I LIBRARY OF CONGRESS, , \V — %p + . jL ©upitrigljt f u> Shelf Mh 'WA?> UNITED STATES OF AMERICA. * .,.-.#..^-.-^;r-,. Plate I J "' Neevtxs LiporrLatocLes . (From a Photograph of one of the author's patients .) (Frontispiece .) A PRACTICAL TREATISE DISEASES OF THE SKIN, FOR THE USE OF STUDENTS AND PRACTITIONERS. THIRD EDITION, THOROUGHLY REVISED AND ENLARGED. BY JAMES NEVINS HYDE, A.M., M.D., PROFESSOR OF SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, CHICAGO ; DERMATOLOGIST TO THE MICHAEL REESE HOSPITAL, CHICAGO; ONE OF THE PHYSICIANS FOR DISEASES OF THE SKIN TO THE PRESBYTERIAN HOSPITAL, CHICAGO ; AND CONSULTING DERMATOLOGIST TO THE CHICAGO HOSPITAL FOR WOMEN AND CHILDREN. %ci ^ 1893 . ^ u PHILADELPHIA: LEA BROTHERS & CO. 1893. / - Cantharid. tinct. J Dissolve the pilocarpine in dients. aa 3j gr. xv ; 5 the alcohol, and then add the other ingre- The treatment described above in outline may be used with success also for the relief of seborrhoea of the non-hairy portions of the body, especially the face. Here, it will be observed, the crusts have a singular tendency to re-form, and the most persistent care is necessary to secure permanent relief. Occasionally, after cleansing the surface by soap and spirit lotions, according to the indications of each case, it is of advantage to apply the ointment selected for subse- quent application, not only by gently smearing it on the part with the tips of the fingers (always the most effective method), but also by spreading it on a compress, which, for the night at least, may be fixed in contact with the part. Unna's lead-plaster mulls, used for this purpose in Germany, may be fairly well imitated by drawing strips of cheese-cloth through heated diachylon ointment and then smoothly smearing them with the same material. When this tendency to reformation of the crust is abated, one or more of the dusting powders may be at times employed with advan- tage for the purpose of protecting the skin or exercising upon it an astringent effect. The local treatment of seborrhcea of the genitals is somewhat different. Ointments rarely answer well in disorders of the mucous surfaces ; and the green soap is too irritating for similar employment. Here washing with a good toilet soap and warm water is sufficient for the purposes of cleanliness, and diluted lotions containing alcohol, in the form of whiskey, brandy, or aromatic wine, suffice to procure relief. These can be made astringent with tannin, alum, or the zinc sulphate, and, when there is pain or tenderness, opium can be added. In this form of the disease, as also in seborrhcea of the umbilicus, carbolic acid or the chlorinated soda may be necessary to correct fetor. After the employment of these lotions, boric acid, with talc (one part to four) or zinc oxide and starch (one to eight), may be dusted over the part. In the generalized varieties of the disease the surface is to be thoroughly anointed with oil. The body, especially that of infants, is to be swathed in flannel or other good non-conductor of heat ; and a roborant treatment directed to the general adynamia. In the grave forms of seborrhcea of infants described as keratosis sebacea, ichthyosis sebacea, etc , the body must be kept anointed with oils or fats. Artificial feeding is demanded by the condition of the mouth. Prognosis. — In forming a prognosis in cases of seborrhcea, it must be remembered that the disease is frequently an obstinate one ; and 126 DISEASES OF THE SKIN. the resulting loss of hair, if symmetrical, may be remediless. Much may be done in the way of saving that which is left. Facial sebor- rhea is much more amenable to treatment; and seborrhea of the genitals and umbilicus is an entirely manageable disease. When the affection is generalized, the prognosis is in the highest degree un- favorable. Comedo. Lat. comedo, spendthrift. (Black-head. Gee., Mitesser; Fk., Acne' Ponctuee.) Statistical frequency in America, 0.989. Comedo is a disease in which an inspissated secretion, lodged in the excretory ducts of the sebaceous glands, becomes visible upon the surface in yellowish- white or brownish-black points. Symptoms. — Comedones occur exclusively in the ducts of the sebaceous glands, and consist of a whitish fatty plug formed by the inspissation of the secretion of these glands, one extremity of which is visible at the surface when the plug is in situ. Occasionally they project to an appreciable distance above the general level of the integument ; but often the extremity of the plug is slightly depressed below that level. There may be but two or three upon the face, which is their most common seat ; or the nose, forehead, cheeks, chin, the front and back of the neck, the back of the trunk, and the penis may be thickly studded with them. The visible extremity of the comedo varies in size from a needle-point to a pin-head. They are readily expressed from the follicles in which they are lodged, and when thus examined are seen to be whitish moulds of inspissated sebum, one or two lines in length, the exposed extremities of w T hich have become blackened by the dust and dirt entrapped at that point. In consequence of this suggestive appearance of the mass, the disease has been vulgarly known as a black-heads" and " skin worms." The deformity produced in the face when these lesions exist there in large numbers, is strikingly conspicuous; and it is for the relief of this chiefly, that the practitioner is consulted. The subjective symptoms awakened are of trifling moment. The disorder is essentially chronic in its course. Isolated comedones may be observed for years in one situation without apparent change or modification of any sort, and without producing the slightest local or constitutional derangement. Others appear, only to disappear under the influence of the usual hygienic regimen of the skin of the face. Others, again, serve to irritate the skin in which they are implanted, precisely as though they were foreign bodies ; and the sebaceous glands and peri-glandular tissues, with and without the operation of such cause, exhibit grades of hyperemia and inflammation. Comedones may occur as the sole lesions of the skin, even to the extent of very great multiplicity ; or they may coexist with other diseases of the glands, chiefly acne. They may occur at any period of life, but, like seborrhoea, are most fre- COMEDO. 127 quently observed at the puberal epoch in both sexes. According to Kaposi, the disease tends to disappear in women earlier than in men, in whose case it may be prolonged to the twentieth or thirtieth year. Crocker 1 has called attention to the occurrence of comedones in children, with a special tendency to grouping in places subjected to heat and moisture, and also to occurrence upon the hairy scalp. Fig. 35. Section of a comedo, a, excretory duct of a sebaceous gland filled with a comedo ; it contains also two small hairs with brush-like inferior extremities ; into it opens a small hair- follicle, c, whose contained hair, d, after touching the opposite wall of the duct, curves down- ward at/. (After Kaposi.) Occasionally a so-called " double" comedo is formed, a plug of inspissated sebum being expressed from the skin, each extremity of which is discolored. Whether this be due to a duplicity of efferent ducts in a single gland, or to an artificial or pathological connection between two adjacent glands, is not clear. 2 Etiology. — Much has been written with reference to the improper care of the skin as a cause of comedo, the neglect of soap in washing the face, and the influence of the trades, as in the case of those who work in metals, dust, and tar. But observation shows that these are exceptional causes. Very obstinate and generalized lesions occur in Lancet, April 19, 1SS4. Ohmann-Dumesnil : Journ. of Cut. and Ven. Dis Feb., 1886. 128 DISEASES OF THE SKIN. the skin of intelligent young men and women of the upper social classes, who regularly wash their faces with toilet soap, are rarely exposed to dust, and whose habits and recreations are of the most healthful character. On the other hand, observing the grimy faces of coal heavers, machinists, masons, and ink manufacturers, one is impressed with the singular rarity of the disease in such laborers. The cause of the constipation of the gland is unquestionably to be sought for elsewhere, in the most of cases. It is true that chlorotic young women, affected also with dyspepsia and torpor of the bowels, may exhibit the disease ; and equally certain that many cases occur in peculiarly thick-skinued brunettes, or men with a characteristic reddish-brown and greasy-looking complexion. But for all this, many such never suffer from comedones, while often a perfectly healthy, fair-skinned girl will be greatly mortified by the disfigure- ment of her face. In yet other patients there is unmistakable connection between this disorder and chlorosis, scrofulosis, dyspepsia, habitual constipation of the bowels, menstrual derangements, and cachexia. This connection is demonstrated by the remarkable improvement manifested in the untreated skin when improvement of the general health is assured. Pathology. — The mass termed the comedo is a collection of con- centrically packed epithelial plates mingled with masses of choles- terine, fragments of epithelia undergone fatty transformation, minute lanugo hairs, and, occasionally, upon the exterior, the acarus follicu- lorum. This little mite, first detected by Henle, in the ceruminous glands, was by Simon and others once thought to be the cause of the comedo, a view which is now abandoned by all dermatologists. The parasite, in persons upon whose skin it exists, can be detected in masses of commingled sebum and epithelial plates scraped from the free surface of the integument, as also upon the surface of those who do not exhibit any disorder of the sebaceous glands. The comedo plug is located either in the excretory duct of the seba- ceous gland or in the pouch-shaped canal common to the sebaceous gland and the hair- follicle. It will be remembered that in the class of sebaceous glands chiefly involved in the comedo, the hair- follicle is rather an appendage to the former, the relation between the two, evident upon the scalp for example, being here reversed. According to Biesiadecki, the hair-follicle often forms here an obtuse or even a right angle with the duct of the gland, and the point of the hair being thus projected against the wall of the duct, is occasionally curved downward upon itself, exciting thus au irritation at the point of impact and subsequent multiplication of the protoplasmic elements lining the canal. Thus he explains the epithelial character of the outer envelope of the plug ; the special occurrence of the disease at the puberal epoch, when, as is well known, there is an especially active growth of the hairs ; and, lastly, the frequent discovery of lanugo filaments in the expressed contents of the common excretory duct. Diagnosis. — The recognition of the disorder is attended with no difficulty, patients themselves being usually sufficiently observant to COMEDO. 129 identify the affection, though frequently misled as to the character of the u skin worm." It is, as might be expected, a frequent coincident of acne ; its lesions, when commingled with those of the disease last named, being either in preponderance or so infrequent as scarcely to attract the attention of the patient. A condition somewhat resembling the comedo may be produced upon the face when tar, or ointments of mercury and sulphur are applied to it at the same time, the resulting black sulphuret appearing conspicuously at various points upon the skin, often at the orifices of the sebaceous glands. Curiously atypical cases, however, are occasionally observed, and these might confuse one unfamiliar with the singular variations dis- played in almost all sebaceous gland disorders. Thus Cauty 1 reports a remarkable case in a boy ten years of age, who was somewhat im- becile but well nourished. The upper part of the back, both shoulders, and the outside of both arms were covered with short bristles, of a clear, darkish brown-yellow color, and acuminated apices. These bristles were, at the edges of the group, gradually shortened from their full length of three thirty-seconds of an inch, until they joined the skin, which was at the junction raised into polygonal, flat disks, finally graduating to the sound integument of the hands, chest, and back. The feeling communicated to the hand on passing it over the shoulders was exactly similar to that of touching a coarse brush, and the bristles gave way under the touch, resuming an upright position afterward. There were a few pink maculae over the body, and con- siderable scaly thickening on and around the patellas. The bristles were expelled comedones, containing very few immature hairs and very little sebum, drying up into a horny substance. They were firmly attached, requiring more force to remove them than to extract a well-rooted hair ; and when removed they left a small, central depression, surrounded by a circle of torn epithelium, which retained them in position. They averaged oue hundred to the square inch, and had existed over three months. A somewhat similar case was exhibited by Dr. Warren, before the New York Dermatological Society, January 26, 1886, and described as keratosis follicularis. Treatment. — The internal treatment of the patient affected with comedo is largely that described in connection with the subject of seborrhcea. Cod-liver oil, iron, the bitter tonics, and preparations indicated by any special condition of the patient's health, are not to be omitted. Open-air exercise, daily cool salt-and -water bathing, as in the management of seborrhcea, and the avoidance of all medicinal and dietary articles which might tend to aggravate the disorder, are also imperative. Even aggravated cases of comedo are completely relieved by natural processes in the course of time. These processes are, however, slow, and may require years for their completion. The rarity of come- dones in middle life and advanced years sufficiently attests this fact. 1 Medical and Surgical Journal, March 4, 18S2, p. 237. 130 DISEASES OF THE SKIN. Presumably this natural cure is due to the more vigorous growth of lanugo hairs with the increment of age, which thus push forward slowly to the surface the excrementitious mass, until it is gradually removed by ordinary friction and ablution. Absence of comedones from the scalp, where the hair is vigorous, is certainly a significant fact. Comedones are removed artificially by the aid of an extractor. The instrument formerly employed for this purpose was shaped like a watch-key, the cylinder of which had a smooth bore and bevelled extremity. This clumsy tool is far surpassed by the exceedingly convenient comedo-extractor designed by Unna and modified by Piffard (see Fig. 33). Each end has a convex bowl-like surface, with apertures cut to gauge and the orifices slightly counter-sunk. It is productive of far less pain to the patient than other instruments, and can be wielded, on account of its long shank, with greater precision and ease by the physician. The surface to be operated upon is best pre- viously moistened by spraying it with a thymol and glycerin, or euca- lyptol and glycerin solution. Often a sharp-edged or well-rounded needle, firmly held in a needle-holder, may be advantageously em- ployed alternately with the extractor, in opening certain follicles or somewhat loosening the plug of others. All of these instruments should be scrupulously disinfected before use. With the present knowledge had on the subject of transmission of disease, the danger of such manipulations as these with uncleansed instruments should never be overlooked. Wigglesworth suggests the performance of the operation at night ; and there are good reasons for selecting the hour before retiring as the time for all vigorous topical applications to the face. Ointments then applied can be left in contact with the skin during the hours of sleep; and the patient be at liberty to resume his usual vocation in the daytime with his face free from con- spicuous evidence of local treatment. An ordinary watch-key, a curette, the thumb-nail, or a spatula may also, on occasion, be used in the extraction of comedones, which may be, if few, removed at one sitting, or, if numerous, on separate occasions. Repetition of the process is usually required by the re- formation of the plugs. Once they are removed, the skin should be sponged and bathed with hot water, then thoroughly dried, and anointed with an oint- ment which may be medicated to suit the indications of each case. Sulphur, as in all the functional disorders of the sebaceous glands, enjoys here also the highest reputation. In the strength of one-half to one drachm (2.-4.) to the ounce (32.) of cold cream or vaseline, it may be applied as an ointment ; or as a lotion, in combination with spirits of wine, glycerin, etc. The author has frequently used with advantage the mild application suggested by Piffard in acne, equal parts of sublimed sulphur, alcohol, compound tincture of lavender, glycerin, and camphor water. Mercurials are also of some advantage locally, and, as before indi- cated, should not be employed at the same time with preparations of COMEDO. 131 sulphur. The use at night, especially in obstinate cases, of the white precipitate ointment, or one compounded of two grains (0.183) of the red oxide to the ounce (32.) of cold cream will often prove of benefit. One to two grains (0.066 to 0.133) of corrosive sublimate to the ounce (32.) of glycerin and rose-water may be substituted for the latter in coarser skins. When the extraction of the plug is not attempted nor permitted, something may yet be done to remove the inspissated mass. Ee- peated sponging every third night with one ounce (32.) of the green soap, digested in an equal quantity of Cologne water, will, at first certainly, seem to render the comedo more conspicuous, but will slowly operate to dissolve the sebaceous secretion. Unna has lately observed that the blackish discoloration of the comedo extends to a certain degree below the external extremity of the plug, a circumstance, in his opinion, militating against the dust and dirt theory, by which the hue of the comedo point has been ex- plained. He concludes that this is the result of pigmentation, such as that producing the coloration of the hair, nails, and skin in several other anomalous conditions. Having this in view, he prescribes an ointment containing four parts of kaolin, three of glycerin, and two of acetic acid, with or without the addition of a small quantity of ethereal oil. This is applied at night, the eyes being carefully closed, for a few nights in succession, when the black points of the lesions are removed, and the comedones then readily extracted. Citric or dilute hydrochloric acid is employed, with the same end in view. These topical remedies cannot be considered as efficient in every form of comedo. Actors, actresses, and women of fashion will occasionally persist in using variously colored toilet powders while under treatment, the injurious ingredients of which are often the cause of the disease. The practitioner may then either refuse to be responsible for the care of the case, substitute a harmless for a noxious powder, or gently anoint the face after his treatment of it with a bland oint- ment or the Lassar paste, upon the surface of which the theat- rical effects are subsequently produced. In such cases the use of soap and water with each dressing is even more than usually im- perative. Comedones of the penis need not be treated. This injunction is suggested by the occasional demand made upon the physician by the sexual hypochondriac, who regards these lesions with a degree of alarm which he can best appreciate who has been confronted with these cases. Prognosis. — As the disease tends naturally to a spontaneous, though occasionally long-deferred resolution, the prognosis is favorable. Treatment in many cases will accomplish much in hastening the re- sult. The most obstinate forms are those in which the face, back of the ears, inside of the auricle, neck, and shoulders are studded with relatively small, indolent, comedo points, about which the orifice of the duct arises in a whitish rim. This, when felt with the finger, 132 DISEASES OF THE SKIN. produces the impression of hyperplasia of the wall of the duct. Such cases, however, are nearly allied to the forms of acne described else- where. With exceeding rarity, the comedo is merely the first step of a more serious local affection. In early life a single prominent lesion is formed, and though the plug be frequently removed and finally be no longer reproduced, the orifice of the duct remains patu- lous in middle life. Slowly thereafter its walls undergo a metamor- phosis and a warty epithelioma may result. Cyst. Gr. Kvcrig, a bladder. Sebaceous cysts are millet-seed to egg-sized and larger, milky-whitish, or yellowisn-white, encysted tumors of the sebaceous glands, occasionally having the color externally of the normal integument, either imbedded within the skin or projecting above it. The term sebaceous cyst is applied by some authors to one merely of the two disorders of the skin to which it properly belongs, viz., the wen. In these pages it includes both milium and steatoma. [A.] Milium. Lat milium., a millet-seed- (Grutum, Strophulus albidus, Acne albida.) Symptoms. — Milia occur upon and about the eyelids, the cheeks, the temples ; the penis, scrotum, and corona glandis of men ; and the internal face of the labia minora of women. They are millet- seed to pin-head sized, globoid masses, rarely attaining the dimen- sions of a coffee-bean, showing within the epidermis as though kernels of rice were lying there immediately beneath a translucent layer of tissue. They occasionally project from the surface to such an extent as to resemble small-sized vesicles having milky con- tents. In color they are yellowish and whitish. They are often congenital, and can be recognized about the lids and temples of the newly born infant ; they are also seen, however, in middle life, when they develop very slowly, and sometimes persist for years. They are often observed in the neighborhood of cicatrices, which latter in such cases have usually been effective in their production. They occasion no subjective sensation, and are commonly so insignifi- cant as to induce no deformity. They never degenerate by ulcerative processes, but when not artificially removed are, in the course of years, exfoliated in the natural processes of physiological desqua- mation. Etiology, — Milia are at times produced mechanically, the stroke of a knife-blade, accidentally or by the processes of surgery, separating one or more of the acini of a sebaceous gland from the main body. The contracting bands of a cicatrix, after the destruction of tissue CYST. 133 from any cause, may operate in a similar way with a precisely similar result. Haviug this in view, it may be said generally that milium is always the result of a cause which prevents the transform- ation of the epithelium lining the gland into fat, and the subsequent excretion of this upon the free surface of the skin. These causes are thus, for the most part, obscure, but all are probably of purely local significance. Pathology. — When a milium is incised externally, a spherical body of nearly corresponding size may be expressed, though it may require tearing from a minute pedicle below, which represents the attach- ment to the hair-follicle. The small mass thus extracted is theu seen to be composed of several thin envelopes suggesting the capsules of the onion, and representing cornified epithelia not undergone fatty metamorphosis, in the centre of which is a fatty nucleus. This mass represents the contents of one or more acini of a superficially situated sebaceous gland, cut oif from the main body of the follicle in the manner described above, and always covered when in situ, as Kaposi has shown, by a delicate layer of the superimposed corium containing papillae. Usually the orifice of the excretory duct cannot be appre- ciated in milia, though occasionally these lesions are developed when the orifice is patulous. These singular 'bodies do not always represent conditions of mechanically pent-up sebum, as the epithelia from which their con- tents are produced seem at times indisposed to fatty transformation and particularly apt to develop into horny or other formations. Thus Foster, of Boston, describes one where the process of calcification had been apparently complete ; Wagner has observed colloid contents in certain opalescent lesions which appeared in the cheeks and temples of a woman ; Barensprung and Hebra report numbers of acutely pro- duced milia following pemphigus and erysipelas ; and Yirchow and Rindfleisch describe milia of the hair-sac and similar lesions accom- panied by cyst of the hair-follicle adjacent. It would seem rational to conclude that, in cases, the cause of milia is to be sought in obscure changes by which the epithelia of the gland are primarily affected. Robinson believes that milia originate from miscarried embryonic epithelia from a hair- follicle or from the mucous layer of the epi- dermis. Diagnosis. — Milia might be mistaken for minute vesicles contain- ing a milky fluid, but puncture of the lesion, with expulsion of its contents, would at once disclose the character of each. Comedones with blackish external points, surrounded by the patulous orifice of the excretory duct and prolonged more deeply into the substance of the skin, could scarcely be confounded with milia. The most minute of the lesions of xanthoma have a yellowish color and cannot be as readily scraped away from the subjacent tissue as can milia. Ireatment.— Milia rarely require treatment, as they are usually relatively few in number, and produce neither subjective sensation nor deformity. If desired, they may be opened w T ith a fine milium 134 DISEASES OF THE SKIN needle, and their contents turned out, or they may be scraped off with the curette. To insure their non-recurrence, the little sac left after the operation may be entered with a needle dipped in a fifty per cent, solution of chromic acid. This operation may have to be repeated in the rare cases where the lesions exhibit a special tendency to recur. The simplest and most elegant method of removing these aud many similar-sized lesions of the skin is by the galvauic battery. With from four to six cells in the current, the negative pole is connected with a fine needle which is introduced within and beneath the lesion, while the moistened sponge of the positive pole is in contact with the skin of the patient. The operation is bloodless and effectual ; insig- nificant or no scars resulting. The prognosis is always favorable. [B.] Steatoma. Gr. areap, fat. Fig. ■m- (Wen, Atheroma.) Statistical frequency in America: 0.122. Symptoms. — The history of the development and career of wens does not greatly differ from that of milia, already described. They are usually slow of growth ; unat- tended by subjective sensation ; occur as single or multiple tumors on the head, trunk, or genitals ; and, being larger than milia, may attain the size of a hen's egg. They are situated beneath, within, or upon the skin ; are usually unattached to the deeper contiguous tissues; and develop into irregularly globular, occasionally large button-shaped, masses, covered by an integument usually unpro- vided with hairs. This envelope may be quite normal in hue ; or un- naturally whitish from pressure ; or, especially upon the bald scalp of certain fleshy men of middle years, reddened, shining, and greasy in ap- pearance. At times they are to be distinguished only by passing the fingers through the long hairs of are hidden ; at others, they are so conspicuous in consequence of physiological alopecia as to occasion considerable disfigurement. They vary greatly in consistency, but usually produce to the touch a certain feeling of elasticity, especially V Cysts of the scalp, one of them being laid open to show its contents. (Gross.) the scalp, beneath which they CYST 135 if the cyst be tensely distended. They are rarely attacked by in- flammation, resulting in suppuration and ulceration. Tumors of this kind are rarely exceedingly numerous. MacLaren's patient, 1 a lad nineteen years old, exhibited tumors over the entire surface of the body, which proved on examination to be sebaceous cysts, but which presented ail the appearances of multiple fibromata. Pathology. — Wens represent an advanced grade of distention of the sebaceous glands by their contents, and a response to the constant pressure in hypertrophy of the glandular envelope. Their contents are semi-solid, curdy, cheesy, aud granular; or fluid and milky; or fluid aud purulent. These are the inspissated or chemically altered products of the gland secretion, recognizable as such by the materials of which they are composed, masses of fat aud debris of epithelia, with an occasional lanugo or undeveloped hair. In some cases they are more than mere retention cysts, a benign new growth of connective tissue forming the mass of the tumor. Calcareous and atheromatous changes in the contents of the cyst are common. Diagnosis. — Steatomata are to be distinguished from fatty tumors, which, however, are more commonly observed about the scapulae, loins, buttocks, and extremities ; while wens are very rare except about the scalp and neck. They lack also the peculiar u pillowy " feel of fatty tumors. Suppurating wens in these regions may readily be mistaken for circumscribed abscesses, if regard be not had for the history of the tumor usually long preceding. Syphilitic nodes of the same part are usually both tender and painful ; osteomata are also firmly attached. Treatment. — The removal of a wen is accomplished by excision, after previous puncture of the sac, and the removal of its contents. Several fatal cases, however, are on record as the result of this operation ; due not so much to the nature of the excised tumor as to its situation, surgical wounds of the scalp being particularly liable to erysipelatous and other complications. As the incision required for the removal of the wen must necessarily extend for some distance on either side of the tumor, a linear scar results which on the bald scalp is often very conspicuous as a relic of the lesion. In conse- quence of the possibility of danger, many surgeons prefer destruction of a prominent section of the mass with acid or alkali, leaving the sac, after expulsion of its contents, to wither gradually, though it may then be often withdrawn by forceps. Complete obliteration is sometimes effected by puncture, expression of contents, and the subsequent induction of artificial inflammation in the walls of the cyst by injection of tincture of iodine, pure sulphuric ether, or other irritating fluids, as in the operation for relief of hydrocele. With the antiseptic precautions observed in surgical practice to-day, the removal of these lesions from any part of the body may be regarded as unattended with great risk. i Brit, Med. Journ., Oct. 1SS6. 136 DISEASES OF THE SKIN. Prognosis. — The removal of the wall of the cyst is Dot followed by a return of the lesion. In debilitated and cachectic patients there may be spontaneous ulceration and sloughing, with or without sur- gical interference. Mr. Thomas Bryant 1 reports a carcinomatous tumor following the removal of a steatoma from the buttock of a woman sixty-three years of age. Asteatosis. Gr. a, privative ; creap, fat. Statistical frequency in America : 0.006. Asteatosis is that condition of the skin in which there is absolute or relative de- ficiency of the sebaceous secretion. Symptoms. — Insufficient lubrication of the skin by its natural unguent may be either general or partial, and occur either as an idio- pathic or symptomatic disorder. It is produced artificially by any agents which continually withdraw the fatty substance from the skin surface, as in those trades necessitating the constant immersion of any parts of the body in strong alkaline solutions, or waters highly impregnated with the salts of lime and potash. As an idiopathic affection, it is of very rare occurrence, but it is not an infrequent accompaniment of other local or constitutional diseases, such as psoriasis, lepra, angioma pigmentosum et atrophicum, ichthyosis, and lichen ruber. In these cases the skin becomes dry, often thickened and indurated, and, as a consequence, friable, prone to desquamation, fissures, and chaps. When handled, the absence of sebaceous secretion is noticeable in the objective sensation produced. It is a well-marked feature of the marasmus of old age. Some authors have described, under this title, the dry thickening and induration of the palm of the hand, accompanied by curving of the fingers toward the plane of their flexor tendons, which is occasionally to be observed among laun- dresses. But considering the absence of sebaceous glands from the palm, where in the author's experience this affection is most pro- nounced, it should be properly excluded from the list of sebaceous disorders. Treatment. — No internal medicaments are known to have the power of stimulating especially the sebaceous secretion. None, indeed, could be capable of having such action when, as is often the case in the disorders described above as characterized by asteatosis, there has resulted an atrophy of the sebaceous glands. The most that can be accomplished is the external application of an artificial unguent ; and for this purpose cod-liver oil, almond oil, lanolin, palm oil, vaseline, lard, or butter may be employed. Vaseline is in many cases to be preferred, as the other articles named are liable to become rancid after oxidation, and thus act as irritants to the skin. With such partial 1 Brit. Med. Journ., May 31, 1884. ASTEATOSIS. 137 or general lubrications, however, a warm bath with soap and water should be ordered every second or third day, immediately after which the inunction may be repeated. Prognosis. — In all those cases where the asteatosis is induced by agents operating externally upon the surface, a reasonable hope of recovery may be entertained after the withdrawal of the cause. Per- sistence of the latter is liable to be succeeded by the occurrence of eczema or dermatitis medicamentosa. A complete cure can scarcely be expected when this condition is really a symptom of one of the dis- orders already named. Congenital Fibro-sebaceous Disease. — Crocker reports two instances, occurring in infants who exhibited signs of the disease at birth, in which patches with an area of u several square inches" were visible on the face, the front of the neck, and in front of and above the ear. These were slightly raised, pale reddish-yellow in color, finely granular over the surface, and consisted of closely aggregated pale-yellowish, pin-point sized papules, the patches being sharply defined with many comedones at the borders. The growths, on section, seemed to be due to a fibrous hypertrophy resulting in atrophy of the hair-follicles and coil-glauds, and separation of the lobes of the sebaceous glands. Multiple Dermoid Cysts. — These occur in cases, either as few or more often exceedingly numerous, uncolored or yellowish-white lesions, pin's-head to small-nut sized, strongly resembling multiple fibromata, but all containing a sebaceous or cheese-like matter when incised and the contents expressed. Jamieson, Hebra, Rayer, Pol- litzer, 1 and others have reported these cases, the last-named observer finding a well-defined cyst wall with cystic contents consisting of typical epithelium transformed into horny cells undergoing fatty degeneration. Bare Consequences of Sebaceous Cystic Disease are re- ported by a few authors, such as Cook, Hutchinson, and others, in cases where steatomata in typical situations have broken down into ulcerations ; in still others fungous tumors have formed of consider- able size requiring surgical attention. 1 Amer Journ. of Cutaneous and Genito-Urinary Diseases, Aug. 1891. 