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 ILLUSTRATED 
 
 SKIN DISEASES 
 
 AN ATLAS AND TEXT-BOOK 
 
 WITH SPECIAL REFERENCE TO MODERN DIAGNOSIS AND THE MOST APPROVED 
 
 METHODS OF TREATMENT 
 
 BY 
 
 WILLIAM S, GOTTHEIL, M.D. 
 
 VISITING DERMATOLOGIST TO THE CITY HOSPITAL AND TO LEBANON HOSPITAL ] CONSULTING 
 
 DERMATOLOGIST TO BETH-ISRAEL HOSPITAL; FELLOW OF THE N. Y. ACADEMY OF 
 
 MEDICINE; MEMBER OF THE MANHATTAN DERMATOLOGICAL SOCIETY, THE N. Y. 
 
 COUNTY MEDICAL SOCIETY, AND THE AMERICAN MEDICAL ASSOCIATION, 
 
 ETC. ,* ETC. 
 
 SECOND EDITION, REVISED AND ENLARGED 
 
 NEW YORK 
 E. B. TREAT & COMPANY 
 
 241-243 WEST 23D STREET 
 
 1906 
 
I LIBRARY of C0N6HESS 
 Two Copies Received 
 MAR 12 1907 
 
 Copyright Entry 
 
 CLASS O. XXc.No. 
 /IOC, 02- 
 COPY B. 
 
 
 Copyright, 1897, 1902, and 1905, by E. B. Treat & Co. 
 
PREFACE TO SECOND EDITION. 
 
 In the attempt to make a general survey of a branch of medicine so young and 
 so rapidly growing as Dermatology there are difficulties that do not occur in older 
 and more thoroughly explored fields. In cutaneous medicine the description and 
 differentiation of new maladies, and the correlation and grouping of older ones, are 
 still in progress ; and the limitations and boundaries of its various subdivisions are 
 still matters of discussion. Classification, upon whatever basis it may be made, is 
 necessarily imperfect, for both the etiology and the pathology of many dermal mal- 
 adies are still unsettled. Even the nomenclature presents difficulties of its own. In 
 some cases dissimilar diseases are known by similar names, and in others the desig- 
 nations of a single malady are varied and confusing. 
 
 In the following pages the field of dermal disease has been covered only so far 
 as it is necessarily of interest to every practitioner of medicine. The nomenclature 
 employed is that in common use. The classification that is followed is the simple 
 pathological one recommended by Jessner, which seems to be as good as any one at 
 our disposal to-day. Especial stress is laid upon the Symptomatology, Diagnosis, 
 and Treatment of the various diseases, while the less practical considerations of Eti- 
 ology and Pathology are condensed and cursorily considered. Questions that are 
 still matters of dispute in Dermatology have been, as far as possible, avoided. No 
 attempt has been made in the therapeutic sections to mention all the measures and 
 plans of treatment that have been found useful in the various diseases. The stan- 
 dard modern methods, and more especially those that the author has himself found 
 useful, have been recommended. It is^ hoped that the simplified and systematized 
 arrangement of the prescriptions will be found useful. 
 
 Pictorial representation, a recognized aid to the practitioner in every department 
 of medicine, is of preeminent importance in Dermatology. Most of the symptoms 
 are objective and visual, and the diagnosis must generally be made by the eyesight 
 alone. It is difficult to represent in words the manifold impressions and the delicate 
 
 3 
 
4 PREFACE. 
 
 variations that are so readily appreciated through the optic nerve. Many attempts 
 have been made to depict on paper and permanently preserve the evanescent 
 features of dermal disease. Photography and its dependent processes are the most 
 suitable means for that purpose ; for the artist's brush necessarily reflects his own 
 individuality, and his work is influenced by factors so many and various as to make 
 it unsuitable for reproduction in quantity. Colored illustrations have been intro- 
 duced in this atlas in all cases in which they have seemed to be necessary or 
 advisable ; but in the many instances in which color is of no importance for the 
 recognition of disease, illustrations in black and white have been supplied. 
 
 The pictures, both plate and text, have been selected with the view of exhibit- 
 ing, as far as possible, the ordinary phases of skin disease as met with in practice. 
 Most of them are from photographs of his own patients made by the author. Those 
 that are not are credited to the physicians from whom they came. A few are taken 
 from foreign sources. The anatomical illustrations are from photomicrographs. 
 
 In this second edition the section on Cosmetics of the Skin and Hair has been 
 entirely rewritten and very greatly enlarged ; for the author believes that it is the 
 neglect of this field which has permitted it to fall to so large an extent into im- 
 proper and non-medical hands. The number of prescriptions has been considerably 
 increased ; and the various changes which the improvement of our knowledge of 
 the nature, pathology, and treatment of certain dermatoses render necessary have 
 been made. 
 
 The author desires to express his thanks to Drs. T. E. Oertel and William 
 Beurman for assistance in the preparation of the plates, and to Dr. J. F. Aitken for 
 his hearty good will and help in the collection of material. He also desires to thank 
 Professor Elsenberg of Warsaw, Poland, Drs. Salvador Garciadiego of Guadalajara, 
 Mexico, A. H. Ohmann-Dumesnil of St. Louis, A. Ravogli of Cincinnati, Ludwig 
 Weiss, F. B. Carpenter, Robert Abrahams, Henry Roth, and Louis Fischer, of New 
 York City, for the photographs and cases that they have placed at his disposal. 
 
 William S. Gottheil. 
 
 January I, 1902. 
 
CONTENTS. 
 
 PAGE 
 
 Anatomy of the Skin 13 
 
 Physiology of the Skin 29 
 
 Classification 52 
 
 Class I. Functional Disorders.... 54 
 
 Pruritus 54 
 
 Hyperidrosis 56 
 
 Sudamina 60 
 
 Seborrhea 61 
 
 Comedo 65 
 
 Milium 67 
 
 Sebaceous Cyst 68 
 
 Asteatosis 69 
 
 Class II. Non-inflammatory Circu- 
 latory Disturbances 71 
 
 Erythema Simplex 71 
 
 Livedo 73 
 
 Urticaria 75 
 
 Prurigo 79 
 
 Purpura 83 
 
 Class III. Inflammations 86 
 
 Morbilli 86 
 
 Rubeola 87 
 
 Scarlatina 87 
 
 Variola 89 
 
 Vaccinia 90 
 
 Varicella 91 
 
 Lichen Planus 92 
 
 Lichen Ruber 94 
 
 Favus 96 
 
 PAGE 
 
 Class III. Inflammations. — Continued. 
 
 Trichophytosis Capitis 101 
 
 Trichophytosis Barbae 105 
 
 Trichophytosis Corporis 108 
 
 Trichophytosis Cruris no 
 
 Chromophytosis 113 
 
 Scabies 116 
 
 Phtheiriasis Capitis 120 
 
 Phtheiriasis Vestimenti 122 
 
 Phtheiriasis Pubis 1 24 
 
 Eczema 125 
 
 Erythema Multiforme 139 
 
 Herpes 140 
 
 Zoster 142 
 
 Dysidrosis 144 
 
 Pemphigus 145 
 
 Dermatitis Herpetiformis ........ 149 
 
 Impetigo Contagiosa 151 
 
 Dermatitis Exfoliativa 152 
 
 Psoriasis 153 
 
 Dermatitis 159 
 
 Erythema Nodosum 166 
 
 Erysipelas 167 
 
 Chancroid 170 
 
 Furunculosis 173 
 
 Carbunculus 175 
 
 Tuberculosis Cutis 177 
 
 Lupus Vulgaris 177 
 
 Scrofuloderma 181 
 
 Tuberculosis Cutis Verrucosa 184 
 
 Chancre » 187 
 
 Syphiloderma 190 
 
CONTENTS. 
 
 PAGE 
 
 Class III. Inflammations. — Continued. 
 
 Lepra 215 
 
 Mycosis Fungoides 219 
 
 Lupus Erythematosus 221 
 
 Rhinoscleroma 225 
 
 Actinomycosis 227 
 
 Hydradenitis 227 
 
 Acne 228 
 
 Rosacea 233 
 
 Folliculitis ' 236 
 
 Onychia 239 
 
 Onychomycosis 240 
 
 Class IV. Hypertrophies 241 
 
 Ichthyosis 241 
 
 Keratosis Pilaris 243 
 
 Callositas 244 
 
 Clavus 246 
 
 Cornu Cutaneum 247 
 
 Condyloma Acuminata 248 
 
 Verruca 250 
 
 Elephantiasis 251 
 
 Molluscum Contagiosum 254 
 
 Hypertrichosis 256 
 
 Onychauxis 258 
 
 Naevus Pigmentosus 259 
 
 Lentigo 261 
 
 Chloasma 262 
 
 tagf. 
 
 Class V. New Growths 264 
 
 Cicatrix 264 
 
 Keloid 265 
 
 Fibroma 267 
 
 Myxoma 268 
 
 Neuroma 268 
 
 Lipoma 268 
 
 Xanthoma 269 
 
 Sarcoma 270 
 
 Myoma , 272 
 
 Angioma 273 
 
 Lymphangioma 2/6 
 
 Adenoma 276 
 
 Carcinoma 277 
 
 Class VI. Atrophies 286 
 
 Atrophia Cutis 286 
 
 Scleroderma 289 
 
 Sclerema Neonatorum 291 
 
 Albinismus 293 
 
 Vitiligo 293 
 
 Canities 295 
 
 Alopecia 298 
 
 Alopecia Areata 304 
 
 Atrophia Pilorum 307 
 
 Atrophia Unguis 309 
 
 Cosmetics of the Skin and Hair ... 311 
 
LIST OF PLATE ILLUSTRATIONS. 
 
 PLATE Facing page 
 
 I. Diagrammatic Section of the Skin 13 
 
 II. Urticaria Papulosa 75 
 
 III. Lichen Planus 95 
 
 IV. Zoster Pectoralis ; Erythema Multiforme 143 
 
 V. Purpura 83 
 
 VI. Scarlatina 87 
 
 VII. Dermatitis Exfoliativa 153 
 
 VIII. Trichophytosis 109 
 
 IX. Dermatitis Venenata 163 
 
 X. Dermatitis Parenchymatosa , 165 
 
 XL Favus 99 
 
 XII. Variola; Morbilli 91 
 
 XIII. Eczema Acutum 129 
 
 XIV. Pemphigus , 145 
 
 XV. Eczema Impetiginosum 125 
 
 XVI. Eczema Palmae ; Syphiloderma Palmse 133 
 
 XVII. Psoriasis 155 
 
 XVIII. Psoriasis Circinata 157 
 
 XIX. Psoriasis Diffusa 159 
 
 XX. Syphiloderma Ulcerosum ; Cathode-ray Dermatitis 215 
 
 XXL Erysipelas 169 
 
 XXII. Impetigo Contagiosa 151 
 
 XXIII. Chromophytosis 113 
 
 XXIV. Ichthyosis Hystrix 271 
 
 XXV. Lupus Vulgaris 177 
 
 XXVI. Lupus Vulgaris 181 
 
 XXVII. Syphiloderma Papulosum ; Syphiloderma Pustulosum 201 
 
 XXVIII. Syphiloderma Tuberculo-ulcerosum 209 
 
 XXIX. Syphiloderma Papulosum 193 
 
 7 
 
8 LIST OF PLATE ILLUSTRATIONS. 
 
 plate Facingpage 
 
 XXX. Gumma Subcutaneum 211 
 
 XXXI. Rupia Syphilitica 213 
 
 XXXII. Syphiloderma Maculosum; Syphiloderma Gummatosum; Glossitis Syphili- 
 tica ; Syphiloderma Papillosum 205 
 
 XXXIII. Syphilodermata 189 
 
 XXXIV. Naevus Pigmentosus 259 
 
 XXXV. Perifolliculitis Barbae 237 
 
 XXXVI. Ichthyosis ; Keratosis Pilaris 243 
 
 XXXVII. Syphiloderma Papulosum 185 
 
 XXXVIII. Elephantiasis Arabum 253 
 
 XXXIX. Syphiloderma Pustulosum 197 
 
 XL. Vitiligo ; Lymphangioma ; Keloid ; Fibromata 265 
 
 XLI. Acne 229 
 
 XLII. Rosacea 233 
 
 XLI 1 1. Naevus Vasculosus 275 
 
 XLIV. Alopecia Areata ; Alopecia Neurotica ; Alopecia Pityrodes ; Alopecia Totalis 299 
 
 XLV. Alopecia Areata 305 
 
 XLVI. Impetigo 149 
 
 XLVII. Erythema Multiforme 1 39 
 
 XLVIII. Elephantiasis; Sarcoma Pigmentosa ; Sarcoma Cutis; Tuberculosis Cutis 
 
 Verrucosa 269 
 
 XLIX. Leucoderma 293 
 
 i.. Verruca ; Alopecia Areata 251 
 
 LI. Eczema Seborrheicurn 131 
 
 LII. Zoster Sacro-cruralis 143 
 
 LIII. Scrofuloderma ; Lupus Hypertrophicus 179 
 
 LIV. Rhinoscleroma ; Chronic Eczema ; Chromophytosis of Face 225 
 
 LV. Comedo and Acne 65 
 
 LVI. Dermatitis Traumatica 3 Dermatitis Herpetiformis 161 
 
 LVII. Eczema Marginatum IIr 
 
 LVIII. Eczema Seborrhoicum I2 j 
 
 LIX. Psoriasis of the Nails; Onycholysis; Eczema Unguium; Leucony- 
 
 china Striata j,* 
 
 LX. Variola; three forms 8o 
 
LIST OF TEXT ILLUSTRATIONS. 
 
 FIG. 
 I. 
 
 2. 
 3- 
 
 4- 
 
 5- 
 6. 
 
 7- 
 
 8. 
 
 9- 
 
 10. 
 
 ii. 
 
 12. 
 
 13- 
 14. 
 
 16. 
 
 *7- 
 18. 
 19. 
 20. 
 21. 
 22. 
 
 23- 
 24. 
 
 2 5- 
 26. 
 27. 
 28. 
 
 PAGE 
 
 Epidermis, corium, and subcutaneous tissue Author 14 
 
 Arrectores pilorum, hair-sacs, etc , 
 
 Pacinian corpuscles, lymph-spaces, panniculus adiposis, etc 
 
 Pacinian corpuscles, nerve-trunks, etc 
 
 Sebaceous glands 
 
 Sweat-glands and ducts 
 
 Hair and hair-follicle 
 
 Hair-shaft and root 
 
 Transverse section of hair and sac 
 
 Hair from head of female J. F. Babcock . 
 
 Cross-sections of hairs from head " " 
 
 Hair from head of child " " 
 
 Hair from back of hand " " 
 
 Transverse section of third phalanx Toldt . 
 
 Scarificator Author . 
 
 Comedo extractor 
 
 Needle and holder for electrolysis 
 
 Dermal curette 
 
 Grappling forceps 
 
 Epilating forceps 
 
 Spear-shaped spud 
 
 Keyes's cutaneous punch 
 Dental bur 
 
 !7 
 
 18 
 
 *9 
 20 
 21 
 2 3 
 24 
 
 25 
 26 
 26 
 26 
 26 
 27 
 .5° 
 5° 
 5° 
 5° 
 5° 
 5° 
 5i 
 5i 
 5 1 
 5 1 
 5i 
 5 1 
 5i 
 5 1 
 
10 LIST OF TEXT ILLUSTRATIONS. 
 
 fig. PAGE 
 
 29. Seborrhea capitis Author 62 
 
 30. Comedo J. F. Aitken 66 
 
 31. Comedo gigantica Author 67 
 
 32. Sebaceous cyst 69 
 
 2,2,. Urticaria gyrata " 75 
 
 34. Urticaria factitia 76 
 
 35. Urticaria pigmentosa Elsejiberg 77 
 
 36. Prurigo Van Haren-Noman 80 
 
 37. Purpura simplex Author 84 
 
 38. Vaccinia _ " 90 
 
 39. Varicella " 91 
 
 40. Lichen planus " 92 
 
 41. Favus corporis Ehenberg 97 
 
 42. Achorion Schonleinii Joseph 98 
 
 43. Favus capitis J. F. Aitken 99 
 
 44. Hair and root-sheath affected with favus Kaposi 100 
 
 45. Trichophytosis capitis Author 102 
 
 40. 102 
 
 47. Ringworm hair Kaposi 103 
 
 48. Trichophytosis barbae Author 1 06 
 
 49. Trichophytosis corporis " 1 09 
 
 50. Dermatomycosis flexurarum " no 
 
 5 1 . Pityriasis rosea J. F. Aitken in 
 
 52. Trichophytosis cruris Author 112 
 
 53 113 
 
 54. Microsporon furfur Joseph 114 
 
 55. Chromophytosis Author 114 
 
 56. Erythrasma " 1 16 
 
 57. Scabies " 117 
 
 58. Acarus scabiei Kilchenvieister and Ziim, and Neumann 118 
 
 59. Pediculus capitis Author 121 
 
 60. Phtheiriasis vestimenti Van Haren-Noman 122 
 
 6 1 . Pediculus vestimenti Kiichenmeister and Zilrn 123 
 
 62. Pediculus pubis Author 1 24 
 
 63. Embryo— Pediculus pubis " t 24 
 
 64. Eczema papulosum , " 126 
 
 65. Eczema vesiculosum Van Haren-Noman 127 
 
 66. Eczema squamosum Author. . ,128 
 
LIST OF TEXT ILLUSTRATIONS. 11 
 
 FIG. PAGE 
 
 67. Eczema faciei Author 129 
 
 68. Eczema of the hands " 130 
 
 69. Eczema acutum " 131 
 
 70. Eczema crustosum " 134 
 
 71. Herpes febrilis " 141 
 
 72. Zoster patch " 143 
 
 73. Acute pemphigus " 146 
 
 74. Pemphigus vulgaris " 147 
 
 75. Impetigo contagiosa " 151 
 
 76. Psoriasis guttata Ludwig Weiss 154 
 
 77. Psoriasis diffusa Louis Fischer 155 
 
 78. Psoriasis nummularis Van Haren-Noma?i 156 
 
 79. Psoriasis gyrata Author 157 
 
 80. Dermatitis traumatica - " 160 
 
 81. Parenchymatous dermatitis " 161 
 
 82. Parenchymatous dermatitis with ulceration " 161 
 
 83. Dermatitis ambustionis bullosa " 162 
 
 84. Dermatitis venenata " 163 
 
 85. Chancroid " 170 
 
 86. Chancroidal ulceration of labia " 171 
 
 87. Ecthyma " 172 
 
 88. Furunculosis " 173 
 
 89. Carbuncle A. H. Ohmann-Dumesnil 175 
 
 90. Lupus hypertrophicus Lesser 178 
 
 91. Lupus vulgaris " 179 
 
 92. Tuberculosis cutis Author 185 
 
 93. Chancre " 187 
 
 94. Exulcerated chancre " 188 
 
 95. Chancre of the lip " 189 
 
 96. Chancre of the meatus " 190 
 
 97. General macular syphiloderm " 191 
 
 98. General papular syphiloderm " 192 
 
 99. Papular plantar syphiloderm " 193 
 
 100. Condylomata lata " 1 94 
 
 101. Large pustular syphiloderm " 196 
 
 102. General pustular syphiloderm " 197 
 
 103. Tuberculo-squamous syphiloderm " 198 
 
 104. Hypertrophic tubercular syphiloderm Elsenberg 198 
 
12 LIST OF TEXT ILLUSTRATIONS. 
 
 FIG. PAGE 
 
 05. Superficial gummata Elsenberg 199 
 
 06. Exulcerated gumma of the knee Author 199 
 
 07. Gumma subcutanea 2 °° 
 
 08. Ulcerative syphiloderm H. Roth 201 
 
 09. Paronychia syphilitica Author 202 
 
 10. Alopecia syphilitica Lesser 202 
 
 1 1. Multiple gummata Author 204 
 
 1 2. Lepra tuberosa S. Garciadiego 216 
 
 13. Lepra mutilans Joseph 217 
 
 14. Lupus erythematosus R. Abrahams 221 
 
 15. " " " 223 
 
 16. Acne punctata Author 228 
 
 1 7. Acne pustulosa " 229 
 
 1 8. Acne bromata Elsenberg 230 
 
 19. Rhinophyma F. B. Carpetiter 234 
 
 20. Folliculitis barbae Author 237 
 
 2 1 . Folliculitis " 238 
 
 22. Callositas " 245 
 
 23. Cornu cutaneum " 247 
 
 24. Condyloma acuminata " 248 
 
 2 5- 2 49 
 
 26. Elephantiasis vulvae Van Hare7i-Noma7i 253 
 
 27. Molluscum contagiosum Author 255 
 
 28. Onychauxis Va?i JJaren-JVbman 258 
 
 29. Naevus pigmentosus Author 260 
 
 30. Keloid " 266 
 
 3 1 . Sarcoma cutis " 271 
 
 3 2 . Naevus venosus " 274 
 
 t,^. Papillary naevus " 275 
 
 34. Rodent ulcer Ludwig Weiss 278 
 
 35. Epithelioma of the penis Author 279 
 
 36. Papillary epithelioma " 280 
 
 37. Epithelioma of the lip " 281 
 
 38. Fungating epithelioma of the scalp " 282 
 
 39. Striae atrophies A. H. Ohmann-Dumesnil 287 
 
 40. Leucoderma Van Haren-Noman 294 
 
 41. Leucoderma Joseph 295 
 
COPYRIGHT BY E. B, TREAT & CO., N. Y. 
 
 PHOTOGRAVURE AND COLOR CO., N. Y. 
 
 DIAGRAMMATIC SECTION OF THE SKIN 
 
 PLATE I. 
 
ANATOMY OF THE SKIN. 
 
 ever 
 
 present 
 
 i 
 ,wi are :. 
 
 ■ 
 
 . hi 
 
 I 
 
 ■ 
 id. 
 
 ling 1 
 

 ■ 
 
 - 
 
 TION OF THE SI 
 
ANATOMY OF THE SKIN. 
 
 THE skin is an elastic and flexible membrane covering the entire body. Its 
 structure is complex, and varies in different parts. Certain elements are present 
 everywhere, and are essential portions of the organ ; such are the epidermis, the 
 corium, and the subcutaneous connective tissue. Others are found only in certain 
 regions, and are called appendages; as the hairs, the sweat and the sebaceous 
 glands, and the nails. It contains also blood-vessels, lymphatics, and nerve- structures. 
 
 Its appearance varies in different individuals and on different portions of the 
 body. Its texture in places feels smooth and velvety, as on the forehead and on 
 the lumbar regions ; in others, as on the outer surface of the thighs, it is rough and 
 uneven. Its color depends on the amount of blood contained in the surface vessels, 
 and on the pigment deposited in the epidermic layers. This latter varies in the 
 different races, and is always more abundant around the nipples and on the 
 genitalia. It is marked by deep furrows over the various joints, while secondary 
 furrows further subdivide it into minute angular fields. At the junction of the 
 angles of these fields are the pores, minute openings which mark the mouths of the 
 hair-follicles and the sebaceous glands. Distinct ridges, corresponding to the regu- 
 larly arranged papillae of the cutis, are found on the palms and soles. 
 
 The skin is thickest on the back, buttocks, palms, and soles, and thinnest on the 
 eyelids and the prepuce. It is in general more or less movable on the subjacent 
 parts ; but in some places, as over the sternum and on the glans penis, it is more 
 closely attached to the tissues beneath. Its entire surface is covered with hair; 
 with ordinary long hair on the hairy parts, and with the fine down known as lanugo 
 hair on the so-called smooth parts ; only the palms and soles, the dorsal surfaces of 
 the third phalanges of the fingers and toes, the glans penis, and the inner surface of 
 the prepuce being hairless. 
 
 Finally, at the larger openings of the body the skin is directly continuous with 
 the mucous membranes lining the cavities into which they lead. 
 
 We distinguish three layers in the skin : I. The epidermis or scarf-skin, the out- 
 ermost layer; 2. The corium, derma, or true skin, containing the glandular, muscu- 
 
 13 
 
14 
 
 ILLUSTRATED SKIN DISEASES. 
 
 lar, vascular, and nervous structures; 3. The subcutis or subcutaneous connective 
 tissue, containing the fat, the panniculus adiposus. 
 
 We have also to consider the following special structures and appendages: 
 4. The blood-vessels ; 5. The lymphatics ; 6. The muscles ; 7. The nerves, with the 
 Pacinian bodies and the tactile corpuscles; 8. The pigment; 9. The sebaceous 
 glands; 10. The sweat-glands ; 11. The hair; 12. The. nails. 
 
 J. THE EPIDERMIS. 
 
 The epidermis, cuticle, or scarf-skin is composed of layers of stratified epithelium- 
 cells united together by a small amount of cement substance, and contains neither 
 vessels nor nerves. Its upper surface is smooth, save for the markings above 
 
 
 
 ■r*jK ~ '*? 
 
 h-'"' '■:-.■ 
 
 
 It 'v 
 
 1ft 1 r i 
 
 — * 
 
 
 J&rx <r- 
 
 iV •. "t'?B&.- ^* 
 
 Fig. 1. — Epidermis, corium, and subcutaneous tissue: section of skin of negro. 
 Photomicrograph, x 21. From the author's collection. 
 
 mentioned; but its lower surface is studded with club-shaped processes that fit 
 into the interpapillary spaces of the corium. It passes down into the hair-sacs, 
 forming a portion of the root-sheaths, and it is continuous with the lining mem- 
 
ANATOMY OF THE SKIN. 15 
 
 branes of the sweat and sebaceous glands. Its average diameter is from j4 to J^ 
 mm. ; but it varies greatly, being especially thick on the palms and soles, and very 
 thin on the lips and the genitals. It is being constantly desquamated ; and it is 
 regenerated as constantly by the growth of new cells from the deeper strata of its 
 own substance. 
 
 It is composed of three layers, being, from without inward : 
 
 1. The stratum corneum or horny layer. This is the outer protecting layer, 
 and is formed of flattened, dried-out epithelial cells, structureless and without 
 nuclei. The inner layers are somewhat rounder and more succulent, but the outer- 
 most ones are merely dried scales. In the palms and soles the deepest cells of this 
 layer appear brighter than the rest, and have been called the stratum lucidum 
 (Oehl). 
 
 2. The stratum granulosum or nuclear layer. This is composed of from two to 
 five rows of granular refractive epithelial cells, with soft protoplasm and round 
 nuclei. They owe their appearance to the numerous highly refractive granules that 
 they contain, composed of a substance called keratohyalin by Waldeyer, which is 
 of importance in the process of cornification. 
 
 3. The rete Malpighii, rete mucosum, stratum spinosum, or prickle-cell layer, 
 consisting of polygonal ceils joined to one another by fine hair-like protoplasmic 
 processes. The upper rows of cells of this layer are flattened, but the lower ones 
 are cylindrical, and rest upon the papilla; of the corium. 
 
 2. THE CORIUM. 
 
 The corium or true skin is the most important part of the cutaneous organ. It 
 is composed of a dense network of interlaced connective-tissue fibers, together with 
 others of the yellow elastic variety. Comparatively thin in children, in the adult it 
 is 2 mm. or more in diameter ; but it varies much in thickness in different parts of 
 the body. Exposure to the weather or other irritants causes increase of its volume, 
 and in the negro race it is naturally of exceptional thickness. It contains vessels, 
 nerves, lymphatics, and bundles of smooth muscular fibers, and it is penetrated by 
 the hairs and their sheaths, and the ducts of the glands. We distinguish in the 
 corium a papillary and a reticular layer. 
 
 The papillary layer or papillary body is the outer portion of the corium, and 
 lies in contact with the rete Malpighii of the epidermis. Its surface is closely 
 studded with nipple-shaped projections or papillae. Upon these, and dipping down 
 into the spaces between them, lie the cells of the lowest layer of the epidermis. 
 The papillae themselves vary much in shape and size, but their average height is 
 Y% mm. They are most marked on the palms and soles, but most abundant on the 
 genitalia. They contain the blood- and lymph-vessels — the vascular papillae ; and 
 the nerve-structures — the sensory papillae. 
 
l(i ILLUSTRATED SKIN DISEASES. 
 
 The reticular layer lies under the papillary layer, is directly continuous with it, 
 and is distinguishable from it only by the more regular arrangement of the connec- 
 tive-tissue bundles of which it is formed. These are so interlaced as to form rhombic 
 figures, the long axes of which usually run transversely to the axis of the part 
 covered. Curling around the bundles are the yellow elastic fibers. The elasticity 
 of the skin is due to this peculiar arrangement. The lowest fibers of this layer are 
 directly continuous with the connective tissue of the subcutis. 
 
 3. THE SUBCUTIS. 
 
 The subcutaneous tissue lies under the corium, and is composed of connective 
 tissue containing many elastic fibers and forming large loose meshes. Through 
 this there run irregular bands and masses of more condensed connective tissue that 
 unite the subcutis to the fasciae and other underlying tissues; and on the closeness 
 of this connection depends the movability of the skin. Larger and smaller collec- 
 tions of fat-cells are found in the meshes. The subcutis contains also large blood- 
 vessels, lymphatics, nervous structures, sweat-glands, and the lower part of the 
 deeper-seated hair-follicles. 
 
 Where the fat in the meshes of the subcutis is collected in larger amount, the 
 structure is known as the panniculus adiposus. This consists of masses of round or 
 polyhedral fat-cells, closely packed in a connective-tissue network. It is most 
 abundant in the skin of the palms and soles, the buttocks, and the female breast, 
 but is absent in that of the ear and nose, where the skin is thin and fixed, and in 
 that of the scrotum, where it is very muscular and movable. 
 
 4. THE BLOOD-VESSELS. 
 
 The epidermis has no blood-vessels, but in the corium and the subcutis they 
 are very numerous. They form two distinct horizontally placed plexuses, one 
 in the corium just beneath the papillary layer, and the other at the boundary line 
 between corium and subcutis. This latter supplies the hair papillae, the sweat- 
 glands, and the fat masses; the former sends branches to the papillae of the cutis. 
 The veins follow the arteries, and form a similar plexus between the corium and 
 the subcutis. 
 
 5. THE LYMPHATICS. 
 
 True lymphatic vessels are not common in the skin, though some are found in 
 the papillae, and form a plexus at their base. The subcutis also contains some large 
 lymph-vessels. Lymphatic spaces are, however, very numerous indeed; they form 
 a dense network in the corium, especially in the neighborhood of the fat collections 
 and the muscles. These spaces originate in the lower epithelial layers, beginning in 
 the interspinal spaces between the prickle-cells. 
 
ANATOMY OF THE SKIN. 
 
 6. THE MUSCLES. 
 
 The intrinsic muscles of the skin are all of the smooth involuntary kind. There 
 are two varieties of them : 
 
 I. The arrectores pilorum. These are small bundles of smooth muscular fibers 
 running diagonally from the connective tissue of the papillary bodies to the base of 
 
 Fig. 2. — Arrector pilorum, hair-sacs, etc. : section of scalp. 
 Photomicrograph, x 35. Fronvauthor's collection. • - 
 
 the hair-sacs, to which they are attached by elastic threads. Their contraction erects 
 the hair, empties the blood and lymphatic vessels, causes pallor of the skin, and finally 
 expresses the contents of the sebaceous glands. Cilia and vibrissa? have no arrectores. 
 2. Larger masses of smooth muscular fibers arranged in layers are found in 
 certain places, notably in the skin of the scrotum, penis, around the mammilla, and in 
 the eyelid. 
 
 ; ! 7. THE NERVES. 
 
 The skin contains both medullated and non-medullated nerve-fibers. The 
 medullated fibers are branches of the deeper subcutaneous nerves, and go to the 
 
18 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Pacinian bodies, the tactile corpuscles, and the end-bulbs. The non-medullated 
 fibers form a network in the papillary layer, and send up branches which form the 
 subepithelial plexus ; from this there ascends a congeries of minute twigs that end 
 in or among the prickle-cells of the rete. 
 
 The Pacinian bodies or corpuscles of Vater are ellipsoid whitish bodies, 2-4 mm. 
 in size, attached to the nerves like berries on their stems. They are found espe- 
 
 Fk;. 3. — Pacinian corpuscles, lymph-spaces, panniculus adiposus, etc. : section of skin of finger-tip. 
 Photomicrograph, x 21. From the author's collection. 
 
 cially in the subcutis of the palms and soles, fingers and toes. A single medullated 
 nerve enters each one at its lower extremity, looses its sheath, and passes to the center 
 of the body as a naked axis-cylinder. In the upper part of the Pacinian body it ter- 
 minates in an irregular enlargement or in pointed processes. Round this central fiber 
 lies the core, composed of connective-tissue corpuscles ; and around this again is the 
 thick capsular envelop that forms the mass of the Pacinian body. This latter 
 consists of a number of layers of concentric fibers, each one composed of a hya- 
 line elastic ground substance, connective-tissue fibers, and an inner layer of endo- 
 thelial cells. 
 
 The tactile corpuscles, known also as the corpuscles of Meissner or Wagner, are 
 
ANATOMY OF THE SKIN. 
 
 19 
 
 rounded or oval bodies, yV mm. in size, lying in the sensory papillae of the corium. 
 They consist of a mass of connective tissue, round which there winds a medullated nerve ; 
 the axis-cylinder enters the corpuscle and is lost. They are found in the regions where 
 sensation is keenest, and especially in the skin of the last phalanges of the fingers. 
 
 Fig. 4. — Pacinian corpuscles, nerve-trunks, artery, etc. : section of skin of finger-tip. 
 Photomicrograph, x 35. From the author's collection. 
 
 The end-bulbs of Krause are rounded bodies, consisting of a mass of cells 
 in a delicate connective-tissue envelope. The nerve-fiber penetrates the bulb, 
 and ends in one or more clubbed extremities. The end-bulbs are found more 
 especially in the tongue, the lips and gums, the glans penis, and the clitoris. 
 
 8. THE PIGMENT. 
 
 Pigment is found in the adult only in the epidermis, its presence in the corium 
 being always pathological. In the white races it is situated only in the deepest lay- 
 ers of the rete Malpighii ; in the colored races it pervades all the cells up to the 
 granular layer. It consists of granular pigment derived from the blood, and placed 
 chiefly around the nuclei of the cells. It is more abundant in parts that are exposed 
 to the light, in consequence of the action of the ultra-violet chemical rays. 
 
■20 
 
 ILLUSTRATED SKIN DISEASES. 
 
 9. THE SEBACEOUS GLANDS. 
 
 These are small racemose glands, situated in the corium and subcutis, and 
 generally connected with the hairs. From 2 to 6 mm. in size, a number of 
 them are attached "to each hair, into the upper portion of whose sacs their ducts 
 open. They are most abundant where the hair-follicles are most numerous, and 
 they are absent where there are no hairs, as on the palms and soles and the glans 
 penis. They are largest on the nose, scrotum, mons veneris, labia majora, and anus. 
 They appear as appendages of the ordinary coarse hair; but the lanugo hair-sacs are 
 apparently diverticula in the wall of the excretory duct of the sebaceous glands. 
 
 They consist of a framework composed of connective tissue and containing the 
 vessels, nerves, and lymphatics. This is lined with a large nucleated epithelium, 
 which is prolonged into the excretory duct of the gland, being continuous with the 
 
 Fig. j. — Sebaceous glands: section of skin of scalp. 
 
 Photomicrograph, x 35. From the author's collection. 
 
 external root-sheath of the hair, and therefore derived from the rete. Inside this 
 lining membrane lies a mass of fatty epithelium-cells and detritus. 
 
 The sebum is a semi-liquid oleaginous material, destined to lubricate the hairs. 
 
ANATOMY OF THE SKIN. 
 
 21 
 
 It consists of fifty per cent, of fatty matter, olein, cholesterin, etc., together with 
 
 the remnants and detritus of the epithelium-cells. 
 
 Certain special sebaceous glands are not connected with the hairs ; they are : 
 I. The Meibomian glands, large glands situated at the free margin of the lids. 
 
 2. Tyson's glands in the glans penis and prepuce. 3. The sebaceous glands of the 
 
 labia minora. 
 
 10. THE SWEAT-GLANDS. 
 
 The sweat, sudoriparous, or coil glands are simple tubular glands coiled up into a 
 ball, and situated deep in the reticular portion of the corium and in the subcutis 
 
 t^ 
 
 
 - 
 
 7. 
 
 
 ife3=;^ 
 
 -Xm 
 
 
 
 ,-'■ & /: ' 
 
 w&d 
 
 ' 
 
 M 
 
 
 
 &j? . y ■ 
 
 
 
 V£j£l 
 
 O? 
 
 FlG. 6. — Sweat-glands and ducts : section of skin of palm. 
 Photomicrograph, x 42. From the author's collection. 
 
22 ILLUSTRATED SKIN DISEASJ 5. 
 
 They are small, round, yellow bodies }4~3 mm. in size, and are found everywhere 
 save on the glans penis and the margins of the lips. They are most developed and 
 abundant on the palms and soles, being sometimes large enough to be seen with the 
 naked eye, and numbering between two and three thousand to the square inch. 
 They are numerous and large also in the axilla and around the anus. Their total 
 number is estimated at from two to three millions. Each tube, uncoiled, measures 
 about 3 mm. in size. The coils end in excretory ducts that pass straight upward 
 through the corium, and open at funnel-shaped depressions on the surface known 
 as pores. 
 
 Each coiled tube consists of a connective-tissue framework or membrana pro- 
 pria, with some smooth muscular fibers, and lined with a cuboidal epithelium. The 
 excretory duct is also lined with cuboidal epithelium ; it ends at the prickle-cell 
 layer of the epidermis, and thence onward to the surface the duct is a simple cork- 
 screw-like passageway, without special cellular lining. 
 
 The secretion of the coil glands is partly sweat, and partly an oily material that 
 serves to lubricate the skin. An abundant vascular supply surrounds each coil. 
 The sweat itself is a watery fluid that differs somewhat in composition in different 
 individuals and in different parts of the same body. It has a saline taste and an 
 alkaline reaction. It is composed almost entirely of water, containing less than two 
 per cent, of solid matter. This latter is mostly sodium and potassium salts, urea, 
 neutral fats, and cholesterin. 
 
 J J. THE HAIR. 
 
 The hairs are columnar epithelial formations, the lower parts of which are 
 embedded in the corium and subcutis, while the upper portions project upward 
 through the epidermis and above the surface of the skin. They are found all over the 
 body, except on the palms and soles, the vermilion border of the lips, the backs of 
 the distal phalanges, the glans penis and the inner surface of the prepuce, the labia 
 minora and the inner surface of the labia majora. We recognize two varieties : the 
 true hairs, found on the scalp, eyebrows, eyelashes, beard, axillae, genitals, and the 
 anus of the male ; and the lanugo hair, the soft down found on the face, the trunk, 
 etc. ; they differ from one another only in point of size. 
 
 Hairs are generally implanted obliquely in the skin in consequence of the 
 arrangement of the connective-tissue bundles of the corium, in which their roots 
 Ire ; but the hairs of the external auditory and the nasal passages, as well as those 
 of the lips, are implanted straight. In certain races, as the Hottentots, for example, 
 all the hairs have a straight implantation. 
 
 Hairs are both elastic and strong, being capable of greta extension and able to 
 bear heavy weights. They grow to a certain length, which varies with different 
 individuals and is different in different locations, and then stop and fall out; the 
 
ANATOMY OF THE SKIN. 
 
 23 
 
 rate of growth being about half an inch a month. The life of an individual hair 
 is from two to five years ; of an eyelash, one hundred to one hundred and fifty 
 days. Warmth and frequent cutting promote their growth. They are among the 
 most enduring portions of the body, as is shown by the well-preserved hair of many 
 of the mummies. 
 
 Fig. 7. — Hair and hair-follicle: section of skin of scalp. 
 Photomicrograph, x 35. From the author's collection. 
 
 We distinguish as belonging to the hair: i. A shaft, being that portion which 
 projects above the surface of the skin; 2. A root, situated in the corium and the 
 subcutaneous connective tissue, and ending in a knobbed extremity; 3. A follicle, 
 being the involution of the dermic layers in which the hair is placed. 
 
 1. The shaft or scapus is a long and usually straight column, tapering at its free 
 extremity. It consists of a central portion, the medulla or marrow, composed of 
 polyhedral cells containing fat and free pigment granules. It is often absent, 
 especially at the extremities of the hair, and is not found in the lanugo hair. The 
 mass of the hair, however, is made up of the cortical substance, consisting of elon- 
 gated, flattened epithelial cells, arranged with their long axes parallel to the long 
 
24 
 
 ILLUSTRATED SKIN DISEASES. 
 
 axes of the hairs. These cells are more or less fused together, and contain gran- 
 ular pigment. Outside of this is the cuticle, a delicate membrane investing the hair 
 substance and binding its bundles closely together. It consists of flat, cornified 
 epithelial cells without nuclei, overlapping one another like shingles on a roof. 
 
 FlG. 8. — Hair-shaft and root. 
 Photomicrograph, x 240. From the author's collection. 
 
 2. The root or radix is thicker than the shaft, and ends in an expansion known 
 as the hair-bulb. In the bottom of the bulb is a cup-shaped depression which rests 
 upon the papilla at the base of the follicle. In its structure the root is essentially 
 
ANATOMY OF THE SKIN. 
 
 25 
 
 the same as the shaft; but the cortical substance is loose and spongy, and consists 
 of cells closely resembling those of the rete mucosum. 
 
 3. The follicle or hair-sac is a bag-like inversion of the corium. It is cylindri- 
 cal, with a narrow mouth on the surface of the skin, and a larger rounded extremity 
 
 Fig. 9. — Transverse section of hair and sac. 
 Photomicrograph. From the author's collection. 
 
 that lies in the corium or subcutis. It is essentially a continuation of the papillary 
 layer of the corium. A little below the level of the corium is a constriction known 
 as the neck, and here the ducts of the sebaceous glands open into the follicle. The 
 
26 
 
 ILLUSTRATED SKIN DISEASES. 
 
 follicles vary much in size in different localities, but in general they are from 2 to 6 
 mm. in length. They consist of a connective tissue, in which several layers may 
 be recognized. The external layers are similar to the loose connective tissue in 
 which the sac is situated. The outermost layer is hyaline and transparent, and 
 is known as the vitreous follicle-sheath. At the base of the follicle rises the papilla, 
 a small club-shaped projection about fo mm. in size, which fits into the hollow at 
 the bottom of the hair-bulb. It is simply a modified papilla of the corium, and it 
 contains the vessels that nourish the hair, as well as non-medullated nerve-fibers. 
 The growth and regeneration of the hair takes place from the papilla; new elements 
 are formed there which elongate and move up, pushing the hair before them. New 
 hairs grow from the old papillse when the former are pulled out or lost. 
 
 Fig. io. 
 
 Hair from head of female. 
 
 Fig. ii. 
 
 Cross-sections of hairs from head. 
 
 Fig. 12. 
 
 Hair from the head of a child. 
 
 Fig. 13. 
 
 Hair from the back of hand. 
 
 Human hair magnified. (After J. F. Babcock.) 
 
 Between the follicle and the root of the hair are two further coats, known as 
 root-sheaths. The external root-sheath lies next to the vitreous follicle-sheath, and 
 is a continuation of the general rete mucosum, consisting of the same stratified 
 epithelial cells. The internal root-sheath lies inside the preceding, surrounding the 
 root of the hair closely. It consists of cylindrical epithelial cells, and is divided 
 into the sheath of Huxley and the sheath of Henle. 
 
 The pigment of the hair depends on the color of the corneous cells of the corti- 
 cal substance, and on the air the medulla contains. The basis color is blond to red ; 
 pigment in granules and diffused gives the shades from brown to black. Soap, alkalis, 
 and especially the peroxide of hydrogen destroy the pigment; the presence of much 
 air in'the cortical substance renders the hair white. 
 
 The cilia or lashes, the vibrissas of the nostrils, and the hairs of the external 
 
ANATOMY OF THE SKIN. 
 
 27 
 
 auditory passages differ from the ordinary true hairs in their implantation, which is 
 straight, and in the fact that they have no arrector muscles connected with their 
 sebaceous glands. Though they are thick hairs, they remain short. 
 
 12. THE NAILS. 
 
 The nails are epidermoidal structures found on the dorsal surfaces of the distal 
 extremities of the fingers and toes. They form quadrilateral plates, curved slightly 
 in their long diameters, and lying with their convex surface upward. Their anterior 
 portion ends in a sharp border that overhangs the end of the last phalanx ; their 
 posterior extremities and sides are embedded in a fold of skin. Their surface is 
 smooth and glistening, and marked with longitudinal striae. They consist of corni- 
 fied epithelial cells arranged in layers, similar to those of the ordinary epidermis, 
 but fused more firmly together. This epithelium lies upon a corium that possesses 
 certain peculiarities. Larger and smaller air- vesicles in the intercellular spaces and 
 inside the lamellae cause the white spots so frequently observed in the nails. 
 
 Fig. 14. — Transverse section of third phalanx. (After Toldt.) 
 a, nail; i, epithelium of nail-bed; c, nail-bed; d, falx; e, bone of phalanx. 
 
 The nail is divided into two distinct areas by a curved line near its posterior 
 extremity, running parallel to the free border of the nail, and known as the lunula. 
 The anterior area, of a pink color, rests upon the nail-bed, which is a corium cov- 
 ered with a stratified epithelium, and represents the rete. This corium possesses no 
 papillae, but its connective-tissue bundles are arranged in longitudinal bands con- 
 taining the blood-vessels and the nerves. The ridges thus formed fit into corre- 
 sponding depressions in the epithelium of the under surface of the nail itself. The 
 posterior smaller portion is whiter, on account of the many light-refracting transi- 
 tional epithelial cells that it contains. The corium under it is studded with papillae, 
 like those of ordinary skin, and is known as the matrix. The posterior extremity 
 
28 
 
 ILLUSTRATED SKIN DISEASES. 
 
 of the nail is embedded in a fold of the skin, the nail-groove or falx. Here the 
 stratum mucosum of the skin gradually passes into the epithelium of the matrix. 
 At the lunula there is a decreased transparency of the nail, due to the presence of a 
 broad layer of actively proliferating cells. 
 
 The nail grows from the matrix, and its thickness is dependent on the breadth 
 of that structure. The rate of growth is stated by Quain to be about 3 \, of an inch 
 per week. The uppermost layers of the epithelial cells that compose it grow 
 from the portion furthest back, while the lower cells are the product of the more 
 anterior portion. Growth is continuous from behind forward. The nails are nour- 
 ished from the subepithelial plexus of the corium of the bed, matrix, and nail-fold. 
 They grow more rapidly in children than in adults, and in summer than in winter 
 time. Under ordinary circumstances their growth is largely in excess of the wear 
 to which they are subjected ; but there is a limit to it, and they cease to extend 
 after a certain length is attained, ending in a narrowed, bent extremity. In some 
 instances a length is attained of I x / 2 to 2 inches, and the nail is then crooked or 
 curved upon itself. 
 
PHYSIOLOGY OF THE SKIN. 
 
 The skin is an organ of great size and complexity, with functions of vital impor- 
 tance in the body economy ; and any very extensive or permanent interference with 
 them is deleterious to health, and may lead to death. The destruction of any very 
 large portion of its area is fatal. The functions of the skin are varied, and are both 
 general and special. General functions are its actions as a protecting envelop for 
 the various other parts of the body, and its regulation of the body heat. Special 
 functions are its activities as a breathing organ, as a secreting and excreting organ, 
 and as an organ of sense. We shall consider them in their order. 
 
 1. The skin as a protecting organ. The corium is elastic, from the large quantity 
 of yellow elastic connective tissue that it contains, and, with the thick panniculus 
 adiposus, protects the various organs of the body from the effects of external vio- 
 lence. This protection is limited, however, and the skin can be ruptured by external 
 pressure or traumatisms, or by internal distention, as in pregnancy, oedema, or tumors. 
 Such ruptures tend to have a definite configuration, varying in different parts of the 
 skin, and depending upon the general arrangement of the connective-tissue bundles 
 of the corium. The epidermis itself is a bad conductor of heat, and protects the 
 deeper parts in some measure from the effects of heat and cold. It also prevents 
 the too free evaporation of fluids from the body. The cholesterin fats that are 
 formed in the cornifying surface epithelial cells act as a check to progress of micro- 
 bic life on the surface, since they do not, like the glycerin fats, form good culture 
 media for them. 
 
 2. The skin as a regulator of the body heat. The skin performs this function 
 automatically, and by its means the body is enabled to withstand external tempera- 
 tures that may vary rapidly and in fairly wide limits. When the temperature of the 
 environment rises the muscles of the skin relax, the vessels of the papillary plexus 
 become turgid with blood, and the surface becomes hot and red. Increased loss of 
 heat by radiation occurs ; and the congestion of the vessels around the coil glands 
 causes an increased production of sweat, the evaporation of which takes further heat 
 from the skin. When the temperature falls the reverse occurs. The skin muscles 
 
 29 
 
.'JO ILLUSTRATED SKIN DISEASES. 
 
 contract under the influence of the cold, causing by the traction that they exert the 
 erection of the obliquely implanted hairs, and giving rise to the condition known as 
 goose-flesh or cutis anserina. The papillary vessels contract, the surface gets pale 
 and cold, and the loss of heat by radiation and by the evaporation of sweat is 
 reduced to a minimum 
 
 3. The skin as a breathing organ. Respiration in its true sense is a function of 
 the skin, oxygen being taken in and both carbonic acid and water being given off. 
 The proportions of these substances are. however, very different from those of 
 lung respiration. The oxygen absorbed is only y^y of that taken in by the lungs, 
 and the carbonic acid excreted amounts to only one hundred and fifty grains in 
 twenty-four hours; both are comparatively insignificant. But the water given off 
 by the skin is twice as great as that excreted from the lungs, being some twenty 
 ounces daily. It passes off mostly as a vapor of whose presence we are not 
 cognizant, the insensible perspiration ; but under certain conditions its excretion is 
 more rapid, and it accumulates in drops as the sensible perspiration or sweat. 
 Muscular exercise, an external high temperature, the emotions, etc., increase the 
 production of water ; the muscles of the skin relax, the vessels fill up, and the sweat 
 pours out. 
 
 4. The skin as a secreting organ. Both the sweat and the sebum are secretory 
 products of the skin. 
 
 The sweat is a clear, watery, saline fluid. It consists of from 97 to 99 5 per cent, 
 of water, together with a small amount of ammonium chloride, ammonia, organic 
 matters such as creatine, etc., and .04 per cent, of urea. Under certain pathological 
 conditions, as in renal disease, this latter element may be increased so much as to 
 be deposited in the form of crystals on the surface of the integument. The amount 
 of solid matter in the perspiration depends, however, very much upon the amount 
 of water that is ingested, and on the quantity of the secretion that is poured out. 
 It is usually acid in reaction ; but it becomes neutral or even alkaline when produced 
 in large quantities and for long periods of time. 
 
 The sweat is a true secretion and is under direct nervous influence, as is shown 
 by its well-known ready response to mental stimuli. There are special sweat-nerves, 
 some coming from the spinal column, and others from the sympathetic, the centers 
 that control the secretion being found in the cortex, the medulla oblongata, and the 
 ganglia of the anterior cornua. The amount of the sweat varies greatly, and is 
 dependent upon many different conditions ; but its average is one and three quarter 
 pounds daily. It is increased by certain conditions, as decrease in the amount 
 of the watery vapor of the atmosphere, warming of the body, muscular exercise, 
 etc ; by direct nervous influence, as from mental emotions, and in certain nervous 
 diseases; and by certain drugs, as pilocarpine and picrotoxin, which directly stimu- 
 late the sweat-nerves. It is lessened by increase of watery vapor in the air, hinder- 
 ing transudation ; by cooling the skin, causing contraction of the vessels, and dimin- 
 
PHYSIOLOGY OF THE SKIN. 31 
 
 ishing tne arterial supply; by inflammations of the skin, when the sweat-nerves are 
 paralyzed ; and by certain drugs that appear to act in the same way, as atropin 
 and agaricin. 
 
 The sweat is the chief product of the coil glands, but it is not their only one. 
 They secrete in addition an oily material, the presence of which causes the odor the 
 perspiration possesses and the staining of the linen that the sweat occasions. It has an 
 important function in the lubrication of the skin ; for the sebaceous glands are appen- 
 dages to the hair, and their secretion is destined mainly for them ; while portions of 
 the integument that have no hairs, and consequently no sebum, as the palms and 
 soles, are nevertheless well lubricated. This is also shown by the fact that animals 
 that do not sweat have coil glands in their skins. 
 
 The sebum is not a true secretion, for it is the product of epithelial proliferation 
 and fatty degeneration in the sebaceous glands, and, moreover, is not under direct 
 nervous influence. It does not, therefore, vary with external and internal conditions 
 as the sweat does. It consists of fat in granules and drops, of fatt3^-degenerated 
 cells and cell detritus, and of cholesterin crystals. It is evidently designed to lubri- 
 cate the hairs, the glands that produce it being found only in connection with these 
 bodies, and opening by their ducts into the hair-follicles. Its production is contin- 
 uous, the sebaceous matter being gradually expressed by the action of the muscular 
 structures of the skin upon the shaft of the growing hair. 
 
 5. The skin as an excreting organ. Many substances, especially pathological 
 ones and drugs, are extruded from the body with the sweat and the sebum. Urea 
 is partly thus disposed of, especially when in excess, as are also iodine, bromine, 
 etc., when taken internally. 
 
 6. The skin as an absorbent organ. This function of the skin is an extremely 
 important one from a therapeutic point of view, since all endermic medication de- 
 pends upon it ; yet it can hardly be said that the integument is an active organ in 
 this respect. The skin is certainly permeable to gases, and animals have been 
 killed by keeping their bodies immersed in an atmosphere of sulphureted-hydrogen 
 or carbonic-acid gas while their heads were free in the air. But water and watery 
 solutions do not permeate the intact and fatty skin. The common idea that there 
 is absorption of water or medicaments by the skin in the bath is an erroneous one. 
 For the purpose of internal treatment medicated baths are quite useless. There is 
 more water in the body after a bath, it is true; but this is simply because the body 
 loses none of it while immersed. 
 
 When, however, the surface fat of the skin has been to some extent carefully 
 removed beforehand by the use of ether or chloroform, we may succeed in intro- 
 ducing substances in watery solution into the body through the integument. More 
 especially is this the case if the substance is used as a fine spray and for a long 
 period of time. The constant current also enables us to introduce non-volatile sub- 
 stances by cataphoresis into the skin ; this is markedly the case with the alkaloids 
 
iJ2 ILLUSTRATED SKIN DISEASES. 
 
 strychnia, atropia, morphia, and cocaine, and the method may be used for local 
 anaesthesia. In all these cases, however, the substance in question enters the skin 
 through the ducts of the sebaceous glands; the epidermis resists all such attempts. 
 It cannot be employed on the palms and soles, where these glands do not exist. 
 Any break in the skin also permits absorption to be much more active. Under such 
 circumstances many substances, such as salicylic acid, tincture of iodine, iodide of 
 potash, etc., may be introduced into the system and demonstrated in the urine. 
 Even salves and ointments are not absorbed by the unbroken skin, except in so far 
 as they can be introduced into the sebaceous glands. 
 
 7. The skin as an organ of sensation. The skin is the essential organ of ordinary 
 sensation ; but the exact relationship of the tactile organs, the end-bulbs, Pacinian 
 and tactile corpuscles to the various forms of the faculty is not known. It is well 
 proven, however, that the parts most abundantly supplied with them and with 
 nerve- fibers have the greatest sensibility. 
 
 We distinguish in the skin the ordinary tactile or pressure sensibility, the tem- 
 perature sensibility, and the sense of location. These different varieties of sensation 
 have each their special nerves ; for it is certain that the kind of sensation experienced 
 depends, not on the nature of the irritant that causes it, but on the nerve that is 
 irritated. The same influence may cause different sensations in different parts of 
 the body — warmth, cold, pain, or pressure; and after certain injuries to the nerve- 
 centers, one kind of sensation, as that of temperature, may be lost in a part, while 
 another, as that of ordinary touch, may remain. 
 
 The ordinary tactile sensibility and its varieties, itching, tingling, formication, 
 pain, etc., varies much in its acuteness in different parts of the body. Thus pin- 
 points can be felt as double on the finger-tips at a distance of only 2—3 mm., on the 
 back of the hands they must be 6 mm. apart, and on the skin of the back 6 cm. 
 distant from one another. The sense of temperature, by which we distinguish the 
 different degrees of heat and cold, and the sense of location, which enables us to 
 refer a certain sensation to a certain portion of the body, also vary greatly in sharp- 
 ness in different portions of the integument. 
 
 SYMPTOMATOLOGY AND DIAGNOSIS. 
 
 The symptoms of cutaneous disease are of varying origin and occur in manifold 
 combinations. They vary in different individuals and in different stages in the same 
 malady ; they are changed by treatment and obscured by accidental and non-essen- 
 tial appearances. In comparatively few maladies is there a characteristic change, a 
 pathognomonic skin symptom. Nevertheless the dermatologist has the great advan- 
 tage of dealing with an organ that can be seen and felt, and of which, if necessary, 
 microscopical examination can be made during life. 
 
 The patient's family and personal history may throw important light on the 
 
THYSIOLOGV OF THE SKIN. 33 
 
 origin and nature of his malady. So also may the history of the disease : the 
 time that it has been present, as in lupus or syphilis ; the manner of its appear- 
 ance, as in an urticaria or an ecthyma; its mode of progression, as in trichophytosis 
 or epithelioma. But we must beware of placing too much reliance upon history. The 
 patient's statements are erroneous as frequently from ignorance or forgetfulness as 
 from intent. In the venereal maladies more especially the history is not only use- 
 less, but misleading; and here we should avoid direct questioning, and rely rather 
 upon the eruptions, anginas, abortions, etc. I do not hesitate to ssv that the diag- 
 nosis of the syphilodermata is better made without the patient's assistance. 
 
 The symptoms themselves are either subjective or objective. The farmer are of 
 minor importance, and are often absent. They are either general symptoms, as 
 malaise, fever, headache, chills, etc., or special ones, referred to the affected skin. 
 There may be anaesthesia, as in lepra ; hyperaesthesia, as in the inflammatory dis- 
 eases ; or, more commonly, some form of paraesthesia, described by the patient as 
 itching, smarting, tingling, formication, a sensation of heat or cold, a sense of con- 
 striction, or pain in various degrees. 
 
 The objective symptoms are more numerous and important, and upon them the 
 diagnosis must finally be made. They consist of the skin changes which the ex- 
 aminer himself can appreciate. They are known as lesions, and their careful study 
 is essential. And in order that the physician may not be misled, it is well to insist 
 in every case upon an examination of the entire integument of the patient, as well 
 as of the visible mucosae. 
 
 Certain general conditions must first be mentioned. A symmetrical general 
 eruption is usually due to internal causes; an unsymmetrical eruption is often the 
 effect of external and local agents. If the covered parts only are involved, the 
 clothing, or things that it contains, may be the cause of the disease. Excoriations 
 and scratch-marks show the presence of pruritus, no matter what the patient's state- 
 ments may be. Eruptions confined to the face, hands, and genitalia lead us to sus- 
 pect the action of some external contagion, as that of poison-ivy or the itch-insect. 
 
 The lesions themselves may be all of one kind or uniform, as in lichen planus, or 
 they may be multiform, as in scabies. They may be discrete, as in acne, or confluent, 
 as in some forms of variola. There is the greatest variety in their distribution. 
 When there are many lesions over the whole body they usually follow the lines of 
 cleavage of the corium, which O. Simon has so beautifully demonstrated, running in 
 a general way from the spinal column parallel to the ribs, and in definite whorls and 
 curves on the limbs and head. In other cases they follow the course of the nerve- 
 trunks, as in zoster and leprosy. The configuration is also various, and a number 
 of terms are employed to designate it. When the lesions are small and pinhead- 
 sized they are called punctate ; when larger, like drops, they are guttate ; when the 
 size of a coin, nummular; all of which occur in ordinary psoriasis. Again, the 
 lesions may be circular or circinate, as in ringworm, or composed of annular con- 
 
34 ILLUSTRATED SKIN DISEASES. 
 
 centric rings, as in herpes iris, or gyrate, as in some of the syphilodermata. They 
 may be hypertrophic, projecting- above the surface of the skin, and perhaps exul- 
 cerated, as in lupus. Sometimes they are dry, as in eczema squamosum, and some- 
 times, as in eczema madidans, moist and weeping. In some maladies there is a def- 
 inite locality of predilection, as in acne and lupus erythematosus for the face, and 
 in erythema multiforme for the backs of the hands; in others, as in syphilis, the 
 lesions may occur anywhere. Some are symmetrical, appearing on both sides of 
 the trunk, or on both palms and soles; this is especially the case with the syphilo- 
 dermata. Finally, as they vary much in color, sometimes in different stages of the 
 same disease, a word descriptive of the color being often incorporated in the name, as 
 is the case with lichen ruber and scarlatina. Many other qualifying terms are em- 
 ployed, the consideration of which is not required here. 
 
 The lesions found on the skin are either primary or secondary. The primary 
 lesions are : 
 
 1. Macules, fetches (Fr.), Flcckc (Ger.), circumscribed alterations in the color of 
 the skin, without other change. They are usually rounded, but may be irregular in 
 shape. Their color depends on their cause, but is most often red or brown or pur- 
 plish. Some disappear on pressure; others do not. They may be due to: (a) 
 Chemical agents, as in the stains caused by nitrate of silver. They are permanent, 
 and do not disappear on pressure. (/;) Hyperemia, giving bright-red spots if arterial, 
 as in roseola, and a purplish discoloration if venous, as in rosacea. They disappear 
 when pressed upon, (<r) Pigmentary changes, as in vitiligo and chloasma, which are 
 permanent, and are not changed by pressure. If the color is increased the spots show 
 various shades of brown; if decreased they are white, (d) Extravasation of blood 
 or blood coloring-matter into the skin. Macules of this kind are bright red at first, 
 changing to purplish, brown, and yellow as they fade away. When the pigment is 
 deposited in streaks they are called vibices ; if in spots they are called petechia ; 
 while larger accumulations are known as ecchymoses or ecchymomata. (c) Perma- 
 nent dilatation of the cutaneous vessels or the formation of new ones. Capillary 
 naevi and telangiectases come under this heading. They are reddish or bluish, 
 according to the variety of vessel chiefly involved, and do not disappear under pres- 
 sure. The diffuse pigmentations of the skin which occur in Addison's disease, 
 argyria, etc., do not belong to this category. 
 
 2. Papules, papules (Fr.), Knotschen (Ger.), circumscribed projections from 
 pinhead to pea size, containing no visible fluid. They are frequently aggregated in 
 groups, as in syphilis. They may be seated in the corium or around the sebaceous 
 glands or the hair- follicles. Their shape may be acuminate, rounded, flat-topped, 
 or umbjlicated. Their color varies, being sometimes pale white or rosy, and at 
 others violaceous or even blackish. They may remain papules throughout their 
 existence, as in lichen planus; or they may become vesicles or pustules, as in variola ; 
 or they may break down into ulcers, as in syphilis, or become enlarged into tuber- 
 
PHYSIOLOGY OF THE SKIN. 35 
 
 cles, as in the same disease. They may itch severely, as in papular eczema, or they 
 may cause no subjective symptoms at all, as in acne. They are due to : (a) cir- 
 cumscribed plastic exudations in the skin (papular eczema) ; {b) collections of sebum 
 in the glands (milium) ; (c) accumulations of epidermic scales around the hair-shafts, 
 as in keratosis pilaris; (d) blood accumulations, as in purpura papulosa; (e) hyper- 
 trophy of normal structures, as of the dermic papillae in warts; (f) circumscribed 
 collections of new cells, as in lupus. They disappear finally by absorption, and often 
 leave a macular stain behind. 
 
 3. Tubercles, tubercules (Fr.), Kiiotcn (Ger.), are circumscribed projections of from 
 pea to cherry size, containing no visible fluid. They may be considered as enlarged 
 papules, but differ from the latter in being seated in the deeper corium and sub- 
 cutis. They project to varying degrees above the surface, the greater part of their 
 mass being often embedded in the skin. Their size and shape are very various ; they 
 may be attached to the skin by a broad base, or be pedunculated. They are caused 
 by: (a) circumscribed collections of new cells, as in lepra and cancer; (b) circum- 
 scribed hypertrophy of a portion of the corium, as in fibroma molluscum. They 
 end by absorption, or by breaking down and ulceration, and usually leave scars 
 behind. 
 
 4. Tumors, tinueurs (Fr.), GescJiwiilste, Knollen (Ger.), are masses of walnut size 
 or over, situated in or under the skin. There is no limit to their size, and their shape 
 and color are very variable. They may be fixed or movable, or they may be pedun- 
 culated. Often they project above the surface, as in fibroma ; but sometimes, as 
 in erythema nodosum, they are deep-seated. They are caused by : (ci) hypertrophy 
 of existing elements of the skin and subcutis, as in warts and fatty tumors ; (b) collec- 
 tions of new cells, as in epithelioma. They may remain stationary for long periods, 
 or break down and ulcerate. 
 
 5. Vesicles, ve'sicules (Fr.), Blaschen (Ger.), are circumscribed elevations of the 
 corneous layer of the epidermis containing a clear fluid, and from pinhead to pea- 
 sized. They may be rounded or acuminate, as in vesicular eczema, or umbilicated, 
 as in variola. They originate in the deeper layers of the epidermis. They may be 
 simple chambers, as in sudamina, or divided into compartments, as in varicella. 
 They are usually short-lived, rupturing and spilling their contents on the surface of 
 the skin ; but these latter may dry up or be absorbed. Again, they may go on to 
 form pustules. They often occur in groups, as in zoster and herpes febrilis ; but 
 they may be scattered over the body, as in varicella. They are generally accom- 
 panied by burning or itching. 
 
 6. Bullae or blebs, bulks (Fr.), Blasen (Ger.), are irregular elevations of the 
 epidermis varying in size from that of a large pea to that of an egg, and containing 
 clear serum, sero-pus, pus, or blood. They are formed, like the vesicles, in the 
 deeper layers of the rete. They vary much in size, large and small ones being 
 usually found together, as in pemphigus ; the smaller bullae are rounded or oval, 
 
36 ILLUSTRATED SKIN DISEASES. 
 
 while the larger ones, often formed by the coalescence of several blebs, are irregular 
 in shape. They are single-chambered, with strong walls that do not easily rupture ; 
 their contents usually dry up, and they end by desiccation. There is no tendency 
 to grouping, as with the vesicles. They occasionally occur in many of the acute 
 inflammations of the skin, as urticaria and eczema; but they are commonest in 
 pemphigus, herpes iris, erysipelas, scalds, and burns. 
 
 7. Pustules, pustules (Fr.), Pusteln (Ger.), are circumscribed elevations of the 
 epidermis containing pus, and varying in size from a pin-point to a filbert. They 
 are really cutaneous abscesses, and always contain pus-cocci. They may originate 
 as such; but usually, as in eczema, variola, etc., they begin as papules or vesicles. 
 Their color is yellowish white, occasionally being darker or reddish when blood is 
 mingled with their purulent contents. Being inflammatory products, they are 
 always surrounded by a more or less extensive red areola of inflamed skin. Their 
 shape may be acuminated or round, as in acne, or umbilicated, as in variola, or 
 flattened and irregular, as in ecthyma. They usually rupture, their contents form- 
 ing thick yellowish-brown or greenish crusts ; but they may also end by desiccation. 
 Pain and tenderness are marked symptoms when the pustules are deep-seated. 
 They may be superficial, as in impetigo, or the process may extend to the corium, as in 
 ecthyma, or they may occur around the sebaceous glands, as in acne, or in connec- 
 tion with the hair-follicles, as in sycosis. They are of common occurrence also in 
 syphilis, scabies, and many dermatites. If the corium is involved they leave scars 
 behind. 
 
 8. Wheals, plaques ortiees (Fr.), Quaddeln (Ger.), are flat elevations of the integ- 
 ument, from pinhead- to egg-sized, caused by a circumscribed oedema of the skin. 
 They are due to a sudden outpouring of a thin serum from the papillary vessels, 
 with subsequent vascular spasm ; when this latter relaxes the effused fluid is rapidly 
 taken up again. The lesions are therefore very fugacious. Sometimes discrete, 
 they usually coalesce into irregular plaques, as is seen in ordinary urticaria. Their 
 color is reddish or whitish, dependent on the degree of vascular spasm, with a pink 
 areola ; occasionally they are purplish in color, as in some forms of purpura. Some- 
 times they are followed by discoloration of the skin, as in urticaria pigmentosa. The 
 itching is intense and is a most marked subjective symptom ; occasionally there is 
 burning or tingling. 
 
 Secondary lesions occur in consequence of the existence of primary ones, or from 
 other causes. They are : 
 
 1. Excoriations or abrasions, excoriations (Fr.), HaiitabscJmrfungen (Ger.), losses 
 of tissue of the skin due to mechanical causes. They vary much in size, shape, and 
 extent. They occur most commonly in the itchy diseases, and are caused by the 
 finger-nails. They are generally superficial lesions, the corneous layer of the epi- 
 dermis only being removed and the mucous layer exposed. A thin serum is exuded, 
 which dries up into brownish crusts ; and after these fall off a temporary discolora- 
 
PHYSIOLOGY OF THE SKIN. '6l 
 
 tion of the skin is left. In rare cases the deeper layers of the epidermis or the corium 
 itself is involved, and scars result. Excoriations usually occur in lines and streaks, 
 which are studded with the minute bleeding points of the denuded dermic papillae. 
 They are most commonly found in eczema, scabies, phtheiriasis, pruritus, etc. 
 
 2. Scales, squdmes (Fr.), Schuppen (Ger.), are dry, laminated masses of epithelium, 
 separated from the tissues below and sometimes mixed with sebum. Their size, 
 shape, and quantity are very variable. They are usually dry, harsh, and brittle 
 (eczema squamosum), their color is whitish or grayish, and they are often shiny. 
 They may occur in large silvery lamellae (psoriasis), or in smaller plates (pityriasis), 
 or as minute bran-like flakes (seborrhea). They are very common in the inflamma- 
 tory diseases of the skin (scarlatina, erysipelas, eczema, etc.). The hyperemia and 
 inflammation of the papillary layer cause an excessive production of epidermic cells, 
 in which the normal process of cornification is replaced by a simple desiccation. 
 They often occur with other lesions, as on the tops of papules and tubercles. 
 
 3. Crusts or scabs, croutes (Fr.), Borken, Krusten (Ger.), are masses composed of 
 dried exudation, or sometimes of a fungous growth. They vary much in size and 
 shape, and may be adherent or loose. They are caused by : (a) Inflammatory 
 exudations. If these be serum they are yellow and friable, as in eczema ; if it be pus 
 they are darker and thicker (ecthyma) ; if mixed with blood they are reddish or 
 blackish (pruritus), (b) Secretions, especially sebum, giving yellow, flat, adherent, 
 and greasy crusts (seborrhea), (c) Fungi, causing yellowish or grayish crusts of 
 varying shape (favus). The crusts of syphilis are dark brown or greenish in color, 
 have a heaped-up, oyster-shell-like appearance, and are known as rupia. 
 
 4. Fissures, fissures (Fr.), Rhagaden, HautscJirilndc (Ger.), are linear solutions of 
 continuity of the skin. They usually involve only the derma, but occasionally they 
 may extend into the corium. They may be dry or secreting or crusted. They 
 occur as the result of motion in parts of the skin that have lost their elasticity, and 
 more especially in the inflammatory diseases (eczema, syphilis, dermatitis). They 
 are oftenest seen about the joints, upon the palms and soles, and around the mouth 
 and anus. They are frequently very painful. 
 
 5. Ulcers, ulceres (Fr.), Geschwiire (Ger.), are losses of substance of the skin in- 
 volving the corium and caused by disease. They occur in a variety of maladies, as 
 dermatitis, syphilis, lupus, leprosy, epithelioma, etc. They may be single or multi- 
 ple, large or small, and rounded, kidney-shaped, or irregular; their edges may be 
 sloping or undermined ; their bases may be dry or moist and covered with healthy 
 granulations, or they may consist of necrotic tissue bathed in a foul discharge. These 
 points are characteristic in the ulcers of many of the above maladies, and are of 
 essential aid in their diagnosis. Ulcers are especially common on the lower extrem- 
 ities on account of the frequency and persistence of dermatitis in that locality. They 
 are sometimes entirely insensitive, but they may be very painful and tender. They 
 frequently last for long periods of time, and they always leave a scar. 
 
38 ll.l.l STkATKD SKIN DISEASES. 
 
 6. Cicatrices or scars, cicatrices (Fr.), Narben (Ger.), are connective-tissue new 
 formations replacing dermal losses of substance in which the corium has been de- 
 stroyed. From this latter condition it follows that papillae, hairs, and glands are 
 absent in scars, though vessels and nerves remain, and the surface epithelium is 
 present. They are of all sizes, shapes, and thicknesses ; they are raised or depressed, 
 smooth or puckered. They are often very characteristic lesions, and they frequently 
 enable us to diagnose the nature of past disease. The new connective tissue shrinks 
 in the course of time, and the scar, at first soft and red, becomes harder, whiter, 
 and glistening, and frequently causes deformity by the traction that it exerts on 
 neighboring parts (ectropion). These changes are due in part to the gradual ex- 
 pression of the blood by the contraction of the new growth, and in part to the de- 
 struction of the mucous layer of the epidermis. Loss of tissue leading to scarring 
 occurs in : {a) Ulceration ; this is the commonest cause, and is seen in many diseases 
 (dermatitis, syphilis, wounds, burns), (b) Interstitial absorption, when the derma is 
 infiltrated with new cells, and the normal elements are destroyed and absorbed, to 
 be replaced by connective tissue (lupus, morphaea). (c) Pressure, causing absorp- 
 tion and new connective-tissue formation ; this may be from within, as is seen in 
 the lineae albicantes caused by distention (pregnancy, tumors), or from without, as 
 by a parasitic growth (favus). There are usually no subjective symptoms, though 
 scars are sometimes painful. 
 
 7. Stains. These occur commonly after the various inflammatory diseases, and 
 are caused by the blood coloring-matter that has escaped during the process. In 
 many of them the redness is not marked, and passes off in a short time, as in erythema 
 multiforme, psoriasis, etc. ; but in others it is darker and more persistent, as in 
 syphilis and lichen planus. 
 
 GENERAL ETIOLOGY. 
 
 The causes of cutaneous diseases are very numerous, and only a cursory review 
 of them can be given here. Many conditions, external and internal, may cause 
 deviation from the normal. We may broadly divide skin diseases into those that 
 are essentially symptomatic (scarlatina, measles), and those that are idiopathic and 
 proper to the organ itself (keloid, verruca). 
 
 Climate has a slight influence, some diseases occurring chiefly in tropical climates 
 (leprosy, elephantiasis Arabum) ; season has more. Some maladies occur chiefly in 
 hot weather (lichen tropicus, lentigo) ; others appear in spring and autumn (erythema 
 multiforme, psoriasis) ; others, again, are worse in winter (eczema and other inflam- 
 matory diseases). Occupation has a well-marked effect, as is shown by the "mortar 
 eczemas " on the hands of masons, the callosities on the palms of laborers, and the 
 dermatites of those employed in chemical factories and dye-works. Clothing, if of 
 flannel, may excite pruritus, and the dyestuffs in it frequently set up eczemas. 
 
PHYSIOLOGY OF THE SKIN. 39 
 
 Uncleanliness, strange to say, does not appear to be of much importance as an 
 etiological factor in the production of skin disease, save in so far as it favors the 
 persistence of the parasitic diseases (phtheiriasis, scabies, etc.), while the too frequent 
 use of water and soap is of marked influence in keeping up catarrhal inflammation 
 of the skin. 
 
 Food is a factor of undoubted importance. It acts directly as an irritant if im- 
 proper in quantity or quality, and indirectly by lowering nutrition, depressing cell 
 vitality, and laying the tissues of the skin open to attack. Shell- fish, strawberries, 
 etc., frequently cause urticarias, and in some individuals furunculosis is brought on 
 by the ingestion of cheese. Drugs cause various eruptions, especially erythemas 
 and urticarias ; iodine and bromine cause special forms of skin disease. Locally em- 
 ployed, many medicinal substances, such as croton-oil, arnica, mustard, cause derma- 
 tites. Contagion is responsible for many maladies of the integument, as is the case with 
 animal and vegetable parasites in the exanthemata, syphilis, and malignant pustule. 
 
 Race influences skin eruptions also. Negroes are prone to have keloid and 
 leucoderma, and Jews are more frequently the victims of sarcoma cutis than others. 
 Heredity is not so important a factor as is usually supposed, most of the instances 
 that are cited being due to accident. The anatomical peculiarities of sex render 
 males subject to sycosis barbae, while females alone suffer from Paget's disease. 
 Apart from these, however, males have epithelioma oftener than females, while the 
 reverse is the case with lupus erythematosus. 
 
 Age is a factor also. Children have trichophytosis capitis and impetigo conta- 
 giosa; ichthyosis generally shows itself by the end of the first year, and lupus vul- 
 garis begins in early life. On the other hand, all the parasitic vegetable diseases are 
 rare after the age of fifty, a time of life when carcinoma most commonly appears. 
 At puberty the development of the glandular and hairy systems causes the es- 
 pecial prevalence of certain cutaneous affections (comedo, seborrhea, acne vulgaris, 
 which latter gets worse in women at the menstrual epoch). Chloasma and hydroa 
 occur with especial frequency during pregnancy. 
 
 Certain internal diseases have a marked effect on the cutaneous envelop. Diges- 
 tive disturbances cause urticaria, rosacea, acne, and pruritus ; catarrhal jaundice and 
 disease of the liver are often accompanied by pruritus and xanthoma ; and boils, 
 carbuncle, and gangrene are frequently seen in Blight's disease and diabetes. 
 
 GENERAL THERAPEUTICS. 
 
 The rules of general therapeusis hold good in the maladies of the skin, and we 
 need be no more afraid of curing a skin lesion too quickly, of " driving the disease 
 in," than we are of stopping the inflammation in a joint or checking a gastro-enteri- 
 tis too precipitately. The quickest cure with the least possible discomfort insures 
 the most permanent result with the smallest amount of damage. The ideal thera- 
 
40 ILLUSTRATED SKIN DISEASES. 
 
 peusis is of course the causative one ; but our present knowledge permits of its ap- 
 plication in only a minority of cases. We are of necessity compelled to rely largely 
 upon symptomatic treatment. Prophylaxis is as important here as elsewhere, and 
 we are constantly called upon to protect the skin from chemical, mechanical, and 
 microbic injuries. 
 
 The intimate relationship between the integument and the system at large, and 
 the frequent interdependence of morbid changes in the skin with those of internal 
 organs, render it clear that a practical acquaintance with general medicine is an 
 essential element in the successful treatment of diseases of the skin. Any attempt 
 to separate the cutaneous envelop, pathologically or therapeutically, from the rest 
 of the system, is foredoomed to the failure that awaits incomplete knowledge and 
 empirical treatment. Hence treatment should be in most cases both constitutional 
 and local ; and, whatever our opinions may be as to their relative importance in in- 
 dividual diseases, neither can be neglected without detriment to the other. A well- 
 balanced combination of both, based on a careful diagnosis both of the local skin 
 lesions and of the underlying and concomitant body conditions, will give the best 
 results. 
 
 Almost all the drugs of the pharmacopoeia have been employed at one time or 
 another in dermato-therapeutics, but the vast majority of them have been rightly 
 abandoned. Recent years have seen many new remedies recommended, mostly the 
 synthetic products of the laboratory. Of these also most have not withstood the 
 test of time, but some valuable ones remain. New methods have been developed 
 which have largely replaced the older ones, and for these we are indebted most 
 largely and in the first place to Unna. But excessive richness of resource does not 
 always mean greatest usefulness; and he who employs but a comparatively small 
 number of methods and remedies will frequently be most successful in their use. 
 
 GENERAL METHODS. 
 
 These must necessarily depend very largely upon the general health and constitu- 
 tional peculiarities of the patient. The appropriate treatment for each diseased con- 
 dition of the internal organs must be employed, but their consideration belongs to 
 the domain of general medicine. 
 
 General hygiene is naturally of the greatest importance, for the nutrition of the 
 skin is improved in the same way as is that of the internal organs. Washing and 
 bathing are primary requisites; they stimulate the circulation of the skin, and re- 
 move parasites and detritus. Exercise and change of climate are efficient aids to 
 our efforts. Tonics — iron, cod-liver oil, quinine, and the simple bitters — must be 
 used on general principles. 
 
 Diet must not be neglected. Diseased conditions of the skin sympathize more 
 closely than most others with gastro-intestinal disturbances, as I have shown above, 
 
PHYSIOLOGY OF THE SKIN. 41 
 
 and much of our success or failure in their treatment will depend on attention to 
 the food. It should be nutritious and bland; and condiments, salted and spiced 
 foods, etc., should generally be avoided as indigestible. When there is abnormal 
 action or disease of the alimentary tract the diet must be varied in accordance with 
 the indications. Ales, wines, and liquors are in general bad ; but they may be used 
 sparingly in those with weak digestions and in the old. A complete change of diet 
 is often of great importance, especially in chronic eczema and psoriasis ; and I have 
 sometimes found the latter disease rebellious in spite of all manner of treatment, 
 until the patient was put on an absolute milk diet. 
 
 Defective cutaneous action, as occurs in the inflammations, can frequently be 
 aided by stimulating the kidneys by diuretics ; the acetate and citrate of potash, with 
 buchu, digitalis, etc., may be frequently administered with benefit. 
 
 Purgatives, saline and other, are of especial value in acne, pruritus, and urticaria, 
 which are so frequently dependent on digestive disturbances. In almost every case 
 of skin disease the regulation of the bowels is a necessity. 
 
 Water is useful to cleanse the skin from foreign matter, living organisms, scales, 
 and crusts. It is an irritant, and must be employed with caution in conditions of 
 acute inflammation ; but it is often useful therapeutically in the chronic forms (chronic 
 eczema, pruritus, psoriasis). It is employed as a general bath or as a lotion. 
 
 Medicated baths : (a) Alkaline, usually of bicarbonate of soda or borax in the 
 proportion of I to 200, are useful to remove crusts and scales, and in some subacute 
 inflammations, {b) Sulphur baths, prepared by adding two to four ounces of sul- 
 phide of potassium or an equal quantity of Vleminckx's solution (No. I, p. 43) to 
 the water (scabies, etc.). (c) Starch and bran baths of varying strengths are useful 
 in urticaria and other itchy eruptions. 
 
 Lotions are often very efficient means of medicating the skin. They are : (a) 
 Sedative, when opium, belladonna, glycerin, carbolic acid, boric acid, lead, etc., are 
 added, and are useful in chronic inflammations (seborrheal eczema, acne vulgaris, 
 rosacea) or as an antipruritic (pruritus, urticaria), (b) Stimulating, with alcohol, 
 corrosive sublimate, tar, and various acids and alkalis (chronic eczema, etc.). {c) 
 Astringent, when prepared with tannin and lead (hyperidrosis). 
 
 Glycerin does not penetrate the skin and therefore should not be employed 
 where more than a superficial effect is required. It is irritant when pure, even 
 when free from formic and butyric acids ; but when diluted with water it is rather 
 sedative. With starch glycerin forms a series of pasty semisolids known as glycer- 
 ols ; their action is mainly protective. Perhaps the commonest is the glycerol of 
 lead. 
 
 Alcohol, ether, and chloroform, when applied pure, take water and fat from the 
 skin, and render it dry and scaly. Their use thus promotes the absorption of watery 
 fluids and fats. Ethereal solutions of drugs, employed as sprays, are useful, cheap, 
 and often very effective. 
 
4l> illustrated skin diseases. 
 
 Kerosene and benzin are employed to destroy vermin. They must be used with 
 caution on account of their inflammability. 
 
 Oils are either bland, as olive-oil, sweet-almond oil, castor- and cod-liver oils, 
 or stimulating, as the oils derived from tar, the oils of cade, birch, juniper, etc. 
 They are employed to soften crusts and facilitate their removal, to protect inflamed 
 dermal surfaces, and to replace the natural fatty matters of the skin and hair. For 
 the first purpose olive-oil and oil of sweet almonds are the best (pityriasis rubra, 
 pustular eczema, psoriasis) ; linseed-oil is the favorite for protective purposes (burns) ; 
 cod-liver oil is employed externally and internally in the tubercular skin diseases 
 with excellent effect ; and castor-oil is frequently added in the proportion of i to 
 10 per cent, to various spirituous lotions. The oils also enter into the composition 
 of many of the ointments. 
 
 Fats are employed to soften crusts, to replace the natural fatty matters, and as 
 bases for ointments. Some are waxy and hard; others, containing more olein, are 
 soft and butter-like. The chief varieties are: (a) Adeps suillis, or lard, best em- 
 ployed, with the addition of 4 per cent, of benzoic acid to prevent decomposition, as 
 benzoated lard. This is a glycerin fat, and has been the one in common use; but 
 it is fast being displaced by (b) adeps lanae (lanolin), a cholesterin fat extracted 
 from lamb's- wool. This is sterile and does not become rancid ; it enters the skin 
 more readily than do the ordinary glycerin fats, and, most important of all, it is 
 readily miscible with water. Being very tenacious, it requires the addition of a 
 small quantity of olive-oil or glycerin. It is undoubtedly the best general ointment 
 basis that we possess, more especially in cases where deep penetration into the skin 
 is required (ringworm, psoriasis, syphilis inunctions), (c) Suet, used chiefly in the 
 preparation of Unna's salve- muslins, {d) Marrow fat, employed for pomades and 
 cosmetics. Cocoa-butter, spermaceti, white wax, and paraffin are also used. 
 
 Vaseline and cosmoline are not fats, but petroleum products. They have been 
 extensively used as ointment bases, and are valuable when applications are to be 
 made to the hairy parts, where lard or adeps lanae are too glutinous. They irritate 
 the skin, however, and Shoemaker has shown that their penetrating power is far in- 
 ferior to that of the other bases. 
 
 Ointments are the oldest, commonest, and in most cases still the best form in 
 which to apply local remedies to the integument. They are made of the various 
 fats above mentioned, mixed with different medicinal substances. They are : (a) Seda- 
 tive, protecting inflamed parts from the air, moisture, etc. (acute eczema, derma- 
 titis) ; cold cream and simple ointment are examples, (b) Astringent, containing 
 zi:ic oxide, lead acetate or oleate, boracic acid (subacute eczema, etc.) (c) Antiseptic, 
 with iodoform, salicylic, boracic, or carbolic acids or ammoniated mercury. These 
 are employed in the pustular skin diseases (impetigo contagiosa, eczema pustulosum). 
 (</) Stimulating, and containing tar, oil of cade, carbolic acid, naphthol, chrysarobin, 
 pyrogallol, salicylic acid, sulphur, mercury salts, etc. (chronic inflammations, psoria- 
 
PHYSIOLOGY OF THE SKIN. 43 
 
 sis, lichen planus, prurigo). In all cases they have a deeper and more permanent 
 effect when spread upon muslin and bound on the part than when they are simply 
 rubbed in. 
 
 Pastes are very efficient applications, being practically salves made stiffer by the 
 addition of various powders ; they may often be substituted for these latter with ad- 
 vantage. They form better protectives, since they adhere more closely to the skin 
 and exercise some pressure upon it. They soon -dry, and their porosity permits the 
 free escape of the dermal secretions. Lassar has given us the formula for one of 
 the first ones, which is known by his name, and is one of the commonest and most 
 useful (No. 2, p. 43). The gum arabic paste of Unna is also widely employed (No. 3, 
 p. 43). Various substances may be incorporated with these pastes, the special for- 
 mulas for which will be given when we consider the treatment of the diseases in 
 which they are used. 
 
 No. J, Vleminckx 's Solution. No. 2. Lassar 's Paste. 
 
 ft Calcis ..... 1 part ft Acid, salicyl. ... 1 part 
 
 Sulphur, sublim. ... 2 parts Zinci oxidi 
 
 Aq. dest. . . . 20 " Amyli .... aa. 12 parts 
 
 Coque ad fvi ; deinde filtra. Adip. lanse ... 24 " 
 
 No. 3. Gum Arabic Paste. No. 4. Glyco-gelatin. 
 
 ft Mucilag. gum. acac. R Zinci oxidi ... 40 parts 
 
 Glycerini . . . aa. 20 parts Gelat. alb. 
 
 Pulv. (zinci oxidi or ac. Glycerini . . . aa. 25 " 
 
 salicyl.) ... 40 " Aq. dest. . . . no " 
 
 No. 5. Hebrals Green Soap Tincture. 
 
 R Sapon. virid. .... 8 parts 
 
 Spirit, vini rect. . . . . 4 " 
 
 Solve, filtra, et adde 
 
 Spirit, lavandulas . 1 part 
 
 Plasters are employed where a continuous and deep-seated action is required. 
 Lead-plaster, being less irritating than that made with resin, is to be preferred for 
 use on the skin. By this means the various drugs can be applied to the skin. Bet- 
 ter, however, and more extensively used, are certain recent modifications. These 
 are : [a) Salve-muslins, which we owe to Unna, and which are ointments already 
 spread upon unbleached muslin. They are made by drawing the muslin through 
 the liquid ointment mass, and, being non-adhesive and coated on both sides, they 
 need the protection and support of an external bandage. They are comfortable, 
 elegant, and very adaptable. All the ordinary ointments can be procured in this 
 form, those most commonly employed being the zinc, salicylic acid, diachylon, and 
 
44 ILLUSTRATED SKIN DISEASES. 
 
 mercurial muslins. Still more desirable than these are the two following prepara- 
 tions, devised respectively by Unna and H. von' Hebra. (&) Plaster-muslins, which 
 are ointments on an impermeable gutta-percha base, and spread only on one side. 
 As they all contain the oleate of alum they are adhesive of themselves, and hence 
 require no external dressing for protection and support. Arsenious, boric, and car- 
 bolic acids, chrysarobin, pyrogallol, iodoform, and all the other drugs that are em- 
 ployed in dermato-therapeutics are now prepared in this form, which is very con- 
 venient and cleanly. It is a specially desirable mode of application where a deep- 
 seated action is required, or when a complicated area, as the lobe of the ear, is to 
 be treated, (c) Collemplastra, made of rubber and adeps lanas with the admixture 
 of various drugs, and spread on muslin, are as convenient as the plaster-muslins, 
 and are much employed. 
 
 The glyco-gelatins are important preparations that we owe to Pick and Unna. 
 They dry up into protecting skins, and, with varying proportions of tar, resorcin, 
 sulphur, chrysarobin, and other drugs, are extremely valuable in the localized der- 
 matoses (dermatitis, eczema, pruritus). Dabbing the surface with absorbent cotton 
 and applying a bandage before the gelatin has hardened increases their thickness 
 and protecting power. They hinder scratching, keep away external irritants, and 
 sustain the parts. Unna's formula (No. 4, p. 43) is good, but the proportion of the 
 various ingredients must be varied with the season of the year and the amount of 
 other fluid or solid ingredients that are added. 
 
 Traumaticin, a 10-per-cent. solution of gutta-percha in chloroform, and flexible 
 collodion are occasionally employed in circumscribed dermatoses. Chrysarobin, 
 iodoform, zinc oxide, salicylic acid, etc., may be thus applied (chilblains, corns, 
 rhagades, ringworm, and lupus erythematosus). 
 
 Salve-pencils are crayons of wax and oil in which are incorporated various drugs 
 — carbolic acid, chrysarobin, ichthyol, corrosive sublimate, etc. They may be em- 
 ployed for very small disease areas (psoriasis, eczema seborrheicum). Paste-pencils 
 contain no fat, being made of starch and gum. Arsenious acid, corrosive sublimate, 
 iodoform, cocaine, etc., may be thus applied to limited surfaces of skin. They are 
 especially valuable in that they can be used on denuded areas and on mucous 
 membranes (chancre, chancroid, condylomata, lupus). 
 
 Soaps are combinations of the fatty acids and alkalis, sodium forming the hard 
 and potash the soft varieties of the article. They are used to cleanse the skin of dirt 
 and crusts, to remove the corneous layer of the epidermis, and as a menstruum for 
 various medicinal substances. They are cleanly, energetic, and cheap; and the per- 
 fection that has been attained in their manufacture has led to their employment in 
 a large variety of dermatoses. The surface may be simply washed with them, or 
 the lather may be allowed to dry in situ ; but when a more deep-seated action is 
 desired, the soaped part may be covered with a layer of rubber tissue. The alka- 
 line soaps are employed to deprive the integument of its fat, and to soften and re- 
 
THYSIOLOGY OF THE SKIN. 45 
 
 move the upper epidermic layers (psoriasis, ichthyosis). They are very irritant, 
 however, and cannot be employed in inflammatory conditions. The most useful o) 
 these is the sapo viridis or green soap, which may be used either pure or in an alco- 
 holic solution, as recommended by Hebra (No. 5, p. 43). The best skin soaps, how- 
 ever, must be either neutral or contain an excess of fatty material, like the so-called 
 superfatted soaps of Unna. Many varieties are manufactured, the most useful being 
 those containing mercury, tar, sulphur, ichthyol, resorcin, creolin, and iodoform 
 (syphilis, chronic eczema, scabies, rosacea, etc.). The marble and sand soaps are 
 employed where a rapid removal of the superficial epidermic layers is desired 
 (comedo, acne). 
 
 Powders are used to protect the skin and to absorb secretions. Starch and tal- 
 cum are those most commonly employed. They may be dusted or insufflated over 
 the affected parts, or applied inclosed in linen bags. Various medicinal powders, 
 as calomel, aristol, iodoform, are also used. 
 
 Caustics are extensively employed in certain diseases. Caustic potash is effec- 
 tive but very diffusible, and must be used with caution ; arsenious acid is excellent, 
 apparently picking out the diseased tissues, but must not be used over a large area 
 or near the mucous orifices, as it is liable to be absorbed (neoplasmata, especially 
 epithelioma, lupus, warts). Chloride of zinc is slow and painful, but appropriate in 
 certain cases. Chromic acid and the acid nitrate of mercury are also used (chan- 
 croid). 
 
 Parasiticides are very numerous. Sulphur, naphthol, and balsam of Peru are 
 used in scabies; corrosive sublimate, ammoniated mercury, and mercurial ointment 
 in pediculosis. Chrysophanic acid is an excellent vegetable parasiticide (trichophy- 
 tosis, favus). 
 
 Of the bactericides one of the most important is iodoform, from its action on 
 the pus-cocci and the tubercle-bacilli. Its odor and the possible dangers of absorp- 
 tion are against it. Aristol and iodol are fairly good substitutes. Pyoctanin has 
 given good results in epithelioma ; but the staining that it causes prevents its exten- 
 sive use in dermatology. 
 
 SPECIAL REMEDIES. 
 
 Arsenic is no panacea for diseases of the skin ; it is useful in but few affections 
 and harmful in many. It acts directly upon the mucous layer of the epidermis, and 
 is employed in chronic scaly diseases and some others (psoriasis, chronic eczema, 
 lichen planus, pemphigus, hydroa). In the inflammatory diseases, during their acute 
 and subacute stages, it does no good at all ; in fact, it increases the gastro-intestinal 
 irritation upon which many of them depend. It should be given always after eating. 
 Fowler's solution is usually employed, the dose being three drops in the beginning, 
 gradually increased to ten or fifteen, in accordance with the patient's tolerance of 
 the drug. Arsenious acid in tablet form, or combined with black pepper in the cele- 
 
4() ILLUSTRATED SKIN DISEASES. 
 
 brated Asiatic pill (No. 6, p. 46), is also an excellent form for its administration. Where 
 the employment of mercury is also indicated, Donovan's solution, the liquor arsenici 
 et hydrargyri iodidi, may be used. It must not be forgotten, however, that a spe- 
 cial idiosyncrasy for arsenic exists in some cases, and we must be on the lookout for 
 the first symptoms of poisoning — the puffy eyelids, the irritated conjunctivae, and 
 the coryza. It occasionally causes a general exanthem. Arsenic is also employed 
 externally (epithelioma, rodent ulcer), in the form of Marsden's paste (No. 7, p. 46). 
 
 No. 6. Asiatic Fill. 
 
 
 
 No. 7. Marsden's Paste. 
 
 
 fy Ac. arseniosi . 
 
 . gr. Ixvi 
 
 & 
 
 Ac. arseniosi 
 
 
 Pulv. pip. nig. 
 
 . 3ix 
 
 
 Pulv. gum. acac. 
 
 aa. p. e. 
 
 Gum. acac. 
 
 
 
 Aq. q. s. ut ft. pasta. 
 
 
 Aq . . . . 
 
 . aa. q. s. 
 
 
 
 
 Div. in pil. No. 800. 
 
 
 
 No. 9. Calomel Suspension. 
 
 
 No. 8. Utigt. Chrysarobini 
 
 Co. 
 
 # 
 
 Calomelani .... 
 
 1 part 
 
 Yji Chrysarobin . 
 
 5 parts 
 
 
 Albolene .... 
 
 10 parts 
 
 Salicylic acid 
 
 2 « 
 
 
 ui 10 = 1 grain. 
 
 
 Ichthyol . 
 
 5 " 
 
 
 
 
 Vaseline . 
 
 88 " 
 
 
 
 
 Tar is a very efficient topical application in many of the more chronic skin dis- 
 eases (eczema, psoriasis). It lessens hyperemia, infiltration, discharge, and scaling, 
 and is an efficient antipruritic. Combined with sulphur, as in Wilkinson's ointment 
 (No. 38, p. 81), it is especially good ; but it is liable to cause local irritation (acne) or 
 systemic irritation if used too strong or in too large quantity. Pix liquida or oleum 
 picis may be employed ; but oleum cadini or oleum rusci is usually to be preferred. 
 They may be used pure, with the addition of a little ether, as a tincture, or in a 10- 
 per-cent. ointment (subacute and chronic inflammations, psoriasis, parasitic diseases, 
 and pruriginous diseases). In acute inflammations, as eczema madidans, they can- 
 not be used. The oil of lavender will mask the odor of the drug. 
 
 Ichthyol is the common name of the sulph-ichthyolate of ammonium, and is a 
 tarry liquid, the distillation product of a fossil bitumen found in the Tyrol and in- 
 troduced into dermato-therapeutics by P. G. Unna. It has been used internally 
 with much success, in pills of from one to five grains, to reduce the hyperemias of 
 the erythematous diseases (rosacea, lupus erythematosus). In weak concentrations, 
 1 to 4 per cent., it is keratoplastic, stimulating proliferation of the corneous layer 
 (intertrigo, acute eczema) ; in the proportions of 10 to 20 per cent, it is keratolytic, 
 destroying the horny layer and acting as a vasoconstringent, antiseborrheic, and 
 antiparasitic agent (chronic eczema, dermatitis, pruritus, acne, rosacea, etc.). Nuss- 
 baum first recommended its use in erysipelas, which has become almost universal ; 
 20- to 50-per-cent. ointments are proper. It may be applied as a salve, a paste, a 
 solution, or a soap. 
 
PHYSIOLOGY OF THE SKIN. 47 
 
 Thiol is employed as a substitute for ichthyol, and, like it, contains a large pro- 
 portion of sulphur. It is less irritating and odorless, but also less active. It comes 
 in both liquid and powder form, and the indications for its use are the same as those 
 for ichthyol (burns, acne, rosacea, zoster). 
 
 Resorcin, like ichthyol, is keratoplastic and keratolytic in solutions of different 
 strengths. Care must be taken to prescribe always the pure white " albissimum " 
 variety. It is a valuable antipruritic, antiseborrheic, and antiparasitic (seborrhea 
 capitis, pruritus, scabies), being employed in I- to 5-per-cent. solution or ointment. 
 It has been used as a 25- to 50-per-cent. paste or plaster in the treatment of super- 
 ficial epitheliomata. 
 
 Sulphur is perhaps our standard parasiticide (scabies, tinea versicolor). It is also 
 employed in acne, comedo, seborrhea, and the other affections of the sebaceous 
 glands. 
 
 Naphthol, a coal-tar phenol, is frequently employed as a substitute for sulphur 
 in the parasitic diseases. It is also used in the chronic inflammations of the skin, 
 especially in psoriasis. 
 
 Chrysarobin is a very efficient stimulant to the skin, causing a dermatitis accom- 
 panied by a peculiar brownish- red to purplish staining of the skin. Patients should 
 be warned that it ruins the clothing, and it should never be employed about the 
 face on account .of the very intense conjunctivitis that it sets up if conveyed to 
 the eyes. In 5- to 1 5-per-cent. ointment, plaster, or collodion it is an extremely 
 useful agent in psoriasis and chronic eczema. It is valuable also in favus and 
 trichophytosis capitis. Unna's compound chrysarobin ointment is useful (No. 8, 
 p. 46). 
 
 Anthrarobin, produced from alizarin, has been used as a substitute for chrysaro- 
 bin, the indications and dosage being the same. It does not inflame the skin nor 
 stain the clothing, but it is a far less active agent. 
 
 Iodoform finds its chief application in chancre, chancroid, and the ulcerative 
 syphilodermata. Aristol, which is odorless, may be used in its place, but cannot re- 
 place it. The same may be said of dermatol or the subgallate of bismuth, a yellow, 
 insoluble, and odorless powder. It is, however, of value in the acute dermatites. 
 
 Pyrogallol is, next to chrysarobin, our most valuable topical agent in the treat- 
 ment of psoriasis. It must be used in weak concentration, and over not too large 
 an area, as systemic absorption and poisoning are liable to occur. In 50-per-cent. 
 plaster it is employed in carcinoma of the skin, where it acts radically, destroying 
 the affected area. It is slow, but comparatively painless. 
 
 Salicylic acid occupies a peculiar place in dermato-therapeutics. It is a slow 
 solvent of the epidermis, loosening it and separating it from the corium beneath 
 without inflammation. It is employed in 10- to 25-per-cent. ointment, collodion, 
 or plaster (callositas, clavus, etc.). In weaker strengths (1 to 5 per cent.) it is a ker- 
 atoplastic agent, and may be used in the acute dermatoses (eczema vesiculosum). 
 
18 ILLUSTRATED SKIN DISEASES. 
 
 Menthol is an excellent antipruritic, and may be employed in 5- to 10-per-cent. 
 ointment or solution. 
 
 The preeminent value of mercury in the syphilodermata is well known. It may 
 be introduced into the body in three chief ways. That by the mouth is the oldest, 
 and is still in many cases the most convenient method. The proto-iodide is the 
 preparation most commonly used, and it fills all the indications and has as few draw- 
 backs as any of the others. While ptyalism and general mercurial intoxication do 
 not readily occur, the gastro-intestinal tract is very liable to be irritated. The bi- 
 chloride also is liable to disagree. Of the multitude of other preparations that have 
 been employed, only the tannate, introduced by Lustgarten, deserves mention here. It 
 causes less irritation than any of the others, can be given in larger doses, and is espe- 
 cially useful in the treatment of children. The cutaneous method, or that of inunc- 
 tion, is a very efficient way of introducing mercury into the system, and is still the 
 favorite one with many authorities. The metal enters the deeper layers of the skin 
 through the glandular openings to some extent, but it is certain that a large part of 
 its efficacy is due to the inhalation and absorption through the lungs of the mer- 
 curial vapors given off during the process. Mercurial ointment, the oleate of mer- 
 cury, and mercurial soap have their advocates. The method is one that requires 
 considerable labor and patience. Stomatitis is apt to occur, and the mouth and teeth 
 must be carefully watched. Mercurial eczemas and erythemas are also seen, but the 
 gastro-intestinal tract escapes. 
 
 The subcutaneous or hypodermatic method we owe to Lewin, and its introduc- 
 tion was certainly an important advance in the treatment of the syphilitic diseases. 
 Either the soluble or the insoluble salts may be employed. The sublimate still re- 
 mains the best of the soluble salts, and is generally preferred to the albuminate of 
 Bamberger and the formidate of Liebreich, etc. They all cause a considerable amount 
 of pain, and the injections must be frequently repeated. The insoluble salts, and 
 especially calomel (Xo. 9, p. 46), first used by Scarenzio, are very effective, and I 
 consider their introduction into the subcutaneous and muscular tissues the best 
 method in our possession for the treatment of luetic disease. Suspended in albo- 
 lene or fluid cosmoline it can be given in doses up to 1 ]/ 2 grains. The abscesses so 
 frequently observed at first are of rare occurrence now that antiseptic precautions 
 are regularly employed. The pain occasioned is moderate, and the resultant infil- 
 trations usually cause but little inconvenience. Silva Arauja employs the salicylate, 
 while Lang and Neisser prefer the so-called gray oil, composed of mercurial oint- 
 ment thinned with oil. Erythemas, etc., and general intoxications are rare with 
 this method, and the gastro-intestinal tract is unaffected. 
 
 Iodine and its compounds are also more especially used in the syphilitic skin 
 diseases. The potassium, sodium, and ammonium salts and iodoform are those 
 chiefly employed. In the non-syphilitic diseases their use is limited. They do 
 
PHYSIOLOGY OF THE SKIN. 49 
 
 some good in scrofuloderma, lupus, keloid, but they are themselves not infrequently 
 the cause of acneform, purpuric, and bullous eruptions. 
 
 Quinine is of value in many diseases, more especially in the neuroses (pruritus, 
 chronic urticaria) and in maladies accompanied by malarial symptoms. It some- 
 times causes a general exanthem. 
 
 Iron is indicated in the diseases accompanied by anemia and chlorosis, as is fre- 
 quently the case with acne and eczema. Cod- liver oil is very useful as a general 
 skin tonic, and was highly esteemed by the elder Hebra on that account. It may 
 be employed in scrofuloderma, lupus, tuberculosis cutis, scleroderma, chronic ec- 
 zema, and syphilis, and is of especial value in children. 
 
 Ergot is of some use in acne, purpura, etc., probably on account of its action 
 upon the unstriped muscular fibers of the skin and the uterus. 
 
 Electrolysis is an agent of great value in the treatment of certain affections of 
 the skin (hirsuties, warts, naevi). 
 
 The instruments required are a galvanic battery, a milliampere-meter, forceps, 
 needles, and holder. Of these latter I have found the one shown in Fig. 1 7 most 
 convenient. Fine irido-platinum needles may be employed, but the ordinary 
 broaches used by watchmakers are much cheaper and just as good. The amount 
 of current that can be borne varies from 2 to 10 milliamperes, depending on the 
 sensitiveness of the patient and the part that is treated. The needle is attached to 
 the negative pole of the battery, and a suitable sponge-holder to the positive one. 
 The hair to be removed is grasped with the epilating forceps, care being taken that 
 no traction is made upon it. The needle is then carefully passed into the follicle 
 along the side of the hair-shaft, and the skin, if possible, is not to be pierced. The 
 depth to which the broach is introduced varies from 2 to 6 lines, dependent on the 
 depth of implantation of the hair. The circuit is then completed by the patient 
 pressing the sponge-holder against his hand or some portion of his body. In a few 
 moments a fine foam appears around the needle, and the electrolytic action has 
 commenced. . It is allowed to go on until the hair is loosened in its sheath and 
 comes away without traction by the forceps. The sponge-electrode is then removed 
 and the needle withdrawn. Care must be taken to introduce the needle before, and 
 remove it only after, the circuit is broken, so as to avoid giving the patient "a shock. 
 From 10 to 50 hairs can be readily removed at a sitting. The success of the opera- 
 tion depends on the electrolytic destruction of the papilla of the hair. This will not 
 always be effected, and we must expect 10 to 25 per cent, of the hairs that are 
 treated to grow again. 
 
 Certain instruments other than the ordinary surgical ones are daily used by the 
 dermatologist. Sharp dermal curettes of various sizes, and fenestrated to allow the 
 escape of collected material, are employed for erosion of the surface (acne, epitheli- 
 oma). Epilating forceps for the removal of hairs (perifolliculitis, trichophytosis) 
 should have broad, flat blades and easy springs. Spoon-shaped comedo extractors, 
 
50 
 
 ILLUSTRATED SKIN DISEASES. 
 
 the plugs being expressed by lateral pressure, are far preferable to the old-fashioned 
 watch-key kind. Grappling forceps are useful to seize small portions of tissue, 
 tumors, etc., that are to be ablated. Keyes's cutaneous punch is employed to re- 
 move small circular areas of skin (nasvi, powder grains). Linear scarification is done 
 
 Fig. 15. 
 
 Scarificator. 
 
 Fig. 16. 
 
 Comedo extractor. 
 
 Fig. 17. - 
 
 Xeedle and holder 
 
 for electrolysis. 
 
 Fig. 18. 
 
 Fig. 19. 
 
