most frequently found on the lateral and posterior surface of the neck but sometimes it may also affect the lateral aspects of the chest, the epigastric region, and the thighs. It usually appears from the third to fifth month of the disease or a little later and may last from a few months to several years. It is refractory to treatment. SYPHILIS. 309 The exact nature of the eruption is not certain. Some authors describe it as parasyphilitic, others as a vitiligo or chloasma resulting from cachexia or as the trace of some previous erup- tion. The papular syphiloderm is characterized by the appearance of small, hard, solid elevations of various size, not containing fluid, and of a coppery or ham-red color, terminating in resolu- tion. It assumes various forms, small and large, scaly, moist and vegetating. The small papular syphiloderm consists of single and disseminate or grouped, pin-head to small pea-sized, hard, round, or pointed papules, at first bright red in color, but later of a dusky tint. It is a well-marked eruption, generally occupying a considerable area, and found commonly about the shoulders, arms, trunk, and thighs. The small papular syphiloderm may occur, as one of the early manifestations, as early as the third or fourth month, or it may occur later, after other lesions have occurred. Relapses are not infrequent. Other lesions, as large papules, small pus- tules, and moist papules are apt to be present at the same time. It is most likely to be mistaken for eczema, especially when it itches slightly, as it does at times, on its first appearance. It may also be mistaken for psoriasis. A reference to the de- scription of these affections will show their distinguishing features. The large papular syphiloderm is, in some respects, similar to the smaller variety, but is met with in other localities, and shows fewer as well as larger lesions. Its favorite seats are the forehead, just beyond the scalp (corona veneris), about the mouth, nape of the neck, back, flexor surface of the extrem- ities, scrotum, labia, perineum, and margin of the anus. It is one of the commonest of all the syphilitic skin diseases. It may occur early or late, .but it is very apt to follow closely on or accom- pany the erythematous syphiloderm. This variety is more amenable to treatment than the small papular, excepting where it takes on the annular or serpiginous form, when it may prove very stubborn and persistent. The moist papule (sometimes called "mucous patch," though 3IO DISEASES OF THE SKIN. this term should be restricted to lesions occurring on mucous membranes) is the ordinary papule, with its horny epithelial surface macerated off, usually on account of the contact of two contiguous surfaces, as in the neighborhood of the anus and scrotum and about the mouth. The surface of these patches is dusky red, moist, and secreting. These lesions are the most dangerous, as to contagion, of all syphilitic lesions, and quite as many cases of chancre are derived from these moist papules and from true mucous patches of the inside of the mouth as from chancres. The favorite seats for moist papules are the glans penis and scrotum in the male, the external genitals in the fe- male, the umbilicus in infants, and the edge of the mouth and the anus in all three. The diagnosis rarely presents any diffi- culty, because there are almost always concomitant lesions. Occasionally the moist papule takes on a luxuriant papillary, warty growth, when the lesions are called vegetating papules. They resemble, but are on no account to be mistaken for, the non-syphilitic, "venereal," or acuminated wart. The secre- tion of the vegetating papule is highly contagious. It dc3s not, however, produce another vegetating lesion on the person inoc- ulated, but an ordinary chancre. The papulo-squamous syphiloderm is a papular eruption where the scaly element is prominent. It is chiefly interesting because it is apt to be mistaken for psoriasis — a misfortune rendered much more likely to happen by the perversity of some writers who call this lesion "syphilitic psoriasis," a misleading and con- fusing term, which should never be employed. The chief ele- ment of distinction lies in the fact that psoriasis is altogether a scaly disease, with but little infiltration, while the papulo-squa- mous syphiloderm shows comparatively few scales, with a hard, sometimes raised base. The syphilitic disease is not uncommonly found on the palms and soles, while psoriasis is very rarely found in this locality. The vesicular syphiloderm, sometimes called the varicella form syphiloderm, occurs as an eczemaform eruption or, in herpes- or varicella-like groups, sometimes mingled with the papular SYPHILIS. 311 and pustular forms of the disease. The vesicle generally has a dusky red, solid, papular, base; it soon develops into a vesico-pus- tule or pustule, the apex dries up and a small papule remains which gradually disappears, leaving a dark stain. It is an exces- sively rare form of the disease. The pustular syphiloderm occurs in a variety of forms. The pustules vary greatly in size, but are all characterized by the rapidity with which they crust, a rapidity increasing with the size of the pustule. The small pointed pustular eruption is abundant and usually occurs with some other characteristic lesions; it presents no peculiarities of interest except that, as it matures, the epidermis around the lesion raises and forms a ring or collarette which is very distinctive. The large pointed pustular syphiloderm is the eruption which used to be called "syphilitic acne," a confusing designation. The pustules resem- ble those of acne, and still more those of small-pox, and when they occur upon the face, accompanied with high fever, care must be exercised in examining all the concomitant symptoms, or a mistake in diagnosis may be made, and a syphilitic patient thrust into a small- pox hospital. The crusts which result from the drying up of the pustules rest upon little ulcers, and this gives an important diagnostic point. For if, upon lifting a crusted pustule, it displays a little well of pus beneath it, the lesion is syphilitic, while if only an excoriation is seen, the lesion is almost certainly not syphilitic. In addition to acne and small- pox this syphilitic eruption is apt to be confounded with the io- dide of potassium eruptions. (See Dermatitis medicamentosa.) The small, flat, pustular syphiloderm is made up of small, flat pustules aggregated in groups and rapidly crusting. It occurs chiefly about the nose, mouth, in the beard, on the scalp, and about the genitalia. On lifting the crusts a shallow or deep ulcer is found. It may be mistaken for impetigo or eczema, but ulcers are not found in those affections. It is one of the more benign syphilodermata. The large, flat, pustular syphiloderm shows itself in finger- nail-sized, flat pustules on a deep red base. Sometimes the 12 DISEASES OF THE SKIN. ulcer underneath is shallow, at other times deep, punched out, and secreting an abundance of pus, which may dry up in thick, oyster-shell-like crusts (rupia). The shallow ulcerated pustules Fig. 54. — Syphiloderma. The large flat pustular variety. {Courtesy of Dr. Stelwagon.) of this variety are benign. The deeper ulcers generally occur in broken-down individuals, and are of more unfavorable signif- icance. They can hardly be mistaken for any other disease. They occur in the ninth to the twelfth month of syphilis. SYPHILIS. 313 The Tubercular Syphiloderm. The eruption here consists of one or more solid elevations of the skin, varying in size from a split pea to a hazel-nut; smooth, glistening, rounded or some- what pointed, hard and felt to be deeply seated. Their color varies from a brownish-ham color to a bright red or true copper color. Sometimes they have an intensely dusky red hue, a color not met with in any other disease of the skin. The lesions may occur singly or grouped, sometimes in circles or crescents, occasionally melting together in indurated patches. Usually only a few lesions or a small patch occurs. This erup- tion is never diffused over a large area. Sometimes the tubercular lesions are grouped in a serpiginous form, and occasionally they ulcerate and crust, but not to a marked degree. The eruption is indolent and occurs late in the history of the disease, rarely showing itself before the second year. Not infrequently its appearance is delayed to five, ten, even twenty years after the initial lesion, and in women, where the initial lesion and early symptoms are often overlooked or ignored, and no history of syphilis can be obtained. Now and then vegetations may spring up on the tubercular syphiloderm, form- ing wart-like and cauliflower excrescences, with a fetid secretion. The tubercular syphiloderm is peculiarly liable to be mis- taken for lupus vulgaris. The tubercles of syphilis, however, are firmer, more deeply seated, and have a history of more rapid development. Lupus, moreover, appears usually first in child- hood, while the tubercular syphiloderm is rarely seen before adult or middle age. Occurring on the face and especially in the region of the cheeks and canthus of the eyelids, the ulcerative tubercular syphiloderm may be mistaken for epithelioma, and this is the more easy because the syphilitic ulcer sometimes becomes converted into an epithelioma. The touchstone of treatment must be used here, and if the suspicious ulcer fails to yield to mercury and iodine it should be cauterized or excised. The Gummatous Syphiloderm. Gummata are among the later lesions of syphilis. They are usually situated primarily in the connective tissue, and only subsequently make their appearance 314 DISEASES OF THE SKIN. in the true skin, but occasionally the skin is first attacked and the gumma appears as a more or less circumscribed, slightly- raised, rounded or flat tumor, variable as to size and strongly tending to break down into an ulcer. The lesion resembles a blind boil abscess, with its dusky, purplish color and almost fluctuating sensation under the finger. Gummata are usually solitary. When ulceration takes place the cavity is deep, but fills up rapidly as a cure takes place. Gummata are apt to be mistaken for furuncle, abscess, enlarged lymphatic glands, carcinoma, and for fibrous and fatty growths. Gummata are occasionally poulticed and then cut open with great resultant chagrin to the operator, when the firm, dry walls gape, where pus was expected to flow. They should never be lanced, as it is much easier to cause resolution by appropriate remedies than to cure the open sore which follows cutting. The bullous syphiloderm is very rare. It is characterized by the appearance of blebs containing a clear, watery fluid, which soon tends to become cloudy and thick. Sometimes the lesion is more like a large pustule than a bleb. The lesions soor> break or dry up with rupial crusts. When these are removed shal- low ulcers are found. The bullous eruption is a late manifes- tation of syphilis, and is met with in the cachectic and broken down. It can only be mistaken for pemphigus or dermatitis herpetiformis, and in both of these affections the bullae contain serum and not pus, and rupial crusts are absent. The treatment of the syphilitic affections of the skin should, in the early diffused eruptions, be internal only. When the lesions are comparatively few in number and of some size, espe- cially when they are ulcerative, local applications may be used with benefit. Finally, in the late and indolent ulcerative, tuber- cular, or gummatous lesions, local treatment alone often suffices to heal the lesion, and since internal treatment, however good, will not insure against a relapse, it need not necessarily be used. Mercury is to be employed in the earlier and generalized lesions. The protiodide of mercury, in doses of one-fourth of a grain, in pill form, thrice daily, gradually increased until the disease yields SYPHILIS. 315 or the gums are touched slightly, is the best average treatment. The biniodide of mercury is also very useful in doses of -^ to J grain, dissolved in water, with the aid of a little iodide of potas- sium, when for any reason it is preferred to give the mercury in a fluid form. Iodide of potassium is to be reserved for the later lesions, or to mix with the mercurial in stubborn cases. A dose of five grains will be found large enough in the great majority of cases, but it must be pushed rapidly if the lesions do not yield. In those cases where the gums are unusually susceptible to the influence of mercury the following formula, suggested by Unna (Monatshejt. /. Prakt. Dermatol., Bd. xvii, No. 9, p. 466), may be employed as a tooth powder: 1^. Potassii chlorat., oiv (16.) Pulv. cretee, Pulv. rhizoma iridis, Pulv. saponis castiliensis, Glycerinae, aa 5 j- ( 4-) M. Local treatment is required when the lesions are situated on the face and hands, and when it is desirable to hasten their dis- appearance by all means, or when ulcers, with profuse and dis- agreeable discharge, are present in any part of the body. For dry lesions, the ammoniated mercury ointment, or a twenty or ten per cent, oleate of mercury, may be rubbed firmly into the skin, once or twice daily. For moist lesions, a solution or stick of nitrate of silver may be employed. In ulcers, bits of soft linen, cut a little smaller than the lesions and spread thickly with ung. hydrarg., full or half strength, may be applied. Skin Diseases in Hereditary Syphilis. The syphilitic erup- tions of infants are, in all respects, the same as those of adults, excepting in so far as their appearance is altered by the pecul- iarities of structure of the infantile integument. The mortality of syphilitic children is very great, fully one- third failing to reach maturity. Abortion, resulting from the death of the foetus, usually occurs about the sixth month. An aborted foetus is usually in a macerated condition, the skin being easily detached, and the surface having a livid purple color. 316 DISEASES OF THE SKIN. The integument either shows nothing characteristic, or large bullae may be found on the palms and soles. Syphilitic children generally present a healthy appearance at birth, and, for a week or two, all seems to go well. Then symptoms of debility and decreased vitality show themselves; the infant begins to emaciate and grows wizened and aged in appearance. Catarrh of the nasal passages — the "snuffles" — shows itself, interfering with respiration, and thus sometimes itself alone being the cause of death. The skin becomes yellow, loose, and wrinkled. It is drawn tight over the bones of the face, which becomes sallow and earthy, with prominent eyes and a peculiar senile expression, the infant presenting the appear- ance of decrepit old age. Now and then, however, excessive emaciation is not observed, even when the syphilitic poison has affected the system to a marked degree. The erythematous syphiloderm is that which is earliest and most frequently observed in infants. It generally makes its appearance about the third week of life, often accompanied by coryza, and showing itself first on the abdomen, in the form of minute, round or oval, pink macules. It spreads rapidly over the surface of the body and limbs and the patches grow larger and darker, until they may be half an inch in diameter, slightly or not at all elevated above the surface, coppery-red in color, and no longer, as at first, disappearing under pressure. There is usually little or no scaliness, excepting slight desquamation, at times, upon the hands and feet. This eruption is very liable to be confounded with the simple erythematous rashes of early infancy. The most important diagnostic points are the tendency to infiltration, and the for- mation of papules in places where the skin comes together in folds, as about the neck, and especially in the region of the genit- alia and nates. In addition, the tendency to scaliness about the palms, soles, and occasionally the nates is more or less char- acteristic. Sometimes, however, it is impossible to distinguish between the syphilitic eruption and simple erythema about the nates, at first sight, and the case must be held under advisement SYPHILIS. 317 for a certain time, local treatment only being employed, before a positive diagnosis can be given. The syphilitic eruption tends to get worse, shows moist and infiltrated patches, etc., while other symptoms show themselves elsewhere. The eczematous eruption will either improve under local treatment or tend, to show weeping and itchy patches, and vesicles or pustules. The papular syphiloderm in infants is usually met with in connection with the erythematous eruption, but sometimes it may occur first. The lesions are dull red, small, flat papules, occasionally mingling to form a patch. When seated about the anus or genitalia, the lesions become changed into typical moist papules, and now and then vegetations or syphilitic condy- lomata grow out of these lesions. These are highly contagious, and must be carefully distinguished from the simple vegetations growing about these parts in children who are poorly cared for. The latter are apt to be smaller, more pointed, and dark, and occur almost invariably near some muco-cutaneous junc- ture. They spring directly from the skin, while the syphilitic vegetations grow from an indurated, often moist, base. The simple vegetations are not so apt to have a fetid odor, whereas the syphilitic condylomata secrete an excessively offensive sero- purulent liquid. Moist papules in the infant are apt to occur at the verge of the anus and the commissure of the lips. In the lat- ter locality they lead to deep fissures, the scars of which form diagnostic marks of hereditary syphilis in later life. The pustular syphiloderm in infants may occur before the eighth week in children profoundly affected with syphilis, but usually shows itself at a later period. The pustules may be large, numerous, and deep, or few and small, according to the severity or mildness of the disease. The thighs, buttocks, and face are usually attacked. On the face they may coalesce and form thick, green, crusted lesions, resembling those of impetigo or pustular eczema. The syphilitic crusts, however, are dark, thick, and greenish, while those of the other diseases are fighter. On removal of the crusts the syphilitic lesions are found ulcerated, while only a shallow erosion is found under the eczema and impet- 318 DISEASES OF THE SKIN. igo crust. Moreover, itching, which is very common in eczema, does not exist in the syphilitic lesion. A furunculoid eruption is sometimes met with in hereditary syphilis. The lesions begin as small nodules in the corium, and gradually increase to the size of half a nutmeg; ulcers form on the summit; sloughs are thrown off, and irregular, unhealthy cavities, with scanty, offensive secretion, are left, the lesions subsequently running a chronic course. They often result in cicatrices. Tubercular and bullar eruptions sometimes occur in hered- itary-syphilitic children; the former show no marked difference from similar lesions found in the adult. The bullar syphilo- derm, the ''pemphigus syphiliticus" of older writers, is usually found on the palms and soles. The skin shows patches of a violet color; in a short time, small, confluent vesicles make their appearance on these spots, and then coalesce and grow larger, until the fully- formed bullae show themselves, varying in size from that of a pea to a hen's egg, with a yellowish- green, opal- escent color and purulent contents. The lesions may be b *ownish or hemorrhagic; they break in a day or two, and leave shallow ulcers. The bullar syphiloderm is a symptom of grave import. It is important to distinguish it from simple pemphigoid erup- tions. This may be done by noting its earlier appearance (it is congenital, or appears very soon after birth), its usually more serious character, and the concomitant symptoms and history. It is rarely the only symptom. Sometimes impetigo contagiosa may be mistaken for the bullar syphiloderm, but its non-ulcera- tive character, place of election, trifling severity, etc., should prevent this mistake. (See Impetigo contagiosa.) The treatment of hereditary, infantile syphilitic skin dis- eases is essentially that of the disease in general. Mercury may be administered by baths, inunctions, or internally. Warm, daily baths, each containing ten grains of the bichloride of mercury, are frequently highly beneficial. A small flannel skirt, with the waist tied around the infant's neck, and then spread over the edge of the tub, will permit it to splash, with- DELHI BOIL. 319 out danger of sending the fluid into its mouth. The dose is sufficient for any age, from one month to twenty. Inunc- tions of mercurial ointment, in full or in half strength, may be employed. The best procedure it to smear a piece of ointment, the size of a small walnut, thinly over a flannel band, and then pin it around the abdomen, not changing it, but applying fresh ointment daily, until the flannel becomes stiff. Gray powder is given internally by many physicians. I rarely use it as it seems almost invariably to derange the child's digestion. In the later furunculous and pustular eruptions the iodide of potassium, in doses of half a grain to two grains, according to the age of the infant, may be given with advantage. Inunctions of cod-liver oil, or the same internally, may be given at times, and nourishing and appropriate diet is absolutely required. DELHI BOIL. An endemic disease, of some parts of the tropics, characterized by the ap- pearance, usually on exposed parts, of one, several or more rounded papu- lar elevations, which slowly enlarge and usually become furuncular and ulcerated. The disease usually appears upon the face, beginning as a roundish itchy papule as if from mosquito bite. It gradually enlarges to the size of a pea or small grape, softens, opens and exudes a serous and later a sero-purulent fluid which dries and crusts. While the crust grows thicker and more ex- tensive the lesion becomes flattened down into an ulcer. The development is slow, several months often elapsing before the lesion reaches the ulcerative stage. There may be only a single lesion, several separate ones, or a con- glomerate which often fungates. Erysipelas, lymphangitis, etc.. may accom pany the disease. Finally repair sets in. The disease is inoculable and probably of microbic origin. The lesions, when single, may be cut or burned out. In conglomerate lesions curettage with subsequent cauteriza- tion or antiseptic applications may be employed. FRAMBCESIA. Frambcesia, called also yaws or plan, is a contagious, endemic skin disease, characterized by general and cutaneous symptoms, occurring in the West Indies and other tropical countries. The eruption consists of variously-sized papules, tubercles, and tumors, of a reddish or yellowish color. After a pro- dromal period of ten days to several weeks after inoculation the lesion appears 320 DISEASES OF THE SKIN. as a yellowish or whitish point or spot, which gradually enlarges and projects from the surface, looking, when fully developed, like a piece of cotton wick, a quarter of an inch or less in diameter, dipped into a dirty yellow fluid, and stuck (on to the skin, in a dirty, crusted, brownish setting, and projecting to a greater or less extent. Or at times the lesions look like red currants, with flat tops, of a bright pink color, glassy, semi-transparent. Larger lesions look like cherries. The tubercles may be smooth, scaly, or ulcerated. The eruption generally manifests itself on the face, upper or lower extremities, and genitalia. The largest growths occur on the lips, eyelids, toes, and gen- ital organs. The lesions are not painful or itchy. Native observers long ago considered this disease contagious, but the fact of contagion was doubted by more scientific observers. As we now know that all diseases of this class are contagious, the treatment which naturally fol- lows would be directed to thorough cleanliness and disinfection. A med- icated soap should be used for purposes of ordinary cleanliness over the whole surface of the body at least once a day, and locally twice or three times a day. In addition to this the secretions should be dried off with absorbent cotton, dabbed with a one-thousandth solution of bichloride oi mercury, and then dusted with europhen, aristol, or some similar disinfectant. In some cases it may be desirable to cauterize the lesions, but this can hardly ever be absolutely necessary, because, like all the other papillomata, the re- moval of the cause will be rapidly followed by disappearance of the growth The disease should be carefully distinguished from syphilis with which the careless observer might confound it. VERRUGA PERUANA. Verruga is a specific inoculable affection endemic in some valleys of the western Andes, in Peru, and characterized by a prodromal febrile period and subsequent outbreak of peculiar pin-head to pea-sized or larger, reddish, rounded, granulomatous, wart-like elevations. The prodromal period is characterized by irregular fever, rheumatic joini and muscular symptoms and more or less anaemia, lasting weeks or months. When the eruption appears these symptoms vanish but may recur later. The lesions appear first on the face and limbs as small papules or incomplete ves- icles, later developing into a sort of papilloma or fungoid vegetation. The lesions are said to occur on the mucous and even serous surfaces. The dis- ease is inoculable and probably due to a bacillus. It is strictly localized as above stated. t The disease is considered grave, the death rate being about one in six or eight. The treatment should include tonics, etc., and when possible removal to a healthy seashore climate. It is said to be best not to attempt to remove the local manifestations but antiseptic dressings should be of value. CARCINOMA CUTIS. 321 CARCINOMA CUTIS. The forms of carcinoma of the skin most interesting to the dermatologists are epithelioma or skin cancer and Paget's disease. Before describing these some mention may be made of the other varieties of carcinoma which, however, are more apt to come under the care of the surgeon. These are the follow- ing : i . Carcinoma lenticular e {scirrhous, hard, fibrous or connec- tive tissue cancer), characterized by smooth, glistening, dull pinkish- or brownish-red, flat or raised papules, tubercles or nodules, from pea- to bean-, or larger size, disseminate, at first separate, later running together, slow in its course, involving the neighboring glands, causing pain, breaking down, recurring on excision and ending fatally. 2. Carcinoma tuberosum; a rare affection, occurring in flat or raised, rounded or ovalish, tubercular or nodular lesions, from pea- to walnut-size or larger; firm, hard, deeply imbedded in the skin and the subcutaneous connective tissue, of a dull reddish, brownish-red or violaceous color, multiple, disseminated, or irregularly grouped, sooner or later breaking down into ulcers and ending fatally. 3. Carcinoma melanodes or pigmentodes; beginning in the form of multiple, small, pin-head, or bean-sized, rounded or ovalish, soft or firm papules, tubercles or nodules, of an iron-gray, brown- ish, bluish-black or blackish color, at first discrete, but tending to aggregate into tumor masses, and then to break down and ulcerate, forming often fungous, gangrenous, and pultaceous masses, commonly found starting in a mole or wart on the face or on the hands and feet, usually encountered in early adult or middle life, and pursuing a malignant course. The treatment of these forms of cancer, when early seen, is essentially the same as that described under epithelioma and sarcoma. Later they necessarily fall under the care of the surgeon. EPITHELIOMA. Epithelial cancer of the skin may be either superficial, deep- seated, or papillary. The superficial or "flat" epithelial cancer 322 DISEASES OF THE SKIN. usually makes its appearance as one or more grouped, small, yellowish or reddish papules or elevations, having their seat in the upper layers of the skin. The disease may originate in a sebaceous gland, wart, or other growth, or in the form of a flat infiltration. After a time, it may be months or even years, the tubercle, wart, or infiltration, as the case may be, becomes fissured or excoriated, a slight brownish crust forms upon it, under which is a scanty, watery, or viscid secretion. The course of the disease is slow, but gradually new lesions appear, usually connected with the original one, and finally the tubercles break down, and ulceration of a superficial character sets in. The ulcer, at first small, may spread until it attains the size of a coin, or even of the palm of the hand. The ulcer is characteristic. It is usually roundish, but may be quite irregular, with either sloping or sharply defined edges. The border may be smooth and on a level with the skin, but is usually elevated into a pearly ridge all around the ulcer. Its base is usually hard, and secretes a scanty, viscid fluid; it bleeds readily. There is usually a peculiar and characteristic picking or crawling sensation in the lesion when it first begins to become fissured or excoriated, but there is usually no pain unless the ulceration is considerable. When fully developed the ulcer may remain in statu quo for an indefinite period, the patient's health, meantime, being excellent; or it may pass into the infiltrating, deep-seated variety, to be described. The lymphatic glands are not involved. Rodent ulcer is a form of this variety of epithelial cancer. Its most frequent seat is upon the eyelids, particularly near the inner canthus, and next to this upon the side of the nose. When fully developed it consists of a circumscribed, sharply defined, greater or less excavation, with a brownish-red or purplish-red, dry, or scantily secreting, mammillated surface, the ulcer having often a rolled border. Its course is very slow but relentless; it invades every tissue with which it comes into contact, including muscles and bones. If neglected, great destruction of the parts may ensue, and even death from hemorrhage in very advanced cases. A peculiarity of this form of epithelioma is, that it is a EPITHELIOMA. 3 2 3 disease of the upper part of the face, occurring usually above a line drawn across the face horizontally, on a level with the alae nasi and the lower border of the ears. Deep-seated Variety. This variety of epithelioma, known also as the "infiltrating" variety, is much more serious than the superficial variety of the disease. It begins as a split-pea- sized tubercle, situated in the skin and subcutaneous connective tissue. It sometimes, however, begins in a wart, like the super- FiG. 55. — Rodent ulcer. {After Cantrell.) fkial variety. It is reddish or purplish in color, surrounded by an areola, firm and hard to the touch, and accompanied by infiltration of the surrounding tissues. In a longer or shorter time, according to the malignancy of the case, usually months, ulceration begins, either from within or upon the surface, the tumor breaks down, and an ulcer of variable size results. This is deeply excavated, irregular in shape, with a violaceous 324 DISEASES OF THE SKIN. base, secretes a viscid, offensive fluid, bleeds freely upon being touched, and is surrounded with infiltration, the skin being reddish in the neighborhood. The lymphatic glands become enlarged at a later period, the lancinating pains, which are often experienced from the beginning, become more severe, the pa- tient suffers extremely and finally succumbs through marasmus and exhaustion. The course of this disease, though sometimes slow, is occasionally rapid. Duhring alludes to a case where the disease ran its fatal course in a year. Papillary Variety. In this variety of epithelioma, the lesion begins as a wart of split-pea size, or occasionally as a raised, lobulated, more markedly papillary formation of larger area. The surface is sometimes covered with dry, horny, epidermic scales, at other times it is moist and macerated. There are usually fissures secreting an offensive fluid, with sometimes cheesy, sebaceous matter. The fungous-looking granulated surface sometimes develops into fleshy protuberances, and at other times spreads out more flatly. After a time it breaks down into a characteristic epitheliomatous ulcer, running the usual course. Occasionally the papillary growth proceeds from a preexisting superficial or deep, infiltrated ulcer. Epithelioma is most commonly met with on the face, either on the lips or tongue, about the nose, the eyelids, the forehead, the temples, or upon the scalp. The genitalia, especially the penis and the scrotum in the male, and the labia in the female, are not uncommon seats of the disease. Epithelioma rarely occurs elsewhere, although it may be found in any part of the body. The lesion is usually single. The exciting causes of epithelioma are often obscure. Epithe- lioma of the lip or tongue often starts at a point where the mucous membrane has been irritated by a pipe-stem or a jagged tooth. Chronic pruritus of the anus or vulva and congenital phimosis may in time be followed by epithelioma, which also occasionally originates in cicatricial tissue or in old ulcers. Warts and naevi, both pigmentary and vascular, are structures in which it often originates. The sebaceous warts of old persons seen so fre- EPITHELIOMA. 325 quently upon the face, the backs of the hands and the scapular region, often form the starting-point of epithelioma. Tumors of the skin called "benign," as fibroma molluscum, may become transformed into epithelioma. Psoriasis, also, as has been pointed out by Dr. J. C. White and others, may gradually develop into verruca and then into epithelioma. The disease known as "xeroderma pigmentosum" is allied in some of its aspects with epithelioma, as epitheliomatous growths occur in one stage of the affection in many cases. Lupus and syphilis of the skin may also become transformed into epithelioma. The disease is com- moner among men than among women. It is less malignant than any other form of cancer. Pathologically the epitheliomatous process consists in the proliferation of epithelial cells — pavement epithelium — from the epidermis or from the epithelium of the hair follicles or glandular structures or from the mucous membrane. The cell growth takes place downward, in the form of finger- like prolongations or columns, or it may spread out laterally or deeply so as to form rounded masses, the centers of which usually undergo horny transformation, resulting in the formation of onion-like bodies, the so-called "pearls," cell-nests," or "globes." The rapid cell growth gives rise to irritation and inflammation and increased blood supply with serous and round-cell infiltra- tion. There are two histological types, the lobulated and the tubular. In the first the cells are massed in globular aggre- gations, while in the tubular or cylindric type the epithelial growth is in the form of cylindric processes anastomosing with one another and sometimes presenting a pseudo-glandular ap- pearance. Bodies thought to be organisms have been found in epithe- lioma but these observations have not been generally accepted as accurate. The diagnosis of epithelioma is usually not difficult, excepting in the earlier stages. It may be confounded with syphilitic tubercles and ulcerations, warts, and lupus. The papule or ulcer of epithelial cancer, especially if about the genitalia, may 2,2b DISEASES OF THE SKIN. also resemble chancre; but the history of the case, the duration of the lesion, and a careful examination of its features, will aid in arriving at a correct opinion. The later syphilitic manifes- tations run a much more rapid course, and change in appearance more rapidly than epithelioma, and, when ulcerative, their secre- tion is much more abundant and purulent. Nevertheless, it is not rare, in my experience, to see cases of epithelioma about the face, which have been mistaken for the tubercular syphilo- derm, and vice versa. What lends additional difficulty to the diagnosis in these cases is, that, as mentioned above, the syphilitic lesion now and then becomes transformed into epithelioma. I recall the case of a middle-aged woman showing a small ulcer near the inner canthus of the eye, which, after some hesitation, was pronounced syphilitic, and being treated with iodide of potas- sium healed up, returning again six months later, however, as unmistakable epithelioma, and quite uninfluenced at this time by the anti- syphilitic treatment. In making a diagnosis between syphilis and epithelioma in any case, the points mentioned should be borne in mind, and also the facts that the ti .bercular syphiloderm when ulcerating, usually shows several points of suppuration, while epithelial cancer is commonly single, and also that there is induration under and about the cancerous sore, while the syphilitic ulcer terminates abruptly against the sound skin. Finally, in cancer there is usually a picking and crawling sensation at first, and later lancinating pain. Syphilis is painless. Many epithelial cancers begin as warts, and it is often difficult to distinguish between a simple wart and a cancerous wart. Usually continued observation alone will decide. In elderly persons any change in a wart of old standing upon the face, especially those flat, brown warts, not uncommon in advanced life, must be looked upon with suspicion. From lupus vulgaris, the diagnosis of epithelial cancer is chiefly to be made by the history. Lupus is a disease usually beginning in early life, and commonly has a long history. It is apt to be found in more parts of the body than one. When EPITHELIOMA. 327 ulceration takes place, the diagnosis becomes more difficult, but a careful examination of the surrounding parts will com- monly show some characteristic lupus lesions in the neighbor- hood. The discharge from a cancerous ulcer is usually pale, scanty, and viscid, and is often offensive; that from lupus is yellowish and puriform, and is not offensive. The treatment of epithelioma is external and local. Only the more superficial forms are apt to come under the care of the dermatologist, the more severe forms usually seeking the aid of the operative surgeon. It should be remembered that every source of irritation is in reality a cause of aggravation, and that, therefore, epithe- lioma is to be attacked only to be destroyed. All temporizing applications, like nitrate of silver, etc., merely add fuel to the flame, and aggravate the disease they are intended to cure. For this reason I shall not speak of several remedies which are mentioned as curative in this affection, as resorcin, chlorate of potassium, etc., because I think they are not thorough and ^effectual. There is one preparation which has the sanction of time and experience to recommend it, and which has been imitated by quacks with great success, that is " Manec's paste." This is com- posed as follows: 1$. Acidi arseniosi, 9j ( 1.30) Hydrarg. sulphat., §ij (32. ) .Spongiae ustae, 3iv. (16. ) M. The ingredients should be powdered and mixed thoroughly and pre- served in a tightly stopped bottle. When needed, the amount necessary is to be mixed with a sufficient quantity of water to make a paste. The epitheliomat- ous patch to be operated upon must first be cleansed com- pletely of all crusts and detritus by the employment of poultices, etc. Then, the paste having been spread upon a bit of lint ac- curately fitted to the size of the lesion, this is to be applied and firmly attached by strips of adhesive plaster. The application must be retained in place from one to two weeks. At the end 328 DISEASES OF THE SKIN. of this time the eschar falls off, carrying with it, it is to be supposed, the entire neoplasm. For my own part (while admitting the value of this paste on the testimony of many experienced dermatologists), an exper- ience of many years induces me to favor the use of caustic potash, which never fails to remove these superficial epitheliomata when used judiciously and thoroughly. A stick of caustic potash is to be wrapped in a piece of lint or placed in a suitable holder, leaving only the point exposed, and this is passed over the growth, gently at first, to dissolve the horny epithelium, when this exists, and then the potash stick is to be bored into every part of the substance of the growth. While operating, the un- healthy tissues are found to give way very readily, so that it may easily be perceived, by the increased resistance offered, when the caustic reaches sound tissue. It must be remembered that the action of the potassa always proceeds a little further after the caustic has been withdrawn. This must be borne in mind when operating in the neighborhood of important organs, as the eye, or where arterial branches may become involved. The application of the caustic potassa gives rise to severe pain, which, however, rapidly ceases after its with- drawal. Pain may be prevented to some extent by applying a four to eight per cent, solution of cocaine to the part before operating. When the effect has proceeded as far as is desirable, the application of dilute acetic acid or weak vinegar will neutralize the caustic influence, and put an immediate end to the pain. There is rarely any hemorrhage. The part operated on may be dressed with europhen powder or other suitable antiseptic powder or ointment. The dressing is to be changed daily, and the eschar usually falls off at the end of ten days or two weeks, after which a rapidly granulating surface ensues, ending in an insignificant scar. Pyrogallic acid in an ointment of ten to twenty per cent, strength, applied on patent lint, from two to six days consecutively, is a good remedy in certain cases, particularly when the patient cannot bear pain. It is usually painless. It may have to be paget's disease. 