138 DISEASES OF THE SKIN. CLASS II. INFLAMMATIONS. Exanthemata. Gr. etjavdrj/ua, blossoming, flowering. The Exanthemata are specific fevers, frequently occurring in epidemic form, com- municable by contagion, preceded by a period of incubation, and characterized by systemic disturbance, with an efflorescence upon the skin, of different type in each, as also by involvement of other organs of the body, a single attack often conferring immunity upon an affected individual during his or her life- time, against subsequent attacks of the same disease. For a detailed consideration of the phenomena of the exanthematons fevers, the reader is referred to the standard treatises on the subject, in the field of general medicine. Brief space is allotted here, merely to a description of the cutaneous lesions by which they are severally characterized. These are unlike in each disease ; and yet all exhibit certain common characteristics. In all, the eruptions are symmetrical ; and in typical cases, general. In each, the efflorescence is succeeded by a desquamative or exfoliating condition of the skin. In each there is, within relatively fixed limits, a distinct stadium of the pathological process, within which it is completed, and beyond which, however persistent may be its remote sequelae, there is no chronic manifestation of the disorder. Each also is produced solely by its own specific contagium, derived exclusively from an animal body affected with the same disease, being never, so far as known, generated from any other source, nor merging by imperceptible degrees the one into another. Two of these may rarely concur, but under such circum- stances the one is always more pronounced in its features, which either closely precede or follow those of another. No specific medication is known to be capable of arresting any one of them, each pursuing its course uninterruptedly to a favorable or fatal termination, according to the intensity of the poison present in each case, and the more or less favorable or unfavorable conditions of the sufferer. Finally, it seems probable that, at no distant date, specific bacteria or micrococci will be demonstrated to be etiological factors in the production of each. Morbilli. (Measles, Rubeola ) Measles is a specific, contagious, febrile disorder accompanied by a cutaneous exanthem and an acute catarrh of the mucous surface of the respiratory tract. This disease is preceded by a period of incubation lasting from eight to twenty-one (usually from ten to twelve) days, a period in MORBILLI. 139 which there may be no evidence of ill health, or merely a moderate degree of lassitude and inappetence. To this succeeds a prodromic fever, the temperature rising to 103°-104° F., occasionally alter- nating with chills, or a sensation of chilliness, dryness of the skin, pains in the head, thirst, occasionally sweating, rarely convulsions in children, and, almost invariably, a serous catarrh of the mucous sur- faces. By the second or third day the temperature begins to decline, while the catarrhal symptoms increase. These are manifested in sneezing, a copious secretion from the eyes and nose, aud engorgement of the exposed mucous surfaces, especially of the conjunctiva, nares, and throat. Occasionally, the tongue aud fauces exhibit a few isolated, minute, reddish puncta. In consequence of the implication of the larynx, trachea, and ultimately the larger bronchi, there is a hoarse, frequently an incessant and teasiug cough, of a convulsive character, accompanied by expectoration of mucus in moderate quantity. This prodromic period lasts from three to five days, but is, iu exceptional cases, prolonged to twice that length of time. Upon its conclusion, the exanthem appears, usually on the fourth day, with aggravation of the fever, the temperature rising to 104°-106° F., and remaining at that point till the eruption has reached its apogee, when it com- monly declines pari passu with the severity of the skin symptoms. The eruption of measles usually appears first upon the face (the forehead and temples), and thence extends in about thirty hours over the neck, upper portion of the trunk, and superior extremities. Between the fourth and sixth days of the disease it has usually attained its deepest shades of color, and its maximum of development over the entire surface of the body, including the palms and soles. This maximum attained, the eruption gradually fades ; the tumid condition of the skin, most noticeable on the face, also subsides ; the catarrhal symptoms and cough become less annoying; and the patient enters upon the period of desquamation. The eruption is characterized by the occurrence of reddish, yellow- ish-red, mulberry-red, deep raspberry-red, or, in extreme cases, vio- laceous-tinted, small finger-nail sized maculae, either not elevated or very slightly raised above the general level of the integument; or by the occurrence of large pin-head sized, discrete papules, much more rarely pin-point sized vesicles, corresponding in color to the shades described above, and highly suggestive of the first efflores- cence in variola. These lesions become pale under pressure, exhibit- ing then a yellowish tint, and are often set together very closely, particularly over the upper segment of the body, in patches suggest- ing a crescentic outline. The term " suggesting " is here used pur- posely, as it is difficult, by selecting a single patch, to determine by the eye alone the existence of such a configuration ; while yet an examination of the eruption as a whole may often very clearly convey this impression to the sight. In other words, the crescentic outline is far less distinct than, for example, in certain of the papulo-crusta- ceous syphilodermata. Usually, patches of sound skin can be recognized, even when the eruption appears to be confluent, complete 140 DISEASES OF THE SKIN. confluence never occurring so as to form a sheet or mask over an entire area of the skin. Individual lesions may so merge as to be well-nigh indistinguishable separately ; yet, on the whole, the erup- tion deserves fully the plural character of its English name. It is made up in all cases of innumerable elements, whose identity is never wholly lost. The subjective sensation awakened is occasionally a severe itching or burning ; frequently this is a matter of insignifi- cance in comparison with other disagreeable symptoms — e. g., the cough, coryza, and fever. Desquamation is accomplished usually with cessation of fever and the production of yellowish-brown pigmentations of the surface where the elements of the eruption have existed, involution being first manifested in the site of the lesions which were earliest to develop. Gradually aud simultaneously, the catarrhal symptoms of the respiratory passages diminish in severity. This final stage of the disease is usually terminated in a fortnight from the date of invasion. The complications and anomalies of measles depend : upon the intensity of the poison, displayed in the most formidable symptoms where human beings are crowded together, as in camps and prisons ; upon the degree of physical vigor ; and also upon the various hygienic surroundings of the victims of the disease. Thus, the period of efflorescence may be unusually prolonged ; the eruption may disappear suddenly, and as rapidly reappear ; the cutaueous symptoms may alone be wanting; the latter may be commingled with petechias due to cutaueous extravasatiou of blood, which may be also accompanied by severe epistaxis ; and the catarrhal condition of the mucous surfaces affected may terminate in croupal or diphthe- ritic disease, may be followed by capillary bronchitis, catarrhal pneumonia, and even by pulmonary tuberculosis. Typhoid condi- tions may also supervene, and chronic inflammatory affections of the eyes and of the Sohneiderian membrane result. The pathology of the cutaneous lesions in measles is that merely of acute hyperemia occasionally passing into exudation, limited for the most part to the vascular papillae of the corium and the peri- follicular plexuses of bloodvessels. Post-mortem, the eruption fades, as the result of the gravity of the blood, from the anterior aspect of the body as it reclines upon the dorsum. While it is possible that the cause of this disease will be one day demonstrated to depend upon some of the inferior organisms, no observer can yet claim to have conclusively established the fact. Bacteria, of small size and great mobility, have, been found in the blood by Coze and Feltz ; microcooci in the trachea by Klebs ; spherical bodies in the breath of children, and, post-mortem, in the lungs and liver by Braidwood and Vacher 1 ; and similar organisms i Braidwood and Vacher (Trans. Path. Soc. of Lond., 1878, pp. 422-423) described sparkling staff-shaped fusiform or ovate bodies slightly tinged with carmine, which were supposed to be the " micro-organisms with which the contagium of measles is intimately associated." These were carefully distinguished from the forms of micrococci found in inflamed tissue, though effects from pure cultures had not been produced. It is, however, interesting to note that MORBILLI. 141 in the vesicles and pustules of malignant measles by Keating and Formad. 1 The disease is one of infancy chiefly, probably because at that age there is always the largest number of individuals unprotected by previous attacks. In every case, the malady results from contagion, mediate or immediate, from an infected human subject. It spares no age or sex, though much rarer in advanced years than at other periods of life, probably because of the large number who, at such period, enjoy immunity. The diagnosis of importance is between scarlatina and variola. Typical cases with a well-developed eruption can be scarcely mis- taken for either, if the symptoms displayed are assigned their full weight. It would be useless, however, to deny the fact that atypical forms occur, which have again and again confused the most expert diagnosticians ; and in all cases of doubt the prudent practitioner will refuse to decide as to the nature of the disease till the symptoms have, in the lapse of time, been fully declared. The resemblance between illy-developed measles and certain of the eruptions seen in varioloid, is in the highest degree striking; and the greatest skill, at a given moment of time, will in cases utterly fail to make a decision between the two. A distinctly crescentic character of the eruption, the presence of catarrhal symptoms, the continuance of the fever after the efflorescence is completed, the color of the eruption, and the discovery of the nature of the disease from which the contagion was derived, will all point in the direction of the truth. From scarla- tina, measles is much more readily differentiated by the macular or papular elements of its eruption ; by their color; by their appear- ance to a marked degree upon the face ; and by the absence of the characteristic sore throat and usually intense febrile access of the first named disease. From the various forms of erythema accompanied by fever, measles can always be distinguished by the irregularity of the temperature record, as well as by the character of the eruption. The distinction between rubeola and rotheln is given later. The treatment of measles should be strictly limited to a careful hygienic attention to the invalid, including a restricted " fever diet," and the use of such medicaments only as are especially indicated. The antithermic remedies employed in the general management of the febrile process may be required in special cases. In the way of local treatment, the skin should be anointed with a bland, oily, or fatty substance, to relieve the pruritic sensations, especially after the sponging of the surface once daily with a weak alkaline solution, which may be used cool without fear of producing " repercussiou " of the exanthem. The chamber of the invalid should be somewhat darkened for the sake of the eyes, but pure air should be constantly admitted. more recently Canon and Pielicke have made observations confirming in part this discovery. They recognized the bacilli in fourteen instances in the blood as also in secretions from the nose and conjunctivse, and in lung tissue after death from measles. These organisms were cultivated with marked success in bouillon. 1 See Sternberg's Magnan's '• Bacteria." New York, 1884. 142 DISEASES OF THE SKIN. The prognosis is, in general, favorable. All the complications named above increase, however, the gravity of the disease, which is also enhanced among men crowded together in camps, children in public charities, pregnant women, the cachectic and greatly enfeebled from other diseases, very young infants, old men and women, and residents of islands that have been long unvisited by epidemics of the malady. The disease has been demonstrated to produce itself by contagion two to four days before the appearance of the rash, while the power of such transmission is usually lost between the twentieth and thir- tieth days after the exanthem is fully developed. Rotheln. (Rubella, German Measles, Hybrid Measles, French Measles.) Rotheln is a specific, feebly contagious, febrile disorder, often epidemic, accom- panied by a characteristic exanthem. The disease has an incubative period lasting from fourteen to twenty-one days, followed either by the eruption or by brief pro- dromes lasting from a few hours to a single day. These are feelings of malaise, cephalalgia, articular pains, anorexia, and nausea. The occipital, cervical, and other glands may at this time become large and tender. After a pyrexic period, rarely lasting longer than a few hours and in many cases entirely absent, the eruption appears, occurring for the most part in the regions affected by measles ; in the form of multiple, pin-point to small pin-head sized macules, but smaller than the lesions displayed in that disease, and decidedly lighter in color. The shade is rosy to a crimson-red, rarely lurid, never of dark mulberry or violaceous hue. This color will, at times, be perceptible beyond the line of the lesions, in a delicate halo, a circumstance which strongly distinguishes the exanthem from mor- billi. The lesions, moreover, are very seldom arranged in crescentic outline, being more often grouped in roundish or oval patches. Often, indeed, the elements of the eruption are discrete and disseminated. The fauces are occasionally reddened in puncta. The eruption com- monly fades in from one to two days, and there may or may not be slight resulting cutaneous desquamation. The rash is to be distinguished from that of measles by the recog- nition of the features described above, particularly by the color, contour, and date of occurrence of the exanthem ; the transitory character of the fever when the latter is present ; the cervical aden- opathy and the rapidity with which involution of the disease pro- gresses. By the temperature record alone of the patient, it may be differentiated from scarlatina, though the rash is dissimilar in the two diseases. It is also not to be confounded with the erythematous affections of the skin. One of the most striking characteristics of the disease can be best recognized in a ward filled with children, all SCARLATINA. 143 of whom are simultaneously affected with the disorder. That char- acteristic is the remarkable mildness of the phenomena displayed in every case. The author has had under observation at one time twenty little patients all exhibiting the exanthein, not one of whom presented the peculiar facies of the sufferer from measles. After an exhaustive study of this disease, Atkinson 1 concludes that while its characters are so denned as to justify a reasonable cer- tainty in its diagnosis, it has no symptom that is not often assumed by measles. The disorder should be treated by rest in bed, a supply of fresh air, the strictest attention to asepsis, and the usual diet of fever patients. Medication by drugs is almost never indicated. Scarlatina. (Scarlet Fever, Scarlet Rash, Canker Rash.) Scarlatina is a specific, contagious, febrile disorder, characterized by a cutaneous exanthem, and by involvement of the throat and other bodily organs. The period of incubation of scarlet fever varies between twenty- four hours and a month or more, the average duration being about eight days. The reason of this wide variation is to be sought, not in any changeability in the mode of evolution of the disease, but in the fact that its poison is less volatile aud less rapidly dissipated than is that of measles, the result being that it may remain potential for longer periods in connection with articles through the medium of which it is transferred from one individual to another. This incu- bative period, like that described in connection with measles, may be quite unproductive of physical symptoms, or be associated with an ill-defined malaise. The prodrome of the disease in typical cases, is marked by the occurrence of a rapid and bounding pulse, an exceedingly dry skin, and a characteristic sore throat. When examination of the mouth is made, the tongue is seen to be thickly coated, and its filiform papillae reddened and prominent, producing the so-called " straw- berry appearance." The velum, pillars of the fauces, tonsils, and all exposed mucous surfaces are engorged, tumid, reddened, and often covered with deep reddish puncta, which unquestionably rep- resent hyperemia of the peri-follicular tissues. Thirst is great, and deglutition often in the highest degree painful. In severe cases, the mucous surfaces named may speedily exhibit finger-nail to pigeon's - egg sized, ashy ulcerations with a lurid halo at the periphery. In children, there may be syncope, delirium, convulsions, vomiting, or, when the poison has been intense, fatal results from shock of the nervous centres. This prodromal period usually lasts from twelve to twenty-four hours, though it may be prolouged for two days more. In this respect scarlatina is markedly distinguished from i Amer. Journ. of the Med. Sci., 1887. 144 DISEASES OF THE SKIN. measles. This stage is terminated by the appearance of the exan- them, but the fever persists without abatement after the explosion ; and the other symptoms of the disease are then in no wise amelio- rated. The eruption in scarlatina usually spares the face, however much the latter may display two damask-colored cheeks under the febrile flush, become tumid with the acceleration to it of the blood pumped through the throbbing carotids, or even exhibit a few scanty lesions upon the forehead and temples. About the mouth the integument is always pallid. This is far different from the picture presented in measles. The eruption is first seen in the form of light or deep red, pin-head sized puncta, so closely agglomerated as to produce upon the eye the impression of a diffuse reddish blush. It is first seen about the neck and clavicular regions, but rapidly spreads to the trunk and extremities, including the dorsal surfaces of the hands and feet, attaining complete development in the course of the second day of the eruption. It is then of a distinctly scarlet color, whence the disease has its name in the Latin, English, and German tongues, a coloration frequently compared to the appearance of a boiled lobster. Upon the limbs it is often developed in punctate form, while the occurrence of a diffuse scarlet blush is most distinctly perceived by the eye in the examination of the trunk. Here it is seen to fade under pressure ; and the finger-nail drawn rapidly over the surface of the skin is followed by the formation of a whitish line, which persists for an instant, a time sufficient to enable one to describe a letter upon the skin. This period of efflorescence lasts for from one to two days to an entire week, during which, as stated above, the febrile and other symptoms continue unabated. The rash usually persists at its maximum of development for from one to three days, the concomitant symptoms continuing without noticeable abatement. Among the latter may be named the occur- rence of albumin in a urinary secretion of diminished specific gravity, with occasionally the presence of epithelium recognizable under the microscope as derived from the lining membrane of the uriniferous tubules of the kidney. Having attained its apogee, the eruption in favorable cases begins to fade, the part first affected exhibiting earliest a lighter shade, while the other pathological phenomena diminish in severity, the sore throat especially in ulcerated conditions, alone persisting. In from four to ten days longer the eruption disappears, leaving a brownish - yellow pigmentation of the surface ; and simultaneously the other symptoms of disease vanish. The desquamation which then ensues, as convalescence progresses, is general and often proportioned in extent to the severity of the preceding eruption, though it may be generalized after a well-nigh imperceptible exanthem. It is more pronounced and characteristic in scarlatina than in any of the other eruptive fevers. It may be superficial and furfuraceous in character, or the epidermis may fall in lamellated plates, the sheath of an entire finger, for example, with SCARLATINA. 145 the nail, or that of the entire palm. In this way sheets, ribbons, and shreds of the horny layer of the skin may fall from its surface and expose beneath a new and often tender epidermis. The hairs may be simultaneously shed. When this desquamation is finished the stadium of the disease may be regarded as concluded, the entire period lasting in uncomplicated cases from a fortnight to a month or six weeks. The complications, anomalies, and remote sequelae of scarlatina are so numerous as to furnish a vast array of facts for the study of the pathologist. The reader need be merely reminded in these pages that the usual incubative and prodromic stages of the disease may be brief as to time, or so brusquely followed by eruptive phenomena as to be indistinguishable. The latter may also first occur upon the extremities or trunk, and later on the neck and over the clavicles ; or at once cover the totality of the surface by a rapid explosion, or be extremely short-lived, or be altogether absent, or be unusually pro- longed and visible for even a fortnight upon the surface of the body, appearing and well-nigh disappearing without appreciable cause. To a proportionate extent, the stage of desquamation may be preco- ciously or tardily reached, and the exfoliating process be tediously prolonged and of intense type, jeoparding in this manner the future of the convalescent prostrated by the fever which has passed or the sympathetic fever which may thus be awakened. The anomalies of the scarlatinal rash are numerous, but depend, in general, less upon a variation in the intensity of the poison than upon the physical condition of the patient. Thus, the affected surface may be slightly elevated above the general level; there may be no coin- cident pyrexia ; it may exhibit irregularly disposed mottlings aud maculations, may be characterized by the occurrence of miliary pap- ules, minute vesicles, or purpuric lesions, well defined against the general scarlet color of the skin by their violaceous shade, and due to cutaneous extravasation of blood. The rare bullous, pustular, and urticarial lesions which may appear upon the skin are accidental and bear no relation to the specific history of the disease. Malignant anginose scarlatina is characterized by the gravity of the throat symptoms. In such cases a parenchymatous inflammation of the tonsils, velum, and fauces supervenes at an early period, with enormous tumefaction ; involvement of the submucous tissue and neighboring glands ; and ulcerative, suppurative, and even gangrenous results, which may prove speedily fatal. Gastro-intestinal disorders may also prove dangerous. An otitis externa, media, or interna, may perforate the tympanum, destroy the ossicles, induce caries of the mastoid process of the temporal bone, and prove fatal by the eventual production of meningitis or phlebitis. Another severe type of the disease is that in which symptoms of typhus are pronounced (Scarlatiniform Typhus). Here the patient may perish within a few hours after being attacked and before the eruption appears, exhibiting comatose or convulsive symptoms indicating the profound influence upon the nervous centres of the 10 146 DISEASES OF THE SKIN, intensely intoxicated blood ; or the eruption may have time to appear, often livid, hemorrhagic, or petechial in type, and be followed by albuminuria, meningitis, diarrhoea, coma, and death. Catarrhal and parenchymatous nephritis is justly dreaded during the desquamative period of the malady, when it may prove fatal after a relatively benignant manifestation of the disease in its prodromal and eruptive stages. To this sufficiently grave list of disorders which may com- plicate scarlet fever must be added pneumonia, pericarditis, pleuritis, peritonitis, chronic purulent nasal catarrh, which may result in caries of the nasal bones, destruction of the cornea as a result of severe keratitis, persistent adenopathy of the subcutaneous glands, and malnutrition in many forms, which may so impair the vigor of the constitution as to leave the sufferer a physical wreck for the remainder of life. Fig 37. Microphotograph of the edge of a. Central zone. i small colony of the bacillus scarlatinee. b. Outer edge of growth The cutaneous lesions of scarlatina, like those of rubeola, depend upon hyperemia and a moderate degree of exudation. The latter, when it occurs, is limited for the most part to the rete and papillary layer of the corium. The signs of the disorder are not apparent in the dead body, unless there has been exudation of blood and the consequent formation of petechia?. The disease is produced exclusively by contagion derived from the animal body affected with scarlatina, either mediately or immediately. It attacks individuals of both sexes and all ages, children and infants more frequently, the aged more rarely, probably in consequence of their respective conditions as regards immunity conferred by a previous SCARLATINA. 147 attack, since, in general, the disease occurs but once in a lifetime. Individual idiosyncrasy must account for the cases in which unpro- tected infants exposed to the disease fail to receive it, a fact noted occasionally in all the exanthemata. The contagious element is volatile in its nature, and seems to be most active during the eruptive stage of the disease. Rod-like bodies and mobile points have been found by Reiss, Coze, and Feltz, in the blood of patients affected with scarlet fever; and injection of rabbits with such blood has proved fatal. Drs. Jameson and Edington 1 have recognized and cultivated the "bacillus scarlatina?," measuring 0.4 m.m. in thickness and 1.2-1.4 m.m. in length, forming long, jointed, and curved, motile leptothrix filaments. Exceedingly interesting clinical facts as to the trans- mission of scarlatina through the medium of the milk of diseased cows have been determined by some of the local health boards in Great Britain. The disease at times follows injuries and surgical operations, due, as Atkinson supposes, 2 to diminished powers of resistance to the disease. The diagnosis is between measles, rotheln, erysipelas, and the ery- themata ; and is, in general, readily established. The sore throat, intense fever, punctiform scarlet rash reaching to the border of the inferior maxilla, and the distinct, whitish-yellow line traceable by the finger-nail passed rapidly over the surface, are all characteristic. In measles, the macular character of the rash, and its crescentic arrange- ment, in connection with the catarrhal symptoms, will usually be recognized. From erysipelas, scarlatina can always be distinguished by the absence of the peculiar, shining, smooth, or glazed and tumid condition of the affected area. From all other rashes, scarlet fever can be distinguished by the pyrexic symptoms and resulting des- quamation. Great care should be taken not to confound the medicinal rashes having a scarlatiniform appearance with the specific disease under consideration. Thus belladonna, in doses of one minim of the tinc- ture every hour to the extent of four doses, has produced an abund- ant scarlatiniform eruption in children, a diagnostic point of impor- tance in view of the fact that the drug named is employed popularly as a prophylactic against the disease. For the medicinal eruption of this sort due to quinine and other drugs, the reader is referred to the pages devoted to dermatitis medicamentosa. The modern treatment of uncomplicated scarlatina is antiseptic and expectant, after provision is made for an abundant supply of fresh air, disinfection, a proper regulation of food and drink, and the local use of baths, tepid or cool, for the purpose of reducing the bodily temperature. After each of these, the skin should be com- pletely anointed with a fatty substance, such as cold cream, scented almond or olive oil ; or, what is most commonly used in this coun- try, vaseline. These inunctions are not only grateful to the patient, i British Medical Journal, June 11, 1887, and August 6, 1887. 2 Journal of Cutaneous and Venereal Diseases, vol. iv, October, 1886. 148 DISEASES OF THE SKIN. but reduce the temperature to a slight degree. All other treatment than that suggested above, should be limited to the special conditions presented in each case, and pertains to the field of general medicine. It includes the management of disorders of the eye, ear, throat, kid- neys, and other viscera, whose involvement constitutes a complica- tion of the disease. The prognosis of the malady should always be established with reserve. It is largely based upon the relative intensity of the symp- toms, the vigor and age of the subject, and the presence or absence of serious complications. Albuminuria is rarely absent, and not per se alarming ; but anasarca and other evidences of profound interference with the renal function, are to be assigned due weight. In general, it may be said that a high range of temperature ; early and ulcerative throat lesions ; tardy development, rapid and untimely disappearance, or undue prolongation of the exanthem ; and its admixture with petechia? to such an extent as to indicate extensive hemorrhagic ex- travasation are all formidable symptoms. Finally, it must not be forgotten that the mildest and simplest forms of the disease, after the fastigium is passed and convalescence actually established, may ter- minate fatally by the supervention of uraemia, cerebral paralysis, or even meningitis, consequent upon secondary changes in the middle or internal ear. Variola. Lat. varus, a blotch. (Smallpox.) Variola is a specific, contagious, and febrile disorder characterized, when un- modified, by the appearance in succession upon the cutaneous surface and occa- sionally also upon the mucous surfaces, of papules, vesicles, pustules, crusts, and cicatrices. The variations of this malady as to the severity, character, and duration of its symptoms, are so great as to preclude its complete description within the limits here assigned to the subject. The fol- lowing paragraphs are devoted to a brief sketch merely of its more commonly recognized characters. The period of incubation of the unmitigated disease varies between ten and twenty days, occupying usually a fortnight. It is character- ized by the peculiarities of that period recognized in all the exan- themata, few and insignificant or no evidences of physical discomfort. The prodromic stage is ushered in generally by a vespertine chill, succeeded by fever, with a temperature rising to 104°-106° F., which is commonly associated with severe and characteristic pain in the loins, headache, nausea or vomiting, and occasionally, in young sub- jects, delirium and convulsions. The fever continues, with alterna- tions of exacerbation and partial relief, or sensations of chilliness, on the second and third days. At the same time there may be faucial hyperemia and moderate dysphagia. Occasionally, before the cuta- VARIOLA. 149 neous exanthem appears, minute reddish papules may be recognized upon the buccal membrane. On the second and third days there appears, in some cases, espe- cially in menstruating women and in young subjects, a cutaneous efflorescence, whose significance has been often misinterpreted and which has led to many errors in diagnosis. It is to Hebra that we are indebted for its distinct recognition as a cutaneous prodrome in variola. It has been termed Variolous Erythema, and Vario- lous Roseola. Its recognition is a matter of special importance to the diagnostician, as many have been deceived respecting its nature and significance. It is characterized by the occurrence of irregularly disposed and distinctly outlined maculatious, puncta, striae, streaks, or a diffuse blush of bright or lurid reddish hue ; the invaded integu- ment being at times slightly tumid, and thus elevated above the general level. It may be also the seat of moderate pruritus. The blush may fade under pressure, but rarely does so perfectly. Oue cannot by the finger produce upon it a visible whitish spot. It occurs most often about the groins, hypogastric region, pubes, and inner faces of the thighs ; and, examining these parts, the physician will usually discover the evidence, in adult women, of recent or present menstruation, or of the puerperal state. It occurs also about the axilla?, the extensor faces of the larger and smaller joints, and the lumbar and clavicular regions. Often a broad area of the integument p & in these parts may exhibit a sheet or mask of dull crimsou erythema, upon which pin-hpad to bean-sized, dull-reddish papules may form, not losing -their color under pressure, more rarely petechia?, vesicles, and wheals. All these are precursory phenomena, and are not trans- formed into characteristic variolous lesions. They fade almost com- pletely before the latter appear. Rarely, a few scattered papules may be distinguished upon the face and arms before the variolous erythema fades. Often the former in full development are even less profusely displayed in the site of the precedent efflorescence. The latter need not be necessarily regarded as a symptom of portentous gravity. The author has seen the entire surface of the belly covered with a uniform erythematous blush of dull crimson hue, confluent variola follow, and the patient ultimately recover. The physician, then, in the face of a deep red erythema of the regions named, especially of the groins, lower part of the belly, and thighs of a menstruating woman affected with high fever, nausea, vomiting, and lumbar pain, should invariably suspect the presence of variola. The period of eruption is characterized, at its earliest, by puncti- form, subcutaneous discolorations which photography alone can reveal. Commonly, after three days of prodromic symptoms, the patient will be seen on the morning of the fourth with the face and scalp covered by pin-head sized and larger, firm, conical papules, whose impression to the finger is compared by most English writers to the feeling of shot. Later, these develop upon the trunk and limbs ; and in well- marked cases every portion of the surface of the body is invaded, including the palms and soles. The lesions may be surrounded by a 150 DISEASES OF THE SKIN. narrow rosy areola upon the trunk. They may be unproductive of subjective sensations, or be slightly tender. As a rule, there is complete defervescence when the exanthem appears, the patient experiencing such relief that if an adult has chanced not to view the face in a mirror nor to be informed of his appearance by those in attendance upon him, he will often regard himself as completely relieved of his three days' illness. In other cases, the febrile symptoms persist, with a lowered temperature. During the first two days of the eruptive period, the papules in- crease in number, and become correspondingly agglomerated ; while those of earliest appearance become transformed into vesicles con- taining a translucent serum, the roof- wall of many of them exhibiting an umbilication. This umbilication of the vesicle is characteristic, Vertical section of pustule at the beginning of pustulation a, umbilication at the site of an excretory canal ; b, reticulum within the epidermis ; c, reticulum of smaller meshes con- taining lymph- and pus-globules. (After Rindfleisch.) and slightly different from that observed in bullous and pustular lesions. The central depression is disproportionately large, and about it the yet undistended epidermis is often irregularly puckered or fluted. Even in this period, the lapse of a few hours will produce a lactescent appearance in their formerly translucent contents. From the eighth to the twelfth day, the transformation of these lesions into pustules is effected, the process beginning, as in all the metamorphoses of the disease, in the vesicles of greatest age ; those, namely, on the face and upper portions of the body. The lesions simultaneously enlarge till they are of the average size of a pea, and, being fully distended, rupture the centrally placed filament which held down the roof-wall, in consequence of which the umbilication of the pustules is lost. With this process of suppuration, is awakened the so-called secondary fever, a pathological process evi- dently not essential to the disease, as it does not occur in mitigated VARIOLA. 