 Dermal curettes. 
 
 Fig. 20. 
 
 with the cutisector (rosacea). A glass pleximeter is useful to express the blood 
 from the skin, rendering new growths therein more visible (lupus vulgaris). Dental 
 burs are employed to destroy localized new growths (lupus nodules). A small 
 spear-shaped spud is useful for opening acne pustules, small dermic abscesses, etc. 
 (See Figs. 15-28, pp. 50, 51). 
 
PHYSIOLOGY OF THE SKIN. 
 
 51 
 
 Fig. 2i. 
 
 Grappling forceps. 
 
 Fig. 22. 
 
 Epilating 
 forceps. 
 
 Fig. 23. 
 
 Fig. 24. 
 
 Spear-shaped spud. Keyes's cutaneous 
 punch. 
 
 Figs. 25, 26, 27, 28. 
 Dental burs. 
 
CLASSIFICATION. 
 
 
 OUR knowledge of the etiology and pathology of cutaneous diseases is still too 
 incomplete to permit of a perfect classification. Yet an imperfect one is better than 
 none at all, for it groups the various maladies according to relationship of some kind, 
 and enables us to take a general survey of the ground to be traversed. The classi- 
 fication of Jessner, slightly modified, is perhaps the most useful. 
 
 Class I. Functional Disorders. 
 i. Sensory: Bromidrosis, 
 
 Pruritus. Chromidrosis, 
 
 2. Motor: Uridrosis. 
 
 Dermatospasmus. (b) Of the sebaceous glands: 
 
 3. Secretory ; Seborrhea, 
 (a) Of the sweat-glands : Comedo, 
 
 Hyperidrosis, Milium, 
 
 Sudamina, Steatoma, 
 
 Anidrosis, Asteatosis. 
 
 Class II. Circulatory Disorders. 
 
 1. Hyperemias: 3. OZdemas : 
 
 (a) Arterial: Urticaria, 
 Erythema. Prurigo. 
 
 (b) Venous : 4. Hemorrhages : 
 Livedo. Purpura, 
 
 2. Anemias: Scorbutus. 
 
 Class III. Inflammations. 
 
 1. Of the corinm a?id snbcutis : Chromophytosis, 
 
 (a) Superficial : Scabies, 
 
 Morbilli, Phtheiriasis, 
 
 Rubeola, Eczema, 
 
 Scarlatina, Erythema multiforme, 
 
 Variola, Herpes, 
 
 Vaccinia, Zoster, 
 
 Varicella, Dysidrosis, 
 
 Lichen planus, Pemphigus, 
 
 Lichen ruber, Dermatitis herpetiformis, 
 
 Favus, Impetigo contagiosa, 
 
 Trichophytosis, Dermatitis exfoliativa, 
 
 Pityriasis rosea, Psoriasis. 
 
 52 
 
CLASSIFICATION. 
 
 53 
 
 Class III. Inflammations {Continued). 
 
 (b) Deep-seated: 
 Dermatitis, 
 Erysipelas, 
 Erythema nodosum. 
 
 (c) Suppurative: 
 Phlegmon, 
 Furunculosis, 
 Carbuncle, 
 
 (d) Granulomatous: 
 Tuberculosis, 
 Lupus, 
 Syphilis, 
 
 Lepra, 
 
 Mycosis fungoides, 
 
 Lupus erythematosus, 
 
 Rhinoscleroma, 
 
 Actinomycosis. 
 Of the glands : 
 
 Hydradenitis, 
 
 Acne, 
 
 Rosacea, 
 
 Folliculitis. 
 Of the nails : 
 
 Onychomycosis. 
 
 Class IV. 
 
 1 . Of the epidermis : 
 
 Ichthyosis, 
 
 Keratosis, 
 
 Callositas, 
 
 Clavus, 
 
 Verruca, 
 
 Cornu cutaneum, 
 
 Condylomata acuminata. 
 
 2. Of the connective tissue : 
 
 Elephantiasis. 
 
 Class V. 
 i. Of the connective tissue : 
 
 Cicatrix, 
 
 Keloid, 
 
 Fibroma, 
 
 Myxoma, 
 
 Lipoma, 
 
 Neuroma, 
 
 Xanthoma, 
 
 Sarcoma. 
 
 Class VI 
 i. Of the cutis and subcutis : 
 
 Atrophia senilis, 
 
 Atrophia maculosa et striata, 
 
 Xeroderma, 
 
 Scleroderma. 
 2. Of the pigment : 
 
 Albinismus, 
 
 Hypertrophies. 
 
 3 . Of the glands : 
 
 Molluscum contagiosum. 
 
 4. Of the hairs: 
 Hypertrichosis. 
 
 5. Of the nails : 
 Onychauxis. 
 
 6. Of the pigment : 
 Lentigo, 
 Chloasma. 
 
 New Growths. 
 
 2 . Of the muscular tissue : 
 Myoma. 
 
 3. Of the vessels : 
 Angioma, 
 Lymphangioma. 
 
 4. Of the glands : 
 Adenoma, 
 Carcinoma. 
 
 Atrophies. 
 
 Vitiligo, 
 
 Canities. 
 Of the hair: 
 
 Alopecia, 
 
 Alopecia areata. 
 Of the nails : 
 
 Atrophia unguis. 
 
CLASS I. 
 FUNCTIONAL DISORDERS. 
 
 Functional disorders, without recognizable anatomical change, and affecting 
 sensibility, motion, and secretion, occur in the skin. The changes of sensibility may 
 consist of hyperesthesia, anaesthesia, or paraesthesia ; the touch, temperature, or 
 pressure sensation may be involved ; or pain may be the only symptom. They are 
 not usually independent diseases, but are caused by other local or general maladies. 
 Dermatalgia and anaesthesia occur, though very rarely, as idiopathic cutaneous affec- 
 tions, and pruritus is the only functional change of sensibility that demands more 
 detailed attention. The functional alterations of secretion are more important, 
 affecting both the coil and the sebaceous glands. They include the various altera- 
 tions of the sweat secretion, known as hyperidrosis, anidrosis, bromidrosis, chromi- 
 drosis, etc., and those of the sebaceous secretion — seborrhea, asteatorrhea, and 
 comedo. 
 
 PRURITUS. 
 
 Definition. — A functional disease of the skin, characterized by itching without 
 any primary cutaneous lesion. 
 
 Symptoms and Course. — Itching occurs as a symptom in various cutaneous mala- 
 dies, as well as in a number of other general and local affections ; but it is some- 
 times a pure neurosis, occurring idiopathically, and showing no objective signs. 
 Certain secondary effects, in the shape of excoriations, blood-crusts, pigmentation 
 and induration of the skin, and even eczema, may be present ; but they are caused 
 by the patient's finger-nails, and are not an essential part of the disease. They 
 appear on the portions of the body most accessible to the sufferer, and they are not 
 seen when scratching is prevented, however violent or extensive the pruritus may 
 be. It is unfortunate that Hebra, who first described the malady, did not give it a 
 name different from that of its only symptom. 
 
 Pruritus universalis is the severest form of the malady, and causes great suffer- 
 ing. Not the entire body, however, is affected at one and the same time;, the itch- 
 ing attacks various portions of the skin in turn. Pruritus senilis is a not infrequent 
 affection in the old. Pruritus hiemalis, first described by Duhring, is apparently 
 dependent on the weather, being commonest in northern climates, regularly getting 
 better or disappearing as the warm weather comes on, and beginning again in the 
 winter. Pruritus aestivus is the opposite to this, and is seen only in summer. Some 
 
 51 
 
FUNCTIONAL DISORDERS. 55 
 
 cases of the so-called " prairie itch " or " Texas mange " are cases of pruritus; but 
 the designation includes cases of parasitic disease also, more especially of scabies. 
 
 Pruritus localis may involve any portion of the body, frequently affecting the 
 face and scalp, and sometimes the palms and soles ; but it more often occurs as pru- 
 ritus genitalium, in the genito-anal region of both sexes, and is a severe and distress- 
 ing affection. Pruritus vulvae may prevent the patient from attending to her duties 
 and unfit her for society. Pruritus ani is very common, but is most frequently 
 secondary to various rectal diseases. 
 
 The itching may be continuous, and then usually varies in intensity at different 
 times and in different portions of the skin. More commonly it is paroxysmal, com- 
 ing on more especially under the influence of mental emotions or sudden changes 
 of temperature. Frequently it is most severe at night, when the patient is in bed. 
 It causes an impulse to scratch that is almost irresistible. The finger-nails, or, if 
 these are insufficient, foreign bodies — rough cloths, hair-brushes, sticks, etc. — are em- 
 ployed to rub and scratch the skin, which is often torn, lacerated, and covered with 
 blood before relief is obtained. The attacks prevent sleep ; the patient emaciates, 
 and his general health is impaired. Occurring in the daytime, neither modesty nor 
 the presence of others can restrain the impetus scabendi (the " impulse to scratch ") ; 
 and the affliction has driven some of these sufferers to suicide. 
 
 Etiology. — Many, perhaps most, cases of so-called pruritus are symptomatic of 
 some local or general disease, and not independent affections. Digestive disturb- 
 ances, diabetes, jaundice, and Bright's disease are the commonest causes of general 
 pruritus ; while the local attacks are due to many various causes, among which may 
 be mentioned vaginitis, vulvitis, and utero-ovarian disease in general, balanitis and 
 urethritis, rectal fissures and hemorrhoids, ascarides, etc. Pruritus senilis is depen- 
 dent on senile atrophy of the skin, with diminution of the sebaceous secretion. In 
 most cases of true pruritus, however, the etiology is unknown. 
 
 Pathology. — No pathological changes have been found in the disease, and it is 
 classed as a true neurosis. 
 
 Diagnosis. — The other itchy diseases of the skin — prurigo, scabies, phtheiriasis, 
 urticaria, etc. — all have objective symptoms which enable them to be readily distin- 
 guished from pruritus, which has none. Even prurigo, the disease with which it is 
 most liable to be confounded, has its primary papules and infiltrated skin, and be- 
 gins at a very early age and continues through life. 
 
 Prognosis is doubtful and often bad. Very frequently no underlying cause can 
 be found, and the senile changes of the skin are permanent. 
 
 Treatment. — The great number of remedies recommended in this disease is a 
 sure index of the inadequacy of our attempts to cope with it. Especial attention 
 must be paid to the gastro-intestinal tract. The bowels must be kept regular with 
 salines, and coffee, liquor, and all indigestible food must be forbidden. General 
 hygiene, and especially proper exercise, must be insisted on. Tonics — iron, qui- 
 

 No. 10. 7tfr Spirit. 
 
 
 No. U. 1 
 
 ft 
 
 01. cadini 
 
 ft 
 
 Acidi carbolici 
 
 
 Spts. vini . . . . aa. p. e. 
 
 
 Spts. vini 
 Glycerini 
 
 
 No. J2. Menthol Ointment. 
 
 
 
 ft 
 
 Menthol i part 
 
 
 No. 13. V 
 
 
 Ol. olivae .... 3 parts 
 
 ft 
 
 Veratrise 
 
 
 Adip. lanas . . . . 24 " 
 
 
 Ungt. simpl. 
 
 56 ILLUSTRATED SKIN DISEASES. 
 
 nine, cod-liver oil, and nux vomica — are occasionally useful. The bromides in 
 large doses sometimes relieve the itching; and salicylate of sodium, in daily doses 
 of from 30 to 60 grains, has occasionally done good. Saalfeld recommends hypo- 
 dermic injections of \ grain of pilocarpine. 
 
 2 parts 
 10 " 
 90 
 
 1 part 
 . 150 parts 
 
 Medicated baths of sulphur, tar, or bran occasionally do good. A good way is to 
 sponge the affected areas with tar spirit (No. 10, p. 56), and then immerse the body for 
 one half to one hour in a warm bath. The tar must not, however, be used over the 
 entire body for fear of poisoning. The local anesthetics are perhaps our most 
 valuable remedies. Carbolic acid may be employed as a lotion (No. 11, p. 56), or 
 menthol in solution with alcohol or as a salve (No. 12, p. 56). Liquor plumbi subace- 
 tatis (3i to water, |i) and cocaine in 5- to 20-per-cent. vaseline ointment may also be 
 employed. Bulkley recommends the inunction of chloral-camphor, a thick liquid 
 obtained by triturating together equal parts of the two drugs ; and Joseph cured 
 some cases by painting the surface daily with the tincture of benzoin. Others have 
 employed veratria with success in pruritus vulvae (No. 13, p. 56), using both in oint- 
 ment and internally in pills of -j4o OI a grain. In obstinate cases the Pacquelin may 
 be used, cauterizing the parts superficially ; and even excision of the affected parts 
 has been recommended. Unfortunately many cases resist all these measures. 
 
 There are no functional disorders of the skin in the motor sphere of any impor- 
 tance. The arrectores pilorum are the only muscular structures. Their temporary 
 contraction under the influence of cold or of the emotions causes the erection of the 
 hairs and the elevation of the epidermis around them, being the condition known 
 as cutis anserina or goose-flesh. Functional disorders of the glandular structures 
 are, however, of more importance. The sweat may be increased in amount (hyperi- 
 drosis) or diminished (anidrosis) or changed in quality (bromidrosis, chromidrosis, 
 uridrosis, hematidrosis). 
 
 HYPERIDROSIS. 
 
 Definition. — A functional disease of the coil glands, consisting of excessive secre- 
 tion of the sweat. 
 
FUNCTIONAL DISORDERS. 57 
 
 Symptoms and Course, — Sweating occurs physiologically when the body is ex- 
 posed to heat or when muscular exertion is undertaken. Pathologically it is a 
 symptom in many abnormal conditions, as of collapse, shock, and fainting, and in 
 asthma, rickets, exophthalmic goitre, rheumatism, malaria, etc., and in the deferves- 
 cence of fevers. It is then a hyperidrosis universalis, affecting the whole body, and 
 frequently coming on in paroxysms at night. The excessive secretion macerates 
 the epidermis and frequently causes inflammation of the skin in localities where the 
 approximation of opposing folds favors retention of the fluid and debris (eczema 
 intertrigo). Miliaria and sudamina are common complications, as are also the my- 
 cotic diseases (chromophytosis, trichophytosis, etc.). Being a symptomatic affection 
 in most cases, its special consideration need not be entered upon here. 
 
 Hyperidrosis localis is more essentially a cutaneous affection. It is very fre- 
 quent, especially on the head, hands, and feet. It may be unilateral or bilateral, or 
 it may affect certain special areas of the skin. Hyperidrosis pedum is perhaps its 
 commonest and most troublesome form. The feet are continually wet and cold ; the 
 socks are soaked ; the skin is macerated, and may even become excoriated or ulcer- 
 ated. Confined in the shoes, the fatty material of the sweat and epidermic cells 
 decomposes, and a peculiar nauseating odor is caused that may be perceptible to 
 others, and, in the worst cases, may render the patient unable to go into society 
 (bromidrosis). Walking is sometimes so interfered with that the sufferer is practi- 
 cally bedridden. 
 
 Hyperidrosis manuum is also quite common, and is almost as great an affliction. 
 The hands are perpetually moist and greasy ; they stain every article that they 
 touch, and gloves can hardly be worn at all. Sometimes the secretion is so abun- 
 dant that the sweat drips from the finger-tips when the hands are at rest. The 
 affection occurs most commonly in nervous and anemic women. Hyperidrosis 
 axillae and hyperidrosis genitalium frequently predispose the skin of the affected 
 parts to intertrigo and eczema marginatum. Like all the other forms of the disease, 
 they are commoner and more annoying during hot weather. 
 
 Etiology. — The cause of the excessive sweating, when not one of the above- 
 mentioned diseases, is often undiscoverable. Some derangement of the sympathetic 
 nervous system is probably at the bottom of it. Uncleanliness certainly plays no 
 part. Mental excitement frequently seems to start the flow. I have noticed that 
 the workmen in the aniline factories, who cleanse their hands of the dyes with 
 chloride of lime, suffer from severe hyperidrosis of the hands ; the affection stops, 
 however, as soon as they cease to use the lime. 
 
 Pathology is practically wanting. The secreted sweat is apparently normal, and 
 Robinson has examined many sections of hyperidrotic skin without finding anything 
 abnormal about the sweat-glands or their epithelium. 
 
 Diagnosis never presents any difficulties, though the underlying cause is some- 
 times impossible to find. 
 
58 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Prognosis should be guarded ; many cases are very intractable. Death has oc- 
 curred, apparently from the exhaustion caused by severe hyperidrosis alone, in the 
 case of an old man reported by Myrtle. 
 
 Treatment. — There is, of course, no truth in the popular idea that checking of 
 the sweat secretion, like driving away an eruption, is liable to occasion internal 
 disease. The cause must be treated when it can be found. The use of water, 
 macerating the already swollen epidermis, must be limited to the smallest necessary 
 amount. The clothing should be woolen, and very frequently changed ; twice a 
 day is none too much for the socks in hyperidrosis pedum. Sleeping between 
 woolen blankets rather than between sheets, and with the least amount of covering 
 that can be borne, will tend to lessen the distressing attacks of sweating that occur 
 during the night in various diseases. 
 
 Of internal remedies there are recommended the usual large number when deal- 
 ing with a more or less intractable disease. The only ones that I have found of 
 value, in addition to the general and the bitter tonics, are : atropin, given hypoder- 
 mically in doses of y-J-^ to ^5- of a grain, and increased up to the point of toleration ; 
 ergot in 3ss doses twice daily; and aromatic sulphuric acid, 10 to 20 drops three 
 times a day. Crocker recommends sulphur, 3i in milk twice a day, very highly ; I 
 have had no experience with it. 
 
 No. 14. Salicylic Dusting Powder. 
 
 R Ac salicylic . 
 Talci . 
 Amyli . 
 
 3 parts 
 
 7 " 
 90 " 
 
 No. 15. Alum Dusting Powder. 
 
 f£ Aluminis 
 Ac. salicylici 
 Amyli . 
 
 aa. 
 
 No. 16. Quinine Dusting Powder. 
 
 % Quin. sulph. 
 Amyli 
 
 1 part 
 5 parts 
 
 External treatment should consist of washing the affected area with vinegar, 
 cologne water, or alcoholic solutions of naphthol 10 per cent., tannin 5 per cent. ; 
 or salicylic acid 1 per cent., followed, after thoroughly drying the parts, by a dust- 
 ing powder (Xo. 14, p. 58). The tincture of belladonna, diluted with equal parts of 
 water, is a good application in some cases; there need be no fear of absorption and 
 poisoning if fissures or excoriations are not present. Where the abnormal sweating is 
 limited to a small area, a 5-per-cent. solution of chromic acid painted once or twice 
 over the part has done me good service ; but it should only be used about once in 
 two weeks. 
 
 In hyperidrosis pedum the feet should be washed daily with a decoction of white- 
 oak bark, then carefully dried, and one of the alcoholic solutions recommended 
 above applied. The parts should then be well dusted with an astringent powder 
 
FUNCTIONAL DISORDERS. 59 
 
 (No. 15, p. 58), pledgets of cotton being placed between the toes. Hebra's celebrated 
 treatment consists in laying diachylon ointment spread on strips of linen on the feet 
 and between the toes. The dressing must be changed daily for two weeks without 
 washing, the parts being simply wiped dry with a cloth. Desquamation of the 
 epidermis occurs, and with it a diminution of the amount of the sweat. Morrow 
 recommends foot-baths of the extract of Pinns Canadensis, followed by one of the 
 various dusting powders. 
 
 Hyperidrosis manuum is best treated by an alcoholic alum or tannin solution. 
 G. H. Fox recommends an alcoholic solution of quinine, I to 100, very highly. 
 Any of these may be followed by a quinine dusting powder (No. 16, p. 58). 
 
 Hyperidrosis genitalium may be treated by washing the parts with a decoction 
 of white-oak bark, followed by powder. A suspensory bandage must be worn by 
 the male ; and in either sex it is advisable to use bandages and layers of absorbent 
 cotton to prevent the affected areas coming in contact. In hyperidrosis axillae the 
 dusting powder may be worn in small linen bags slung round the shoulders or at- 
 tached to the clothing. 
 
 ANIDROSIS is not a definite disease of the skin, but is a diminution in the amount 
 of the sensible perspiration below the normal. It occurs in various diseases ; in 
 fevers, diabetes, and various maladies of the brain and spinal cord, as well as in 
 ichthyosis, scleroderma, prurigo, and some forms of eczema and psoriasis. Treat- 
 ment must be directed to the malady of which it is a symptom. Steam and Turk- 
 ish baths, general tonics, exercise, etc., do good; and pilocarpine hypodermically in 
 small doses may be tried. 
 
 BROMIDROSIS. — The exhibition by the sweat of a peculiar and usually disagreea- 
 ble odor is not a distinct malady, but is either symptomatic of other affections or is 
 due to the decomposition of the sweat under the influence of bacterial life. Sympto- 
 matic general bromidrosis occurs in some of the exanthemata and fevers where the 
 sweat has a distinctive odor (variola, typhus). A few drugs, such as sulphur, iodine, 
 and musk, also cause it. But the commonest variety is the local bromidrosis oc- 
 curring in connection with hyperidrosis of the axillae, the genitals, and more espe- 
 cially of the feet. Hebra has proved that even in the worst of these cases the sweat 
 is odorless when excreted ; and it has been shown that the fetor that supervenes is 
 due to the growth of the Bacterium fetidum in the exuded sweat and sebum. 
 
 The odor of bromidrosis is a heavy and peculiar one, and has been compared by 
 Crocker to that of moldy cheese. The clothing covering the affected part, more es- 
 pecially the socks and shoes, is its source, rather than the skin itself. This latter 
 is tender, red, and excoriated; or the epithelium may be swollen by the excessive 
 secretion, and it becomes sodden and white. Its cause is most often the organism 
 mentioned above. But hyperidrosis is usually associated with it, and our custom 
 of enveloping the feet in an impervious leather covering favors its development. 
 
 The treatment is essentially that of hyperidrosis. Frequent bathing and change 
 
60 ILLUSTRATED SKIN DISEASES. 
 
 of clothing are essential. Thin's plan is effective,, and consists in first soaking the 
 clean socks in a solution of boric acid and letting them dry. The feet are then well 
 powdered with the acid, which is also dusted freely in the socks and shoes. A 
 solution of the permanganate of potassium, I to 3 grains to the ounce, and applied 
 to the feet several times a day, is also useful. Chromic acid in 5-per-cent. solution 
 may be applied cautiously once in two or three weeks. In the German army it has 
 been found useful, especially when on the march, to anoint the feet with suet con- 
 taining 2 per cent, of salicylic acid, and then to wrap up the feet in bandages soaked 
 in the same instead of using stockings. Crocker has obtained good results from 
 the internal use of sulphur, as in hyperidrosis. 
 
 CHROMIDROSIS or colored sweating is an extremely rare malady. The reported 
 cases have occurred mostly in hysterical women, and some of them have been found 
 to be the result of imposture. The very existence of the affection has been doubted, 
 but a sufficient number of cases have been seen by competent observers to prove 
 that it occurs. Blue, yellow, brown, and red sweat have been seen, but the source 
 and nature of the coloring- matters are not definitely known. Pyocyanine, the color- 
 ing-matter of blue pus, and indigo, have been thought to be the cause of the cases 
 of blue sweating observed by Hofmann, Le Roy de Mericourt, and T. C. Fox. The 
 yellow and the black colors respectively of the secretion in the cases of Mibelli and 
 Kollmann were apparently due to the ingestion of chrysarobin and of phosphate of 
 iron. On the other hand, Babesieu and others have reported cases that were un- 
 doubtedly bacterial in origin. In most instances the sweating has been confined to 
 a very limited area, the lower eyelids being most frequently affected. The treat- 
 ment attempted has been entirely useless. 
 
 Uridrosis, or the excretion of urea with the sweat, is simply an exaggeration of a 
 normal condition, that compound being always present in the secretion. It occurs 
 in certain general conditions, as in cholera, but is more commonly seen in uremia, 
 where the amount of urea excreted by the coil glands may not only give the sweat 
 a urinous odor, but may be deposited in the form of minute white crystals on the 
 surface of the skin. 
 
 HEMATIDROSIS or bloody sweat is sweat containing a number of red blood-cells 
 that have escaped from the vessels by diapedesis. This extremely rare affection 
 occurs in persons suffering from hemophilia, and is then associated with hemorrhages 
 and blood-extravasations in the various organs and tissues. The subjects affected 
 have always been hysterical women, and the process has been regarded as a vicarious 
 menstruation. The case of Louise Lateau with " bleeding stigmata " is well known. 
 
 SUDAMINA. 
 Synonym. — Miliaria crystallina. 
 
 Definition. — Retention cysts of the coil glands, appearing as discrete, pinhead- 
 sized, translucent vesicles containing sweat. 
 
FUNCTIONAL DISORDER? 
 
 1)1 
 
 Symptoms and Course. — The vesicles look like drops of dew upon the surface of 
 the skin, and are usually present in large numbers. They may appear on any part 
 of the body, but the neck, chest, and abdomen are most frequently affected. They 
 never become pustular or coalesce or show any signs of inflammatory reaction. 
 After persisting for a day or two they dry up ; and their disappearance is followed 
 by a slight furfuraceous desquamation. 
 
 Etiology and Pathology. — Sudamina is essentially dependent on general hyperi- 
 drosis, and is most commonly seen in diseases characterized by abundant sweat- 
 ing (phthisis, rheumatic fever, typhoid, etc.). Violent exercise, excessive warmth of 
 the clothing, and exposure to moist heat will also cause its appearance. Robinson, 
 who has carefully studied their anatomy, finds that the fluid is an accumulation of 
 pure sweat under the corneous layer, the duct of a coil gland opening into each 
 little cyst. 
 
 Treatment. — The treatment of sudamina is usually unnecessary, since they are 
 most often phenomena of little importance occurring in the course of other diseases. 
 The general treatment recommended for hyperidrosis may be employed. If they 
 cause any annoyance a mildly astringent lotion (No. lj, p. 61) may be sponged over 
 the affected area. The zinc-and-starch powder (No. 18, p. 61) is also useful. 
 
 No. J7. Lead Lotion. 
 
 fy Liq. plumbi subacet. dil. . 3 parts 
 
 Glycerini . . . 8 " 
 
 Aq. cologniensis . 16 " 
 
 Aq. destil 60 " 
 
 No. J8. Zmc Dusting Powder. 
 
 1 part 
 
 aa. 4 parts 
 
 fy Pulv. zinci ox. . 
 Talc, venet. 
 Amyli . . 
 
 SEBORRHEA. 
 
 Synonym. — Steatorrhea. 
 
 Definition. — Seborrhea is a functional disease of the sebaceous glands, character- 
 ized by an excessive and abnormal secretion of sebum, which appears as an oily 
 coating or as crusts upon the skin. 
 
 Symptoms and Course. — Seborrhea occurs anywhere where there are sebaceous 
 glands, and is commonest upon the scalp, the face, the genitals, and the anterior 
 and posterior surfaces of the chest. The affection may be a slight one, limited in 
 area, and readily removed ; or it may be extensive and severe, and very rebellious 
 to treatment. We distinguish two separate clinical forms, in accordance with 
 whether the sebaceous material that accumulates upon the skin is fluid and oily, or 
 solid, forming crusts and scales. 
 
 Seborrhea oleosa is the more frequent form of the affection, especially in the 
 negro race, where it is so frequent as to be almost the normal condition. The skin 
 is greasy to the touch, and glistening, and the fatty material may even be abundant 
 enough to accumulate as minute drops of oil. It occurs on the nose and face, and 
 bald scalps are rendered more shining by its presence. The dust and coal-soot of 
 
62 
 
 ILLUSTRATED SKIN DISEASES. 
 
 the atmosphere settle on the oily coating and stick there, giving to the skin a 
 dirty gray or blackish appearance. The ducts of the sebaceous glands are usually 
 markedly dilated, and may be seen large and patulous, or plugged with comedones. 
 Seborrhea sicca is also a common condition, affecting both the hairy and the 
 non-hairy regions of the body. It is of especial frequency upon the scalp, and is 
 the common cause of premature baldness. It appears as thin, white, and greasy 
 scales, which become yellowish or brownish as they desiccate and become dirty. 
 The skin beneath is grayish white and anemic, and when excessive accumulation of 
 the scales causes irritation, a mild eczematous inflammation is set up. 
 
 Seborrhea may in rare cases be universal. This is physiological in the new-born 
 infant, where the half-dried sebaceous secretion forms the vernix caseosa. The super- 
 abundant secretion usually continues in the scalp during the first year of life, and 
 where there is not sufficient cleanliness accumulates in thick dark-yellow or brown- 
 ish masses, the so-called " cradle crust." But in most cases seborrhea is partial and 
 affects only a limited area of the skin. 
 
 Seborrhea capitis is the commonest form of the malady, and, as the chief cause 
 of baldness, one of the most important. The excessive glandular secretion accumu- 
 lates as more or less fatty, dirty yellowish-white scales, occupying circumscribed 
 
 areas or diffused over the entire 
 scalp. The hairs are fatty and 
 sticky, and become matted to- 
 gether, and want of cleanliness 
 may lead to a tangling up of the 
 hair with sebum and dirt. Later 
 on there occurs excessive cornifi- 
 cation and desquamation of the 
 epithelial cells ; and the mingled 
 sebum and scales are cast off as 
 dandruff, the white scales of which 
 powder the patient's clothes. 
 Being unaccompanied by any 
 subjective sensation further than 
 a moderate itching, this condition 
 is usually allowed to persist for 
 years without treatment, and it is 
 only when the final stage sets in 
 that medical aid is sought. The 
 hairs then lose their luster and get loose ; the follicles begin to atrophy and the hair 
 to fall out. The baldness begins upon the vertex, or above the forehead, and may 
 go so far that only a fringe of hair is left around the nape of the neck and the ears. 
 The denuded scalp is shiny, and attached firmly to the skull beneath. More rarely 
 
 Fig. 29. — Seborrhea capitis. 
 
 From photograph in the author's collection. 
 
FUNCTIONAL DISORDERS. 63 
 
 than upon the head a similar process takes place in the mustache, beard, and eye- 
 brows. In some of these cases there is more or less hyperemia; epithelial prolifera- 
 tion is a more prominent factor; the itching is more intense ; and they stand on the 
 boundary line between pityriasis and the malady under consideration. 
 
 Seborrhea facei and seborrhea nasi are common localizations of the disease, and 
 appear both in the oily and the dry form. In the former the alae nasi and the 
 cheeks are the parts most commonly affected. The skin is covered with a layer of 
 oily matter, mingled with more or less dirt from the atmosphere. The mouths of 
 the glands are large and prominent, and comedones, acne papules, and rosaceous 
 patches are often present. In the dry form the sides and tip of the nose and the 
 forehead are covered with small, dark-yellow, fatty, adherent scales, and the skin 
 beneath is frequently irritated. 
 
 Seborrhea genitalium is common in both the male and the female, more espe- 
 cially when cleanliness is not observed. The sebaceous glands of the labia and fossa 
 of the glans are large and numerous ; sebum accumulates and decomposes, giving 
 rise to a foul and characteristic odor, and inflammation and excoriations may be the 
 secondary results. 
 
 Etiology. — General impairment of health seems to be the main predisposing 
 factor to the disease ; it occurs most commonly in anemic and chlorotic individuals 
 suffering from irregularities of the bowels or of the menstrual function. Neverthe- 
 less it is often seen in robust individuals, in whom we are at a loss to account for 
 its advent. 
 
 Pathology. — The disease process in pure seborrhea is an entirely functional one, 
 and the sebaceous glands themselves are not in any way changed. The difference 
 between the oily and the dry form depends on personal peculiarities, and Duhring 
 claims that brunettes most commonly have the former, while individuals of a light 
 complexion suffer oftenest from the latter variety. Some authorities believe, with 
 Jessner, that a low, chronic inflammatory process is present in most cases, an opin- 
 ion which is supported by the atrophy of the glandular structures that finally occurs. 
 We may follow Unna in classifying the more inflammatory forms of the affection 
 by themselves, and considering them under the heading of seborrheal eczema, 
 leaving the ordinary forms to represent the functional disease. 
 
 Diagnosis. — Seborrhea, more especially of the scalp, must be differentiated 
 from eczema, psoriasis, and lupus erythematosus. As regards eczema, the sebor- 
 rheal crusts are fatty, and are not composed of inflammatory exudation ; and the 
 skin beneath them is dry and white, or at the most slightly reddened, not moist, 
 thickened, and inflamed. In psoriasis the scales are large and silvery white ; in 
 seborrhea they are smaller, grayish, and fatty. The skin of a psoriasis patch is 
 reddened, while that of a seborrheal area is pale and anemic ; and we will always in 
 the former disease find other patches, more especially on the outer surfaces of the 
 joints. The distinction from lupus erythematosus is more difficult, and may in some 
 
64 
 
 ILLUSTRATED SKIN" DISEASES. 
 
 cases be impossible. This is the less to be wondered at from the fact that, as Hebra 
 long ago pointed out, erythematous lupus begins as a congestive form of seborrhea, 
 and persists as such for a long time before taking on a characteristic form. But 
 lupus erythematosus is distinctly inflammatory, the skin is thickened and infiltrated, 
 and superficial scars result in the center of the patch as the disease progresses ; 
 moreover, it is rare on the scalp. Seborrhea, on the other hand, shows no inflam- 
 matory reaction and no scar tissue ; its scales are soft and fatty, and its favorite 
 location is upon the head. 
 
 Prognosis. — The general prognosis of seborrhea is good, though some cases are 
 very obstinate, especially where the genitals are affected. In seborrhea of the 
 scalp also, our opinion as to the possibility of a regrowth of hair must be a guarded 
 one. We have no means of telling what proportion of the hair-follicles are still 
 capable of growth. The patient should also be informed that treatment will inev- 
 itably cause an increased falling out of the hairs at first, but that none will be lost 
 that are not loosened and ready to come out, while feeble ones will be strength- 
 ened and stimulated. 
 
 No. 19. Startups Mixture. 
 
 ft Magnes. sulphat. . . 16 parts 
 
 Ferri sulphat. ... i part 
 
 Acid, sulph. dilut. . . 3 parts 
 
 Infus. quassias . . ad. 30 " 
 
 S. A teaspoonful in water, after eating. 
 
 No. 21. Tannin-Resorcin Spirit. 
 
 ft Ac. tannic, or resorc. albissim. 1 part 
 01. ricin. . . . 1 " 
 
 Spirit, coloniensis . . 50 parts 
 
 No. 23. Bronsoif s Mercurial Ointment. 
 
 No. 20. Resorcin Ointment. 
 
 ft Hg. ammoniati 
 Hg. chlor. mit. 
 Petrolati 
 
 1 part 
 
 2 parts 
 
 ft Resorc. albissim. 
 Sulph. depur. 
 Adip. lana? 
 Ungt. simpl 
 
 aa. 1 part 
 
 aa. 
 
 parts 
 
 No. 22. Tor Ointment. 
 
 ft 01. cadini 
 Ungt. simpl. 
 
 1 part 
 8 parts 
 
 No. 24. Sulphur Paste. 
 
 ft Sulphur, depur. 
 Pulv. zinci ox. 
 Amyli 
 Petrolati . 
 
 1 part 
 
 aa. 2 parts 
 5 " 
 
 No. 25. Sulphur Ointment. 
 
 ft Sulphur, lot. 
 Ungt. aquae ros. 
 
 1 to 2 parts 
 
 8 " 
 
 Treatment. — The treatment of seborrhea is, above all things, a matter requiring 
 much time and great patience. The general treatment must be directed to regu- 
 lation of hygiene and correction of any ascertainable fault in gastro-intestinal and 
 uterine functions. Fresh air, abundant exercise, daily salt-water baths, and proper 
 

TYP03RAVURE. 
 
 COPYRIGnT, 19C2, BY E. B. TREAT & CO. . N. Y. 
 
 COMEDO AND ACNE. 
 
 PLATE I_V. 
 

 Th 
 
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 the parts n 
 
 3 
 
 the rest 
 The vai 
 the affe< 
 In E 
 move the c 
 
 oini 
 
 until thi 
 ur most 
 nbination 
 
 or ■ 
 
 equired 
 
 In seboi 
 
 eat c 
 
 
 
 
 Dcfi 
 
 
COMEDO AND AC 
 
FUNCTIONAL DISORDERS. 65 
 
 food are of importance ; cod-liver oil is frequently indicated in anemic cases, "Where 
 Startin's acid iron mixture (No. 19, p. 64) also does good service. 
 
 The local treatment consists in removing the crusts and lessening the excessive 
 secretory action of the sebaceous glands. The former is effected by softening them 
 by the continuous application of cloths soaked thoroughly with olive-oil, sweet- 
 almond oil, cod-liver oil, or glycerin. If the scalp is affected, a piece of oil silk or 
 a bathing-cap should be worn during the night to protect the bedclothes and keep 
 the parts moist. If this is not sufficient, green soap should be employed, best in 
 the form of the spiritus saponis kalinus recommended by Hebra (No. 5, p. 43). 
 This used as a shampoo with hot water once a day, with the oils as above described 
 during the rest of the time, will cause most of the crusts to disappear, and so soften 
 the rest that there is no difficulty in removing them with a soft cloth or a comb. 
 The various sulphur, resorcin, and tannin lotions and salves can then be applied to 
 the affected skin (Nos. 21, 24, 25, p. 64). 
 
 In seborrhea capitis the above preliminary treatment should be employed to re- 
 move the crusts, and, since they accumulate quite rapidly, it must be repeated once 
 or twice a week during the entire course of the treatment. It is never necessary to 
 cut the hair ; by carefully parting it and using a hard-bristle brush dipped in the 
 ointment or lotion, and brushing it into the scalp, successive areas of skin may be 
 treated until the whole has been covered. Sulphur in 5- to 10-per-cent. ointment 
 is our most valuable remedy, and resorcin is almost as effective. I have found the 
 combination (No. 20, p. 64) very useful. As the secretion diminishes, tannic acid 
 or resorcin in alcoholic solution is preferable (No. 21, p. 64). In obstinate cases tar 
 is required (No. 22, p. 64), and the ointment recommended by Bronson is very ser- 
 viceable (No. 23, p. 64). 
 
 For seborrhea of the face the spiritus saponis kalinus is too irrtant, and the 
 crusts must be removed by the use of one of the medicated soaps, those of ichthyol, 
 resorcin, and sulphur being most employed. A 5-per-cent. sulphur paste (No. 24, 
 p. 64) or the resorcin ointment (No. 20, p. 64) may be applied. 
 
 In seborrhea of the body, sulphur, 10 to 30 grains to the ounce of adeps lanas, 
 is most useful. Seborrhea of the genitals is treated by keeping the parts clean with 
 ordinary soap and warm water, followed by the application of a slightly astringent 
 dusting powder (No. 15, p. 58; No. 18, p. 61). 
 
 The treatment of seborrhea oleosa differs in no way from that of the dry form 
 of the disease, save that the preliminary treatment for the removal of the crusts is 
 not required. 
 
 COMEDO. 
 
 Synonyms. — Blackhead, Mitesser (Ger.), acne ponctuee (Fr.). 
 
 Definition. — A disease of the sebaceous glands, characterized by pin-point- or 
 pinhead-sized papules, with minute bluish or black centers. 
 
66 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Symptoms and Course. — Blackheads are present to some extent in all skins, and 
 are frequently numerous enough to form an annoying deformity. This is especially 
 the case at the time of puberty, when the sebaceous follicles participate in the 
 
 general glandular development of 
 the skin that takes place at that 
 time. The comedones appear as 
 minute blackish or bluish points, 
 each one of which marks the situ- 
 ation of the mouth of a gland. 
 They are almost always accom- 
 panied by more or less seborrhea, 
 and the irritation of the retained 
 secretion frequently causes an in- 
 flammatory acne. Their seat is 
 most often on the face, the fore- 
 head, nose, and chin being more 
 especially affected ; but they oc- 
 cur also in the lobe of the ear and 
 behind it, and on the nape of the 
 neck. The back is sometimes 
 extensively affected, and they 
 have even been found on the 
 penis. 
 
 Etiology. — We do not know- 
 why comedones develop ; but 
 dirt, formerly supposed to be the 
 cause of their appearance, has 
 nothing to do with it. Uncleanly 
 people and those whose avoca- 
 tions expose them to dirt and 
 dust are perhaps less liable to them than those of unexceptionable personal habits 
 and refined occupations. Thick, muddy skins with well-developed and patulous 
 sebaceous glands, and with a tendency to seborrhea, show them most frequently. 
 Anemia and chlorosis, and the general causes of seborrhea, are undoubtedly of in- 
 fluence in their formation. 
 
 Pathology. — The black plug which closes the dilated orifice of the sebaceous 
 gland consists of masses of epithelial cells and detritus, inspissated sebum, choles- 
 terin crystals, and minute lanugo hairs. The little parasite known as the Acari/s or 
 Demodex folliailoriini is frequently found in the mass; but it is not the cause of 
 the affection, being non-pathogenic in man, though in the dog it causes what is 
 termed follicular mange. The color of the comedo is not due to the accumulation 
 
 Fig. 30. — Comedo. 
 Case of Dr. J. F. Aitken. 
 
FUNCTIONAL DISORDERS. 
 
 67 
 
 of dust from the atmosphere, as was formerly supposed ; Unna has clearly demon- 
 strated that it is caused by a peculiar black, blue, or brown pigment. 
 
 Diagnosis needs no consideration. Milium is closely allied to comedo, but has 
 no central duct closed with the character- 
 istic black plug. 
 
 Prognosis is good as to the immediate 
 removal of thedisfigurement ; but thecome- 
 dones frequently return with an annoying 
 obstinacy, and some cases are not perma- 
 nently curable. 
 
 Treatment consists in removing the 
 cause, and more especially the seborrhea 
 that is so frequently present. Fresh air, 
 sea-bathing, tonics, and other hygienic 
 measures are useful. Local treatment must 
 begin with the use of plenty of hot water 
 and soap, and an alkaline lotion, such as a 
 5-per-cent. solution of bicarbonate of soda, 
 to soften the plugs. The comedones can 
 then be removed with the expresser. The 
 old-fashioned watch-key and instruments 
 fashioned like it are not appropriate ; they 
 injure and bruise the skin, become clogged 
 very rapidly, and cannot be kept clean. 
 Blunt-edged, curette-shaped instruments 
 (Fig. 1 6, p. 50), by means of which lateral 
 
 pressure can be exerted on the ducts of the glands and the plugs expressed, are much 
 better. The rounded handle of the ordinary metallic pocket-case instruments makes 
 a very useful comedo extractor when none other is handy. The after treatment 
 consists of frequent hot ablutions and the use of an alkaline soap to prevent, if pos- 
 sible, the inspissation of the sebum in the ducts. A sulphur ointment (No. 25, p. 64) 
 is also useful. 
 
 Fig. 31. — Comedo gigantica. 
 
 From photograph in the author's collection. 
 
 MILIUM. 
 
 Synonyms. — Grutian, Hautgriesz (Ger.), acne miliaire (Fr.). 
 
 Definition. — Milium consists in the formation of small, hard, round, whitish, 
 non-inflammatory subepidermal tumors of the skin. 
 
 Symptoms and Course. — The small, pearl-white, millet-seed-sized elevations that 
 are characteristic of the disease may occur anywhere where there are sebaceous 
 glands, but are found most frequently on the face, in the region of the eyelids, 
 temples, and cheeks, and on the penis and scrotum. There may be only one or 
 
68 ILLUSTRATED SKIN DISEASES. 
 
 two, but frequently they are very numerous. They occur at all ages, but are most 
 common during the first two years of life. 
 
 Etiology. — The cause of milium is similar to that of comedo ; they are retention 
 cysts caused by the obliteration of the ducts of the sebaceous glands. We do not 
 know why or under what circumstances this obliteration occurs. 
 
 Pathology. — The cysts are situated in the corium, and are covered with a layer 
 of epidermis that seems to be thinned out by pressure. Their contents are seba- 
 ceous matter, with epithelium-cells and cholesterin crystals. In rare instances they 
 become infiltrated with lime salts, forming cutaneous calculi. Once formed, they 
 remain stationary for years, and are obnoxious solely on account of the deformity 
 that they occasion. 
 
 Diagnosis. — Milium is distinguished from comedo in that it has no dilated gland 
 duct, and no blackhead plugging it. The seborrhea and acne that so frequently 
 accompany comedo are also absent. It can hardly be confounded with xanthoma, 
 which occurs later in life and never in children, is yellow in color, soft in consis- 
 tence, and cannot be squeezed out after incision. 
 
 Prognosis is good ; the malady is a purely local one, and can be readily re- 
 moved. 
 
 Treatment. — This consists in incising the epidermis over each tumor, and squeez- 
 ing or shelling it out. To obliterate the acinus and prevent reaccumulation of the 
 sebum, Piffard's recommendation to touch the inside of each follicle with tincture 
 of iodine, or that of Hardaway to use the electrolytic needle in the way recom- 
 mended for the electrolysis of hairs, may be followed. 
 
 SEBACEOUS CYST. 
 
 Synonyms. — Steatoma, wen, Balggeschiviilst (Ger.), loupe (Fr.). 
 
 Definition. — Encapsulated cystic tumors containing sebaceous matter, and situ- 
 ated in the corium or subcutaneous connective tissue. 
 
 Symptoms and Course. — Wens appear as rounded or flattened, freely movable 
 tumors of the skin, covered with the epidermis. Their size varies greatly ; the small- 
 est are not larger than millet seeds, while the larger ones may be as big as an egg 
 or even an orange. Most often they are soft, their contents being semifluid ; but 
 they may be harder, more especially if calcareous infiltration has occurred. They 
 may appear anywhere on the body where there are sebaceous follicles; their favor- 
 ite location is the scalp, but the face, the scrotum, and the back are not infrequently 
 affected. Growing very slowly, they usually remain quiescent for years after attain- 
 ing a certain size ; and, since they give rise to no subjective symptoms at all, they 
 are obnoxious only on account of the deformity that they cause. Wens are often 
 single, and it is rare to find more than a few on one individual. They sometimes 
 terminate spontaneously by suppuration and ulceration. 
 
FUNCTIONAL DISORDERS. 
 
 69 
 
 Etiology. — Wens may be considered as developments of the affections previously 
 considered, milium and comedo. They arise from the obliteration of the duct of a 
 sebaceous gland, with accumulation of the secre- 
 tion that continues to be formed within it. 
 
 Pathology. — The tumors have a distinct and 
 firm cyst wall, and soft, cheesy, and semifluid or 
 harder yellowish-white contents. These latter 
 are often fetid, and consist of sebum, epithelial 
 cells, cholesterin crystals, and an occasional lanugo 
 hair. Cheesy and calcareous degeneration fre- 
 quently occurs, and the thickening of the cyst 
 wall is evidently due to the pressure of the seba- 
 ceous matter in its cavity. To this cause also is 
 to be attributed the atrophy of the hair-follicles 
 and the falling of the hair on the surface of the 
 tumors. 
 
 Diagnosis. — Fatty tumors are the only growths 
 likely to be mistaken for wens ; but they are situ- 
 ated most often on the back, buttocks, and ex- 
 tremities, and are distinctly lobulated, while wens 
 are generally located on the scalp and neck, and 
 are of even consistency throughout. 
 
 Prognosis is good; there will be no return of the tumor if the cyst wall is re- 
 moved. Carcinoma has occurred after operation, however, as in the case that 
 Bryant reported. 
 
 Treatment. — Excision is the only remedy. The entire cyst should be dissected 
 out whole if possible ; if the tumor be ruptured or cut into, the wall should be seized 
 and carefully removed afterward. If operation is to be avoided, the contents of the 
 sac may be expressed through the duct of the gland if it is still patent, or through 
 a small artificial opening, and the cavity afterward injected with tincture of iodine. 
 
 Fig. 32. — Sebaceous cyst. 
 
 From photograph in the author's collection. 
 
 ASTEATOSIS. 
 
 Definition. — An abnormal diminution in the amount of the sebaceous secretion. 
 
 Symptoms and Course. — The skin, being deficient in the fatty matter that nor- 
 mally renders it soft and pliable, is dry, harsh, inelastic, and readily fissured. The 
 hairs are dry and lusterless, and finally fall out. The affection may be general or 
 partial, as well as idiopathic or symptomatic. Idiopathic asteatosis is very rare, but 
 symptomatic partial or general asteatosis is commoner, occurring in many diseases. 
 
 Etiology. — Symptomatic asteatosis occurs in various constitutional diseases, as 
 in ichthyosis, hereditary syphilis, cancer, diabetes, and leprosy ; it is a very common 
 
70 ILLUSTRATED SKIX DISEASES. 
 
 result of senile marasmus. Local forms of the affection occur from the action of 
 various mechanical, chemical, and physical irritants. It may originate in exposure 
 to cold, or, as is frequently the case with washerwomen, in the excessive use of 
 water and alkaline soaps. Alcohol and alkaline solutions also cause it. 
 
 Prognosis. — This depends upon the cause. If this is removable the disease can 
 be cured ; but if the asteatosis is due to some serious malady, as cancer, or to a 
 congenital deficient development of the sebaceous glands, as in ichthyosis, or to 
 their atrophy, as in old age, the affection is incurable. 
 
 Treatment. — The cause of the asteatorrhea must be removed if possible. The 
 excessive use of water must be avoided, and a superfatted soap substituted for the 
 alkaline and irritant varieties. We have no means at our disposal to increase the 
 sebaceous secretion, and we can therefore only attempt to supply its deficiency by 
 external applications. Any of the various animal fats, almond-oil, cod-liver oil, or 
 olive-oil may be used for the daily inunction. Ungt. aq. rosae, cold-cream, is use- 
 ful. Adeps lanae, with vaseline (No. 26, p. 70), or the salol-menthol oil (No. 27, 
 p. 70) may be employed with advantage. 
 
 No. 26. Simple Ointment. No. 27. Salol-Menthol Oil. 
 
 3: Adip. lanae . 
 Petrolati 
 01. rosae. 1 part 01. oliv. . . . aa. part. aeq. 
 
 Glycerin is an excellent application, but it must be used diluted with water. 
 Pure glycerin is not only an irritant, but it still further dries the skin by abstracting 
 water from it. In bad cases washing must be stopped entirely for a time, and Las- 
 sar's paste (No. 2, p. 43) should be used freely on the affected parts. 
 
 50 parts 
 
 $ Salol 
 
 50 " 
 
 Menthol 
 
 1 part 
 
 01. oliv. 
 
CLASS H. 
 
 NON-INFLAMMATORY CIRCULATORY 
 DISTURBANCES. 
 
 In this class we place the various affections that are characterized by changes in 
 the normal distribution of blood in the skin, but unaccompanied by any inflamma- 
 tory phenomena, and not followed by scaling. When they occur, as is frequently 
 the case, as the first stage of various inflammatory affections they belong to the 
 following class. It includes the hyperemias, anemias, cedemas, and hemorrhages of 
 the skin. 
 
 HYPEREMIAS. 
 
 These are diffused or circumscribed reddenings of the skin due to the presence 
 of an abnormal quantity of blood in its vessels. They are dependent on circulatory 
 disturbances of vasomotor origin. They appear as spots or patches of varying size, 
 discrete or confluent, and ranging in color from a delicate pink to a dark, purplish 
 red. It is characteristic of them that their redness can be temporarily removed by 
 pressure, showing that the congestion is located in the vessels of the superficial 
 capillary plexus. We distinguish between acute or arterial hyperemia, with quick- 
 ened circulation and heightened blood-pressure, and passive or venous hyperemia, 
 with lessened pressure and slowed current. The arterial hyperemias include the 
 various forms of simple erythema and roseola, though the latter is rather an exter- 
 nal symptom of various internal circulatory disturbances than a distinct cutaneous 
 affection. 
 
 ACTIVE ARTERIAL HYPEREMIA. 
 
 ERYTHEMA SIMPLEX. 
 
 Synonyms. — Rose-rash, erytheme (Fr.), Hautrote (Ger.). 
 
 Definition. — Various-sized, diffuse or circumscribed, non-elevated, reddish or 
 purplish patches, disappearing on pressure. 
 
 Symptoms and Course. — Erythema simplex appears as non-elevated spots or 
 
 71 
 
72 illustrated skin diseases. 
 
 macules, varying from pin-point size to large, irregular blotches. The entire 
 body or only certain special regions may be affected. Their color may be faint 
 red-pink, or deeper red, or bluish; and, not being elevated above the level of the 
 skin, the spots cannot be distinguished by the touch. They are sometimes discovered 
 only accidentally, since they are often unaccompanied by any subjective sensations 
 whatsoever; but burning or itching may be present. They last for a few hours, 
 days, or weeks, and they disappear without leaving pigmentation or being followed 
 by desquamation. Special varieties of erythema simplex are the following: 
 
 1. Erythema traumaticum, from continued pressure, as of tight bandages, or 
 of the clothing, or from friction of any kind, or from the irritation of the finger- 
 nails. It appears as a diffuse redness limited to the part involved, and usually of 
 short duration ; for it disappears quickly when its cause is removed. If this does 
 not occur, however, it may go on and become a dermatitis. 
 
 2. Erythema solare, caused by the action on the skin of the ultra-violet rays of 
 the sun and electric light. It occurs among the workmen in electric-light factories, 
 and in tourists, more especially among the mountain-climbers who are exposed to 
 the reflected light from the snow as well as to the direct rays. The exposed parts 
 only are affected ; and the diffuse erythema that is set up disappears with fairly 
 great rapidity when its cause is removed, but is apt to leave a lasting pigmentation 
 behind. The irritant, if too long continued, may cause the erythema to pass into a 
 true eczematous inflammation. 
 
 3. Erythema caloricum is due to the action of a high or a low temperature upon 
 the skin. It is more diffused and may affect parts covered by the clothing. 
 
 4. Erythema venenatum. Here the irritant may be directly applied to the 
 skin, or it may reach that organ through the circulation after having been taken 
 into the stomach. The results of the local application of cantharides, mustard, 
 pepper, etc., are examples of the first variety; and the erythematous medicinal 
 rashes following the ingestion of quinine, belladonna, copaiba, and many other drugs, 
 as well as those following the eating of oysters, shrimps, strawberries, etc., are ex- 
 amples of the second. Personal idiosyncrasy plays an all-important part in this 
 latter variety of erythema. 
 
 5. Erythema symptomaticum. This occurs from various internal causes, and 
 more especially during the course of the infectious diseases. It is a reflex from the 
 central nervous system. Thus we have the erythema that occurs during sup- 
 puration ; the erythema vaccinicum, so commonly seen in infants after vaccination ; 
 the erythema variolosum that marks the suppurating stage of smallpox ; the ery- 
 thema cholericum that appears in the convalescent stage of cholera ; and the erythe- 
 mas of typhoid fever, of diphtheria, and of malaria. Erythema infantilis occurs in 
 young children in connection with various febrile conditions, more especially with 
 derangements of the gastro-intestinal tract ; from its short duration it is called also 
 erythema fugax. In all these forms of the affection the macules are of fairly large 
 
NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 73 
 
 size, and by their coalescence frequently cover extensive areas of the skin with a 
 diffuse redness. In erythema scarletiniforme, however, one of the commonest forms 
 of the malady, the redness is punctate and closely resembles that of scarlet fever. 
 It occurs after surgical operations, in uremia, septicemia, acute rheumatism, and 
 many other conditions. When the spots are pea-sized and generally distributed over 
 the body they have been termed roseola ; but this has been largely abandoned as a 
 specific designation. 
 
 Pathology. — The dilatation of the blood-vessels does not persist after death, and 
 erythema simplex has practically no • pathology. The occurrence of permanent 
 changes in the vessels and tissues would place the case in question in another class 
 of diseases. 
 
 Diagnosis. — The diagnosis of erythema simplex depends on its fugacity, the pos- 
 sibility of causing the macules to disappear temporarily by pressure, and the absence 
 of any signs of inflammation of the skin. The non-appearance of general symp- 
 toms, of temperature, gastric and intestinal disturbance, coryza, etc., will prevent 
 our confounding it with the specific exanthemata of the infectious diseases. 
 
 Treatment. — This consists essentially in removal of the cause of the affection ; 
 local treatment is rarely necessary. In erythema solare prophylaxis is the chief 
 thing; Jessner recommends the application of quinine in solution or of glycerin to 
 the exposed parts in those subject to it. In erythema scarletiniforme alkaline and 
 bran baths are useful. Cold-cream and dusting powders (Nos. 15, 16, p. 58, No. 18, 
 p. 61) are useful in all cases; alkaline solutions of borax or washing powder may 
 be employed with benefit before they are applied. 
 
 PASSIVE VENOUS HYPEREMIAS. 
 LIVEDO. 
 
 Definition. — A circumscribed or diffused dark, bluish-red discoloration of the 
 skin, disappearing on pressure. 
 
 Symptoms and Course. — The affected skin is cold, and is either uniformly dis- 
 colored or mottled with bluish or purple spots removable by pressure. If too long 
 continued, permanent dilatation of the veins, oedema, blood-extravasations, and even 
 local gangrene (decubitus) may occur. The subjective symptoms are coldness of 
 the part, with formication, prickling, and other disturbances of sensibility. The ex- 
 tent of the livedo depends on the size and the situation of the vessel affected ; the 
 smaller and the nearer the periphery it is, the less its size. A central venous ob- 
 struction or one affecting one of the larger vessels gives rise to the general lividity 
 known as cyanosis, a condition whose discussion belongs to the domain of general 
 medicine. 
 
 Pernio or chilblain is a variety of livedo. It appears as dusky-red, livid patches 
 
74 ILLUSTRATED SKIN DISEASES. 
 
 of skin on the fingers, nose, toes, heel, or external border of the foot, and is seen 
 most often in children and in old persons with poor circulations. Subjectively 
 there is tenderness, itching, and burning; and the local process may go on to vesicu- 
 lation, ulceration, and even superficial sloughing. 
 
 Etiology. — The obstacle to the venous reflux which causes the passive conges- 
 tion is usually mechanical in its nature. Paralysis of the vessel or disease of ils 
 walls, thrombosis, embolism, or pressure, as by the bed or a tumor, etc., are the 
 usual causes. 
 
 Treatment. — This consists, above all, in the removal of the cause of the hypere- 
 mia, if it can be found. Bandages may be employed to support the dilated veins, 
 and elevation of the part affected will favor the return flow of blood through the 
 veins. Massage and friction of the part are useful. Ergot is of some benefit to 
 stimulate the muscular structure of the vessels. 
 
 In the treatment of chilblains we must attempt to stimulate the stagnant circu- 
 lation by frictions with camphorated oil or linimentum ammoniac, combined with 
 brisk exercise and a suitable and warm clothing of the part affected. Iodine oint- 
 ment, or the tincture of iodine, preferably discolorized by the addition to it of half 
 its amount of aqua ammonia, is a useful application, as is also the ointment recom- 
 mended by Sack (No. 28, p. 74). If the surface is broken and ulceration has oc- 
 curred, boracic-acid ointment (No. 29, p. 74) can be employed. 
 
 No. 28. Sack's Camphor Ointment. No. 29. Boracic-acid Ointment. 
 
 R Balsam. Peruv. . . 1 part R Ac. boric. ... 1 part 
 
 Camphor, trit. . . 2 parts Adip. lanae ... 3 parts 
 
 01. amygdal. . . . 16 " Adip. suillis ... 4 " 
 
 Adip. lanae 
 
 Aq. rosae . . aa. 20 " 
 
 ANEMIAS. 
 
 General anemia of the skin, due to the blood-changes of excessive hemorrhage, 
 anemia, chlorosis, leucemia, etc., is a symptomatic affection whose consideration 
 belongs to general medicine. Circumscribed anemia, characterized by blanching of 
 the skin, decrease of temperature, and cold sweat, may occur from spasm of the 
 cutaneous vessels, or from their occlusion by an embolism or through stretching. 
 None of these conditions causes dermal changes of sufficient importance to notice 
 here. 
 
 CEDEMAS. 
 
 Diffuse and generalized oedema of the skin or anasarca occurs as a symptom in 
 various internal diseases. Of the circumscribed cedemas, urticaria and prurigo de- 
 mand our attention. 
 
COPYRIGHT BY E. B. TREAT 4 CO. , N. Y. 
 
 PHOTOGRAVURE 4 COLOR CO., N. Y. 
 
 URTICARIA 
 
 PLATE II 
 

 Synom, . 
 Definition,- 
 or reddish w 
 
 Symptoms and 
 
 ache, an 
 skin, th 
 
 aa) 
 of a redd i- 
 ble 
 sting of th 
 
 is, from 
 the common n 
 rived. Th< 
 ing from on 
 they disappeai 
 leaving 
 maj 
 
 •o cover a ; 
 they are never 
 the 
 mucosje are not exempt 
 
 tract m 
 
 ritant mate 
 it. And while ■' 
 and disapp' 
 the dise 
 
 r ions and 
 A 
 
 coal esc 
 
 - 
 
 
 
 i 
 
 
NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 
 
 75 
 
 URTICARIA. 
 
 Synonyms. — Hives, nettle-rash, Ncsselcmsschlag (Ger.), urticaire (Fr.). 
 
 Definition. — An eruption characterized by the appearance of ephemeral white 
 or reddish wheals, accompanied by intense pruritus and burning. 
 
 Symptoms and Course. — The outbreak of an attack of urticaria is frequently 
 ushered in by symptoms of gastric disturbance, anorexia, nausea, malaise, head- 
 ache, and a moderate fever. Then, preceded perhaps by burning and tingling of the 
 skin, there suddenly appear wheals, firm, circumscribed, convex elevations of the 
 skin, usually oval or rounded in shape and 
 of a reddish or whitish color. They resem- 
 ble very closely the lesions caused by the 
 sting of the common nettle, the Urtica 
 urens, from which both the scientific and 
 the common name of the disease are de- 
 rived. They are always ephemeral, last- 
 ing from one to a number of hours ; and 
 they disappear without desquamation, 
 leaving no trace upon the skin. They 
 may be few in number, or so numerous 
 as to cover a great part of the body, but 
 they are never symmetrical. Any part of 
 the integument may be affected, and the 
 mucosae are not exempt ; the mouth, phar- 
 ynx, air-passages, and gastro-intestinal 
 
 tract may be involved, as is shown by the dyspnoea and vomiting that not infre- 
 quently precede the outbreaks of cutaneous urticaria caused by the ingestion of ir- 
 ritant materials. It occurs at all periods of life, but children are especially prone to 
 it. And while the individual lesions are extremely fugacious, coming out suddenly 
 and disappearing with almost equal rapidity, successive recurrent attacks may make 
 the disease a chronic one if the irritation that causes it continues to act. The wheals 
 sometimes occasion burning and tingling; but itching is the prominent subjective 
 symptom, and it is usually so severe that the patient's body is marked with exco- 
 riations and scratch-marks long after the individual wheals or the whole eruption 
 has disappeared. 
 
 A number of subvarieties of urticaria may be mentioned. Thus we have 
 urticaria annularis when the wheals occur in rings ; urticaria gyrata and urticaria 
 figurata when they appear as irregular circular or crescentic forms due to the 
 coalescence of adjacent lesions. Occasionally the wheals are red, giving us urti- 
 caria rubra; more frequently the white form, urticaria alba, is present. When 
 the wheals are very large, perhaps equaling a hen's egg in size, we have urticaria 
 
 FlG. 33. — Urticaria gyrata. 
 From a photograph in the author's collection. 
 
76 
 
 ILLUSTRATED SKIN DISEASES. 
 
 tuberosa or gigantica. Urticaria chronica differs from urticaria acuta, as before 
 said, only in the appearance of successive lesions for a long period of time. More 
 important are the following varieties: 
 
 1. Urticaria papulosa, the equivalent of the lichen urticatus of the older writers. 
 This occurs in ill-nourished children with faulty digestions, and is a combination of 
 the features of the wheal and the papule. The wheals are pea- to bean-sized, and 
 are accompanied by intense itching. The child uses its finger-nails freely, and the 
 torn papules tipped with blood-crusts, with the excoriations and pustules due to 
 secondary infection, may remain long after the original lesion has vanished. 
 
 2. Urticaria vesiculosa and urticaria bullosa are rarer, especially the latter. 
 Here the oedema is sufficient to cause an accumulation of fluid under the epidermis, 
 
 so that the wheal is tipped 
 with a vesicle or a bleb 
 The affections may even be 
 mistaken for herpes or pem- 
 phigus if seen after the oede- 
 ma has subsided. 
 
 3. Urticaria factitia is ; 
 form of the malady that ma\ 
 be excited at will in cases 
 where there is excessive 
 irritability of the cutaneous 
 nerves. The application of 
 any irritant to the skin causes 
 the appearance of a wheal 
 corresponding in shape and 
 extent to the dermal area in- 
 volved. The scratch of a 
 finger-nail results in a white 
 stripe, that turns first red, 
 then white again, and finally 
 develops into a regular urti- 
 carial wheal. 
 
 4. Urticaria hemorrha- 
 gica, called also purpura urti- 
 cans, where there is an effu- 
 sion of blood as well as serum 
 
 from the vessels, appears as a wheal with a hemorrhage in its center. An ecchy- 
 mosis is left behind when the urticaria disappears. 
 
 5. Urticaria pigmentosa is a rare form of the disease, cases of which have been 
 described by Morrow and others. It is an extremely chronic form, the wheals be- 
 
 Fk;. 34. — Urticaria factitia. 
 From a photograph in the author's collection. 
 
NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 
 
 il 
 
 ginning in early or even in intra-uterine life ; they are very persistent, and brown- 
 ish red in color ; and they leave pigmented spots behind. 
 
 Etiology. — Urticaria is due to disturbances of the vasomotor nerves, occurring 
 either directly or by reflex action, giving us the idiopathic and the symptomatic forms 
 of the disease. Such disturbances occur from a 
 great variety of causes. Idiopathic urticaria is 
 caused by the bites and stings of insects, mosqui- 
 tos, bedbugs, lice, bees, wasps, etc. Leech bites, 
 nettle stings, and contact with jellyfishes will 
 also cause it. Direct mechanical violence will 
 occasion its appearance, as will also certain medi- 
 cinal substances. Symptomatic urticaria is the 
 form most frequently met with, and is commonly 
 dependent on digestive disturbance. Among the 
 things that cause it are lobsters, clams, and vari- 
 ous kinds of fish ; strawberries, gooseberries, and 
 other fruits ; cucumbers, mushrooms, oatmeal, 
 peas, beans, garlic, salad, etc. ; beer and alcoholic 
 beverages. Sausage seems to be an especially 
 frequent cause ; and Singer found that in many 
 of these cases there was a marked increase in 
 number of the normal bacteria of putrefaction of 
 the lower intestine. Various medicines used in- 
 ternally, as the balsams, arsenic, salicylic acid and 
 the salicylates, quinine, chloral, opium, turpen- 
 tine, and the iodide of potassium, will cause it. 
 Moral emotions, shame, fear, and anger, some- 
 times provoke an attack. Urticaria also occurs 
 frequently in the course of rheumatism, purpura, 
 prurigo, and pemphigus, and in the prodromal 
 stages of the acute exanthemata. 
 
 Sometimes no efficient cause for the urticaria 
 can be found, more especially in the chronic 
 cases. Personal idiosyncrasy performs an all- 
 important part in its causation, and substances 
 that give no trouble at all to most people invari- 
 ably cause an attack of urticaria in those suscep- 
 tible to their noxious influences. 
 
 Pathology. — The pathology of urticaria, as found by Neumann, Vidal, and 
 others, consists simply in a circumscribed oedema marked by serous effusion into the 
 papillary body and the rete. Under the influence of the vasomotor nerves there 
 
 Fig. 35.— Urticaria pigmentosa. 1 
 
 Professor Elsenberg's case, Warsaw, Russia. 
 
IS 
 
 ILLUSTRATED SKIN DISEASES. 
 
 occurs capillary spasm, followed by paralytic dilatation and transudation of serum. 
 The white color of the center of the wheal is caused by the greater pressure of the 
 effusion at that point. 
 
 Diagnosis. — Urticarial wheals when present are usually too characteristic to be 
 mistaken for anything else. The points to be noted are the rapid appearance, the 
 short duration, the itching and stinging, the rapid subsidence without desquama- 
 tion, and the possibility of producing an urticaria factitia by irritating the skin. It 
 can be distinguished from scabies by the absence of burrows and the non-involve- 
 ment of the finger-clefts and other characteristic localities ; but it must not be for- 
 gotten that it sometimes occurs in conjunction with that disease. In erythema sim- 
 plex the patches are larger, more diffuse, and have no whitish centers. When the 
 urticarial wheals coalesce, especially upon the face, the condition may resemble an 
 erysipelas ; but the itching, evanescence, absence of a definite point of origin and 
 of constitutional symptoms will serve to prevent mistake. 
 
 No. 30. Saline draught. 
 
 fy. Magnes. carb. 
 Magnes. sulph. 
 Aq. menth. pip. 
 
 i part 
 2 parts 
 16 " 
 
 No. 32. Menthol Capsules. 
 
 fy Menthol .... 
 01. amygdal. 
 
 In caps, gelat. 
 
 g«. 4 
 
 No. 31. Atropia Pills. 
 
 5: Atropia sulph. . . gr. yi 
 
 Glycerin 
 
 Aquae . . . . . aa. 3i 
 Gum. tragacanth. . . . q. s. 
 M., et ft. pil. No. 20. 
 
 No. 33. Saalfeld's Menthol Lotion. 
 
 fy Menthol 
 Alcohol 
 
 5 parts 
 
 100 
 
 No. 34. Carbolic Spirit. 
 
 fy Ac. carbolic 
 Alcohol . 
 
 3 parts 
 ioo " 
 
 No. 35. Chloral Lotion. 
 
 # Chloral 
 
 Aq. laur. cer. 
 Aq. dest. 
 
 3 parts 
 5o '* 
 200 " 
 
 No. 36. Chloral- Camphor Ointment. 
 
 fy Chloral 
 Camphor. 
 
 Misce, et adde 
 Glycerin. 
 Ungt. simpl. 
 
 aa. 1 part 
 
 2 parts 
 16 " 
 
 Prognosis. — The acute form of the disease always gets well in a few days ; but 
 the prognosis of the chronic form depends on the possibility of ascertaining and 
 removing its cause. The papular urticaria of children is frequently a very obstinate 
 malady, getting better in the winter, but recurring during the warm weather. 
 
 Treatment. — The treatment of urticaria in its more refractory varieties is entirely 
 
NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 79 
 
 empirical. For the acuter and fugacious forms it suffices to find out and remove 
 the cause. If, as is usually the case, it is located in the gastro-intestinal canal and 
 has not yet left the stomach, a mild emetic, ipecac or mustard, is sufficient. This 
 should be followed by a saline cathartic (No. 30, p. 78) or one of the mineral waters. 
 The bowels being thus regulated, they should be kept in order Math small quantities 
 of rhubarb and soda; and salol in doses of 5 grains may be administered several 
 times daily with advantage. 
 
 The treatment of the more chronic forms of urticaria is often a difficult and 
 perplexing task. The underlying cause is frequently undiscoverable or irremovable. 
 If rheumatism or gout is present the alkalis and colchicum are in order. Any 
 concomitant disease of the internal organs, and more especially of the uterus, must 
 be treated. Of the internal remedies, atropia, pilocarpine, menthol, and arsenic are 
 the most useful. Atropia is recommended by Schwimmer in doses of ^20 °f a 
 grain (No. 31, p. 78). Arsenic may be given in the form of the Asiatic pill (No. 6, 
 p. 46), or as Fowler's solution, 4 to 10 drops in water three times daily. Joseph 
 reports good results from the use of menthol (No. 32, p. 78). Pilocarpine is rec- 
 ommended by Pick. The bromide of potash in large doses has accomplished good 
 results in my hands ; and so have the salicylate of sodium, 1 to 2 drams daily, anti- 
 pyrin, 15 to 45 grains daily, and the iodide of potassium, 15 to 90 grains daily, in 
 those of others. 
 
 Local treatment is of great importance, for the patients demand relief from the 
 intolerable itching. This can be accomplished by dusting the surface freely with 
 flour, or by the application of compresses wrung out in cold water. Any of the 
 antipruritic lotions and powders recommended for pruritus may be useful (Nos. 11, 
 12, p. 56, No. 17, p. 61, No. 27, p. 70). Alkaline, bran, or starch baths are service- 
 able. Sponging the surface with vinegar and water or with a strong solution of 
 baking-soda is valuable. Saalfeld recommends menthol in alcoholic solution (No. 33, 
 p. 78) sprayed or dabbed on the affected parts. Carbolized alcohol (No. 34, p. 78) 
 may be employed. Finally, chloral in the form of a lotion (No. 35, p. 78), or together 
 with camphor as an ointment (No. 36 p. 78), is one of our most efficient antipruritics. 
 
 Intractable cases are sometimes benefited by change of air, a sea voyage, or 
 a course of mineral waters at Saratoga, Vichy, etc. 
 
 PRURIGO. 
 
 Synonyms, — Juckfleckte (Ger.), strophulus prnrigineux (Fr.). 
 
 Definition. — A chronic affection characterized by the appearance of small, pin- 
 head-sized, whitish or pinkish resistant papules, with general thickening and pig- 
 mentation of the skin and intense pruritus. 
 
 Symptoms and Course. — This malady, first differentiated and described by the 
 elder Hebra, while fairly common in Austria and certain other parts of Europe, is 
 
80 
 
 ILLUSTRATED SKIN DISEASES. 
 
 extremely rare in England and in this country. A few American cases have, how- 
 ever, been reported by Wigglesworth, Campbell, and others, and it is probable that 
 
 the milder forms of the dis- 
 ease occur here with greater 
 frequency than is generally 
 recognized. 
 
 The malady always begins 
 during the first or second year 
 of life, making its appearance 
 as an urticaria most commonly 
 of the papular variety, lichen 
 urticatus. Sooner or later 
 there appear small, millet- 
 sized, deep-seated, firm pap- 
 ules covered with normal skin. 
 They occur first on the exten- 
 sor surfaces of the limbs ; the 
 trunk may be invaded later; 
 but the palms, soles, and face 
 are always exempt. The in- 
 ner surfaces of the joints are 
 also unaffected. The papules 
 may be quite colorless, so that 
 they are hardly visible, or 
 they may have a faint rosy 
 tint ; but they can always be 
 readily felt, and the skin in a 
 well-developed case feels like 
 the surface of a nutmeg- grater. 
 After they have existed for 
 some time the skin becomes 
 markedly thickened, its furrows are exaggerated, and a brown discoloration due to 
 blood-pigment replaces the normal hue of the integument. The neighboring lym- 
 phatic glands enlarge, forming the so-called "prurigo buboes." 
 
 Itching is the predominant subjective symptom, and has given a name to the 
 disease. The impetus scabendi is so intense that resistance to it is out of the 
 question. The patient must scratch, no matter where he is ; and he tears off the 
 tops of the papules and lacerates his skin in the attempt to relieve himself. Hence 
 arise excoriations, blood effusions and crusts, and inflamed areas, secondary appear- 
 ances that may almost mask the original disease. At night the itching is especially 
 severe, and causes obstinate insomnia ; but the attacks come on at other times, and 
 
 Fig. 36. — Prurigo. 
 After Van Haren-Noman. 
 
NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 81 
 
 render the patient unfit for society, for marriage, and for most of the ordinary avo- 
 cations ; they have even driven him to suicide. 
 
 Once firmly established, the malady usually lasts for life, becoming worse dur- 
 ing each winter season. But the cases vary much in severity, and we distinguish 
 between prurigo ferox or agria, to which the above description more especially ap- 
 plies, and the milder form of the disease, known as prurigo mitis. 
 
 Etiology. — The cause of the disease is unknown. It was formerly supposed to be 
 especially common among the poorest classes, where improper nutrition and faulty 
 hygiene are the rule ; but later investigators (Joseph and others) have found it just 
 as frequently among the healthy and the well nourished. 
 
 Pathology. — The papules are due to exudation and cell-infiltration in the rete 
 and the papillary body. The thickening of the skin that is so marked in old cases 
 is due to increase of the corneous layer, and the pigment in the rete is greatly in 
 excess of the normal amount. The erector muscles of the hairs are hypertrophied 
 and the sweat-glands are enlarged, while the sebaceous glands are atrophied. 
 
 Diagnosis. — The deep-seated, hard papules, irregularly distributed over the 
 body and most numerous on the extensor surfaces of the limbs, and the beginning 
 of the malady in early life, are characteristic points and will facilitate the diagnosis. 
 Eczema has no characteristic nodules, is vesicular, pustular, moist, or crustaceous, 
 and affects by preference the flexor surfaces. Pruritus is very common and also has 
 no nodules or thickening of the skin, and no local lesion save from the scratch effects; 
 it begins at any age and is quite indeterminate in its locality. Scabies has its favorite 
 location on the hands and genitals, and has the characteristic burrows. In phtheiriasis 
 the presence of the parasite and the absence of the papules will serve to prevent mistake. 
 
 Prognosis. — Prurigo mitis is curable, and prurigo ferox can be relieved. The 
 opinion of Hebra as to the absolute intractability of the disease is no longer held. 
 
 Treatment. — Attention to the general health is of the greatest importance, and 
 fresh air, exercise, change of scene, and regulation of the digestive and other func- 
 tions must be the basis of our treatment. Children should sleep in tightly closed 
 flannel night-garments, and their hands should be bound up if necessary. Iron, 
 quinine, and more especially cod-liver oil are indicated. Of internal remedies 
 ergotine in 3- to 15-grain and bromide of potassium in 15- to 90-grain doses are 
 perhaps the most useful. Pilocarpine, either hypodermically or by the mouth, has 
 done good in some cases. 
 
 Externally, hot water and soft soap in abundance are necessary with any treatment. 
 The naphthol method introduced by Kaposi is perhaps the best. A 3- to 10-per- 
 cent. naphthol ointment (No. 37, p. 82) must be vigorously rubbed into the affected 
 skin daily for from four to eight days ; meantime the surface must not be washed, 
 and the patient can take a bath only when the peeling that results has set in. Pro- 
 longed sulphur baths (for one half to one hour) taken several times weekly, and fol- 
 lowed each time by the naphthol ointment (No. 37, p. 82) or a chloral-camphor salve 
 
82 ILLUSTRATED SKIN DISEASES. 
 
 (No. 36, p. 78), are efficacious. Tar baths or painting the parts with tar spirit (No. 
 10, p. 56) is recommended. Sulphur and tar, preferably in the form of Wilkinson's 
 ointment (No. 38, p. 82), is a favorite remedy, as are frictions with cod-liver oil used 
 persistently for long periods of time. 
 
 No. 3/. Kaposi's Naphthol Ointment. No. 38. Wilkinson's Ointment. 
 
 ft Naphthol . 
 Sapo. virid. . 
 Petrolati 
 
 5 parts 
 
 ft Sulphur, sublim. 
 
 
 30 " 
 
 01. cadin. 
 
 aa. 4 parts 
 
 60 " 
 
 Cret. prsep. 
 Sapo. virid. 
 
 5 " 
 
 
 Adipis . 
 
 . aa. 16 " 
 
 The intervening eczemas, dermatites, ecthymas, etc., must be treated appropri- 
 ately. Since in any case the treatment must be long continued, it is well to change 
 from one to another of the above from time to time. And, in view of the extreme 
 chronicity of the malady and the great tendency to relapses, a careful toilet of the 
 skin and attention to its hygiene must be persisted in for life. 
 
 HEMORRHAGES. 
 
 Under this heading we class the various affections in which blood is present in 
 the skin outside its normal position in the vessels. This may occur through rupture 
 of the cutaneous vessels (rhexis), the skin itself remaining intact or not, or through 
 diapedesis, the serum and corpuscles exuding through the apparently unbroken ves- 
 sel wall. In either case the effused blood forms a sharply limited discoloration, 
 which is not removable by pressure, and which undergoes the characteristic hematin 
 color-changes, red, purple, yellowish-green, and brown, before it is finally absorbed. 
 It is situated either between the layers of the epidermis or more deeply in the co- 
 rium and the papillae. When the spots are rounded, oval, or irregular, non-elevated, 
 and from pinhead to finger-nail in size, they are known as petechise ; longer and 
 narrower effusions are vibices ; larger, rounded, non-elevated patches are ecchy- 
 moses; while ecchymomata are extensive, deep-seated, flat or raised tumors. 
 
 Cutaneous hemorrhages occur from the most moderate traumatisms in those 
 affected with hemophilia (bleeders). This is an affection whose etiology and pa- 
 thology is unknown, but which seems to be hereditary, and which occurs in people 
 apparently otherwise perfectly healthy. Hemorrhages occur in any one as the result 
 of traumatism, and usually go on to absorption. In exceptional cases only do they 
 cause a reactive inflammation with casting off of the necrosed parts. In both vari- 
 eties rest, the application of cold compresses, and later massage is the appropriate 
 treatment. A symptomatic and secondary dermal hemorrhage occurs in certain 
 cutaneous diseases (pemphigus, ecthyma, parenchymatous dermatitis) and in some 
 general diseases (pyemia, diphtheria, smallpox, etc.). 
 
 In two affections, however, purpura and scurvy, cutaneous hemorrhage is the 
 prominent and sometimes the only symptom. 
 
COPYRIGHT, BV F. B. TREAT & CO., N. Y. PHOTOGRAVURE A COLOR CO., N. Y. 
 
 PURPURA 
 
 PLATE V. 
 

 
 Synonyms, 
 
 Definition.— 
 
 or purplish I 1 
 
 Symptoms and Cou ura are 
 
 sudder. app 
 Fever, general 
 and 
 
 presence and 
 four forms of tl ■ 
 
 I. Purpura im 
 
 are frequently dis 
 pea- 
 trunk and u] 
 They sometime 
 Purpura 
 potassium, a 
 
 the usual r< 
 
 more 
 
 diameter. I 
 
 genito-i. 
 
 hemorrhagei 
 
 the 
 
 of the eruption 
 
 orifices may 
 
 • 
 li 
 
 th 
 
 size and 
 
 ■ 
 
 head- to 
 
 ■ 
 
 i 
 
 hiae apt 
 
 • natients 
 
 both int 
 
 e hemorrl 
 
 h muo 
 
 n. There i 
 
 e frequent. The affecti< 
 i often se 
 
 ■ 
 
: 
 
NON-INFLAMMATORY CIRCULATORY DISTURBANCES. 83 
 
 PURPURA. 
 
 Synonyms. — Blutfleckenkranklieit (Ger.), purpura (Fr.). 
 
 Definition. — Purpura consists in the appearance of various-sized, flat or raised, 
 red or purplish hemorrhagic patches, not disappearing on pressure. 
 
 Symptoms and Course. — All the varieties of purpura are characterized by the 
 sudden appearance of hemorrhagic spots in the skin of varying size and shape. 
 Fever, general malaise, pains in the limbs and joints, gastro-intestinal disturbances, 
 and gingivitis may or may not accompany the outbreak. In accordance with the 
 presence and severity, or absence, of these concomitant symptoms, we distinguish 
 four forms of the malady : 
 
 1. Purpura simplex. Here the constitutional symptoms are very slight or ab- 
 sent, and the hemorrhages small in size and comparatively few in number. They 
 come on quite suddenly, often at night ; and, as they cause no inconvenience, they 
 are frequently discovered only by accident. They appear as bright-red, pinhead- to 
 pea-sized spots, occurring first and most abundantly on the lower extremities ; the 
 trunk and upper extremities are more slightly affected, and the face remains free. 
 They sometimes show a distinct tendency to become urticarial (purpura urticans). 
 Purpura simplex has been seen after the use of quinine, salicylic acid, iodide of 
 potassium, and other drugs, but its cause is frequently undiscoverable, and it occurs 
 most commonly in healthy individuals. The malady is self-limited ; the spots undergo 
 the usual retrogressive color-changes, and the affection ends in two to three weeks. 
 Successive crops of eruption may, however, prolong it for some time. 
 
 2. Purpura hemorrhagica, known also as morbus maculosus Werlhofii and land- 
 scurvy. This is a much more serious malady, with marked general symptoms and 
 more extensive hemorrhages. The fever is high and is accompanied by headache, 
 anorexia, nausea, constipation, and pains in the limbs. The petechiae appear sud- 
 denly, and are larger than those in the simple variety, being frequently an inch in 
 diameter. Petechiae appear also in the nasal, buccal, bronchial, gastro-intestinal, and 
 genito-urinary mucous membranes, and, the epidermis being thin and readily removed, 
 hemorrhages are very liable to occur. In most cases the patients get well, though 
 the disease may be prolonged for many weeks by the outbreak of successive crops 
 of the eruption ; but the loss of blood both into the skin and through the mucous 
 orifices may be so severe as to cause collapse and death. 
 
 3. Purpura rheumatica or peliosis rheumatica. Here the hemorrhages into the 
 skin itself are usually small, the mucosa are affected, and the joints are always 
 involved, several of them being usually red, painful, and swollen. There is marked 
 fever and lassitude, with gastro-intestinal derangement, constipation, colic, and 
 vomiting. Hematuria and albuminuria are frequent. The affection appears epi- 
 demically in the spring and autumn, and is often seen in conjunction with erythema 
 multiforme and erythema nodosum, which has led some authorities to classify it with 
 the polymorphous erythema, and others (Joseph) to regard it as an infectious disease. 
 
84 
 
 ILLUSTRATED SKIN DISEASES. 
 
 4. Purpura scorbutica or scurvy. This formerly common malady is now rarely 
 seen, thanks to improved methods of hygiene and feeding. Growing anemia and a 
 gradually increasing depression of the general health precede the appearance of the 
 cutaneous hemorrhages, which may take the form of petechias, vibices, sanguineous 
 bullae, ecchymoses, and ecchymomata : while intramuscular and subseral blood-effu- 
 sions also occur. Slight inju- 
 ries to the affected skin lead to 
 gangrene and the formation of 
 scorbutic ulcers, with spongy 
 bleeding bases, and showing 
 little tendency to heal. The 
 danger of internal hemorrhages 
 is not so great as in the other 
 forms, but hematemesis does 
 occur, as also albuminuria, 
 hemorrhagicpleurisy, and per- 
 icarditis, pneumonia, and in- 
 flammations of the joints. The 
 gingivitis that accompanies the 
 affection is characteristic. The 
 gums are swollen, soft, spongy, 
 and covered with a dirty gray- 
 ish coating. They bleed easily, 
 and there is marked fetor ex 
 ore. 
 
 Etiology. — The cause of 
 purpura is in many cases undis- 
 coverable. It occurs, however, 
 secondarily to certain blood- 
 alterations, as in the specific 
 fevers, typhus, typhoid, vari- 
 ola, etc.; in snake-poisoning; 
 after the use of certain drugs, 
 as iodine, quinine, copaiba, bel- 
 ladonna, mercury, and others ; 
 in scurvy, leucocythemia, pernicious anemia, chronic kidney and cardiac disease. 
 Personal idiosyncrasy undoubtedly plays a large part in its production. In purpura 
 simplex there is most often no cause discoverable; the patients are often in the best 
 of health. Purpura hemorrhagica is apparently dependent on bad hygiene and im- 
 proper diet. Purpura rheumatica is related to erythema multiforme, and its cause is 
 similarly obscure. Purpura scorbutica is probably microbic in origin, though faulty 
 
 Fig. 37. — Purpura simplex. 
 From photograph in the author's collection. 
 
NON-INFLAMMATORY CIRCULATORY DISTURBANCES. . 85 
 
 nutrition and the want of fresh food, especially of vegetables, and the absence of fresh 
 air furnish the necessary conditions for its development. It was formerly common 
 on shipboard and in penal and other institutions where large bodies of men were 
 kept under unhygienic conditions. 
 
 Pathology. — The pathological process consists in a simple hemorrhage unattended 
 by inflammation ; the blood is effused in the papillary bodies or in the subcutis, and 
 the vessels from which it comes may or may not be ruptured. It forms a foreign 
 body that is slowly removed by absorption. Lardaceous and inflammatory changes 
 of the vessel walls have been noted in some cases, while in others thrombosis or 
 embolism has been found. 
 
 Diagnosis. — This is rarely attended with any difficulty. The sharply circum- 
 scribed spots, unaffected by pressure, can hardly be mistaken. In purpura simplex 
 there are no other symptoms. In purpura hemorrhagica the mucosae are affected 
 and internal hemorrhages occur. The joint complications are characteristic of pur- 
 pura rheumatica. Purpura scorbutica is readily recognized by the gingivitis com- 
 bined with the cutaneous hemorrhages. Inflammatory spots differ from purpuric ones 
 in their elevation, disappearance under pressure, and subsequent desquamation. 
 
 Prognosis. — This varies with the variety of the disease. In general the less frequent 
 and extensive the hemorrhages, and the less the general constitutional involvement, 
 the better the prognosis. Purpura simplex always ends in recovery, though its course 
 may be slow. Purpura rheumatica is a stubborn malady, and relapses frequently 
 occur. Purpura hemorrhagica is a dangerous and treacherous disease, and it is im- 
 possible to foretell its termination. In scurvy the prognosis is also doubtful. 
 
 Treatment. — This should be directed to the cause when that is ascertainable. 
 Absolute rest in bed is essential in all but the mild cases. The patient should be 
 kept very quiet, and care be taken that he obtains sufficient sleep. The diet should 
 be mild and composed chiefly of milk. Alcohol in moderation may be given, es- 
 pecially if the pulse is weak. Of the internal remedies ergotine in 15- to 30-grain 
 daily doses is valuable, as is also turpentine, I dram every three hours. Nitrate 
 of silver in doses of £ to ^ grain, or the tincture of the chloride of iron in full doses, 
 may be tried. In the rheumatic form cold and anodyne applications should be 
 made to the joints. Hemorrhages must be treated on general principles. Tam- 
 ponade may be necessary if they occur from the nose ; ice pills or ice- water enemata 
 when coming from the stomach or intestines. If collapse occurs, alcohol, camphor, 
 and musk should be employed, and subcutaneous and intravenous infusions of 0.5- 
 per-cent. saline solution may be required. In the scorbutic form prophylaxis by 
 means of a proper supply of fresh vegetable food and a careful attention to hygienic 
 details is the most important part of the treatment. Acids, and especially those of 
 the vegetable variety, must be freely employed (lemons and similar fruits). The 
 constitutional treatment is that suitable to anemia, and the various agents mentioned 
 above may be employed for the purpose. 
 
CLASS III. 
 INFLAMMATIONS. 
 
 1 SUPERFICIAL INFLAMMATIONS AFFECTING THE CUTIS 
 
 AND SUBCUTIS. 
 
 THIS class includes some of the exanthemata, the dermatomycoses, the dermatites, 
 catarrh of the skin (eczema), and the various forms of herpes, pemphigus, psoriasis, 
 etc. All these maladies are characterized by a superficial inflammation of a transi- 
 tory character, with circumscribed exudation and trifling tissue-changes. Many of 
 them are caused by organisms, and it seems likely that a similar etiology will be 
 finally established for others. By common consent some of them belong rather to 
 the domain of general medicine than to dermatology ; and of these the cutaneous 
 lesions alone will receive consideration. 
 
 MORBILLI. 
 
 Measles, Maseru (Ger.), rougeole (Fr.), is a specific contagious fever, character- 
 ized by catarrh of the respiratory mucous membrane and a general papular eruption. 
 After a stage of incubation lasting from nine to eleven days there occurs a catarrh 
 of the mucous membranes of the bronchi, larynx, nose, and eyes, accompanied by 
 a general febrile movement and lasting four days. Then the eruption appears, show- 
 ing first upon the cheeks or forehead, spreading thence on to the neck, chest, breast, 
 and back, and finally invading the extremities. In two or three days the body is 
 covered, and by the time that the extremities are involved the exanthem has begun 
 to fade on the parts first attacked. It appears as small, flat or slightly raised papules, 
 which tend to coalesce and form characteristic circular or crescentic figures. The 
 lesions, however, always remain more or less discrete, and they never form large 
 diffusely reddened areas. Their color is a pink or red of varying intensity, depen- 
 dent on the amount of the hyperemia; and this may be intense enough to occasion 
 capillary hemorrhages on the surface of the papules, without, however, indicating 
 
 86 
 
< 
 
 z 
 
 H 
 < 
 
 _J 
 
 <r 
 < 
 o 
 
 CO 
 
The i 
 
 po; 
 
 he al 
 
 Ge 
 
 anthem. 
 
 the face . 
 
 
 ■ 
 

 < 
 
 z 
 
 < 
 
 cc 
 < 
 
 o 
 
 CO 
 
INFLAMMATIONS. 87 
 
 an especially serious form of the disease. The rash disappears by the fourth or 
 sixth day, and with it the fever ; and it is followed by a small, fine desquamation, 
 which may be so slight as almost to escape notice. We are ignorant of the cause 
 of the disease. 
 
 The contagium is present in the blood, the secretions of the mucosae, and the 
 epidermic scales cast off during the process of desquamation. The dermic process 
 consists of an acute hyperemia, with exudation into the vascular papillae of the corium, 
 and congestion of the perifollicular plexuses of vessels. The skin eruption disappears 
 after death. 
 
 From rubeola, morbilli may be distinguished by its persistence for several days 
 and the crescentic grouping of the papules. The diagnosis from scarlatina is im- 
 portant, and is made mainly by the absence of the characteristic sore throat and the 
 discreteness of the macular or papular eruption. From variola it may be distin- 
 guished by the catarrhal symptoms, the persistence of the fever after the eruption 
 is developed, the absence of vesicles and umbilicated pustules, and the discovery of 
 the source of the contagion. The eruption of measles requires no treatment. 
 
 RUBEOLA. 
 
 German, French, or hybrid measles, Rotlieln (Ger.), rubeole (Fr.), is a conta- 
 gious disease, marked by a slight febrile movement and a general macular ex- 
 anthem. After an incubation of about two weeks there occurs a mild catarrhal 
 conjunctivitis and rhinitis lasting two or three days. The eruption then begins on 
 the face and scalp, and extends rapidly downward on to the trunk and extremities. 
 It consists of pale rosy or reddish macules, varying in size from a pinhead to a large 
 pea. By the fourth day it has disappeared, and it is not followed by any desquama- 
 tion. Fever may be absent. It requires to be distinguished from measles, scarla- 
 tina, and the syphilitic roseola. The macules differ from those of measles in that 
 they are paler, more discrete, and not crescentic ; the duration of the disease is 
 shorter, and its course is milder. In scarlatina the temperature is higher; the onset 
 is marked with vomiting; the pharyngitis is characteristic; the rash appears first on 
 the neck and breast, and is more of the nature of a diffuse erythema. The roseola 
 of syphilis is accompanied by other evidences of the presence of lues, the sclerosis, 
 polyadenitis, etc. Rubeola requires no special treatment. 
 
 SCARLATINA. 
 
 Scarlet fever, Scharlach (Ger.), scarlatine (Fr.), is a specific contagious fever, 
 characterized by a macular and diffuse cutaneous exanthem, with involvement of the 
 throat and the internal organs. 
 
 After an incubation of from one to eight days, fever suddenly sets in, accom- 
 panied by sore throat and often by vomiting. The red and swollen filiform papillae 
 
88 ILLUSTRATED SKIN DISEASES. 
 
 projecting through the thickly coated surface of the tongue give to that organ a 
 characteristic strawberry-like appearance. In from twelve to twenty-four hours 
 after these initial symptoms the exanthem makes its appearance, beginning on the 
 neck, and rapidly spreading over the chest, trunk, back, limbs, and the dorsal sur- 
 faces of the hands and feet, the face remaining comparatively free. It consists of 
 small pin-point- to pinhead-sized bright- red papules, disappearing on pressure, and 
 in places so closely grouped together as to form a diffuse redness. This is most 
 marked upon the trunk, and here the general color of the skin may be compared to 
 that of a boiled lobster. The rash remains at its height for from three to four days ; 
 it then begins to fade slowly, and in from four to ten days has entirely disappeared. 
 Then follows a desquamation that is characteristic, being more complete and exten- 
 sive than that of any other of the eruptive fevers. It may be furfuraceous or lamel- 
 lar ; in the latter case the skin peels in large flakes, and complete casts of the palms 
 and soles, or of the fingers with the nails, may be formed. 
 
 Sometimes the eruption is slightly papular or even vesicular. In severe cases 
 there may occur an extravasation of blood into the superficial layers of the skin, 
 giving us the hemorrhagic form of the exanthem. 
 
 The contagion of scarlatina is a fixed one, and is most active during the stage 
 of eruption. It is present in the exhalations of the patient, as well as in the des- 
 quamated scales, and may be carried from one person to another by an immune 
 individual, or in the clothing, etc. It is probably a microorganism, or a product of 
 microorganic growth ; but we are still entirely in the dark as to the actual patho- 
 genic agent. The hyperemia and exudation are limited to the rete and the papillary 
 layer of the corium, but the process is more intense than in the case of measles. 
 The eruption disappears after death. 
 
 Scarlatina requires to be differentiated from measles, rubeola, erysipelas, and the 
 erythemata. The throat involvement, sudden onset, high fever, and the punctate 
 rash beginning on the chest are characteristic of scarlet fever. In measles the erup- 
 tion consists of larger macules arranged in crescentic form ; the face and especially 
 the lips are first affected ; the symptoms of conjunctivitis and other catarrhs are 
 marked; the disease does not begin with vomiting, and the desquamation is small 
 and very fine. In erysipelas the smooth, glazed surface of the affected skin and the 
 limited area involved should prevent mistake. The erythemata from digestive and 
 other disturbances are as a rule unaccompanied by fever and are not followed by 
 desquamation. Certain medicinal rashes, such as those occasioned by belladonna 
 and quinine, may resemble scarlatina closely ; but they may be distinguished from 
 it by their fugacity and by the absence of the fever and the throat symptoms. So 
 far as the rash is concerned, any deviation from its normal course, too slow develop- 
 ment, too rapid disappearance, or an undue prolongation, are of bad prognosis ; so 
 also is a petechial or hemorrhagic eruption. 
 
 The skin during the course of the disease should be regularly inuncted with 
 
UNVACCINATED GIRL. SECOND DAY OF ERUPTION. 
 
 PUSTULAR AND EARLY DESICCATIVE STAGE. EIGHTH DAY OF THE ERUPTION 
 
 TYPOGRAVURE. 
 
 COPYRIGHT, 1905, BY E. B. TREAT & QO. , N. Y, 
 
 SMALL POX IN STAGE OF DESICCATION AND D EC R USTATIO N . 
 CASES OF OR. J.ftF. SCHAMBERG. 
 
 VARIOLA. 
 
 PLATE LX. 
 
r 
 
 
 racterizei 
 
 i 
 into sm 
 
 i 
 suppural 
 
 ;i peculi 
 
 the cm 
 mam 
 
 thoi 
 
 ■ 
 
 unki, 
 
 - 
 
 - 
 In mea; 
 
. AIMO 
 
 ■it: CBurrton 
 
 
 COPVRi'v :. B. TREAT A 
 
 N (NO DEC. 
 C»»l ■'•.vtJtBv. 
 
 VARIOLA. 
 
 PLATE 
 
INFLAMMATIONS. 89 
 
 almond-oil, vaseline, or cold-cream; this is especially useful in the desquamative 
 stage/since it not only protects the surface, but also tends to prevent the d ; ssemina- 
 tion, through the atmosphere, of the scales, that are one of the main carriers of the 
 contagion. 
 
 VARIOLA. 
 
 Smallpox, Slattern {Get), petite ve'role (Fr.), is a specific contagious febrile disease, 
 characterized by the appearance of a papular, vesicular, and pustular eruption on the 
 skin. After an incubation of from twelve to fourteen days the disease begins with a 
 severe chill, followed by high fever, with frontal headache and pain in the back. These 
 symptoms last for from two to three days ; and then, with a diminution or complete 
 cessation of the fever, the eruption appears. It consists of minute red. spots, coming- 
 first on the face around the lips and chin and on the neck and wrists. In two to 
 three days they spread over the entire body. At first macular, the lesions soon 
 develop into small, round, hard papules ; a day later they become vesicular, and by 
 the fifth day the vesicles are fully developed, umbilicated, and surrounded by a red- 
 dened, indurated, and tender base. They then become pustular, and the advent of 
 suppuration is marked by a fresh rise of temperature, the secondary fever. By the 
 tenth or twelfth day the pustules begin to retrogress by rupture or desiccation, and 
 a peculiar and characteristic odor emanates from the patient. In a variable number 
 of days the crusts and scabs fall off, leaving reddened areas that disappear, or per- 
 manent cicatrices, in accordance with the involvement of the corium in the destruc- 
 tive process. The number of pustules may be few, even less than a dozen, or there 
 may be thousands of them; they may be discrete or confluent, and their contents, 
 though usually pus alone, may, in the hemorrhagic form of the disease, be more or 
 less mixed with blood. The mucosae are generally affected ; but here, on account 
 of the thinness of the epidermic layer and the maceration to which it is subjected, 
 erosions and superficial ulcerations take the place of the papules, vesicles, and pustules. 
 
 Variola is eminently contagious, being transmitted in the volatile emanations of 
 the patients. It is probably due to an organic cause, though its nature is as yet 
 unknown. The secondary fever is septicemic, and is due to presence of the pus- 
 cocci and their products. 
 
 The prodromata and initial symptoms above enumerated, the papules developing 
 into umbilicated vesicles and pustules, the cessation of the fever with the appearance 
 of the eruption, and its subsequent recrudescence when suppuration begins, are char- 
 acteristic. Nevertheless the diagnosis from measles, scarlatina, varicella, and the 
 general pustular syphiloderm is often difficult. In measles we have the initial stage 
 of catarrh of the respiratory and conjunctival mucosas, and the larger, flatter, discrete 
 papules, never becoming pustules. In scarlatina there is the sudden onset, with 
 vomiting and throat symptoms ; there is no remission of the fever as the eruption 
 spreads, and the rash appears first on the chest and neck. In varicella the general 
 
90 
 
 ILLUSTRATED SKIN DISEASES. 
 
 symptoms are very slight; the vesicles are usually few, discrete, and filled with a 
 clear serum ; they are rarely umbilicated, and there is no suppuration and but little 
 scarring. The pustular syphilide is often accompanied by fever, and may greatly 
 resemble smallpox. It can be distinguished from it by the absence of umbilication, 
 its irregular spread, its frequent arrangement in crescentic or circular figures, the 
 presence of other symptoms, and the history of the disease. 
 
 VACCINIA. 
 
 Cowpox, Kuhpocken (Ger.), vaccine (Fr.), is an eruptive disease of the cow, with 
 
 a local lesion resembling that of variola at the site of inoculation, and occasionally 
 
 with other general eruptions of varying form. 
 When the inoculation material is taken from 
 the human subject the course of the affection 
 is more rapid and milder than when taken 
 directly from the cow. In from three to ten 
 days there appear small, red, indurated pap- 
 ules on the inoculated area, which in two or 
 three days more become vesicular and um- 
 bilicated. Two to three days later they be- 
 come purulent, and their base becomes hard 
 and inflamed. With this there are moderate 
 fever and mild symptoms of constitutional 
 disturbance. Retrogressive changes and des- 
 iccation then commence ; the inflammation 
 disappears, and a hard, dark-colored scab re- 
 mains on the site of the lesion and falls off 
 by the third or fourth week. A reddened 
 punctate cicatrice, which later turns white, is 
 left behind. The amount of inflammation and 
 destruction of tissue vary much in different 
 cases. Not infrequently a so-called " rasp- 
 berry growth " follows the vaccination, which 
 is simply the exuberant dry granulation tissue 
 resulting from the ulcerative process. 
 
 A generalized eruption occasionally oc- 
 curs at the same time and from the same cause. 
 This is sometimes a roseola, running a rapid 
 course, and disappearing in two days with a 
 slight desquamation; or it may be a scarlatiniform reddening of the skin, or consist 
 of a dusky mottling with patches like those of rubeola. Very rarely the eruption is 
 
 Fig. 38. — Vaccinia. 
 
 I Kiin photograph by the author. 
 
VARIOLA. 
 
 TYPOGRAVURE. 
 
 COPYRIGHT BY E. B. TREAT 4 CO. , N. Y. 
 
 MORBILLI. 
 

 OCCU: 
 
 and child! 
 
 fined 
 
 the c 
 
 but tl 
 
 -in sua; 
 illy do i 
 
 [ 
 
VARIOLA. 
 
 
 COFYRI^- ' TREAT i. CC 
 
 MORBiLU. 
 
 PLATE XII. 
 
INFLAMMATIONS. 
 
 91 
 
 vesicular, and it then resembles a beginning variola closely. Urticaria and erythema 
 multiforme have been seen in connection with vaccinia. 
 
 VARICELLA. 
 
 Chicken-pox, Windpocken (Ger.), petite verole volante (Fr.), is a contagious febrile 
 disease, characterized by the formation of vesicles filled with a clear serum. It 
 occurs most often in infancy 
 and childhood, and the gen- 
 eral symptoms that accom- 
 pany it are so slight that the 
 patients are not usually con- 
 fined to bed, and are often 
 ignorant of the existence of 
 the disease until the erup- 
 tion appears. After fifteen 
 to eighteen days of incuba- 
 tion a mild fever occurs, and 
 hyperemic macules appear 
 scattered over the body, 
 which rapidly become pap- 
 ules, but never have the 
 hardness that is so character- 
 istic of variola. They soon 
 develop into clear vesicles 
 situated on slightly hyper- 
 emic bases, but they rarely 
 become umbilicated. They 
 come in successive crops, and 
 usually do not exceed pea- 
 size. Twenty-four hours 
 after their appearance des- 
 iccation begins, and in five 
 days the scales fall off. Scar- 
 ring rarely results, for the corium is affected only where there has been much 
 scratching. The mucosae are usually involved. The vesicles may be few or numer- 
 ous, but they are very rarely confluent. 
 
 The diagnosis between varicella and variola is often very important. Character- 
 istic of the former disease are the occurrence in crops, the slight severity of the 
 initial symptoms, the softness of the papules, and the absence of suppuration. In 
 variola the invasion is severe, the papules are hard, and umbilicated vesicles and 
 
 Fig. 39. — Varicella. 
 
 From photograph by the author. 
 
92 
 
 ILLUSTRATED SKIN DISEASES. 
 
 pustules soon make their appearance. In measles there are the prodromal catarrhal 
 symptoms, the larger flat macules, and there is no fluid in the lesions. Scarlatina 
 has a severe invasion, sore throat, a punctate or confluent rash, and neither vesicles 
 nor pustules. 
 
 LICHEN PLANUS. 
 
 Synonym. — Lichen ruber planus. 
 
 Definition. — A chronic circumscribed inflammation of the skin, characterized by 
 the formation of multiple, discrete or confluent, minute, purplish, waxy or scaly, 
 umbilicated papules. 
 
 Symptoms and Course. — Lichen planus occurs most frequently as a chronic and 
 localized malady, the more acute and general form of the disease being rare. The 
 site of the eruption is usually on the flexor surface of the forearms, especially around 
 
 Fig. 40. — Lichen planus. 
 From photograph of negress in the author's collection. 
 
 the wrists, and on the backs of the hands and feet ; but other regions are not infre- 
 quently affected, and it occurs occasionally on the palms, soles, and genitals. It is 
 
INFLAMMATIONS. 9.'! 
 
 tare, however, on the face and scalp. It is frequently symmetrical. The lesions 
 appear first as extremely minute papules of a characteristic dusky-red or purplish 
 color, with a waxy glance, and sharply differentiated from the surrounding skin. 
 Their sides are steep, and their shape is distinctly angular; while their tops are flat 
 and marked with a central depression or capped with a minute scale. On the palms 
 and soles the individual lesions may be hard to distinguish, the entire epidermis of 
 the affected region being elevated and thickened, cracked in places, of a dusky-pur- 
 plish hue, and covered with whitish scales. On the mucosas they appear as whitish 
 flattened papules. They may be scattered or irregularly grouped. As they grad- 
 ually enlarge to pea-size, adjacent papules coalesce, and thus extensive indurated 
 and scaly areas are formed ; but the individual lesions do not increase beyond their 
 original size. After persisting for a long time — months and years — they slowly 
 undergo absorption, leaving atrophic pigmented areas behind. No vesicles or pus- 
 tules are ever formed, nor are the nails or hair affected. 
 
 The subjective symptoms are usually confined to a moderate itching, and it is 
 only in the very extensive forms that it becomes severe. The patients are sometimes 
 debilitated and run down by excesses or overwork, but not infrequently they are in 
 excellent health. The malady occurs with about equal frequency in both sexes; it 
 is seen at all ages, but is most frequent during middle life. 
 
 Etiology. — The cause of the disease is unknown. It is not contagious. Most 
 probably Kobner is right in attributing to it a neurotic origin. 
 