329 reapplied, from time to time, the slough being cut or scraped away as it forms. Pyrogallic acid should not usually be trusted in the patient's hands, as too much action may be produced, or the effect may penetrate too deeply. Among other means of removing epithelioma the galvano- cautery, especially in operations near the eye, is recommended by those who have used it. Scraping with the dermal curette, or sharp spoon, alone, or followed by the actual cautery, is another mode of removal. For the use of the knife, which is not needed in the majority of superficial epitheliomata, if these are taken in time, reference may be made to the standard works on surgery. Of late the Rontgen or X-ray has been used very successfully in the treatment of epithelioma and although not by any means superseding the forms of treatment detailed above will, in care- ful hands, prove an important aid to the treatment of certain forms of the disease. The scope of the present work will not permit a description of the technique, for which the reader is referred to the special works on X-ray treatment. PAGET'S DISEASE. "Paget's disease of the nipple" is a malignant disease, usually occurring in the nipple and adjacent structures and at first closely resembling eczema. The disease begins with roughness, redness, and scaling about the center of the nipple, with occasional slight oozing or crusting, and, in some cases, the formation of a fissure. The process goes slowly on, presenting to all appear- ance the symptoms of eczema with intense itching, in many cases the nipple becoming retracted and finally melting away. When fully developed a considerable portion of the breast may be covered by the red, infiltrated, weeping patch, which is slightly sunken at the sharply defined edge below the level of the surround- ing skin, and presents a peculiar livid crimson, different in tint from the bright red of eczema rubrum. Taken between the fingers, the infiltration of the skin does not extend as deeply as would be thought from the appearance of the disease. The 330 • DISEASES OF THE SKIN. points just given, together with the fact that the infiltration is firmer than that observed in eczema, and that the surface exudes a serous fluid without much discharge, crusting, vesiculation, etc., will serve to distinguish the disease from eczema of the nipple, with which it is very apt to be confounded. Any eczema of the nipple should, however, be viewed with suspicion, above all if chronic in character, tending to spread slowly and steadily, and with more or less progressive retraction of the nipple. Though usually occurring in the nipple and breast, Paget's disease is sometimes found elsewhere, as about the genital region in both sexes, on the face, nose, etc. The morbid changes in Paget's disease, according to Fordyce may be briefly stated as inflammation of the papillary region of the derma, leading to an oedema and vacuolation of the con- stituent cells of the epidermis, followed by their complete de- struction in places and their abnormal proliferation in others. The lactiferous canals and glandular epithelium may be changed by a secondary process. As regards treatment, in the earliest stages when eczema alone is probably existent, the treatment for this disease may be employed. It is reasonable to suppose that such a disease as simple eczema of the nipple exists in a certain number of cases. But if the eczema does not quickly yield and if the peculiar symptoms of Paget's disease begin to appear, the treatment of malignant disease is called for, and here I am inclined to favor surgical interference at an early date. In selected or doubtful cases or when operative procedures are declined the X-ray treatment may prove successful. XERODERMA PIGMENTOSUM. This affection, sometimes also called "angioma pigmentosum et atroph- icum " is a malignant disease, usually developing in early life, characterized primarily by freckle -like spots, especially upon exposed surfaces, followed by telangiectases, atrophic changes, angiomatous and verrucous lesions, with increased pigmentary deposit, and, finally, after some years, by epitheliomat- ous growths and fatal ending. The disease is very rare, only some eighty cases being on record. It begins almost invariably in the first years or even SARCOMA CUTIS. 33 1 months of life and may last for years, the patient finally dying of exhaustion or marasmus. Several cases may occur in a single family. The pathology of the disease is obscure. The various lesions display the histological character which their appearance respectively denotes. Xo satisfactory treatment can be suggested beyond the applications suit- able to the various lesions as they develop. Stel wagon suggests the pro- longed employment of hypodermic injections of arsenic. The prognosis is unfavorable.* SARCOMA CUTIS. Sarcoma of the skin appears in the form of shot, pea, hazel-nut, or larger sized, variously shaped, discrete, non-pigmented or pigmented tubercles, or tumors. Non-pigmented tumors, occurring as single or multiple growths upon the various regions, represent, perhaps, the commonest manifestations of the disease. They are smooth, firm, elastic, not markedly painful upon pressure; in color, reddish, violaceous, or brownish-red. Two other varie- ties are also described, the melanotic sarcoma and the multiple pigmented hemorrhagic sarcoma. It is said that the multiple pigmented sarcoma al- ways appears first upon the soles and backs of the feet. The disease may be mistaken for the papular or for the gummatous syphiloderm, lupus and lepra. It occurs generally toward middle age. The growths of the non- pigmented variety are made up chiefly of round cells or mixed round and spindle cells. In the earlier stages of development these form nodular col- lections at the junction of the cutis and subcutaneous cellular tissue. Occa- sionally a fibrous or lymphatic element is predominant. Pigmentation, when this is present, is due to capillary hemorrhages. The disease is malig- nant, usually proving fatal in the course of a few years. Recently, hypo- dermic injections of Fowler's solution, in the dose of two drops, gradually increased to nine drops, diluted with two parts distilled water, daily, have been used successfully. The X-ray treatment has been said to have proved successful in one or two cases. GRANULOMA FUNGOIDES. Granuloma jungoides or mycosis fungoides is a chronic malig- nant disease characterized usually by precursory symptoms of months or years duration, of an eczematous, urticarial or erysip- elatous aspect, with the subsequent appearance of pinkish or reddish, tubercular, nodular, lobulated or furrowed tumors *See Kaposi, Wien. Med. Jahrb., 1882, p. 619, and Taylor, N. Y. Med. Record, Mar. 10, 1888. For recent literature of. Stelwagon. 33 2 DISEASES OF THE SKIN. or flat infiltrations, which frequently ulcerate and form fungoidal or mushroom-like growths. The symptoms characteristic of mycosis are variable at different periods of the disease. At first, bright red erythem- atous patches on a level with the skin, or slightly raised above the general surface, appear at one or more points, accompanied by pruritus. These occasionally resemble the lesions of urticaria — in fact, urticarial patches have been observed in some cases. Later the lesions become covered with scales, or vesicles and papules, or may become raised, hard, and fissured, assuming somewhat the appearance of chronic, infiltrated eczema papillo- sum ("lichen"). At other times they may diminish and dis- appear like eczema, without leaving a trace. While these ery- thematous or lichenoid lesions mark the earlier stage of the affection, sooner or later, after months, or perhaps years, it takes on the more especial features which give mycosis its peculiar and characteristic aspect. On, or alongside of, the lichenoid patches, vegetations and growths occur, at first wart-like, later profusely hypertrophic — frambcesioid lesions. Once formed, these lesions increase rapidly in size, and they may attain the dimensions of a cherry-stone, an almond, or a small orange. They are red, sometimes violaceous, vascular, somewhat firm, of uneven sur- face, so as sometimes to resemble tomatoes. The growths may be solitary or grouped and united at the base, but separated at the summit. The surface of the hypertrophied tumors is a first dry, smooth, and sometimes slightly scaly. The pruritus, a marked symptom of the early lesions, diminishes at this stage, and there may be even a slight diminution of sensibility, and any hairs which may grow from the surface are apt to fall out. After continuing in this state for a considerable time the tumors may suddenly change in one of two quite diverse directions. Either they may, as some do, undergo rapid interstitial absorp- tion, become retracted, shrivel up and disappear, without leaving any trace, in ten to twenty days, or, on the other hand, they may become moist and crusted, or break down and suppurate pro- GRANULOMA FUXGOIDES. 333 fusely, with an ichorous discharge. Now and then the body of the tumor remains firm, while a crater-like cavity forms in its center, and in rare cases the new growth, followed by destructive Fig. — Granuloma (mycosis) fungoides. (After De Amicis.)* metamorphosis, may go beyond the skin and penetrate the sub- jacent tissues to the very bone. Simultaneously with the development of the skin lesions the lymphatic glands, especially those in the axillae, groins, and cervical regions, increase in size and become painful. While *Contrib. clin. ed anatomo-patholog alio studio del Dermo-linfo-adenoma. Fungo de micosi. di Alibert. Napoli, 1882. Abst. Annales de Dermet de Syph, 1882, p. 452. 334 DISEASES OF THE SKIN. these glands may attain a considerable size, they rarely suppur- ate. In the earlier stages of the disease patients usually preserve their health to a fair degree, but when the tumors multiply rapidly, and especially when they begin to suppurate, the general health fails; indigestion, diarrhoea, and marasmus supervene. Mycosis may invade any and every portion of the integument, but the lesions are more frequently observed on the trunk, and on the proximal and inner portions of the limbs, than on the face and extremities. Mycosis is an essentially chronic disease, taking usually years to run its course of erythematous and papular development, retrogression, relapse, hypertrophy, ulceration, etc. Excep- tions occur, and the hypertrophic and rapidly ulcerating lesions may form the first stage in its development. Pathologically, granuloma has by some been supposed to be allied to sarcoma. The prefungoidal or premycosic stage, however, together with the whole clinical course of the disease, and to a less extent the histological data place it as a distinct affection. Histological examination shows thinning of the rete which becomes a mere wavy line, the papillae are squeezed out by the pressure of the growth below making them shorter and broader, and the corium is infiltrated with small, round, lym- phoid cells. The disease usually terminates fatally, and even in those cases in which a return to health has been observed, the patients do not seem to have been kept under observation long enough to make it certain that a permanent cure had been obtained. Ordinarily the patient succumbs to some accidental complic- ation, or to cachexia, or more frequently with the symptoms of leucocythaemia. The treatment consists in the administration of tonics and nutritives, together with the continued administration of arsenic, hypodermically when possible. Of late the X-ray treatment has been employed with remarkably good effect in a few cases. LEPRA. 335 LEPRA. Lepra, or leprosy, is an endemic, chronic, malignant, con- stitutional disease, due to the invasion of the bacillus leprae, characterized by alterations in the cutaneous, nerve, and bone structures, resulting in anaesthesia, ulceration, necrosis, general Fig. 57. — Macular leprosy. (Leloir.) atrophy, and deformity. It is a constitutional affection and involves the whole organism most profoundly. Its invasion is slow and insidious. Premonitory symptoms of malaise, mental depression, languor, sleepiness, loss of appetite, nausea, chills, repeated attacks of fever, general debility, nervous pros- tration, and pains in the bones are usually present and may 336 DISEASES OF THE SKIN. last for weeks, months, or years, without other symptoms. Sooner or later, however, the more characteristic features of the disease, the bullous, macular, pigmentary, or tubercular skin lesions, make their appearance. These may appear sepa- rately, successively, or together. Sometimes the skin lesions are prominent symptoms of the disease; at other times they are subordinate. Other organs of the body, as the nerves, are also affected. Two forms of leprosy are recognized, the tubercular and the anaesthetic. No absolute line, however, separates them; they often appear simultaneously upon different parts of the body, and one may pass into the other. The tubercular variety is characterized by the formation of masses of infiltration and tubercles. Other lesions are also found. An eruption of pem- phigus-like blebs, showing themselves irregularly for some time before the appearance of other lesions, is one of the earliest symptoms. It is said that these more frequently precede the macular variety of leprosy than the tubercular. Macules now make their appearance as smooth, shining, erythematous patches, sharply defined, infiltrated, not commonly raised above the level of the skin, yellowish or reddish in color, and growing dusky yellow and brownish as they grow older. Sometimes they are paler, and look like a piece of cut raw bacon set into the skin. They are commonly surrounded by a pinkish or lilac border of small blood-vessels. The sensibility of the skin is altered from the beginning, the patches being at first hyperaesthetic and later anaesthetic. They may appear anywhere on the body, but most commonly upon the trunk and extensor surfaces of the extremities. Sometimes they are present in such numbers as to involve a considerable area of the body. They may dis- appear and reappear from time to time, or they may remain as permanent lesions, in which case they increase in size.* Sooner or later the disease shows itself in the form of variously - *The plates representing macular and tubercular leprosy, here given, are from Norwegian cases, and have been reproduced from Leloir's monograph on Leprosy. LEPRA. 337 shaped and sized nodules and tubercles, situated in the skin and subcutaneous tissues, which may develop into roundish, irregularly-shaped prominences and elevated masses, from cherry to walnut size, or larger, conspicuous and prominent, Fig. 58. — Tubercular leprosy — Early stage. (Leloir.) or slightly raised, and having a yellowish, brownish, or bronze color. They are more or less painful when pressed upon. They are usually found upon the face; and chiefly the forehead, eyebrows, cheeks, nose, lips, chin, and ears are apt to be invaded, giving rise to deformity, often of a hideous character. Later, the mucous membrane of the mouth, pharynx, epiglottis, larynx, 338 DISEASES OF THE SKIN. and nares are attacked; the eye also suffers. Besides the face, other portions of the body, notably the trunk, buttocks, arms and legs, fingers and toes, are invaded. The course of the tubercle varies; it may last a long time without change, or it may soften or ulcerate at once, or it may be absorbed. Ulcer- ation is apt to occur about the fingers and toes, the ulcers being covered with adherent brownish crusts. The anaesthetic variety of leprosy may occur in conjunction with the tubercular variety or alone, in which case it is character- ized by the presence of a number of symptoms in addition to the anaesthesia. Blebs are apt to appear, first coming out in an irregular manner, from time to time, and being followed by pigmentation, and, after a longer or shorter time, by anaesthesia about the seat of the former lesions. In other cases, macules, like those which sometimes precede the tubercular form, come first. Hyperaesthesia of the skin sometimes occurs, with pains and burning sensations, followed by anaesthesia affecting a limited portion or the greater part of the surface. Later the skin becomes atrophic, dry, yellowish, or brownish in color, and more or less wrinkled. Following this alteration in the structure of the skin, the subcutaneous tissues and muscles undergo atrophy, giving rise to deformity, especially of the fingers and toes; the hairs and nails become altered in structure or are shed; the hands and feet become greatly mutilated; the fingers and toes bent, crooked and contracted. Sooner or later the bones are attacked, causing destruction of the joints and of the bones themselves; the skin over the joints becomes excoriated and ulcerated; the ends of the bones undergo disintegration, and the phalanges, finally, either become absorbed or drop of. Even the hands and feet may gradually be lost; the extremities become more or less completely anaesthetic and are greatly wasted, at times to half their former size. The disease does not usually give rise to much pain or suffering. Death occurs more commonly after some years, by diarrhoea or exhaustion. LEPRA. 339 The causes of leprosy still remain obscure. It is endemic in Africa, along the shores of the Mediterranean, and of the Atlantic and Indian Oceans, as well as in the interior of the country; also in Asia Minor, Arabia, Persia, India, China, Japan, Kamtschatka, the various islands of the Pacific Ocean, Fig. 59. — Tubercular leprosy — Late stage, with ulceration. (Leloir.) and Australia. In Europe, it is found in Norway, Southern Spain, Sicily, Greece, and Southern Russia. Upon the Western Hemisphere, it occurs in Mexico, Central America, the Islands of the West Indies, along the coast of South America, and especi- ally in Brazil; it also exists in Iceland. There are old centers of the disease in Tracadie, N. B., in South Carolina, and in 340 DISEASES OF THE SKIN. Louisiana. Norwegian emigrants have introduced it into Minnesota, but it has not spread, nor have the Chinese lepers in San Francisco and elsewhere conveyed this disease to natives. Within the past few years, cases of undoubted authenticity have been reported as occurring among natives of the United States who have never been out of the country nor come in contact with lepers. The method by which the organisms gain access to the system is not known. Recent observations seem to indicate that the mucous membrane of the nose and probably of the mouth also may be a not uncommon source of communication and infection. It is not improbable, also, that entrance may take place through some abrasion in the skin. The discovery of the bacillus leprae places beyond doubt the contagious nature of leprosy. Practically, however, we know so little of the cir- cumstances favoring the growth, propagation, and transmis- sion of this bacillus, and the clinical evidence is so contradictory, that we cannot put this affection in the same class as the conta- gious exanthemata, or with syphilis as regards the practical danger of transmission.* The most potent causes favoring the spread of the disease appear to be connected with climate, state of the soil, food, and habits of the people. The disease usually occurs among the lowest classes, but it may attack those in the most favored cir- cumstances. It occurs in both sexes and at any period of life. The diagnosis of leprosy, in countries where the disease is endemic, is usually easily made. The earliest premonitory symptoms arouse suspicion, which the appearance of the cuta- neous manifestations places beyond doubt. When the disease * There are still great differences of opinion as to the necessity of segregation. The views of Morrow ("Prophylaxis and Control of Leprosy in this Country," Trans. Am. Dermatol Assn., for 1900) are those usually held by American derm- atologists. The anaesthetic cases are less dangerous to a community than the tubercular form and seggregation less urgent. The necessity of segregation in locatities where the disease may occur sporadically or may be imported in the person of a single patient is not obvious. Unfortunately, the prejudice of the ignorant, not combated as energetically as it should be by physicians, has led, even in recent years, to scenes of revolting cruelty in the persecution and even hounding to death of unfortunate lepers who may have unknowingly appeared in our midst. LEPRA. 341 occurs sporadically, in countries where it is not endemic, it may, however, be mistaken for other affections. The macular and tubercular varieties are apt to be mistaken for syphilis. The lesions of leprosy, however, are larger and more irregular in size and distribution. The pigmentation of leprosy is of a peculiar yellowish or brownish tint. The lesions have a smooth, glazed appearance. The tubercles are apt to be much larger than those of syphilis, being often hazel-nut- or walnut-sized, and are darker in color; their course is usually Fig. 60. — Nerve or Anaesthetic leprosy, showing mutilation of hands. (Leloir.) slower than that of syphilitic tubercles. The general expression of the face (the usual seat of the tubercles in leprosy), is much changed, the features having an ugly, leonine appearance. (See plates.) Later, when the tubercles break down into ulcers, the black- ish, adherent crusts which cover them are seen to be less bulky than those observed in syphilis. With ulceration come other 342 DISEASES OF THE SKIN. very marked features of the disease, as anaesthesia, distortion of the hands and feet, absorption of bone tissue, and atrophy, all unmistakably characteristic. The yellowish, roundish patches of macular leprosy should not be mistaken for vitiligo, although this may readily occur in the early stages of the disease. The health in vitiligo is generally good, and the decolorized patch of disease consists of simple absence of pigment, with usually a border of increased amount of coloring matter. The skin is normal in texture. In leprosy, on the other hand, the macules are infiltrated with a lardaceous-looking substance, of firm consistence, and are gener- ally anaesthetic or hyperaesthetic. Morphcea, which is an affection of an entirely different nature (see Morphcea), presents lardaceous-looking patches, some- what resembling those of macular leprosy. But the general health in morphoea is good, and the patches show normal sensi- bility and tend to spontaneous recovery. Leprosy and syringomyelia are sometimes confounded but they may be distinguished by the following differences: In syringomyelia there is disassociation of the sensory disturbances, integrity of the superficial muscles of the face, absence of dis- coloration of the skin the hair is unaffected; there are devia- tions of the spine. In anaesthetic leprosy there is abolition of tactile sense, atrophy and paresis of the superficial muscles of the face, thickening and nodular swelling of nerves. There are pain- less discolorations upon the body, zones of anaesthesia and thermo-anaesthesia irregularly distributed in the shape of patches, with sharp transitions from the affected to the normal areas. These spots or islets of anaesthesia are circumscribed by a red- dish line, a little raised and very irregular. In syringomyelia, on the contrary, the anaesthetic zones of thermo-anaesthesia occupy large areas limited by regular fines. Unfortunately the diagnosis between the two affections is made more difficult by the fact that they may exist concurrently. The treatment of leprosy has thus far proved very unsatis- factory. As in the case of most diseases refractory to treatment, LEPRA. 343 the remedies and pretended cures have been exceedingly numer- ous, but as they have failed for the most part, they need not be mentioned here. The remedies now employed are valuable in improving the general condition of the leper. Change of climate and residence, usually to a temperate and bracing atmos- sphere, is imperative. Strict hygienic rules should be adopted, including exercise and bathing, with the most nourishing food. Quinine and strychina are important as tonics, and the usual alteratives may also be employed. Symptoms are to be treated as they arise. Local treatment is valuable. Baths, plain or medicated with iron or sulphur, are said to be of service. Of recent remedies, ichthyol, the oil of cashew nut, gurjun oil, and chaulmoogra oil, internally and in the form of inunctions, are recommended on good authority. The formula for the use of gurjun oil is as follows: 1$. 01. gurjun, 5j (32.) Aquae calcis, §iij. (96.) M. Churn well together, to make a cream. Apply to ulcers. Cashew-nut oil is applied, pure or diluted with almond oil, to the anaesthetic patches, being rubbed in until it nearly blisters. One part to three of almond oil is strong enough to begin with. The oil of cashew nut may also be applied pure to the tubercles until they open, when the sores may be dressed with gurjun oil. Strychnia is a very valuable remedy and should be given alone or in conjunction with other remedies. The prognosis of leprosy is unfavorable. Although a few cures have been reported, yet up to the present time the disease has almost invariably, sooner or later, resulted fatally. 344 DISEASES OF THE SKIN. CLASS VII. NEUROSES. PRURITUS. .Pruritus is a functional cutaneous affection manifesting itself solely by the presence of the sensation of itching, without structural alteration of the skin. The various forms of itching encountered in the course of many diseases of the skin, accompanied by organic changes, have been mentioned elsewhere, in connection with the diseases in which they occur. Pruritus, it must be re- membered, is a distinct affection. The first thing that occurs is itching, and any lesion of the skin visible later is the result of the scratching to which this symptom gives rise. The feeling varies in different cases. Sometimes the patient describes it as though a piece of rough flannel were in contact with the skin. At other times it is said to be like the crawling of insects, or like a tingling sensation, with the desire to scratch. It may be slight, or so severe as to be almost intolerable. It is most frequent in middle life and old age. The itching arouses an irresistible desire to scratch and rub, with the result that the surface is generally seen to be somewhat roughened, hyperaemic, and excoriated in a slight or marked degree. In other cases the external signs are slight, so that, were it not for the statement of the patient, the presence of any marked disorder might be doubted. The itching is usually intermittent, and is often worse at night. Pruritus rarely invades the whole body at one time, though various regions may in turn be attacked. In most cases it occurs in certain localities, and chiefly the trunk, scalp, genitalia, and anus. Pruritus vulvae must not be confounded with other itching affections of the female genitals. The itching may be seated in the labia, vagina, or clitoris, and is an exceedingly distressing pruritus. 345 affection. It is more apt to occur in middle life or in old age. In children it is often caused by the presence of ascarides in the rectum and about the anus. Sometimes puritus vulvas is accompanied by occasional ner- vous sensations starting from the clitoris and neighborhood and radiating through the body. The sensation is not, strictly speak- ing, one of itching, but rather a " nervous crisis." Pruritus scroti is the form of genital pruritus generally met with in the male. It may involve this region alone, or may extend along the perineum to the anus. The orifice of the urethra may also be the seat of the disease. The sensations are usually intensely annoying, and cause the patient to rub and scratch violently. It is worse at night, and is aggravated by warmth. In puritus scroti the same radiating nervous impression is at times observed as that which occurs in P. vulvae. Pruritus ani occurs in both sexes, and in children as well as adults. The itching may be around the orifice or just within the rectum. In middle-aged or elderly persons it is very often associated with hemorrhoids. It is, if possible, more intoler- able than any other of the local varieties. Sometimes it is con- stant, but more often it comes and goes from time to time, and is also worse when the patient removes his clothing or at night. Pruritus hiemalis (winter itch, frost-itch) was first described by Duhring. Corlett* has also given a full account of the disease. It is observed, as a rule, only in adults, appearing with the first frosts of autumn and lasting through the winter, to disappear in the spring. Fine, frosty, cold weather seems to aggravate the disease. It is worse when the patient removes his clothing at night and is somewhat relieved when he becomes warm in bed. The itching is usually perceived on the lower extremities, the body and arms being rarelly attacked. Bath pruritus has been described by Stelwagon.f The itching or burning follows a bath and is aggravated if the patient goes at once to bed. If he dons his clothing and moves about for a while the itching usually diminishes. * Jour. Cutan. Dis., 1891, p. 41. f Phila. Med. Jour., Oct. 22, 1898. 346 DISEASES OF THE SKIN. The causes of pruritus are extremely varied, and it is important to keep this in mind, for the cause must, in most cases, be removed in order to obtain a cure. It may be caused by physiological changes, as gestation, or by any irregularity of the menstrual function in young women. Occasionally, it is associated with hysteria, and it is sometimes met with at the climacteric period. Leucorrhoea is a common cause. Organic diseases of the uterus and ovaries are, at times, accompanied by it. Pruritus is like- wise met with in many cases of jaundice, and is sometimes a distressing symptom. Various diseases of the nervous system are accompanied by pruritus. Gastro-intestinal derangement, constipation, genito-urinary diseases, in both sexes, and, finally, the ingestion of certain medicines, and notably of opium, may give rise to the affection. It would hardly be necessary to add, were not the mistake so often made, that true pruritus is in no way caused by either vegetable or animal parasites. When these are present it is by accident, or the disease is not to be termed pruritus. The diagnosis of pruritus presents no difficulties. It is a disease of the skin, without any primary sign of alteration in its structure. Whatever lesions may be present are secondary, and the result of scratching, or of strong applications made by the patient. The diagnosis depends upon the patient's state- ment as to the subjective symptom of itching. Pruritus is most apt to be confounded with pediculosis, the secondary symptoms of the two diseases, scratch marks and excoriations, being simi- lar. These, however, are more marked and definite in character in pediculosis. The finding of lice will settle the question. They are to be carefully looked for in the clothing, and every case of so-called pruritus should be suspected to be pediculosis until the absence of the parasite is demonstrated. The treatment of pruritus is a matter demanding careful con- sideration and study in each individual case. A successful result will, in most cases, only be attained by recognition and removal of the cause. Constitutional and local remedies are both demanded. The internal remedies are to be directed pruritus. 347 against the cause, whatever the nature of this may prove. If constipation exists, the bowels are to be suitably regulated, sa- lines being usually preferable. If there is flatulence or dyspep- sia of any kind, such a diet is to be prescribed as shall overcome the digestive difficulty, and coarse, irritating, and indigestible foods are, in all cases, to be avoided. Exercise and fresh air are beneficial. A sojourn at some mineral springs may at times be recommended, where a course of aperient waters, may be taken. In many cases, close attention to these details will be followed by the most gratifying results. As regards drugs, the usual tonic and alterative medicines are to be employed. Irregular menstruation must be treated by the judicious use of iron or other remedies, cod-liver oil, etc. Quinia and strychnia are sometimes of use. Recourse may be had to bromide of potassium and chloral, alone or together, in order to subdue general nervous symptoms. Morphia should in no case be used, as it tends to aggravate the itching. Schamberg recommends moderate to full doses of carbolic acid. General galvanization, static insulation, and the applica- tion of static electricity by the roller electrode down the spine furnish relief in occasional instances. (Stelwagon). External treatment affords great relief, and is to be used in all cases. Cold and hot douches, used alternately, or hot water, applied as hot as it can be borne, or plain vapor baths are often useful. Medicated baths, containing three to six ounces (96.- 192.) of bicarbonate of sodium, or two to four ounces (64.-128.) of carbonate of potassium or borax, to thirty gallons (60 liters) of water, will at times afford relief. Besnier recommends starch baths and sponging the whole body with a mixture of aromatic vinegar, two hundred and fifty parts, carbolic acid, five parts, after which, powder the surface with ninety parts of starch and ten parts salicylate of bismuth or salicylic acid. Sulphuret of potassium and sulphur-vapor baths are sometimes used with suc- cess. Inunctions with a bland oil, as almond oil, may be prac- ticed after these baths. Lotions of various kinds are the most generally useful applic- 348 DISEASES OF THE SKIN. ations in pruritus, and those containing carbolic acid are, by far, the most generally efficient. Carbolic acid, in fact, is worth all the other remedies put together as an anti-pruritic, and should always be preferred, to begin with, unless some reason exists against its use. It may be employed in lotion, in the strength of five to twenty grains (0.3-1.2) to the ounce (32.) of water, with a little glycerine. In the following lotion the anti-pruritic effect of potash is added to that of carbolic acid : 1$. Acidi carbolici, O j ( 4-) Potassae fusae, 5ss ( 2.) Aquae, f5viij. (256.) M. When other remedies fail, oil of peppermint or menthol may be applied, especially over circumscribed, itchy localities, avoid- ing the mucous and muco-cutaneous surfaces, where such applic- ations are apt to give pain. Cyanide of potassium, fifteen to thirty grains (1.-2.) to the pint (480.); dilute hydrocyanic acid, from one to four drachms (4. -16.) to the pint (480.) ; chloroform; chloroform, a drachm (4.) to the pint (480.) of alcohol; lead- water; dilute ammonia water, acetic acid, or vinegar; chloral lotion, fif- teen to thirty grains (1.-2.) to the ounce (32.) of water, are all serviceable remedies, which may be tried singly or in succession in troublesome cases. "Liquor picis alkalinus," an alkaline solution of tar, the formula of which is given under eczema, a most valuable remedy; also "Liquor carbonis detergens." They should be used at first in the strength of two or more drachms (4.) to the pint (480.) of water, gradually increasing. In some localized forms of the disease ointments are to be used in preference to lotions; the following is a good one: 1^. Acidi carbolici, gr. x-xv (0.6 to 1.) Ung. zinci oxidi, OJ- (32. ) M. The following is recommended in pruritus vulvae (though oint- ments should rarely be used in this form of pruritus): 1$. Hydrarg. chlor. mite, Ext. belladonnas, . . . . .aa 5j ( 4-.) Ung. aquae rosae, §j. (30.) M. pruritus. 349 The following is a good ointment, but not to be used on abraded surfaces, and only with caution on the muco-cutaneous surfaces : 1$. Cainphorse, Chloralis hydratis, aa oj (4. ) Ung. aquae rosae, 5j- (32.) M. The camphor and chloral are to be rubbed together until fluid, and then added to the ointment. The mixture may also be used as a lotion with glycerine and water. In pruritus of the female genital organs, water as hot as can be borne, sponged upon the parts, forms an admirable anaesthetic, and should be used in all cases, whatever other treatment is added. Sponging with hot water may be followed by the applic- ation of one of the following lotions: Carbolic lotion as given above; sulphurous acid, or, solution of alum in barley water. A lotion containing a drachm (4.) of the sulphite of sodium, four drachms (16.) of water and an ounce (30.) of glycerine may be painted on. Sometimes emollient poultices, particularly a poultice of freshly-made almond meal, which evolves a small quantity of hydrocyanic acid, will be found very soothing. Such poultices should always be sprinkled with boric acid. Injections of sulphate of zinc, five to ten grains (.3-. 6) to the ounce (30.) of water, used on alternate days with similar injections of bi- chloride of mercury, 1 to 2000, while the external genitals are bathed once or twice daily with one of Eichoff's corrosive sub- limate soaps, form together a useful adjuvant to any treatment wiiich may be employed. When the affection is marked by "nervous crises," starting from the clitoris and radiating through the body "like a shock," as patients describe it, a little finely pow T dered cocaine dusted over the clitoris and neighboring parts will give instant though only temporary relief. The following formula may be employed : 1^. Pulv. cocaine muriat., 5j (4-) Pulv. acid, boric, 3iij- (12.) M. Pruritus ani is usually connected with congestion and enlarge- 35° DISEASES OF THE SKIN. merit of the haemorrhoidal veins. The bowels should be kept open and the following injection should be used after each stool: 1$. Pulv. zinci sulphat., Pulv. aluminis, aa gr. xv. (i.) M. Heat in an earthen vessel until all the water of crystalliza- tion is driven out. Then divide into eight powders. Dissolve one in an ounce (32.) of water for each injection. The injection of hot (saturated) solutions of boric acid in water before relieving the bowels, or perhaps, even better, the use of enemata containing carbolic acid, ten to fifteen grains .6-1.) to the ounce, are beneficial. Pruritus ani is generally best treated by means of ointments. One of the best of these is an ointment containing two drachms (8.) of tar to the ounce (30.) of cold cream. Another, composed of equal parts of belladonna and mercurial ointments, is to be applied on a pledget of lint. A solution in the strength of 12 to 25 per cent, of carbolic acid in oil of sweet almonds, is a more agreeable application than those mentioned, and I think just as efficacious. Penciling with oil of peppermint, pure or with an equal pro- portion of glycerine, may do in mild cases, where the patient does not scratch and tear the parts, but it cannot be employed where there are abrasions or fissures of the muco-cutaneous surface. Eichoff's menthol soap is also useful. Cocaine in ten per cent, solution gives temporary but complete relief. % The application of any of these remedies should be preceded by sponging with very hot water. In pruritus scroti the following prescription will be found use- ful: 1$. Bismuthi subnitratis, oij ( 8.) Acidi hydrocyanici, dU., f 3ij ( 8.) Mist, amygdalae, fgiv. (128.) M. In the pruritus of jaundice, mercurial ointment is said to be of value, also lotions of chloroform, one drachm (4.) to five (20.) of glycerine, cyanide of potassium, one drachm (4.) to the pint PRURITUS. 