151 cases. It is born of the extensive process of suppuration occurring in the skin and other organs, and may be symptomatic, sympathetic, or septicemic in character. It thus varies in different cases with the character and severity of the process by which it is excited, being transitory in mild cases, and in others terminating only with death. At this time the patient is usually in a most distressing con- dition. The skin of the face and other attacked regions is swollen, thickly covered with pustules, and the features indistinguishable in the tumid and closed lids, the oedematous lips, disfigured nostrils, and pus-obstructed mucous outlets. Deglutition becomes painful and often impossible ; the saliva flows from the lips ; and the mucus of the nares dries with the pus upon the exterior of the visage. The pustules recognized upon the integument are represented also in the Vertical section of one-half of an undeveloped pustule, a, old epidermis ; b, epithelia of rete above the alveoli ; c, new-formed epidermis ; d, alveoli filled with pus-globules ; g, flattened and infiltrated papillse lying beneath the pustule. (After Auspitz and Basch.) gastro-intestinal tract. In an autopsy of a patient dead at this stage of the disease, made by myself in company with Dr. McGill, of the United States Army, we discovered the entire canal from the mouth to the anus, as also the genito-urinary and respiratory passages, com- pletely covered with closely agglomerated and well distended pus- tules. The career of those within the mouth can be usually studied by observation with the eye. In this situation they rapidly lose their epithelial roof- wall by reason of the heat, moisture, and friction to which they are subjected, and then exhibit a reddened and exco- riated surface, over which there is reformation of the epidermal layer. Gangrenous complications are rare. Between the thirteenth and fourteenth days desiccation begins, and is usually completed within from ten days to a fortnight afterward ; the pustules rupture, and the exuded pus concretes into yellowish and brownish, rarely blackish crusts, or the latter are formed by the 152 DISEASES OF THE SKIN. desiccation of the entire envelope and contents. The pulse usually at the same time diminishes iu frequency ; a secondary defervescence occurs ; the tumefaction of the integument decreases ; and at times the peculiarly characteristic, and often intolerably fetid odor of the patient is less perceptibly exhaled. In from four to six weeks the course of the disease is completed. The immediate traces of the eruption are purplish and violaceous pigmentations, which slowly disappear. When cicatrices result, they are slightly depressed, dead- white, lustrous, usually symmetrical in disposition, and most distinct upon the surfaces exposed to the light and air, as the face. Though persistent, they are rendered somewhat less deforming in the progress of years. When closely set together, they produce a characteristic ridged and corded appearance, due to the elevation of narrow bands of unaffected integument between the depressed surfaces of scars. The several departures from the pronounced type of the disease described above present variations differing widely from the most benignant forms. Brief reference only can be made to these. Varioloid, whether occurring after vaccination or not, is a modi- fied form of the disease. With it should be classed all those forms of the disorder occurring in the human subject, and described by authors under the title of " Swine-pox," " Horn-pox," etc. In these cases there may be severe prodromic fever and a scantily developed exanthem ; mild fever, abundant exanthem, and rapid involution of lesions ; abortion of the latter in any of their several stages from papule to crust ; absence of secondary fever ; transmission of the disease in a mild or mitigated form, from one individual to another, so that an entire community, vaccinated and unvaccinated alike, may suffer from an epidemic disorder of this moderate grade without the occurrence among them of a single case of typical Variola. It is scarcely necessary to add that the patient with varioloid, especially during an epidemic, may transmit to the unprotected a malignant form of the disease. Much more formidable, viewed from every standpoint, is Hemor- rhagic Variola, fortunately rare and too often confounded in the past with " black measles." When cutaneous haemorrhages occur during the course of smallpox, they do not necessarily indicate that the case is one of the so-called varioliform purpura, since these may be accidents of the pathological process. In this malignant form of the disease, against whose ravages vaccination often presents a feeble barrier, the prodromic stage is followed by a deep purplish redness of the surface which is characterized by pin-head to split-pea sized, firm, closely set, papular lesions, suggesting the occurrence of measles in a peculiarly severe form. The febrile, nervous, and other symp- toms of the disease are proportionately intense. Ecchymoses appear upon the conjunctival membrane. Gradually the color of the exan- them, which at first disappeared under pressure, refuses thus to yield, and assumes a bluish-black shade. Ecchymotic patches may be intermingled with these, rapidly widening to palm-siz^d and VARIOLA. 153 larger areas. The raucous surfaces share in these colors, being also infiltrated with effused blood; and the mucocutaneous orifices are crust-covered and exhale an extreme fetor. Blood may escape from the bowels, bladder, mouth, and vagina. Signs of grave systemic and visceral complications are always present. Vesiculation, pustula- tion, and the typical transformations of the variolous lesions are all wanting. In the few cases observed by the author, death has always speedily supervened, either from shock, coma, hemorrhagic infarc- tion of the lungs, or rapid exhaustion. Intermediate forms between hemorrhagic and true variola are described, in which the pustules occurring in the latter form of the disease merely fill with blood in consequence of accidents possessing a purely local significance. The Confluent is another severe form of variola, less malignant, however, than that just described. It is characterized by intensity of the prodromic fever, which often scarcely abates with the appear- ance of the exanthem. The latter is developed in deeply implanted, firm papules, closely set together, succeeded by vesicles and pustules, which, as they enlarge, fully occupy the entire surface of the integu- ment, and accomplish a perfect coalescence. In well-marked cases there is scarcely a pin-head sized area of the entire surface of the body which is not invaded. The tissues become enormously oedema- tous ; the deformity of the face renders the features indistinguishable. Hemorrhagic pustules and even patches of a gangrenous pulp may be intermingled with the sheets of suppurating surface. Phouation, respiration, and deglutition are proportionately impeded or absolutely subverted by the tumefaction and suppuration of the mucous mem- branes of the respiratory and gastro-intestinal tracts. When the patient survives till the stage of desiccation is reached, the body pre- sents an aspect as revolting as that ever displayed by a living being. A thick, brownish, or blackish-brown mask envelopes the swollen head, trunk, and limbs ; and the odor exhaled from the body is intolerably repulsive. All the systemic phenomena are proportion- ately grave and accompanied by one or more of the complications of the malady, pneumonia, pleuro-pneumonia, albuminuria, diarrhoea, various motor and sensory paralyses, subcutaneous furuncles, and abscesses. The eyes may suffer from pustular and ulcerative changes in the conjunctiva, cornea, and deeper tissues, with resulting inflam- mation of every grade to panophthalmia, and resulting loss of vision. Often the patients, with surprising powers of resistance, will survive till extensive sheets of crusts have fallen from the surface, and then perish slowly in a typhoid condition with low remittent or continuous fever. Every such case does not, however, conclude fatally. Chil- dren may rally from the severest form of confluent variola, and enjoy afterward a vigor which illustrates well the wonderful recu- perative energy of the natural forces under the most adverse circum- stances. Variola is always the result of mediate or immediate contagion. It is a disease which is both contagious and infectious, being trans- missible by volatile emanations from the victims of the disease. It 154 DISEASES OF THE SKIN. is also artificially inoculable. When transmitted by the latter pro- cess, its period of incubation is somewhat shortened, and often its successive manifestations become then less formidable. The history of inoculated human variola has, however, received but little atten- tion during the last decade, in which the practice has been properly forbidden by law. The disease is, to a certain extent, transmissible from man to the lower animals, and the reverse. It attacks indi- viduals of both sexes and all ages, including the foetus in utero, which may be ushered at an untimely hour into the world macerated or recently dead and covered with the lesions of variola. The disease in the larger cities is decidedly more frequent in winter than in summer, possibly because in the colder months the opportunities are greater for spreading the contagion in artificially heated dwellings where numbers of individuals are crowded together. Islanders long unvisited by an epidemic and unprotected by vaccination, may suffer equally in the summer season. The parasitic nature of variola has not yet been demonstrated. Coze, Feltz, Baudouin, Luginbuhl, Weigert, Hallier, and Cohn have recognized micro-organisms, both bacteria and micrococci, in the blood of variolous patients. None of these have as yet been utilized in the production of the disease ; but Cohn 1 regards these parasites as a twin race of the micrococcus vaccinae discovered in vaccine lymph. The secondary fever of the disease is without question septicemic and due to the pus cocci and their toxine. The difficulty attending the diagnosis of variola in its prodromic and earliest eruptive stages, from rubeola, has been already men- tioned. The general demand, indeed, upon the physician for an exact and definite diagnosis of every case before its typical develop- ment, is founded upon an erroneous conception of possibilities ; and the sooner this is generally recognized, the better for all concerned. A delay of even a few hours will often verify or remove a suspicion, and the author is confident that he has seen fully as much mortifica- tion on the part of the physician and damage to the best interests of the patient, result from an error in one direction as in the other. The wisest course in every doubtful case is to admit the doubt and to visit the patient frequently for the purpose of observing the de- velopment of the disease till that doubt is removed. Typical cases of variola are recognized with ease from the character of the symp- toms presented. Syphilis and acne are always distinguished by the absence of fever and their relative chronicity. Two cases of sud- denly occurring medicamentous acneiform rash have come under the author's observation, where a diagnosis of variola had been pre- viously made. In each, the absence of a prodromic stage and the subjective sensation excited, were sufficient to point to the nature of the disease when considered in connection with the peculiar character of the lesions. The prognosis of variola is largely dependent upon the degree of 1 See Magnan, loc. cit., p. 411. VARICELLA. 155 protection conferred by previous vaccination. This aside, the age and vigor of the patient, the presence or absence of an epidemic of severe or mild type, the extent of the eruption, and the character of the surroundings of the patient, are elements of prime importance. Very young and aged subjects, women pregnant or in the puerperal state, and, as Hebra has shown, those who have suffered from a pre- vious attack of the same disorder, are all unfavorably related to the final result. Confluent and hsemorrhagic forms of the disease are, naturally, the gravest. Unmitigated variola is, under the most favor- able circumstances, one of the greatest scourges of humanity ; and as such will probably always destroy a frightful proportion of its victims. At the same time, the conscientious physician needs to be impressed with the fact, that under the most discouraging circum- stances, the patient, disfigured to the greatest extent by an envelope of blackened crust, and in a state of extreme physical prostration, with many of his bodily functions almost completely suspended, may even from the midst of such peril be won back to life and vigor. The assiduous attentions of a gentle nurse, guided by the inspiring presence and counsels of a physician who is himself fearless of the malady, will often achieve the result. Upon the latter point, it is interesting to note, that physicians in active practice who do not hesitate to expose themselves freely to the disease in the discharge of the duties of their profession, rarely suffer in their own persons. Varicella. (Chicken-pox.) Varicella is a contagious, febrile disorder of benignant and mild character, accompanied by a vesicular exanthem. The disease has an incubative period lasting for about a fortnight, after which there is occurrence of malaise, chilliness, and languor. The patients are usually children who may suffer thus from fever of a moderate grade lasting from a few hours to two or three days, after which defervescence is commonly complete. With its onset, or with- out it, the rash appears, first on the head and trunk, in the form of rosy maculae or slightly elevated lesions lacking the characteristic " shot-like " feeling of the variolous papule. These rapidly become vesicular, the lesions being pin-head to pea-sized, limpid, superficial in situation, differently shaped and very rarely umbilicated, puckered, or " fluted" as in smallpox. They appear in successive crops, and are often surrounded by a faint halo. Their contents become cloudy or lactescent rather than puriform, and desiccate often as early as the second day, forming thin, light, superficial crusts. The lesions may be abundant in one region, as, for example, over the back or the chest ; but are practically never both abundant and generalized, and never confluent. Like variolous lesions, they extend at times to the mucous surfaces of the eyes, mouth, and genital regions. Occasionally they are productive of pruritic sensations. Often the course of the 156 DISEASES OF THE SKIN. disease is so mild and the exanthem so slight as scarcely to attract attention. Cicatrices result only in places, chiefly the face, where the lesions have been subjected to local irritation. Diagnosis. — It is well known that a number of German authori- ties, following Hebra, have given assent to the doctrines taught by the latter that varicella is only a mitigated form of variola. That doctrine is offensive to American and English physicians, who in practice find it vastly wiser to distinguish carefully and exactly be- tween the diseases in question. The settlement of the discussion may well be relegated to a date when the probable parasitic nature of both disorders can be exactly determined. In variola, the invasion period, of relatively fixed limits, the speedy transformation of the lesions into minute, firm papules, their early appearance on the exposed parts of the face and wrists, the age of the patient, the thermic variations, the prodromic rashes, and the speedy transformation of the papules into umbilicated vesicles, are all impor- tant diagnostic points In varicella, the trunk usually exhibits the greater number of lesions, which appear also in successive crops. Beside the characteristics of the cutaneous lesions, the catarrhal symp- toms of measles and the sore throat of scarlatina, will point to the nature of these disorders. Fox's impetigo contagiosa is to be very carefully distinguished from varicella, since the two affections occur at times side by side in one hospital ward ; and occasionally the former succeeds the latter. The lesions of impetigo contagiosa are often larger, generally more persistent, the crusts bulkier, and the patients may be of a more advanced age. The treatment of variola should, in general, be limited to the indi- cations presented in each case. No remedies can be employed which have the least power to abort the disease. Kaposi calls attention to the striking fact in this connection, that in syphilis, for many of whose manifestations mercury is a specific, we find a disease whose second incubative period is measured by weeks, and yet neither by excision of its initial sclerosis nor by mercurials can the subsequent manifestations of the disease be completely prevented. Certainly, no specifics are recognized as of value in variola. The patient should be kept in a relatively darkened room with au abundant supply of fresh air of a uniform temperature ; and antiseptic solutions should be constantly at hand into which all the ejecta are immediately received. He should be given ice when this is grateful to the palate, cool water ad libitum, and his strength should be sedulously supported by a liquid animal diet. The body may be sponged with or bathed in cool or tepid water, as often as is grateful to the patient. In severe or confluent cases, the constant immersion of the body in the continu- ous warm water bath, as practised in Vienna, is followed by the most brilliant results in hastening the desiccation and fall of the crusts and the subsequent repair. A bath of this character given for merely two or three hours in the day, is often of great value. With and without these external measures, gargles of chlorate of potash, myrrh, honey, VACCINIA. 157 or carbolic acid, will be found acceptable to the mouth and palate. Indeed, the constant attention of an efficient nurse bestowing assidu- ous care upon the mouth, skin, and eyes, may be regarded as an esseutial part of all sound treatment. As regards the prevention of pitting, it may be remarked that no measures of a therapeutic character will prevent the occurrence of a distinct cicatrix whenever pus has eroded or otherwise destroyed the integrity of the papillary layer of the corium. Every effort, therefore, should be exerted to prevent the extension of the suppura- tive process to the true skin. The following are measures which have approved themselves as of practical value : first, the sick-room should be moderately darkened, and yet amply provided with fresh air; second, a solution of the hyposulphite of sodium (Squibb's is supe- rior to the ordinary preparations in the market) should be adminis- tered night and day in the dose of from fifteen to twenty grains (1.— 1.3) every three or four hours. Certainly the variolous lesions pursue a milder course under this internal treatment, and even, in cases, the vesicles shrivel before pustulation is fairly begun. Third, the skin of the face should be anointed with a bland fatty substance such as vaseline, almond oil, or fresh lard, and over this may be laid silk-enveloped compresses, dipped in tepid and weak solutions of carbolic or boric acid, or thymol. The anointing of the surface before the application of the lotion is commonly more grateful to the patient, but the skin may be constantly moistened with the aqueous lotion alone. Here, again, the assiduous attention of the nurse is a matter of importance. The powder of iodoform topically is often applied with advantage. The edges of the eyelids should be daily anointed with freshly pre- pared cold cream. Puncture of the cornea may be required for the relief of hypopion. Diarrhoea and other symptoms of visceral de- rangement should be relieved by appropriate medication. As a rule, the administration of narcotics for the relief of pain is objectionable. Throughout all, the strength of the sufferer should be supported by a general use of animal broths or milk ; and in typhoid conditions a judicious employment of stimulants may be necessary. Vaccinia. (Cowpox.) Vaccinia is a specific bovine fever, accompanied by a vesicular exanthem, trans- missible to man by inoculation. The limits of these pages forbid a discussion of the interesting questions which concern the relations of cowpox as it occurs sponta- neously in the milch-cow, to human variola. A careful collation of the results obtained by the large number of vacciniculturists of later days, renders it clear that it is a matter of great difficulty to transmit variola from man to the heifer ; that where this rare result is ob- tained, the lymph derived from the lesions on the udder or the belly 158 DISEASES OF THE SKIN. of the latter is liable to produce variola when retransmitted to man ; and that spontaneous cowpox alone seems to furnish a lymph which is safely inoculable in generations to the human race. Of greater importance is it to note here that, either by arm-to- arm vaccination, as was formerly extensively practised, or by the use of the animal virus which has of late been well-nigh exclusively em- ployed in this country, there has been conferred upon millions of human beings a degree of protection against variola whose value is beyond estimate. In both methods, the lymph is derived originally from the female of the bovine race, preferably in the puerperal state ; and its sources are the vesicular lesions of vaccinia spontaneously arising or artificially cultivated about the teats, udder, and adjacent parts. The introduction of this lymph into the skin of the human subject is termed vaccination. The simple operation of vaccination is performed in many ways, but that which especially commends itself to the prudent man is the method which eliminates to the largest extent the possibility of trans- mitting any other contagious disease than the one intended. With this object in view, no better instrument can be devised than a clean needle, one which has been properly disinfected and not previously employed for any purpose. The skin of the part selected for vacci- nation being first cleansed antiseptically, and subjected to slight tension by the left hand, the vaccinator should scratch or scrape off the epidermis with the needle, held in the right, by a series of parallel and crossed strokes, so as to make three or four superficial erosions, at a distance of three or more inches apart. Each of these multiplex wounds should have the size of the little finger-nail, and should in no case bleed, but merely ooze with serum slightly tinged with blood. At such points the lymph is to be thoroughly and slowly rubbed in, whether it be supplied in a dry form upon ivory points which have been dipped in the serum oozing from vaccine lesions upon the heifer, or be a fluid obtained by crushing and dissolving in water the crust taken from the similar lesions on the arm of a child previously unprotected and recently vaccinated. In public charities, where, for the most part, such procedures are practicable, it is usually sufficient to dip a needle into the lymph flowing from the arm of the vaccini- fer and to plunge it, thus charged, once or twice into the part selected for the operation. Between the third and fourth days after a successful vaccination of the unprotected, a light reddish, pin-head sized papule rises at each inoculated point. Between the fifth and sixth days, it becomes transformed into a translucent, well-distended, occasionally umbili- cated vesicle. This, when single, may attain the size of the finger- nail. Springing from the multiplex abrasions described above, a minute papule usually forms at each point of intersection of the crossed lines produced by the scratching with the needle, and the subsequent vesicles coalesce, forming thus a compound lesion of rather peculiar aspect. It appears often as a small coin-sized plaque, elevated to the extent of a line or more beyond the general level, VACCINIA. 159 with a rim formed of numerous discrete or confluent vesicles, which. in either case are closely set together. The compound plaque seems to develop afterward as a single lesion, its centre being depressed. After the ninth day, the fluid becomes opalescent, and desiccates in a reddish-brown crust, which, examined in section by a good light after it is completely dried, exhibits a smooth, homogeneous, shining appearance, with a color having the shade of amber. Fully as important as any of these metamorphoses of this lesion, is its rosy-reddish areola, in the absence of which some authorities declare that there is not proper protection. It completely encircles the compound vesicle in the form of a halo having a diameter of several inches, the tissue it invades being often slightly tumid. When the pathological process in the focus of this areola is intensified, either as the result of the irritant character of the virus, or from extrinsic causes (undue exertion of the vaccinated part), the areola may spread extensively down the arm, or over the thigh or leg, and eventually cover a dense, brawny, and deeply reddened integument. Dermatitis, erysipelas, lymphangitis, adenopathy, and severe grades of inflammation of the subcutaneous tissues, may for similar reasons complicate the process, which may terminate by central sloughing, ulceration, slow repair, and the production of an atypical cicatrix. Ordinarily, the subjective phenomena are limited to a mild or annoy- ing itching of the vaccinated surface ; in other cases, severe burning pain, a feeling of tension, and even sympathetic fever may be aroused. The acme of a successful vaccination is usually attained between the tenth and the fourteenth days, after which the symptoms of the disorder gradually subside, the crust falling, if undisturbed, in the course of the ensuing week. When " animal " virus is employed, the duration of each of these stages of the disease is usually some- what prolonged. The cicatrix, at first slightly reddened or pigmented, gradually assumes the dead white appearance of scars in general. When typical, it is slightly depressed, circular, not irregular, nor deformed by ridges, cords, or bands, and " foveolated," exhibiting a series of peripheral pits or depressions, each of which represents the site of a former minute vesicle of simple type. There is strong reason to believe, in the face of authoritative statements to the contrary, that the degree of protection is based in part upon the multiplicity of typical cicatrices, and, in view of the rarity of variolous patients with four such traces of successful vaccination upon the person, many are prejudiced in favor of the English method of producing multiple scars. The complications of vaccination are due, first, to the character of the virus employed ; second, to the character of the soil in which it is implanted ; and third, to the external accidents to which the vac- cine lesion is subjected. Respecting the first of these sources, there are few contagious diseases which may be transmitted by vaccination, beside syphilis. When this accident occurs, it may be due either to 160 DISEASES OF THE SKIN. the fact of syphilis in the vaccinifer, or to the use of instruments soiled with infectious secretions. It is both asserted and denied, that the lymph from a typical vacciue vesicle in a syphilitic vacciuifer will necessarily transmit syphilis, if it be accidentally commingled with either blood or the products of inflammation at the base of the pock. The demonstration of any such fact requires a mass of evi- dence exceedingly difficult to collect, inasmuch as the stage and intensity of the disease in the vaccinifer are elements which cannot be ignored in a decision of the question. When thus transmitted, it will be remembered that the vaccine lesion may complete its career during the incubative period of the initial sclerosis, whose existence at the site of vaccination is commonly declared later by induration, ulceration, pigmentation, and axillary adenopathy. The occurrence of a generalized syphiloderm before the chancre of vaccination is completely healed, is often the first symptom to arouse suspicion. Those further interested in the subject should study the cases collected and admirably illustrated by Mr. Jonathan Hutchinson, 1 of London. It should be added, that the popular impression regarding the fre- quency of this accident is greatly erroneous. In the experience of the author the rarest of all modes of transmission of syphilis is that by vaccination. In all such cases, the possibility that the syphilis may be hereditary, and its symptoms simply coincident in point of time with those of vaccinia, should not be forgotten. Exceedingly dangerous is that virus, however good its early char- acter, in which decomposition or putrefactive changes have occurred after exposure, in a liquid form, to the action of heat and the atmos- phere. Vaccination with lymph thus changed has been rapidly followed by fatal results, in consequence of the supervention of pyaemia or septicaemia. Complications of vaccinia, due to the character or predisposition of the tissues in which the virus is introduced by the vaccinator, are usually ascribed by the ignorant or prejudiced to the causes just con- sidered. Post hoc ergo propter hoe is the sole logic of the uninformed. In this way almost all other ills of the human family have been in turn ascribed to " impurities " and " humors " introduced by vaccina- tion. The language and arguments used in support of these positions have been as extravagant as they were unreasonable, and have borne fruit in the refusal of many physicians of repute to perform vaccina- tion and thereafter to assume the responsibility of all the subsequent ailments of the vaccinated. The cutaneous symptoms which may thus be awakened are numerous. It will be remembered that the contents of the typical vaccine vesicle are auto-inoculable, and that thus the scratching of young patients may produce an abundant crop of typical or torn vesicles upon the arms, legs, thighs, hands, and fingers. But vaccination may also awaken in the patient, as ex- plained above, a latent syphilis, as also a list of cutaneous disorders not contagious in character. Thus an erythema (roseola vaccinia, vaccinola, etc.), eczema in many of its forms, and other exudative 1 Illustrations of Clinical Surgery. Phila., 1875. VACCINIA. 161 processes may be first aroused in the integument by the turbulence of a successful vaccination. These rashes may become generalized, and even assume a formid- able appearance. They may appear at auy time from the second to the fourteenth day after vaccination. A scarlatiniform rash, diffused or in patches, is described by some authors as occurring in this way, accompanied by mild fever, and resembling German measles. Simi- larly generalized eruptions, resembling erythema multiforme, psoriasis, urticaria, impetigo contagiosa, varicella, and other cutaneous disorders, may appear for the first time within the limits named above. They usually disappear within a brief time after the vaccine vesicle has completed its involution, and may be followed by slight desquama- tion or pigmentation. 1 Very rarely vaccinia is followed by pupuric symptoms. Anomalies of the vaccine vesicle are occasionally noted as to its shape, career, and resulting cicatrix which it is difficult to explain. Thus, the papulo-vesicle may not exhibit an umbilicated centre, or may complete its course within unusually short limits ; or a harmless ulceration may progress beneath its crust, requiring a week, or even more, for complete cicatrization. The so-called " raspberry sore " is explained by Robinson as resulting from coalescence of small papules, so as to form a pigmented tubercle. The scars resulting from many of these irregular and non-protective results of vaccination may in each direction form a typical cicatrix, being, on the one hand, small palm-sized, deforming, corded, and representative of large tissue-loss ; and, on the other, feeble, irregular, and inconspicuous. Lastly, the complications of vaccinia due to external accidents of the lesion are usually inflammatory in character. The excessive use of the vaccinated arm in labor, and of the vaccinated leg in walking, standing, and other exertion, may induce, as indicated above, every grade of dermatitis, and even ulcerative changes in the site of the inoculation, as a result of the intensity of the process. For these accidents rest is essential, with the free use of a dusting powder over the inflamed surface. In exaggerated cases, lotions of lead-water and opium may be employed. These conditions are usually relieved without difficulty as soon as the part is put to rest. The atypical scar which results seems to be in such cases as protective as others, if only the accident have occurred to a typically progressing lesion with distinctly perfect areola. Vaccine cicatrices are to be distinguished in anomalous situations from maculae atrophica, the scars of syphilis, and of other scar- leaving disorders. Micrococci have been recognized by Cohn in vaccine-lymph. These have been named micrococci vaccinas, but their relation to similar organisms discovered in the blood and tissues of variolous patients has not yet been determined. Wolff 2 claims to have cultivated these 1 An interesting paper on vaccinal eruptions was read by Dr. Gustav Behrend, before the Dermatological Section of the International Medical Congress, in London, August 5, 1881. (See a translation of his paper by Dr. Alexander, Arch of Derm., No. 4, 1881, vol. vii. p. 383.) 2 Berl. klin. Wochenschr., January 22, 1883. 11 162 DISEASES OF THE SKIN. organisms through fifteen generations. Strauss has demonstrated their existence in the vaccinal pustules of the calf. 1 Lipp, of Gratz, reported to the International Medical Congress, in London, that he had recognized great similarity, if not identity, between the micrococci of vaccinia and variola, which he had culti- vated to the second generation, but had then been unsuccessful in producing inoculation effects. These organisms were always arranged in groups of four, or multiples of four. Erythema Simplex. Gr. kpWrj/ia, redness. (Rose rash. Fr., Erytheme ; Ger., Hautrbthe.) Statistical frequency in America, 0.859. Erythema Simplex is a coloration of the skin in various shades of redness, temporarily disappearing under pressure, the lesions differing in size and shape according to the extent and degree of the hyperemia by which they are induced. Hypersemia of the skin, due to increased velocity or amount of the fluid in the cutaneous capillaries, results in increased coloration of the integument. The shades of this color vary from a delicate pink or rosy hue to a dark reddish color. Thus, hypersemiaB may be dif- fuse or circumscribed, idiopathic or symptomatic, and due to active or passive congestion of the vessels. Idiopathic Erythema. Erythema Traumaticum. — Here the redness is the result of friction, rubbing, pressure, scratching, and similar external contacts. It is observed, for example, in the part pressed by the pad of a truss ; in the colored circle left about the leg where a tight garter has been worn ; on the sides of the nose where pressure is exerted by a newly applied pair of eye-glasses. These traumatic hyperemias are readily converted into exudative affections, if the traumatism be long con- tinued. Intermittent pressure upon the skin permits restoration of the vascular equilibrium, and the skin responds to the demand made upon it, by increasing in thickness; continued pressure, on the con- trary, admits of no such restoration ; and the integument finally becomes thinner, and yields before the agent inflicting the injury. Inflammation resulting in ulceration may finally supervene. Erythema Caloricum. — Solar heat in excess and extremes of cold ; very hot and very cold water ; and other heat-conducting sub- stances, are also sufficient to induce transitory redness of the surface. In the erythemata induced by solar heat especially, there is frequently See Magnan, loc. cit. ERYTHEMA SIMPLEX. 