 Pathology. — As Robinson has shown, the papules of lichen planus are caused by 
 an inflammatory process in the papillae and the upper portion of the corium, shown 
 by round cell-infiltration and other tissue-changes. In old papules the rete and the 
 corneous layer are hypertrophied as a secondary change. The cell-infiltration is 
 dense, presses on the vessels, and interferes with their nutrition ; and the consequent 
 diapedesis of the red blood-cells is the cause of the purplish color of the lesions and 
 the pigmentation after the atrophy of the papules. 
 
 Diagnosis. — This rests on the peculiar shape, size, grouping, and appearance of 
 the papules, as described above. Papular eczema, especially when situated on the 
 forearm, may resemble lichen planus, but the papules are rounded and frequently 
 have a little serum at their apices ; they are intensely itchy, run a rapid course, leave 
 no pigmentation behind ; and other eczematous changes, excoriations, oozing, or 
 crusting will probably be found somewhere on the skin. In the papular syphiloderm 
 the lesions are round-topped and often arranged in crescentic or circular form ; 
 they are generally distributed and more or less polymorphic; there is no itching; 
 their color is reddish. Other signs of syphilis are probably present, and the disease 
 responds to antiluetic treatment. In lichen scrofulosus the round papules are' grouped 
 upon the trunk and are accompanied by no subjective sensations whatsoever. Fi- 
 nally, in the papular psoriasis the lesions are pink, covered with abundant heaped- 
 up scales, and are situated mostly on the flexor surfaces. 
 
94 ILLUSTRATED SKIN DISEASES. 
 
 Prognosis. — This is favorable always. The disease is chronic and obstinate, but 
 it tends to recovery. 
 
 Treatment. — The general treatment must be tonic and roborant, since many of 
 these patients are anemic and run down. Quinine, iron, and cod-liver oil are useful, 
 together with regulation of the diet and general hygiene. Arsenic is, however, our 
 main reliance, and it must be administered in full doses until the gastric oppression, 
 the sense of constriction of the throat, etc., give warning of approaching intoxica- 
 tion. It is best given in the form of the Asiatic pill (No. 6, p. 46), beginning with 
 two daily, and gradually increasing the amount, or as Fowler's solution, 3 to 10 
 drops in water three times daily. Joseph especially recommends the hypodermatic 
 use of the drug, for which purpose Fowler's solution, diluted with twice the quantity 
 of water, can be employed in the same doses as per orem. Kobner uses the arseniate 
 of soda in the same way. The injections are painless, and the results are said to be 
 brilliant. I have found that the preparation or mode of administration is of less 
 importance than the persistence in the use of the drug for a long period of time. 
 
 No. 39. UnncCs Carbolic- Sublimate Ointment. No. 40. Chrysarobin Ointment. 
 
 $ Acid, carbolic. ... 20 parts fy Chrysarobin ... 1 part 
 
 Hg. chlor. corr. 1 part Adip. lanse 
 
 Ungt. zinci benzoat. . .500 parts Aq. rosae 
 
 Adip. suillis . . . aa. 3 parts 
 
 Locally, bran and alkaline baths are useful to allay the itching, or the various 
 antipruritic lotions and salves (Nos. II, 12, p. 56, Nos. 33, 35, 36, p. 78) may be 
 employed. Unna's carbolic-sublimate ointment (No. 39, p. 94) rarely fails to do 
 some good, and should be tried in every case. Chrysarobin has been recommended 
 by Herxheimer (No. 40, p. 94). 
 
 LICHEN RUBER. 
 
 Synonym. — Lichen ruber acuminatus. 
 
 Definition. — A chronic inflammatory disease of the skin, characterized by the 
 appearance of pinhead- to millet-seed-sized, firm, conical, red papules, coalescing into 
 infiltrated scaly patches, and leading sometimes to marasmus and death. 
 
 Symptoms and Course. — Lichen ruber is very rare in this country, and is by some 
 authorities considered essentially identical with ordinary lichen planus. Commenc- 
 ing on the trunk, the above-described papules spread over the entire body and even 
 invade the mucosae. They remain stationary for a long period of time, and are not 
 subject to retrogressive changes. New papules appear between the old ones, and 
 finally the lesions fuse together into larger scaly masses. The integument of the 
 entire body is then infiltrated, so that it is twice as thick as the normal skin ; it is 
 dusky reddish brown in color, and rough to the touch like a nutmeg-grater, though 
 
COPYRIGHT BY E. B. TREAT 4 CO., N. Y. 
 
 PHOTOGRAVURE 4 COLOR CO., N. Y. 
 
 LICHEN PLANUS 
 
 PLATE III 
 

 but v 
 mara< 
 
 reco. 
 
 int flexur 
 
 
 - 
 of the d 
 four 
 bee 
 
 _ 
 Etiolog, -riost fre 
 
 middle 
 
 Pathology. - 
 in the chronic 
 ; 
 Diagnosis.- 
 
 i 
 It must be 
 
 papu 
 
 ■ 
 
 Prognosis.--- 
 occur. Tl 
 me; 
 
 Treatment. — Ai 
 
 ; 
 
 Slat, 
 rm. 
 
 
 
 seldom 
 
 
 i 
 ; 
 
 an baths and the 
 
 - 
 
- 
 
 HEN PL* 
 
INFLAMMATIONS. 95 
 
 no individual papules may be visible; and fissures appear at the joint flexure and at 
 the natural folds. The nails become thickened, dark, and brittle ; the hairs lose their 
 luster and fall out. 
 
 The malady is an eminently chronic one, lasting for years and steadily advanc- 
 ing. In its first stages the subjective symptoms are limited to a moderate itching; 
 but when the whole skin is affected this becomes more severe, and emaciation, 
 marasmus, and death, without any special lesion that we know of, may occur. The 
 recognition and description of the disease are due to the elder Hebra, and his first 
 fourteen cases ended fatally. As seen to-day, the lesions in the course of time 
 become flatter and paler, and are finally absorbed, leaving pigmented scars behind. 
 Vesiculation, pustulation, or ulceration does not occur. 
 
 Etiology. — The cause of the disease is entirely unknown. It is most frequent in 
 middle age, and is seen oftener in males than in females. 
 
 Pathology. — This is still unsettled. All the layers of the skin seem to be involved 
 in the chronic inflammatory process, but the cellular increase is most marked in the 
 upper layers of the corium, in the papillae, and especially around the hair-sacs. 
 
 Diagnosis. — The diagnosis can be difficult only on account of the rarity of the 
 malady. The conical red papules, surmounted by a small scale, are characteristic. 
 It must be differentiated from: I. A general papular psoriasis. This rarely covers 
 the entire body, some portions being always unaffected ; there is a comparativelv 
 large amount of heaped-up silvery scales; the flexor surfaces are most involved 
 and the malady comes and goes, the efflorescences getting better and worse from 
 time to time. 2. A general papular eczema. Here we have acute inflammatory 
 papules of a vivid-red color, much itching, weeping surfaces, and a general poly- 
 morphism. 3. Lichen planus, which has polygonal violaceous papules, with flat, 
 smooth, waxy, and slightly umbilicated tops. 4. A general papular syphiloderm. 
 This is never entirely universal ; it is grouped in circles or crescents ; and other 
 symptoms of lues are almost always present. 5. Pityriasis rubra, in which the 
 bright-red color, the apparent atrophy of the skin, and the non-involvement of the 
 nails are characteristic. 
 
 Prognosis. — This is good if the disease is properly treated ; relapses seldom 
 occur. The bad prognosis of Hebra antedated the introduction of the arsenic treat- 
 ment. 
 
 Treatment. — Arsenic must be given in large and long-continued doses. If symp- 
 toms of poisoning occur the dose must be diminished ; but the system soon accom- 
 modates itself to the drug, and the doses can be increased again. The Asiatic pill 
 (No. 6, p. 46) may be employed, commencing with two and going up to six or 
 more daily ; or we may use Fowler's solution by the mouth, or hypodermically, as 
 recommended in lichen planus (p. 94). Iron, cod-liver oil, and other tonics, with 
 general hygienic measures, are also required. Locally, alkaline bran baths and the 
 various antipruritic salves and lotions (Nos. 33, 34, 35, 36, p. 78, etc.) are useful. 
 
96 ILLUSTRATED SKIN DISEASES. 
 
 DERMATOMYCOSES. 
 
 The presence and growth of parasites, vegetable and animal, upon and amcng 
 the epithelial layers of the skin and in the glandular structures that open into it, 
 cause inflammation of that organ. This is mostly of a superficial character, and its 
 consideration belongs under this heading. The vegetable parasites are fungi belong- 
 ing to the class of the Hyphomycctcs, and they cause a series of affections known as 
 the dermatomycoses. In some of them the morphology of the etiological factor is 
 well established, but in others it is still a matter of doubt. All the various forms of 
 ringworm are known to be due to varieties of the TricopJiytou tonsurans; pityriasis 
 versicolor is caused by the Microsporon furfur; but Quincke, Unna, and Jessner 
 have proved that several fungi may cause favus, and the exact nature of the parasite 
 of pityriasis rosea and eczema marginatum is still undecided. The maladies that 
 they cause are naturally all contagious; but the fungi require varying conditions for 
 their growth, and hence their transmission is largely dependent on individual condi- 
 tions, age, surroundings, and general health. 
 
 The Hyphomycetes are fungous plants containing no chlorophyl and deriving 
 their nourishment from organic substances. They consist of a network of double- 
 contoured, branched threads or mycelium, constituting the thallus, from which spring 
 upright branches known as the hyphae, containing the reproductive organs and 
 spores. They are so similar in their size and general structure that the elder Hebra 
 regarded them all as mere varieties of one parasite ; but both microscopical inves- 
 tigation and clinical research have shown the erroneousness of this view. The par- 
 asitic growth can be readily demonstrated in the epidermic scales and hair-structures 
 after immersing them for a short time in a io-per-cent. solution of caustic potash. 
 
 FAVUS. 
 
 Synonyms. — Tinea favosa, dermatomycosis favosa, Erbgrind (Ger.), teigne fa- 
 re use (Fr.). 
 
 Definition. — A contagious parasitic disease of the skin, due to the growth in and 
 upon it of the AcJiorion Scli'dnlcinii, characterized by the appearance of lemon- 
 yellow cupped crusts, and leading to atrophy of the skin and its appendages. 
 
 Symptoms and Course. — Favus is a rare disease in this country, almost all the 
 cases that are seen here occurring in emigrants of the lowest classfrom Russia. Itoccurs 
 most often on the scalp, but no part of the body is exempt, and Kaposi has even seen it 
 on the mucosae. It begins as minute pinhead-sized reddish spots around the orifices of 
 the hair-follicles, which soon enlarge and assume a yellowish tinge. The fungoid ac- 
 cumulation grows until the fully developed, small, pea-sized mass, the scutulum, shield, 
 or cup, is formed. This appears as a lemon-yellow disk firmly attached to the skin, 
 and pierced in its center by one or more hairs. Its surface is concave or umbilicated, 
 and its edges are raised ; and if it is forcibly removed it is found that its concave under 
 

 INFLAMMATIONS. 
 
 97 
 
 surface is situated in a red and moist cup-shaped depression of the epidermis. It is 
 formed of a series of concentric layers of a friable yellow material, which excavates 
 and destroys the epidermic layers by its pressure. In the human subject this does not 
 extend below the superficial layers of the skin ; but Sherwell has seen mice in which 
 the bones of the cranium were perforated by the pressure of the growing cup. 
 
 The single scutula may grow until they are V x of an inch or more in size. 
 Adjacent ones then coalesce, and thus 
 irregular, dirty, whitish-yellow, mortar- 
 like masses are formed, and the charac- 
 teristic cups are seen only at the edges 
 of the patch, where the disease is pro- 
 gressing. Left to themselves, the cups 
 finally fall off, leaving depressed, circum- 
 scribed, hairless, atrophic areas behind. 
 More or less eczematous inflammation 
 and suppurative folliculitis may accom- 
 pany the disease, which in old cases may 
 be very extensive. The hair in scalps 
 affected with favus has a characteristic 
 dusty, lusterless appearance, and feels 
 dry and wiry to the touch. The pro- 
 gressive pressure-atrophy finally leads 
 to the entire destruction of the papillae 
 and the glandular structures. The odor 
 of favus is characteristic and mouse- 
 like. 
 
 Favus of the non-hairy parts is ex- 
 tremely rare, and usually occurs in con- 
 nection with favus capitis. The lanugo 
 hair-follicles are more superficial than 
 those of the scalp, and the parasite does 
 not find as good a soil to grow on. The 
 scutula are single or few in number, and 
 are usually surrounded by a reddish, scab', 
 or vesicular zone, looking very like ring- 
 worm. The duration of favus corporis is 
 generally short. 
 
 Favus of the nails, onychomycosis fa- 
 vosa, is very rare, and occurs from inoc- 
 ulation of the finger-nails from scratching 
 the head. Deep-seated yellowish spots, 
 
 Fig. 41. — Favus corporis. 
 Case of Professor Elsenberg, Warsaw, Russia. 
 
98 
 
 ILLUSTRATED SKIN DISEASES. 
 
 . ; 
 
 due to the accumulation of the parasitic growth, appear in the nails, and they be- 
 come dry, lusterless, furrowed, and raised. 
 
 The malady is a very chronic one, usually beginning in childhood, and lasting 
 for twenty years or more, so long as there are any hair-follicles left to be invaded. 
 It sometimes, however, ends spontaneously. The subjective symptoms are limited 
 to itching. 
 
 Etiology. — The Acliorion Schonleinii, discovered by Schonlein in 1839, is the 
 etiological factor of the disease, as has been proved experimentally by the inocula- 
 tion of pure cultures. It grows on the skins of rabbits, cats, dogs, and mice, as well 
 
 as on that of the human subject, and in a good 
 many cases it originates in the household cat, who 
 gets it from the mice. The parasite requires to be 
 left undisturbed for two or three weeks before it 
 obtains a firm hold on the tissues ; hence people 
 of cleanly habits are not liable to contract it. It 
 is far commoner in children than in adults. Only 
 a single member of a family is attacked, as a rule ; 
 but this is not always the case, and Duhring men- 
 tions one instance in which ten cases were found 
 in a single household. 
 
 Pathology. — A moderate amount of inflamma- 
 tion and cell-infiltration is caused by the growth 
 of the parasite, which consists of an abundant net- 
 work of mycelial threads and many spores. The 
 mycelium is composed of flat threads about -gjf^ of 
 an inch in diameter, divided by partitions into elon- 
 gated cells. Inside these the oval spores or conidia 
 develop ; but large masses of them are also found lying free. The fungus in its 
 downward growth presses on the succulent rete-cells and causes their atrophy ; it 
 also invades the hair and corionic papillae, and destroys them. Passing through the 
 external root-sheath, it enters the hair and grows in the marrow substance. When 
 the glandular structures are entirely destroyed the parasite no longer finds a suitable 
 soil, and disappears. 
 
 Diagnosis. — This is usually readily made. The destruction of the hair-follicles 
 and the wiry condition of the hairs that remain ; the sulphur-yellow, round, concave, 
 friable scutula pierced by hairs ; the depressed and atrophic but otherwise uninjured 
 skin below them; the sparse, badly nourished, and wiry hairs that are left; the 
 mouse-like odor; and, finally, the microscopic demonstration of the fungus in the 
 crusts, will prevent error. When the disease is extensive the heaped-up mortar-like 
 crusts may resemble the accumulated secretion of an impetiginous eczema ; but these 
 latter are greenish yellow in color, and an inflammatory, moist, and weeping surface 
 
 Fig. 42. — Aclwrion Schonleinii. 
 
 x 400. After Joseph. 
 
COPYRIGHT, BY E. B. TREAT & CO., N. Y. 
 
 PHOTOGRAVURE 4 COLOR CO., N. Y. 
 
 FAVUS 
 
 PLATE XI. 
 
Progx' 
 
 the 
 the 
 
 Treatment. 
 
 the emjii 
 
 the 
 
 imultaneouj 
 
 clot!: 
 
 tholated 
 
 : 
 
 ■ 
 
 ula. Thi j 
 washed < 
 phur p 
 
 a 10-. 
 
 se is rep. 
 ■ ointmc' 
 

 
 
INFLAMMATIONS. 
 
 99 
 
 is found under and around them. Ringworm may in some cases resemble favus 
 very closely, but there are no distinct cups or mortar-like masses or atrophy, and 
 the frayed, nibbled-off hairs are characteristic. Microscopically the parasites in both 
 diseases are too similar to be readily differentiated. 
 
 Prognosis. — Favus, once deemed incurable, is not so rebellious to modern meth- 
 ods ; but it is still very difficult to eradicate. In every case there is a more or less 
 extensive permanent atrophy of the skin and destruction of the glandular structures. 
 On the non-hairy parts it is read- 
 ily removed, and sometimes dis- 
 appears spontaneously. Favus of 
 the nails is as obstinate as that of 
 the scalp. 
 
 Treatment. — This consists of 
 the employment of epilation and 
 parasiticide applications, and al- 
 ways requires much patience and 
 a long period of time. The hair 
 should be cut short over the entire 
 scalp, and a daily systematic re- 
 moval of the affected hairs with 
 the epilating forceps must go 
 on simultaneously with whatever 
 treatment is adopted. The crusts 
 should be softened by binding 
 cloths soaked in I per cent, naph- 
 tholated oil (No. 41, p. 100) or 2 
 per cent, salicylated or 5 per cent, 
 carbolated oil on the scalp under 
 an oilskin cap, until all the visible 
 crusts can be removed with a spat- 
 ula. The scalp is then thoroughly 
 
 washed with the green soap tincture (No. 5, p. 43), and the resorcin-salicylic-sul- 
 phur paste (No. 42, p. 100) is applied to the scalp. A 10- to 20-per-cent. pyrogallol 
 ointment, or a 20-per-cent. oleate-of-mercury ointment, or the balsam of Peru, or 
 a 10-per-cent. chrysarobin ointment (No. 40, p. 94) may also be employed. These 
 are best first rubbed in with a stiff-bristle brush before being applied on cloths. 
 The treatment must be persisted in for five or six days, and then several days can 
 be allowed to elapse to see how many new scutula make their appearance. The 
 course is repeated again and again until no new ones are seen. If the treatment 
 irritates the scalp too much, it can be stopped from time to time, and a mild subli- 
 mate ointment (No. 43, p. 100) used instead. 
 
 Fig. 43. — Favus capitis. 
 Case of Dr. J. F. Aitken. 
 
 LOFC 
 
100 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Favus of the body is readily removed by means of frictions with the tincture of 
 green soap (No. 5, p. 43) or the use of the pyrogallol ointment (No. 44, p. 100). 
 
 Fig. 44.— Hair-shaft and root-sheaths affected with favus. 
 After Kaposi. 
 
 Favus of the nails is obstinate, and the treatment must consist in scraping away with 
 a knife as much as possible of the diseased structure, and applying mercurial plaster 
 or the sublimate ointment (No. 43, p. 100). 
 
 No. 41. Naphtholated Oil. 
 
 R j3.-naphthol 
 01. olivae 
 
 1 part 
 100 parts 
 
 No. 42. Resorcin- Salicylic-Sulphur Paste. 
 
 R Resorc. albissim. 
 Ac. salicyl. 
 Sulphur, depur. 
 Amyli 
 
 Zinc. oxid. . . . aa. 1 part 
 Petrolati 5 P arts 
 
 No. 43. Sublimate Ointment. 
 
 1 part 
 
 . aa. 500 parts 
 
 No. 44. Pxrogallol Ointment. 
 
 R Hydrarg. chlor. corr. 
 
 01. amygdal. 
 Adip. lanae 
 
 R Pyrogallol 
 Petrolati 
 
 1 part 
 20 parts 
 
INFLAMMATIONS. . 101 
 
 TRICHOPHYTOSIS. 
 
 The presence and growth in the skin of the Trichophyton tonsurans, discovered 
 by Gruby and Malmsten in 1844, cause an inflammation of that organ, the clinical 
 appearance of which varies in different portions of the body, and which has been 
 given different names in accordance with the region affected. It was formerly sup- 
 posed to consist of several distinct diseases, and the varieties do indeed differ so 
 much that their symptoms, course, and mode of treatment require separate consid- 
 eration. Certain general considerations are, however, in place here. 
 
 Definition. — A contagious vegetable parasitic disease of the skin, caused by the 
 Trichophyton tonsurans, and characterized by the presence of inflammation of the 
 skin and destruction of its glandular appendages. 
 
 Etiology. — The exact botanical position of the ringworm parasite is not yet set- 
 tled, and Sabouraud and others have described several varieties in different forms of 
 the disease. The consensus of opinion, however, is that there is but one parasite, 
 and that the different forms are due only to different conditions of soil, etc. A 
 secondary coccigenic infection is frequently added to the fungoid one, giving rise to 
 deep-seated suppuration and abscess formation. It is eminently contagious, and 
 much more common than favus. It affects, in its various forms, all ages and condi- 
 tions, and is usually transferred from one patient to another through toilet utensils, 
 articles of wearing apparel, etc. Dogs, cats, horses, and other animals are subject 
 to ringworm, and are not very infrequently the sources of contagion. 
 
 Pathology. — The trichophyton parasite consists of mycelium and spores, the 
 former being double-contoured, branched threads, partitioned into cells, and similar 
 in appearance, but more slender, than those of favus. The rounded spores are 
 exceedingly abundant. It grows underneath the superficial layers of the corneous 
 layer, and may invade the hair-bulbs and -shafts. It causes a superficial or deep- 
 seated reactive inflammation, marked by scaling, redness, papulation, vesiculation, 
 or, when pus infection has also occurred, follicular or more diffuse suppuration. The 
 mycelium and spores can generally be readily demonstrated in the epidermic scales 
 or the hairs after maceration in dilute liquor potassae. 
 
 Prognosis. — This is good in all cases if appropriately treated. Care and labor 
 and a long period of time are required, however, in many cases. 
 
 TRICHOPHYTOSIS CAPITIS. 
 
 Synonyms. — Tinea tonsurans, herpes tonsurans, ringworm of the head, scJicerende 
 Flechte (Ger.), teigne tonsurante (Fr.). 
 
 Definition. — Ringworm of the head, characterized by circular or diffuse, inflamed, 
 scaly, or tumid patches, with diseased and broken-off hairs. 
 
 Symptoms and Course. — Ringworm of the head is of fairly common occurrence 
 
102 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Fig. 45. — Trichophytosis capitis. 
 
 From photograph by the author. 
 
 most of them are broken off within a line 
 frayed and ragged ends looking like a 
 coarse stubble covering the affected area. 
 
 This is the usual form of the disease ; 
 but sometimes there is associated with it 
 a suppurative folliculitis of the hair-sacs, 
 forming the condition known as kerion. 
 The affected portion of the scalp is cov- 
 ered with pustules ; there is considerable 
 swelling; and crusts and exuding surfaces 
 cause it to greatly resemble a pustular 
 eczema. In very old cases, again, there 
 are no circular areas, the whole scalp is 
 covered with dry scales, the scattered hairs 
 that are present are evidently diseased, and 
 the entire appearance is that of a sebor- 
 rhea or a chronic eczema. 
 
 Etiology. — The common sources of 
 contagion are the hats, hair-brushes, tow- 
 els, and bed-linen used in common by in- 
 
 in this country, and is almost always 
 seen in children. It begins as a red 
 macule, papule, or group of vesicles 
 around the opening of a hair-follicle, 
 which gradually enlarges into a round, 
 grayish-red or slate-colored, slightly 
 scaly patch. It may remain stationary 
 at any size, and rarely exceeds an inch 
 and a half in diameter. It may be 
 single or there may be a number of 
 spots ; adjacent patches may coalesce, 
 and thus a large portion of the scalp, 
 or even its entire area, may be affected. 
 At the margins of the patches there are 
 usually found inflammatory papules, 
 vesicles, or pustules. The hairs are 
 characteristically affected as the fungus 
 grows down into the follicles and in- 
 vades the shafts. The few long ones 
 that remain look dull and lusterless, and 
 are covered with a grayish dust ; but 
 or two of the surface of the skin, their 
 
 Fig. 46. — Trichophytosis capitis of long standing. 
 From photograph by the author. 
 
INFLAMMATIONS. 
 
 103 
 
 fected and healthy children. The impossibility of enforcing the necessary hygienic 
 measures in institutions where large numbers of children are herded together ex- 
 plains its epidemic appearance. 
 
 Pathology. — The parasite grows first in the epithelial layers of the scalp, but 
 soon invades the hair-follicles and -shafts. The hair-bulbs are distorted and swollen, 
 and when pulled out are found covered with a mass of white fungus. The shafts are 
 filled with mycelium and spores, 
 looking as if stuffed with fish-roe ; ' 7 v i 
 
 and, as soon as they lose the sup- 
 port of the follicle walls, split lon- 
 gitudinally, and are broken off. 
 
 Diagnosis. — This is readily 
 made in typical cases, for the 
 round, scaly patches and the nib- 
 bled-off, frayed-out hairs are char- 
 acteristic. But in the chronic and 
 more diffuse cases it is sometimes 
 very difficult. The malady often 
 resembles a seborrhea ; and in 
 other cases ringworm of the scalp 
 must be differentiated from squa- 
 mous eczema, alopecia areata, pso- 
 riasis, and favus. Seborrhea of the 
 head, causing baldness, is rare in 
 children ; the scales are fatty, there 
 are no broken-off hairs, and it is 
 from the beginning a diffuse affec- 
 tion, and does not commence as a discrete ring. The diagnosis from alopecia areata 
 may also be difficult ; but in that disease there is little or no scaliness, no inflamma- 
 tion, and few or no hair-stumps. Eczema squamosum is a diffuse affection, and the 
 hairs are firm and unbroken. In psoriasis the scales are thick and silvery white ; 
 there is no defluvium ; and patches of the disease will probably be found on other 
 portions of the body. In favus the peculiar sulphur-yellow cups will always appear 
 if the disease is left untreated for a week or so, and in old cases the presence of 
 cicatricial tissue is characteristic. Finally, the microscope must be resorted to in 
 doubtful cases. 
 
 In many instances, however, and more especially in the chronic epidemics that 
 occur in public institutions, the question of the presence or absence of ringworm is 
 often a most difficult one to answer, since the large number of the cases renders in- 
 dividual microscopic examination impracticable. Here Duckworth's chloroform test 
 may be of value. A few drops are poured upon the affected area and allowed to 
 
 Fig. 47.- 
 
 -Hair and root-sheath of trichophytosis capitis. 
 After Kaposi. 
 
104 ILLUSTRATED SKIN DISEASES. 
 
 evaporate ; the mouths of follicles and the hairs that are affected turn yellowish 
 white in color, and the scalp looks as if powdered with sulphur. The addition of a 
 little oil restores it to its former appearance. 
 
 Prognosis. — Many cases are very obstinate, especially in badly nourished children, 
 and the treatment of ringworm of the scalp is still a very unsatisfactory chapter in 
 dermato-therapeutics. Cases in which the characteristic appearances have vanished, 
 but in which a persistent scaliness of the scalp remains, are not cured; a lens will 
 reveal the frayed-out hairs, and the persistent use of the microscope will show that 
 the parasite is still present. A cure is always a matter of months, and sometimes 
 of years. 
 
 Treatment. — Good food, fresh air, scrupulous cleanliness, and the use of tonics 
 are important, in that they render the soil less suitable for the growth of the tri- 
 chophyton parasite. The hair should be cut short to facilitate the recognition and 
 treatment of affected areas. The scalp should be thoroughly washed at least twice 
 a week with the green soap tincture (No. 5, p. 43), and a mixture of equal parts of 
 alcohol and chloroform should be employed to remove the scales and fat before any 
 parasiticide is applied. Epilation is required in many of the cases, the hairs remain- 
 ing on the patch, and especially at its margins, being removed with the flat, broad- 
 bladed epilating forceps. Thus the fungus-filled hairs are gotten rid of and the 
 mouths of the follicles are opened so that the remedies employed can reach their 
 depths. 
 
 Of the many applications that are used corrosive sublimate is perhaps the most 
 valuable. In a strength of 2 grains to the ounce of alcohol it should be thoroughly 
 rubbed into the scalp with a brush or sprayed on it twice daily. It may also be 
 used in ointment form, I to 250 or less (No. 43, p. 100). The compound tar spirit 
 (No. 45, p. 104) and the sulphur-soap spirit (No. 46, p. 104) are favored by Wolff, 
 Joseph, and others. The oleates, especially those of copper and mercury, are highly 
 recommended by Shoemaker (No. 47, p. 105). A 5-per-cent. naphthol salve (No. 
 48, p. 105) is valuable in very young children, and in recent cases chrysarobin (No. 
 40, p. 94) is undoubtedly effective; but it must be used carefully, the eyes being 
 protected and the head tightly covered. Blistering the surface with croton-oil, either 
 pure or mixed with equal parts of olive-oil, and thus setting up a suppurative follic- 
 ulitis, is required in very obstinate cases. The application should be made by the 
 physician himself, care being taken to localize the action of the oil to the affected 
 area. The part should then be poulticed and epilated. 
 
 No. 45, Compound Tar Spirit. No. 46. Sulphur-soap Spirit. 
 
 fy. 01. rusci . . . . .25 parts fy Sulphur, lot. . . 1 part 
 Spts. vini Tr. saponis vir. . . .5 parts 
 
 Ether, sulph. . . . aa. 40 " 
 
 Spts. lavand. . . . .1 part 
 
INFLAMMATIONS. 105 
 
 No. 47. Copper Oleate Ointment. No. 48. Naphthol Ointment. 
 
 R 
 
 Cupri s. hydrarg. oleat. . 
 
 i part 
 
 fy Naphthol 
 
 01. olivae 
 
 i " 
 
 01. olivae 
 
 Adip. lanae . 
 
 io parts 
 
 Adip. lanae 
 
 i part 
 2 parts 
 
 20 " 
 
 In any case, the patient should be as far as possible segregated, and care should 
 be taken that no other child uses the brushes, towels, clothing, etc., without thorough 
 disinfection with strong bichloride solutions. A cap should be worn all the time, 
 and this should be either so cheap that it can be frequently renewed, or it should be 
 fitted with a paper lining that can be changed every day or two. A modified treat- 
 ment must be persisted in long after the disease is apparently cured. Two or three 
 times a week a bichloride lotion or ointment (No. 43, p. 100, No. 49, p. 108) should 
 be thoroughly applied. 
 
 TRICHOPHYTOSIS BARBAE. 
 
 Synonyms. — Tinea barbae, tinea sycosis, sycosis parasitica, dermatomycosis bar- 
 bae, ringworm of the beard, barber's itch, Bartflcclite (Ger.), trichopJiytie sycosique 
 (Fr.). 
 
 Definition. — Ringworm of the beard, characterized by inflammation of the skin, 
 with the appearance of papular, tubercular, and pustular lesions, and destruction of 
 the hairs. 
 
 Symptoms and Course. — Ringworm of the beard differs in appearance from the 
 similar affection on other parts of the body in consequence of the anatomical pecu- 
 liarities of its site. It begins as one or more pea-sized, or larger, circular red spots, 
 with some papules and vesicles, and covered with branny scales, the hairs over the 
 affected area being early loosened or broken off. Soon, however, if unchecked, it 
 assumes the more characteristic form of the severer variety of the disease. The 
 adjacent inflammatory areas coalesce, and deep-seated nodular lesions make their 
 appearance. Large infiltrated masses are thus formed, of a deep purplish color, and 
 tender and boggy to the touch. The subcutaneous connective tissue is undermined, 
 and pus or a foul-smelling seropurulent secretion exudes from the orifices of the 
 hair-follicles. This crusts upon the surface, and mats together the hairs over the 
 whole swollen and infiltrated area. A condylomatous papillary growth from the 
 surface of the mass frequently occurs, and the neighboring lymphatic glands are 
 swollen and tender. The hairs over the affected area may fall out spontaneously, 
 or they may be broken off close to the skin and frayed ; in any case, they lie entirely 
 loose in their sheaths, and may be removed, as Anderson says, as readily as pins 
 from a pincushion. Their sheaths are white from the mass of fungus material ad- 
 hering to them. The process finally results in the complete destruction of the glan- 
 dular structures of the skin, and atrophic, cicatricial, hairless areas are left behind. 
 
106 
 
 ILLUSTRATED SKIX DISEASES. 
 
 bearded face. Though acute fa its imrS iZ t^oT tueV^ ~ ? "" 
 one, aud may ta for nl0 „ ths „ Rm^o™ To* ' !> ? " ChPOnic 
 
 B sometimes present at the same time. POrtl °" s ° f the b ° d y 
 
 Fig. 48.— Trichophytosis barba?. 
 
 From photograph by the author. 
 
 Trichophytosis barbs of the classical f™ ■ 
 York a superficial form is in 1 "* * C ° mm ° n d, ' SeaSe - T " New 
 
 which the maladvpre n \ air"" 1106 ; ^ ^ ^^ «* with, in 
 worm of the body prance and runs the course of the ordinary ri„o- 
 
 dar^^Lc Z ^^^T ^^ " ^ * * «~" 
 ^ead in the barber-shops ad not t ^ °?* The COnt ^ 0n is USUaU y 
 
 the towels, lather-brush and he h f , raZ °''' " " ^^ SU ^ ed - bu t by 
 frequently observed on ■ i t e It ' \ Z^" '' "* ^ the ™ d ™™ ^ are 
 
 children affected with ringwonn. ^mmonly gotten from animals or 
 
 ihe^d:^ been already described, grows in 
 
 The perifollicular inflammation il ty"£ & ^ "* * *" ^ 
 
INFLAMMATIONS. 107 
 
 Diagnosis. — The red scaly spots, deep tubercular infiltrations, broken-off hairs, 
 the quick spreading, and the microscopic demonstration of the parasite are sufficiently 
 characteristic. Nevertheless trichophytosis barbae requires to be carefully differen- 
 tiated from two other affections of the beard which are included under the popular 
 designation of barber's itch, viz., perifolliculitis barbae and eczema barbae. In peri- 
 folliculitis the course of the disease is slower; it begins most frequently on the upper 
 lip ; the hairs are only affected later, after suppuration of the follicles has set in ; 
 there are no deep tubercular infiltrations or papillary growths ; the trichophyton is 
 not present ; and the small, discrete pustules, each pierced by a hair, are character- 
 istic. Eczema of the beard is also most frequent on the upper lip, and a catarrhal 
 or suppurative rhinitis is often present ; it is an entirely superficial affection, with 
 vesicles, serous discharge, and crusts ; the parasite is not present ; the hairs are not 
 affected; no scar tissue results; and non-hairy parts in the neighborhood are usually 
 involved. A papular syphiloderm of the bearded face may occasionally resemble 
 ringworm ; but the circular arrangement of the tubercles, the ulceration, the absence of 
 deep-seated suppuration and of the fungus, with the history, should prevent mistake. 
 
 Prognosis. — These cases are often very rebellious. Left to itself, the process 
 goes on until all the hairs of the beard are destroyed. 
 
 Treatment. — In the superficial ringed form any of the parasitic applications (No. 23, 
 p. 64, No. 34, p. 78, No. 38, p. 82) may be used. In obstinate cases it is sometimes nec- 
 essary to have recourse to a strong sublimate spirit or lotion (No. 49, p. 1 08), which must 
 be cautiously dabbed over the surface two or three times daily and allowed to dry. 
 In the deeper-seated suppurative forms the hair of the beard and mustache must be cut 
 close with the scissors ; shaving must not be resorted to, because it spreads the infec- 
 tion to neighboring healthy parts. Epilation is required in every case. It can be done 
 readily and painlessly, for the affected hairs are so loose in their sheaths that they come 
 out with ease. It must be done systematically, an area of skin being cleared each 
 day. The healthy portion of the beard should be protected from further infection by 
 dabbing sublimate spirit (No. 49, p. 108) over it once daily. The affected part is then 
 washed thoroughly with the green soap tincture (No. 5, p. 43), then with chloroform 
 and Lassar's paste (No. 2, p. 43) or Wilkinson's ointment (No. 38, p. 82) or the 
 tannin-sulphur paste (No. 50, p. 108), applied twice daily for several days, until irri- 
 tation and peeling of the skin occur. Having thus removed the scales and a large 
 quantity of the fungus, the part is ready for the parasiticide applications. 
 
 Of parasiticides the most efficacious is perhaps the 10-per-cent. chrysarobin col- 
 lodion (No. 51, p. 108), which must be applied to the part with a stiff brush twice a 
 day for three or four days, and then stopped until desquamation occurs. There 
 need be no fear of using chrysarobin on the face in this form ; it causes no trouble, 
 save for a slight discoloration of the skin. The oleate of mercury, 10-per-cent. so- 
 lution in oleic acid, or the copper oleate ointment (No. 47, p. 105) or the sublimate 
 ointment (No. 43, p. 100) may also be used. 
 
108 ILLUSTRATED SKIN DISEASES. 
 
 No. 49. Sublimate Spirit. No. 50. Tannin- Sulphur Paste. 
 
 % Hydrarg. chlor. corr. . . i part $ Acid, tannic. ... 5 parts 
 
 Spts. vini rect. . . . 500 parts Lac. sulph. . . . . 10 " 
 
 Petrolati . . . . 50 " 
 Zinci oxidi 
 Amyli aa. 17.5 " 
 
 No. 5J. Chrysarobin Collodion. 
 
 $: Chrysarobini 1 part 
 
 Collodion flexile . . .10 parts 
 
 The abscesses must be freely opened, and the deep infiltrations are best treated 
 by the application of the mercury-carbolic plaster mull, which has an excellent effect 
 and quickly causes their resorption. Papillary growths must be scraped away, and 
 the free use of the curette on the deep infiltrations after their incision removes large 
 masses of fungus and greatly hastens their cure. The application of poultices, as 
 recommended by some authorities, only promotes the growth of the parasite. 
 
 TRICHOPHYTOSIS CORPORIS. 
 
 Synonyms. — Tinea circinata, herpes circinatus, ringworm of the body, herpes 
 circine (Fr.). 
 
 Definition. — Ringworm of the general integument, characterized by macular, 
 vesicular, papular, or squamous lesions of circular outline, with scaly or normal 
 centers. 
 
 Symptoms and Course* — Ringworm of the body in its milder varieties, with one 
 to half a dozen lesions, is a common disease ; but the more chronic and generalized 
 forms are rarely observed in this country. It begins as a small, circular, slightly 
 raised reddish macule, sharply circumscribed, and removable by pressure. It spreads 
 peripherically until it may attain the size of a large coin, and while the advancing 
 margin remains red, the color of the center gradually fades into a pale yellowish 
 pink. Fine branny gray scales cover the patch. Adjacent patches may coalesce, 
 forming irregular circinate areas, and in rare instances concentric rings of parasitic 
 growth may appear. This form, in which ringworm of the body always begins, is 
 known as herpes tonsurans maculosus, and is most commonly found on the exposed 
 parts of the body, where there is but little heat, moisture, and friction, as the face, 
 neck, and arms. 
 
 Occasionally a row of vesicles filled with a clear serum marks the edges of the 
 patch, forming the variety known as herpes tonsurans vesiculosus. They soon dry 
 up into fine branny scales. Where there is much friction and heat, as in the in- 
 framammary region in stout persons, the parasitic growth is more abundant, and the 
 
COPYRIGHT BY E. B. TREAT & CO., N. Y. 
 
 PHOTOGRAVURE AND COLOR CO., N. Y. 
 
 TRICHOPHYTOSIS 
 
 PLATE VIII. 
 
- 
 
 Etiology.— - 
 
 ■ 
 
 ■ 
 
 Dia 
 
 
 
 i 
 
- ' ; 
 
 HOPHYT 
 
 
INFLAMMATIONS. 
 
 KM) 
 
 formation of inflammatory papules gives us the variety known as herpes tonsurans 
 papulosus. Finally, when there is much scaling, we have herpes tonsurans squa- 
 mosus. In the chronic generalized cases the lesions are ill defined, irregular or con- 
 fluent, and scattered over the surface 
 of the body as reddish scaly spots. 
 
 Ringworm of the body occurs espe- 
 cially in the young, and is most com- 
 mon at the seasons when the heat and 
 moisture in the atmosphere are most 
 favorable to fungus growth. It may 
 disappear spontaneously in a few 
 months or weeks, or it may last for 
 years. There is a good deal of itching 
 in some cases, and secondary scratch 
 effects are not uncommon. 
 
 Etiology. — Not all individuals are 
 susceptible to ringworm infection, and 
 the condition of the skin and of the 
 general health are undoubtedly im- 
 portant factors in its occurrence. It 
 is rare in infants and in adults, and 
 occurs most commonly in weak, ane- 
 mic, and badly nourished children, and 
 those that live in damp, unhealthy 
 dwellings. It is often contracted from 
 cats, dogs, horses, and cattle, and is 
 very contagious. 
 
 Pathology. — The presence of the fungus causes a more or less superficial eczema 
 or dermatitis, with vesiculation, papulation, or scaling. Its location is in the corneous 
 layers, and the lanugo hairs are not affected. 
 
 Diagnosis. — In addition to the clinical characteristics above mentioned, the pres- 
 ence of the parasite is readily demonstrated in ordinary cases under the microscope. 
 In the chronic cases of disseminated ringworm the parasite is much more difficult to 
 find. The malady requires to be differentiated from : I. Eczema, which has no sharp 
 margins, and is rarely circular or clearing in the center, itches much more, and is 
 much more frankly inflammatory. 2. Seborrhea, which on the chest and back often 
 looks much like ringworm, having circular scaly patches with clearing centers; the 
 greasiness of the scales and the almost entire absence of inflammation will serve to 
 distinguish it. 3. Psoriasis, which frequently appears as rings with cleared centers, 
 but which the abundance of the dried silvery scales, the absence of exudation, vesi- 
 cles, or papules, and the characteristic location, will sufficiently distinguish. 
 
 Fig. 49. — Trichophytosis corporis. 
 
 From photograph by the author. 
 
110 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Prognosis. — Ringworm of the body is readily cured, but relapses not infrequently 
 
 occur and prolong the cases. 
 
 Treatment. — The parasite is superficially placed, and has but a feeble hold upon 
 
 the skin. After the removal of the superficial scales with the tincture of green soap 
 
 (No. 5, p. 43), or by the use for a 
 day or two of the pure green soap 
 spread upon a piece of lint, the ap- 
 plication of almost any of the ordi- 
 nary parasiticides will suffice to re- 
 move the fungus. Corrosive subli- 
 mate in l-per-cent. solution may be 
 dabbed on the patches once a day, 
 and allowed to dry ; or the tincture 
 of iodine, or carbolic acid in glyce- 
 rin, 1 to 16, or the white precipitate 
 ointment, may be employed. I 
 prefer the chrysarobin collodion 
 (No. 51, p. 108), painted over the 
 patch every day or every other day. 
 Kaposi's naphthol ointment is rec- 
 ommended (No. 37, p. 82) by Las- 
 sar. Tar or sulphur ointments (Nos. 
 22, 25, p. 64) or Lassar's paste (No. 
 2, p. 43) may be employed in obsti- 
 nate cases. Morris's thymol-chlo- 
 roform oil is also beneficial (No. 52, 
 p. no). 
 
 No. 52. Morris's Thymol- Chloroform 
 Oil. 
 
 Fig. 50. — Dermatomycosis flexurarum. 
 From photograph by the author. 
 
 fy Thymol. 
 Chloroform. 
 Ol. olivae 
 
 1 part 
 4 parts 
 12 " 
 
 Pityriasis rosea, described by Gibert as a special disease, is probably only a gen- 
 eralized form of ringworm of the body. 
 
 TRICHOPHYTOSIS CRURIS. 
 
 Synonyms. — Eczema marginatum, dermatomycosis marginata, ringworm of the 
 crotch. 
 
 Definition. — Ringworm of the genitocrural region, characterized by the appear- 
 
TYPOGRAVURE. 
 
 COPYRI3HT, 1905, BY E, B, TRfAT 4 CO., N, Y. 
 
 ECZEMA MARGINATUM. 
 
 PUATE LVII. 
 
Symptoms and Cot 
 
 
 
 - 
 
 . 
 
 I 
 
E. B. T&- 
 
 ECZF. 
 
INFLAMMATIONS. Ill 
 
 ance of spreading, circular, discolored patches with inflammatory margins and grayish 
 or brownish centers. 
 
 Symptoms and Course. — Ringworm of the crotch is most common in hot and 
 damp climates, but is not infrequently seen here. It occurs on the par-ts that are in 
 contact, and therefore most exposed to the effects of heat, moisture, and friction. 
 
 Fig. 51. — Pityriasis rosea. 
 Case of Dr. J. F. Aitken. 
 
 It is most frequent in the genitocrural fold, and spreads from thence to the inside 
 of the thigh, the anal and suprapubic regions, the penis and scrotum being usually 
 free. Much more rarely it affects the axillary and inframammary regions. It be- 
 gins as a rounded, scaly, slightly raised reddish disk spreading peripherically and 
 paling at the center. The margins are markedly inflammatory and are studded 
 with papules and vesicles. The central portions may be reddened, moist, and eczem- 
 atous, or pale and slightly discolored. Adjacent patches coalesce, and thus large 
 symmetrical areas of the disease, with crescentic and sharply marked borders, are 
 formed. Considerable thickening of the skin finally results. The itching is very 
 intense, and scratch-marks and excoriations are common. The malady is a very 
 
112 
 
 ILLUSTRATED SKIN DISEASES. 
 
 chronic one, and may last for years; it shows no tendency to spontaneous healing. 
 The hairs are never affected. 
 
 Etiolojry.— The dependence of the disease upon the presence of the trichophyton 
 parasite has been proved by Kobner, Pick, and Kaposi. The contact ot profusely 
 sweating surfaces and the maceration of the skin that ensues seem to be necessary 
 for its growth. 
 
 FlG. 52. — Trichophytosis cruris. 
 From photograph by the author. 
 
 Diagnosis.— The crescentic patches with elevated brownish-red margins and dis- 
 colored centers, the intense itching, and the location, are sufficiently characteristic 
 The disease requires to be differentiated from an eczema intertrigo of the gemtocrural 
 regions, which has a red, frankly inflammatory, and freely secreting surface, most 
 inflamed in the center of the patch, an irregular, ill-defined margin, and vesicles and 
 papules outside the area affected. 
 
 Prognosis.— The malady is not very contagious, and men affected with it do not 
 usually give it to their wives. Though curable, it is often very obstinate, and re- 
 lapses frequently occur. 
 
COPYRIGHT BY E. B. TREAT * CO., N. Y. 
 
 PHOTOGRAVURE & COLOR CO., N. Y. 
 
 CHROMOPHYTOSIS 
 
 PLATE XXIII 
 
Tre 
 
 - 
 
 - 
 10- 
 
 tpplied t tl •» 
 
 to 
 rem ish- 
 
 No. 53 
 
 or otr 
 
 - 
 
 
 Syr 
 
 
 :^YTOS 
 
 

 CHROMC 
 
 
INFLAMMATIONS. 
 
 113 
 
 r 
 
 r 
 
 Treatment. — After thorough preliminary washing with the tincture of green soap 
 (No. 5, p. 43), Wilkinson's ointment (No. 38, p. 82) should be applied for several 
 days, followed by naphthol in 5-per-cent. ointment (No. 48, p. 105) or in i-per-cent. 
 spirit or oil (No. 41, 
 p. 100). This is per- 
 haps the best means at 
 our command for the 
 eradication of the dis- 
 ease. Chrysarobin in 
 10-per-cent. ointment 
 (No. 40, p. 94) or as 
 collodion (No. 51, p. 
 108), applied to the 
 patch once daily for 
 several days, and the 
 parts then allowed to 
 remain without wash- 
 ing for several days 
 more, is also efficacious. 
 
 The ichthyol-mercury ointment is employed by Wolff (No. 53, p. 1 13). Joseph rec- 
 ommends that in obstinate cases the whole surface should be touched with a 10- 
 per-cent. solution of caustic potash, followed by the application of a zinc paste (No. 
 54, p. 113), and treatment completed by the use of Wilkinson's ointment (No. 38, 
 p. 82). The menthol or carbolic spirit may be used to relieve the itching (Nos. 33, 
 34, p. 78). 
 
 No. 53. Ichthyol-Mercury Ointment. 
 
 R Amnion, sulph-ichthyol. 
 Ungt. hydrarg. amnion. 
 
 Fig. 53. — Trichophytosis cruris. 
 From photograph by the author. 
 
 mt. 
 
 No. 54. Zinc Paste. 
 
 1 part 
 
 R TeiT. silic. . . . 10 to 20 parts 
 
 10 parts 
 
 Ungt. zinci ox. . 80 " 
 
 Prophylaxis must consist of frequent washing, followed by the free use of a zinc 
 or other dusting powder (No. 18, p. 61). The parts should be kept separated by a 
 pad of absorbent cotton, and a suspensory bandage should always be worn. 
 
 CHROMOPHYTOSIS. 
 
 Synonyms. — Pityriasis versicolor, tinea versicolor, dermatomycosis furfuracea, 
 Kleienflechte (Ger.). 
 
 Definition. — A vegetable parasitic disease, characterized by the appearance of 
 yellowish or brownish slightly furfuraceous macules or larger areas, and caused by 
 the growth upon the skin of the Microsporon furfur. 
 
114: 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Fig. 54. — Microsporon furfur. 
 x 600. After Joseph. 
 
 Symptoms and Course. — Chromophytosis is a very common disease, more espe- 
 cially in those suffering from phthisis or hyperidrosis. It begins as small pinhead- 
 to pea-sized rounded macules, situated around the orifices of the hair-follicles. They 
 
 are very slightly elevated, and are covered with 
 minute grayish-white scales, which can be rendered 
 more evident by scraping. Their color varies from 
 light yellowish brown and buff to a deeper reddish 
 tint ; they may be few in number or numerous, and 
 in the latter case they frequently enlarge and co- 
 alesce into irregular areas of varying size. They 
 are found upon the covered portions of the body, 
 most often on the chest, abdomen, and back ; the 
 neck and the backs of the hands are rarely affected, 
 and the face, palms, and soles are always free. Sub- 
 jectively, slight itching is the only symptom. The 
 malady occurs chiefly in adults, and is rare in chil- 
 dren and the aged. Its duration is entirely indefinite ; it may last months or years. 
 In exaggerated forms the entire trunk may be covered. 
 
 Etiology. — Chromophytosis is caused by the growth on the skin of the Micro- 
 sporon furfur, discovered by Eichstadt in 1846. The parasite does not grow on parts 
 exposed tothe lightand that 
 are frequently washed ; and 
 lowered general nutrition 
 and defective hygiene of 
 the skin, more especially 
 when combined with ex- 
 cessive sweating, are the 
 factors that favor its devel- 
 opment. It is but very 
 slightly contagious, and ex- 
 amples of direct transmis- 
 sion from sleeping together 
 and using the same towels, 
 etc., are rare. 
 
 Pathology. — The para- 
 site grows very luxuriously 
 in the upper cells of the cor- 
 neous layer, and the furfu- 
 raceous scales are almost 
 
 entirely composed of its mycelium and spores. The hairs are not invaded. The 
 mycelium is very like that of the trichophyton, but slenderer, and the spores are 
 
 Fig. 55. — Chromophytosis. 
 From photograph by the author. 
 
INFLAMMATIONS. 115 
 
 collected in groups or appear at the ends of the mycelial threads. The exact bo- 
 tanical position of the parasite is still undecided. 
 
 Diagnosis. — The sharply limited brownish spots, the slight scaling, and the char- 
 acteristic location sufficiently distinguish the disease. The microscopic demonstra- 
 tion of the parasite is readily made if a few of the scales are put on a slide with a 
 drop of dilute liquor potassae. In chloasma there is no scaling and no parasite; it 
 occurs on the uncovered parts, and cannot be removed by scratching. Seborrhea 
 has an inflammatory margin of red papules; the scales are greasy and more abun- 
 dant, and no parasitic fungus is present. A macular syphiloderm may occasionally 
 resemble chromophytosis, but its color is more coppery, there is no itching and no 
 parasite, and other symptoms of lues will almost certainly be present. 
 
 Prognosis. — This is good, for the parasitic growth is easily removed. 
 
 Treatment. — Prophylaxis consists in frequent bathing, together with the treat- 
 ment of the hyperidrosis. The underclothing should be frequently changed, and, 
 especially if it is of flannel, should be well sterilized by boiling before it is used 
 again. 
 
 Treatment of the disease itself consists in the thorough removal of the scales and 
 superficial masses of the parasite by the free use of the tincture of green soap (No. 
 5, p. 43) and hot water, after which any of the ordinary parasiticides may be em- 
 ployed. Sulphur paste or ointment (Nos. 24, 25, p. 64) or Wilkinson's ointment 
 (No. 38, p. 82) or naphthol in ointment or oil (No. 37, p. 82, No. 41, p. 100) may be 
 used for from four to eight days, until scaling sets in, when a hot bath may be taken. 
 The tar spirit (No. 10, p. 56) and the sublimate spirit (No. 49, p. 108) are also effi- 
 cacious. The naphthol green soap spirit (No. 55, p. 115) is highly recommended by 
 Joseph. I use the hyposulphite of soda as a lotion (No. 56, p. 1 15), and find it suf- 
 ficient in almost all cases. One very obstinate and extensive case in my experience 
 resisted all manner of treatment, but was finally cured by a course of prolonged 
 sea-baths. 
 
 No. 55. Joseph's Naphthol Green Soap Spirit. No. 56. Sodic Hyposulphite Lotion. 
 
 R- Naphthol .... 5 parts R- Sod. hyposulphitis . . . 1 part 
 
 Solve in spir. vini rectif. q. s. Aquae 8 parts 
 
 Sapo. virid. ad. . . 100 " 
 
 Erythrasma, described as a distinct disease by some authorities, is probably a 
 form of chromophytosis affecting the upper and inner surfaces of the thighs, and 
 often complicated with eczema intertrigo. Its dark red color and location are char- 
 acteristic. 
 
 The animal parasites of the skin belong to various classes, and may be divided 
 in a general way into the Dermatozoa, living in the skin, and including the itch-insect 
 
11(5 
 
 ILLUSTRATED SKIN DISEASES. 
 
 and some less common parasites, and the Epizoa, living on the surface of the integu- 
 ment or in the hair or the clothes, such as lice, fleas, bedbugs, etc. They are all 
 transferable, though all persons are not equally liable to their invasion; they are 
 
 Fig. 56. — Erythrasma. 
 From photograph by the author. 
 
 all more or less itchy, causing scratching, which leads to excoriations, blood-crusts, 
 papules, vesicles, pustules, and pigmentation of the skin. Most of them belong to 
 the class of the Acarina. The important ones are the itch-insect and lice, and only 
 the maladies that thev occasion will be considered. 
 
 SCABIES. 
 
 Synonyms. — The itch, Kratze (Ger.), Gale (Fr.). 
 
 Definition. — A contagious animal parasitic disease, due to the presence in the 
 skin of the Acarus scabici, and characterized by itching and by varying evidences 
 of the secondary general dermatitis, papules, vesicles, pustules, crusts, excoriations, 
 and pigmentations. 
 
 Symptoms and Course. — The itch is a very common disease in certain regions ; in 
 England, according to Crocker, it forms 8 per cent, of all cases, while M'Call Ander- 
 son found it in one quarter of all cases seen in dispensary practice in Scotland. It 
 is common also in many other parts of Europe and in Asia; but in the United States 
 Bulkley places the percentage of its occurrence as low as 2. Increasing emigration 
 has made it more common, especially in the seaport towns. 
 
 The itch-insect itself causes but few symptoms, especially at first, when present 
 only in small numbers ; but it multiplies rapidly, and the new broods, burrowing 
 
INFLAMMATIONS. 
 
 117 
 
 into the skin, soon cause an irritation and itching that are generally quite severe, 
 though they vary in intensity in different persons. They are worst at night, when the 
 patient is warm in bed, and the parasite is most active. The acarus itself lives in 
 the deeper succulent layers of the rete, from which it derives its nourishment; and 
 to attain this position it digs a long, nar- 
 row cuniculus or burrow, which passes 
 obliquely downward through the upper 
 epidermic layers, and is then extended 
 onward through the rete parallel to the 
 surface of the skin. It appears as a 
 whitish or yellowish streak, from ^ to 
 I inch in length, and is further marked 
 by a succession of minute black spots, the 
 little heaps of excrement and ova that the 
 female acarus leaves behind in its onward 
 progress. A few papules, vesicles, or pus- 
 tules may be present at the site of the 
 burrows, but there are no other signs of 
 the presence of the parasite. 
 
 Soon, however, another set of symp- 
 toms, of much greater extent and severity, 
 make their appearance, due to the increas- 
 ing irritation caused by the multiplying 
 parasite and the action of the patient's 
 finger-nails. They are those of a more 
 or less general eczema and dermatitis, and 
 are so various in form that the eruption of 
 
 scabies is essentially a polymorphic one. Papules, vesicles, pustules, excoriation?, 
 blood- and pus-crusts, wheals, and hemorrhages are present in varying quantity ; 
 they are most marked at the places favored by the parasite, but may be present over 
 the whole surface of the body. In neglected cases these secondary inflammatory 
 lesions may entirely mask the original disease, as in the so-called Norway itch. The 
 itching is enormously increased, and may interfere with sleep to such an extent as 
 to impair the patient's health. Finally, in very old cases, the repeated hemorrhages 
 into the cutis, caused by the action of the finger-nails, may lead to a permanent 
 diffuse pigmentation of the skin similar to that seen in prurigo and phtheiriasis. 
 
 The portions of the body selected by the parasite for its habitat are characteristic. 
 These are the soft skin of the interdigital clefts of the hands and feet, of the anterior 
 surface of the wrists, of the penis and mammae, together with the areas subjected to 
 steady pressure, as by garters, corsets, etc. The face and head are not involved. 
 Untreated, the malady lasts indefinitely. 
 
 Fig. 57. — Scabies. 
 
 From photograph by the author. 
 
118 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Etiology. — Infection with the itch-insect occurs almost always from other persons 
 affected with the disease, but varieties of the same parasite are found on animals 
 also, and occasionally the malady is acquired from horses, dogs, and other animals. 
 The transfer from one human subject to another always occurs at night, when the 
 skin is warm and the parasite most active ; there is no danger in the mere handling 
 of affected individuals. Since the adult animals are rarely seen upon the surface, it 
 is probably the larvae that are most frequently transferred. 
 
 Pathology. — The Acarus scabiei belongs to the Acarina, and is an oval, crab-like 
 organism with a straight intestinal canal, but no demonstrable vascular or respira- 
 tory apparatus. The female is yellowish white in color, \ of a line in length, and 
 just visible to the naked eye. Its margin is serrated; its convex back is studded 
 with spines, and shows the transverse striae that mark the divisions of its chitinous 
 
 envelop. The head is armed 
 with four strong claw-like 
 mandibles and two palpas. 
 It has two anterior pairs of 
 five-jointed legs armed with 
 suckers and two similar pos- 
 terior pairs provided with 
 bristles. The oviducts and 
 vagina open into the genito- 
 urinary fold at the posterior 
 end of the abdomen. The 
 male acarus is one third 
 smaller than the female, of 
 similar structure, but has 
 suckers on all its legs. The 
 forked penis is placed in a 
 horseshoe-shaped depres- 
 sion in the abdomen. It 
 lives upon the surface of the 
 skin or under the crusts and 
 scales, and dies soon after 
 impregnation of the female 
 has occurred. 
 
 The female after fecunda- 
 tion cuts through the horny 
 epidermic cells with its sharp mandibles, and, elevating itself on its hind legs, bur- 
 rows obliquely down into the skin toward the rete, and tunnels on along its upper 
 surface. Thus the cuniculus is formed, along the course of which the parasite leaves 
 behind it alternate ova and heaps of feces, the latter of which form the minute black 
 
 Male. 
 
 Track of itch-insect. 
 After Neumann. 
 
 Female. 
 
 Acarus scabiei. 
 After Kiichenmeister and Ziirn. 
 
 Fig. 58. 
 
INFLAMMATIONS. 119 
 
 dots that mark the burrows. The ova are oval, ^ of an inch in length, and 
 from twenty to twenty-six are deposited by each acarus before its death, at the rate 
 of about one daily. The larvae develop in from three to six days, dig separate holes 
 for themselves in the walls of the burrow, and in from two to three weeks appear 
 on the surface as fully developed parasites. 
 
 The inflammatory reaction caused by these processes varies greatly in accordance 
 with individual susceptibilities. Papules, vesicles, and pustules are present over the 
 burrows ; but when the skin is delicate and the itching more intense, all the poly- 
 morphous phenomena of eczema may be present, and affect extensive areas or the 
 whole body. In bad cases the crusts and scales are full of acari, with their ova and 
 remains. 
 
 Diagnosis. — The characteristic features of the disease are the burrows, the parasites, 
 and their ova ; the other lesions are those of the complicating eczema or dermatitis. 
 The acarus is situated in the white non-inflammatory papule at the deeper extremity 
 of the burrow. It may be obtained by opening the track with a fine needle and 
 examining the fluid and detritus under the microscope in io-per-cent. caustic potash 
 solution ; or the entire track can be snipped off with a pair of curved scissors, and 
 similarly treated. The acarus itself, or its ova or feces, will certainly be found. 
 The location of the eczema on the hands, more especially on the interdigital folds, 
 on the penis, and around the genitals, etc., and the marked polymorphism, are also 
 characteristic. Jessner has called attention to the fact that a black streak is left 
 over the burrow if ink be brushed over the suspected surface and then wiped away. 
 
 The diagnosis from other itchy diseases requires to be carefully made. Phtheiriasis 
 shows the characteristic excoriations and the nits, but no general dermatitis. Simple 
 pruritis has no seat of election and shows no burrows. Prurigo begins in very early 
 life, has the characteristic nodules, and is situated on the extensor surfaces. Eczema 
 has not the typical location or the tracks. In urticaria the wheals and the reflex 
 excitability of the skin should suffice to prevent error. 
 
 Prognosis is always good, and most cases can be speedily cured. 
 
 Treatment. — If the skin is much inflamed, a short preliminary treatment with one 
 of the anti-eczematous applications is required; and of these Lassar's salicylic-acid 
 paste (No. 2, p. 43) is the best. Then a vigorous use of green soap, either pure or 
 in the form of the tincture (No. 5, p. 43), will prepare the skin for the parasiticide. 
 Sulphur is the one most generally used, either as the simple ointment (Nos. 24, 25, 
 p. 64) or in accordance with Wilkinson's formula (No. 38, p. 82). This must be 
 rubbed in thoroughly over the entire affected surfaces of the body nightly for three 
 or four days and allowed to remain until morning, when a hot water-and-soap 
 bath should be taken. Naphthol is more agreeable for private practice, and is to be 
 used in the same way. It may be employed as ointment or oil (No. 41, p. 100, No. 
 48, p. 105), but is especially efficacious in combination with green soap (No. 37, 
 p. 82). The balsams of Peru or Tolu, either pure or diluted with oil, and more espe- 
 
120 ILLUSTRATED SKIN DISEASES. 
 
 cially in combination with styrax (No. 5 7, p. 1 20), are preferred by Anderson on account 
 of the absence of disagreeable odor and irritant effects. In the St. Louis Hospital 
 at Paris, where very large numbers of these cases are treated, Hardy's modification 
 of Helmerich's ointment (No. 58, p. 120) is uniformly employed. None other of the 
 legion of antiscabitic applications need be mentioned here, since the above will suf- 
 fice in all cases. 
 
 No. 57. Scabies Ointment. No. 58. Hardy's Helmerich's Ointment. 
 
 R: Bals. Peruv. R: Potass, carb. 1 part 
 
 Styrac. . . . . aa. p. e. Sulphur sublim. ... 2 parts 
 
 Adipis .... \]/ 2 
 
 PHTHEIRIASIS. 
 
 Synonyms* — Pediculosis. 
 
 Definition. — A contagious animal parasitic disease of the skin, characterized by 
 the presence thereon of pediculi and their ova, together with a secondary eczema 
 and dermatitis. 
 
 Three varieties of the hemipterous family Pediculidce or lice are parasitic on the 
 human body. They are wingless, non-metamorphosing insects that live on the blood 
 and the secretions of the body, which they obtain by suction. They are the so- 
 called head-lice, body-lice, and crab-lice ; and they differ sufficiently in appearance, 
 habits, and effects to require separate description. 
 
 PHTHEIRIASIS CAPITIS. 
 
 Synonyms. — Pediculosis capitis. 
 
 Definition. — Pediculosis of the head, characterized by the appearance on the scalp 
 and the hair of the Pediculiis capitis and its ova, together with a secondary eczema 
 and dermatitis. 
 
 Symptoms and Course. — The first symptom of pediculosis of the head is the itch- 
 ing caused by the motion of the parasite and the suction by which it obtains its 
 nourishment. This leads to scratching, excoriations, and eczematous and follicular 
 inflammations, until finally more or less extensive areas of the scalp are raw and 
 weeping, or covered with impetiginous crusts that mat the hair together. Washing 
 the scalp and combing the hair become so painful that they are omitted, and the para- 
 site flourishes in the foul-smelling, decomposing mass. The eczema may spread on to 
 the face and neck, and the neighboring lymphatic glands become swollen and tender. 
 The so-called plica polonica, where the hair remains for years matted together and 
 swarming with vermin, is simply an exaggerated condition of phtheiriasis capitis. 
 The malady is commonest among children on account of the greater chances of con- 
 tagion in schools, and among the poorer classes on account of their uncleanliness ; 
 but it occurs also in adults and among the well-to-do. 
 
INFLAMMATIONS. 121 
 
 Etiology. — The parasite is always directly transferred. Sleeping together and 
 the interchange of hats are the commonest methods of contagion. 
 
 Pathology. — The Pediculus capitis is a small oval insect, 2-3 mm. long, with 
 a segmented abdomen containing the genital organs, a broad thorax, from which 
 project six hairy legs ending in strong hooked claws, and a triangular head provided 
 with a pair of antennae, a suction-tube, and two prominent black eyes. The female 
 is somewhat larger than the male, and lays from fifty to sixty eggs, which take from 
 five to six days to hatch ; and in twenty days more the young are sexually mature. 
 The rate of increase of the parasite is therefore extremely rapid, and it has been 
 calculated that a single female will have five thousand descendants in eight weeks. 
 The males are less numerous than the females, and are provided with a wedge-shaped 
 penis on the upper surface of the last abdominal segment. The color of the pediculi 
 varies with that of the skin, being white in the Eskimo, gray in the European, 
 yellowish brown in the Chinese and Japanese, and black in the negro. 
 
 The ovum is deposited in a bag known as the " nit," which is a pear-shaped 
 chitinous envelop surrounding the hair and fastened to it by a sort of ferrule. Its 
 broader end is directed toward the scalp, and is closed by a 
 round operculum or lid, through which the embryo escapes. 
 The empty nit remains ; and since the pediculus always affixes 
 it to the portion of the hair close to the scalp, successive bags 
 are attached as the hair grows, and their number on a single 
 shaft, which may reach fifteen or twenty, will enable an estimate 
 to be made of the length of time that the disease has existed. 
 The secondary eczemas and dermatites, caused by the irritation 
 of the parasite and infection by the finger-nails, do not differ FlG - S9-— Pediculus 
 
 capitis. 
 
 from the ordinary forms of these affections. The adenopathy photomicrograph by the author, 
 is caused by absorption. 
 
 Diagnosis. — The presence of the pediculi and their nits will distinguish phtheiriasis 
 from eczema capitis, the only disease with which it is liable to be confounded. Ec- 
 zema of the nape of the neck and the back of the head is almost always due to 
 pediculosis, even in cases where the parasite is no longer present. 
 
 Prognosis is of course good if the cause is recognized and the patient appropri- 
 ately treated. 
 
 No. 59. Kerosene Lotion. 
 
 1J Petrolii . . . .60 parts 
 
 01. olivae . . . . 30 " 
 Bals. Peruv. . . . . 10 " 
 
 Treatment. — Cutting the hair is not necessary, though it facilitates treatment and 
 removes large numbers of nits. The carbolic or sublimate spirit (No. 34, p. 78, No. 
 49, p. 108) can then be used daily, together with plenty of hot water and soap and 
 
122 
 
 ILLUSTRATED SKIN DISEASES. 
 
 the fine-tooth comb. In dispensary practice kerosene, either alone or with olive-oil 
 and balsam of Peru (No. 59, p. 121), is the readiest and best application. It should 
 be rubbed thoroughly into the hair in the evening (care being taken to avoid acci- 
 dental ignition), the head closely bound up until morning, and then thoroughly 
 washed. This, repeated three or four nights in succession, will destroy the parasites 
 and embryos ; but the nits are more resistant, and require the free use of alcohol or 
 
 vinegar and the comb for 
 their removal. The eczema 
 and dermatitis sometimes re- 
 quire treatment, though the 
 removal of their cause will 
 generally suffice. The oint- 
 ment of ammoniated mercury 
 fulfils this indication, and is a 
 parasiticide also ; it is there- 
 fore to be preferred in private 
 practice. The same may be 
 said of the 5-per-cent. naph- 
 tholated oil (No. 41, p. 100). 
 
 PHTHEIRIASIS VESTI- 
 MENTI. 
 
 Synonyms. — Pediculosis 
 vestimenti s. corporis. 
 
 Definition. — Pediculosis 
 of the bod}-, characterized by 
 the presence of the Pcdiculus 
 corporis and its ova in the 
 clothing, by the lesions caused 
 by it upon the skin, and by a 
 secondary eczema and der- 
 matitis. 
 
 Symptoms and Course. — 
 When the pediculus with- 
 draws its haustellum from a 
 glandularorificeasmall hem- 
 orrhage occurs in the follicle, 
 with an area of cedema around it, appearing as a minute red dot surrounded by a 
 wheal. Itching and burning are felt, which the patient relieves by scratching. When 
 the top of the cedematous papules is torn off, and bleeding relieves the congested 
 vessels, the itching ceases. The original lesions are transitory and unimportant; 
 
 FlG. 60. — Phtheiriasis vestimenti. 
 After Van Haren-Nomaii. 
 
INFLAMMATIONS. 123 
 
 but the scratch lesions are much more permanent, appearing as characteristic linear, 
 parallel, hemorrhagic streaks or rows of torn papules. They are located more espe- 
 cially on the neck and waist, where the folds of the clothing fit tightest, and where 
 the parasite finds a home in the seams. In bad cases infection from the finger-nails 
 gives rise to furuncles, abscesses, and deeper ulcerations, ending in superficial scars. 
 When the malady has been present for many years, as is frequently the case with 
 tramps and lodging-house dwellers, the multitudinous hemorrhages occasion a gen- 
 eral diffuse pigmentation of the skin which is characteristic. 
 
 Etiology. — Body-lice are transferred from one person to another by contact with 
 infected bed-linen, clothing, furniture, etc. While most frequently seen in persons 
 of dirty habits, any one may acquire them in street-cars and 
 other public places. 
 
 Pathology. — The Pediculus corporis is a grayish-yellow 
 oval insect, similar in form and structure to the head-louse, 
 but somewhat larger, measuring 2—3 mm. Its habitat is the 
 seams and folds of the clothing next to the skin, and it seeks 
 the integument only for the purpose of feeding. It obtains 
 its nourishment by suction after thrusting its haustellum into 
 a follicle-mouth. Its color when swollen with blood is red. 
 The nits are small, yellowish, rounded bodies, and are laid in 
 the seams or in the meshes of coarse underwear. The num- Fig. bi.—Pedkuhis vesti- 
 ber of the embryos and the time required for their hatching After KucheTIeistir and Ziim. 
 and maturity are about the same as with the Pedicttlus capitis. 
 
 Diagnosis. — The location of the secondary lesions on the neck, waist, buttocks, 
 thighs, etc., the parallel scratch- marks, the minute hemorrhagic papules, the pigmen- 
 tation, and the finding of the parasite and its nits in the clothing will distinguish 
 phtheiriasis corporis from the other itchy diseases. General pruritus is rare, and the 
 partial form is usually localized around the orifices of the body. Urticaria has its 
 wheals, which appear anywhere, and an irritable skin, and is associated with diges- 
 tive disturbances. Scabies has the characteristic tracks and the equally characteristic 
 location around the genitals and in the interdigital folds. Prurigo begins in youth 
 and affects the extensor surfaces chiefly. Eczema is more frankly inflammatory, 
 with weeping surfaces and crusts at its favorite seats. 
 
 Prognosis. — This is good if the nits and embryos can be destroyed. This is not 
 always possible, and some of these patients go on for years affected with the disease, 
 sharing the supposition, so common in the lower classes, that the skin breeds the 
 vermin. 
 
 Treatment. — Disinfection of the clothes is the only treatment. Underwear can 
 be boiled, but the outer clothing must be exposed to a dry heat of at least 160 to 
 I 7S°, by wrapping it up in paper and placing it in a carefully heated oven. 
 The skin need not be treated, though the staphisagria ointment recommended by 
 
124 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Duhring (No. 60, p. 124) will destroy any parasites or embryos that may be on it. 
 The excoriations may require a bland ointment or dusting powder (No. 18, p. 61, 
 No. 26, p. 70, No. 54, p. 113). 
 
 No. 60. Duhring 1 s Staphisagria Ointment. 
 
 $ Pulv. staphisagrise 
 Ungt. simplicis . 
 
 1 part 
 4 parts 
 
 PHTHEIRIASIS PUBIS. 
 
 Synonyms. — Phtheiriasis inguinalis, pediculosis pubis, crabs. 
 
 Definition. — Pediculosis of the genital regions, and sometimes of all the other 
 
 hairy surfaces except the scalp, characterized by the presence of the Pediculus pubis 
 
 and its ova, together with a secondary eczema and dermatitis. 
 
 Symptoms and Course. — The crab-louse is found most commonly in the pubic 
 
 region, but sometimes seen in the axillae, in the beard, mustache, eyebrows, and lashes. 
 
 In very hairy individuals the entire body, save the head, hands, and feet, may be 
 
 affected. The symptoms caused by its presence consist of the itching, together 
 
 with the secondary excoriations and eczemas, as is the 
 
 case with the other pediculi. The parasites are small 
 
 and transparent, and therefore sometimes hard to de- 
 tect ; but they can be seen lying along the hairs, which 
 
 they clutch with their strong claws, while their heads 
 
 remain buried in the follicle-mouths. Minute heaps 
 
 of reddish excrement are visible on the skin among the 
 
 hair-shafts. Considerable traction with the forceps is 
 
 required to detach them. The nits are smaller than 
 
 those of the other varieties, but 
 of similar structure, and at- 
 tached to the hairs in the same 
 way. 
 
 Etiology. — Contagion al- 
 most always occurs during 
 sexual intercourse. It may, 
 however, happen without it, as 
 was shown to my satisfaction 
 quite recently, when almost all 
 
 the tenants and employees on one floor of a very large office building in New York 
 
 became infected, and the parasites were found on the woodwork of the public 
 
 water-closets. 
 
 Pathology. — The pubic is the smallest of the three varieties of pediculi, and is 
 
 Fig. 62. — Pediculus pubis. 
 Photomicrograph by the author. 
 
 Fig. 63. — Nit and embryo — Pedicu- 
 lus pubis. 
 Photomicrograph by the author. 
 
COPYRIGHT BY E. B. TREAT 4 CO. , N. Y. 
 
 PHOTOGRAVURE 4 COLOR CO., N. Y. 
 
 ECZEMA IMPETIGINOSUM 
 
 PLATE XV 
 
I . 
 Diagno; 
 
 TfCAtl!': 
 
 jrms ; 
 
 
 
 
 
 
 - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 ECZEMA IMPETIGINOSUM 
 
 
INFLAMMATIONS. 125 
 
 a crab-like insect 1-2 mm. in length. Its flat body is short and round, and the 
 thorax and abdomen are merged into one. Its color is a transparent grayish yellow. 
 It obtains its nourishment by means of an haustellum, as do the other lice. 
 
 Diagnosis. — The itching in the genital region is sufficiently characteristic, and a 
 close inspection in a good light will always reveal the presence of the parasite. In 
 the better class of patients a sort of " pediculiphobia " is sometimes left behind, and 
 they will often complain of itching, and claim to be still infected, long after all the 
 vermin have been destroyed. 
 
 Treatment. — Almost any of the parasiticides previously recommended will be 
 found efficacious. The sublimate spirit (No. 49, p. 108) does very well, but it is liable 
 to irritate the skin of the scrotum and the thighs, and cannot be used over the whole 
 body for fear of absorption. Mercurial ointment, the common remedy for the con- 
 dition, has similar limitations. In extensive cases the naphtholated oil (No. 41, 
 p. 100) or the carbolic lotion (No. 11, p. 56) or the ointment of ammoniated mercury 
 may be used ; they are slower, but safe and effective. Rosenbach recommends a 
 mixture of balsam of Peru and ether (No. 61, p. 125). 
 
 No. 61. .Rosenbach' s Lotion for Pediculosis. 
 
 fy Bals. Peruv. . . . -3° parts 
 Ether, sulph. . . . 100 " 
 
 ECZEMA. 
 
 Synonyms. — Salt rheum, tetter, Salzfluss (Ger.). 
 
 Definition. — A catarrhal inflammation of the skin, characterized by the appear- 
 ance of erythematous areas, papules, vesicles, pustules, or weeping or scaling surfaces, 
 and accompanied by itching. 
 
 Symptoms and Course. — Eczema is the commonest of all the diseases of the skin, 
 forming about one fourth of all cases. It is essentially a simple catarrhal inflam- 
 mation, and its symptoms in general are the classical ones of heat, redness, pain, 
 and swelling. They are modified, however, by the fact that the skin is exposed to 
 the action of the external influences, and is not confined in the midst of other organs 
 and tissues. These factors diminish the heat and redness ; cause pain to be replaced 
 most often by itching, though occasionally by burning ; permit the exudation and 
 emigration incidental to the inflammatory process to flow off from the surface of the 
 affected tissue ; and render the affected organ liable to external injuries and microbic 
 infection. As with other inflammations, the process terminates either in resolution, 
 with absorption or extrusion of the effused products, or in organization, or, finally, 
 in pus formation. The disease may be a transitory one, lasting only for a few days ; 
 or it may endure, with exacerbations and remissions, for a lifetime. Save in very 
 extensive and unusual cases there is no accompanying constitutional disturbance. 
 
1:26 
 
 ILLUSTRATED SKIN DISEASES. 
 
 The symptomatology of eczema is essentially protean ; it may appear as an 
 erythematous patch, as a moist and oozing surface, as a collection of vesicles, pap- 
 ules, or pustules, or as a crusted and desquamating area. These differences depend 
 upon the cause of the affection, the stage that it is in, and the conditions and sur- 
 roundings of the affected skin. Several varieties of lesion are often present together, 
 and,. in accordance with the predominant one, various kinds or, more properly, vari- 
 ous stages of ecze- 
 ma are recognized. 
 The course, loca- 
 tion, and etiology of 
 the disease give rise 
 to still other vari- 
 eties that require 
 consideration. 
 
 i. Eczema ery- 
 thematosum. The 
 process commences 
 with the appearance 
 of one or a number 
 of slightly elevated, 
 pinkish, itchy mac- 
 ules, of indefinite 
 outline, which soon 
 spread and coalesce 
 into larger reddened 
 areas. The entire 
 surface is swollen ; 
 its color varies from 
 a light pink to a 
 dusky red ; there is 
 moderate heat and 
 a varying amount of 
 itching. It is seen 
 most commonly 
 upon the face, where 
 
 it appears as a general diffuse redness, with accentuation of the natural folds and 
 wrinkles of the skin; but it may affect the palms, the soles, and the regions around 
 the genitals. The process may last only a short time, but it is frequently very chronic, 
 especially in the old. Mental excitement, external heat, a heavy meal, or the use 
 of alcohol aggravates it temporarily. It usually terminates in resolution ; the red- 
 ness and swelling fade, the itching ceases, and the process ends with a fine epithelial 
 
 Fig. 64. — Eczema papillosum. 
 From photograph by the author. 
 
TYPOGRAVURE. 
 
 COPYRIGHT, 1905, BY E. S. TREAT 4 CO., N. Y. 
 
 ECZEMA SEBORRHOICUM. 
 
 PLATE LVIII. 
 
INFLAMMATIONS. 
 
 127 
 
 desquamation; but it may develop into one of the other forms of eczema. When it 
 has been long present, a permanent thickening of the skin, due to an inflammatory- 
 new growth of connective tissue, is left behind. 
 
 2. Eczema papulosum. This is a common and very obstinate form of eczema, 
 and is usually seen on the trunk and the extensor surfaces of the limbs, but rarely 
 affecting the head or face. The eruption consists of millet-sized, acuminate, inflam- 
 matory papules, isolated or grouped, and often spread over a considerable area of 
 the body. Their color is reddish or violaceous. They may remain papules during 
 the entire course of the disease, they may become confluent in places and form 
 larger, irregular patches, or they may go on to form vesicles and weeping surfaces. 
 The itching is intense, and excoriations and blood-crusts are common. 
 
 3. Eczema vesiculosum. This begins with a diffuse or punctate redness, accom- 
 panied by itching and burning, and papules soon appear that rapidly become vesicles. 
 They are pin-point sized, acuminate, irregularly arranged, filled with a clear serum, 
 
 Fig. 65. — Eczema vesiculosum. 
 
 After Van Haren-Noman. 
 
 and surrounded by a narrow inflammatory areola. Occasionally they are grouped, 
 and sometimes they become confluent and form irregular masses. The vesicles grow 
 slowly until they finally rupture, either spontaneously or in consequence of the 
 scratching. A red, weeping surface is left behind, the secretion of which dries up 
 into thin, yellow, honey-like crusts, or flows off in drops. As the inflammation sub- 
 sides the serous discharge lessens, the redness fades, the crusts fall off, and, with slight 
 desquamation, a new epithelial covering is formed. Eczema vesiculosum occurs with 
 especial frequency on the faces of children. It may last for some time unchanged, but 
 more commonly it runs into the form known as eczema rubrum or eczema madidans. 
 
128 
 
 ILLUSTRATED SKIN DISEASES. 
 
 4. Eczema pustulosum or eczema impetiginosum is the variety in which the 
 lesions either originate as pustules or rapidly become such after a vesicular stage. 
 A secondary infection with pus-cocci probably occurs. At first minute, the pustules 
 rapidly become larger and then rupture, and their contents dry up into dark, black- 
 ish or greenish or yel- 
 lowish crusts. It occurs 
 most frequently on the 
 scalp and face of chil- 
 dren and in debilitated 
 patients. After persist- 
 ing foranindefinitetime, 
 it gradually disappears 
 in the same way as does 
 the vesicular form. 
 
 While each one of 
 these four chief types of 
 eczema may occuralone 
 and persist unchanged, 
 it is more common to 
 find them intermingled. 
 They are, in fact, rather 
 to be considered as dif- 
 ferent stages of the same 
 process ; and an eczema 
 may, and often does, 
 pass through all of them 
 before the inflammation 
 subsides. A number 
 of other terms are em- 
 ployed to describe va- 
 rieties of this protean 
 malady, and of these 
 the following forms are 
 characteristic and im- 
 portant enough to merit 
 especial mention. 
 
 5. Eczema acutum. This may be of the erythematous, vesicular, papular, or 
 pustular form, and usually passes through all four stages. The reddened and swollen 
 skin soon becomes covered with papules, vesicles, and pustules ; these latter rupture, 
 leaving a red and oozing surface behind. After a few davs or weeks the secretion 
 diminishes, the redness disappears, and the process ends with desquamation. It may 
 also terminate in chronic eczema. The itching and burning are intense, and there 
 
 FlG. 66. — Eczema squamosum. 
 From photograph by the author. 
 
5 
 D 
 H- 
 D 
 O 
 < 
 
 < 
 
 LU 
 
 N 
 O 
 
 LU 
 
- 
 
 
 
 
 [till 
 
 • 
 
 
 tns tilt wl 
 
 
 ! 
 
s 
 
 K 
 => 
 O 
 < 
 
 < 
 
 s 
 
 u 1 
 
INFLAMMATIONS. 
 
 129 
 
 may be much oedema in locations, as on the eyelids, where the subcutaneous connec- 
 tive tissue is loose. The extensive general forms of acute eczema are rare, and may be 
 accompanied by a febrile movement. It is very liable to relapse at irregular intervals. 
 
 6. Eczema chronicum. This may appear as any one of the chief varieties, but is 
 usually squamous in form, and follows an acute attack. The long-standing chronic 
 inflammation leads to hypertrophic thickening, Assuring, and pigmentation of the 
 affected parts. It is usually due to some permanent cause, most frequently the 
 patient's occupation. It often persists for years. 
 
 7. Eczema squamosum represents the final stage of any of the other forms of the 
 disease ; but extremely chronic cases may be squamous almost from the beginning. 
 The amount of exudation is small ; the skin is reddened in patches or more diffusely, 
 and is covered with fine, grayish-white scales. 
 
 8. Eczema crustosum is simply one of the other forms in which the serum has 
 dried up into crusts, whose color depends on the nature of the secretion and the 
 varying amounts of serum, pus, sebum, blood, and dirt that are intermingled. 
 Under these crusts we find a diffusely reddened, weeping surface. 
 
 9. Eczema verrucosum occurs more especially on the lower extremities in the aged, 
 when the long-continued chronic inflammation leads to hypertrophy and thickening of 
 the skin. The entire surface is dry and warty and covered with thin crusts and scales. 
 
 10. Eczema rubrum or eczema madidans is 
 usually a consequence or continuance of eczema 
 vesiculosum. The affected surface is red and 
 moist ; and a thick, gummy serum exudes from it, 
 which may either flow away or dry up into yel- 
 lowish- or greenish-brown crusts. It is oftenest 
 seen on the lower extremities of elderly people, 
 and may be very extensive, involving the whole 
 limb. It is very chronic, often lasting for years. 
 
 1 1. Eczema intertrigo. This is seen where the 
 surfaces of the skin are in apposition, and where 
 maceration of the parts with sweat and serum oc- 
 curs. It appears as a diffuse, red, weeping surface, 
 and is commonest at the flexures of the joints, on 
 the nates and genitals (especially in children), and 
 around the neck. 
 
 12. Eczema capitis. This may occur in iso- 
 lated patches, or be generally diffused over the head. The sticky serum mats the 
 hair together, and pediculi, which are the cause of the inflammation, are almost always 
 present. In the more chronic forms the whole scalp is scaly, forming what is known 
 as pityriasis of the head. 
 
 13. Eczema faciei. This is usually primary and acute, and is very common in 
 infants, forming the crusta lactea. It is generally at first vesicular and then diffuse, 
 
 Fig. 67. — Eczema faciei. 
 From photograph by the author. 
 
130 
 
 ILLUSTRATED SKIN DISEASES. 
 
 and is accompanied by much oozing. The more chronic forms in adults are often 
 erythematous; the skin is red and swollen, the natural wrinkles are exaggerated, the 
 lids are swollen, and the itching and burning are intense. 
 
 14. Eczema barbae is one of the varieties of the so-called barber's itch. The 
 bearded skin is red, swollen, and tender, and the hairs are matted together with 
 gummy secretion. Secondary coccigenic infection, leading to the formation of 
 pustules around the hair-follicles, is common. 
 
 Fig. 68. — Eczema of the hands. 
 From photograph by the author. 
 
 15. Eczema manuum. This is a very common affection, and while it may be 
 acutely vesicular or pustular, it usually assumes the chronic indurated form. When 
 the palms are affected the skin is thickened and fissured at the flexures and folds. 
 It is commonly due to the patient's occupation, and is found in masons, gilders, pol- 
 ishers, etc., being caused by the irritating materials that they use. 
 
 16. Eczema genitalium is usually of the chronic erythematous or squamous form, 
 and most commonly affects the scrotum. The itching is frequently intense, and the 
 malady is very rebellious to treatment. 
 
- Z '.J 2 -- . = 1 
 
 COPYRIGHT, 1902, BY F. B. TREAT 4 CO., N. Y. 
 
 ECZEMA SEBORRHEICUM. 
 
 FLATE LI. 
 
V 
 
 
 
 
 
 
 
 , 
 
 
 - 
 
 
 
v 
 
 
 
 
 
INFLAMMATIONS. 
 
 131 
 
 1 7. Eczema unguium. This occasionally occurs in connection with other eczem- 
 atous eruptions. The nails become brittle and break, are furrowed with dark lines, 
 and finally fall off. 
 
 1 8. Eczema seborrheicum. This is a form that Unna first called attention to, and 
 which certainly differs very markedly from all the ordinary types of eczema. It ap- 
 pears as rounded or circinate yellowish-red patches, spreading peripherically, with 
 a papular or scaly margin and a fading center. Its favorite location is the sternum 
 and the center of the back, the scalp, eyebrows, and mustache, the axillae, and the 
 genitocrural fold. On .the scalp it appears as a diffuse or general redness, with 
 minute oily scales, and a very distinct reddish border along the forehead and temples, 
 the corona seborrheicum. It is really a combination of seborrhea in either its dry 
 or oily form with an eczematous inflammation. It is undoubtedly of parasitic origin, 
 and belongs in the section with ringworm and similar affections rather than in that 
 of the simple inflammations. 
 
 Etiology. — Eczema occurs at 
 all ages and in all conditions of life. 
 Its frequency during infancy is to 
 be ascribed to the delicacy of the 
 skin at that age and its prompt re- 
 action to irritants of external and 
 internal origin. The causes of ec- 
 zema are very numerous, and are 
 either internal and general, or ex- 
 ternal and local. 
 
 The internal causes of eczema 
 are, of course, more or less indefi- 
 nite and incapable of exact proof. 
 Nevertheless the malady does oc- 
 cur with especial frequency in con- 
 nection with nervous diseases, in 
 anemia, chlorosis and leucocy- 
 themia, in rickety individuals, in 
 gravid women, in those affected 
 with asthma, and together with 
 digestive disturbances and obsti- 
 nate constipation. 
 
 The local causes of eczema are 
 too many to be enumerated in de- 
 tail. They consist of : [a) Parasites. 
 While the claim advanced by Unna to have found a bacterial cause for the various 
 eczemas is by no means substantiated, some of these maladies are undoubtedly of 
 
 Fig. 69. — Eczema acutuni. 
 From photograph by the author. 
 
132 ILLUSTRATED SKIN DISEASES. 
 
 that nature. This is notably the case with eczema seborrheicum. I believe that 
 only the eczemas that have a marked seborrheal element, or that appear with sharply 
 circumscribed circular or gyrate outlines, can in the present state of our knowledge 
 be positively claimed as parasitic. The animal parasites, pediculi and the itch-insect, 
 cause a secondary eczema of the skin, and the same is true of the trichophyton. 
 (b) Mechanical, chemical, and thermic irritants. Many substances, such as mercury, 
 iodoform, creolin, carbolic acid, petroleum, turpentine, sulphur, and the aniline dyes 
 cause an eczematous inflammation of the parts exposed to their influence ; so also do 
 the poisons of the Rhus toxicodendron and Rhus venenata. The ultra-violet chem- 
 ical rays of sunlight cause eczema solare, and the electric-light rays have a similar 
 effect. Strong acids and alkalis are efficient causes ; so also are many soaps ; and 
 even water, when used to excess, can set up an eczematous inflammation. Finally, 
 the finger-nails are responsible for many eczemas, more especially in the itchy erup- 
 tions, pruritus, prurigo, scabies, etc. 
 
 Pathology. — Eczema is a simple catarrhal inflammation of the skin, and does 
 not differ essentially from similar inflammations of the mucosae. The ordinary vas- 
 cular phenomena of inflammation and their consequences are present ; but the process 
 varies somewhat in accordance with the intensity and the duration of the inflamma- 
 tion. The fluid that is poured out is the blood-serum, a yellow, clear, sticky, syrupy 
 material, drying up into yellowish crusts. In the erythematous form the exudation 
 is moderate and there is increased activity of the epidermic cells, as is shown by the 
 desquamation. In the papular form the papillary vessels are chiefly affected, and 
 the exudation and emigration are great enough to elevate the corneous layer. The 
 vesicular form is simply an exaggeration of the papular; the exudation is sufficient 
 to accumulate as a fluid mass in the corium. In the pustular form there is in- 
 creased cell-emigration and multiplication of the connective-tissue corpuscles. The 
 changes of chronic eczema are more deeply seated in the corium and subcutis. The 
 parts are thickened by the infiltration and new connective-tissue formation, and 
 pigment is deposited in the deeper layers of the rete and corium. The verrucous 
 form is marked chiefly by the permanent enlargement of the papillae. In the 
 squamous form the epithelial-cell proliferation is increased. 
 
 Diagnosis. — Eczema is the most frequent and important disease of the skin, and 
 its diagnosis is often difficult on account of the polymorphous nature of its manifes- 
 tations, and from the fact that in various other maladies the secondary lesions are 
 eczematous in character and may mask the original disease. Where one of the chief 
 typical forms is present the diagnosis will present no difficulties ; but the mixed forms 
 may resemble a number of other affections. In a general way the diagnosis is made 
 from the inflammatory symptoms and the formation of acuminate papules and vesi- 
 cles, exudation, crusting and scaling and thickening, together with the absence of 
 sharp limitation of the eruption, the polymorphism, and the intense itching. The 
 principal maladies which require differentiation from it are : 
 
ECZEMA PALM/E. 
 
 TYPOGRAVURE. 
 
 COPYRIGHT BY E. B. TREAT * CO., N. Y. 
 
 SYPHILODERMA Palm*. 
 
 PLATE XVI. 
 

 - 
 
 
 
 
 (0) Psi 
 
 
 
 
 • 
 
 
 . 
 
 
 
 * 
 
 
 
 fold. 
 
 
 
 
 
 -ular 
 
 
 
 
 _ 
 
 in. (g) Ph 
 
 
 
 - 
 
 to prev 
 
 
 3, the hi. 
 
 
 idsuffio: 
 
 - 
 
 - 
 
 ■ - 
 
 d b 
 
 : 
 
 arac- 
 
 I 
 
 mar- 
 
 ed. 
 Progfnosi 
 
 ■ ■ 
 
 -o relapi 
 
 I - 
 
 Ec- 
 
uM-C. 
 
 ■ 
 
 SYPH mm*. 
 
 PLATE X> 
 
INFLAMMATIONS. 133 
 
 (a) Erysipelas, which has marked and acute general febrile symptoms, with a vivid, 
 smooth, shining redness, swelling, sharp borders, and is never weeping or papular or 
 vesicular, (d) Psoriasis, which has shining silvery scales on a punctate bleeding 
 base, is sharply circumscribed, never shows vesiculation or oozing, and is situated 
 most often on the extensor surfaces of the limbs, (c) Herpes facialis, which may- 
 be distinguished by the presence of a sharply limited group of vesicles of the same 
 age situated on an inflamed base, (d) Eczema marginatum has a sharply limited 
 brownish-red margin of curved outline, and is situated in the axilla and the genito- 
 crural fold, (e) Lupus erythematosus. This sometimes resembles an eczema very 
 closely, but differs from it in its very slow progress, the absence of vesiculation and 
 itching, and the presence of scanty seborrheal scales with plugs from the glandular 
 orifices projecting from their under surfaces, and is followed by superficial central 
 scarring. (/") Pemphigus, which has large blebs separated from one another by 
 sound skin, (g) Phtheiriasis vestimenti. This often causes lesions that are essen- 
 tially those of a papular eczema; but the discovery of the cause in the clothing will 
 serve to prevent error. (A) Scabies. Here also the lesions are eczematous ; but the 
 tracks, the history of contagion, the seat at the clefts of the fingers and on the geni- 
 tals, should suffice to prevent mistake. (/) Syphilis. The papules of syphilis are hard, 
 copper-colored, do not disappear on pressure, and are unaccompanied by itching. The 
 ulcers of syphilis have hard, infiltrated edges and dirty necrotic bases, while ulceration 
 does not occur in eczema. The diagnosis between syphilis and eczema of the palms is 
 often a matter of difficulty ; but the sharply limited dark-brown infiltration, with semi- 
 detached scales at the margins, the central clearing, and the presence of other mani- 
 festations of the disease are characteristic, (j) Impetigo contagiosa has isolated yellow 
 circular crusts on reddened bases, and usually a history of contagion, (k) Lichen 
 planus. Here the papules are flat-topped, angular, often umbilicated, and violaceous 
 in color ; they are grouped and symmetrical, and affect the backs of the hands and 
 the forearms by preference. (/) Seborrhea is never moist, and shows the charac- 
 teristic fatty scales, (m) Trichophytosis may resemble a papulo-erythematous 
 eczema very closely ; but the patches are distinctly circular or gyrate, their mar- 
 gins are abrupt, and the microscope will always settle the diagnosis. (;z) Dermatitis, 
 as from external irritants, while it may resemble an eczema very closely, has a 
 history and course that are characteristic, and rapidly subsides when its cause is 
 removed. 
 
 Prognosis. — This in a general way is good, though there are exceptions. Acute 
 eczema is always curable, but is very liable to relapse. Chronic eczema may be 
 incurable when its underlying cause cannot be removed. In those rare cases in 
 which the entire integument is involved the affection is a grave one ; the important 
 functions of the skin are interfered with, and the excessive discharge causes ex- 
 haustion, which is increased by the loss of rest due to the itching. The chronic 
 eczemas of the aged may be incurable, though they can always be relieved. Ec- 
 
 I 
 
134 
 
 ILLUSTRATED SKIN DISEASES. 
 
 zema leaves no permanent mark on the skin; it never causes ulceration or the 
 formation of cicatricial tissue, and the thickening and pigmentation that some- 
 times result from it disappear in the course of time. 
 
 Treatment. — A methodic and careful treat- 
 ment, which takes into account the underlying 
 and accompanying general conditions as well 
 as the nature and stage of the local malady, 
 will give the best results. The topical treat- 
 ment is undoubtedly the most important, but 
 the other means must not be neglected. 
 
 No. 62. Diuretic Mixture. 
 
 $ Kali acetat. . 
 Spts. aether, nit. 
 Syrp. aurant. 
 Aq. fcenic. . 
 
 i part 
 2 parts 
 4 " 
 
 12 " 
 
 Fig. 70. — Eczema crustosum. 
 From photograph by the author. 
 
 General Treatment. — This consists in 
 the appropriate management of any abnormal 
 condition of the general system or of other or- 
 gans which may influence the origin or per- 
 sistence of the eczematous malady. Anemic 
 and chlorotic patients require phosphorus, 
 quinine, iron, strychnine, and the mineral 
 acids, with carefully prescribed diet and ex- 
 ercise. Startin's mixture (No. 19, p. 64) is 
 very useful here. Where rheumatic or gouty 
 symptoms are present the alkalis, more espe- 
 cially the alkaline diuretics (No. 62, p. 134), 
 either alone or with colchicum, are required. 
 They are also useful where there is functional 
 kidney derangement. When dyspepsia and 
 constipation are present the diet must be care- 
 fully regulated, more especially as regards 
 meats ; and laxatives, such as cascara and the 
 various mineral waters, must be regularly used. 
 It is sometimes necessary to put the patient 
 on a milk diet for a time. In fact, the care of 
 the digestive tract is of the utmost importance 
 in eczema; and, in the infantile forms more 
 especially, little permanent good will be ac- 
 
INFLAMMATIONS. 
 
 135 
 
 complished unless the diet and the bowels be most carefully regulated. In the 
 impetiginous eczemas, and in general in all the so-called strumous cases, where the 
 tendency to chronic inflammation is marked, cod-liver oil in full doses, perhaps 
 combined with the syrup of the iodide of iron, is most useful. 
 
 Of the internal remedies directed to the eczema itself we need mention only two, 
 arsenic and ichthyol. The former may be given as the Asiatic pill (No. 6, p. 46) or 
 as Fowler's solution in doses of 3 to 1 5 drops three times daily, well diluted with 
 water and administered after meals. It is useful only in the chronic squamous 
 cases when the digestive tract is in good condition, and it must be pushed up to the 
 point of toleration. Ichthyol may be given in pill form, preferably combined with 
 arsenic (No. 63, p. 135). 
 
 No. 63. Ichthyol-Arsenic Pills. 
 
 Bt Amnion, sulph-ichthyolat. 3i ss 
 Ac. arseniosi . . . gr. 2 
 Pulv. glycyrrhizae . . q. s. ut f. pil. No. 90 
 Sig. 2 to 3 t. d. after meals. 
 
 LOCAL TREATMENT. — An indispensable preliminary step is to remove all irrita- 
 tion from the inflamed surface. Perhaps the commonest source of this is water, and 
 in the acuter cases its use must be restricted or even forbidden altogether. Warm 
 olive-oil may be employed for cleansing. Other irritants are the atmosphere, soaps, 
 decomposing secretions, the finger-nails, and mechanical or chemical influences. 
 The crusts and scales must be removed after a thorough soaking with olive-oil, and 
 for this purpose a single application of the tincture of green soap (No. 5, p. 43) and 
 water is admissible. The further local treatment will depend on the nature and stage 
 of the eczematous process. 
 
 No. 64. Zinc- Camphor Powder. 
 
 ft Pulv. camph. 
 Pulv. zinci ox. 
 Pulv. amyli . 
 
 1 part 
 3 parts 
 12 " 
 
 No. 65. Zinc-oil. 
 
 ft Pulv. zinci ox. 
 01. olivae 
 
 30 parts 
 
 25 " 
 
 No. 66. Lime-oil. 
 R 01. amygdal. 
 Aq. calcis 
 
 aa. p. e. 
 
 No. 67. Alkaline Lotion. 
 
 ft Sod. bicarb. 
 Aquae . 
 
 1 part 
 50 parts 
 
 No. 68. Cooling Salve. 
 
 ft Adip. lanae ... 1 part 
 
 Adip. suillis ... 2 parts 
 
 Aq. rosse (s. calcis) . . 3 to 5 " 
 
 No. 69. Rose-water Ointment. 
 
 ft Aq. rosae 
 Adip. lanae 
 Adip. suillis 
 
 3 parts 
 
 3 " 
 2 " 
 
136 ILLUSTRATED SKIN DISEASES. 
 
 Acute eczema. Remedies of the mildest kind are here required, and lotions and 
 powders are more generally applicable than salves and pastes. In the erythematous 
 and acute vesicular forms the zinc-oxide powder (No. 18, p. 61), either alone or 
 with camphor (No. 64, p. 135), may be employed; or the zinc- or lime-oils (Nos. 65, 
 66, p. 135), followed by a dusting" powder. Weak alkaline lotions are often useful in 
 the early stages (No. 67, p. 135). In the less acute degrees the various cooling salves, 
 of which No. 68 (p. 135) is an example, may be used, as may also the boracic-acid 
 ointment (No. 29, p. 74) or the rose-water ointment (No. 69, p. 135). The use of 
 powders after these various applications must be persisted in as long as there is 
 much secretion. The salves and plaster-mulls can often be employed with ad- 
 vantage. 
 
 For the relief of the itching, which is especially intense in the papular form of 
 the disease, the 5-per-cent. menthol spirit (No. 33, p. 78) or the 3-per-cent. carbolic 
 spirit (No. 34, p. 78) may be employed. As the inflammation subsides, painting the 
 parts once daily with the tar tincture (No. 45, p. 104), followed by the salicylic-men- 
 thol paste (No. 70, p. 136), will be found useful. 
 
 No. 70. Salicylic- Menthol Paste. No. 71. Diachylon Ointment. 
 
 R Ac. salicyl. ... 1 part fy Emplast. diachyli . . 3 parts 
 
 Menthol . . . . 1 to 2 parts Aq. rosae 
 
 Pulv. zinci ox. Adip. Iana3 
 
 Pulv. amyli Adip. suillis . . . aa. 1 part 
 
 Adip. lanse 
 
 Petrolati . . . . aa. 10 " 
 
 Chronic eczema. Acute exacerbations or acutely inflamed portions of a chronic 
 eczema must be treated with powders and pastes, as above directed. For the more 
 usual forms the diachylon ointment (No. 71, p. 136) or Lassar's paste (No. 2, p. 43) 
 is appropriate. The mode of their employment is by no means unimportant. They 
 should not be rubbed into the affected part or applied with the finger, but should be 
 spread about as thick as the back of a table-knife on narrow pieces of linen or band- 
 age, and fastened to the affected part in overlapping strips. The tar preparations 
 are perhaps our most valuable remedies in the squamous stage, but they should 
 never be used so long as there is much secretion. We may employ the tar spirit 
 (No. 10, p. 56) or the ointment (No. 22, p. 64), gradually increasing the propor- 
 tion of tar as the process requires it. In some cases we must use the ol. cadini or 
 rusci pure, with the addition of 10 per cent, of ether. The tar plaster-mulls are 
 elegant and efficacious applications. Ichthyol acts like tar and may be similarly 
 employed (No. 72, p. 137). In chronic seborrheal eczema, so frequent upon the 
 head, sternum, and back, the sulphur paste (No. 24, p. 64) or the sulphur and the 
 resorcin ointments (Nos. 20, 25, p. 64) are of use. 
 
PSORIASIS OF THE NAILS. 
 
 ONYCHOLYSIS. 
 
 TYPOGRAVURE. 
 
 COPYRIGHT, 1905, BY E. B. TREAT A CO., N. Y. 
 
 ECZEMA UNGUIUM. 
 
 LEUCONYCHINA STRIATA. 
 
 PLATE LIX. 
 
■• 
 
 
 In eczei 
 
 ' 
 
 No. 72. 
 
 t. . 
 
 t. . 
 lae 
 
 
 
 
 
 
 i 
 
 . ad theii n 
 
 ; 
 
 . . . 
 
 I 
 - 
 
 
 
 I accural 
 
 - 
 i 
 
 m the fii 
 
 
 
 uum. 
 
 
 
 ' 
 
 ■ 
 

 ONYCHOLYSIS. 
 
 
 LEUCONYCHINA STRIATA. 
 
 E LIX. 
 
Amnion, sulph-ichthyolat. 
 
 
 $ Pulv. calamini 
 
 Aq. dest. . 
 
 aa. 5 parts 
 
 Pulv. zinci ox. 
 
 Adip. benzoat. . 
 
 i5 " 
 
 Glycerini 
 
 Adip. lanae 
 
 25 " 
 
 Aq. rosas 
 
 INFLAMMATIONS. 137 
 
 In the chronic indurated eczemas the 10- to 40-per-cent. salicylic plaster is 
 effective, as is also the free use of tar soap. Where the thickening is very marked, 
 daily friction of green soap, followed by one of the above-mentioned salves, is indi- 
 cated. In eczemas of parasitic origin 5- to 10-per-cent. chrysarobin and pyrogallol 
 ointments are very serviceable. Whatever application we employ in chronic eczema 
 we must be careful to avoid too much irritation, lest we make an acute inflamma- 
 tion of a chronic one. This applies especially to tar and similar preparations. 
 
 No. 72. Ichthyol Ointment. No. 73. Calamine Lotion. 
 
 2 parts 
 2 " 
 1 part 
 . 30 parts 
 
 There remains to be mentioned the most appropriate treatment for some of the 
 commoner varieties of the disease. In eczema capitis we must first remove the 
 pediculi and their nits. This may be effected by soaking the head with kerosene 
 at night, and washing it with soap and hot water in the morning, or by the use of 
 the sublimate spirit (No. 49, p. 108). It is rarely necessary to cut the hair. The crusts 
 must be softened and carefully removed by means of compresses soaked in olive- or 
 cod-liver oil, followed by washings with ordinary or green soap. The lime-oil (No. 
 66, p. 135) or the boracic-acid salve (No. 29, p. 74) can then be employed. 
 
 Eczema faciei. The zinc salve or plaster-mulls cut into strips and accurately 
 fitted to the face are very excellent. In the acute erythematous form the calamine 
 lotion (No. 73, p. 137) will be found effective, as will also the cooling and rose-water 
 salves (Nos. 68, 69, p. 135). The more chronic cases require the sulphur and 
 tannin pastes (No. 20, p. 64, No. 50, p. 108). I have found a 2-per-cent. ichthyol 
 salve very useful in the acute facial eczemas of children. Fissures of the lips may 
 be touched with the nitrate-of-silver stick, and if there are any discharges from the 
 nasal or aural cavities the affected mucosae must be appropriately treated. For 
 eczema of the eyelids the white precipitate ointment will be most appropriate. In 
 children a mask must be worn, more especially at night, to prevent irritation and 
 infection from the finger-nails. 
 