351 (480.) of water, and acetic acid baths or lotions in the strength of half a pint (240.) of the acid, to three gallons (four liters) of water, or about two quarts of strong vinegar to an ordinary thirty- gallon (sixty liter) bath. I cannot leave the discussion of this important subject, the treatment of one of the most painful and annoying of all diseases of the skin without adding some general remarks, the result of my experience, not only in the treatment of pruritus, but also of other skin diseases of a chronic and stubborn nature. In all of these much depends upon the care and thoroughness with which the physician's directions regarding diet and regimen are carried out. To ensure this the directions themselves must be full and expilcit. The patient's case must be made the sub- ject of careful study; the exact diet suitable to the individual must be decided upon and enforced in such terms as to leave no doubt in the patient's mind as to the importance of every detail. Generalities in the way of directions, with a careless indication, in broad terms, of the articles of diet to be used and avoided, are not likely to produce a serious impression on the patient's mind, and the failure to amend is followed by a general despondency and distrust of all remedies. The prognosis of pruritus should be guarded. The disorder, as a rule, is obstinate, often extremely so. The prognosis depends largely upon the cause and our ability to remove it. The patient must be encouraged to persevere with and thoroughly carry out the treatment. In grave cases melancholic symptoms may be present. Occurring in the aged, the prospect of ultimate cure is poor. In middle-aged females, pruritus vulvas is the commonest form met with; a most distressing malady, and one which calls for every possible effort to ameliorate it on the part of the phys- ician. Anesthesia, strictly speaking belongs to the domain of the neurologist. It may be central or peripheral in origin, local or general, although it is usually limited to certain areas. Numbness may exist, or the sense of feeling may be entirely lost. The sense of touch may also be partially or completely lost 352 DISEASES OF THE SKIN. Sometimes acute pain in the part may coexist. Anaesthesia occurs in such diseases as syphilis, scleroderma and leprosy. Hysterical anaesthesia is not uncommon. Hyperesthesia, like anaesthesia, is usually met with in general nervous af- fections, hysteria, etc., and is not ordinarily connected with any disease of the skin. Dermatalgia (sometimes called rheumatism of the skin) is characterized by pain in the skin independently of any structural lesion. Burning, sting- ing, pricking, shooting pains, aggravated by night, by movement, etc., are experienced It is seated more commonly in the hairy parts of the skin. Erythromelalgia, first described by Weir Mitchell, is characterized by burning, aching and neuralgic pain, with redness of the extremities. It may involve one or all the toes or fingers. The pain is aggravated when the part is warm. It may present an almost phlegmonous appearance. According to Spiller and Mitchell* it is in some cases due to peripheral neuritis. Mod- ified Raynaud's disease sometimes coexists. *See Spiller and Mitchell, Am. J. Med. Sci., 1899, p. 1. DISEASES OF THE NAILS. 353 CLASS VIII. DISEASES OF THE APPENDAGES. 1. DISEASES OF THE NAILS.* The diseases of the nails to be here considered are hyper- trophy, atrophy, trial formations, deformities, separation 0} the nail plate, discoloration, parasitic diseases, onychia and paro- nychia. Hypertrophy. Increase in the substance of the nail may take place simply as a thickening, or as a general enlargement of the whole substance of the nail. Both are known as onychauxis. In the first form the nail is unshapely, thick, opaque, glossy on the surface, or spherically curved, and of a grayish- white color, has a massive feel, is heavy, and so hard that it can only be cut by a saw. When the change affects the whole nail it often shows, at its free border, a tendency to curve downward. In the second form of hypertrophy, should the nail increase in a lateral direc- tion, the effect is felt in the soft parts; should it increase longitu- dinally, it may grow several inches in length, curving and twist- ing grotesquely, and forming the deformity known as onycho- gryphosis. Onychogryphotic nails have a dirty yellow, brown- ish, or grayish color, with a shining lustre, and are marked with longitudinal and also transverse ribs, with occasional horny plates. The under surface is usually brownish, with an irregu- lar, flaky exterior interrupted by smaller or larger cavities, and crossed here and there by transverse ridge-like projections. The anterior portion of the matrix, and the entire area of the nail- bed, are shown by microscopical examination to be in a chronic state of irritation. Onychauxis may be congenital or acquired. At birth the nail may be only slightly developed in excess of its normal average, * For a full account of the diseases of the nails see Heller, Die Krankheiten der Nagel, Berlin, 1901. Also C. J. White, Clinical Study of 485 Cases, Boston Med. and Surg. Jour., Nov. 13. 1902. 23 354 DISEASES OF THE SKIN. but it grows with a greater relative rapidity. The various dis- eases associated with papillary hypertrophy (e.g., ichthyosis) seem to favor the development of this inborn tendency in the nail. More commonly onychauxis is acquired and may be traced to some traumatic cause — to neglect, to the extension of morbid inflammatory processes of the corium and the connective tissue of the cutis to the matrix of the nail (e. g., psoriasis, chronic ec- Fig. 61. — Hypertrophy of Nail. zema, lichen ruber, lepra, elephantiasis, etc.). Some pre- disposition to onychauxis must, however, exist in these cases, as not every case of these diseases shows hypertrophy of the nail (some even show atrophy), and as, furthermore, the nails are, at times, affected when the skin disease does not exist in contiguous parts. Symptomatic hypertrophy of the nails sometimes occurs in DISEASES OF THE XAILS. 355 neuropathic affections of a degenerative or irritative character, most frequently in spontaneous neuritis, neuralgia, chronic myelitis, traumatic lesions of mixed nerve trunks (" glossy skin"), etc. The same alteration of the nails may occur after various chronic diseases, as articular rheumatism, affections of the bones, or ankylosis. Partial hypertrophy may occur after various ulcera- tive processes in the nail-bed, in which the remaining part of the matrix appears to attempt to make up the loss. The effect of hypertrophy of the nails is not only cosmetic deformity, but absolute loss of tactile sense to a greater or less degree. The person is unable to execute delicate or fine work. Fortunately, onychogryphosis of the fingers is rare, and even onchyauxis to a marked degree is uncommon. When the toes are affected, walking may be more or less interfered with, and in advanced cases may become altogether impossible. Lateral hypertrophy may produce inflammation and ulceration in the surrounding soft tissues (ingrown toe-nail). The prognosis in hypertrophy of the nail depends upon the chance of removing the cause. Of course, the hypertrophied nail can in no wise be altered, but if the eczema, psoriasis, etc., can be cured, there is good reason to hope that a healthy nail may be developed from the matrix. In the case of such diseases as lepra or elephantiasis, where the disease is incurable, but little hope can be entertained of improving the state of the nail. The same is true when the matrix has been altered by traumatic influences to an irremediable extent. The treatment consists in removing the cause when attainable, and in doing away with the hypertrophied product when this becomes a serious annoyance. The nail may be removed by means of the knife, cutting pliers, or, in extreme cases, the saw. Where the nail has enlarged in width, it may press upon the lateral furrow to a greater or less extent, and when to this is added pressure from a tight shoe, considerable irritation and inflamma- tion of the soft parts may ensue, followed in extreme cases by great destruction of the neighboring tissues, even involving the tendons and bone. 356 DISEASES OF THE SKIN. With regard to the treatment by removal of the cause, if eczema, psoriasis, or other disease exists, this must be removed by appro- priate local remedies, ointments, rubber finger-stalls, etc. When eczema is present on the body, iron, arsenic, and other remedies appropriate to these affections of the skin will also be found to affect the nails favorably. When the disease of the matrix and the nail-bed is due to any form of syphilis, internal treatment appropriate to that disease is called for, and, in addition, the local application of iodoform, mercurial ointment, or solution of corrosive sublimate, i to 250 of water. When the cause is traumatic, as from an ill-fitting shoe, this should be remedied, or when from severe occupation, protection of the finger or toe by soft wax or other mechanical device. Atrophy of the nail, may be congenital or acquired. The congenital form is met with in connection with imperfectly devel- oped fingers and toes, the nail being cither entirely absent, imperfectly developed, mutilated, or coalescing with other nails. The acquired form of atrophy of the nail is met with as a result of traumatic influence, as pressure of shoes, etc., which at times may produce hypertrophy, and at other times atrophy. The nail formation may also be hindered by a knock, blow, pinch- ing, etc. "Leukopathia unguium" is a form of atrophy in which white spots or transverse bands occur. This may be congenital but is most frequently observed after fever or wasting diseases. Geber looks upon white spots on the nails as a sign of insuffi- cient cornification of the nail cells, traceable to mechanical in- fluences.* Thermic and chemical sources of irritation are not uncom- mon causes of atrophy of the nail, as are also inflammations associated with suppuration and ulcerative processes. Among the constitutional causes of retarded nail growth are febrile conditions and chronic wasting conditions of the general organism. Typhoid fever on the one hand, and tuberculosis on the other, may be mentioned as typical causes. Those cuta- *See Heidingsfeld, Leucopathia Unguium, Jour. Cut. Dis., 1900, p. 490. DISEASES OF THE NAILS. 357 neous diseases and nervous affections which produce hyperplasia of the nails, such as ichthyosis or ataxia, may, under other con- ditions, give rise to precisely the opposite effect. The imperfectly developed nail is whitish-gray, lustreless, thin, and delicate, giving the impression of a thickened mem- brane, possessing but slight hardness, readily broken and flex- ible. At times the substance is so friable that it exfoliates longit- udinally and fractures through its thickness, thereby rendering the nail uneven. The treatment includes, first, frequent trimming and cover- ing of the affected nail with a protective layer of wax. The removal of the etiological factor is next to be attended to. The main point is to keep away any possible injurious influences, to cure, if possible, any accompanying skin diseases, dyscrasic or nervous affections, inflammations and ulcerative processes, and to support the strength of the patient when impaired nutrition may be the cause. When the defective nail formation is due to some incurable disease, it is, of course, impossible to expect a change for the better. Geber thinks that equable pressure exerted by strips of adhesive plaster upon a wax nail fastened to the nail-bed will hasten the regeneration of the nail. Malformation of the nail plate is a result of disturbed function of the matrix. The latter may be the result of nerve disturbance (paralysis), of injury, malformation of the lateral furrow, inflam- mation of the underlying connective tissue, periosteum, bone, etc. Nails suffering from deformity may be long, short, narrowed, or curved one way or another, occasionally pointed. A not very uncommon form is the so-called "spoon nail" in which one or more of the nails are hollowed into a concavity. I have reported a case where the nails were curved or rolled in at the edges so as to present a semi-cylindrical figure., and so shrunken that they occupied only about one-half the normal width of the nail-bed. The case was that of an infant suffering from hereditary syphilis. The deformed nails were gradually replaced by normal ones as the infant regained health under treatment. . Sometimes deformity of the nails may be hereditary. As the 358 DISEASES OF THE SKIN. cause can rarely be removed, the affection is usually irremediable. Fortunately, it is rarely more than a mere disfigurement. Degeneration of the nail may occur as a result of faulty nutrition, but is also met with following chronic inflammatory processes (paronychia sicca) of the matrix. The nail may be thick or thin, or more frequently fibrous, and spread with an irregular detach- ment of particles. The color changes to a grayish- white or dirty yellowish-gray. Aside from disfigurement, these nails are very troublesome, as they are continually breaking and splitting, and occasionally denude the nail-bed. Removal of the cause, when this can be ascertained, and protection by the wax nail covering and bandage, may be recommended when practicable. Separation of the nail plate occasionally takes place in one or more nails; a grayish strip of coloration appears along each side of the nail and gradually spreads toward the median line until the whole nail plate is invaded. This is then seen to be raised above the surface of the subungual structures, remaining united to the matrix only at its edges and root. The nail plate thus elevated above the underlying structures may be moved about slightly without causing pain. It grows as usual, and its structure remains unchanged excepting as to its ashen-gray color. Occasionally, white achromic patches are seen scattered over the surface. Such cases are very rare. Bazin considers them due to eczema. One case under his care was cured by applications of tincture of iodine. Discoloration of the nail is only worthy of a passing notice. The changes to purple, to chalky- white, to yellow, etc., in various diseases, are probably due to only the translucency of the nail, showing the congestion or discoloration of the tissues beneath. Traumatic and chemical injuries may affect the texture of the nail from a distance. Thus, workers in acids, etc., and those who use peculiar tools, may have alterations in the nail following long-continued action at a distance. The animal and vegetable parasites may also affect the texture of the nail. Parasitic Diseases of the Nail. — The itch insect, "sarcoptes DISEASES OF THE NAILS. 359 scabiei, " may give rise to various changes in the nail. Boeck states that the ova and excrement of the sarcoptes are to be found in the degenerated nail substance. Bergh has shown that the deviations in the nail due to the sarcoptes are brought about on the one hand by affection of the nail-bed and matrix, and on the other by implication of the nail substance. Various tropical flies, which lay their eggs under the nails, may cause disease, but none of these is so harmful as the sand- flea {Ptil ex penetrans), which causes at first violent pain and, following this, paronychia. Vegetable parasitic diseases of the nails are less uncommon than those caused by animal parasites. The disease is more apt to spread from the adjacent skin than it is to be implanted directly under the nail. The onychomycoses are, so far as yet known, of only two kinds, that due to favus, and ring-worm. The clinical appearance is not very different, and will be des- cribed once for both. Favus is the more rare. The nail affected shows signs of change at an early date after the implantation of the fungus, becoming brittle, frayed out, and intersected by furrows, and presenting a discolored, opaque, grayish or yel- lowish-white appearance, and is more or less lifted up. When the process has continued for a considerable time the alternation extends to the entire nail, and the matrix being implicated, changes in growth are perceptible. The nail becomes claw-like, thickened, flakes off even on the surface, and being detached here and there, and acquiring a faded, dirty yellow color, becomes exceedingly disfiguring. Rare cases of favus infiltration of the nail show the peculiar sulphur-yellow crusts or scutulate depres- sions; but the worm-eaten appearance produced by numerous other affections must not be mistaken for this, and, in fact, apart from the actual discovery of the fungus, an exact diagnosis can- not often be made. In this country parasitic disease of the nail is excessively rare. Longitudinal or transverse sections through a nail changed by the infiltration of fungus show disintegration of the substance, and by treatment with glycerine, convoluted threads of myce- 360 DISEASES OF THE SKIN. Hum and conidia mixed with cornified epithelium can be observed under the microscope. The treatment consists in scraping the nail very thin and apply- ing a parasiticide. Strong acetic acid is the best, as it softens and penetrates the horny tissues. Onychia and paronychia are the names given to certain inflammatory conditions occurring about the base of the nail plate in the first instance or about the sides of the nail in the latter. The affection in both cases is usually due to traumatism, pressure of the nail or the accidental introduction of pus organ- isms. In paronychia the invasion of the staphylococcus may penetrate further into the tissues and give rise to whitlow or felon. I have described a peculiar herpetiform onychia in which the for- mation of vesicles or vesico-pustules took place at the root and sides of several nails, accompanied by severe pain and subse- quent alterations in the nail structures. The treatment of onychia and paronychia consists in the removal of the cause (pressure from the nails, ill-fitting shoes, etc.), careful disinfection of the parts by soaking in hot solutions of bichloride of mercury (1-2000) and subsequent dressing with ichthyol and lead-water or other sedatives. 2. DISEASES OF THE HAIR AND HAIR FOLLICLES. HYPERTRICHOSIS. Hypertrichosis or excessive growth of hair may be congenital or acquired. Congenital hypertrichosis may be partial or general. The partial hypertrichoses are generally pigmented naevi. (See Figs. 62, 63 and also under Naevus pigmentosis.) Generalized or universal hypertrichosis is an abnormal de- velopment of the hair in all those regions in which it nor- mally grows, either as adult hair or lanugo. Those parts of the body, as the palms and soles, which are normally hairless never take part in the overgrowth of generalized hypertrichosis. Acquired hypertrichosis is usually localized, although a few cases are on record where it has been nearly universally distributed. Hairs growing on the face, arms and other exposed parts in HYPERTRICHOSIS. ;6i women are those for which relief is commonly sought. The other forms of the disease are rather medical curiosities. Many females experience an extra growth during youth or adult age, which in certain cases may assume excessive pro- portions; usually the upper lip is the part most markedly affected, Fig. 62. Hypertrichosis Localis. (After Eckert.) : but the overgrowth may also occur on the chin and cheeks, form- ing a genuine beard, sometimes of very considerable proportion, as in the case reported by Duhring, of which a picture is here appended.f (Archives oj Dermatology, April, 1877.) *Ecker. Abnorm. Behaarung des Menschen. Braunschweig, 1878. t The woman, who was married and twenty-three years old, said that the hair had begun to grow in childhood, and had gradually increased year by year, grow- ing more vigorously as the period of puberty approached. The hair of the scalp, at the [age of twelve, was quite long, extending to the hips, and by no means 3 62 DISEASES OF THE SKIN. It has been asserted that this form of hypertrichosis occur- ring in women is closely related to disturbances of the genital Fig. 64. — Hypertrichosis (Bearded Woman. Dr. Duhring's case.) functions and also that it is not infrequently connected with strong sexual inclination. With regard to the latter point, thick. Menstruation began at the age of fourteen and has been normal. The establishment of menstruation did not seem to increase particularly the over- growth of hair in the beard. Hair first manifested itself now in the axilla, on the pubes, and on certain regions of the trunk and the extremities. The increase in the growth of the beard continued until the age of eighteen, since which time it had been stationary. She was married at the age of seventeen and a half, and had had two children, living to the age of two and four years, respectively, with- out showing any signs of overgrowth of hair. The hair of the scalp having fallen out during fever, was cut, and at the time of examination was rather scanty. The hairs of the moustache were about one-half inch long, of fine texture; those of the beard were about five inches in length, curly, thickly set, and of fine quality, dark brown in color. There was a diffused hairy patch, about the width of the hand, extending across from shoulder to shoulder on the back. There was a per- ceptibly excessive growth of hair down the whole back, rather sparse, starting from either side of the spinal column, and taking a course downward and forward around the sides of the thorax, covering the latter portions of the trunk. The vertebral column itself was almost entirely destitute of hair. The hair upon the axilla was no more profuse than normal, and Dr. Duhring was assured that the pubic hair was no more abundant than in most hirsute women. The limbs, with the exception of the forearm, were not remarkably hairy; the latter showed con- siderable growth of hair, but not very excessive. HYPERTRICHOSIS. 3 6 3 I am convinced there is rarely any relation whatever between the two conditions. The result of my experience is that the majority of cases which I have been describing occur in women who are not only not consciously subject to strong sexual feeling, but in many cases, as far as can be ascertained, are perhaps more than is usual, even in the case of women, devoid of those feelings. There is no question that in some cases there is a relationship between uterine and ovarian disturbances and excessive growth of hair on the face of females, but an examination of a large number of cases has brought me to the conclusion that the two conditions are by no means fre- quently dependent upon one another. In fact, I do not think that we can accurately state what the causes of this form of hypertrichosis are, although there is no question that the nerves have more or less direct influence, especially the trigeminal or fifth pair. It will be observed in most cases of overgrowth of hair upon the female face and chin, that the largest hairs appear at and about the points on either side of the chin at which the submaxillary branch of the fifth pair emerges from the bone. Hypertrichosis may occur at four different epochs in the life of women. It may exist at birth; it may appear between fourteen and sixteen years, about the period of puberty, or when the beard appears in men; it may occur in adult life, or it may not appear until the menopause. Hypertrichoses of the first two varieties are usually most abundant; to these two classes belong those well-developed beards of a decidedly masculine character which are most usually the object of public curiosity. Fig. 65. — Hypertrichosis Universalis (Julia Pastrana). (After Ecker.) 3 6 4 DISEASES OF THE SKIN. The third variety of hypertrichosis in women, that which occurs in the adult, is generally less profuse than in the first two varieties. Occasionally, however, cases have been reported in which adult women have developed full beards. It is said that this form of hypertrichosis frequently coexists with dis- turbances of menstruation (amenorrhcea or dysmenorrhcea). Occasionally pregnancy, which causes cessation of the menses and also marked modifications in the entire organism, brings Fig. 66. — Hypertrichosis (the Russian Dog-faced Man). (After Ecker.) with it an excessive growth of hair. Slocum (N. Y. Medical Record, July 10, 1875) reports a case of this kind. Hypertrichosis occurring at the epoch of the menopause is extremely common. I should even say that the majority of women present a slight hypertrichosis at this period. This form of hypertrichosis is of anthropological interest, but excepting when well-marked, the dermatologist is not often called upon to treat it as a pathological condition. I think that this form of hypertrichosis is not due directly to any change in the sexual or reproductive organs themselves, but is the effect of the peculiar nervous changes which accompany in the majority of cases HYPERTRICHOSIS. 365 this period of life in women. Brocq says that when excessive hypertrichosis occurs in such cases women are apt to become nervous, impressionable, melancholy; sometimes the woman at this period becomes morbidly afraid of venturing out-of- doors ; she imagines that every one is watching her and examining the extraordinary growth of hair; she even thinks that she is followed in the street at times; and the woman who is under 'his form of hallucination or morbid sensitiveness becomes a torment to herself and a misery to those around her. The moustache and beard, as it is called, becomes in these women what the French call an idee fixe, which may lead to insanity. Pathological Hypertrichosis. The hypertrichoses which form this group are distinguished from all other forms by the fact that they occur as the result of a detrimental lesion. The seat of the original lesion as well as its nature may vary greatly; sometimes it is a cutaneous irritation provoked by some local irritative application; at other times the cause is a nervous lesion usually of traumatic character. Hebra describes a case in which the employment of mercurial ointment brought out a growth of hair, and numerous similar cases have been reported by various authors, and, in fact, such growths may be observed by any practitioner of large experience. It is not unusual to meet with individuals of either sex who have small bunches of hair growing from a flat pigmentary spot or from a pigmentary mole or wart. These are the pigmentary naevi of which illustra- tions are given here and which may occur on almost any part of the body, and which are described in most works on diseases of the skin. Hairy Growths Produced by other Cutaneous Disorders. The hypertrichoses of this kind are neither frequent nor well marked, nevertheless they are met with from time to time. Excessive growths of hair sometimes occur on the surface which has been occupied by the lesions of prurigo. Keloid growths may also favor the growth of hair. Hypertrichoses Resulting from Lesions oj the Nerves. Hy- pertrichoses of this kind most frequently occur after traumatic 366 . DISEASES OF THE SKIN. lesions of the nerves. Mitchell and Keen have reported cases of this character occurring after gun-shot wounds. In all these cases, which resemble each other very closely in their origin and mode of occurrence, the overgrowth of hair always followed a neuritis. There is a hypernutrition of the elements of the region involved, especially those of the skin, the epidermis, pigmentary granules, sebaceous and sudoriferous glands, and hairs all being involved. Hypertrichosis Caused by Lesions of Central Nervous System. Spontaneous or traumatic lesions of the cord may sometimes be the cause of hairy overgrowths. Treatment is only called for in those cases of hypertrichosis when a cosmetic effect is required. Here in many cases depila- tories may be employed. The following are those generally recommended. Baetge uses a paste of sulphite of calcium made by passing sulphuretted hydrogen through milk of lime. This, to be effectual, must be used fresh. Another formula is the following: 1$. Pulv. orpiment, Pulv. lithargyri, aa ovijss (30.) Hydrarg. vivi, 5xv (60.) Pulv. amyli, ovijss (30.) M. The following formula is said to be that in vogue among the Turks: ty. Arsenici trisulphureti, oij (8. ) Calcis vivi, oij (64. ) Amyli, 3ij ad. v (8.-20.) Aquae bulliente, q. s. M. This is also made into a paste and applied with a spatula. After remaining in contact with the skin five or ten minutes, or until a slight tingling sensation is felt, the paste is removed, the skin washed, and the surface is powdered with starch. I may say that I have had little experience with these preparations. A great number of similar formulae may be found in the standard works upon diseases of the skin, to which the inquirer HYPERTRICHOSIS. 367 may be referred. None of these, however, can do more than destroy the hair down to the level of the skin or a short distance into its follicle. The hair begins to grow again at once, and I cannot see any advantage to be gained by depilatories over that obtained by simple shaving. Moreover, the skin itself suffers from these caustic applications, and any sharp-sighted observer can immediately detect the artifice. The application of peroxide of hydrogen bleaches the hair, and this procedure is worth trial in the case of brunettes having an abundant growth of downy black hair upon the face. The treatment of hypertrichosis is only a matter of practical interest when the hairy growth occupies such a position as to make it a conspicuous deformity. Hairy moles may some- times be removed by the knife when favorably situated and not too large. Circumscribed or diffuse growths of hair, occur- ring chiefly about the face and in females, are best removed by electrolysis. In former times depilation, shaving, and the application of caustic depilatories formed the only modes of treatment, and these were highly unsatisfactory, as only in part removing the disfigurement, and at the same time requiring fre- quent repetition. In fact, depilation by means of forceps is said, and probably with truth, to stimulate the growth of new hair in the neighborhood. To Michel and to Hardaway, of St Louis, we are indebted for a safe, easy, and effectual method of removing superfluous hairs by electrolysis. Though electrolysis had been suggested at a somewhat earlier date by Piffard, as a means of destroying the hairs in hairy naevi, the method was first employed systematic- ally by Michel in trichiasis, and was adopted to general dermato- logical use by Hardaway, who read a paper upon the subject before the American Dermatological Association in 1878. The operation, as described by Hardaway, is performed as follows: A No. 13 cambric needle is attached to a convenient handle, see Fig. 67, which latter is connected with the negative wire of a galvanic battery; a moistened sponge electrode is con- nected with the positive pole. Under a strong lens, held in the 368 DISEASES OF THE SKIN. left hand (or without this if the operator has very good eyesight), the patient being seated in a reclining chair, facing a good light, the needle is entered, as near as possible, into the hair follicle; after this has been accomplished, and not till then, the patient is told to bring the sponge (positive) electrode in contact with the palm of the hand. The needle is not withdrawn until a slight frothing is observed around the stem, showing that the electrolytic action has been fully developed; but to avoid shock the sponge Fig. 67. — Flemming's needle holder for electrolysis (about two-thirds size). electrode is first released by the patient, the needle being removed subsequently, this order being exactly the reverse of the initial steps.* The hair should always be left in situ, and not extracted before the needle is introduced, as it is a guide for the introduction of the latter, the instrument being passed in alongside of it. Besides this, it is an immediate guarantee of the success of the operation; for if the hair comes away with the very gentlest traction of the depilating forceps, a point always to be tested, at once we know that the papilla has been destroyed; but if force is required for its extraction, it is a sign that the follicle has not been properly entered. In this case the needle is rein- troduced, or, better, it is not removed at all, repeated attempts being made from time to time to withdraw the hair until finally it is loosened. Eight cells of a freshly- charged zinc carbon galvanic battery (See Fig. 68) will usually suffice, or 8 to 16 silver chloride cells. A greater or less number, however, may be required in one case or another. The strength of the current required is from \ to 1 \ milliamperes. The operation is a painful one, and but few hairs can usually be removed at a sitting. * Some operators make and break the current by means of the button and spring shown in the figure. This is more convenient but much more painful to the patient. ATROPHIA PILORUM PROPRIA. 369 The needle should be as fine as can be procured, even finer than a No. 13 cambric, if such is procurable. An expert mechani- cian can grind an ordinary needle down to the finest diameter. Some operators prefer an irido-platinum needle; others a watch- maker's very fine steel wire. It must be remembered that the larger the needle the longer it can be retained in situ, and the stronger the battery power the more rapidly and thoroughly Fig. 6S. — 20-cell constant-current battery for electrolysis. can the hairs be removed. But if either of these conditions overstep the proper limits, abscess and scars are apt to follow, and much unnecessary pain is caused. In most cases, ten to twenty per cent, of the hairs remain (or appear to remain, for the growth of neighboring fine hairs seems to be stimulated by the use of the electricity), and the ground must almost always be gone over once, or several times. ATROPHIA PILORUM PROPRIA. Atrophy of the hair is a general term employed to cover various hair changes of an atrophic or destructive character. Whether or not a true progressive and morbid diminution in bulk of the hairs takes place, it is certain that their physiological term of life may, under some circumstances, be diminished. 24 370 DISEASES OF THE SKIN. The hairs lose their normal condition, become dry, lustreless, rough, brittle, cleft, and fibrillated; they swell out and break off. These changes often take place as the result of morbid proc- esses occurring in the parts from which the hairs arise — their follicles, the sebaceous glands, or the cutaneous structures immediately adjoining. After fevers and other severe consti- tutional disturbances, likewise, the hair may become dry and lustreless, and tend to fracture and splitting. In addition to these conditions which affect the hairs in general, there are several forms of atrophic structural alteration which must for the present be termed idiopathic, because we cannot assign any cause for them. One of these is the well-known phenomenon known as jragil- itas crinium, in which the hairs become split up at their extrem- ities. In some persons, particularly in females with long hair, or men with long beards, nearly all the hairs split up in this way. But this splitting is probably without significance, and does not affect the growth of the hair. Duhring has reported a single case of an "undescribed form of atrophy of the hair of the beard,"* characterized by atrophy of the hair bulb and by splitting of the hair substance. To the naked eye the affected hairs varied in size and form, some having a uniform diameter several times greater than normal, while others throughout their length were unusually slender. The bulbs were in nearly all instances smaller than normal, and had a markedly contracted look. Not infrequently the diameter of the bulb and root was considerably less than that of the shaft. The majority of the hairs showed splitting into two, three, or more parts throughout their entire length. Under the microscope, atrophy of the bulbs and fission of the hair substance were the conspicuous features. In the majority of the specimens the bulbs were distinctly shrunken and atrophied, appearing as small, contracted points or knobs. The hairs, as a rule, began to split within the bulb. The cause of the disease is not known. Some observers *Am. Jour. Med. Sci., July, 1878 (with illustration). ATROPHIA PILORUM PROPRIA. 371 have considered it due to a parasite invading the hair, while others have thought the swelling and bursting of the hair to be due to the development of gas in its tissues. Frequent shaving and the use of parasiticide remedies offer the most reasonable means of treating the disease. Monilethrix, moniliform or beaded hair, resembles trichor- rhexis nodosa excepting that the hairs break at the point of Fig. 69. — Monilethrix-hair showing breaks at the internodes. (Lesser.)* constriction. The disease usually occurs on the scalp, some- times over a single patch, but occasionally is found in the beard. The broken off hairs give the patch on the scalp somewhat the appearance of ring-worm. The cause of the disease and its pathology are unknown. Treatment in cases recorded has had little or no effect.! * Lesser, Ringelhaaren Vierteljahrreschrift f fSee Beatty and Scott, Brit. Jour. Derm., 181 Cut. Dis., 1898, p. 157. (Review of recorded cases.) Derm. u. Syph, 1886, p. 51. 2, p. 171. Also Gilchrist, Jour. 372 DISEASES OF THE SKIN. Piedra is a nodose condition of the hairs characterized by minute pin-head sized, hard nodules situated on or around the hair shaft, in appearance somewhat suggestive of nits but much smaller. The hair shaft itself is not involved. It usually occurs in the scalp but has been observed elsewhere. With the exception of a very few cases the disease has only been observed in South America. It is due to fungus growths.* The treatment of fragilitas crinium, especially that form which shows splitting of the ends of the hair, should include attention to the general nutrition, and stimulation of the scalp, when this is affected, by the hair tonics mentioned under alopecia. When involving the shaft or ends, the hair should be clipped off just below the cleft part. Vaseline should be rubbed into the scalp frequently. In the beard, clipping the ends or shaving should be continued for some time. Trichorrhexis nodosa is the name given to a peculiar atrophy taking place at certain points in the hair and giving the appear- ance of nodes to the intervening parts. Some hairs have a conical, or fan- or brush-shaped enlarge- ment at the end of each, and if this occurs on many hairs, on the moustache, for instance, the impression is conveyed that the hair has been singed by a flame, and has curled up at the burned ends. The hairs thus affected are firmly fixed on their papillae, but break easily at the seat of the swellings. The stump of the hair which remains shows the lower half of a node as its ex- tremity. Microscopic examination shows the nodes to consist of spindle- shaped swellings produced by a splitting asunder of the fibres of the hair structure, so that the appearance presented is that of two besoms or birch brooms rammed end-to-end together. It would seem that a separation or swelling takes place in the body of the hair, and that this produces a lighter color in the hair at the nodal points, as seen by reflected light, while the split- ting takes place at a later stage of the disease. *See J uhel-Renoy, A nnales de Derm, et de Syph., 1888, p. 777. (Illustrations of hair and fungus.) ATROPHIA PILORUM PROPRIA. 373 The part usually affected is the moustache, though the beard, scalp and exceptionally other parts may show it.* Tinea Nodosa. Under this name a peculiar nodose condition of the hairs of the moustache and axilla has been described. f To the naked eye the hair appears thickened and rough, with some incrusting material, and here and there nodular swellings, sometimes hard and glistening, and in other cases soft. Numbers of hairs are broken off short, with brush-like ends. Under the microscope the roughness and thickening are seen to be due partly to an irregular incrustation of granular-looking material around the shaft, and external to it, and partly to the swelling of the shaft itself by the incipient separation of the fibre cells of the cortex. These incrustations or nodules have been found to be com- posed of an aggregation of the zooglea-form of a species of bacterium. The so-called "red chromidrosis, " which is in reality a parasitic hair disease, may be mentioned here. The hairs are surrounded at various points with closely adherent, irregular masses of a grayish, red or yellowish-red color. On microscopic examination these are found to be composed of parasites, the exact nature of which is not known. Some writers have considered this affection under the desig- nation lepothrix. The hairs of the axillae are those most commonly affected, but I have seen the disease on the downy hairs of the cheek. The red color is supposed to be due to a micrococcus derived possibly from the sweat. J Shaving or cutting the hairs close, with the applications of parasiticides, has resulted in a cure in the cases which have come under my observation. Ingrowing Hairs. These show themselves as small bluish-whiie papules from pin-head to small pea-size, situated usually about the chin where the *Heidingsfeld, Jour. Cut. Dis., 1905, p. 246, gives resume of literature and bibliography. tCheadle and Morris, Lancet, 1879, i, p. 190 (with illustration). |Sonnenbetg, Monatsh. j. Prakt. Derm., vol. xxvii, 1898, p. 538. With a review of the subject and literature references. 