163 an increase in the pigmentation of the surface, as in the production of freckles and " tan " in persons whose skins are reddened by the sun. The darker, brownish, and chocolate-colored stains of the hands and face are thus induced. Erythema caloricum (Erythema ab Igne) may occur in annular and odd-looking gyrate patches on the anterior faces of the legs in cooks, firemen, stokers, and persons exposing that portion of the body to the direct action of heat. The annular patches may be several cen- timetres in diameter, and vary in shade from a light to deep red or even purplish tint, deep pigmentation resulting as the erythema subsides. Erythema Vekenatum. — A number of chemical substances, dyes, and vegetable poisons are capable of producing transient hyper- emia of the skin. Among these may be mentioned cantharides, capsicum, mustard, aniline, chloroform, ether, arnica, and several of the essential oils. Erythema Gangrenosum. — Under this title several singular affections of the skin have been described, in which erythematous patches appeared and were followed by more or less extensive destruction of one or more of the several layers of the skin. T. C. Fox, in a description of the appearances in two cases under his observation, concludes that these are the symptoms of a feigned disease, or one produced artificially for the purpose of exciting sympathy, etc. Symptomatic Erythema. This may be of either active or passive form. A long list of physiological and pathological causes operating upon the system at large are capable of inducing active symptomatic hyperemia of the skin. This may be generally diffused, or occur in surface mottlings and markings of various sizes and shapes. Thus, the skin of the face may be intensely reddened in a paroxysm of rage ; and that of the limbs of a teething child covered with rosy maculations in consequence of the reflection to the surface, through the medium of the nervous system, of the irritation induced by eruption of a tooth. In conse- quence of the rosy tint assumed by several of these rashes, they have long been termed "roseola," a name which to-day is held to describe a symptom rather than a disease. The word "roseola" is still associated in the minds of many with the earliest syphiloderm ; but that eruption is now designated by the best authors as the erythematous or macular syphilide. Several of the severer constitutional maladies betray their morbid influence upon the central nervous system by a speedy efflorescence of this character. A lurid erythema of the axillary or inguinal region may precede by several days the eruption of confluent variola. Cholera, cerebro-spinal meningitis, enteric and other fevers are thus at times accompanied, preceded, or followed by rashes. A study of these is of the utmost importance to the diagnostician. Children 164 DISEASES OF THE SKIN. who are really susceptible to the disease are often supposed to possess an immunity from scarlatina, as the symptomatic erythema pre- viously displayed was misconstrued. Symptomatic passive erythema is usually characterized by a cyanotic, purplish, or darker hue of the integument, resulting largely from accumulation in excess of carbonic acid in the blood. The temperature of such skins is either normal or below the normal standard, as in those cases where gangreue ensues. A long list of conditions may be named in which these symptoms may be noted, including derangement of the bloodvessels from imperfect innerva- tion, direct pressure, or disease of the heart or vascular walls. These erythemas may be either circumscribed in area or general. The term u livedo " is applied to circumscribed regions of passive erythema. Sometimes the nose, cheeks, fingers, or toes exhibit this form of disease. The so-called symmetrical gangrene of the fingers belongs to the same category. Cardiac cyanosis, or morbus cseruleus., is a name given to a generalized dark blue discoloration of the entire surface, due often to continued patency of the foramen ovale. Erythema Pernio (Pernio, "Chilblains") is a form of this affection occurring in persons having a feeble circulation, usually in the young and the very old. The redness is most conspicuous, as a rule, on the hands and feet, merely because of the distance of these organs from the centres of circulation. The redness is of either a light or dusky shade; is accompanied by tenderness, itching, and burning sensations, especially when the part is brought near an artificial source of heat ; and may be the origin of exudative and other affections of the skin, though the ulceration and sloughing which occur in extreme cases are really the results of freezing the organs rather than of simple exposure to cold when the circulation is impaired. The diagnosis of all these varieties of hyperemia is readily made when it is observed that the redness disappears on pressure and also that the parts are actually cool rather than hot, the coolness being appreciable by the touch. Not rarely they are both cool and moist- ened with sweat. The treatment is by brisk friction, and stimulat- ing lotions, such as camphorated soap liniment ; acetous, spirituous, and vinous lotions; or the use of the ordinary "bay rum" of the shops. Afterward the parts should be well dusted with boric acid, and all woollen stockings discarded for the feet. Erythema Paratrimma is a term once employed for the form of deep and lurid redness preceding the formation of a bedsore, an ac- cident that in the modern methods of nursing is as obsolete as the name once given it. Erythema L^eve is an obsolete term once employed to desig- nate the shining redness of the skiu in oedema of the lower extremi- ties following any disorder sufficient to induce such local tume- faction. ERYTHEMA SIMPLEX. 165 Diagnosis. — If an erythema of the surface exists and is manifestly unattended by exudative symptoms, the recognition of the condition of the skin is not difficult. A more serious problem, however, con- cerns the significance of this symptom when it occurs in connection with grave constitutional maladies. A high temperature, severe lumbar pain, great gastric or intestinal irritability, coryza, and injec- tion of the ocular conjunctivae, are symptoms which should always put the practitioner on his guard in pronouncing upon the nature of an erythema. On the other hand, patients in a state of alarm frequently seek relief for an idiopathic erythema, of the nature of which they are ignorant. Here the locality, contour, and general appearance of the eruption, taken in connection with the history of the case, will usually suffice to establish a diagnosis. Treatment. — The symptomatic erythemata are usually of such trifling significance in comparison with the constitutional disorder by which they are occasioned, that the removal or management of the latter becomes of the higher importance. The idiopathic erythemata are usually relieved at once by the suspension of the cause Occa- sionally cold water, weak spirit lotions, dilute solutions of carbolic acid, or one of the dusting powders may be required. The ordinary rubber, adhesive, or lead plaster, may be applied to erythematous surfaces where the friction must be necessarily continued (surgical appliances, orthopaedic apparatus, etc.), and in those produced by constant pressure (nates and sacrum in low fevers or surgical confine- ment), it should never be forgotten that the hyperaernic is also a weakened skin. Here stimulating applications may be needed, alco- holic, camphorated, etc., with a view to the restoration of the tone of the weakened capillaries. Erythema Scarlatiniforme. (Scarlatinoid Erythema, Des- quamative Scarlatiniform Erythema, Scarlatino'ide, Erythema Puuc- tatum, Roseola Scarlatini forme; " Scarlet Rash;" Erytheme In- fectueux.) This disorder is declared by prodromata of malaise, slight or severe rigors, and a general feeling of lassitude succeeded by fever attain- ing its maximum in the course of two or three days. Suddenly appear, minute, punctiform lesions, or scarlet-tinted papules, which may coalesce, with however defined limitations, especially on the face. The subjective sensations are burning, smarting, and itching. As distinguished from scarlatina, which it somewhat resembles, there may be a beginning of the eruptive features on the lower extremities, spreading thence upward, or the reverse ; and this extension may be quite rapid, so that the exanthem may become universal in a few hours. In the course of a few days desquamation ensues with exfoli- ation of large lamella? from the surface, the epidermis of the palms and soles being shed in a single sheet resembling those cut for the manu- facture of kid-gloves. Relapses may occur from time to time, though the first attack is usually most severe. 166 DISEASES OF THE SKIN. Under this title, as Brocq has well shown, are included several differing conditions. In one class may be named those best described under the titles, pityriasis rubra and exfoliative dermatitis. In a second may be named the cases resulting from septicemic, blen- norrhagic, and other poisons. Such are the cases reported as oc- curring in typhoid fever (Ohmann-Dumesnil, August, 1890). In yet a third class are those which result from drug-ingestion or ex- ternal application — the medicamentous rashes. Given a suscepti- bility to any specially irritating cause, and these recurrent rashes, even with extensive desquamation, may occur. Erythema Intertrigo. Lat. inter, between ; terere, to rub. Erythema Intertrigo is a hypersemic condition of those cutaneous and muco- cutaneous surfaces which are in constant apposition, and between which there is a hypersecretion or retention of sweat. Symptoms. — The erythema which is limited to portions of the integument which lie in contact with each other is subject to certain modifications. The sites of such contacts in the human body are the axillae, the groins, the cleft between the nates, the inter-mammary and infra-mammary spaces in women, the superior and inner faces of the thighs, the scroto-femoral and the labio-femoral clefts in the sexes respectively, the flexures of the joints, and in especially fat individuals, all those parts where the integument is thrown into fleshy folds, as about the neck of infants, and even over the crest of the ilia in fat women. In these localities the disorder, beginning as an erythema traumaticum, proceeds by its irritative effects to stimulate the secretion of sweat, which is freely poured out between the adjacent folds of the skin, and may there be temporarily imprisoned. The surface, heated and reddened, is also somewhat macerated by the effused perspiration ; and the latter, when chemically altered, as it is frequently under these circumstances, adds still further to the original disorder. The ground is thus well prepared for an exudative process, but the disorder may be limited to mere hypersemia with hyperidrosis, and disappear before the supervention of actual inflammation. The sensations produced are those of heat and tenderness. When the parts in contact are separated the surfaces are seen to be reddened and chafed. Here and there very superficial abrasions of the macerated epidermis become evident. One such is always especially significant, of is the linear and superficial excoriation which marks the line of deepest contact of the two apposed surfaces of the skin at the bottom It the angle formed by the two. An offeusive odor usually proceeds from the part in consequence of the fluid secreted. Fox, of Loudon, has called attention to the fact that the secretions of an intertrigo stain, but do not stiffen the linen of the patient, and thus differ from the serous fluid poured out in an exudative dermatitis. ERYTHEMA INTERTRIGO. 167 Etiology. — The disease is chiefly induced by heat, friction, and moisture — these causes occasionally co-operating. The heat may be merely that of the natural temperature of the body, or it may be increased by that due to season and climate. The friction also may be merely that originating between the surfaces in apposition, or may be increased by clothing or other articles worn next the skin. The moisture which produces maceration of the epidermis is that origi- nating in the perspiratory follicles, their secretion being doubtless stimulated by the heat and friction. The interchange of operation of these three factors is, lastly, shown by the fact that the friction, if severe, is capable of increasing the temperature of the part to which it is applied. As aggravating causes may be named other physiological secretions and excretions, retained in contact with the surfaces affected with an intertrigo. Thus, the feces of the infant left in contact with its nates upon the napkin ; the urine of the old man with paralysis of the bladder, or with "overflow" from prostatic disease; the milk of the nursing women dribbling over the breast to the infra-mammary region ; retained lochial, menstrual, and similar discharges, are all efficient in this regard, and particularly apt to induce that form of dermatitis to which the intertrigo then plays a subordinate part. Occurring in fleshy and gouty persons, these conditions find their most fertile field. Diagnosis. — The recognition of a simple erythema intertrigo is a matter of no difficulty, if regard be had to the exciting and aggra- vating causes enumerated above, and to the special localities where such hyperemia generally originates. If an eczema or dermatitis supervene, the fact will appear from increased subjective sensation (usually a severe itching), from an infiltration of the affected integu- ment, and from the appearance of those lesions and discharges which are significant of these forms of inflammation of the skin. The special sites of preference of an intertrigo are those also of the disease named by Hebra " eczema marginatum," or riug-worm as it occurs upon the parts of the thighs covered by the " reinforced " patch in the trowsers of the cavalryman. The disease is properly named, tinea circinata cruris, though it is found also about the axillae, but- tocks, and groins of both sexes. Here the disorder is, however, of the exudative type, and, moreover, is distinguished by a characteristic " festooning" of the elevated border marking the advancing limit of the disease. The microscope, by revealing the existence of a fungus, will, of course, put an end to any doubt. In intertrigo the most marked evidence of disease is to be distinguished in the deeper parts of the cleft between the two adjacent skin surfaces, while in tinea circinata cruris the growth of the parasite is most active at the ad- vancing border of the patch, which is, moreover, perceptibly elevated above the sound skin. Treatment. — Erythema intertrigo is an exceedingly common affec- tion of the skin and occasionally proves of great annoyance to those suffering from it. The skill of the young practitioner is often tested 168 DISEASES OF THE SKIN. early in his professional career by his management of just such cases ; and not a little may depend upon the success with which he may A be rewarded. The affected surfaces should be gently cleansed by ablution with soap and warm water, aud the offensive odor of the secretions reme- died by the addition to the water of a weak solution of carbolic acid, or the dilute liquor sodse chlorinatse. The parts are then to be care- fully dried with a freshly lauudered towel or soft handkerchief, and afterward oue of the dusting powders very thoroughly applied. To be of service, these must be quite impalpable, aud, if compouuded by a druggist, be sifted through millers' fine silk boltiug-cloth. The articles chiefly used for this purpose are: bismuth, starch, ziuc oxide, French chalk, lycopodium, and, when an anti-pruritic effect is designed, camphor. Combinations of several of these are at times effective. The formula of McCall Anderson is highly esteemed : R. Zinci oxid. pulv. ^ss; 16 Camphorse pulv. ^jss ; 6 Amylipulv. % j ; 32 Sig. Anderson's dusting powder. M. The following is the formula for a dusting powder recommended by Klamann •} K . Talc, venet. pulv. ^v; 20 i Acid, salicyl. gr. iij ; 1 2 Magnes. ust. subtil, pulv. 3Jss; 5j M. Sig. Dusting powder. The "Oswego gloss starch" and the "corn-starch farina" sold by most of the green-grocers in this country, are finely bolted, aud answer well alone, or in combination with some of the other articles named. The chief objection to the starch-containing powders is their tendency to form "cakes" or rolls when wetted with sweat, these masses further irritating the tender surface of the skin. Such an objection does not apply to lycopodium, which not only under the microscope exhibits no salient angles, but on account of the oil it contains is not miscible with water. 2 The affected surfaces of the skin must also be separated in order to prevent further friction. A thin strip of lint, antiseptic cotton, or medicated wool, may be used for this purpose ; and must be pushed well up to the deeper portions of the cleft where the secretion chiefly forms. Occasionally, it will be found useful to anoint this absorbent layer with cold cream or vaseline. Where an astringent effect is desired, the lycopodium or other dusting powder may be com- pounded with tannin, alum, or similar substances. The list of lotions may be also at times consulted with advantage. Thus, cologne water, weak spirit lotions, tannin, and aromatic wine, or carbonate of mag- nesium, may each be serviceable. Lastly, the carron oil (equal parts 1 Hebam. Kalend., Obstet. Gazette, March, 1882. 2 Unna's salve muslins and pastes will be found effectual and neat applications, in many forms of intertrigo. ERYTHEMA MULTIFORME. 169 of lime-water and linseed-oil), spread thickly upon linen, will possibly give more relief than the other articles named; the chief objection to it being the consequent soiling of the patient's clothing. Erythema Multiforme. Statistical frequency in America, 1.021. Erythema Multiforme is an exudative disease of the skin, in which appear flat or elevated lesions of an erythematous type in various forms, the exanthem being at times symptomatic of constitutional derangement. Symptoms. — In this affection, which is usually of symmetrical de- velopment, erythematous maculae, flattened papulae, and even large flat nodosities, very rarely vesicles, occur, usually upon portions of the extremities, the forearms, the legs, and the dorsum of the hands and feet. The eruption which is much more generally recognized in clearly defined patches, usually commences with pin-head to finger- nail sized macules of a darkish-red shade, losing their color under the pressure of the finger, which in the course of some hours exhibit tumefaction in various degrees, producing thus the papules, tubercles, and nodes already described. The disease may persist for but a few days, but in severer grades it lasts for several weeks. In the height of the exudative process there is usually an efflux of the coloring matter of the blood into the skin which is the site of the several lesions ; and thus are produced the singular shades of reddish-black, purple and red, blue and red, yellow and orange, which are so char- acteristic of simple bruises of the extremities wheu the injury has been sufficient to cause extravasation of blood. The lesions occur in various shapes, sizes, and shades, and a number of names have been used to designate their several appearances, which require explanation, though they are without any practical value. Erythema Annulare (or Circinatum) is characterized by cen- tral paling of color and peripheral extension of the erythematous patch, in the form of a ring, Erythema Figuratum occurs in gyrations formed by coalescence of two or more annular circles. Erythema Iris (Herpes Iris) is the result of successive new ery- thematous centric colorations, by which at times several differently shaded concentric rings are formed. This variety of multiform erythema often occurs without other mani- festations of the same disease in the patient exhibiting its lesions. It is not rarely observed in a single patch on the back of one hand. There may be a central vesicle or bulla with a series of concentric rings about it, the latter constituted either of discrete or confluent vesicles or bullae. There is always a narrow and purplish shaded 170 DISEASES OF THE SKIN. areola about the fully disteuded or flattened and depressed central lesion, and the " iris " effect is produced by the contrast of the whitish fluid in the chambers with the color of the pinkish zone. Patches may symmetrically develop on both hands or the fingers of the two hands, and finally, desiccating complete a cycle of three or four weeks' duration. Variations occur by reason of effusion of fluid until large bullae form, which may coalesce or be filled with blood ; while, according to Crocker, hematuria may result with severe in- volvement of the mucous membrane of the lips, tongue, soft palate, and other parts of the mouth, ulceration rapidly ensuing. Cases with these complications should be really classified with the grave forms of pemphigus, to which they properly belong. Under the title Herpes Iris of Bateman, French authors de- scribe the Hydroa Vesiculeux of Bazin. In this affection there first appear reddish papules, in the centre of which a faintly devel- oped vesicle forms, which desiccates and forms thus a delicate crust. New well-distended or abortive vesicular lesions form peripherally in successive reddish, bluish, or purplish rings about the central crust, with an erythematous zone about the patch. In this disorder, also, may succeed generalization of the eruption, involvement of the mucous surfaces (including severe oral and labial lesions) and grave symptoms of a general character. Erythema Marginatum is that form in which a distinctly ele- vated and defined marginal band is left as the sequel of an erythe- matous patch. Erythema Nodosum (Dermatitis Contusiformis : Fr., Erytheme Noueux) is regarded by several authors as a distinct affection. In it the characteristic lesions are of the dimensions of semi-globular pea to fist-sized tumors, pale red to livid blue in color, tender upon pressure, exhibiting in their involution the variegations of hue already described. They occur at times not only in the localities named above, but also upon the trunk and face. Though occasion- ally becoming so soft to the touch that fluctuation may seem to be present, they never terminate by suppuration. They occur most often in youth, in girls more often than in boys, with acute or subacute symptoms, frequently with rheumatoid pains and febrile temperatures. The oval or roundish erythematous or empurpled nodes, varying in size from a small nut to a pigeon's egg, are most often seen on the lower limbs, though they appear also on the thighs, the buttocks, and the forearms. They are usually tender on pressure, and often painful. They may disappear in a fortnight but occasionally observe a stadium of six weeks' duration, forming and disappearing in crops. The petechial appearance of the spots where they have existed is that of the characteristic " black-and- blue " mark. By some authors the disease is recorded as associated with tuberculosis, an observation probably due to the fact that it appears so often among the poorly nourished and ill housed. It ERYTHEMA MULTIFORME. 171 unquestionably occurs most frequently in the spring and autumn. Other causes cited are malarial chills, temperature changes, rheuma- tism, gout (rare in young adults), arthritis, endocarditis, urethral irritation (blennorrhagic, instrumental, medicamentous) ingesta, alcoholic excesses, and dentition (?). Erythema Papulatum (or Papulosum) and Erythema Tuberculatum (or Tuberculosum) are those forms in which occur lesions respectively of a papular or tubercular type. Erythema Urticatum is that form in which there is severe itching and, as a result, scratching of the lesions, with crusts of dark dried blood at the summit of each. This crust is surrounded by the light red or bluish-red, flattened or elevated patch characteristic of the disease. Erythema Vesiculosum and Erythema Bullosum are rare and exceptional forms where the exudation is sufficient to raise the horny layer of the epidermis into larger or smaller serum-containing chambers. These may be, as regards the erythematous patch, of central or peripheral situation ; and may crown the summit of papule or tubercle. The fluid is usually removed by absorption, and is rarely set free by rupture of the vesicle or bleb. Robinson 1 describes definitely an Erythema Diphtheriticum, which is a rash of septic diphtheria. The early eruption is a diffuse erythema of the skin of the chest or of the belly, light red to pale red, mottled, scarlatiniform, or punctate, non-pruritic, disappearing under pressure, unaccompanied by fever, and vanishing in one or two days. The rash of septic diphtheria occurs only after several days of the disease, and is a limited or generalized erythema. It begins as pin- head or larger sized erythematous maculae, each of which spreads at the periphery and pales in the centre, by which process rings are formed. The latter increase until a diameter of several inches is attained. While these erythematous rings with clearing centre and reel, elevated rims are enlarging new spots continue to form, until the eruption has all the features of a multiform erythema. Gyrate and figured forms result from coalescence of lesions. Occasionally, the centre of a ring is cyanotic. The eruption does not itch. In fatal cases it persists until death. A number of medicaments, when ingested or externally employed, are capable of producing eruptions identical in appearance with the lesions of erythema multiforme. For descriptions of these the reader is referred to the chapters devoted to dermatitis medicamentosa and 1 Journ. of Cutan. and Ven. Dis., 18S3, p. 83. 172 DISEASES OF THE SKIN. dermatitis venenata. Quinine, the iodine and bromine compounds, arsenic, belladonna, chloral, salicylic acid, and other substances, are often responsible for these symptoms. The name, multiforme, given to this disease by Hebra, is justified by the singular diversity of lesions which it displays. These are remarkable not merely for their variety but for their occurrence in such variety both simultaneously and successively, and for their rapid change from one type to another. The subjective symptoms, save in the urticarial form of the dis- ease, are usually of a trifling character. The slight sense of heat and burning awakened by the lesions is altogether out of proportion to the extent of development of the latter. The symptoms, however, indicative of a general disturbance of the system may be of a marked character. General malaise, fever, inappetence, pharyngeal inflammation, chills, severe gastro-intestinal disorder, rheumatoid involvement of the articulations, and even organic changes in the heart (valves, endocardium, and pericardium), lungs, and kidneys (Kaposi), have all been noted as coincident or causative phenomena. In many of these cases it is clear that the exauthem belongs to the list of symptomatic erythemata, aud is of insignificance in comparison with the grave general condition. It may thus be the precursor of typhoid fever, malaria, severe articular rheumatism, or become even an abortive expression of these disor- ders. With these exceptions, however, the prognosis is in general quite favorable, as the disease may terminate in a few days, and rarely exceeds a month in duration. Occasionally the mucous membranes are affected to a disagreeable or even painful extent. Thus a sudden tumefaction of the uvula may supervene upon the cutaneous symptoms, even in cases suffi- cient to impede respiration ; or the lining membrane of the larynx be involved, and the resulting aphonia in various degrees persist for two or three days. Etiology. — The affection is more common in the spring aud autumn ; it occurs in the young or in the early periods of adult life; the papular and tubercular forms are more commou in men, aud the nodose forms in women ; in mauy cases it occurs in those who are affected with rheumatism. There can be but little doubt that its etiology includes a list of varying and widely differing causes. The author has seen severe manifestations of the disease in a young woman with extensive ulceration of the cervix uteri. Tilbury Fox noticed its frequency in young servants brought to town from the country. It is not rare in young female immigrants who have re- cently made a " steerage " passage to this country. Pathology. — Erythema multiforme is essentially an hyperemia of the integument which, under certain obscure influences, advances more or less rapidly to the stage of a mild grade of inflammation with consequent exudation. If, with Landois and Lewin, it be accepted that the process is the result of vasomotor nerve influence, it cannot be determined whether these nerves are irritated at points ERYTHEMA MULTIFORME. 173 of origin or distribution. In the case of erythema nodosum, Hebra advances what he admits to be an hypothesis, in saying that the morbid process is essentially an inflammation of the lymphatic ves- sels. In some cases it is evident that there is extravasation of blood from the vessels into the skin of the affected parts. Leloir 1 discovered in the papules, tubercles, and bulla? of the ery- themata, only the phenomena of hyperemia and exudation limited to the corinm and subcutaneous tissue; and Yillemin 2 simply con- firms these facts. Crocker, examining a patch of erythema tuberculatum recognized merely a cell effusion in the upper portion of the corium extending sparsely below, and then along the ducts and follicles chiefly. There was slight rete proliferation. Diagnosis. — Erythema multiforme is always to be carefully dis- tinguished from the traumatisms producing bruises, especially upon the lower extremities. This is a point which may have an interest- ing bearing upon certain medico-legal questions, especially in the case of young children. 3 The tendency of the disease here consid- ered to symmetrical arrangement upon the two sides of the body ; the occurrence of lesions evidently dating from several periods, where successive crops appear, and the absence of all history of ex- ternal injury, will usually suffice to establish a diagnosis. Among the precocious affections of the subcutaneous connective tissue in syphilis, Mauriac has described a lesion resembling somewhat the symptoms of erythema nodosum ; but in such cases, and especially in women, mucous patches of the vulva, anus, or mouth, with coin- cident adenopathy, would point to the real nature of the disease. Syphilitic nodes and gummata are distinguished from the lesions of the nodose forms of erythema by the pain attending the former, their fewness, their untinted overlying integument sore when actu- ally softening and near the point of disintegration, their obviously subcutaneous site, and the usual concomitant symptoms of late lues. The chief points by which a diagnosis of the erythemata in gen- eral is established are : the recognition of the vivid coloring of most of the lesions ; the pigmentation following those situated on the lower limbs ; their association with rheumatism or rheumatoid pains ; their febrile phenomena ; their symmetry as a rule ; and the accompa- nying malaise. The wheals of urticaria are smaller, more whitish centrally, more closely packed together, less symmetrical, rarely grouped, and, as a rule, decidedly more acute. Cases difficult to assign to either disease are common, and an error in either direction is not serious. Rubella (German measles) is to be distinguished by its adenopathy, its pharyngeal symptoms, and its flattish spots. In eczema erythematosum there is less definition of each patch, and the redness is commonly diffuse; papular forms of eczema are usually i Bull, de la Soc. Anat, 1884, p. 294. 2 Gaz. Hebdom., 1886, Xos. 22, 23. 3 Since this paragraph was written, the author, in conjunction with a number of other phy- sicians, was summoned as a witness in a case where both parents of a lad who exhibited the lesions of polymorphous erythema, and who died suddenly, were ctiarged with beating their child to death. They were exonerated on the basis of the evidence of the experts. 174 DISEASES OF THE SKIN. commingled with other readily distinguished symptoms of that dis- ease. Lastly, the iodide of potassium and a few other drugs adminis- tered internally, are capable of producing almost every one of the lesions described above. In the erythemata for which that remedy has been administered with the production of skin symptoms, the confusion is erroneous. Treatment. — As the disease under consideration progresses natur- ally to a favorable termination within the course of a few weeks, the duty of the physician is usually limited to the question of diagnosis merely. He should remember that the larger lesions seen in ery- thema nodosum never suppurate ; and thus be not tempted to open them with a lancet. Local treatment is rarely called for ; and in any case should be restricted to the application of hot or cold water, as found most grateful to the patient, with possibly the use of a weak lead lotion. Internally such medication should be employed as is indicated by the general condition of the patient. Iron, quinine, strychnia, and dilute hydrochloric acid will be found beneficial in many cases. Constipation and indigestion are to be corrected by appropriate measures. When the disorder is evidently purely symp- tomatic the internal treatment is to be directed to the general con- dition present. In rheumatic cases, the indications for such treat- ment are clear. When the erythema produces extensive oedema of the uvula, incisions may be requisite to prevent dyspnoea and dys- phagia. Prognosis. — It will be gathered from what has preceded, that the prognosis is always favorable. The fatal cases reported are usually those where the result was due to grave constitutional conditions, and where the erythema multiforme was an insignificant feature of the malady. The disease may relapse in susceptible individuals at those periods of the year when it is most frequently observed. Urticaria. Lat. itrtica, the nettle. (Hives, Nettle-rash. Fu., TJrticaire ; Ger., Nesselsuch, Nesselfieber.) Statistical frequency in America, 2.47. Urticaria is an exudative affection of the skin in which appear ephemeral, whitish, or rosy-tinted wheals surrounded by a reddish areola, giving rise to an intense pruritus. Symptoms. — This disorder may be ushered in by constitutional symptoms, such as inappetence, malaise, cephalalgia, or mild pyrexic symptoms lasting for a few hours or even for a day or more. With, and often without, such prodromic symptoms the eruption suddenly appears in the form of wheals upon the surface, which URTICARIA. 