 Eczema manuum. This is frequently a most difficult affection to cure, more 
 especially when it is dependent on the patient's occupation, as is the case with 
 washerwomen, bakers, plasterers, etc. In so far as it is possible these sources of 
 irritation must be removed, and in some cases rubber gloves can be worn while at 
 work. The balsam-of-Peru ointment (No. 74, p. 138) or a tar paste (No. 75, p. 138) 
 is a useful local application. Very chronic cases may require to be painted with 
 the pure tar spirit (No. 10, p. 56) or pure tar. Eczema of the palms is a very fre- 
 quent affection, the parts being hard, thickened, and fissured at the folds of the 
 
138 ILLUSTRATED SKIN DISEASES. 
 
 skin. Here the thickened epidermis must be removed by friction with pumice-stone 
 or by means of the salicylic plaster recommended by Unna, after which the ointment 
 of ammoniated mercury or a tar preparation may be used. 
 
 No. 74. Peru-Balsam Ointment. 
 
 fy Bals. Peruv. 
 Ac. salicyl. 
 Petrolati 
 Adip. lanse 
 Pulv. zinci 
 Pulv. amyl 
 
 \ 
 
 ox. > 
 
 i ) 
 
 tment. 
 
 
 No. 75. 
 
 Tar Paste. 
 
 10 parts 
 i part 
 
 $ 
 
 01. cadini . 
 Pulv. zinci ox. 
 Pulv. amyli . 
 Petrolati 
 
 io to 15 parts 
 
 aa. 20 " 
 ad. 100 " 
 
 aa. 10 parts 
 
 
 
 
 Eczema cruris. Here the best method is to use some mildly stimulating appli- 
 cation, such as Lassar's paste (No. 2, p. 43), after thoroughly disinfecting the surface. 
 The acuter cases can be treated with the various dusting powders (No. 18, p. 61, 
 No. 64, p. 135) or powdered boracic acid. If varicosities exist, as is usually the case, 
 a properly applied bandage must be worn continuously. In the chronic scaly cases 
 support and protection of the surface with the glyco-gelatin application (No. 4, p. 43) 
 is very useful. It must be melted in a water bath, and applied freely with a brush 
 to the part after careful cleansing and disinfection ; bandages are applied before it 
 has set ; and the dressing may remain in situ for from three to seven days. 
 
 Eczema genitalium is often a very chronic and intractable affection. The parts 
 must be supported and kept apart by means of pads of borated cotton, suspensories, 
 and T-bandages. In the most acute cases the calamine lotion (No. 73, p. 137) or the 
 boracic-acid plaster-mull should be employed ; in others a carbolized zinc or simple 
 ointment is appropriate. Chronic eczema of the scrotum, with much thickening, 
 requires the cautious use of tar or mercurial preparations, such as the white precipi- 
 tate ointment, Bronson's mercurial ointment (No. 23, p. 64), or the tar paste (No. 
 75, p. 138). Eczema of the anus requires attention to possible causes in the way of 
 ascarides or hemorrhoids, with careful regulation of the diet and evacuations. A 
 3- to 5-per-cent. carbolic-acid lotion, or water as hot as can be borne, applied to the 
 anus immediately after each defecation will do much to relieve the itching. Lassar's 
 paste (No. 2, p. 43) and the tar spirit or ointment (No. 22, p. 64, No. 45, p. 104) are 
 useful applications. Van Harlingen recommends a carbolized almond-oil very 
 highly. 
 
 Eczema of the nails is a very chronic affection, in which the nails become rough, 
 uneven, and marked with dark striae or dots. The various tar applications or the 
 milder mercurial salves must be persistently used. 
 
 Eczema barbae is of frequent occurrence; the affected surface is reddened and 
 covered with yellowish-green crusts that mat the hairs together; and as the hair- 
 sacs are usually affected, folliculitis and destruction of these structures usually occur. 
 
1 
 
 COPYRIGHT BY E. B. TREAT 4 CO. , N. Y. 
 
 PHOTOGRAVURE & COLOR CO., N. Y. 
 
 ERYTHEMA MULTIFORME 
 
 PLATE XLVII 
 
INI 
 
 The : 
 
 Ecz- 
 
 . 
 
 Lichen I 
 
 I 
 
 MA MULTIFOF 
 
 ■ 
 
 I 
 
 ^rytheni;. 
 
 p 
 
 - 
 
 • i 
 

 
 
 ERYTHEMA ? 3ME 
 
INFLAMMATIONS. 139 
 
 The parts must be shaved or epilated ; mere clipping of the hair will not suffice. 
 The various sulphur or zinc salves and pastes (Nos. 24, 25, p. 64, etc.) or the diach- 
 ylon salve (No. 71, p. 136) can then be employed. 
 
 Eczema intertrigo must not be washed; the parts can be cleansed with warm 
 olive-oil, and must be kept apart with pads of absorbent cotton. The various dusting- 
 powders (No. 18, p. 6 1, No. 64, p. 135) or the boracic-acid lotion or ointment (No. 
 29, p. 74) may be used. 
 
 Lichen tropicus or prickly heat is a more or less acute papulo-vesicular eczema 
 occurring on the body during the hot weather. It is best treated by means of alka- 
 line lotions (No. 67, p. 135) or the dusting powders (No. 18, p. 61, No. 64, p. 135). 
 The zinc- and lime-oils (Nos. 65, 66, p. 135) are also useful. 
 
 ERYTHEMA MULTIFORME. 
 
 Synonyms. — Erythema exudativum multiforme s. polymorphum, ery theme poly - 
 morplie (Fr.). 
 
 Definition. — An acute inflammatory disease, characterized by the appearance of 
 reddish papules, tubercles, vesicles, or blebs of symmetrical distribution, and affect- 
 ing by preference the backs of the hands and feet. 
 
 Symptoms and Course. — After a prodromal period marked by a moderate febrile 
 movement, there appear on the backs of the hands and feet, or on the palms and 
 soles, and more rarely on other parts of the body, a varying number of slightly ele- 
 vated, firm, reddish-violet papules, fading on pressure. This condition is known 
 as erythema papulatum. In a few days the papules grow into tubercles perhaps 
 \ of an inch in size (erythema tuberculatum). The centers then begin to flatten 
 and fade out, and assume a characteristic bluish-red hue (erythema annulare). At 
 the periphery, where the eruption is extending, the lesions preserve their elevated 
 form and reddish tint. Adjacent patches may coalesce and form irregular figures 
 known as erythema gyratum and erythema figuratum. More rarely the appearance 
 of blebs gives us the form known as erythema bullosum. Herpes iris is the desig- 
 nation given to a vesicular form of this erythema, in which new concentric rings of 
 papulo-vesicles appear in the depressed purplish center of an annular erythema. 
 These various forms, once looked upon as distinct diseases, are in reality merely 
 stages of the same process with varying amounts of exudation. A case may go 
 through several of them, and even show them simultaneously ; for multiformity is 
 characteristic of the disease ; but usually one type only is present, and the common- 
 est by far is the papular one. The malady occurs especially in the spring and the 
 fall, and lasts for from four to six weeks. It happens at any age, and is somewhat 
 more frequent in females than in males. The mucosas are occasionally affected. It 
 
140 ILLUSTRATED SKIN DISEASES. 
 
 is prone to relapse, and usually reappears in its original type. It is occasionally 
 complicated with purpura, acute articular rheumatism, and endocarditis. 
 
 Etiology. — The cyclic course of erythema multiforme and its prevalence at certain 
 seasons of the year lead us to believe that in some cases at least it is an infectious 
 disease, though the etiological agent has not yet been discovered. It is sometimes, 
 however, merely symptomatic, occurring with cholera, typhus, syphilis, and acute 
 rheumatism, or after the ingestion of certain drugs. It is occasionally caused by 
 local irritation, Kaposi having had a case in which the inunction of gray ointment 
 always caused its appearance ; or reflexly, as in Lewin's case, in which it was caused 
 by irritation of the urethra. 
 
 Diagnosis. — Its typical course and location, the papules or tubercles whose red 
 color is removable on pressure, and the absence of desquamation, are sufficient to 
 characterize the disease. An eczema has exudation, scales, and crusts, and itches 
 intensely. Urticaria has pale or pinkish fugacious elevations, with much itching and 
 reflex irritability of the skin. A papular syphiloderm is copper- colored and not re- 
 movable by pressure ; the palms and soles are usually involved, and other syphilitic 
 symptoms are generally present. Prurigo has deep-seated colorless papules, begins 
 in childhood, and itches intensely. Trichophytosis corporis is scaly in the center, 
 and the parasite can usually be readily found. 
 
 Pathology. — The process consists in an inflammation of moderate intensity of 
 the upper portion of the corium, with vascular dilatation and some exudation and 
 cell-infiltration. 
 
 Prognosis. — This is always good, save when the erythema is symptomatic of or 
 complicated with some one of the more serious maladies mentioned above. 
 
 Treatment. — The cause must be removed when it can be found; and this is most 
 likely to be possible when the erythema follows the use of some one of the drugs 
 that react upon the skin, copaiba, quinine, antipyrin, etc. Rheumatism or any other 
 coincident affection must be appropriately treated; and saline purges, tonics, etc., are 
 useful adjuncts. The local treatment need only be of the simplest character, cala- 
 mine lotion (No. 73, p. 137) or a cooling salve (No. 68, p. 135) or dusting powder (No. 
 64, p. 135) being all that is required. 
 
 HERPES. 
 
 Definition. — An acute inflammatory eruption, characterized by the appearance 
 of groups of pinhead- to small pea-sized vesicles on slightly reddened bases, and 
 situated usually on the face or genitals. 
 
 Symptoms and Course. — This very common affection begins with swelling and 
 redness of the area affected, followed by the eruption thereon of small papules which 
 rapidly become vesicular. The vesicles occur in groups of from six to twelve and 
 
INFLAMMATIONS. 
 
 141 
 
 are often confluent. In one or two days their contents become cloudy, and in a few 
 days to a week they dry up into thin crusts, under which repair of the epithelium 
 progresses. Slightly pigmented spots are left behind when the crusts fall off, which 
 disappear without trace in a week or two more. Moderate itching and heat accom- 
 pany the eruption. Scratching and re- 
 moval of the crusts prolong it, and may 
 even lead to superficial ulceration. 
 
 Two chief varieties of herpes are en- 
 countered as the eruption affects the face 
 or the genital regions. Herpes facialis, 
 s. labialis, s. febrilis, or fever-sore, occurs 
 around the mouth and nose near the muco- 
 cutaneous boundaries. The lips, cheeks, 
 and alae nasi are most frequently affected. 
 Vesicles may appear on the mucosae ; but 
 here, on account of the delicacy of the epi- 
 thelial covering, they soon lose their ves- 
 icular form and appear as circular grayish 
 or reddish eroded areas. Herpes progen- 
 italis, s. preputialis, s. vulvarum, occurs on 
 the glans penis, prepuce, labia majora, or 
 nymphae. Its course is similar to the her- 
 pes of the face, but it is very prone to re- 
 cur at irregular intervals, and is liable to 
 be prolonged and to ulcerate from the 
 irritation caused by coitus or uncleanliness. 
 
 Etiology. — Herpes occurs frequently 
 in healthy individuals, and we are ignorant of its real cause. It is often seen in febrile 
 internal diseases, pneumonia, malaria, and meningitis, in catarrhal affection of the 
 mucous membranes, bronchitis, rhinitis, etc., and also after nervous disturbances. 
 
 Pathology. — The inflammatory exudate is in the rete, and the amount of cell- 
 infiltration varies with the intensity of the inflammation. The vesicles are multi- 
 locular. 
 
 Prognosis. — This is of course good; herpes facialis is short-lived, but herpes 
 progenitalis is more obstinate and recurs frequently. The dangers of the possibilities 
 of syphilitic inoculation must not be lost sight of in these latter cases. 
 
 Diagnosis. — This is of great importance in the genital variety, where the differ- 
 entiation between herpes, chancroid, and chancre must always be made. The 
 groups of vesicles or the convex-bordered confluent erosions in the favorite locations 
 are sufficiently characteristic. In chancroid the vesicle rapidly becomes pustular; 
 a round, undermined sore with dirty base results from its rupture; it is painful, 
 
 Fig. 71. — Herpes febrilis. 
 From photograph by the author. 
 
142 ILLUSTRATED SKIN DISEASES. 
 
 auto-inoculable, and is accompanied by the inflammatory bubo. Chancre has the 
 induration and the characteristic hard, painless adenopathy. But it must not be 
 forgotten that either or both may coexist with herpes, and that a definite opinion 
 cannot be given in the case of chancroid for several days, and in that of chancre 
 until the longest period of possible primary incubation has passed. 
 
 Treatment. — In many cases none is necessary. The crusts should not be re- 
 moved, and a mild dusting powder (No. 18, p. 61) or a rose-water ointment or cooling 
 salve applied to the part (No. 29, p. 74, Nos. 68, 69, p. 135). Dermatol, iodoform, 
 etc., may also be employed. A layer of absorbent cotton between glans and prepuce 
 will serve to protect the parts. 
 
 ZOSTER. 
 
 Synonyms. — Herpes zoster, zona, ignis sacer, shingles, Giirtelrose, Fenerrose 
 (Ger.), sona (Fr.). 
 
 Definition. — An acute inflammatory disease of definite duration and course, 
 characterized by the appearance of groups of vesicles on inflamed bases situated on 
 the course of one or more of the cranial or spinal nerves, and accompanied by neu- 
 ralgic pain. 
 
 Symptoms and Course. — For a varying number of days the patient suffers from 
 burning, itching, and neuralgic pains in the area of the skin that is about to be af- 
 fected, with perhaps a moderate pyrexia and its accompanying symptoms. Exam- 
 ination reveals nothing locally, save perhaps slight tenderness to deep pressure over 
 the roots of the nerves that supply the skin of the part, or at the sensitive points of 
 Romberg. Suddenly a circumscribed area of the integument becomes erythematous, 
 and in a few hours is covered with a group or groups of minute papules, which rap- 
 idly become vesicles. In thirty-six to forty-eight hours they have become pea-sized, 
 and the serum has become milky or frankly purulent; by the third or fourth day 
 adjacent pustules have usually coalesced to form blebs of varying size. If they are 
 not ruptured the serum is absorbed, the blebs shrink, and by the end of the week 
 the affected area is covered with crusts of shriveled epidermis, under which repair 
 of the destroyed integument slowly takes place. If the pustules or blebs are rup- 
 tured, excoriated or ulcerated surfaces are left behind, which heal in the course of 
 the second or third week, often leaving behind depressed cicatrices, which are at 
 first pigmented, and later white. 
 
 While the first groups of vesicles are passing through these various stages other 
 groups have appeared on other areas of skin, or even among the original set. The 
 successive crops appear along the course of the nerve at intervals of a few hours or 
 a few days, and each one runs its own independent course, irrespective of the older 
 or younger groups around it. Thus we may have present at the same time a red 
 and pigmented scar, representing the primary efflorescence ; excoriated surfaces with 
 
ZOSTER PECTORALIS. 
 
 TYPOGRAVURE. 
 
 COPYRIGHT BY E. B. TREAT 4 CO., N. Y. 
 
 ERYTHEMA MULTIFORME. 
 
 PLATE IV. 
 

 
 ■ 
 
 em ; grou 
 
 The m 
 poussees st ccessh 
 
 Zoster oca 
 
 a case in ai i ■-• amples of it in 
 
 very rat I election 
 
 for the m rous 
 
 individuals der- 
 
 ■ 
 
 I re- 
 ap- 
 pare; 
 
 cases ap; - in 
 
 New York City in It is aim 
 
 always unilater.- md 
 
 I enter, Hen 
 ■ 
 - encircle 
 
 gainst the disease; but there are ex 
 
 rated case I 
 
 be the seat of sh 
 
 st. 
 are named according to tl i — zoster 
 
 cial mention is z< 
 uently accompanied by conji 
 panophtha 'ruction of the eye, and even by a 
 
 ier cases, when the inflammation is severe 
 enough to I die diar white 
 
 variety kno ! the inflammatory si 
 
 isofsufficiei tanddi use gangrem 
 
 The neuralgic pains tl 
 severe, and th iv persist for aid months after its termination. Tumei 
 
 tion of the lymphatic glands of the affe( a almost always occurs. 
 
 Etiology.— Barensprung in 1862 first showed that the d 
 dependent on an inflammation of the I the pos 
 
 and spinal nerves, inflammat 
 
 In other cases a peripheral neuri been foi number 
 
 reported in connection with traumatisms, compressi< geal 
 
 exudations, spinal 1 The prevalence of the d ds of 
 
'ECTORALIS. 
 
 - 
 
 
 COPYRIGHT BY E. B. TREAT 1 CO., N. Y. 
 
 ERYTHEMA MULTIFORME. 
 
 PLATE IV. 
 
INFLAMMATIONS. 
 
 143 
 
 Fig. 72. — Zoster patch. 
 
 From photograph by the author. 
 
 the semi-detached epithelium still covering them ; groups of coalescent bullae ; as- 
 semblages of pustules and vesicles large and small; and reddened areas where the 
 primary erythema has but just appeared. The malady advances " schubweise" a 
 poussees successives. 
 
 Zoster occurs at all ages, but is commonest in childhood. Lomer has reported 
 a case in an infant four days old, and examples of it in elderly individuals are not 
 very rare in our clinics. It shows no predilection 
 for the weak or debilitated ; healthy and vigorous 
 individuals are frequently attacked. It is a moder- 
 ately rare disease. My own statistics show thirty- 
 two cases in eight thousand consecutive cases in 
 private and public practice. It is seen most fre- 
 quently in the spring and fall ; sometimes it is ap- 
 parently epidemic, a comparatively large number of 
 cases appearing at the clinics ; such was the case in 
 New York City in the autumn of 1895. It is almost 
 always unilateral, but double zoster does occur, and 
 cases have been reported by Carpenter, Henoch, 
 and others. It is a superstition of the laity that if 
 shingles encircles the body it is necessarily fatal. Almost invariably one attack 
 protects against the recurrence of the disease ; but there are exceptions, and in 
 Kaposi's celebrated case there have been eleven separate attacks. 
 
 Any portion of the body may be the seat of shingles, but I have found it most 
 frequently by far on the upper extremities and chest. 
 
 For descriptive purposes the zosters are named according to their location — zoster 
 facialis, cruralis, etc. ; but the only localization that deserves especial mention is zoster 
 ophthalmicus. This is a severe affection and is frequently accompanied by conjunc- 
 tivitis, corneal ulceration, panophthalmitis, destruction of the eye, and even by a 
 fatal phlebitis and meningitis. In other cases, when the inflammation is severe 
 enough to lead to the diapedesis of red as well as white blood-cells, we have the 
 variety known as zoster hemorrhagicus. Very rarely indeed the inflammatory stasis 
 is of sufficient extent and duration to cause gangrene, giving us zoster gangrenosus. 
 
 The neuralgic pains that precede and accompany the disease are frequently very 
 severe, and they may persist for weeks and months after its termination. Tumefac- 
 tion of the lymphatic glands of the affected area almost always occurs. 
 
 Etiology. — Barensprung in 1862 first showed that the disease was in some cases 
 dependent on an inflammation of the ganglia of the posterior roots of the cerebral 
 and spinal nerves, inflammatory and hemorrhagic foci being found in these structures. 
 In other cases a peripheral neuritis has been found. A number of cases have been 
 reported in connection with traumatisms, compression by tumors, pachymeningeal 
 exudations, spinal caries, etc. The prevalence of the disease at certain periods of 
 
144 ILLUSTRATED SKIN DISEASES. 
 
 the year has led Wasielewski to claim that it is an infectious disease, further evidence 
 in that direction being afforded by the immunity from recurrence which one attack 
 seems to confer. Probably an infection, like the other causes mentioned, may be the 
 injury that starts the neuritis that is at the root of the disease. 
 
 Pathology. — Cell-multiplication and serous exudation occur in the tissue of the 
 coriura, and the latter raises the corneous layer and the upper rete-cells into a 
 multilocular vesicle. 
 
 Diagnosis. — The vesicular eruption, the peculiar location following the course of a 
 nerve-trunk, with the accompanying neuralgia, prevent any difficulty in this direction. 
 
 Prognosis. — This is good when there is no serious disease, such as spinal caries 
 or carcinoma, behind the zoster eruption. In zoster ophthalmicus our prognosis must 
 be guarded. In many cases an obstinate neuralgia is left behind. 
 
 No. 76. Duhring's Morphine Collodion. No. 77. Laudanum Ointment. 
 
 # Morph. sulph. 
 Collod. flexile 
 
 i part 
 
 R Tr. opii 
 
 . 
 
 20 parts 
 
 ioo parts 
 
 Ac. carbolic. ■ 
 
 . 
 
 i part 
 
 
 01. amygd. dulc. 
 
 . 
 
 20 parts 
 
 
 Adip. lanae . 
 
 . 
 
 • 300 " 
 
 Treatment. — Zoster is a self-limited disease, and we cannot influence its course. 
 For the neuralgia, quinine, antipyrin, and phenacetin may be given in large doses ; 
 and sometimes we are compelled to have recourse to morphine, either by the mouth 
 or hypodermically. After the eruption has gone, arsenic in the form of the Asiatic 
 pill (No. 6, p. 46) or as Fowler's solution is indicated. Locally we must protect and 
 soothe the inflamed surfaces. A 20-per-cent. mixture of chloroform and olive-oil 
 or a 5- to 20-per-cent. cocaine salve will be found useful. Duhring recommends 
 morphine in collodion (No. 76, p. 144) painted on the part. I usually employ a lau- 
 danum ointment (No. yy, p. 144). The bitter tonics, iron, and cod-liver oil are gener- 
 ally required after the disease has run its course. 
 
 DYSIDROSIS. 
 
 Synonyms. — Pompholyx, cheiropompholyx. 
 
 Definition. — An acute inflammatory disease affecting the palms and soles, and 
 characterized by the appearance of deep-seated grouped vesicles filled with a clear 
 serum, later becoming opaque, and disappearing by rupture or absorption. 
 
 Symptoms and Course. — The affection is most commonly seen on the sides of the 
 fingers and on the palms, and less often on the toes and soles ; in rare instances other 
 portions of the integument are affected. There appear smaller or larger, deep-seated, 
 sago-grain-like vesicles arranged in groups and seated on a slightly reddened base. 
 The clear serum with which they are filled becomes cloudy in a few days, and the 
 
COPYRIGHT BV E. B, TREAT & CO., N. Y. 
 
 PHOTOGRAVURE A COLOR CO., N. Y. 
 
 PEMPHIGUS 
 
 PLATE XIV 
 

 
 I 
 
 - 
 
 Etiology.- 
 
 Patholog-, 
 
 a 
 
 
 
 
 - 
 
 . 
 
 
 ap- 
 
 chro; 
 
 
 i 
 
 I 
 - 
 
 .eddene' 
 
 e 
 beco 
 
PEMPHi' 
 
INFLAMMATIONS. 145 
 
 coalescence of adjacent vesicles may form larger blebs. In the course of a number 
 of days they dry up or rupture, and the process ends with some exfoliation of the 
 epidermis. Slight burning and itching accompany the eruption. The process may 
 be a chronic one, and be prolonged for weeks and months by the appearance of 
 successive crops of vesicles. 
 
 Etiology. — Dysidrosis occurs most often in nervous women, and more especially 
 in those suffering from dyspepsia. We are ignorant of the real cause of its appear- 
 ance. 
 
 Pathology. — According to Robinson, this consists in an obstruction of the sweat- 
 duct and accumulation of fluid in the upper layers of the rete. A cystic degenera- 
 tion of the sweat-glands has been noted by some observers. 
 
 Diagnosis. — The affection could only be confounded with a vesicular eczema, 
 and it can readily be distinguished from this by the peculiar location and the absence 
 of any tendency to rupture or form crusts or weeping surfaces. 
 
 Prognosis. — The malady is troublesome, but otherwise harmless. 
 
 Treatment. — The nervous and dyspeptic conditions underlying the malady must 
 be attended to. Locally the 10- to 20-per-cent. collemplastrum of salicylic acid 
 can be applied to the part. The tar spirit (No. 10, p. 56) is useful in some cases, 
 and all the ordinary antipruritic remedies (p. 56) may be employed. 
 
 PEMPHIGUS. 
 
 Synonym. — BlasenansscJilag (Ger.). 
 
 Definition. — An acute or chronic inflammatory disease, characterized by the ap- 
 pearance of successive crops of bullae of varying size, containing a clear or cloudy 
 serum, seated on slightly inflamed bases, and accompanied or not by constitutional 
 symptoms of varying intensity. 
 
 Symptoms and Course. — Bullous eruptions occur in various diseases (syphilis, 
 urticaria, leprosy, etc.) ; but in pemphigus they constitute the essential phenomenon 
 of the malady. We distinguish two chief forms : pemphigus vulgaris, the com- 
 moner acute or chronic variety, and pemphigus foliaceus, a rarer and more serious 
 disease. 
 
 In pemphigus vulgaris, with or without a prodromal fever, there appear on one 
 or more portions of the integument, most frequently on the lower extremities and 
 exceptionally upon the mucosae, wheal-like erythematous spots that soon develop 
 into the blebs that are characteristic of the disease. The bulla? are oval or rounded, 
 with tense or lax walls, and are filled with a serum that is at first clear, but later 
 becomes cloudy and purulent or even mixed with blood (pemphigus hemorrhagicus). 
 Their size varies from that of a lentil to that of a large egg ; they are seated on 
 slightly reddened bases; there may be one only (pemphigus solitarius) or a hundred 
 
146 
 
 ILLUSTRATED SKIN DISEASES. 
 
 r 
 
 
 or more; and they show no tendency to grouping or regularit)- of arrangement. 
 They grow for several days, and adjacent ones may coalesce ; in a week or so they 
 have attained their full size, and retrogression commences. If the bullae are not 
 
 ruptured the serum 
 begins to disappear 
 by absorption or 
 evaporation ; the 
 tense walls of the 
 blebs become lax 
 and shriveled ; and 
 they dry up into 
 scabs, under which 
 regeneration of the 
 epidermis takes 
 place. The scabs 
 fall off in time, leav- 
 ing a temporary 
 pigmentation, but 
 no loss of tissue, be- 
 hind. There may 
 be only one out- 
 break, or successive 
 crops of the erup- 
 tion appearing at irregular intervals may prolong the malady for several months. 
 The subjective symptoms are usually limited to slight itching and burning. In ac- 
 cordance with its course, we have an acute and a chronic form of the disease. 
 
 Pemphigus vulgaris acutus is a rare affection, especially in adults ; in children it 
 assumes the form of an infectious disease and occurs epidemically. The outbreak of 
 the eruption is accompanied by considerable fever and constitutional disturbance, and 
 successive crops of blebs appear at frequent intervals for some two or three weeks. 
 Any portion of the integument, and even the mucosas, may be affected ; but the 
 backs of the hands and feet are most frequently involved. It is of importance from 
 a diagnostic point of view that the palms and soles usually escape. As a rule the 
 disease terminates in recovery, but some cases run a malignant course and end fatally. 
 In the case of a woman sixty years of age, that I saw in the winter of 1895, the 
 eruption began with moderate prodromal symptoms, and a few blebs appeared in the 
 axillae and on the chest; successive crops of vesicles came out almost daily, until in 
 a week the entire body was covered with various-sized confluent and discrete bullae 
 and excoriated surfaces; the patient took to her bed and succumbed to an intercur- 
 rent pneumonia two weeks later. 
 
 Pemphigus vulgaris chronicus is the common form of the affection. The number 
 
 Fig. 73. — Acute Pemphigus. 
 From photograph by the author. 
 
TYPOGRAVURE. 
 
 COPYRIGHT, 1902, BY E. B. TREAT 4 CO., N. ' 
 
 ZOSTER SACRO-CRURALIS. 
 
 PLATE Lll. 
 
INFLAMMATIONS. 
 
 147 
 
 of bullae present at any one time is very various ; there may be only one, or an in- 
 definite number may be scattered over the body. The individual blebs last but a 
 few days ; they disappear by rupture or absorption and evaporation, leaving scabs 
 covering a red and 
 secreting skin. The 
 outbreaks occur ir- 
 regularly, and va- 
 rious stages of the 
 lesions are usually 
 present at one and 
 the same time. As 
 a rule the mal- 
 ady runs a benign 
 course, especially 
 in children ; the 
 general condition 
 remains good, there 
 is little or no fever, 
 and the local symp- 
 toms are compara- 
 tively slight. In 
 rare instances it as- 
 sumes a malignant 
 form. The bullae 
 are numerous, run 
 a rapid course, and 
 frequently coal- 
 esce ; and when 
 
 they rupture, thick crusts covering suppurating surfaces are left behind. The itch- 
 ing and burning are great, sleep and nutrition are interfered with, and the patient 
 dies of exhaustion or from intercurrent disease of the internal organs. In the severe 
 form of the disease known as pemphigus diphtheriticus, the denuded areas left when 
 the bullae rupture become covered with a dense grayish- white pseudo-membrane ; 
 and in that known as pemphigus vegetans, frambcesia-like masses of granulations 
 grow from them, which are very liable to undergo superficial gangrene. 
 
 Pemphigus foliaceus often begins as the ordinary form of the disease, by the 
 long continuance of which the patient has been debilitated and worn out. The bullae 
 are small, with flabby walls, and have milky or reddish contents. After rupture and 
 escape of their fluid contents, reddened, excoriated, and weeping surfaces are left 
 behind, on which the epidermis shows no tendency to regeneration. The remains 
 of the blebs with the dried secretion form partially detached threads and flakes. In 
 
 Fig. 74. — Pemphigus Vulgaris. 
 
 From photograph by the author. 
 
148 ILLUSTRATED SKIN DISEASES. 
 
 advanced cases the entire integument may be affected, and the palms and soles are 
 especially liable to be involved. No bullae may be present ; the skin is dark red, dry 
 or moist, and more or less covered with scales and crusts. The hairs become dry 
 and brittle and fall out, and the buccal, conjunctival, and other mucosae may become 
 affected. The general symptoms are marked ; there is fever, diarrhea, pain, and 
 sleeplessness, and the patient finally dies of exhaustion. 
 
 Pemphigus pruriginosus is another malignant form of the disease, which is marked 
 by continuous and intense itching, with pigmentation of the skin in consequence of 
 the scratching that ensues. It is usually associated with nervous disturbances. 
 
 Etiology. — Pemphigus occurs much oftener in children than in adults ; but we are 
 entirely in the dark as to its nature and cause. Low and depressed states of the 
 general system, such as result from overwork, insufficient nutrition, etc., seem to 
 favor its development. It is neither infectious nor communicable. Parasitic organ- 
 isms have been found in the blebs by Spillman, Vidal, and Gibier, but their etiological 
 relationship to the disease has not been proved. 
 
 Pathology, — The fluid in the blebs is serous and alkaline, and contains a few 
 leucocytes, epithelial and red blood-cells, etc. It lies between the stratum granu- 
 losum and the stratum lucidum, the covers of the single-chambered bullae being 
 chiefly composed of the corneous layer. 
 
 Diagnosis, — The presence of bullae alone is not sufficient for the diagnosis of 
 pemphigus, since they occur in a number of other diseases; but it is rarely difficult 
 to form a definite opinion. The scattered, moderately tense, thin- walled blebs, ap- 
 pearing in successive crops, together with the general symptoms, are usually suffi- 
 ciently characteristic. The same may be said of the heaped-up layers of shredded 
 epidermis and the general reddening of the integument in the foliaceous form. Ecze- 
 ma is rarely bullous; the vesicles are smaller, and weeping surfaces, crusts, and other 
 symptoms of catarrhal inflammation of the skin are present. Herpetiform dermatitis 
 is distinguished by its polymorphism, erythematous areas, the presence of papules 
 and vesicles, by its grouped herpetic arrangement, and by the itching. Bullous urti- 
 caria is rare, runs a very acute course, and has wheals and intense itching. Erythema 
 multiforme is acute and does not relapse, appears in rings, and is seated usually on the 
 arms and the backs of the hands and the lower limbs. Impetigo contagiosa has doubt- 
 less often been mistaken for pemphigus ; but its location on the face and hands, slow 
 course, and the presence of other cases in the same family, house, or school, should 
 be sufficient to prevent error. It is not likely that scabies, with its location on the 
 hands, arms, and genitals, its polymorphism, its characteristic tracks, and the history 
 of contagion, will be mistaken for a pemphigus, even if bullae are present. An ex- 
 foliative dermatitis may resemble a pemphigus foliaceus ; but the scales are larger 
 and thinner, the skin on which they are situated is reddened and dry, there are no 
 bullae, and the malady does not advance in successive crops. The commonest source 
 of error is probably a bullous syphiloderm ; but here the individual lesions are 
 
COPYRIGHT BY E. B. TREAT i CO., N. 
 
 PHOTOGRAVURE 4 COLOR CO., N. 
 
 IMPETIGO 
 
 PLATE XLVI 
 

 
 
 
 Trei 
 
 
 ' 
 
 - 
 daily. 
 
 
 
 - 
 
 
 ■ 
 
 ; 
 
 - 
 pruriginos 
 
 as recommer. 
 
 Tie. 
 
 DERMATJ HTIFORMIS. 
 
OR CC. 
 
 
 PUAT? 
 
INFLAMMATIONS. 149 
 
 of slow course, dry up into thick, greenish-brown crusts under which ulceration 
 takes place, and other evidences of lues are usually present. 
 
 Prognosis. — This should be a cautious one, for even the benign forms of pemphi- 
 gus may become malignant in the course of time. In pemphigus foliaceus and 
 vegetans it is always bad; they almost always end fatally, though the patients may 
 survive for a long time. In a general way, the laxer the blebs, the greater the ad- 
 mixture of red blood-cells with their serum, and the more rapid the appearance of 
 the successive crops, the worse the prognosis. 
 
 Treatment. — This must necessarily be almost entirely symptomatic. Any inter- 
 nal disease that may be present must be appropriately treated, and rest, abundant 
 nourishment, fresh air, and general hygienic measures are of the greatest importance. 
 Arsenic has been lauded by Hutchinson as almost a specific for the disease, and is 
 undoubtedly of benefit. It may be given in the form of the Asiatic pill (No. 6, 
 p. 46) or as Fowler's solution, 3 to 15 drops administered well diluted after meals. 
 Sherwell has gotten good results from the use of linseed-oil both externally and in- 
 ternally ; I ounce may be administered in milk three times daily. 
 
 No. 78. Unna's Soft Zinc Paste. 
 
 ft 01. lini 
 Aq. calcis 
 Zinci ox. 
 Cretan . . . . . aa. p. e. 
 
 The local treatment should consist of the puncture of the blebs, and the free use 
 of one of the dusting powders (No. 18, p. 61, No. 64, p. 135) or a mild ointment, 
 paste, or oil (No. 26, p. 70, No. 29, p. 74, No. 66, p. 135, No. 69, p. 135, etc.). Unna 
 recommends a soft zinc paste (No. 78, p. 149). Sulphur baths (p. 41) may be tried. 
 In bad cases the continuous bath recommended by Hebra is perhaps the most effica- 
 cious remedy that we possess, and contributes greatly to the comfort of the patient. 
 It may be employed continuously for days, weeks, or even months, if proper arrange- 
 ments are made for the renewal of the water, its maintenance at an even temperature, 
 and the comfort of the patient therein. For pemphigus foliaceus, if extensive, it is 
 the only method that promises relief. In pemphigus vegetans a vigorous curetting 
 of the affected spots, followed by the free application of the tincture of iodine, has 
 done very well in some cases. In pemphigus pruriginosus the bichloride bath (3i to 
 the bath) may be cautiously used. In any case linseed-oil as recommended by 
 Sherwell may be freely employed. 
 
 DERMATITIS HERPETIFORMIS. 
 
 Synonyms. — Dermatite polymorpJie prurigineuse a pousse'es successives (Fr.), hy- 
 droa, hydroa herpetiforme. 
 
150 ILLUSTRATED SKIN DISEASES. 
 
 Definition. — A recurrent polymorphous eruption, most often of vesicular type 
 and herpetic arrangement, but showing also macules, papules, and bullae. 
 
 Symptoms and Course. — This disease, first recognized by Duhring, is characterized 
 by the variety of its lesions to such an extent that Hyde recommends dermatitis 
 multiforme as a more appropriate name. Its exact relationship to hydroa, herpes 
 gestationis, and pemphigus is not yet settled. With a preliminary fever, rigors, 
 malaise, and gastric disturbance, there occur flat, slightly elevated, irregularly defined 
 macules on a limited area of the body, which soon develop into vesicles or bullae 
 with cloudy, hemorrhagic, or purulent contents. They are arranged in groups or 
 concentric rings. In about a week the vesicles rupture or dry up, and the crusts 
 leave a pigmented surface behind when they fall off. New groups appear from 
 time to time, run the same course, and thus prolong the disease for weeks and 
 months. Any portion of the body may be affected, but successive crops usually 
 appear at the margins or in the neighborhood of the primary eruption, and the dis- 
 ease is usually limited to a definite area of the body. The mucosae may be affected ; 
 and here the eruption appears as a group of irregular superficial ulcerations, with 
 dirty and unhealthy-looking bases. Intense itching is a marked feature. The mal- 
 ady occurs in both sexes and at all ages. 
 
 Etiology. — This is as yet entirely unknown. 
 
 Diagnosis. — The polymorphous nature of the eruption, its herpetic arrangement, 
 the intense itching, the relapses at irregular intervals, and the good condition of 
 the general health will serve to distinguish the malady from pemphigus, with which 
 it has been long confounded. 
 
 Prognosis. — The malady is obstinate and of long duration, but is not accompanied 
 with any danger. 
 
 Treatment. — Duhring recommends arsenic given persistently, and antipyrin has 
 done good in some cases. Externally, medicated baths or the various antipruritic 
 applications recommended for pruritus, eczema, etc., may be employed. 
 
 Impetigo, formerly considered a distinct disease, is to be regarded rather as a 
 symptom, and has been proved by Bockhardt to be directly due to infection of the 
 skin with pus organisms. By means of inunctions and inoculations with cultures of the 
 staphylococcus pyogenes albus and fiavus he caused the appearance of large single- 
 chambered pustules seated on slightly inflamed bases. This occurs in a variety of 
 conditions when purulent processes are present in the person affected or those 
 that he comes in contact with. There appear one or a number of isolated vesicles 
 or vesico-pustules, which finally develop into small, rounded blebs filled with 
 pus. They dry up into yellow superficial crusts, which leave a reddened and 
 slightly pigmented surface behind when they fall off. The malady is self-limited 
 and runs its course in two or three weeks. 
 
COPYRIGHT BY E. B, TREAT & CO., N. Y. 
 
 PHOTOGRAVURE 4 COLOR CO., N. Y. 
 
 IMPETIGO CONTAGIOSA 
 
 PLATE XXII 
 
INFLAMMATIONS. 
 
 151 
 
 IMPETIGO CONTAGIOSA. 
 
 Synonym. — Porrigo contagiosa. 
 
 Definition. — An acute inflammatory contagious disease, marked by the appear- 
 ance of one or more isolated vesicles or pustules, drying up into yellow adherent crusts. 
 
 Symptoms and Course. — 'With or without febrile disturbance, there occurs an 
 eruption of circumscribed, small, thin-walled vesicles, which soon enlarge in size and 
 become distinctly pustular. 
 Umbilication is occasionally 
 present. After persisting for 
 a few days they dry up 
 into bright-yellow adherent 
 crusts, looking, as Tilbury 
 Fox says, as if stuck on to 
 the skin. Adjacent pustules 
 and crusts may coalesce to 
 form larger affected areas ; 
 but they are always sharply 
 limited, and the surrounding 
 skin and that between the 
 lesions are not affected. In 
 the course of two or three 
 weeks the crusts fall off, leav- 
 ing a reddened and slightly 
 pigmented skin behind. Nei- 
 ther ulceration nor scarring 
 occurs. Successive crops of 
 pustules appear from time to 
 time, either among the older 
 crusts or on other places, and 
 thus the disease may be pro- 
 longed for weeks. The sub- 
 jective symptoms are con- 
 fined to slight itching. The 
 seat of the malady is usu- 
 ally on the face around the 
 mouth, chin, and nose ; the 
 backs of the hands are not 
 infrequently affected, and 
 
 occasionally the pustules appear on the neck, buttocks, and other portions of the 
 body. The mucosae are sometimes involved. The malady is seen almost exclusively 
 
 Fig. 75. — Impetigo contagiosa. 
 From photograph by the author. 
 
152 ILLUSTRATED SKIN DISEASES. 
 
 in children ; it is contagious, and appears in epidemics, of which the very severe one 
 on the island of Riigen in 1885 is a well-known example. Localized epidemics 
 occur every fall, many cases occurring in the same tenement-house, street, or school. 
 It is far more frequent among the poor, where the conditions of uncleanliness, close 
 contact, etc., necessary for its development, are most often found. 
 
 Etiology. — Impetigo contagiosa is most probably due to direct local infection 
 with pus-cocci. It is both auto-inoculable and inoculable on others. 
 
 Pathology. — The pus collections are covered with epidermis ; the corium is not 
 involved, and cicatrization does not result. 
 
 Diagnosis. — The discrete and isolated pustular lesions or adherent yellow crusts, 
 the absence of surrounding inflammation, and the inoculability will serve to distin- 
 guish the disease. It is liable to be confounded with a pustular eczema of the face; 
 but here the surrounding inflammation, the weeping surfaces, the absence of discrete 
 lesions, and the history of contagion should suffice to prevent mistake. 
 
 Prognosis. — This is good ; the malady ends spontaneously in from two to three 
 weeks. 
 
 Treatment. — The crusts should be softened with olive-oil and removed, and the 
 surface of the skin below treated with Lassar's salicylic-acid paste (No. 2, p. 43). 
 Further contagion may be avoided by cleanliness, together with a daily sponging of 
 the faces and hands of the children with a mild bichloride or other antiseptic lotion. 
 
 DERMATITIS EXFOLIATIVA. 
 
 Synonym. — Pityriasis rubra. 
 
 Definition. — A general inflammatory disease of the skin, characterized by uniform 
 deep redness and an abundant, large , thin-scaled desquamation. 
 
 Symptoms and Course. — The malady begins with the appearance of red scaly 
 patches, which rapidly extend and coalesce until the entire integument is affected. 
 The skin is uniformly and deeply reddened, but dry and shiny, and is covered with 
 thin, papery, whitish scales. On the face these scales are small, but on the trunk 
 and limbs they are larger and may be an inch or more in size. They are attached 
 at their centers, but free at the margins, and they frequently overlap more or less 
 like the shingles on a roof. The amount of scaling may be very large, even up to 
 one or two pints daily, and heaps of scales fall out of the patient's clothing when he 
 removes it. The nails become opaque and fissured, or are raised from their bases 
 by the collection of epithelium beneath them. The hair becomes thin and falls out. 
 On the palms and soles the epidermis may fall off 01 masse, like a cast. The red- 
 ness of the skin under the scales is diffuse and even, and besides this and the scaling 
 there are no dermic lesions. The subjective symptoms are confined to itching or a 
 feeling of tension of the skin. In mild cases there are no constitutional symptoms; 
 but in the severer ones the general atrophy of the skin that occurs in the course of 
 
TyPOGRAVURE. 
 
 COPYRIGHT, 1903, BY E. B. TREAT A CO., N. Y. 
 
 DERMATITIS EXFOLIATIVA. 
 
 PLATE VII. 
 
INFLAMMATIONS. 153 
 
 time causes stiffness and disability, curvature of the fingers, ectropion, etc., and the 
 patients may die of general marasmus or tuberculosis of the internal organs. 
 
 Etiology. — The cause of the disease is unknown ; it is supposed to be dependent 
 on tuberculosis. 
 
 Pathology. — The malady is essentially a chronic dermatitis, which is at first 
 superficial, but later involves all the structures of the skin. There is a general cell- 
 infiltration, and finally a formation of new connective tissue with subsequent atrophy. 
 The skin shrinks, the papillae and the glandular structures are destroyed, and the 
 entire integument becomes too small for the body. 
 
 Diagnosis. — Exfoliative dermatitis is characterized by the rather sudden onset, 
 the diffuse dry redness, the scaliness, and the absence of any other forms of efflo- 
 rescence. A general psoriasis may resemble it ; but it never covers the body so en- 
 tirely, and patches of normal skin will be seen somewhere ; and the heaped- up silvery 
 scales, with bleeding puncta beneath them, are distinctive. Pemphigus foliaceus 
 has lax blebs, and dirty fatty scales situated on an eroded granular or secreting base. 
 In universal eczema we have the thickened skin, small scales, and a polymorphous 
 eruption — papules, vesicles, crusts, and weeping surfaces. 
 
 Prognosis.— This is always doubtful. The German authorities regard it as uni- 
 formly bad, but our experience here hardly confirms this view. Generalized cases 
 usually terminate fatally, but less extensive ones recover. 
 
 No. 79. Salicylic- Sulphur Paste. 
 
 Ix Ac. salicyl. ... i part 
 
 Sulph. depur. ... 5 parts 
 
 Petrolati . . . 25 " 
 
 Zinci oxidi 
 
 Amyli . . . . aa. 10 " 
 
 Treatment. — We have not much control over the course of dermatitis exfoliativa. 
 Care of the general health and the adoption of all means possible to promote general 
 nutrition must be our main reliance. Arsenic has been recommended to be given 
 as in psoriasis. Frequent warm baths are useful, as is the external and internal use 
 of cod-liver- and linseed-oils. Painting the affected area with tar spirit (Xo. 10, 
 p. 56), followed by a prolonged warm bath, with the subsequent use of the salicylic- 
 sulphur paste (No. 79, p. 153), has been recommended. 
 
 PSORIASIS. 
 
 Synonym. — ScJi uppc nflccJi tc ( G e r . ) . 
 
 Definition. — A chronic inflammatory disease of the skin, characterized by the 
 formation of red, dry, easily bleeding, infiltrated patches, covered with whitish or 
 grayish, glistening, heaped-up scales. 
 
154 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Symptoms and Course. — This very 
 common skin affection begins uniformly 
 with the appearance of a number of 
 small, red, slightly elevated, and sharply 
 denned papules, each capped with a 
 minute silvery scale. They grow slowly 
 by peripheral extension, the scaling and 
 elevation both becoming more marked 
 as the papules increase in size. Adja- 
 cent ones may coalesce so as to form 
 irregular figures or larger areas with a 
 thickened, infiltrated skin, which tends 
 to fissure and crack at the joints and 
 natural folds. The color of the psoriatic 
 spots themselves is pale red or a dirty 
 yellowish red, being more livid on the 
 lower extremities ; but it is more or less 
 masked by the heaped-up scales that 
 cover the efflorescences, and if the scales 
 are permitted to accumulate the color of 
 the eruption is white and silvery. The 
 scales are peculiar, being very abundant 
 and rapidly formed ; so that when the 
 disease is extensive the patient's under- 
 clothing may be so full of them that they 
 fall out in showers when he removes it. 
 They owe their white and glistening ap- 
 pearance to the presence of air between 
 the lamellae of the dried-up epithelial 
 cells. When the scales are removed 
 from a spot by scratching, a number of 
 minute bleeding points appear ; these 
 are the scratched-off tops of the con- 
 gested papillae of the skin. The appear- 
 ance is characteristic, and is of impor- 
 tance diagnostically. The size and shape 
 of the individual lesions vary greatly ; 
 so also does their number ; there may be 
 Fig. 76.— Psoriasis guttata. oru y a f ew small papules, or one or more 
 
 Case of Dr. Ludwig Weiss. From photograph by ihe author. larger areas, or there may be thousands 
 of individual lesions covering the entire body. The extensor surfaces of the limbs 
 
COPYRIGHT BY E. B. TSEAT & CO., N. Y. 
 
 PHOTOGRAVURE & COLOR CO., N. V. 
 
 PSORIASIS 
 
 PLATE XVII 
 

 r i - 
 
 
 
 
 ■ 
 
 ! 
 
 -ens 
 
 i 
 
 - 
 - 
 

 PSORIASIS 
 
INFLAMMATIONS. 
 
 155 
 
 are the seat of election of the psoriatic eruption, the flexor surfaces being either free 
 or, at all events, less extensively affected. The trunk, genitals, and scalp are fre- 
 quently covered, but the face is rarely involved. The palms and soles are almost 
 always free ; in the rare cases in which they are affected there is diffuse thickening of 
 the tissues, with scaling, and the diagnosis from a syphiloderm is both important and 
 difficult. 
 
 The disease occurs most often between the sixth and the twentieth year ; it is 
 very rare in early childhood, though Elliot has recorded a case at the age of eighteen 
 months. Its course is very 
 variable, but it is essential- 
 ly chronic. The majority 
 of cases last for months or 
 years, and many persist for 
 life. The individual spots 
 may slowly grow to a cer- 
 tain size and then remain 
 unchanged for an indefi- 
 nite period, or they may 
 undergo retrogressive 
 
 changes and new ones ap- 
 pear to take their place. 
 At times and from un- 
 known causes, the disease 
 may almost or entirely dis- 
 appear ; but many patients 
 are never quite free from 
 it and suffer from attack 
 after attack at varying in- 
 tervals. When involution 
 begins the faint red border 
 around the patch becomes 
 pale, the scaling lessens 
 and stops, and the redness 
 and elevation slowly subside. In the larger spots this process frequently begins in 
 the center, while the disease is still progressing at the margins ; and thus the vari- 
 ous circinate and gyrate forms of the disease are caused. 
 
 Psoriatic patients are usually robust, and even in the most extensive generalized 
 cases the general health is but little affected. The only subjective symptom, if any 
 is present at all, is a very moderate amount of itching. The hairs are usually not 
 affected, even when the scalp is the seat of the disease; in very chronic cases, 
 however, their nutrition is finally impaired and they fall out. The nails, on the 
 
 Fig. 77. — Psoriasis diffusa. 
 Case of Dr. Louis Fischer. From photograph by the author. 
 
156 ILLUSTRATED SKIN DISEASES. 
 
 other hand, are frequently involved and may be the sole seat of the disease. Small 
 white puncta appear in the lunula and gradually spread, the nail finally becoming 
 fissured, furrowed, dull, and scaly. The mucosae are never affected, the so-called 
 psoriasis buccalis being a leucoplacia due to syphilis, lichen ruber, etc. 
 
 In accordance with the form and the extent of the eruption, we have certain 
 subvarieties of the disease. When there are many pinhead-sized efflorescences we 
 
 Fig. 78. — Psoriasis nummularis. 
 After Van Haren-Noman 
 
 have psoriasis punctata ; this is rather rare as an independent variety, for although 
 all forms begin as puncta, they do not usually remain so long. Psoriasis guttata 
 has larger lesions, looking like drops of mortar flung upon the skin. In psoriasis 
 nummularis the spots are coin-sized. Psoriasis gyrata, figurata, and serpiginosa are 
 formed by the coalescence of guttate and nummular lesions. Psoriasis annularis is 
 ring-shaped, retrogression having occurred in the centers of the nummular areas. 
 In psoriasis diffusa the patches are large, irregular, and greatly infiltrated. In 
 psoriasis universalis the entire body is affected ; it is uniformly red, and is covered 
 with scales that are rapidly cast off and regenerated ; it is frequently difficult to 
 distinguish from dermatitis exfoliativa. Kobner has called attention to an artificial 
 form of the disease, which can sometimes be produced in a psoriatic patient by a pin- 
 scratch or other lesion. 
 
 Psoriasis has but few complications. Eczema is the commonest of these, and is 
 usually caused by too vigorous treatment. Seborrhea capitis is also seen. 
 
 Etiology. — We know very little of the causes of psoriasis. It occurs at all ages, 
 save in young children, and in all conditions of life. It is undoubtedly hereditary ; 
 in a very large number of cases a history of its existence in the family can be ob- 
 tained. The claims of various observers to have discovered a parasitic etiological 
 factor have not been confirmed. 
 
 Pathology. — In spite of the great amount of labor that has been expended on 
 this subject, there is some doubt as to the exact nature of the process. Apparently 
 
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INFLAMMATIONS. 
 
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 it is an inflammation of moderate intensity of the upper corium, with increased 
 development of the rete, cellular infiltration around the vessels, and an enormous 
 increase of the corneous layers. 
 
 Diagnosis. — The primary efflorescence of the disease is characteristic, consisting 
 of bright, shiny, dry scales on a circumscribed reddened base, and showing bleeding 
 puncta when the scales are removed. This, with its seat on the flexor surfaces, the non- 
 involvement of the palms and soles, the 
 slio-ht itchinsr the absence of moisture 
 and of falling of the hair, the chronic 
 course and frequent relapses, forms a 
 picture that is distinctive. It must be 
 differentiated from : (a) chronic squa- 
 mous eczema, which often resembles 
 psoriasis closely, especially upon the 
 legs ; but eczema has no sharp boun- 
 daries, has serous exudation and crust- 
 ing, itches greatly, is seated by prefer- 
 ence on the flexor surfaces, and its scales 
 are comparatively few, grayish, and 
 sticky, (b) Seborrhea, which is a dif- 
 fuse disease of the scalp, is compara- 
 tively pale and non-indurated, and has 
 scales that are dirty gray and fatty. 
 (c) Lupus erythematosus, which has 
 gray adherent seborrheal scales, with 
 processes projecting from their under 
 
 surfaces that fit into the dilated orifices of the sebaceous glands, shows central atrophy 
 of the skin and destruction of the hair when the scalp is involved, and is commonest 
 on the face, (d) Lichen planus has lesions that are polygonal, waxy, and shiny; 
 they are of a dull red color, show fine sparse scales and no puncta. (e) A squamous 
 syphiloderm is often difficult to distinguish from a psoriasis. The lesions are more 
 infiltrated, however; they are copper-colored, non-symmetrical, less scaly than those 
 of psoriasis ; they last only a short time ; and other lesions of syphilis are almost 
 always present. (/) Dermatitis exfoliativa, as above stated, may closely resemble a 
 generalized psoriasis; but, however extensive this latter disease may be, there are 
 always areas where discrete psoriatic lesions are visible, while the dermatitis affects 
 the entire surface uniformly ; the history of the disease will also help us to form an 
 opinion. 
 
 Prognosis. — This is good as to life and the general health, but bad as to the cure 
 of the disease. The psoriatic spots can be removed and the body cleaned, but the 
 malady will certainly return sooner or later. 
 
 Fig. 79. — Psoriasis gyrata. 
 From photograph by the author. 
 
15S ILLUSTRATED SKIN DISEASES. 
 
 Treatment. — General hygiene and tonics are sometimes useful, though the health 
 of these patients is usually good. Robinson recommends colchicum and potassic 
 acetate (No. 80, p. 158) in gouty and plethoric subjects. Of the numerous internal 
 remedies employed for the disease, only two or three deserve mention here. The 
 most useful is undoubtedly arsenic ; it may be given as Fowler's solution with the wine 
 of iron, as recommended by Duhring (No. 81, p. 158), or more conveniently as the 
 Asiatic pill (No. 6, p. 46). It must be persisted in for a long time in gradually in- 
 creasing doses up to the limit of toleration; and from 500 to 1000 pills must some- 
 times be taken before a decided effect is observed. Fowler's solution given subcu- 
 taneously, 10 minims of a i-per-cent. solution in distilled water, is of value in obsti- 
 nate cases. The iodide of potash, given in gradually increasing doses up to 150 
 grains and administered in milk after meals, has given good results in some instances. 
 Ichthyol and arsenic in combination (No. 82, p. 158) are also beneficial. Internal treat- 
 ment is especially useful when the disease is extensive or the patient is disinclined 
 to undertake the troublesome and uncleanly local measures that are required. The 
 arsenical mineral waters, as those of Roncegno and Levico, can also be used. 
 
 No. 80. Diuretic Mixture. No. 81. Duhring's Arsenic Mixture. 
 
 6: Liq- pot. arsenitis . . 1 part 
 
 Vin. ferri . . . .24 parts 
 
 3i in water t. d. after meals. 
 b parts 
 
 4 " ad. 
 
 3ii t. d., well diluted. 
 
 No. 82. Ichthyol-Arsenie Pills. No. 83. Pyrogallol Collodion. 
 
 fy Ac. arsen gr. 1 R Pyrogallol .... 3 parts 
 
 Ammon. sulph-ichthyolat. . . 3ii Bals. canaden. . . 2 " 
 
 90 pills; 2 or 3 t. d. after eating. Collodion flexile . . . 32 " 
 
 The local treatment is the more important, however, and it must be employed 
 in the majority of cases. Any irritation or eczematous inflammation must be first 
 gotten rid of by the use of Lassar's paste (No. 2, p. 43) or the zinc-oil (No. 65, 
 p. 135). The scales must then be removed with hot water, a flesh-brush, and the green 
 soap tincture (No. 5, p. 43). Of the local remedies to be employed, chrysarobin 
 is the most reliable and efficacious. It is best used as a collodion (No. 51, p. 108), 
 for its action can then be localized, and the indelible staining of the clothes that it 
 occasions is much less marked than when it is used as an ointment. It excites a 
 dermatitis if too freely applied to the unaffected skin, and an intense conjunctivitis 
 if it happens to get into the eyes. It should therefore never be employed on the 
 head and face. Under its use the scaling stops, the elevated masses subside, and 
 there are finally left pale areas that represent the efflorescences of the disease, sur- 
 
 R Kali acetat. . 
 
 . 
 
 . 
 
 4 parts 
 
 Spts. aether, nit. 
 
 . 
 
 . 
 
 2 " 
 
 Vin. colchic. 
 
 • 
 
 • 
 
 1 part 
 
 Syrp. aurant. . 
 
 . 
 
 . 
 
 6 parts 
 
 Aq. carui 
 
 . 
 
 . 
 
 24 " ad. 
 
COPYRIGHT, BY E. B. TREAT 4 CO., N. Y. 
 
 PHOTOGRAVJRE & COUOR CO., N. Y. 
 
 PSORIASIS DIFFUSA 
 
 PLATE XIX 
 
. 
 
 CUTIS AND SUBCUT: 
 
 DERMATITIS. 
 
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 ition. 
 
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 PHOTOGR/-VJRE * COL 
 
 PSORIASIS DIFFUSA 
 
 plat; 
 
INFLAMMATIONS. 159 
 
 rounded by more or less deeply pigmented skin. The removal of this secondary 
 pigmentation may be hastened by the local use of a citric-acid solution. 
 
 Pyrogallol may be employed, like chrysarobin, as a salve or a varnish (No. 83, 
 p. 158). It is not as efficacious as the latter, but it does not cause conjunctivitis, 
 or stain the skin and linen or dye the hair so deeply. It must not, however, be 
 used over too extensive a surface, since cases of poisoning have occurred. Tar, as 
 the tincture (No. 10, p. 56) or as Wilkinson's ointment (No. 38, p. 82), is sometimes 
 useful. The ointment of ammoniated mercury is slow, but moderately effective ; it 
 is the preparation that should be used about the head and face. Anthrarobin in 
 10-per-cent. ointment is harmless, but not nearly so effective as the others mentioned. 
 Finally, any of these drugs can be used in the form of salve-mulls, plaster-mulls, 
 collemplastra, or pencils in appropriate cases. 
 
 2. DEEP-SEATED INFLAMMATIONS AFFECTING THE 
 CUTIS AND SUBCUTIS. 
 
 DERMATITIS. 
 
 Synonym. — Inflammation of the skin. 
 
 Definition. — An affection of the skin, characterized by the phenomena of inflam- 
 mation, heat, redness, pain, and swelling, and ending in resolution, suppuration, or 
 gangrene. 
 
 Symptoms and Course. — Inflammation of the skin occurs as the essential phe- 
 nomenon or as a secondary condition in many skin affections, some of which have 
 been already considered. In certain forms, however, the inflammation is the primary 
 process, and is directly caused by irritation of the skin from without or through the 
 medium of the blood ; and these forms belong more specifically under this heading. 
 The symptoms are the ordinary ones of inflammation of any organ, modified by the pe- 
 culiarities of the skin and the predisposition of the individual. They can be produced 
 artificially, as shown by Hebra. If a little croton-oil be rubbed into the skin for 
 a short time, a transitory redness and swelling, the erythematous stage of dermatitis, 
 are produced. This soon subsides and the process ends with a slight desquamation. 
 If the action of the irritant is more prolonged we get successively the papular stage, 
 with small elevated nodules appearing on the affected area, the vesicular and pustular 
 stages, or the weeping stage, with a reddened skin secreting serum and pus. The 
 inflammation may subside at any one of these stages, ending with desquamation, as 
 the squamous stage ; or the process may terminate in chronic dermatitis or in gangrene 
 and death of the affected skin. Finally, when the inflammation involves the hair- 
 follicles or the sebaceous glands, a circumscribed inflammation, such as we see in 
 furunculosis and folliculitis, is set up. Varieties of the affection have been clas- 
 sified according to cause ; we shall consider dermatitis traumatica, dermatitis calorica, 
 dermatitis venenata, and dermatitis medicamentosa. 
 
160 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Dermatitis traumatica. Injuries to the skin cause the ordinary phenomena of 
 inflammation, accompanied by itching, burning, or stinging. The process may not 
 go beyond the hyperemic stage, but not infrequently suppuration with granulation 
 and cicatricial repair, or even gangrene and sloughing, may result. Among its com- 
 monest manifestations are the excoriations from scratching, which form an important 
 part of the lesions in the various itchy diseases. Each such traumatism, with its sec- 
 ondary inflammation, leaves a small deposit of blood-pigment in the skin, causing in 
 the course of time that diffuse pigmentation which is seen as the result of long contin- 
 uance of the pru- 
 riginous maladies. 
 Under this 
 heading belongs 
 the deep-seated 
 or so-called paren- 
 chymatous der- 
 matitis of the 
 lower extremities, 
 that so frequently 
 leads to chronic 
 ulceration asasec- 
 ondary phenom- 
 enon. An injur}-, 
 which may be 
 very sliarht, a 
 mere scratch or 
 bruise, causes an 
 inflammation in 
 skin whose nutri- 
 tion is already depressed by imperfect circulation due to the dilatation of the veins 
 and lymphatics and consequent oedema. Under these circumstances the process 
 shows no tendency to repair, molecular disintegration occurs in the center, and the 
 chronic leg ulcer, the varicose ulcer, results. This may remain stationary for months 
 or years, or it may slowly grow in size until it occupies the greater portion of the 
 skin of the leg. One or several may be present, and they vary greatly in shape, 
 size, and appearance. Their margins may be steep or sloping, thickened and cal- 
 lous ; their bases may be covered with necrotic tissue, or with abundant, easily 
 bleeding granulations, or they ma)' be red, dry, and shiny. The surrounding der- 
 matitis is almost always extensive, and the amount of pain and tenderness varies 
 greatly in different cases. This form of dermatitis is rare among the well-to-do, 
 where the cleanliness and rest that are required for cure are usually promptly em- 
 ployed ; but it is extremely common among the poorer classes, and is not only very 
 
 Fig. 80. — Dermatitis traumatica (local action of arsenious acid). 
 From photograph by the author. 
 
I 
 
 DERMATITIS TRAUMATICA. 
 
 TYPOGRAVURE. 
 
 DERMATITIS HERPETIFORMIS. 
 
 Pt'STULO-CRUSTACEOUS FORM. 
 
 COPYRIGHT, 1902. BY E. B. TREAT i CO.. N. Y. 
 
 DERMATITIS HERPETIFORMIS. 
 
 VES1CULO HULLOUS FORM. 
 
 PLATE LVI. 
 
INFLAMMATIONS. 
 
 161 
 
 chronic, but sometimes absolutely incurable, since they do not give the inflamed 
 skin the care that it requires, and prolonged rest is an impossibility for them. 
 
 Dermatitis calorica. Extremes of both heat and cold cause inflammation of the 
 skin, but the former is by far the commonest causative agent. 
 
 Dermatitis ambustionis or combustio, the inflammation of the skin caused by a 
 burn or scald, is a frequently severe and a common affection. In its lightest form, 
 the erythematous, the action of the irritant has either been momentary or of slight 
 
 Fig. 8i. — Parenchymatous dermatitis. Fig. 82. — Parenchymatous dermatitis with ulceration. 
 
 From photographs by the author. 
 
 intensity. The skin is hyperemic, evenly pink or reddish, and there is moderate swell- 
 ing and pain. The vascular dilatation soon diminishes, the redness fades, and the 
 process ends in a few days with a slight desquamation. A severer form is the bullous 
 one. The hyperemia is more marked, liquid and formed elements escape from the 
 vessels, and semi-transparent globular bullae or blebs filled with a yellowish serum are 
 formed. The papillary vessels of the inflamed area are dilated, and the connective- tissue 
 
162 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Fig. 83. — Dermatitis ambustionis bullosa. 
 
 From photograph by the author. 
 
 fibers of the corium are swollen and infiltrated with cells. The serum may be 
 absorbed and the blebs dry up into crusts under which the epidermis reforms, or 
 they may be ruptured, and the cell-proliferation go on to suppuration and granu- 
 lation, slowly terminating with more or less cicatrization. This is a much more 
 painful and serious affection than is the erythematous form ; fever is usually present ; 
 and when at all extensive, or when it occurs in debilitated subjects or at the extremes 
 of life, it is liable to be fatal. Finally, in the escharotic form of combustio the irritant 
 
 has been severe 
 enough to cause 
 death of the skin, 
 and perhaps of 
 the deeper parts. 
 The integument is 
 brownish or black- 
 ish, or white when 
 steam has been the 
 escharotic agent. 
 It may appear un- 
 altered, but it is 
 absolutely de- 
 
 stroyed ; it is devoid of sensation and feels hard and dry to the touch. The dead 
 mass must be cast off by the reactive inflammation of the adjacent living tissues 
 with the formation of a line of demarcation and a suppurative process. The cavity 
 left behind is filled up with new connective tissue, forming a scar without hair-papillaj 
 or -glands. The subjective symptoms in this form of burn are marked and grave. 
 Usually more than one variety or stage of dermatitis ambustionis is present in the 
 same patient. 
 
 Dermatitis congelationis or frost-bite also occurs in three degrees. Predisposition 
 to its occurrence, especially in the lighter forms, seems to be necessary ; for healthy 
 and vigorous individuals are not affected even after considerable exposure to cold. 
 The mildest or erythematous form is the common chilblain or pernio. This occurs 
 on the hands and feet, more rarely on the nose and ears. It appears as a bright- 
 red or livid elevated area, and is accompanied by much itching and pain. A slug- 
 gish inflammatory process is set up, which may end in resolution or go on to ulcera- 
 tion. In the bullous form blebs appear exactly as in combustio. In the severest 
 or escharotic form there are large bullae, possibly with hemorrhagic contents, or the 
 skin is white, cold, and senseless. The part is gangrenous, and must be cast off by 
 suppuration ; and phlebitis, septicemia, and death not infrequently occur. More often 
 than in similar lesions caused by heat, however, there is a suspension rather than a 
 cessation of vitality, and with appropriate treatment the part may return to the 
 normal after an inflammation of greater or less severity. 
 

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INFLAMMATIONS. 
 
 16:5 
 
 Dermatitis venenata. When due to the action of poisonous plants the inflam- 
 mation may be erythematous, papular, vesicular, pustular, or bullous in form, ac- 
 cording to the susceptibility of the skin and the amount of irritation caused by the 
 poison. Some persons can handle the poisonous plants with impunity ; others suffer 
 slightly when they 
 come in contact with 
 them ; while others, 
 again, have the sever- 
 est forms of the erup- 
 tion when they come 
 in their neighborhood. 
 Individuals once af- 
 fected are very liable 
 to have recurrences at 
 certain times, more 
 often in the spring and 
 the fall. Most usu- 
 ally the eruption is 
 markedly vesicular, 
 with much swelling 
 and erythematous 
 redness. The hands 
 and face are most fre- 
 quently affected, and 
 by direct transfer of the poison the genitals are usually involved. The malady lasts 
 from one to several weeks. When due to the local action of drugs or to dyes in the 
 clothing the inflammation may be very severe ; vesicles and bullae appear, and even 
 gangrene may result. 
 
 Dermatitis medicamentosa is an affection that closely simulates other cutaneous 
 disorders, and is doubtless often mistaken for them. A large number of drugs, many 
 of them in common use, may give rise to it. The eruption is frequently pustular, 
 and the peculiar drug has in many cases been found in the pus. This seems to be 
 largely due to an attempt on the part of the glandular structures of the skin to 
 eliminate the foreign material. Such are the common iodine and bromine eruptions. 
 Others are exanthematous and are accompanied by constitutional symptoms. Ar- 
 senic and copaiba cause a papular eruption similar to erythema multiforme. Atropia, 
 belladonna, and chloral cause a scarlatinoid rash. Opium, quinine, turpentine, and 
 salicylic acid cause an erythematous eruption. 
 
 Etiology. — Dermatitis traumatica is caused by contusions, wounds, pressure, as 
 of tight clothing and bandages, excoriations with the finger-nails, lesions from tools 
 used in the trades, and the non-toxic bites and stings of animals and insects. Der- 
 
 FlG. 84. — Dermatitis venenata. 
 From photograph by the author. 
 
164 ILLUSTRATED SKIN DISEASES. 
 
 matitis calorica is due to the action of flame, hot or exploding vapor, hot solids or 
 liquids, acid or alkaline caustics, lightning, electricity, and the sun's rays, or to cold 
 air, snow and ice, etc. Dermatitis venenata is occasioned chiefly by the plants of 
 the Rhus family, probably on account of the volatile toxicodendric acid that they 
 contain. Two varieties are found on this continent, the Rhus venenata, poison-sumac 
 or -dogwood, and the Rhus toxicodendron, the poison-ivy or -oak. The aniline dyes 
 now so extensively used may cause dermatitis, as do also cantharides, savin, mezereon, 
 arnica, mustard, croton-oil, mercurial salve, and other substances, when applied to 
 the skin. Dermatitis medicamentosa may be caused by a large number of drugs, 
 among which we may mention iodine, bromine, arsenic, atropia, chloral, copaiba, 
 mercury, morphia, quinine, salicylic acid, and turpentine. 
 
 Pathology. — The process is a simple inflammation of the skin of varying intensity, 
 sometimes affecting the deeper parts and accompanied by certain secondary lesions, 
 ulceration, etc. The ordinary phenomena and results of inflammation need no re- 
 capitulation here. 
 
 Diagnosis. — The history of the cause is usually obtainable ; the patient has been 
 exposed to heat or cold or to injury, or he has been taking some one of the above- 
 mentioned drugs. The marked vesicular eruption of poison-ivy, its location on the 
 hands, face, and genitals, and the fact that the patient has been in some locality 
 where the plant exists, will serve to prevent mistake. 
 
 Prognosis. — This varies, of course, with the severity of the affection. It is good 
 in the milder forms, but in the severer ones the possibility of incurability or the 
 occurrence of gangrene, pyemia, and septicemia must not be lost sight of. In der- 
 matitis calorica death may occur in the early stages from shock or later on from 
 exhaustion and intercurrent disease. Severe burns, even if of slight extent, and 
 burns that have not gone beyond the hyperemic stage, but involve one third of the 
 entire integument, are of grave portent. In dermatitis venenata and medicamentosa 
 the prognosis is always good. 
 
 Treatment. — In dermatitis traumatica the first essential of treatment is to remove 
 the cause. The inflammation usually then subsides spontaneously, but its disap- 
 pearance may be hastened by the use of cold compresses or lead-water applications. 
 Later on Lassar's paste (No. 2, p. 43) may be used, and the salicylic-sulphur paste 
 (No. 79, P- 153) is useful where there is much desquamation. 
 
 In parenchymatous dermatitis our first attention must be directed to the predis- 
 posing and active causes of the inflammation. All sources of irritation must be 
 avoided and the dilated veins must be supported with a carefully applied muslin 
 bandage. Elastic stockings are expensive, since they soon wear out, and the ordi- 
 nary rubber bandage macerates the skin and confines the secretions. Rest in bed 
 and elevation of the limb are of the first importance ; unfortunately they cannot 
 usually be employed in the patients that suffer from this affection. Of the many 
 forms of treatment, I have found the most generally useful to be that with the 
 
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 COPYRIGHT BY E. B. TREAT & CO. , N. Y. 
 
 PHOTOGRAVURE 4 COLOR CC. , N. Y. 
 
 DERMATITIS PARENCHYMATOSUS 
 

 
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 PLAT£ X 
 
INFLAMMATIONS. 16f) 
 
 glyco-gelatin, recommended by Unna. The entire leg and foot are first thoroughly 
 washed with hot water and soap, and then the whole surface is antiseptically cleansed 
 with a i-per-cent. creolinora3-per-cent. carbolic- oraboracic-acid solution. After dry- 
 ing, the glyco-gelatin (No. 4, p. 43), melted in a water bath, is evenly applied with a 
 broad brush ; as it dries it is to be dabbed over with a fluff of cotton to increase its 
 strength. A little iodoform is powdered over the sore, to be replaced by subnitrate 
 of bismuth or dermatol if there is much secretion ; and if the granulations are abun- 
 dant they must be cut down with the nitrate-of-silver stick. A layer of silk protec- 
 tive and cotton is then applied over the limb from toe to knee; and after the 
 glyco-gelatin has set, still another bandage. Before the gelatin is entirely hard a 
 dry gauze bandage is evenly applied. Fenestras may be cut in the bandages to 
 facilitate dressing of the ulceration if thought desirable. The dressing may remain 
 on for from four to fourteen days, according to the amount of secretion. Besides 
 this method of treatment, I can recommend the use of Lassar's paste (No. 2, p. 43) 
 if the dermatitis is very intense. Bad cases may require ablation of the indurated 
 edges of the ulcerations, skin-grafting, ligation of the dilated veins, etc. 
 
 No. 84. Carron-oil. 
 
 R Thymol 1 part 
 
 Menthol 90 parts 
 
 Aq. calcis 
 
 01. lini 500 " 
 
 No. 85. Ichthyol Collodion. No. 86. Duhring's Poisoti-ivy Lotion. 
 
 Yji Amnion, sulph-ichthyolat. . 1 part ft Extract, grindelias rob. fid. . 1 part 
 
 Collod. flexile . . .5 parts Aquae . . . . • 5° parts 
 
 The treatment of burns consists, in the first place, in the use of stimulants as may 
 be necessary, together with the administration of a full dose of opium or morphine. 
 In burns of the erythematous and bullous degrees the blebs and vesicles should be 
 punctured and the parts thickly dredged with starch or flour to protect them from 
 the air and save the patient the excruciating pain that contact occasions. A good 
 plan is the following: after the blebs are emptied the parts should be thoroughly 
 cleansed with a 5-per-cent. salt or a i-per-cent. creolin or a boracic-acid solution; 
 then carron-oil, possibly with the addition of thymol and menthol, should be used 
 (No. 84, p. 165), or the lime-water-and-zinc paste (No. 78, p. 149). The iodoform 
 treatment is applicable especially to severe cases, but is excellent for general use. 
 After antiseptic cleansing the parts are covered with iodoform gauze, then with gutta- 
 percha tissue, and lastly with cotton and a bandage. The cotton should be changed 
 whenever the discharges soak through it; but the gauze may remain in situ for from 
 eight to fourteen days. If the burn is extensive, or the patient is a child or aged, 
 and iodoform poisoning is feared, the creolin gauze may be used instead. The sub- 
 
166 ILLUSTRATED SKIN DISEASES. 
 
 nitrate of bismuth or dermatol, with gauze, cotton, and a bandage, is often used. 
 In bad and extensive cases the permanent water bath has given good results. The 
 patient is suspended in the bath by a stout sheet attached to its edges. Skin-grafting 
 is often required for the extensive ulcerations left from burns. 
 
 For chilblains stimulating applications and local frictions are useful. Hot com- 
 presses may be applied frequently for short intervals of time. The 5-per-cent. col- 
 lemplastrum of salicylic acid or a 10-per-cent. ichthyol collodion (No. 85, p. 165) 
 is a good local application. In obstinate cases the epidermis should be removed by 
 the application of a mixture of equal parts of dilute nitric acid and peppermint-water 
 once or twice daily. Severer frost-bites require frictions in a cold room with ice- 
 water or snow to prevent too great reaction. Sloughing and ulceration must be 
 treated with antiseptic dressings. Cases of suspended animation from cold should 
 not be regarded as dead until after artificial respiration has been persistently tried 
 a long time, for cases have recovered when apparently dead for hours. 
 
 In dermatitis venenata the parts should be protected from the air, and for this 
 purpose alkaline lotions, bicarbonate of soda or borax, or a saturated solution of 
 hyposulphite of soda, are useful. Dilute lead-water compresses are a favorite rem- 
 edy. Duhring recommends Grindelia robusta very highly (No. 86, p. 165). The 
 various soothing ointments, pastes, lotions, and oils can also be used (No. 26, p. 70, 
 No. 29, p. 74, Nos. 65, 66, 68, 69, p. 135). 
 
 Dermatitis medicamentosa requires only symptomatic treatment after its cause 
 is removed. 
 
 Cathode-ray dermatitis (see Plate XX.) has been seen in a number of cases. 
 The lesions are those of an ordinary chronic or acute dermatitis, followed by marked 
 exfoliation; but the deeper tissues, even to the periosteum of the bones, are some- 
 times affected. 
 
 ERYTHEMA NODOSUM. 
 
 Synonyms. — Dermatitis hemorrhagica, dermatitis contusiformis, erytheme nonenx 
 (Fr.). 
 
 Definition. — An acute inflammatory disease, characterized by the formation of 
 various-sized, rounded or oval, erythematous-looking nodes, situated most commonly 
 on the lower extremities. 
 
 Symptoms and Course. — The malady usually begins with marked general symp- 
 toms — vomiting and fairly high fever, sometimes accompanied by delirium and 
 pains in the joints. Then the eruption rapidly appears in the form of contusion-like 
 nodes of considerable elevation, rounded or oval in shape. Their size varies from 
 that of a nut to that of an egg ; they are warm to the touch, surrounded by an oedem- 
 atous area, and painless, but tender to pressure. Their color is at first rosy red, 
 changing to a duskier and more livid hue, and not removable by pressure. They 
 
INFLAMMATIONS. 167 
 
 never coalesce or suppurate. In the course of eight or ten days they gradually 
 disappear, going through the color-changes that are seen in blood-extravasations, 
 and leaving a temporary dark-brown discoloration behind. Three or four nodes 
 only are usually present, and their number rarely exceeds a dozen. Their regular 
 seat is on the lower legs, more especially on their tibial aspects ; but they are 
 sometimes seen on the arms, rump, face, and even on the mucosae. Though the 
 individual lesions last only a few days, a succession of fresh ones often prolongs the 
 disease for two or three weeks. Recurrences are rare. Fairly frequent complica- 
 tions are purpura and erythema multiforme ; rarer ones are inflammations of the 
 joints and serous membranes, and ulcerations of the skin or mucosae. The malady 
 occurs in youth, and is most often seen in weak individuals. It is most frequent 
 in the spring and autumn, and much commoner in the female than the male sex. 
 
 Etiology. — The cause of this rather rare disease is still unknown. It is probably 
 an infectious malady related in some way to acute articular rheumatism. 
 
 Pathology. — This consists essentially of serous infiltration and blood-extravasa- 
 tion of the various tissues of the skin down to the subcutis. 
 
 Diagnosis. — Ordinary contusions may be mistaken for the nodes of erythema 
 nodosum, but they never have the peculiar rosy color, are not usually multiple, are 
 not rounded, there are no general symptoms, and there is the history of an injury. 
 Syphilitic gummata may resemble them closely ; but the antecedent pains are much 
 severer, they are slower in their course, are very rarely seen -in the young, and are 
 almost always accompanied by other symptoms of lues, past or present. 
 
 Prognosis. — This is generally good, though the complications above mentioned 
 may cause death. 
 
 Treatment. — This consists almost entirely in the symptomatic treatment of the 
 initial fever and joint pains, with the administration of tonics. The disease will run 
 its course without our aid. Lassar recommends the internal use of salicylic acid 
 very strongly. Lead-water applications may be made to the nodes. 
 
 ERYSIPELAS. 
 
 Synonyms. — Rose, Rotlauf (Ger.), crysipcle (Fr.). 
 
 Definition. — An acute infectious inflammation of the skin and mucosas, caused by 
 the growth in them of the Streptococcus erysipelatis, and characterized by a diffuse 
 'shiny redness with pain and swelling, and perhaps vesiculation, together with fever 
 and general constitutional symptoms. 
 
 Symptoms and Course. — The malady usually begins with a chill, followed by a 
 marked rise of temperature and constitutional disturbance. About twenty-four hours 
 later the temperature falls and the eruption appears, beginning as an irregular, red, 
 glazed patch, with moderate itching and burning. The affected skin is hot, tense, 
 cedematous, and infiltrated. Its margins are sharply limited, and the eruption spreads 
 
168 ILLUSTRATED SKIN DISEASES. 
 
 at irregular intervals, marked by exacerbations of the fever. After extending for 
 from three days to a week, retrogression begins, usually at one border ; the margin 
 becomes indistinct, the redness and tension diminish, and the desquamation that 
 marks the termination of the process begins. It may still, however, advance at the 
 opposite margin ; and it may thus travel around the head more than once, or cover 
 large areas of the body (erysipelas migrans, erysipelas ambulans). In bad cases the 
 cedema and swelling are very great. If the face is affected the entire visage is 
 deformed, swollen, and red, the eyes are closed, and the saliva dribbles from the 
 tumefied lips. Vesiculation and crusting may occur, giving us the varieties known 
 as erysipelas vesiculosum, bullosum, crustosum ; and subcutaneous abscesses and even 
 gangrene may supervene. 
 
 The general symptoms are usually severe. The remittent fever may reach 105 
 to 107 . Temperature, pulse, and prostration are more dependent on the extent of 
 skin inflamed than on the severity of the infection. The duration of mild cases is 
 about a week ; but the migrating form may last much longer, and the patients once 
 affected are extremely liable to recurrences of the disease. The malady may occur 
 anywhere; but it is most frequent on the face, commencing about the nares, where 
 eczema, fissures, etc., are so common. When erysipelas occurs on the scalp there 
 is always danger of the occurrence of meningitis, as shown by the advent of head- 
 ache, delirium, stupor, and vomiting ; and recovery is followed by falling of the hair. 
 When erysipelas occurs on the scrotum gangrene is a frequent result. The malady 
 is extremely infectious. 
 
 As complications there may occur abscesses of the subcutis, gangrene of the af- 
 fected part (erysipelas gangrenosum), suppurative inflammations of the joints and 
 serosae, etc. Death may happen from exhaustion or pyemia. 
 
 Etiology. — The Streptococcus crysipelatis, discovered by Fehleisen, is the cause 
 of the disease ; but a lesion of the skin is required for it to enter the lymphatics. 
 This may be a surgical or an accidental wound, an excoriation, a pus-crust, or an acne 
 pustule, etc. In many cases the lesion is so insignificant that it cannot be found. 
 The surgical and obstetrical form of the disease is becoming rarer every year, as 
 antisepticism and cleanliness are more carefully observed. 
 
 Pathology. — Erysipelas is a superficial or deep dermatitis of varying intensity, 
 due to the growth of the cocci in the lymph-vessels and -spaces. The blood-vessels 
 are dilated and distended with blood, and the cell-infiltration may extend down into 
 the subcutis. Streptococci are heaped up in the lymph-vessels an inch or more 
 beyond the red border of the disease on the skin. 
 
 Diagnosis. — The peculiar shiny pinkish-red and swollen area, with the general 
 symptoms, is quite characteristic. An erythema has no general symptoms, no pain, 
 and no infiltration. Acute eczema also presents slight general symptoms, or none at 
 all ; there are papules, vesicles, or weeping surfaces ; there is less infiltration, and there 
 are no sharp borders. Chronic dermatitis is called by some authorities erysipelas 
 
COPYRIGHT, BY E. B. TREAT & CO., N. Y. 
 
 PHOTOGRAVURE & COLOR CO., N. Y. 
 
 ERYSIPELAS 
 
 PLATE XXI. 
 

 ans, or chronic erysipelas 
 11 as its course, 
 
 l 
 
 Prognosis,— This depends on tl 
 of time that it has been present, and the 
 tions most to be feared are gangrene 
 tons area will help us in deciding as 
 ;ted the :-ad. 
 
 Treatment.— of anti- 
 
 of erysipe careful steriliza; 
 
 etc. — act with them, 
 
 The basis of tent is a no. ! fluid 
 
 alcohol i ith the amount of pr 
 
 with antipyretics and baths. The tinctun 
 20 to 30 drops every two or three hours, is 
 
 ;il cond 
 
 i 
 
 - 
 - 
 
 I 
 I 
 
 : 
 ;1 
 
 No. 87. Ichlh 
 
 ■ 
 
 R: Ichthyol 
 Collod. 
 
 5 parts 
 
 
 . 
 
 
 as clean . 
 
 3 small amc. 
 evacuated. An ice 
 grene is feared it should nc: 
 can employ, and it has displaced aim- 
 : per-cent. solution, paste, colic- 
 9, 90, p. 169). The most convenient is th 
 tily. On the head the iclitlv 
 oil, is efficacious. The ointments and lol 
 siJe the patch toward the center, and in ... 
 the apparent margins of the disease 
 cent, pa Ive and tl 
 
 •Its. We n 
 ing strips of plaster 2 inches be 
 
 ■ 
 
 ted; 
 
 - 
 
 used as a 
 
 : 
 i 
 

 >£LAS 
 
 
 
INFLAMMATIONS. 
 
 169 
 
 perstans, or chronic erysipelas ; but the absence of the characteristic color and sharp 
 outline, as well as its course, will serve to distinguish it. 
 
 Prognosis. — This depends on the grade and extent of the erysipelas, the length 
 of time that it has been present, and the patient's general condition. The complica- 
 tions most to be feared are gangrene and meningitis. The border of the erysipela- 
 tous area will help us in deciding as to its future course ; so long as it is sharp and 
 elevated the disease will spread. 
 
 Treatment. — The application of antisepsis to the smallest wound, the segregation 
 of erysipelas patients, and the careful sterilization of everything — instruments, hands, 
 etc. — that has come in contact with them, will prevent the spread of the disease. 
 The basis of the general treatment is a nourishing fluid diet, with the free use of 
 alcohol in accordance with the amount of prostration. The fever must be combated 
 with antipyretics and baths. The tincture of the chloride of iron given in full doses, 
 20 to 30 drops every two or three hours, is undoubtedly of service in many cases. 
 
 No. 87. Ichthyol Collodion. 
 
 ft Ichthyol 
 
 Collod. flexile 
 
 1 part 
 5 parts 
 
 No. 88. Ichthyol Ointment, No. 2. 
 
 fy Ichthyol 
 Aq. dest. 
 Adip. lanse 
 
 aa. p. e. 
 
 No. 89. Ichthyol Lotion. 
 
 ft Ichthyol . 
 Ether 
 Glycerin . 
 
 1 part 
 aa. 3 parts 
 
 No. 90. Ichthyol Spray. 
 
 ft Ichthyol 
 Ether . 
 
 1 part 
 10 parts 
 
 The local treatment consists, in the first place, in keeping the surface of the skin 
 as clean and aseptic as possible by frequent washing with alcohol and ether contain- 
 ing a small amount of the bichloride of mercury. Crusts must be removed and pus 
 evacuated. An ice-bag may be applied to the head if that is affected; but if gan- 
 grene is feared it should not be used. Ichthyol is the best local application that we 
 can employ, and it has displaced almost all other remedies. It should be used as a 20- 
 to 50-per-cent. solution, paste, collodion, or ethereal spray (No. 86, p. 165, Nos. 87, 
 88, 89, 90, p. 169). The most convenient is the collodion, which should be applied sev- 
 eral times daily. On the head the ichthyol spray, followed by inunctions of linseed- 
 oil, is efficacious. The ointments and lotions must be rubbed in from the area out- 
 side the patch toward the center, and in any case a surface at least 1 inch beyond 
 the apparent margins of the disease must be treated. Resorcin in a 10- to 50-per- 
 cent, paste or salve and the ^--per-cent. sublimate ointment (No. 43, p. 100) have also 
 given good results. We may attempt to check the spread of the disease by apply- 
 ing strips of plaster 2 inches beyond its advancing border and painting them over 
 with flexible collodion ; and on the limbs rubber bands may be similarly employed. 
 
170 
 
 ILLUSTRATED SKIN DISEASES. 
 
 CHANCROID. 
 
 Synonyms, — Soft chancre, non-infecting chancre, ulcus molle, weicher Schanker 
 (Ger.), chancrelle (Fr.). 
 
 Definition. — A specific, local, contagious, auto-inoculable, spreading ulceration 
 of the skin. 
 
 Symptoms and Course. — Chancroid has no period of incubation, the process be- 
 ginning immediately after infection ; but it is usually two or three days later before 
 the lesion is perceived. It first appears as a minute nodule or vesicle, which rapidly 
 increases in size and becomes pustular. In exceptional cases, where the virus has 
 been lodged in a crypt or follicle, it may be one or two weeks before the patient's 
 attention is drawn to it. The pustule finally ruptures or dries up into a crust, re- 
 vealing the characteristic chancroidal ulcer. This in its early stages is round, with 
 sharp, undermined, punched-out edges, surrounded by a narrow, vivid-red, inflam- 
 matory areola. No induration is present. The floor of the ulcer is irregular, bathed 
 with pus, or covered with grayish fragments of necrotic tissue. As it grows to lentil- 
 size suppuration becomes more profuse. A benign case goes on in this way for 
 three to four weeks, until the ulcer has attained the size of a bean or a penny. When 
 repair sets in the signs of inflammation diminish, the edges of the ulcer lose their 
 
 sharpness, the areola disappears, and granulations 
 spring up on the base of the sore. The seat of chan- 
 croid is upon the genitals in almost all cases, most 
 often upon the corona, glans, prepuce, frenum, me- 
 atus, and labia minora ; in very rare instances it has 
 been found on other portions of the body. It is 
 always very sensitive, and pain is a marked feature 
 in extensive cases. There is often more than one at 
 the same time ; being auto-inoculable, parts that come 
 in contact with the sore are frequently infected. The 
 coalescence of adjacent lesions gives rise to ulcera- 
 tions of irregular shape. 
 
 Sometimes the chancroid does not follow this 
 comparatively benign course, but becomes phage- 
 denic, assuming a diphtheritic or gangrenous appear- 
 ance. It advances rapidly and leads to deep and extensive destruction of tissue. In 
 other cases it heals at one margin while advancing at the other, forming the serpigi- 
 nous variety of the disease. The lymphatic glands leading from the affected area 
 are always swollen and tender, and a tumefaction of the inguinal lymphatic glands, 
 the bubo, is a regular accompaniment of the disease. This latter frequently goes 
 on to suppuration, the abscess bursts or is opened, and a large chancroidal ulcer, 
 
 Fig. 85. — Chancroid. 
 
 From cast from life by the author. 
 
INFLAMMATIONS. 
 
 171 
 
 with ragged, sloughing base and undermined edges, is left behind. The ulcerative 
 process is frequently very chronic and may last for months ; pocketing and sinus for- 
 mation frequently occur ; and I have known the destruction in one case to extend on to 
 the abdomen and cause death by opening the peritoneal cavity. In any case the mark 
 of the chancroidal process is permanent. The papillary layer of the affected skin is 
 destroyed, and scars, contractures, and deformities result. Destruction of the frenum, 
 phimosis, and paraphimosis are liable to occur, as are also erysipelas and gangrene. 
 The possible presence of syphilis 
 as a complication, the patient hav- 
 ing contracted that disease at the 
 same time as the chancroid, must 
 never be lost sight of. 
 
 Etiology. — We can say nothing 
 positive in this regard as yet, save 
 that it is undoubtedly due to an 
 organic body of some kind. Micro- 
 organisms have been described by 
 Ducrey and by Unna, but their re- 
 lationship to the disease has not yet 
 been proved. 
 
 Pathology. — The process is an 
 acute inflammation of the skin, with 
 rapid molecular destruction of the 
 tissues. The corium under and 
 around the ulcer is infiltrated with 
 small cells, and the papillary layer 
 is ultimately destroyed. The open 
 mouths of the lymphatic vessels 
 can be found in the bases of the 
 ulcers. 
 
 Diagnosis. — The short incuba- 
 tion, the beginning with a pustule, 
 the undermined irregular edges and 
 dirty necrotic base, the inflammatory areola, the multiplicity, and the auto-inocula- 
 bility are sufficiently characteristic of chancroid. It requires to be carefully differ- 
 entiated, however, from two other conditions that are common on the genitals, 
 chancre and herpes. Hard chancre has an incubation of from ten to fifty days ; it 
 begins as a papule, and is usually single ; it has an extensive induration which re- 
 mains long after the lesion has passed away ; its edges are not undermined ; it secretes 
 a small amount of seropurulent fluid ; and the swelling of the lymphatic glands is 
 moderate, very hard, and painless. The absence of these points does not enable us, 
 
 -Chancroidal ulceration of labia. 
 From photograph by the author. 
 
172 
 
 ILLUSTRATED SKIN DISEASES. 
 
 however, to exclude chancre ; we must wait for that until the longest possible period 
 of primary incubation of syphilis has passed, since double infection may have oc- 
 curred, and induration may appear around the chancroidal ulcer or in its scar later 
 on. In herpes progenitalis we have grouped vesicles, not pustules ; there is no tend- 
 ency to spreading and no bubo ; the affection is very superficial and not followed by 
 scarring; there is usually a history of previous attacks; and the lesion has no neces- 
 sary connection with coitus. 
 
 Prognosis. — In uncomplicated cases 
 this is very good, but no opinion as to 
 the presence of syphilis can be given un- 
 til two and a half months later. The 
 occurrence of bubo has no relation to 
 the size or extent of the chancroid. In 
 bad serpiginous and phagedenic cases 
 death sometimes occurs by sepsis. 
 
 Treatment. — Scrupulous cleanliness 
 and the prevention of contact of the sore 
 with other portions of the integument 
 by means of pledgets of cotton and 
 bandages are essential. Our object in 
 treatment is to transform the virulent 
 into a simple sore. After thorough 
 cleansing of the base of the ulcer pure 
 carbolic acid can be freely applied, care 
 being taken that all the recesses and 
 crevices of the ulceration be reached. 
 If that is not effective, nitric acid or 
 the acid nitrate of mercury can be used 
 in the same way. Hyde prefers the 
 galvanocautery. In all these cases co- 
 caine should be used to mitigate the 
 pain. A simple iodoform or other anti- 
 septic dressing suffices for the after 
 treatment. In phagedenic cases the 
 continuous hot-water bath at a tem- 
 perature of 98 has given the best re- 
 sults. 
 
 Fig. 87. —Ecthyma. 
 
 From photograph by the author. 
 
 Ecthyma, like impetigo, is no longer regarded as a distinct disease, but rather as 
 a form of cutaneous inflammation that occurs in various affections. It appears as a 
 round or oval, deep-seated, yellow pustule, bean- to Albert-size, and situated on 
 a markedly inflammatory base. The contents dry up into a thick, rough, adherent 
 
INFLAMMATIONS. 
 
 173 
 
 crust composed of pus and blood. Under the crust we find a deep ulceration, with 
 a grayish or reddish base covered with indolent granulations. The papillae are fre- 
 quently destroyed, and scarring results. The cause of the inflammation is always 
 infection with pus-cocci, most commonly transplanted into the skin with the finger- 
 nails. Hence ecthyma occurs in the various itchy diseases, more especially in 
 phtheiriasis, scabies, and urticaria, and is most commonly seen in poor and uncleanly 
 individuals. Other diseases, as variola and chancroid, occasionally exhibit deep- 
 seated pustules of ecthymatous form, probably on account of infection with pus-cocci 
 as well as with the specific organisms of the main disease. 
 
 FURUNCULOSIS. 
 
 Synonyms. — Boil, furuncle, Furunkel, Blutschwar (Ger.), furoncle (Fr.). 
 
 Definition. — An acute circumscribed phlegmonous inflammation of the skin 
 around a cutaneous gland, 
 ending in necrosis of the cen- 
 tral area, and caused by the 
 presence of pus-organisms. 
 
 Symptoms and Course. — 
 A small punctate spot first 
 appears on the skin, usually 
 pierced in its center by a 
 lanugo hair. This rapidly in- 
 creases in size, and in a day 
 or two becomes a circum- 
 scribed, elevated, hard, pain- 
 ful infiltration \ to I inch in 
 diameter. It becomes acu- 
 minate, and in twenty-four to 
 forty-eight hours a minute 
 yellow point at the apex 
 shows the presence of pus. 
 Suppuration goes on for a 
 week or longer, and then the 
 furuncle breaks, and a day or 
 two later the central core is 
 extruded. The crateriform 
 ulceration heals rapidly, leav- 
 ing a temporary pigmentation 
 and small permanent scar be- 
 hind. Furuncles may appear 
 
 . Fig. 88. — Furunculosis. 
 
 anywhere on the body where From photograph by the autho r. 
 
174 ILLUSTRATED SKIN DISEASES. 
 
 there are sebaceous follicles and hair-sacs ; but they are commonest on the neck, 
 buttocks, axillae, and in the external auditory passages. There may be one or many ; 
 but, since auto-inoculation usually occurs, the patients generally suffer from a suc- 
 cession of single boils or of crops of them, which may prolong the malady for months, 
 forming the condition known as furunculosis. The amount of pain depends on the 
 seat of the lesion and the tension that it is subjected to. It is frequently consider- 
 able in situations like the perineum and the external auditory meatus. Fever and 
 constitutional symptoms often accompany the outbreaks. 
 
 Etiology. — Furunculosis is caused by the growth in and around the follicles of the 
 skin of the pyogenic staphylococci. It is usually inoculated in the integument 
 with the finger-nails. Certain constitutional conditions, and cachexias, diabetes, 
 uremia, and the gastro-intestinal diseases of children, seem to predispose the skin 
 to its occurrence. So also does the external use of tar, chrysarobin, and pyrogallol. 
 It is not surprising that it is of common occurrence in many of the itchy skin diseases, 
 more especially in eczema, scabies, and prurigo. 
 
 Pathology. — The circumscribed phlegmonous inflammation occurs in and around 
 a follicle, most often a hair-sac, and involves all the tissues of the skin. The inten- 
 sity of the inflammation is such that necrosis of the central inflamed area takes place, 
 and the dead tissue is cast off as the " plug " in the reactive inflammation that ensues. 
 
 Diag-nosis. — The hard, circumscribed, painful, acuminate infiltration with yellow 
 apex is characteristic. An ecthymatous pustule has no core, is not so deep, and has 
 a larger inflamed areola round it. Carbuncle is larger, often several inches in di- 
 ameter, and flatter ; it has two or more points of suppuration, and it is almost always 
 single. 
 
 Prognosis. — This is almost always good. On the face, however, the dangers of 
 phlebitis and thrombosis of the cerebral veins must not be lost sight of. When it 
 occurs in the course of grave constitutional disease, like diabetes, furunculosis may 
 be a more serious affection, and hasten a fatal termination by the pain, exhaustion, 
 and loss of sleep that it occasions. 
 
 No. 91. Menthol-oil. 
 
 $ Menthol . i part 
 
 Ol. olivae . ... 4 parts 
 
 Treatment. — The cause, if possible, must be found and removed. The urine 
 should be examined for sugar, and any underlying disease should be appropriately 
 treated. Tonics are always useful in long-continued cases. Prophylaxis consists 
 in cleanliness ; frequent bathing, more especially with enough of the permanganate 
 of potash added to the bath to give the water a claret color, is required. Internal 
 remedies supposed to have a specific action on the suppurative process, such as the 
 sulphide of calcium, and local procedures designed to abort the boils, have been 
 
INFLAMMATIONS. 
 
 175 
 
 absolutely useless in my hands. The entire affected area should be thoroughly 
 cleansed with sublimate, carbolic- or boric-acid solutions,, and then a piece of the 
 mercury-carbolic plaster-mull applied to the boil. This should be done at least 
 three times daily. Incision, which should be free, and followed by a thorough curet- 
 ting, is frequently required. Wolff recommends the thorough rubbing in of iodoform 
 or aristol and an occlusive dressing after it. Boils should never be squeezed to ex- 
 press pus or necrotic tissue. In furuncle of the external auditory meatus the passage 
 should be cleansed as well as possible with a warm 3-per-cent. boric-acid solution, 
 followed by warmed menthol-oil on cotton (No. 90, p. 1 74). 
 
 CARBUNCULUS. 
 
 Synonyms* — Anthrax, Brandschwdr (Ger.). 
 
 Definition. — An acute circumscribed phlegmonous inflammation of the skin and 
 subcutis, ending in gangrene, and caused by the presence in the skin of pus-organ- 
 isms. The term " anthrax," though commonly 
 used for this affection, is incorrect ; anthrax is a 
 specific disease of animals and men caused by the 
 Bacillus anthracis; its initial lesion is known as 
 the malignant pustule, and it has no connection 
 with the disease under consideration. 
 
 Symptoms and Course. — Carbuncle begins as 
 a circumscribed, deep-seated, hard, painful, red, 
 and erysipelatous-looking infiltration, of consid- 
 erable extent from the first. It increases in size 
 for about two weeks, and finally forms a firm, 
 brawny, dusky-red or violaceous swelling. Points 
 of suppuration appear in the center of the mass, 
 from which a thin sanious pus trickles out; and 
 from each opening a core or plug of necrotic tis- 
 sue is finally expelled. The tumor softens in 
 the center, the ridges of dusky skin between 
 the numerous openings break down, and, after 
 the sloughing is complete, the dead parts are 
 cast off and a deep granulating ulceration is left 
 
 behind. The size of the carbuncle varies from that of a child's fist to that of a din- 
 ner-plate ; and by peripheral progression while sloughing and suppuration are going 
 on in the center, extensive lesions, covering perhaps half the back, may be formed. 
 In bad cases not only is there complete and extensive necrosis of the cutis and sub- 
 cutaneous tissue, but even the muscles and the periosteum of the bones may be in- 
 
 FlG. 89. — Carbuncle. 
 Case of Dr. A. H. Ohmann-Dumesnil. 
 
176 ILLUSTRATED SKIN DISEASES. 
 
 volved. An extensive stellate and often pigmented cicatrix is left behind when the 
 ulceration heals. 
 
 The carbuncle is usually single, and its seat is most often upon the back, neck, 
 cheeks, and lips. The constitutional symptoms vary with the extent of the inflam- 
 mation and the general condition of the patient. Fever, gastro- intestinal disturb- 
 ance, and general malaise are present in all cases, and in bad ones septic infection 
 and pyemia may set in. Local extension may cause pleurisy, peritonitis, and cere- 
 bral or spinal meningitis. The entire process lasts from two to six weeks. 
 
 Etiology. — Infection with pus-cocci is the cause of carbuncle. This probably 
 occurs simultaneously in a number of neighboring follicles. Diabetes, uremia, and 
 a number of other constitutional conditions predispose to the occurrence of the 
 disease. 
 
 Pathology. — The process is analogous to that in furuncle ; the staphylococci 
 excite a perifollicular inflammation which is intense enough to cause connective- 
 tissue necrosis. The dead parts are then cast off by reactive inflammation. 
 
 Diagnosis. — From a furuncle a carbuncle may be distinguished by its greater 
 size, its flatness, its multiple suppurative centers, and the fact that it is usually single. 
 Malignant pustule is not so inflamed and brawny, nor so painful, and the character- 
 istic organisms can be found in the fluids of the charbonous part. 
 
 Prognosis. — With the smaller tumors the prognosis is good ; but in extensive 
 cases, and especially in those occurring in the course of grave constitutional disease, 
 it is bad. It should be guarded in any case ; septicemia and pyemia may always 
 occur ; local spreading may erode the vessels and lead to a fatal hemorrhage, and 
 the patient may die of exhaustion from the long-continued suppurative process. 
 
 Treatment. — Any underlying disease, diabetes or Bright's, must be appropriately 
 treated. Tonics, a generous diet, alcoholics in moderation, and all other means to 
 sustain the organism must be employed. In the beginning the mercury-carbolic 
 plaster-mull is useful. Free and deep incision followed by a thorough curetting is 
 undoubtedly of benefit in some cases, but complete surgical extirpation of the tumor 
 is better. The ethyl-chloride spray may be employed to anesthetize the parts 
 before operation, and the wound should be dressed with iodoform. In moderately 
 extensive cases the old-fashioned method of poulticing to promote the separation of 
 the sloughs is perhaps as good as any. • , 
 
 THE GRANULOMATA. 
 
 The granulomata are inflammatory processes somewhat similar to the new growths. 
 They are all caused by the invasion of the integument by a microorganism, though 
 in some cases no decision has yet been reached as to its exact nature. They are: 
 (i) tuberculosis; (2) syphilis; (3) lepra; (4) mycosis fungoides; (5) lupus erythe- 
 matosus; (6) rhinoscleroma; (7) actinomycosis. 
 
COPYRIGHT BY E. B. TREAT & CO., N. 
 
 PHOTOGRAVURE 4 COLOR CO., N. Y. 
 
 LUPUS VULGARIS 
 
 PLATE XXV 
 

 
 - 
 cal factor and even th 
 
 y are small c 
 They are, however, clin 
 (2) lupus vulgari 
 
 , TUBERCULOSIS CUTIS. 
 
 . Tn 
 
 in pa >und 
 
 themuco penis, 
 
 these areas. T 
 \ to 1 inch Jrec l 
 
 i 
 occas 
 
 internal 1 
 diffic 
 
 . 
 
 
 ■ 
 
 The 
 
 - 
 
 VULGARIS. 
 
 Synonyms.- 
 
 (Ger.). 
 Definition. — A chroi 
 
 with on 
 
 Symptoms and Course* — Thi 
 
 I 
 
 1 
 
 ■ 
 
 1 
 

INFLAMMATIONS. 177 
 
 Several affections, formerly considered distinct diseases, have been found to be 
 caused by the tubercle bacillus and are really tuberculoses of the skin. The etiologi- 
 cal factor and even the elementary pathological lesion are the same in all cases. 
 They are small cell-accumulations containing varying numbers of the specific bacillus. 
 They are, however, clinically distinct. We shall consider: (i) tuberculosis cutis; 
 (2) lupus vulgaris; (3) scrofuloderma; (4) tuberculosis cutis verrucosa. 
 
 TUBERCULOSIS CUTIS. 
 
 True tuberculosis cutis is very rare, and occurs almost always from auto-infection 
 in patients suffering from tuberculosis of other organs. It is seen in the skin around 
 the mucous orifices of the body, about the mouth, nose, anus, and on the glans penis, 
 infection being directly transmitted in the saliva and the discharges that come in con- 
 tact with these areas. It appears as one or more small, shallow, painless ulcerations, 
 £ to I inch in diameter, with flat borders, sloping margins, and with bases covered 
 with reddish granulations, in which minute yellowish-white miliary nodules can 
 occasionally be seen. In exceptional instances it is primary, and no tuberculosis of 
 the internal organs has been found. The diagnosis is usually made, without much 
 difficulty, from the presence of internal tuberculosis and the finding of tubercle-bacilli 
 in the secretions. An ulcerating syphilide, the only affection with which it is liable 
 to be confounded, has infiltrated hard borders and a dirty base, and other symptoms 
 of lues are present. The prognosis depends on that of the internal lesions. The 
 best local treatment is the thorough use of the sharp curette or the Paquelin cau- 
 tery, followed by an iodoform dressing. Diluted acetic or chromic acid may also be 
 employed. 
 
 LUPUS VULGARIS. 
 
 Synonyms. — Lupus vulgaire, dartre rongeantc, scrofulide tuberculeuse (Fr.), 
 fressende Flechte (Ger.). 
 
 Definition. — A chronic local tuberculosis of the skin and adjoining mucosae, charac- 
 terized by the appearance of various-sized, reddish-brown, soft, deep-seated nodules, 
 with subsequent ulceration or interstitial absorption, and ending in cicatrization. 
 
 Symptoms and Course. — The lesion of lupus, the primary efflorescence, is char- 
 acteristic ; it is present to some extent in all forms of the disease, and the diagnosis 
 of the malady rests finally upon its discovery. It is a pinhead- to small pea-sized 
 nodule, yellowish or brownish red in color, and seated so deep in the corium that 
 usually it does not project from the surface and cannot be felt. It is composed of a 
 granulation tissue so soft that, when a pin is introduced into it, its point can readily 
 be moved about in all directions. In many cases these nodules can be seen only 
 with difficulty ; but pressure on the part with a glass pleximeter or microscopic slide 
 
178 
 
 ILLUSTRATED SKIN DISEASES. 
 
 
 
 1 
 
 
 V""* Mi- ■ 
 
 vmi 
 
 
 
 ?m 
 
 Fig. 90. — Lupus hypertrophicus. 
 
 After Lesser. 
 
 (diascopy) expresses the blood from the surrounding parts, so that the lesion appears 
 as a brown discoloration when seen through the transparent medium. 
 