374 DISEASES OF THE SKIN. hair grows thickest. It usually occurs in adults who have shaved for years, and is apt, at first, to be taken for "black-heads" or comedo and irritated by pressure with watch keys and attempts to squeeze out. Careful inspection of the cheeks and chin (which should be made when the patient has not recently shaved) shows here and there the presence of " giant hairs." Slight traction with forceps enables these to be extracted, when a deposit of dark soft ma- terial which envelopes the hair over its entire extent is perceived. This is easily separated and the hairs are found to be blurred and indistinct in struc- ture and very brittle. There is no monilform appearance. The presence of the small, bluish-white tumors is explained by the fact that in shaving, particu- larly when a blunt razor is used, these diseased and fragile hairs are dragged upon and broken off within the hair sheath. The remainder of the hair still grows but the orifice of the follicle having become blocked before the hair reaches it, the latter continues to grow spirally like a watch spring within its sheath. Occasionally these ingrowing hairs are met with about the neck and on the border of the scalp behind. The spiral hair sometimes grows- round and round until it forms quite a tumor — a retention cyst. From such cysts hairs of several inches in length may sometimes be extracted. Occasionally small tufts of a dozen or more fine hairs are found in these cysts, which are particularly common on the under surface of the penis, due here, probably, to the rubbing of clothing, etc. Sometimes these cysts become irritated and form furuncle like inflam- mations, which recur until the hairs are removed. The treatment is removal of the diseased hair, but this must be performed with great care, as the slightest overtraction will cause the brittle hair to break within the follicle. When destruction of the hair papilla can be ac- complished by the electrolytic needle this should be employed as the only sure cure. CANITIES. Graying of the hair may be congenital or acquired. Congen- ital graying of the hair is quite rare. It is usually confined to one or several tufts or patches and in some cases has been noted as hereditary even through several generations. General con- gential gray or white hair is usually associated with albinism. Canities prematura may occur gradually or in tufts or patches, commonly showing at first over the temples, or it may occur sud- denly or at least with great rapidity. The causes of premature graying are various, severe illness, sudden shock, deterioration of the nervous system, or in some cases, where there is an CANITIES. 375 hereditary tendency, without any appreciable cause. The hair may come out gray after some local disease, as alopecia areata or lupus erythematosus, afterwards recovering its normal color. Cases of graying in bands have been recorded. In some few authenticated cases the hair has turned suddenly and entirely white.* Other changes in the color of the hair from one shade or color to another have been noted, and dyeing, a discoloration from the internal or external use of drugs, has also been observed. Senile canities is usually observed from the forty-fifth to the fiftieth year or later, varying very much in different individuals. Persons with very dark or black hair are apt to experience graying earlier than blonde-haired persons, although this may occur simply from the fact that any change is apt to show more in dark hair. Grayness is the result of some lack of pigment production in the papilla of the hair, or due to the presence of air in the cortical portion. Wilson and Landois have explained sudden blanching of the hair by a rapid formation or collection, for some reason, of air bubbles, especially between the cells of the cortical layers, which renders the hair opaque and white, the contained pigment being obscured. Canities is usually progressive and permanent, but cases have been reported by Jackson t and others where there has been a return to the original color. In some cases of graying after acute disease in the young the color of the hair has returned on com- plete recovery. No treatment of canities can be relied upon as effectual. When this occurs in the young or in young adults after sickness, tonics, as strychnia, quinine, iron, etc., may aid and hasten a restoration to the normal when there is a tendency to recovery. The employ- ment of dyes and stains to conceal the grayness of the hair is rather a matter for the barber to deal with than the dermatologist. *Landois, Das Plotzlich Ergrauende Haupthaare. Yirchow's Archiv., vol. xxxv, 1866, p. 575. Raymond, Revue de Med., 1882, vol. 2, p. 770. Laycock, Brit. and For. Med. Chir. Rev., 1861, vol. i, p. 458, and Brown-Sequard, Archives de Physiologie, 1869, p. 442, the latter a personal experience. t Diseases of the Hair and Scalp, New York, 1890. 376 DISEASES OF THE SKIN. ALOPECIA. Alopecia is a general term applied to loss of hair which may vary in extent from slight thinning to complete baldness. The varieties of alopecia are usually included under the heads of congenital, senile, premature and alopecia areata. Congenital alopecia is the name given to those rare forms of the disease where an individual is born without hair. In one such case microscopic examination showed absence of hair bulbs. I am acquainted with the case of an otherwise healthy infant, upon whose scalp only lanugo (fine downy hairs) grew until the third year of life. A hereditary predisposition to scanty growth, or early loss of hair, may often be traced. Senile alopecia, or the baldness of old age, is connected with the general atrophy of the cutaneous tissues which occurs at this period of life. The hairs become gray, thin and dry, and are cast off, not to be renewed. The hairs of the body generally become thinner, and drop out to a less extent, at the same time. Premature alopecia may be subdivided into idiopathic and symptomatic. Idiopathic premature alopecia, or premature baldness, may take place either rapidly in the course of weeks or months, or, as is most generally the case, slowly, through a period of years. The hair may begin to come out at any period after puberty, although it does not generally fall much before the age of twenty-five to thirty. The scalp is healthy to all appearance, no pityriasis being present. At first only a few hairs fall, and these are succeeded by new ones growing from the same follicles, but coming earlier to maturity and falling out before they have attained a normal length. The process is progressive, more and more hairs fall- ing prematurely. Each new crop of hairs is shorter and finer than the preceding, until finally only lanugo or short, fine, soft, woolly hairs are produced. In the course of time even these are no longer produced; the hair follicles become atrophied, and complete baldness ensues. The process is sometimes ar- ALOPECIA. 377 rested and normal hairs may be produced for a time, but the im- provement is apt to be transitory. This form of alopecia is very common; it is more frequent among men than among women; as in senile alopecia, it ordin- arily begins about the vertex and extends toward the forehead, or it may begin upon the temples. Symptomatic premature alopecia includes those forms of more or less complete baldness, caused by local or general diseases. The loss of hair may be temporary or permanent. Fevers, nervous disorders, violent shocks to the nervous system, and men- tal distress, worry or overwork, may give rise to sudden or grad- ual loss of hair. In a case coming under my own care an attack of cystitis seemed to have been the exciting cause. Local affec- tions, particularly those attacking the follicles, as seborrhceic eczema, lupus erythematosus, etc., may give rise to baldness, generalized or in patches, which may be permanent. When baldness results from erysipelas, psoriasis, eczema variola, or similar affections, the hair is apt to return again after the dis- ease has passed away and with the recovery of the general health. Syphilis and leprosy also occasion alopecia. In syphilis loss of hair occurs in the first general outbreak, just as in other fevers; the hair is then usually reproduced. Later in the history of the disease it may occur in consequence of local lesions, and when these are ulcerative the hair does not grow again. Such cases are rare, and the notion that premature baldness is the result of syphilis, is absurd, except in the limited sense that debauchery may reduce the tone of the general system, and thus give occa- sion to falling of the hair. The remedies to be used in alopecia must depend upon the exciting cause and the circumstances of the disease. The first two forms described are, of course, not amenable to treatment. Idiopathic premature' baldness, when there is a hereditary ten- dency to an early fall of the hair, is almost hopeless as regards any permanent effect to be produced by medication. When there is no history of early baldness in the family, the disease, when taken in hand early, can often be arrested in its progress. 37^ DISEASES OF THE SKIN. Local stimulation is the plan of treatment to be followed. Weekly, semi-weekly, or even daily shampooing may be practiced with the soap wash known as "spiritus saponis kalinus": I£. Saponis viridis, §iv (128.) Alcoholis, oij. ( 64.) M. Dissolve with heat, and filter. This tends to keep the scalp free from the natural accumulation of sebum and epidermic scales, and likewise stimulates the cir- culation. After shampooing, the scalp is to be thoroughly cleansed with clear water, dried as thoroughly as possible, and the following "oil" is to be applied: 1$. Acidi carbolici, gr. xv ( 1.) Glycerinae, f oij (8.) Aquae cologniensis, ad f§j- (32.) M. A good method of applying this oil, so as to get the full benefit of it upon the scalp, is to divide the hair in long "parts" by means of a comb, and then, with the aid of a dropper, such as is used for dropping solutions into the eye, let a drop or so of the oil be placed there and here upon the scalp, in the line of the part at intervals of an inch, and well rubbed in with a soft brush like a tooth brush. Having gone over the scalp in one line thus, let new parts be made, parallel with the first, and the same procedure gone through with. Thus each portion of the scalp is in turn reached by the oil, which is thoroughly rubbed into it, a comparatively small portion getting into the hair to make a mess, as such applications certainly will do if rubbed in at random. After a time shampooing with the soap spirit may be dis- pensed with, or only employed at long intervals, as, in the case of women, especially, this is a very troublesome business. The rubbing with the oil should, however, be persevered in until the hair has ceased to fall, or until the case must be given up as hopeless. The majority of cases, however, will do well under this treatment, if carefully carried out. I think that local treatment alone can be relied upon in this form of alopecia, but, ALOPECIA. 379 of course, each case must be judged by its total aspect and the patient's general health cannot be left out of account. Sometimes a hard soap may be used for shampooing. Eic- hoff's salicylic acid, resorcin, sulphur and tar soap is a good one to use. Rohe, in cases where there is much scaliness, washes the scalp with a tar soap and then rubs in the following : 1$. Pulv. resorcin., oss-j (2.-4.) Sp. myrciae, f§xij. ( 360.)- M. A small quantity of glycerine, say half an ounce, may be added to this formula if the scalp is dry. Stelwagon recommends the following: 1$. Resorcin, 5 j-ij ( 4.-8. ) Ol. ricini, n^x-xx ( 0.65-1.33) Ol. tiglii, rqiv-xx (0.265-1.33) Alcoholis, Sen. sp. myrciae., . . . .aa §iv. ( 128. ) M. The croton oil is to be used cautiously and in the smallest quantity at first, later increasing considerably. Lassar recommends that the scalp should be washed with tar soap and then a two percent, solution of corrosive sublimate in alcohol should be well rubbed in. This should be followed by the application of a one to three per cent, alcoholic solution of naphtol, to dry the hair, and the scalp should finally be anointed with a two per cent, solution of salicylic acid in olive oil. Many cases of alopecia do better under treatment by parasiticides than under the use of merely stimulating applications. If a single application alone is to be used, as in the milder cases of alopecia following fevers, etc., the following will be found convenient : 1$. Sodii biborat., 5ss ( 2. ) Acid, salicylic, gr. x ( 0.6 ) Tinct. cantharidis, f oij ( 8. ) Spir. myrciae, Aquae rosae, aa 1*5 j ( 32 ) Aquae bullientis, ad f§iv. (128. ) M. The treatment of that form of alopecia which is in the stricter sense symptomatic, such, for instance, as is found in nursing 380 * DISEASES OF THE SKIN. women, in students preparing for examination, and after exhaust- ing illness or mental troubles, is in general the same as that above given, only that here the patient's general condition is more ob- viously at the bottom of the alopecia, and attention must first be given to obviating or neutralizing the cause. Iron, quinine, arsenic, occasionally cod-liver oil, and, above all, nux vomica and strychnia, are the remedies upon which we chiefly depend. In addition, moreover, to the local remedies above given, cold- water douches, frictions, frequent brushing, and the application of one of the stimulating washes to be mentioned under alopecia areata, will be found useful. Massage has been employed with success in some cases. The prognosis in premature idiopathic baldness without obvious cause must always be guarded. If we can stop the fall of the hair and prevent matters getting any worse, that is about all that can be expected. To restore what has been already lost is usu- ally more than we can succeed in accomplishing. In baldness following fevers, etc., on the other hand, much can be hoped for as the result of early and vigorous treatment faithfully carried out. ALOPECIA AREATA. Alopecia areata is an atrophic disease of the hair system, char- acterized by the, usually sudden, appearance of one or more cir- cumscribed, whitish bald patches, varying in size and shape, or of more or less universal baldness. Alopecia areata may attack any portion of the hairy surface, but the scalp is by far the commonest seat of the disease. In rare instances the entire hair system is involved, and the patient may not only lose the hair from the scalp, but that of the eyebrows and lashes, the beard, the axillae and pubis, and the fine hairs over the general surface of the skin. Upon the scalp the disease is usually observed to consist of one or several patches of baldness, roundish, sharply circumscribed and conspicuous. They may vary in size from a small coin to the palm of the hand. The baldness is generally complete, the area presenting a whitish, perfectly smooth, polished ALOPECIA AREATA. 381 surface, often without a trace of hair. There is sometimes a ring of short or broken-off hairs around the margin of the patch. Less frequently a thin growth of hair persists over the nearly bald areas. The skin is slightly or not at all altered, excepting that the hair follicles gradually atrophy. The course of the disease is variable; in some instances the hair thins out slowly; in other cases a bunch of hair may come out in a single night, leaving a fully developed patch. The fig. 70. — April 29, 1886. July 20, 1886. ultimate size of the area is soon reached, and it usually grows no larger. When several patches exist they usually form one after another, and one may be recovering while another is form- ing. The disease may continue weeks, or oftener months, or even a year or two; its course is very variable. Relapses are not uncommon. A growth of lanugo, or fine, downy hairs, often occurs in the course of the disease, leading to the false hope that the hair is at length about to return; but the soft, fine hairs drop cut again, leaving the patch as bald as before. When, however. 3 82 DISEASES OF THE SKIN. *Fig. 72. — October 12, iS86. Fig. 73. — December 16, 1886. Fig. 74.— February 18, 1887. Fig. 75.— April 18, 1887. * These series of plates (Figs. 70 to 75) show the course of a typical case of alopecia areata from beginning nearly to end. ALOPECIA AREATA. 383 complete repair once sets in, recovery is occasionally rapid. The new hair is sometimes at first pale, gray, or mixed in color, sub- sequently assuming the normal or even a darker shade. There are no subjective symptoms, as a general thing, but patients now and then suffer from neuralgia, or notice a premonitory itching, heat, or soreness. The causes which produce the disease are not understood. Some cases may possibly be parasitic in character, and all cases occurring in children must be now considered as suspicious with regard to the possibility of contagion. (See Ringworm of the Scalp.) We should warn patients, particularly children, against exchang- ing caps and otherwise coming into close contact with those suffering from this affection. This matter should be considered also in giving certificates to school children who may have suffered from alopecia areata.* The majority of cases of alopecia are, in all likelihood, due to some functional nerve distur- bance. It has been noted to follow FlG - 7&— Alopecia areata fol- lowing wound of nerve. neuralgias, sudden nervous shocks, and debility resulting from various causes. In many cases, however, patients enjoy excellent health, and no appreciable cause for the attack can be assigned. Occasionally alopecia areata appears to be hereditary. Crocker t reports cases of the disease extending through three generations. The affection is not a very uncom- mon disease, the American statistics showing its occurrence in 794 of the 123,746 cases reported, i.e., in .641 per cent. Alopecia areata is more apt to be mistaken for ring- worm of the scalp than for anything else. The suddenness of the attack, however, the more or less complete baldness, the absence of desquamation, the whiteness and remarkable smoothness of * See a very interesting account of an epidemic of alopecia areata, occurring in Boston, by Dr. John T. Bo wen, British Journal of Dermatology, March, 1894, p. 80. t British Journal of Dermatology, vol. v, June, 1893, p. 176. 384 DISEASES OF THE SKIN. the patch, always enable it to be distinguished from tinea ton- surans. Difficulty can only arise in old cases of ring- worm, where the short, characteristic hairs have disappeared; but even here more or less desquamation exists, with a grayish, "goose- flesh" like surface, very different from the ivory-like appearance of the scalp in alopecia areata. Tinea tonsurans begins as a small patch and spreads slowly ; there are always, or almost inva- riably, a certain number of nibbled-looking, broken-off hairs in the patch, and there is a history of contagion. The microscope revealing the characteristic fungus (see under ring-worm) will settle the matter, and should always be employed in cases of doubt. But as has been remarked above, the two affections may occur simultaneously, or nearly so, in the same individual, a point to be taken into consideration. The treatment of alopecia areata should be both internal and external. The ordinary tonics — iron, quinine, arsenic and nux vomica, or strychnia — are ordinarily to be employed. In some cases, phosphorus and cod-liver oil may be given with advantage. Often the patient's general health appears to be perfect, and only after long and careful search can the weak point be found to which the failure in nutritive power is to be attributed. Occa- sionally the minutest examination will fail to yield any evidence of disturbance of the normal equilibrium of the system. Treat- ment must then be purely empirical. Hygiene is always of importance. The external applications which have been found useful, or which have been thought to be of use, in alopecia areata, have mostly been directed with a view to one object, namely, to stimulate the skin and to cause a more active flow of blood to the affected parts. Alcohol, cantharides, the essential oils, carbolic acid, iodine, turpentine, ammonia, tannic acid, nux vomica, pepper, quinine, sulphur, kerosene oil, and crude petroleum, have been employed at one time or another. These substances may be applied either in the form of ointments or of lotions, in sufficient strength to produce a stimulant or rubefacient ALOPECIA AREATA. 385 effect, once or twice daily, as occasion may require. Before making any of these applications it will be well to have the scalp or other affected part washed well with castile soap and water, or, better, with the " spiritus saponis kalinus." (See Alopecia.) After washing, the scalp is to be dried with a coarse towel, and brushed with a thick-set but not too stiff brush, until moderately stimu- lated. One of the hard medicated soaps may also be employed. In view of the possible presence of a parasite a bichloride soap per- haps would be preferable. Patients sometimes express the fear that a vigorous applica- tion of the external remedy may itself produce baldness to a greater degree, but it will be found that after the patches have fairly formed the remaining hairs are firmly seated. Among the formulae published in such numbers in books and medical journals, those following will be found most efficient. R. Tinct. cantharidis, Tinct. capsici, aa fgss (16.) Olei ricini, 5ss ( 2.) Aquae cologniensis, f § j. (32.) M. Sir Erasmus Wilson used to recommend the following: 1$. Olei amygdalae dulcis, Liquoris ammoniae fort.,. . . .aa foss ( 16.) Olei limonis, f 5ss ( 2.) Spiritus rosmarini, ad f§iv. (128.) M. Wilson also recommended frictions with a liniment of aconite etc. 1$. Tinct. aconiti rad., f oiv (16.) Chlorof ormi , foij ( 8.) Liquor ammoniae, f 5 j (4-) Pulv. camphorae, oj (4-) Olei olivae, ad foij (64.) M. Oil of turpentine, brushed or rubbed into the patches with a small stiff brush, once a day or less frequently, until the scalp becomes sensitive, is recommended by some writers. The late Tilbury Fox recommended the following, which I have used with satisfaction: 25 386 DISEASES OF THE SKIN. 1$. Tinct. nucis vomicae, f§ss (16.) Tinct. cantharidis, f 3vj (24.) Glycerinae, f5ij ( 8.) Aquae destillatae, f §iss (48.) Aquae rosae, fSiij- (96.) M. I have sometimes blistered the bald patches with cantharidal collodion with success. Crocker, while blistering recent patches, directs the loose hairs about the patches to be pulled out and the following ointment rubbed in: 1$. Chrysarobin, 3ss-j ( 2.-4.) Lanolin, oj (32. ) Olei olivae, q. s. M. Some caution should be employed in the use of this remedy on account of its tendency to produce inflammation. Another prescription recommended by Crocker as well as others, is the following: 1$. Hydrarg. bichlor., gr. ij-v ( 0.10-0.30) Alcoholis, f 3j ( 4-) Olei terebinthinae, f ovij. (28. > M. Bulkley recommends a 95 per cent, solution of carbolic acid brushed lightly over the affected surface with a swab and then rubbed in. I prefer trikresol for this purpose. All of these forms of treatment prove useful at one time or another, but unfortunately, any or all may at times prove unsuc- cessful. One after another should be tried with great persever- ance. Electricity also is used in some cases with advantage, four to ten cells of the constant current battery being used, and the negative pole placed in contact with the diseased patch. The treatment of alopecia of the beard is essentially the same as that of alopecia of the scalp. The prognosis of alopecia areata should be guarded. Sometimes recovery takes place in a few months, in other cases it may be delayed for years. Now and then the hair is not restored at all. As a rule, in young persons, the baldness is not permanent. Treatment should be persevered in. ALOPECIA AREATA. 38 Alopecia Syphilitica. Loss of hair occurring in the course of syphilis may result from early or late lesions of the scalp. The early form of syph- ilitic alopecia usually occurs in the first months of the disease and is unac- companied by any lesions perceptible to the naked eye. Its most character- istic feature is its generally disseminate character. The hair is thinned on various irregular areas over all parts of the scalp, and the loss is not usually confined to any one locality. In rare cases, however, alopecia areata may occur in similar disseminate patches of thinning, so that this characteristic of syphilitic alopecia is not absolutely diagnostic. The hairs in syphilitic alopecia are dry and dead looking, and seem to be attenuated. The hair bulbs are atrophied. They fall rapidly, sometimes "by the handful," as patients express it. However, every degree of bald- ness may be observed at one time or another in different cases. In rare cases generalized alopecia over the whole body is observed. A very conspic- uous symptom of syphilitic alopecia is the denudation of the external part of the eyebrow on one or both sides. This is not, as is sometimes asserted, pathognomonic. It may occur in alopecia areata, and also in keratosis pil- aris. The best treatment of this form of alopecia is that demanded by the syph- ilitic disease, and the earlier this is undertaken, when once the diagnosis of syphilis has been arrived at, the less likely is alopecia to occur, and the more trifling in any case is the fall of hair likely to be. Lotions of bichloride of mercury, 1 to 1000 or 1 to 500, are called for in the early stages of the alopecia, and these may be followed by the following pomade when the case will admit: 1$. Quiniae sulphat., Turbith. mineral., aa gr. viij ( 0.50) Medullae bovis, o j- (32. ) M. These applications may be alternated every few days with the following: 1^. Sodii carbonat., Sodii biborat, aa gr. xx ( 1.20) Aquae destillat., f 5v (160. ) M. Fournier has the hair cut short; washed well with sapo viridis and hot water every morning, and the rcalp well subbed with the following pomade: 1^. Acid, salicylic gr. xv ( 1.) Sulphuris prsecipitat., o ss (2.) Lanolin, Vaseline, aa o iv. (16.) M. In the evening the scalp is brushed with the following: ly. Acid, salicylic, gr. xv ( 1.) Tinct. cantharidis, f 5 ss ( 2.) Tinct. rosmarin., ad f5 iv. (128.) M. 388 DISEASES OF THE SKIN. The prognosis of alopecia syphilitica is almost always favorable. In some cases, when the patient has a hereditary tendency to premature baldness, where the health is much impaired, or at a more or less advanced age, a complete restitution does not take place; but in general a tolerably speedy return to the normal condition may be predicted. FOLLICULITIS DECALVANS. Folliculitis decalvans is a rare inflammatory disease of the hair follicles, resulting in destruction of the follicle with scarring. The disease is usually found upon the scalp, especially on the anterior portion, but it. may occur on the beard or in the pubic and axillary regions. The first lesion is a pin-head papule or red follicular elevation or it may be a small pustule. The center is pierced by a hair as in sycosis. This soon loosens and falls out and a cicatrix results. The lesions may be discrete and scattered or they may occur in a patch. As usually seen, there is a central coin-sized, -roundish, depressed, bald, cicatricial patch, smooth, white and glistening, the periphery studded here and there with the minute, red, follicular elevations, Pustules or crusted points. Occasionally one or two islets of hair may be seen in the cicatricial area. The disease, though slow, is progressive and destroys the hair follicles and often all the dermic tissues. In another form of the disease the patches resemble those of alopecia areta excepting that they are cicatricial and there is a faint rose-tinted border when the hairs can be extracted easily; sometimes there is a ring of keratosis. The treatment is that of sycosis. SYCOSIS VULGARIS. Sycosis is an acute or chronic, inflammatory, parasitic affec- tion, involving the hair follicles, and often the perifollicular structures, characterized by pustules, papules, and tubercles, perforated by hairs, accompanied by burning and itching. The disease is confined to the beard and hairy parts of the face. Papules and then pustules form, each one having a hair as its center, and showing little inclination to rupture. The pustules SYCOSIS VULGARIS. 389 are generally discrete, but are sometimes so numerous as to be crowded together. They are accompanied by marked redness of the surrounding skin, sometimes by swelling, burning, and pai . and result in a cicatrix. Unless the suppuration is pro- fuse, the hairs cannot be extracted without giving much pain. Fig. 77. — Sycosis Vulgaris. (Courtesy of Dr. Duhring.) It sometimes occurs on the upper lip, following catarrh of the nose. It occurs equally in those who shave and those who do not. The essential cause of sycosis is microbic. The pyogenic 39° DISEASES OF THE SKIN. cocci (staphylococcus aureus and albus) are the usual causative agents. The disease is feebly contagious. The micro-organisms gaining access give rise to the inflam- matory changes and the clinical manifestations, and the process starting at one point soon involves neighboring follicles by continuous and repeated inoculation. The disease is primarily a perifolliculitis, the follicles and their sheath becoming rapidly involved secondarily in the inflammatory process. The hair- papilla is not as a rule destroyed, so that hair loss except in very chronic and markedly suppurative cases does not com- monly occur. Sycosis is apt to be mistaken for eczema of the beard, and sometimes for tinea sycosis, or true barber's itch. From the latter it is, however, distinguished by several marked features. In both affections the hair follicles are attacked, but in the para- sitic disease the lesions are simply large, rounded, red lumps, or variously-sized nodules, with few or no pustules. The hairs, however, in spite of the fact that there is no suppuration about their roots, come away easily, and sometimes drop out spon- taneously. The presence of the spores of the vegetable parasite, when looked for in the roots of the diseased hairs under the microscope, will greatly aid in the diagnosis. (See Tinea sycosis.) From eczema of the beard sycosis is distinguished by the absence of oozing or weeping, and also by the fact that eczema rarely attacks the beard without showing itself elsewhere. It spreads about in pustules and crusts in the neighborhood, while sycosis is strictly marked by discrete pustules, each with its hair running through the center. External treatment is that most generally useful in sycosis. Exposure to irritating influences is to be avoided. The hair should be kept clipped close or shaved. The latter is to be preferred. Although painful at first, I regard it as the sine qua non of successful treatment, and usually insist upon it. In this, as in some other matters, it is only the first step which costs; after shaving a few times, the patient is brought to see the reasonableness of the procedure by the comfort which it brings SYCOSIS VULGARIS. 39 1 Shaving should be practiced every second or third day, according to the rapidity with which the beard grows. When shaving is to be performed for the first time, the hairs should first be clipped close, and then a poultice should be applied, to soften the crusts. When there is much inflammation, this poultice may be made of bread-crumb and dilute lead-water, and applied cold. This is very soothing. After such careful preparation, shaving is a much less painful operation than it would otherwise have been. Shaving having been established as a habit, the local medical treatment may be put into operation. When the disease is acute and there is a good deal of pain and swelling, black wash may be thoroughly applied every two or three hours, followed each time, as soon as it is dry, by oxide of zinc ointment, gently applied by means of the finger, or spread upon pieces of soft linen and bound upon the parts. The following wash, not to be followed by ointment, is like- wise of service in acute sycosis: 1$. Pulv. zinci carb. praecip., Pulv. zinci oxidi, aa . . . . oij ( 8. ) Glycerinae, Liq. plumbi subacetat. dil., .. .aa. . . . f oij ( 8. ) Aquae rosae, f oviiss. (230. ) M. In subacute cases the following wash is very good: 1$. Sulphur, praecipitat., 3ij ( 8. ) Pulv. camphorae, gr. x ( 0.6) Pulv. tragacanth, 9j ( 1.2) Aquae calcis, foiv. (128. ) M. SiG. — Shake well, and apply two to four times daily. This sometimes succeeds when all else fails. If ointments are employed, the following will be found sooth- ing, in the acute stage: 1$. Pulv. zinci carb. praecipitat., Pulv. zinci oxidi aa 5j ( 4.) Ung. aquae rosae, §j, (32.) M. To be applied immediately after shaving. In other cases depilation of pustules, washing with and the ap- plication of five per cent, alcoholic solution resorcin to each affected 39 2 DISEASES OF THE SKIN. follicle is practiced. Sulphur, resorcin, ichthyol, pyrogallol, and chrysarobin ointments, two to five per cent, are used, or ichthyol in ten per cent, strength in water, as a fomentation. Mercurial ointment, with ten per cent, carbolic acid, and up to one per cent, corrosive sublimate, is also useful. If the beard cannot be shaved, each affected hair must be extracted, the follicle washed out, a^d a zinc-sulphur or weak resorcin sublim- ate salve then applied. Rhinitis, which is often present in sycosis of the upper lip, should be treated by the nasal douche with a one per cent, solution of ichthyol in water, or by other means commonly employed. When the affection is of long standing, and when there is much infiltration, sapo viridis well rubbed in with a flannel rag and a little water, and after washing off followed by ung. diachylon, may be employed. When the eruption exists only at one or two points, and is subacute or chronic, stronger stimulants may be used. Sulphur ointment, half a drachm to a drachm to the ounce, or one of the mercurial ointments, may be employed. Depilation is only to be used when the roots of the hairs are loosened by sup- puration. For some time after the disease appears to be cured, the face should be shaved (using sublimate soap), and each inflamed follicle that may appear should be treated as above, and followed by one of the ointments. The prognosis in sycosis should be guarded, for, while some cases yield readily to treatment, others, particularly when the disease involves a considerable area of the face, last for months, and even years, in spite of the most assiduous attention. Re- lapses are not uncommon. 3. DISEASES OF THE SEBACEOUS GLANDS. SEBORRHCEA. Seborrhea is a disease of the sebaceous glands of the skin, characterized by an increase in the quantity of the sebum poured out, and also, in most cases, by an alteration in quality of the secretion. There are two varieties, S. oleosa and S. sicca. SEBORRHCEA. 393 Seborrhea oleosa appears in the form of an oily coating upon the skin, giving it an unctuous and greasy feel. Its most com- mon seat is on the scalp and about the face, particularly the nose and forehead, where it appears as a greasy coating, containing more or less dust and dirt, and looking as though the skin had been smeared with dirty ointment.* In the scalp it collects on the hair, giving it a dark, limp look, as if it had been freely oiled, or when the scalp is bald it looks as if oil had been poured over it. Seborrhea sicca, or dry seborrhcea, occurs in infants as the vemix caseosa or smegma of the new-born. Here it is almost physiological, and is usually soon removed. If it remain, it becomes a diseased condition, and as such is often seen on the scalp. Dry seborrhcea shows itself on both the hairy and non- hair} 7 portions of the body, as a more or less greasy mass of scales, of a dirty, yellowish color, and somewhat adherent to the skin. On the scalp, these masses are larger and oilier, tending to cling to the skin in thick plates, and leaving, when picked off, a smooth, grayish, moist or oily surface beneath. In old persons the scalp, and sometimes the region of the beard, is covered to a greater or less extent, with a brown, adherent, greasy coating, which is essentially seborrhceic in character. Seborrhcea sicca of the scalp, like eczema seborrhceicum, with which it is sometimes confounded (see Eczema seborrhceicum), is sometimes followed in the young by premature baldness. If taken in time, however, baldness from this cause can be prevented, or at least postponed, and it is desirable in all cases to remove the seborrhceic condition, even if it gives rise to little or no annoyance. Seborrhcea of the foreskin and glans penis is an abnormal flow of the normal secretion of this part, known as smegma preputii. If unattended to, it leads to balanitis, from the irrit- ation of its rapidly decomposing sebaceous products. * In rare cases this secretion as it occurs over the nose and adjacent parts of the cheeks takes on a bluish-black color, the so-called " Seborrhcea nigricans." What part is played by the sweat glands in this condition has never been made perfectly clear and some writers have included such cases under the head of " black chromidrosis." 394 DISEASES OF THE SKIN. Seborrhoea is induced by a variety of causes, prominent among which is the chlorotic or anaemic state. It is more apt to occur about puberty, or in early adult age. It may occur in persons otherwise healthy. In such cases it is usually curable by local measures. The diagnosis of seborrhoea is usually not a matter of much difficulty; the evidently sebaceous character of the lesions point- ing out its nature with sufficient certainty. Seborrhceic eczema, however, closely resembles seborrhoea and the line of demarca- tion between them is in some instances uncertain. The treatment of seborrhoea should usually be both constitu- tional and local. Fresh air and exercise, especially in the case of young women, is to be insisted upon. Attention should also be paid to diet. The history should be looked into, and any functional irregularities corrected when possible. Success in treatment often depends upon ascertaining and meeting the exciting cause in the individual. Cod-liver oil, iron, and arsenic are the most generally useful remedies. The following is a useful prescription: 1$. Tinct. ferri chlor., Acid, phosphoric, dil., foj (32.) Syrupi limonis, f o i j • (64.) M. SiG. — Half a teaspoonful to a teaspoonful, in a wineglass of water, three times a day. Arsenic is best given in the form of Fowler's solution, in four- minim (.24) doses at first, gradually increased until the disease begins to disappear, or until the limit of tolerance is reached. It should never be prescribed to be taken in drops, but always in combination with some adjuvant. The following is an excellent formula : 1^. Liq. potas. arsenit., 3ij ( 8.) Vini ferri, ad f§iv. (128.) M. SiG. — A teaspoonful after meals, in water. The local treatment of seborrhoea is very important. In seborrhoea of the scalp the scales and crusts must first be removed. If hard and caked, as is sometimes the case in old people, the SEBORRHCEA. 