175 frequently disappear with equal rapidity, leaving behind no traces of their existence save a slight and transitory hyperemia of the affected spot. The lesions may be as small as a finger-nail or a coffee-bean, and are usually of this size ; but in certain rare instances " giant wheals " are seen, large tomato-sized projections or flat elevations of broad areas of the integument, covering the greater part of the belly or the buttock. In color, they are either rosy-red or whitish ; and are usually surrounded by an hypergemic areola. They may be isolated and few ; or numerous and closely packed together ; may even coalesce so that individual lesions are scarcely recognizable. They are usually firm and semi-solid to the touch. Rarely the horny layer of the skin is raised in fluid-containing lesions by the sudden effusion of serum beneath. In contour, they are roundish or oval- shaped ; but a variety of curious outlines may result from the irregu- larity of their development. Concentric circles, lines, bands, and even figures, are in this way produced. The finger-nail drawn across the unaffected portions of the skin, in a patient with urticaria, will often produce a linear wheal of extent corresponding to the line of irritation. It is said that in this way the so-called " medium " with a sensitive skin exhibits written characters upon the surface of his body. The subjective sensations induced by these lesions are distressing in various degrees, according to the susceptibility of the individual. Every grade of pruritic burning, tickling, crawling, pricking, and especially stinging sensations are thus engendered. The efforts of the patient to secure relief by scratching, not only serve still further to develop the eruption, but to irritate, tear, and otherwise wound those lesions already in full evolution. In this way the serous effusions are produced at the summits of the wheal ; and in this way, also, lesions really transitory in their course may be changed to more persistent, deeply colored, flat, lenticular papules. Where the skin is delicate and thin, as that of the lids and prepuce, considerable oedemra may result. All parts of the body may become affected, and this irrespective of age and sex, though children are particularly liable to the disease. There are few very young children with skins unwashed for an entire month, who will not exhibit urticarial symptoms if there be an added irritation of the surface. The lesions may be numerically few, or so numerous as to cover the entire surface of the body. Though more frequently acute in course, they may recur frequently from apparently insignificant causes, or even become chronic. In many cases trivial, the disease may become so aggravated as to make the largest demands upon the skill of the physician. The rapidity of appearance and disappearance of the lesions visible upon the skin is a characteristic feature of the disease. In some instances but a few moments are required after the operation of an efficient cause, to develop a large number of closely packed wheals upon the skin. Even while these are under inspection, it can be 176 DISEASES OF THE SKIN. noted that there is a change in individual lesions, some fading or completely disappearing, while others are newly developing. A number of names have been employed to designate the several external peculiarities of the lesions as they are presented to the eye. Thus U. Annularis occurs in rings ; U. Figurata, in gyrations from union of several lesions or patches of lesions ; U. Vesiculosa and U. Bullosa, where there is a vesicular or bullous development at the summit of the lesion; and U. Papulosa (or Lichen Urticatus), where there is a combination of the features of the wheal and the papule, the lesions being usually rape-seed to coffee-bean in size, and covered with blood crusts where their fig. 40. apices have been torn in scratch- ing; U. Tuberosa, where " giant" wheals occur, some attaining the size of a hen's egg ; U. Hemor- rhagica (Purpura Urticata), where the urticarial element is developed in a lesion produced by cutaneous haemorrhage ; and U. Evanida, or Perstans, where there is respec- tively a rapid or slow process of involution in the character- istic symptoms. Urticaria Pigmentosa (Xanthelasmoidea of Fox). — This disorder, once regarded as an affection of great rarity, has now been observed in a sufficient num- ber of cases in almost all of the larger centres of population. The disease is one characterized by the occurrence in early infancy, some- times but a few hours or weeks after birth, of elevated rosy or reddish wheals which are suc- ceeded later by flattish or slightly elevated light or dark-brownish or buff-colored macules. There are three tolerably distinct types of the affection : those exhibiting plane lesions with equally flat- tened maculations ; those with tubercular, nodular, or variously sized and shaped wheals ; and mixed varieties, the latter being most common. The mingling of a factitious urticaria with lesions long existing and long maculated is not rare. Cases are sometimes divided into those accompanied by itching and those not so characterized ; but it appears that these differences are due to accidental rather than essential causes. The eruption, which Urticaria pigmentosa. (From a photograph of one of the author's patients.) URTICARIA. 177 may first appear as late as the third year, commonly displays itself first on the neck and shoulders and spreads rapidly to the head and extremities, eventually invading the entire surface — in well-marked eases even including the mucous surfaces. The lesions are at first of the usual urticarial type, with delicate zone, but soon lose their distinct contour and elevation, and become flatter and pigmented, the color in pronounced cases being a distinct yellow, deepening to a decided coffee-and-milk hue. After isolated tubercles once acquire the deeper tint, they may persist for years ; may return in crops ; may even be at times commingled with bullse which desiccate in crusts ; may form plaques of infiltration ; may be covered at times with an erythematous blush due to hyperemia of parts long affected ; and when itching is intense may exhibit the general signs of the scratched skin. In some of the reported cases whitish instead of pigmented spots were left after involution in a smooth or wrinkled and scar-like skin. Etiology. — The cause is unknown. The sexes are nearly equally represented among patients. Pathology. — Sections of tubercles have been made by numerous observers, including Unna, Raymond, Pick, and Thin. It is clear that some effusion occurs in the corium with cell infiltration and small haemorrhages. The disorder is unquestionably an angeio-neu- rosis due to special changes of the vasomotor centres. According to Brocq, the predominant elements of the infiltration are the mastzellen. Diagnosis. — It is to be distinguished from the slight pigmentation left after well-marked urticaria of later years by the beginning of the disease in infancy and by the persistent buff- colored tubercles. Xanthoma in all its forms is readily distinguished by its persistence in special regions, the eyelids, for example ; by its first appearance at a later period of life ; and by its characteristic chamois-leather-yellow shade. Treatment. — No treatment has been hitherto so successful as to justify its recommendation. The author has had best results in stimulating rather than soothing baths, at a later period of life than the first six months. After such stimulation with salt and water and alcohol and water, a boric acid dusting powder is always applied. Angeio-neurotic OEdema (Acute Circumscribed (Edema, Acute Idiopathic (Edema, Periodic Swelling, Acute Non-inflammatory (Edema, Giant Swelling) is characterized by the appearance on various parts of the body, particularly the face, extremities, and throat, chiefly of male subjects who may have inherited a tendency to this or a similar disorder, of suddenly evolved swellings of the skin, usually dull red in hue, contrasting vividly with the color of the surrounding integument, and disappearing in the course of a few hours. They are commonly the seat of disagreeable sensations of fullness, burning, throbbing, or scalding ; aud if the swelling chance to obstruct a mucous tract (nasal, pharyngeal, laryngeal, etc.), there are symptoms of a distress- ing character, due to the transitory occlusion. The tumefactions are 12 178 DISEASES OF THE SKIN. so large as to involve an entire organ or limb. Collins/ who has drawn an excellent portrait of this disorder, believes it to be at least closely allied to, if not identical with, urticaria tuberosa, or giant urticaria, and that its seat is in the vessels, vascular and lymphatic, traversing the corium ; the swelling being the result of disturbance of the sympathetic nervous system. It is to be distinguished from the " blue oedema" of hysteria (Sydenham) and from the " white oedematous swellings " of the same disease as observed by Charcot. This disorder is also described in this work in connection with other oedematous affections of the skin. Baker 2 reported a case of Urticaria Tuberosa characterized by the presence of persistent, yellowish-red tubercles in various parts of the body which proceeded to ulceration. The parts most affected were the knuckles, elbows, and ears. These tubercles are said to have begun in a manner similar to that which characterizes the onset of evanescent urticarial wheals and tubercles. A somewhat similar case was observed by McCall Anderson. 3 Urticaria, like erythema, may be either idiopathic or symptomatic ; and in either the urticarial conditions may underlie or be superim- posed upon almost every elementary lesion noted in the integument. Its lesion may complicate (or be complicated by) the macule, papule, tubercle, vesicle, bulla, and pustule. It may spring from an excoria- tion, or result in a fissure. It is common is traumatisms, and is a prominent symptom in the skin bitten by insects, reptiles, and the domestic animals. Etiology. — Idiopathic urticaria always results from the action of external irritants. The enumeration of these would require a recital of all the external agencies which are capable of irritating the skin. Prominent among them are the bites and stings of mosquitoes, lice, fleas, bed-bugs, flies, gnats, wasps, caterpillars, and bees. Contact with certain species of the jelly-fish is also effective. The wounds thus inflicted usually excite a stinging or burning sensation, by which the patient is excited to rub or scratch the part. Then a wheal is rapidly formed at the site of the injury, and the irritation thus set up is conveyed to other parts of the skin in the vicinity, so that, especially in children, a single traumatism by an insect may excite an urticaria covering a much larger area. Many medicaments operate similarly, and it should be added that some of them, though applied externally without toxic effect to the mass of men, may pro- duce urticaria in exceptional cases. Thus a common flaxseed poul- tice when made to cover but a small portion of the body has pro- duced violent symptoms of the disease under consideration. The irritant action of the nettle (U. urens and U. dioica) has given the malady its name. Climatic influences, more particularly those in which the surface of the body is exposed to cold air, are very efficient 1 Amer. Journ. of the Med. Sci., Nov., 1892. 2 Lancet, August, 1881, p. 153. 3 Brit. Med. Journ., December 8, 1883. URTICARIA. 179 in the production of urticaria, as also of bronchial asthma, with the symptoms of which the disease under consideration may often coexist or alternate, in the case of adults. Mechanical violence, the applica- tion of leeches to the surface, and surgical traumatisms may also in- duce the disease. Symptomatic urticaria is chiefly of the variety named by authors, ab ingestis, since it most frequently results from medicinal or dietary articles taken into the stomach. Of the latter class may be named eggs, cheese, pork, sausage, coffee, tea, cocoa, and confectionery ; crabs, lobsters, clams, caviar, and several species of fish-roe, oysters, and fish generally ; strawberries, cucumbers, skins of grapes, nuts, dates, raisins, almonds, figs, prunes, gooseberries, and raspberries ; canned fruits, meats, and vegetables ; oatmeal, peas, beans, onions, garlic, and "corn;" pickles, sauces, honey, mushrooms, pastry, salads, and spinach. Vinegar, champagne, beer, and alcoholic bever- ages in general are capable of inducing a similar effect. Among the medicinal articles capable of inducing urticaria may be named the balsams, the turpentines, quinine, glycerin, chloral, valerian, arsenic, hyoscyamus, cinchonidia, salicylic acid and the salicylates, senna, santonine, and opium and its alkaloids. In the case of children and infants, a severe urticarial efflorescence may be provoked by worms, or by any undigested morsel of food, or indigestible material of any sort which may have been passed into the stomach. Thus a bit of orange-peel, or fragment of potato-par- ing, or the skin of grapes, may be discovered to lie at the root of the trouble. In the case of adults also who have suffered from repeated attacks of urticaria, and have a fully developed sensitiveness of the gastro-intestinal tract, almost any unusual alimentary substance, if ingested, may induce a return of the disagreeable symptoms. It must be borne in mind that this undue sensitiveness to the effect of ingesta or external irritants is often an idiosyncrasy peculiar to the individual either on special occasions or at all times, and that, given this susceptibility, the effect is often great with a relatively insignifi- cant etiological factor. Thus one may see cases in which a teaspoonful of beer, one grain of quinine, the smallest fragment of cheese, and but a single strawberry will not only induce an urticarial rash of such extent as to cover the greater part of the surface of the body, but will do the same on every occasion when the articles named are swallowed in the quantities given. This, it is important to re- member, is in general characteristic of the medicament on s eruptions. The a priori reasoning, that the greater the quantity of the toxic agent applied or swallowed, the graver the effect, may lead to gross errors. It should always be remembered, in seeking the explanation for an urticarial rash, that the smallest amounts of apparently inno- cent substances may be responsible for the largest annoyance. Other causes of urticaria may be cited, such as moral emotions (fear, shame, anger) ; pulmonary diseases, especially asthma • gastro- intestinal disorders, where ingesta play no part; intestinal parasites; malaria ; the exanthematous fevers, particularly in their prodromal 180 DISEASES OF THE SKIN. stages ; disorders of the uterus, kidneys, and nervous centres ; preg- nancy, dentition, and the irregularities attending the menopause; and, lastly, the following special diseases : asthma, pemphigus, prurigo (of Hebra), rheumatism, and purpura. Pathology. — The wheal of urticaria is produced by an interchange of play between bloodvessels, muscles, nerves, and tissue, under the operation of a principle which the French term the choc en retour. There is, first, most probably under the influence of the vasomotor nerves, a clonic spasm of the capillaries in a limited area of the derma, by which an acute oedema is produced with some serous exu- dation. The rapidity with which this occurs is greater than that with which the tissues of the vicinage can accommodate themselves to it, either by imbibition or more diffuse tumefaction, and there results a counter pressure upon the affected capillaries, by which their lumen is still further restricted. As the wheal is not a purely fluid- containing nor yet an entirely solid lesion, but is semi-fluid in con- sistency, the mechanical pressure is greatest at the centre and least at the periphery. Thus is explained the white and relatively bloodless appearance of the centre of certain wheals, and their rosy or reddened outer border. It is confirmed also by the fact that generally the most acute lesions, those springing into view most rapidly, are chiefly characterized by this wiiitened centre, while those more indolent or even chronic in their career, have been less subject to the inter-play of the forces described above, permit of more general vascular injec- tion, and have a light crimson or even at times a dull red centre. Wheals have been excised and examined microscopically by Neumann, Vidal, Poncet, and others, with the result of discovering merely evi- dences of dilatation and engorgement of blood and lymph vessels and infiltration. According to the last-named author, the lymphatic vessels are also choked with " lymph clots." R0I16 1 explains the occurrence of the wheal by supposing that certain seusitive nerve- fibres of the skin possess also a vasomotor function. The process described, occurring as an epiphenomenon after the traumatisms or other cutaneous lesions enumerated above, merely adds its characteristic symptoms to those previously apparent. Diagnosis. — The diagnosis of typical urticaria is so readily made that the disease is often recognized before the attention of a physician is called to it. As usual, the atypical cases are those in which con- fusion may arise. The chief points to be remembered are : the rapidity of evolution of symptoms, their ephemeral duration, and the char- acteristic sensations they awaken. The action of the animal parasites and insects not parasitic should not be overlooked, and the rash be closely examined for the minute wounds inflicted in this way, often covered with a minute pin-point to pin -head sized dried " blood- scale." The various forms of erythema papulatum, tuberculatum, and nodosum are liable to be mistaken for urticaria ; but this is in many cases inevitable, as the intermediate forms between the two 1 Maryland Med. Journ., May 15, 1881. URTICARIA. 181 disorders are with difficulty assigned to either category. Absence of marked subjective sensations and persistence of lesions would gen- erally imply the existence of an erythema, while marked prevalence of these symptoms would properly decide in favor of urticarial disease. In many cases the physician is consulted by a patient who gives a history of well-nigh intolerable distress at night or at other capriciously selected hours, who repeatedly and vainly endeavors to exhibit the lesions as they appear upon the skin. Being examined on occasions, scarcely a trace of cutaneous disorder is manifest. Here the practi- tioner has practically to decide upon the character of an eruption he never sees. The task is rarely a difficult one. No other than the urticarial eruption behaves in this fashion. Occasionally the physi- cian will discover delicate, rosy, or deeper stained mottlings of the surface where the wheals have been but are not. At times also he will succeed, on the flexor aspect of the forearm, or in some situation where the skin is equally delicate, in producing the appearance of one or more typical lesions by the aid of his finger-nail in scratching or rubbing. These cases are more frequently of the chronic or at least relapsing class ; and the victims of the disease may have a char- teristic facies, a worn look from loss of sleep or mental emotion. One is apt to discover in this class those who are mourning over the death of relatives, loss of property, separation from home and friends, and those harassed by anxieties. The several lesions of erythema are larger than those of urticaria, and do not develop from characteristic wheals ; in erythema multi- forme the lesions are far more persistent in type and do not provoke the characteristic subjective sensations of urticaria ; in erysipelas the redness is characteristic aud the swelling more diffuse. Treatment. — Many cases of acute urticaria demand no treatment. The physician is summoned for a diagnosis. The patient and his friends are alarmed by the dread of variola or other severe affection, and learning that perhaps a pickled cucumber is alone responsible for the disorder they wait with equanimity for the conclusion which is always reached. Fortunately, the unusual, severe, and relapsing forms rarely begin with acute symptoms. Naturally the first indication to be observed is the removal of the cause, and this, if possible, accomplished, the exclusion next of all aggravating agencies. The discovery of the cause, at times readily effected, is often the most serious problem which is presented. An exhaustive and minute examination of the person and history of the patient, a study of his food, drink, medicine, regime, clothing, sleep- ing apartment, habits, occupations of life, and mental state, are here essential. When the disorder is recent, and is an urticaria ab ingestis, a brisk emetic or carthartic may rid the stomach or bowels of offending matters. This done, it should be borne in mind that an idiosyncrasy of the patient may at this moment render the skin peculiarly sensitive to the action of other ingesta, and the diet, for a few days certainly, should be carefully prescribed. In many cases 182 DISEASES OF THE SKIN. the alkalies are indicated by an acid condition of the stomach, and then the preparations of sodium, potassium, and magnesium are use- ful. Laxatives, such as rhubarb, magnesia, the cathartic mineral waters, and, in the case of children, small doses of castor oil are frequently indicated when there is no suspicion of irritating ingesta. At other times there is marked atony of the digestive organs, when the mineral acids, the bitters, and the ferruginous tonics may be needed. Again, lactopeptine, pepsine, or the subcarbonate or the sub- nitrate of bismuth may be exhibited with advantage for the relief of the indigestion which may be the prominent feature of the attack. Other remedies found useful in the internal treatment of urticaria are sulphurous acid in drachm (4.) doses three times daily in sweetened water (Da Costa) ; copaiba ; strychnia (Gruibout) ; the arseniate of sodium, employed by Blondeau, in doses from one- thirtieth (0.002) to one-fiftieth (0.0013) of a grain ; the fluid extract of ergot in half-drachm (2.) doses (Morrow) ; the sulphate of atropia, given by Schwimmer in doses of one-sixtieth (0.001) of a grain j and the salicylate of sodium in scruple (1.33) doses. The last- named drug has been highly praised by a number of writers. It is often given in one grain (0.06) doses every hour. Pilocarpine, or the fluid extract of jaborandi, is known to produce at times a pow- erful effect in relieving surface congestions of the skin by means of the excessive hyperidrosis which it occasions, and in proportion to which it may become dangerous. Schwimmer endorses the following formula for this affection : R . Atropise sulph. gr. £ ; SSI »*■: Gum. tragacanth. q. s. ; Ft. pil. No. xx. 01 M. The treatment of a symptomatic urticaria should have regard also to that disorder of the viscera or general system to which the cutaneous symptoms may be attributed. Gout, as a not infrequent cause of the disease, should not be forgotten in advising treatment. The uterine complaint of a woman may require appropriate treat- ment, as also the diabetes of the patient with an affection of the kid- neys. Quinine is, of course, indicated in periodical attacks, but its action in exceptional cases as a direct cause of urticaria should not be forgotten. The same, to a greater extent, is true of arsenic, the bromide and iodide of potassium, hydrate of chloral, and gelsemium. The larger number of patients are best treated without the employ- ment of these drugs. In the local treatment of urticaria, which is chiefly intended to assuage the disagreeable sensations experienced in the skin, the greatest diversity exists in the methods employed. This is to be largely explained by the fact that a similar difference is to be noted in the relief experienced by different patients after the application of the same medicinal agent. Thus cold and hot water baths, baths medicated by marine salt, aromatic vinegar, alcohol, cologne, camphor, URTICARIA. 183 the alkalies, and sulphuric ether ; compresses dipped in such solutions and laid over the part affected ; douches and vapor baths will, auy of them, in the case of some individuals produce a marked allevia- tion of symptoms, and in others be either inoperative or actually serve to aggravate the symptoms in the highest degree. Hebra asserted that several of the baths named above are quite useless, while Kaposi recommends cold lotions medicated with aromatic volatile substances. Fox prefers alcohol, or cologne water to which benzoic acid has been added, dabbed over the part, and permitted to evaporate. Hillairet and Gaucher employ in a simi- lar way a solution consisting of one-third of ether and two of warm water. The alkaline bath should contain the carbonate of sodium, the bi- borate of sodium, alum, or the bicarbonate of potassium, either singly or in combination in the strength of about six ounces (1 92.) of the salt to thirty gallons of water. One or two ounces (32.-64.) of the sulphuret of potassium may be substituted for these. The water is made demulcent by the addition of starch or gelatin, or by immers- ing in it a bag of muslin containing bran. When it is desired to employ the acid bath, half an ounce (16.) of either the muriatic or nitric acid is added to the quantity of water given above. The bath of this size may also be medicated with one drachm (4.) of corrosive sublimate ; or this drug may be used as a lotion in the strength of from one-fourth (0.0016) to one-half (0.0033) a grain to the pint. Carbolic, benzoic, salicylic, boric, dilute hydrocyanic, and dilute nitric acids in weak solution, are also employed with advantage in some cases. Other external applications are thymol, carbonate of ammonium, bromide of potassium, ether, chloroform, and chloral- camphor in the strength of half to one drachm (2.-4.) to the ounce (32 ) of ointment. This last is prepared by rubbing together equal parts of camphor and chloral till a semi-liquid substance results. It is an antipruritic remedy of some value, but will increase the uneasy sensations produced, if not largely diluted. In other cases the oily or fatty substances will give more prompt relief, especially if the eruption has been much irritated by scratching and tends to persist. Among them may be named the linimentum calcis of the pharmacopoeia, and cold cream to which have been added a few drops of the fluid extract of grindelia robusta. Mention should also be made here of the dusting powders which the reader will find described in the chapters relating to general therapeutics and the erythemata. They are the most cleanly of all external preparations in urticaria, and are often the only local measures required. With internal medication, as each case may sug- gest, the practitioner will be careful to note that the clothing of the patient is of a character that will not aggravate the eruption, that sleep is secured without an excess of bed-covering, and that places where the temperature is for any reason elevated are carefully avoided, such as the proximity to a fire-place or drop-light, the opera-house, the kitchen, etc. 184 DISEASES OF THE SKIN. Among the Germans, sulphur, naphthol, and tar salves are em- ployed iu the management of the disease. One of the most effective and trustworthy of local applications in severe urticaria is a starch solution. The starch is first mixed with cold water, and then boiled till the solution is of the consistency of thin mucilage. To each pint of this a drachm (4.) of the oxide of zinc, and a couple of drachms of glycerin (8.) are added before ebullition is completed. When cool, and applied to the surface, this often gives prompt relief. The same is true of a thin solution of boiled oatmeal. Such is the empirical treatment of urticaria. It will be seen to be founded upon no rational method of procedure, and this because the very capriciousness of the disease demands and secures relief in one instance by a treatment which should be reversed in another. It must be admitted that cases occur in which all treatment seems abso- lutely valueless, often really injurious to the patient. These cases will usually be found to be of the relapsing or chronic type. The subjects of this form of disease are often plunged in morbid mental states ; dreading by day the exacerbations of the night ; brooding over misfortunes experienced or anticipated ; w r orn with loss of sleep ; fearful of a generous regime at the table. Here the treatment is largely moral, and makes demands upon the tact and courage of the physician. Travel, change of climate, variation in the routine of life, new social surroundings, are here valuable. The widow must be made to lay aside the heavy crape veil beneath which her urticaria plays ; the solitary patient must secure a companion capable of diverting the nervous attention for a few hours each day. It seems probable that to these efficient agencies must be in part ascribed the relief so often obtained at the various mineral springs, both in this country and abroad. Thus the Karlsbad, Vichy, Sara- toga, and White Sulphur Springs, have all been credited with the production of beneficial effects in urticaria. Prognosis. — The prognosis of an attack of urticaria is, as may be seen in what has preceded, exceedingly variable in different cases. Simple attacks of the acute sort are trivial, and in a few days the patient may retain but the slightest souvenir of the trouble. In the case of children, the attack is often at an end in the course of twenty- four hours. It should, however, never be forgotten that urticaria may torment the life of a patient to the utmost bounds of tolerance, and seriously impair the general health. Persistent and rebellious chronic urticaria may prove to be a more formidable affection than a mild attack of syphilis, Dermatitis. Dermatitis is an affection of the skin characterized by the phenomena of in- flammation, including heat, redness, pain, and infiltration, terminating in resolution, suppuration, or the occurrence of gangrene. Inflammation of the skin occurs in a large number of cutaneous affections. Under this title, however, are grouped those inflamma- DERMATITIS. 185 tioDs where the result is plainly due to a direct influence exerted upon the skin by thermal, chemical, or mechanical agencies. These inflammations may be mild or severe. The milder forms of dermatitis disappear without leaving behind them persistent lesions. The graver forms may terminate in gan- grene, or produce death by shock or exhaustion. Dermatitis, then, is that idiopathic morbid state whose phenomena are induced by the action of certain special agencies, such as heat, cold, poisons, and traumatism. The inflammatory process may in- volve the superficial or deep portion of the integument, or may extend to the subcutaneous tissues, or even deeper. The symptoms vary with the nature of the cause, the extent and degree of its influ- ence, and the circumstances attending its operation. Hyperemia usually precedes aud may be followed by a fluid or plastic exudate, by the production of one or more of the several recognized cutaneous lesions, by diphtheritic deposits upon the surface, or by gangrene. With these there may be general symptoms of mild or severe grade, due to the influence excited by the local process upon the general economy. [A.] Dermatitis Traumatica. External violence, various in character and severity, is capable of inducing dermatitis whose symptoms differ in degree, though their career is, in general, the same. In this list are included the inflam- mations produced by surgical interference with the continuity of the integument ; excoriations caused by scratching, by the friction of garments and other articles injuriously acting upon the skin ; by the various implements handled in the trades ; and by the bites and stings of beasts, insects, reptiles, and fishes, when the result is trau- matic and not toxic in character. These injuries may be in the form of contusion, blow, concussion, pressure, puncture, incision, or lacera- tion ; aud the consequences are declared in heat, swelling, redness, and pain ; and in itching, burning, stinging, or pricking sensations, with subsequent inflammatory symptoms varying in grade from mild and transitory hyperemia and exudation to severe grades of inflam- mation with consequent production of pus, granulation, and repair ; or gangrene, and separation of the slough ; or, finally, by repair without consequences. [B.] Dermatitis Venenata. Certain medicinal and other substances applied to the external surface of the skin are capable of exciting inflammation either by operating as caustic, irritant, toxic, or even traumatic agents. In this list are included most of the strong acids and alkalies ; croton oil ; cantharides ; mustard ; tartar emetic ; mezereou ; the compounds of mercury ; arnica ; turpentine ; ether ; chloroform ; the tarry com- pounds ; many of the dyes ; several members of the rhus family (the Rhus toxicodendron and Rhus venenata, poison ivy, poison oak) ; the 186 DISEASES OF THE SKIN. nettle ; the smart-weed (Polygonum punetatum) ; cowhage (Mucuna pruriens) ; and glass in fine powder or delicate filaments, such as are thrust into the skin when handling certain articles of Venetian glass- ware. The list might be indefinitely extended, as there are few articles which are not capable of producing some irritation of the surface of the skin, if applied to it with sufficient vigor and for a certain period of time ; and in some it is difficult to decide whether the effect is more traumatic or toxic. An almost equally long list of substances of animal origin might be also named having poisonous effects upon the integument, such as decomposed or ammoniacal urine, feces, ichorous pus, pathologically altered secretions from the uterus, eye, ear, nose, etc. The symptoms of dermatitis venenata are substantially such as have been already described. Numerous types of cutaneous lesions, macules, pustules, papules, vesicles, bullae, wheals, scales, crusts, free serous aud purulent discharges, subcutaneous abscesses, and even gan- grene with sloughing, may result from the operation of such causes, the result being largely proportioned to the character of the agent producing the injury. A few of the more common sources of such accidents may be briefly considered. The use of soap for laundry, toilet, or other domestic purposes, containing an excess of alkali, or even minute particles of bone, is a frequent source of trouble, as are also several of the proprietary arti- cles sold in the shops for similar employment. In these instances, the erythema, vesiculation, infiltration, or other symptoms, will naturally be distinguished on the hands, or the hands and the face. Stockings and other undergarments dyed with aniline, picric acid, chromium, or arsenic, the leather lining of the inside of the hat or the cap, and the painted toys to which the lips of children are ap- plied, will beget mischief in the various regions of contact for each. Duhring reports cases where the dye-stuff in the lining of shoes penetrated the material of the stockings in women, and produced dermatitis of the feet or legs. The tincture of arnica, an article unfortunately much used as a domestic application for contused and incised wounds of a simple character, has produced very serious annoyance in some cases, two such having been recently presented at the author's clinic. The number of these accidents is annually increasing. Cartier 1 reports excessive erysipelatous swelliug, a phlyctenular eruption, and submaxillary adenopathy resulting from the external use of arnica. Beauvais reported to the Paris Medical Society gangrenous results in one case. Buehner believes this poisonous action to be due to insects (particularly the atherix maculatus) found in the calyx of the arnica flower. Other native plants, a large number of which are enumerated in a valuable work by Dr. James C. White, 2 presented before the American 1 Lyon Med.. April 13, 1884. 2 Dermatitis Venenata, Boston, 1887. DEKMATITIS. 187 Derraatological Association in 1886, are similarly effective. Wesener 1 reports that the Malacca bean tree (Auacardiuni Orientale) furnishes a caustic oil, called cardol, or cardoleum prurieus, which produces, after application to the skin, vesicles aud vesico-pustules which con- tain cardol and terminate by crusting. He reports a generalized eruption, beginning on the face, due to this cause. The antiseptic dressings of modern surgery are at times responsible for eruptive troubles. Among these may be named iodoform, which has produced erythema, vesicles, pustules, and wheals. 2 Carbolic acid and corrosive sublimate dressings have had similar effects. Many of the articles employed therapeutically by the dermatologist should be placed in the same category. Dr. N". E. Green, 3 of London, reports severe oedema of the skin followed by desquamation, resulting from the application to it of the ointment of ammoniated mercury in the strength of two drachms (8.) to the ounce (32.). Leszinsky reports a case of dermatitis following the use of a " triple extract of heliotrope " as a toilet preparation over the face. An exceedingly common source of such dermatitis is urine retained upon underclothing in adults. A persistent dermatitis of the scrotum, perineum, or inner faces of the thighs in either sex, always calls for a careful examination as to whether a few drops of urine are left in contact with such underclothing after each act of micturition. Fis- tula?, urinary incontinence, prostatic disease, u stammering of the bladder," imperfect finish of the coup de piston in men, especially after a gonorrhoea, and similar troubles, are all to be remembered. The eruption produced by the poison ivy and other varieties of rhus, is almost exclusively an American disease ; and from its fre- quency in this country has attracted a great deal of attention. A certain degree of susceptibility to the poisonous action of the plant is requisite for the production of its effects, as some individuals can handle the leaves of the plant with impunity, and others are said to be affected by its exhalations within a circle having a radius of several feet. It is, however, difficult to demonstrate the truth of the last statement, suspecting, as one may, that such instances are usually cases of contact with other than the suspected plant. The parts commonly affected are the hands and the regions to which the latter are carried, such as the face, genitals, arms, thighs, and neck. Bare- footed children suffer in the feet aud legs. Usually the symptoms are developed in the course of a few hours, and consist of erythematous patches, scanty or profuse vesiculation with abundant, serous weeping after rupture of the lesions, swelling, oedema, disfigurement, and intense burning and itching sensations. Serious effects are occasion- ally produced. The author has seen deeply attached scars result from subcutaneous abscesses of parts greatly swollen. Occasionally, in particularly sensitive skins, the eruption spreads from the surface affected by the poison, to that where presumably none has been 1 Deutsche Arch. f. klin. Med., vol. xxxvi. p. 578. 