 The lupoid process is varied in its manifestations, but its different names do not 
 designate distinct varieties. They are all formed by groupings of numbers of the 
 
 primary lesions, together with the results and sequelae 
 that ensue. It begins always as a red spot, in which 
 the primary nodule can be appreciated only with the 
 aid of pressure. The spot is usually small in area 
 at first, and in this stage the disease is known as 
 lupus maculosus. The nodule increases in size very 
 slowly, and it may be months before it becomes per- 
 ceptible to the touch. When it attains the size of a 
 small pea retrogressive changes, consisting of fatty 
 degeneration of the new cells, with interstitial ab- 
 sorption, begin ; there is rather abundant scaling 
 (lupus exfoliativus), and the process ends with scar 
 formation. In other cases disintegration and ulcera- 
 tion occur (lupus exedens or exulcerans). The lu- 
 poid ulcerations are rounded, shallow excavations, 
 with soft red borders, and pink, granulation-covered, 
 easily bleeding bases. Like all the other stages of 
 the disease, they are exceedingly chronic, lasting for months and years ; there is mod- 
 erate suppuration and crusting, but no pain. Not infrequently there occur papillary 
 outgrowths from the bases of the ulcers — lupus papillaris or hypertrophicus ; and 
 larger connective-tissue masses in with the scar give us lupus verrucosus. 
 
 Groups of papules aggregated together give us the form known as lupus tuber- 
 culosus. If the lesions are isolated, we have lupus discretus ; if they are spread over 
 a large area of the body, lupus disseminatus. Very frequently they spread peri- 
 pherically, the older ones breaking down and being absorbed while new nodules are 
 appearing at the periphery of the patch ; this variety is known as lupus serpiginosus. 
 Of especial importance, and pathognomonic, is the appearance of new nodules in the 
 scars that have resulted from the lupoid process. 
 
 The lupoid nodules are deep-seated in the corium, and the subcutaneous tissue 
 is frequently affected. When the skin lies over cartilage, as on the nose and ears, 
 the perichondrium and the cartilage itself are often involved in the destructive pro- 
 cess, but the bones are rarely attacked. The disease may affect any part of the body, 
 but is most frequent upon the face, and especially upon the nose ; and here the process 
 is most commonly of the tubercular variety. In bad cases of long standing it leads 
 to terrible deformity : the cartilages of the ear and the alae nasi may be destroyed ; 
 the anterior nares may be entirely closed up with cicatricial tissue; ectropion and 
 other deformities may result from cicatricial contraction ; a circle of ulcerations may 
 
TYPOGRAVURE. 
 
 COPYRIGHT, 1902, BY E. B. TREAT 4 CO.. N. Y. 
 
 SCROFULODERMA. 
 
 LUPUS HYPERTROPHICUS. 
 
 PLATE Llll. 
 
INFLAMMATIONS. 
 
 179 
 
 surround the mouth ; while the rest of the visage is covered with cicatricial tissue. 
 On the trunk the malady is usually extensive, very chronic, and of the serpiginous 
 variety. On the legs the lesions are commonly of the warty, hypertrophic form. 
 The malady is very rare on the scalp and genitals. 
 
 The mucosae are usually affected secondarily, from extension of the disease from 
 the skin around one of the mucous orifices ; but it may occur primarily on the gums, 
 on the tongue, inside the nose, on the con- 
 junctivae, and even in the larynx. Here the 
 characteristic lesion is rarely seen ; instead 
 of it we have shallow ulcerations or patches 
 of papillary excrescences. In the larynx 
 the cartilages, and more especially the epi- 
 glottis, are frequently destroyed. 
 
 Lupus begins in childhood, and may last 
 for fifteen or twenty years. As a rule, even 
 in bad cases, the general health is not in- 
 terfered with. It is seldom associated with 
 internal tuberculosis, even when the lupoid 
 ulcerations have invaded the buccal cavity. 
 In the circumscribed cases but little scar- 
 ring, and that superficial, results. 
 
 Etiology. — The cause of the disease is 
 the presence of the tubercle-bacillus in the 
 skin. This was first proved to be the case 
 by Koch, and it has been confirmed by the 
 experimental production of both local and 
 general tuberculosis with the material de- 
 rived from the lupus nodule. It seems probable that in a good many cases the 
 disease is caused by direct inoculation, infection being gotten from kissing persons 
 affected with tuberculosis of the lungs. For some unknown reason it is much 
 commoner in females than in males. It is very rare before the third year of life, 
 though cases have been reported in infants; and it seldom originates after puberty. 
 
 Pathology. — The lupus nodule is a granuloma, due to the irritation caused by 
 the presence of the tubercle-bacillus and its products. It is a true miliary tubercle, 
 a round-cell collection appearing first along the vessels of the cutis. The cells always 
 undergo necrobiosis and fatty and cheesy degeneration; organization never occurs. 
 The tubercle-bacilli are few in number and hard to find ; they are most readily 
 demonstrated in the new nodules on the margins of the lupoid patch. 
 
 Diagnosis. — Lupus usually presents a characteristic and readily recognizable 
 picture, but in some cases the diagnosis is a matter of difficulty. It begins in youth ; 
 has a very chronic course ; shows the characteristic nodules either to the unaided 
 
 Fig. 91. — Lupus vulgaris 
 After Lesser. 
 
180 ILLUSTRATED SKIN DISEASES. 
 
 eye or by means oL diascopy ; has painless ulcerations, with soft borders and exu- 
 berant granulations ; is situated most frequently upon the face, more especially on 
 the nose; destroys the cartilages, but does not affect the bones; and shows a con- 
 tinuous production of fresh lesions, sometimes in the scars of the formerly dis- 
 eased area. It most frequently requires to be differentiated from syphilis of the 
 ulcerative and gummatous forms, lupus erythematosus, tuberculosis cutis, and cancer. 
 Syphilis is comparatively rapid in its development, covering in weeks an area that 
 lupus takes years to occupy ; its papules are hard, projecting, and copper-colored ; 
 its ulcers have elevated and indurated edges, sunken dirty bases, and are painful; 
 its scars are at first pigmented; the bones are frequently affected; it usually begins 
 after puberty ; and other signs of syphilis are generally present. Lupus erythema- 
 tosus has a bright-red border, a slight central atrophy, no ulceration, and the char- 
 acteristic seborrheal scales with projecting plugs on their under surfaces. The ulcers 
 of tuberculosis cutis are covered with weak, flabby granulations, occasionally -show 
 visible miliary tubercles, and generally coexist with tuberculosis of the internal 
 organs. Carcinomatous ulceration should not be mistaken for lupus ; its extreme 
 hardness, its elevated and indurated edges, its pain, the involvement of the lymphatic 
 glands, together with its almost invariable occurrence in old age, being characteristic. 
 It does not seem likely that eczema, with its secretion, absence of ulceration and 
 scarring, or rosacea, with its dilated vessels, comedones, and non- destruction of 
 tissue, can be confounded with the disease. 
 
 Prognosis. — Lupus does not endanger life ; but its intractability, and the deformi- 
 ties caused by the destruction of large areas of the skin, more especially upon the 
 face, together with those caused by the inevitable contracture of the scars, render 
 the prognosis bad. We are entirely unable to prevent the fresh appearance of nod- 
 ules. Besides this, every case harbors the tubercle-bacillus, and the possibility of 
 the infection of important organs or the system at large must not be lost sight of. 
 
 Treatment. — General treatment is of little use, since most of these patients enjoy 
 good health. Creosote and cod-liver oil may be given, as for internal tuberculosis. 
 Good effects, but no cures, have been gotten from the use of thiosinamine, recom- 
 mended by H. von Hebra, a few minims of a 15-per-cent. alcoholic solution of the 
 drug being injected between the shoulder-blades daily. 
 
 Local treatment consists in endeavoring to procure the absorption of the new 
 tissue or in destroying and removing it. The first may be tried in the localized and 
 non-ulcerative forms of the disease, the parts being covered with the salicylic-acid- 
 creosote plaster-mull, or the mercurial plaster, which may be kept in place by means 
 of glyco-gelatin (No. 4, p. 43), and should be changed daily. Good results, with 
 comparatively little scarring, are sometimes obtained in this way. But in most cases i 
 especially in the ulcerative and hypertrophic forms of the disease, it is best to pro- 
 ceed at once to the destruction of the granulomata. The most radical method is 
 complete excision, followed by any plastic operation that may be necessary; it is 
 
COPYRIGHT, BY E. B. TREAT & CO. , N. Y. 
 
 PHOTOGRAVURE 4 COLOR CO. , N. Y. 
 
 LUPUS VULGARIS 
 
 PLATE XXV! 
 
o on] 
 
 iould be very thoroi ieed 
 
 no fear of destr r uon 
 
 10-per-cent the 
 
 aiocaute ly method of de 
 
 ..^tion of hypertn | 
 hap; rice. Scarificatk 
 
 ■ 
 
 ita. 
 ■ 
 
 a of 
 caus* ir ply 
 
 pointed, may be dug into ea 
 still 
 
 ,ults; it should be rubb the part b, or 
 
 be used -..lied on 
 
 >:y minu 
 Ten-per-cent. p> 
 into a sc 
 
 re to 
 
 I 
 
 10 
 
 . 
 
 
 Which e 
 
 i ■ 
 
 SCROFULODF 
 
 c I 
 
 - 
 
INFLAMMATIONS. 181 
 
 applicable, however, to only a few cases. Much more generally useful is curetting, 
 which should be very thoroughly done, preferably under anaesthesia. There need 
 be no fear of destroying the much more resistant healthy tissue. The application 
 of a io-per-cent. sublimate spirit should follow the operation. The Paquelin or the 
 galvanocautery is a ready method of destroying the nodules, but it is very liable 
 to be followed by the formation of hypertrophic scar tissue or false keloid, as has 
 happened in my own experience. Scarification, followed by the application of 
 mercurial plaster, is less efficacious, but is not open to the same objection. 
 
 Chemical substances are most frequently resorted to to destroy the granulomata. 
 They should be used on the end of a wooden toothpick wrapped with a little cotton, 
 which must be dug into each lupus nodule. Pure carbolic acid, or a solution of 
 caustic potash, I to 2 of water, may be used. The nitrate-of-silver stick, sharply 
 pointed, may be dug into each visible nodule ; this is painful, but effective, and is 
 still the favorite method with many dermatologists. Lactic acid has given very 
 good results; it should be rubbed vigorously into the part by means of a swab, or 
 it may be used in ointment form (No. 92, p. 181), applied on lint to the part for 
 twenty minutes every other day. It acts better if scarification precedes its use. 
 Ten-per-cent. pyrogallol ointment (No. 93, p. 181) will transform the lupoid tissue 
 into a soft, dark mass, and destroy it. Very lately the use of cinnamonic acid has 
 been highly recommended. One or two drops of the solution (No. 94, p. 181) are to 
 be injected with the hypodermic syringe into each lupus nodule, especially at the 
 margins of the patch ; about ten injections can be given at a sitting. 
 
 No. 92. Lactic-acid Ointment. No. 93. Pyrogallol Ointment, No. 2. 
 
 FJ: Ac. lact. .... 1 part R Pyrogallol .... 3 parts 
 
 Adip. lanae . ... 9 parts Adip. lanas . . . 10 " 
 
 Petrolati . . . . 20 " 
 
 No. 94. Cinnamonic-acid Injection. 
 
 R Ac. cinnamyl 
 
 Cocaine mur. . . aa. 1 part 
 
 Spirit, vini . . . 18 parts 
 
 Whichever method is selected, cocaine in io-per-cent. solution externally or 
 i-per-cent. subcutaneously, or the ethyl-chloride spray, should be employed when 
 no general anesthetic is used. 
 
 SCROFULODERMA. 
 
 Synonyms. — Lichen scrofulosorum, lichen lividus, acne cachecticorum, gommes 
 scrofulenscs (Fr.). 
 
 All the so-called " scrofulous " affections are now regarded as either tubercular 
 
182 ILLUSTRATED SKIN DISEASES. 
 
 or syphilitic in nature. The scrofulodermata are local tuberculoses of the skin, 
 closely related to true tuberculosis of that organ and to lupus vulgaris. At least 
 three clinically distinct forms are to be described under this heading, according 
 to whether the tuberculous nodule remains a small, circumscribed, non-ulcerating, 
 and non-degenerating tumor, or whether it develops into larger infiltrations that 
 end in degenerative and suppurative processes. 
 
 i. Scrofuloderma papulosum, lichen scrofulosorum, or lichen lividus. This form 
 of dermal tuberculosis is rare in this country; Hyde says it does not occur; yet I 
 described and figured a case in the " Journal of Cutaneous and Venereal Diseases " 
 as long-ago as May, 1886. It appears as pinhead- to lentil-sized, flattish, slightly 
 elevated, pale or livid red papules, moderately resistant, and mostly capped with a 
 minute scale. They are arranged in groups of varying size, more rarely in rings, 
 and there may be a single group or a number of them scattered over the body. 
 Each single papule corresponds to a hair-follicle, and many of them are pierced by 
 a minute hair; the skin between them is normal. The seat of the groups is most 
 often upon the trunk, more especially on the chest, abdomen, and back ; only in old 
 and extensive cases are the limbs invaded. The malady occurs in young individuals 
 only ; it is very chronic, the individual lesions lasting a long time, and successive crops 
 may prolong the disease for years. The papules disappear by absorption, leaving 
 no trace behind, or they may go on to develop into the pustular form of the disease. 
 They cause no subjective symptoms, and are sometimes discovered only accidentally. 
 
 2. Scrofuloderma pustulosum or acne cachecticorum is similar in its location 
 and general symptomatology to the papular form, and probably follows it in most 
 cases. The pustules rupture or dry up into crusts, giving rise to very sluggish, 
 ecthyma-like ulcerations. 
 
 3. Scrofuloderma ulcerosum, scrofuloderma tubero-ulcerosum, or tubercular 
 gummata. Here the tubercular mass forms a hard, painless, movable, nodular 
 infiltration of varying size, deep-seated in the skin, which slowly turns into a cold 
 abscess. The process may stop at any stage and the mass undergo fatty and cheesy 
 degeneration, and even calcification; but it usually goes on to softening. The skin 
 gets thin, red, and adherent, and there appear one or more perforations, through 
 which a thin, purulent, detritus-containing material trickles out. Finally the integu- 
 ment gives way, and a painless ulcer, with lax, thin, undermined edges, an uneven 
 base covered with pale, flabby, yellow granulations, and running a very sluggish 
 course, is left behind. Crusts may be formed by desiccation of the secretion of the 
 ulcer, and under these the destruction may extend far into the underlying tissues. 
 Wolff records a case in which the frontal bone was perforated so that the pulsating 
 dura could be seen at the bottom of the ulcer. One or several of these tumors or 
 ulcers may be present. They finally heal with a flat, soft scar, which is depressed 
 where bone or lymphatic- gland tissue has been destroyed. This is by far the com- 
 monest form of scrofuloderma ; it occurs usually in the young, and may last for years. 
 
INFLAMMATIONS. 183 
 
 Etiology. — The cause of these varying phenomena of cutaneous disease is the 
 presence of the tubercle-bacillus in the skin. We do not know the special conditions 
 that determine the occurrence of one or other form of these tubercular diseases. 
 Negroes seem to be predisposed to them ; and exposure to cold and wet, and want 
 of pure air and proper food and exercise, seem to favor their development. 
 
 Pathology. — In scrofuloderma papulosum we are dealing with a tubercular peri- 
 folliculitis ; the cell-accumulation is in the corium, more especially around the hair- 
 papillae. Jacobi and Neisser have found both giant cells and tubercle-bacilli in 
 the papillae. In the more extensive forms of tubercular infiltration they have also 
 been found, but only in small numbers. 
 
 Diagnosis. — The lesion in the papular form of the disease is characteristic, one 
 or more groups of discrete, painless papules, occurring in youth, of chronic course, 
 and presenting no subjective symptoms. A papular syphiloderm, with which it may 
 be confounded, has copper-colored, hard papules arranged in circles, appears on the 
 extremities also, and is almost always accompanied by other symptoms of the disease. 
 Lichen planus has polygonal, purplish, flat-topped papules, with a central depres- 
 sion. A papular eczema is more diffused, has vivid red acuminate papules, is accom- 
 panied by itching, and some vesicles will be always found. 
 
 The pustular scrofuloderm must be differentiated from the pustular syphiloderm. 
 In the latter the infiltration is greater, the course is more rapid ; it is found oftenest 
 on the face, more especially upon the forehead ; and other luetic lesions are generally 
 present. Acne vulgaris is found on the face and back ; it is acutely inflammatory, 
 and accompanied by comedones. 
 
 The ulcerative scrofuloderm may be confounded with the gumma. But gum- 
 mata occur mostly over bones, especially the sternum and tibia; they are harder, 
 and run an acuter course ; the gummy discharge is characteristic ; they react to 
 mercury and the iodide, of potash ; and other lesions of the disease can usually be 
 found. After ulceration has occurred the scrofuloderma may be distinguished from 
 the ulcerative syphilide by the sharp edges, extensive infiltration, pain, the circular 
 or kidney shape, the good general health, the reaction to antiluetic treatment, etc., 
 that characterize the latter. For the distinction of lupus vulgaris the exuberant 
 granulations and the characteristic lupus nodules will suffice. 
 
 No. 95. Crocker's Lead Thymol Ointment. 
 
 fy Liq. plumbi subacet. . . 3 parts 
 Thymol 1 part 
 
 Petrolati . . . .100 parts 
 
 Prognosis. — This is good; the scrofulodermata can usually be cured by appro- 
 priate treatment. The patient is always liable, however, to infection of the internal 
 organs or the general system. 
 
184 ILLUSTRATED SKIN DISEASES. 
 
 Treatment. — In all cases the internal treatment is of the greatest importance, 
 and should be essentially the same as for other tuberculoses. A nourishing diet, 
 good hygienic surroundings, fresh air, and more especially sea air, with salt-water 
 baths, are required. Cod-liver oil and creosote are useful. Shoemaker recommends 
 the chlorate of potash. In scrofuloderma papulosum Neisser has used chrysarobin 
 locally with remarkable effect. The treatment originally recommended by Hebra, 
 cod-liver oil internally and externally, is as good as any that we can employ ; but 
 it is disagreeable, since the skin must be kept soaked with the oil. Crocker recom- 
 mends in its place a subacetate-of-lead ointment (No. 95, p. 183), cod-liver oil being 
 used internally. The treatment of the pustular is very much the same as that of 
 the papular form. Cod-liver oil or the iodoform plaster may be used locally. In 
 the tubercular form, if the glands are softening and threaten to break down, arsenic 
 should be given internally (No. 6, p. 46, No. 81, p. 158). Locally, if there is no 
 fluctuation, a 10-per-cent. iodoform salve or the collemplastrum hydrargyri should 
 be used. If fluctuation is distinct we can prevent unnecessary destruction of the 
 skin by incision. A thorough curetting, followed by an iodoform gauze tampon, is 
 the proper method to pursue. When ulceration has occurred the overhanging edges 
 of skin should be cut away and the surface dressed with iodoform. If the granula- 
 tions are exuberant they may be cut down with the nitrate-of-silver stick, or a I -per- 
 cent, nitrate-of-silver salve, followed by pressure. 
 
 TUBERCULOSIS CUTIS VERRUCOSA. 
 
 Synonyms. — Verruca necrogenica, post-mortem, anatomical, or dissection tuber- 
 cle, Leiclientuberkel (Ger.). 
 
 Definition. — A local tuberculosis of the skin, appearing as a vesico-pustular erup- 
 tion or a warty outgrowth, usually situated on the hands, and resulting from direct 
 inoculation with the tubercular virus. 
 
 Symptoms and Course. — At the site of an abrasion or wound there appear one or 
 more vesico-pustules, situated on an infiltrated purplish area. The pustules dry up 
 or are ruptured, and there begins a slow hypertrophy of the papillae at the affected 
 point, which develop into a livid red warty growth, often fissured, and situ- 
 ated on an infiltrated area of skin. Its progress is extremely slow, and it may 
 persist for many years. Finally large, erythematous, infiltrated masses may be 
 formed, with hypertrophic, warty, and fissured areas in their centers. Retrogressive 
 changes occur spontaneously in the course of time, and a thin stellate or punctiform 
 scar is left behind. The affection occurs in persons whose occupations bring them 
 in contact with dead animals or their products, — cooks, butchers, hostlers, patholo- 
 gists, etc., — as well as in those affected with tuberculosis of the lungs, and their 
 attendants. It appears almost always on the backs of the fingers and hands, these 
 
COPYRIGHT, BY E. B. TREAT & CO. . N. Y. 
 
 PHOTOGRAVURE 4 COLOR CO., N. Y. 
 
 SYPHILODERMA PAPULOSUM 
 
 PLATE XXXVII. 
 

 
 the parts 
 
 i 
 
 because 
 the grow 
 
 - 
 Etfolot 
 
 ease : this has 
 been den 
 
 I ed 
 pathologically 
 by inocu- 
 lation experi- 
 ments on 
 
 
 
 Diagnosis.- 
 
 ficientl 
 
 Prognosis. - 
 that 
 
 Treatment. — Tb 
 effect! 
 
 tinued applica .ercuriai 
 
 and disappearance of la: 
 
 e, causii 
 
 
 
 :i 
 
i coto 
 
 SYP 1 JLOSUM 
 
 
INFLAMMATIONS. 
 
 185 
 
 being the parts most exposed to local infection. In rare cases erysipelas, septicemia, 
 pyemia, or gangrene occurs in connection with the process. The malady is rarely 
 reported, possibly because of its slight extent at first and very slow progress, and also 
 because many cases occur among physicians who do post-mortem work, who destroy 
 the growth 
 themselves. 
 
 Etiology. — 
 
 Infection with 
 the tubercle- 
 bacillus and its 
 virus is the 
 cause of the dis- 
 ease ; this has 
 been demon- 
 strated both 
 pathologically 
 and by inocu- 
 lation experi- 
 ments on 
 
 animals. 
 
 Pathology. — 
 
 The diffuse in- 
 filtration is 
 granulomatous 
 
 in character, the papillary outgrowth and hyperkeratosis being secondary. Giant 
 cells and the characteristic microorganisms have been found by Baumgarten and 
 others. 
 
 Diagnosis. — Its occurrence on the hands in persons whose occupations render 
 them liable to such infection or who suffer from tuberculosis of the lungs, and the 
 slow progress of the warty growth, sufficiently distinguish the disease. . 
 
 Prognosis. — This is very good, provided none of the accidental complications 
 that are mentioned above occur. 
 
 Treatment. — This consists in the complete removal of the growth, which is readily 
 effected, especially in the early stages. It may be done with the Paquelin or the 
 galvanocautery, or with the curette, or by means of the mineral acids. The long- 
 continued application of mercurial plaster will cause the gradual melting down 
 and disappearance of larger growths. A good plan is to employ a strong salicylic- 
 acid plaster for a time, causing the exfoliation of a part of the mass, followed up by 
 the vigorous use of nitric acid. 
 
 Fig. 92. — Tuberculosis cutis. 
 
 From photograph by the author. 
 
186 ILLUSTRATED SKIN DISEASES. 
 
 SYPHILIS. 
 
 Syphilis, like the other granulomata, may affect any organ of the body ; but it is 
 especially liable to show itself in the skin, and most cases of the disease come within 
 the province of the dermatologist. It is essentially wrong to classify the malady as 
 a venereal one. The virus of syphilis is non-volatile and cannot be transmitted 
 at a distance ; prolonged contact with it, and probably the occurrence of a lesion of 
 the skin or mucosae, are necessary for its implantation. These conditions occur most 
 frequently during sexual congress, and hence the point of entrance of the virus is 
 situated in most instances upon the sexual organs. But in a proportion of cases so 
 large as to be estimated at 20 per cent, by some authorities it is seated elsewhere, and 
 is transmitted by other than sexual acts ; and in another smaller proportion of cases 
 it is gotten by heredity. Non-venereal syphilis, the syphilis insontium of Bulkley, 
 is of sufficiently frequent occurrence to remove the disease from the small category 
 of exclusively venereal maladies. 
 
 There are many points of resemblance between lues and the infectious granulo- 
 mata on the one hand, and the exanthemata on the other. Like tuberculosis and 
 leprosy, syphilis is a locally contagious disease, gotten always and only by the direct 
 transfer of a definite virus, which increases enormously in quantity during the 
 course of the malady, and runs a definite course with appropriate symptoms. And, 
 like the acute exanthemata, syphilis has its regular period of incubation, its point 
 of primary invasion, its regular succession of phenomena, and its sequelae. It is 
 really a chronic exanthematous disease. 
 
 These facts are explicable only on the supposition that, like the maladies of the 
 other two classes, syphilis is caused by the growth in the body of a living organism. 
 Such a one has, indeed, been described by Lustgarten and others ; but positive 
 proof of the exact nature of the etiological factor of luetic disease is still wanting. 
 
 Ricord was the first to classify the phenomena of the disease chronologically ; 
 and, although we have learned that his order is not an invariable one, it is suffi- 
 ciently accurate to be of use, and has been generally accepted. After a period of 
 primary incubation of from four to six weeks, during which the patient, though 
 infected, shows no sign of disease, there begins the first or primary stage of the 
 malady, marked by the appearance of the chancre or sclerosis at the site of inocula- 
 tion of the virus, together with swelling of the adjacent lymphatic glands. This 
 stage lasts some four to eight weeks. Then occurs another period of quiescence of 
 from six to twelve weeks, the period of secondary incubation, during which the 
 patient is apparently well, save perhaps for the presence of the remains of the pri- 
 mary lesion. This is followed by the secondary stage of the disease, marked by 
 general constitutional symptoms and fever, swelling of all the lymphatic glands of 
 the body, generalized eruptions, mucous patches, cephalalgia, angina, etc. It lasts 
 for a varying number of months, and is followed by a third period of quiescence of 
 
INFLAMMATIONS. 
 
 187 
 
 varying length. Finally there occurs in many cases a third stage, lasting for an 
 indefinite number of years, in which occur the sequelae of the disease — the more cir- 
 cumscribed and deeper-seated eruptions, gummatous and ulcerative lesions, and the 
 affections of the bones and the internal organs. 
 
 Not all cases, however, exhibit this regular succession of stages separated by 
 periods of quiescence. The tertiary stage may be entirely absent, or its character- 
 istic lesions may occur very early in the course of the malady. The first and sec- 
 ond stages, however, are never absent in any case of the disease. 
 
 We are only concerned here with those phenomena of syphilitic disease that 
 occur on the skin and the mucosas, and we shall consider: I. The chancre; 2. The 
 macular syphiloderm ; 3. The papular (squamous) syphiloderm ; 4. The pustular 
 syphiloderm ; 5. The tubercular syphiloderm; 6. The gummatous syphiloderm; 7. 
 The ulcerative syphiloderm ; 8. Syphilis of the hair and nails ; 9. Hereditary syphi- 
 lis, which differs in some important respects from the acquired variety, and demands 
 separate consideration. 
 
 CHANCRE. 
 
 Synonyms, — Hard chancre, initial lesion, sclerosis, ulcus durum. 
 
 Definition. — The primary lesion of syphilis, appearing at the point of inoculation 
 of the virus of the disease. 
 
 Symptoms and Course. — A chancre is not a definite lesion, since it may appear 
 as a papule, a vesicle, an erosion, or an ulceration ; but it is a disease entity, because 
 the distinctive symptoms of induration and 
 adenopathy always accompany it, and con- 
 stitutional syphilis always follows it. It 
 appears, on the average, twenty-one days 
 after inoculation ; but the limits of the 
 period of primary incubation are wide, 
 and it may show itself from ten days to 
 ten weeks after the infection. In its com- 
 monest form it begins as a minute desqua- 
 mating papule, and grows to be a moder- 
 ate-sized, flat tubercle. In many cases it 
 is an insignificant lesion, and, especially 
 when located inconspicuously, as in the 
 vagina, it may never attract the patient's 
 attention. The skin over the papule may 
 be merely reddened, or it may be eroded 
 or ulcerated ; and the ulceration may be 
 shallow, with a smooth, shiny base and 
 scanty, viscid secretion, or it may be deep 
 
 and covered with diphtheritic sloughs and From photograph by the author. 
 
188 
 
 ILLUSTRATED SKIN DISEASES. 
 
 fragments of necrotic tissue. In rarer cases the lesion may be vesicular or even 
 bullous from the beginning. 
 
 In almost all cases, however, there occurs after a time in the lesion a hardness or 
 induration that is typical and has given it a name. It varies in density, but is 
 usually cartilaginous to the touch. It may be so small in amount as to feel like a 
 thin sheet of wax, " let in," as it were, into the base of the lesion; or it may be so 
 extensive and thick as to be visible to the naked eye when the tissues are moved. 
 It may be quite small, \ of an inch in size, or it may be i^- inches or more in diameter. 
 It is the real lesion, the chancrous tumor itself; the appearance of the surface change 
 being determined in each case by other and usually adventitious circumstances. 
 
 A second and characteristic concomitant of the chancre is the hard, stony, pain- 
 less swelling of the lymphatic glands belonging to the tissue involved. A third one 
 is the invariable occurrence, after a period of secondary incubation of some weeks, 
 of some of the phenomena of constitutional syphilis. 
 
 The seat of chancre is most often upon the genitals, since those are the parts 
 most exposed to contagion. It is common upon the glans penis, especially around 
 
 the meatus, on the sulcus and frenum, and on the 
 prepuce ; in the female it is most often seen upon 
 the labia. But it is not infrequently seen on the 
 thighs, lips, nipples, fingers, and other parts of the 
 body. Its location depends upon accident, and 
 I have observed it upon the forearm of a nurse 
 who carried around a half-clad syphilitic child, 
 and on the neck of a woman as the result of 
 the over-affectionate kiss of a long-absent hus- 
 band. 
 
 The chancre is generally a single lesion, but 
 sometimes there are two or more, usually on con- 
 tiguous parts. Its termination is in resorption ; 
 the papule or ulceration soon disappears, but it 
 may be months or years before the last traces of 
 the induration vanish. A pigmented spot, more 
 rarely a scar, is left behind. Very characteristic is 
 the almost entire absence of pain and tenderness, 
 except when the ulceration is extensive and the 
 sclerosis is complicated with other infection. Other 
 complications are, in the first place, chancroid, 
 which is frequent and often obscures the diagnosis ; phimosis and paraphimosis ; gan- 
 grene ; and, in debilitated subjects, phagedena. 
 
 Etiology. — The cause of the chancre is the same as yet unknown living organism 
 that causes the general disease. 
 
 Fig. 94. — Exulcerated chancre. 
 
 From photograph by the author. 
 
COPYRIGHT BY E. B. TREAT &. CO. , N. Y. 
 
 PHOTOGRAVURE i. COLOR CO., N. Y. 
 
 SYPHILODERMA PAPULO-PUSTULOSUM 
 
 PLATE XXXIII 
 

 
 
 Pathology. — The chanc 
 cell infiltration, very similar 
 
 The cause of the peculiar indu 
 claim that it is due to an excessive ( 
 incloses and subdivides the cell-ma 
 Diagnosis. — Although its initial 
 the full '■ chancre pos 
 
 a suspicious integr- 
 ation and r 
 induration >tic - 
 
 retion - ; but, above all, th 
 stony, painless polygangliar lymphadeni- 
 tis, progres \ idually from the lym- 
 phatic glands nearest to the lesion to mo 
 distant ones until those of the entice 
 are involved— all these symptoms are char- 
 acteristic. But the diagnosis from chan- 
 croid is often difficult and s ^es im- 
 possible. This is especially the case 
 udicious use 
 • uncertain natr 
 mal 
 
 with undermined ed 
 tion 
 
 painful 
 
 have occurred, and the • 
 
 upon the patient at one and 
 
 teristics of the purely I 
 
 the infecting chanc 
 
 appearing as circula short-lived 
 
 I accompanied neither by the indurati 
 
 inflamed by i 
 In view isiderati: 
 
 
 ! 
 
 terizi 
 inter! 
 
 

 ■LODERM ">UM 
 
 PLATE 
 
INFLAMMATIONS. 
 
 189 
 
 Pathology. — The chancrous tumor is a granuloma of the cutis, a dense round- 
 cell infiltration, very similar to those that characterize the later stages of the disease. 
 The cause of the peculiar induration is still a matter of doubt. Some authorities 
 claim that it is due to an excessive development of the fibrillar connective tissue that 
 incloses and subdivides the cell-mass. 
 
 Diagnosis. — Although its initial appearance varies greatly, as has been stated, 
 the fully developed chancre possesses fairly well-marked features. Its advent two 
 or three weeks after a suspicious inter- 
 course ; the tumor-like elevation and the 
 induration ; the absence of pain and notice- 
 able secretion ; but, above all, the indolent, 
 stony, painless polygangliar lymphadeni- 
 tis, progressing gradually from the lym- 
 phatic glands nearest to the lesion to more 
 distant ones until those of the entire body 
 are involved — all these symptoms are char- 
 acteristic. But the diagnosis from chan- 
 croid is often difficult and sometimes im- 
 possible. This is especially the case when, 
 by the early and injudicious use of caustics 
 on a sore of uncertain nature, an inflam- 
 matory induration has been set up that 
 may closely resemble the specific one. 
 Chancroid, indeed, is usually multiple, be- 
 ginning as a round, deeply cut ulceration 
 with undermined edges ; it has an incuba- 
 tion of a few hours or a day or so, with the 
 painful suppurating buboes, and is auto-inoculable. But a mixed infection may 
 have occurred, and the chancrous and chancroidal virus may have been inoculated 
 upon the patient at one and the same time ; and a sore that presents the charac- 
 teristics of the purely local lesion may in the course of time develop all the signs of 
 the infecting chancre. Herpes of the genitals also, though usually multiple, and 
 appearing as circular, shallow, short-lived erosions, unconnected with intercourse, 
 and accompanied neither by the induration nor by the characteristic glands, may be 
 so inflamed by irritating applications as to look not unlike an initial lesion. 
 
 In view of these considerations, and on account of the great practical importance 
 of a decision as to the presence or absence of syphilis, it is well to make a probable 
 and not a positive diagnosis of any suspicious lesion of the genitals until at least the 
 ordinary period of incubation of the systemic disease has passed ; to treat with cau- 
 terizing agents only such chancroidal-looking sores whose extension demands active 
 interference ; and to treat all other suspicious lesions with mild local measures alone 
 
 Fig. 95.— Chancre of the lip. 
 
 From photograph by the author. 
 
190 
 
 ILLUSTRATED SKIN DISEASES. 
 
 until the appearance or non-appearance of definite signs of systemic infection — poly- 
 adenitis, angina, exanthem, etc. — settles the question. 
 
 Prognosis. — A chancre is a lesion of small importance in itself, since it rarely 
 causes discomfort, permanent injury, or deformity. The location or mode of origin 
 
 of the lesion has no connection with the 
 severity of the systemic disease. There 
 are, however, reasons for believing that the 
 smaller the sclerosis, and the freer it is from 
 ulcerative and other complicating processes, 
 the less severe the subsequent manifesta- 
 tions will be. 
 
 Treatment. — Prophylaxis consists in a 
 search for lesions of the skin and mucosae 
 after a suspicious contact, their cauteriza- 
 tion when found, and the use of cleansing 
 and disinfectant solutions ; above all, of 
 course, in the avoidance of intercourse or 
 contact in any form with known syphilitics. 
 When the chancre has appeared, its ex- 
 cision with the knife or its destruction with the Paquelin cautery has proved to be 
 of no use at all. The mercurial collemplastrum should be put on the sclerosis and 
 on the indurated glands, or the ordinary mercurial plaster or ointment may be em- 
 ployed ; and it should be continued until the hardness has entirely disappeared. 
 If ulceration occurs, calomel, iodoform, or aristol may be used locally as a powder. 
 Constitutional treatment should only be begun when the diagnosis is definitely set- 
 tled by the appearance of secondary symptoms. 
 
 Fig. 96. — Chancre of the meatus. 
 
 From photograph by the author. 
 
 SYPHILODERMA. 
 
 Synonyms. — Dermatosyphilis ; syphilis cutanea ; syphilides. 
 
 Definition. — Macular, papular, vesicular, pustular, squamous, gummatous, or 
 ulcerative eruptions, affecting the skin and its adnexa and the mucosae, and caused 
 by systemic infection with the virus of syphilis. 
 
 Symptoms and Course. — Although cutaneous syphilis appears in a variety of 
 forms, the lesions in each case are generally of one kind only, and polymorphism 
 like that of eczema does not occur. Many of them bear a close resemblance to 
 other diseases, and the question of differential diagnosis is often a most important 
 one. The manifestations are not, as a rule, accompanied by general symptoms or 
 marked subjective sensations. A fever, sometimes quite high, with headache, ano- 
 rexia, and muscular pains, may usher in the early secondary eruptions ; but it is 
 usually entirely absent. The deeper ulcerative lesions are sometimes painful, 
 
INFLAMMATIONS. 
 
 191 
 
 but more often the patient has no complaint to make, and the eruption is sometimes 
 discovered accidentally. With the early syphilodermata we usually find the sclero- 
 sis or its remains, the local and general adenopathy, the angina, the headache, etc. 
 With the later ones there are often the osteocopic pains, the permanent alopecia, and 
 the cicatricial remains of previous lesions. The lesions themselves may be macular, 
 papular, tubercular, vesicular, pustular, squamous, bullous, gummatous, or ulcerative 
 in form; occasionally two or more varieties are present at one and the same time. 
 They are found anywhere on the body, but some of them show preferences for cer- 
 tain locations. The early 
 eruptions are more or less 
 general and superficial, and 
 are most commonly macular 
 or papular. The erythema- 
 tous eruptions are usually 
 most plainly seen upon the 
 trunk ; the papular ones are 
 most prominent about the 
 genitals ; the tubercular forms 
 reach their greatest develop- 
 ment upon the face and neck ; 
 and the papulo-squamous 
 lesions are commonest upon 
 the palms and soles. In all 
 forms the lesions show a tend- 
 ency to assume a circular, 
 semicircular, or crescentic 
 shape ; this is most marked, 
 however, in the later circum- 
 scribed manifestations. In all 
 save the macular forms the 
 lesions are sharply limited in- 
 filtrations, elevated and mod- 
 erately hard to the touch. 
 Their color is peculiar. At 
 
 first bright red, "they soon fade into a dull brownish red or coppery hue, which is 
 commonly likened to the color of lean ham. These infiltrations are incapable of 
 higher organization ; they finally retrogress, and disappear by fatty degeneration and 
 absorption or ulceration. In the later localized forms the infiltrations break down 
 and ulcerate in their central older portions while the infiltration is still progressing 
 at the periphery ; and thus crusts of varying thickness covering ulcers with hard' 
 infiltrated margins are formed. 
 
 Fig. 97. — General macular syphiloderm. 
 From photograph by the author. 
 
192 
 
 ILLUSTRATED SKIN DISEASES. 
 
 i. Syphiloderma maculosa, roseola s. erythema syphiliticum, the erythematous 
 or macular syphilide, is the commonest general cutaneous manifestation of the dis- 
 ease, and is sometimes the only one. It 
 appears from the third to the tenth week 
 after the advent of the chancre, and, 
 being unaccompanied by itching, pain, or 
 desquamation, is often not noticed by the 
 patient. It shows itself as lentil- to 
 finger-nail-sized, non-elevated, and usu- 
 ally discrete spots ; but sometimes the 
 eruption is more or less confluent, giving 
 rise to a general mottling of the integu- 
 ment. Its seat is on the trunk, and it is 
 especially noticeable upon the back ; the 
 face nearly always escapes. Its color is 
 at first pale rose red, and fades away 
 completely under pressure ; but later it 
 assumes a darker hue, and yellowish- 
 brown stains are left behind when it 
 passes away. Occurring with it are usu- 
 ally the polyadenitis, the angina, the 
 defluvium capillorum, and other early 
 signs of the disease, together with the 
 remains of the sclerosis. A later macu- 
 lar eruption, the roseola figurata or an- 
 nulata, also occurs, in which the spots are 
 larger and often arranged in crescentic 
 or ring shapes. Circumscribed or con- 
 fluent reddened areas occur on the mu- 
 cosae coincident with the roseola. 
 
 2. Syphiloderma papulosa, the papu- 
 lar svphilide, occurs with large and with 
 small papules, forming two varieties of 
 the exanthem sufficiently different to 
 require separate descriptions. The large 
 papular syphiloderm is a common form 
 of specific eruption, appearing usually 
 about three months after the infection ; 
 less frequently it is seen as a late or 
 tertiary lesion. Often it immediately 
 
 succeeds the roseola or occurs together 
 5. — General papular syphiloderm. . 
 
 From photograph by the author. with it, the papules developing in the 
 
COPYRIGHT BY E. B. TREAT & CO., N. Y. 
 
 PHOTOGRAVURE AND COLOR CO., N. Y. 
 
 SYPHILODERMA PAPULOSUM 
 
 PLATE XXIX. 
 

 •1 
 
 hard nodule 
 
 a large number of them 
 i ii 
 
 ::>e affected, . 
 
 >rms th 
 
 : s. In th . 
 the p; atively fe 
 
 tendency to circular grouping is m 
 
 egular cr 
 papules in variou 
 
 ;ion are present a: one ai d 
 
 They increas 
 
 ' 
 
 - 
 
 
 
 - 
 
 the i 
 
 • Ij 
 
 ■ 
 
 
 
 
 
 
 
 et pi 
 
 >yp 
 
 stinate and chron 
 

 SYP; MA PAPULC 
 
 PLATE 
 
INFLAMMATIONS. 
 
 193 
 
 
 '•- 
 
 u 
 
 center of the macules, and rapidly increasing in size (syphiloderma maculo-papulosa). 
 The fully developed papules are lentil- to pea-sized, or even larger, sharply limited, 
 hard nodules, conical or flat, and with smooth, shining tops. Their color is a cop- 
 pery red that does not disappear under pressure. In the early and commoner form 
 a large number of them are scattered irregularly over the entire body, with some 
 tendency to grouping in circles, or segments 
 of circles, or curved lines. The face is espe- 
 cially apt to be affected, and a row of papules 
 on the upper part of the forehead near the 
 margin of the hair forms the commonest va- 
 riety of the corona veneris. In the later forms 
 the papules are comparatively few, and the 
 tendency to circular grouping is more marked. 
 The lesions come in irregular crops, so that 
 papules in various stages of growth.and retro- 
 gression are present at one and the same time. 
 They increase slowly by peripheral growth, 
 remaining stationary for weeks or months as 
 fully developed papules ; and then they grad- 
 ually disappear by fatty degeneration and ab- 
 sorption, leaving behind atrophic spots, which 
 at first are pigmented, and later become 
 white. 
 
 Some scaling marks the process of invo- 
 lution, and this, when extensive, gives rise to 
 the variety known as syphiloderma papulo- 
 squamosum. Here the papular lesions above 
 described are covered with a greater or less 
 amount of dry, grayish, partially adherent 
 scales ; and, as the central oldest portion of 
 the papule" undergoes involution and loses its 
 scales while the peripheral portions are still 
 advancing, we get a very characteristic collar 
 
 of semi-detached scales at the margin of the 
 
 FlG. 99. — Papular plantar syphiloderm. 
 
 From photograph by the author. 
 
 infiltration. Adjacent papules may coalesce, 
 
 forming more extensive infiltrated and scaly 
 
 patches, especially in the later and more circumscribed forms, and closely resembling 
 
 a psoriasis. 
 
 In certain localities the large papular syphiloderm differs greatly in appearance 
 from the above-described typical form; this is notably the case on the palms and 
 soles and around the muco-cutaneous orifices. Syphiloderma papulosum palmarjs 
 et plantaris is a very obstinate and chronic form of the malady ; it occurs as an 
 
194 
 
 ILLUSTRATED SKIN DISEASES. 
 
 early lesion from four to six months after infection, and is also a common late mani- 
 festation. The early palmar syphiloderm appears as lentil-sized papules symmetri- 
 cally distributed over both palms and soles, and of a reddish, coppery color ; but, on 
 account of the thickness of the corneous layer in these locations, the lesions are 
 not perceptible to touch. Central scaling appears after a time, and this scaling 
 extends to the periphery as involution begins in the oldest portion of the infiltra- 
 tion. Thus the fully developed eruption appears as isolated or confluent purplish- 
 copper-colored macules, each surrounded by a margin of semi-detached scales. The 
 
 later form may occur many years 
 after infection ; it is very intract- 
 able and it may last a long time. 
 Here the papules are usually fewer 
 in number and arranged in a group; 
 one palm or one sole only is gen- 
 erally affected. It appears as a 
 rounded patch of varying size, with 
 an atrophic center where the pap- 
 ules have already disappeared, and 
 an inflammatory margin composed 
 of a row of deep-seated papules 
 with grayish-yellow, semi-detached 
 scales. Fissuring of the skin is nut 
 uncommon from the pressure of the 
 infiltration, and localized keratoses, 
 hypertrophies of the epidermis, and 
 papillary outgrowths also occur. 
 
 When the large papular syphi- 
 loderm occurs in the neighborhood 
 of the mucous orifices, or in loca- 
 tions where folds of the skin are in 
 juxtaposition, so that maceration ot 
 the papules with sebum and sweat 
 occurs, as between the folds of the 
 buttocks, around the genitals, in the 
 axillae, the submammary regions, and between the toes, its lesions undergo a peculiar 
 hypertrophic modification, and are known as condylomata lata. These may occur 
 alone, or together with a general papular eruption ; and the identity of the lesions is 
 shown by the fact that when the condylomata are kept clean and dry they become 
 ordinary papules. They appear as reddish flat or button-shaped outgrowths ; they 
 may be pea- or bean-sized when derived from a single lesion, or form larger cauli- 
 flower-like masses when formed by the coalescence of neighboring hypertrophied 
 
 Fig. ioo. — Condylomata lata. 
 
 From photograph by the author. 
 
INFLAMMATIONS. 195 
 
 papillae. They are elastic to the touch, and have a smooth or papillary surface, 
 usually covered with a grayish, very foul-smelling secretion. They generally occur 
 symmetrically, the opposing layer of skin being directly irritated and infected. Super- 
 ficial erosion is frequent, and the lesions may even undergo ulceration and lead to 
 the formation of cicatrices ; but they generally disappear by involution, a pigmented 
 spot that subsequently becomes white being left behind. Condylomata lata usually 
 occur during the first years after infection, but are very prone to relapse. Their 
 secretion is very contagious. 
 
 On the mucous membranes themselves, or in localities of the skin where, from 
 the approximation of its folds, the conditions as to heat and moisture resemble those 
 of the mucosas, the large papular syphiloderm appears as the mucous patch {plaque 
 uiuqueuse [Fr.], nassende Papel, Scldeimpapel [Ger.]). This is a very frequent 
 lesion of syphilis, occurring early in the disease as well as in its later stages, and is es- 
 pecially common in women. The mucous patches are seen in the mouth and throat 
 and upon the tongue, in the external auditory canal, the vagina, the anus, the 
 preputial cavity, the scrotum, the interdigital spaces of the toes, the umbilicus, etc. 
 They may be regarded as macerated and eroded papules, whose peculiar appearance 
 is caused, as in the case of the hypertrophic papules known as condylomata, by local 
 conditions. They appear as small pea- to finger-nail-sized areas of rounded outline, 
 and are usually whitish or grayish in color, on account of the delicate transparent 
 gray pellicle, composed of sodden epithelium and exudation, that covers the inflamed 
 or eroded area. They are sometimes accompanied by fissures, and occasionally they 
 are the seat of papillary or warty outgrowths. Mucous patches are exceedingly 
 contagious, and are probably a much more frequent source of syphilis than the initial 
 lesion itself. 
 
 The small papular or miliary papular syphiloderm is rarer than the large form ; 
 and occurring, as it usually does, in tubercular or otherwise debilitated subjects, it 
 indicates the presence of a severe type of the disease and is usually of a bad 
 prognosis. It is seen as a generalized eruption occurring early, three months or 
 later after infection, or as a later more localized and grouped affection. The lesions 
 are conical, millet-sized, coppery-brown papules, abundantly scattered over the body 
 or grouped into irregular circular areas. It is especially prone to occur on the face 
 and forehead, in which latter situation it forms one variety of the corona veneris. 
 The papules in the course of time become scaly, but the amount of scaling is very 
 much less than in the large papular form. After persisting for a varying time, 
 involution by fatty degeneration occurs, and brownish spots with central atrophic 
 depressions are left behind. The miliary papular syphiloderm is an obstinate erup- 
 tion and very prone to recur. 
 
 3. Syphiloderma pustulosa is a rarer manifestation of acquired syphilis than the 
 preceding forms, and, since it occurs in marasmic subjects, is of more serious prog- 
 nosis. It may be pustular from the beginning, or it may develop from the papular 
 
106 
 
 ILLUSTRATED SKIN DISEASES. 
 
 form after a brief vesicular stage, in which case it is probable that infection with 
 pus-cocci is the factor that prevents the normal involution of the papule. The 
 pustules vary much in size, number, course, depth of tissue invaded, and it has been 
 customary to designate them by the names of the non-syphilitic lesions — acne, vari- 
 ola, impetigo, ecthyma, etc. — that they resemble. The early forms are more super- 
 ficial, disseminated over the body, and often accompanied by constitutional symptoms, 
 
 fever, etc., while the later forms are 
 grouped and more discrete, and lead 
 to deeper destruction of tissue. 
 We may distinguish a large and a 
 small pustular syphiloderm. 
 
 The large pustular syphiloderm 
 (ecthyma and rupia syphilitica) 
 rarely occurs as a general eruption 
 in acquired syphilis, being com- 
 moner in the later circumscribed 
 and the hereditary forms of the dis- 
 ease. As a general exanthem it 
 appears after the sixth month or 
 later, beginning as an eruption of 
 papules more or less thickly scat- 
 tered over the back, shoulders, and 
 extremities, and soon developing 
 into small pea- to bean-sized flat 
 pustules, surrounded by dark-red, 
 sharply limited, infiltrated areolae. 
 The pustules soon rupture or dry 
 up into dirty brown crusts, under- 
 neath which is a more or less deep, 
 irregular ulceration ; and they heal 
 with the formation of a circular, de- 
 pressed scar. The circumscribed 
 forms occur later, rarely before the end of the first year. Here the pustules are 
 few, isolated, and large ; and they dry up into thick greenish-brown or black crusts, 
 under which are deep, irregular, steep-walled ulcerations, with dark-brown or more 
 frankly inflammatory walls of infiltration around them. Still more circumscribed 
 is the form known as rupia, which begins as large, flat, isolated pustules, which dry up 
 into superficial crusts. The infiltration progresses at the margins as breaking down 
 and suppuration extend from the center; new rings of suppuration are formed 
 around and under the central crust, which in their turn dry up. Thus the older por- 
 tions are gradually raised up by successive and more extensive layers of dried pus, 
 
 Fig. ioi 
 
 Pustular syphiloderm 
 (negress). 
 
 From photograph by the author. 
 
COPYRIGHT, BY E. B. TREAT £ CO. , N. V. 
 
 PHOTOGRAVURE & COLOR CO., N. V. 
 
 SYPHILODERMA PUSTULOSUM 
 
 PLATE XXXIX. 
 

 ug us the pecuii and 
 
 surrounded by the red, 
 deep, irregular V 
 s pus. This form of 
 and if, a? is frequently the ca s at 
 
 one margin while healing at 
 .e kidne 
 
 small pustular or miliar) 
 either acumina 
 • 
 beii. o split pea i 
 
 variety may occur in an e<v 
 later more circumscribed form. -eral 
 
 eruption the acuminate pustules beg iical 
 
 vesicles, the contents of 
 purulent and dry up into 
 
 or collaret of partia Hum 
 
 surrounds the ci 
 scar be: 
 
 j.irts. In the small, 
 
 
 - . 
 
 'hat Hfrfr.r.- 
 disease. 
 
 subjacei t in the ;'■ 
 
 superfici:. 
 
 4. Syp rculosa is a _Gen< 
 
 form of skin 
 respects, save as 
 
 the lesion's, to the large popular eruj 
 ; before the second year 
 
 ■ 
 
 dark or ng tops, 
 
 in size. are 
 
 general iked ten 
 
 - 
 

 
INFLAMMATIONS. 
 
 197 
 
 giving us the peculiar oyster-shell crusts resting on the pus-filled ulcerations, and 
 surrounded by the red, infiltrated, advancing margins. Removal of the crusts re- 
 veals a deep, irregular loss of tissue, with a dirty, uneven base covered with an icho- 
 rous pus. This form of pustular syphiloderm may be very chronic, lasting for years ; 
 and if, as is frequently the case, it advances at 
 one margin while healing at the other, it gives 
 rise to the kidney-shaped serpiginous ulcerations 
 that are so characteristic. 
 
 The small pustular or miliary pustular syphi- 
 loderm may be either acuminate or flat (acne, 
 variola, and impetigo syphiliticum), the pustules 
 being millet seed to split pea in size. Either 
 variety may occur in an early generalized or a 
 later more circumscribed form. As a general 
 eruption the acuminate pustules begin as conical 
 vesicles, the contents of which rapidly become 
 purulent and dry up into minute crusts. A fringe 
 or collaret of partially desquamated epithelium 
 surrounds the crust, and it leaves a small deep 
 scar behind when it falls off. It is especially 
 prone to attack the hairy parts. In the small, 
 flatter form the lesions are more numerous, espe- 
 cially upon the trunk and face ; and as their out- 
 break is often accompanied by fever and general 
 constitutional disturbance, it may be difficult to 
 distinguish it from variola, especially in the col- 
 ored races. I have seen case after case of this 
 variety of luetic eruption sent to the hospital as 
 cases of smallpox during an epidemic of that 
 disease. The crusts eventually dry up, and the 
 subjacent ulcerations result in the formation of 
 superficial scars. 
 
 4. Syphiloderma tuberculosa is a rather rare 
 form of skin syphilis, and corresponds in most 
 respects, save as regards the size and number of 
 the lesions, to the large papular eruption. It is essentially a late form, rarely occur- 
 ring before the second year, and being often seen ten, twenty, or more years after 
 infection. The lesions appear as rounded, firm, semiglobular or irregular elevations, 
 dark or coppery red in color, with smooth, shining tops, and coffee-bean to large nut 
 in size. Usually a few only are present, and there are never very many ; they are 
 generally closely aggregated, and show a marked tendency to assume a circular, semi- 
 
 Fig. 102. 
 
 General pustular syphiloderm 
 (negro). 
 
 From photograph by the author. 
 
198 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Fig. 103. — Tuberculo-squamous syphiloderm. 
 
 From photograph by the author. 
 
 circular, or cres- 
 centic arrange- 
 ment. They are 
 generally confined 
 to certain regions, 
 and are commonest 
 on the face and 
 neck. Growth is 
 very slow, but in 
 the course of time 
 the tubercle may 
 reach the size of 2 
 inches or more ; 
 and, as it com- 
 monly spreads on 
 one side only, it is 
 very prone to as- 
 sume the horseshoe 
 or kidney shape. 
 The lesions go on 
 finally to fatty de- 
 generation and interstitial absorption, and leave pigmented scars or atrophic areas 
 
 behind ; or they break down and ulcerate, with 
 
 or without the formation of rupial crusts. Their 
 
 irregular mode of extension causes them to become 
 
 serpiginous, spreading slowly in a definite direction 
 
 over the skin ; and this is the case with both the 
 
 ulcerative and the non-ulcerative forms. Papillary 
 
 out-growths from the ulcerated tubercles occasion- 
 ally occur, giving us the form known as syphiloder- 
 
 mata papillomatosa, with warty, cauliflower-like 
 
 excrescences covered with an offensive, yellow, 
 
 puriform discharge. 
 
 5. Syphiloderma gummatosum. The gumma 
 
 or syphiloma is the commonest lesion of late syphi- 
 lis, and occurs in the internal organs as well as on 
 
 the skin. In the rare malignant cases it is multiple 
 
 and occurs early ; but more often one or a few only 
 
 are present, appearing not before the third or fourth 
 
 year after infection, and possibly ten, twenty, or 
 
 more years thereafter. It appears as a various-sized, FlG - 104. —Hypertrophic tubercular 
 
 a j 1 1 1 1 t • i 1 • 1 syphiloderm. 
 
 flat or rounded, globular or oval, indolent, painless case of Professor Hsenberg,Wanaw, Poland. 
 
INFLAMMATIONS. 
 
 199 
 
 tumor, and is not usually accompanied by 
 
 any constitutional disturbance. It grows 
 
 slowly for weeks or months till it attains 
 
 the size of a walnut or an egg. Then it 
 
 begins to soften in the center, and the skin 
 
 covering it becomes reddened and adhe- 
 rent, giving it a deceptive resemblance 
 
 to a chronic abscess. Involution may be 
 
 accomplished by interstitial absorption, 
 
 with sinking and atrophy of the skin ; but 
 
 more commonly the thin covering of the 
 
 tumor breaks, and a thick glairy fluid, 
 
 more or less mixed with detritus and pus, 
 
 is poured out, leaving a deep circular or 
 
 irregular ulcer, with an uneven base cov- 
 ered with necrotic tissue and pus. This 
 
 finally heals by granulation, cicatrization, 
 
 and the formation of smooth, circular, 
 
 white, and often adherent scars. 
 
 Two forms of gummata of the skin are 
 
 to be distinguished — the superficial and 
 
 the deep. The superficial variety usually 
 
 consists of circumscribed groups of pea- to 
 hazelnut-sized tumors arranged in a crescentic 
 or circular form. The infiltration often increases 
 on one margin while involution, either by inter- 
 stitial absorption or by ulceration, advances on 
 the other, giving us the creeping or serpiginous 
 form of gummatous infiltration of the skin. The 
 deeper forms are larger, egg to orange size ; I 
 have met them 6 inches in diameter. There is 
 usually a single tumor, or at most three or four ; 
 yet there are exceptions, and I have recorded 
 a fatal case in which death from exhaustion 
 occurred, and in which there were no less than 
 sixty deep cutaneous gummata, most of them 
 2 or 3 inches, and some of them 6 inches in 
 diameter. 
 
 Gangrene and phagedena sometimes occur, 
 with deep and wide-spread destruction of tis- 
 sue, so that the aponeuroses, muscles, and even 
 
 Fig. 106. — Exulcerated gumma of the knee. . , . ,, -^. i j 
 
 From photograph b y the author. the bones are laid bare. The exulcerated gumma 
 
 FlG. 105. — Superficial gummata. 
 Case of Professor Elsenberg, Warsaw, Poland. 
 
200 
 
 ILLUSTRATED SKIX DISEASES. 
 
 sometimes develops exuberant granulations, which form fungoid masses, the fram- 
 bcesia syphilitica. Gummata also occur on the mucosae, but cause little subjective 
 trouble and have usually reached the ulcerative stage before their presence is de- 
 tected. 
 
 6. Syphiloderma ulcerosa is not a distinct form of the disease, but occurs as the 
 terminal stage in the papular, tubercular, pustular, and gummatous syphilodermata. 
 
 The ulcers have certain characteristic features. 
 Their margins are infiltrated, elevated, sharply lim- 
 ited, and dark red ; their edges are undermined ; 
 and their bases are irregular, and covered with 
 grayish-yellow fragments of necrotic tissue. Their 
 shape is round, oval, or kidney-like, and they are 
 often covered with thick, greenish-black, heaped - 
 up (rupial) crusts. They leave thin, rounded scars, 
 that are at first red and later white, and that are 
 movable or adherent in accordance with the depth 
 of tissue involved in the destructive process. Super- 
 ficial ulcerations arise from papules, tubercles, or 
 superficial gummata, and are round, reniform, or 
 irregular in shape ; deep ulceration, arising from the 
 deeper cutaneous or the subcutaneous gummata, 
 is irregular and crateriform. 
 
 7. Syphilis of the hair and nails. The syphi- 
 litic virus may affect the nutrition of the nails, giv- 
 ing rise to various forms of onychia; or the inflam- 
 matory lesions characteristic of the disease mav 
 appear in or around the matrix, causing paronychia. 
 In onychia, which is non-inflammatory, the nail loses 
 its luster and becomes dry and brittle ; furrows and 
 ridges appear on its surface ; its free edge is thickened and filled with dirt ; it breaks 
 off irregularly, and portions of the nail itself may be cast off, leaving the nail-bed 
 exposed. Or, again, the entire nail may become gradually detached and shed, a 
 white line marking the point of division between it and the new nail that gradually 
 grows up behind it. All the nails of the fingers and toes, or most of them, are 
 usually involved. The affection occurs in the early stages of the disease, coincident 
 with the other nutritive changes. 
 
 Paronychia syphilitica is an inflammatory lesion beginning in the tissues around 
 the nail and gradually extending to its bed. Papules or pustules may appear as 
 part of a general eruption, or as isolated lesions, at the margins of the nails. The 
 papules may be visible through the nail as brownish-red spots, and the pustules may 
 raise the entire nail from its bed and destrov the matrix. Around the margins of 
 
 Fig. 107. — Gumma subcutanea. 
 From cast by the author. 
 
SYPHILODERMA PAPULOSUM. 
 
 • ._ 
 
 «f 
 
 * ■ 
 
 : t 
 
 
 TYPOGRAVURE. 
 
 COPYRIGHT, 1903, Br E. 6. TREAT 4 CO., N. 
 
 SYPHILODERMA POSTULOSUM. 
 
 PLATE XXVII. 
 
••■ ■ 
 
 nmatory 
 
 iiation of the epid 
 re commonly frankly inflammatc 
 in the groove rounded 
 
 tion not infreque: severe' 
 
 of the dist< »ns spring 
 
 md a 
 
 The nail 
 
 d, and is 
 
 by cicatricial 
 In b n of the 
 
 phak in the inflammatory 
 
 process. Gummatous infiltration of the 
 matr : subsequent ulc 
 
 occurs. Paronychia n the 
 
 early second: lilitic dis- 
 
 ease, but mma 
 
 rhea, bu 
 flammate" 
 
 alope >mplete ; 
 
 ally , the 
 
 in as the nes 
 
 under t 
 
 In the later stages of 
 atrophic or u 
 ►ns of that pc 
 
 
 
■i 
 
 
 OSTUL'. 
 
INFLAMMATIONS. 
 
 201 
 
 the nail the inflammatory process may be chronic and manifest itself as a hyper- 
 trophy and exfoliation of the epidermic scales ; but, in my experience, it is much 
 more commonly frankly inflammatory. The papules at the margins of the nail and 
 in the groove coalesce, and a rounded or oval dusky-red swelling is formed. Ulcera- 
 tion not infrequently occurs in severe types 
 of the disease ; fungous granulations spring 
 up and cover the edge of the nail ; and a 
 fetid pus exudes from the mass. The nail 
 becomes discolored and loosened, and is 
 finally cast off ; and the nail-bed, destroyed 
 wholly or in part, is replaced by cicatricial 
 tissue. In bad cases the skin of the entire 
 phalanx is involved in the inflammatory 
 process. Gummatous infiltration of the 
 matrix, with subsequent ulceration, also 
 occurs. Paronychia is commonest in the 
 early secondary stage of the syphilitic dis- 
 ease, but it may occur at any time ; gumma 
 of the nail is a late lesion. 
 
 The hirsute appendages of the skin suf- 
 fer more commonly than do the nails from 
 the effects of the syphilitic poison, and alo- 
 pecia syphilitica is a fairly constant symp- 
 tom of the disease. From four to five 
 months after infection, and later, the hair 
 becomes dry and lusterless, and the diffuse 
 falling out, giving the head a characteristic 
 moth-eaten appearance, occurs. This is 
 sometimes accompanied by a dry sebor- 
 rhea, but more commonly there are no in- 
 flammatory symptoms whatsoever. The 
 alopecia is very rarely complete ; and the 
 hair usually, though not always, grows in 
 again as the poison of the disease becomes 
 less virulent under the influence of time and 
 treatment. In rare cases the hair of the axillae, eyebrows, beard, etc., also falls out. 
 In the later stages of the disease a permanent alopecia may occur in consequence of 
 atrophic or ulcerative changes in the scalp after papular, tubercular, or gummatous 
 lesions of that portion of the body. 
 
 8. Hereditary syphilis. In hereditary syphilis the fetus is infected in utero by 
 one or both parents ; and the disease thus acquired differs in some respects from 
 
 Fig. 108. — Ulcerative syphiloderm. 
 Case of Dr. H. Roth. 
 
202 
 
 ILLUSTRATED SKIN DISEASES. 
 
 the more ordinary variety. The initial sclerosis is absent, and the regular order of 
 the phenomena, so marked in most cases of the acquired variety, is entirely lost. 
 
 The so-called secondary and tertiary 
 lesions may occur together, or the 
 latter alone may be present ; gum- 
 mata may appear in utero or at birth, 
 and irritative lesions later on. The 
 virulence of the disease depends on 
 the age of the parental infection and 
 the thoroughness of the treatment 
 that has been employed. In the 
 worst cases the fetus dies in utero, 
 and abortion results. In others a 
 living child, small, ill developed, with 
 wrinkled skin, a characteristic " old- 
 man " appearance, and showing one 
 of the eruptions to be described be- 
 low, is born. Coryza (" snuffles ") 
 appears ; the voice is hoarse and 
 squeaky ; the skin of the palms and 
 soles is red and shining; marasmus 
 soon sets in; and the child dies of diarrhea or visceral complications. Again, the 
 child may be born apparently perfectly health}-, but soon becomes weak and sickly, 
 and the symptoms above enumerated, with a charac- 
 teristic eruption, appear. The survival of the child 
 depends largely on the vigor and appropriateness of 
 the treatment that is instituted. Finally, in some 
 cases the children present no symptoms of active 
 syphilis at first, but show in the course of time the 
 well-known Hutchinsonian triad of signs: the inter- 
 stitial keratitis, the purulent otitis, and the notched 
 and peg-top-shaped incisor teeth. Epiphysitis, dac- 
 tylitis, and other bone and visceral lesions occur later, 
 with serpiginous ulcerative or rupial skin lesions. 
 This last form, in which so-called tertiary lesions oc- 
 cur later in life without the appearance of the earlier 
 ones, is the syphilis hereditaria tarda, and can with dif- 
 ficulty be distinguished from the acquired form of the 
 disease. Wolff has recorded a case occurring at the age 
 
 of thirty-four years, and still later ones have been noted. 
 
 . Fig. i io. — Alopecia syphilitica. 
 
 The skin eruptions of the hereditary luetic disease After Lesser. 
 
 Fig. 109. — Paronychia syphilitica. 
 
 From photograph by the author. 
 
INFLAMMATIONS. 203 
 
 are similar in a general way to those of the acquired variety. They appear in 
 almost all cases within three months of birth, and are rare after the sixth month. 
 They may be erythematous, papular, pustular, or gummato- ulcerative in character. 
 The erythematous hereditary syphiloderm is rather uncommon, appearing in the first 
 days of extra-uterine life. The face, especially around the mouth, the sides of the 
 abdomen, and the palms and soles are reddened diffusely or in spots. The exanthem 
 is sometimes a. precursor of other forms of eruption. The papular hereditary syphilo- 
 derm is by far the commonest form of the disease. It appears as large, red or copper- 
 colored, slightly elevated, shiny papules ; at the folds of the skin they sometimes 
 become hypertrophic (condylomata lata), but they are more liable in the delicate 
 infantile skin to become eroded ; on the mucous membranes they appear as mucous 
 patches; on the palms and soles the eruption is often slightly scaly. The pustular 
 form of the hereditary syphiloderm is known as pemphigus syphiliticus neonatorum, 
 and, while commoner than the same form in the acquired variety of the disease, is 
 much rarer than the papular eruption. It appears at birth or a few days after, and is 
 most marked on the palms and soles ; the lower extremities are frequently affected, 
 but the face and trunk are seldom involved. The bullae are flat, pea to hazelnut in 
 size, with contents of clear fluid or cloudy or greenish pus. Destruction of the 
 derma occurs underneath, and scars result if the child survives. Syphiloderma 
 hereditaria gummatosa-ulcerosa is rare, and usually appears three months or more after 
 birth ; softening and ulceration almost invariably occur. 
 
 Onychia occurs in the hereditary disease both as a nutritive change and as an 
 inflammation of the matrix. Alopecia is also seen, similar to that of the acquired 
 form. 
 
 Pathology. — Though the various dermal lesions of syphilis differ greatly from 
 one another in external appearance, they are essentially alike in their microscopic 
 structure. They are all granulomatous tumors, caused by the presence and growth 
 in the tissues of an infective agent as yet unknown. Even in its macular form the 
 microscope shows that the syphiloma consists of a dense, sharply limited infiltration 
 of indeterminate small round cells, situated in the upper corium and papillary bodies 
 in the earlier, and in the lower corium and subcutis in the later lesions. Around 
 these masses are the results of inflammation, evidences of suppuration, caseation, 
 fatty degeneration, etc. It is characteristic of these tumors that they are never 
 capable of higher organization, but always undergo fatty degeneration and absorp- 
 tion, or ulcerative disintegration, or suppuration. In these retrograde changes the 
 normal elements of the tissue invaded are also destroyed, and hence arise the atro- 
 phies and cicatrices that are characteristic of the disease. The changes are always 
 centrifugal, so that the peripheral portion of a lesion or of a series of lesions is a 
 recently formed and growing infiltration, while the central and older portions are 
 already far advanced in the retrogressive changes. Endarteritis is a common accom- 
 paniment of the process and explains many of its features. In the hypertrophic form 
 
204 ILLUSTRATED SKIN DISEASES. 
 
 of the syphiloma known as the condyloma there is considerable growth of the 
 papilla itself in addition to the granulomatous infiltration ; and the gumma is a 
 granuloma with a network of connective-tissue fibers ramifying through the mass. 
 
 Fig. hi. — Multiple gummata. 
 
 From photograph of one of the author's patients. 
 
 Etiology. — The syphilodermata are caused by a virus that enters the system 
 through an abrasion of the skin or mucosae in the acquired form, and that is trans- 
 mitted through the blood in the hereditary variety of the disease. This inoculation, 
 after leading to local inflammatory changes already considered under the heading of 
 chancre, passes through the lymphatics and causes inflammation of first the neigh- 
 boring and then the more distant lymphatic glands ; and finally, reaching the blood, 
 causes the phenomena of the general disease, the symptoms of which appear on the 
 skin and mucosae and in the internal organs. That the agent is organic in its nature 
 is probable from the fact that this has been proved to be the case in many of the 
 chronic infective granulomata — tuberculosis, leprosy, glanders, etc. — most closely 
 related to syphilis in their pathological and clinical features ; and still more so because 
 upon no other supposition can its enormous increase in quantity in the infected indi- 
 vidual during the course of the disease be explained. Positive proof in this respect 
 has so far been unattainable ; the various microorganisms found by Lustgarten, 
 Doutrelepont, and others have not been seen by all observers, and both culture 
 experiments and inoculations upon the lower animals have entirely failed. 
 
 All the phenomena of the disease are explainable on the supposition that it is 
 due to the presence of a microorganism and its toxins in the blood and the tissues. 
 The chancre and the secondary eruptions are the direct product of the microbe, either 
 alone or plus its toxins, while the tertiary lesions are due to the toxins deposited in 
 
SYPHILODERMA MACULOSUM. 
 
 SYPHILODERMA GUMMATOSUM. 
 
 TYPOGRAVURE. 
 
 COPYRIGHT BY E. B. TREAT 4 CO., N. Y. 
 
 GLOSSITIS SYPHILITICA. 
 
 SYPHILODERMA PAPULOSUM 
 
 PLATE XXXII. 
 
INFLAMMATIONS. 205 
 
 the tissues and roused into activity by various causes; and the immunity from rein- 
 fection is due to the presence of the toxins in the blood. The resisting power of 
 the organism plays an important part in the growth of the virus ; tubercular and 
 malarial subjects have severe forms of syphilis ; and parts irritated or inflamed from 
 any cause are more prone to show the lesions of the disease than are others. 
 Secondary infection with pyogenic organisms plays an important part in many mani- 
 festations, more especially of the hereditary form. 
 
 Not all the varieties of syphilis contain the virus in an active form, and from 
 some lesions the disease cannot be produced in healthy individuals. In a general 
 way all the moist and discharging lesions, both of the acquired and the hereditary 
 form, are contagious; the sclerosis, the secondary papules and mucous patches, and 
 the condylomata being eminently so. The blood-serum is not contagious, but the 
 blood-corpuscles contain the virus. The physiological secretions — the milk, saliva, 
 tears, etc. — cannot carry the contagion, save when contaminated with blood-glob- 
 ules or the detritus of lesions ; and the same is true of ordinary pathological secretions. 
 The lesions of tertiary syphilis do not contain the virus, but only its products, and 
 are not contagious. 
 
 The modes of transmission of the virus are extremely various. It can be gotten 
 by direct contact, as in intercourse, kissing, vaginal examination, etc. ; or by medi- 
 ate infection, the virus being deposited on some article, and then conveyed to the 
 body of the recipient, as on a lead-pencil, tooth-brush, dental instrument, etc. ; or 
 it can be transmitted with the semen or ovum to the fetus. In all cases but the 
 latter a lesion of the skin or mucosa, however minute, is required to permit the virus 
 to enter the system of the recipient. 
 
 Diagnosis. — The protean lesions of the syphilodermata are often with difficulty 
 distinguishable from those caused by other diseases ; and this has led to the use of 
 such inapplicable terms as acne syphilitica, pemphigus syphilitica, varicella syphili- 
 tica, etc. No single set of differentiations is, however, of greater importance in 
 the whole field of medicine, since it is but too often not merely a question of accu- 
 rate diagnosis and correct treatment, but one which involves the happiness, mental 
 quietude, and domestic peace of many human beings. A discreet reticence 
 should always be observed in the statements made to our patients, whatever our 
 convictions as to the nature of the disease may be ; and concealment is in many 
 cases an imperative duty. Nevertheless, our paramount concern is the cure of the 
 disease, and if a plain statement of facts is necessary for that purpose, other con- 
 siderations must be subordinated to it. 
 
 Certain general considerations are in place before considering the diagnosis of 
 the various syphilodermata in detail. First and foremost, the patient's history is 
 hot only useless, but is positively misleading. Forgetfulness and inattention to the 
 often trivial early manifestations of the disease, combined with the very natural dis- 
 position to deny the facts, deprive it of all reliability. It should be inquired into, if 
 
206 ILLUSTRATED SKIN DISEASES. 
 
 at all, only after the diagnosis has been made from the objective symptoms. Sec- 
 ondly, in some doubtful cases we can employ the touchstone of treatment. Our 
 means for the cure of syphilitic manifestations are so powerful and certain that the 
 mere fact that a lesion is refractory to the ordinary treatment of the disease is prima 
 facie evidence against its luetic nature. But the treatment must be vigorous and 
 the dosage large, for many of the lesions, more especially of late syphilis, react only 
 to energetic measures. Finally, the syphilodermata have certain general character- 
 istics (p. 191); and a circular or crescentic arrangement, a copper-color, secondary 
 ulceration or heaped-up crusts, the absence of subjective symptoms and the presence 
 of characteristic symptoms or lesions elsewhere, of adenopathy, angina, cephalal- 
 gia, alopecia, osteocopic pains, or the remains of the sclerosis, will often help us to 
 reach a definite conclusion. 
 
 Syphiloderma maculosa may be faintly marked, and is doubtless often over- 
 looked; but it is not difficult to diagnose. The non-scaling, non-elevated, discrete 
 spots, situated chiefly upon the trunk, are quite characteristic. Urticarias, and 
 more especially the roseolous eruptions that sometimes follow the ingestion of drugs 
 like copaiba, cubebs, quinine, etc. (roseola balsamica), have more or less well-marked 
 wheals and itch greatly. The eruptive fevers, and more especially measles, may 
 resemble it ; but the presence of the symptoms on the mucous membranes, together 
 with the fever, will distinguish them. The eruption of typhoid fever consists usually 
 of but a few spots, and is accompanied by the characteristic temperature curve. In 
 erythema multiforme the spots are elevated, and are especially apt to appear on the 
 backs of the hands and the flexor surfaces of the limbs. It would seem impossible 
 to confound trichophytosis corporis, pityriasis rosea, or chromophytosis with the 
 roseola of syphilis ; the discrete spots with fading centers and scaly margins of the 
 first two, and the diffuse or circumscribed brownish discolorations of the third, should 
 suffice to prevent error without resort to the microscope. The marbling of the skin 
 apparent in some individuals when the body is exposed to cold air fades away as 
 soon as the integument is warmed. 
 
 The papular syphiloderm, large and small, may resemble a psoriasis very closely, 
 both in appearance and in distribution. But the papules of syphilis are dark-red, 
 dense infiltrations, and the scaling is central, and consists of dirty cast-off epi- 
 thelium. In psoriasis the scales are shining, abundant, heaped up, and seated on 
 bright-red non-infiltrated areas; scraping shows the bleeding points of the hyper- 
 trophied papillae, and the seat of the lesions is mostly upon the extensor surfaces of 
 the limbs. Acne is situated mostly upon the face, and is accompanied by come- 
 dones ; its papules are short-lived, bright-red, acuminate, and often become pustules. 
 In eczema the papules are not sharply limited and not infiltrated, and other forms 
 of the disease, marked by moisture, vesiculation, crusting, and itching, are almost 
 always present at the same time. The lesions of scrofuloderma are small, livid, red 
 or skin-colored papules occurring in childhood in groups on the trunk and the ex- 
 
INFLAMMATIONS. 207 
 
 tensor surfaces of the limbs, are very chronic, and are usually accompanied by glandu- 
 lar swellings, mucous discharges, etc. 
 
 On the palms and soles the papulo-squamous syphiloderm must be differentiated 
 from eczema. This may be difficult ; but careful observation will reveal the dusky- 
 red, infiltrated papules with semi-detached scales at their margins, and arranged 
 often in groups, or a larger discolored area with a coppery, infiltrated wall. Eczema 
 has no papules, and is more irregular ; the epidermis is thickened and cracked near the 
 fingers; itching is present; and weeping or crusted surfaces extend into the clefts of 
 the fingers or on to the surrounding skin. Psoriasis is almost unknown upon the palms 
 and soles, and occurs as a diffuse scaling without infiltration ; and other distinctly psori- 
 atic lesions will be found at the seats of election of that disease. The hypertrophic 
 moist papule must be distinguished from the acuminate or simple condyloma. These 
 latter are caused by the irritation of gonorrheal, chancroidal, or other discharges, 
 and are distinctly warty, fissured, and pedunculated ; while the syphilitic lesions are 
 broad, mushroom-like growths, and are almost always accompanied by the correla- 
 tive forms of the efflorescence, dry papules or mucous patches. 
 
 The pustular syphiloderm consists of more or less regularly grouped papules 
 seated on infiltrated bases. It may resemble a variola so closely that an immediate 
 diagnosis is impossible. There are the same stages, — papules, vesicles, and pus- 
 tules, — followed by scarring; and high fever and marked general symptoms are 
 sometimes present. The rapid and definite course of the smallpox lesion to its 
 termination in eight to twelve days finally removes all doubt. In pustular acne we 
 have the seat of the disease on the face and back, the absence of fever and other 
 acute symptoms, and the presence of small acuminate papulo-pustules, situated on 
 inflammatory bases, in various stages of development. In impetigo contagiosa 
 there are flat pustules, drying up into yellow crusts, under which is a moist, non-infil- 
 trated surface ; the disease occurs mostly in children. 
 
 The tubercular syphiloderm may resemble lupus vulgaris, leprosy, epithelioma, 
 or psoriasis. In lupus the numerous small, soft, deep-seated, apple-jelly-like nod- 
 ules, appearing in early life and progressing very slowly, are peculiar. Leprosy has 
 its characteristic history : the tubercles are large and form enormous nodular, var- 
 nished-looking masses, growing very slowly ; and anesthetic areas are almost always 
 present. Epithelioma usually develops from a wart, is most often single, occurs in 
 the aged, and has prominent, hard, waxy edges with minute blood-vessels running 
 over them. Finally, in a psoriasis, though it may closely resemble a tuberculo- 
 squamous syphiloderm, the lesions are pinkish, abundantly covered with silvery 
 scales, and there is never any loss of tissue. 
 
 The gummatous syphiloderm is sometimes easily recognized, being present as a 
 single one or only a few tumors ; it is hard, of large size, and sharply limited, ele- 
 vated, and coppery or ham-colored; or appears as a kidney-shaped ulceration with 
 hard, infiltrated, coppery margins. Its distinction from certain non-luetic affections 
 
208 ILLUSTRATED SKIN DISEASES. 
 
 of the skin, more especially from certain tumors, is sometimes very difficult. So far 
 as the non-ulcerated gumma is concerned, fibroma is harder and denser, and lipoma 
 softer; and in both the continued absence of inflammatory symptoms will in time 
 elucidate the diagnosis. Rhinoscleroma is marked by its location, its excessive and 
 cartilaginous hardness, the extreme chronicity of its course, and the very rare occur- 
 rence of ulceration. In sarcoma the tumors are numerous and pigmented, the 
 cachexia that sets in is characteristic, and the general health is markedly involved. 
 The softened gumma has often been mistaken for an abscess ; it may be distinguished 
 from it by the chronicity of its course, and the absence of pain and active inflamma- 
 tory symptoms. 
 
 The exulcerated gumma may resemble a lupus so closely that a special term, 
 lupus syphiliticus, is employed by some writers to designate this variety of the lu-. 
 etic disease. Lupus, however, begins in childhood or in youth ; its nodules are small, 
 numerous, yellowish brown in color, non-elevated, and soft, and their growth is 
 very slow. If breaking down has occurred, the ulcers are elevated and filled with 
 hypertrophic, easily bleeding granulations ; there is no continuous infiltrated margin ; 
 characteristic papules are seen outside the ulceration, and also in the old scar tissue 
 already traversed by the disease; and only exceptionally are the cartilages and 
 bones involved. The ulcerative scrofuloderm may also be mistaken for a gumma ; 
 but its edges are less hard, non-infiltrated, and lax and undermined; and the 
 ulceration is most apt to occur on the neck and in children who exhibit evidences 
 of disease of the lymphatic glands and the bones. In carcinoma, more especially in 
 its epitheliomatous form, the ulcer has a red, easily bleeding base ; its margins are 
 hard and waxy ; it grows very slowly ; and it is accompanied later by involvement of 
 the lymphatic glands. Lupus erythematosus is a superficial inflammation with 
 slightly elevated edges ; ulceration never occurs, and the scar is soft and superficial. 
 Gumma of the genitals has been mistaken for a chancre, but the absence of the 
 characteristic hardness, the non-appearance of secondary symptoms, and the pres- 
 ence of evidences of past luetic disease should prevent mistake. 
 
 The ulceration of syphilis requires to be differentiated from that which accom- 
 panies other dermal affections, and more especially the common ones, lupus and 
 simple dermatitis. It can be done with readiness if the nature of the syphilitic 
 process is borne in mind. The specific ulceration always arises from the breaking 
 down of the characteristic infiltration, which is a sharply limited, densely packed 
 collection of small round cells in the corium. Each ulcer commences in the center 
 of a papule, tubercle, or gumma, and spreads by peripheral extension of the infil- 
 tration with central extension of the breaking down. A sharply limited and dense 
 zone of infiltration therefore surrounds each such loss of tissue, the skin around it 
 being entirely unaffected. The ulcer of dermatitis is more frankly inflammatory, 
 and lacks the infiltrated wall around it ; it is shallower, has redder, softer, and more 
 s\r ping edges, its margins are not sharply limited, and an extensive area of inflamed 
 
TTPOGRAVUF.F. 
 
 COPYRIGHT BY E. B. TREAT 4 CO., N. Y. 
 
 SYPHILODERMA Tuberculo— Ulcerosum. 
 
 PLATE XXVIII. 
 
INFLAMMATIONS. 209 
 
 skin surrounds it. The ulceration of lupus is extremely slow, begins in youth, is 
 often covered with hypertrophic granulations, and shows at its margins the char- 
 acteristic nodules of the disease. 
 
 Prognosis. — The prognosis of the syphilodermata in general is good, though some 
 are more resistant to antiluetic treatment than others. The macular are the easiest, 
 and the pustular and ulcerative the most difficult, forms to cure. The general con- 
 dition of the patient is of great importance, the prospects of cure being worse in 
 broken-down, intemperate individuals, and in those debilitated by chronic or acute 
 disease. The early appearance of late forms of gummatous lesions is of bad prog- 
 nosis, as is also the rapid occurrence of relapses of the dermic lesions. The ulcera- 
 tive and gummatous syphilodermata may themselves, if very extensive, determine 
 a fatal ending to the disease. In hereditary syphilis the prognosis is doubtful. In 
 all cases thorough and appropriate treatment is an important element in determin- 
 ing the result. 
 
 Treatment. — The treatment of the syphilodermata is that of constitutional syphi- 
 lis, together with certain local measures. The systemic poison is in all cases the 
 same, and the severity of its manifestations depends on the condition of the patient 
 and the treatment to which he is subjected. Care of the general health is therefore 
 of the utmost importance, and tonics, nourishing food, fresh air, bathing, exercise, 
 and travel should be judiciously employed, so as to place the patient in the condition 
 most favorable to resist the ravages of the disease. Special attention should be 
 paid to the hygiene of the skin, since that is the organ most frequently attacked. 
 The mucosae are hardly less liable to be involved ; and that of the buccal cavity is 
 not only a frequent seat of characteristic lesions of the disease, but is of especial 
 importance, because it is also liable to be injured by the drugs that are required in 
 the treatment. In every case of syphilis, therefore, even before treatment is begun, 
 the mouth should be carefully examined and all defects remedied ; the teeth should 
 be put in good order, and an antiseptic mouth wash (No. 96, p. 209) should be regularly 
 employed. If the gums are at all inflamed or spongy, an astringent lotion (No. 97, 
 p. 209) may be used several times a day. 
 
 No. 96. Antiseptic Mouth Wash. No. 97. Astringefit Mouth Wash. 
 
 R Acid, carbolic. . . 1 part R Acid, tannic. ... 1 part 
 
 Spts. vini Glycerini 
 
 Aquae destil. . . . aa. 50 parts Aquae destil. . . . aa. 10 parts 
 
 Mercury and iodine are the two drugs most useful in the treatment of the syphilo- 
 dermata. Mercury is an antidote to the specific poison, and is of benefit in almost 
 all the stages of the disease. Iodine causes the disappearance of the gummatous 
 accumulations, but does not prevent their formation ; it is therefore most efficient 
 for the later lesions. The treatment with mercury is to be commenced as soon 
 
210 
 
 ILLUSTRATED SKIN DISEASES. 
 
 as the diagnosis of syphilis is made. This, as we have already seen, cannot be done 
 from the initial lesion alone, and premature treatment may prevent the appearance 
 of the secondary symptoms, and leave us forever in doubt as to whether infection 
 has taken place. The appearance of the general adenopathy, the angina, or the 
 eruption is the signal that we must await. The dose of mercury then given should 
 be as large a one as the patient can bear without the occurrence of salivation or 
 gastro-intestinal disturbance. With the retrocession of the symptoms it may be 
 diminished, and the patient should be kept steadily on the smaller dose for a num- 
 ber of months. The reappearance of active symptoms on the skin and elsewhere is 
 the signal for pushing the medication ; and even if that does not occur, two or three 
 courses of active medication should be given during each of the first two or three 
 years of the disease. During the second year, when the dermic symptoms become 
 more localized, the iodine preparations, together with the mercury, give us the best 
 results. After that, in the stage of the late lesions of which the gumma is the type, 
 iodine is still more efficacious and must be given in larger dose ; but mercury in 
 small amounts is always useful, and sometimes indispensable, to effect a cure. 
 
 No. 98. Protiodide Pill. 
 
 fy Hg. iodid. virid. 
 Pulv. opii 
 Extr. gent. 
 
 F. pil. No. 60. 
 
 3i 
 
 gr. 10 
 q.s. 
 
 No. 99. Mixed Treatment. 
 
 & 
 
 Hg. chlor. corr. 
 Kali iodidi . 
 Syrp. zingiber 
 Aquae . 
 
 Dose 3i 
 
 ad. 
 
 gr- 1 
 
 fss 
 
 fii 
 
 No. 100. Calomel Powders. 
 
 $ Calomelani 
 Sacch. alb. 
 
 Div. in pulv. No. 10. 
 
 No. JO J. Oleate of Mercury Ointment. 
 
 gr. 1 I£ 01. hydrarg., 20-per-cent. solu- 
 
 3ss tion ..... 1 part 
 
 Petrolati ... .2 parts 
 
 The most convenient method for the administration of mercury (see p. 48) is 
 undoubtedly by the mouth, and it is the one preferred by most practitioners. It is 
 slow, however, and uncertain, since we cannot know what proportion of the drug is 
 absorbed by the digestive tract ; and it is liable to cause salivation and gastro-intes- 
 tinal irritation. The protiodide is the most commonly used preparation, and it 
 should be given in A- to 1 -grain doses, in accordance with its effect. The griping 
 and diarrhea that it sometimes occasions may be obviated by combining a small 
 dose of opium with it (No. 98, p. 210). The biniodide and bichloride are both irritat- 
 ing, and are most frequently used in combination with the iodide of potash in the 
 so-called " mixed treatment " suitable to the late secondary stages of the disease 
 (Xo. 99, p. 210). The tannate is less irritating than most other preparations of the 
 drug, but it is less effective than the protiodide and must be given in larger doses. 
 
COPYRIOHT BY E. B. TREAT 4 CO., N. Y. 
 
 PHOTOGRAVURE AND COLOR CO., N. Y. 
 
 GUMMA SUBCUTANEUM 
 
 PLATE XXX. 
 
is especially efi' 
 ■ iren in r 
 limes claih , or in 
 The percutaneous o 
 with many- syphiiographers; it 
 
 when destructive pr 
 by its use the gastro-intestina 
 patients object to it; and it i 
 
 Mercurial ointment 
 oughly rubbed for fifteen minm 
 to allow as long a val as possibi : 
 
 rubbed. The loins, insides of the 
 be avoided, as a troublesoi le folli< 
 employed in very hirsute individ 
 and may be used in the same 
 reliable, and it is not so efficii 
 
 mnction (No. 102, p. 212). 
 Mercurial plaster applied to the trunk 
 situ for several days, is u 
 infantile skin, and there is n< 
 mercurial ointment reduced by 2 or 3 p 
 should be rubbed into the skin of the abd 
 spread upon a cloth ana 
 a rapid effect is de:- : : 
 they must b^ given in a 
 of one of ordinary siz< 
 patients should rem:: 
 The method that I 
 
 em when prompt and \ 
 rather intramuscular injection. 
 
 disabilit advantages 
 
 effic ill, it ne 
 
 dance of the physician. The 
 very rare when antiseptic pi 
 serious results therefrom 
 tion is scrubbed with soap and 
 then with ether. The neec 
 flame immediately before 
 immediately upc 
 deep into the musc'h 
 than the ordinary 
 
 a 
 
JBCIITA' 
 
INFLAMMATIONS. 211 
 
 Calomel is especially efficacious in the hereditary and acquired syphilis of children; 
 it may be given in powder (No. ioo, p. 210), or as tablets in doses of yo of a grain 
 two to four times daily, or in the form of half-grain doses of gray powder. 
 
 The percutaneous or inunction method of mercurial medication is a favorite one 
 with many syphilographers ; it is efficient and rapid enough to be preferred to inges- 
 tion when destructive processes are in progress or important organs are threatened ; 
 by its use the gastro-intestinal tract is entirely spared. It is troublesome and dirty ; 
 patients object to it ; and it is very liable to cause eczematous eruptions in sensitive 
 skins. Mercurial ointment is the favorite preparation; ^ to 1 dram should be thor- 
 oughly rubbed for fifteen minutes every night on a different part of the body, so as 
 to allow as long an interval as possible to elapse before returning to the part first 
 rubbed. The loins, insides of the thighs, etc., should be selected; hairy parts must 
 be avoided, as a troublesome folliculitis is liable to occur, and the method cannot be 
 employed in very hirsute individuals. Mercurial soap is cleaner than the ointment, 
 and may be used in the same way ; but the commercial preparations are not very 
 reliable, and it is not so efficient. The oleate of mercury is an eligible preparation 
 for inunction (No. 102, p. 212). 
 
 Mercurial plaster applied to the trunk and extremities, and allowed to remain in 
 situ for several days, is useful, especially in children. Absorption is rapid in the 
 infantile skin, and there is no better way of treating hereditary syphilis than by 
 mercurial ointment reduced by 2 or 3 parts of an excipient. A bean-sized piece 
 should be rubbed into the skin of the abdomen daily, and a small additional quantity 
 spread upon a cloth and placed next to the skin under the child's belly-band if 
 a rapid effect is desired. In the same class of cases the sublimate baths are useful ; 
 they must be given in a wooden wash-tub, 5 to 30 grains being used to the contents 
 of one of ordinary size. Adults can take from 75 to 150 grains to the bath; the 
 patients should remain immersed therein for from twenty minutes to an hour. 
 
 The method that I prefer, however, for the introduction of mercury into the 
 system when prompt and vigorous action is required, is that by subcutaneous or 
 rather intramuscular injection. Its disadvantages are a moderate amount of pain 
 and disability ; its advantages are cleanliness, exactitude in dosage, rapidity and 
 efficiency, and, above all, it necessarily keeps the patient under the care and gui- 
 dance of the physician. The painful infiltrations and abscesses formerly noticed are 
 very rare when antiseptic precautions are employed, and I have never seen the 
 serious results therefrom that have been recorded. The skin at the site of the injec- 
 tion is scrubbed with soap and water, and with 1 : IOOO corrosive chloride solution, and 
 then with ether. The needle is kept in carbolized oil, and is passed through the 
 flame immediately before the puncture; and this latter is closed with rubber plaster 
 immediately upon the withdrawal of the instrument. The injection should be made 
 deep into the muscles of the buttock or back, a needle somewhat longer and coarser 
 than the ordinary hypodermic one being employed. 
 
212 ILLUSTRATED SKIN DISEASES. 
 
 Either the insoluble salts first used by Scarenzio in 1864, or the soluble ones 
 introduced by Lewin in 1867, may be employed. The soluble salts act most 
 quickly, but only a small quantity can be introduced at a time, and the injections 
 must be repeated daily or every other day. The most commonly used is the subli- 
 mate (No. 102, p. 212) in i-per-cent. solution, of which 10 minims may be injected 
 at a dose. Twenty to thirty such injections form a course, according to the neces- 
 sities of the case. The albuminate, peptonate, and many other soluble preparations 
 have been recommended, but they do not seem to possess any advantages over the 
 corrosive chloride. 
 
 The insoluble salts cause moderate pain ; deep infiltrations sometimes occur, 
 but abscess formation is rare. The injection needs to be repeated only once in five 
 to fourteen days, the mercurial deposited in the tissues being slowly transformed 
 into a soluble salt and absorbed. Eight to ten injections form the usual course. 
 Calomel in 10-per-cent. suspension in liquid vaseline (No. 9, p. 46) is most often 
 employed, the dose being from 3 to 10 minims. The salicylate of mercury may be 
 used in the same way (No. 103, p. 212) ; it is less painful than calomel, and less liable 
 to salivate. The so-called gray oil, highly recommended by Lang, is a form of 
 mercury in oily suspension (No. 104, p. 212), and should be slightly warmed before 
 using. 
 
 No. J02. Sublimate Injection. No. J03. Salicylate-of-mercury Suspension. 
 
 R Hydrarg. chlor. corr. . . 1 part R Hydrarg. salicyl. 1 part 
 
 Sod. chlorid. . . .10 parts Petrol, liquid. . . .10 parts 
 
 Aq. destil. . 
 
 1 part R 
 10 parts 
 
 Hydrarg. salicyl, 
 Petrol, liquid. 
 
 . 100 " 
 
 
 No. J04. Gray 
 
 Oil. 
 
 R Hydrargyri 
 Adip. lanae 
 Petrol, liquid. 
 
 . aa. 3 parts 
 4 " 
 
 In the ordinary syphilodermata, which may be regarded as part of the regular 
 symptomatology of the disease, internal treatment is the easiest and is perhaps 
 sufficiently reliable. But in obstinate cases, and especially where the irritability of 
 the gastro-intestinal tract is too great to allow a sufficient quantity of the remedy to 
 be absorbed, inunctions are to be preferred. Where the skin lesions are obstinate, 
 numerous, and deep-seated, in the late ulcerative processes, and in cases where a 
 differential diagnosis between syphilis and malignant or tubercular disease must be 
 speedily made, the hypodermatic method of administration should be employed. 
 
 While mercury is no longer given in the doses that were once customary, and 
 salivation is not now a necessary accompaniment of the treatment, the drug must 
 frequently be pushed to the point of toleration, and slight stomatitis, swelling of the 
 gums, and salivary flow are sometimes developed. The more serious forms of mer- 
 

COPYRIGHT, BY E. B. TREAT & CO., N. Y. 
 
 PHOTOGRAVURE & COLOR CO., N. Y. 
 
 RUPIA SYPHILITICA 
 
 PLATE XXXI. 
 

 very rai t 
 Iodine is, next to m< 
 mata, more espt 
 most c aly used 
 
 ometimes be employ 
 best prescril> 
 taken in a considers 
 dary and early t< 
 ■ 
 
 3 a day, but the on: 
 tient and the effect 
 especially in the very late l< 
 in some cases. The 
 stomach rebels, and the iodide in >n, an 
 
 almost as efficient when 
 
 
 No, 105. 
 
 . [ ali s. nat. iod 
 
 
 
 No. J07. 
 fy Tra. iodinii 
 
 : - 
 
 Iodoform is sometimes 
 as also 2 to 3 drop d< 
 
 itated and anemic c 
 
 Like mercur 
 
 - i 
 
 
 it 
 
PHIL 
 
 
INFLAMMATIONS. 213 
 
 curial poisoning, with diarrheal and bloody discharges from the bowels, and albu- 
 minuria, are very rarely seen to-day. 
 
 Iodine is, next to mercury, our main reliance in the treatment of the syphiloder- 
 mata, more especially in the later forms. The iodides of potassium and sodium are 
 most commonly used ; the latter salt, being less of an irritant and cardiac depressant, 
 can sometimes be employed when the former cannot. Being deliquescent, they are 
 best prescribed in a saturated solution (No. 105, p. 213), and should invariably be 
 taken in a considerable quantity of milk or water after eating. In the late secon- 
 dary and early tertiary lesions they are often given in combination with mercury 
 (No. 99, p. 210) ; but it is best to give them separately, as the relative doses can be 
 more conveniently changed. The ordinary amount is from 15 to 60 grains three 
 times a day, but the only limit to the dose administered is the tolerance of the pa- 
 tient and the effect on the disease. Ordinary quantities are frequently inefficient, 
 especially in the very late lesions; and 500 grains or more daily must be adminis- 
 tered in some cases. The rectum may be called upon for assistance when the 
 stomach rebels, and the iodide in solution, and well diluted with water and milk, is 
 almost as efficient when given in this way as when administered by the mouth. 
 
 No. J05. Iodide-of-potash Solution. No. 106. Iodoform Pills. 
 
 R; Kali s. nat. iodidi fy Iodoformi 
 
 Aq. dest. . . . . aa. 1 part Extract, glycyrrhizs . . aa. p. e. 
 
 No. 107. Iodine Mixture. No. 108. Syrup of the Iodide of Iron. 
 
 fy Tra. iodinii 1 part R Syrp. ferri iodidi . . .1 part 
 
 Aq. dest 100 parts Syrp- simplicis . . .2 parts 
 
 Iodoform is sometimes employed with good effect in 2-grain pills (No. 106, p. 213), 
 as also 2 to 3 drop doses of the tincture of iodine in solution (No. 107, p. 213). In 
 debilitated and anemic cases, more especially of children, the syrup of the iodide of 
 iron is appropriate (No. 108, p. 213). 
 
 Like mercury, iodine sometimes causes constitutional disturbance, and it is there- 
 fore desirable to begin with a small dose and increase it gradually. The symptoms 
 of iodism are coryza, catarrh of the pharyngeal and laryngeal tracts, gastritis, head- 
 ache, redness of the face, and more especially acneform, furuncular, and nodular 
 eruptions of the skin. 
 
 Local treatment of the syphilodermata is not necessary when the symptoms are 
 not extensive or threatening, but it is a powerful adjuvant to the internal method. 
 When the general eruptions are situated on the skin of the face or hands, they are 
 best treated by rubbing in the white precipitate ointment, either alone or with a 
 small proportion of mercurial ointment, at night (No. 109, p. 214). In bad cases the 
 
214 ILLUSTRxVTED SKIN DISEASES. 
 
 mercurial ointment or plaster, or the mercurial plaster-mull, may be applied to limited 
 areas during the night. 
 
 No. 109. Compound Mercurial Ointment. No. J JO. Mercurial Ointment and Pou<der. 
 
 ft Ungt. hydrarg. ammon. ft Hydrarg. sozoiodol. . . i part 
 
 Ungt. hydrarg. . . . aa. i part Amyli s. petrolati . . .20 parts 
 
 No. UJ. Black Wash. No. JJ2. Sublimate Gargle. 
 
 ft Calomel. ... 1 part ft Hydrarg. bichloridi . . 1 part 
 
 Aq. calcis . . . ad. 100 parts Mel. ros. .... 1000 parts 
 
 Aquae .... 4000 " 
 
 No. 113. Permanganate Gargle. 
 
 ft Kali permangan. . . 1 part 
 
 Aquae .... 2500 parts 
 
 The condylomata lata or moist papules should be first thoroughly cleansed with 
 a 1 : 1000 sublimate solution ; or, if situated on the genitals, immersed in the sublimate 
 sitz-bath (p. 211). They should then be washed with a saline solution and well 
 sprinkled with calomel. The mercurial collemplastrum may be used in some cases. 
 If the growths are very exuberant, they may be cautiously touched with a 5- to 
 10-per-cent. sublimate alcohol, or nitric acid, or the acid nitrate of mercury, or pure 
 carbolic acid ; but this will rarely be necessary. 
 
 The palmar and plantar syphiloderms should be treated with local sublimate 
 baths, followed by mercurial plaster. 
 
 In the ulcerative affections, if there is not too much secretion, the mercurial plas- 
 ter or collemplastrum or plaster-mull is very efficacious. Where there is crusting 
 and suppuration, the crusts are to be removed by soaking with olive-oil or poultic- 
 ing, the parts thoroughly cleansed, the ulcerated areas sprinkled with iodoform and 
 covered with mercurial plaster. The sozoiodolate of mercury in 5-per-cent. powder 
 or ointment (No. 1 10, p. 214) may be advantageously employed instead of the iodo- 
 form. 
 
 If the alopecia syphilitica requires treatment, frictions of 1 : 1000 sublimate solu- 
 tion or of the ointment of ammoniated mercury may be employed. 
 
 Paronychia and onychia are best treated with local sublimate baths, the affected 
 parts being then carefully covered with mercurial plaster. 
 
 For the mucous patches a I : 10000 or 5000 sublimate gargle (No. 1 12, p. 214) is 
 useful, as is also the black wash (No. 1 1 1, p. 214). If they are very extensive, they 
 may be sprayed once a day by the physician with a J-per-cent. sublimate ether, or 
 touched with the nitrate-of-silver stick. 
 

 I rili 
 
SYPHILODERMA ULCEROSUM. 
 
 TYPOGRAVURE. 
 
 COPYRIGHT BY E. B. TREAT i. CO. , N. 
 
 CATHODE RAY DERMATITIS. 
 
 PLATE XX. 
 
INFLAMMATIONS. 
 
 215 
 
 Gummata are never to be opened, no matter how marked the fluctuation may- 
 be; resorption without the formation of scar tissue may occur even under these cir- 
 cumstances. They should be kept covered with the collemplastrum or plaster-mull 
 or the simple mercurial plaster. When ulceration has occurred, the treatment 
 must consist in cleansing, sprinkling with iodoform, and covering with mercurial 
 plaster. When the destructive process is rapid it is sometimes necessary to destroy 
 the infiltrated advancing margin ; this may be effected by boring into it at various 
 places with the nitrate-of-silver stick ; but I prefer to use the galvanocautery or the 
 Paquelin. 
 
 Mercurial stomatitis requires the immediate stoppage of all mercurial medication. 
 A 5-per-cent. chlorate-of-potash solution must be freely employed as a mouth 
 wash; permanganate of potash (No. 113, p. 214) is also useful. The ulcerations 
 should be touched every two or three days with the nitrate-of-silver stick or with 
 a 5-per-cent. chromic-acid solution. 
 
 
 LEPRA. 
 
 Synonyms. — Leprosy, elephantiasis Graecorum, lepra Arabum, Aussatz (Ger.), 
 lepre (Fr.). 
 
 Definition. — A chronic infectious disease, caused by the growth of the lepra 
 bacilli in .the skin, mucosae, the connective tissue of the internal organs and periph- 
 eral nerves, and manifesting itself on the skin by yellowish-brown macules or 
 reddish and bronzed confluent tubercles, together with various paraesthesise and 
 affections of the internal organs, and ending in death from internal complications or 
 marasmus. 
 
 Symptoms and Course. — Leprosy, so common in the civilized world up to the 
 fifteenth century that laws regarding the marriage of lepers were made by Charle- 
 magne, and that so small a country as England contained one hundred and twelve 
 houses devoted to their care, had long been so infrequent that its existence had 
 almost been forgotten when it was rediscovered by Daniellsen and Boeck early 
 last century. It had, however, by no means disappeared. India, China, and Japan 
 had been its main seat, but cases have always existed in the outlying districts of 
 Europe, in Spain, Portugal, Italy, southern Russia, Norway, and the Baltic prov- 
 inces. In the western hemisphere it is now found in Brazil, Guiana, the West Indies, 
 and the Sandwich Islands ; and there are lepers among the Chinese of San Fran- 
 cisco, the Norwegians of the Northwestern States, and the Creoles of Louisiana. 
 Occasional cases are seen here, but they are all importations from countries where 
 the disease prevails. 
 
 Leprosy is a most chronic disease, lasting from five to twenty years before it 
 reaches its fatal termination. Its onset is insidious, indefinite prodromal symptoms 
 appearing for months or years before its definite outbreak. These consist of malaise, 
 
216 
 
 ILLUSTRATED SKIN DISEASES. 
 
 depression, lassitude, anorexia, diarrhea, and general gastro-intestinal disturbance, 
 with occasional febrile attacks of a malarial type. Then comes the prodromal erup- 
 tion, sometimes taking the form of lentil- to hand-sized, irregular, deep-seated 
 infiltrations of a brownish-red color (lepra maculosa), and at others that of serous 
 bullae, that leave ulcerated areas behind (pemphigus leprosus). After one or more 
 of these eruptions there occurs an interval of some months or a year or two before 
 the regular symptoms appear. These take two distinct forms, the tubercular and 
 the anesthetic. 
 
 Lepra tuberosa or tubercular leprosy is the commoner form of the disease, 
 including 60 to 70 per cent, of all cases. After the prodromal macular stage above 
 
 mentioned there appear on the body pea- to bean-sized, 
 isolated, circumscribed, infiltrated spots, which finally be- 
 come elevated into rounded tumors. They increase very 
 slowly in size, and by coalescence finally form large nodu- 
 lar masses. Their color is reddish brown, coppery, or 
 bronze, and their surface is covered with a smooth and 
 shining skin. They appear anywhere on the body, save 
 on the scalp and glans penis ; but the face is always in- 
 volved, and here they cause great and characteristic deform- 
 ity. The nose and upper lip are swollen and infiltrated ; 
 the lower lip and ears are thickened and stiffened ; the cheeks 
 and forehead are occupied by large tuberous masses, and 
 the whole face assumes a sullen, scowling expression (facies 
 leonina). The trunk, the knees, and the dorsal surface of 
 the hands are also markedly affected. Tubercles appear in 
 the mucosae of the nose, mouth, and throat ; the tongue is 
 infiltrated, swollen, and fissured; the voice becomes rough 
 and toneless, and oedema of the glottis may occur ; and there 
 is a peculiar sweet and sickly odor to the breath. The hair becomes dry and falls out. 
 The nodules may be few or many ; they are frequently very painful, and always 
 tender to pressure, so that motion of the parts is greatly interfered with. As they 
 slowly grow in size and coalesce into larger tuberous masses, erysipelas- like attacks 
 occur from time to time, marked with fever, diffuse reddening of the affected areas, 
 and the appearance of new papules or the involvement of the internal organs. 
 This was very noticeable in a case that I had under observation for a long time at 
 Charity Hospital some years ago ; he had several severe attacks of this character 
 each year, each one coincident with an increase of the tubercular eruption. 
 