395 scalp should be soaked in oil over night. Hot water and castile soap will then remove the softened crusts, or, if this should fail, the alcoholic solution of sapo viridis, known as "spiritus saponis kalinus," may be employed. A teaspoonful of this may be ap- plied to the sca'p with a sponge and a considerable quantity of warm water added, so as to make a lather. After vigorously shampooing the scalp for a few minutes, the soapy matters are to be washed away with an abundance of clear, warm water, the scalp dried quickly with a soft towel, and it is ready for the application of the more strictly remedial agents. These should be in the form of oils, if the hair is at all thick, because oint- ments are so apt to stick the hairs together and make a mess. The sort of application to be made will depend upon the con- dition of the skin. Generally the scalp will bear more stimulat- ing applications. Of these, carbolic acid is one of the most efficient, as in the following combination: R. Acidi carbolici, gr. xv ( i.) Ol. ricini, aa qss ( 2.) Ol. limonis, Aquae cologniensis, ad f5j. (32.) M. Sig. — Apply after washing. When there is little hair upon the scalp, the following ointment may be used: 1$. Sulphuris praecipitat., 3j (4-) Ung. petrolii, : 5 j. (3 2 -) M. Sig. — A small quantity to be rubbed in, once a day. This preparation is also useful in seborrhcea about the body. Another preparation useful about both scalp and body, especially in S. oleosa, is this: ly:. Acid, tannic, 3 j (4-) Ung. petrolii, §j. (32.) M. Mercurials are sometimes of value. Either ointment of the red oxide of mercury, 2 to 5 per cent., or the ointment of nitrate of mercury diluted with 4 to 6 parts of vaseline may be employed. In severe and stubborn cases Vidal uses multiple scarifications 39^ DISEASES OF THE SKIN. with the view of cicatrizing the enlarged oil glands, and I am inclined to believe that the X-ray will be useful in a certain number of cases. The prognosis of seborrhcea will depend upon the duration and extent of the disease and upon the patient's general health. Dry seborrhcea can generally be gotten well, under proper treat- ment, in a reasonably short time. But when in the scalp and mixed with more or less seborrhceic eczema, the prognosis is not so favorable. Premature baldness may follow neglected seborrhcea. If the hair has already begun to fall out a cautious prognosis must be given. Even if the most active treatment is followed out there is little hope of bringing back the hair, although its fall may be arrested. ASTEATOSIS. Asteatosis is the opposite of seborrhcea and is characterized by a diminu- tion in the amount of sebum secreted by the skin. It occurs in senile dry- ness of the skin, in connection with ichthyosis, prurigo, pityriasis rubra pil- aris, scleroderma, dermatitis exfoliativa, long-continued scaly ~czema, etc. The secretion of the sweat glands is apt to be diminished at the same time. The condition, for it is such rather than a disease, may be mitigated by the substitution of inunction with fats to take the place of the natural se- cretion. When partial asteatosis results from failure in general nutrition the condition disappears with the return of health, or when it occurs in con- nection with curable skin diseases it disappears as those get well. In other cases the condition is apt to persist. MILIUM. Milia are small, rounded, whitish or yellowish, pearly, non- inflammatory elevations, situated in the skin just beneath the epidermis. They are usually met with upon the face, although they may occur elsewhere, particularly on the penis and scrotum and upon the labia majora. They may occur singly or in great numbers, and when formed may last for years without change. They give rise to no subjective sensations, and no annoyance, beyond the slight disfigurement which they cause. In rare in- stances one or more of the larger ones may undergo calcareous STEATOMA. 397 metamorphosis. Milia are met with at all ages but are particu- larly common in adolescence and early adult life, especially in women. The affection consists in an accumulation of sebum within the sebaceous gland, which owing to the obliteration of the duct- is unable to escape. In other words milia are retention cysts. They do not tend to grow beyond a certain very small size and do not degenerate or become malignant. The treatment con- sists in opening each one of the little pearly cysts, squeezing out the cheesy sebaceous matter which forms its contents and cauterizing the sac with a point of nitrate of silver or a drop of iodine. STEATOMA. Steatoma, also known as sebaceous cyst or wen, appears as a variously-sized, firm or soft, roundish tumor, seated in the skin or subcutaneous connective tissue. The skin covering the tumor is natural in color, or whitish, from stretching. The tumors may occur singly or in great numbers, and vary in size from that of a pea to a walnut or larger. They are usually firm, but sometimes doughy, and are generally freely movable and painless. Their usual seat is upon the scalp, face, back, and scrotum, though they may be met with anywhere, even on the soles of the feet. They may last for years unchanged, but some- times break down and ulcerate. They may degenerate into epithelioma in old persons. Some sebaceous cysts are flat, with a minute hole in the center; others tend to rise and become semi-globular. The latter are those commonly found on the scalp, where they are devoid of hair. The contents of a sebaceous cyst may be milky or cheesy in consistence, and are often decomposed and fetid. The tumors are enormously distended, sebaceous ducts and glands, the walls of which have become hypertrophied until they form a tough sac. Sometimes calcareous masses are found in sebaceous cysts and occasionally the cyst opens and a papilloma or even a cutaneous 398 DISEASES OF THE SKIN. horn develops and appears through the opening. Hairs are also found at times. They are benign tumors and rarely de- velop malignant growths. The treatment of sebaceous cyst is by incision of the mass and dissecting out the complete enveloping sac. In small tumors incision and the introduction of a bit of nitrate of silver will cause eversion of the sac, or the electric needle may be used. COMEDO. Comedo is a disorder of the sebaceous glands, characterized by yellowish or whitish, pin-head size elevations, containing in their centre blackish points. Very often the black points appear alone upon the unchanged skin. The disease is observed chiefly about the face, neck, chest, and back. Each single elevation is called a comedo (plural comedones). The common name " flesh worms," or "grubs," is calculated to convey the erroneous idea that the small inspissated plug of altered sebum which can be expressed from the follicle is a parasitic worm. It is true that a little mite, the microscopic Demodex folliculorutn, is occasionally found in the mass, but this cannot be regarded as in any way essentially connected with the disease. Its presence is merely fortuitous and without significance, the plug consisting of altered sebaceous matter, mingled with epithelial cells. The affection, though comparatively trifling, and' without subjective symptoms, is often extremely annoying to patients. It is due in part to idiosyncrasy, in part to a general sluggish performance, not only of the functions of the skin, but also of those of the whole body. Patients are apt to suffer from dyspepsia and with constipation. In young women chlorosis and menstrual difficulties are apt to be present. The disease is pre-eminently one of the period of puberty; patients seeking relief from this complaint are almost invariably young men and young women, although the disease may occur in infants and young children. Crocker and other English dermatologists have reported a form of comedo occurring in children, which appears to be con- comedo. 399 tagious. It occurs ordinarily on either side of the forehead in groups, rather than disseminated irregularly as the lesions of ordinary comedo are.* Local treatment suffices in some cases to relieve the condition. Frequent bathing of the affected surface with hot water will aid the process of removal. Stimulating ointments, especially such as contain sulphur, are useful, as the following: Of. Sulphur, praecipitat., 5j (4.) Ung. aquae rosae, §j. (32.) M. Sig. — To be rubbed in at night. Sulphur lotions, such as those given under the head of acne, may also be useful. Should the skin tend to become harsh under the use of these remedies, weak alkaline ointments may be used for a time, as this: 1^. Sodii biborat., oss (2.) Glycerinae, rr|xvj ( 1.) Ung. aq. rosae, oj. (32.) M. An excellent application is the following: 1$. Aceti, oij ( 8.) Glycerinae, oiij ( 12.) Kaolini, oiv. (12S.) M. This forms a soft paste, which is to be spread over the surface at night, and, if possible, in the morning also. If applied on the face, the eyes should be kept shut, on account of the pungency of the vinegar. It loosens and dislodges the sebaceous plugs more satisfactorily than any other preparation with which I am acquainted. A watch-key or one of the "comedo expressors" sold by surgical instrument makers, may be employed to press out the comedones, the end being gently but firmly pressed down over the sebaceous plug. Should this not yield readily, the point of a fine needle may be run into the follicle, alongside of the comedo, and then moved around, so as to loosen and detach the plug from its surrounding wall. Care should be taken not to use too much force, for fear of inflaming the skin. The staphy- * Crocker, Lancet, 1S94, i, p. 704, and Colcott Fox, lb., 1888, i, p. 665. 400 DISEASES OF THE SKIN. lococcus pyogenes is usually present, and if pressed down into the succulent tissues in the neighborhood finds its favorite pabu- lum and gives rise to a pustule. If the comedo plug does not come out easily, it should be left for another time. It must be remem- bered that so long as the condition which produces comedo is present and effective, the comedones are apt to be reproduced. Several in succession may have to be removed from the same glandular opening. In carefully selected cases the X-ray em- ployed with caution will cure very obstinate cases. The patient should be warned, however, that numerous minute cicatricial pits may be left after the treatment is completed. Occasionally the tonic internal treatment required in acne (see Acne) is called for. Sometimes the contents of the sebaceous follicles become even more condensed and hardened than above described. The firm, almost horn-like plugs are gradually forced out of the mouth of the follicles, until they may stand up stiffly above the surface of the skin. Such a case came under my notice some years ago, the skin of the body, particularly over the shoulder, being the seat of the disease. The hardened sebaceous plugs, in great numbers, projected to the height of an eighth of an inch or more, giving the surface of the skin a nutmeg-grater appear- ance, viewed from a little distance. Hot baths, frictions with sapo viridis, and inunction of sulphur ointment may be used in such cases. Occasionally a horny outgrowth occurs in comedo. Sometimes this is a kerotasis (see Keratosis). At other times, as in a case I once had under observation, a bunch of fifteen to twenty hairs are found growing out of each lesion. ACNE. Sometimes called acne vulgaris, is an inflammatory disease of the sebaceous glands, characterized by the formation of papules or pustules, or a combination of these lesions, together with a certain degree of erythema, and occurring chiefly upon the face and over the shoulders, although it may occur upon any part of the surface where sebaceous glands exist. ACNE. 401 It may occur alone or in connection with other affections of the sebaceous glands, as comedo and seborrhcea. The lesions are of various size, from a pin's head to a large split pea, and Fig. 78. — Acne with Comedo. (Courtesyof Dr. Duhring.) are commonly seen in both the papular and pustular, or the tuber- cular and pustular forms combined. 26 4-02 DISEASES OF THE SKIN. The pustules of acne are pin-head to large pea-sized, rounded or acuminated, seated on a more or less infiltrated base of super- ficial or deep inflammatory product. Suppuration may be slight or abundant. When the base is deeply infiltrated the affection is known as acne indurata. In this last form the process sometimes runs on to the production of abscesses, which appear chiefly on the face and down the shoulders and back, forming a most serious and annoying phase of the disease. Indurated acne is apt to result in the formation of cicatrices of a pitted or atro- phic character, which are quite disfiguring. Sometimes keloid occurs as a result of indurated acne, the lumpy scars lasting some months, but finally, in most cases, disappearing spontaneously. There is usually no discomfort from the lesions excepting a feeling of soreness when touched. Their color is bright red to dusky violaceous. The number of lesions varies in different cases from one or two to a very great number. The inflammation may be superficial or deep, even forming abscesses. The individual lesions may run their course in a few days, but the course of the disease, as a whole, is apt to be chronic, running on for years. If there has been much suppuration, more or less unsightly scars may remain. Acne is one of the commonest diseases of the skin. It occurs in the young of both sexes, appearing about the age of puberty. It does not often occur in children, and, on the other hand, only rarely makes its appearance for the first time in mature years. The causes predisposing to acne are numerous and varied in their nature. In its commoner forms it appears to be depen- dent to some extent upon the character of the skin. Persons with thick, oily skins are most apt to suffer from the diffuse form of acne, with numerous papular and pustular lesions mingled with comedones, while the sparse eruption of flat and papular lesions is often found in pale, anaemic individuals with dry, rather harsh skins. The most frequent predisposing cause of acne is puberty. The affection shows itself for the first time, in the vast majority of cases, at this period, and is apt to continue, unless remedial measures are adopted, until the system has assumed ACNE. 403 the equilibrium of adult life, or in women until a later period. It is at the period of puberty that the sebaceous system takes on a new activity, the hairs begin to develop, and there is a sort of normal hyperemia about the follicles, which may easily deter- mine an abnormal condition resulting in the development of sebaceous disorders. Other causes which may, either alone or combined, predispose to the occurrence of acne are "scrofula" and cachexia ("acne cachecticorum") or general debility. Anaemia and chlorosis may also be mentioned in close connection with these other causes, as favoring the development of acne, and in the more markedly pustular and indurated varieties a family history of tuberculosis is very often noted. Of great importance in the causation of acne, and especially in favoring its continuance, is habitual derangement of the ali- mentary canal. Dyspepsia and constipation will be found pres- ent in the majority of cases, and often in such intimate relation to the disease that a fresh crop of lesions shall follow every attack of indigestion or of costiveness. Disease of the nasal cavities may at times occur in connection with acne, but its causative influence has not been satisfactorily established. Uterine disorders, especially of a functional character, are often the indirect cause of acne; but at other times the remote cause of the affection seems beyond finding out, the patient remaining in an apparently perfect condition of general health. The question as to the immediate cause of acne is a disputed one. Some observers maintain that there is a parasitic factor. The pus organisms have been believed to be the chief immediate cause of the disease but Gilchrist * and others have demonstrated a special bacillus, and believe that the cocci found are somewhat distinct from the ordinary pus cocci. It would appear that the existence of seborrhcea predisposes to some forms, at least, of acne. Seborrhceic eczema of the scalp * Trans. Am. Dermatolog. Assn., for 1899, p. 97, and Jour. Cutan. Dis., 1903, p. 107. 404 DISEASES OF THE SKIN. is a very common, in fact almost constant, accompaniment. The existence of comedones favors the occurrence of acne but the blocking up of the duct is not the cause of the disease. That the etiologic factor is present in the comedo, would, however, appear from the fact that pressure to expel a comedo by means of a watch key, etc., is often followed by the development of an acne lesion at the spot. Pathologically acne is an inflammation of the sebaceous glands. The inflammation begins either in or around the gland. One or several glands may be involved. The character of the lesion is determined by the activity and intensity of the process ; inflam- matory infiltration around the gland outlet giving rise to the smaller papules, and, when more extensive and periglandular as well, to larger indurated papules and tubercles; and, when suppurative action ensues, to the pustule. If the suppurative action is abundant the small dermic abscess results, and when intense, deep-seated and involving several glands, the large dermic abscesses are formed (Stelwagon). The diagnosis of well-developed acne presents few difficulties. We often meet with cases, however, where only a few imperfectly developed lesions are present, and where the affection may easily be mistaken for others of a widely different character. The age of the patient, the seat of the lesions, their chronic char- acter and their inflammatory nature must be taken into account. The acneform eruption caused by tar may be recognized usually by the smell of that substance and its presence in the follicles, giving the appearance of numerous black points differing in appearance from comedones. In the eruption caused by brom- ine and iodine (see Dermatitis medicamentosa) the lesions are apt to be larger, of a brighter and more acutely inflammatory nature, and, when well-developed, the lesions tend to coalesce and to form elevated, inflammatory areas covered with characteristic sebaceous crusts. Acne often closely resembles the papular and pustular syphilodermata, and great care must be taken to avoid mistakes in diagnosis. The history, the absence of syphilitic lesions on other parts of the body than those commonly affected by the erup- ACNE. 405 tion of acne, the uniform distribution of the lesions, those of syph- ilis tending to group, all serve to denote the presence of acne. When syphilis occurs on the forehead, or in one or two lesions on the nose alone, without any history whatever, as I have sometimes seen it, it is extremely apt to be taken for acne, and great caution must be exercised in coming to a decision as to the nature of the affection in a case seen for the first time. Severe cases of acne are some- times taken for variola, but this can hardly occur if a careful examination is made into the general symptoms and history of the eruption. Sycosis also must be distinguished from acne. The treatment of acne is both constitutional and local. In order to treat a case of acne with any hope of success, we must first ascertain the causes which have operated in bringing it about. The foundation of the successful treatment of acne lies in the knowledge of its etiology. The patient should be carefully examined regarding every organ and every function. The habits of life, the surroundings, the occupation of the patient, should all be known to the physician, who should also study the case well, to discover, if possible, what is the exact cause or group of causes of which the acne eruption is the expression and result. External treatment, although in the light of recent advances in the eti- ology of the disease of much more importance than formerly, will rarely accomplish a cure, and internal measures must therefore be employed in almost every case. From what has been said under the head of etiology it will be perceived that in general the patient's health must be looked after and the system rendered more resistant to the invasion and spread of the disease. If anaemic, tonics are required, among which iron and arsenic are prominent; if the uterine functions are not regularly performed, these must be regulated; if dyspepsia exists, this must be com- bated by diet, regimen and the remedies appropriate to the condition. Constipation is a frequent concomitant with acne, and its removal is necessary to a cure. Acidity of the stomach, flatulence, coated tongue, are ordinary symptoms, and these, together with irregular and perverted appetite, are constantly met with in connection with the affection under consideration. 406 DISEASES OF THE SKIN. If constipation exist, saline or vegetable laxatives should be prescribed in sufficient quantity to open the bowels once or twice in the day. An occasional mercurial, as blue pill or a compound cathartic pill, may be prescribed in some cases. The following pill has proved useful in my hands: 1$. Pil. hydrarg., Ext. colocynth comp., aa gr. iiss (.15) Pulv. ipecac, gr. ss. (.03) M. Fiat in pil. No. j. Two or more of these pills are 'o be taken at bedtime, fol- lowed by a saline, as a wineglass of Hunyadi water in a goblet of plain hot water before breakfast the next morning. They are not, of course, to be taken habitually. The "mistura ferri acida" mentioned under eczema is likewise a valuable medicine Crocker suggests the following: 1$. Ext. cascara sagrada liq. (B. P.), rrpc-xx (0.55-1.12) Tinct. nucis vomicae, nyvij-x (0.^8-0.55) Aq. menth pip., ad foj. (32. ) M. Sig. — Three times a day. The natural mineral waters are used with good success in acne. The Hathorn and Geyser springs of Saratoga, the Ger- man, Hunyadi Janos and Ofener Racoczy, Arpenta and other cathartic waters are of use, the dose, of course, varying with the amount of constipation present. There are many cases of acne, however, which depend upon some general derangement of the system, the " scrofulous taint," anaemia, etc., and these must be treated quite differently. Cod- liver oil will in many cases be found a very efficient curative agent, particularly when the lesions are indurated and tend to extensive multiplication over the trunk as well as the face, with the formation of numerous abscesses. The compound syrup of the hypophosphites is likewise of benefit in these cases, as is also the extract of malt, which may be employed in some instances to replace cod-liver oil when this is found to disagree. ACXE. 407 The bitter and ferruginous tonics are occasionally called for in this class of cases, and the mineral acids are often of value. The following formula will be found useful in indurated acne with a tendency to the formation of abscesses, occurring in cachectic and scrofulous individuals: R. Quiniae sulphat., gr. viij ( 0.5) Acid, sulphuric, dil., rqx ( 0.6) Ferri sulphat., gr. xxxij ( 2. ) Magnesii sulphat., oiij ( 12. ) Tinct. zingiberis, f oij ( 8. ) Aquae, ad fS^iij- (256. ) M. SiG. — A tablespoonful in a tablespoonful of water, with a teaspoonfu 1 of cod-liver oil floating in it, morning and evening. (T. Colcott Fox.) The following combination of iron with a mineral acid has sometimes proved of value when dyspeptic symptoms with anaemia coexist with the eruption of acne: R. Tinct. ferri chlor., Acid, phosphoric, dil., aa. . . . f§j (32.) Syrupi limonis f§ij. (64.) M. SiG. — A teaspoonful in a wineglass of water thrice daily, after meals. Among tonics arsenic stands first, sometimes appearing to act almost as a specific in anaemic cases. It may be given con- veniently in the form of Fowler's solution, in two to four minim (0.10-0.22) doses, gradually increased until the limit of tolerance is reached, and then dropped a little below this and continued for a considerable period. The following formula is a favorite with me; it combines the arsenic with iron: R. Liq. potassii arsenitis, f oij ( 8.) Vim ferri, ad f§iv. (128.) M, Sig. — A teaspoonful in water, after meals. I may say here that iron does not agree with some acne patients. As Dr. Fotheroill says, iron does not a^ree with ''bilious'' people. Instead of arsenic, mercury may be given. Dr. R. W. Taylor prefers the following formula: 408 DISEASES OF THE SKIN. 1^. Hydrarg. bichloridi, gr. j ( .06) Ammoniae muriat., gr. vj ( 0.40) Tinct. cinchonae comp., f giij (96. ) Aquae, fgj. (32. ) M. SiG. — Ateaspoonful in a wineglassf ul of water three times a day, an hour after meals. The dose here is the thirty-second of a grain (.002), which may be increased every ten days until in general the limit of toleration is reached. The effect of this treatment begins in about two or three weeks. Of course, it is not to 'be understood that syphilis is suspected in the cases in which mercury is recommended. It is simply as a tonic alterative. In cases when it may be desired to combine mercury and arsenic, Dr. Taylor recommends "De Valangin's solution," liquor arsenici chloridi, which can be given in connection with the bichloride of mercury. The dose of this solution is the same as that of Fowler's solution. The sulphur mineral waters, as those of Richfield, and the White Sulphur of Virginia, etc., have a reputation for beneficial influence in acne. I am inclined to believe that there is something specific in the effects of the waters themselves, though much of the good effected is gained by the pure air and general tonic effect of the surroundings. Hygiene, in the form of fresh air, exercise, cold bathing, and a sojourn in the country or by the seashore, will now and then effect what medicines may fail to do. It should be added that the seashore life occasionally is found to disagree with acne patients, bringing out the eruption in great abundance. Inquiry should be made before sending patients to the seashore, and they should be directed to change at once if the climate should prove unsuitable. The local treatment of acne is of great importance, the more so in the present state of our knowledge regarding the important part played by the organisms which induce inflammation and suppuration, especially so with regard to the choice of remedies. There is perhaps no skin disease in which so many local applic- ations have, at one time or another, been recommended. Used with discretion a few will suffice, but the great number of formulae ACNE. 409 extant serve only to confuse the practitioner in search of an appropriate topical application. For this reason only a selec- tion of those ordinarily used is here given. The external treatment of acne may be either soothing or stimulating. In a small number of cases there is much heat, redness, and acute inflammation present, and here mild washes and bland ointments, such as those to be given under the treat- ment of eczema of the face, will best answer. When the case is a mild one and there is not too much irrit- ation, a medicated soap* containing sulphur, salicylic acid, ichthyol, or a small percentage of bichloride of mercury, may be employed to cleanse the surface and remove some of the oily and epithelial debris, after which a saturated solution of boric acid in alcohol of 96 may be sopped on or applied on compresses to the lesions. The parasiticidal effect of this remedy upon the purulent lesions is quite marked. Sometimes the more recent lesions may be aborted by means of this or similar applic- ations. Bathing the affected parts with hot water is usually of advantage and may be practiced twice daily, once when washing with medicated soap and once without. Immediately after the hot water applications the borated alcohol may be employed, or if a somewhat more active application is needed or can be borne, the folio wing lotion may be employed : I£. Hydrarg. bichlor., gr. vj-xij( 0.4-0.8) Alcoholis, f 5iss ( 6.) Aquae destillat., ad fgiv. (128.) M. This may be diluted with water at first and gradually made stronger. The patient should be warned against its possible irritating effects, and also with regard to its influence upon metals, as rings, etc. It should not, of course, be employed with sulphur in any form. Another formula often used is the following: * The medicated soaps devised by Eichoff are those which I find most con- venient. They are well made, and' although their therapeutic activity is not great, they form useful adjuncts to treatment. 4IO DISEASES OF THE SKIN. 1$. Hydrarg. bichlor., gr. iv ad viij ( 0.25-0.50) Tinct. benzoini, ttjxxx ad f 3 j ( 2.-4.) Emuls. amygdalae amarae, . . ..ad f5iv. (128.) M. A combination of bichloride of mercury with sal ammoniac is often employed, which is composed of 1 part each of chloride of ammonium and bichloride of mercury in 200 parts of emul- sion of bitter almonds. The following is a convenient combin- ation : J$. Hydrarg. bichlor., Ammonii chloridi, aa gr. iv ( 0.25) Aquae destillat., £§iv. (128. ) M. (Brocq.) Sometimes sulphur preparations are serviceable, especially in more severe cases. One of the sulphur lotions most com- monly employed is the following: fy Sulphuris praecipitat., 5 j ( 4-) /Etheris, fovj ( 24.) Alcoholis, ad foiv. (128.) M. SiG. — Shake well before using. Among the compounds of sulphur the following are fre- quently beneficial, particularly in sluggish cases of acne : 1$. Potass, sulphuret., 9j ( 1.3) Tinct. benzoini, f 5j ( 4- ) Glycerinae, f5iss ( 6. ) Aquae rosae, ad foiv. (128. ) M. Another prescription which I have often used with benefit is the following: 1$. Potassii sulphuret., Zinci sulphat., aa 3ss ad oj ( 2.-4.) Aquae rosae, f§iv. (128.) M. The ingredients are each dissolved in one-half the water, forming clear solutions. They are then mixed, and a white precipitate falls, which is to be shaken up and applied to the face. This should be used in a diluted form at first and gradually made stronger. It is not suitable when the skin is irritable. When the skin is rather coarse and sluggish the face may be rubbed and washed every night with the soap known as "sapo ACNE. 411 viridis," an imported soft soap, the use of which was introduced into this country from Germany. It is of the consistency of ointment, and contains a slight excess of caustic potash. The solution of this soap in one-half its weight of alcohol, known as "spiritus saponis kalinus,"* may be used instead of the soap itself, when a milder effect is desired. A small portion of soap or a few drops to half a teaspoonful of the spiritus saponis should be rubbed briskly over the affected skin for several minutes. It must be remembered that these are strongly stimulant prep- arations, and their chief use is to cause absorption when the lesions are sluggish and indurated. They should be washed carefully off after use, and the part covered with powdered starch or a small quantity of cold cream or some other bland ointment. If they make the skin harsh, their use should be suspended or stopped. When the sebaceous gland ducts are unhealthy and plugged up, and when comedones abound, the soapy applications, especially if combined with copious bathing with hot water, loosen and aid in pressing out the plug of inspis- sated sebum, and in bringing the glands back to a more healthy condition. The watch-key or the comedo-extractor may also aid here in pressing out the comedones present, although these must be used with caution to prevent irritation. Sulphur and its preparations are, as has been said, among the most valuable remedies in our possession for the treatment of acne in most of its forms. The following may be given as among the most eligible sulphur ointments with which I have had experience: 1$. Sulphuris prascipitat., 5j (4-) Ung. aquae rosae, Petrolati, aa 5iv. (16.) M. Camphor may sometimes be added with advantage: 1$. Sulphuris prascipitat., 5 j ( 4- ) Pulv. camphorae, '. gr. xx ( 1.3) Ung. aquae rosae, Petrolati, aa oiv. (16. ) M. * The Tinctura Saponis Viridis, U. S. P., intended as a substitute for this, is not so efficient. 412 DISEASES OF THE SKIN. Indurated and pustular acne may sometimes be benefited by the application to each lesion of a drop of solution of the acid ni- trate of mercury, on the end of a sharpened match, followed by bathing with hot water. Puncture with the point of a fine bis- toury or with a lance especially designed for this purpose, is a good procedure in indurated acne with a tendency to the for- mation of abscesses. It is a good plan to follow the puncture of the pustular lesions of acne by the application of some parasiticide. A sharp stick wet with a solution of bichloride of mercury (i-ioo) or with a drop of pure ichthyol will be found to discourage pus formation and to prevent recurrence of the pustule. The indolent indur- ated inflammatory masses which show no sign of suppuration may often be dispersed by the application of a 10 to 25 per cent, salicylic acid rubber plaster. Medicated soaps, particularly bichloride and ichthyol soap, should be used to cleanse the surface after puncturing or scari- fication. Unna highly recommends the employment of ichthyol, in the treatment of acne. He recommends to wash the parts thoroughly morning and evening with ichthyol soap and then to rub in the following lotion : fy Ammoniae sulph. ichthyolat., gr. xij-oij ( 0.7-8.) Alcoholis (90 ), Athens, aa f3iv. (16. ) M. It is usually well to begin with the milder strength of ichthyol and gradually increase it. The application can usually be allowed to remain on over night. If found irritating, it can be removed after half an hour and the parts covered with a slight application of the following ointment: 1$. Acid, boric, 5ss ( 2. ) Acid, salicylic, gr. x (0.6) Ung. zinci oxid., § j. (32. ) M. Unfortunately ichthyol discolors the skin and patients often object to its use on this account. ACNE. 413 Naphtol has been recommended in rebellious acne. In mild cases Brocq employs an ointment containing eight grains (0.5) each of naphtol, camphor and resorcin, forty- five grains (3.) of sulphur, twelve grains (0.7) of sapo viridis, and five drachms (20.) of vaseline. This may be allowed to remain in contact with the skin all night. In extensive acne indurata with small abscesses, especially when the back is covered with numerous suppurating lesions, a system of disinfection of the surface should be employed. The patient should remain in a warm bath until the skin is thoroughly softened, and then a bichloride of mercury soap of some kind, or the compound soap of resorcin, sali- cylic acid, and sulphur (Eichojj), should be thoroughly rub- bed into the surface. The larger suppurating lesions should be opened with an acne lancet, the contents very gently expressed, and a small quantity of pure ichthyol should be introduced into the cavity on a small probe or sharpened stick. Too much pressure should be avoided in emptying the contents of acne pustules, as it is possible to press the virulent matter into the surrounding tissues and thus create new foci of suppura- tion. Some of the soapsuds may be left in contact with the skin, or an ointment containing ten to twenty grains (0.65-1.30) of salicylic acid, and a drachm (4.) of boric acid to the ounce (32.) of vaseline, may be gently applied. If there is any con- siderable amount of serous leaking, which may occur where many abscesses have been opened, a dusting powder composed of one part of boric acid to four each of oxide of zinc and starch may be dusted over the surface. Recently the X-ray treatment has been used in the treatment of acne and in some cases with brilliant success. The cases in which the X-ray is particularly indicated are those in which the glandular element is prominent and, particularly where there are large indurated lesions and abscesses. This plan of treat- ment should be entered on with some caution, however, and the process should be kept under careful control. At times the prolonged use of the ray results in the formation of countless 414 DISEASES OF THE SKIN. small cicatricial pits at the openings of the sebaceous glands, presenting on the face a pock-marked appearance. In the hands of the skilled operator, however, very excellent results are obtained. The prognosis of acne should always be guarded. While by no means the desperate and incurable malady which it is sometimes said to be, by pessimistic or incapable practitioners, yet it often offers a stubborn resistance to treatment, and shows a marked tendency to relapse. The most extensively developed cases, moreover, are sometimes more amenable to treatment than those where half a dozen lesions alone represent the disease, and where the patient enjoys apparently good health. The question is, in the long run, one of time only, as a spontaneous cure sooner or later almost invariably occurs. If neglected, however, unsightly and disfiguring scars supervene in severe cases, and our efforts, therefore, should be unremitting to obtain a speedy cure, if possible. Now and then keloid follows as a result of pustular acne. This condition, though unsightly and disfiguring, aisappears spontaneously with the lapse of time, perhaps in three to twelve months. Treatment usually fails to hasten its disappearance, but see on this point under Keloid. ACNE VARIOLIFORMIS. Acne varioliformis is an affection characterized by lesions of a papulo- pustular type, discrete or grouped, occurring most commonly on the upper part of the forehead and scalp, sometimes on the extremities and other parts and leaving scars somewhat similar to those of variola. Various names have been given to this affection and to the small group resembling it. as acne necrotica, lupoid acne, jolliclis, hidradinitis suppurativa, small pustular scrofuloderm, etc. The disease is not to be confounded with that to which the French formerly gave the same name and which is allied to molluscum contagiosum. The eruption is usually rather scanty, sometimes not more than a dozen or so lesions. It first appears in the form of a minute macule or maculo- papule, scarcely rising above the surface. The lesions soon become more elevated, bright red at first, later a dull red and often pierced by a hair. The acme is reached in several days to weeks, when a slight pustulation or ACNE ROSACEA. 415 crusting shows on the apex. This lasts some days and then the dried scale becomes detached, leaving a puckered red depression. The depression finally changes in appearance to that of a depressed cica- trix, pin-head to small pea-sized, rounded, clean cut, variola-like scar. The lesions may be discrete or grouped and sometimes aggregated or bunched together. The favorite sites are, the forehead, just at the edge of the hair and the scalp, but the eruption may occur over the back, on the arms and legs, etc. There are usually no subjective symptoms but occasionally itching is ex- perienced. The eruption is probably the result of microbic invasion. It is a destruc- tive inflammation of the pilo-sebaceous structures. It is probable that the disease is of tuberculous origin or at least a paratuberculosis. Acne varioliformis is to be distinguished from the pustular syphiloderm which it closely resembles. The latter, however, is more widely distributed and the pustule is deeper and with more pus contained in it. The lesions of acne are larger, show more inflammatory action and suppuration and are usually preceded by comedo. Treatment should be antiseptic; a 3 to 6 per cent, ointment of ammoniated mercury, or a 10 to 20 per cent, ointment of resorcin may be used. ACNE ROSACEA. Acne rosacea is a chronic, hyperaemic or inflammatory disease of the face, more particularly the nose, characterized by redness, dilatation and enlargement of the blood-vessels, hypertrophy, and more or less acne. There are two classes of cases: 1. Those in which acne papules and pustules form the most prom- inent symptoms, while bright red congestion, with some infil- tration of the skin, forms the background. 2. Those in which a sort of erythema or flushing is the first symptom, superadded to which occurs in chronic cases an enlarged and varicose condi- dion of the superficial cutaneous veins, with occasionally hyper- trophy of the nose. The first variety is in reality more closely allied to simple acne. It occurs, however, usually in older persons, not often showing itself in women before twenty-five or thirty years of age and in men not until an even more advanced period. While the nose is the chief seat of this form of acne rosacea, it is likewise fre- 4i6 DISEASES OF THE SKIN. quently encountered upon the cheeks and sometimes upon the forehead and chin. While the entire course of the disease may be chronic, it usually proceeds by acute exacerbations or attacks following some digestive, uterine, or other derangement. In the second variety, hyperemia, or flushing, is the earliest symp- tom, intermittent at first and noticeable only after exposure to a close atmosphere or following the use of alcoholic stimulants Fig. 79. — Acne rosacea. (Seu hypertrophica.) (Dr. Duhring's case.)* or a full meal. This hyperemia is passive at first; the nose is cold to the touch and sometimes shows slight seborrhcea. Grad- ually the redness grows more marked and permanent. If now the nose is examined, small tortuous blood-vessels can be seen ramifying in the skin of the affected part. The disease varies in intensity in different cases, from a slight blush to a marked deformity. The face and particularly the nose are the parts * Photographic Review of Medicine and Surgery, vol. ii, 1871-72, p. 32. ACNE ROSACEA. 