2 See paper of Dr. R. W. Taylor, read to the New York Academv of Medicine, 1887. 3 Brit. Med. Journ., May 3, 1884. 188 DISEASES OF THE SKIN. applied. It should be remembered, however, that articles of clothing may, for brief periods of time certainly, furnish sources of further trouble, being worn at the moment of contact with the plant, then laid aside, and, the occasion being forgotten, being subsequently employed. Thus a pair of undressed kid gloves after lying for two weeks untouched have sufficed to reawaken the disease. A number of cases of dermatitis have originated in some parts of the Orient from contact with the varnish employed in the finishing of lacquered ware. This is manufactured from the rhus varnish. A few instances of such dermatitis have occurred in this country from handling the newly imported articles of this class. Careful observation of a typical case, soon after the onset of symp- toms, will disclose the exact surface of contact, each being delicately outlined by a reddened, tolerably well-defined line, within whose limitations will be seen a slightly tumefied, erythematous surface, at times displaying closely packed, pin-point sized papules, which may be embryonic vesicles, or may proceed to resolution without serous effusion. The diagnosis of the eruption will be aided by recalling the features described in a careful monograph on the subject by Dr. White, of Boston. 1 According to this author, the lateral surfaces of the digits first exhibit the symptoms of the eruption ; later, the dorsal sur- faces ; and latest, the thickened palms. The efflorescence also is more irregularly distributed, more uniformly vesicular, and the vesicles less transparent than in eczema. These lesions are, more- over, more vesicular, and less papular at the onset ; and, though suggesting papules by their situation in the palm, are in that situation readily made to exude serum by puncture with a needle. Internal medication is not required. The local treatment is that of acute eczema. The application of an alkali for the purpose of neutralizing the poisonous volatile alkaloid in the leaves of the plant (toxicodendric acid, Maisch) should evidently be considered solely with a view to prophylaxis, as it is difficult to understand how such neutralization can control the inflammatory process after its onset. The black wash, solution of sugar of lead, or oleated lime-water, should be employed at first, and be followed later by the dusting- powders. The late Prof. Babcock, of Chicago, a frequent sufferer from the disease during his extended botanical excursions, first taught the value of an ointment made by incorporating a decoction of the inner bark of the American spice-bush (Benzoin odoriferum) with cold cream. It certainly has afforded very prompt relief in the cases in which one is able to employ it, the difficulty lying in securing the bark of the shrub in its young and tender state. A long list of topical remedies have been vaunted as specific for the relief of this disorder, from the brine of a pork-barrel to a decoction of the leaves of the plant itself. As the eruption subsides with satis- 1 New York: D. Appleton & Co., 1878, from the March number of the New York Medical Journal of the same year. DERMATITIS. 189 factory results when protected and not irritated by the local treatment, it is not difficult to explain these facts. In this way corrosive subli- mate lotions ; the tincture of iron ; bromine, fifteen drops to the ounce (32.) of olive oil (Brown); dilute nitric acid ; hyposulphite of sodium ; bicarbonate of sodium ; saturated solutions of chlorate of potassium ; and grindelia robusta, a drachm (4.) of the fluid extract to eight ounces (250.) of water, have all been found useful. [C] Dermatitis Calorica. Under this title are included those affections of the skin induced by extremes of thermal variation. Unduly high temperatures produce in the skin some redness and a slight degree of swelling, the color not completely disappearing under pressure. If the exciting agent be withdrawn before further effects are induced, the color first deepens, then becomes paler, and in twenty- four hours the process is usually concluded with a very delicate and transitory resulting pigmentation. Rays of heat and heated objects at a temperature above 125° to 175° F. produce immediately, or after a brief interval, first an erythema, which disappears when the source of heat is removed ; second, after more prolonged exposure, the symptoms of active in- flammation and exudation. Vesicles or bullae, isolated or confluent according to the severity of the cause, may rise from a reddened skin which is usually intensely painful. These lesions are persistent or transitory, and generally filled with a clear serum, which exudes and dries into crusts after rupture of the chamber in which it was im- prisoned. At other times the serous exudation is so great that the epidermis rises in broad plates, from beneath which the serum is exuded. This process may terminate by a free production of pus upon the surface and gradual resolution. Adenopathy is a frequent concomitant symptom. In such dermatitis of extensive areas of the skin, the intensity of the process may awaken a violent fever • or death may result from shock or exhaustion. In yet severer grades there is the production of an eschar, which is dry, brown, blackish, and destitute of all signs of vitality ; or, as Kaposi describes it, dense, coriaceous, and as white as alabaster, upon which, nevertheless, some vesicles may appear, and by their presence suggest a false conclusion as to the vitality of the tissues upon which they rest. In from eight to ten days the eschar is removed by sup- purative processes, and the scene is closed by the usual phenomena of granulation and cicatrization. The characteristics of the scar thus produced are, its great irregularity, its tendency to stellate radiation, and the production of ridges, folds, pockets, and bridles. Burns involving one-third of the surface of the body are of grave portent, and those affecting one-half are generally fatal, even though for from twenty-four to forty-eight hours there may be little complaint as to pain. The causes of death in these fatal cases are often obscure, as the post-mortem results are usually negative. Gastric and duodenal 190 DISEASES OF THE SKIN. ulceration are, however, often recognized Overheating of the blood, heart-paralysis, oligo-cythaemia, and actual destruction of leucocytes have all been supposed to be effective. In cases where life is pro- longed to the third day, the complications of pyaemia, erysipelas, and tetanus may arise. Lastly, exhaustion following fever, suppuration, haemorrhage, and visceral affections may lead to fatal results. In the treatment of the simplest burns, rest, lotions of lead-water, and cool water with the application of compresses, are usually suffi- cient to secure relief; occasionally the dusting powders may be substituted advantageously for these. In the cases where the serum is invited rapidly to the surface, with the production of vesicles and bullae, the latter should be gently punctured to give relief to the tension by the evacuation of their contents, but the roof-wall should be preserved, as it may subsequently form an attachment to the ex- posed derma beneath. The indication then is to exclude the air as perfectly as possible and to prevent suppuration, indications admirably met by the application of carbolated oil and lime-water with the Lister diessing. Continuous immersion in water of the temperature most agreeable to the patient, as practised by Hebra in cases of severe and extensive burning, produces speedy and certain amelioration of the pain, and a favorable condition of the wounds, though it does not avert a fatal issue in any dangerous case. The strictest antiseptic precautions are demanded when the sup- purative process in the skin is both active and extensive. Disin- fection with a five per cent, solution of carbolic acid, or a two per cent, resorcin solution, should be followed by the application of pro- tective silk wet with a five per cent, solution of the sodic biborate, or sodic bicarbonate, and the whole enveloped either in borax-lint, antiseptic (mercuric iodide) avooI, carbolized gauze, or salicylated cotton ; over all, the impermeable rubber tissue should be wrapped. Nitzsche l first disinfects the surface thoroughly with carbolic acid, having previously protected the blebs, after which it is covered with a thick varnish of linseed oil and litharge mixed by the aid of heat with five per cent, of salicylic acid. When this is dry, a second coat is applied, and the whole finally covered with a thick layer of wad- ding retained in place by an elastic bandage exercising moderate compression. Cicatrization progresses beneath the dressing without changing the latter. When suppuration does occur, the upper layer of the wadding is removed, and dried salicylic acid in powder is sprinkled over the surface, the waddiug being afterward reapplied. Skin-grafting may be required to cover the extensive ulcers left by the larger burns. In Congelatio, or dermatitis from congelation, there are also, usually in the milder forms, circumscribed erythematous patches or plaques, generally recognized under the name of Pernio, or chilblain, seated upon the digits or, more rarely, upon the face, and occasioning a disagreeable sensation of heat, smarting, or itching, especially after i Deutsche med. Zeit., 1881. DERMATITIS. 191 the chilled part has again been warmed. They are bluish or pur- plish-red in color, and often seated on a slightly cedematous integu- ment. They are often cool to the touch, when subjectively hot. Authors have claimed that anaemia is a chief predisposing cause of the complaint, but it frequently occurs in perfectly healthy young people. Sir Erasmus Wilson has intimated that some cases of so- called lupus erythematosus of the hands belong to this category. In the second grade of inflammatory reaction from the state of contracted bloodvessels and pallid integument produced immediately by the action of cold, bulla? and vesicles form, with, in severe cases, underlying ulcers. In the third grade gangrene may occur, with and without the formation of bullae. The frozen part may become insensible, white, and cold, without the circulation in it of blood- and lymph-currents. From this condition reaction occurs, with the formation of an eschar, differing in depth according to the severity of the exposure to cold. If, however, over and beyond the interference with the circulation, the tissue itself has been destroyed, when reaction occurs the part falls at once into gangrene ; or bullae form larger than those described above, filled with sanguinolent serum ; or the skin is smooth, marbled with bluish lines, whitish, cold, and insensitive. Mortification ensues, followed by the well-known phenomena of the " line of demarcation," and in favorable issues, suppurative separation of the dead part, granulation, repair, and cicatrization. As the injuries induced by congelation are more frequent upon the extremities, the bones largely participate in the losses of tissue, especially those of the digits. Sep- ticaemia and a fatal result may follow. Chilblains are treated internally by the ferruginous tonics, particu- larly the tincture of iron ; externally by stimulant applications, such as those containing iodine, camphor, carbolic acid, tincture of benzoin, and balsam of Peru. Kaposi recommends : &. Pulv. camphorse gr. x ; 50 Cretae prseparat. Ei ; 30! 01. lini f.?ij; 60 Balsam. Peruvian. nix*; l| M. Frictions, with or without medication, are generally useful. The parts are to be carefully protected from pressure and undue friction effects. Dilute nitric acid and peppermint water in equal proportions, painted over the part for three or four successive days, have been recommended by Lapatin for the treatment of frost-bitten fingers and toes. Hydrochloric and pyroligneous acids, lemon-juice, collo- dion, and acetate of lead, both in lotions and poultices, are also recommended. Meurisse advises in the management of both severe ambustio and congelatio, that goldbeater's skin be applied over any salves or lotions employed over the surface. In cases of severe congelation, the circulation is to be cautiously restored by friction in an apartment where the air is cool, in order to prevent too energetic reaction. Friction with snow is employed with safety in our own country and in the steppes of Russia, where these 192 DISEASES OF THE SKIN. accidents are frequent and grave in consequences. Perseverance for hours in this course is often rewarded with success in apparently desperate cases. Antiseptic dressings are usually demanded when sloughing and ulceration ensue. [D.] Dermatitis Medicamentosa. The importance of recognizing the fact that a given eruption is produced by an ingested drug can scarcely be overestimated from the point of view of the diagnostician. The errors committed in this connection are so frequent and so annoying to the patient that it is necessary for the physician to inquire very carefully before treating any cutaneous disease, as to the medicaments previously swallowed by the patient ; and also to be prompt to connect any aggravation of a cutaneous disease with remedies ordered by himself for internal use. The following is but an imperfect list of the drugs whose internal administration may be followed by an exanthem — imperfect, because without question many have yet to be recognized as possessing such an action. As to the modus operandi of such medicinal agents, for the most part our knowledge on this subject is purely conjectural. Some, for example, the iodide of potassium, are eliminated in part by the glands of the skin, and presumably have thus a local effect upon such emunctories ; others, and in this class, the author believes, should be included quinia, induce an urticaria scarcely to be distin- guished from an urticaria ab ingertis. Some, possibly, operate in either or both ways at different times or in different individuals. The absurdity of supposing that any disease can be " driven out " by the ingestion of such drugs should be relegated to the specious ignor- ance which first framed such an hypothesis. Acids. — The acids capable of producing macules, papules, ery- thema, desquamation, etc., are carbolic, nitric, tannic, benzoic (and benzoate of sodium), and boric (and borate of sodium). Modadewkow reports a case in which the pleura was washed out with a five per cent, solution of boric acid, a part of which was not removed. There occurred as a result an erythematous rash over the face, trunk, and extremities. Aconite — This drug is said to be productive at certain times of marked diaphoresis with the occurrence of vesiculation and consider- able itching. The diaphoresis in an irritable skin may be responsible for the trouble. Antipykine and Other Remedies of its Class manufactured by the action of glacial acetic acid upon the petroleum products. — Ernst * has been followed by many observers in recording rashes re suiting from the administration of antipyrine. The symptoms are discrete and confluent patches of bright red, scarlatiniform, erythema- i Centralbl. f. klin. Med.. 1885. DERMATITIS. 193 tous, and pruritic macules or papules. Veiel (Arch. f. Derm. u. Syph., 1891, Hft. 1) reports oedema with bullae upon the lips and toes, and over the palate, with urticarial lesions of palms and soles, after ingestion of antipyrine. Arsenic. — Erythematous, vesicular, papular, and much more rarely pustular, bullous, and ulcerative lesions, occur upon the face, back, and hands, after the ingestion of arsenic. The well-known effects of the administration of the drug in toxic doses, upon the mucous membranes of the eyes, nose, and mouth, need not be described in this connection ; nor yet the grave, gangrenous symp- toms, with osseous necrosis, which have been observed in the workers with the metal. The author has seen a bright red, scarlatiniform blush with few isolated vesicles cover both shoulders of a young woman with a del- icate skin after taking three medicinal doses of Fowler's solution, the eruption being present, but less distinct upon the face and hands. In two cases the rash in poly morphic type was limited to the hands alone. A number of young patients have been sent to the author's clinic from that for nervous diseases, w T ho, having taken arsenic in the largest medicinal doses for relief of chorea, presented as a result, a dark discoloration of the skin of the chest and neck chiefly, but also of other parts of the body. This was suggestive of the bronzing seen in Addison's disease. In some instances there had been no other cutaneous symptoms. Guaita and Liege have noted these phe- nomena, usually in the fifth month after ingestion of the drug. By far the largest number of such rashes are, however, produced in those previously suffering from cutaneous disease, for whose relief the drug is administered. Here the toxic effect is declared either by — first, increased hyperemia of the skin visible in an erythematous patch, or beneath the scales of a squamous patch ; or, as an areola of bright red hue about any aggregations of lesions ; second, by simple aggravation of the type of a disease already in existence (recurrence of acuity in a subacute eczema); third, by rapid peripheral extension of a disease which had previously been well limited in contour ; fourth, by converting a disease exhibiting uniformity of lesions into one characterized by multiformity. Each of these results might be illustrated by cases. In a series of eight cases of poisonous effects produced by arsenical paper hangings, and reported by Dr. F. H. Brown, 1 there were, curiously, no cutaneous symptoms. Belladonna, Atropia. — The well-known erythematous, scarla- tiniform, or reddish efflorescence produced by belladonna and its alkaloids, is usually limited to the upper segment of the body, but may become generalized. It is said to occur more frequently in children, probably because it has been administered largely to indi- 1 Paper read before the Boston Society for Medical Observation, March 6, 1876. 13 194 DISEASES OF THE SKIN. viduals of that age under the superstition that it is useful as a prophylactic in scarlatina. Very disagreeable and even dangerous results have followed the instillation into the eye of atropia as a mydriatic, the rash being accompanied by constitutional symptoms. Bromine and its Compounds. — A full and valuable account of the cutaneous effects of this drug and its compounds, when adminis- tered internally, is contained in a paper on medicinal eruptions, read by Dr. Arthur Van Harlingen, of Philadelphia, before the American Dermatological Association in 1880. Acneiform lesions, pustules, macules, maculo-papules, papules, eczema-form moist patches, fur- uncles, urticarial wheals, scales, and ulcers have been induced by swallowing the bromides of potassium, sodium, ammonium, and lithium. By far the most common are the acneiform and pustular lesions, occasionally accompanied by pruritus, which appear upon the face and upper portion of the trunk, though the author has seen the rash very distinct upon the genital region. Duhring reports an interesting observation of a case in which the eruption simulated very closely the maculo-papular syphiloderm, the patient having taken the remedy for three years. The eruption first appeared within five or six days after decreasing the dose. Kaposi has observed a case in a nine-months-old suckling, the mother having taken one hundred and twenty grammes of the bromide of potassium in two months, herself not exhibiting traces of eruption. In one patient treated by myself the eruption was generalized, but in no part exaggerated. It occurred in an adult male after three months' contiuual employment of large doses of the same salt. Mr. Browse, of Cambridge, England, recommends for relief of these symptoms the application of a solution of salicylic acid, one grain to the ouuce (0.066-32.) of water, frequently applied on lint, having successfully treated in this way sores as large as the palm of the hand. T. C. Fox and Gibbes report condyloma-form lesions in the case of an infant where the histology of the lesions was carefully studied ; aud Fay, in a child eleven months old, also recognized lesions which had been mistaken for molluscum epitheliale. These were undoubt- edly similar to the condyloma-form rash seen in children after the administration of the iodide of potassium. Cannabis Indica. — The only instance thus far reported of an eruption produced by the ingestion of this drug was observed by myself in the case of an adult male, who was extensively covered with papulo-vesicular lesions after swallowing a grain (0.066) of the extract. 1 Chloral. — An erythematous rash is the most common of the eruptions produced by chloral, though wheals, red and yellowish papules, vesicles, pustules, and petechial blotches have been observed. It occurs upon the face, neck, trunk, and limbs, of the latter, especially i N. Y. Med. Record, May 11, 1878. DERMATITIS. 195 on the extensor surfaces. In a man of advanced years, totally deaf, who had slept only under the influence of chloral for four years, the author observed discrete scaly patches as large as saucers over the lower extremities, hands, and feet. Martinet 1 reports an erythematous and scarlatiniform rash, occa- sionally commingled with urticarial and purpuric lesions, occurring upon the face, neck, front of the chest, the extensor surfaces of the larger joints, and the dorsum of the hands and feet. There was no pyrexia nor indisposition, but in cases dyspnoea and cardiac palpitation. Cod-liver Oil. — According to Farquharson, 2 cod-liver oil after being swallowed is capable of producing an acne. This can be true only of very inferior specimens, such as are not rarely found in the English market. Copaiba axd Cubebs. — The ingestion of copaiba is occasionally followed by a vividly red rash, in the form of discrete macules, more rarely maculo- papules, invading chiefly the lower segments of the extremities and the skin of the belly, but often completely covering the surface. The author has seen the rash occur in dark mulberry- red petechia? ; and always in his experience accompanied by pruritus. Inasmuch as the drug: is often administered for the relief of a venereal disorder not syphilitic, care should always be taken not to confound the eruption it may excite with the early macular syphiloderm. Cubebs is much more rarely followed by a similar result. Cundurango. — Guntz 3 reports the occurrence of furuncular and acneiform lesions in twenty patients out of one thousand who were taking cundurango for the relief of syphilis. Digitalis. — In Behrend's treatise on diseases of the skin 4 refer- ence is made to cases where macular and maculo-papular rashes suc- ceeded the ingestion of digitalis. Iodine and its Compounds. — The iodide of potassium is respon- sible for the larger number of all eruptions in this category. The frequent employment of this drug and the very marked influence which it possesses over the skin, render the study of these morbid results important. Unlike many of the other substances in the list, the iodine com- pounds are followed by some species of rash in probably the larger number of all persons who swallow them. The resulting lesions may be macular, papular, vesicular, bullous, pustular, petechial, multiform, or in the form of circumscribed, sub- cutaneous abscesses. The macular rash is best seen fully developed over the upper extremities, in discrete erythematous patches or in a diffuse blush. The cases in which the author has studied it, all displayed symmetry. 1 These de Paris, 1879. °- Brit. Med. Journ , Feb. 22, 1879. 3 Vierteljahrschft. f. Derm. u. Syph.,1882. * Braunschweig, 1879. 196 DISEASES OF THE SKIN. The hands were chiefly affected, and suggested in appearance the dyed hands of the aniline worker. It is said to assume at times the papu- lar type, a transformation the author has not noticed, though he has seen coexistence of papules upon the face. Berenguier describes a scarlatiniform rash of sudden occurrence upon the surface of which were numerous minute discrete vesicles. Eczema-form eruptions with abundant serous exudations are also reported. A number of interesting cases are on record where the adminis- tration of the drug was followed by the production of bullae. Bum- stead, Taylor, Duhring, Tilbury Fox, and Finny, have described such in adults, and the author has seen several cases in children. 1 Hallopeau 2 also reports a case in which a bullous eruption followed the ingestion of the iodide of potassium. The patient died, and the post-mortem appearances are reported in full. The eruption occurred chiefly about the head, neck, and the upper extremities. The author has called attention to the significant rarity of vesicular and bullous lesions in acquired syphilis, and suggested that at least some of the cases on record were those of rashes induced by the remedy given for relief of the disease. A careful analysis of these bullous rashes leads to their division into three categories : first, those occurring often with fatal results in cachectic adult patients ; second, those occurring as part of the erup- tive lesions in a polymorphic group ; third, those occurring in well nourished children, taking on the appearance of molluscum epitheliale and condyloma lesions, usually compounded of papulo-vesicles and pustules. Erythanthemata of a similar type have been also recognized in infants after the ingestion of bromide of potassium. The pustules induced by the administration of iodine compounds are seen chiefly upon the face, neck, trunk, and arms. They are usually seated upon a firm base, and may be followed by cicatrices. Duhring has seen an annular patch upon the forehead, made up of minute vesico-pustules, which eventually developed into a globular violaceous mass, nearly two inches in diameter. On several occasions the author has observed large cherry-sized, tubercular elevations abruptly rising from the surface of the integument, and presenting a cribriform appearance, which showed the open ducts of several sup- purating follicles (chin, cheek, nose). The purpuric rash occurs in petechial macules, discrete and miliary, situated chiefly on the lower extremities. In a case reported by Dr. Mackenzie (quoted by Van Harlingen) a single dose of two and a half grains (0.166) in an infant, was followed by a fatal result after the petechias appeared. Jaborandi and Pilocarpine are capable, when ingested, of inducing free diaphoresis ; and erythematous macules, wheals, and pin- head sized papules have been seen upon the surface as a result. i Arch, of Derm., Oct., 1870. Journ. of Cutan. and Ven. Dis., 1886, p. 383. 2 Union Med., March 25, 1882. DERMATITIS. 197 Mercury. — The statement that mercury when ingested is capable of producing an erythematous rash upon the surface of the skin is made by several authors of reputation. In view of the fact that the metal has been, in its various compounds, administered for so long a period of time, and for so many various diseases without the produc- tion of cutaneous symptoms, it is a fair hypothesis that the few reported cases are those in which there was coincidence rather than causation. The author has had the opportunity of observing a large number of individuals in whom the drug had been both properly and very injudiciously employed for long periods of time, and has not been able in a single instance to discover any evidences upon which to base a belief in its power to produce a cutaneous exanthem. A similar statement was made by Dr. White, of Boston, when this subject was under discussion in the American Dermatological Associa- tion. Mercurials, when applied to the external surface of the body are, as is well known, capable of exciting, in various degrees, cuta- neous irritation and inflammation. Opium axd its Alkaloids. — Erythema, wheals, and occasion- ally intense pruritus, with oedema, and subsequent desquamation, have followed the ingestion of opium and several of its alkaloids, notably morphia. In its mildest expression this cutaneous effect is limited to a characteristic itching about the nostrils, which can be perceived in a large proportion of all patients as soon as the general effect of the opiate becomes apparent. In several cases the author has observed an intense and distressing general pruritus without efflor- escence ; and in some instances has been certain that the subsequent urticarial efflorescence was induced by the free diaphoresis which the medicament induced. This is a matter of some practical moment, as the use of an anodyne for the purpose of procuring sleep for a patient tormented with a nocturnal pruritus would seem to be occasionally indicated. Inasmuch as chloral, the bromide of potas- sium, and the opiates are all capable of aggravating such distress, great caution is in such emergencies needful. In general, it may be said that the employment of these and similar remedies for such a purpose should be interpreted as a confession of weakness on the part of the physician, who ought to be able to alleviate the distress of his patient by a judicious employment of topical remedies. Petroleum and its products are responsible for a large list of medicamentous rashes. Phosphorus. — Hasse (quoted by Van Harlingen) cites the case of a young girl who exhibited a pemphigoid rash after the ingestion of phosphoric acid ; and, according to Farquharson, 1 phosphorus itself is occasionally responsible for purpura with gastro-intestinal derangement and jaundice preceding a fatal issue. 1 Loc. cit. 198 DISEASES OF THE SKIN. Podophyllin. — Winterburn 1 reports that those who work in resinoid podophyllin are liable to suffer, as a consequence of this exposure, from a cutaneous disease of the scrotum. Potassium Chlorate. — Stellwagon and others report that papules and macules have followed the use of this remedy, adminis- tered in the form of tablets. Quinine, Cinchona, and its Alkaloids. — Morrow 2 has col- lected in an interesting paper, the record of over sixty cases of quinine exanthem, and shows that its prevailing type is exanthe- matous, the rash being of a bright vivid hue, disappearing on pressure, aud resembling scarlatina. Other lesions produced are wheals, papules, vesicles, petechia?, hsemorrhagic purpura, bulla?, and, in one instance, an intense localized dermatitis with commencing gangrene of the scrotum. In some cases the rash reappeared on repetition of the dose, and even after recourse to the other alkaloids. The subjects were mostly women. As with most of the other exan- them-producing drugs, small doses, where the idiosyncrasy existed, sufficed for the effect. The author has seen the rash in an adult male, who, after taking two grains (0.133) of the sulphate of quinia for the first time in six years, exhibited an efflorescence over the entire surface of the body, of discrete, finger-nail sized, salmon- and pinkish-tinted, scarcely elevated patches, accompanied by a moderate pruritus. A repetition of the dose was followed by a recurrence of the exanthem. In several cases desquamation is reported as resulting from the rash. As to the occurrence of the general symptoms recognized under the title of cinchonism (tinnitus aurium, etc.), these may and may not accompany the lesions. Morrow makes the pertinent sug- gestion, in view of the frequent similarity of the rash to that exhib- ited in scarlatina, that many cases hitherto recorded as recurrent attacks of that disease and measles, with other anomalous cutaneous eruptions, may have been instances of the quinine exanthem. Salicylic Acid and the Salicylates. — Reports of cases where these substances after ingestion have produced cutaneous symptoms have been made by Heinlein, Wheeler, and Freudenberg, all cited by Van Harlingen. The symptoms were diffused redness, urticarial lesions, vesicles, pustules, petechia?, and vibices, accom- panied by intense pruritus, and followed by desquamation. Santonine. — A generalized eruption of urticarial lesions seated upon a reddened surface, and accompanied by oedema, is reported by Sieveking as occurring in a child to whom santonine had been administered as a vermifuge. 3 i Louisville Med. News. April 21. 1882. 2 n. y. Med. Journ., March, 1880, p. 244. 3 British Medical Journal, February 18, 1871. DERMATITIS. 199 Sodium Benzoate. — Rohe 1 reports two cases in which an ery- thematous rash, with well-defined border, accompanied by itching and slight desquamation, occurred during the use of the benzoate of sodium. The patients were a woman, aged thirty-five, and a boy with diphtheria. The eruption disappeared on the discontinuance of the remedy, and was made successively to appear and disappear by its alternate use and disuse. Sodium Biborate. — Gowers 2 reports the occurrence, especially on the arms, but also over the trunk and legs, of an eruption resembling psoriasis, after the ingestion of the biborate of sodium. Some of the resulting patches were one inch and a half in diameter. Three cases in all are collated. In two the eruption faded when a solution of arsenic was added to the sodium salt. Stramonium. — Deschamps (cited by Duhring) reports au erythem- atous rash after the administration of the thorn-apple. Strychnia. — Skinner (cited by Van Harlingen) reports a case where an eruption of six weeks' duration ensued upon the adminis- tration of quinine and strychnia together ; the former in the dose of one and a half grains (0. 10), the latter in the dose of one-twenty- fourth of a grain (0.0025). Tanacetum. — A varioliform eruption produced by the ingestion of a drachm and a half (6.) of the oil of tansy, administered for abortifacient purposes, is reported by Potter. 3 There were antecedent clonic convulsions. The result was not fatal. Tar and Turpentine. — Erythematous, vesicular, and papular rashes are reported as resulting from the ingestion of these substances. The following named medicaments have been recently added to the list of drugs capable, when administered by the mouth, of producing rashes. Many of these drugs have been effective in but few instances. There is no reason why the list should not be in the future greatly enlarged, as it is probable that every medicament is capable of pro- ducing a temporary effloresence when the system is suffering from a special sensitiveness to its action : Anacardium, bitter almonds, antimony, bittersweet, capsicum, cantharides, chloroform (after administration for anaesthetic pur- poses), duboisia, creasote, resin, castor-oil, ipecacuanha, hyoscyamus, matico, lead and its compounds, sulphur and the calcium sulphide, veratrum viride, cocaine, and conium. The diagnosis of the various medicinal rashes described above does not, fortunately, demand a recognition of the essential peculiarities 1 Maryland Medical Journal June 15, 1881, p. 91. 2 Lancet, September 24, 1881. 3 New England Medical Journal, October 15, 1881. 