 After growing slowly for months and years, retrogressive changes finally set in. 
 These may be interstitial in their nature, the mass gradually melting away, leaving 
 dark, pigmented, atrophic areas behind. The cartilages and the bones may thus be 
 destroyed without the appearance of ulceration. Usually, however, that process 
 
 Fig. 112. — Lepra tuberosa. 
 
 Case of Dr. S. Garciadiego, Guada 
 lajara, Mexico. 
 
INFLAMMATIONS. 
 
 217 
 
 Fig. 113. — Lepra mutilans. 
 After Joseph. 
 
 finally sets in, probably occasioned by added exter- 
 nal traumatisms, and flat, dry, and indolent leprous 
 ulcers result. They lead to great destruction of tis- 
 sue; the nose, fingers, toes, and even an entire limb, 
 may be lost (lepra mutilans). The eyes may be de- 
 stroyed by the breaking down of tubercles of the cor- 
 nea and iris; oedema of the glottis may occur; and 
 the facial deformity becomes a terrible one. Marked 
 symptoms of mental deterioration set in, and the pa- 
 tient finally dies from an intercurrent disease, — pneu- 
 monia, phthisis, Bright's disease, etc., — from involve- 
 ment of the internal organs or from general marasmus. 
 The process is an extremely chronic one, frequently 
 lasting for ten or more years. 
 
 Lepra nervorum, anesthetic or macular leprosy, is 
 commoner in the tropics, and is characterized by nerve 
 lesions and subsequent trophic changes in the skin. 
 After a preliminary period, marked by formication, 
 pain, numbness, tenderness in various places, or gen- 
 eral hyperaesthesia of the skin and shooting pains in 
 the nerves, there occurs a gradual loss of sensibility and the power of motion in cer- 
 tain parts. Then appear pale-yellow, circumscribed discolorations of varying size, 
 which spread peripherically, with clearing centers, and coalescing into irregular areas. 
 They finally become atrophic, preternaturally white, wrinkled, dry, and glazed, or 
 covered with a fine desquamation. Complete anaesthesia finally sets in, either limited 
 to the spots or extending over the entire body ; in consequence of which the patients 
 suffer from traumatisms, ending in ulcerative processes that form the mutilating 
 variety of the disease described above. Bullae occasionally appear, leaving anesthetic 
 areas behind. Atrophy and contraction of the muscles go hand in hand with the 
 other trophic processes. The hands become clawed, there is wrist-drop, the face is 
 deformed, the eyelids and mouth cannot be closed, and the tears and saliva flow 
 away. The nails become dark and fall off; the hair loses its luster and falls out. 
 Painful swellings appear along the course of the peripheral nerves. The patient's 
 strength gradually decreases ; ulcerative, pyemic, and erysipeloid complications set 
 in; the intellect is dulled; and death occurs from diarrhea, Bright's disease, phthisis, 
 or general marasmus. The malady is even slower than the tubercular form, lasting 
 from fifteen to twenty years. 
 
 Etiology. — The cause of leprosy is the presence and growth of the specific micro- 
 organism, the Bacillus leprce, in the tissues. First discovered by Hanson in 1880, it 
 has been found in all the various lesions of the disease. That it is transmitted 
 by heredity is very questionable. It is undoubtedly contagious : Father Damien 
 
218 ILLUSTRATED SKIN DISEASES. 
 
 acquired it after devoting himself for years to the care of the lepers on the Sandwich 
 Islands, and Arning successfully inoculated a malefactor in Madeira. But its con- 
 tagiousness differs from that of syphilis, tuberculosis, and the other infectious 
 granulomata in that a very prolonged exposure is required. There is absolutely no 
 danger from the disease under ordinary conditions. Lepers lived for years in the 
 dermatological wards of the Charity Hospital of New York without communicating 
 the disease. As is the case with syphilis, all attempts to inoculate it on animals 
 have failed. 
 
 Pathology. — The lesion of leprosy is a granuloma like that of syphilis and 
 tuberculosis, a round-cell infiltration containing the bacilli and caused by their pres- 
 ence. It is found in the corium of the skin, in the mucosae, the lymphatic glands, 
 kidneys, liver, and other internal organs, and along the course of the peripheral nerves. 
 The bacilli are readily demonstrated in sections of the tubercles ; they are rod-shaped 
 organisms about half the size of a red blood-corpuscle, and are often contained 
 in large cells, the so-called lepra cells. A slight cellular infiltration gives us the 
 macular form of the disease, and a larger accumulation the tubercular. In the nerve- 
 sheaths the bacillus causes a connective-tissue new growth with subsequent degen- 
 eration of the nerve-fibers, an ascending neuritis, and, finally, disease of the central 
 organs. The skin or mucous membrane lesions are always primary, though we do 
 not know the point at which the virus enters the system. 
 
 Diagnosis. — Lepra rarely or never occurs in individuals who have not resided in 
 regions where it is endemic, a point of great value in its earlier and less characteristic 
 stages. When fully developed, whether tubercular, anesthetic, mutilating, or mixed, it 
 can hardly be mistaken for any other disease. The tubercular or tuberculo-ulcerative 
 syphiloderm runs a much more rapid course, and soon undergoes absorption or 
 ulceration ; there are no disturbances of sensibility ; the characteristic location and 
 symmetry of lepra are absent ; other symptoms of syphilis are present, and the reac- 
 tion to antiluetic treatment is marked. Syringomyelia causes deformities of the 
 extremities similar to those of leprosy, but anaesthesia is always absent. Lupus is 
 not so symmetrical, nor are its tubercles so large and varnished. Sarcoma cutis is 
 more generally distributed : it has a quicker course and is rapidly fatal. Morphea 
 and vitiligo show neither hyperaesthesia nor anaesthesia, and are not accompanied 
 by constitutional symptoms. 
 
 Prognosis. — This is entirely- bad ; the malady is slow, but invariably ends 
 fatally. 
 
 Treatment. — Prophylaxis consists in forbidding the intimate contact of leprous 
 with healthy people; but strict isolation, and the barbarous methods too frequently 
 employed to effect it, are entirely unnecessary. Remedial treatment can only be 
 palliative, since all the various remedies that have been recommended have had no 
 effect on the disease. Of these the chief are gurjun balsam, in doses of 75 to 150 
 
INFLAMMATIONS. 219 
 
 grains daily; chaulmugra oil externally, and internally in doses of 3 drops to 1 
 dram thrice daily ; ichthyol and resorcin, internally and externally. Each has had 
 its advocates, but none has stood the test. A change to a climate where the disease 
 is not endemic has a good effect in many cases ; but it must not be forgotten that 
 the malady frequently remains stationary for long periods of time. 
 
 MYCOSIS FUNGOIDES. 
 
 Synonyms. — Granuloma fungoides, eczema tuberculatum, lymphadenie cutanee 
 (Fr.). 
 
 Definition. — A chronic infectious disease of the skin, caused by the growth 
 therein of an as yet unrecognized microorganism, and characterized by the 
 appearance of one or more firm, reddish, fungating tumors, together with various 
 secondary dermal phenomena, and terminating in death from marasmus or 
 complications. 
 
 Symptoms and Course. — This rare disease is regarded by some authorities as a 
 variety of sarcoma, and by others as a lymphadenoma of the skin ; but it is certainly 
 a true infective granuloma. Two distinct stages are usually observed, but in some 
 cases the first one is absent or passes unnoticed. This is the stadium praemy- 
 coticum, in which the symptoms are often indefinite and closely resemble those of 
 other more common skin diseases. Pruritus, either local or general, is very marked, 
 and with it there occur eczematous, erythematous, psoriatic, and urticarial lesions 
 on the skin of the trunk and extremities. The excoriations from scratching still 
 further diversify the picture, and in this stage the malady may remain for months 
 and years. Then there appear flat, irregular or curved, reddish or livid, and itchy 
 infiltrations, which may remain dry or become covered with secretion or scales. 
 This leads to the second, more characteristic stage, the stadium mycoticum. The 
 circumscribed infiltrations, bean- to hand-sized or larger, develop into broad or 
 pedunculated papillary tumors. Their color is pinkish or brownish red, or darker; 
 there may be few or many ; and their papillary and rugose surface may be dry and 
 covered with epithelium, or crusted, or excoriated and secreting. In the latter case 
 a fetid fluid exudes from the tumors and renders the patient an object of disgust to 
 himself and others. Any part of the body may be affected, but the face and neck 
 are especially apt to be involved. The tumors occasionally disappear by resorption, 
 leaving pigmented areas behind ; but new ones continually arise in their place. 
 Enlargement of the lymphatic glandular system now becomes a prominent symptom. 
 The general health finally suffers, diarrhea sets in, and the patient dies of exhaus- 
 tion or intercurrent disease. The malady occurs at all ages, but is most often 
 
220 ILLUSTRATED SKIN DISEASES. 
 
 seen after the fortieth year, and, with the exception of isolated instances in which 
 the first stage is absent, takes a number of years — ten to fifteen — to run its 
 course. 
 
 Etiology. — The exact cause of the disease is unknown, the pathogenic microbe 
 not having yet been isolated. 
 
 Pathology. — The process consists of the development of a granulation tumor in 
 the corium, which does not differ essentially from that of the other infective diseases 
 of this class. 
 
 Diagnosis. — The persistent and violent itching, with the scratch effects, lasting 
 for years, and the appearance and retrogression of the eczema-like infiltrations, are 
 our only diagnostic criteria in the early stages of the disease. These are often not 
 sufficiently characteristic to permit a diagnosis to be made. The indolent papillary 
 tumors of a fully developed case render the diagnosis more easy. Syphilis has no 
 itching, has copper-colored infiltrations, and reacts to antiluetic treatment. Cutane- 
 ous gummata tend to early purulent degeneration, which only occurs exceptionally 
 in the latest stages of mycosis fungoides, more especially after irritation. Lepra has 
 the anaesthesia and other nervous symptoms, the bullae, and the mutilations ; it does 
 not occur here, and the characteristic bacilli can be readily demonstrated. Lupus 
 vulgaris has a rapid involution, and the occurrence of ulceration and scarring is 
 characteristic. 
 
 Prog-nosis. — This is generally unfavorable, more especially in the later stages. 
 Intercurrent erysipelas has cured one case, and Kobner and Marianelli have each 
 reported a cure under arsenic. The earlier the diagnosis is made the better the out- 
 look. 
 
 No. JJ4. Arsenic Solution. No. H5. Sodium Arseniate Solution. 
 
 R: Sol. Fowleri fy Natr. arseniosi . . . . gr. 5 
 
 Aq. cinnamom. . . . aa. p. e. Aq. dest. ..... |i 
 
 Sig. Gtt. 6 to 20 t. d. in water after meals. m. 1 = T ^o grain. 
 
 No. JJ6. Camphor- Naphthol. 
 
 V>L /3-naphthol 1 part 
 
 Camphor pulv. . . .2 parts 
 
 Treatment. — The treatment of mycosis fungoides is not to be regarded as hope- 
 less, in view of the successes noted above. Arsenic must be given, either inter- 
 nally as Asiatic pill (No. 6, p. 46) or Fowler's solution (No. 114, p. 220), or, better, 
 by the hypodermic administration of sodium arseniate (No. 115, p. 220), one half to 
 one syringeful being injected daily into the skin of the back. Naphthol, prefer- 
 ably combined with camphor (No. 116, p. 220), the 10-per-cent. pyrogallol ointment 
 (No. 93, p. 181), and the 10- to 20-per-cent. resorcin ointment (No. 20, p. 64) are 
 recommended as local applications. 
 
INFLAMMATIONS. 
 
 221 
 
 LUPUS ERYTHEMATOSUS. 
 
 Synonyms. — Seborrhea congestiva, lupus seborrheicus s. sebaceus, ulerythema 
 centrifugum. 
 
 Definition. — A small-celled new growth of the skin, appearing as various-sized 
 reddish patches covered with grayish-yellow fatty and adherent scales, ending in 
 interstitial atrophy and cicatrix formation, and sometimes accompanied by general 
 symptoms and terminating in death. 
 
 Symptoms and Course. — When Cazenave gave this malady its name in 185 i his 
 selection was not a happy one ; for there is no relationship between lupus vulgaris, 
 which is a tubercular granuloma, 
 and this circumscribed erythema 
 of unknown origin associated with 
 seborrhea and ending in interstitial 
 atrophy. Hebra, in fact, described 
 it as a congestive seborrhea, and in 
 some of its manifestations it is ap- 
 parently closely related to atrophic 
 rosacea. It begins with one or 
 more primary efflorescences con- 
 sisting of reddish, pinhead- to pea- 
 sized, slightly elevated, shining 
 spots, with small adherent sebor- 
 rheal scales in their centers. When 
 these scales are lifted up one or more 
 minute plugs are found projecting 
 from their under surfaces, which 
 have evidently fitted into the dilated 
 ducts of the sebaceous glands, which 
 are patulous and open. The spots 
 grow slowly by peripheral exten- 
 sion, adjacent lesions unite, and 
 new ones appear at the margins 
 until the disease is fully developed. 
 Two distinct varieties occur, differ- 
 ing from each other in form of invasion and subsequent course. 
 
 The more usual form is that known as lupus erythematosus discoides, in which 
 the primary lesions unite to form one or more sharply circumscribed efflorescences 
 which spread slowly by peripheral extension and by the coalescence of new marginal 
 papules. The advancing edges of the patch are broad, and somewhat elevated ; they 
 
 Fig. 114. — Lupus erythematosus. 
 Case of Dr. R. Abrahams. 
 
 
222 ILLUSTRATED SKIN DISEASES. 
 
 end abruptly toward the sound skin, and slope gradually to the center of the patch. 
 Their color is a vivid red, disappearing under pressure. The center of the patch 
 sinks in and becomes atrophic, ajid finally there is formed a flat, smooth scar, often 
 marked with tortuous and dilated vessels. Seborrheal scales are usually present : 
 they are firmly attached, and on removal show the characteristic plugs projecting 
 from their under surfaces. Comedones and sebaceous accumulations are common 
 in the neighborhood of the lesions, and there is often a marked accumulation of pig- 
 ment in the normal skin near the advancing infiltrated wall. In some few cases the 
 inflammation and infiltration are slight, the margin of the patch is pale and but little 
 elevated, and the scales absent ; but interstitial atrophy of the center of the diseased 
 area always occurs and is a characteristic change. Where there are no sebaceous 
 glands the scales and their plugs are not present ; thus on the palms the affected skin 
 is dry and hard (lupus erythematosus corneus), or cedematous and inflamed. 
 
 The fully developed lesion is rounded or discoid in shape, though it may be 
 gyrate when adjacent areas have united. Its seat is oftenest on the nose and neigh- 
 boring parts, appearing as two symmetrical lateral masses, one on each cheek, with a 
 smaller central connecting portion occupying the bridge of the nose (butterfly lupus). 
 The scalp is frequently affected, and here the atrophic process leads to permanent loss 
 of hair. The lips, eyelids, and ears are not uncommonly symmetrically involved, 
 but the affection is rare upon the trunk. 
 
 The course of lupus erythematosus discoides is exceedingly slow, lasting many 
 years. It may remain apparently stationary for long periods of time. Pallor of 
 the margin shows cessation of the peripheral cell growth, and when cure has taken 
 place a thin, shining, and very superficial scar is left behind. The disease is seen 
 oftenest in women from twenty to forty years of age. Spontaneous ulceration never 
 occurs, and there are no subjective symptoms and no disturbance of the general 
 health ; but the deformity that is entailed is serious. 
 
 Lupus erythematosus disseminatus s. aggregatus is a very much rarer form of 
 the disease, and, though the primary efflorescences are similar to those of the dis- 
 coid form, it runs a very different course and shows all the symptoms of an acute or 
 subacute infective disease. Its onset is accompanied by high fever, even up to 104 
 F., with gastro-intestinal disturbance, pains in the limbs, and headache of marked 
 severity ; with which are sometimes associated inflammatory effusions in the joints. 
 The acuity of the invasion may be such that coma and death may occur therein ; 
 even cases that recover from the first attack suffer from relapses and finally die, and 
 the general mortality from this form of the malady reaches 50 per cent. The con- 
 stitutional symptoms are accompanied by an eruption of the characteristic efflores- 
 cences of the disease, which usually first appear on the face, but soon spread over 
 the body ; they are often well-nigh universal, even the soles and palms being affected. 
 It is characteristic of this form of the disease that, while the lesions are identical 
 with those of the discoid variety, they do not spread peripherically ; the eruption 
 
INFLAMMATIONS. 
 
 223 
 
 comes out as a whole within a short time, and remains stationary. Retrogression of 
 the general symptoms has no effect, however, on the dermal lesions. An intense, 
 persistent, diffuse reddening of the face (erysipelas perstans faciei) frequently results 
 from the acute attacks, and 
 in the worst cases an erup- 
 tion of clear or hemorrha- 
 gic bullae accompanies the 
 process. 
 
 Etiology. — The cause 
 of lupus erythematosus 
 is unknown, but it is 
 undoubtedly a bacillary 
 infectious disease. The 
 French authorities regard 
 it as a tuberculosis, but 
 this can hardly be the case, 
 since tubercle bacilli have 
 not been found, and in- 
 oculation experiments on 
 the lower animals have not 
 succeeded. Seborrhea, ro- 
 sacea, and erysipelas seem 
 to predispose to its occur- 
 rence. Many cases begin 
 as a congestive seborrhea, 
 the symptoms of which 
 frequently remain present 
 throughout the disease; so 
 that there is ground for 
 the assumption of a rela- 
 tionship between the pro- 
 cesses. 
 
 Pathology. — The disease process is a chronic inflammation of the cutis, leading 
 to degeneration, and ending in atrophy. The entire tissue or a part of it is infil- 
 trated with an accumulation of small round cells, often appearing first in the neigh- 
 borhood of the vessels; and the sebaceous glands are always involved and hyperse- 
 creting. The new cells finally undergo fatty degeneration ; the glandular structures 
 atrophy ; the hairs fall out ; and a new connective tissue, which undergoes cicatricial 
 contraction, replaces the destroyed elements. 
 
 Diagnosis. — The broad, somewhat elevated margins of the patch ; the seborrheal 
 scales with processes from their under surfaces dipping into the dilated mouths of 
 
 Fig. 115. — Lupus erythematosus. 
 Case of Dr. R. Abrahams. 
 
224 ILLUSTRATED SKIN DISEASES. 
 
 the glands; the central and very superficial scarring; and the extreme chronicity 
 of the process, are characteristic of lupus erythematosus. Lupus vulgaris has its 
 peculiar brownish-red, soft, deep-seated papules, and usually ulcerates ; the carti- 
 lages are involved ; the malady begins in youth ; and the seborrheal scales and plugs 
 are entirely absent. A rosacea is found in the location that is the favorite seat of 
 lupus erythematosus ; but the dilated vessels, the acne pustules, the absence of sharp 
 limitation and of scarring will serve to distinguish it. Chronic eczema of the im- 
 petiginous or squamous form shows moisture, papules, vesicles, and crusts ; it is not 
 sharply limited and is never followed by scarring. Trichophytosis is rapid in its 
 course, has no infiltrated margin, has a paler center, shows readily detachable 
 scales, is accompanied by itching, and the nibbled-off hairs are characteristic when 
 the scalp is affected. A non-ulcerated serpiginous syphiloderm may resemble lupus 
 erythematosus ; but the marked infiltration, the coppery color, the absence of sebor- 
 rheal scales, with the presence of other luetic symptoms will serve to distinguish it. 
 It seems impossible that psoriasis, with its shining scales and bleeding points, its 
 characteristic seat, and the absence of scarring and loss of hair, should be mistaken 
 for the disease. 
 
 Prognosis. — The general health is not affected in lupus erythematosus of the dis- 
 coid variety, but the prognosis as to cure is always doubtful. Some cases recover 
 even without treatment, while others are most obstinate. In all cases some scarring 
 results. The aggregate form is more serious ; acute exacerbations, with inflamma- 
 tions of the thoracic organs, not infrequently occur, and lead to a fatal termination. 
 
 Treatment. — Phosphorus has been recommended by Bulkley ; and anemia, 
 chlorosis, and other general conditions that may be present must be appropriately 
 treated ; but internal medication is of little use in the disease. In the local treat- 
 ment we must always remember that recovery with a very superficial scar is the 
 rule, and that destructive measures are to be employed only when the milder ones 
 fail. No certain rules can be laid down ; some cases are very sensitive and will bear 
 only the mildest ointments. The following method has been useful to me. After 
 'the removal of the seborrheal scales with soap and water, green soap, preferably in 
 the form of the tincture (No. 5, p. 43), should be rubbed into the patch daily, fol- 
 lowed by the permanent application of mercurial ointment or plaster, or plaster- 
 mull. Duhring recommends the sulphur ointment (Nos. 24, 25, p. 64), and 
 naphthol (No. 48, p. 105, No. 124, p. 243) does well in some cases. Ichthyol in 
 10- to 20-per-cent. strength as salve, paste, plaster, solution, or varnish (No. 72, 
 p. 137, No. 85, p. 165, No. 87, p. 169), or the ichthyol- mercury salve (No. 53, 
 p. 113), are somewhat more irritant but efficacious applications. The 10-per-cent. 
 pyrogallol salve (No. 44, p. 100, No. 93, p. 181) may also be tried; and in cases that 
 can bear it the cade-sulphur-green soap ointment (No. 117, p. 225) is a good appli- 
 cation. 
 
 Obstinate cases may resist all these measures, and we must have recourse to 
 
CHRONIC ECZEMA WITH LICHENIFICATION. 
 
 W ^V^^w 
 
 
 
 § 1 
 
 / W f 
 
 4? 
 
 t. 
 
 TYPOGRAVURE. 
 
 COPYRIGHT, 1902. BY E. B. TREAT A CO., N. Y. 
 
 RHINOSCLEROMA. 
 
 CHROMOPHYTOSIS OF FACE - . 
 
 PLATE LIV. 
 
INFLAMMATIONS. 225 
 
 the more active agents. Iodized glycerin (No. 119, p. 225) may be applied to the 
 part once daily, or lactic acid (No. 1 18, p. 225) as recommended by Joseph may be 
 similarly employed. Some cases require the use of the stronger acids — trichlora- 
 cetic, chromic, nitric, or even sulphuric acid being cautiously applied by means of a 
 glass rod, followed by the use of a soothing ointment. A solution of caustic pot- 
 ash, 1 part to 2 or 4 of water, may be used every fifth day or so, care being taken 
 to prevent too deep an effect by the use of dilute acetic acid immediately afterward. 
 The superficial use of the Paquelin cautery upon the margins of the patch, or " cross- 
 hatching" it with the scarificator (Fig. 15, p. 50), followed by a dressing of pow- 
 dered iodoform, has given good results in some cases. 
 
 No. JJ7. Cade- Sulphur- Green Soap Ointment. No. JJ8. Lactic-acid Solution. 
 
 fy 01. cadini g: Ac. lactici 
 
 Sulph. lot. Aq. destil aa. p. e. 
 
 Sapo. virid. . . . . aa. p. e. 
 
 No. U9. Iodized Glycerin. 
 
 R Iodin. pur. 
 
 Kal. iodidi . . . aa. 1 part 
 
 Glycerin .... 2 parts 
 
 In the diffuse form of the malady local treatment is restricted to cold applica- 
 tions, lead lotions, and the simple ointments (No. 17, p. 61, No. 26, p. 70, No. 29, 
 p. 74, Nos. 68, 69, p. 135). Pallor and diminishing size of the infiltrated margin are 
 the first signs of improvement in the patches ; and they are the signal for us to stop 
 all more irritating measures and go back to green soap and mercurials, or even milder 
 measures. 
 
 RHINOSCLEROMA. 
 
 Definition. — A chronic infectious granuloma affecting the skin of the nose and 
 upper lip, and the nasal and pharyngeal mucosae, and characterized by the forma- 
 tion of permanent, dense, contracting infiltrations. 
 
 Symptoms and Course. — This very rare disease, first described by Hebra and 
 Kaposi in 1870, begins as one or more nodular infiltrations in the nasal mucous 
 membrane or in the skin around the anterior nares. At first isolated, they slowly 
 increase in size, unite into larger tuberous masses, and spread forward on to the 
 upper lip, the alae and the septum of the nose, as well as backward along the floor 
 of the nostril on to the velum, pharynx, soft palate, epiglottis, and even the larynx. 
 Their consistency is peculiarly hard and dense, resembling ivory to the touch ; the 
 skin and mucosa covering them are immovable, and their glandular structures are 
 
226 ILLUSTRATED SKIN DISEASES. 
 
 destroyed. Around the anterior nares the tumors form rounded or oval masses 
 covered with a smooth, brownish-red or pale skin, in which neither hair-follicles nor 
 sebaceous glands are to be found. Here they occasion a characteristic deformity, 
 the nose and upper lip being greatly indurated and thickened, and all the structures 
 flattened, as it were, upon the face. Slight superficial excoriations of the skin over 
 the tumors are sometimes seen, but otherwise they are not subject to any retrogres- 
 sive changes ; once formed, they are permanent. 
 
 The affection is a very chronic one, often lasting for from ten to twenty years, 
 and has been most commonly seen between the ages of twenty and thirty. It in- 
 terferes in no way with the general health ; but the obstruction of the anterior nares 
 finally prevents nasal respiration, and the extension of the process into the fauces, 
 epiglottis, and larynx so interferes with respiration that the patients die therefrom 
 or from intercurrent chest disease. 
 
 Etiology. — The cause of the disease is the bacillus described by Frisch, Cornil, 
 Alvarez, and others. It is an elongated, rod-shaped organism enveloped in an oval 
 capsule, and closely resembles the pneumococcus in appearance. It is found among 
 the connective-tissue fibers of the part, in the lymphatic vessels, and in the peculiar 
 large cells. 
 
 Pathology. — The small- celled infiltration in the corium does not differ from that 
 of the other granulomata in its early stages, but it rapidly develops into a firm con- 
 nective tissue, and even into cartilaginous and bone-tissue. Characteristic giant 
 cells have been described by Mikulicz, and the bacilli mentioned above are always 
 present. 
 
 Diagnosis. — The seat of the tumors, their ivory hardness, the smooth skin cover- 
 ing them, the absence of any retrogressive changes, and the extreme chronicity of 
 the disease, are characteristic. Rhinophyma is a soft, doughy, lobulated tumor of 
 the nose, with enlargement of the sebaceous glands and increase of their secretion, 
 and follows long-standing rosacea. Keloid is rare on the nose, but some of the 
 harder forms might resemble rhinoscleroma closely. Microscopic examination of an 
 excised fragment will, however, show it to be composed of ordinary connective tis- 
 sue, and no bacilli will be found. A syphiloderma is very much less dense, ulcer- 
 ates or undergoes other retrogressive changes, and has a much more rapid course. 
 
 Prognosis. — This is essentially bad ; the growth of the tumor is steady, though 
 slow, and it finally destroys life by its interference with respiration. There is little 
 to be hoped for from treatment, even as regards temporary relief from the deformity 
 and disability. 
 
 Treatment. — Interference should be postponed so long as the patient is not seri- 
 ously inconvenienced by the growth. Complete excision is impossible, on account 
 of its location, and partial removal is always followed by renewed growth. At- 
 tempts may be made to keep the nostrils open by means of tents, metallic or glass 
 tubes, or by the excision of portions of the mass. Temporary good results have 
 
INFLAMMATIONS. 227 
 
 been reported from the use of i-per-cent. sublimate (No. 43, p. 100), and salicylic- 
 acid ointments or pastes (No. 125, p. 243), combined with the internal administra- 
 tion of the latter drug. 
 
 ACTINOMYCOSIS. 
 
 Actinomycosis is very rare as a primary disease of the skin, usually occurring 
 secondarily to actinomycosis of the jaw, to which the ray parasite, the cause of the 
 disease, obtains access through a carious tooth. It appears as one or more deep, 
 subcutaneous, livid nodules, situated most commonly around the jaw or on the neck, 
 which spread, undermine the skin, break down, and finally give vent to a purulent 
 or sanguineous fluid. In this are pinhead- to pea-sized sulphur-yellow bodies, 
 which the microscope shows to be composed of masses of the ray-shaped fungus. 
 The malady is very slow in its course ; it was formerly supposed to always termi- 
 nate fatally from marasmus caused by the long-continued suppuration, or from me- 
 tastasis to the internal organs ; but the prognosis is now regarded as more favorable, 
 spontaneous recovery taking place in many cases, and others remaining stationary 
 for years. The only treatment is the surgical one. The tumors may be laid open 
 and scraped out ; fistulous tracts can be curetted, and the galvano or Paquelin 
 cautery can be freely used. In many cases ordinary antiseptic dressings will suffice. 
 
 3. INFLAMMATIONS OF THE GLANDS. 
 
 Inflammation of the sweat-glands is of rare occurrence, and can be briefly dis- 
 cussed. Inflammations of the sebaceous glands are among the most frequent of 
 dermal affections, including acne, rosacea, and folliculitis. 
 
 HYDRADENITIS. 
 
 Hydradenitis, an inflammatory affection of the sweat-glands, appears as circum- 
 scribed, firm, hard, deep-seated nodules, from pinhead- to pea-size, from the upper 
 surface of which a hard cord, the inflamed duct, can be felt passing to the surface. 
 It is a rare affection, its most usual seat being the face, the genitocrural fold, and 
 the neighborhood of the anus. The inflammatory products usually undergo absorp- 
 tion; more rarely, suppuration and perforation, followed by fistula formation, ensue. 
 It occurs most often in persons affected with hyperidrosis, more especially when 
 complicated with other inflammatory infections of the skin — eczema, ringworm, etc. 
 The treatment is that appropriate to the hyperidrosis or other disease conditions that 
 may be present. The mercurial-carbolic plaster-mull is a good local application, but 
 if suppuration has set in incision is required. 
 
228 
 
 ILLUSTRATED SKIN DISEASES. 
 
 ACNE. 
 
 Synonyms. — Acne vulgaris, Hautfinuc (Ger.), acne (Fr.). 
 
 Definition. — A chronic inflammation of the sebaceous glands and their peri- 
 glandular tissue, characterized by the appearance of multiple, firm, painful, reddish 
 or violaceous papules or tubercles, and of pustules, on the face, back, and other 
 portions of the body. 
 
 Symptoms and Course. — This very common affection is most often seen in persons 
 of dark complexion and with coarse, greasy skins, and is usually associated with 
 
 seborrhea of the dry and 
 oily varieties, and come- 
 do. Sebaceous hyperse- 
 cretion and plugging of 
 the gland orifices are fol- 
 lowed by a follicular and 
 perifollicular inflamma- 
 tion. The lesion begins 
 as a minute, acuminate, 
 hard, reddish papule, in 
 the center of which there 
 is usually a comedo (acne 
 punctata). Increase of 
 the inflammation leads to 
 the formation of pea- 
 sized or larger nodules 
 and tubercles of a reddish 
 or violaceous color (acne 
 papulosa). The inspis- 
 sated sebum is usually in- 
 fected with pus organ- 
 isms ; suppuration begins 
 in the deeper portions, 
 and though no pus may 
 be visible, puncture or in- 
 cision will reveal its presence. Finally the pus reaches the surface, and the lesion 
 becomes an acuminate pustule seated on an infiltrated, inflamed base (acne pustulosa). 
 As the inflammation subsides the pus desiccates into a crust, and when this falls off 
 a small circular or elliptical scar is left behind, for in all but the most superficial lesions 
 the corium is destroyed. Each separate papule and pustule runs an acute course 
 and ends in a few days ; but the constant appearance of new ones prolongs the dis- 
 
 FlG. 116. — Acne punctata. 
 From photograph by the author. 
 
COPYRIGHT, BY E. B. TREAT & CO., N. Y. 
 
 PHOTOGRAVURE 4 COLOR CO., N. Y. 
 
 ACNE. 
 
 PLATE XLI. 
 
ich may 
 
 ■ 
 rata), and oc 
 trations, and dermic ab 
 
 while the irritation of 
 covered with an oily seer 
 
 The erupt i 
 tion. It is found on 
 where the sebaceous * 
 
 and most active, li fl| 
 
 elsewhere, and on the 
 
 hich have no seb 
 glands, it does not occur. 
 seen in both sexes, 
 moner in males than in fern; 
 is a disease of eai 
 
 ;n the pei 
 and the thirtieth 
 
 [] spontaneoi 
 
 Certa./ 
 
 am to be d I 
 
 iphica tli 
 
 isorj 
 
 depressed ci< 
 
 ■ 
 Tubercular, anc j^H 
 
 pat! 
 
 - 
 
 upon 
 
 Acne varii 
 

 
 
 
INFLAMMATIONS. 
 
 229 
 
 ease, which may last for many years. The lesions appear irregularly, and all the 
 various stages are usually present at one and the same time. 
 
 Sometimes the amount of the inflammatory induration is very great (acne indu- 
 rata), and occasionally adjacent nodules and pustules coalesce to form larger infil- 
 trations, and dermic abscesses of varying size result. In the worst cases the skin is 
 covered with scars and sown with inflammatory nodules, pustules, and comedones, 
 while the irritation of the sebaceous glands causes the integuerrent to be constantly 
 covered with an oily secretion of unpleasant odor (acne inveterata). 
 
 The eruption of ordinary acne is symmetrical, though irregular in its distribu- 
 tion. It is found on the forehead, cheeks, chin, and upon the back, the regions 
 where the sebaceous glands are 
 largest and most active. It is rare 
 elsewhere, and on the palms and 
 soles, which have no sebaceous 
 glands, it does not occur. It is 
 seen in both sexes, but is com- 
 moner in males than in females. It 
 is a disease of early youth, occur- 
 ring between the period of puberty 
 and the thirtieth ) T ear, and it usually 
 gets well spontaneously when that 
 age is past. 
 
 Certain varieties of the disease 
 remain to be described. In acne 
 atrophica there is no pus formation ; 
 interstitial absorption of the pro- 
 ducts of inflammation occurs, and 
 depressed cicatrices are formed. 
 Acne hypertrophica is due to the 
 not uncommon development of 
 keloidal outgrowths from the scars. 
 Tubercular, anemic, and marantic 
 patients suffer from acne cachecti- 
 corum, an obstinate affection, in 
 which flat livid or violaceous pap- 
 ules occur rather on the body than 
 
 upon the face, and, though they do not suppurate frankly, leave deep cicatrices be- 
 hind them. Acne varioliformis s. necrotica occurs on forehead, temples, scalp, and 
 the nape of the neck, and appears as pustules that leave deep, variola-like depressions 
 behind. Irritation of the sebaceous glands by certain medicinal substances, either 
 coming into the follicles from without when applied to the skin, or taken internally 
 
 Fig. 117. — Acne pustulosa. 
 
 From photograph by the author. 
 
230 
 
 ILLUSTRATED SKIN DISEASES. 
 
 and excreted through the sebaceous glands, causes an artificial acne. This may 
 occur from the application of paraffin, tar, oil of cade, creosote, petroleum, etc. (acne 
 medicamentosa s. picealis). The internal use of iodine and bromine may have the 
 same result. The iodine acne appears as large conical infiltrations on vivid red bases, 
 
 while bromine causes more extensive infil- 
 trations with suppurative destruction of the 
 follicles and surrounding tissue. These 
 various drugs have been demonstrated in 
 the secretion of the glands. 
 
 Acne in its superficial and slightly 
 marked forms is a trivial disorder, but in its 
 severer ones it is a serious evil. This is 
 more especially the case in the female, since 
 it occurs during the years when marriage is 
 most frequently contracted. It is always 
 a very chronic and often a very obstinate 
 disease. 
 
 Etiology. — Mechanical irritation from 
 inspissated and changed sebum, and infec- 
 tion with pus-cocci, are the immediate 
 causes of the development of the acne 
 lesions. In the acne from the internal use 
 of the bromides and iodides the noxious 
 material is excreted with the products of 
 the glands ; in those from the use of tar, 
 pyrogallol, chrysarobin, etc., it reaches these 
 organs from without. But the real reason 
 of the inspissation and change in secretion 
 is often obscure. The most important fac- 
 tor of all is undoubtedly the advent of pu- 
 berty. The sebaceous glands at that time 
 participate in thegeneral glandular develop- 
 ment, there being a close physiological re- 
 lationship between the genital organs and 
 the skin, as Hyde has pointed out (antlers 
 of the stags, plumage of birds). Uterine 
 diseases and disorders of sexuality are undoubtedly important factors. Gastroin- 
 testinal disturbances, general cachexias, anemia, chlorosis, etc., are the causes of 
 some cases. But acne not infrequently occurs in otherwise perfectly healthy in- 
 dividuals. 
 
 Pathology. — The anomaly of secretion causes a folliculitis of the sebaceous 
 
 Fig. 1 1 8.— Acne bromata. 
 Case of Professor Elsenberg, Warsaw, Poland. 
 
INFLAMMATIONS. 231 
 
 glands, and to this there succeeds a varying amount of perifollicular inflammation, 
 often ending in suppuration. The glands are frequently destroyed, but the hairs 
 are lost only in the worst cases. The deeper-seated nodules and pustules lead to 
 permanent scarring! 
 
 Diagnosis. — The age of the patient, the seat of the eruption on the face and back, 
 the acute course of the individual lesions and the chronic course of the entire malady, 
 the presence of comedones, seborrhea, and dermic abscesses, with the absence of 
 grouping, ulceration, and crusting, sufficiently distinguish the malady. Its diagno- 
 sis from the early pustular syphiloderm is sometimes difficult ; but the latter has 
 greater infiltration, is copper- colored, affects the whole body, and often the palms 
 and soles, is grouped, and is almost always associated with other syphilitic symp- 
 toms. The tertiary pustular lesion of syphilis is grouped and has characteristic crusts 
 and spreading ulcerations. Variola sometimes resembles an acne ; but the umbilica- 
 tion of the pustules, their acute course, and the presence of general symptoms should 
 prevent mistakes. Rosacea occurs almost always after the thirtieth year, affects 
 the middle two thirds and not the sides of the face or the back, and shows marked 
 hyperemia and dilated vessels; and, though acne pustules are frequently present, 
 there is no danger of confounding the two diseases. 
 
 Prognosis. — This is good ; spontaneous recovery occurs in most cases before 
 the twenty-fifth year, and few last beyond the thirtieth. Successful treatment 
 depends much on our ability to discover and remove the cause. Permanent cica- 
 trices and keloidal scars occur in some cases. 
 
 Treatment. — The removal of the cause of the acne, if such can be found, is the 
 first essential of successful treatment. Dyspepsia and constipation must be carefully 
 attended to, saline cathartics and the laxative mineral waters being regularly em- 
 ployed. Anemia and chlorosis must be treated with iron, bitter tonics, and the 
 mineral acids; and here Startin's mixture (No. 19, p. 64) is especially serviceable. 
 The uterine functions must be carefully inquired into and any anomalies corrected. 
 The use of iodine, bromine, and their salts must be stopped, and external irritants, 
 dust, tar preparations, etc., must be kept away from the skin. The diet should be 
 carefully regulated, and usually much restricted, more especially as regards meats. 
 Confectionery, pastry, pickles, etc., must be entirely forbidden. Obstinate cases 
 should be restricted to a diet of fish, fruit, and light vegetables, and it is sometimes 
 necessary to put our patients on a strict milk diet. The care of the general health 
 is of the utmost importance ; fresh air, bathing, and exercise must be sufficiently 
 provided for. An excellent general measure is the daily sponging of the body with 
 salt water as cool as can be borne, followed by a vigorous rubbing with a rough 
 towel. 
 
 Internal treatment directed to the acne itself is not of much use. Ichthyol in 
 pill form has seemed to do good in some cases (No. 120, p. 232). Cod-liver oil is 
 effective in the frankly suppurative cases. 
 
232 ILLUSTRATED SKIN DISEASES. 
 
 Local treatment is our main reliance, and of the many methods that have been 
 advocated, the use of the curette, combined with massage and friction, is, in my 
 experience, the best. The first step is to remove all comedones with the extractor 
 (Fig. 1 6, p. 50), or by lateral pressure with the flat metallic handle of the scarifica- 
 tor or other instrument. A watch-key is a very inappropriate instrument for the pur- 
 pose, since it cannot be kept clean and unnecessarily injures the skin. Then all nod- 
 ular masses and pus collections must be thoroughly opened with the spud (Fig. 23, 
 p. 51) or a tenotomy knife, care being taken to go deep enough to open up the 
 infiltrations. Multiple punctures are required in the more extensive infiltrations, 
 and even when no pus is obtained the opening up of the inflamed tissues and the 
 slight hemorrhage do good. The entire affected skin must be thoroughly worked 
 over with the dermal curette (Figs. 18, 19, 20, p. 50), the tops of all papules and 
 infiltrations being torn off and the superficial epidermis and sebum removed. This 
 process of comedo extraction, puncture, and curetting must be repeated once in 
 three to ten days, in accordance with the sensitiveness of the patient's skin. 
 
 No. 120, Ichthyol Pills. No. J2I. Lassen's Peeling Paste. 
 
 R Ammon. sulph-ichthyolat. . 3iii R /3-naphthol ... 1 part 
 
 Extr. glycyrrhiz. . q. s. ft. pil. No. 90 Sulph. praecip. ... 5 parts 
 
 Sig. 2 to 4 t. d. Petrolati 
 
 Sapon. virid. . . aa. 2 " 
 
 Meantime the patient must employ certain auxiliary measures. Once or twice 
 daily, or every other day, steaming, massage, and friction of the face must be per- 
 formed, to stimulate the muscular structures of the skin and prevent the accumu- 
 lation of epidermis, sebum, and dirt in the glandular orifices. With the head bent 
 over a basin of steaming hot water, the face must be bathed continuously with a 
 clean sponge or cloth for from fifteen to twenty minutes. The face is then vigor- 
 ously rubbed with the tincture of green soap (No. 5, p. 43), washed off, and anointed 
 with a mild sulphur ointment (Nos. 24, 25, p. 64). 
 
 These measures will suffice in the milder cases ; but many severer ones are met 
 with, in which the papules, pustules, and dermic abscesses continue to appear, and 
 more radical measures are required. A peeling paste must be employed, to cause 
 a desquamation of the epidermis and remove the accumulated material from the 
 skin. I have found the one suggested by Lassar (No. 121, p. 232) efficacious ; it 
 should be spread over the face as thick as the back of a table-knife, and allowed to 
 remain on for half an hour or until vigorous burning sets in. It is then wiped off 
 with a soft cloth, and cold-cream (No. 69, p. 135) or simple ointment (No. 26, p. 70) 
 applied, followed by a powder (No. 18, p. 61). This is repeated daily for from 
 four to six days, until redness, swelling, and tension of the skin, followed by des- 
 quamation, set in. Then a mild powder or ointment is employed for a number of 
 days ; and the process is repeated as often as may be necessary. The resorcin-sali- 
 
COPYRIOHT BY E. B. TREAT 4 CO., N. Y. PHOTOGRAVURE AND COLOR CO., N. Y. 
 
 ROSACEA 
 
 PLATE XLII. 
 
J 
 
 -sulphur pa.-- 
 sublimate solul 
 
 Other lo 
 icht 
 
 the sulphur ; 
 curetted should be c< 
 which hastens the ab- 
 
 
 
 ft 
 
 Relapses are very prone to c c 
 ment of the cause underlyi 
 the skin. For this latter objec r 
 soap and plenty of hot wai 
 
 Synonyms. — Acne rosacea, 
 ■/ rosee, t 
 Definition. — A chr 
 
 the nose, cheeks, and chin, char-, 
 
 integument of ti 
 Symptoms and Course 
 I oration of the skin 
 time to time after the ingest 
 coughing, excitement, e 
 and somewhat smooth skin 
 dusky red and cold wher 
 course. In its first and s 
 to the !. 
 manent and has spread c 
 
 reddish < 
 
 >me case 
 Most cases i 
 where wine 
 

INFLAMMATIONS. 233 
 
 cylic-sulphur paste can be used in the same way (No. 42, p. 100), or the i-per-cent. 
 sublimate solution may be employed. 
 
 Other local applications that can be recommended are the 5- to 10-per-cent. 
 ichthyol salves, pastes, and varnishes (No. 85, p. 165, Nos. 87, 88, 89, p. 169), and 
 the sulphur lotion (No. 122, p. 233). Extensive hard infiltrations that cannot be 
 curetted should be covered with the emplastrum or collemplastrum hydrargyri, 
 which hastens the absorption of the inflammatory material. 
 
 No. J22. Sulphur Lotion. 
 
 fy Sulphur, prsecip. 
 
 Aq. amygdal. . . . aa. 1 part 
 Aq. calcis ... 5 parts 
 
 Relapses are very prone to occur. We must endeavor to prevent them by treat- 
 ment of the cause underlying the acne and by careful attention to the hygiene of 
 the skin. For this latter object the chief means is the free use of a good non-irri- 
 tant soap and plenty of hot water. 
 
 ROSACEA. 
 
 Synonyms. — Acne rosacea, brandy or wine nose, Kupferfinne, Kupfemase (Ger.), 
 acne rose'e, couperose (Fr.). 
 
 Definition. — A chronic inflammation of the skin of the face, more especially of 
 the nose, cheeks, and chin, characterized by the presence of diffuse redness, dilated 
 blood-vessels, and inflammatory papules and pustules, and ending in hypertrophy of 
 the integument of the part. 
 
 Symptoms and Course. — This common affection begins as a diffuse hyperemic 
 discoloration of the skin of the nose, chin, cheeks, and forehead, which occurs from 
 time to time after the ingestion of food, and especially of alcohol, and after laughing, 
 coughing, excitement, exposure to cold, etc. Its color is bright red, with a tender 
 and somewhat smooth skin, when the hyperemia is mainly arterial ; and bluish or 
 dusky red and cold when it is venous. Three stages are to be distinguished in its 
 course. In its first and slightest form the diffuse pink or dusky redness is confined 
 to the nose and disappears on pressure. In the second stage the redness is per- 
 manent and has spread on to the forehead, cheeks, and chin. The smaller arterioles 
 and veins are permanently dilated and appear on the surface as minute tortuous 
 reddish or bluish lines. Inflammatory nodules and pustules now appear, and form 
 in some cases so prominent a part of the disease that it is often called acne rosacea. 
 Most cases do not go beyond this stage ; but sometimes, especially in the countries 
 where wine or beer is the daily beverage, the third stage of rhinophyma or 
 Pfundnase completes the cycle of changes in the integument of the face. Over- 
 
234 
 
 ILLUSTRATED SKIN DISEASES. 
 
 growth of the connective tissue of the skin is added to the hyperemia, vascular dila- 
 tation, and acneform manifestations. Small outgrowths appear on the nose, and 
 gradually enlarge and coalesce until they form violaceous or livid, pedunculated or 
 sessile tumors and masses of varying size. The sebaceous glands become 
 
 enormously enlarged, and the dilated ducts 
 are plugged with dark, hard masses of inspis- 
 sated sebum. In the worst cases the deform- 
 ity is a very serious one, and the discolored 
 hypertrophic mass hangs down in front of the 
 mouth. On the cheeks and forehead the 
 connective-tissue hypertrophy is usually not 
 marked, and the process remains in the second 
 stage. This third stage of rosacea is, strange 
 to say, found in the male subject only. 
 
 Seborrhea of the dry or the oily variety 
 is a regular accompaniment of rosacea, and 
 forms a marked feature of the last or hyper- 
 trophic stage. The inflammatory follicular 
 and perifollicular lesions are essentially the 
 same as those of acne, and the papules and 
 pustules are sometimes so numerous that the 
 diagnosis between the two affections is diffi- 
 cult. Suppuration of the glands and follicular abscesses also occur. 
 
 Etiology. — Rosacea has many causes, and in a general way is due to anything 
 that causes congestion of the head. The commonest of these causes is the abuse of 
 alcohol ; but it is by no means the only one, and the malady occurs on many people 
 who do not drink at all. Chronic dyspepsia, especially when associated with gastric 
 dilatation, often determines its appearance ; and since drinkers usually suffer from 
 this affection, there are two causes for the rosacea in these cases. Sexual dis- 
 turbances, and more especial!}- uterine derangements (endometritis, dysmenorrhea, 
 etc.), are efficient causes and account for many of the cases seen in women. Sud- 
 den changes of temperature, such as firemen, cooks, etc., are subject to, are also 
 causative, and more or less rosacea is generally present in those whose occupation 
 exposes them to the weather — coachmen, sailors, etc. Parts that have once been 
 frozen are especially liable to become rosaceous. 
 
 Pathology. — The process is in the beginning a hyperemic stasis, affecting both 
 the deep and the superficial vessels of the skin. This is followed by a hypertrophy 
 and overgrowth of these structures, which is so characteristic a feature of the dis- 
 ease that the malady might be classed as a vascular new growth. Inflammation of 
 the glands and the periglandular tissue ensues, and a connective-tissue new growth 
 gives us the final stage of the disease. 
 
 Fig. ng. — Rhinophyma. 
 
 Case of Dr. F. B. Carpenter. 
 
INFLAMMATIONS. 235 
 
 Diagnosis. — This is usually readily made, in spite of the varied appearance of the 
 malady. The mature age of the patient, the localization of the eruption upon the 
 face, and the vascular and connective-tissue overgrowth are characteristic points. 
 Rhinophyma is not likely to be confounded with rhinoscleroma, which is a very 
 hard, smooth, and shining tumor, usually growing from the interior of the nose and 
 affecting the skin only secondarily. Lupus vulgaris shows the characteristic non-ele- 
 vated, soft, brownish nodules, and has a distinct limitation, ulceration, and a scar-tissue 
 formation in which the tubercles are found. Lupus erythematosus is of slow growth, 
 has infiltrations covered with adherent fatty scales with plugs projecting from their 
 under surfaces, and central scarring. The tubercular syphiloderm has dark-brown 
 grouped tubercles and ulceration, and never shows vascular overgrowth or glandular 
 inflammation. Acne papules and pustules commonly occur with rosacea; but acne 
 is not limited to the face, being found also on the back and chest ; it is accompanied 
 by comedones and inflammatory lesions, and there is no vascular hypertrophy. 
 
 Prognosis. — This is good in mild cases, more especially when the cause can be 
 removed. Much depends upon the energy with which an appropriate treatment is 
 carried out. The diffuse redness is harder to remove than the newly formed vessels 
 and connective tissue. 
 
 Treatment. — A necessary preliminary to all measures directed against the rosa- 
 cea itself is the treatment of any internal abnormality that may be present — more 
 especially dyspepsia, and allied diseases of the gastro-intestinal tract, and uterine 
 derangements. The use of alcohol must be entirely forbidden, and tea and coffee 
 must be taken but sparingly. Very little can be done for the cases in which the 
 rosacea is dependent upon the patient's occupation and in which the cause cannot 
 be removed. In those necessarily exposed to the effects of wind and weather, or 
 heat, our best efforts will be merely palliative. Ichthyol in i- to 3-grain pills thrice 
 daily has been recommended (No. 120, p. 232). Ergot in half-dram doses twice or 
 thrice daily for long periods has done good in my hands, probably on account of its 
 vasoconstrictor properties. 
 
 The local treatment for mild cases is similar to that recommended for acne. We 
 must distinguish between the arterial and the venous form of rosacea in our choice 
 of topical remedies. In arterial rosacea, with a hot, dry skin, sulphur in 10-per-cent. 
 paste or salve, or ichthyol in 5- to 10-per-cent. solution, ointment, paste, collemplas- 
 trum, or varnish (No. 72, p. 137, Nos. 87, 88, 89, p. 169, etc.), may be ap- 
 plied nightly, a bland ointment or cold-cream (Nos. 68, 69, p. 135), followed 
 by a powder (No. 18, p. 61), being used during the day. If the skin becomes too 
 much inflamed the zinc-oil (No. 65, p. 135) should be employed until the irritation 
 subsides. 
 
 Destruction of the dilated blood-vessels is necessary in all advanced cases, and 
 may be effected in a variety of ways. If there are very many minute vessels visible, 
 scarification may be employed, a limited area being " cross-hatched " in the artist's 
 
236 ILLUSTRATED SKIN DISEASES. 
 
 manner daily or every few days. An ordinary bistoury or the scarificator (Fig. 15, 
 p. 50) may be employed. Larger vessels should be split open lengthwise with a 
 tenotomy knife, a very efficacious method of obliterating them. A small galvano- 
 caustic point may be employed for the same purpose, a number of minute punctures 
 being made along the course of the vessel, thus destroying it. Electrolysis has 
 proved very serviceable in my hands, multiple punctures being made along the 
 course of the vessel with the needle in the manner described under the treatment of 
 hirsuties (p. 49). A very small amount of current, 2 to 5 milliamperes, suffices to 
 occlude the vessel. 
 
 FOLLICULITIS, 
 
 Synonyms. — Sycosis non parasitica, sycosis coccygenes, perifolliculitis, mentagra, 
 Bartfinne (Ger.), sycosis non parasitaire (Fr.). 
 
 Definition. — A chronic suppurative inflammation of the hair-follicles and neigh- 
 boring tissue, chiefly affecting the beard, and characterized by the appearance of 
 papules, tubercles, and pustules pierced by hairs. 
 
 Symptoms and Course. — Folliculitis begins with the appearance of small, red, 
 hard, conical papules surrounding hairs, and scattered through the affected area or 
 collected into groups. The papules are usually discrete, and they may increase in size 
 so as to form tubercles and deeper nodules ; but as a rule the fluid exudation becomes 
 sufficient to form a pustule. In the papules the centrally implanted hairs are firmly 
 seated, and are removed only with pain ; the entire sheath is swollen and white or yel- 
 lowish from infiltration with pus-cells. In the fluid of the pustules the hair and its 
 sheath lie loose ; the pilous structure can be readily removed, and sometimes falls 
 out of itself. The pus may be evacuated or it may dry up into a crust ; in any case 
 the hair-follicle is destroyed and cicatricial tissue results. The continuous appear- 
 ance of new papules in crops among the old ones may lead to the formation of more 
 extensive infiltrations, in which the single papules can no longer be seen, and whose 
 surface is covered with pustules and crusts pierced with hairs. Considerable losses 
 of tissue may thus occur. Burning and itching, sometimes very considerable, ac- 
 company the process. 
 
 The malady is a very chronic one ; advancing irregularly with the appearance of 
 new papules, it may last for years confined to a limited area, or it may slowly spread 
 over extensive surfaces of integument. Fully developed cases show a reddened, 
 swollen, infiltrated skin covered with papules, pustules, crusts, and scales, and the 
 entire hairy portion of the face is usually affected symmetrically. Sooner or later 
 most of the hair-follicles are destroyed and their place is taken by cicatricial tissue. 
 Old cases show a more or less completely cicatricial surface, in which there may remain 
 a few scattered and badly nourished hairs. 
 
 Folliculitis is commonest on the bearded face and the mustache, but it may ap- 
 
COPYRIGHT BY B. 6. TREAT A CO., N. Y. PHOTOGRAVURE 4 COLCR CO., N. Y. 
 
 PERIFOLLICULITIS BARBAE. 
 
 PLATE XXXV. 
 
h 
 
 the mali 
 
 variety of the barber', 
 en. 
 Etiology.- - 
 
 ; 
 le hair-. with 9[ 
 
 pus-cocci, most con ■ 
 
 neans of brushes, tow- 
 
 of the skin by h 
 
 aps, p<:. 
 Mctics, i he ^H 
 
 or that predisposes tl 
 
 ■ o their reception. Ec- 
 
 i is a not infrequent 
 
 prelude to the appearance 
 
 the disc ; 
 
 onic rhinitis that so com- 
 monly coexi: 
 affection upon 
 
 lip is indi ! ^^^B 
 
 for the folliculitis. 
 
 Pathology. — T I 
 case is an acute suppura- Hi 
 
 • inflammation 
 folh ■illcular 
 
 .structures, leading to the 
 destruction of the hai 
 
 which varies in am 
 The term " non-parasitic syc 
 
 Diagnosis, — Tl 
 
 pierced by an a 
 
 the very chronic cour 
 
 beard, or para 
 
 I 
 
 

INFLAMMATIONS. 
 
 237 
 
 pear in any locality that is provided with strong hairs. It is found in the eyebrows 
 and lashes, and occasionally occurs in the nostrils, and on the axillae, pubis, and other 
 portions of the body. It is rarest upon the head. It occurs almost invariably in 
 the male sex, being one 
 variety of the barber's itch 
 of laymen. 
 
 Etiology. — Folliculitis 
 is caused by the infection 
 of the hair-follicles with 
 pus-cocci, most commonly 
 by means of brushes, tow- 
 els, pillows, etc. Irritation 
 of the skin by heat or cold, 
 noxious soaps, powders, 
 or cosmetics, etc., is the 
 factor that predisposes the 
 soil to their reception. Ec- 
 zema is a not infrequent 
 prelude to the appearance 
 of the disease, and the 
 chronic rhinitis that so com- 
 monly coexists with this 
 affection upon the upper 
 lip is indirectly responsible 
 for the folliculitis. 
 
 Pathology. — The dis- 
 ease is an acute suppura- 
 tive inflammation of the 
 follicular and perifollicular 
 structures, leading to the 
 
 destruction of the hair-follicles and papillae. The gaps are filled with cicatricial tis- 
 sue, which varies in amount with the depth and extent of the destructive process. 
 The term " non-parasitic sycosis" is a misnomer, since the disease is due to cocci- 
 genic infection. 
 
 Diagnosis. — This is usually not difficult. The minute papules and pustules, each 
 pierced by an apparently unaffected hair, usually beginning on the upper lip, and 
 the very chronic course, are characteristic. Trichophytosis barbae, ringworm of the 
 beard, or parasitic sycosis, is more acute, progresses continuously, often shows ring- 
 worm on other parts of the body, has round, sharply limited affected areas or deep 
 nodular and suppurating masses ; the hairs are early affected, becoming loose and 
 brittle, and break off with frayed ends ; the malady is contagious ; and the parasite 
 
 Fig. 120.— Folliculitis barbae. 
 
 From photograph by the author. 
 
238 
 
 ILLUSTRATED SKIN DISEASES. 
 
 can be readily demonstrated under the microscope. Eczema may occur with follicu- 
 litis ; when it appears alone it shows moist, red, not sharply limited surfaces, cov- 
 ered perhaps with scales and scabs ; and the isolated lesions are not pierced by hairs. 
 
 Acne occurs on the non- 
 bearded parts, chiefly in young 
 persons ; and the lesions are 
 not situated around hairs. The 
 tubercular syphiloderm has 
 copper-colored infiltrations of 
 slow development, and causes 
 no pain ; ulceration and other 
 syphilitic symptoms are pres- 
 ent, and it reacts to specific 
 treatment. 
 
 Prognosis. — This is not en- 
 tirely favorable ; the malady is 
 curable, but relapses are fre- 
 quent. It may last for a few 
 weeks or for many years. The 
 greater the amount of suppu- 
 ration, the more destruction of 
 tissue will there be. 
 
 Treatment. — The treat- 
 ment is a local one, and con- 
 sists, in the first place, in treat- 
 ing the eczema or the rhinitis 
 that may be at the base of the disease. The hair over the affected area should be 
 cut short, shaving being painful and tending to spread the infection. Crusts and 
 scabs must be removed with compresses of olive-oil or poultices, aided by the use 
 of the tincture of green soap when necessary (No. 5, p. 43). 
 
 Irritation of the skin should be allayed by a simple or cooling ointment (No. 26, 
 p. 70, No. 29, p. 74, Nos. 68, 69, p. 135). Later on diachylon ointment (No. 71, 
 p. 136) or Lassar's paste (No. 2, p. 43) is useful. In bad cases the resorcin-salicylic- 
 sulphur paste (No. 42, p. 100) or the tannin-sulphur paste (No. 50, p. 108) should 
 be applied until peeling occurs. The salicylic-sulphur paste (No. 79, p. 153) has 
 done me good service in some cases. The combination of 1 or 2 per cent, of the 
 oleate of mercury with simple ointment is also efficacious. 
 
 In all the severer cases removal of the hairs becomes necessary. This can be 
 readily effected without pain, as soon as suppuration has loosened the hair, by 
 means of the epilating forceps (Fig. 22, p. 51); one hair is seized at a time, and 
 removed by a sudden sharp traction. The hair-root and -sheath are infiltrated 
 
 Fig. 121.— Folliculitis. 
 
 From a cast by the author. 
 
INFLAMMATIONS. 239 
 
 with a multitude of pus-cocci ; epilation removes them and opens the follicle for the 
 exit of pus and for the entrance of medicaments. It must be systematically carried 
 out, together with the other treatment; in most cases it is sufficient to remove all 
 the hairs seated in pustules once or twice a week. 
 
 4. INFLAMMATIONS OF THE NAILS. 
 
 The nails are non-vascular structures, and the inflammatory processes that affect 
 them take place in the nail-bed, the falx, arid the matrix ; the nail itself being only 
 secondarily involved. The process may be primary and idiopathic, or it may occur 
 secondarily to inflammatory or parasitic diseases of the general integument. 
 
 ONYCHIA. 
 
 Inflammation of the nail-bed occurs rarely as an idiopathic affection, as from 
 traumatisms ; more frequently it forms a part of other inflammatory skin affections, 
 such as psoriasis, eczema, the syphilodermata, etc. The nails become thickened, 
 lusterless, and furrowed, and the nail-bed becomes inflamed and tender. The ap- 
 pearance of the affected nail itself is rarely characteristic, and we must usually rely upon 
 the symptoms of disease that are generally present at other points for the diagnosis. 
 The treatment should consist in the removal of the cause, where that is ascertainable, 
 the relief of tension by incisions, or possibly by the removal of the nail, followed by 
 an iodoform or boric-acid dressing. The further treatment is that of the underlying 
 disease. 
 
 Onychia maligna is a chronic or acute inflammation of the nail- bed occurring in 
 debilitated and cachectic individuals, more especially in children affected with chronic 
 inflammations of the glands or mucous membranes (so-called scrofulous or stru- 
 mous individuals). It is possibly due to a local tubercular infection. The nail is 
 thickened, opaque, discolored, and raised from its bed ; the matrix and falx are in- 
 flamed, and suppuration may occur ; and after the nail is loosened or cast off the 
 bed undergoes an ulcerative or granular inflammation. The affection is very pain- 
 ful, and several nails, either at one time or consecutively, are usually involved. 
 The nails are usually lost, and are replaced either by a deformed and irregular organ, 
 or by cicatricial tissue ; occasionally the whole phalanx is destroyed. The local 
 treatment consists in the removal of the nail and the treatment of the affected area 
 by general surgical measures, together with tonic treatment. 
 
 Paronychia, whitlow, inflammation of the tissues around the nail-bed, occurs 
 occasionally spontaneously from excessive growth of the nail, but is more commonly 
 caused by pressure, as of improper footwear. One of the upper angles of the great 
 toe-nail is usually affected. Hypertrophy of the nail is generally present, and will 
 
240 ILLUSTRATED SKIN DISEASES. 
 
 be considered under its appropriate heading. The treatment consists in the relief 
 of pressure, the repression of exuberant granulations with the nitrate-of-silver stick, 
 the use of sedative or astringent ointments, iodoform, etc. (No. 29, p. 74, No. 54, 
 p. 113, Nos. 68, 69, p. 135). If ingrowing toe-nail is present, it must be appro- 
 priately treated. 
 
 ONYCHOMYCOSIS. 
 
 All the parasitic affections of the nails look so much alike that they may be con- 
 sidered under one heading. The nails lose their gloss and become spotted and dirty 
 yellow; they are ridged, furrowed, and brittle. The prognosis as to the preserva- 
 tion of the nail in bad cases is doubtful. In favus the anterior ends become thick- 
 ened, and chip or split off, and dust-like masses of parasite are visible under them ; 
 but the diagnosis here also must be made from the presence of the disease elsewhere, 
 since in the nail itself the fungus is difficult to demonstrate. The frequent use of 
 hot water, green soap, and a stiff brush is useful in all cases. The treatment for 
 ringworm of the nails consists in thorough scraping, followed by the application of 
 sulphurous acid or the hyposulphite of soda (1 to 4 of water) on lint covered with 
 oiled silk. In favus the nails may be soaked in a warm 40-per-cent. solution of caus- 
 tic potash, and then scraped, and a parasiticide ointment applied (No. 74, p. 138, 
 No. 37, p. 82, etc.). The i-per-cent. sublimate collodion is also useful. 
 
CLASS IV. 
 HYPERTROPHIES. 
 
 In this class of dermic changes the cells of the whole or of certain elements of 
 the skin are increased in number. The epidermis alone may be affected, as in cal- 
 lositas ; the papillae may be also involved, as in warts ; the pigment may be increased, 
 as in chloasma; the hair may be multiplied, as in hypertrichosis; or the connective 
 tissue may be chiefly involved, as in elephantiasis. 
 
 U HYPERTROPHIES OF THE EPIDERMIS. 
 
 These may be congenital or acquired, general or local, and include ichthyosis 
 and keratosis, callus, callositas, clavus, verruca, cornu cutaneum, and the acuminate 
 condyloma. 
 
 ICHTHYOSIS. 
 
 Synonyms. — Xeroderma, lichen pilaris, keratosis pilaris, fish-skin disease, Fisch- 
 sclmppenkranklieit (Ger.), ichtJiyose (Fr.). 
 
 Definition. — A congenital deformity of the skin, characterized by dryness and 
 scaliness of the epidermis, and sometimes by horny, acuminate papules, plates, or 
 larger warty masses. 
 
 Symptoms and Course. — Ichthyosis is a deformity and not a disease. In its 
 commonest and mildest form (xeroderma) the skin is rough, dry, slightly 
 thickened, and its natural furrows are exaggerated; it is pearly white in 
 color, and its surface is covered with a slight furfuraceous desquamation. The 
 change may be so slight as to be discovered only accidentally. In some cases the 
 epithelial accumulation occurs mostly around the hair-follicles, giving rise to small, 
 acuminate, horny masses either surrounding a hair or containing a small curled-up 
 hair within them (lichen s. keratosis pilaris). A somewhat severer form is known as 
 ichthyosis simplex, in which the epithelial formation is so rapid that the scales ac- 
 cumulate as polygonal, dry, white or pearly scales or plates, giving the surface a tes- 
 
 241 
 
242 ILLUSTRATED SKIN DISEASES. 
 
 sellated appearance (ichthyosis serpentina). Here the color is darker and may even 
 be brownish or greenish black. The scales are attached with moderate firmness, but 
 they can be removed without causing bleeding. The nails are friable and thickened, 
 and the scalp is scaly, as in seborrhea. 
 
 Ichthyosis hystrix is rare, and is rather a distinct form than an advanced stage 
 of the preceding. Here the corneous scales accumulate to form rough, irregular, 
 heaped-up masses of tissue, spines, or larger warty eminences, projecting half an inch 
 or more above the surface, and yellow or brownish black in color. The scales and 
 masses are occasionally shed, as if by a process of moulting ; but they soon reaccumu- 
 late. Extreme instances of the deformity pose as curiosities under the name of por- 
 cupine or hedgehog men; the Lambert family was a notable example during the 
 last century, three generations having been affected. Ichthyosis congenita com- 
 mences in intra-uterine life. The children are born small and puny, the entire body 
 being covered with horny plates and scales, traversed by deep fissures, and looking 
 like a covering of armor. The growing fetus has split and fissured the resistant 
 integument ; the lips, eyelids, and external ears are wanting, and the fingers and 
 toes are cramped and bent by the unyielding skin. These cases live only a few 
 days, dying from the loss of heat, impossibility of suckling, etc. 
 
 Ichthyosis may extend over the entire skin, or it may be localized ; but the 
 extensor surfaces of the limbs are always most affected, and the deformity may be 
 present in these locations only. The backs of the hands and feet are often involved, 
 as are also the thighs, shoulders, and trunk. The face, palms, and soles are often 
 free. In bad cases, however, ectropion and deformity of the lips ensue from the 
 unyielding texture of the skin. The simple forms are usually more or less general, 
 but ichthyosis hystrix is rarely symmetrical, and the lesions often follow the track 
 of the cutaneous nerves. 
 
 A marked feature of the disease is the diminution in the secretion of both the 
 sebum and the sweat. Yet the general health of these patients is good even in 
 advanced degrees of the affection. As a rule no sign of it is visible at birth, but it 
 appears during the first or second year, showing first at its points of election, the 
 elbows and knees. It gradually advances until puberty is reached, at which time 
 there is often a marked increase in its severity ; and thereafter it is but little subject 
 to change. It improves in summer, when the sweat-glands are more active, and 
 gets worse in the winter. 
 
 Etiology. — Ichthyosis is a congenital deformity, the real cause of which is entirely 
 unknown to us. It is often hereditary, either in the direct line, or in alternate gen- 
 erations, or by a collateral branch ; sometimes one sex only in a family is affected. 
 It is very common in Paraguay, and in the Moluccas 5 per cent, of the male popu- 
 lation is said to show its manifestations. 
 
 Pathology. — The process is a true hyperkeratosis. Robinson found the corne- 
 ous layer hypertrophied, consisting of many superimposed layers of cells, and the 
 
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HYPERTROPHIES. 243 
 
 sebaceous glands imperfectly developed ; the other elements of the skin were unaf- 
 fected. The dark color of the scales is due to increased pigment formation and 
 extraneous particles. In ichthyosis hystrix the papillae are surmounted by dense 
 epidermoidal cones. 
 
 Diagnosis. — This hardly ever presents any difficulties. The hereditary history 
 and the development soon afterbirth; the dry, rough, furrowed skin of xeroderma; 
 the horny papillae of keratosis pilaris; the plates and scales of simple ichthyosis; 
 and the warty outgrowths and more extensive keratoses of the hystricoid form, are 
 characteristic. The absence of inflammatory symptoms and of the peculiar primary 
 lesions will serve to distinguish the disease from psoriasis, lichen planus, etc. 
 
 Prognosis. — This is bad as to cure, but the general health remains unaffected. 
 Cases other than the very mildest can only be relieved. 
 
 No. 123. Resorcin Ointment No. 2. No. 124. Salicylic-acid Ointment. 
 
 R- Resorcin. albiss. . . 2 parts Ac. salicyl. ... 2 parts 
 
 Ungt. simplicis. . . ad. ioo " Petrolati . . . ad. ioo " 
 
 No. J25. Naphthol Ointment. 
 
 fy /3-naphthol ... 5 parts 
 
 Solve in spir. vini rectif. q. s. 
 Petrolati . . . ad. 100 " 
 
 Treatment. — This can be merely palliative in almost all cases. Good results 
 have been claimed from the use of pilocarpine given subcutaneously in f--grain 
 doses, and arsenic may be tried; but internal treatment is of little avail. Continu- 
 ous local treatment may do much to render the patient's condition a more tolerable 
 one. A daily hot bath, alkaline or bran (p. 41), preceded by frictions with green 
 soap, should be prescribed. After that an oleaginous or other emollient preparation 
 should be used, and for that purpose linseed, olive, benne, or any other oil may be 
 employed. Cod-liver oil is very good, though slightly objectionable on account of its 
 odor; in very mild cases a glycerin lotion, 1 to 10, is quite sufficient. After the 
 scales are removed severer cases require a 2-per-cent. resorcin or salicylic-acid oint- 
 ment (Nos. 123, 124, p. 243). Kaposi recommends naphthol, either alone (No. 125, 
 p. 243) or with green soap (No. 37, p. 82). In localized forms of ichthyosis the re- 
 sorcin or salicylic-acid collemplastra may be employed. In ichthyosis hystrix the 
 warty growths may be curetted, or they may be removed by means of a saturated 
 solution of salicylic acid in alcohol ; then one of the above ointments should be used. 
 The treatment selected must be persisted in indefinitely. 
 
 KERATOSIS PILARIS. 
 
 Synonyms. — Pityriasis pilaris, lichen pilaris. 
 
 Definition. — An accumulation of corneous cells at the orifices of the hair- 
 
244 ILLUSTRATED SKIN DISEASES. 
 
 follicles, forming numerous minute grayish- or pinkish-white acuminate hard 
 papules. 
 
 Symptoms and Course. — Keratosis pilaris appears as pinhead-sized, hard, conical 
 papules situated at the orifices of the hair-follicles. Their color is similar to that of 
 the skin, or pinkish or grayish white. The hair of the follicle pierces the papule, or 
 is broken off level with its apex, appearing as a minute dark point, or is coiled up 
 among the epithelium-cells. The extensor surfaces of the limbs, more especially of 
 the thighs and arms, are the usual site of the disease ; but the trunk is occasionally 
 involved. In bad cases the skin feels like a nutmeg-grater and is fairly studded 
 with the conical grayish horny prominences. Sometimes the malady occurs in con- 
 junction with xeroderma or ichthyosis. It occasions no subjective symptoms. 
 
 Etiology. — The affection occurs most frequently in persons more or less subject 
 to ichthyotic deformity of the integument, and heredity is undoubtedly influential in 
 determining its appearance. Personal uncleanliness naturally increases the tendency 
 to the accumulation of epithelial detritus upon the skin, and intensifies the condition. 
 
 Pathology. — The papules are accumulations of cells of the horny layer of the 
 epidermis, mixed with a little inspissated sebum. The mass is seated in a minute 
 depression around the orifice of the hair-follicle, from which it can be shelled out. 
 
 Diagnosis. — Its seat upon the extensor surfaces of the limbs, and the character- 
 istic minute acuminate horny papules at the mouths of the hair-follicles render ker- 
 atosis follicularis readily distinguishable. Ichthyosis is not limited to the hair-follicles, 
 and the entire absence of inflammatory symptoms will serve to distinguish the affec- 
 tion from a papular eczema. 
 
 Treatment. — This is essentially the same as that of the milder forms of ichthyo- 
 sis. Alkaline, vapor, and hot baths, the free use of soft soap and the flesh-brush, 
 together with inunctions of the various bland oils, will keep the process in abeyance 
 and will sometimes cure it. 
 
 CALLOSITAS. 
 
 Synonyms. — Tyloma, keratoma, callus, Schwiele (Ger.). 
 
 Definition. — A localized thickening of the corneous layer of the skin, gradually 
 sloping down to the healthy integument. 
 
 Symptoms and Course. — Callositas is rare as a congenital condition, being usually 
 acquired on parts exposed to intermittent pressure or to friction, more especially 
 over the various bony prominences. It appears as a finger-nail-sized and larger 
 biconcave lens-shaped mass, seated in a depression of the epidermis. It is semi- 
 transparent, and of a dirty grayish- or brownish-white color; the normal folds of 
 the skin are obliterated and the tactile sensibility is lessened. Rhagades, inflamma- 
 tory processes, and suppuration not infrequently occur, and complete exfoliation 
 may take place. 
 
 The size, number, and location of the callosities vary with their cause, are more 
 
HYPERTROPHIES. 
 
 245 
 
 or less characteristic of the different occupations that occasion them, and are some- 
 times essential to work. Thus they are found upon the hands of mechanics, more 
 especially of metal-workers and shoemakers ; on the hands of musicians at the 
 places that come in contact with the strings ; 
 on the soles of the feet of those whose 
 occupations compel them to stand or walk 
 much, or who wear ill-fitting shoes ; and on 
 the body from the pressure of trusses and 
 other apparatus. Though essentially pro- 
 tective, they may occasion discomfort from 
 the pressure of the mass upon the deeper 
 layers of the derma, the Assuring or the 
 inflammatory action in the surrounding tis- 
 sue, and the interference with the tactile 
 sensibility ; they may even interfere with 
 the patient's vocation, or render walking 
 impossible. 
 
 Etiology. — Long-continued and inter- 
 mittent pressure is the usual cause of cal- 
 losities; more rarely they are due to the 
 action of some chemical agent, lye, etc. In 
 some cases the cause is not to be ascer- 
 tained. 
 
 Pathology, — A callosity is a simple in- 
 crease in the corneous layer of the skin, 
 the cells of which are more coherent than 
 usual. There is a depression of the deeper 
 tissues at the site of the tumor, but other- 
 wise they are entirely normal. 
 
 Diagnosis and Prognosis. — The diagno- 
 sis never presents any difficulties. The 
 prognosis as to recurrence after removal is 
 good; but it must be remembered that in 
 many cases the formation of the callosity 
 is conservative, protecting the deeper struc- 
 tures from mechanical injury, and is neces- 
 sary in the patient's occupation. 
 
 No. J26. Salicylic-soap Ointment. 
 
 .3 parts 
 
 . aa. 5 " 
 
 1 
 
 
 
 1 
 
 i%Q 
 
 
 
 t » ^ 
 
 • 
 
 JL_ . - 
 
 
 vE 
 
 
 V[ 
 
 
 
 
 1 
 1 
 
 
 "i£^ 
 
 t i 
 
 n ■ *- 
 
 *di EL 
 
 Fig. 122. — Callositas. 
 
 From photograph by the author. 
 
 No. 127. Salicylic- Cannabis Collodion. 
 
 R: Ac. salicyl. 
 Sapon. virid. 
 Petrolati . 
 
 fy Ac. salicyl. 
 
 Extr. cannabis indie. 
 Collod. flex. . 
 
 10 parts 
 1 part 
 100 part 
 
246 ILLUSTRATED SKIN DISEASES. 
 
 Treatment, — The protective callosities must not be interfered with. In other 
 cases the cause must be removed, proper shoes must be worn, and the local injuries 
 that cause the development of the epithelial overgrowth must be avoided as far as 
 possible. Soaking with hot water, maceration with oil, green-soap frictions, or 
 poulticings are useful to soften the thickened epidermis and facilitate its removal. 
 The mass can then be shaved off with the scalpel, the 20-per-cent. salicylic plaster- 
 mull, the 10-per-cent. salicylic collodion, the salicylic-cannabis collodion (Xo. 
 127, p. 245), the salicylic-soap ointment (No. 126, p. 245) being afterward employed. 
 Pure salicylic acid can be sprinkled over the surface, and the callosity then covered 
 with gutta-percha paper and plaster. These measures will after a time transform 
 the thickened corneous layer into a swollen soft white mass, which can be removed 
 from the underlying tissue without trouble. Inflamed or suppurating callosities 
 must be poulticed, to promote the separation of the cornified tissue. 
 
 . CLAVUS. 
 
 Synonyms. — Corn, Hilhnerauge, Leichdom (Ger.), cor (Fr.). 
 
 Definition. — A circumscribed callosity, usually situated upon the toes, and pro- 
 vided on its under surface with a conical spur of corneous tissue fitting into a de- 
 pression in the corium. 
 
 Symptoms and Course. — A corn is a circumscribed, grayish- white, hard or soft 
 hypertrophy of the epidermis, with one or more projections from its lower surface. 
 It is usually situated over a bony prominence, more especially upon the toes and the 
 soles of the feet ; more rarely it occurs upon the hands. It varies in size from a 
 small pea to a chestnut. On the exposed surfaces its texture is dense ; but under 
 the influence of heat and moisture, as between the toes, it becomes macerated and 
 Soft. Corns are painful from the pressure exerted by the projecting spur upon the 
 sensitive papillae and corium, and are also sensitive to weather- changes. 
 
 Etiology. — Corns are almost always due to pressure and friction from the use 
 of improper footwear. 
 
 Pathology. — The corneous layer at the affected place is increased, the epithelial 
 cells being more coherent than normal, and arranged in superimposed and sometimes 
 concentric layers. The corium is thinned and atrophic from the pressure of the 
 downward-projecting mass. Bursae frequently form between the lower surface of 
 the corn and the bone beneath. 
 
 Diagnosis and Prognosis. — Removal of the corn is easy; but pyemia has occa- 
 sionally followed operative interference with these growths, most probably from the 
 opening of the bursa that are formed underneath the corn in the absence of proper 
 antiseptic precautions. 
 
 Treatment. — This is essentially the same as for callositas. Prophylaxis consists 
 
HYPERTROPHIES. 
 
 247 
 
 in the wearing of proper footwear and the removal of pressure from the part by the 
 use of concentric rings of plaster. The hypertrophic tissue can be removed with 
 the knife or the curette after softening it with hot water or oil; but operative in- 
 terference is rarely necessary. Duhring recom- 
 mends the use of a 4- to 8-per-cent. caustic- 
 potash solution, after carefully protecting the sur- 
 rounding parts with rubber plaster. The salicylic- 
 cannabis collodion (No. 127, p. 245) is the most 
 useful application in ordinary cases; it should be 
 painted over the corn several times daily for a 
 week, at the end of which time the hypertrophied 
 mass can be easily picked off. Soft corns can be 
 removed by the use of the ointment of the nitrate 
 of mercury or the nitrate-of-silver stick. Inflamed 
 and suppurating corns must be poulticed until the 
 hypertrophied mass comes away. 
 
 CORNU CUTANEUM. 
 
 Synonyms. — Cutaneous horn, Hauthorn (Ger.), 
 come de la peau (Fr.). 
 
 Definition. — A circumscribed hypertrophy of 
 the epidermis, forming a various-sized and -shaped 
 excrescence. 
 
 Symptoms and Course. — Cutaneous horns are 
 epithelial proliferations that project outward from 
 the skin, forming cylindrical or pyramidal horny 
 eminences. Their color is yellowish brown or 
 greenish or blackish ; their texture generally hard, 
 and laminated or fibrillated ; and their shape is 
 straight or curved. They are of very rare occur- 
 rence, and usually one only is present ; but sometimes there are several, and 
 Hesch has described one case in which there were sixteen of these growths. They 
 are usually small, the largest I have seen being 1 inch in size ; but they have been 
 found of a size of 10 inches and more. They have been most often seen upon the 
 face, scalp, and hands, and occasionally upon the genitals ; and I have seen one upon the 
 sole of the foot. As a rule they fall off spontaneously after attaining a certain size ; 
 and in a considerable proportion of cases they finally undergo malignant degenera- 
 tion and develop into carcinomata. 
 
 Etiology. — We are ignorant of the cause of these outgrowths, though some of 
 
 Fig. 123. — Cornu cutaneum. 
 
 From photograph by the author. 
 
250 ILLUSTRATED SKIN DISEASES. 
 
 Sprinkling the surface with an astringent powder (No. 18, p. 61) or with iodoform 
 and tannin (No. 128, p. 249) does very well; the salicylic dusting powder is more 
 efficacious (No. 14, p. 58). Contiguous surfaces must be kept apart with cotton, 
 bandages, etc. Chromic or carbolic acid may be employed in obstinate cases. 
 Occasionally it is preferable to snip the growths off with the scissors, the liquor 
 ferri sesquichloridi or carbolic acid being used afterward. The galvanocautery or 
 electrolysis (p. 49) may also be used. 
 
 VERRUCA. 
 
 Synonyms. — Wart, Warze (Ger.), verrue (Fr.). 
 
 Definition. — Various-sized, hard or soft, papillary or fiat elevations of the skin, 
 due to a localized hypertrophy of the papillae and epidermis. 
 
 Symptoms and Course. — The so-called congenital warts are hairy and pigmentary 
 growths belonging to the class of the naevi ; we shall consider here only the common 
 and the senile wart. 
 
 Verrucas vulgares are small pinhead- to bean-sized, circumscribed growths pro- 
 jecting above the surface of the skin, and firmly seated on broad and slightly indurated 
 bases. They may be single or multiple ; they are usually isolated, but are occa- 
 sionally found grouped into larger confluent masses. Their shape is conical or flat; 
 and their dry and horny surface is often cleft and furrowed, giving to their tops a 
 brush-like appearance. Their color is at first that of the skin, but later it becomes 
 brownish or even blackish, from the accumulation of dirt in the interstices of the 
 horny layer. Their seat is usually on the hands, more especially upon the fingers ; 
 but they occur also upon the toes, trunk, face, and scalp. They grow quickly 
 or slowly ; they may persist for an indefinite time, but they sometimes drop off 
 spontaneously. They are seen in young individuals, and most commonly in 
 males. 
 
 Verrucse seniles s. planae are soft, smooth, and usually flat excrescences that 
 appear on the face and the back of the aged. They vary in size from that of 
 a pea to that of a finger-nail, and they are usually of a dark-brown or blackish 
 color. 
 
 Etiology. — The cause of ordinary warts is unknown ; the microorganisms that 
 have been described have not been proved to be pathogenetic. There seems to be 
 some ground for the popular belief in their contagiousness and auto-inoculability. 
 The senile warts are an expression of the general tendency of the epithelial tissues 
 to hypertrophy late in life. 
 
 Pathology. — There is a localized hypertrophy of the papillae, enlargement of the 
 capillary loops within them, and an enormous increase in the superincumbent corne- 
 ous layers. 
 
 Diagnosis, — This is of importance only with the senile warts, as regards their 
 

 
VERRUCA. 
 
 TYPOGRAVURE. 
 
 COPYRIGHT BY E. B. TREAT 4 CO. , N. Y. 
 
 ALOPECIA AREATA. 
 
 PLATE L. 
 
HYPERTROPHIES. 251 
 
 differentiation from epitheliomata. A tendency to ulceration or papillary outgrowth 
 is suspicious in a senile wart ; and the presence of an indurated base, and any trace 
 of a hard, waxy, shining border with dilated vessels running over it, is conclusive as 
 to the presence of carcinomatous degeneration. 
 
 Prognosis. — Ordinary warts are important only from a cosmetic point of view ; 
 they do not return if their bases are thoroughly destroyed after removal. The 
 senile warts are of importance in that they are not infrequently the starting-point of 
 cutaneous cancer. 
 
 No. 129. Sublimate Collodion. 
 
 IJs Hydrarg. chlor. corr. . . i part 
 Collod. flexile . . .10 parts 
 
 Treatment. — This is entirely local. Various means may be employed ; but care 
 must be taken in their selection not to cause unnecessary destruction of tissue. I 
 prefer electrolysis, the base of the wart being punctured in various directions with a 
 fine needle connected with the negative pole of the galvanic battery, and a current 
 of 1 to 4 milliamperes being passed through it for a few minutes. If care is taken 
 to transfix and destroy the base of the growth, the wart drops off in a few days, 
 leaving only a reddened surface and hardly any scar behind. (See p. 49.) The 
 growths may be cut off with the scissors, or scraped out with the sharp curette, their 
 bases being afterward cauterized with nitric acid, the acid nitrate of mercury, or 
 pure carbolic acid. The galvanocautery or the Paquelin may also be employed. 
 Even these minor surgical procedures are often unnecessary. Painting the wart 
 repeatedly with sublimate collodion (No. 129, p. 251) will cause it to drop off. The 
 20- to40-per-cent. salicylic-acid plaster-mull, the salicylic-cannabis collodion (No. 127, 
 p. 245), or the salicylic-acid ointment (No. 124, p. 243) will destroy the epithelial coat- 
 ing, and the bases of the growths can then be cauterized with chromic or other acid. 
 
 2. HYPERTROPHY OF THE CONNECTIVE TISSUE. 
 
 Under this heading we shall consider only elephantiasis Arabum, a malady 
 formerly confounded with leprosy. 
 
 ELEPHANTIASIS. 
 
 Synonyms. — Elephantiasis Arabum, pachydermia, Barbados or elephant leg, 
 elephantiasis (Fr.). 
 
 Definition. — A chronic localized hypertrophy of the skin and subcutis, caused 
 by circulatory disturbances due to repeated attacks of inflammation or to embolism 
 by the Filaria sanguinis or its ova, and appearing as enlarged, thickened, indurated, 
 and pigmented areas of skin. 
 
252 ILLUSTRATED SKIN DISEASES. 
 
 Elephantiasis Graecorum is leprosy ; and naevus and other conditions often called 
 elephantiasis belong under angioma, lymphangioma, fibroma, etc. 
 
 Symptoms and Course. — Elephantiasis begins with a series of inflammatory or 
 erysipeloid attacks, usually affecting the entire integument of an extremity, and 
 commencing in a local lesion, a wound, or a scar, or in apparently healthy tissue. 
 Lymphangitis and phlebitis are frequent concomitants ; the lymphatic vessels become 
 thickened and hardened, and the lymphatic glands swollen and tender. The attacks 
 occur at irregular intervals; and each one leaves the skin somewhat more swollen, 
 and the vessels and glands somewhat larger and harder. After months or years 
 they cease to occur, and the morbid process stops ; but the patient is left with a 
 permanently deformed part, in which all the tissues of the skin are hypertrophied, 
 and in which the fasciae and muscles, and even the underlying bones, may be 
 affected. The enlargement is often enormous; the integument is rugose and warty 
 (elephantiasis verrucosa, tuberosa, papillosa), or smooth and shiny (elephantiasis 
 glabra). The enlarged lymphatics not infrequently rupture, and a permanent tric- 
 kling of the fluid, a lymphorrhea, is set up; and eczema and ulcerations of varying 
 depth not infrequently complicate the process. 
 
 The commonest location of the disease is on the legs, and not infrequently one 
 limb is affected alone or more severely than the other. The entire extremity is 
 more or less swollen from the sole of the foot to the middle of the thigh, the natural 
 contours are obliterated, and the surface is covered with irregular masses of indu- 
 rated tissue firmly bound down to the subjacent parts. The integument may be 
 dry and shining ; but, as more or less epidermic hypertrophy usually accompanies 
 the process, it is often deeply pigmented, scaly, and covered with seborrheal and 
 epithelial detritus. Most often, however, the surface is dry, horny, and irregularly 
 tuberculated, with a foul secretion in the interstices of the wart}' excrescences. 
 Excoriations, dirty-based ulcerations, and eczematous processes are usually present 
 to a greater or less extent. The skin may be I to 2 inches thick, and the underly- 
 ing tissues may be hypertrophied even to the bones. 
 
 Elephantiasis of the genitals is less common. The scrotum may attain an 
 enormous size and the penis disappear entirely in a funnel-shaped orifice. Alpin 
 and Larrey record a case in which this organ weighed 120 pounds, and others have 
 been noted in which the tumor reached below the knees and even to the ankles. 
 In the female the labia are most often affected, and the ostium vaginae and the 
 clitoris are obliterated. The skin over these tumors is usually rough, hard, and 
 tuberculated, and more or less deeply pigmented. In other locations the disease is 
 very rare, though it has been seen on the upper extremities and on the ears. 
 
 Elephantiasis usually begins in adult life, and has rarely been seen in children. 
 The subjective symptoms are not marked. The inflammatory attacks are painful, 
 and later there is permanent discomfort from the tightness and "dead" feeling of 
 the skin. In advanced cases locomotion is interfered with or rendered impossible, 
 
TYPOGRAVURf. 
 
 COPYRIGHT BY E. B. TRFAT & CO. , N. Y. 
 
 ELEPHANTIASIS ARABUM 
 
 PLATE XXXVill. 
 
HYPERTROPHIES. 
 
 253 
 
 and not the least of the sufferings of the patients affected with elephantiasis of the 
 genitals is the fact that it prevents the gratification of the sexual appetite. The 
 malady is common in the tropics, but occasional cases are seen here. 
 
 Etiology. — Chronic lymphatic stasis is the immediate factor that causes the de- 
 velopment of elephantiasis, and the obstruction may be due to a variety of causes. 
 Long-standing inflammatory pro- 
 cesses affecting the lymphatic 
 glands and leading to connective- 
 tissue hyperplasia, and inflamma- 
 tory affections of the skin, eczemas, 
 erysipelas, syphilitic and lupoid 
 ulcerations, together with the pres- 
 sure of tumors and cicatrices, are 
 the causes of the sporadic cases 
 met with in the temperate zones. 
 The cases that occur endemically 
 in the tropics have been proved by 
 Manson, Silva Araujo, Cobbold, 
 and others to be due to the pres- 
 ence in the fluids of the body of the 
 Filaria sanguinis hominis and its 
 embryos. These are readily found 
 in the chylous urine and the lymph, 
 but swarm in the blood only in the 
 night-time. During that time they 
 are absorbed by the mosquitos, in 
 whose bodies they pass the inter- 
 mediate stage of their existence. 
 In about three days the insects die, 
 and, by bathing, or through the 
 drinking-water, are taken into the 
 human body again. The presence 
 of the parasite and its embryos in 
 
 the lymph-channels and -glands obstructs the lymphatic flow and leads to the hyper- 
 trophy. 
 
 Pathology. — The lymphatic vessels and the veins are enormously dilated, and 
 the tissues are saturated with lymph. All the elements of the skin are more or less 
 hypertrophied from the presence of new connective tissue, but the greatest change 
 is in the subcutis. Even the muscles are enlarged, and the bones show new osteo- 
 phyte growth. All the glandular structures are more or less atrophied. 
 
 Diagnosis. — This is readily made from the enormous enlargement of the part, 
 
 Fig. 126. — Elephantiasis vulvas. 
 After Van Haren-Noman. 
 
254 ILLUSTRATED SKIN DISEASES. 
 
 ' the firm oedema, the papillary outgrowths, lymphorrhea, etc., and there is no other 
 malady with which it is liable to be confounded. 
 
 Prognosis. — The prognosis as to cure is bad, though the malady does not endan- 
 ger life. The interference with motility and work is very serious. The difficulties 
 of sexual congress when the genitals are affected have already been adverted to. 
 Treatment. — Prophylaxis consists in the treatment and cure of all conditions 
 
 "causing venous and lymphatic stasis of the lower limbs or genitals, eczema, simple 
 or specific ulcerations, lupus, etc., and the removal of mechanical obstructions, scars, 
 tumors, etc., to the lymphatic flow. The direct treatment of the condition is not 
 hopeful, since neither local measures nor internal remedies will remove the new- 
 formed connective tissue. Rest in bed, with elevation of the limb, together with 
 
 ;the use of rubber or other bandages, may do good in the beginning. In advanced 
 cases excision of the hypertrophied tissues or amputation of the part may be ad- 
 visable ; but the course of the wound is a very uncertain one. Other measures, such 
 
 ■as the ligation of arteries, the excision of nerves, the use of galvanism, etc., have 
 given no satisfactory results. 
 
 3. HYPERTROPHY OF THE SEBACEOUS GLANDS. 
 
 This hardly occurs as a distinct affection. We include molluscum contagiosum 
 under this heading; for though it is probably not a sebaceous-gland hypertrophy, as 
 was formerly supposed, it is best considered here. 
 
 MOLLUSCUM CONTAGIOSUM. 
 
 j|fe Synonyms. — Molluscum sebaceum, epithelioma molluscum, acne varioliformis 
 
 Definition. — An affection characterized by the appearance on the skin of small, 
 semi-transparent, flesh-colored, wart-like or globular, umbilicated tumors. 
 
 Symptoms and Course. — Molluscum contagiosum begins with the appearance of 
 one or more minute, slightly prominent, transparent, shining whitish nodules, which 
 slowly grow into pea-sized or larger sessile or pedunculated tumors. Their surface 
 is usually smooth; their color is that of the normal skin, the stretching of the epider- 
 mis over their tops giving them a faint whitish, waxy glance ; and they are some- 
 times situated on slightly reddened bases, though the skin around them is perfectly 
 normal. Their flattened summits are marked with a slight but distinct depression, 
 to which is due the French designation of the disease ; and in the center of this the 
 ■small opening into the mass can almost always be seen. Though moderately firm 
 to the touch, their contents can be expelled by pressure, and form a greasy or tal- 
 low-like mass containing the peculiar bodies known as molluscum corpuscles. The 
 
HYPERTROPHIES. 
 
 255 
 
 tumors grow very slowly and may be present for months or years. They may 
 disappear spontaneously in time, or be destroyed by inflammatory processes, sup- 
 puration, or ulceration. They may be single, but are usually multiple, and in some 
 cases large numbers are present. 
 Their commonest seat is upon the 
 face, and next commonest upon the 
 genitals and hands; but they are 
 occasionally found on other portions 
 of the body. The malady is com- 
 moner in children than among adults. 
 
 Etiology. — The molluscum cor- 
 puscles are oval- or lemon-shaped 
 bodies which have been identified 
 by some observers with parasites 
 belonging to the Coccidia subclass 
 of the Sporozoa (Bollinger and Neis- 
 ser), but are regarded by others as 
 peculiarly modified and swollen rete- 
 cells (Lesser, Israel, Kromayer, etc.). 
 The facts that several cases some- 
 times occur in one family, that parts 
 that are liable to be brought in con- 
 tact are their usual seat, as well as 
 the direct and successful inoculation 
 experiments of Haab and Pick, suffi- 
 ciently demonstrate their contagious 
 nature. 
 
 Pathology. — The tumors are 
 composed of densely packed lobular masses containing epithelial detritus, fat-glob- 
 ules and -crystals, and the above-mentioned peculiar corpuscles. It is a question 
 whether the lobules are the remains of sebaceous glands or not, for the process seems 
 to start in the rete. 
 
 Diagnosis. — The tumors situated on normal non-inflamed skin, with central de- 
 pressions and expressible, semi-solid contents, and containing the molluscum corpus- 
 cles, are characteristic. In milium the nodules are small and flat, yellowish white 
 or brown in color, with no central opening and with tallowy contents. Fibroma 
 molluscum is a solid new growth, with no central opening and no expressible contents, 
 and resembles the contagious molluscum only in its name. In variola the fluid con- 
 tents of the vesicles and the fever and course of the disease will prevent mistake. 
 
 Prognosis. — This is invariably good ; the tumors may end spontaneously, and in 
 any case they can be readily removed. 
 
 Fig. 127. — Molluscum contagiosum. 
 From photograph by the author. 
 
 L 
 
256 ILLUSTRATED SKIN DISEASES. 
 
 Treatment. — Mollusca are readily removed by expression, more especially after 
 an incision has been made to facilitate the extrusion of the mass. The curette may 
 also be employed. It is not necessary to cauterize the sac. 
 
 4. HYPERTROPHY OF THE HAIRS. 
 
 This may be quantitative, an increase in number, or qualitative, an increase in 
 size or length of the appendages. Both conditions may be considered under the next 
 heading. 
 
 HYPERTRICHOSIS. 
 
 Synonyms. — Hirsuties, hypertrichiasis, polytrichia. 
 
 Definition. — An increase in the size or the amount of the hair, or its growth in 
 unusual locations. 
 
 Symptoms and Course. — An abnormal growth of the hair occurs only where hair- 
 follicles are normally present, and is never seen on the palms and soles, the dorsal 
 surfaces of the terminal phalanges, or on the lips. Excessive length and thickness 
 of the stiff hair in normal situations is not uncommon. Beigel records one case 
 where the hair was 9 feet long, and Leonard one where the beard measured 7 feet. 
 Similar growth of the hair of the eyebrows, pubes, and axillae, as well as of that on 
 the trunk and limbs of males, is often seen. A hairy growth, normal in the male, 
 becomes hirsuties in the female, and is usually associated with some disorder of the 
 generative organs. Examples of bearded women are exhibited as curiosities; and 
 I have had one under my care whose beard was heavier than that of the average 
 man, and whose husband shaved her daily. Females occasionally have hair on the 
 breast or around the nipple, and a line of hair extending from the pubes to the 
 umbilicus, as in the male. In both sexes long hair is occasionally found in locations 
 usually covered only with the fine down of the lanugo, as the small of the back and 
 the extensor surfaces of the limbs. Cases in which the normal hairy growth appears 
 too early on the face and around the genitals are usually accompanied by preco- 
 cious sexual development. Beigel has recorded one of a girl of six, whose pubic hair 
 was as long and vigorous as that of an adult. Again, hirsuties frequently occurs on 
 the chin of females after the menopause. Irritation, as from blistering, the use of 
 stimulating applications, the pressure of bandages, may cause similar local hyper- 
 trichosis. 
 
 Unusual growth of the fine lanugo hair that covers the surface of the body 
 almost everywhere occurs in cases of universal hirsuties. Such were the well-known 
 Shwe-Maon family, in which the anomaly was observed by Beigel and -Crawford 
 during three generations, and the Russian Andrian Leftichjew. Here the downy 
 hair develops into a soft brown or blond growth an inch or more in length, usually 
 
HYPERTROPHIES. 257 
 
 most pronounced upon the face. Deficient development of the teeth is present in 
 most of these cases. 
 
 Etiology. — General hypertrichosis of the lanugo hair is usually hereditary, and 
 is to be regarded as a defect of development, and a persistence of the fetal hair that 
 is usually shed before or soon after birth. The same condition of the ordinary hair 
 is generally a race or family characteristic, and is commoner in persons of dark com- 
 plexions. Partial hypertrichosis may be caused by the increased nutrition due to 
 the long determination of blood to a part, as by the persistent use of sinapisms, lini- 
 ments, etc., or by perverted, precocious, or arrested activity of the sexual functions. 
 The hirsuties of the lumbar and dorsal regions is sometimes connected with a con- 
 cealed spina bifida. In many cases, however, the cause of the hypertrichosis is 
 entirely obscure. 
 
 Pathology. — The abnormal growth does not differ in structure from that of the 
 ordinary amount and in the usual situations. 
 
 Diagnosis. — Hairy naevi may be confounded with localized hypertrichoses ; but 
 the unchanged texture and color of the skin should readily distinguish them from 
 the latter, which are usually pigmented and hypertrophic. 
 
 Prognosis. — The abnormal hairs are readily removed temporarily. Permanent 
 removal depends on the possibility of the destruction of the hair-papillae, and this, 
 being very slow and troublesome, cannot be done where very large surfaces of the 
 skin are affected, or where there is a general overgrowth of the lanugo hair. I 
 have, however, removed over 14,000 hairs from the face of a woman in the course 
 of two years, with a finally satisfactory result. 
 
 No. J30. Duhring's Depilatory. 
 
 R Barii sulphidi ... 2 parts 
 
 Pulv. zinci ox. 
 Pulv. amyli . . . aa. 3 " 
 
 Treatment. — Extraction with the forceps is not much better than shaving; the 
 papillae are left behind, and the hairs grow again in a short time. The same may 
 be said of depilatories, though they do destroy the shaft of the hair down to its neck. 
 Perhaps the best of them is the combination recommended by Duhring (No. 130, 
 p. 257). It should be made into a thin paste with water, applied for ten or fifteen 
 minutes, and scraped off as soon as burning is felt, and cold cream applied. Those 
 containing arsenic are dangerous, and they all stimulate the growth of the lanugo 
 hair more or less. The only radical and satisfactory treatment is by electrolysis, 
 which we owe to Michel and Hardaway, of St. Louis. The method will be found 
 described in detail on page 49. Much patience is required if the growth is at all 
 extensive. The operation is uncomfortable, but not really painful, and a 20-per- 
 cent, cocaine-adeps lanae ointment may be applied before the electrolysis, to mitigate 
 
258 
 
 ILLUSTRATED SKIN DISEASES. 
 
 it. Removal of lanugo hairs should never be attempted ; the remaining hairs are 
 inevitably stimulated in their growth by the irritation caused by the current, and the 
 patient's last condition is worse than the first. 
 
 5. HYPERTROPHY OF THE NAILS. 
 
 One affection only, onychauxis, is to be considered under this heading. 
 
 ONYCHAUXIS. 
 
 Synonym. — Onychogryphosis. 
 
 Definition. — An increase in the size or the thickness, or both, of the nail. 
 
 Symptoms and Course. — Hypertrophic nails may be of normal thickness and 
 texture, and be simply increased in length up to 3 inches or more. Or they 
 
 may be broad and thick, tend to split 
 in a lamellar manner, and, by their 
 pressure on the neighboring soft parts, 
 be the cause of paronychia. Or again, 
 they may be bent and curved in vari- 
 ous directions, and often in a spiral 
 shape ; which latter condition is more 
 correctly called onychogryphosis. The 
 nails lose their luster, become rough, 
 furrowed, fissured, and of a blackish- 
 or brownish-gray color. Increase in 
 size of the nails also occurs during the 
 course of various diseases, eczema, 
 psoriasis, lepra, syphilis, etc. (pp. 200, 
 217). Onychauxis occurs most often 
 in the toe-nails, and is rarely seen upon 
 the hands. 
 
 Etiology. — These conditions are 
 sometimes congenital; but they are 
 more commonly seen in elderly per- 
 sons, in the bedridden, and in other 
 cases where proper care is not taken 
 of the nails. The pressure of improper 
 footwear is a potent cause of the 
 affection. 
 
 Pathology. — The papillary body of the nail-bed is hypertrophied, but there is 
 probably a change in quality as well as in quantity of the epidermic cells. 
 
 Fig. 128. — Onychauxis 
 
 After Van Haren-Xoman. 
 
COPYRIGHT, BY E. B. TREAT & CO. , N. Y. 
 
 PHOTOGRAVURE 4 COLOR CO., N. Y. 
 
 NAEVUS PIGMENTOSUS 
 
 PLATE XXXIV. 
 
Treatment. — Frequent < i 
 of appropriate footwear, is the 
 Inflammation of the matrix, and or 
 only a symptom, must be approprkr 
 be softened in hot water, and then cut < 
 cylic-acid ointment (No. 124 
 
 use 
 
 6. HYPERTROPHY Ol 
 
 Excessive pigmentation 
 coloring-matters; and this ■■'■ 
 rus, and argyria, or local, as in tattoo-mark 
 from dyes, acids, etc. Hyp 
 
 circumscribed and is often and under me naevus 
 
 mentosus,- lentigo, ephelis, an 
 
 N#/v GMENTOSUS. 
 
 Synonyms.— Pigmenta; 
 (Ger.), tache pigmentairc (Fr.). 
 
 Definition. — A congenital ci 
 with or without increase oi 
 tissue and the hairs. 
 
 Symptoms and Course.- 
 as a single spot, or a-^ many 
 small, even pinhead in size 
 Their shape is oval, circular 
 shade from light-yellow br 
 pearing spontaneously 
 is an increase in size with 
 tribution follows the course 
 
 iave them. 
 
 In accordance with th 
 elements of 
 
 ture and functio 
 
 are shari 
 where on the b 
 face, the ne<- 
 trophy of t; 
 
 
 
 : 
 
 ■ 
 
 ns. Thes 
 
 1 any 
 
 ■i'ormities, disap- 
 
 eiopment 
 
 >nally their dis- 
 
 Both sexes are equally liable 
 
 ■ 
 
 be noted. In 
 
 is unaltered in tex- 
 
 -pots 
 
 yellow to lark-bro\ They occur' any- 
 
 n the mui ut are most frequently seen U] 
 
 cs of the hands. In naevus veri 
 
 discolor. ,d or in 
 
COPYRIGHT. 6V 
 
 . 
 
 
HYPERTROPHIES. 259 
 
 Treatment. — Frequent cutting and proper care of the nails, together with the use 
 of appropriate footwear, is the best treatment, both prophylactic and curative. 
 Inflammation of the matrix, and other skin affections, of which the onychauxis is 
 only a symptom, must be appropriately treated. The exuberant horny growth can 
 be softened in hot water, and then cut or scraped away ; or be treated with the sali- 
 cylic-acid ointment (No. 124, p. 243) increased to a strength of 1 to 10. 
 
 6. HYPERTROPHY OF THE PIGMENT. 
 
 Excessive pigmentation of the skin may occur from the deposition in it of foreign 
 coloring-matters; and this deposition may be general, as in Addison's disease, icte- 
 rus, and argyria, or local, as in tattoo-marks and the various stainings of the skin 
 from dyes, acids, etc. Hypertrophy of the normal pigment of the skin is always 
 circumscribed and is often congenital ; and under that heading come naevus pig- 
 mentosus, lentigo, ephelis, and chloasma. 
 
 NiEVUS PIGMENTOSUM 
 
 Synonyms. — Pigmentary naevus or mole, Fleckenmal, Pigmentmal, Muttermal 
 (Ger.), tache pigmentaire (Fr.). 
 
 Definition. — A congenital circumscribed hypertrophy of the pigment of the skin, 
 with or without increase of its other elements, most commonly of the connective 
 tissue and the hairs. 
 
 Symptoms and Course. — The deposit of pigment is congenital, and may appear 
 as a single spot, or as many, even hundreds, of discolorations. These may be very 
 small, even pinhead in size, or so large as to occupy extensive areas of the body. 
 Their shape is oval, circular, or irregular. Their color varies greatly, being of any 
 shade from light-yellow brown to black. They are permanent deformities, disap- 
 pearing spontaneously only in very exceptional cases ; and their only development 
 is an increase in size with the general growth of the skin. Occasionally their dis- 
 tribution follows the course of the cutaneous nerves. Both sexes are equally liable 
 to have them. 
 