417 usually attacked. The course of this form of the disease is chronic, sometimes extending over years. The process usu- ally goes no further than the formation of swollen and tortuous blood-vessels, with diffuse redness, but sometimes hypertrophy of the connective tissue takes place, with grotesque enlargement and deformity of the nose, which becomes knobby, irregular in shape and may grow to enormous size. The causes of acne rosacea are various. It occurs both in men and women, but in the latter does not often tend to go beyond the first stages. In women also the disease is more prone to occur at two periods of life, at early womanhood and at the cli- macteric period. When occurring in young women, seborrhcea is apt to be present, and the disease appears to be due, in some measure certainly, to dyspepsia, anaemia, chlorosis, and men- strual difficulties. Sometimes the first variety occurs during pregnancy without any other sign of ill-health and in persons who seem perfectly robust. It usually goes away under treat- ment, but may return in later fife. When it occurs in later life it is apt to be more severe. In men the disease may occur at any period. In early life it is generally due to anaemia and debility, nervous prostration, and dyspepsia. In later life the use of spirituous liquors is often the cause, and, perhaps, nearly as often, dyspepsia in some of its forms. Habitual indulgence in alcoholic or malt liquors gives rise to this condition in various re- gions of the face. The first stage in acne rosacea is a hyperaemia, probably angio- neurotic, but in some cases in consequence of a seborrhoeic process. Persistent hyperemia results in permanent enlarge- ment of the blood-vessels and in some cases in a condition of hyper- nutrition which may lead to hypertrophy. The sebaceous glands become involved, nodules, first of a gelatinous, later of a fibrous character, and acne or acne-like lesions are usually superadded, either secondarily or as part of the pathologic process. In the markedly hypertrophic forms there is connec- tive tissue growth and enlargement of the glands. The walls of the blood-vessels may be thickened and surrounded by con- 27 41 8 DISEASES OF THE SKIN. nective tissue and some of the veins may in places resemble cavernous tissue. The nodular and pustular lesions strongly resemble those of ordinary acne but some observers are inclined to believe them different. The diagnosis of the second variety of acne rosacea presents no difficulties. In the first variety, however, where acneform lesions, pustules, sebaceous crusts, etc., predominate, the diag- nosis is not always plain. The tubercular syphiloderm of the nose and face, lupus vulgaris, lupus erythematosus and severe forms of eczema are most commonly confounded with acne ro- sacea. A reference to the description of these diseases will serve to indicate the differential characters. The treatment of acne rosacea depends upon the stage of the disease and upon its cause in the given case. Constitutional and local remedies are both used. The causes giving rise to the affection should be diligently sought for and removed, when possible. Uterine and menstrual derangements are to be looked after, the stomach and bowels kept in good order, and all hygi- enic measures used to improve the general health. Alcoholic and malt liquors are to be totally eschewed. Tea and coffee should be drunk in moderation and not strong. Inveterate tea drinkers are very apt to have red noses. Tea is often made to take the place of food, and gradually brings on a sort of dyspepsia peculiar to itself. The food should be of the plainest character. The general medical treatment is that of acne. Local treatment, however, is of the most value. Sulphur ointments, as in acne, may be used in the early stages, the following formula being a useful one: 1$. Sulphuris prsecipitat., 3j-ij (4.-8.) Ung. aquae rosas, o j. ( 32.) M. Sometimes lotions are more useful. The following lotion, known as Lotto sulphuris cum traga- canthce, is one of the very best in the treatment of acne rosacea, as well as all forms of acne simplex in which the rosaceous ele- ment is prominent: ACXE ROSACEA. 419 Lotio Sulphuris Cum Tragacantele. (" Kurnmerfeldt's Lotion.") ly. Sulphuris praecipitat., 5ij ( 8. ) Pulv. camphorse, . . . . gr. x ( 0.6) Pulv. tragacanth., gr. xx ( 1.2) Aquae calcis, Aquae rosae, aa f o i j • (64. ) M. This may be applied once to several times a day. Sometimes the wash seems to "draw" the skin and gives rise to an uncomfortable sensation. In this case the sulphur oint- ment mentioned just above may be applied in small quantity after each application of the wash. On the whole, I have gotten more benefit for patients out of this wash than any other, and I count it the best application in acne rosacea. It will not always do good, however, and we are sometimes driven to try other plans of treatment. Ichthyol washes of various strengths are often useful in acne rosacea. A wash of corrosive sublimate, of the strength of one-fourth grain (.015) to two grains (.12) to the ounce of alcohol, or corrosive sublimate ointment somewhat stronger, sometimes answers well in the first stage of the disease. Neumann and Hebra recommended mercurial plaster spread on cloths. George H. Fox suggests the employment of chrysarobin, as in acne. Of course, this is to be watched, lest the irritative effect of chrysarobin be produced. In the second variety of acne rosacea, where numerous well- defined blood-vessels can be seen coursing under the skin, the treatment must be somewhat different. Scarification in some form here offers the best chance of improving the condition of the skin. The dilated capillaries may be incised with a tine sharp knife, in the hope that adhesive inflammation may result, with the effect of closing the vessels. The plan which I follow by preference, however, is that of cross-hatching the entire sur- face involved, not at one sitting, but in a series of operations. The larger vessels, if such are present, may first be slit up, and then with a multiple-blade knife, such as that figured under lupus erythematosus, held like a pen in the hand, a series of parallel cuts are to be made extending to about one-sixteenth of an inch 420 DISEASES OF THE SKIN. below the surface. These are then crossed by a similar series of cuts at right angles, and in some cases a third series of cuts may be practiced. As the object is not precisely the same as in the similar treatment of lupus, it is not necessary or desirable to hash up the skin by a number of successive incisions at various angles. To prevent cicatrices, it is indeed sometimes better to practice only a single series of parallel cuts at one sitting. It is usually desirable to benumb the surface before operating in this way, especially on timid or nervous persons, and this may be done by means of freezing. A small gauze bag filled with min- gled ice and salt will produce the effect desired, but this may be accomplished more readily by the use of a hand-ball atomizer charged with rhigolene, or with chloride of ethyl now generally obtainable in glass tubes provided with a stop-cock. The little operation completed, the parts may be bathed with cold water or tightly compressed with absorbent cotton until bleeding has ceased. Cold water compresses are to be applied subsequently, to control the bleeding. After this a bit of dry lint or some simple dressing may be applied for a few hours. So soon as the soreness has passed away, perhaps in a week's time, scarification may again be practiced. A number of scarifications are usually required, the treatment running over a number of months, and requiring patience on the part of both operator and patient. Eventually, however, success is attained by this method. The skin heals over without any scar, or with such minute cica- trices as are hardly worth notice, and a marked amelioration in the appearance of the nose is the result. Of course, there is a strong tendency to relapse. The closure of some capillary chan- nels naturally leads to the dilatation of those collateral, and thus new vessels appear as old ones are obliterated. Sooner or later, however, a marked impression is made, and a fair result may be hoped for, even in severe cases. The sulphur and tragacanth wash may be employed con- currently with the surgical treatment described; it tends to keep down the preliminary erythema. Another treatment consists in painting the affected parts once ACNE ROSACEA. 42 1 or twice weekly with a ten- to twenty-grain solution of caustic potassa and following this by an emollient poultice. In cases where there is but little thickening, carbolic acid dissolved in three to four parts of alcohol may be painted on the part every second day. Hardaway recommends electrolysis, using a num- ber thirteen cambric needle inserted into any convenient handle, and connected with the negative pole of a galvanic battery. A sponge electrode is then connected with the positive pole. The needle is inserted sufficiently deep to enter the dilated vessel; so soon as this has been accomplished, the patient completes the circuit by taking the sponge electrode in his hand. So soon as the electrolytic action has been properly developed, the patient releases the sponge electrode, after which the operator withdraws the needle. Six to eight elements will generally suffice. If the vessel to be operated upon is a long one, several punctures must be made at suitable intervals of space. The needle may be inserted perpendicularly or in a line with the course of the vessel. Of late years I have employed the electro-cautery as in lupus. Though some scarring results the cure is more rapid than by any other form of treatment. In those rare and severe cases where knobby and gross deformity of the nose exists, decortica- tion with the knife is the only remedy. The prognosis of the first variety of acne rosacea, at least in the early stages, is favorable, and there are few affections of the face in which more striking and rapid results can be attained, up to a certain point, than in those cases of acne rosacea where there is a "red face" with numerous papular and pustular lesions, with little or no capillary dilatation. When, however, we have the second form to deal with, and especially when the disease has become thoroughly established, only thorough and- long-continued treatment will avail. Where the capillary enlargement is already marked, treatment beyond a certain point is, in most cases, little more than palliative; it may prevent further progress, but this is much, and patients should be encouraged to persevere, especially in the treatment by scarification. 422 DISEASES OF THE SKIN. 4. DISEASES OF THE SWEAT GLANDS. HYPERIDROSIS. Hyperidrosis is an habitual general hypersecretion of the sweat glands. The condition may arise in health from heat, muscular exercise, the ingestion of hot drinks, etc., and in fevers, phthisis, and certain affections of the peripheral, central, and sympathetic nervous systems as a symptom of more or less import- ance. Hyperidrosis may, moreover, occur as a substantive affec- tion, and looking at it from this point of view, it may be described as a functional disorder of the sweat glands consisting in an in- creased flow of sweat. It may vary greatly in degree, from an amount scarcely in excess of health to a profuse stansudation. The local form of the disease, which is by far the most common, may occur upon almost any portion of the body, but is more commonly encountered about the palms, soles, axillae, and gen- itals. It may or may not be symmetrical, and is sometimes con- stant, while at other times it is intermittent or paroxysmal. Numerous cases of unilateral sweating are on record. Hyperidrosis upon the palms and soles is sometimes excessive. From the palms it may be so profuse that the fluid will accumu- late in the hollow of the hand until it runs over the edge. Upon wiping off the secretion in these severe cases the skin is observed damp, and sodden. The flow appears to come from the whole surface. The soles show the disease to a still more marked degree at times, the soaked epidermis becoming macerated and peeling off, and leaving the tender skin exposed. The pain on walking is often so severe as to keep the patient off his feet. Hyperi- drosis of the sole is almost always accompanied by decomposition of the sweat, which gives rise to a peculiar penetrating odor (see Bromidrosis). Lesser* says that there is some connection between the condi- tion known as flat-footedness and hyperidrosis. Trendelenburg thinks that the connection is through the nerves; either there is some reflex action or there is a mechanical pressure upon the plan- er nerve. Permanent flat-foot, Lucke thinks, occurs in persons * Deutsche Med. Wochens., Nov. 2, 1893. HYPERIDROSIS. 423 of a "venous habit," that condition which coincides with weak muscles, cold feet, and excessive perspiration. With muscular weakness the formation of varices may occur; not necessarily of the superficial veins, but of the deeper veins, with perhaps thromboses. In 189 cases of hyperidrosis pedum, of which 98 were males and 91 females, Lesser found that 51 per cent, of the men and 27.4 per cent, of the women were flat-footed. Varicose veins were found in 40.8 per cent, of the males and 39.5 per cent', of the females. The immediate causes of hyperidrosis are not well under- stood. It appears in some cases to be hereditary. It affects the cleanly and the dirty, the sickly and the healthy alike, and is met with in persons of all ages and both sexes. In addition to diseases of the nervous system, debility, malaria, and occasionally functional or organic disease of the internal organs, as the heart and lungs, may give rise to hyperidrosis. The affection is aggravated by high temperature, and is usually, though not always, worse in summer than in winter. Excite- ment of any kind, physical or mental, increases the flow of sweat. The treatment of hyperidrosis must vary with the individual case. When the cause is proximately or exactly known, inter- nal remedies appropriate to the general condition may be employed with good effect. If there be debility, a general tonic treatment is indicated. Iron, quinia, strychnia, and the mineral acids, especially aromatic sulphuric acid, may be used with advantage. Atropia is the most efficient remedy, and may be used at first to gain time for the further investigation of a case, or to introduce other treatment; its effect is apt to be tem- porary, however. It may be given by the stomach in doses of 2-9-0 to -^q grain (0.0003-0.0012) dissolved in water, three times a day, until the physiological effects are produced. Or, in some cases, the hypodermic use of the drug may be found advisable, in the same dose, only with more caution. Pilocarpine has been highly recommended by some writers. Tincture of jaborandi, in doses of five to ten minims every second or third hour, or the 424 DISEASES OF THE SKIN. muriate (or nitrate) of pilocarpine, in pill form, in the dose of 2V grain (0.03) at similar intervals, may be prescribed. Local treatment in hyperidrosis is particularly useful, and, in some cases, may alone be required. Patients are apt to use too much water, particularly warm water, in washing the parts too frequently. The parts affected should be washed as rarely is possible — only when they are really dirty. Formalin soap may be used in bathing. They should be wiped, however, from time to time, with a damp cloth, and immediately dried witha soft towel, without friction. Various dusting powders, as starch, lycopodium, magnesia, and oxide of zinc, or the same with the addition of half a drachm of salicylic acid to the ounce, may be used. The following combination is useful: 1$. Pulv. acid, salicylic, Pulv. zinc. carb. praecip., Pulv. magnesiae-ustae, aa 5iv (16.) Pulv. amyli, 5xv (60.) Pulv. talci, oxx. (80.) M. The powder should be removed and renewed so soon as it becomes moist and caked. Chloral in powder, in the proportion of one drachm (4.) to one ounce (32.) of starch powder, is one of the most efficient of all these powders. They are ordinarily only serviceable in mild cases. Slight cases of hyperidrosis may also often be cured by the use of juniper tar, carbolic acid and sulphur soaps. Lotions containing alcohol, alone or with the addition of some astringent, will be found useful. The following is a convenient formula : 1$. Acidi tannici, 5 j ( 4-) Alcoholis, f oviij. (256.) M. SiG. — Use as a lotion. Salt baths are sometimes found serviceable. Tincture of belladonna, diluted or in full strength, may be employed, its constitutional effects being guarded against. Weak solutions of chloral, permanganate of potassium, and salicylic acid have been employed with success. In hyperidrosis of the palms and soles, washing with carbolic acid or juniper tar soap may be followed HYPERIDROSIS. 425 by the application of the following ointment, spread upon cloths, and kept in place with a bandage : 1^. Ung. picis, U. S. P., Ung. sulphuris, U. S. P., aa oss. (16.) M. In obstinate and severe cases, especially when the soles of the feet are affected, Hebra's treatment is the best. It is as follows: The parts having been cleansed with soap and water, the following ointment is applied: 1$. Emplast. diachyli Olei olivae, aa oiv. (128.) M. The plaster is to be melted, and the oil added and stirred until a homogeneous mass results. Pieces of muslin or cotton cloth are to be cut to the size of the parts, and the ointment spread on thickly and applied. Lint, smeared with the ointment, is also to be placed between the toes (or fingers) so that every portion of the skin may be completely covered with a layer of the ointment. The dressings are to be bound down closely by means of a bandage. The cloths are to be changed twice in the twenty-four hours, when the parts are not to be washed, but simply rubbed dry with lint and a starch dusting powder after which new dressings are to be applied in exactly the same manner. This treatment is to be continued from one to several weeks, according to the severity of the case. Even when the disease is on the soles, the patient may be per- mitted to walk about in loose shoes. At the expiration of eight or ten days the parts are to be rubbed with the dusting powder and the dressings discontinued. The powder should be used for several weeks longer. Usually the sweating tends to lessen and gradually disappear after two or three weeks from the begin- ning of the treatment. A repetition of the course in severe cases is sometimes necessary before attaining a complete cure. I have sometimes obtained a good result with a 5 per cent, solution of chromic acid. Of course, the patient must give up his occupation while under- going this treatment — a sacrifice of time which is impossible in 426 DISEASES OF THE SKIN. many cases. When, however, circumstances will permit, the treatment just prescribed will succeed when milder measures, however, faithfully applied, have failed. The prognosis of hyperidrosis depends somewhat upon the state of the patient's health, the duration and locality of the disease, and its extent. Many cases are easily cured, while others are extremely intractable. The ability of the patient to follow the treatment must also be considered, as careful attention to the directions given is essential to a cure. ANIDROSIS. Anidrosis is a functional disorder of the sweat glands, consist- ing in a diminished and insufficient secretion of sweat. It some- times occurs in connection with ichthyosis. (See Ichthyosis.) In rare cases an individual ceases to sweat entirely at times. In these cases the health is greatly impaired, and much suffering may ensue, especially in warm weather. The disease in this form is very rare. In the treatment every effort should be made to increase the activity of the skin. Hot or cold baths, steam baths, and frictions may be employed. Pilocarpine would seem to be indicated, but I do not know if this remedy has been em- ployed as yet. Of course, the general health should be looked after. BROMIDROSIS.* Bromidrosis is a functional disorder of the sweat glands, char- acterized by more or less sweating and an offensive odor. The sweating may be imperceptible or at times there is a condition of hyperidrosis to which an offensive odor is added. The body may give out a disagreeable odor as the result of ingestion of certain foods or medicines as onions, asafcetida, copaiba, musk, etc. In some cases the odor is the result of dis- *Cf. Monin, Sur les Odeurs du Corps Humain, Paris, 1885. Also, Ham- mond, The Odor of the Human Body as Developed by Certain Affections of the. Nervous System, New York Med. Record, vol. xii, 1877, p. 460. BROMIDROSIS. 427 ease. In incontinence of urine a mousey odor is observed, in chronic constipation a fcecal odor. The ward smell of hospit- als comes from diseased body emanations. An infant ward may have a sour butyric acid odor while men's wards have an alkaline or ammoniacal odor. In rare cases the odor of the body is agreeable, resembling violets, banana, orris, etc. All these odors are, like those of typical bromidrosis, due to decom- position of fatty acids in the sweat. In practice bromidrosis of the hands and feet chiefly claim attention. As a general thing these occur in connection with hyperidrosis and therefore the treatment must be directed to both conditions. Many patients suffering from bromidrosis demand general tonic and hygienic treatment to raise the whole tone of the system. Aromatic sulphuric acid, twelve to twenty drops diluted with water three times a day, or atropine in doses of 2W t0 tw grain (0.0003-0.0006) may be employed. Sodium sal- icylate in five to ten grain (0.3-0.6) doses has been used in some cases. Crocker recommends the following : J$. Pulv. cretae com. (B.P.), 5 y i (24.); pulv. cinamomii comp. (B.P.) 5ij (8-) ; sul- phuris precipitat, §i (32.). A teaspoonful of this to be taken twice a day. As regards local treatment, that used in hyperidrosis may be employed and in addition the following: 1$. Pulv. acid, salicylic, 5j (4.); Pulv. aluminis ustae, 5 V (20.). M. Fox recommends a one per cent, solution of chloral or permanganate of potassium. Thin found in bromidrosis pedum that the moisture was alkaline and swarming with bacteria. He recommends that the stock- ings should be changed twice daily and that they should be placed in a jar containing a saturated solution of boric acid. They may then be dried and worn again, the odor having disappeared. Cork insoles should be worn through the day and soaked in boric acid solution through the night. In bromidrosis of the axilla formaline soap may be employed, or sponging with pure alcohol followed by inunction with a ten per cent, oleate of mer- cury ointment. Tschappe recommends the following: 428 DISEASES OF THE SKIN. 1$. Zinci sulphat., Ferri sulphatis aa §ij (62. ) Cupri sulphat., §ss ( 16. ) Betanaphtol., gr. ij-x ( 0.12-0.60) Thymol, gr. iv-x ( 0.25-0.60) Acidi hypophosphorici gr. ij-x ( 0.12-0.60) Aquae destillatae. Oj. (480. ) M. Of course, medicated soaps should be used in bathing the parts. Formaline soap, tar, salicylic, boric and sulphur soaps are all useful. The patient should be cautioned not to. take hot baths or sponge with hot water which favors excessive sweat secretion. CHROMIDROSIS.* Chromidrosis. An affection of the sweat glands in which the secretion poured out is colored, being usually blue or bluish- black. The so-called red and yellow chromidrosis is usually rather a parasitic growth on the hairs. In chromidrosis the quantity of sweat secreted is always in- creased. The affection occurs chiefly in hysterical women and usually affects the face, paticularly the lower eyelids, the chest, abdomen, the scrotum (in the few cases reported in males), the arms, and th e feet. It commonly appears in an* intermittent manner, following emotional excitement, or without appreciable cause. t The sebaceous glands are also involved in some cases and a black sooty oil may be wiped off. In a case under my care the patient "blushed blue" at times but after the "blush" had passed away bluish-black oily matter could be wiped off the skin. The pathology of chromidrosis is very imperfectly understood. The blue color has been said to be due to the presence of a phos- phate of iron (Scherer), to a compound of cyanogen analogous * For a full discussion of this subject with references, see the author's article on "Diseases of the Sweat Glands" in Twentieth Century Practice of Medicine, vol. v, New York, 1896. fHechelin {Sajous' Annual, 1895) reports the case of a boy ten years of age who displayed blue chromidrosis on the nose following a contusion. Exercise or emotion caused the color to show more distinctly as a blue perspiration. The coloring matter dissolved in chloroform and showed irregularly crystalline forms under the microscope. It appeared to be some derivative of indigo. HLEMATIDROSIS. 429 to pyocyanine (Schwartzenbach), to a microbe, to a microscopic fungus, to indican, or Prussian blue (Bizio, Apjohn, Foot, etc.). Some observers have supposed this form of chromidrosis to be merely a simulated affection. I think, indeed, that some cases have been feigned, but the majority are unquestionably genuine. The treatment should be stimulating and astringent. The following ointment will be found useful: 1$. Acid boric, gr. x Acid salicylic, gr. xv Ung. aquae rosae, o j- M. The customary treatment for hyperidrosis will also prove use- ful in severe cases. A general tonic treatment will usually be found indicated. HiEMATIDROSIS. This affection, known also as bloody sweat, ephidrosis cruenta, sudor sanguinosa, dia pedes is, etc., is a hemorrhage from the un- broken skin through the orifices of the sweat ducts. There is no such thing as an actual pouring out of blood as a secretion of the sweat glands, the hemorrhage in question probably oc- curring from the plexus of blood-vessels surrounding the glands into the ducts of these glands. The affection, 'though excessively rare, is so striking as to attract universal attention, and, consequently, records of its occurrence are found, not only in medical, but also in histor- ical works. A shallow skepticism, denying all extraordinary phenomena not coming within its own immediate observation, had, at the beginning of the century, swept aside all accounts of sweating blood as fabulous. More accurate observation has of late years established the fact that, under certain conditions, blood, in a more or less pure condition, may exude from the ori- fices of the sweat glands. The mechanism by which this exuda- tion takes place has not as yet, however, been satisfactorily explained, nor is it likely to be explained until we know much more, both of the physiology of the sweat secretion and of the circulation of the blood. A hemorrhage takes place from the capillary plexus about the gland coil and into the gland duct, 430 DISEASES OF THE SKIN. but whether this is the result of passive dilatation, increased blood pressure, alteration in the structure of the vascular walls, or in the composition of the circulating fluid, cannot, in the present state of our knowledge, be positively stated. The process has some points of resemblance with that which goes on in purpura (see Purpura). As regards the appearances presented to the eye, these vary in different cases reported. Sometimes blood oozes or spurts from the uninjured and unchanged skin. At other times an erythem- atous patch first forms, or a thin scale, which is later lifted up by the sanguineous exudation beneath. In some cases a milia- ria-like, vesicular eruption precedes the diapedesis. Haematidrosis may occur in either sex, and among those appa- rently in the enjoyment of good health as well as among those who belong to "bleeder" families, or who are in a low state of vitality. In many cases the affection occurs in connection with " vicarious" or disordered menstruation. At other times it may occur as the result of an impoverished condition of the blood, or from sudden and strong moral impressions, as fright, anguish, etc. At times fever with high blood pressure precedes the effu- sion, while at other times a state of depression with slow pulse ushers in the phenomenon. Occasionally the affection is one of a number of symptoms connected with purpura. The diagnosis of the disease presents no difhculty, excepting in those cases in which simulation may be suspected. The treatment of the disease must in many cases be purely empirical, and be directed by circumstances. When, however, there are indications of increased excitement and vascular tension, the abstraction of blood by a vein or some other method of reduc- ing blood pressure is called for. Closely allied to haematridrosis is the curious affection known as stigmata. (See Feigned Dis- eases of the Skin.) Tears of blood are sometimes observed. Such cases have been reported by Damalix, Hasner, and Brun. {Med. Record and Weekly Med. Review, about i89o- , 92.) In these cases the eyes filled quickly with the bloody tears, the sanguineous character URIDROSIS. 431 of which was demonstrated by microscopical examination. This affection is to be carefully distinguished from hemorrhages depen- dent upon orbital or conjunctival disease, such as polypoid con- junctival vegetations developed in the culs-de-sac of the conjunc- tiva. Genuine bloody tears are quite independent of any ocular or conjunctival disease, and their appearance is irregular. No apparent cause leads to their effusion. In some cases the escape of the tears is unattended by pain, in others the patient experi- ences pain in the forehead, the eyebrow, and at the root of the nose, or a sensation of pruritus, formication, or heat in the eye- lids. These morbid sensations persist only a few moments and cease with the appearance of the tears; the escape of the tears continues only a few minutes and the quantity of sanguin- eous lachrymal secretion varies from a few drops to a wineglass- ful. The phenomenon is usually intermittent, sometimes regular, but almost always transitory and attended by hemor- rhages from various cutaneous or mucous surfaces. Sanguin- eous lachrymation usually occurs in anaemic individuals, in those inclined to haematophilia and in hysterical women. URIDROSIS. Uridrosis is the name given to an excretion from the sweat glands containing the elements of the urine, especially urea. It appears as a colorless or whitish, saline, crystalline deposit, or coating, looking as if flour had been sprinkled upon the sur- face. The deposit can be scraped off with a knife, and is seen, under the microscope, to present minute crystalline spiculae. The disease is very rare. In most of the cases reported, partial or complete suppression of the renal function with disease of the kidneys and uraemic poisoning were present. PHOSPHORIDROSIS. Phosphorescent sweat has been observed in a few rare cases. It has been noted in the later stages of phthisis, in miliaria and in persons who have eaten putrid fish. The skin and sometimes the body linen becomes lumin- ous in the dark. It is probably due to the presence of photogenic bacteria 43 2 DISEASES OF THE SKIN. SUDAMEN. This affection, also known as miliaria crystallina, shows itself in the form of minute, pin-point to pin-head size, clear, or pearly vesicles, closely crowded together, but never confluent, occurring usually on the trunk, especially on the neck, chest, and abdomen, though they may appear anywhere. They form rapidly, do not enlarge after the first few hours, get well in a few days, unless fresh crops appear, which may keep up the eruption for weeks. The lesions are the result of the sweat being unable to escape, owing probably to an accumulation of epithelium at the orifice of the duct, when the sweat function is in abeyance, as in fevers ; then, when the secretion is restored, especially by a "critical sweating," the fluid, being unable to escape by a natural channel, is effused under the horny layer and forms a vesicle. (Crocker.) Robinson and Pollitzer have made careful and critical micro- scopic studies of the lesions. The treatment is essentially the same as that of miliaria, q.v. HYDROCYSTOMA. Hydrocy stoma is the name given to a non-inflammatory affection charac- terized by discrete, pin-head to pea-sized, shining, translucent, somewhat deep-seated, persistent vesicles appearing on the face. The lesions occur generally in considerable number, single, grouped, or occasionally crowded together. They are rounded or ovoid, translucent, solid-looking, tense, shining, whitish or light yellowish projecting vesicles. They have a somewhat thick covering and show no tendency to rupture. The deeper seated lesions look like boiled sago grains. There are no ob- jective inflammatory symptoms in spite of the fact that the affection is classed as inflammatory. Hydrocystoma is apt to appear in summer. The lesions long remain unchanged but finally tend to dry up and disappear. The affection is often connected with excessive sweating. Pathologically the lesion is a cyst-like formation of the duct of the sweat gland. The process does not affect the sebaceous glands nor the hair fol- licles. Hydrocystoma is to be distinguished from milium, sudamen, adenoma of the sweat glands and vesicular eczema. The treatment consists in puncturing the lesions and applying an astrin- gent dusting powder. MILIARIA. 433 GRANULOSIS RUBRA NASI. This rare affection occurs chiefly among children and is confined to the front and sides of the nose, although it has occurred on the upper lip, cheek and eyebrow. At first sight it looks like lupus. The part is of a bright red color, diminishing in intensity towards the sides of the nose and fading into the surrounding skin. Pin-point to pin-head-sized, deep red or brown- ish-red specks and papules are scattered over the surface. There is no dis- position to coalesce. The papules gradually develop into pustules and some dry up. There is always hyperidrosis of the affected area, the sweat appear- ing as droplets. The disease pursues a chronic course but apparently dis- appears with the approach to adult age. The affection appears to be a chronic inflammation originating in the vessels around the sweat apparatus. Treatment has hitherto seemed of little avail, though linear scarification has been suggested. MILIARIA. Miliaria vesiculosa, or rubra, says Crocker, has the same relation to sudamen as acne vulgaris has to comedo. Inflam- mation occurs in the gland as a consequence of retention of the sweat secretion, vesicles arise in great numbers upon the trunk, especially upon the back, but they may also come upon the face and limbs. The lesions are acuminate in form, whitish or yel- lowish in color, and situated on a raised red base. The vesicles run an acute course, drying up in a day or two and terminating in slight desquamation. The affection may come to an end in a few days, or may last some time, depending upon the persistence of the cause, usually hot weather or excessive clothing. It is very common among infants, especially in summer. There is a good deal of prickling or itching as a general thing. Miliaria papulosa is the affection formerly known as lichen tropicus, or "prickly heat." It manifests itself in the form of minute red, acuminate, discrete papules closely crowded to- gether, with vesicles or vesico-papules interpersed. The erup- tion comes out suddenly over large areas and is accompanied by excessive sweating and intolerable prickling and tingling. It is said to differ from M. vesiculosa in that the inflammation produces the obstruction to the sweat secretion instead of vice 434 DISEASES OF THE SKIN. versa, as in the former disease. It is essentially a tropical dis- ease, though in a milder form often met with in our hot American summers. The disease may run on into eczema. The treatment of miliaria includes removal of the cause when this is possible, that is, keeping the patient cool and lightly clothed. Cool baths and saline diuretics are usually to be recommended. Vinegar and water, dilute lead- water, black wash, or some sooth- ing and astringent lotion, such as is recommended under eczema, may be employed. Solution of sulphate of copper, ten grains (0.65) to the ounce, (32.) may also be employed. It is a favorite remedy, I understand, in Cuba and the West Indies. Astringent powders, as bismuth subnitrate, oxide of zinc or kaolin, are also useful. The camphor powder described under acute eczema will often relieve the pricking and burning. Ointments are out of place. In the severe forms of the tropical variety, I should think that tincture of belladonna in two-drop (0.10) doses, or sulphate of atropia, in -^to grain (0.0003) doses, pushed to its physiological effect, might prove useful. I have never had an opportunity to try this treatment, as the milder local measures mentioned always suffice in our climate. HYDROADENITIS SUPPURATIVA. Hydradenitis suppurativa, known also as " hydradenitis destruens sup- purativa,"* is a rare disease of the sweat glands, characterized by the appear- ance of one or several deep cutaneous shot-like nodules, which gradually en- large to the size of a pea, undergo softening and suppuration, with subse- quent discharge and cicatrization. The disease, when well marked, may occur in the face or neck, but when the lesions are scanty in numbers or single the axilla, genitalia, nipple or anus is more apt to be the seat of the disease. When fully developed the shot-like lesions redden, suppurate at one or more points, give exit to a drop or two of pus, blood or a glairy yellow fluid, and then dry up leaving a de- pressed scar. The disease is probably of microbic origin. It is not to be confounded with acne and small sluggish furuncles Treatment is the same as for acne varioliformis. The disease is apt to last for years. * Pollitzer, Jour. Cutan. Dis., 1892, p. 9, gives a full review of allied forms with literature. favus. 435 CLASS IX. PARASITIC AFFECTIONS. A. DISEASES DUE TO VEGETABLE PARASITES. FAVUS. Tinea favosa or favus is a vegetable parasitic disease of the skin, characterized by pin-head to pea-sized, friable, cup-shaped, yellow crusts tending sooner or later to form mortar-like masses. The affection first appears as a diffused or circumscribed super- ficial inflammation, with slight scaling, followed by the appearance of one or several pin-head-sized, pale yellow crusts seated about the hair follicles, which develope into the characteristic lesions of the disease, raised, sulphur-yellow cups, which can be detached from the skin underneath, having a moist, excoriated surface. The cups are friable and can be powdered between the fingers. They sometimes aggregate into masses. Usually each cup has a hair running through its center. When the disease is extensive, ulceration may exist under the crusts. It is usually situated in the scalp, but the nails and skin generally may be attacked in rare cases. When the nails are attacked they become thickened, yellow, opaque, and brittle. Favus pos- sesses a peculiar odor like musty straw, or like the smell of mice. The disease gives rise to some, but not to excessive itching. When favus has existed in the scalp to a severe degree and for a long time, a cicatricial condition with permanent baldness may ensue. It is a chronic disease. Situated in the scalp, it requires most energetic treatment to dislodge it, and is very prone to relapse. It is a rare disease. Favus is due to the invasion of the cutaneous structures, espe- cially the epidermal portion, by a vegetable parasite, the achorion Schoenleinii. The parasite consists of mycelium and spores and occurs in such abundance in the "cups" that it is easily dis- 43 6 DISEASES OF THE SKIN. tinguished under the microscope. The spores are usually rounded or ovalish. The mycelium is composed of narrow, apparently flattened tubes or threads, sometimes chain-like, which ramify in all directions without definite arrangements and are of vary- ing width and length. For purposes of examination a small fragment of the sulphur-yellow crust is placed on a slide with a few drops of liquor potassae and a cover-glass is placed upon it and gently pressed down to dissociate the elements. After Fig. 80. — Achorion schonleinii. (X5°° diameters.) standing a few moments, examination with a power of 300 to 500 diameters will show the fungus, as described, in great abundance. According to Robinson, the parasite first obtains a lodgement in the funnel-shaped depression in the epidermis through which the hair shaft emerges upon the surface. It grows luxuriantly in the upper part of the hair sac and insinuates itself on all sides between the superficial layers of the epidermis. When it reaches a short distance on all sides of the follicle mouth, it TINEA TRICOPHYTINA. 