200 DISEASES OF THE SKIN. impressed upon each by the exciting cause, since in many cases such peculiarities do not exist. The urticarial resulting from the ingestion of "head-cheese," quinine, and chloral may be absolutely indistin- guishable. But to establish the fact that a medicamentous eruption is present in any given case is a long step in the direction of reaching the precise cause that has been in that case effective. This fact must often be obtained from the lips of the patient. The medicinal rashes are in general remarkable for their sudden appearance, their symmetry, their diffusion over large areas of the integument, the presence of pruritus, the absence of fever, and their existence alike upon exposed and protected surfaces of the skin, hinting thus at the action of some cause not operating externally. Excluding syphilis and the exanthematous fevers, a generalized rash of suddeu occurrence should always raise the suspicion of a dermatitis medicamentosa. Similarly in cases of pre-existing cutaneous disease, syphilis, eczema, or psoriasis, the sudden occurrence of lesions of a new type widely diffused, or of rapid aggravation in situ, or of speedy extension as to area of those already in existence, should awaken the suspicion, if there be fever, of the exanthemata ; and, without a febrile process, of the medicinal rashes. Thus the author has seen two patieuts with eczema exhibit rapid rise in temperature, and subsequently develop a generalized variolous rash j and it is a matter of common experience to examine patients on the eve of a macular syphiloderm, or even long past the eruptive stage of that disease, showing their faces, necks, and shoulders covered with an acueiform rash produced by the potassium iodide. The practitioner cannot be too strongly urged to view with exceeding watchfulness the skin of any patient affected with either of the common disorders, eczema, acne, and psoriasis, when the eruption in any instance becomes anomalous as to type, distribution, or symp- toms. An illustrative example has come under my observation since the first paragraph of this chapter was written. A physician, on a trip from Colorado to Chicago, with a long-standing eczema of the scrotum and thigh, suddenly exhibited tumefaction of both hands with small egg-sized, discrete, dull-red plaques over the palms and dorsa; and in the centre of nearly all such lesions a firm, whitish, elevated wheal, accompanied by severe burning, tingling, and pricking sensations. He had been swallowing " bromidia," a proprietary preparation con- taining the bromide of potassium, the hydrate of chloral, and cannabis indica, each single drug being capable of inducing an exanthem, and yet he had not the slightest suspicion of the real nature of his symp- toms, having been questioned by a brother physician, to whom he exhibited his hands, as to the possibility of syphilis. The medicamentous rashes, as a rule, disappear rapidly after the withdrawal of the exciting cause, and require no further manage- ment. In some cases the soothiug lotions, baths, and dusting powders employed in the treatment of acute eczema may be required. It should not be forgotten that the patient who exhibits these lesions is usually one who has been suffering from the real or fancied DERMATITIS. 201 disease for relief of which the drug was taken, and that condition may require recognition and management. In Morrow's contribution to this subject, it is clearly shown that the same drug may produce a variety of eruptive phenomena, and that the same eruptive features may result from the ingestion of different drugs. He points to what he concludes to be the neurotic origin of many of these rashes, and believes that the proof is incon- clusive that these are, to any considerable degree, brought about by elimination, through the cutaneous glands, of the noxious element introduced with the drug. Tilden, however, calls attention to the fact that many of these eruptive phenomena are of the nature of angioneuroses, similar to Trousseau's " tache cerebrate ," requiring often increase in the irritability of the cutaneous vessels, with exuda- tion of serum, outwandering of cells, and, in case of hemorrhagic lesions, some change in the vascular walls themselves. Fig. 41. Feigned Eruptions are usually varieties of dermatitis (erythem- atous, bullous, traumatic), discolorations, or ulcers produced by acids, caustics, other chemical agents, or friction for the purpose of exciting sympathy, extorting charity, securing hospital comforts, transporta- tion to city life, etc. The persons employing these devices are, as a rule, criminals, hysterical young women, mendicants, soldiers, sailors, or servants seeking release from service. The peculiarities of these artificial eruptions are briefly : their odd appearance, not resembling the well-known types of ordinary disease ; their sharp definition, due to the limi- tation of the disease to the area of contact of the article employed in its production ; and their appear- ance on the parts most accessible to the hands and eyes of the sup- posed victim of the disease, being in right-handed persons most perceptible on the anterior por- tions of the body, particularly over the face of the right thigh or leg, and over the left arm or shoulder. Evidences of drops where a caustic liquid has been spilled over the surface ; of angu- larity in outline, due, as a rule, to downward flow of a fluid from above ; and of staining of fingers, or nails, or tissue beneath the latter by the operator, are all significant. Feigned eruption. [From a photograph of one of the author's patients.] 202 DISEASES OF THE SKIN. A " Chronic Pustular Dermatitis with Extension in Peripheral Patches," has been described and figured by Hallo- peau {Int. Journ. of Rare Skin Diseases, iii., 1890, 1). The trunk and thighs were extensively covered with large deep brown plaques, having defined borders, and exhibiting indurated projections of the size of a small coin here and there over the indurated integument. The elementary lesion was a vesico-pustule with a red areola, which spread centrifugally by multiplication and which eventually became covered with a crust. [E.] Dermatitis Gangrenosa. Gangrene of the skin may result from dermatitis originally due to the action of excessive cold or heat ; to the action of externally ap- plied chemical agents (caustics, strong acids, alkalies, etc.) ; to shock ; to ergot and other substances ingested ; to infectious diseases (lepra, tuberculosis, syphilis, erysipelas) ; to central nervous disease (decubi- tus, Raynaud's disease) ; to disorder of the vessels (embolism, throm- bosis, acute and chronic endarteritis obliterans, calcareous changes in the arterial vascular tunics) ; or to compression by ligature, or tumors. Spontaneous Gangrene of the Skin occurs chiefly in hys- terical female subjects, the affected plaques being irregular in outline, superficial or deep, which after the slough has been separated usually cicatrize without serious mischief resulting. Occasionally they spread in serpiginous directions over the surface. Though doubt has been cast ou these cases, in consequence of the discovery among them of feigned diseases, it is certain that the malady occurs as de- scribed without the operation of external agencies. These cases are included in those described elsewhere as erythema gangrsenosum. Dermatitis Gangrenosa Infantum. (Multiple Disseminated Gangrene of the Skin in Infants ; Varicella Gangrsenosa ; Pemphigus Gangrsenosus ; liupia Escharotica ; Gangrenous Infantile Ecthyma). — As a consequence of the exanthemata (variola, varicella, rubeola, purpura, erythema nodosum), the head, shoulders, and trunk of some children exhibit crust-covered lesions which ulcerate and finally throw off a gangrenous slough, split-pea to small coin-sized, deep or shallow, after which repair commonly sets in. Severe losses are produced by a species of coalescence of smaller ulcers. These gangrenous points may occur beneath some previously exist- ing lesion or crust ; or may be at the outset spontaneous. In the most of cases a vesicular lesion forms with rosy areola which speedily bursts, leaving a blackish slough about which a circle of eliminating inflammation spreads. Thromboses result in the blood- vessels of the neighboring parts ; oedema becomes apparent ; and there is excited a train of reactive symptoms, fever, vomiting, diar- rhoea, albuminuria, cardiac or pulmonary troubles. The patient DERMATITIS. 203 becomes greatly reduced. Crocker reports hemorrhagic vesicles and bullae in grave cases. Brocq is careful to distinguish between these grave forms of dis- ease aud those to which should be denied the appellation dermatitis gangrenosa. In these milder forms the vesicular lesions of varicella, accompanied by a mild fever, and occurring perhaps in crops, develop in course ; while some among them are covered with a blackish crust, indurate at the base, surround themselves w T ith an angry zone of inflammation, and, especially about the trunk, thighs, and ano-genital region, ulcerate beneath the crust. Even though these ulcers coalesce and acquire a grave aspect, the result as a rule is not unfavorable. Etiology and Pathology. — The subjects of this affection are infants and young children, from three months to several years of age. Besides the exanthemata which may precede, cases are on record fol- lowing tuberculosis, rickets, and syphilis. The process is one which, originally dependent upon the toxic effects of specific cocci, evidently requires a certain soil for its effective operation. The treatment should be supporting for the general system, and local antisepsis by the aid of boric acid solutions, aristol, iodol, and the dressing of the parts which slough by the usual deodorizing agents. The prognosis is at times grave. Multiple Gangrene in Adults. — Under this title, Crocker describes two cases, one in a male, a second in a female patient, where as a consequence of scarlatina or some poorly defined antece- dent disorder, crops of pustules followed by gangrenous sloughing occurred in almost all parts of the body, one attack rapidly following another w 7 ith rise of temperature. Spontaneous Gangrene of the Eyelids. — (Hilbert). A pustulo-crustaceous lesion of the upper lids with gangrene resulting in a small circular ulcer, is reported as of occurrence in two healthy children. Symmetrical Gangrene of the Extremities. — {Local As- phyxia, Raynaud's Disease.) This affection is usually first announced by the common signs of arrest of circulation in the capillaries, numbness, loss of sensibility, and color of passive congestion (local asphyxia, digiti mortui), in fingers and toes exposed to extremes of cold or heat. The face, nose, ears, brows, and other regions and organs may also be involved. Eventually subjective sensations are awakened, stinging and lancinat- ing pains, pricking and crawling sensations. The parts involved, often the second and third phalanges of the digits, become first livid, then cold, firm, and black, and the epidermis over them rises in bullous efflorescences, which speedily become ulcerative lesions, sphacelation ensuing in the course of a few hours or days. Varia- tions occur in a singular thinning of the digits, which may become indurated and slender ; or be covered with small whitish cicatrices where a superficial slough has been separated ; or the parts become 204 DISEASES OF THE SKIN. cool, white, like alabaster, and recover their tone without loss of tissue ; the nails alone may fall ; or indeed the entire process may meet with arrest in the early stage of blueness and asphyxiation of the extremities. Etiology and Pathology. — The disease occurs equally in the two sexes and at all ages ; often in the cold weather of the winter season. There is a growing suspicion that many cases are of syphilitic origin, as these have followed infection. It has also succeeded tuberculosis, diphtheria, the exanthemata, diabetes, and hemoglobinuria. It is without question due to either centric or peripheral nerve excitation ; and immediately produced by venous stasis. Treatment is by employment of the galvanic current, stimulation (as in dermatitis with congelation) ; and friction with stimulating lotions, alcoholic, camphorated, oleaginous. It is desirable to apply both electricity and (in some cases) dry cupping over the spinal region. The Prognosis is in some cases grave ; when the morbid condition is limited to a small part of the body, recovery is often satisfactory. Erysipelas, Gr. epvdpdg, red ; ireXka y the skin. Erysipelas is an acute and specific inflammation of the skin and subcutaneous tissue, characterized by diffuse, shining redness, pain, swelling, and elevated temperature of the affected part, terminating in desquamation, and usually accompanied by fever, due to the presence of the streptococcus erysipelatis. Symptoms. — The disease is usually preceded by a prodromic period of malaise, lasting for tweuty-four hours or less, which may be ushered in by one or several chills followed by febrile symptoms. The latter are accompanied by anorexia and often by vomiting, with general depression and headache. The eruptive symptoms are generally first displayed at a given point, from which the disease progresses. It is commonly first noticed in a nut- or egg-sized patch, the integument of which is tumid, slightly elevated, irregular in contour, distinctly circum- scribed, and presents a rosy or crimson-reddish color with a pecu- liarly smooth and characteristic shining or glazed appearance. The sensations awakened may be those of moderate pruritus, pain, heat, or burning. To the touch, the affected part is tender, moderately firm, and perceptibly hotter than normal. The color fades under pres- sure to a yellowish-white. In typical cases, the erysipelatous blush and swelling spread over an area which may be of the size of the palm, or may even cover the surface of an entire limb or region of the body. In cases of moderate grade, the inflammation attains a maximum of extent and severity within a week, remains apparently unaltered for a day or ERYSIPELAS. 205 more, and then begins to abate, with amelioration of all the concom- itant symptoms. The fever which often precedes the eruption, con- tinues unabated during its progress, the temperature rising to 105° or 106° F., with nocturnal exacerbation, cephalic and lumbar pain, dryness of the tongue, gastric distress, and occasional delirium. As involution of the disorder is accomplished, the redness is replaced by the brownish, bluish-red, and dirty-white shades often seen after the disappearance of erythema multiforme, the epidermis finally desquamating in various degrees according to the extent of the pre- ceding inflammation. In other cases, where the exudation of serum beneath the epidermis has been rapid, the latter is raised in the form of vesicles, pustules, or bullae, more often the latter ; and, precisely as in the severe forms of dermatitis calorica, with which erysipelas presents a certain analogy, gangrene of the skin may result in the part affected. This is particularly apt to follow the disorder when it attacks the seat of surgical wounds and injuries. Erysipelas Ambulans is a term used to describe that form of the affection in which the erysipelatous blush, after involving a given area, spreads with greater or less rapidity to the parts in the vicinage, either by direct extension and uniform advancement in one direction, of the tumid and distinctly circumscribed border; or by linear, digital, or irregular prolongations radiating from the inflam- matory focus. As the blush and swelling advance in one direction, there is usually correspondingly rapid disappearance on the other. At other times, the disease, while extending to a new area and abandoning the old, is relighted in the latter, and thus an irregu- larly involved and irregularly extending erysipelatous surface pre- sents for weeks the varying phenomena of the disease. In yet other cases again, chiefly those in which there has been a history of trau- matism, a long erysipelatous linear streak or band may spread from the site of the traumatism in one direction or another, suggesting the indurated lines observed in lymphangitis. In severe cases, the febrile, nervous, and other symptoms are grave, including coma, delirium, meningitis, and the signs of serious involvement of the lungs, pericardium, pleura, and bowels. Metastatic abscesses may also occur in the cutaneous and subcutaneous tissues, the joints, peri- toneal cavity, and even in the viscera. Death may result from these complications, or from shock, exhaustion, or pyaemia. Surgical accidents aside, the face is the most common seat of the disease, where it may be first seen upon one side of the nose, one cheek, the lips, or the eyelid. It often attacks the lobe of the ear after the operation of piercing the lobule for the insertion of ear- rings in women. Thence it may extend over the whole face, inclu- sive of the mucous linings of the mouth and nose, which present a dry, tumid, and glazed appearance, suggestive of the symptoms dis- played upon the skin. 206 DISEASES OF THE SKIN. The inflammation may extend to the hairy parts, but in many cases it exhibits a species of reluctance to transgress the limits there presented. It may be noticed in cases of mild grade where no appli- cations have been made to arrest a local progress, that the elevated border spreads symmetrically to within a few lines of the male beard or the hairs at the edge of the forehead, and there spontane- ously rests. In severer grades these limits are readily surpassed ; and then, as a rule, the extension is rapid and formidable. In this way the entire head may become enormously swollen, suggesting to a casual observer that it is fully twice its normal size. The patient may then be greatly disfigured; his scarlet lips, swollen, parted, and permitting the escape of saliva; the ears, as usual when greatly en- larged, projecting in a marked degree from the side of the head ; the lids cedematous and incapable of separation ; the face, disfigured by bullae or crusts ; and the mind disordered by violence of the fever or the accesses of delirium. When recovery ensues, the hairs are apt to fall. All other regions of the body may be invaded, as the vaccinated arm, the leg w T hose skin is involved in venous varicosities, the scrotum or umbilicus of the infant, the genitalia of the newly deliv- ered woman, the breast of the nursing mother, and every surface which has been the seat of punctured, incised, contused, or poisoned wounds, or other accidents of the integument, where the germs of the disease may have access to the economy. Several authors describe habitually recurrent and Chronic forms of Erysipelas, whose identity with the disease here described it is difficult to establish. The diagnostician is sufficiently often con- sulted in cases where an erythematous eczema of the face, an acne rosacea, or a symptomatic erythema, is described by a patient as chronic or recurrent " erysipelas." The lesions to which such terms, however, are restricted by careful writers, are often forms of chronic dermatitis, such, for example, as occasionally follow dermatitis calorica. Instances occur in which the face, or parts of it, are the seat of a low grade of inflammation with local heat, swelling, red- ness, considerable infiltration, and some tenderness, the part being irritable and worse after exposure to a high wind or after excesses at the table. But the most of such cases fail to exhibit the distinct imprint of erysipelas ; they are not only chronic in course, but ex- ceedingly indolent, lasting for years ; they are unaccompanied by fever ; they are distinctly limited in all accesses of aggravation to the same part of the face ; they are never characterized by a bullous efflorescence; they never completely disappear; many occur in the subjects of chronic alcoholism, and the specific germs of erysipelas are not present. The febrile symptoms are, throughout, persistent and character- istic of a specific toxaemia. The temperature, as has been seen, may reach 105°-107°F., with vespertine exacerbations and remissions; ERYSIPELAS. 207 it may also become subnormal. If not relieved in the course of seven or eight days, complications may be expected. These are oedema, abscess, phlegmonous inflammation, gangrene, and inflammatory accidents involving the membranes of the brain, lungs, heart, bowels, kidneys, peritoneum, and joints. Etiology. — The modern view of the invariable origin of erysipelas from some point, however insignificant as to size, where a morbid germ has secured access to the economy, is generally accepted and adds interest to the study of the local manifestations of the disease. Whether it be the slightest or severest traumatism, an erosion, a torn pustule, or a puncture by a pin, such lesions are now interrogated whenever erysipelas occurs in any part of the body or in the course of any other disease. In the face, catarrhal and ulcerative processes involving the mucous membrane of the mouth, ears, and nose, are often the cause of an erysipelas, these processes occurring in a wide range of disor- ders from syphilis of the nasal bones to caries of the teeth. Injuries of, and surgical operations upon, the scalp not conducted with anti- septic precautions, and the common piercing of the lobe of the ear in women and female children for the insertion of ear-rings, may be followed by the appearance of the disease upon the scalp, as a result of which the hair often falls. Fistulas, vaccination, lesions of the tender umbilicus of the newly born infant, and railroad accidents may be named as common causes of the disease in other regions. Predisposing causes of this disease are to be sought for in cachexia, epidemic influences, traumatism, violation of hygienic rules, and occasionally, the recurrence of previous attacks. Besides these, it is alleged that constitutional predisposition and particular articles of diet may be responsible for the disease (mussels). If the malady be invariably the result of infection due to the pres- ence of a micrococcus, the essential cause lies in the specific germ, in the absence of which none of the predisposing causes named can be effective. It is clear, however that the predisposing causes suggested are those in which the multiplication of such germs and their en- trance to the general economy are most facilitated. . The infectious nature of erysipelas has been demonstrated by clinical proof and by the experiments of many observers, including Huter, Nepveu, Wahlberg, Lukomsky, Koch, Orth, Fehleisen, 1 and others. The micrococci are seen in great abundance, often arranged in chains, in the corium, subcutaneous tissue, and lymph spaces of erysipelatous skin. The streptococcus is a schizomycete which after cultivation in pep- tonized meat infusion, produces the disease both in man and the lower animals. The cocci multiply in chains whose colonies block up the vascular and lymphatic channels and spread beyond the latter to the tissues in the neighborhood. The inflammation excited and the small cell infiltration which results are directly proportioned to 1 Die Aetiologie des Erysipelas. Berlin, 1883. 208 DISEASES OF THE SKIN. the abundance of cocci present in any case, whose active multiplica- tion is greatest at the border of the erysipelatous patch. The cause of spontaneous subsidence of the disease is not wholly clear, but proba- bly due to the action of some toxic agent evolved from the tissues. Metastasis of the erysipelatous affection is due to the introduction of the streptococci to the vascular currents. According to Ziegler there is a possibility that the streptococcus of this disease may be related to or even identical with those of pus. Pathological Anatomy. — Under the microscope, the skin and subcutaneous tissues are seen to be infiltrated, the exudate being more serous and less rich in protoplasm than that observed in ordi- nary phlegmonous inflammation of the skin. The bullae represent rapid exudation of this same serosity to the congested epidermis, and the elevation of the latter in consequence. The elements of the rete and connective tissue are for the same reason swollen, the lymphatic and bloodvessels enlarged, and the cutaneous follicles engorged, the root- sheaths of the hairs being occasionally separated, necessitating thus temporary loss of the pilary growth. In proportion to the severity of the exudative process, pus-corpuscles may appear and represent, for the most part, degenerative changes in the subcutaneous tissues resulting in abscess. The phenomena are, in short, those of superficial or deep-spreading dermatitis. After death, the skin which has been the seat of the disease cannot be distinguished micro- scopically from that of another body. Diagnosis. — Erysipelas is to be distinguished from the erythemata, from dermatitis of various grades, from eczema, and from scarlatina. As a rule, its recognition from all is readily effected, when the presence of the fever in erysipelas is had in view, as also the peculiar shining, swollen, and rosy-reddish to damask hue of the affected parts. The redness is never produced as in scarlatina, by multiplicity of reddish puncta, nor is it so widely diffused as in that disease. Erysipelas may be at times accompanied by a pruritic sensation, but the patch which it affects is never by any possibilty scratched. By this simple test alone one may often distinguish an erysipelas of the face from an eczema of the same region in a child. From a chronic dermatitis with thickening of the affected tissues and redness of the surface, erysipelas is to be distinguished by its tendency to spread, by its acute career, by its frequent association with bullous or vesicu- lar lesions, and by the color, outline, and raised border of the affected patch. However, it must be understood that to these localized patches of chronic dermatitis several authors have given the name, chronic erysipelas, the difference between the views held on this point being chiefly one of terms. Treatment — Upon the continent of Europe, the therapeutic man- agement of erysipelas is in general limited to the employment of such systemic and topical measures as are specially required in each case. Quinine is administered whenever indicated by the temperature record ; and the erysipelatous surface is either left exposed to the EKYSIPELAS. 209 air, covered by dry compresses, moistened by cold or hot aqueous lotions, or anointed with unguents, simple, mercurial, or anodyne, as suggested in each case. Occasionally cataplasms are applied over the inflamed surface. Abscesses, whether subcutaneous or connected with a carious tooth, are opened ; the contents of all pustules evacu- ated ; and crusts carefully removed. Kaposi lays stress upon freeing the nasal cavities of all inflammatory products, whenever the face is attacked. The method of treating erysipelas by the administration of the tincture of iron internally has long been popularized among American practitioners. This preparation is given in full doses, from twenty to fifty drops, day and night every two to three hours, irrespective of the febrile state. When the erysipelatous blush has a distinctly cir- cumscribed outline, the annular zone extending for an inch or more in width upon the sound and affected skin is either covered with the tincture of iodine, pencilled with a crayon of nitrate of silver, or painted with a saturated solution of the same salt. This is done with a view to limit the extension of the disease. It is true that these measures will not always succeed, but it is erroneous to assert with some authors that they always fail. Certain it is that, whether effective or not in the production of the result, the advancing border of the disease will often fail to surpass the limits thus artificially described. Collodion has been employed for a similar purpose, and Darlin 1 has written in advocacy of the revival of this method of treating the disorder, basing its claim on the fact that it dimin- ishes the temperature of the part thus protected, and that, by the compression excited, it interferes with septic absorption. Heppel 8 recommends the painting over the surface of a ten per cent, solution of carbolic acid in alcohol, as an abortive treatment, for which Braithwaite 3 substitutes a similar solution of tannin. Excellent results are occasionally reached in the local treatment of erysipelas, first by attempting to limit the extension of the disease by the application of the tincture of iodine over the peripheral zone ; and, secondly, by retaining over the entire surface affected, neatly applied compresses saturated with a solution of the hyposulphite of sodium in the strength of about one drachm (4.) to the ounce (32.). Dr. Spencer, of the United States Army, has frequently seen the dis- order upon the face entirely relieved in this way in forty-eight hours. With many judicious practitioners all attempts to limit the exten- sion of the disease by local applications of an irritating sort (corrosive sublimate, nitrate of silver, carbolic acid, tar, turpentine, etc.) are condemned as positively injurious. Dry heat is applied by the aid of cotton or wool ; or cold compresses are laid over the part ; or iced lead lotions with intermissions of application ; or salicylic acid, boric acid, iodol, or iodoform, in powder. Resorcin in solution has been followed in some cases by excellent results. Koch applies one part of creolin, four of iodoform, and ten of 1 Bull. Gen. de Ther., 1881, vol. ii, p. 239. 2 Arch, of Derm., April, 1881. 3 Brit. Med. Journ., April 1881. 14 210 DISEASES OF THE SKIN. lanolin, covered with gutta-percha. Nussbaum uses ichthyol and collodion ; or equal parts of ichthyol and vaseline covered with a ten per cent, salicylic lint. Hallopeau uses one part to twenty of the sodic salicylate upon folds of linen. Erysipelas rarely attacks a patient in vigorous health. The large majority of all the subjects of the disease are either those who have previously suffered from manifest general ill-health, or who have been complaining of local ailments, trifling wounds, nasal catarrh, or surgical accidents. It is these precedent conditions which often demand the special attention of the physician or surgeon. It is needless to add that all surgical indications are to be fully met when these are present : pus is to be evacuated, crusts removed, and drainage secured. The physician and surgeon alike should never forget that the disease is infectious, that the patient is to be isolated, and to be supplied with an abundance of pure air ; and that fomites, surgical instruments, and even the non-disinfected hands of the attendants are capable of transmitting the disease. Finally, there are forms of erysipelas which are remediless. These are usually septic in character. The scarlet blush spreading from an irreparable injury of loug duration, is often the last protest of nature against the damage which even her final resort of gangrene will not avail to repair. Prognosis. — Under favorable circumstances, erysipelas, even of severe grade and extensive invasion, terminates in complete resolu- tion. Reserve should be made, however, in every case, as a serious complication has often transformed the simplest into the gravest forms of the disease. The very young, the cachectic, the victims of drink, the aged, the inmates of hospital wards depressed by other illness, and those mentally distressed by destitution and neglect, are particularly liable to suffer from grave and fatal forms of the malady. The patients who fill the beds in most lying-in hospitals are young women, either unmarried or deserted by their husbands, and unprovided with the necessities of life by those upon whom such a responsibility rests. The mental depression thus originating in con- nection with the septicemic influences, too common in all large chari- ties, is responsible for much of the relation which erysipelas often seems to sustain to the puerperal state, as also for the appalling mor- tality which it may exhibit under these circumstances. THE COCCOGENOUS DEKMATOSES. 211 The Coccogenous and Bacillogenous Dermatoses. A group of disorders differing among themselves are now recog- nized as essentially due to the invasion of the skin or its follicles with pathogenic cocci and bacilli. The dermatoses next to be con- sidered are not occasioned solely by such organisms, nor are all the cutaneous affections produced by such a cause here included. Their etiological relations, however, are of importance sufficient to justify the grouping of those next described. [A.] Furunculus. Lat., furunculus, a petty knave. (Boils.) Furunculosis is a disease characterized by the occurrence of one or more circum- scribed, cutaneous or subcutaneous abscesses called furuncles, which usually terminate by necrosis of tissue in the centre of the phlegmon, its expulsion in the form of pus or a core, and a resulting cicatrix. Symptoms. — Furuncles, commonly begin as both tender and pain- ful indurations in the skin or its subjacent tissues, the summit of which soon becomes visible in the epidermis as a reddish punctum. It is the result of an active inflammatory process, limited to a defi- nite area, and of greatest intensity at the centre of the involved mass. This centre is often represented by a hair-follicle, the pustules that form subsequently being perforated by a hair. More or less rapidly thereafter these symptoms are succeeded by increased redness, heat, and tumefaction, the latter producing a nut- or egg-sized tuberosity, well projected from the surface, or fairly imbedded within or beneath the derma. A yellowish point in the centre of the erythematous swelling soon announces the occurrence of suppuration. When accidentally or artificially opened at this summit, exit is given to a thick yellowish pus which may be com- mingled with blood from the traumatism of the neighboring capil- laries. The small abscess may then, after discharging its purulent contents for a few days, gradually close by granulation, or may also expel from its cavity a tenacious, pus-covered, yellowish-green slough, known as the " core." This evacuation is usually followed by relief of the tense and throbbing pain which is the well-known subjective characteristic of the furuncle. The length of time requisite for the completion of this process varies, with the extent of tissue involved, from a few days to several weeks. Boils may occur in any part of the body, but are most common about the face, the auricular region, the neck, the armpits, the ano-genital region, the hips, the buttocks, the breast, and the extremities. They may occur as single or multiple lesions, or may succeed each other in crops, especially about the buttocks, trunk, and thighs, for a period of several months. It is this succession of boils to which the term furunculosis is specially applied. The disease of 212 DISEASES OF THE SKIN. the skin, in such cases, may produce a constitutional effect manifested in pyrexia. This is usually encountered when the furuncles are few and short-lived, only in individuals of irritable constitution. There is also a decided chloro-ansemia due to the pain, fever, purulent drain, derangement of the nervous centres, inappetence, and consequent perversion of nutrition. The sequelae of boils are maculations of a violaceous tint, often perceptible in the skin for weeks and even months after their disap- pearance ; and cicatrices, pin-head to coin-sized, which are permanent. Hydroadenitis, as described by certain French authors, is not to be regarded as productive of furuncles, but of benign tumors of epithelial type possibly originating in the coil glands. Etiology. — The microbe producing boils is the staphylococcus pyogenes aureus. The remote cause is, however, often exceedingly obscure. It is true that they are encountered in typical subjects of diabetes, of the exanthemata, and of " hospitalism," where anaemia, asthenia, marasmus, malnutrition, and exhaustion resulting from excesses, from grave general disease, from low fevers, and from nervous strain, play a prominent part. But the reverse is also true. On the other hand, scratching, eczema, scabies, and other cutaneous diseases, lice, and external irritants of various sorts are responsible for many boils, especially those that are few and not followed by similar lesions. When, however, such sequence occurs, it should never be forgotten that the furuncles, if sufficiently numerous and large, are amply capable of disturbing the general economy. The collar-button at the back of the neck ; the edges of an unyielding corset, for one unaccustomed to it; a hard bench; the saddle-tree; and many similar articles, may be the exciting cause of furuncles. Account should always be had, in cases of persistent furunculosis, of externally operating poisons. In this category must be included sewer-gas emanations, arsenical wall-papers, and the poisons handled in the trades, e. g., by dyers, lead manufacturers, etc. Lastly, it is exceedingly common for patients thus affected to apply to practitioners for remedies intended to " purify the blood f and, inasmuch as the iodide of potassium is often mischievously prescribed in response to this demand, the original trouble is thus enhanced to a manifold extent. Many cases of furunculosis are instances of boils resulting originally from external irritation, which have greatly mul- tiplied and finally profoundly affected the system under the impulse of the so-called " blood-purifying " process. Pathology. — Authors have attempted to explain the phenomena of furuncle by supposing the process to be due to inflammation attack- ing a sebaceous follicle in the derma ; or a pilary follicle or sweat- gland beneath the skin ; or the peri-follicular tissues , or the con- nective tissue pedicle which passes downward from the fundus of the hair-follicle to the subcutaneous tissue ; or the blood and lymphatic vessels which surround the sac. It is reasonable to suppose that they are all in the right. No one of these component parts of the skin is THE COCCOGENOUS DERMATOSES. 