 In accordance with the presence or absence of coincident hypertrophy of other 
 elements of the skin, several varieties of pigmentary naevus are to be noted. In 
 naevus spilus the skin is smooth and, save for the discoloration, is unaltered in tex- 
 ture and function; the round or irregular, small or large, few or numerous spots 
 are sharply limited, and of a yellow to dark-brown or black color. They occur any- 
 where on the body, even on the mucosae, but are most frequently seen upon the 
 face, the neck, and the backs of the hands. In naevus verrucosus there is hyper- 
 trophy of the papillae in addition to the discoloration, giving us round or irregular, 
 
i2»;o 
 
 ILLUSTRATED SKIN DISEASES. 
 
 various-sized, warty, and pigmented masses. Epidermal proliferation and scaling 
 and increased sebaceous secretion are often present. In naevus pilosus the hyper- 
 trophied area, whether smooth or rough, is more or less covered with coarse lanugo 
 
 or longer hairs. Extensive naevi of this variety, 
 covering large surfaces of the body, and causing 
 the skin to resemble the hide of an animal, have 
 been reported. The color of the smooth or warty 
 skin varies, as does that of the hair upon it ; and 
 verrucas, fibromata, and lipomata are often present 
 either in the area of the naevus or outside it. As 
 is the case in general hypertrichosis, congenital 
 defects of the teeth are often found in conjunction 
 with these deformities. In naevus lipomatodes s. 
 mollusciformis there are elevations and projections 
 — tumors of fatty or connective tissue of varying 
 size and shape — in the pigmented area. Some 
 cases of extensive naevi are unilateral, or follow 
 the tracks of the nerves, and are described as naevus 
 unius lateris, Xcrvcnncevi (Ger. ). 
 
 Etiology. — There is no scientific foundation 
 for the belief that maternal impressions have any- 
 thing to do with the appearance of naevi. The 
 condition is hereditary in some instances ; but 
 we are ignorant of its real cause. 
 
 Pathology. — In naevus spilus there is simply an accumulation of pigment in the 
 rete and the upper layers of the corium. In all the other forms there is in addition 
 hypertrophy of the corium, more especially of the papillae, of the epidermis, and of 
 the glandular structures of the skin. 
 
 Prognosis. — This is good as to life and health, though occasionally naevi form 
 the starting-point of sarcoma and carcinoma later on. The possibility of removal 
 depends, of course, on the site and the extent of the deformity. 
 
 Treatment. — No attempt should be made to treat very extensive pigmentary 
 naevi either of the smooth or the warty and hairy varieties ; for, apart from the 
 difficulties and length of time that is required, the cicatricial tissue may be more 
 deforming than the original lesion. Circumscribed smooth naevi may be treated 
 with trichloracetic acid, carefully applied to the part by means of a glass rod at 
 intervals of a few days, or with the sublimate collodion (No. 129, p. 251). But for 
 these, as for the smaller hairy and warty naevi, electrolysis is usually the most suit- 
 able and efficacious means of treatment. The process is similar to that for epilation of 
 the hairs (p. 49), but a somewhat coarse needle may be employed. If the pigment 
 deposit is superficial, the needle should be passed in obliquely under the epidermis, 
 
 Fig. 129. — Xtevus pigmentosus. 
 
 From photograph by the author. 
 
HYPERTROPHIES. 261 
 
 so as to " blister the spot," as Fox terms it. Larger growths may be curetted, or 
 destroyed with the Paquelin, and an iodoform dressing applied. For the mollus- 
 coid forms the knife or the galvanocaustic snare offers the only means of relief. 
 
 LENTIGO. 
 
 Synonyms. — Ephelides, freckles, Linsenflecke, Sommersprossen (Ger.), taches de 
 rousseur (Fr.). 
 
 Definition. — Small, circumscribed deposits of pigment, appearing as spots or 
 patches, and most commonly seen on the face and the backs of the hands. 
 
 Symptoms and Course. — Freckles are never congenital, and rarely appear before 
 the second decade of life. They are pinhead- to pea-sized discolorations, varying 
 in tint from a salmon yellow through brown to a sepia black. Their form is 
 rounded, oval, polygonal, or irregular, and they are never elevated above the surface 
 of the skin. Their usual site is upon the face, especially the cheeks and nose, and 
 on the backs of the hands. In rare instances they have been seen on other and 
 covered parts of the body. There may be few or many, and the patches may be 
 isolated or confluent; and in extensive and deeply colored cases the deformity is 
 considerable. Both sexes are equally liable to them ; but they occur most com- 
 monly in individuals of light complexion and with red or auburn hair. Mulattos 
 are very much subject to them, as they are to other pigment anomalies. They 
 grow darker in summer, and fade, but do not entirely disappear, in the winter. 
 
 Etiology. — Heredity has some influence here, as with other pigmentations. The 
 sun's rays, more especially the ultra-violet ones, cause their appearance and exten- 
 sion; but a congenital predisposition to their appearance is also necessary. 
 
 Pathology. — A freckle is a collection of pigment granules in a circumscribed 
 group of rete-cells, and it differs from chloasma only in the shape and size of the 
 affected area. 
 
 Prognosis. — Freckles may be removed, but they are almost certain to return 
 upon renewed exposure to sunlight. 
 
 No. J3J. Bulklefs Lotion. 
 
 fy Hydrarg. chlor. corr. . 
 
 . 
 
 3 parts 
 
 Boracis 
 
 . 
 
 20 " 
 
 Acid, acetic, dil. 
 
 . 
 
 60 " 
 
 Aq. ros. 
 
 . ' 
 
 500 
 
 Treatment. — This is in general that of chloasma and other pigment accumula- 
 tions. Any agent that will cause inflammation and subsequent desquamation of the 
 epidermis will remove them for the time being. I have found 1 : 500 sublimate 
 compresses, allowed to remain in situ for three or four hours, efficacious; but the 
 
262 ILLUSTRATED SKIN DISEASES. 
 
 patient should be warned beforehand of the swelling and redness that will ensue. 
 Bulkley recommends sublimate and acetic acid (No. 13 1, p. 261) to be brushed over 
 or rubbed into the affected areas night and morning. 
 
 CHLOASMA. 
 
 Synonyms, — Liver-spot, masque de la grossesse (Fr.). 
 
 Definition. — An abnormal deposit of pigment in the skin, appearing as a smooth, 
 yellow-brown to blackish, circumscribed or diffuse discolored patch. 
 
 Symptoms and Course. — The pigmentation of chloasma may be sharply limited, 
 or it may be diffuse and shade gradually into the color of the normal skin. Its 
 shape may be circular, oval, or irregular; and its size varies from that of a thumb- 
 nail up. Its color may be so light a yellowish brown as to be barely perceptible ; 
 or it may be darker brown or even blackish, and is then called melanoderma. It 
 may be due to external agents and local affections of the skin, or it may be caused 
 by derangements of the internal organs and by general diseases. Chloasma calori- 
 cum is the tanning of the skin that is caused by exposure to the rays of the sun. 
 It soon fades away when its cause is removed. Chloasma traumaticum is caused by 
 the local action of external agents upon the skin, or follows the lesions of various 
 dermal affections, and appears as a diffuse or circumscribed discoloration which lasts 
 for a long time or is permanent. Chloasma symptomaticum s. uterinum appears in 
 conjunction with abnormalities, derangements, or diseases of the uterine organs, and 
 forms a diffuse or well-defined spot or patch of varying shade, oftenest situated on 
 the forehead, the sides of the nose, cheeks, and neck. It usually disappears when 
 its cause its removed. 
 
 Etiology. — An excessive deposition of the natural pigment in the skin may be 
 due to external or to internal causes. Any chemical, mechanical, or thermic irri- 
 tant that causes long-standing hyperemia of the skin may occasion its appearance. 
 Such are the long-continued use of counter-irritants, vesicants, and plasters, expo- 
 sure to sunlight, the pressure of clothing, apparatus, etc. Similar discolorations 
 accompany or follow certain dermal affections. After the erythematous lesions the 
 discoloration is fugitive; but that following lichen planus, the syphilodermata, etc., 
 is darker and more persistent. More diffuse pigmentations may follow all the itch- 
 ing skin diseases, eczema, phtheiriasis, prurigo, etc., and is due to the deposit of 
 blood-pigment in the skin from the lesions caused by scratching. 
 
 Internal causes may be various affections of the system and of special organs; 
 least commonly, however, in spite of the popular name of the deformity, diseases of the 
 liver. Diffuse discolorations occur with cancer and phthisis. Most often by far, how- 
 ever, they occur in connection with affections of the uterine tract, functional dis- 
 orders, sterility, amenorrhea, displacements, tumors, ovarian disease, etc., and they are 
 found with especial frequency in gravidity. There is a well-established relationship 
 
HYPERTROPHIES. 263 
 
 between these conditions and the pigment deposits, and the latter disappear when 
 the former are relieved ; but we are ignorant of the reasons for it. 
 
 Pathology. — The skin is entirely unaltered in chloasma, save for the excessive 
 deposit of pigment granules in the rete. 
 
 Diagnosis. — The unaltered condition of the skin, save for the pigmentation that 
 does not disappear under pressure, and the entire absence of inflammatory appear- 
 ances and subjective sensations, are characteristic. Chloasma and chromophytosis 
 might be confounded; but the slight furfuraceous desquamation and the demon- 
 stration of the etiological agent under the microscope will always enable us to dis- 
 tinguish the parasitic disease. 
 
 Prognosis. — This is uncertain. We may be able to remove the spots, but they 
 are very liable to return. The means employed for their eradication are necessarily 
 such as are liable themselves to cause pigmentation of the skin. 
 
 Treatment. — This consists in the first place in the removal of the cause, when 
 such can be ascertained to exist. Locally, the old pigmented epithelial cells must 
 be removed. This is best done by means of bichloride compresses, I to iooo or 
 500, allowed to remain on for several hours, until inflammation and vesiculation 
 occur; the parts are then to be dressed with a mild dusting powder or ointment 
 (No. 18, p. 61, No. 26, p. 70, Nos. 68, 69, p. 135). Bulkley's lotion (No. 131, p. 26 1) 
 or citric acid in watery solution of a strength of I to 16 may be used in a similar 
 way. Touching the spots with pure carbolic acid has done well in some cases. 
 Salicylic acid, in ointment, paste, or plaster (No. 79, p. 153, No. 124, p. 243), is an 
 efficient agent to remove the superficial epidermic layers. It is a safe application, 
 and should always be tried before more active agents are used. We must never 
 lose sight of the fact, however, that all these agents are themselves liable to cause 
 pigmentation of the skin. 
 
CLASS V. 
 NEW GROWTHS. 
 
 Under this heading we classify a number of dermal changes that consist essen- 
 tially in the growth and infiltration of the skin with new elements, and usually appear- 
 ing as tumors. They may be homologous or heterologous, benign or malignant. The 
 new elements are of connective tissue in cicatrix, keloid, fibroma, myxoma, neuroma, 
 lipoma, xanthoma, and sarcoma; of muscular tissue in myoma; of vascular tissue 
 in angioma and lymphangioma; and of epithelial tissue in adenoma and carcinoma. 
 
 U NEW GROWTHS OF CONNECTIVE TISSUE. 
 
 CICATRIX. 
 
 Cicatrix, scar, Narbe (Ger.), is a dense, smooth, attached or movable, connective- 
 tissue new growth covered with epithelium, which replaces the normal elements and 
 glandular structures of the skin where the connective tissue of that organ has been 
 destroyed by traumatic, ulcerative, or necrotic processes. It occurs after destructive 
 injuries and after the various inflammatory diseases, as acne, variola, zoster, ecthyma, 
 lupus, syphilis, dermatitis, etc. It forms an important secondary lesion of the skin, 
 and as such its chief characteristics have already been described (p. 38). Scars are 
 usually atrophic, and cause deformity and disability by the traction that they exert 
 and the loss of motion that they occasion. They are sometimes hypertrophic ; but as 
 there is no practical distinction to be made between this condition and spontaneous 
 keloid, the hypertrophic scar will be considered in connection with that subject. 
 
 The kind of scar resulting from any one of the above-mentioned processes 
 depends upon the course of the granulations from which the new connective tissue 
 develops, and it is therefore necessary to watch the granulation process and control its 
 growth. Either excessive or deficient granulation will prevent cicatrization and the 
 
 264 
 
LYMPHANGIOMA. 
 
 VITILIGO. 
 
 TVPO&RAVURE. 
 
 KELOID. 
 
 COPYRIGHT, 1903, BV E. B. TREAT 4 CO. , N. Y. 
 
 FIBROMATA. 
 
 PLATE XL. 
 
NEW GROWTHS. 265 
 
 formation of the epithelial covering that terminates the process ; for both can only 
 occur when the granulations are just on a level with the surrounding skin. Deficient 
 granulations must be stimulated with camphor, iodoform, or the nitrate of silver in 
 1- to2-per-cent. solution. Exuberant granulations must be repressed with the nitrate- 
 of-silver stick, straps of adhesive plaster, or compresses soaked in alcohol. The 
 treatment of scars after their formation is simple when the surrounding tissues are 
 lax and elastic enough to permit of their excision and replacement by a simple linear 
 cicatrix. Where this is not the case, scarification (p. 50) offers the best chances of 
 improvement, though electrolysis and galvanopuncture may also be tried. All 
 these measures should be followed by the persistent use of the mercurial plaster. 
 Baths, douches, and massage may be employed to soften scars and render them 
 elastic. 
 
 KELOID. 
 
 Synonyms. — Cheloid, Narbenkrebs, Knollenkrebs (Ger.). 
 
 Definition. — A benign connective-tissue new growth of the skin, characterized 
 by the appearance of raised, variously shaped and sized, smooth, elastic, white or 
 pinkish tumors, occurring after injuries to the cutis or spontaneously. ■ 
 
 Symptoms and Course. — Keloid begins as a small, pale, pea-sized nodule which 
 gradually grows into a sharply circumscribed, dense, elevated tumor which may 
 occupy an area of several square inches. Its shape may be circular, oval, elongated, 
 or irregular; and in many cases it consists of a central mass with projecting arms, 
 which gives to the growth a crab-like appearance. Its color is white or pinkish ; it 
 is hard but elastic to the touch ; and its surface is covered with a thin epidermis in 
 which sweat-glands are present, but no hairs and sebaceous glands are to be found. 
 A single tumor, or many, may be present. De Amicis records a case that had three 
 hundred and eighteen of these neoplasms. Keloids grow very slowly, and, having 
 attained a certain size, usually remain unchanged for life. In exceptional cases they 
 undergo retrogressive changes and disappear, and sometimes they develop into epi- 
 theliomata. Their commonest seat is upon the sternum, but they are also found 
 upon the face, trunk, and extremities. The subjective symptoms that they occa- 
 sion are limited to slight pain and tenderness on pressure. 
 
 Two varieties of keloid are to be distinguished. The false or cicatricial keloid is 
 often single, and here the new growth develops from the scars of any of the dermal 
 affections that are accompanied by loss of tissue, — acne, zoster, variola, syphilis, etc., 
 — from traumatisms, and with especial frequency from burns. The shape, size, num- 
 ber, and location of the keloids will depend largely upon the characters of the origi- 
 nal scars. They may be distinguished from the simple hypertrophic scar by the 
 fact that the connective-tissue new growth extends beyond the limits of the original 
 lesion. The true keloid develops in the normal connective tissue of the skin with- 
 out antecedent cicatrix formation. As, however, we necessarily depend on the 
 
266 
 
 ILLUSTRATED SKIN DISEASES. 
 
 history of the patient for information upon this subject, it must always remain a 
 matter of doubt ; and it is possible that spontaneous keloid may have developed at 
 the site of pressure, contusions, or small and forgotten lesions of the skin. 
 
 Etiology. — This is really unknown. Family predisposition may have some 
 influence, and syphilitic scars and those produced by burns seem especially prone to 
 
 become keloidal. The very young and the 
 aged are rarely affected. The colored races 
 seem more prone to the disease than other 
 people. Many apparently spontaneous cases 
 follow the slight lesions of acne, varicella, 
 herpes, etc. 
 
 Pathology. — The keloidal tumor is com- 
 posed of bundles and masses of connective 
 tissue imbedded in the skin. In the false 
 form the new tissue is irregularly disposed, 
 and the papilla; of the skin are destroyed. 
 In the true form the dense connective-tissue 
 bundles are horizontally arranged in the 
 corium, and the rete and papillae are intact. 
 Diagnosis. — The hard, elastic, elevated, 
 permanent, scar-like, and usually insensitive 
 tumors are quite characteristic. The hyper- 
 trophied cicatrix is to be distinguished from 
 keloid by its exact limitation to the site of 
 the original lesion ; and this is a matter of 
 some importance, since the operative inter- 
 ference that might be proper in the one 
 case is useless or even hurtful in the other. 
 Prognosis. — This is very doubtful so far 
 as the removal of the tumors is concerned. 
 They frequently resist all ordinary measures, and are very prone to recur after re- 
 moval. 
 
 Treatment. — This should only be undertaken when, for cosmetic or other rea- 
 sons, it is very desirable to remove the tumors. Treatment by excision or destruc- 
 tion with the cautery is very unsatisfactory, as the tumor is almost certain to return 
 in the scar. Multiple scarification, cross-hatching the tumor with a bistoury or the 
 scarificator (Fig. 15, p. 50), the incisions being deep enough to entirely divide the 
 growth, is the most promising course of treatment to pursue. This should be done 
 once a week, the mercurial plaster or the 20- to 50-per-cent. resorcin plaster being 
 applied during the intervals. The process is not as painful as it seems, and I have 
 obtained good results from it in one case. Electrolysis, as described for the de- 
 
 Fig. 130.— Keloid. 
 
 From photograph by the author. 
 
NEW GROWTHS. 267 
 
 struction of hairs (p. 49), has been successfully employed, the needle being passed 
 obliquely from the margins through the center of the growth. 
 
 FIBROMA. 
 
 Synonyms. — Fibroma molluscum, molluscum fibrosum, molluscum pendulum. 
 
 Definition. — A connective-tissue new growth, characterized by the appearance 
 in the skin of flat or pedunculated, rounded, painless, soft or firm tumors of varying 
 size. 
 
 Symptoms and Course. — True fibroma begins as a minute, circumscribed, nodular 
 tumor deeply seated in the normal skin, and varying in consistency in accordance 
 with the hardness of the connective tissue of which it is composed. It usually appears 
 first in childhood, and may even be present at birth ; and it increases slowly but 
 continuously up to a certain size, and then remains stationary and persists for life. 
 When fully developed it forms a tumor that varies in size from that of a pea to a 
 mass as large as a child's head and weighing many pounds. A single one may 
 be present, but there are usually several of them ; often they are very numerous, 
 and as many as three thousand have been counted in a single case. In shape 
 they may be semiglobular, broad-based and adherent, or they may be project- 
 ing, ball- or club-shaped, and pedunculated (molluscum pendulum). Their consis- 
 tence may be soft, or firm and elastic. The skin over them is normal and loose or 
 tense and reddened ; it may be hypertrophied or atrophic, and sometimes shows 
 hairs and a few large comedones on its surface. Fibromata, when numerous, are 
 usually most abundant upon the trunk; but the head and limbs are often affected. 
 They are rare upon the palms and soles. In some cases fibroma appears as a single 
 large, not distinctly circumscribed, and pendulous growth. Occasionally the growth 
 of the tumors is rapid, and excoriation, ulceration, and even sloughing may occur. 
 In very rare instances they finally undergo a sarcomatous or carcinomatous degen- 
 eration. Save in these cases, however, the general health is not affected, and the 
 patient suffers only from the cosmetic effects of the deformity, and the interference 
 with his vocation when the tumors are very large and heavy or are situated on the 
 face, and with sexual intercourse when they are upon the genitals. The malady 
 occurs with equal frequency in both sexes, but it is very rare in this country. 
 
 Etiology. — The cause of fibroma is unknown ; heredity has some influence, as is 
 evidenced by the records of several cases in one family. 
 
 Pathology. — In the softer fibromata the connective tissue is loosely arranged in 
 alveoli, and is gelatinous and in a more or less imperfectly developed condition. 
 The older and firmer tumors are more densely fibrous. 
 
 Diagnosis. — The multiple hard or soft tumors, deep-seated or projecting, their 
 stability and very slow course, and the entire absence of general and subjective 
 
 • 
 
268 ILLUSTRATED SKIN DISEASES. 
 
 symptoms, are characteristic. Molluscum contagiosum grows quickly, is very super- 
 ficial, has a central depression and opening, and expressible, hyaline contents. 
 Neuromata may be distinguished by their painfulness and sensitiveness. Lipoinata 
 are soft and lobulated, and never pedunculated. 
 
 Prognosis. — Fibromata are benign tumors, and rarely undergo inflammatory 
 changes or carcinomatous or sarcomatous degeneration. Very exceptionally they 
 undergo spontaneous involution. If few in number, they may be removed ; but we 
 can do little for the cases in which they are numerous. 
 
 Treatment. — Arsenic given persistently in full doses may be tried; but the only 
 treatment that is at all hopeful of results is the surgical one, and that is applicable 
 only to cases in which the tumors are not numerous. Excision, or destruction with 
 the galvanocautery or the ecraseur, may be employed to remove the growths. 
 
 MYXOMA. 
 
 Myxoma is a rare affection of the skin, appearing first as a small subcutaneous 
 nodule of a soft and jelly-like consistency, and rapidly increasing in size. The skin 
 over it, at first normal and freely movable, becomes attached and reddened, and 
 finally ulceration and perforation occur. It may appear anywhere, more especially 
 where the panniculus adiposus is thick, and myxomatous tumors have been found 
 on the back, shoulders, gluteal regions, thigh, and the labia majora. They may 
 be single or multiple. They are composed of immature gelatinous connective tissue, 
 and are not benign tumors ; for while metastasis and general infection are rare, they 
 are apt to return in situ after operation. They are frequently mixed growths, myxo- 
 fibromata, myxosarcomata, myxolipomata, etc., and then they partake more or less 
 of the characteristics of the other tumor elements of which they are composed. The 
 only treatment is excision. 
 
 NEUROMA. 
 
 Under the name of neuroma is described a very rare tumor of the skin which is 
 in almost all cases a fibroma starting from the perineurium of the superficial nerves. 
 It occurs in middle or advanced life, and appears as pinhead- to hazelnut-sized, 
 round or oval, and usually multiple tubercles, seated in the skin of the shoulders, 
 thighs, buttocks, etc. Their color is pinkish or purplish ; they are firmly seated in 
 the corium ; and they are both tender and spontaneously painful. The nerve-struc- 
 tures suffer only secondarily. The only treatment is excision. It is doubtful if 
 tumors composed of true nerve-tissue occur in the skin. 
 
 LIPOMA. 
 
 A lipoma, adipoma, fatty tumor, Fettgeschwiilst (Ger.), is a circumscribed or 
 diffuse cutaneous or subcutaneous tumor composed of fatty tissue. It forms a soft 
 
ELEPHANTIASIS 
 
 SARCOMA PIGMENTOSA. 
 
 TYPOGPAVURF. 
 
 COPYRIGHT BY E. B. TREAT 4 CO., N. Y. 
 
 SARCOMA CUTIS. 
 
 TUBERCULOSIS CUTIS VERRUCOSA. 
 
 PLATE XLVIII. 
 
NEW GROWTHS. 269 
 
 lobulated mass of varying size ; occasional examples are iarge and weigh many- 
 pounds. The superjacent skin is normal and movable, and, if the growth is large, 
 may be distended and thinned (lipoma polyposum s. pendulum). Lipoma is a com- 
 mon affection ; the tumors may be single or multiple ; as many as two hundred have 
 been found by Weber in a single case. They may occur anywhere where fatty tis- 
 sue exists, and are commonest on the back and shoulders. They are most often 
 seen in females, and usually appear late in life. They are most often distinctly cir- 
 cumscribed, but occasionally they form more diffuse and pendulous masses. They are 
 benign tumors, and are not much subject to change ; but sometimes they retrogress 
 spontaneously, or degenerate into a cheesy mass ; and, if they are very large, ulcer- 
 ation may be occasioned by mechanical causes. The treatment is excision. 
 
 XANTHOMA. 
 
 Synonyms. — Xanthelasma, vitiligoidea. 
 
 Definition. — A new growth of the integument and the mucous membranes, 
 composed of fattily infiltrated connective tissue, and characterized by the appearance 
 of circumscribed yellow plates, papules, or tubercles, situated most commonly 
 upon the eyelids. 
 
 Symptoms and Course. — Xanthoma appears as yellow, yellowish-white, or yel- 
 lowish-brown patches, nodules, or larger masses embedded in the skin or mucous 
 membrane, and sometimes projecting above the surface. Their consistency is soft, 
 and the integument over them feels velvety and normal. They begin as minute 
 nodules, increase slowly up to a certain size, and then remain stationary for life ; in 
 the rarest instances only do they undergo spontaneous involution. They are some- 
 times seen in children, but are commoner in adults, more especially in females of 
 dark complexion ; and they are sometimes associated with gout and hepatic dis- 
 orders. They are accompanied by no subjective symptoms at all, and are obnoxious 
 only for cosmetic reasons, and occasionally because of their interference with the 
 use of joints when situated around them. 
 
 Several varieties are to be distinguished. Xanthoma planum is by far the com- 
 monest form, and appears as bean- to finger-nail-sized, distinctly limited plaques or 
 streaks, which a close inspection reveals to be composed of a multitude of fine yel- 
 low nodules, each one with a minute central pinkish point. They are soft and 
 usually not elevated. They occur most often upon the eyelids, appearing first at 
 the inner canthus, and gradually spreading as confluent patches or separate plates 
 over the lid and even onto the cheeks and nose. Patches may also appear upon 
 the neck and on the oral mucous membrane. Xanthoma tuberosum may coexist 
 with the plane form, and consists of papules or tubercles or roughened plaques of 
 varying size, somewhat firmer in consistency than the former variety, and covered 
 with an unaltered epidermis. Sometimes the growths form sessile or pedunculated 
 
270 ILLUSTRATED SKIN DISEAS] S. 
 
 tumors, usually of small size. Their commonest seat is over the flexures of the 
 joints and on the hands, feet, and scalp. Xanthoma diabeticorum is a rare variety 
 that occurs in connection with diabetes. The papules are numerous, conical, dis- 
 crete or confluent, and of the characteristic color with red areoli. The new growth 
 has been seen on the buttocks, loins, elbows, face, palms, soles, scalp, and in the 
 mucous membrane of the mouth. It is sometimes quite extensive. It differs fn m 
 xanthoma of the ordinary variety in its rapid development; and it may disappear as 
 quickly, leaving no trace behind. 
 
 Etiology. — The causes of xanthoma are obscure ; some cases are apparently 
 hereditary, and others seem to occur in connection with diseases of the liver. In 
 xanthoma diabeticorum the skin lesion has been seen to disappear spontaneously 
 with the disappearance of the glycosuria, and there seems to be ground for the belief 
 that there is a connection between the two symptoms. 
 
 Pathology. — Xanthoma is a connective-tissue new growth of the corium covered 
 with a thin epithelium. Its yellow color is due to the fatty infiltration of the new 
 elements. 
 
 Diagnosis. — The chamois-yellow patches embedded in the corium, with no 
 change in the texture of the skin that is perceptible to the touch, are characteristic. 
 The tumors of milium, which occur in the same situation, are tense, hard, and white ; 
 they are superficially situated in the epidermis, and their contents are expressible. 
 
 Prognosis. — The tumors cause little trouble. They occasionally require removal 
 on account of the disfigurement that they entail, or because they interfere with the 
 patient's work. 
 
 Treatment. — The xanthoma tumors or plaques may be removed with the 
 curette, excised, or destroyed with the Paquelin cautery or by electrolysis. When 
 they are situated upon the eyelids care must be taken to avoid deformity, as ectro- 
 pion, etc., from the contraction of the resulting scar. 
 
 SARCOMA. 
 
 Synonym. — Sarcomatosis cutis. 
 
 Definition. — 'Single or multiple, various-sized and -shaped, white or pigmented 
 malignant tumors of the skin and subcutis. 
 
 Symptoms and Course. — The affection usually occurs secondarily to sarcoma of 
 the internal organs, and belongs to the domain of surgery. It is rare as a primary 
 affection of the skin, and is seen in three forms. The commonest is the melanotic 
 sarcoma, or melanosarcoma, in which the affection begins as discrete, rounded or 
 lobulated, pea- to bean- or egg-sized tumors, of a grayish-brown or bluish-black 
 color. There may be a single tumor or several. As they increase in size, adjacent 
 tumors may coalesce to form irregular, various-sized, projecting masses, in which 
 ulceration not infrequently occurs. Their commonest site is on the backs of the 
 hands and feet, on the genitals, or on the face near the orbit. They originate not 
 
TYPOGRAVURE. 
 
 COPYRIGHT BY F. E. TREAT i CO., N. Y. 
 
 ICHTHYOSIS HYSTRIX. 
 
 PLATE XXIV. 
 
NEW GROWTHS. 
 
 271 
 
 infrequently from a pigmentary mole or a naevus, from the pigmented tissues, and 
 from the general integument in the colored races. 
 
 The non-pigmented sarcoma is rarer, and appears as one or more isolated, hard, 
 elastic tumors, usually small in size, and covered with smooth, shining, white or 
 sometimes reddened epidermis. As the growths increase in size they may coalesce 
 to form nodular plates and masses. The localized form frequently begins in a naevus 
 or a warty growth that has been irritated. In the generalized form the numerous 
 tumors are smooth and spherical, cutaneous or subcutaneous, growing rapidly and 
 coalescing into larger infiltrations which finally undergo ulceration. 
 
 Still rarer is the multiple pigmented form, which differs from the preceding in 
 that the tumors are more or less deeply discolored from the hemorrhages that occur 
 in their substance. They begin as a few or many pinhead- to pea-sized, brownish- 
 red, bluish, or purplish, smooth, shining nodules. These increase in size, multiply, 
 
 Fig. 131. — Sarcoma cutis. 
 From photograph by the author. 
 
 and become confluent, forming larger rugose infiltrations. Ulceration is rare, but 
 the central portions of the masses not infrequently undergo involution, forming 
 cicatricial, darkly pigmented depressions. The isolated tumors may also undergo 
 resorption or become gangrenous. Late in the disease sarcomatous nodules appear 
 in the mucosae of the respiratory and the gastro-intestinal tract. 
 
 Sarcomatous tumors of the localized form occur most often on the backs of the 
 hands and feet and on the face; in the more diffused forms the skin of the trunk and 
 
'll'l ILLUSTRATED SKIN DISEASES. 
 
 extremities is chiefly involved. Their number varies greatly ; there may be one, or 
 only a few, or hundreds of them. Their course also is very uncertain. In some 
 cases they take years to spread, apparently remaining stationary or even retrogress- 
 ing for long periods of time, and the general health remains good. In most instances, 
 however, their progress is rapid, and coalescence and ulceration soon set in. In all 
 cases death ultimately occurs from exhaustion, intercurrent disease, or sarcomatous 
 involvement of the viscera. Sarcoma occurs not infrequently in youthful individuals, 
 and the disease takes from two to six years to reach a fatal termination. 
 
 Etiology. — The cause of sarcoma is unknown to us. Melanotic sarcoma, in at 
 least one fourth of all cases, has developed from a wart or a naevus. Certain races, 
 notably the Russian and Polish Jews, seem especially prone to the affection. 
 
 Pathology. — Sarcoma is a growth composed of embryonic connective tissue 
 with round or spindle-shaped cells. The pigmented forms show hemorrhages, and 
 pigment granules in the new cell- mass. 
 
 Diagnosis. — The small, painful, sometimes discolored tumors, beginning on the 
 hands and feet, are not especially characteristic. The diagnosis is frequently a 
 matter of difficulty, largely on account of the rarity of the affection. Examination 
 of an excised piece under the microscope is usually necessary. Sarcoma is most 
 likely to be confounded with gumma ; but in this latter the tumors are not so 
 numerous, they run a quicker course, and rapidly go on to ulceration. The palmar 
 and plantar syphilide, fibroma, and the tumors of lepra, lupus, and mycosis 'fun- 
 goides might possibly be confounded with sarcoma; but it is not necessary to re- 
 capitulate their characteristics. 
 
 Prognosis. — This is bad in most cases. The disease usually ends fatally, though 
 involution and recovery are recorded. 
 
 Treatment. — Prophylaxis consists in the removal of warts and naevi that might 
 form the starting-point of sarcoma. Excision is, of course, to be advised in all 
 cases in which the number, size, and location of the tumors render it practical; but 
 the results have not been good, since return in situ or metastasis finally occurs. 
 Good effects have been seen from the long-continued subcutaneous injection of 
 arsenic, as recommended by Kobner; and both he and Shattuck have seen a com- 
 plete cure effected. Fowler's solution, diluted with 2 or 3 parts of water, must be 
 injected every other day or every third day in full doses. It should be tried in 
 every case, since it is claimed that it retards the development of the tumors, even if 
 it does not cure the disease. 
 
 2. NEW GROWTHS OF MUSCULAR TISSUE. 
 
 MYOMA. 
 
 Dermato- or leiomyomata are extremely rare new growths of the skin, composed, 
 as their name indicates, of unstriped muscular fibers, which are arranged in a net- 
 
NEW GROWTHS. 273 
 
 work bound together by a greater or less amount of connective tissue. There may 
 be a single tumor, which may be as large as a hen's egg, and exhibit a slow vermic- 
 ular motion; but more frequently there are a number of small, red, hard tumors 
 scattered over the body. They are seated in the cutis and covered with a normal 
 epithelium ; and they are most often found in places that are abundantly provided 
 with smooth muscle, as in the region around the mamilla, on the scrotum, labia 
 majora, etc. ; but they may originate anywhere on the body from the arrectores 
 pilorum. Sometimes they occur in combination with other tissue, forming fibro- 
 myomata, angiomyomata, etc. Their growth is extremely slow, and they hardly give 
 rise to any subjective symptoms. Their etiology is unknown, and the diagnosis can 
 only be made by the microscopic examination. Arsenic has been recommended in 
 their treatment; but enucleation or excision, or removal by electrolysis or the liga- 
 ture, is preferable. 
 
 3. NEW GROWTHS OF VASCULAR TISSUE. 
 
 ANGIOMA. 
 
 Synonyms. — Naevus vasculosus, naevus sanguineus, telangiectasis, angioma cav- 
 ernosum, tumor cavernosus, port-wine stain, mother's mark, Gefassmal (Ger.), tdche 
 de fen (Fr.). 
 
 Definition. — New growths of the skin composed of vascular tissue. 
 
 Symptoms and Course. — Three kinds of vascular new growths of the skin are to 
 be distinguished : 
 
 Naevus vasculosus, sanguineus, or flammeus is a vascular anomaly that is visible 
 at birth or shortly afterward, and is often combined with some increase of the con- 
 nective tissue of the area involved. It usually appears as a smooth, sharply limited 
 discoloration ; but it is sometimes rugose and more or less elevated, so as to form 
 papular or tubercular or even cauliflower-like elevations. Naevi are most com- 
 monly composed of capillaries, and then their color varies from a light to a dark red ; 
 arterial naevi are bright red in color, and venous ones dark blue or violet. They 
 are found most often upon the head, but they also occur upon other parts of the 
 body. They may be single or numerous, small or large, superficial or deep-seated, 
 and are almost always compressible. They usually increase slowly after birth until 
 they have attained a certain size, and then remain stationary. In some cases, how- 
 ever, they undergo spontaneous involution ; adhesion of the walls of the vessels and 
 obliteration of their lumen occurs, and a small amount of cicatricial tissue remains to 
 mark the place of the vascular tumor. In rare cases thrombosis, followed by gan- 
 grene, occurs. 
 
 Telangiectasis is an acquired vascular overgrowth, consisting mainly of an enlarge- 
 ment of preexisting vessels, without increase of the connective tissue. The capilla- 
 
274 
 
 ILLUSTRATED SKIN DISEASES. 
 
 ries and the fine arterial and venous branches are involved, forming a simple stain 
 of the skin, or appearing as a plexus of fine dilated vessels often arranged in radiate 
 order around a central spot (naevus araneus). Its color varies from a bright red to 
 
 a bluish purple, depending 
 upon the preponderance of 
 arterial or venous branches 
 in the spot. Its size is from 
 that of a small pea upward. 
 Telangiectases are situated 
 most commonly about the 
 face ; and, when localized 
 about the nasal or buccal ori- 
 fices, they may spread on to 
 the mucous surfaces. They 
 appear most commonly in 
 middle life, and increase in 
 size and number as the pa- 
 tient progresses toward old 
 age. They form a part of 
 the ordinary symptoma- 
 tology of rosacea. 
 
 Angioma cavernosum is 
 also a non-congenital form, 
 appearing as rounded, often 
 fairly large-sized tumors 
 which are both compressible and erectile and are frequently pulsating. They are rare 
 new growths, and vary in color like the ordinary naevi. 
 
 Etiology. — Our knowledge of the etiology of these growths is very unsatisfac- 
 tory. There is no proof that they are in any way connected with antenatal mater- 
 nal impressions, the popular belief to the contrary notwithstanding. The telangiec- 
 tases are often symptomatic, being the expression of an attempt at a collateral 
 circulation when there is obstruction from a tumor or the contraction of new-formed 
 connective tissue, etc. Some of these vascular overgrowths occupy the area supplied 
 by a cutaneous nerve; but their relationship to the nerve-distribution is unknown. 
 Pathologfy. — Naevi consist of dilated and hypertrophied or newly formed arte- 
 ries, veins, and capillaries, usually covered with a normal epidermis. More or less 
 newly formed connective tissue is present in all cases, though in the telangiectases it 
 is not apparent ; and there is often an increased development of the sebaceous glands, 
 hair-follicles, arrectores pilorum, and fatty tissue (naevus lipomatodes, angio-ele- 
 phantiasis). The cavernous angiomata are composed of true erectile tissue, there 
 being a connective-tissue framework with large spaces lined with endothelium, these 
 
 Fig. 132. — Nsevus venosus. 
 
 From photograph by the author. 
 
COPYRIGHT BY E. B. TREAT & CO., N. Y. 
 
 PHOTOGRAVURE i COLOR CO. , N. 
 
 NAEVUS VASCULOSUS 
 
 PLATE XLIII 
 

 
 I free commi veen 
 
 the . and ye 
 
 Diagnosis.- The flat re purplish 
 
 ins, the I outoro. • charac- 
 
 teristic. 
 
 Prognosis, 
 treatment, . 
 
 i sometimes disappear ■ 
 ulceration. In g 
 the 
 
 Treatr 
 
 ■ 
 
 and telangiectases may 
 on a number of layers of 
 J29, p. 251), the sur 
 tected with plasl 
 tion being aV- 
 off. Cau ti 
 app'h 
 days, 
 
 - 
 
 zinc or 
 advisal 
 Vaccinat 
 
 
 . 
 
 
 a needle being e 
 
 Cross-hatch. 
 
 skin in a series of pai 
 
 with the ether spray 
 
 by pressure. 
 
 fixed on a co 
 
 bolic or 
 
 all exten 
 
 '- 
 
 them 
 lions of ■ of 
 
 occui 
 
 thai 
 
 1 throug ted 
 
 > ;:en 
 - 
 aeedles 
 ■per-cent. car- 
 at 
 
 new 
 
 oain an ....- imal 
 
 • that employed f 
 :, or several mounted upo> 
 
 

NEW GROWTHS. 
 
 275 
 
 
 
 _ 
 
 
 latter forming a free communication instead of the ordinary capillary one between 
 the arteries and veins. 
 
 Diagnosis. — This can hardly present any difficulties. The flat reddish or purplish 
 stains, the blue and red projecting tumors, and the erectile outgrowths are charac- 
 teristic. 
 
 Prognosis. — This depends largely upon the 
 treatment, and must be cautiously expressed. 
 Nasvi sometimes disappear spontaneously or by 
 ulceration. In general the prognosis is better in 
 the telangiectases and simple stains than in the 
 larger and the erectile tumors. 
 
 Treatment. — This should only be undertaken 
 when the vascular new growth is rapidly increas- 
 ing, or for cosmetic reasons. The smaller stains 
 and telangiectases may be removed by painting 
 on a number of layers of the sublimate collodion 
 (No. 129, p. 25 1), the surrounding parts being pro- 
 tected with plaster or collodion, and the applica- 
 tion being allowed to remain in place until it peals 
 off. Caustic potash, 3i— iv, to water, 5i, may be 
 applied two or three times at intervals of a few 
 days. In the very superficial forms painting the 
 affected surface with nitric acid or the acid nitrate 
 of mercury is sometimes efficacious ; and very min- 
 ute naevi may be destroyed by plunging a red-hot needle into them, or by means of 
 the Paquelin or the galvanocautery. The injection of solutions of the chloride of 
 zinc or of tannin, or of the tincture of the chloride of iron, into these growths is not 
 advisable, inflammation, sloughing, and even death having occurred therefrom. 
 Vaccination upon the n void growth may be tried in suitable cases, punctures with 
 a needle being employed to avoid the hemorrhage that would follow scarification. 
 Cross-hatching with the scarificator (Fig. 15, p. 50), cutting through the affected 
 skin in a series of parallel and crossed lines, is effective. The part should be frozen 
 with the ether spray beforehand, and the hemorrhage, which is free, can be controlled 
 by pressure. Multiple puncture is recommended by Sherwell, a bundle of needles 
 fixed on a cork or other suitable holder, and dipped into a 50- or 90-per-cent. car- 
 bolic or a 25-per-cent. chromic-acid solution, being used. Where the angioma is at 
 all extensive, it must, of course, be operated upon in sections. 
 
 Electrolysis, however, is by far the best method of treatment for these new 
 growths, being both successful and safe, with no subsequent pain and a minimal 
 amount of scarring. The process is exactly similar to that employed for the removal 
 of hairs (p. 49). A single needle, or several mounted upon one holder, may 
 
 FlG. 133. — Papillary ncevus. 
 From photograph by the author. 
 
276 ILLUSTRATED SKIN DISEASES. 
 
 be employed. In the flat angiomata the needle should be passed horizontally 
 through the skin among the enlarged vessels ; visible ones can be pierced singly, 
 and the more projecting tumors should be transfixed through their bases in various 
 directions. A current as strong as the patient can comfortably bear should be 
 employed, varying from 2 to 10 milliamperes, depending upon the sensitiveness of 
 the region operated upon, with the object of destroying the vascular walls and coagu- 
 lating the blood within them. 
 
 Warty and pigmented nsevi may be curetted or excised, or removed with the 
 Paquelin or treatment of the galvanocautery. The pendulous forms require excision 
 or the ligature ; but the larger growths, angio-elephantiases, and the cavernous 
 tumors belong to the domain of general surgery. 
 
 LYMPHANGIOMA. 
 
 This rare tumor of the skin is composed of dilated, hypertrophied, and newly 
 formed lymphatic vessels, together with a varying amount of new connective tissue. 
 It appears in two forms. In the commoner, lymphangioma simplex, there occur small 
 aggregations of irregularly grouped, deep-seated, transparent vesicles, with thick walls, 
 and with healthy skin between the patches. The tumors are usually multiple, deeply 
 seated in the cutis, and pinhead- to pea-sized ; they are colorless or pinkish, or 
 somewhat darker and resembling warts. On pricking them a colorless fluid con- 
 taining a few lymphatic cells exudes from them. They begin in youth, running a 
 very chronic course, and spreading slowly by the formation of new groups of vesicles 
 outside the original patches. Lymphangioma cavernosum is even rarer, and is usually 
 congenital. Its structure is similar to that of the cavernous angiomata, but it con- 
 tains lymph instead of blood. It affects a circumscribed portion of the body, as the 
 tongue or lips, causing a diffuse enlargement of the part (macroglossia, macrochilia). 
 Of the treatment of these conditions not much need be said; the general health is 
 good, and surgical interference is not advisable. Destruction by caustics or excision 
 is apt to be followed by the appearance of new lesions at the margins of the patch. 
 Electrolysis, as done for hirsuties and naevus, has given good results in Crocker's 
 hands. 
 
 4. NEW GROWTHS OF GLANDULAR TISSUE. 
 
 ADENOMA. 
 
 New growths composed of glandular tissue are of rare occurrence in the skin, and 
 may develop from the sebaceous or the coil glands ; they may be found wherever 
 these structures are present, but have been most often seen on the neck, head, and 
 face, more especially upon the sides of the nose and on the forehead. They may 
 
NEW GROWTHS. 277 
 
 be congenital or acquired, and appear as pinhead- to pea- and even marble-sized, 
 rounded or acuminate tumors, firm or soft, and of a normal color, or a yellowish- or 
 brownish-red hue. They may remain stationary or undergo fatty or colloid de- 
 generation, or ulcerate spontaneously, leaving scars behind. When they grow from 
 the sweat-glands the tumors contain a drop of clear encysted fluid. A positive diag- 
 nosis, and a differentiation from steatoma, lipoma, and epithelioma, usually require a 
 microscopic examination. The prognosis is good, and the treatment consists of their 
 removal by surgical measures. 
 
 CARCINOMA. 
 
 Synonyms* — Cancer, epithelioma, epithelial cancer, cancroid, Krebs, EpitJieliom 
 (Ger.), epitheliome, cancroide (Fr.). 
 
 Definition. — A malignant new growth of the skin, characterized by the develop- 
 ment of heterologous epithelium in the corium and subcutis, appearing as infiltrations 
 and ulcerations of the skin, and terminating in death by exhaustion or from infection 
 of the internal organs. 
 
 Symptoms and Course. — Carcinoma occurs in the skin, as in other organs, either 
 as a primary or a secondary new growth, and usually in individuals over forty years 
 of age. General considerations as to its nature and treatment belong to the domain 
 of genera' surgery. Certain varieties, however, are peculiar to the skin and mucosae, 
 and are of common occurrence there ; and the others will be considered only in so 
 far as they are of interest to the dermatologist. 
 
 True carcinoma cutis is always of the scirrhus variety, and is usually a secondary 
 affection, spreading either by contiguity or metastasis from cancer of the breast or 
 of the alimentary canal. A lenticular and a tuberous form occur. 
 
 Carcinoma lenticulare is the commonest variety of the cutaneous scirrhus, usually 
 appearing in the scar or in the skin of the chest after the extirpation of a cancerous 
 breast. It begins as multiple, various-sized, very hard, smooth, and glistening nod- 
 ules of a dull brownish or reddish color. At first they are deep-seated and dis- 
 crete ; but as they increase in size they project above the surface of the skin and 
 coalesce into irregular tuberous masses. Not infrequently they form large indurated 
 plates which may cover the chest with a stiff, leather-like envelop and impede res- 
 piration (cancer en cuirasse). The vascular supply is finally interfered with, and 
 ulcerations, often covered with fungous and easily bleeding granulations, occur. The 
 lymphatic glands enlarge, and the interference with the lymphatic circulation causes 
 marked and characteristic swelling of the neighboring limb. Pain is very great, and 
 the process terminates usually in a few months, death occurring from exhaustion or 
 from metastasis into the internal organs. 
 
 Carcinoma tuberosum is rarer, and may also be primary, or secondary to cancer 
 of other organs. It shows itself as multiple large tubercles, usually distributed ovef 
 
278 
 
 ILLUSTRATED SKIN DISEASES. 
 
 the body, but most abundant upon the face, head, arms, and chest. The lesions are 
 hard, sharply limited, flat or elevated and rounded, and vary from the size of a pea 
 to that of an egg. Their color is dull brown, reddish, or violaceous. At first they 
 
 are deep-seated, but they project 
 from the surface as they increase 
 in size. They remain discrete; 
 but breaking down finally occurs, 
 and foul and painful fungating 
 ulcerations appear. The process 
 terminates in death from exhaus- 
 tion or from metastasis. 
 
 Epithelioma or cancroid is by 
 far the most frequent form of can- 
 cer of the skin, forming, according 
 to Hyde, ys °f * P er cent, of all 
 cases of skin disease. It usually 
 begins at one of the points of 
 coalescence of the skin and the 
 mucous membranes, being seen 
 most often upon the face, more 
 especially around the eyelids and 
 the nose. It is common also upon 
 the genitals, especially upon the 
 prepuce and the glans penis. It 
 occurs also upon the nasal, buccal, 
 vaginal, and rectal mucosae, but it 
 is much more rarely found in other 
 localities. It may originate in nor- 
 mal skin or mucous membrane, or 
 begin in a wart, a fissure, or an 
 excoriation, more especially when 
 these lesions have been irritated 
 by scratching, the use of caustics, 
 etc. A seborrheal patch or a 
 senile wart is not infrequently its 
 starting-point, and it sometimes 
 appears in the scars of syphilitic or lupoid disease. It is preeminently an affection of 
 old age, occurring very rarely indeed in the young. Three varieties of epithelioma 
 are to be distinguished ; but the pathological process is the same in all of them, though 
 they may differ in clinical appearance and mode of growth. The varieties may 
 coexist in different portions of the same integument, or develop from one another. 
 
 Fig. 134. Rodent ulcer. 
 Case of Dr. L. Weiss. 
 
NEW GROWTHS. 
 
 279 
 
 1. Superficial discoid or flat epithelioma, rodent ulcer, flache Hautkrebs (Ger.), 
 occurs upon the face, prepuce, etc. This is the most benign and least troublesome 
 of the epitheliomata, and may exist for years without causing any special inconve- 
 nience to the patient. It begins as one or, more rarely, as several neighboring pink- 
 ish- or yellowish- white, small, hard papules or disks or flat infiltrations, with a char- 
 acteristic dirty waxy hue and a surface that has a glance like that of mother-of-pearl 
 and is marked with minute tortuous vessels. It increases very slowly indeed in size, 
 and it may be years before breaking down occurs ; but sooner or later an excoriation 
 appears upon its surface, covered, perhaps, with a minute crust. This gradually grows 
 into a superficial ulceration covered with a scanty viscid secretion. The fully de- 
 veloped epitheliomatous ulceration is a more or less circularly shaped, sharply defined 
 excavation, with a purplish or reddish base that may be dry and varnished-looking 
 or slightly moist, and showing embedded in it peculiar minute waxy bodies, the 
 cancroid pearls. The edges of the ulceration are 
 
 prominent, rolled, and somewhat undermined ; and 
 both they and the base of the ulcer are of the 
 same cartilaginous hardness as the papule from 
 which they develop. Very characteristic also is 
 the presence of the dilated blood-vessels running 
 over the waxy margin. Such an ulceration may 
 grow very slowly for many years, spreading over 
 the surface, and showing no tendency to spread 
 downward. It may cease to enlarge after a time, 
 and cicatrization may occur, especially in the center 
 of the ulceration ; this is usually partial, but may 
 be occasionally complete. More commonly, how- 
 ever, the new growth finally invades the deeper 
 structures, and develops into the infiltrating or 
 papillary form of the disease. Pain is rarely 
 marked in this variety of the affection until the 
 ulceration is very large ; and the lymphatic glands 
 are usually not involved at all, or only very late. 
 
 Since it is almost invariably a disease of old age, the patient frequently dies from 
 some other cause. 
 
 2. Deep-seated, tubercular, or infiltrating epithelioma is a rarer affection than 
 the superficial form, and runs a much more rapid course. It occurs oftenest upon 
 the lips, tongue, and forehead, and may originate in a wart or develop upon normal 
 skin. It begins as a number of hard, closely aggregated, pea-sized tubercles, deeply 
 seated, and closely united to the subcutaneous connective tissue. The tubercles may 
 be flattened or globular, their color is dark reddish or purplish, and their surfaces 
 are shiny and marked with dilated and tortuous vessels. As they increase in size 
 
 Fig. 135. — Epithelioma of the penis. 
 From photograph by the author. 
 
280 
 
 ILLUSTRATED SKIN DISEASES. 
 
 they coalesce into a thick infiltrated plaque, which may be elevated or not above 
 the surface of the skin, but which shows the characteristic hardness, waxy glance, 
 and superficial vascularization. The entire mass may reach the size of a silver dollar 
 or a small egg; and isolated nodules, similar in character to the original lesion, 
 
 appear in the skin around the growth. 
 In the course of time breaking down 
 occurs in the surface or at the periphery 
 of the nodules or infiltration, and a char- 
 acteristic ulcer results. This isarounded 
 or irregular crateriform loss of tissue, 
 with an uneven, reddish, often granulat- 
 ingand easily bleeding base, and everted, 
 raised, hard, and purplish borders. The 
 secretion from it is, usually pale yellow, 
 viscid, and scanty; but it may be foul 
 and purulent if destruction is rapid. 
 The hard infiltration of the base and 
 margins of the ulcer is marked, and ex- 
 tends to the tissues beneath and around 
 it. Pain of a sharp, lancinating variety 
 is present at all stages, and is very 
 marked in the later ones. The deeper 
 tissues, fasciae, muscles, cartilage, and 
 bone are eventually involved; the lym- 
 phatic glands enlarge and sometimes 
 break down ; and death occurs from marasmus, exhaustion, or hemorrhage in from 
 one to three years. 
 
 3. Papillary epithelioma, malignant papilloma, Blutgezvachs (Ger.), is a rapidly 
 fatal form of cutaneous epithelioma. It may occur as an independent growth in 
 normal skin, or grow from a mole, a wart, a naevus, or a scar in which enlargement, 
 induration, and proliferation of the epithelium occur; or it may develop from the 
 superficial or the infiltrating form. It occurs most often upon the glans penis, prepuce, 
 scrotum, labia, or the mucous membranes, appearing as a more or less elevated, 
 pedunculated or sessile, raspberry-like vegetation of a bright-red color, and so vas- 
 cular that it bleeds readily to the touch. Its surface may be dry and covered with 
 a yellowish-white epithelium, or macerated and bathed with a foul-smelling, perhaps 
 bloody secretion ; and its base is characteristically hard. At first pea-sized and 
 slightly elevated, it grows into a projecting, egg-sized or larger, lobulated or spongy 
 mass. Fissures, excoriations, and deeper ulcerations occur; the mass finally breaks 
 down ; and an ulcer similar to that of the preceding forms results. It is rounded or 
 oval in shape, with an irregular base covered with granulations and bathed with a 
 
 Fig. 136. — Papillary epithelioma. 
 
 From photograph by the author. 
 
NEW GROWTHS. 
 
 281 
 
 serous discharge, or crusted, and with hard eroded or undermined borders of a pur- 
 plish-red color. If the infiltration of the cutis is slight, the ulcer will assume the 
 form of the superficial epithelioma ; if it is greater in extent, the malignant deeper 
 ulceration will result. More or less pain, dull or acute, is usually present during the 
 process. In the course of several 
 years the fatty tissues, the fasciae, 
 the muscles, and the bones become 
 involved ; the lymphatic glands en- 
 large, harden, coalesce, and break 
 down ; and death finally results 
 from exhaustion. 
 
 Under the name of Paget's dis- 
 ease or eczematoid epitheliomatosis 
 is known a very superficial form of 
 epithelioma affecting the nipple in 
 the female. In the beginning it 
 appears as an ordinary but intract- 
 able eczema ; when fully developed 
 the mammilla and areola are red, 
 weeping or crusted, and careful 
 examination reveals the presence 
 of an induration under and around 
 the affected tissues. Moderate 
 itching and burning accompany the 
 process; one breast only is usually 
 affected ; and the cases occur in 
 women from forty to sixty years 
 
 of age. After an exceedingly chronic course, lasting for years, it develops finally 
 into one of the other forms of the disease. 
 
 Etiology. — In spite of extensive investigations that have been carried on in 
 regard to this subject, Ave are still in the dark as to the cause of carcinoma. Certain 
 protozoa have been described as the etiological factor by Adamkiewicz and others; 
 but their relationship to the disease is doubtful. Heredity seems to be of some 
 influence, and cases are on record where several instances have occurred in one family. 
 Epitheliomata frequently develop from warts, pigmentary and vascular nsevi, etc. ; 
 and in fact all the senile changes of the skin predispose to its occurrence. Irritation, 
 either mechanical or chemical, of traumata, warts, ulcerations, etc., seems to excite 
 the epithelial overgrowth. This is a factor in the cancer of the lower lip of pipe- 
 smokers, the cancer of the scrotum that is seen in workers in paraffin factories and 
 in chimney-sweepers, in cancer of the cervix uteri, etc. The malady is very rare 
 before middle life, but cases have been reported in children. 
 
 Fig. 137. — Epithelioma of the lip. 
 
 From photograph by the author. 
 
282 
 
 ILLUSTRATED SKIN DISEASES. 
 
 Pathology. — Carcinoma consists essentially of an excessive proliferation of the 
 epithelium, which accumulates in concentric masses contained in connective-tissue 
 alveoli. In the skin the growth begins in the rete-cells, and the increasing mass 
 extends downward as well as on the surface, penetrating the deeper layers of the 
 
 corium, and causing irritation and in- 
 flammatory change. The new cells 
 are arranged in compact concentric 
 masses or nests ; the central cells 
 undergo horny transformation, and 
 finally degenerate and break down 
 in consequence of insufficiency of the 
 blood-supply ; ulceration occurs in 
 the center of the mass while cell- 
 proliferation is still progressing at the 
 margin. Elements of the new growth 
 pass into the lymphatic channels and 
 cause inflammation and epithelioma- 
 tous degeneration of the lymphatic 
 glands. 
 
 Diagnosis. — The occurrence of 
 the neoplasm in old age, and its ap- 
 pearance secondarily to cancer of the 
 internal organs, is sufficiently distinc- 
 tive for the lenticular and tuberous 
 forms of the disease. For epithelioma 
 the slowly growing, hard, cartilagi- 
 nous, waxy, and transparent tumor 
 is fairly characteristic ; and the same 
 is true of the ulcerative form, with 
 its chronicity and pain, its indurated 
 and everted edges showing" the same characters as the original tumor, and its character- 
 istic glands. Nevertheless the diagnosis is sometimes a matter of difficulty. Before 
 ulceration has occurred the epithelioma maybe confounded with the syphilitic chancre, 
 tubercle, or gumma, with an ordinary wart, and with the lesions of lupus and sarcoma. 
 None of the syphilitic affections have the ivory hardness, the lancinating pain, the 
 peculiar adenopathy, and the very chronic course of cancer; other symptoms of lues, 
 past or present, will usually be found; they occur, as a rule, earlier in life, and they 
 react to specific treatment. The gumma is never so hard, and goes on fairly rapidly 
 to softening and fluctuation. Warts are very liable to be confounded with epithe- 
 liomata in the aged, and the diagnosis between them is of special importance, since 
 these growths frequently develop into the malignant form of tumor. As soon as a 
 
 Fig. 138. — Fungating epithelioma of the scalp. 
 From photograph by the author. 
 
NEW GROWTHS. 283 
 
 wart becomes painful, irritated, bleeding, or indurated at its base, it should be 
 removed. Lupus occurs in youth, rarely beginning after the thirty-fifth year; the 
 malady is more diffuse than epithelioma, the lesions are multiple, and the soft, brown- 
 ish, translucent nodules are characteristic. Sarcoma is of rapid development and 
 takes only a few months to run its course ; it occurs in early life ; there is little ten- 
 dency to ulceration, and a great tendency to reappearance in neighboring and dis- 
 tant parts. When ulceration of the epithelioma has occurred it must be differentiated 
 from the ulcerative syphiloderm and from lupus ; the papillary form must be dis- 
 tinguished from condyloma, and Paget's disease from a simple eczema. In the 
 ulcerations of luetic disease the marginal induration is not so hard as in cancer, and 
 the waxy appearance is absent ; its course is much quicker ; several points are usually 
 affected at once ; there is little pain ; and the touchstone of treatment soon settles 
 the diagnosis. The lupoid ulceration shows the characteristic nodules outside the 
 loss of tissue. Condyloma may resemble a papillomatous epithelioma in its early 
 stages very greatly ; but it occurs earlier in life, and the presence of induration and 
 ulceration settles the diagnosis in favor of the malignant disease. The induration 
 and intractability, together with the extreme chronicity of its course, will distinguish 
 Paget's disease from an ordinary eczema. There are always doubtful cases, how- 
 ever, in which the excision of a fragment of tissue and its examination under the 
 microscope will be necessary. 
 
 Prognosis. — The general prognosis of cancer of the skin is grave, but is dependent 
 largely on the variety, location, and stage of the disease. The superficial forms may 
 last for many years without interfering with the general health. The true carcino- 
 mata, as well as the deeper-seated, nodular, and more destructive varieties of epi- 
 thelioma, runs a more rapid course, and may reach a fatal termination in one to two 
 years. Of bad prognosis, are excessive pain, a rapidly advancing adenopathy, 
 occurrence in advanced age, and location in situations where the growth cannot 
 readily be removed. Beginning and superficial cases can be cured by operative and 
 other measures ; but recurrences are prone to occur in any form. 
 
 Treatment. — The true cutaneous carcinomata are not amenable to treatment. 
 Neither local destruction nor internal remedies have any effect upon the disease, and 
 our efforts must be limited to the relief of the pain and the promotion of euthanasia. 
 
 The treatment of the epitheliomata is a purely local one, and consists in the 
 removal or the radical destruction of the morbid growth and the neighboring lymphatic 
 glands when infected. Excision with the knife, curettement, or destruction with 
 caustics may be employed, our choice being determined by the variety, location, and 
 extent of the disease. Whichever method is employed must be used on the appa- 
 rently healthy tissue outside the limits of the growth ; for the epithelial-cell nests 
 and processes extend farther than is visible upon the surface, and any portion that 
 is left behind will serve as a nucleus for renewed growth. Upon the mucosae, near 
 the orifices of the body, and in general in the very deep-seated and infiltrating forms, 
 
284 ILLUSTRATED SKIN DISEASES. 
 
 removal by the knife, followed if necessary by a plastic operation to fill up defects 
 of tissue, is the most promising and sometimes the only available method. The 
 details of such operations, however, belong to the domain of surgery. 
 
 The commoner superficial discoid and papillary forms are better treated by less 
 radical measures, cautery, curetting, or caustic applications. Erasion with the sharp 
 dermal curette under local anaesthesia (Figs. 18, 19, 20, p. 50) is an excellent measure 
 for the removal of the papillary forms of the disease; it is never, however, sufficient 
 alone, and is best used as a step preparatory to the application of the cautery or of 
 caustic applications. The thermo- or galvanocautery causes little pain and leaves a 
 good scar ; it is suitable for smaller growths that are situated on the mucosae or near 
 the mouth or eye, situations where caustics cannot be used. Caustic applications 
 are to be employed in all cases in which the location of the cancer makes it possible ; 
 for they not only cause actual destruction of the cells with which they come in con- 
 tact, but they also excite so violent an inflammation in the surrounding tissues that 
 the new epithelial structures, less resistant than the healthy tissues, speedily succumb. 
 Thus outlying epithelial masses situated in apparently normal tissue, which might 
 be left behind were knife or cautery employed, are thoroughly destroyed. Potassa 
 fusa is frequently employed. The solid stick, suitably pointed, is bored into the 
 growth and its margins in various directions, dilute acetic acid being afterward 
 employed to neutralize any excess of caustic action. Healthy tissues may be distin- 
 guished by their greater resistance to the point ; the process is not very painful, but 
 must usually be repeated several times, an indifferent ointment (No. 26, p. 70, Nos. 
 68, 69, p. 135) being employed during the intervals. Pyrogallic acid, I to 4 or 6, in 
 ointment or powder (No. 44, p. 100), is a favorite application with Kaposi, Jarisch, 
 and others. It is not painful and does not affect the healthy tissues; it must be 
 kept in place a week or more, and be followed by the use of an indifferent ointment. 
 Trichloracetic acid bored into the mass on a pointed glass rod is efficacious, and 
 nitric acid can be used cautiously in the same way. 
 
 No. 132. Hebra's Cosine's Paste. No. 133. Kaposi's Caustic Paste. 
 
 fy Ac. arseniosi 1 part fy Ac. arseniosi ... 2 parts 
 
 Hydrarg. sulphuret. rub. . 3 parts Creosoti . . . . 60 " 
 
 Ungt. aq. rosas . . . 24 " Pulv. opii 1 part 
 
 The best agent, however, for the destruction of the epitheliomata is arsenious acid, 
 made into a paste either as Hebra's modification of that of Cosme (No. 132, p. 284), 
 together with creosote and opium, as proposed by Kaposi (No. 133, p. 284), or, as I 
 think preferable, in the concentrated form suggested by Marsden (No. 7, p. 46). 
 Arsenic cannot be used near the eye, since it causes a rather violent inflammation 
 of the surrounding tissues; nor upon the margins of the lips, on account of the 
 danger of poisoning. But in all other situations, and in all forms save the very deep 
 
NEW GROWTHS. 
 
 285 
 
 and infiltrating ones, Marsden's paste is the best application and has done me 
 excellent service. Its use should be preceded by a curetting to remove papillary 
 masses and resistant epithelium. The powered gum arabic and the arsenious acid 
 are made into a soft paste with a little water, applied spread upon a cloth, and cov- 
 ered with rubber plaster. It should remain in situ for twenty-four hours, or as long 
 as the patient can bear the pain. This latter, while constant, is not very severe, and 
 is usually well borne ; a little morphia added to the paste will mitigate it. There is 
 no danger of absorption, and the arsenic does not affect the healthy tissues, while 
 the new carcinomatous cells are thoroughly destroyed. The more extensive growths 
 and ulcerations must be treated in sections, not more than 2 or 3 square inches of 
 surface being covered at one time. The dead tissue appears as a black necrotic 
 mass after the paste is removed, and the part must then be poulticed until the slough 
 separates. The simple ulceration that is left behind can be treated with rose-water 
 or simple ointment (Nos. 68, 69, p. 135) until it heals. The other arsenical pastes 
 are used in the same way. They not infrequently require to be applied twice or 
 oftener; but the destruction is radical, and a thin smooth scar is left behind that 
 becomes almost invisible in the course of time. Successful removal is shown by the 
 rapid and complete cicatrization of the ulceration left after the slough has separated. 
 If this does not occur, or if the characteristic cancerous nodules appear in the scar, 
 the treatment must be repeated. 
 
CLASS VL 
 ATROPHIES. 
 
 UNDER this heading are classified those changes in the skin that consist essen- 
 tially of a diminution in the size or number of the cells of one or more or all the 
 tissues that compose that organ. Degeneration not infrequently accompanies the 
 process. The whole cutis and subcutis may be affected, as in the various forms of 
 circumscribed and partial atrophy, xeroderma, and scleroderma ; or the pigment 
 only is involved, as in albinismus, vitiligo, and canities ; or the atrophy may affect the 
 hair, as in the various forms of alopecia, or the nails, as in onychatrophia. Certain 
 congenital deficiencies of parts of the skin, though not strictly pathological atrophies, 
 can be most conveniently considered here. 
 
 U ATROPHY OF THE CUTIS AND SUBCUTIS. 
 
 General atrophy of the skin and subcutaneous tissue may be localized and par- 
 tial, or generalized and spread over the whole body. They are rare as idiopathic 
 conditions, more commonly occurring together with or following other pathological 
 or physiological changes. We shall consider atrophia cutis propria and scleroderma. 
 
 ATROPHIA CUTIS. 
 
 Synonyms. — Atrophoderma, maculae et striae atrophica?, atrophia senilis, xero- 
 derma, glossy skin, atrophia neuriticum, atrophy of the skin. 
 
 Definition. — A diminution in quantity of the histological elements of the skin, 
 often accompanied by degeneration. 
 
 Symptoms and Course. — Atrophy of the skin may be general or localized, idio- 
 pathic or symptomatic. Its various forms differ sufficiently to require separate 
 consideration. 
 
 General idiopathic atrophy of the skin is rare as a congenital condition, and is 
 
 286 
 
ATROPHIES. 
 
 287 
 
 known as xeroderma or parchment-skin, though that name is also employed to 
 designate the milder varieties of ichthyosis. In this condition the integument of 
 the feet and legs and hands and arms is most markedly affected. The skin is 
 thinned, tense, and wanting in pigment; the epidermis is thin and shining; and the 
 parts most affected are very sensitive. Idiopathic atrophy of the skin is a not 
 uncommon acquired condition in old age. Atrophia senilis is really a physiological 
 process, the general integument partaking in the diminution in size that occurs in 
 all the tissues in old age. The subcutaneous fat gradually disappears ; the skin 
 becomes lessened in thickness, lax, wrinkled, and hangs in thin folds. All the ele- 
 ments of the integument save the 
 pigment are atrophied; the de- 
 crease in the secretion of sweat and 
 sebum causes a slight but persistent 
 desquamation (pityriasis tabescen- 
 tium) ; and the color of the integu- 
 ment gradually gets darker, either 
 diffusely or in spots. Verrucae seniles 
 (senile warts), dirty yellow-brown 
 accumulations of sebaceous scales, 
 frequently appear, and are very prone 
 to undergo carcinomatous degenera- 
 tion. The condition is only patho- 
 logical when, as is frequently the 
 case, it is accompanied by violent 
 itching. 
 
 Circumscribed atrophies of the 
 skin are of common occurrence, and 
 may be idiopathic or symptomatic. 
 In atrophia maculosa et striata, macu- 
 lae et striae atrophicae, or vergetures 
 (Fr.), they occur as stripes or spots 
 that at first are red, but in the course of time become purplish, grayish, or silvery 
 white, smooth, scar-like depressions. In its commonest form the affection appears 
 as a number of parallel stripes 1—2 mm. wide and 1 to several inches long. The 
 streaks are isolated, rounded or oval, and pinhead to finger-nail in size. They may 
 appear anywhere on the body, but are most commonly seen upon the neck, thighs, 
 buttocks, and abdomen. They occur in both sexes, grow to their full size very 
 slowly, and, once formed, are permanent. As they cause no subjective symptoms 
 at all, their presence is frequently discovered only by accident. 
 
 Localized atrophy of the skin occurs after injury to the nerve supplying the part 
 affected. Atrophoderma neuriticum, glossy skin, GlanzJiaut (Ger.), gives us a 
 
 Fig. 139. — Stride atrophicae. 
 Case of Dr. A. H. Ohmann-Dumesnil. 
 
288 ILLUSTRATED SKIN DISEASES. 
 
 thinned, smooth, glossy, and apparently varnished skin, of a pinkish or reddish color. 
 The natural lines are obliterated, the hair is lost, and the nails become incurved. 
 Vesiculation, ulceration, and gangrene sometimes take place ; and the patients suffer 
 from paroxysmal neuralgic pains. The fingers are the parts usually affected. 
 
 Under the name of cutis laxa is known a condition usually hereditary, in which 
 the normal extensibility of the skin is greatly increased, and its usually firm attach- 
 ment to the deeper tissues is diminished, so that it can be drawn out in folds like a 
 sheet of rubber tissue. The condition causes no inconvenience to its bearers, some 
 of whom are put on exhibition as rubber- or elastic-skinned men. 
 
 Etiology. — Some forms of cutaneous atrophy are of unknown origin, while others 
 are due to obvious mechanical causes. Concerning the cause of the more general 
 and congenital cases and of cutis laxa we are in ignorance. Partial atrophy is 
 usually due to laceration of the subcutaneous tissues, either from external violence, 
 blows, the pressure of corns, favus crusts, etc., or from internal distention, as occurs 
 in anasarca, ascites, abdominal tumors, pregnancy, and excessive development of fat. 
 It also follows lepra and syphilis. Glossy skin occurs in parts where the circulation 
 is bad, and that have been exposed to cold ; and also in gouty, rheumatic, and 
 other general conditions. Some cases are distinctly due to nerve injuries, a neuritis, 
 perhaps accompanied by muscular atrophy, being the cause of the trophic changes 
 in the skin. 
 
 Pathology. — In the various forms of atrophy of the skin the epidermis and the 
 mucous layer are thinned, the papillae are flattened out, and the fatty tissue and 
 vessels are much diminished in quantity. There is often a marked change in the 
 connective tissue of the corium and subcutis. The bundles are much smaller than 
 normal, are arranged in parallel rows instead of being interlaced, and fat-cells are 
 not present in their meshes. In some cases there is fatty, amyloid, or colloid 
 degeneration of the elements of the skin. In an advanced case of cutis laxa 
 Ohmann-Dumesnil found myxomatous degeneration of the cutaneous tissues to be 
 present. 
 
 Diagnosis and Prognosis. — The diagnosis of these various conditions presents no 
 difficulties. The prognosis is generally bad ; most of the changes are permanent, 
 and we are limited in treatment to the relief of the symptoms that they may cause. 
 The neuritic form tends to get well when its cause is removed. 
 
 No. J34. Cocaine Ointment. 
 
 $ Cocain. hydrochlor. . . i part 
 
 Petrolati . . . .20 parts 
 
 Treatment. — This can only be symptomatic, and consists of the use of emollient 
 applications (No. 26, p. 70, No. 29, p. 74, No. 54, p. 113, Nos. 65, 66, 67, p. 135) 
 to relieve the dryness, and antipruritics (Nos. 11, 12, p. 56) to mitigate the itching 
 
ATROPHIES. 289 
 
 of the senile forms of the malady. Glossy skin tends to get well if protected from 
 cold and other external irritants. Cold or very hot water may be used to relieve 
 the pain; as also a cocaine ointment, 5 to 10 per cent. (No. 134, p. 288). 
 
 SCLERODERMA. 
 
 Synonyms. — Sclerema adultorum, dermatosclerosis, morphoea, sclerodermic (Fr.), 
 Hautsclerem (Ger.). 
 
 Definition. — 'A chronic disease of the skin, characterized by circumscribed or 
 diffuse, waxy or pigmented induration of the skin, with subsequent rigidity, fixation, 
 and atrophy of that organ, and ending in resolution or permanent cicatricial fixation, 
 and sometimes in death from marasmus. 
 
 Symptoms and Course. — This rare disease begins insidiously, without any local 
 or general symptoms, or accompanied only by slight malaise and rheumatoid pains, 
 and itching and formication in the parts about to be affected. It begins with the 
 stadium elevatum, in which larger or smaller areas of the skin become cedematous, 
 thickened, hardened, and elevated. The integument of the affected parts is moder- 
 ately tense, immovable, of a rosy or ivory-like and waxy appearance, and very 
 shiny ; the parts look as if they were frozen, and are sometimes covered with a slight 
 desquamation. The spots spread slowly by peripheral extension to a certain size; 
 and the malady may retrogress spontaneously at this period of the disease, but it 
 usually goes on to the second stage, the stadium atrophicum. Here the affected 
 skin is shrunken, thinned, scar-like, depressed, and shiny. It is firmly adherent to 
 the subjacent tissues, which are also involved in the process, and its color may be 
 normal, or white and ivory-like, or pigmented, or even bronzed. Two distinct forms 
 are to be mentioned, in accordance with whether the process remains a localized 
 one or spreads over large areas of skin or the whole body. 
 
 In scleroderma circumscriptum or morphoea one or more rounded or oval areas 
 or stripes of varying size appear, which, after passing through the hypertrophic 
 stage above mentioned, develop into flattened or depressed lesions of a dead-white, 
 ivory, or pinkish color, usually bordered by a violaceous or pinkish zone of dilated 
 vessels. The patches are dry and smooth ; the natural lines of the skin are oblit- 
 erated ; the hairs disappear; and the surfaces may be corrugated from contraction. 
 They may long remain in this condition, and then they may slowly fade away or 
 gradually spread by the appearance of new lesions at the margins and their slow 
 coalescence with the original patch. The affected areas may appear anywhere, but 
 are most often seen upon the limbs, head, and neck ; they usually persist for many 
 years ; atrophy of the deeper tissues and adhesion to the skin, with subsequent 
 contractures and deformity, sometimes occur ; but there are no symptoms, either 
 special or general, save slight itching and an absence of sweat. Sensibility is usu- 
 ally undisturbed. 
 
290 ILLUSTRATED SKIN DISEASES. 
 
 Scleroderma universalis is the variety of the disease in which larger areas or the 
 entire skin is affected. After perhaps the indefinite prodromal symptoms above 
 mentioned the affected skin becomes obscurely oedematous, elevated, and slightly 
 reddened; and it gradually becomes more and more indurated until it assumes the 
 consistency of hard leather. The integument looks waxy, or is of a dirty yellow 
 color ; the margins of the infiltration fade gradually into the normal skin, and the 
 affected area is firmly bound down to the subjacent parts. Finally the skin becomes 
 thinned and hide-bound, and apparently too small for its contents. The muscles 
 become affected with a true interstitial myositis, followed by atrophy, and even the 
 fasciae and bones become involved; so also do the mucosae, more especially of the 
 mouth and throat. Sensibility is little affected, though there may be a troublesome 
 pruritus. The secretion of the sweat and sebum is diminished or absent. The firm 
 tension of the skin of the affected parts renders them very liable to injury from 
 slight causes, and ulcerative processes are readily set up. 
 
 The appearance of a well-developed case varies with the part affected. The face 
 is fixed — gorgonized, as it were ; the features are immovable and stony ; the mouth 
 can be opened with difficulty; the lips are shortened; the gums are shrunk; the 
 nostrils are compressed. The strained, pallid skin and the expressionless features 
 give the face a ghastly, corpse-like appearance. If the limbs are affected, the fin- 
 gers are semiflexed and rigid (sclerodactylie), the nails are hypertrophied (onycho- 
 gryphosis), and all the joints covered by the sclerosed skin are fixed and rigid. 
 Walking may become impossible. On the chest wall the breasts are flattened and 
 almost obliterated, and respiration is interfered with. 
 
 The malady often remains stationary for years. In the early stages recovery 
 may take place, but in the later ones, when the lesions have become atrophic and 
 the parts fixed, a return to the normal is impossible. The patients die of marasmus 
 or of intercurrent disease. 
 
 Etiology. — We know nothing certain in this regard. The malady occurs much 
 oftener in females than in males, and most frequently in youth or early adult life. 
 Attacks of rheumatism and of erysipelas, privation, exposure, and mental worry 
 seem to be etiological factors in some cases, but often there is no such history. It 
 is probably connected in some way with a lesion of the central nervous system. 
 
 Pathology. — This is equally obscure. There is a small-celled new growth 
 around the vessels, with subsequent thickening and atrophy of these structures and 
 obstruction to the flow of the blood and the lymph. The epidermis is thinned and 
 pigmented ; the fat is atrophied, and the ordinary connective tissue and elastic fibers 
 are enormously increased. The contraction of this new tissue finally binds all the 
 structures of the skin together into a sclerotic mass. 
 
 Diagnosis. — This is usually not difficult in view of the solid, white, indurated, 
 parchment-like skin. Vitiligo is milky-white in color and shows no structural 
 change. Sclerema neonatorum occurs immediately after birth, while ordinary 
 
ATROPHIES. 291 
 
 scleroderma is rare in very young children. Keloid is distinctly limited in area, 
 and hypertrophic. The trophic changes of syringomyelia and lepra are accompanied 
 by analgesia, and in the former there is the marked change in the temperature-sense. 
 Cancer en cnirasse may greatly resemble a scleroderma, but it is usually secondary 
 to cancer of the breast ; the characteristic nodules are deep-seated, firm, and pig- 
 mented ; there is unilateral oedema and lymphangitis, as well as an indurated mar- 
 gin, great tendency to ulceration, and a rapidly fatal course. 
 
 Prognosis is doubtful. Some cases, more especially in the earlier stages, and 
 in the circumscribed forms known as morphcea, recover. Other cases last for years 
 without the general health becoming affected. After atrophy has set in restitution 
 to the normal is impossible ; and if recovery occurs at all, it is with thinned and 
 adherent skin, deformity, and fixation of the joints. Perhaps 20 per cent, of all 
 cases terminate fatally. 
 
 Treatment. — Recovery occurs spontaneously in some cases, which accounts for 
 some of the cures reported from the use of the iodide of potash, mercury, arsenic, 
 etc. Removal to a dry and equable climate, together with tonics, iron, strychnine, 
 and cod-liver oil, and general hygienic measures, are undoubtedly of importance. 
 Massage of the affected parts is especially useful, and should be combined with daily 
 hot-water or sulphur or vapor baths. Galvanism has done good in some cases. 
 The thorough inunction of olive-oil into the affected skin two or three times daily 
 is an excellent measure, either alone or combined with massage or electricity. 
 
 SCLEREMA NEONATORUM. 
 
 Synonyms. — Scleroderma neonatorum, sclerema of the new-born, algidite pro- 
 gressive (Fr.). 
 
 Definition. — A progressive, hard oedema, with discoloration and coldness of the 
 skin, appearing at birth or shortly thereafter, and usually terminating fatally within 
 a few days. 
 
 Symptoms and Course. — Sclerema of the new-born is seen chiefly in foundling 
 asylums among the prematurely born or weakly children of the poorer classes. It 
 appears at birth or a few days after it, beginning as a hard cedema of the skin of 
 the lower extremities, which gradually spreads over the rest of the body. In 
 exceptional cases it begins on the head or face, and in other exceptional cases it 
 remains localized in certain areas and does not spread over the entire body. The 
 skin at first is swollen, yellowish-white or waxy-looking, shining, hard, and cold. 
 In a short time the cedema goes down, but the skin remains hard and mummified, 
 and is of a dusky reddish or livid color. It is firmly attached to the deeper tissues, 
 and cannot be wrinkled or pinched up into folds. As the process spreads to the 
 subcutis and the muscles the joints become immovable from the hardening of the 
 surrounding tissues; the face is fixed and motionless; and the entire body is rigid 
 
292 ILLUSTRATED SKIN DISEASES. 
 
 and cold as if in a condition of rigor mortis. The pulse falls to 60; the respirations 
 are shallow from the stiffening of the chest walls, and are 14 or less to the minute, 
 and the temperature is several degrees below normal. The infant's vitality may be 
 so depressed that even the cry is absent. The fixation of the facial muscles is rarely 
 complete, but their stiffness interferes with or may entirely prevent suckling. Icte- 
 rus is commonly present ; diarrhea and vomiting may set in, and the cases in which 
 the entire integument is affected usually die before the ninth day. Partial cases 
 sometimes recover. 
 
 Etiology. — The immediate cause of the sclerema is a retardation of the circula- 
 tion in the cutaneous capillaries, possibly due to disease of the vessel walls. Con- 
 genital syphilis, intra-uterine, pulmonary, and intestinal disease, exposure to cold, etc., 
 are supposed to be among the factors that cause its appearance. 
 
 Pathology. — The epidermis of the scleremic skin is thickened, and the connective 
 tissue is increased, while the fatty tissue is mostly or entirely gone. The lumen of 
 the vessels is much diminished. Some observers have found a partial crystallization 
 of the fat that remains in the connective-tissue cells. 
 
 Diagnosis. — The indurated oedema, the color, the coldness, together with the age 
 of the patient, are characteristic. The only malady with which it might be con- 
 founded is scleroderma ; but this latter is very rare indeed in infants and has a 
 much more chronic course. 
 
 Prognosis. — This is bad, since most cases die in a few days. Signs of bad omen 
 are rapidly increasing weakness, quick spreading of the induration, a greatly sub- 
 normal temperature, the occurrence of hemorrhage, icterus, etc. A few of the 
 incomplete cases recover. 
 
 Treatment. — We may endeavor to compensate for the fall in temperature by 
 keeping the child in an incubator, enveloping it in cotton-wool, or by the frequent 
 use of hot baths. Nutrition must be kept up as well as possible by artificial feeding 
 if the child cannot nurse, and both food and stimulants must be introduced by means 
 of a tube passed through the nose if the rigidity of the mouth and throat is such 
 that they cannot be administered in the ordinary way. Systematic massage, and 
 rubbing the body with warm oil or camphorated alcohol, are useful to stimulate the 
 circulation. Galvanism of the sympathetic nerve has been recommended. 
 
 2. ATROPHY OF THE PIGMENT. 
 
 Absence of the pigment of the skin occurs as a congenital or an acquired condi- 
 tion, and may be partial or general. The form known as albinismus is not an 
 atrophy ; it is a congenital deformity of the skin and its appendages, which can 
 most appropriately be considered here. Acquired atrophy of the pigment is known 
 as vitiligo, and when the hair alone is affected, as canities. Loss of pigment, together 
 with atrophy of other elements of the skin, occurs in morphcea and in maculae and 
 
TYPOGRAVuRE. 
 
 9. TREAT A CO., N. Y. 
 
 LEUCODERMA. 
 
 PLATE XLIX. 
 
ATROPHIES. 293 
 
 striae atrophica?, which have already been considered. Some of these affections are 
 much commoner in the colored than in the white race. 
 
 ALBINISMUS. 
 
 Synonyms. — Congenital achroma, congenital leucoderma, albinism. 
 
 Definition. — A congenital absence of pigment in the skin and its appendages. 
 
 Symptoms and Course. — Albinism is an anomaly that occurs in the lower animals 
 as well as in man, and may be general or partial. In albinismus universalis the pig- 
 ment is congenitally absent from all the normally pigmented surfaces of the body, 
 the skin, the hair, and the iris, choroid, and retina. The integument is milky white 
 or pinkish in color; the hair, which is usually very fine and silky, is white or yellow- 
 ish white. The eyes look red, from the absence of pigment in the iris, which is of 
 a pale-bluish or pinkish hue ; there is photophobia, the pupils are continually in 
 motion, and nystagmus is often present. Individuals so affected are known as albinos 
 or kakerlaken, and are usually deficient in stature and in mental and physical vigor, 
 though their general health is not necessarily bad. They are found in all races. 
 
 Albinismus partialis is a circumscribed congenital absence of pigment, appearing 
 as single or multiple, larger or smaller spots, streaks, or areas of a white or pinkish- 
 white color. The skin otherwise is perfectly normal. The discoloration is some- 
 times symmetrical, and occasionally follows the track of certain nerves. The hair 
 over these areas is colorless; but congenital absence of pigment in hair situated on 
 normally colored skin also occurs, being known as canities or poliosis circumscripta. 
 The affection is much commoner in the negro than in the white race. The spots 
 usually remain stationary, but sometimes they spread ; more rarely the pigment is 
 redeposited spontaneously in the affected area. 
 
 Etiology. — The cause of the deformity is entirely unknown. It is sometimes 
 hereditary, occurring in several members of a family in one or several generations. 
 Many cases occur, however, as isolated examples. 
 
 Pathology. — The absence of pigment is the only change in the skin and the 
 other tissues. 
 
 Diagnosis and Prognosis. — The entire absence of any symptom, either subjective 
 or objective, other than the want of pigment, is sufficiently characteristic. The 
 prognosis as to cure is bad ; we know of no measures that will cause the redeposi- 
 tion of the pigment. 
 
 Treatment. — This is practically useless. Chrysarobin and salt baths have been 
 recommended, but have given no results. 
 
 VITILIGO. 
 
 Synonyms. — Leucoderma, leucoderma acquisita, acquired achroma. 
 
 Definition. — Vitiligo appears as one or more sharply limited, rounded or irregu- 
 
294 
 
 ILLUSTRATED SKIX DISLA.sK>. 
 
 lar, smooth white spots, increasing in size by peripheral extension, and surrounded 
 by a zone of abnormally pigmented skin. 
 
 Symptoms and Course. — Vitiligo is rare in this country, but is commoner in the 
 tropics and among the dark races. It usually begins during adolescence or early adult 
 
 life, appearing as one or more 
 circular, pigmentless spots, with 
 smooth, level, and unaltered sur- 
 faces, and whitish or milky in 
 color. They are invariably sur- 
 rounded by a well-defined, 
 darkly pigmented border. The 
 size of the spots varies from 
 that of a small coin to that of 
 the palm of the hand; they in- 
 crease by peripheral extension ; 
 new ones may appear from time 
 to time, and by the coalescence 
 of adjacent spots larger irregu- 
 lar leucodermic areas, bordered 
 by curved lines, are formed. 
 Their number is from one to a 
 dozen or more, but they are 
 usually not numerous, and they 
 areoftensymmetrically arranged 
 upon the body. The hairs on 
 the affected areas are usually 
 white (poliosis). The spots ap- 
 pear anywhere, but are most commonly seen upon the trunk and the backs of the 
 hands. Their course is very chronic ; they extend slowly for years, and then may 
 remain stationary ; sometimes they increase until the greater part of the integument 
 is involved. They look worse in summer, when the normal skin is most deeply 
 pigmented. Beyond the change in color there is no disturbance or alteration in the 
 appearance or in the functions of the skin. Symptomatic vitiligo occurs in the 
 course of lepra and syphilis. 
 
 Etiology. — Vitiligo is probably trophoneurotic in origin, but its exact cause is 
 unknown. Some cases occur after the acute febrile diseases, and others with vari- 
 ous affections of the nervous system. 
 
 Pathology. — There is atrophy of the pigment in the whitened spot, together 
 with an increase of the same element at its margins. It appears as if the pigment 
 were gradually pushed outward as the process advances, so that it accumulates in 
 the healthy tissue just outside the affected area. 
 
 Fig. 140. — Leucoderma. 
 After Van Haren-Noman. 
 
ATROPHIES. 
 
 295 
 
 Diagnosis. — 'The whitened spots surrounded by a dark border must be distin- 
 guished from the discolorations of chloasma, chromophytosis, morphoea, and leprosy. 
 In chloasma the color is yellow or brownish, and there is no accumulation of pig- 
 ment at the margins. In chromophytosis the spots are yellowish or reddish brown ; 
 the skin around them is normal in color; there is desquamation, and the microscope 
 reveals the presence of the characteristic parasite in the scales. In morphcea the 
 atrophy is characteristic; as is the anaesthesia, and possibly the presence of 
 tubercular deposits elsewhere in the skin, in lepra 
 nervorum. 
 
 Prognosis. — Leucodermic spots usually increase 
 slowly in area until a considerable extent of the skin 
 is involved, and then remain stationary. In excep- 
 tional cases the normal pigmentation of the skin 
 gradually returns. 
 
 Treatment. — This can consist only of care of the 
 general health, the use of tonics, roberants, etc. 
 There is little to be hoped for from the local treat- 
 ment, though penciling with cantharidal solutions 
 or collodion and the use of galvanism have been 
 recommended. 
 
 CANITIES. 
 
 Synonyms. — Poliosis, blanching of the hair. 
 
 Definition. — Whitening of the hairs from the 
 atrophy of their pigment. 
 
 Symptoms and Course. — Atrophy of the pigment 
 of the hair causes it to change from its normal color 
 to a grayish or a silvery white. It may be a con- 
 genital or an acquired condition. All the hair may 
 
 be affected, or only part of it, and in the latter case the affected hairs may appear 
 in scattered tufts or cover a definite area of surface, or they may be distributed 
 more or less abundantly among the normally pigmented structures. 
 
 Congenital complete canities is always present in albinismus, where the hairs 
 share with the other tissues of the skin in the general absence of pigment. Under 
 other conditions it is usually partial, the uncolored hairs being seated on pigmented 
 or on non-pigmented skin. 
 
 Acquired canities occurs as a physiological change in old age, either because the 
 papillae of the hair no longer produce pigment, or the epithelial cells of the shaft can 
 no longer take it up ; but it sometimes appears comparatively early in life, being 
 apparently due to an hereditary predisposition. It begins in the scalp around the 
 temples, and in the beard, and later extends to the vertex. As a pathological con- 
 
 Fig. 141. — Leucoderma. 
 After Joseph. 
 
296 ILLUSTRATED SKIN DISEASES. 
 
 dition it may occur at any age. Like the congenital form, it may be complete or 
 partial. Complete acquired canities is almost always a permanent condition, yet 
 Wilson records a case in which the hair was gray in the winter and colored in the 
 summer. As a partial affection it is seen in vitiligo, where patches of uncolored hair 
 occur upon the whitened areas of skin, in the first hairs that grow upon areas 
 affected with alopecia areata, and as a simple white tuft or tufts of hair in the midst 
 of normally colored appendages. 
 
 Acquired canities is often an hereditary affection, occurring in families and appear- 
 ing either as a general blanching or as grayish or white tufts or patches. It usually 
 comes on slowly, but, though the fact has been denied by Hebra, Kaposi, Joseph, 
 and others, authentic cases are recorded in which it has appeared with great rapidity. 
 Thus in Landois's case of a patient suffering from delirium tremens, the hair of 
 the beard and head turned gray overnight ; and Raymond and Vulpian record an 
 instance in which the hair turned white in the course of two days in a patient 
 suffering from a severe neuralgia following mental strain. Intense mental depres- 
 sion, psychic influences, neuralgias, wasting diseases, the fevers, etc., may cause 
 grayness and whitening of the hair in a comparatively short space of time. 
 
 Ringed hair, pili annulati, is a very rare condition, in which the hair is marked 
 with alternate white and colored bands of varying size. Occasionally the whitening 
 affects only a portion, either distal or proximal, of the affected hairs, as in the cases 
 reported by Falkenstein and others. 
 
 Etiology. — Congenital canities is a deformity rather than a disease. The dimi- 
 nution in the activity of pigment formation in the papillae that is normal in old age 
 occurs comparatively early in life in some families. It also occurs during the course 
 of severe neuralgias in the hair of the affected area, after the specific fevers, more 
 especially after scarlet and typhoid, following prolonged nervous strain, mental or 
 bodily in origin, after nervous shocks or prolonged exposure to the emotions of grief 
 or fear, etc. 
 
 Pathology. — The color of the hair depends on the quantity and distribution of 
 the pigment in its shaft. When the peripheral layer of the shaft contains air and 
 not pigment, though the central part may be normally colored, the hair is white. 
 There is usually an actual diminution of the amount of pigment. Cases of canities 
 of sudden occurrence seem to be due to the appearance of air-bubbles in the shaft 
 of the hair. Alternate colors are apparently caused by. the occurrence of successive 
 periods of activity and rest in the pigment-producing functions of the follicle. 
 
 Prognosis. — This is in general bad, though in exceptional cases the affected hair 
 does regain its color. The canities after alopecia areata is usually temporary, and 
 the same is sometimes the case with that following the fevers and general con- 
 ditions of depressed vitality. 
 
 Treatment. — A radical treatment of canities is an impossibility, since we possess 
 no means of stimulating the pigment supply of the papillae. In the premature forms 
 and the partial ones the use of general tonics, with arsenic and local stimulation, may 
 
ATROPHIES. 297 
 
 be of some benefit. Pilocarpine nitrate, given hypodermically in quantities of n> 
 grain, or the tincture of jaborandi in io-drop doses, may be employed, as also may 
 the faradic brush. 
 
 In almost all cases, however, these means fail us, and our only resource is to use 
 dyes to stain the uncolored hair. The objections to their employment are that they 
 discolor the scalp, render the hair dry and dead-looking, and require to be frequently 
 applied to the part of the hair next to the skin on account of the rapid growth of the 
 pilous structures. The fatty oils give a darker color to the hair, and may be regu- 
 larly employed as a dressing; the most useful of these are the oils of mace, walnut, 
 and cassia. As true dyes the nitrate of silver, mercury, and pyrogallol are most 
 frequently used. Paschkis recommends the following procedure : The hair is cleansed 
 with soap and water, rinsed out with warm water, and dried. Then the pyrogallol 
 solution (No. 135, p. 297) is brushed on the hair, from the root to the end, by means 
 of a soft tooth-brush. This is allowed to dry, and then the silver solution (No. 136, 
 p. 297) is applied in the same way. The stains of the skin that are very liable to 
 occur accidentally may be removed with a 33-per-cent. iodide-of-potash solution. 
 Anderson prefers the use of the bichloride of mercury, followed by a hyposulphite- 
 of-sodium solution (Nos. 137, 138, p. 297). The nitrate of silver alone is, however, 
 most frequently used (Nos. 139, 140, p. 297), exposure to the sunlight changing the 
 hair to brown or black, in accordance with the amount and strength of the solution 
 employed. Discolorations of the skin may be removed by washing the parts with a 
 solution of the cyanide of potassium, or, more safely, with one of chloride of sodium. 
 For the brown shades the pyrogallol dye (No. 141, p. 297) may be used. Whichever 
 method is employed, the dyeing must be repeated every two or three weeks. 
 
 No. 135. Paschkis 's Hair-dye No. 1. No. 136, Paschkis 's Hair-dye No. 2. 
 
 R Pyrogallol 1 part ft Argent, nitrat. 1 part 
 
 Aq. dest. . . . . 50 parts Aq. dest. . . . .80 parts 
 
 Aq. amnion, q. s. ad. solut. enasc. sedim. 
 
 No. 137. Anderson'' s Hair-dye No. 1. No. J38. Anderson's Hair-dye No. 2. 
 
 ft 
 
 Hydrarg. bichloridi 
 
 1 part 
 
 R Sod. hyposulphitis 
 
 . 
 
 1 part 
 
 
 Aq. dest. 
 
 
 250 parts 
 
 Aquae 
 
 • 
 
 . 8 parts 
 
 
 No. J39. Kaposi's 
 
 Dy 
 
 ? Formula No. 1 . 
 
 No. 140. Kaposi's Dye 
 
 Formula No. 2. 
 
 ft 
 
 Argent, nitrat. 
 
 . 
 
 1 part 
 
 R Argent, nitrat. 
 
 . 
 
 5 parts 
 
 
 Amnion, carb. 
 
 . 
 
 150 parts 
 
 Plumbi acet. 
 
 . 
 
 1 part 
 
 
 Ungt. simpl. 
 
 
 • • 30 " 
 
 No. 141. Pyro t 
 
 R Pyrogallol 
 Aq. colognien. 
 Aq. rosae 
 
 Aq. colognien. 
 Aq. rosae 
 
 <*allol Hair-dye. 
 
 1 part 
 ... .2 parts 
 
 . 40 
 
 
 1 " 
 
 100 parts 
 
298 ILLUSTRATED SKIN DISEASES. 
 
 Change of color of the hair other than whitening is an extremely rare condition ; 
 Alibert and Beigel have reported such cases following severe fevers. Discolora- 
 tions from the effect of external agents are more common. The excessive use of alkalis 
 and alkaline soaps tends to turn the hair red ; oxygen and compounds containing it in 
 readily separable (as peroxide of hydrogen) form lighten its hue ; the fatty oils, as those 
 of mace, walnut, and chrysarobin, darken it. Various occupations give rise to accidental 
 discolorations of the hair; thus that of workers in cobalt-mines and indigo factories 
 is liable to be stained blue, that of copper-smelters green, while those employed in 
 crude aniline works frequently have their hair stained a dark reddish brown. 
 
 3. ATROPHY OF THE HAIR. 
 
 Atrophy of the hairs occurs as a quantitative change, as in the various forms of 
 alopecia and in alopecia areata ; and as a qualitative one, as in several rarer and less 
 important conditions, as atrophia pilorum propria, fragilitas, monilethrix, trichor- 
 rhexis nodosa, etc. It may be symptomatic, as in the atrophy that occurs with or 
 after certain constitutional diseases, as syphilis, diabetes, phthisis, the fevers, etc., or 
 it may occur idiopathically, unassociated with any disorder of the general system. 
 
 ALOPECIA. 
 
 Synonyms. — Calvities, defluvium capillorum, baldness, Kahlheit (Ger.). 
 
 Definition. — A diminution in the quantity of the hair. 
 
 Symptoms and Course. — Alopecia is really the name for the symptom of bald- 
 ness which appears in the course of various diseases ; but it is used as a generic term 
 for baldness from any cause, and is best considered as an entity. It is customary 
 to distinguish several varieties, in accordance with the causation, time of appearance, 
 etc., of the atrophy. 
 
 I. Alopecia congenita s. adnata. Most infants have plenty of hair at birth; but 
 in certain cases it is deficient in quantity, and in rare instances it is entirely wanting. 
 The alopecia is usually partial, both in degree and in extent, the hair being simply 
 thinner than normal over certain areas. But cases are on record in which the alo- 
 pecia was complete over part or even over the whole of the body. Schultz has re- 
 ported the case of a man thirty- five years old who never had any hair upon his body, 
 save about ten short ones grouped around the corners of his mouth. Sometimes 
 the hair grows in later in life ; Luce's case had no hair until its sixth year. The de- 
 formity — for it is this rather than a disease — seems to be hereditary and run in 
 families, and even a hairless race has been reported by Hill as existing in Australia. 
 Marked cases show other defects of the skin, general atrophy, or diminution or ab- 
 sence of the sudoriparous or sebaceous secretion, as well as defects of the teeth. 
 
■ m 
 
 n 
 
 HI 
 
 

 ALOPECIA AREATA. 
 
 ALOPECIA NEUROTICA. 
 
 TYPOGRAVURE. 
 
 ALOPECIA PITYRODES. 
 
 ALOPECIA TOTALIS. 
 
 PLATE XL.IV. 
 
ATROPHIES. 299 
 
 2. Alopecia senilis, senile calvities. This is the permanent loss of hair that 
 occurs in old age ; it is to a certain extent a physiological process, though it occurs 
 most markedly in cases affected with seborrhea sicca. The hair turns gray, be- 
 comes dry and lusterless, falls out, and is not replaced. There is often a lanugo 
 growth of hair before the definite defluvium sets in. The skin of the affected 
 area is at first normal ; but later it becomes atrophic, thinned, shining, and tense. 
 The affection is always symmetrical in its spread, beginning at the vertex and 
 spreading backward and forward ; the hairs remain longest on the lateral portions 
 of the scalp. Men are much more frequently affected than women, possibly on 
 account of the difference in the head-gear of the sexes. It is curious 'that while 
 atrophy of the hair of the scalp is the normal occurrence in old age, the hair on 
 other portions of the body, as the beard and eyebrows, and also the vibrissas, is 
 rather increased in growth in old age. 
 
 3. Alopecia prematura, presenilis, or simplex. In this very common affection 
 the process is similar to that in senile alopecia ; but it occurs in younger subjects, 
 often beginning between the twentieth and the thirtieth year, and is not preceded 
 by grayness of the hair. Usually the baldness begins at the vertex and spreads an- 
 teroposteriorly ; but it may begin on the temples at either side ; it is always sym- 
 metrical. The process is a continuous one ; as the hairs fall out fewer and fewer 
 new ones, of decreasing length and thickness, are produced ; finally lanugo hair, and 
 then none at all, grows out. In exceptional cases the course of the affection is quite 
 rapid, and baldness ensues in a few weeks or months; usually, however, it takes 
 years before that is complete. The skin is left tense, smooth, and shiny, or covered 
 with lanugo hair. The secretion of sweat and sebum may be increased ; but many 
 cases show no evidences of seborrhea. Both sexes are affected, but males more fre- 
 quently than females, and more especially those with sedentary occupations. Not 
 infrequently a tendency to the affection runs in certain families. Only the hair of 
 the scalp is affected, and many of these cases have strong and luxuriant beards. 
 
 4. Alopecia symptomatica. Alopecia occurs as a symptom of various general 
 and local affections in which changes of the hirsute skin take place. It may be 
 partial or complete, temporary or permanent. The local affections of the hairy sur- 
 face that are accompanied by ulceration or interstitial absorption are not infrequent 
 causes of partial alopecia. Thus in the ulcerative syphilides and leprides, with vari- 
 ola and folliculitis, there is a direct destruction of the hair-follicles and a permanent 
 baldness of the part affected. In favus, from the pressure of the mass of fungus, as 
 well as in lupus erythematosus and the non-ulcerative syphiloderm, the same result 
 is brought about by interstitial absorption. Seborrhea sicca is a common cause of 
 general defluvium of the hair, especially in women ; as also is erysipelas of the scalp. 
 Trichophytosis and alopecia areata cause a temporary falling of the hair over the 
 areas affected. 
 
 Many general affections are accompanied by a symptomatic falling of the hair, the 
 
300 ILLUSTRATED SKIN DISEASES-. 
 
 skin sharing in the general nutritive depression of the body tissues, and showing it 
 most commonly in atrophic changes of the hair and the nails. This is notably the 
 case in syphilis, where a general diffuse falling of the hair occurs as a regular symp- 
 tom some three to six months after the infection. The hairs become dry, dull, 
 brittle, and loose, and are shed with greater or less rapidity. The resultant alopecia 
 may be slight or very well marked, and even the hair of the eyebrows and beard 
 may be affected. Very often it falls out more or less completely in irregular patches, 
 giving the scalp a characteristic " moth-eaten " appearance. In erysipelas the gen- 
 eral affection causes more or less defluvium, in addition to the local action of the 
 disease upon the scalp. The infective fevers, typhoid, scarlet, variola, etc., are reg- 
 ularly followed by falling of the hair ; and I have seen it occur after major operations 
 with prolonged convalescence. In all these cases the hair usually grows out again, 
 often with increased luxuriance. 
 
 Symptomatic falling of the hair also occurs with diseases of the nervous system, 
 epilepsy, migraine, certain psychoses, and after nervous shocks. I have seen com- 
 plete alopecia affecting not only the head, but the eyebrows, eyelashes, mustache, 
 beard, the axillary and pubic regions, and the trunk and limbs, occurring very rap- 
 idly in consequence of worry and insomnia. Here the hair may or may not grow 
 again. 
 
 5. Alopecia pityrodes, alopecia furfuracea, or pityriasis capitis, is perhaps the 
 commonest form of baldness, and occurs associated with a chronic seborrhea, the 
 influence of which malady in causing atrophy of the hair has been already referred 
 to. It occurs at all ages, but begins most frequently between the twentieth and the 
 thirtieth year ; males are most often affected, and in them the beard and eyebrows 
 are sometimes involved as well as the scalp. It begins as an ordinary dry seborrhea, 
 with slight reddening, scaling, and itchiness of the scalp. The scales may be white, 
 dry, and composed chiefly of epithelium ; but more commonly they are grayish, 
 greasy, and seborrheal. The nutrition of the hairs is interfered with ; they become 
 harsh, dry, lusterless, and fall out slowly. After remaining in this condition for 
 years, a more rapid falling begins, and baldness soon sets in. It usually commences at 
 the sides of the temples and gradually spreads to the vertex ; in women it begins at 
 the part. When the baldness is complete the seborrhea ends, and the scalp is left 
 thinned, shining, and atrophic, as in the other forms of alopecia. The affection 
 occurs in infants, and frequently causes thinning and loss of the hair, but no per- 
 manent baldness. 
 
 Etiology. — Alopecia senilis is a physiological change, being a part of the atrophic 
 changes of old age. So also is premature alopecia, which is peculiar only in its 
 early occurrence. Alopecia adnata is a deformity of unknown origin. Alopecia 
 symptomatica is due to the disease with which it occurs ; it occasions either a direct 
 destruction of the hair-follicles, or such nutritive depression of the hairy skin that 
 the pilous structures fall out. Alopecia furfuracea is caused by the same agencies 
 
ATROPHIES. 301 
 
 that cause seborrhea, among which may be mentioned neglect of the hygiene of the 
 scalp, and the wearing of heavy hats and bonnets. It is possible that direct transfer 
 of a contagion in the barber-shops is its essential cause. Lassar and Bishop pro- 
 duced an alopecia in the skin of healthy animals by rubbing in an ointment com- 
 pounded of the epithelial detritus and hairs of a patient affected with the disease. 
 Boeck, Malassez, Balzer, and others have described cocci and bacteria as the etio- 
 logical factors. Definite proof of this, however, is still wanting. 
 
 Pathologfy. — In alopecia adnata there is an arrest of development of the pilous 
 structures. Schede found in his cases that the hair-follicles were either absent or 
 aborted and atrophic, while the other elements of the skin were normal. In the 
 senile and premature alopecias there is a fibrous endarteritis of the follicular vessels ; 
 the epidermis and derma are thinned and shrunken; and the hair-follicles are atro- 
 phied and empty, or contain aborted hairs. Alopecia symptomatica shows atrophied 
 follicles and hairs, or complete destruction of the pilous apparatus. In the furfura- 
 ceous form of alopecia the corium is atrophied, and its connective-tissue fibers have 
 undergone more or less fatty and colloid degeneration ; the sebaceous glands are 
 shrunken ; and the hair-follicles are filled with epithelial scales and rudimentary hair. 
 
 Diagnosis. — The general thinning and atrophy of the hair in the first three forms 
 of the disease are sufficiently distinctive. In alopecia furfuracea the epithelial char- 
 acter of the scales and its symmetrical appearance will distinguish the affection from 
 seborrhea sicca, which is asymmetrical and has grayish-white, greasy scales. Tri- 
 chophytosis capitis has sharply limited patches with nibbled-off hairs ; and patches of 
 ringworm will frequently be found on other portions of the body. Alopecia areata 
 has sharply circumscribed patches, at least at first, and the skin is normal, showing 
 neither scaling nor induration. 
 
 Prognosis. — The prognosis of alopecia congenita is usually good ; in most cases 
 the hair grows in time, though not with the abundance that characterizes the normal 
 skin. That of alopecia senilis is bad ; in rare cases only the hair grows again. 
 Alopecia prematura, if not too far advanced, can be stopped ; but when the scalp 
 has become hide-bound and atrophic, treatment is useless. To determine the prog- 
 nosis in individual cases, the hairs that fall out in a day should be collected, and, in 
 the male, the number of pointed and uncut as compared with the number of cut hairs 
 noted ; in the female, where all the hairs are uncut, those under and over 6 inches 
 in length should be counted. If the pointed hairs or those under 6 inches in length 
 exceed one quarter of the entire amount, the disease is progressive, and the prog- 
 nosis is bad. The prognosis of symptomatic alopecia varies with the cause. If it 
 is due to nutritive depression alone it is good; the hair usually grows in as abun- 
 dantly or more so than before. If it is due to atrophic changes the prognosis is hope- 
 less. Alopecia furfuracea is of fairly good prognosis if it is not too far advanced, if 
 atrophy has not set in, and if the cause can be removed. 
 