437 breaks the looser layers and appears on the surface, giving rise to the familiar cup-shaped bodies. The achorion invades the hair shaft but not to the extent that the ring-worm fungus does. The nutrition of the hair is interfered with by the mechanical pressure of the growth upon the papilla. The hair falls out and eventually in many cases the papilla atrophies and a new growth becomes impossible. Favus of the scalp results in baldness far more frequently than does ring- worm. The diagnosis of favus is usually easy; the peculiar yellow cups and the odor are commonly present, and even where the shape of the cups has been lost by suppuration or broken down by treatment, a patch of characteristic color can usually be seen here and there. The mousy odor is almost always perceptible, and most cases can be diagnosticated by this alone. In the treatment of favus of the scalp the hair is to be cut as short as possible, after which the crusts are to be removed with poultices,' or applications of olive or almond oil, and soap and hot water, as in pustular eczema of the scalp. After they have been removed, the scalp, in severe cases, will show pits and depres- sions, with atrophy, baldness, or areas of superficial ulceration, resembling the effects of syphilis. Depilation is then to be practiced by means of a pair of flat-bladed forceps, especially made for that purpose, or by other means. A small patch should be cleared each day. Immediately after depilation a parasiticide should be applied, and there is none better than a saturated solu- tion of sulphurous acid. Sulphur ointment, alone or with tar, may also be employed. Yellow sulphate of mercury, half a drachm (4.) to the ounce (32.), or chrysarobin ointment of the same strength, cautiously used, may also be used with benefit. The disease is, of course, contagious, and precautions must be taken against its transmission, particularly among children in families. TINEA TRICOPHYTINA. Tinea tricophytina, or ringworm, is a vegetable parasitic dis- ease of the hair follicles, hairs and smooth skin. There are 438 DISEASES OF THE SKIN. two distinct forms of fungi which may produce ringworm, the Microsporon Audouini, or small spored fungus, and the Tri- chophyton megalosporon, or large spored fungus. Of the latter several varieties are recognized.* The microsporon appears under the microscope chiefly in the form of a large number of round spores, irregularly grouped or massed about the follicular por- tion of the hair. Mycelial threads, large and branching, are also seen chiefly within the hair proper. After dividing and sub-dividing they ter- minate on the outer surface of the shaft in fine filaments, at the ex- tremities of which are the spores, which in this fungus are external. The microsporon is not found in ringworm of the beard and rarely in that of the body. It is never found in kerion. The tricophyton is composed of spores which vary greatly, but which, as a rule, are considerably larger than those of the micro- sporon. They are frequently cuboidal, oval or irregularly rounded; but their chief character- istic lies in the arrangement in lines or chains extending up and down the hair shaft. The mycelium is found without but never within the hairs. The tricophyton occurs in three varieties: the endothrix, in which the spores occur wholly within ; the ectothrix, in which the spores are distributed wholly without; and the endo- ectothrix, in which the spores are partly within and partly without the hair. The endothrix, like the microsporon, is found chiefly in the ring- worm of the scalp in children. The lesions, however, are some- * This description is taken from the text-book of Hyde and Montgomery. Fig.8i. — Tricophyton (endothrix). TINEA TRICOPHYTINA. 439 what different from those of microsporon. The ectothrix and the endoectothrix apparently are derived either directly or indirectly from the domestic animals, and are responsible for the ring- worm of the body, of the beard and from all suppurating forms of the disease. Charles J. White found the microsporon in 139 out 279 cases of ringworm examined. For ordinary, clinical, microscopic examinations the hair may be placed on a glass slide and a drop of liquor potassa poured Fig. 82. — Tricophyton. (T. circinata.) (X 500 diameters.) over it and then covered with a cover-glass with light pressure. Stronger solutions quickly disintegrate the hair, but weaker solu- tions, 5 to 10 per cent., require several hours to clear the field. To stain the fungus the Morris- Calhoun method is as follows: The hair is first washed with ether to remove the fatty debris; it is then put for one or two minutes in the Gram iodine solution, and after drying is stained for from one to five minutes in gen- tian-violet and anilin-water. It is again dried and treated for a 44° DISEASES OF THE SKIN. minute or two with the iodine solution, and for an equal length of time in aniline oil containing pure iodine, after which it is cleared with aniline oil, washed in xylol and mounted in Canada balsam. Coarse, dark hairs and spores within the hairs require more time for staining than do fine, light-colored hairs and the fungus-ele- ments situated without the hair. The features, character and behavior of ring-worm vary con- siderably according to the part involved, whether it be the gen- eral non-hairy surface, the genito- crural parts, the scalp, or the bearded region. The symptoms and diagnostic characters may best be described under the general regional headings. RINGWORM OF THE GENERAL SURFACE. Ringworm of the general surface, or tinea circinata, is char- acterized by the occurrence of one or more circumscribed, cir- cular, variously-sized, inflammatory, squamous patches, occur- ring on the general surface of the body, accompanied by itching. The disease usually begins as a small, reddish, scaly, rounded or irregular-shaped spot, which in a few days assumes a circular form, healing in the center as it spreads on the periphery, which is usually papular, but may occasionally be made up of small vesicles. Sometimes the rings coalesce and form gyrate figures. The disease may attack any part of the body, and is transmitted by contagion from one part to another. In children who have ringworm of the scalp more or less ringworm of the body is almost sure to be found at one time or another. A rather rare form of ringworm of the body shows itself as a somewhat raised, inflammatory patch beset with crowded follic- ular papules, papulo-pustules or pustules. Usually but one or two areas are present, of 2 cm. to 5 cm. in diameter, rounded in outline and showing considerable infiltration and thickening. The patches usually occur on the buttock, forearm or back of the hand. In the latter locality it constitutes what Leloir de- scribed as "discoid suppurative perifolliculitis." * * Leloir, Sur un Variete Nouvelle de Perifolliculitis Suppurees et Conglomerees en Placards, Annates de Derm, et de Syph., 1884, p. 436. RINGWORM OF THE SCALP. 441 The hairs of the area drop out and occasionally a boggy, pseu- docarbuncular aspect is produced, somewhat resembling kerion of the scalp. Tinea cruris occurs in the genito-crural region and beginning like ordinary ringworm spreads rapidly, favored by the heat and moisture of the part, until a considerable area is involved. The disease resembles eczema very closely, but a slightly raised, sharply defined border may usually be distinguished. The diagnosis of ringworm of the body is usually not diffi- cult. The growth and charac- ter of the patch, the tendency to disappear in the center and to spread upon the periphery are characteristic. Psoriasis occurs in rings but the scales are more abundant and coarser and the distribution is quite Fig. 83. — Ringworm ot inflammatory different. (Set Psoriasis.) The kerion-type on back of hand. (Discoid circinate syphiloderm has fewer suppurative perifolliculitis. Leloir.) scales, a more dusky color and more infiltration. Eczema seborrhceicum as it occurs in rings on the sternal and inter- scapular region, resembles ringworm closely, but the scales are more adhesive and greasy, and the glandular openings are in- volved. Microscopic examination of the scales will determine the diagnosis in doubtful cases. RINGWORM OF THE SCALP. Ringworm of the scalp is characterized by one or more, usu- ally circular, variously-sized, more or less bald patches, covered with ashen-gray scales, with a "goose-flesh" appearance and numerous small, broken-off stumps of hair. Sometimes the dis- 442 DISEASES OF THE SKIN. ease is disseminated, when a search through the scalp will show black points scattered here and there, which are the stumps of p IO g 4 — Ringworm of the body and scalp in the same individual. diseased hairs broken off level with the scalp. Ringworm of the scalp is a disease of childhood, and is not met with in the adult. RINGWORM OF THE SCALP. 443 It is highly contagious among children. Microscopic examina- tion shows the hairs filled with roe-like spores, infiltrating their tissue and rendering them highly brittle. The diagnosis of ringworm of the scalp is usually easy. The only disease with which it is liable to be confounded is alopecia areata,* but here the hairs fall out entire, leaving a smooth, ivory- like surface. Now and then squamous eczema of the scalp looks like ring- worm, but there are no broken-off hairs. The treatment of the ringworm of the scalp is tedious and difficult, because it is hard to get the remedies down to the roots of the hair, where the fungus greatly flourishes. Of the great number of remedies constantly turning up almost all would be good if they could be gotten into contact with the fungus, but the best will fail if it cannot be made to reach the last and remotest spore in the deepest hair follicle. As a preliminary to treatment the hair should be cut short, scales should be cleansed from the scalp, and the diseased hairs should be pulled out by means of convenient forceps, immedi- ately after which the parasiticide should be applied. In boys, when the eruption is extensive, the scalp may be shaved from time to time. Daily depilation of diseased hairs is an exceed- ingly troublesome, but very necessary procedure. It may be greatly aided by the employment of Bulkley's depilating sticks composed as follows : 1^. Cerae flavae oiij (12.) Laccae in tabulis, ! oiv (16.) Resinae, 3vj (24.) Picis Burgundicis, ox (40.) Gummi Samar, oiss. (48.) This compound is to be melted and moulded into sticks six to eight centimeters in length and one centimeter in diameter. When moulded for use, the end of the stick is warmed in a flame until it begins to melt and is then pressed down upon the * In exceptional cases the loss of hair in ringworm of the scalp is rapid and complete, the hairs not breaking off at the surface level but falling out complete ("bald ringworm"). Such cases are difficult to diagnosticate, but the presence of ringworm at other points may usually be demonstrated. 444 DISEASES OF THE SKIN. diseased patch with a slightly circular motion. In a few minutes when the gummy stick has cooled sufficiently it may be jerked off with a quick motion and will bring away a score or more of dis- eased hairs at once. Some practice is required to operate with- out giving unnecessary pain and in particular not to burn the patient by applying the stick to the scalp while too hot. As the hair invariably breaks off, depilation is incomplete. But by this means we remove a mass of the fungus and allow the penetration of the remedy more deeply than otherwise. Among local remedies, carbolic glycerine is one of the best. It may be applied to the diseased patches in strength varying from i in 8 to i in 3, according to the age of the patient, while a weaker lotion of the same should be rubbed in over the scalp generally to prevent drying of the scales and spread of the conta- gion. Laillier, as the result of an enormous experience at the St. Louis Hospital, in Paris, recommends solutions of corrosive sublimate, i to 300 to 1 to 1000. Of course, a certain amount of caution should be observed in the application of this remedy. Thin employs sulphur ointment, one drachm (4.) to the ounce (32-)- Iodized collodion, 1 to 30, has sometimes been employed with success. An ointment highly recommended by Alder Smith is the following: 1^. Acid, carbolic, cryst., Ung. hydrarg. nitrat., Ung. sulphuris, aa oss. (16.) M. The ingredients are to be mixed without heat. This oint- ment may be used in children over eleven years of age. Under this age it is advisable to use a double proportion or even more of the sulphur ointment. This may be used once a day over the entire scalp, the patches themselves being rubbed twice a day. As made in this country, it is apt to be very soft, which is an incon- venience. In disseminated ringworm of the scalp, oleate of mer- cury (a five per cent, solution in children under eight years of age, and a ten per cent, solution in older children) may be used. RINGWORM OF THE SCALP. 445 The oil is to be rubbed in nightly with a sponge mop, care being taken not to allow it to run over the face; a cap should be worn at night. When the scalp is very irritable and the application of any of these remedies causes inflammation and superficial crust- ing, the following ointment may be used with advantage: 1$. Ol. cadini, Sulphuris, Tinct. iodini, aa. . . . oiss ( 6.) Acid, carbolic, n|xx-xl ( 1.60-3.2) Adipis benzoat., 3iv. (16.) M. In weakly children cod-liver oil, arsenic, and iron are often required, and should always be prescribed if the case seems to demand them, or if the eruption spreads from one place to another while under treatment. The prognosis of ringworm of the scalp should be guarded as to the time required to effect a cure. In cases of average se- verity, if there are several coin-sized patches of disease, and if the hairs are at all markedly involved, four months, at least, of careful treatment will usually be required to effect a cure. When the disease is disseminated a much longer time will be required. A cure should not be promised, unless all directions as to shaving, depilation, etc., are faithfully carried out. In cases where kerion forms, as the result of treatment, or in the course of the disease, a more rapid cure may be expected. Tinea kerion is an inflammatory and suppurative form of ringworm of the scalp. It shows smooth, yellow, reddish, or purplish patches, more or less raised, cedematous, and boggy. They are honeycombed and studded with yellowish, suppurative pits, the openings of the distended hair follicles deprived of their hairs, which discharge a mucoid, gummy, honey-like fluid. The lesions sometimes itch, burn, and pain. In severe cases baldness results. The condition sometimes supervenes to a mild degree during the treatment of ringworm of the scalp. The treatment is the same as for the latter, excepting that lotions of sulphurous acid may be added to the parasiticides above men- tioned. Alder Smith has suggested the artificial production of 446 DISEASES OF THE SKIN. T. kerion by penetrating the hair follicles by a needle moistened with croton oil. This must be practiced with caution, and only over a small area, say a quarter of an inch square, at any one time, for fear of exciting too great inflammatory action. RINGWORM OF THE BEARDED REGION. Ringworm of the bearded region, or tinea sycosis, is not of such common occurrence as the disease on the scalp or general surface. Two types are observed, one superficial, and the other the deep-seated or nodular form. In the superficial variety the dis- ease begins very much as in the non-hairy regions, but the rings are not usually so typical in character. Commencing at one or more points in the beard the disease heals in the center as it spreads on the periphery and often encloses a rather large, irreg- ular area. Ringworm in this form does not show any tendency to pustulation but it may develop into the deep-seated f orm. The deep-seated variety begins on the surface, but soon in- volves the deeper structures and as a result more or less subcu- taneous swelling ensues and the affected parts assume a distinctly lumpy and nodular form resembling deep-seated furuncles or carbuncles. The nodules usually break down after a time and discharge at one or more of the follicular openings a glairy, glu- tinous, muco-purulent or purulent material which may dry to thick, adherent crusts. The eruption may involve the whole of the beard around the chin and neck, producing marked dis- figurement. It seldom involves the upper lip. The superficial variety of ringworm of the beard often closely resembles eczema seborrhceicum of this locality which is a very common affection. The tendency to form rings, or at least to spread on the periphery, is characteristic of ringworm and, of course, an examination of the scales will show the presence of ring- worm fungus. The deep-seated nodular form when fully developed can scarcely be mistaken for any other disease. In partly developed cases it RINGWORM OF THE BEARDED REGION. 447 sometimes looks like the nodular syphiloderm. The evident involvement of the hair follicles, the hairs being loose or having fallen out and leaving patulous openings, together with the pres- ence of the ringworm fungus abundantly in the hairs, will decide Fig. 85. — Rinj ;\vorm of the beard, deep seated variety (tinea sycosis). (From a model by Baretta.) the diagnosis. This last feature also will distinguish singworm of the beard from ordinary sycosis. The latter is a more super- ficial, pustular disease and the hairs are adherent to their sheathes and extracted with some difficulty and pain. In the treatment of ringworm of the bearded region extraction 448 DISEASES OF THE SKIN. of the diseased hairs should invariably precede the application of remedies. The hair of the beard generally should be kept close clipped so as to admit careful inspection in order to fore- stall the development of new foci of disease. The remedies suit- Fig. 86. — Hair from tinea sycosis. able for other forms of ringworm are called for here but, in par- ticular, lotions of sodium hyposulphite 3j a d Sj (4. ad 32.) may be sopped on, followed by a 10 to 20 per cent, sulphur ointment as recommended by Stelwagon. Dilute solution of sulphurous TINEA IMBRICATA. 449 acid may also be used. In some cases Stelwagon recommends the use of a corrosive sublimate lotion, from i to 3 grains (0.065- 0.20) to the ounce (32.) followed by a 10 per cent, oleate of mercury, calomel or white precipitate ointment. I have found an ointment of pyrogallol, 3 ss ~j to 5j ( 2 -~4- to 32.) very valuable in some cases. TINEA IMBRICATA. This affection, known also as Burmese ringworm, Malabar itch, and by various other designations, is a vegetable parasitic disease peculiar to trop- ical countries. The disease begins at one or several points as a brownish, slightly raised spot which spreads at the periphery to almost half an inch in diameter, when the central part of the dry epidermis cracks, becomes detached centrally and leaves a border or ring with the epidermis curling up on the inner side As this ring increases in size on the outer edge a new lesion forms in the center so that when fully developed several concentric rings are seen. Sev- eral of such rings may become joined together forming irregular serpentine lesions and the whole surface may become invaded by the disease. The effect is like that of a surface of "watered silk." The disease is due to a vegetable parasite resembling that of ordinary ringworm but distinct from it. The treatment is that of ordinary ringworm, but the clothing should be sterilized or burned, as relapses are common. TINEA VERSICOLOR. Tinea versicolor is a vegetable parasitic disease, characterized by variously- sized and shaped furfuraceous, macular patches of a yellowish-fawn color, and occurring for the most part on the upper portion of the trunk. The disease begins by the formation of pin-head and split- pea-sized, yellowish spots, usually scattered here and there over the affected region. These grow gradually larger and coalesce, forming hand-sized and even extensive patches, with extremely irregular margins sharply defined against the sound skin. There may be only a few patches, or, on the other hand, the disease may be quite extensive. The patches are usually more or less scaly. The disease does not usually itch in cool weather but when the pa- tient grows warm and sweats, there is apt to be a good deal of itch- 29 45° DISEASES OF THE SKIN. ing. In some cases, there is never any itching. The chest and back are the parts usually and chiefly affected, the disease also spread- ing down the flanks, and over the buttocks, abdomen, and groins. The disease rarely extends above the shirt-collar, below the elbows or below mid-thigh. Practically, it is an affection of the trunk, which often presents a mapped appearance, owing to the pecul- iar and irregular configuration of the lesions. The disease usu- ally spreads slowly, and without treatment may continue for an Fig. 87. — Microsporon furfur. (X500 diameters.) indefinite period. Relapses are not uncommon, even when the treatment has been most judicious. The disease is due to the vegetable parasite known as the microsporon jurfur. The fungus consists of mycelium and spores, the latter being disposed in distinct groups or masses. The para- site luxuriates in the corneous layer of the epidermis, sparing the rete, hairs and true skin. TINEA VERSICOLOR. 45 1 The diagnosis of tinea versicolor is not usually difficult. The seat of the disease is commonly upon the trunk alone, and, where- ever else it occurs, it is always to be found there. Vitiligo, chloasma, and the macular syphiloderm are the diseases with which T. versicolor is most apt to be confounded. In vitiligo, however, the patches are rounded and white ; it is the surrounding skin which is dark; in chloasma the face and forehead are the chief seats of the disease, and are rarely spared, while in T. versicolor the face is never attacked. The macular syphiloderm does not often occur in large patches and sheets, and it is not con- fined to the localities of T. versicolor; also, there are almost in- variably concomitant symptoms of syphilis. From all these affections T. versicolor is distinguished by its proneness to itch. Finally, a microscopic examination of a few of the scales, to which a drop of liquor potassae has been added, under a power of 350 to 500, will show the peculiar and characteristic fungus, which, it may be remarked, is different from both that of ring- worm and that of favus. The treatment of tinea versicolor is simple, and, if thoroughly carried out, quite efficacious. The best plan is to anoint the affected parts with sapo viridis, well rubbed in daily, for a week, avoiding the contact of water. After a pause of forty-eight hours, a hot bath, with soap, is taken and the disease, if mild and recent, will be found to have disappeared. If some remains, the same process may be repeated until a cure is effected. Another excel- lent application is sulphite of sodium, in the form of a lotion, one drachm to the ounce of water. Whatever treatment is employed must be thoroughly applied. If a single patch is left untouched the whole disease may return. Two or three weeks usually suffice for a cure if the remedies have been well applied; but the patient should be inspected a little later, to see if the disease has begun to crop out again in some obscure point. From its nature T. versicolor is contagious. I have never been able, however, to demonstrate the fact of con- tagion in practice. 45 2 DISEASES OF THE SKIN. ERYTHRASMA. Erythrasma is a vegetable parasitic disease characterized by reddish-brown patches, presenting in situations where there are moist and opposing sur- faces, as the genito-crural and auxiliary regions. The affection is of slow development, beginning in the form of small spots of a reddish-brown or orange-red color and usually in the genito-crural region. The spots grow and coalesce into sheets and confluent areas, but rarely go beyond the groins and axillae. There is little or no itching. The disease is caused by a vegetable parasite, the microsporon minutissi- mum, about one-third the size of the microsporon furfur and showing no groups of spores like the latter. Erythrasma is to be distinguished from tinea versicolor, which it closely resembles. It pursues a slower course, however, and does not show the same tendency to spread beyond its chosen areas. Tinea circinata is more inflammatory and pityriasis rosea more patchy and diffuse. A somewhat higher power of the microscope is required to detect the spores but these are characteristic. The treatment is the same as that of tinea versicolor. Pinta Disease.* A contagious affection of certain tropical countries characterized by the appearance of whitish, bluish-gray or blue, or even black, scaly spots appearing first most frequently upon the face or neck but developing also upon other exposed regions', as the forearms, hands, lower part of the legs and feet and upper part of the chest. The palms and soles are not invaded. Occasionally the mucous membranes are invaded. The disease spreads by extension and is sometimes after a long time accompanied by thickening and Assuring of the skin in the folds. It is due to a fungus of the aspergillus class. The treatment is that of the vegetable parasitic dis- eases. Perhaps iodine and chrysarobin are the best drugs to use. ACTINOMYCOSIS.! Actinomycosis of the skin is an affection due to the ray fungus, characterized by a sluggish, red, nodular, or lumpy infiltration, usually with a tendency to break down and form sinuses and most commonly involving the cervico-facial region. The usual situation of the disease is about the jaw, neck, and face. The organism finds entrance through the mouth, most frequently to the jaw through a decayed tooth. The first evi- *See Barbe, Annates de Dermatol, et de Syph., 1898, p. 985 (with a colored plate), and La Pratique Dermatotogique, T. i, p. 1900. fThis description is taken from Stelwagon, I. c. ACTINOMYCOSIS. 453 dence is a hard, subcutaneous swelling or infiltration which may attain moderate or quite conspicuous dimensions, the over- lying skin soon becoming of a sluggish, dark red color. Soften- ing occurs sooner or later with the occurrence of sinuses oozing sero-purulent or purulent, sometimes sanguinolent fluid. Con- tained in the discharge are minute, friable, yellowish or yellow- ish-gray bodies composed of the fungus. The disease spreads until quite an area is involved with a nodular irregular mass of a bluish, red or red color with here and there openings from which oozes more or less discharge. The course of the affec- tion is slow. There are no subjective symptoms. The disease is due to the actinomyces or ray fungus. It is con- tagious by inoculation and is commonly contracted from cattle and horses and therefore is seen among those having to do with these animals. It is rare in this country. The actinomyces fungus consists of a central network mass of interwoven threads, from which the mycelia radiate like pro- jecting rays. The fungus is usually readily demonstrable, both in the discharge (the yellowish grains), and in the tissues. His- tologically the nodular and infiltrated mass is made up of granu- lation tissue, having a resemblance to that of round-celled sar- coma; in some instances epithelioid, giant cells and mast cells are to be seen. Actinomycosis is to be distinguished from syphilis, sarcoma, carcinoma, tuberculous affections, mycetoma, and phlegmon- ous inflammation. The presence of disease, particularly about the lower jaw, the history of infection, and especially the pres- ence of the peculiar yellowish bodies all help to make the diag- nosis likely. A m croscopic examination of the discharge or of the tissues would make the diagnosis certain. The prognosis of the disease is generally favorable, unless some part, as the orbit or some internal organ, is attacked. The treatment consists in the removal of the local lesions by curet- ting, etc., followed by strict antiseptic treatment. Iodide of potassium has been given internally with success in some cases while in others it has failed. 454 DISEASES OF THE SKIN. MYCETOMA. This disease, known also as fungous foot of India, is an endemic affection occurring chiefly in India,* and characterized by swelling and the formation of tubercular or nodular lesions which tend to break down and form sinuses leading into the subcutaneous structures, and finally resulting in disintegra tion of the affected part. The disease usually occurs in one foot, more rarely in the hand or shoulder. Furunculoid swellings or tumors appear, blebs form on the sur- face which become the point of exist of sinuses, giving exit to whitish gran- ules or black, roe-like masses, mingled with a sanious discharge. The parasite finds entrance to the skin through some slight traumatism, as a splinter, etc. The organism is the actinomyces madurce consisting of mycelium of branching threads and hyphae and ovoid spores. There are two varieties, the black and yellow, and the small black and yellow gran- ules discharged from the sinuses are made up of masses of fungi closely re- sembling the ray fungus. Sections of the tissues involved show branching sinuses and cavities filled with a fatty or gelatinous substance, hard and dark in the black variety, soft and ochre-colored in the yellow. The disease maybe distinguished from actinomycosis by its origin, locality, clinical features, and finally by microscopic examination of the fungus. The disease pursues a chronic course sometimes lasting ten or twenty years, and leading inevitably to destruction of the parts involved. Surgical removal offers the only relief. Care should be taken to leave no trace of disease behind or recurrence may confidently be expected. BLASTOMYCETIC DERMATITIS.f Blastomycetic dermatitis is an inflammatory affection of the skin, due to the yeast fungus or blastomyces, and characterized by the appearance of papules or papulo-pustules which increase peripherally while flattening in the center so as to cover consider- able areas. The lesions when fully developed are covered with a crust, the removal of which shows a papillomatous surface. The disease begins as a papule or papulo-pustule which slowly *Five cases have been reported in this country, two by Hyde, Senn and Bishop and by Adami and Kirkpatrick, Jour. Cut. Dis., 1896, and three by Pope and Lamb, N. Y. Med. Jour., 1896, p. 386, Wright Trans. Assn. Am. Phys., 1898, p. 471, and Arwine and Lamb, Am. Jour. Med. Set., 1899, p. 393. fSee the papers of Gilchrist, Johns Hopkins Hosp Rep., 1896, vol. i, p. 269; Hyde, Hektoen and Bevan, B. J. Derm., 1899, p. 261, and F. H. Montgomery, Jour. Am. Med. Assn., June 7, 1902, for full description and illustrations. pediculosis. 455 spreads while flattening down in the center and showing a crust. The removal of this crust shows a papillomatous surface with, later, purulent deposits at various points. The border of the patch is elevated, reddish, usually of a deep red tinge and well- defined by moderate infiltration. In the older parts of a diseased patch healing may take place, the surface skinning over and exhibiting a thin atrophic or scar-like appearance. The affection has usually been observed in the back of the hand, face and lower part of the leg, but may occur elsewhere, new foci of dis- ease sometimes appearing at some distance. The disease is rare. It has usually been observed in men over forty. Investigations have disclosed the yeast fungus as the cau- sative agent. The histopathologic characters are in a measure similar to those found in tuberculosis verrucosa cutis, the bla- tomyces being found chiefly in miliary abscesses in the tissues. The disease is to be distinguished from tuberculosis verrucosa cutis, the vegetating syphiloderm and lupus vulgaris. The bor- der of the tuberculous lesion, however, has a deeper and more violaceous color and is less likely to be extensive. The syphilitic disease is more rapid in its development and shows much more purulent discharge. Lupus vulgaris is relatively slow in its course, with a more distinct ulcerative tendency and frequently rather tough, firm scarring. Microscopic examination alone, however, will in some cases decide the diagnosis. The treatment should include the internal administration of iodide of potassium which has in some cases proved valuable, but most reliance should be placed upon local measures. Anti- sepsis, curettage and the X-ray may be employed. B. DISEASES DUE TO ANIMAL PARASITES. PEDICULOSIS. Pediculosis (lousiness) is a contagious animal parasitic affec- tion, characterized by the presence of pediculi or lice, and the lesions which they produce, together with scratch marks and excorations, accompanied by itching. Three varieties of the dis- 456 DISEASES OF THE SKIN. ease are encountered, which are designated, according to the locality affected, viz., pediculosis capillitii, pediculosis vestimen- torum, and pediculosis pubis, or head, body, and crab lice. Pediculosis always occurs as the result of contagion; a spon- taneous origin of the parasites is quite incredible. The pedic- uli do not bite, but are furnished with a sucking apparatus, which they insert into the mouth of a follicle, and obtain blood by the means of this. The diagnosis of pediculosis may almost always be made by finding the parasites, but these are frequently few in number in any given case, and must be carefully searched for, remembering in the case of each variety its special habitat. When the pediculi cannot be found, the location of the scratch marks offers valuable circumstantial evidence pointing to the parasitic character of the disease. In the scalp and pubis the presence of nits or ova may almost always be made out, and also at times in the seams of the clothing, and they, of course, are distinctive. The prognosis of pediculosis is always favorable, and when the directions are carried out faithfully, a speedy cure may be expected. Pediculosis capillitii is due to the presence of the Pediculus capitis, or head louse. It is the commonest form of pediculosis. The parasite is found on the scalp alone, the occipital region being the favorite seat. The lice are sometimes found in the scalp and sometimes on the hairs. The ova, or- "nits, " small whitish, pear- shaped bodies, glued to the hairs by the smaller end, some dis- tance from the scalp, resemble scales of epidermis. Head lice are usually met with among women and children of the poorer class, though they are sometimes found on persons of refinement, where they appeared to have been contracted on sleeping cars while traveling or in other accidental associations. The para- sites attack the scalp and give rise to considerable irritation, itch- ing, and consequent scratching. Effusion of serum, pus, and blood results from this, and the hairs become matted together in a crust. Lice, as a rule, cause more mischief in those who are poorly nourished and ill-cared for. The majority of cases of eczema in the back of the head, in the poorer class of children, PEDICULOSIS. 457 are caused by lice, and Dr. J. C. White has pointed out that, in children, when a characteristic form of eczematous eruption can be seen about the mouth, the nostrils, and the ears, the lobes especially, the diagnosis can almost certainly be made of pedic- ulosis capillitii. This eruption, in some respects, resembles that of impetigo contagiosa. When the affection has existed for some time there is a disgusting odor about the scalp; the patient loses sleep from the itching; the mind becomes harassed, and the general health may be more or less impaired. The best treatment for head lice is to saturate the scalp nightly, for several successive times, with kerosene, care being taken not Fig. 88. — Ova of pediculus capitis (nits) attached to hairs. Fig. 89. — Pediculus cap- itis, (female.) to allow the oil to trickle down over the face and neck, for fear of its causing excoriations. A nightcap is to be used, and the head washed with castile soap and warm water in the morning. When kerosene cannot be used, the next best thing is the tincture of coc- culus indicus. Where, owing to shortness of hair and the presence of eczema, ointments can be employed conveniently and profitably, that of ammoniated mercury, in the strength of twenty to sixty (1.30-4.) grains to the ounce (32.), wall be found useful. An ointment of one drachm (4.) of powdered stavesacre seeds to the ounce (32.) of lard is also a good remedy. The nits, which are, however, usually killed by the applications of kerosene, are to 458 DISEASES OF THE SKIN. be removed by repeated washings with soda or borax washes, soft soap, vinegar, dilute acetic acid, or alcohol. Greenough thinks the following formula best in the majority of cases : 1$. Acid, carbolic, gr. xv-xxv ( 1.-1.60) Petrolati., §j. (32.) M. This not only destroys the lice, he says, but sterilizes the ova. Persian insect powder (pulvis pyrethri) may also be used. The scalp should be dried of moisture and the powder should be dusted or blown through a tube or blower, sold in the shops for such purposes. A muslin cap should then be placed on the head and retained for an hour or so, after which the scalp should be washed out with vinegar and water to kill the nits, which are not de- stroyed by the powder. It is seldom or never necessary to cut the hair. In children it is often more con- venient to do so, but in adults it is an unnecessary sacrifice, which may be avoided by patience in relieving the hair of pediculi and nits. The head coverings should be destroyed or thoroughly disinfected by baking or boiling. Pediculosis vestimentorum, or lousiness of the body, is produced by the pediculis corporis — body, or, more properly, clothes louse — which lives in the garments, and thence makes predatory excursions upon the skin. It is very similar to the head louse, but is considerably larger and somewhat longer in proportion to its breadth, and shows a blackish tinge on the back. Body lice are apt to be found along the seams of the clothing, partic- ularly where this comes in close contact with the skin, as about the neck, shoulders, waist and buttocks. As they move over the surface or attack the skin, they give rise to intensely Fig. 90. — Pediculus vestimento rum. (female.) PEDICULOSIS. 459 disagreeable, itching sensations. As the parasites multiply, the itching becomes so violent that the distress is almost unendu- rable; the scratching is generally severe, and long and streaked, or short and jagged scratch marks, with blood crusts and pig- mentation, are characteristic features of the disease. On close inspection, the primary lesions, which are minute, reddish puncta, with slight areola, may be seen marking the points at which the parasite has drawn blood. The chief seats of the lesions are the back, especially about the scapular region, the chest, abdomen, hips, and thighs. When the affection has lasted for months and years general pigmenta- tion may occur, as the result of long-continued irritation and scratching. Children are very seldom attacked. The disease is one of want, poverty, and neglect. It sometimes occurs among the better class of people, particularly in the aged; but even here it will be found to have been brought about by want of personal care. Occasionally one is consulted by persons suffering from what may be called pediculophobia. This is, in reality, a mental affection or a neurosis of the skin. Itching can hardly be pres- ent in the ordinary sense of the term, but undoubtedly there must be some perversion of sensation. On examination the skin is found to be absolutely free from symptoms of disease. Such cases require to be managed with much tact. A local placebo with attention to the general health may be used in some cases with success. To get rid of body lice, a hot bath, with soap, should be taken, while the clothing is being heated in an oven or boiled, or when this cannot be done, ironed along the seams with a hot iron, to destroy the parasites with their ova. After the bath, inunctions are to be practiced with an ointment of powdered stavesacre seeds, two drachms (4.) to the ounce (32.), digested in hot lard and strained. A lotion of carbolic acid is useful to allay the itching: 1^. Acidi carbolici, oiij ( 12.) Glycerinae, f o j ( 32.) Aquae, Oj. (480.) M. 460 DISEASES OF THE SKIN. The following is even better in old cases: J\. Acidi carbolici, 5ij ( 8.) Potass, caustic, 5j ( 4-) Aquae, fgiv. (128.) M. The potash is dissolved in water, and slowly added to the carbolic acid in a mortar. The wash should be much diluted before applying. The disinfection of clothing should be carefully carried out, and must be repeated again after a few days, if it has not been entirely successful. Pediculosis Pubis. The pediculus pubis, or crab louse, though usually found on the pubis, is also encountered in the axillae, sternal region, and beard, in the male, and in children, especially, upon the eyebrows and eyelashes. Crab lice are found adhering closely to the hairs at the surface of the ^1^15^ skin; their strong claws permit them to $s take such hold of the hairs that they %^^^^S^\^ are often detached only with difficulty. The ova are very much like those of the pediculus capitis, but smaller and ^ISPIHIC^ are f° un d firmly attached to the hairs. They infest adults chiefly, and give Fig. qi. — Pediculus pubis. • ,-■ ,1 ,1 1 rise to the same symptoms as the other pediculi. Although almost always contracted in sexual inter- course, yet they now and then find their way to the pubis of persons who are entirely unable to account for their presence. They may occur from sleeping in berths of sleeping cars, etc., or from water closets. The amount of irritation caused by their presence varies with the individual; it is, as a general thing, comparatively slight. Crab lice may be removed by the application of tincture of cocculus indicus, of full strength or diluted, or by any of the ointments or lotions used in the other forms of pediculosis. Mer- curial ointment, the well-known popular remedy, is no more effectual than the others, and makes a nasty mess. Its use, in general, is to be avoided, in favor of any of the other applica- ANIMAL PARASITES OF MINOR IMPORTANCE. 