213 known to be exempt from the changes which are induced by the inflam- matory process. It is difficult to discover in the furuncular lesion any symptoms which set it apart from the other results of localized inflammation, its phenomena differing from those of ecthyma, acne, pustular eczema, anthrax, etc., only by the seat and extent of the inflammation. The core of the furuncle represents a necrosis in- duced by the violence of the exudation, and so does the gangrenous slough which falls after a severe dermatitis calorica. The core of the furuncle is moist, yellowish, and puriform, because it is com- pletely immeshed beneath the epidermis, and pus-soaked. The core or slough of a gangrenous dermatitis may be as dry as a crust, from desiccation in consequence of exposure to the air, or be in various degrees moistened by the fluids escaping from the tissues beneath. Where there is no core in furunculus, this absence is probably due to the fact that the purulent products of the inflammation pass with readiness from the peripheral to the central parts of the phlegmon without having to leak through or between, or to be pressed against, masses of centrally disposed elements, whose vitality is thus the more readily lost. Inflammation of tissue in a practically closed chamber, under tense pressure, under slight pressure, exposed freely to the air, or in all grades protected from it, will always differ in its phenomena. It is wiser to attribute these differences to the circum- stances under which it is displayed than to any peculiarities in the nature of the process itself. The contagious character and parasitic origin of furuncles have been studied by a number of observers. Gingeot, 1 Startin, Trastour, Lowenberg, Pick, Pasteur, and others have, with varying success, reproduced these lesions by experimental inoculation. The name torula pyogenica has been given to a vegetable parasite recognized in furuncular products, which, however, in development, is to a marked degree modified by the nature of the site in which it is implanted. It is with these demonstrations in view that Giug&ot suggests the employment of parasiticides in the treatment of furunculosis, the acid nitrate of mercury, iodine in tincture, carbolic acid, and borated alcohol. Internally sulphur and the hyposulphite of sodium in large dilution are administered. Diagnosis. — Boils are to be distinguished from carbuncles by the exaggerated symptoms of the latter, described elsewhere. Circum- scribed furuncular abscesses of the groins and axillse are not to be confounded with suppurating, sympathetic, or virulent buboes of these regions, associated with genital or extra-genital, contagious, venereal sores. This goes without saying ; but many such errors have been made. Furuncles of the anal and genital region may be significant of surgical affections of the neighboring parts (perineal, peri-prostatic, peri-urethral, and scrotal abscesses in men ; suppura- tion of the vulvo-vaginal gland in women, etc.). Treatment. — The debilitated constitution of many patients affected with boils indicates clearly the need of atonic regimen, including the 1 Bulletin gen de Tkerap., Jan., Feb., and Mar. 1885. 214 DISEASES OF THE SKIN". administration of iron, quinine, and strychnine, the mineral acids, and, contrary to the generally accepted opinion of the laity, a gene- rous diet of milk, cream, eggs, and fresh meats. To these, wines and malt liquors may be at times added with advantage. Change of climate, of diet, of cooks, and of the habits of life is most service- able in cases of prolonged furunculosis. The mineral waters, at some of our health resorts, prove especially valuable for the debility which often results from these disorders. The urine should always be examined for sugar, albumen, and an excess of urates. The internal remedies which possess reputation in this complaint are ar- senic, sulphur, and the sodic sulphites, the alkalies, tar, fresh yeast, in tablespoonful doses, phosphorus, and the syrup of the hypophos- phites of lime, iron, soda, and potassa, and the sulphide of calcium. The last-named is probably more highly esteemed by the larger number of practitioners than all other internal remedies, and is given in doses of one-fifth to one-tenth of a grain (0.0133-0.0066) every three or four hours in the day. In lithsemia, the acetate or citrate of potassium is given in large dilution or the liquor potassa?; in gouty states, colchicum and the alkalies, including the sodic salicy- late. No one of these articles, however, may be described as an efficient and certain remedy for the complaint ; many cases will pro- gress without hindrance from any or all of them. Attempts in the direction of aborting a furuncle by the topical ap- plication of the stronger alkalies (aqua arnmonise) or acids ; caustics or cautery, ice, or premature complete incision with the scalpel occa- sionally succeed ; more often they fail. The best methods of local treatment are the simplest. The part may be frequently bathed in a hot, saturated solution of boric acid ; and immediately after covered with lint thickly spread with a paste form of two drachms each of the zinc oxide and powdered starch to the half ounce of vaseline ; or with a freshly made benzoinated zinc ointment. Where the pain is unusually intense, the parts may be covered with hot borated lotions covered with protective. When the pus is evacuated and the slough wholly or in part detached, the dressings for most cases are after washing with the hot borated lotion, boric acid in powder, iodol, iodoform (objectionable on account of its odor), aristol, or hydronaphthol one part to one-hundred of one of the former articles. Violent squeezing of a furuncle in order to separate its slough or to evacuate its contents should never be practised. Prognosis. — The future of the patient affected with a prolonged furunculosis is that only of which there can be question. Eventually the worst cases are relieved when unaccompanied by systemic or visceral disorders, and where the circumstances of the sufferer permit him to pursue the most advantageous course (travel, diet, abstraction from business, etc.). The resulting cicatrices depend upon the severity of the process. Often they are small, and in the course of years scarcely distinguishable. In exceptional cases they are large, persistent, and disfiguring. Anthrax is a term which has been applied, not without some confusion in the past, to two affections here separately considered. THE COCCOGENOUS DERMATOSES. 215 [B.] Anthrax. Gr., avdpai;, a live coal. 1. Anthrax Simplex. (Carbunculus, carbuncle.) Anthrax Simplex is a circumscribed, cutaneous, and subcutaneous abscess, usually larger than a furuncle, due to the pressure of staphylococci, characterized by dense induration and sloughing, and terminating, in favorable cases, by the production of a per- sistent cicatrix. Symptoms. — Carbuncles are often preceded by malaise, chill, and pyrexia of severe grades. There is commonly a burning pain at the site of the lesion. In cases where the anthrax is formidable and seated upon or near the head, alarming symptoms of prostration, stupor, somnolence, and even coma, may be noted. With and with- out these concomitants, a dense, dull-red, indurated, and painful phlegmon soon appears, varying in size from a small hen's-egg to an orange, and even much larger, involving not only the skin, but the tissues beneath. Suppuration finally occurs ; but the pus is not con- fined to a single sac. It undermines the integument, and often, through several apertures, leaks out indolently to the free surface. The fenestrated or cribriform appearance of the skin covering the carbuncle constitutes, in this stage, one of its most striking features. Through these apertures may be distinguished the whitish or yel- lowish pus-soaked sloughs, or portions of a single slough, which can be at times extracted through the orifice. Often the entire mass sepa- rates in a single slough, involving the skin and subcutaneous tissues, leaving a crateriform ulcer of formidable size, which, in favorable cases, proceeds to heal by granulation. The resulting cicatrix is at first of a deep violaceous tint, and later becomes blanched. It is indelible. The fever which usually accompanies this process may be mild or severe, or, more commonly in dangerous cases, of a typhoid character. It results unquestionably from sepsis due to unliberated pus and necrotic tissue, and is naturally most grave in consequences where the patients are weakened by previous asthenic disorders. Under these unfavorable circumstances, the carbuncle may spread at the periphery, with islands of necrotic tissue and ill-conditioned pus sep- arated by bridges of empurpled, infiltrated, and yielding skin. The peculiar lesions of this disease most often appear upon the back of the neck, the back of the trunk, and the lateral aspect of the hips and thighs, usually in a single development, though occasion- ally two or even three carbuncles of small or medium size may co- exist. The reason for their appearance in the localities named is clear. It is here that the skin is most thick and resisting, and, as a consequence, purulent foci when formed are covered in by the most voluminous layers of the connective tissue of the corium. 216 DISEASES OF THE SKIN. Etiology. — Anthrax simplex is produced by the obscure causes to which reference has already been made as probably effective in the production of boils. The two may coexist ; or the one follow the other ; and intermediate forms occur which might be assigned to either class. The disease is encountered more often in men than in women, and in later than in earlier life, simply because the tissues constituting its sites of preference offer in these individuals, and at these ages, a greater resistance to the exit of pus. The pus cocci may sustain an etiological or purely accidental relation to the lesion. It is at times an epiphenomeuon in cachexia, diabetes, albuminuria, syphilis, pemphigus, and exfoliative dermatitis. Fig. 42. Vertical section of anthrax. Dense network of fibrous bundles, with interspaces communicat- ing and extending to the subcutaneous tissue. (After Warren.) Fig Section of anthrax. Infiltrated papillse are seen at I, distended in .balloon-shaped figures, between which the rete is compressed ; at p and mp columnse adiposse are seen ; /, division of elements, the fibrous bundles resolving into protoplasm. (After Warren.) Pathology. — The pathological anatomy of carbuncle is well de- scribed by Warren, 1 whose observations conclusively show that the inflammatory process here is one with that seen in the simplest pustule. The peculiar symptoms of carbuncle are due solely to the formation of the phlegmon beneath the dense and extremely thick masses of fibrous tissue found in the back " for the protection of The Pathology of Carbuncle, or Anthrax. Cambridge, 1881, p. 15. THE COCCOGENOUS DERMATOSES. 217 that comparatively defenceless portion of the body." The elements, multiplying with the intensity of the inflammatory process, first in the subcutaneous adipose tissue, pass upward along the fat columns described by Warren as columnar adipose, crowd these, push along their horizontal clefts branching from either side, infiltrating the derma, pass along the edges of the hair-follicles, fill the papillae till the latter "balloon " with pus, ooze to the surface through the cribri- form apertures in the undermined epidermis, and soak the bundles of fibrous tissue, relatively intact, which constitute the undetached mass of sloughing tissue. The general symptoms in anthrax, pyseinie, septicemic, sympathetic, are due solely to pus imprisonment. The pus formation is due to the presence of the staphylococcus pyogenes aureus and the toxine it produces. Back of all lies the favorable soil (in the diabetic, the cachectic, etc.) for multiplication of these micro-organisms. Diagnosis. — It follows from what has preceded that carbuncle and furuncle differ solely in consequence of the depth of the starting- point of the phlegmou, and the density and resisting power of over- lying tissue. The former is therefore flatter, denser, less rapidly de- veloped, larger, less tender, and more painful, opens by many rather than by one or two apertures, and is followed by larger sloughs, ulcers, and cicatrices, and occasionally by fatal results. Treatment. — Crucial and other deep incisions in the local treat- ment of carbuncle are certainly inferior in results to the method advocated by Wood l and Talor, 2 which is employed in cases with complete success. A saturated solution of pure carbolic acid is injected through the several apertures in every direction into the sloughing tissues by the aid of an hypodermatic syringe. When the orifices are not sufficiently numerous, the point of the needle is thrust through the thinned integument at the summit of the swelling in several points. The pain is severe, but short-lived ; the tissues are blanched, indurated, and destroyed ; the slough in a few days is readily separated after division of its slender fibrous attachments ; and the ulcer rapidly contracts with the sequel of a smaller scar. It is necessary to use pure acid in saturated solution to prevent absorp- tion of the injected fluid and resulting toxic effects. Relief is afforded in many cases by hot borated lotions and fomen- tations, with the requisite skill in the surgical dressing of the parts by carbolated lotions, extraction of the slough wholly or in portions by the forceps, and the subsequent employment of boric acid, iodol, iodoform, aristol, or the paste recommended in the treatment of furuncles. An excellent method of withdrawing the purulent and sloughing contents of the carbuncle is to apply over it, at the proper period, an exhausted receiver, such as a common cupping-glass. Erasion of the entire abscess with the curette, and subsequent antiseptic dressing is the best radical measure of relief. In many cases the antiseptic treatment of a carbuncle furnishes 1 Toledo Medical and Surgical Journal, Dec. 1880. 2 Austral. Medical Gazette, Dec. 1, 1881. 218 DISEASES OF THE SKIN. decidedly the best results as regards the comfort of the patient and limitation of the disease. Here there is absolutely no surgical inter- ference with the lesion, beyond the incisions made for the evacuation of pus. Violent squeezing and manipulation of the carbuncle are interdicted. It is freely powdered with boric acid, iodol, or iodoform, and on it is laid soft, felt cloth, thickly spread with any emollient and antiseptic salve. Bulkley 1 advises the use of the ordinary zinc salve for this purpose. Boric acid in powder, or iodol, thickly dusted over the carbuncle and covered with antiseptic wool will also be found a useful dressing. Internally calx sulphurata should be administered in full doses. it has an unquestionable effect in diminishing the pus-formation. Other constitutional treatment is that demanded in the case of furunculosis, including the liberal employment of tonics, a generous diet, a strict observance of the rules of hygiene, and stimulants when indicated. Pyrexic, septicemic, pysemic, and adynamic states require the special management of such complications, including cold sponging of the surface in fever, and the use of quinine and stimu- lants, with artificially applied heat in the algid condition. The urine should always be examined for sugar and albumin. Prognosis. — A serious issue need be anticipated only when the complications described above are grave in character, or occur in asthenic constitutions. 2. Anthrax Maligna (Malignant pustule, Fr., pustule maligue, Charbon). Anthrax Maligna is a carbuncular lesion resulting from infection of the skin or another organ of the body, with a virus containing the anthrax bacillus, furnished by some animal infected with splenic fever. This disease in man is fortunately rare of occurrence, and is usually derived from some animal affected with the specific malady variously termed "Anthrax," " Charbon," " Splenic Fever," "Splenic Apoplexy," or " Texas Fever." The lesion under consideration is also termed Splenic Fever Carbuncle. After inoculation with the disease from any infected animal, the human subject may (a) perish from systemic poisoning wholly septicemic in character with few external symptoms ; or, (b) when life is sufficiently prolonged, suffer from visceral symptoms, and exhibit subcutaneous tumors ; or (c) exhibit the symptoms of the disease now under consideration. In from twelve to eighteen hours after inoculation a painless macule is first manifested, usually upon the dorsum or other parts of the hands or face to which the virus has had access. This is followed by an inflammatory and pruritic papule, which is rapidly transformed into a flaccid vesicle filled with a bloody serum and sur- mounting a firm indurated " nucleus," or a larger blood-filled bleb reposing upon a somewhat painful, engorged, and often densely in- durated base involving extensively the subcutaneous tissue. One or more similar lesions may follow in the surrounding integument, 1 Journ. of the Amer. Med. Assoc, May 16, 1885. THE COCCOQENOUS DERMATOSES. 219 coalescence of which produces a large, angry, oedematous, and often gangrenous ulcer. The involved skin may be as large as a small coin, or of the size of the palm of the hand. The lymphatic vessels and ganglia enlarge, and often suppurate ; metastatic abscesses form ; and the constitutional symptoms supervening are those described in conuection with equinia. If recovery ensues, the gangrenous mass is sloughed off as in favorable cases of carbuncle ; if the result is to be fatal, the process is rapidly aggravated by oedematous infiltration extending to a wider area and by larger quantities of tissue falling into necrosis. In some cases the accompanying fever is high, with marked delirium ; in others, it is of a typhoid character. Death results from shock, septicaemia, or exhaustion, though in cases where the lesion is circumscribed and unattended by constitutional symptoms, recovery may ensue. 1 Etiology. — The disease is induced by infection from one of the lower animals, usually horned cattle, who suffer from charbon or splenic fever, and are in relation to herders, ranchmen, etc. The susceptibility of the carnivora to the disease is very much less than that of the her- bivora. It is claimed that not only direct inoculation may produce the disease, but that it may be extended by the medium of flies and other insects. More recently it is claimed that food, drink, and even inspired air may be the medium by which the disease is conveyed. Pathology. — Since the first investigations reported by Davaine to the French Academy in 1864, Pasteur, Klebs, Koch, Carnevin, and others have fully demonstrated that splenic fever is solely due to the multiplication in the blood and tissues of a rod-shaped bacillus, the bacillus anthracis, which is always motionless. Under culture the bacilli may develop long filaments, many times larger than the original rods, with a distinct sheath about a protoplasmic cylinder, which after segmentation furnishes oval and shining spores. These have been cultivated again and again, with re- sulting germs that have produced the disease FlG - 44 - artificially in the lower animals. i The pathological anatomy of the malignant g^ <$ pustule is that of carbuncle with the added 5* ********* fact that specific bacilli and spores are abun- ^^ /#^» ftt dantly present in the blood and debris of ( #) " / tissue. _ . y^^ ^#* In establishing a diagnosis, care must be xS^m^ JSS^ taken to avoid one source of error. Malig- #" fc nant pustule in man is not of frequent occur- . ,-i . i . • n • Malignant pustule bacilli rence in this country, but occasionally various and pus CO rpuscies. cutaneous eruptions are induced upon the hands, About x 300. after contact with animals or hides upon w r hich chemical solutions have been applied for the destruction of lice. These solutions usually contain arsenic, corrosive sublimate, or other 1 A chromo-lithograpb exhibiting the peculiar features of the malignant pustule in the neck, will be found in the British Med. Journ. of June 13, 1834, illustrating a paper by Mr. Morrant Baker. 220 DISEASES OF THE SKIN. substances capable of exciting a localized dermatitis. Chancre of the face, severe anthrax simplex (carbuncle), and poisoned wounds, are all differentiated by their relatively indolent course and the ab- sence of gangrene. The treatment is to be conducted on the principles of general thera- peutics. Popper/ an Hungarian physician with a large experience in malignant pustule, reports success by deep excision of the lesion, extending the operation to the subcutaneous connective tissue. This has always proved successful when practised before the occurrence of general symptoms. A number of other authors have had successful results after ex- cision. Pitts, for example {Brit. Med. Journ., March 19, 1887), reports two successful excisions of malignant pustule in the case of brothers. Johnson, of New York, and Robinson, of England, each reported in 1892 successful results after excision. Hebra was not in favor of the early cauterization of the malignant pustule, and it may be considered as a questionable method of procedure. A grave case of malignant pustule is recorded, 2 in which recovery ensued after the hypodermatic injection of the tincture of iodine. Three syringefuls of the pure tincture were deposited beneath the skin at the periphery of the diseased surface, and lint soaked in the same was applied over the slough. Internally, fourteen drops of the tincture (1.) with three grains (0.26) of the iodide of potassium, were also administered. Normal cicatrization followed in this and six other cases recorded. Crucial incisions with the free application afterward of pure car- bolic acid have been followed by good results. Mr. Baker, of Lon- don, reports rapid and complete relief after excision and the free use of iodoform. Internally, the hyposulphite of sodium and quinine are successfully employed. The febrile, typhoid, and adynamic features of the disease are to be treated in accordance with the recog- nized principles of general medicine. Prognosis. — The disease proves fatal in about one-third of all cases. Early excision in a healthy subject gives promise of satisfactory results. [C] Equinia. Lat., equus, a horse. (Glanders, Farcy. Fr., Morve, Farcin. Ger., Rotzkrankheit, Maliasmus.) Equinia is a contagious, virulent, and inoculable disease, transmitted to man from the horse, mule, or ass, and produced by a bacillus resembling that of tubercu- losis. Symptoms. — The acute form of the disease commonly follows a period of malaise lasting a few hours or as many weeks, in which the i Centralbl. f. Chir., 1881, No. 33. 2 Arch. gen. de Med., Feb. 1883. THE COCCOGENOUS DEKMATOSES. 221 patieDt complains of vague pains of a rheumatoid type, followed by thermal variations. The temperature rises rapidly to a point of danger, with chills, fever, diarrhoea (often following constipation), and rapid exhaustion, the picture being nearly that of acute septi- caemia. The cutaneous symptoms begin often with an erysipelatoid blush, the surface, affected and swollen, also producing papules, vesicles, pustules, and bullae, with dense but ill-defined induration of the sub- cutaneous tissue ; or reddish and yellowish papules appear, which, as in the case of the fluid-containing lesions, coalesce and furnish a bloody discharge. A more or less rapidly occurring sloughing ensues, sometimes with extensive gangrene, though the patient often succumbs before the culmination of the morbid process. The lym- phatic vessels are swollen and well defined, often indurated. These symptoms affect chiefly the face, hands, feet, and other exposed parts of the body. There is often a sanious or purulent and offensive catarrh from the nostrils, the mouth, and the eyes, the inflammatory process spreading rapidly to the deeper mucous surfaces. This catarrh, chiefly nasal in site and declared conspicuously by the nasal voice, due to the blocking up of the nose by the viscid, foul-smelling, and haemorrhagic discharge, is one of the most characteristic features of the malady, and of importance in the diagnosis. In the chronic form of the disease this nasal catarrh is less con- spicuous at the outset, though it may be later a prominent feature of the malady. A few days or weeks after infection, pustules, as in the acute form, resembling those of variola, but flattened and never umbilicated, begin as vesicles or even papules, coalesce to bullae, occur in successive crops, and run on to the production of multiple abscesses, poorly defined on the extremities and about the face ; much more rarely on the trunk. These may be of phlegmonous type, or be deep, brawny infiltrations with purulent foci, extending over months of invasion and decline of the disease. From these abscesses, pea- to nut-sized over the face, larger on the limbs, flows an abundant, sanious, semi-liquid, or viscid, yellowish, and offensive pus. Ulcers form at many points, with purplish borders, oval or roundish contour, and thin edges suggesting the appearance of the scrofulous ulcer of classical type. The edges may be softish or indurated. By their multiplication or coalescence the lips, nose, lids, and other parts of the face may be in part or wholly destroyed. The disease may steadily advance, or may seem to be arrested for a time and reawaken to activity. Meantime the lymphatic glands are either unchanged or enlarged by sympathy. In the course of months or years there is a fatal issue. The disease is fortunately rare. Etiology and Pathology. — The disease is almost invariably pro- duced by infection from horses, a history of contact with such ani- mals being one of the important points in establishing a diagnosis. The infection is produced by the glanders bacillus (Weichselbaum, Schiitz, Loeffler, Bouchard). They have nearly the size of the tubercle bacillus, being cultivated and capable of producing the dis- 222 DISEASES OF THE SKIN. ease in the lower animals after injection of cultures. They are found in the greatest abundance in papules, abscesses, blood, and brain tissues of the diseased. The treatment is that of the septic condition, and is of little avail. The prognosis is in the highest degree grave. Pustules from Cadaveric Infection. — In a number of lesions recognized especially upon the fingers and hands of those in contact with the bodies of the dead, tubercle bacilli have been recognized. Such lesions are the verruca necrogenica described in the chapter on tuberculosis cutis. Other lesions, however, generally known as dissec- tion-wounds, occur with symptoms of acute poisoning upon the hands of those exposed to the danger of post-mortem examinations and dis- sections. At the point of inoculation, which may be either the site of a former abrasion, rent, or the mouth of an open follicle, a painful vesico-pustule, papule, tubercle, wart, furuncle, or hemorrhagic bulla rises rapidly from an angry and indurated base, with hypersemic areola in dull red shades. Suppuration, crusting, or ulceration may follow, limited to the seat of the lesion; or lymphangitis in various grades with consequent pysemic or septicemic involvement of the system. Suppurative and non-suppurative axillary buboes are common. Gangrene and necrosis of the soft parts and bones, especi- ally the phalanges, may ensue, as also a fatal result from the systemic disorders named. In a few cases a chronic marasmus is induced. Prophylaxis, by proper protection of the hands and the immediate cleansing and disinfection of any accidentally wounded point, is of the highest importance. The treatment is to be conducted in accord- ance with the principles already described. There is reason to believe that accidents of this kind may be pro- duced by absorption of the alkaloids engendered in the cadaver by the decomposition of proteid substances, called ptomaines. These were first isolated and named by the late Professor Selmi, of Bologna, subsequent investigation seeming to prove that in chemical constitu- tion they do not differ from the alkaloids produced by albuminous decomposition in vegetables. Brieger has identified neuridine, cada- verine, putrescene, and saprine in the dead body, and, with these a peculiarly toxic alkaloid to which he has given the name mydale'in. All these are capable, after ingestion or admission by other avenues to the circulation, of inducing salivation, vomiting, diarrhoea, dysp- noea, paralysis, and death. The lethal issue in the case of lesions of the character here designated, is probably due to the fact that, at the site of the pustule of irritation or traumatism, one or more of these toxic alkaloids has gained admission to the lymphatic circulation. Pustules and Other Lesions resulting from Wounds In- flicted by Keptiles and Insects are often of an insignificant character. Such are the trivial results of the bites and stings of flies, fleas, mosquitoes, ants, bees, hornets, etc. At other times, however, serious and even fatal consequences have been recorded. THE COCCOGENOUS DERMATOSES. 223 The wounds produced by the tarantula and scorpion (which frequently lurk in the clusters of tropical fruits now imported to almost every part of this country), as also of the venemous reptiles, may prove to be grave. Urticarial, vesicular, pustular, papular, bullous, and petechial lesions may thus originate and be the cause of a more or less severe dermatitis with toxic symptoms. In the latter event, it is common in this country to administer as remedial agents, alcoholic stimulants as freely as they can be ingested. [D.] Delhi Boil, Aleppo Evil, Biskra Bouton, Oriental Boil, Gafsa Button, Natal Sore. Fk., Clou de Biskra. This is a chronic endemic disorder characterized by the occurrence of painful nodosities upon the face, hands, and other portions of the body. The lesions are one or multiple papules, pea- to bean-sized, which subsequently become purulent and ulcerate indolently, or be- come covered with scales. They are often grouped in patches aud followed by cicatrices. The exact nature of the malady thus named, is unknown. It is quite fully described by Fox, Farquhar, Pollack, Willemin, and other authors, as occurring in India, the region about the Euphrates and Tigris Rivers, and along the northern coast of Africa, especially Algeria and Morocco. • The descriptions given suggest that, in some instances at least, several different disorders have been included under these titles, such as the lesions of lupus, syphilis, and the frequently formidable symptoms produced in the skin by the vegetable parasites in tropical countries. Laveran 1 has lately described afresh the Biskra bouton. It occurs not only in Biskra but also in the adjoining oasis. It shows itself as an endemic only in the months of September and October, and continues until December. Xo new cases appear in January and February. All ages, both sexes, the strong and weak, are liable to it. The eruption affects the face and extremities by preference, sometimes also the trunk. It ordinarily attacks the same person but once, yet may recur. So long as the disease prevails, the least excoriation has a tendency to become Biskra button. At first there is a reddish, painless, elevation of the skin, the size of a pin's head ; the centre of this soon dries and a brownish crust forms, easily re- movable. Beneath this there is a small round ulcer. The papules may occur in patches, bearing thick crusts which long resist. The crusts are remarkably dry. When the latter are removed and the ulcer left undressed, a new, less firm crust forms ; when dressed, the crust-formation is prevented and an ulcer of an obstinate character remains, which in the leg is not unlike a varicose ulcer. If the original crusts be not disturbed, these eventually fall and leave no scar. Should, on the contrary, the crust be removed at the begin- ning of cicatrization, this is accomplished slowly and a permanent scar remains. Lymphangitis, erysipelas, and phlebitis, occur as complications. There are no peculiarities in the crusts. Epidermic 1 Annal. de Derm, et de Syph., 1881, t. i. p. 173. 224 DISEASES OF THE SKIN". cells, pus corpuscles, aud bacteria, are commonly recognized by the microscope. An expectant treatment is the best. Should the crusts be removed or fall off it is advisable to powder the ulcer with henna, which favors the production of fresh crusts and cicatrization. As regards its pathogenesis, the author holds Weber's view, that the disease is contagious and inoculable, and perhaps auto-inoculable. The virus exists in the crusts, but its nature is not established. Carter's opinion as to its parasitic nature is not tenable. Dr. Altounyan, of Turkey, 1 protests against the view, given above, entertained by Geber and others, that the Aleppo button is a term applied indefinitely to various cutaneous disorders. In his view it is a specific disease beginning, independently of the hair-follicles, as a small acne-form papule, disappearing on pressure and pinkish in color. Afterward it grows deeper, larger, and harder, and becomes more adherent and more vascular. Still it is livid, sensitive, smooth, and boggy to the touch. Pus forms centrally and dries into grayish- brown crusts which are rupioid in character. Beneath is a spongy ulcer, with ragged margin, ovoid contour, and ichorous discharge. Healing is by the production of a permanent and deforming scar, the entire course of the disease lasting one year. Dr. G. B>. Eliott, of New York, who made a microscopical exami- nation of some specimens' furnished him by Altounyan, reports that the disease was limited to the epidermis and corium and its area, occupied by small round inflammatory or formative cells and epithelial elements. There was a distinct line of separation between the healthy and diseased tissue. No cryptogamous or other micro- organisms were recognized. The hair-follicles and other glandular structures were intact. Altounyan found the best treatment to be the painting of the button with the tinctnre of iodine ; and that one attack furnished immunity against a second. He believes the disease to result from the bite or sting of an insect. Phagedena Tropica. (Aden ulcer ; Malabar ulcer.) Hirsch, Parke, and others describe a condition peculiar to trav- ellers in tropical countries, rarely in temperate zones, attacking those particularly Avho have been exhausted by fatigue, malaria, and mal- nutrition. In these cases a slight traumatism becomes later the seat of a vesicle or bleb from which as a centre spreads a rapidly phagedenic sore extending by sloughs through skin, muscle, tendon, and bone. The disorder is usually first noticed on the exposed parts of the lower limbs, but other regions may be earliest involved. In mild cases there is arrest of the process before severe destruction is accomplished, and then cicatrization follows. The disease occurs chiefly among the natives of the tropics, but also attacks travellers. It is aggravated by all unfavorable climatic and individual conditions. Microbes have been discovered, supposed 1 Journ. of Cutan. and Ven. Dis., viii., No 6, June, 1885. THE COCCOGENOUS DERMATOSES. 225 to be pathogenic, by Boinet, who has also cultivated the same and produced successful inoculations of animals. The treatment is precisely that employed for all similar surgical emergencies, viz., support by proper food and medicines ; locally, antisepsis and parasiticides. The caustics employed by the French are inferior to effective parasiticides, such as the bora ted, salicylated, and sublimate dressings. [E.] Phlegmona Diffusa. Gr.,