 Treatment, — Systematic treatment is of importance in most varieties of alopecia, 
 
302 ILLUSTRATED SKIN DISEASES. 
 
 but more especially in the symptomatic and furfuraceous forms, as well as for pro- 
 phylactic purposes in cases where the family history shows a tendency to the early 
 advent of baldness. It consists of the use of tonics and all measures calculated to 
 improve the nutrition of the tissues in general and of the skin in particular. Nour- 
 ishing diet, fresh air, exercise, bathing, etc., the administration of iron, strychnia, 
 phosphorus, arsenic, and cod-liver oil, will be found useful. Shoemaker recommends 
 the tincture of ignatia in io-drop doses three times daily. Attention to the hy- 
 giene of the scalp is of the very greatest importance. This consists essentially in 
 the careful combing and brushing of the hair, and the free use of soap and warm 
 water on the scalp. The use of heavy and closely fitting head-gear is to be avoided 
 as far as possible. 
 
 The local treatment consists in all cases in the endeavor to stimulate the nutrition 
 of the hair-follicles by causing a temporary and artificial hyperemia of the skin in 
 which they are seated. The thoroughness of the frictions, brushings, and sham- 
 pooings by means of which the various applications are applied is of more impor- 
 tance than the nature of the special medicament that is used ; for we know of no 
 specific drug which increases the nutritive activity of the hair-papillae. In most 
 cases the applications are better made with a stiff brush than with the fingers; and 
 in all cases they should be vigorously rubbed into the scalp rather than applied to 
 the hair. As most of them dissolve and remove from the surface of the scalp and 
 hair the fatty substances necessary for their healthful growth, it is well to use a 
 moderate amount of vaseline, benne-oil, or a pomade after applying them. 
 
 Alopecia adnata, as a rule, requires no treatment ; the hair grows of itself in the 
 course of time. Frictions with green soap or with the green soap tincture (No. 5, 
 p. 43), followed by a stimulating application (No. 142, p. 303), may be used if treat- 
 ment becomes necessary. Senile alopecia is best left alone ; the condition is almost 
 always a permanent one. 
 
 Presenile alopecia is an affection for which we are frequently consulted, and in 
 predisposed cases the prophylactic measures above described should be carefully and 
 systematically carried out. General treatment is often required ; for there is an 
 undoubted connection between the early appearance of baldness and dissipation, 
 overwork, worry, etc. Hypodermic injection of -p 2 to -jt of a grain of the muriate of 
 pilocarpine has done good in the hands of Schmitz, Schuller, and others. Static 
 electricity is recommended by some authorities. In mild cases a bicarbonate-of- 
 soda lotion (No. 143, p. 303) should be rubbed into the scalp every day or every 
 other day. More advanced cases require stimulating applications of greater power 
 (Nos. 142, 144, p. 303). Naphthol or resorcin ointments (No. 37, p. 82, No. 41, 
 p. 100, No. 48, p. 105, Nos. 123, 125, p. 243), or the combinations of naphthol and 
 sulphur with green soap (No. 46, p. 104, No. 55, p. 115), can be employed. Ihle's 
 resorcin lotion (No. 145, p. 303) may be rubbed into the scalp daily with a piece 
 of flannel. Tar applications are recommended by Piffard (No. 146, p. 303). The 
 
ATROPHIES. 
 
 303 
 
 sublimate lotion (No. 148, p. 303) and a 15-per-cent. tannic-acid ointment (No. 147, 
 p. 303) are also useful. 
 
 No. J42. Stimulant Lotion. 
 
 ft Tra. capsic. 
 Tra. cantharid. 
 Spts. colognien. 
 
 aa. 1 part 
 8 parts 
 
 No. 144. Quinine Lotion. 
 
 ft Quin. sulphat. 
 Spts. vini Gallici 
 Aq. colognien. 
 
 1 part 
 60 parts 
 ad. 100 " 
 
 No. 146. Tifard's Tar Lotion. 
 
 ft 01. rusci 
 Ol. lavandul. 
 Ol. pini sylvestri 
 
 aa. 1 part 
 50 parts 
 
 No. J48. Sublimate Lotion. 
 
 ft Hydrarg. chlor. corn 
 Aquas . 
 
 1 part 
 500 parts 
 
 No. J50. Naphthol Spirit. 
 
 ft /3-naphthol . 
 Alcohol absol. 
 
 1 part 
 200 parts 
 
 No, J43. Sodic Bicarbonate Lotion. 
 
 ft Sod. bicarb. 
 Aq. dest. 
 
 1 part 
 50 parts 
 
 No. 145. Lhle's Resorcin Lotion. 
 
 ft Resorcin. albiss. 
 Ol. ricini 
 Spts. vini . 
 Bals. Peruv. 
 
 No. 147. Tannic-acid Ointment. 
 
 10 
 
 parts 
 
 90 
 
 
 300 
 
 " 
 
 I 
 
 part 
 
 tit. 
 I 
 
 part 
 
 2 
 
 parts 
 
 • 4 
 
 a 
 
 ft Ac. tannic 
 01. ricini 
 Adip. lanse 
 
 No. J49. Lassar's Sublimate Lotion. 
 
 1 part 
 
 ft Hydrarg. bichlorid 
 Glycerini 
 Spts. colognien. 
 Aquae . 
 
 aa. 300 parts 
 
 No. 15J. Lassar's Salicylic-acid Ointment. 
 
 ft Ac. salicyl. 
 Tra. benzoin 
 01. bubuli . 
 
 2 parts 
 
 3 " 
 100 " 
 
 The treatment of alopecia symptomatica is essentially that of the underlying dis- 
 ease. General antisyphilitic treatment, together with the use of the sublimate lotion 
 (No. 148, p. 303) or the white precipitate ointment, is appropriate for the luetic alo- 
 pecia. Erysipelas, the infective fevers, diabetes, etc., must be appropriately treated, 
 while any one of the stimulating applications above mentioned may be used. As a 
 rule, the alopecia gets well of itself. 
 
 Alopecia furfuracea is so common a cause of baldness that its prophylactic treat- 
 ment in cases affected with seborrhea of the scalp becomes a matter of importance. 
 The means to be employed are essentially the same as those for seborrhea (pp. 64, 65), 
 and must be used steadily for months, combined with careful washing, combing, and 
 brushing of the scalp. In advanced cases the scales should be removed with soap 
 and water, or the tincture of green soap (No. 5, p. 43), or borax and water, and the 
 scalp and hair then thoroughly rinsed. Any one of the various stimulating applica- 
 tions can then be used, Sulphur is a very valuable remedy in this affection. It can 
 
304 ILLUSTRATED SKIN DISEASES. 
 
 be used as ointment (No. 25, p. 64), applied every night at first, and less often as 
 the desquamation lessens. The head should be thoroughly washed every three days. 
 The mercurial ointment recommended by Bronson (No. 23, p. 64) and the resorcin 
 ointment (No. 20, p. 64) are efficacious. 
 
 The treatment advocated by Lassar is based upon his belief in the parasitic ori- 
 gin of this form of baldness. It is somewhat troublesome, but has proved fairly 
 satisfactory in my hands. The head is first lathered with strong tar soap for ten 
 minutes, and then washed out with first warm and then cold water. The scalp is 
 dried, and the sublimate lotion (No. 149, p. 303) applied. Then the scalp is dried by 
 rubbing in the naphthol spirit (No. 150, p. 303), and anointed with a salicylic-acid 
 ointment (No. 151, p. 303). 
 
 ALOPECIA AREATA, 
 
 Synonyms. — Area Celsi, porrigo s. tinea decalvans, alopecia circumscripta, pelade 
 (Fr.), die krcisfleckige Kahlheit (Ger.). 
 
 Definition. — Loss of hair, causing the appearance of one or more circumscribed 
 white bald patches of varying size and shape, sometimes spreading to more or less 
 complete baldness. 
 
 Symptoms and Course. — Occasionally after a period of general ill health, with 
 localized headache and pruritus, but more commonly with no prodromal symptoms 
 at all, there appear upon the hairy surfaces of the body one or several areas of 
 baldness. The advent of the disease is sudden ; the hair may come out overnight, 
 and the denuded patch be discovered by the patient or his friends ; in other cases 
 the loosened tuft of hair is accidentally pulled out. The hairs are not broken 
 off, as in ringworm ; they fall out in their entirety. The denuded areas are almost 
 always round, but they may be elongated or band-shaped ; occasionally they follow 
 zigzag or irregular tracks. The site of the alopecia is most commonly the scalp, and 
 next most frequently the beard ; other regions, such as the axillae, pubes, and the 
 trunk and limbs, are much more rarely affected. In exceptional cases the falling of 
 the hair occurs more diffusely ; the areas are not well marked ; and the general 
 appearance of the malady on the scalp is like that of alopecia furfuracea. 
 
 The denuded areas in the beginning are usually small, from \ to 1 inch in 
 size ; they often spread with rapidity until they have attained a certain size, and 
 then remain stationary. One only, or a few, may be present at one and the same 
 time ; but not infrequently patch after patch forms, the earliest ones being already 
 covered with lanugo hair and progressing to recovery while the latest are appearing. 
 Adjacent areas may coalesce so as to form irregular bald spots bounded by curved 
 lines. In these composite patches, however, a thin and irregular band of lanugo or 
 atrophic hair usually remains to mark the original boundary of the area. Finally, 
 in some cases, the number of patches may be so great that complete baldness results. 
 
TYP03R4VURE. 
 
 COPYRIGHT BY E. B. TREAT 4 CO , N. Y. 
 
 ALOPECIA AREATA. 
 
 PLATE XLV. 
 
ATROPHIES. 
 
 
 and pubes, and 
 
 genet 
 The 
 
 the hair- 
 are distir tppears 
 
 ^ome c . There is ah 
 
 no he patches are 
 
 3vable, or stunted 
 i 
 
 becomes stroi 
 spread raj 
 
 OCCUi 
 
 come 
 
 Gruby, i 
 with one 
 scribed; a.nd ma> 
 microorg 
 
 epid i 
 
 deal In 
 
 heir pei ->< 
 
 the whole of time 
 
 In malt; 
 
 neral and n 
 pecia, m< be- 
 
 ■ ■ i 
 indi\ 
 
 [de 
 para 
 
 their point of o 
 Ide n 
 
 ntal sho< 
 
 ata occur in 
 i 
 I he . al factor I obsen 
 
 Robinson, et. 
 
 . and in o ^een de- 
 
 i< eriologist 
 
 e that the disease seems o< 
 ribed b; 
 
 ools. Dermat' 
 id graduall}-, and are always ac< 
 torn- >s, swei. 
 
 Pat f the 
 
 pat' - : changes. There is an infill 
 
 coriu. of the pap ; h new small I an atR 
 
 of the I ts, and the sebaceous gh >vho has ex 
 
 ined i .ss than twenty cases, cone. s is a deep- 
 

 -ECIA ARE. 
 
 PLVTE XLV. 
 
ATROPHIES. 305 
 
 and all the hair, not only of the head, but also of the beard, axillae, pubes, and the 
 general surface of the body, may be lost. 
 
 The skin of the affected areas is first normal, though whiter than usual ; it is en- 
 tirely bald, or shows only a few scattered hairs, but the orifices of the hair-follicles 
 are distinct ; later on it appears shrunken, thinned, and quite smooth. Sensation is 
 usually normal, though in some cases there is anaesthesia. There is absolutely 
 no inflammatory action or scaling. In the early stages, while the patches are 
 spreading, the hairs at the margins may be readily removable, or stunted and 
 atrophic; later on, when the disease is not progressing, they are healthy and firmly 
 seated. 
 
 The course of the disease varies a good deal. In benign cases the spots are few 
 in number and remain small. After lasting for a number of months new and firmly 
 seated hairs begin to grow at their periphery, and they get smaller; in other cases 
 a fine lanugo growth appears over the whole patch, which in the course of time 
 becomes stronger and pigmented. In malignant cases the patches are numerous, 
 spread rapidly, and coalesce, and a general and more irregular falling of the hair 
 occurs ; in these instances the alopecia, more especially in children, is apt to be- 
 come universal. Relapses are not infrequent in both forms ; recovery takes months, 
 but is the rule, especially in young individuals. 
 
 Etiology. — The causation of alopecia areata is still a matter of dispute ; and it is 
 possible, as Crocker holds, that there are grouped under this designation several 
 distinct diseases, some of which are parasitic and others neurotic in origin. Many 
 of the cases seem to point distinctly to the nervous system as their point of origin. 
 The preliminary headaches, the sudden onset, the anaesthesia that is sometimes 
 present, and the cases reported as following nerve injuries and mental shocks are of 
 this category. Mibelli, Pantoppidan, and Joseph have seen alopecia areata occur in 
 men and animals after surgical injuries to the cervical nerves. 
 
 Parasites have been described as the etiological factor by a number of observers, 
 Gruby, Bazin, Thin, Von Sehlen, Robinson, etc. But their results do not agree 
 with one another; in some a bacterium and in others a micrococcus have been de- 
 scribed ; and many competent bacteriologists have failed to find any characteristic 
 microorganism at all. It is true that the disease seems occasionally to occur in 
 epidemics ; such have been described by Voillard and Vincent, Feulard, and others 
 as occurring in regiments and schools. Dermatomycoses, however, invariably begin 
 slowly, start in distinct foci, spread gradually, and are always accompanied by symp- 
 toms of inflammation, redness, swelling, vesiculation, and crusting. 
 
 Pathology. — This also is still a matter of debate. The marginal hairs of the 
 patches show atrophic changes. There is an infiltration of the upper part of the 
 corium, more especially of the papillae, with new small round cells, and an atrophy 
 of the hair-follicles, roots, and the sebaceous glands. Giovannini, who has exam- 
 ined sections from no less than twenty cases, concludes that the process is a deep- 
 
306 ILLUSTRATED SKIN DISEASES. 
 
 seated folliculitis. Regarding the cause of this folliculitis no more can be said than 
 has been stated under the etiology. 
 
 Diagnosis. — This is rarely a matter of difficulty. The sudden appearance of the 
 bald areas, their rapid extension, their circular form, the absence of nibbled-off hairs, 
 scales, and crusts, the smooth and shining skin, with the occurrence only on the hairy 
 portions of the body, are sufficiently characteristic. Nevertheless the affection must 
 be distinguished from trichophytosis capitis, favus, lupus erythematosus, and the 
 baldness caused by burns and ulcerative processes, as well as from the other forms 
 of alopecia. Ringworm begins at one point as a small inflammatory papule or 
 patch; it spreads slowly; is circular in form; has frayed and broken-off hairs over 
 its surface ; shows signs of inflammation, redness, papules, vesicles, crusts, and scales ; 
 occurs also on the non-hairy parts; and the fungus can be readily demonstrated in 
 the hairs and scales. Chronic cases of ringworm, in which the circular patches have 
 disappeared, and in which there is a general alopecia and scaling, are more difficult 
 to distinguish ; yet here also the signs of inflammation, and the presence of some 
 characteristic broken-off hairs, together with the detection of the fungus, will serve 
 to prevent error. In favus there are no circumscribed denuded areas ; the characteris- 
 tic sulphur-yellow crusts or powdery scales are present ; the malady is very slow, 
 inflammatory, and leaves cicatricial tissue behind ; and the microscope readily reveals 
 the fungus in the crusts. Lupus erythematosus is inflammatory, is slow in its course, 
 finally causes atrophic changes, and has the characteristic seborrheal scales with plugs 
 upon their under surfaces. Baldness from actual destruction of hair-bearing tissue 
 should not be mistaken for alopecia areata. Whether caused by a burn, or by an 
 ulcerative process such as syphilis, its permanence and the presence of cicatricial 
 tissue will serve to differentiate it from the affection under consideration. The gen- 
 eral defluvium capillorum that occurs in the early stages of syphilis may be mistaken 
 for an aggravated alopecia areata; but there are never any circles, there is a char- 
 acteristic " moth-eaten " look to the affected surfaces, and the history and the presence 
 of other syphilitic symptoms will elucidate the diagnosis. Alopecia of the senile 
 and the premature forms is preceded by grayness and is slow of onset ; it does not 
 appear in circles ; it begins at the vertex or on the temples, and gradually spreads ; 
 it is usually preceded by a seborrhea; and it takes years for complete baldness to 
 be effected. 
 
 Prognosis. — Alopecia areata tends to spontaneous recovery, especially in the 
 young; but it takes a long time to run its course, most cases lasting from six months 
 to two years. In older individuals recovery often does not take place. The more 
 numerous the patches, and the quicker their spread, the worse the prognosis. 
 Malignant cases, with general diffuse alopecia of the whole body, are usually of bad 
 prognosis. 
 
 Treatment. — Though internal remedies have little or no effect upon the disease 
 itself, they are of importance for the general health, which undoubtedly influences 
 
ATROPHIES. 
 
 307 
 
 the malady. Tonics, fresh air, exercise, baths, especially of salt water, are impor- 
 tant agents in the treatment of alopecia areata ; so also are cod-liver oil, iron, phos- 
 phorus, arsenic, and quinine. Hypodermatic injections of the muriate of pilocarpine, 
 8 to tV grain every five to six days, have been reported to have a very beneficial 
 effect upon the disease. The malady tends to spontaneous recovery, but we can do 
 much by these means to hasten its course. 
 
 No. 152. Croton-oil Ointment. 
 
 fy 01. tiglii .... 2 parts 
 
 Cer. alb. 
 01. theobrom. . . aa. i part 
 
 No. J53. Bulklefs Carbolic-Iodine Application. 
 fy Ac. carbolic 
 
 Chloral. 
 Iodinii 
 
 aa. p. 
 
 No. 154. Jessner's Carbolic -Sulphur Ointment. 
 
 fy Acid, carbol. 
 
 01. bergam. . . . aa. i part 
 
 Sulphur, sublim. . . 5 parts 
 
 Adip. benzoat . . . 50 " 
 
 The local treatment consists, as in the other forms of alopecia, in the stimulation 
 of the nutrition of the scalp ; and any of the stimulating applications recommended 
 on p. 303 is appropriate. The epilation of the loose hairs at the margins of the 
 patch with the fingers is advisable in most cases. Static electricity has done well, 
 in the hands of G. H. Fox, in stimulating the new growth of hair. The local stim- 
 ulation must be quite vigorous ; the skin stands it very well in these cases. A favor- 
 ite method is to blister the skin of the affected areas with croton-oil or cantharidal 
 collodion, dressing afterward with olive-oil. A croton-oil ointment (No. 152, p. 307) 
 may be rubbed in in small quantity every five or six days ; twelve to twenty-four 
 hours after the application the inflammatory reaction appears. Bulkley recom- 
 mends a carbolic-acid and iodine application (No. 153, p. 307) which may be applied 
 every other day; Jessner's carbolic-sulphur ointment (No. 154, p. 307) maybe used 
 daily. Acetic acid may be painted over the part till the skin whitens, and then 
 sponged off with water ; or the stronger water of ammonia may be applied daily to 
 the patches for weeks. The various corrosive-sublimate lotions (No. 148, p. 303, 
 etc.) may be used, and Lassar recommends his process for the treatment of alopecia 
 furfuracea (p. 304). I have found the use of chrysarobin ointment (No. 8, p. 46, 
 No. 40, p. 94) a very satisfactory method, more especially when preceded by vigor- 
 ous friction with the tincture of green soap (No. 5, p. 43). Our efforts must be 
 directed to effecting the greatest possible amount of stimulation that the skin will 
 bear, the special means employed for that purpose being comparatively unimportant. 
 
 ATROPHIA PILORUM. 
 
 Defective nutrition of the hairs may cause atrophic changes of various kinds in 
 these structures. They consist essentially in a diminution of the size of the pilous 
 
 
308 ILLUSTRATED SKIN DISEASES. 
 
 structures, with consequent fracture. We shall consider briefly the conditions 
 known as aplasia pilorum propria, fragilitas crinium, and trichorrhexis nodosa. 
 
 1. Aplasia pilorum, monilethrix, pili annulati, moniliform or beaded hairs, Ring- 
 elhaare (Ger.), cheveaux moniliformes (Fr.), is a rare condition in which the shaft of 
 the hair is not of uniform size, but consists of a succession of thicker dark and thinner 
 lighter-colored portions. The thicker portions are normal shaft; the thinner ones, 
 one third their size, occur at regular intervals along the entire shaft and contain 
 neither medulla nor pigment. The hair-bulbs are usually atrophied. Fracture of 
 the hair occurs, probably from slight mechanical causes, at the thinned internodal 
 parts, and the fractured ends may be smooth, or frayed-out and brush-like. The 
 affection usually begins in early infancy, and may go on to complete baldness; it is 
 frequently inherited, and is to be looked upon rather as a deformity than as a dis- 
 ease. All the hairy regions of the body may be affected. Its cause is unknown. 
 Treatment is of little value, though occasional cases go on spontaneously to partial 
 recovery. 
 
 2. Fragilitas crinium, scissura pilorum. Here the hair becomes dry and splits 
 either at its end or in its course. It occurs as a symptom in the parasitic diseases of 
 the hairy portions of the body, trichophytosis and favus, and occasionally also in dry 
 seborrhea and eczema. After various fevers and cachexiae also the hair loses its 
 luster and becomes fragile. It is seen as an idiopathic affection from causes, as yet 
 unknown, that interfere with the nutrition of the hair. The hair becomes dry, brittle, 
 and dull ; and the splitting into two or more filaments may begin at its end and run 
 part or all the way to the root, or it may commence at any portion of the shaft. 
 The split hairs show a marked tendency to curl up. The affection occurs most fre- 
 quently in the scalp, especially in women, and next most frequently in the beard. 
 Only a few scattered hairs or a large number may be affected. It is not associated 
 with any general affection or any local disease of the scalp. The microscope shows 
 the hair-bulb either normal or atrophied, and the medulla of the shaft more or less 
 broken up; but there is no other recognizable change. Treatment consists in atten- 
 tion to the hygiene of the scalp, more especially by the free use of the comb and 
 brush. The split hairs should be cut above the cleft. 
 
 3. Trichorrhexis nodosa or nodositas crinium. Here there occur peculiar nodose 
 swellings, involving the entire circumference of the hair at irregular intervals along 
 the shafts, and of a transparent and shining grayish hue. When they occur in red 
 hair their color is said to be black. From one to five are usually present on a single 
 hair, most commonly at its distal end. The hairs themselves are brittle, and 
 prone to fracture at the nodes, leaving a brush-like mass of filaments projecting from 
 the free end of the structure. The hair is firmly seated in its follicle, and the bulbs 
 are apparently normal, as also are the internodal parts of the shaft. The etiology 
 of the disease is obscure ; no parasite has been found. The affection occurs almost 
 exclusively in the male beard. The most hopeful treatment consists in shaving, and 
 
i 
 
 ATROPHIES. 309 
 
 the use of the various stimulating applications to the skin from which the hairs 
 grow (Nos. 144, 148, 149, p. 303, No. 154, p. 307). 
 
 4. ATROPHY OF THE NAILS. 
 
 Atrophy of the entire structure of the nail or of a portion of it occasionally 
 occurs. We shall consider atrophia and leucoma unguium. 
 
 ATROPHIA UNGUIS. 
 
 Onychatrophia, atrophia unguis, or general atrophy of the nail occurs as a con- 
 genital or as an acquired condition. In the congenital cases the digits are usually 
 poorly developed, the nails themselves being distorted, rudimentary, or absent. The 
 hair also is generally defective. The acquired cases arise from traumata, as on the 
 feet from the pressure of improperly fitting boots and shoes, and on the fingers from 
 injuries of common occurrence in the various trades. They also occur from the action 
 of heat and cold ; from chemicals, as with druggists and photographers ; from inflam- 
 matory affections of the nail-bed, onychia and paronychia; in the course of various 
 internal diseases, tuberculosis, syphilis, peripheral nerve lesions, etc., and after sur- 
 gical accidents ; and as a part of many affections of the general integument, psoriasis, 
 eczema, parasitic diseases, etc. The nails lose their luster; they may become 
 expanded, thinned, and curved, but more frequently they are abnormally brittle, and 
 become thickened, split, and furrowed in various directions. They may finally fall 
 out. Both the prognosis and the treatment depend upon the cause of the atrophy. 
 The only local measure required is the protection of the fragile nails by means of 
 leather stalls or rubber finger-tips. 
 
 Leucoma unguium appears not infrequently in perfectly healthy persons, but 
 occurs also after the various fevers, nervous affections, etc. White spots or stripes 
 occur in the otherwise normal nail, and grow outward with it. They are supposed 
 by some to be due to an infiltration of air in the epithelial cells, similar to that which 
 occurs in the hair in canities. By others they are thought to be due to a tropho- 
 neurosis which causes nutritive changes in the matrix. There is no treatment for 
 the affection. 
 
COSMETICS OF THE SKIN AND HAIR. 
 
 The cosmetic care of the skin and its appendages has usually received but scant 
 attention ; yet the subject is of importance, especially to the female half of our 
 patients. Its real basis is hygiene ; and the health of so important and vital an 
 organ as the skin is a matter of just concern, and one about which the practitioner 
 is frequently consulted. The subject includes the proper methods of cleansing and 
 caring for the skin, and the means to be employed for that purpose ; the remedying 
 of such defects as excessive roughness and dryness, superfluous moisture and oili- 
 ness, undesirability of hue and abnormal colorations or discoloration, unusual size, 
 form, color, quantity, or implantation of the hair and nails ; and, in fact, the pre- 
 vention and treatment of a number of conditions not sufficiently marked to be 
 recorded and treated as diseases. Various means are at our disposal for these 
 purposes, which may be classified as cleansing agents, stimulating or soothing agents, 
 coloring or discoloring agents, and agents for the removal of other abnormalities. 
 
 L CLEANSING AGENTS. 
 
 The first and most important requisite for the health and beauty of the skin 
 and its appendages is cleanliness, in spite of the fact that a direct connection 
 between uncleanness and dermal abnormalities and diseases can sometimes not be 
 recognized. The regular removal of dirt, dust, dried sebum and sweat, and des- 
 quamated epithelium is necessary for that proper nutrition, good circulation, and 
 normal performance of function of the organ which is essential to its proper appear- 
 ance. The chief agent for this purpose is of course water ; and its importance is 
 such that the amount in which it is used may almost be taken as the index of 
 civilization of an individual or a people. In many cases it is undoubtedly insuffi- 
 ciently employed, and we have certainly retrograded in some respects from the 
 ablutionary habits of the classical nations. The considerable prejudice that still 
 remains against its employment in an amount and with a frequency sufficient to be 
 fully effective has some basis in the facts that not all forms of the fluid are suitable 
 for every person, and that in some abnormal conditions of the integument its influ- 
 ence is distinctly harmful. 
 
 310 
 
CLEANSING AGENTS. 311 
 
 For cleansing purposes water should be employed warm. Hot water is only 
 exceptionally necessary when especially vigorous action is desired ; its continuous 
 use is relaxing and enervating, and renders the skin abnormally sensitive to exter- 
 nal influences. Hot steam or air, as gotten in the Russian or Turkish baths, are 
 rather to be classed as therapeutic than as hygienic and cosmetic agents, though a 
 cleansing bath is usually conjoined with their use, and the cold douche or plunge 
 with which they usually end counteracts their undesirable relaxing effects. Abso- 
 lutely cold water is a stimulant, and falls in the same category. 
 
 The entire surface of the body should be bathed for from five to ten minutes, or 
 washed, several times a week, if not daily. For whilst the covered portions of the 
 body are not so subject as the exposed ones to contaminations from the atmosphere 
 and adventitious agents, evaporation and the removal of excrementitious matter is 
 much less free, and all material, fluid and solid, which should normally be cast off 
 from the skin remains upon the surface or is kept in close apposition to it by the 
 underclothing. Water dissolves and removes the salts, part of the fatty acids, the 
 dead epithelium, and much foreign matter ; and by doing so is the most important 
 single means that we possess for securing a proper nutrition and a healthy and 
 desirable appearance of the general integument. 
 
 An occasional disadvantage of water is dependent upon the fact that it may be 
 too hard from the presence of calcium and magnesium salts, and so make the skin 
 rough and coarse. If a soft water is not obtainable, the ordinary variety may be 
 made suitable by prolonged boiling, or by the addition of a small amount of soap, 
 or of soda or potash. Of more importance, however, is the damage that is some- 
 times done by water on account of its faculty of causing swelling of the epidermic 
 cells by imbibition, which in certain cases may be so marked as to render the skin 
 raw and fissured. The greater the length of time during which water acts upon the 
 skin the more marked do these undesirable effects become in certain cases ; and 
 they may be produced even in insusceptible skins by very long-continued action. 
 Hence prolonged baths are not to be recommended as a rule, and thorough drying 
 is essential to prevent as far as possible these undesirable effects. Vigorous friction 
 with a rough towel not only takes up and removes the last traces of superficial 
 moisture, but mechanically removes detritus which has been softened but not carried 
 away, and stimulates the circulation in the cutaneous organ. In certain diseased 
 conditions, more especially of the inflammatory types, water of any kind has an irri- 
 tant effect ; yet even here the addition of a little bran to the fluid will render it 
 milder in effect. Washing should be avoided in these cases as much as possible, 
 of course ; but even an eczematous skin need not be left dirty, and should not be. 
 The cleansing should mostly be done with a bland oil ; the ordinary olive or table 
 oil of good quality is usually the most convenient to use. But once every few days, 
 or even daily, the part should be well washed with water and a mild soap, care 
 
312 COSMETICS OF THE SKIN AND HAIR. 
 
 being taken to dry the part thoroughly and apply an oily material thoroughly 
 immediately thereafter. 
 
 An excellent method of applying water for cleansing purposes is by means of a 
 sponge, provided that this latter is soft, clean, and new. Unfortunately sponge 
 rapidly become greasy and is difficult to cleanse ; its interstices become filled with 
 detritus and decomposable material ; and no more unsuitable cleanser can be found 
 than a sponge that has been some time in use and has been neglected, more espe- 
 cially if the skin to which it is applied has any tendency to disease. The loofa, 
 the sponge-like dried interior of the fruit of the Loofa ^Egyptica, is to be preferred 
 for use upon the general surface of the body. The woody fiber absorbs watei 
 readily, and becomes soft ; and it is easier to cleanse and less liable to harbor con- 
 taminating elements than the sponges usually employed. 
 
 Water is not in itself injurious to the hair, the wide-spread prejudice to the con> 
 trary, especially among females, notwithstanding. The normal amount of fat upon 
 the cutaneous surface is doubly necessary upon the hair ; without it the pilous 
 structures become dry, lustreless, and brittle, and suffer greatly in appearance. 
 This is due, however, not to the water but to the soap, often of a markedly alkaline 
 kind, which is employed in conjunction with it, and to the non-replacement of the 
 oily material that is abstracted from the scalp and hair. It is safe to say that water 
 of the proper kind does not rot the hair or affect the scalp injuriously, and that any 
 possible evil effects of the soap employed in conjunction with it can be avoided by 
 the judicious use of a bland, oily, or fatty material on the scalp immediately after 
 the cleansing. Owing to the very imperfect head-covering universally worn by 
 women, their scalps and hair are exposed to every noxious influence ; and no more 
 suitable breeding-ground for living infectious material can be imagined. Cleansing 
 should be correspondingly frequent ; a thorough Aveekly washing is none too much, 
 and will have no ill effect if the precaution mentioned above is employed. 
 
 Brushing and combing are important cleansing agents for the hairy portions of 
 the body, though they can only be regarded as adjuncts to washing, which they 
 cannot replace. An important point, and one but too frequently neglected, is the 
 proper care of the instruments employed for these purposes. This is more espe- 
 cially the case since the recognition of the fact that one of the commonest causes of 
 baldness is a seborrhcea of infective nature, the etiological factor of which is prob- 
 ably transmitted through the medium of the hair-brush. These implements should 
 be thoroughly cleansed with hot water, soap, and an alkali at frequent intervals, 
 followed by a bichloride or other disinfection and exposure to the sun and air. 
 
 For the more energetic detergent effect upon the skin which is desirable in 
 almost all cases, soap must be employed in addition to water in cleansing. Its 
 therapeutic action has already been discussed (p. 44). Soap softens, swells, and 
 dissolves the epidermic scales, saponifies and renders soluble the fatty materials, 
 
CLEANSING AGENTS. 313 
 
 and promotes the removal of foreign matter. Its action is therefore chemical as 
 well as mechanical. It is essentially a combination of fatty acids with alkalies ; 
 and in accordance with the employment of soda or potash we have the hard and 
 soft varieties of the substance. Different proportions of fat give us the neutral and 
 the superfatted soaps ; and the addition of various drugs give us the medicated 
 kinds. 
 
 For ordinary cleansing a pure neutral soap is the best ; and the unscented 
 varieties are usually preferable, since the odorous materials are but too frequently 
 added to conceal imperfections in the body of the article. A good toilet soap 
 should be neutral in reaction, since an excess of alkali is irritant ; it should foam 
 readily, showing that the proportion of water and of free fat is not too great ; and 
 it should leave the skin soft and flexible. 
 
 More strongly alkaline soaps, more especially of the potash varieties, are better 
 cleansers, since they cause greater swelling and solution of the superficial epidermic 
 scales, and remove all fatty matter with greater freedom than neutral soaps. They 
 are therefore necessarily more irritant ; and whilst they must be employed when 
 there is much dirt or detritus present upon the skin, or when larger collections of 
 crusts or dead epidermis are to be removed, their use cannot generally be recom- 
 mended, and they are very apt to occasion excessive dryness, harshness, roughness, 
 and even Assuring of the skin. Green soap, either pure or in the form of Hebra's 
 tincture (No. 5, p. 43), is the best known representative of the class, and may be 
 employed to advantage occasionally on thick greasy skins with a marked tendency 
 to acne. Even here, however, it is too irritant to be used regularly ; it must be 
 employed only from time to time, and a bland neutral preparation used in the 
 intervals. A still greater detergent action can be gotten by the employment of 
 soaps containing sand, or finely powdered pumice-stone, or marble-dust, of which 
 several excellent kinds are now on the market. Here the mechanical action of the 
 insoluble elements comes into play, and the preparations are to be employed upon 
 skins that are hard, thick, badly stained, or affected with indurated acne. From 
 their mechanically detergent effects such soaps are very effective as a part of the 
 surgical disinfection of the hands and other parts. 
 
 The superfatted soaps, on the other hand, are valuable in cases where a mild 
 alkaline or even a neutral soap is irritant ; where the skin is dry and fatless, and 
 where conditions of asteatorrhea, keratosis, and ichthyosis prevail. Unna has given 
 a formula for a soda soap of this description (No. 155, p. 314), in which four parts 
 of the fat remain unsaponified, and which is very valuable. The excess of fat 
 leaves the alkali but little room for action. All soaps of this class, however, have 
 the disadvantages of being unattractive in odor and appearance, and of not keeping 
 well ; for the fat readily becomes rancid. 
 
 Occasionally we meet with skin which will not tolerate even the mildest soaps, 
 
314 
 
 COSMETICS OF THE SKIN AXD HAIR. 
 
 more especially upon the face ; though such instances are rarer than is usually sup- 
 posed, and the use of an improper variety of the article is usually the reason for the 
 supposed intolerance. Here the pure fats and oils must be employed for cleansing 
 purposes ; at the same time they tend -to render the skin smooth, soft, and pliable, 
 and improve its nutrition. Milk is a favorite agent in these cases, or olive-, benne-, 
 or almond-oil may be employed. They are best applied -by means of large pledgets 
 of cotton, since cloths and sponges rapidly become foul and contaminated when 
 used for this purpose. A much more thorough cleansing than is usually supposed 
 possible can be effected, more especially if the milk or oil is employed warm and 
 sufficient friction is applied. Adeps lanae or lanolin is perhaps still better than the 
 agents mentioned above, more especially in the form of an emulsion (No. 1 56, p. 314). 
 All these fatty agents are contraindicated in greasy seborrheal skins showing an 
 abundance of comedoes. Here glycerin may be substituted for soap as the cleansing 
 agent, as in the paste recommended by Hager (No. 157, p. 314). 
 
 No. 155. Sapo Super adiposus. 
 
 No. 156. Lanolin Emulsion, 
 
 Beef tallow 
 
 . 59.3 parts 
 
 3 Adeps lanae 
 
 . 
 
 19 parts 
 
 Olive oil . 
 
 . 7-4 " 
 
 Borax 
 
 . 
 
 1 part 
 
 Potash lye (28 Baume) . 11. 1 " 
 
 Aq. rosae . 
 
 • 
 
 1000 parts 
 
 No. 157. Hager s 
 
 Glycerin Paste. 
 
 No. 158. Toilet Water. 
 
 
 Pulv. tragacanth . 
 
 30 parts 
 
 5 Boracis 
 
 , 
 
 1 part 
 
 Aq. rosae 
 
 70 " 
 
 Aq. rosae 
 
 . 
 
 5 P arts 
 
 Glycerini 
 
 . 125 " 
 
 Aq. Coloniensis . . 
 
 . 
 
 10 " 
 
 Tinct. benzoini . 
 
 . 30 « 
 
 Aq. distil. . 
 
 . 
 
 no " 
 
 01. aurant. flor. . 
 
 1 part 
 
 
 
 
 Alcohol greatly diluted, or bay-rum or cologne water in strengths of 5 to 10 per 
 cent., as found in the better class of toilet-waters, are excellent cleansing agents, dis- 
 solving and removing much of the foreign matter that maybe present upon the skin. 
 As these waters, however, are very liable to contain ingredients which are harmful 
 to the skin, they had better be prescribed. No. 158, p. 314, is a useful formula. The 
 addition of a little borax increases the detergent effect, and it is often advantageous 
 to add a small amount of an oil soluble in alcohol to the mixture to prevent a too 
 great drying of the skin (No. 159, p. 315). 
 
 Alkalies are usually employed in the form of one of the alkaline soaps mentioned 
 above, but they may be used as washes, and they form the basis of many of the 
 proprietary articles recommended for cosmetic purposes. Caution must be used in 
 their employment, since many of them tend to render the skin dry and rough and 
 the hair brittle. Borax is one of the best and is harmless, and may be employed 
 even in concentrated solution anywhere. Formulae Nos. 160 and 161, p. 315, or 
 the plain alkaline lotion, No. 67, p. 135, may be used. When a still stronger alka- 
 
STIMULATING AGENTS. 
 
 315 
 
 line effect is desired a little of the Detergent Solution (No. 162, p. 315) may be 
 added to the wash-water. 
 
 Acids are usually found in the form of the toilet vinegars, which are especially 
 useful to remedy excessive secretion or abnormal decomposition of the sweat, and 
 to keep parts so affected pure and sweet. Among the most useful of these are the 
 Cologne Vinegar (No. 163, p. 316) and the Aromatic Vinegar (No. 164, p. 316), to 
 be employed diluted. Boric acid is efficient and harmless, and can be used when- 
 ever an application of this nature is indicated. 
 
 No. 159. Face Lotion. 
 
 ^ 01. ricin 
 
 Tinct. benzoin 
 Spts. Colonien. 
 Spts. vini 
 
 1 part 
 
 2 parts 
 8 " 
 
 25 " 
 
 No. J6J. Borax Lotion No. 2. 
 
 B Kali carbon 5 parts 
 
 Boracis . . . . 10 " 
 
 Aq. Colonien. . . . 40 " 
 
 Aq. rosae . . . . 80 " 
 
 $ 
 
 $ 
 
 No, J60. Borax Lotion No. 1. 
 
 Sod. carb. 
 
 Boraci 
 
 Aq. 
 
 rosEe 
 
 1 part 
 
 5 P arts 
 200 " 
 
 No. 162. Detergent Solution. 
 
 Potassii carbon. . . . 1 part 
 
 Tinct. benzoini ... 6 parts 
 
 Aq. rosee . . . 7 " 
 
 2. STIMULATING AGENTS. 
 
 These are not very frequently employed for purely cosmetic purposes, save on 
 the scalp, though they are useful when the skin is pale and anaemic, and when 
 deficient muscular action seems to be the cause of glandular congestion and the 
 various lesions of acne and comedo. Chief among them are massage and friction, 
 both of whichrare best done in conjunction with some bland oil. Pure almond-, 
 benne-, or olive-oil is usually to be preferred ; but the various cold creams may be 
 employed, or one of the lanolin preparations (Nos. 165, p. 316, 156, p. 314) may 
 be used. A soap is sometimes preferable. Cold or hot water alone, or an alcoholic 
 lotion (No. 159, p. 315) or soap essence (No. 166, p. 316), may be used. Very 
 eligible for this purpose also is the green-soap tincture (No. 45, p. 43), though it 
 must be employed well diluted to prevent undue irritation. The combination of a 
 mild alkali with glycerin is often a desirable preparation to employ for frictions and 
 massage ; a good formula is the borax-soap spirit (No. 167, p. 316). 
 
 Stimulant applications are commonly employed upon the scalp, and sometimes 
 upon the bearded portions of the face when the pilous growth is deficient. Bald- 
 ness, especially in its slighter forms, is certainly increasing in frequency in males ; 
 and it is commoner in females than is generally supposed, though usually more 
 successfully hidden from sight. We need not inquire whether the wide-spread 
 
316 
 
 COSMETICS OF THE SKIN AND HAIR. 
 
 contagious seborrhea, which is the commonest form of dandruff and which is com- 
 municated mostly through the barber-shops, or the prevalent custom of wearing 
 hats that encircle the head with a tight rim and thus interfere with the circulation 
 of the scalp for large portions of the day, is the cause of the increasing tendency to 
 the early development of alopecia. Undoubtedly, however, the general disuse 
 of the oily applications that formed an essential part of the hair toilet of our ances- 
 tors is responsible to some degree, at all events, for the deficient nutrition, imperfect 
 growth, and early decay of the pilous structures. 
 
 No. 163. Cologne Vinegar. 
 
 No. 164. Aromatic Vinegar. 
 
 ]J Acid. acet. cone. 
 Aq. Colonien. 
 
 No. 165. Massage Ointment. 
 
 i part 
 
 5 
 
 Tinct. rosmarin. 
 
 1 part 
 
 30 parts 
 
 
 Tinct. caryophyl. 
 
 1 " 
 
 
 
 Tinct. lavandulae 
 
 2 parts 
 
 
 
 Camphorae . . 
 
 180 " 
 
 
 
 Acid. acet. cone. 
 
 1000 " 
 
 
 
 No. J66. Soap Essence. 
 
 
 
 5 
 
 Sapon. alb. 
 Aq. rosae 
 
 
 . 1 part 
 
 
 Aq. naphae . . 
 
 aa. 1 part 
 
 
 
 Spts. vini rect. . 
 
 4 parts 
 
 §, Adeps lanae 
 01. theobromae 
 01. amygdal. dulc. 
 
 Under the headings of seborrhea (p. 64) and alopecia (p. 301) will be found 
 the general directions for the treatment of these conditions. The various sulphur 
 and resorcin applications (Nos. 20, 24, and 25, p. 64), and the antiseptic and stimulant 
 lotions (Nos. 142, 144, 145, 149, etc., p. 303), are often useful when deficient hairy 
 growth is to be stimulated. The long-continued employment of the stronger ones 
 among them, however, is not advisable, since they may render the hairs brittle, 
 and even alter it in texture and color. This is especially the case with those con- 
 taining alcohol and alkalies. 
 
 No. 167. Borax Soap Spirit. 
 
 No. 168. Bichloride Hair Wash. 
 
 ^ Boracis 
 
 Spirit, vini rect. 
 Glycerin 
 Sapon. kalin. 
 
 1 part 
 50 parts 
 
 aa. 100 
 
 5 Hydrarg. bichloridi 
 Glycerini . 
 Spirit, colon. 
 Spirit, myrciae . 
 
 1 part 
 100 parts 
 
 No. 169. Quinine Spirit. 
 
 . aa. 1500 
 No. 170. Stimulant Hair Wash. 
 
 IJ, 01. sabinae . 
 Tinct. quinae 
 Spirit, vini Gall 
 
 1 part 
 50 parts 
 100 " 
 
 3 Tinct. cantharid. 
 Tinct. gallar. 
 Aq. Colonien. 
 
 1 part 
 5 parts 
 50 " 
 
 As a general stimulant to the scalp and hair there is no more generally useful 
 application than the bichloride wash (No. 168, p. 316) or the quinine spirit. 
 Cantharides is also commonly employed, as in the stimulant hair wash (No. 170, 
 
SOOTHING AGENTS. 
 
 317 
 
 p. 316). It is of importance, however, to use an oily application after these irritant 
 and desiccating preparations, and for that purpose nothing is better than the ointment 
 or oil given under formulae Nos. 171 and 172, p. 317. 
 
 No. J7J. Stimulant Hair Ointment. 
 
 5 Balsam. Peruv. 
 
 Ungt. simplic, s. petrolati 
 
 No. J 72. Stimulant Hair Oil. 
 
 1 part 
 
 §. Acid, tannic. 
 
 • 
 
 • . i part 
 
 50 parts 
 
 01. amygdal. 
 
 • 
 
 • .10 parts 
 
 
 Spirit, vini rect. 
 
 • 
 
 • q. s. ad solut. 
 
 3. SOOTHING AGENTS. 
 
 These are required when the skin is roughened, irritated, and hypersemic, and 
 shows a tendency to undergo inflammatory reaction under the influence of slight 
 external irritants. The most important of them are the various fats and oils, the 
 use of which renders the skin supple, smooth, clean, and glossy, makes it less sus- 
 ceptible to atmospheric and other noxious influences, and undoubtedly improves its 
 nutrition and appearance when properly employed. The general use of fats for 
 inunction, especially after the bath, was common in the ancient world ; and it would 
 undoubtedly be of benefit if it were still employed for that purpose. 
 
 Lard is the commonest fat that is employed for inunction purposes ; but it has 
 various disadvantages even when combined with benzoin and other preservatives. 
 Like tallow and beef marrow, it is very prone to turn rancid ; and its peculiar odor, 
 even when corrected by the addition of an essential oil, is very evident when it is 
 employed in considerable quantity and over a large surface of the body. One of 
 the various bland ointments (Nos. 26, p. 70, 68, 69, p. 135), or the glycerin cream 
 (No. 173, p. 317), or the adeps lanae cream (No. 174, p. 317) is preferable to the 
 pure fats. 
 
 No. 173. Glycerin Cream. 
 
 No. 174. Adeps Lance Cream No. I. 
 
 5, Cetaceum . 
 
 ■ • 
 
 . 13 parts 
 
 3 
 
 Tinct. benzoin 
 
 Glycerini 
 
 
 
 
 Petrolati . 
 
 Aq. rosse . 
 
 • 
 
 . aa. 20 " 
 
 
 Adip. lana? . 
 
 Paraffin . . 
 
 • 
 
 . 10 " 
 
 
 
 01. amygdal. . 
 
 • 
 
 . • 50 " 
 
 
 
 01. rosae 
 
 . 
 
 . q. s. 
 
 
 
 No. 175. 
 
 Inunction Oil. 
 
 
 No. J 76. Adej 
 
 Yp 01. amygdal. . 
 
 • 
 
 . 1 part 
 
 3 Adip. Ian. 
 
 01. olivae . 
 
 • 
 
 . 5 parts 
 
 
 Vasehm 
 
 01. odorat. . 
 
 • 
 
 . q. s. 
 
 
 Aq. calcis 
 
 1 part 
 10 parts 
 20 " 
 
 5 parts 
 . 10 " 
 20-60 " 
 
 Better still are the fluid oils, especially olive and almond, which are best 
 employed both for general inunction and local soothing in mixtures suitably flavored 
 and scented (No. 175, p. 317). Lanolin, though not a true fat, acts upon the skin 
 
318 
 
 COSMETICS OF THE SKIN AND HAIR. 
 
 in a similar manner, and may be used as the adeps lanae cream No. I (No. 176, 
 p. 317) or the lanolin cream (No. 177, p. 318). It is sometimes desirable to employ 
 the fat in more solid form ; in which case Bernatzik's crystal pomade (No. 178, 
 p. 318) is eligible. 
 
 No, 177. Lanolin Cream. 
 
 No. 178. Bernatziks Crystal Pomade. 
 
 R Lanolin . 
 01. amygdal. 
 Vanillin . 
 
 3 parts 
 1 part 
 q. s. 
 
 R 
 
 Cetacei . . 
 01. ricini 
 01. amygdal. . 
 01. odorat. 
 
 12 parts 
 64 " 
 
 20 " 
 1 part 
 
 No. 179. White Face Powder. 
 
 No. 180. Almond-meal Powder. 
 
 R Magnes. carb. 
 Zinci oxidi . 
 Talc, venet. . 
 01. millifl. . 
 
 1 part 
 7 parts 
 
 12 " 
 
 q. s. 
 
 R Farin. amygd. decort. 
 Rad. irid. pulv. 
 Ess. citri 
 Ess. amygdal. 
 
 60 parts 
 5 " 
 
 aa. 
 
 The various powders, of which those composed of starch, talcum, and the car- 
 bonate of magnesia are the best, may be applied as soothing and cooling applica- 
 tions to the skin, and are largely used in summer for that purpose. The zinc dust- 
 ing powder (No. 18, p. 61) can be employed, being but very slightly astringent, as 
 also can the white face powder (No. 179, p. 318) and the almond-meal powder 
 (No. 180, p. 318). 
 
 No, 181. Glycerin Cold Cream. 
 
 No. 182. Delay's Pomade. 
 
 R Amyli 
 
 Aq. rosae . . . aa. 1 part 
 Glycerini . . . .25 parts 
 01. rosae . . . . q. s. 
 
 R Tinct. benzoin 
 Bals. Peruv. . 
 01. amygdal. dulc. 
 Axung. . 
 
 • • 
 
 • • 
 
 • • 
 • 
 
 1 part 
 
 2 parts 
 
 4 " 
 
 50 " 
 
 No. 183. Rose Pomade. 
 
 No. 184. Brillianline. 
 
 
 R 01. rosse 1 part 
 01. amygdal. dulc. . . 30 parts 
 Medull. oss. bovis . . 150 " 
 
 R 01. aeth. flor. aur. . 
 01. ricini 
 Spirit, vini rect. . 
 
 • • 
 
 • • 
 e 
 
 1 part 
 30 parts 
 
 35° " 
 
 No. 185. Hair Oil. 
 
 
 
 R 01. amygdal. amar. 
 01. flor. aurant. 
 01. jasmin. . 
 01. amygdal. dulc. 
 
 1 part 
 . 30 parts 
 . 60 " 
 • 35° " 
 
 
 
 Glycerin in proper dilution is very valuable for soothing purposes, though it 
 does not agree with all skins. It may be employed in the form of the glycerin 
 cream (No. 173, p. 316) or the glycerin cold cream (No. 181, p. 318). 
 
 The various pomades and hair oils may be considered here, though many of 
 them are stimulating rather than soothing agents, and tend to increase the growth 
 
COLORING AGENTS. 
 
 319 
 
 of the hair. They are made of various mixtures of solid and fluid fats, to which 
 coloring and odorous materials are usually added. Their use in moderation is to 
 be advocated, more especially since a proper employment of soap and water to the 
 scalp for cleansing removes the natural fat more rapidly than it is reproduced. 
 
 Lard is the usual basis of these applications, and is apparently just as good as 
 the marrow or bear's fat that was formerly employed. Vegetable oils are employed 
 to make the hair oils ; and the addition of wax, spermaceti, etc., gives us the solid 
 stick varieties. Nos. 182 (p. 318), 183 (p. 318), 184 (p. 318) are suitable formulas 
 of solid and fluid preparations of this kind. 
 
 4. COLORING AGENTS. 
 
 These are occasionally required to hide excessive pallor, sallowness, darkness, 
 or redness of the complexion, in cases of jaundice, to conceal the local discolora- 
 tions of leucoderma, or the local pigmentations of ephelides, chloasmata or no&vi, 
 or to improve the hair. In a general way their use is objectionable, and some of 
 the agents employed are injurious to the skin. But they are sometimes necessary, 
 and are used to a greater extent than is generally supposed ; henee they require 
 some consideration here. 
 
 White face powder is commonly employed to some extent by females, more 
 especially in the hot weather ; and here, if of the proper kind, it does have the good 
 effect of cooling and soothing the skin, drying off the superabundant moisture, and 
 preventing the disagreeable oiliness to which the brunette complexion especially is 
 so liable at that time. A pure powder of rice, talcum, or carbonate of magnesia 
 is perfectly harmless ; unfortunately many of the commercial preparations contain 
 mineral ingredients of which that cannot be said. All such as contain lead or bismuth 
 should be rejected, though a small amount of zinc oxide does no harm and improves 
 the covering properties of the preparation. Perhaps a simple mixture of starch and 
 talcum (No. 186, p. 320) or the magnesia powder (No. 187, p. 320) is the best. 
 
 A flesh tint can be imparted to either of these powders by the addition of a 
 very little carmine, or No. 188, p. 320, can be used. As a rule, however, coloration 
 of this kind is better done with one of the fluid or ointment preparations mentioned 
 below. 
 
 Fluid coloring agents are sometimes employed, the princess water (No. 189, 
 p. 320), among others, enjoying a considerable vogue. It is to be applied with a 
 brush after shaking, and the sediment thoroughly rubbed into the skin with a cloth. 
 Carmine may also be applied in this form, a little rubbed up in glycerin being 
 applied to the part. 
 
 White salve preparations are rarely employed ; and the ointment form is the 
 
320 
 
 COSMETICS OF THE SKIN AND HAIR. 
 
 most eligible one for the red coloration. Either of the pink pigments (No. 190, 
 p. 320, 191, p. 320) may be used, being applied by means of a cloth. 
 
 Dyes for coloring the hair are sometimes required in cases of premature or senile 
 blanching, and they will always be used to some extent by females in accordance 
 with the dictates of caprice or fashion. Several formulae for the preparation of 
 black and brown hair dyes, together with details of the method, will be found 
 under the heading of canities (Nos. 135 to 141, p. 297). The vegetable dyes are 
 the most harmless. A serviceable though temporary dye can be made from the 
 fresh juice of unripe walnuts, giving a dark brown color ; and henna, obtained 
 from the leaves of the Lawsonia inermis, gives a reddish dye which can be made 
 darker by the subsequent employment of alkalies, and removed by means of acids. 
 Neither of these substances is much used nowadays, however, to darken the hair, 
 pyrogallo being the only agent of organic nature employed (Nos. 135 and 141, p. 297). 
 
 No. 186. Face Powder. 
 
 No. J 87. Magnesia Face Powder. 
 
 5 Amyli trit. 
 Hale, venet. 
 
 aa. 
 
 p.e. 
 
 No. J88. Carmine Face Powder. 
 
 5 Carmine opt. 
 Talc, venet. 
 
 1 part 
 100 parts 
 
 5 
 
 No. J90. Pink Pigment No. I. 
 
 5 Carmine 1 part 
 
 Spermaceti .... 5 parts 
 Talc, venet. . . . 100 " 
 
 5 
 
 Magnes. carb. . 
 
 
 1 part 
 
 Zinci oxidi . 
 
 
 5 parts 
 
 Talc, venet. . 
 
 
 12 " 
 
 01. millifl. . 
 
 
 q. s. 
 
 No. 189. Princess Water. 
 
 
 Cerussa . . 
 
 
 5 parts 
 
 Talc, praecip. 
 
 
 
 Magnes. carb. 
 
 aa. 
 
 3 " 
 
 Tinct. benzoin . 
 
 
 1 part 
 
 Aq. rosge 
 
 
 
 Aq. Colonien. 
 
 aa. 
 
 75 P arts 
 
 No. J9J. Pink Pigment 
 
 No. 
 
 2. 
 
 Carmine . . . 
 
 
 1 part 
 
 Ungt. simplic. 
 
 
 100 parts 
 
 The inorganic or mineral dyes are more commonly used, as the nitrate of 
 silver and the bichloride of mercury in formulae 136, 137, 139, 140, p. 297. The 
 hair both of the head and the beard should be thoroughly washed before applying 
 any of these preparations, since fatty substances containing sulphur are liable to 
 change the inorganic and mineral materials employed. The dye itself should be 
 applied by means of a tooth-brush, entire strands from their roots to tips being sepa- 
 rately treated, and the surrounding skin and the fingers being protected by means 
 of rubber coverings or coating the surface with glycerin or oil. 
 
 To produce the lighter blond tints in the hair peroxide of hydrogen is the 
 material usually employed. It should always be used fresh and with caution ; the 
 tint depending upon the amount employed and upon its concentration. 
 
DECOLORING AGENTS. 821 
 
 Any one of these dyestuffs must be reapplied at regular intervals, dependent 
 upon the rate of growth of the hair. None of them penetrate below the level of 
 the skin, so that it is not possible to dye the part of the hair shaft which will rise 
 above the surface during the days following the application. The scalp hair needs 
 redyeing every two or three weeks ; that of the beard and mustache, which grows 
 more rapidly, every eight or ten days. 
 
 A word of caution as to the employment of these various hair dyes is not out of 
 place. Many of them, more especially the mineral varieties, have an injurious effect 
 upon the pilous structures ; their continued employment renders the hair dry and 
 brittle, and apparently effects a chemical change in the shaft itself. Unless great 
 care is taken in making the applications, unexpected and undesired color effects are 
 sometimes obtained. Some of them stain the skin as well as the hair. Over and 
 above all these results, however, they sometimes exert a directly irritant effect 
 upon the skin of parts even remote from the site of application. Erythematous, 
 papular, and pustular dermatites affecting the scalp and the whole face have been 
 noted ; and in Paris during the past year (1901) have been sufficiently frequent to 
 lead to official notice and condemnation of the materials employed in some of the 
 commercial dyes. 
 
 5. DECOLORING AGENTS. 
 
 But few of these come under the heading of articles for ordinary cosmetic use ; 
 if the abnormal coloration cannot be hidden by the ordinary powders and salve 
 recommended above (Nos. 186, 187, p. 320, etc.), the chloasmata, lentigines, and 
 pigmentary naevi that are their cause are objects for the medicinal treatment which 
 is detailed under the headings of these affections. The peroxide of hydrogen in 10 
 to 20 per cent solution is perhaps the safest bleaching agent for domestic use. 
 
 6. AGENTS FOR THE REMOVAL OF OTHER ABNORMALITIES. 
 
 The removal of naevi, verrucse, callosities, etc., belong to the medicinal rather 
 than to the cosmetic chapter, and have already been dealt with under their appro- 
 priate heading. Methods for the radical removal of abnormal hair will be found 
 under hirsuties ; there remains only to mention the depilatories, the use of which is 
 sometimes advisable, more especially in females. 
 
 Palliative treatment of hirsuties is sometimes necessary in cases where radical 
 treatment by electrolysis (p. 257) is not possible ; and depilatory pastes are better 
 for this purpose than the razor, since they are easier of employment, need not be 
 used so often, and remove the hair to a considerably greater depth than does mere 
 ablation by shaving. The formula for one of the best of these, recommended by 
 
>22 
 
 COSMETICS OF "THE SKIN AND HAIR. 
 
 Duhring, will be found on page 257 (No. 130; together with the method of its 
 employment. One of the most ancient is the Rusma employed in Oriental harems 
 to destroy pubic and axillary hair (No. 192, p. 322). It is applied by means of a 
 spatula, left in situ for ten minutes until dry, scraped off, and the skin then washed 
 and powdered. Pastes made of the sulphydrate of calcium or sodium or of barium 
 (Nos. 193, p. 322, 194, p. 322) are to be employed in the same manner ; but prepa- 
 rations containing orpiment should not be left on so long, some two to five minutes 
 sufficing (Nos. 196, 197, p. 322, 198, p. 322). Amongst the least irritating of 
 them all is Boettger's depilatory (No. 199, p. 322), which is therefore most suitable 
 for the face and where light lanugo hair is to be removed. 
 
 No. 192. Rusma Depilatory Paste. No. 193. Redwood's Depilatory. 
 
 B> Yellow sulphide of arsenic . 1 part B Barii sulphurat. solut. concentr. 1 part 
 
 10 parts Amyli . q. s. ut f. pasta 
 
 Unslaked lime 
 M. S. Boil. 
 
 No. 194. Rondel's Depilatory. 
 
 B Sodii hydr. sulph. . . 1 part 
 
 Calc. caust. pulv. 
 
 Amyli . . . . aa. 5 parts 
 
 To be rubbed into a thin paste with water 
 for use. 
 
 No. 196. Neumanns Depilatory. 
 
 B Orpiment 1 part 
 
 Amyli .... 3 parts 
 
 Calc. hydrat. . . . 5 " 
 
 Aq. calcis q. s. ut f. pasta mollis. 
 
 No. 198. Depilatory Water. 
 
 B Orpiment .... 
 
 Calc. viv. .... 
 Coque c. 
 
 Liq. potas. caust. . 
 
 No. 195. Depilatory Powder. 
 
 B Sodii sulphid. 1 part 
 
 Cretae prsep. ... 3 parts 
 
 No. 197. Debay's Depilatory. 
 
 B Orpiment 1 par: 
 
 Pulv. calc. caust. . . .8 parts 
 Pulv. irid 16 " 
 
 No. 199. Boettger's Depilatory. 
 
 1 part 
 
 B Essent. citr. 
 
 1 part 
 
 2 parts 
 
 Amyli 
 
 
 
 Ungt. glycerini . . aa. 
 
 4 part: 
 
 2 " 
 
 Calc. hydr. sulph. in aqua 
 
 38 " 
 

INDEX. 
 
 Abrasions 
 
 Acarina 
 
 Acarus folliadorum 
 
 Acants scabiei 
 
 Achorion Schonleinii 9c 
 
 Achromia 
 
 Acne 
 
 atrophica 
 
 bromata 
 
 cachecticorum 182, 
 
 hypertrophica 
 
 indurata 
 
 inveterata 
 
 medicamentosa 
 
 necrotica 
 
 papulosa 
 
 picealis , 
 
 punctata 
 
 pustulosa 
 
 rosacea 
 
 syphiliticum 
 
 varioliformis 
 
 vulgaris 
 
 Acne 
 
 miliaire 
 
 ponctuee 
 
 rose'e 
 
 varioliforme 
 
 Actinomycosis 
 
 Adenoma 
 
 Adeps Lanse Cream 
 
 Adipoma 
 
 Albinism 
 
 Albinismus 
 
 A Igidite progressive 
 
 Alkaline Lotion 
 
 Alopecia 
 
 adnata 
 
 areata 
 
 circumscripta 
 
 congenita 
 
 furfuracea 
 
 pityrodes 
 
 prematura 
 
 presenilis 
 
 senilis 
 
 simplex 
 
 symptomatica 
 
 syphilitica 201, 
 
 FAGE PAGE 
 
 36 Alum Dusting Powder 58 
 
 116 Anatomical tubercle 184 
 
 66 Anatomy of the skin 13 
 
 118 Anderson's Hair-dye No. 1 297 
 
 , 98 Anderson's Hair-dye No. 2 297 
 
 293 Anemias 74 
 
 228 Angio-elephantiasis 274 
 
 229 Angioma 273 
 
 230 cavernosum 273, 274 
 
 229 Anidrosis jq 
 
 229 Anthrarobin 47 
 
 229 Anthrax 175 
 
 229 Antiseptic Mouth Wash 209 
 
 230 Aplasia pilorum 30S 
 
 229 Area Celsi 304 
 
 228 Aristol 47 
 
 230 Arrectores pilorum 17 
 
 228 Arsenic 45 
 
 229 Arsenic Solution 220 
 
 233 Asiatic Pill 46 
 
 197 Asteatosis 69 
 
 229 Astringent Mouth Wash 209 
 
 228 Atrophia cutis 286 
 
 228 maculosa et striata 287 
 
 67 neuriticum 287 
 
 65 pilorum 307 
 
 233 senilis 286 
 
 254 unguis 309 
 
 227 Atrophies 28b 
 
 276 Atrophoderma 286 
 
 3*7 neuriticum 287 
 
 268 Atrophy of cutis and subcutis 286 
 
 293 of hair 298 
 
 293 of nails 309 
 
 291 of pigment 292 
 
 135 of skin 286 
 
 298 Atropia Pills 78 
 
 298 Anssatz 215 
 
 304 Bacillus anthracis 175 
 
 304 lepra 217 
 
 298 Baldness 298 
 
 300 Balggeschwulst 68 
 
 300 Barbados leg 251 
 
 299 Barber's itch 105 
 
 299 Bartfinne . . . . , 236 
 
 299 Bartjlechte 105 
 
 299 Baths 41 
 
 299 Beaded hairs 308 
 
 202 Black Wash 214 
 
 437 
 
438 
 
 INDEX. 
 
 PAGE 
 
 Blackheads 65 
 
 Bliisclien 35 
 
 Blasen 35 
 
 Blasenansschlag 145 
 
 Blattern „ 89 
 
 Webs 35 
 
 Blood-vessels of the skin 16 
 
 Blutfleckenkrankheit 83 
 
 Blutgewdchs 280 
 
 Blutschwar 1 73 
 
 Boil 1 73 
 
 Boracic-acid Ointment 74 
 
 Borax Lotion No. 1 315 
 
 Borax Lotion No. 2 315 
 
 Borken 37 
 
 Brandschwar 175 
 
 Brandy nose 233 
 
 Bromidrosis 57, 59 
 
 Bronson's Mercurial Ointment 64 
 
 Bulkley's Carbolic-Iodine Application 307 
 
 Bulkley's Lotion ." 261 
 
 Bullae 35 
 
 Bulks 35 
 
 Burn 161 
 
 Burs, dental 51 
 
 Butterfly lupus 222 
 
 Cade-Sulphur-Green Soap Ointment 225 
 
 Calamine Lotion 137 
 
 Callositas 244 
 
 pedis 245 
 
 Callus 244 
 
 Calomel Powders 210 
 
 Calomel Suspension 46 
 
 Calvities 298 
 
 senile 299 
 
 Camphor-Naphthol 220 
 
 Cancer 277 
 
 en cuirasse 277 
 
 Cancroid 278 
 
 Cancroide 277 
 
 Canities 293, 295 
 
 Carbolic Lotion 56 
 
 Carbolic Spirit 78 
 
 Carbunculus 175 
 
 Carcinoma 277 
 
 lenticulare 277 
 
 tuberosum 277 
 
 Carron-oil 165 
 
 Caustics 45 
 
 Chancre 187, 190 
 
 hard 187 
 
 non-infecting 1 70 
 
 soft 1 70 
 
 Chancrelle 1 70 
 
 Chancroid 1 70 
 
 Cheiropompholyx 144 
 
 Cheloid 265 
 
 Cheveaux moniliformes 308 
 
 Chicken-pox 91 
 
 Chilblains 73, 162 
 
 Chloasma 262 
 
 caloricum 262 
 
 symptomaticum 262 
 
 traumaticum 262 
 
 uterinum 262 
 
 Chloral-Camphor Ointment. . 
 
 Chloral Lotion 
 
 Chromidrosis 
 
 Chromophytosis 
 
 Chrysarobin , 
 
 Chrysarobin Collodion 
 
 Chrysarobin Ointment 
 
 Chrysarobin Ointment Comp. 
 
 Cicatrices 
 
 Cicatrix 
 
 Cilia 
 
 Cinnamonic-acid Injection. . . , 
 
 Classification 
 
 Clavus 
 
 Cocaine Ointment 
 
 Coil-glands 
 
 Collemplastra 
 
 Combustio 
 
 Comedo 
 
 extractor 
 
 Condyloma acuminata . . . 
 
 lata , 
 
 Cooling Salve 
 
 Copper Oleate Ointment 
 Cor , 
 
 Corium 
 
 Corn 
 
 Come de la pean 
 
 Cornu cutaneum 
 
 Cosmetics of skin and hair 
 
 Conperose 
 
 Cowpox 
 
 Crabs 
 
 Cradle crust 
 
 Crocker's Lead Thymol Ointment. 
 
 Croton-oil Ointment 
 
 Cro-Ates 
 
 Crusts 
 
 Curettes 
 
 Cuticle 
 
 Cutis laxa 
 
 Dartre rongeante 
 
 Deflnvium capillorum 
 
 Demodex folliculorum 
 
 Depilatory Powder 
 
 Depilatory Water. 
 
 Dermatite polymorphe prurigineuse a pousse'es suc- 
 cessive! 
 
 Dermatitis 
 
 ambustionis 
 
 calorica 
 
 cathode-ray 
 
 congelationis 
 
 contusiformis 
 
 exfoliativa 
 
 hemorrhagica 
 
 herpetiformis 
 
 medicamentosa 
 
 parenchymatosus 
 
 traumatic 
 
 venenata 
 
 Dermatol 
 
 Dermatomycoses 
 
 Dermatomycosis barbae 
 
 favosa 
 
 7° 
 78 
 60 
 
 113 
 
 47 
 108 
 
 94 
 46 
 
 38 
 264 
 
 26 
 181 
 
 52 
 246 
 288 
 
 21 
 
 43 
 lbi 
 
 65 
 5° 
 248 
 194 
 135 
 105 
 246 
 
 15 
 246 
 247 
 
 247 
 310 
 
 233 
 90 
 
 124 
 62 
 
 183 
 
 307 
 37 
 37 
 50 
 14 
 
 288 
 
 177 
 298 
 66 
 322 
 322 
 
 149 
 
 159 
 161 
 161 
 166 
 162 
 166 
 
 152 
 166 
 149 
 
 163 
 160 
 160 
 163 
 47 
 
 06 
 105 
 
 9* 
 
INDEX. 
 
 439 
 
 PAGE 
 
 Dermatomycosis furfuracea 123 
 
 marginata 1 10 
 
 Dermatomyomata 272 
 
 Dermatosclerosis 289 
 
 Dermatosyphilis , 190 
 
 Dermatozoa 115 
 
 Diachylon Ointment 136 
 
 Diagnosis , 32 
 
 Diascopy 137 
 
 Dissection tubercle 184 
 
 Diuretic Mixtures 134, 158 
 
 Duhring's Arsenic Mixture 158 
 
 Duhring's Depilatory 257 
 
 Duhring's Morphine Collodion 144 
 
 Duhring's Poison-ivy Lotion 165 
 
 Duhring's Staphisagria Ointment 124 
 
 Dysidrosis 144 
 
 Ecthyma 172 
 
 syphilitica 196 
 
 Eczema 125 
 
 acutum 128 
 
 barbae 130 
 
 capitis 1 29 
 
 chronicum 129 
 
 crustosum 129 
 
 erythematosum 126 
 
 faciei 129 
 
 genitalium 130 
 
 impetiginosum 128 
 
 intertrigo 129 
 
 madidans 129 
 
 manuum 130 
 
 marginatum 1 10 
 
 papulosum 127 
 
 pustulosum , . . . . 128 
 
 rubrum . . . , 129 
 
 seborrheicum 131 
 
 squamosum 129 
 
 tuberculatum 219 
 
 unguium 131 
 
 verrucosum 1 29 
 
 vesiculosum 127 
 
 Electrolysis 49 
 
 Elephant leg 251 
 
 Elephantiasis 251 
 
 Arabum 251 
 
 glabra 252 
 
 Grsecorum 215 
 
 papillosa 252 
 
 tuberosa 252 
 
 verrucosa 252 
 
 vulvas 253 
 
 Elephantiasis 251 
 
 Ephelides 261 
 
 Epidermis 14 
 
 Epilating forceps 51 
 
 Epithelial cancer 277 
 
 Epitheliom 277 
 
 Epithelioma 277, 278 
 
 discoid 279 
 
 flat 279 
 
 fungating 282 
 
 infiltrating 279 
 
 molluscum 254 
 
 of lip , . , . . 281 
 
 PAGE 
 
 Epithelioma of penis 279 
 
 papillary 280 
 
 tubercular 279 
 
 Epitheliomatosis, eczematoid 281 
 
 Epitheliome 277 
 
 Epizoa 116 
 
 Erbgrind 96 
 
 Erysipelas 167 
 
 ambulans 1 1>8 
 
 bullosum 168 
 
 chronic 1 69 
 
 crustosum 168 
 
 gangrenosum 168 
 
 migrans 168 
 
 perstans 168 
 
 vesiculosum 168 
 
 Erysipele 167 
 
 Erythema annulare 139 
 
 bullosum 139 
 
 caloricum 72 
 
 exudativum multiforme 139 
 
 exudativum polymorphum 139 
 
 figuratum 1 39 
 
 gyratum 139 
 
 infantilis 72 
 
 multiforme 139 
 
 nodosum 166 
 
 papulatum 139 
 
 scarletiniforme 73 
 
 simplex 71 
 
 solare 72 
 
 symptomaticum 72 
 
 syphiliticum 192 
 
 traumaticum 72 
 
 tuberculatum 139 
 
 venenatum 72 
 
 Erytheme 71 
 
 ?ionenx 1 66 
 
 polymorphe 139 
 
 Erythrasma 1 15 
 
 Etiology 38 
 
 Excoriations 36 
 
 Face Lotion 315 
 
 Face Powder 320 
 
 Falx 28 
 
 Fatty tumor 268 
 
 Favus 96 
 
 capitis 97 
 
 corporis 97 
 
 unguium 97 
 
 Fettgeschwiilst 268 
 
 Ee iter rose 142 
 
 Fever-sore 141 
 
 Fibroma 267 
 
 molluscum 267 
 
 Filaria sanguinis 251, 253 
 
 Eisehschuppenkrankheit 241 
 
 Fish-skin disease 241 
 
 Fissures 37 
 
 Flechte, fressende 177 
 
 scheerende 101 
 
 Flecke 34 
 
 Fleckenmal 259 
 
 Folliculitis 236, 238 
 
 barbae 237 
 
440 
 
 INDEX. 
 
 PAGE 
 
 Fragilitas crinium 308 
 
 Freckles 261 
 
 Frost-bite 162 
 
 Functional disorders 54 
 
 Furoncle 173 
 
 Furuncle 1 73 
 
 Furunculosis 1 73 
 
 Funtnkel 1 73 
 
 Gale 116 
 
 Gcfdssmal 273 
 
 Gesckwiilste , . . 35 
 
 Geschwiire 37 
 
 Glanzhaui 287 
 
 Glossy skin 286, 287 
 
 Glycerin Cream 317 
 
 Glyco-gelatin 43, 44 
 
 Gommes scrofuleuses 181 
 
 Granuloma fungoides 219 
 
 Granulomata, the 1 76 
 
 Grappling forceps 51 
 
 Gray Oil 212 
 
 Grutum 67 
 
 Gum Arabic Paste 43 
 
 Gumma, exulcerated 199 
 
 subcutaneous 200 
 
 superficial 199 
 
 Gummata, multiple 204 
 
 tubercular 182 
 
 Giirtelrose 142 
 
 Hair, anatomy of 22 
 
 Hardy's Helmerieh's Ointment 120 
 
 Hautabschnrfungen 36 
 
 Hautfinne 228 
 
 Hautgriesz 67 
 
 Hauthorn 247 
 
 Hautkrebs 279 
 
 Hautrote 71 
 
 Ha11tschriin.de 37 
 
 Hantsclerem , 289 
 
 Hebra's Cosine's Paste 284 
 
 Hebra's Green Soap Tincture 43 
 
 Hematidrosis 60 
 
 Hemophilia 82 
 
 Hemorrhages 82 
 
 Herpes 140 
 
 circinatus 108 
 
 facialis 141 
 
 febrilis 141 
 
 i ris . . 139 
 
 labialis 141 
 
 preputialis 141 
 
 progenitalis 141 
 
 tonsurans 101 
 
 vulvarum 141 
 
 zoster 142 
 
 Herpes circine 108 
 
 Hirsuties 256 
 
 Hives 75 
 
 Horn, cutaneous 247 
 
 Horny layer, the 15 
 
 Hiihneraiige 24O 
 
 Hydradenitis 227 
 
 Hydroa 149 
 
 herpetiforme 149 
 
 Hyperemias ,.,,,., 71 
 
 PAGE 
 
 Hyperemias passive 73 
 
 Hyperidrosis 56 
 
 axillae 57 
 
 genitalium 57 
 
 localis 57 
 
 manuum 57 
 
 pedum 57 
 
 universalis 57 
 
 Hypertrichiasis 25b 
 
 Hypertrichosis 25b 
 
 Hypertrophies 241 
 
 of connective tissue 251 
 
 of epidermis 241 
 
 of hair 256 
 
 of nails 258 
 
 of pigment 259 
 
 Hypertrophy of sebaceous glands 254 
 
 Hyphomycetes 9b 
 
 Ichthyol 46 
 
 Ichthyol-Arsenic Pills 135 
 
 Ichthyol Collodion ■ bq 
 
 Ichthyol Lotion 169 
 
 Ichthyol-Mercury Ointment 113 
 
 Ichthyol Ointment No. 1 137 
 
 Ichthyol Ointment No. 2 1619 
 
 Ichthyol Pills 232 
 
 Ichthyol Spray 1(39 
 
 Ichthyose 241 
 
 Ichthyosis 241 
 
 congenita 242 
 
 hystrix 242 
 
 serpentina 242 
 
 Ignis sacer 142 
 
 Ihle's Resorcin Lotion 303 
 
 Impetigo 150 
 
 contagiosa 151 
 
 syphiliticum 197 
 
 Inflammations 86 
 
 deep-seated 159 
 
 of glands 227 
 
 of nails 239 
 
 superficial 86 
 
 Initial lesion 187 
 
 Iodide-of-Potash Solution 213 
 
 Iodine 48 
 
 Iodine Mixture 213 
 
 Iodized Glycerin 225 
 
 Iodoform 47 
 
 Iodoform Pills 213 
 
 Iodoform-Tannin Powder 249 
 
 Itch, the 116 
 
 Jessner's Carbolic-Sulphur Ointment 307 
 
 Joseph's Naphthol Green Soap Spirit 115 
 
 Juchflechte 79 
 
 Kahlheit 298 
 
 Kaposi's Caustic Paste 284 
 
 Kaposi's Dye Formula No. I 297 
 
 Kaposi's Dye Formula No. 2 297 
 
 Kaposi's Naphthol Ointment 82 
 
 Keloid 265, 266 
 
 Keratohyalin 15 
 
 Keratoma 244 
 
 Keratosis pilaris 241, 243 
 
 Kerion 102 
 
 Kerosene Lotion , , 121 
 
INDEX. 
 
 441 
 
 PAGE 
 
 Keyes's Cutaneous Punch 51 
 
 Kleienflechte 113 
 
 Knollen 35 
 
 Knollenkrebs 265 
 
 Knotcn , 35 
 
 Knotschen 34 
 
 A'ratze lib 
 
 Krause, end-bulbs of 19 
 
 Krebs 277 
 
 Kriesfleckige Kahlhtit 304 
 
 Knisten 37 
 
 Kuhpocken go 
 
 Kupferfinne 233 
 
 Kupfernase 230 
 
 Lactic-acid Ointment 181 
 
 Lactic-acid Solution 225 
 
 Lanugo hair 22 
 
 Lassar's Paste 43 
 
 Lassar's Peeling Paste 232 
 
 Lassar's Salicylic-acid Ointment 303 
 
 Lassar's Sublimate Lotion 303 
 
 Laudanum Ointment 144 
 
 Lead Lotion 61 
 
 Leichdorn 246 
 
 Leichentuberkel 184 
 
 Leiomyomata 272 
 
 Lentigo 261 
 
 Lepra 215 
 
 anesthetica 217 
 
 Arabum 215 
 
 macular 216 
 
 mutilans 217 
 
 nervorum 217 
 
 tuberosa 216 
 
 Lepre 215 
 
 Leprosy 215 
 
 Lesions 33 
 
 primary 34 
 
 secondary 36 
 
 Leucoderma 293-295 
 
 acquisita 293 
 
 congenita 293 
 
 Leucoma unguium T 309 
 
 Lichen lividus 181 
 
 pilaris 241, 243 
 
 planus 92 
 
 ruber 94 
 
 ruber acuminatus 94 
 
 ruber planus 92 
 
 scrofulosorum 181, 182 
 
 tropicus 139 
 
 urticatus 76 
 
 Lime-oil 135 
 
 Linsenflecke 201 
 
 Lipoma 268 
 
 pendulum 269 
 
 polyposum 269 
 
 Livedo 73 
 
 Liver-spot 262 
 
 Lotions 41 
 
 Loupe 68 
 
 Lupus discretus 1 78 
 
 disseminatus 1 78 
 
 erythematosus 221 
 
 erythematosus aggregatus , 222 
 
 PAGE 
 
 Lupus erythematosus corneus 222 
 
 erythematosus discoides 222 
 
 erythematosus disseminatus 222 
 
 exedens 1 78 
 
 exfoliativus 1 78 
 
 exulcerans 178 
 
 hypertrophicus 1 78 
 
 maculosus 178 
 
 papillaris 1 78 
 
 sebaceus 221 
 
 seborrheicus 221 
 
 serpiginosus 178 
 
 tuberculosus 178 
 
 verrucosus 1 78 
 
 vulgaris 177 
 
 Lupus vulgaire 177 
 
 Lymphadenie cutane'e 219 
 
 Lymphangioma 27b 
 
 cavernosus 276 
 
 simplex 27b 
 
 Lymphatics 16 
 
 Macrochilia 276. 
 
 Macroglossia 276 
 
 Maculse et striae atrophica; 28b 
 
 Macules 34 
 
 Marsden's Paste 46 
 
 Maseru 86 
 
 Masque de la grossesse 262 
 
 Matrix of nail 28 
 
 Measles 86 
 
 German 87 
 
 hybrid 87 
 
 Meibomian glands 21 
 
 Meissner, corpuscles of 18 
 
 Melanoderma 262 
 
 Melanosarcoma 270 
 
 Mentagra 236 
 
 Menthol 48 
 
 Menthol Capsules 78 
 
 Menthol-oil 174 
 
 Menthol Ointment 5b 
 
 Mercurial Ointment, Compound 214 
 
 Mercurial Ointment and Powder 214 
 
 M ercury 48 
 
 Microspnron furfur 96, 1 14 
 
 Miliaria crystallina 60 
 
 Milium 67 
 
 Mitesser 65 
 
 Mixed Treatment 210 
 
 Mole 259 
 
 Molluscum contagiosum 254, 255 
 
 fibrosum 267 
 
 pendulum 267 
 
 sebaceum 254 
 
 Monilethrix 308 
 
 Moniliform hairs 308 
 
 Morbilli 86 
 
 Morbus maculosus Werlhofii 83 
 
 Morphcea 289 
 
 Morris's Thymol-Chloroform Oil 120 
 
 Mother's mark 273 
 
 Mucous patch 195 
 
 Muscles of the skin 17 
 
 Muttermal 259 
 
 Mycosis fungoides 219 
 
442 
 
 INDEX. 
 
 PAGE 
 
 Myoma 272 
 
 Myxofibroma. 268 
 
 Myxolipoma 268 
 
 Myxoma 208 
 
 Myxosarcoma 268 
 
 Noevus araneus 274 
 
 flammeus 273 
 
 lipomatodes 260, 274 
 
 mollusciformis 260 
 
 papillary 275 
 
 pigmentosus 259, 260 
 
 pilosus 260 
 
 sanguineus 273 
 
 spilus 259 
 
 unius lateris 260 
 
 vasculosus 273 
 
 venosus 274 
 
 verrucosus 259 
 
 Nails, the 27 
 
 Naphthol 47 
 
 Naphthol Ointment 105, 243 
 
 Naphtholated Oil 100 
 
 Naphtholated Spirit 303 
 
 A T arbe 264 
 
 Narben ' 38 
 
 Narbenkrebs 265 
 
 Nassende Papel 195 
 
 Nervennavi 260 
 
 Nerves of the skin 17 
 
 A'esselausschlag 75 
 
 Nettle-rash 75 
 
 Neuroma 268 
 
 New growths 264 
 
 of connective tissue 264 
 
 of glandular tissue 276 
 
 of muscular tissue 272 
 
 of vascular tissue 273 
 
 Nodositas crinium 308 
 
 Nuclear layer 15 
 
 CEdemas 74 
 
 Ointments 42 
 
 Oleate of Mercury Ointment 210 
 
 Onychatrophia 309 
 
 Onychauxis 258 
 
 Onychia 239 
 
 maligna 239 
 
 syphilitica 200 
 
 Onychogryphosis 258, 290 
 
 Onychomycosis 240 
 
 favosa 97 
 
 Pachydermia 251 
 
 Pacinian bodies 18 
 
 Paget's disease 287 
 
 Panniculus adiposus 16 
 
 Papillse of the skin 15 
 
 Papillary layer of the skin 15 
 
 Papilloma, malignant 280 
 
 Papules 34 
 
 Parasiticides 45 
 
 Paronychia 239 
 
 syphilitica .*. . 200, 202 
 
 Paschkis's Hair-dye No. 1 297 
 
 Paschkis's Hair-dye No. 2 297 
 
 Pastes 43 
 
 Pediculidc? , 120 
 
 PACB 
 
 Pediculosis 1 20 
 
 capitis 1 20 
 
 corporis 122 
 
 pubis 124 
 
 vestimenti 122 
 
 Pediculus capitis 120 
 
 corporis 122,123 
 
 pubis 124 
 
 Pelade 304 
 
 Peliosis rheumatica , 83 
 
 Pemphigus 145 
 
 diphtheritica 147 
 
 foliaceus 147 
 
 hemorrhagicus 145 
 
 leprosus 21b 
 
 pruriginosus 148 
 
 solitarius 145 
 
 syphiliticus 203 
 
 vegetans 147 
 
 vulgaris 145 
 
 Perifolliculitis 23b 
 
 Permanganate Gargle 214 
 
 Pernio 73, ib2 
 
 Peru-Balsam Ointment 138 
 
 Petite ve'role 89 
 
 Petite ve'role volatile 91 
 
 Pfitndnase 233 
 
 Phtheiriasis 120 
 
 capitis 1 20 
 
 inguinalis 124 
 
 pubis 124 
 
 vestimenti 122 
 
 Physiology 29 
 
 PifT ard's Tar Lotion 303 
 
 Pigment of the skin 19 
 
 Pigmentary ncevus 259 
 
 Pigmentmal 259 
 
 Pili annulati 296, 308 
 
 Pink Pigment No. I 320 
 
 Pink Pigment No. 2 320 
 
 Pityriasis capitis 300 
 
 pilaris 243 
 
 rosea no 
 
 rubra 152 
 
 tabescentium 287 
 
 versicolor 113 
 
 Plaque muqueuse 195 
 
 Plaques ortie'es 36 
 
 Plaster-muslins 43 
 
 Plasters 44 
 
 Poliosis 294, 295 
 
 circumscripta 293 
 
 Polytrichia 256 
 
 Pompholyx 144 
 
 Porrigo contagiosa 151 
 
 decalvans 304 
 
 Port-wine stain 273 
 
 Post-mortem tubercle 184 
 
 Prairie itch 55 
 
 Prescriptions. 
 
 No. I. Vleminckx's Solution 43 
 
 2. Lassar's Paste 43 
 
 3. Gum Arabic Paste 43 
 
 4. Glyco-gelatin 43 
 
 5. Hebra's Green Soap Tincture 43 
 
INDEX. 
 
 443 
 
 No. 6. 
 
 7- 
 8. 
 
 9- 
 io. 
 
 13- 
 14. 
 
 IS- 
 16. 
 
 17- 
 18. 
 19. 
 20. 
 
 23- 
 
 24. 
 
 25- 
 
 26. 
 27. 
 28. 
 29. 
 3°- 
 31- 
 32. 
 
 33- 
 34- 
 35- 
 3&- 
 37- 
 38- 
 39- 
 40. 
 41. 
 42. 
 
 43- 
 
 44. 
 
 45- 
 46. 
 
 47- 
 48. 
 49. 
 50. 
 5i- 
 52- 
 53- 
 54- 
 55- 
 5&- 
 57- 
 5*- 
 59- 
 60. 
 61. 
 62. 
 63- 
 64. 
 65. 
 66. 
 67. 
 68. 
 69. 
 70. 
 
 Asiatic Pill 46 
 
 Marsden's Paste 46 
 
 Ungt. Chrysarobini Comp 46 
 
 Calomel Suspension 46 
 
 Tar Spirit 56 
 
 Carbolic Lotion i;6 
 
 Menthol Ointment 56 
 
 Veratria Ointment 56 
 
 Salicylic Dusting Powder 58 
 
 Alum Dusting Powder 58 
 
 Quinine Dusting Powder 58 
 
 Lead Lotion 61 
 
 Zinc Dusting Powder 61 
 
 Startin's Mixture 64 
 
 Resorcin Ointment 64 
 
 Tannin-Resorcin Spirit 64 
 
 Tar Ointment 64 
 
 Bronson's Mercurial Ointment 64 
 
 Sulphur Paste 64 
 
 Sulphur Ointment 64 
 
 Simple Ointment 70 
 
 Salol-Menthol Oil 70 
 
 Sack's Camphor Ointment 74 
 
 Boracic-acid Ointment 74 
 
 Saline Draught 78 
 
 Atropia Pills 78 
 
 Menthol Capsules 78 
 
 Saalfeld's Menthol Lotion 78 
 
 Carbolic Spirit 78 
 
 Chloral Lotion 78 
 
 Chloral-Camphor Ointment 78 
 
 Kaposi's Naphthol Ointment 82 
 
 Wilkinson's Ointment 82 
 
 Unna's Carbolic-Sublimate Ointment. 94 
 
 Chrysarobin Ointment 94 
 
 Naphtholated Oil 100 
 
 Resorcin-Salicylic-Sulphur Paste .... 100 
 
 Sublimate Ointment 100 
 
 Pyrogallol Ointment 100 
 
 Compound Tar Spirit 104 
 
 Sulphur-soap Spirit 104 
 
 Copper Oleate Ointment 105 
 
 Naphthol Ointment 105 
 
 Sublimate Spirit 108 
 
 Tannin-Sulphur Paste 108 
 
 Chrysarobin Collodion 108 
 
 Morris's Thymol-Chloroform Oil .... no 
 
 Ichthyol-Mercury Ointment 113 
 
 Zinc Paste 113 
 
 Joseph's Naphthol Green Soap Spirit 115 
 
 Sodic Hyposulphite Lotion 115 
 
 Scabies Ointment 120 
 
 Hardy's Helmerich's Ointment 120 
 
 Kerosene Lotion 121 
 
 Duhring's Staphisagria Ointment ... . 124 
 
 Rosenbach's Lotion for Pediculosis . . 125 
 
 Diuretic Mixture 134 
 
 Ichthyol-Arsenic Pills 135 
 
 Zinc-Camphor Powder 135 
 
 Zinc-oil 135 
 
 Lime-oil 135 
 
 Alkaline Lotion 135 
 
 Cooling Salve 135 
 
 Rose-water Ointment 135 
 
 Salicylic-Menthol Paste 136 
 
 No. 71. 
 72. 
 73- 
 
 74- 
 75- 
 76. 
 
 77- 
 78. 
 
 79- 
 80. 
 81. 
 
 82. 
 
 83- 
 84. 
 
 85- 
 86. 
 87. 
 
 90. 
 
 91. 
 92. 
 
 93- 
 94. 
 
 95- 
 96. 
 
 97- 
 98. 
 99. 
 
 100. 
 
 101. 
 
 102. 
 
 103. 
 
 104. 
 
 105. 
 
 106. 
 
 107. 
 
 108. 
 
 109. 
 
 no. 
 
 III. 
 
 112. 
 
 "3- 
 
 114. 
 
 "5- 
 116. 
 117. 
 118. 
 119. 
 120. 
 121. 
 122. 
 123. 
 124. 
 125. 
 126. 
 127. 
 128. 
 129. 
 130. 
 
 131- 
 
 132. 
 
 133- 
 134- 
 135- 
 
 PAGE 
 
 Diachylon Ointment 136 
 
 Ichthyol Ointment 137 
 
 Calaxine Lotion 137 
 
 Peru-Balsam Ointment 138 
 
 Tar Paste 1 38 
 
 Duhring's Morphine Collodion 144 
 
 Laudanum Ointment 144 
 
 Unna's Soft Zinc Paste 149 
 
 Salicylic-Sulphur Paste 153 
 
 Diuretic Mixture 158 
 
 Duhring's Arsenic Mixture 158 
 
 Ichthyol Arsenic Pills 158 
 
 Pyrogallol Collodion 158 
 
 Carron-oil 165 
 
 Ichthyol Collodion 165 
 
 Duhring's Poison-ivy Lotion 165 
 
 Ichthyol Collodion 169 
 
 Ichthyol Ointment No. 2. 169 
 
 Ichthyol Lotion 169 
 
 Ichthyol Spray 169 
 
 Menthol-oil 174 
 
 Lactic-acid Ointment 181 
 
 Pyrogallol Ointment No. 2 181 
 
 Cinnamonic-acid Injection 181 
 
 Crocker's Lead Thymol Ointment . . . 183 
 
 Antiseptic Mouth Wash 209 
 
 Astringent Mouth Wash 209 
 
 Protiodide Pill 210 
 
 Mixed Treatment 210 
 
 Calomel Powders 210 
 
 Oleate of Mercury Ointment 210 
 
 Sublimate Injection 212 
 
 Salicylate-of-mercury Suspension .... 212 
 
 Gray Oil 212 
 
 Iodide-of-Potash Solution 213 
 
 Iodoform Pills 213 
 
 Iodine Mixture 213 
 
 Syrup of the Iodide of Iron 213 
 
 Compound Mercurial Ointment 214 
 
 Mercurial Ointment and Powder .... 214 
 
 Black Wash 214 
 
 Sublimate Gargle 214 
 
 Permanganate Gargle 214 
 
 Arsenic Solution 220 
 
 Sodium Arseniate Solution 220 
 
 Camphor-Naphthol . . . . . 220 
 
 Cade-Sulphur-Green Soap Ointment. . 225 
 
 Lactic-acid Solution 225 
 
 Iodized Glycerin 225 
 
 Ichthyol Pills 232 
 
 Lassar's Peeling Paste 232 
 
 Sulphur Lotion 233 
 
 Resorcin Ointment No. 2 243 
 
 Salicylic-acid Ointment 243 
 
 Naphthol Ointment 243 
 
 Salicylic-soap Ointment 245 
 
 Salicylic-Cannabis Collodion 245 
 
 Iodoform-Tannin Powder 249 
 
 Sublimate Collodion 251 
 
 Duhring's Depilatory 257 
 
 Bulkley's Lotion 261 
 
 Hebra's Cosme's Paste 284 
 
 Kaposi's Caustic Paste 284 
 
 Cocaine Ointment 28S 
 
 Paschkis's Hair-dye No. I 297 
 
444 
 
 INDEX. 
 
 139- 
 141. 
 142. 
 
 143- 
 145. 
 
 147- 
 148. 
 149. 
 150. 
 151. 
 l S 2 - 
 *53- 
 
 No. 136. I'aschkis's Hair-dye No. 2 297 
 
 137. Anderson's Hair-dye No. I ; 138. No. 2 297 
 Kaposi's Dye Formula No. I ; 140. No. 2 297 
 
 Pyrogallol Hair-dye 297 
 
 Stimulant Lotion 303 
 
 Sodic Bicarbonate Lotion; 144-Quinine 303 
 Ihle's Resorcin ; 146. Piffard's Tar Lotion 303 
 
 Tannic-acid Ointment 303 
 
 Sublimate Ix>tion 303 
 
 Lassar's Sublimate Lotion 303 
 
 N.iphthol Spirit 303 
 
 Lassar's Salicylij-acid Ointment 303 
 
 Croton oil Ointment .... 307 
 
 Bulkley's Carb.dic- Iodine Application. 307 
 
 154. Jessner's Carbolic -Sulphur Ointment.. 307 
 
 155. Sapo Supsradiposus 314 
 
 156. Lanolin Emulsion 314 
 
 157. Hager's Glycerin Paste 314 
 
 158. Toilet Water, 314; 159. Face Lotion . 315 
 160. Borax Lotion. No. 1; 161. No. 2 315 
 
 162. Detergent Solution ..... 315 
 
 163. Cologne Vinegar; 164. Aromatic Vinegar 316 
 165. Massage Ointment; 166. Soap Essence 316 
 
 167. Bjrax Soap Spirit 316 
 
 168. Bichloride Hair Wash 316 
 
 169. Quinine Spirit 316 
 
 Stimulant Hair Wash 3 16 
 
 Stimulant Hair Ointment; I72.HairOil 317 
 
 Glycerin Cream 317 
 
 Adeps Lanse Cream; 175. Inunction Oil 317 
 
 Adeps Lanse Cream No. 2 317 
 
 Lanolin Cream 318 
 
 Bernatzik's Crystal Pomade 318 
 
 White Face Powder 318 
 
 Almond-meal Powder 318 
 
 Glycerin Cold Cream 318 
 
 182. Debay's Pomade; 183. Rose Pomade. . 318 
 
 184. Brilliantine; 185. Hair Oil 318 
 
 Face Powder 320 
 
 Magnesia Face Powder 320 
 
 Carmine Face Powder 320 
 
 Princess Water 320 
 
 Pink Pigment No. 1; 191. No. 2 320 
 
 Rusma Depilatory Paste 322 
 
 Redwood's Depilatory 322 
 
 Boudet's Depilatory 322 
 
 Depilatory Powder 322 
 
 Neumann's Depilatory 322 
 
 Debay's Depilatory 322 
 
 Depilatory Water . 322 
 
 Boettger's Depilatory 322 
 
 Prickle-cell layer 15 
 
 Prickly heat 139 
 
 Princess Water 320 
 
 Protiodide Pill 210 
 
 Prurigo 70 
 
 agria ; ferox; mitis 81 
 
 Pruritus — aestivus; hiemalis; senilis; universalis 54 
 
 ani ; localis ; vulvae .... 55 
 
 Psoriasis 153 
 
 annularis; buccalis; diffusa; figurata; guttata; 
 gyrata; nummularis; punctata; serpiginosa; 
 
 universalis igfj 
 
 Purpura — hemorrhagica; rheumatica; simplex.. 83 
 scorbutica 84 
 
 170. 
 171. 
 
 173- 
 174. 
 176. 
 177. 
 178. 
 179. 
 180. 
 181. 
 
 186. 
 187. 
 188. 
 189. 
 190. 
 192. 
 
 *93- 
 194. 
 
 195- 
 196. 
 197. 
 198. 
 199. 
 
 Purpura urticans 76 
 
 Pusteln 36 
 
 Pustules 36 
 
 Pyrogallol 47 
 
 Pyrogallol Collodion 158 
 
 Pyrogallol Hair-dye 297 
 
 Pyrogallol Ointment No. I 100 
 
 Pyrogallol Ointment No. 2 181 
 
 Quaddeln 36 
 
 Quinine Dusting Powder 5^ 
 
 Quinine Lotion 303 
 
 Radix 24 
 
 Resorcin 47 
 
 Resorcin Ointment No 1 64 
 
 Resorcin Ointment No. 2 243 
 
 Resorcin-Salicylic-Sulphur Paste 100 
 
 Rete Malpighii 15 
 
 mucosum 15 
 
 Reticular layer 16 
 
 Rhagaden 37 
 
 Rhinophyma 233, 234 
 
 Rhinoscleroma 225 
 
 Rhus toxicodendron 1 64 
 
 venenata 164 
 
 Ringed hair 296 
 
 Ringelhaare 3 & 
 
 Ringworm of the beard 105 
 
 of the body 108 
 
 of the crotch no 
 
 of the head 107 
 
 Rodent ulcer 278 
 
 Rosacea 233 
 
 Rose 107 
 
 Rosenbach's Lotion 125 
 
 Roseola 73 
 
 annulata 192 
 
 figurata 192 
 
 syphiliticum 19 2 
 
 Rose-rash 7 1 
 
 Rose-water Ointment 135 
 
 Rotheln 87 
 
 Rotlauf 167 
 
 Rougeole 86 
 
 Rubeola 87 
 
 Rubeole 87 
 
 Rupia syphilitica 196 
 
 Saalfeld's Menthol Lotion 78 
 
 Sack's Camphor Ointment 74 
 
 Salicylate-of-Mercury Suspension 212 
 
 Salicylic Acid 47 
 
 Salicylic-acid Ointment 243 
 
 Salicylic-Cannabis Collodion 245 
 
 Salicylic Dusting Powder 58 
 
 Salicylic-Menthol Paste 136 
 
 Salicylic-soap Ointment 245 
 
 Salicylic-Sulphur Paste 153 
 
 Saline Draught 7& 
 
 Salol-Menthol Oil 7° 
 
 Salt rheum 125 
 
 Salve-muslins 43 
 
 Salve-pencils 44 
 
 Salzfluss 125 
 
 Sarcoma 270 
 
 melanotic 2 70 
 
 Sarcomatosis cutis 270 
 
INDEX. 
 
 445 
 
 FACE 
 
 Scabies Ii6 
 
 Scabies Ointment 120 
 
 Scabs 37 
 
 Scales 37 
 
 Scapus 23 
 
 Scar 264 
 
 Scarf-skin 14 
 
 Scarificator 50 
 
 Scarlatina 87 
 
 Scarlatine 87 
 
 Scarlet fever 87 
 
 Scars 38 
 
 Sc hanker, weicher 1 70 
 
 Scharlach 87 
 
 Schleimpapel 195 
 
 Sckuppcn 37 
 
 Schuppenflechte 153 
 
 Schweile 244 
 
 Scissura pilorum 308 
 
 Sclerema adultorum 289 
 
 neonatorum 291 
 
 of the new-born 291 
 
 Sclerodactylie 290 
 
 Scleroderma 289 
 
 circumscriptum 289 
 
 neonatorum 29 1 
 
 universalis 290 
 
 Sclerodermic 289 
 
 Sclerosis 187 
 
 Scrofulide hiberculeicse 177 
 
 Scrofuloderma 181 
 
 papulosum 182 
 
 pustulosum 182 
 
 tubero-ulcerosum 182 
 
 ulcerosum 182 
 
 Scurvy 84 
 
 land 83 
 
 Sebaceous cyst 68 
 
 Sebaceous glands 20 
 
 Seborrhea 61 
 
 capitis 62 
 
 congestiva 221 
 
 faciei 63 
 
 genitalium 63 
 
 nasi 63 
 
 oleosa 61 
 
 sicca 62 
 
 Sebum 20 
 
 Shingles 142 
 
 Simple Ointment 7° 
 
 Smallpox 89 
 
 Sodic Bicarbonate Lotion 303 
 
 Sodic Hyposulphite Lotion 115 
 
 Sodium Arseniate Solution 220 
 
 Sommersprossen 261 
 
 Spitzencondylom 248 
 
 Spud 51 
 
 Squames 37 
 
 Stains 38 
 
 Startin's Mixture 64 
 
 Steatoma 68 
 
 Steatorrhea 62 
 
 Stimulant Hair Ointment 317 
 
 Stimulant Hair Wash 316 
 
 Stimulant Lotion 303 
 
 PAGE 
 
 Stratum corneum 15 
 
 Stratum granulosum 15 
 
 lucidum 15 
 
 spinosum 15 
 
 Streptococctis erysipelatis 167, 168 
 
 Striae atrophica; 287 
 
 Strophulus pruiigincux 79 
 
 Subcutis, the 16 
 
 Sublimate Collodion 251 
 
 Sublimate Gargle 214 
 
 Sublimate Injection 212 
 
 Sublimate Lotion 303 
 
 Sublimate Ointment 100 
 
 Sublimate Spirit 108 
 
 Sudamina 60 
 
 Sudoriparous glands 21 
 
 Sulphur 47 
 
 Sulphur Lotion 233 
 
 Sulphur Ointment 64 
 
 Sulphur Paste 64 
 
 Sulphur-soap Spirit 104 
 
 Sweat 22 
 
 Sweat-glands 21 
 
 Sycosis coccygenes .'.... 23b 
 
 non parasitica 236 
 
 parasitica 105 
 
 Sycosis non parasitaire 236 
 
 Symptomatology 32 
 
 Syphilide, erythematous 192 
 
 macular 192 
 
 papular 192 
 
 Syphilides 190 
 
 Syphilis 186 
 
 cutanea 190 
 
 hereditary 202 
 
 insontium 186 
 
 of hair and nails 200, 201 
 
 Syphiloderma 190 
 
 gummatosa 198 
 
 maculosa 191, 192 
 
 maculo-papulosa 193 
 
 palmaris et plantaris 193 
 
 papillomatosa 198 
 
 papulosa 192 
 
 papulosa, large 192 
 
 papulosa, miliary 195 
 
 papulo-squamosa 193 
 
 pustulosa 195 
 
 pustulosa, large 196 
 
 pustulosa, miliary 197 
 
 tuberculosa 197 
 
 tuberculo-squamosa 198 
 
 ulcerosa 200 
 
 Syphiloma 198 
 
 Syrup of the Iodide of Iron 213 
 
 Tache de feu 273 
 
 pigmentaire 259 
 
 Taches 34 
 
 de rousseur 261 
 
 Tactile corpuscles 18 
 
 Tannic-acid Ointment 303 
 
 Tannin-Resorcin Spirit 64 
 
 Tannin-Sulphur Paste 108 
 
 Tar 46 
 
 Tar Paste 138 
 
446 
 
 INDEX. 
 
 Tar Ointment 64 
 
 Tar Spirit 56 
 
 Tar Spirit, Compound 104 
 
 Teigne favense 96 
 
 tonsurante 101 
 
 Telangiectasis 273 
 
 Tetter 125 
 
 Texas mange 55 
 
 Therapeutics 39 
 
 Thiol 47 
 
 Tinea barbae 105 
 
 circinata 108 
 
 decalvans 304 
 
 favosa 96 
 
 sycosis 105 
 
 tonsurans 101 
 
 versicolor 113 
 
 Trichophytie sycosique 105 
 
 Trichophyton tonsurans 96, 101 
 
 Trichophytosis 101 
 
 barbre 105 
 
 capitis 101 
 
 corporis 108 
 
 cruris 1 10 
 
 Trichorrhexis nodosa 308 
 
 Tubercles 35 
 
 Tuberculosis cutis 177, 185 
 
 cutis verrucosa 184 
 
 Tnmenrs 35 
 
 Tumor cavernosus 273 
 
 Tumors 35 
 
 Tyloma 244 
 
 Tyson's glands 21 
 
 Ulceres 37 
 
 Ulcers 37 
 
 Ulcus durum 187 
 
 molle 170 
 
 Ulerythema centrifugum 221 
 
 Unna's Carbolic-Sublimate Ointment 94 
 
 Unna's Soft Zinc Paste 149 
 
 Uridrosis 60 
 
 Urtica urens 75 
 
 I 'rticaire 75 
 
 Urticaria 75 
 
 acuta 76 
 
 alba 75 
 
 annularis 75 
 
 bullosa 76 
 
 factitia 76 
 
 figurata ... 75 
 
 gigantica 7b 
 
 gyrata 75 
 
 PACE 
 
 Urticaria hemorrhagica 76 
 
 papulosa 76 
 
 pigmentosa 76 
 
 rubra 75 
 
 tuberosa 76 
 
 vesiculosa 76 
 
 Vaccine 90 
 
 Vaccinia 90 
 
 Varicella 91 
 
 Variola 89 
 
 syphilitica 197 
 
 Vater, corpuscles of 18 
 
 Vegetations dermiqnes 248 
 
 Venereal warts 248 
 
 Veratria Ointment 56 
 
 Vergetnres 287 
 
 Verruca 250 
 
 necrogenica 184 
 
 planse 250 
 
 seniles 250, 287 
 
 Verrne 250 
 
 Vesicles 35 
 
 Vcsicnles 35 
 
 Vibrissae 20 
 
 Vitiligo 293 
 
 Vitiligoidea 269 
 
 Vleminckx's Solution 43 
 
 Wagner, corpuscles of 18 
 
 Wart 250 
 
 senile 287 
 
 Warze 250 
 
 Wen 68 
 
 Wheals 36 
 
 White Face Powder 318 
 
 Whitlow 239 
 
 Wilkinson's Ointment 82 
 
 Windpocken 92 
 
 Wine nose 233 
 
 Xanthelasma 269 
 
 Xanthoma 269 
 
 diabeticorum 270 
 
 tuberosum 269 
 
 Xeroderma 241, 286 
 
 Zinc-Camphor Powder 135 
 
 Zinc Dusting Powder 61 
 
 Zinc-oil 135 
 
 Zinc Paste 113 
 
 Zona 142 
 
 Zoster 142 
 
 gangrenosus 143 
 
 hemorrhagicus 143 
 
 ophthalmicus 143 
 
 X291 
 

 
 
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