461 tions. Covering the pubis for a few moments with a cloth satur- ated with a small quantity of chloroform will kill all living crab lice instantly. The hair may then be washed with hot soapsuds, sponged with vinegar, and combed. The sponging with vinegar may be continued once or twice daily for a week, to get rid of all nits. When patients will permit, shaving the pubis shortens the cure greatly. ANIMAL PARASITES OF MINOR IMPORTANCE ATTACKING THE SKIN. Cimex lectularius, or bed-bug, is an insect of universal distribution. It simply goes to the skin for nourishment, puncturing it, injecting, in all prob- ability, an irritating fluid, and sucking blood. An inflammatory papule or wheal results, sometimes purpuric in character, which may last for days. Several punctures are sometimes made in a group which are seen covered with a blood crust. The legs, especially in the neighborhood of the ankles, are a favorite point of attack. Sometimes considerable irritation and pustu- lation is caused by scratching. The condition at times resembles urticaria, but may be distinguished by the hemorrhagic tendency, central puncture and persistence of the wheals not seen in urticaria. Pulex irritans, or flea, is of general distribution over the inhabited world but is perhaps more common in tropical countries. The irritation caused by it varies in different individuals. The most usual lesion is a small ring- like erythematous spot with a minute, central hemorrhagic point marking the place of attack. It has sometimes been mistaken for purpura. In some persons the lesion is barely perceptible and gives rise to no discomfort. In others urticaria-like lesions with more or less persistent itching,, tender- ness and a burning feeling may result. The puncture of the insect leaves a minute, central hemorrhagic point which is characteristic from a diagnostic point of view. Washes of camphor, thymol, menthol or carbolic acid or a combination of these will give relief and by their odor discourage the visits of the insects. Travelers, especially women, find a small piece of camphor suspended around the neck in a bag a sometimes efficient preventive. Stel wagon says that small bags containing powdered pyrethrum stitched inside the clothing at various points will produce an atmosphere repugnant to fleas. Ixodes. Of the ixodes or ticks there is a great variety, of which the ixodes bovis is a type. These parasites are transmitted to man from the domestic animals, as the cow, sheep, etc., or are picked up in the woods They are practically leathery bags with lancet-like mandibles and suction 462 DISEASES OF THE SKIN. apparatus. When the bag is empty the legs can be employed in locomotion, but when filled with blood the tick is a pea-sized, red ball with the legs ex- tended and lying flat upon the surface. It fastens itself to the skin by two small claw T s extending on each side the suction apparatus. The tick does not inject venom and therefore does not give rise to burning or itching sen- sations. It may be detached from the skin by dropping a little essential oil, as oil of cloves, upon it, or benzine or ordinary kerosene. If the tick once becomes imbedded in the skin it cannot be pulled out. The body sep- arates from the head, leaving the latter under the skin, where its presence gives rise to inflammation and suppuration. Fig. 92. — Ixodes bovis. (Riley.) Fig. 93. — Dermanyssus gallinae. (Chicken louse.) Closely allied to the ixodes by nature, although different in appearance, is the argas, or dove -tick, found in dove cotes and pigeon roosts, from which it spreads to human habitations. This tick has its legs, as well as its mouth and suction apparatus, situated on the under surface, so that when attached to the skin it sometimes looks like a minute clam-shell closely adherent to the surface. Unlike the ixodes, this form of tick injects venom, and thus becomes very irritating to the skin. Moreover, as it only remains on the skin while feeding and moves from host to host, it may be the means of transmitting disease. When the dove-tick invades a human habitation it may become a perfect plague. Unlike the ixodes it is nocturnal, and is apt to attack the uncovered parts. The effects of its venom are sometimes se- vere, giving rise, in persons subject to urticaria, to severe attacks of this af- fection or to localized oedema. Belonging to the acari is the dermanyssus gallince, or hen louse, found in hen-houses and dove-cotes. It is different from the argas, or dove-tick, in appearance and habits and is apt to occur in persons living close to hen- houses or having much to do with fowls. The eruption is a dermatitis from scratching and is very itchy. It is confined to the arms and legs. Carbolic washes or inunction with a mild sulphur ointment constitutes the treatment . Disinfection of the habitation of the fowls should, of course, be practiced. SCABIES. 463 Other parasites which attack the human skin for nourishment are the mosquito {culex anxijer), gnat {culex pipiens), and certain kinds of flies and other insects, which give rise to erythematous and urticarial lesions varying in intensity in different individuals, but usually being more more severe in chil- dren. Some insects, as bees, wasps, spiders ants, caterpillars, etc., only irrit- ate the skin inadvertently or on self-defense The remedies mentioned above, and, in addition, tincture of camphor or dilute ammonia water may be employed to mitigate the pain. A 2 or 3 per cent, solution of menthol, oil of eucalyptus, or tar oil may be spread upon the surface to prevent the attack of the insects just mentioned. SCABIES. Scabies, or "the itch," is a contagious, animal parasitic disease, a sort of eczema or dermatitis, caused by the presence of the acarus or sarcoptes scabiei in the skin. It is highly The Fig. 94. — Sarcoptes scabiei. (female.) Fig. 95. — Sarcoptes scabiei. (male.) female itch mite no sooner finds itself on the skin than it begins the work of burrowing, forming, just below the surface of the skin, a burrow in which the eggs are laid, the faeces deposited, and in which the itch mite lives. The male is said never to enter the skin, but to live upon the surface. After a time, a certain num- 464 DISEASES OF THE SKIN. ber of young itch mites are hatched forth, all of which begin at once to take care of themselves, and to burrow. Thus, the early symptoms of the disease are caused by the irritating presence of these parasites at various points, and characterized by the formation of minute, more or less inflammatory, puncta, papules, and vesicles. Later, the burrows can be seen in the shape of more or less tortuous, beaded, yellowish or blackish lines, not thicker than a thread, and one-eighth to one-quarter of an inch in length. Later still, scratch marks, blood crusts, etc., show themselves, and the disease spreads day by day. The affection usually begins about the hands, and especially about the fingers. The wrists, the penis in men, and in women the mammae, are next involved. The other softer and more protected parts of the body are then invaded. The anterior fold Fig. 96. — The female acarus in its tunnel showing ova, evacua- tions and detritus. (After Kaposi.) of the axillae and the buttocks are very apt to be attacked. The lower limbs are generally spared, excepting the feet in children. Itching, oftentimes very severe, is a marked feature of the disease, increasing in severity with its extension. It is worse at night, when the patient is warm in bed. The cause of scabies lies, as has been said, in the irritating presence of the itch mite in the skin. It is so contagious that it may be conveyed by bedding or clothes, or even by a shake of the hand'. It is not a common disease in this country, occurring only in the proportion of one per cent, among all skin dis- eases. In Europe, on the other hand, the unwashed populations furnish a larger proportion of scabies than of any other skin SCABIES. 465 disease. The recent increased immigration of Italians, Poles, etc., has much increased the percentage of scabies in public clinics in our large cities. The "army itch," frequently encountered in closely quartered Fig. 97. — Scabies showing a favorite seat of the disease. armies, is a severe form of scabies. Other names are given to the disease, depending upon the real or supposed origin of groups of cases, as "Hungarian itch," "Polish itch," "Italian itch," "lumbermen's itch," etc. The affections formerly known as 30 466 DISEASES OF THE SKIN. "grocer's itch" and "baker's itch," on the other hand, are forms of eczema. The diagnosis of scabies is, as a rule, not difficult. The pres- ence of the burrow is sufficient to decide the matter, and this should be looked for in every suspected case. The mite itself may usually be extracted from the minute vesicle at the end of the burrow by the aid of the point of a pin or needle, but fail- ure to capture it need not be regarded as negative evidence in the diagnosis, for it requires a good light, sharp eyes, and some dexterity to succeed. The burrows must not be confounded with irregular lines of epidermis filled with dust or dirt. The resemblance is, at first sight, strong. In the majority of cases the burrows are only to be detected upon the sides of the fingers, or on the flexor surface of the wrists. The regions of the body mentioned as the favorite seat of scabies must be taken into con- sideration in making the diagnosis, and finally, it must be remem- bered that other affections may be concurrent with scabies upon the body. Once recognized the disease is, in most cases, easily cured. The great point is to use the applications in such a manner that the parasite may be destroyed without undue irritation of the skin, and, indeed, with relief to this condition. When the case is recent, a cure can be rapidly and easily effected, but when of old standing there is apt to be a good deal of eczema in connection with the scabies, and after the parasite is destroyed the eczema remains for treatment. The following ointment seems to cure the eczema while killing the itch mite: 1$. Pulv. naphthol, 5j (4-) Ung. adipis, oj- (32.) M. On coarse skins sapo viridis may be used with the naphthol : 1$. Pulv. naphthol, 5iss ( 6.) Saponis viridis, 3v (20.) Cretae alb. pulv., 5j ( 4-) Axungiae, ox. (40.) M ANIMAL PARASITES OF MINOR IMPORTANCE. 467 A formula recommended by Stelwagon is; 1^. Sulphur sublimat., 5iv-vi ( 16. -24.) Bals. peruvian, 5iv (16. ) Beta, naphtol, 5i-ij ( 4--8- ) Adipis benzoinat., Petrolati aa q. s. ad §iv. (128. ) I have used one or another of these prescriptions almost exclu- sively, for several years past, and prefer them above all others. Sulphur is the old standard remedy, and may be used in the form of ointment, ranging in strength from one to four drachms to the ounce, according to the tenderness of the skin. The treatment, whatever it be, should be preceded by a hot bath with soft soap, after which the ointment should be rubbed in, and allowed to remain. After seven days of treatment, an inunction being made daily, and the underclothing remaining unchanged, the patient should bathe and report for inspection. Too vigorous a course of treatment may give rise to a dermatitis, which will require weeks to cure. The prognosis of scabies is always favorable; a few weeks will suffice in average cases, but the irritation of the skin requires longer treatment to overcome. ANIMAL PARASITES OF MINOR IMPORTANCE PENETRA- TING THE SKIN. The leptus, or harvest mite, more properly termed trombidium or tetrany- chus, is of several varieties. As it is usually met with it is in the immature or "leptus" stage. The appearance is depicted in the accompanying cuts. As met with in the Middle Atlantic States the harvest mite is a minute, active, brick -red-colored, elongate pyriform creature with six long legs barely visible to the naked eye. It is found in the axilla, upon the scalp and on other parts of the body, and more frequently upon children than upon adults. It does not completely bury itself in the flesh but insinuates the an - terior portion of the body only beneath the skin, causing a small inflamma- tory papule. The little red mite encountered in the swamps and low grounds in Pennsylvania, New Jersey and Delaware, especially about black- berry bushes, is in all probability the same species. Duhring recommends sulphur ointment as a treatment for the parasites. Ointments of balsam of Peru may also be employed. 4 68 DISEASES OF THE SKIN. Pidex penetrans, "chigoe," jigger or sand flea, is found in warmer or tropical climates. It inhabits dwellings and frequented forests, attaching itself indiscriminately to men and beasts. The buccal apparatus of this flea is furnished with mandibles carrying reverted spines, so that when the pulex has penetrated the skin it is detached with some difficulty. It has a pro- boscis almost as long as its body. The impregnated female perforates and burrows into the skin and in the course of a few days becomes enormously enlarged. The feet, especially about the toe-nails, are the especial seat of the para- site, and persons going habitually barefoot are much more likely to be at- tacked. Itching is first experienced, then pain, while a tumor appears which soon suppurates. The "jigger" can be found bathed in the pus of the Fig. 98. — Trombidium Americanum (tick.) (Century Die.) Fig. 99. — Leptus irritans. (Century Die.) Fig. 100. — Six legged carvae of leptus Jau- tumnalis. (Kuchen- meister.) abscess. It is smaller than the common flea, being about one and three-tenths millimeters in length. Unless treated the abscess tends to grow worse and gangrene has been known to result. The treatment is early removal by means of a needle, care being taken not to break the sac-like body and set free the ova. Strong carbolic acid should then be applied. Filaria Medinensis, sometimes called Dracunculus, or Guinea-worm dis- ease is an affection chiefly of tropical countries, caused by a parasitic worm. It is particularly common along the west coast of Africa, in Senegal and Guinea, and in Egypt, Persia, and India. It has also been met with in the West Indies. Cases have likewise been reported as occurring in this country, but usually in persons who have lived in tropical climates. The appearance presented is sometimes that of a cord under the skin, often of a dusky red color, sinuous and slightly raised above the general level of the skin. At other times, especially when the pregnant worm is ANIMAL PARASITES OF MINOR IMPORTANCE. 469 very much swollen and about to bring forth its ova, the lesion of the skin resembles a boil. Sometimes the parasite is single, at other times a great number, even hundreds, may exist under the skin, in the intermuscular areolar tissue and even in the parenchyma of some of the internal organs. The full-grown worm is from 2V to tV inch in thickness, and varies from several inches to three feet in length, according to its age. The young worm, when of microscopic size, finds its way by boring into the skin and deeper tissues, and there takes up its habitat, growing gradually, for months, with- out attracting attention, until it attains a sufficient size to excite irritation and inflam- mation. The disease is usually contracted in low swampy places, by persons who go barefoot, and usually attacks the feet and lower extremities, though the exact mode of entrance is unknown. The treatment com- monly employed in the countries where the disease is endemic consists in extracting the worm, inch by inch, and day by day, as soon as it makes its appearance on the surface, ^ ,_, .. a , . . rr . rio. 101. — I he jigger flea (cm- being careful not to break the creature during g0 e). (After Karsten.) the operation. Galvanism has also been applied with success, one pole of the battery being placed on the head of the worm, and the other held by the patient. Among medicines iodide of potassium in moderate doses has been em- ployed successfully, but the best treatment is that of Horton, by means of large doses of asafcetida (foj-ij, (4-8.) twice daily). Emily recommends the injection of a 1-1000 solution of bichloride of mercury into the little convoluted cord-like swelling produced by the Guinea- worm when she begins to approach the skin prior to piercing it; the worm is killed and gives no further trouble, being absorbed subsequently like a piece of aseptic cat-gut. He uses a hypodermic syringeful of the solution, in- jecting it through several punctures. Should the head of the worm be pro- truding he pierces the worm itself with the needle and injects the solution into her body. Next day she can readily be withdrawn. There is no pain and no inflammation and the duration of treatment is three or four days. Cysticercus Cellulosce. The cysticercus is found in the skin in about 5 per cent, of all affected cases. It is chiefly encountered in North Germany where raw or half -cooked pork is a favorite article of diet. The tumor caused by its presence is situated under rather than in the skin and varies in size from a large pea to that of a walnut, and is firm, round or ovalish in shape. There may be several or many. The tumors are usually not painful unless in- flamed. The outer skin does not usually show any change. After reaching 47o DISEASES OF THE SKIN. a variable size the tumors may become stationary or even retrograde when calcification of the contents has taken place. The trunk and to a less de- gree the extremities are the usual localities. Demodex jolliculorum is a minute, microscopic 'parasite found in the se- baceous follicles, chiefly those of the nose. It is entirely without signifi- cance in man, although in animals a similar parasite sometimes causes in- flammatory reaction. (Estrus (gad-fly; bot-fly). The larva of the oestrus, or bot-fly, sometimes gives rise to serious symptoms in the human being. The ibot-fly of cattle lays its eggs in the skin, opened for that purpose by its lancet-like ovipositor, about August, and when the egg is hatched the larva penetrates more deeply by means of hooklets attached to its head, and disappears entirely, being not more than fifteen millimeters in length by four in diameter. The larva develops slowly and produces no irritation for some time; it is about nine months before it becomes fully developed. When fully grown the larva of oestrus bovis is twenty-two to twenty- eight millimeters in length by eleven to fifteen millimeters in breadth. It then emerges from the skin. It is when about two-thirds grown — that is some six months after having been deposited in the skin — that the para- site begins to be felt, producing a furuncle-like lesion growing more and more painful, until the insect is finally expelled in the spring. The lesions usually occur on uncovered parts, as the scalp, neck, face and nucha. Some varieties, as the "Macaque," "Dermatobia noxialis," etc., occurring in Cen- tral and South America, are more severe in their effects than the oestrus. The treatment consists in opening the skin with a lancet and applying pure carbolic acid. Creeping Larvce. Under the name of " creeping eruption," '' larvae mi- grans," etc., a curious and rare disease of the skin has been described which is characterized by the appearance of a thin, red, serpiginous line, ele- Fio. 102. — Creeping eruption (larva migrans). (Courtesy of Stelwagon.) ANIMAL PARASITES OF MINOR IMPORTANCE. 47 1 vated or not, which extends from one or the other extremity sinuously from point to point under the skin. Any part of the body may be attacked but it is more usual in the extremities. It appears, in some cases, to have oc- curred after exposure in the bare feet to sandy seashores. The formation is due to a wandering larva which, it is said, may be perceived by pressing a piece of glass on the skin and examining it with a lens, when a minute black speck is seen. The treatment consists in applying a caustic just be- yond the apparent point of progression of the red line which marks the progress of the larvae, although in one case under my care the internal ad- ministration of large doses of asafcetida seemed to kill the parasite and put an end to the progress of the disease. Craw-Craw is a disease of the west coast of Africa, somewhat resembling scabies. The exact parasite is a subject of dispute. The eruption appears usually in the fingers and forearms, consisting of papules, vesicles and pus- tules, discrete or crowded, and sometimes with considerable crusting and is exceedingly itchy. There are no cuniculi, however, as in scabies. Baths and parasiticides constitute the treatment. The Echinococcus larva and the distoma hepaticum have both been found in the skin. They are described in works on internal medicine and on human parasites in general. INDEX Absorp ion, 22 Acarus scabiei, 463 Acanthosis nigricans, 224 Acne, 400 diagnosis, 404 etiology, 402 pathology, 404 treatment, 405 Acne cachecticorum, 403 Acne hypertrophica, see acne rosacea, 416 Acne indurata, 402 Acne varioliformis, 414 necrotica, 414 lupoid, 414 Acne vulgaris, see acne, 400 Acne rosacea, 415 diagnosis, 418 etiology, 417 pathology, 417 treatment, 418 Acromegaly, 253 Actinomycosis, 452 Adenoma sebaceum, 272 Adenoma of the sweat glands, 273 Ainhum, 263 Albinismus, 263 Alopecia, 376 idiopathic premature, 376 senile, 376 congenital, 376 symptomatic, 377 treatment, 377 Alopecia areata, 380 diagnosis, 383 etiology, 383* treatment, 384 Alopecia syphilitica, 387 treatment, 387 Anaesthesia of the skin, 351 Anatomical tubercle, 287 Anatomical wart, 287 Anatomy of the skin, 1 Arrectores pilorum, 10 Angiokeratoma, 244 Angioma pigmentosum et atrophicum, see xeroderma pigmentosum, 33° Angioma, see naevus vasculosus, 277 cavernosum, 277, 279 Angioma serpiginosum, 280 Anidrosis, 426 Animal parasites, diseases due to, 455 Animal parasites of minor import- ance attacking the skin, 461 Animal parasites of minor importance penetrating the skin, 467 Anthrax, see pustula maligna, 185 Ants, 463 Argas, 462 Argyria, 220 Asteatosis, 396 Atrophia cutis, 259 Atrophia maculata et striata, 260 Atrophia pilorum propria, 369 Atrophies, 259 Atrophy, cutaneous, see atrophia cutis, 259 unilateral facial, 260 Atrophy of hair, 369 * Bath pruritus, 343 Bearded woman, see hypertrichosis, 362 Bed-bug, 461 Bees, 463 Birth mark, see naevus vasculosus, 277 Blastomycetic dermatitis, 454 Blebs, 25 Bloody sweat, see haematidrosis, 429 Blood, tears of, see haematidrosis, 43° Blood-vessels of the skin, 7 Boil, Delhi, 319 Boil, see furuncle, 177 Bot-fly, 470 473 474 INDEX. Bromidrosis, 426 treatment, 427 Bullae, see blebs, 25 Bullous syphiloderm, Burmese ring-worm, 314 449 Callositas, 226 Canities, 374 Carbun cuius, 181 diagnosis, 182 etiology, 182 pathology, 182 treatment, 182 Carbuncle, 181 Carcinoma cutis, 321 Caterpillars, 463 Cauliflower excrescence, see verruca acuminata, 232 Cells, horn, 5 Cerumen, 21 Chloasma, 218 diagnosis, 219 etiology, 219 pathology, 219 treatment, 220 Chloasma, 218 idiopathic, 219 symptomatic, 219 uterinum, 219 Chicken-pox, see varicella, 209 Chigoe, 468 Chilblain, see dermatitis calorica, 193 Chromidrosis, 428 black, 428 See also seborrhcea nigricans Chromidrosis, red, 373 Cicatrix, 265 Cimex lectularius, 461 Classification, 30 Clavus, 225 Colloid degeneration of the skin, 277 Colloid milium, 277 Comedo, 398 treatment, 399 Cornu cutaneum, 235 Corn, see clavus, 225 hard, 225 soft, 225 Condyloma acuminata, 231 Corpuscles, tactile, 9 Corium, 5 Craw-craw, 471 Creeping larvae, 470 eruption, 470 Crusts, 27 Culex anxifer, 463 Culex pipieus, 463 Cutis pendula, see fibroma, 284 Cysticercus cellulosae, 469 Delhi boil, 319 Demodex folliculorum, 470 See comedo, 398 Depilatories, 366 Dermatitis, blastomycetic, 454 Dermatitis calorica, 192 Dermatitis congelationis, 192 Dermatitis exfoliativa, 61 diagnosis, 62 etiology, 62 pathology, 62 treatment, 63 epidemica, 63 neonatorum, 63 Dermatitis factitia, 202 Dermatitis gangrenosa infantum, 189 Dermatitis herpetiformis, 160 diagnosis, 163 etiology, 163 pathology, 163 treatment, 163 Dermatiis medicamentosa, 205 Dermatitis papillaris capillitii, 268 Dermatitis repens, 169 Dermatitis venenata, 195 diagnosis, 196 etiology, 195 treatment, 197 Dermatitis, X-ray, 200 Dermanyssus gallinae, 402 Dermatalgia, 352 Dermatobia noxialis, 470 Dermatolysis, 257 See fibroma, 284 Diabetic gangrene, 191 Diseases of the appendages of the skin, 353 Diseases of the nails, 353 Diseases of the sebaceous glands, 392 Dissection wounds, 184 Distoma hepaticum, 471 Dog-faced man, the Russian, see hy- pertrichosis, 364 Dracunculus, 468 INDEX. 475 Drug eruptions, see dermatitis medic- amentosa, 205 Ecchymoses, 23 Echinococcus larvae, 471 Ecthyma, 174 diagnosis, 175 etiology, 175 pathology, 175 treatment, 176 Eczema, 83 erythematosum, 84 impetiginosum, 85 papulosum, 87 pustulosum, 85 rub rum, 87 squamosum, 89 vesiculosum, 85 Eczema, etiology, 90 diagnosis, 91 treatment, 95 Eczema sycosiforme, 122 anus, 128 beard, 123 breasts, 129 ears, 124 eyelids, 121 face, 117 genitals, 126 hands, 133 in infants, 137 intertrigo, 129 leg, 130 lips, 119 nares, 121 of the scalp, 114 treatment, 115 palms, 134 soles, 134 umbilicus, 130 universal, 114 Eczema seborrhceicum, 141 diagnosis, 142 etiology, 142 pathology, 142 treatment, 143 Elastic skin man, see dermatolysis, 257 Elephantiasis, 251 arabum, 251 etiology, 253 pathology, 253 treatment, 253 Elephantiasis, telangiectodes, 253 Ephidrosis cruenta, see haematidrosis, 429 Epidermis, 1 Epidermolysis bullosa, 168 Epithelioma, 321 diagnosis, 325 etiology, 324 pathology, 325 treatment, 327 Epithelioma, multiple benign cystic, 272 Epithelioma adenoides cysticum, see multiple benign cystic ade- noma, 272 Equinia, 184 Erysipelas, 186 diagnosis, 187 etiology, 187 pathology, 187 treatment, 187 Erysipeloid, 188 Erythema, 37 hyperaemicum, 37 simplex, diagnosis, 37 treatment, ^8 infectiosum, 37 intertrigo, ^8 diagnosis, 39 treatment, 39 Erythema gangrenosum. 189 See dermatitis gangrenosa infan- tum Erythema induratum, 48 diagnosis, 49 etiology, 49 treatment, 49 Erythema nodosum, 47 diagnosis, 48 pathology, 47 treatment, 48 Erythema scarlatinoides, 40 scarlatiniforme, 40 diagnosis, 41 etiology, 41 prognosis, 42 treatment, 42 Erythema multiforme, 43 papulatum, 43 iris, 43 _ diagnosis, 45 etiology, 45 476 INDEX. Erythema multiforme, pathology, 45 treatment, 46 Erythematous syphiloderm, 308 Erythrasma, 452 Erythromelalgia, 352 Excoriations, neurotic, see multiple gangrene of the skin in adults, 189 Farcy, see equinia, 184 Favus, 435 Feigned diseases of the skin, see der- matitis factitia, 202 Fibroma, 281 diagnosis, 285 etiology, 284 pathology, 285 treatment, 285 Fibromyomata, see myoma, 286 Filaria medinensis, 468 Fissures, 28 Flea, 461 Flea, sand, 468 Flies, 463 Fly, bot, 470 Fly, gad, 470 Folliclis, see acne varioliformis, 414 Folliculitis decalvans, 388 Fragilitas crinium, 370 Frambcesia, 319 Freckles, see lentigo, 218 Fungous foot of India, see mycetoma, 454 Furun cuius, 177 diagnosis, 179 etiology, 178 pathology, 179 treatment, 179 Furuncle, 177 Gad-fly, 470 Gangrene, diabetic, 191 Gangrene, disseminated, see multiple gangrene of the skin in adults, 189 Gangrene, hysteric, see multiple gan- grene of the skin in adults, 189 Gangrene of the skin, multiple, in adults, 189 Gangrene of the skin, spontaneous, see multiple gangrene of the skin in adults, 189 Gangrene, symmetric, 191 Gangrenous zoster, see multiple gan- grene of the skin in adults, 189 "Gelatine, Pick's," in "Jameson's," 112 Geromorphism cutanee, 260 Glands, diseases of sweat, 422 Glands, sebaceous, n sweat, 12 coil, 12 Glanders, see equinia, 184 Glossy skin, 260 " Glycerol e of the r.ubacetate of lead, Squire's," 112 Gnat, 463 Goose flesh, 9 Granuloma, fungoides, 331 Granulosis rubra nasi, 433 Guinea-worm disease, 468 Gumma, scrofulous, 290 Gummatous syphiloderm, 313 Haematidrosis, 217, 429 Hemorrhages, 213 Hair, 14 follicle, 14 papilla, 16 minute structure, 16 root, 17 Hair and hair follicles, diseases of, 360 Hair, atrophy of, 369 beaded, 371 moniliform, 371 ingrowing, 374 graying of, 374 falling of, see alopecia, 376 Hair, loss of, from syphilis, 377 Harvest mite, see leptus, 467 Hereditary syphilis, skin diseases in, Hemiatrophia facialis, 260 Herpes, 144 simplex, 144 diagnosis, 146 etiology, 145 treatment,' 147 progenitalis, 148 diagnosis, 149 treatment, 149 Herpes zoster, 150 diagnosis, 157 etiology, 152 INDEX. 477 Herpes zoster, pathology, 153 treatment, 157 Herxheimer's spirals, 3 Hidradenitis suppurativa, see acne varioliformis, 414 Horn cells, 5 Horns, see cornu cutaneum, 235 Hydradenome eruptif, see multiple benign cystic adenoma, 272 Hydroa vacciniforme, 159 Hydroadenitis suppurativa, 434 Hydrocystoma, 432 Hyperemias, 37 Hyperesthesia of the skin, 352 Hyperidrosis, 422 etiology, 423 treatment, 423 Hypertrichosis, 360 Hypertricosis, pathological, 365 from diseases of nervous system, 3 6 5> 3 66 treatment, 366 Hypertrophies, 218 Ichthyosis, 238 diagnosis, 240 etiology, 240 pathology, 240 treatment, 240 fcetalis, 242 hystrix, 243 Ihle's ointment, 112 Impetigo contagiosa, 171 diagnosis, 173 etiology, 173 pathology, 173 treatment, 174 Impetigo herpetiformis, 177 Impetigo simplex, 169 diagnosis, 170 etiology, 170 treatment, 171 Inflammations, 43 Ingrowing hairs, 374 Itch, grocer's, bakers, See eczema, 133 Itch, Malabar, see tinea imbricata, 449 Itch, the, see scabies, 463 Hungarian, 465 Polish, 465 Italian, 465 Itch, lumbermen's, see scabies, 465 Itch, winter, 345 frost, 345 Ixodes, 461 bovis, 461 Jigger, 468 flea (fig.), 469 Keloid, 265 diagnosis, 267 etiology, 266 pathology, 267 treatment, 267 Keloid of Addison, see scleroderma localis, 247 Keratohyalin, 4 Keratin, 5 Keratosis follicularis, 230 contagiosa, 231 Keratosis palmaris et plantaris, 227 Keratosis pilaris, 229 Keratosis senilis, 228 " Kummerfeldt's lotion," 419 Larvae, creeping, 470 migrans, 470 "Lassar's paste," 103 Layer, basal, 41 prickle cell, 3 granular, 3 papillary, 5 reticular, 5 "Lead, glycerole of the subacetate, Squire's," 112 Lentigo, 218 Lepothrix, 373 Lepra, 335 diagnosis, 340 etiology, 339 pathology, 340 treatment, 343 Leprosy, see lepra, 335 Leptus, 467 irritans, 468 autumnalis, 468 Lesions, primary, 23 Leukopathia ungu um, 356 Lichen tropicus, see miliaria, 433 Lichen ruber, 65 acuminatus, 65 diagnosis, 66 pathology, 66 478 INDEX. Lichen ruber, treatment, 66 Lichen ruber planus, 65, 66 diagnosis, 67 etiology, 67 pathology, 67 treatment, 68 Lichen scrofulosus, 69 diagnosis, 71 etiology, 71 pathology, 71 treatment, 71 Lichen urticatus, 52 "Liquor carbonis de'ergens," 118 "Liquor picis alkalinus," 109 Lotion, " Kummerfeldt's," 419 Lotio sulphuris cum tragacanthae, 418 Louse, head, 456 body, 458 crab, 460 Louse, chicken, see dermanyssus gal- linae, 462 Lousiness, see pediculosis, 455 Lupus vulgaris, 292 diagnosis, 294 treatment, 295 Lupus erythematosus, 302 diagnosis, 304 etiology, 303 pathology, 303 treatment, 304 Lymphatics, 8 Lymphangiona, 273 Lymphangioma tuberosum multiplex, 274 Lymphangioma simplex, 273 cystoides, 273 cavernosum, 273 circumscriptum, 273 Lymph scrotum, 253 Macaque, 470 Macrocheilia, 273 Macroglossia, 273 Maculae atrophicae, 260 Macules, 23 Malabar itch, see tinea imbricata, 449 Malignant pustule, 185 Malpighii, stratum, 3 " Manec's paste," 327 "McCall Anderson's ointment," 105 "powder," 102 Megalosporon, tricophyton, 438 Microsporon Audouini, 438 Microsporon furfur, 450 Miliaria crystallina, see sudamen, 432 Miliaria, 433 vesiculosa, 433 rubra, 433 papulosa, 433 Milium, 396 Milk crust, 85 "Mistura ferri acida, " 95 Mite, harvest, see leptus, 467 Moist papule, 309 Mole, see naevus pigmentosus, 221 Molluscum, contagiosum, 270 Molluscum fibrosum, see fibroma, 281 Morbus maculosus Werlhofii, see pur- pura, 214 Mother's mark, see naevus vasculosus, 277 Monilethrix, 371 Morphcea, see scleroderma localis, 247 Mosquito, 463 Mucous patch, 309 Multiple benign cystic epithelioma, 272 Multiple gangrene of the skin in adults, 189 Muscles of the skin, 10 Mycetoma, 454 Mycosis fungoides, see granuloma fun- goides, 331 Myoma, 286 Naevus pigmentosus, 221 linear, 223 lipomatodes, 223 pilosus, 222 spilus, 221 verrucosus, 223 Naevus vasculosus. 277 treatment, 278 Nails, 18 Nail bed, 18 matrix, 19 Nails, diseases of, 353 atrophy, 356 degeneration, 358 disco 1 oration, 358 hypertrophy, 353 parasitic diseases of, 35S INDEX. 479 Nail plate, malformation of, 357 separation of, 358 Nerves of the skin, 9 motor, 9 Neuro ic excoriations, see multiple gangrene of the skin in adults, 189 Neuroma, 285 Neuroses, 344 New growths, 265 Nits, see pediculosis capillitii, 457 Odors of human body, see bromidro- sis, 426 (Edema angioneuroticum, 57 diagnosis, 58 etiology, 58 pathology, 58 treatment, 58 (Edema neonatorum, 251 (Estrus, 470 Ointment, "McCall Anderson's," 105 "Hebra's diachylon," 106 "Wilkinson's," 109 "Ihle's," 112 Onychia, 360 Onychauxis, 353 Onychogryphosis, 353 Pachydermatocele, see fibroma, 284 Pacinian bodies, 9 Paget's disease, 329 pathology, 330 treatment, 330 Papillae, 6 vascular, 6 sensory, 6 compound, 6 Papular syphiloderm, 309 Papule, moist, 310 Papules, 24 Parasitic affections, 435 Parasites, animal, of minor import- ance attacking the skin, 461 Parasites, animal, of minor importance penetrating the skin, 467 Parasites, diseases due to animal, 455 Parasites, vegetable, disease due to, 435 Paronychia, 360 Paste, "Lassar's, " 103 Paste, "Manec's," 327 Patch, mucous, 309 Pediculus capitis, 456 corporis, 458 pubis, 460 Pediculosis, 455 capillitii, 456 vestimentorum, 458 pubis, 460 Pelio_is rheumatica, see purpura rheu- matica, 214 Pellagra, 50 diagnosis, 50 etiology, 50 treatment, 51 Pemphigus, 165 etiology, 166 prognosis, 167 treatment, 167 Pemphigus foliaceus, 165 vegetans, 166 vulgaris, 165 Perforating ulcer of the foot, 264' Perifolliculitis, discoid suppurative, see ring-worm, 441 Petechias, 23 Phlegmona diffusa, 183 Phosphoridrosis, 431 Physiology of the skin, 19 Pian, see frambcesia, 319 "Pick's gelatine," in Piedra, 372 Pigmentary syphiloderm, 308 Pigment of the skin, 10 Pinta disease, 452 Pityriasis rosea, 59 diagnosis, 60 pathology, 60 treatment, 60 Pityriasis rubra pilaris, 65 Psoriasis, 71 diagnosis, 76 etiology, 75 pathology, 75 treatment, 78 Poison vine eruption, see dermatitis venenata, 195 Pompholyx, 159 Porokeratosis, 244 Port wine mark, see naevus vasculo- sus, 277 Powder, "McCall Anderson's," 102 Prickly heat, see miliaria, 433 Primary lesions, 23 480 INDEX. Primary lesions of the skin, 23 Prurigo, 64 diagnosis, 64 pathology, 64 treatment, 65 Pruritus, 344 diagnosis, 346 etiology, 346 treatment, 346 Pruritus ani, 345 Pruritus, bath, 345 Pruritus hiemalis, 345 Pruritus scroti, 345 Pruritus vulvae, 344 Pulex irritans, 461 Pulex penetrans, 468 Purpura, diagnosis, 215 etiology, 215 pathology, 215 treatment, 216 Purpura, 213 simplex, 213 haemorrhagica, 213 Henoch's, 214 rheumatica, 214 scorbutica, 217 Pustula maligna, 185 diagnosis, 185 etiology, 185 pathology, 185 treatment, 185 Pustular syphiloderm, 311 Pustules, 25 Rhinoscleroma, 286 Rhus poisoning, see'dermatitis vene nata, 195 Ringworm of the bearded region, 446 Ringworm of the general surface, 440 Ringworm of the scalp, 441 treatment, 443 Ring-worm, see tinea tricophytina, 437 burmese, 449 Rodent ulcer, 322 Roseola, 37, 38 Sand flea, 468 Sarcoma utis, 331 Sarcoptes scabiei, 464 Scabies, 463 diagnosis, 466 treatment, 466 Scales, 28 Scalled head, 85 Scarlet rash, 40 Scars, 29 Sclerema neonatorum, 249 etiology, 250 pathology, 250 treatment, 250 Scleroderma, 245 diagnosis, 248 etiology, 247 pathology, 248 treatment, 249 localis, 247 Scrofuloderma, 289 Scrofuloderm, small pustular, see acne varioliformis, 414 Scrofuloderm, large flat pustular, 291 Scrofuloderm, small pustular, 290 Scurvy, see purpura scorbutica, 217 Sebaceous cyst, see steatoma, 397 Sebaceous glands, diseases of, 392 Sebaceous glands, n Sebaceous secretion, 21 Seborrhcea, 392 diagnosis, 394 etiology, 394 oleosa, 393 nigricans, 393 sicca, 393 treatment, 394 Sebum, 21 Secondary lesions of the skin, 27 Skin as a protective organ, 19 as a sensory organ, 19 as a respiratory organ, 20 as a secretory organ, 20 Skin, blood-vessels of, 7 Skin cancer, see epithelioma, 321 Skin diseases in hereditary syphilis, Smegma praeputii, see seborrhcea, 393 Smegma praeputialis, 21 Spiders, 463 Spirals, Herxheimer's, 3 "Spiritus saponis kalinus," 109 Spoon nail, 357 "Squire's glycerole of the subacetate of lead," 112 Steatoma, 397 Stigmata, see haematidrosis, 450 INDEX. 481 Stratum granulosum, 3 corneum, 4 lucidum, 4 lucidum, 4 malpighi, 3 Striae atrophica^, 260 Subcutaneous connective tissue, 7 Sudamen, 432 Sudor sanguinosa, see haematidrosis, 429 Sweat, bloody, see haematidrosis, 217 Sweat, bloody, see haematidrosis, 429 uric acid, see uridrosis, 431 phosphorescent, see phosphori- drosis, 431 Sweat glands, 12 Sweat glands, diseases of, 422 Sweat secretion, 20 Sycosis vulgaris, 388 diagnosis, 390 etiology, 389 pathology, 390 treatment, 390 Symmetric gangrene, 191 Symptomatology, 22 Symptoms, objective, 22 Syphilis, 307 Syphilitic affections of the skin, treat- ment of, 314 in children, treatment of, 318 Syphiloderm, the erythematous or macular, 308 bullous, 314 gummatous, 313 papular, 309 pigmentary, 308 pustular, 311 tubercular, 313 vesicular, 310 Syphilis, hereditary skin diseases in, Tactile corpuscles, 9 Tattoo marks, 220 Tears of blood, see haematidrosis, 430 Telangiectasis, 277, 280 Tetranychus, see leptus, 467 Tetter, moist, 85 Tick, see ixodes, 461 dove, see argas, 462 "Tinctura saponis cum pice," 108 Tinea cruris, 441 31 Tinea favosa, see favus, 435 Tinea nodosa, 373 Tinea sycosis, see ring-worm of the bearded region, 446 Tinea imbricata, 449 Tinea tricophytina, 437 Tinea versicolor, 449 diagnosis, 451 treatment, 451 Tissue, subcutaneous connective, 7 Tooth rash, 85 Trichorrhexis nodosa, 372 Trombidium, see leptus, 467 Americanum, 468 Tubercular syphiloderm, 313 Tubercle, anatomical, 287 Tubercles, 26 Tuberculosis cutis, 287 accidental inoculations, 287 treatment, 291 pathology, 301 Tuberculous ulcers, 289 Tuberculosis verrucosum, 288 Tumors, 27 Tylosis, see callositas, 226 See keratosis palmaris et plan- taris, 227 Ulcers, 29 Ulcer, perforating, of foot, 264 Ulcer, rodent, 322 Ulcers, tuberculous, 289 Unilateral facial atrophy, 260 Uridrosis, 431 Urticaria, 57 diagnosis, 53 etiology, 52 pathology, 53 treatment, 53 bullosa, 52 haemorrhagica, 52 papulosa, 51 tuberosa, 52 Urticaria pigmentosa, diagnosis, 57 etiology, 56 pathology, 57 treatment, 57 Vaccinal eruptions, 211 Varicella, 209 Varicella gangrenosum, see dermatitis gangrenosa infantum, 189 482 INDEX. Vegetable parasites, diseases due to, 435 Venereal wart, 232 Vernix caseosa, 21 Verruca, diagnosis, 233 etiology, 233 pathology, 233 treatment, 233 Verruca, 231 acuminata, 232 digitata, 232 juvenilis, 232 plana, 232 sebacea, 232 vulgaris, 231 Verruga Peruana, 320 Vesicles, 24 Vesicular syphiloderm, 310 Vibices, 23 Vitiligo, 262 Wart, anatomical, 287 Wart, see verruca, 231 venereal, 232 Wasps, 463 Wheals, 26 Wen, see steatoma, 397 Xanthoma, 275 etiology, 275 pathology, 275 treatment, 275 Xanthoma, 275 multiplex, 275 palpebrarum, 275 planum, 275 tuberculatum, 275 tuberosum, 275 Xanthoma diabeticorum, 276 etiology, 276 pathology, 276 treatment, 277 Xeroderma pigmentosum, 330 X-ray dermatitis, 200 X-ray in the treatment of eczema, "3- I 37 seborrhceicum, 143 Yaws, see frambcesia, 319 SEP 28 190/